Carpal tunnel syndrome
- Carpal tunnel formed by flexor retinaculum stretching across carpus
- Forms a tight tunnel through which passes
- Long flexors to fingers and thumb
- Median nerve
- Swelling within the tunnel causes nerve compression and ischaemia
- Carpal tunnel syndrome affects 3% of women and 2% of men
- 30% cases due to underlying medical condition
Causes
- Idiopathic
- Hormonal - pregnancy / menopause
- Rheumatoid arthritis
- Hypothyroidism
- Diabetes
Clinical features
- Usually presents in middle age
- Female : male ratio is 8:1
- Pain and paraesthesia in distribution of median nerve
- Symptoms are often worse at night
- Signs are few
- Tapping over carpal tunnel can reproduce symptoms (Tinel's sign)
- Flexion of wrist for 60 seconds reproduces symptoms (Phalen's sign)
- Thenar wasting and loss of 2-point discrimination are late features
- Diagnosis confirmed by electomyelogram
- Shows slowed nerve conduction across the wrist
Management
- Treat underlying associated medical problems
- Nocturnal symptoms can often be controlled with night splints
- Steroid injections may produce temporary symptomatic relief
- Troublesome symptoms require division of flexor retinaculum
- May be performed endoscopically
- 70-90% are symptom-free following surgery
de Quervain's disease
- Also known as stenosing tenovaginitis
- Due to inflammation and thickening of tendon sheaths of
- Extensor pollicis brevis
- Abductor pollicis longus
- Occurs where both tendons cross the distal radius
Clinical features
- Usually presents in middle age
- Pain noted over radial aspect of wrist
- Often occurs after repetitive activity
- Tendon sheath is thickened and tender over the radial styloid
- Pain often worsened by abduction of thumb against resistance
- Passive abduction across palm often causes pain (=Finkelstein's test)
Management
- Symptoms can often be improved with steroid injections into tendon sheath
- Persistent symptoms require surgery
- Tendon sheath should be split avoiding the dorsal sensory branch of radial nerve
Dupuytren's contracture
- Fibroproliferative disease of the palmar fascia
- First described in 1614
- Detailed anatomical study presented by Dupuytren in 1831
- Aetiology unclear
- Possibly inherited as an autosomal dominant condition with limited penetrance
- Occasionally associated with plantar fasciitis and Peyronie's disease
- More common in northern Europe
- Male to female ratio 4:1
- Affects 5% men older than 50 years
Clinical features
- Thickening of palmar fascia with nodule formation
- Flexion contracture at MCPJ and PIPJ
- Usually affects ring and little finger
- In late stage of the disease cords develop proximal to the nodules
- 65% cases are bilateral
Risk factors
- Diabetes mellitus
- Alcohol excess
- HIV infection
- Epilepsy
- Trauma
- Manual labour
Management
- Excision or incision of the palmar fascia
- Options include fasciotomy, fasciectomy or dermofasciectomy
- Consider surgery if:
- MCP contracture is greater than 30 degrees
- There is functional disability
- Need intensive postoperative physiotherapy
- Approximately 20% patients develop complications
- Recurrence rate is approximately 50%
Ganglions
- Commonest cause of swellings around the hand and wrist
- Cystic lesions arising from either the joint capsule of tendon sheath
- Aetiology is unknown
- More common in women
- Usually occur between 20 and 40 yrs of age
- 70% of ganglions occur around the wrist
Clinical features
- Most present as smooth swellings 2-4 cm in diameter
- Most are painless
- Pain can occur due to compression of adjacent neurovascular structures
Management
- If ganglion is asymptomatic no specific treatment is required
- The hold treatment of 'hitting with the family bible' should be condemned
- Aspiration can be attempted but outcome is poor
- Excision is the treatment of choice
- Lesion should be explored down to joint capsule or tendon sheath
- Inadequate surgery results in a high recurrence rate
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