Syndrome of a carpal tunnel
Syndrome of a carpal tunnel — compression and ischemic damage of a middle nerve in the carpal (karpalny) tunnel. It is shown by pain, decrease in sensitivity and paresteziya in the field of the palmar surface of the I-IV fingers, some weakness and awkwardness at the movements by a brush, especially in need of the fascinating movement by a thumb. The diagnostic algorithm includes survey of the neurologist, electrophysiological testing, biochemical blood test, a X-ray analysis, ultrasonography, KT or MPT of area of a wrist. Treatment generally conservative — anti-inflammatory, antiedematous, antipainful, physiotherapeutic. At its insolvency the operational section of a carpal sheaf is shown. The forecast favorable on condition of timeliness of medical actions.
Syndrome of a carpal tunnel
Syndrome of a carpal tunnel (syndrome of the karpalny channel) — a compression and ischemia of a middle nerve at reduction of volume of a carpal tunnel in which it passes, passing from a forearm to a brush. In neurology treats so-called tunnel syndromes. The Karpalny channel is at the brush basis from its palmar surface, is formed by bones of a wrist and the cross ligament tense over them. Passing through it, the middle nerve comes to a palm. In the channel under a trunk of a middle nerve also there pass sinews of muscles-sgibateley of fingers. On a brush the middle nerve innervates the muscles which are responsible for assignment and opposition of a thumb, bending of proximal phalanxes of index and average fingers, extension of average and disteel phalanxes of the same fingers. Sensitive branches provide superficial sensitivity of skin of the tenor (a thumb eminence), a palmar surface of the first three and a half of the 4th finger, the back of disteel and average phalanxes of the 2nd and 3rd fingers. Besides, the middle nerve carries out a vegetative innervation of a brush.
Reasons of a syndrome of a carpal tunnel
The syndrome of a carpal tunnel arises at any pathological processes leading to reduction of volume of the channel. Tendency to a disease can be caused by congenital narrowness or features of a structure of the channel. So, women have narrower karpalny channel, and the syndrome of a carpal tunnel occurs at them considerably more often than at men.
One of the reasons of narrowing of a carpal tunnel is the wrist injury: a bruise, a fracture of bones of a wrist, dislocation in a luchezapyastny joint. At the same time the volume of the channel can decrease not only at the expense of the shift of bones, but also at the expense of post-traumatic hypostasis. The change of a ratio of the anatomical structures forming the karpalny channel caused by the excess growth of bones is observed in case of an akromegaliya. The syndrome of a carpal tunnel can develop against the background of inflammatory diseases (a sinovit, a tendovaginit, rheumatoid arthritis, the deforming osteoarthrosis, sharp and chronic arthritis, tuberculosis of joints, gout) and tumors (a lipoma, a gigroma, a hondroma, a sinovioma) areas of a wrist. Excess puffiness of fabrics can act as the reason of a karpalny syndrome that is noted at pregnancy, a renal failure, endocrine pathology (a hypothyroidism, a climax, a state after an ovariektomiya, diabetes), reception of oral contraception.
Chronic inflammatory process in a carpal tunnel is possible at the constant travmatization connected with the professional activity assuming repeated bendings extensions of a brush, for example at pianists, cellists, packers, carpenters. A number of authors assume that long daily work on the computer keyboard can also provoke a syndrome of a carpal tunnel. However statistical researches did not reveal essential distinctions between incidence among working at the keyboard and average incidence of the population.
The compression of a middle nerve first of all leads to disorder of its blood supply, i.e. to ischemia. At the beginning only the cover of a nervous trunk suffers, in process of increase of a sdavleniye pathological changes affect deeper layers of a nerve. The first breaks function of touch fibers, then — motive and vegetative. It is long the existing ischemia leads to degenerate changes in nervous fibers, replacement of nervous tissue with soyedinitelnotkanny elements and, as a result, permanent loss of function of a middle nerve.
Symptoms of a syndrome of a carpal tunnel
The syndrome of a carpal tunnel demonstrates pains and paresteziya. Patients note a sleep, a pricking, "lumbago" in a palm and in the first 3-4 fingers of a brush. Pain often extends up, to the internal surface of a forearm, but can go down, from a wrist to fingers. The night painful attacks forcing patients to waken are characteristic. Intensity of pain and expressiveness of a sleep decrease when grinding palms, lowering brushes down, stirring or a swinging them in the lowered state. The carpal syndrome can have bilateral character, but more often and stronger the dominating brush is surprised.
