Treatment of Hand Numbness & Tingling Carpal vs Cubital Tunnel SyndromeJianjun Ma, MD Department of Orthopedic Surgery

www.SpringfieldClinic.com

Case40 year old male, professional guitar player.

Numbness and tingling in the right small finger for one month.

Questions:

Is this carpal tunnel syndrome?Can I wait for a few months to see doctors?What kind of treatment will I need?

Peripheral nerves connect our brain/spinal cord to the other parts of your body.

A peripheral nerve injury can interfere with brain's ability to communicate with your hands.

3. Abnormal sensations caused by peripheral nerve dysfunction, common in nerve compression.

Hand numbness and tingling

Three types of nerve fibers:

Sensory: Sensation.Motor: Muscle strength.Autonomic: Involuntary activity, such as sweating etc.Sensory fibers

Motor fibers

Autonomic fibersPeripheral Nerve Fiber types

Histology of Peripheral Nerve

Peripheral nerves are fragile and easily damaged.

Peripheral nerves follow a path from the spinal cord to the hand where they can be pinched.

Sensory fibers: small, susceptible to nerve compression injuryMotor fibers: large, not susceptible to nerve compression injuryPeripheral Nerve Injury

Acute versus Chronic Peripheral Nerve Injury

Pathophysiologyic classification of nerve compression

SeverityPathophysiologyClinical

Blood-nerve barrier breakdown Symptoms, no signs on exam

DemyelinationAbnormal thresholdSymptoms, signs, and/or of weakness

Axonal lossDecreased innervationSymptoms, signs, and muscle wasting

Mild

Moderate

Severe

Sensory Nerve Innervation in the Hand

Median nerve: Thumb, index, long, and radial side of the ring finger.

Ulnar nerve: Small finger and ulnar aspect of the ring finger.

Radial nerve:The radial aspect of the dorsum of the hand and thumb, index, and long finger.

Sensation in the Hand

Nerve Compression Syndromes of the HandMedian nerveCarpal tunnel syndrome Pronator syndromeAnterior interosseous syndrome

Ulnar nerveCubital tunnel syndromeGuyon canal syndrome

Radial nerveRadial tunnel syndromePosterior interosseous syndromeSuperficial radial nerve syndrome

----------------- Most common--------------- Second most common

Systemic Diseases Predisposing to Nerve Compression in the USDiabetesThyroid diseaseCollagen vascular disease (vasculitis) most common: RA, SLE, MS.4. Chemotherapy-induced neuropathy5. Alcoholism6. Vitamin deficiency (folate, B12, B6)7. Heavy metal toxicity8. Lyme disease9. Multiple myeloma10. AIDS

Carpal Tunnel versus Cubital Tunnel Syndrome Carpal tunnel syndromeMost common

Demographics of Carpal Tunnel SyndromeIncidence: 1-3 per 1000 subjects per year.

Prevalence: 5 per 100 subjects in general population. 14 per 100 in diabetics 30 per 100 in diabetics with neuropathy

3. Women are three times more likely than men to develop CTS.

4. The dominant hand is usually affected first.

5. The estimated lifetime risk: 10% of adults.

What is carpal tunnel?A narrow passageway on the palm side of the wrist.Made up of bone, tendons, and ligaments. Cross section area: 134.9 23.6 mm2.One nerve, nine tendons, and synovium.Size of median nerve: 10 mm2.Number of nerve fiber: 7,457-27,190.With repetitive wrist movement or constant pressure, the canal can become inflamed.

carpal tunnel pressure median nerve compression carpal tunnel syndrome

Symptoms of Carpal Tunnel SyndromeNumbness/tingling in the index and middle fingers, followed by thumb, uncommon in the ring finger.Night time awakening (Wrist flexion).Thenar muscle wasting: classic but rare.Dropping objects and weakness.

Tests and DiagnosisHistory Pattern of signs and symptoms Timing of the symptoms

Physical exam Sensation Muscle strength Tinels sign Phalen test Durkan test

X-ray Rule out arthritis or a fracture.

Electromyogram To measure electrical discharges produced in muscles.

To determine if muscle damage has occurred.

Nerve conduction studyTo measure if electrical impulses are slowed in the carpal tunnel.

To rule out other condition in the neck.Tests

Risk Factors

Anatomic factors. 1. a wrist fracture or dislocation; 2. smaller carpal tunnel in women.

Nerve-damaging conditions. Diabetes and alcoholism: risk of nerve damage.

Inflammatory conditions. RA or infection can affect the tendons and exert pressure on median N.

Alterations in the balance of body fluids. Certain conditions (pregnancy, menopause, obesity, thyroid disorders, or kidney failure) fluid retention pressure increase within carpal tunnel.

Workplace factors. Vibrating tools/ work requiring prolonged or repetitive flexing of the wrist pressure increase within carpal tunnel.

Risk factors of carpal tunnel syndrome

Job tasks and occupations associated with CTS

Job TasksOccupationsGrasping and tugging fabric, pulling clothProduction sewer, tailor, garment worker/stitcherMilking cowsFarmerHandling objects on conveyor beltsAssembly-line workerPushing down ratchet, using screwdriverMechanicHand weedingGardenerKeyboarding / mouse useOffice workersKnittingHomemakerScrubbingJanitorPlaying stringed instruments with bowMusicianUsing laser scanner at checkoutCashierAssembling small partsElectronic industry workerPressing tool into palmPainter, carpenter, stablehandUsing air-powered hand toolsAssembly worker

2. Nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Wrist splinting

4. Corticosteroids Steroid injection Oral steroid1. Activity modificationNonsurgical Treatment

The goal of carpal tunnel surgery:To relieve pressure on the median nerve by cutting the ligament pressing on the nerve.

Open surgery Surgery involves making an incision in the palm of the hand over the carpal tunnel and cutting through the ligament to free the nerve.

Endoscopic surgeryA small incision in the wrist . Higher complication rate.Surgical Treatment

Postoperative CareElevate your hand above your heart for 2-3 days after surgery.Dressing off three to four days after surgery. Keep the incision clean and dry.Move your fingers. Light daily activity such as eating, brushing your teeth, etc.Take prescribed medications for pain as indicated and necessary.Do not drive until evaluated.Do not lift anything over 1-2 pounds until evaluated.Expected recovery time and release to work depends on the job and healing time.

Postoperative Therapy1-2 weeks Postop: Gentle exercise and light use of the hand and isolated tendon glide exercises for all digits

2-6 weeks Postop: Active Range of motion exercises of the wristEdema controlScar massage/desensitization

6-12 weeks Postop: Progressive strengthening exercises

Take quick breaks from repetitive activities.

Rotate your wrists and stretch your palms/fingers.

Take a NSAID pain reliever.

Wearing a wrist splint at night.

Avoid sleeping on your hands.Prevention

Prevention of carpal tunnel syndrome

Carpal Tunnel versus Cubital Tunnel Syndrome Cubital tunnel syndromeSecond most common

Demographics of Cubital Tunnel SyndromeIncidence: 24.7 cases/100,000 person years.USA: 75,000 cases annually World-wide: 1.5 million casesPrevalence: 2.8% to 6.8% in occupations requiring repetitive work.Affects men 3-8 times as often as women. Employees working with flexed elbows and direct pressure on the ulnar nerve are at risk.

What is cubital tunnel?Cubital tunnel: fascia covers a gap of about 4mm between the medial epicondyle and the olecranon.

Number of nerve fiber: 10,365-22,690Size of ulnar nerve: 6 mm2

Cubital Tunnel SyndromeMechanismsThe altered shape of the cubital tunnel.Traction and excursion of the ulnar nerve.Subluxation of the ulnar nerve: Constant friction. Susceptible to trauma.

cubital tunnel pressure ulnar nerve compression cubital tunnel syndrome

Symptoms of Cubital Tunnel SyndromeAltered sensation in the little and ring fingersSensory loss is the first symptom to be reportedWasting of the ulnar-sided muscles of the forearmClumsiness in the hand5. Wasting of the small muscles of the hand6. Claw deformity

Risk Factors Elbow injury Rheumatoid arthritis Repetitive pulling Repetitive reaching Prolonged leaning on the elbow Overuse and stress injuries Using vibrating tools

Daily activity and cubital tunnel syndrome

Sleeping and cubital tunnel syndrome

Tests and DiagnosisHistoryNumbness/tingling in the ring and little fingers. Timing of the symptoms.