Over time, along with touch violations, difficulties of movements by a brush, especially those which demand fascinating participation of a thumb are observed. The affected hand it is difficult to patients to hold the book, to draw, hold the top hand-rail in transport, to hold the mobile phone near an ear, it is long to operate an automobile wheel, etc. There is an inaccuracy and a diskoordination of movements by a brush which is described by patients as if at them "the fingers are all thumbs". Disorder of vegetative function of a median nerve is shown by feeling of "swelling of a brush", its cold snap or, on the contrary, feeling of temperature increase in it, hypersensibility by cold, a pobledneniye or hyperaemia of skin of a brush.
Diagnostics of a syndrome of a carpal tunnel
Neurologic inspection reveals the area of a gipesteziya corresponding to a zone of an innervation of a middle nerve, some decrease in force in the muscles innervated by a middle nerve, vegetative changes of skin of a brush (coloring and temperature of skin, its mramornost). Additional tests which reveal are carried out: Falen's symptom — emergence of paresteziya or a sleep in a brush at its passive bending extension for a minute, Tinel's symptom — the pricking in a brush arising at percussion in the field of the karpalny channel. Exact data on a topic of defeat can be obtained by means of an electromyography and an elektroneyrografiya.
For the purpose of studying of genesis of a carpal syndrome blood test to the Russian Federation, blood biochemistry, a X-ray analysis of a luchezapyastny joint and a brush, ultrasonography of a luchezapyastny joint, KT of a luchezapyastny joint or MRT, in the presence of indications — its puncture is carried out. Consultation of the orthopedist or traumatologist, endocrinologist, oncologist is possible. It is necessary to differentiate a syndrome of a carpal tunnel from a neuropathy of a beam nerve, a neuropathy of an elbow nerve, a polyneuropathy of the top extremities, vertebrogenny syndromes caused by a cervical spondiloartroz and osteochondrosis.
Treatment of a syndrome of a carpal tunnel
The fundamentals of medical tactics are made by elimination of the reasons of narrowing of the karpalny channel. Here repositions of dislocations, a brush immobilization, correction of endocrine and exchange violations, knocking over of an inflammation and decrease in puffiness of fabrics belong. Conservative therapy is carried out by the neurologist, if necessary together with other experts. The issue of surgical treatment is resolved with the neurosurgeon.
Conservative methods of therapy come down to an immobilization of the struck brush the tire for about 2 weeks, to carrying out the anti-inflammatory, anesthetizing, antiedematous pharmacotherapy. Apply NPVP (an ibuprofen, indometacin, diclofenac, , etc.), in hard cases resort to purpose of glucocorticosteroids (a hydrocortisone, Prednisolonum), at the expressed pain syndrome carry out medical blockade of area of a wrist with introduction of local anesthetics (lidocaine). Antiedematous therapy is carried out by means of diuretic, mainly furosemide. The positive effect is rendered by vitamin therapy by medicines . In, mud cure, an electrophoresis, , compresses with a dimethyl sulfoxide. Vascular therapy pentoksifilliny, nicotinic acid allows to reduce ischemia of a middle nerve. After achievement of clinical improvement for restoration of function of a nerve and force in muscles of a brush physiotherapy exercises, massage of a hand, miofastsialny massage of a brush are recommended.
At inefficiency of conservative actions the karpalny syndrome demands surgical treatment. Operation consists in a section of a cross ligament of wrist. It is carried out on an outpatient basis with use of the endoscopic equipment. At considerable structural changes in area of the karpalny channel because of impossibility of application of an endoscopic technique operation is performed in the open way. Increase in volume of a carpal tunnel and removal of a compression of a middle nerve is result of intervention. In 2 weeks after operation the patient can already carry out a hand of the movement, not demanding considerable loading. However restoration of a brush in full requires several months.
Forecast and prevention of a syndrome of a carpal tunnel
At timely complex treatment the syndrome of a carpal tunnel, as a rule, has the favorable forecast. However about 10% of cases of a compression will not respond even to the most optimum conservative treatment and demand carrying out operation. The cases which are not followed by total loss of sensitivity and an atrophy of muscles of a brush have the best postoperative forecast. In most cases in a month after operation function of a brush is restored approximately for 70%. However awkwardness and weakness can be noted also several months later. In some cases the recurrence of a carpal syndrome meets.
Prevention consists in normalization of working conditions: adequate equipment of a workplace, ergonomic organization of working process, change of kinds of activity, existence of breaks. Carry to preventive actions also the prevention and timely treatment of injuries and diseases of area of a wrist.