Physical exam Sensory changes in ulnar nerve distribution (little+ring finger).Intrinsic weakness.Tinels sign at medial elbow.Elbow flexion test (3 min @ 120 flexion reproduces symptoms).Wartenbergs sign.6. Fromments sign.

X-ray Rule out arthritis or pre-existing trauma.

Electromyogram To measure electrical discharges produced in muscles.

To determine if muscle damage has occurred.

Nerve conduction studyTo measure if electrical impulses are slowed in the cubital tunnel.Stage its severity.

To rule out other condition in the neck.Tests

Non Surgical TreatmentNon-steroidal anti-inflammatory medication (NSAID). A splint or brace use while sleeping to keep the elbow from bending while you sleep. Watch and modify your posture during the day to avoid long periods of time with your elbow bent. Make more space between your work and your chest, so that your elbows are more straight.

Surgical TreatmentThe goal of surgery: to relieve the compression of the ulnar nerve within the cubital tunnel.

Indication of surgery: Failure to non surgical treatment

Timing of surgery: No prolonged waiting

Surgical TreatmentIn situ release

Anterior ulnar nerve transposition

Anterior Ulnar Nerve TranspositionThe nerve can be placed underneath or within the forearm muscles that insert onto the bone at the inside of the elbow for protection.

The bone which forms the bottom of the tunnel can be shaved and smoothed out, or a small portion removed if necessary.

Postoperative CareKeep the initial cast and incision clean and dry. Once the cast is removed (usually in 2-4 weeks), change the bandages as needed.Keep the fingers moving. Avoid bending the wrist forward for 4 weeks after surgery to let the muscles heal.Begin gently bending and straightening the elbow after splint removal.Scar massage. Gradual strengthening at 6 weeks post-surgery.

Postoperative TherapyProtective splinting with the wrist neutral. Elbow sleeve to protect the healing area from re-injury and for comfort.Scar management including silicone gel sheeting, ultrasound. Swelling reduction techniques. Desensitization techniques for a sensitive scar. Active motion including tendon and nerve gliding exercises. Work conditioning activities at 6 weeks after surgery.

Postoperative RecoveryA large portion of the numbness/tingling is relieved.The pain radiating up the arm into the shoulder/neck is often relieved.The inside edge of the elbow will likely be tender for 4-6 months after surgery. 4. Numbness/tingling on the back side of elbow.5. Rate of peripheral nerve regeneration: 1mm/day.6. Hand muscle atrophy unlikely to be recovered.

PreventionAvoid leaning on the inside edge of the elbow. Avoid holding the elbow in flexion for prolong time. Minimize repetition and periodically rest the arms. Slow down the activity. Use the lightest grip possible. Use the least amount of force during the activity. Use ergonomically designed tools if available.Alternate work activities between hands.

Prevention of cubital tunnel syndrome

Case Analysis40 year old male, professional guitar player.

Numbness and tingling in the right hand small finger for one month.

Diagnosis: Right cubital tunnel syndrome

Treatment:Activity modification.Elbow brace at night.Posture modification.

3 month follow up: Normal.

Hand Numbness and Tingling carpal/cubital tunnel syndrome only?Very common.

Carpal tunnel syndrome or/and cubital tunnel syndrome likely.

However, some other conditions to be ruled out.

Hand Numbness and TinglingDifferential diagnosisDiabetic NeuropathyCervical Disc DiseaseCervical SpondylosisThoracic Outlet SyndromeLateral EpicondylitisMedial EpicondylitisMyofascial PainMedial elbow instability Compartment Syndrome

Cardiac ischemiaApical lung tumor LeprosyLyme DiseaseMononeuritis MultiplexMultiple SclerosisPosttraumatic SyringomyeliaRadiation-Induced Brachial PlexopathyTraumatic Brachial Plexopathy

Hand Numbness and TinglingWhen to actAs soon as possible

Who to seeFamily physician or orthopedist

What to expectEvaluated earlyTreated earlyRecover better

Thank you

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