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Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a median entrapment neuropathy that causes paraesthesia, pain, numbness,

, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel

It isn't known why the median nerve becomes compressed in most cases. Patient presents with The median nerve passes through the carpal tunnel in the wrist and controls the movement of the thumb, as well as sensation in the thumb and the next two-and-a-half fingers. Gradual Onset - Daily Pattern: worse at night or early in the morning - tingling, numbness, pain can Unilateral or bilateral Other possible symptoms of CTS include: a dull ache and discomfort in the hand, forearm or upper arm a burning, prickling sensation (paraesthesia) in the hand similar to pins and needles dry skin, swelling or changes in the skin colour of the hand becoming much less sensitive to touch (hypoaesthesia) weakness abduction and opposition of the thumb weakness and wasting away (atrophy) of the muscles in the thumb

Risk factors for CTS developing >Family history of CTS one in four people with CTS have a close relative, such as a parent, brother or sister, who also has the condition >Pregnancy up to about 50% of pregnant women develop CTS Pressure changes inside the blood vessels of a pregnant woman cause more fluids to be retained inside the body tissues and organs. The reason why body tissues and organs swell is because more water is retained in them during pregnancy Injuries to the wrist. Strenuous, repetitive work with the hand and working with vibration tools. >Obesity It causes you to retain more fluid within the fat deposits of your body, therefore your carpal tunnel within your wrist area may retain more fluid eventually exerting more pressure over time on the median nerve resulting in carpal tunnel syndrome.

Gout >Nerve entrapment may be another manifestation of gout in the upper extremity. Carpal tunnel syndrome related to tophaceous Flexor tenosynovitis has been reported. >Hypothyroidism Untreated hypothyroidism, myxedema. Myxedema produces a cutaneous and dermal odema caused by excess deposition of glycosaminoglycans which can lead to CTS >Diabetes The link is possibly due to the fact that when blood glucose levels are high, the proteins in the tendons of the carpal tunnel become glycosylated; that is, glucose attaches to the tendon proteins, inflaming them and forming a sort of biological superglue that makes the tendons less able to slide freely Rheumatoid arthritis Where your own immune system breaks down your own tissues and or joints] that causes chronic inflammation of the membranes or tissues that line the joint. Wrist ganglia Ganglion cysts are the most common mass or lump in the hand. They are not cancerous and, in most cases, are harmless. They occur in various locations, but most frequently develop on the back of the wrist.It is not known what triggers the formation of a ganglion. They are most common in younger people between the ages of 15 and 40 years, and women are more likely to be affected than men. These cysts are also common among gymnasts, who repeatedly apply stress to the wrist. Acromegaly: Excessive growth hormone will lead to enlarge bones of the wrist and enlarged and swollen soft tissues Less commonly, CTS develops when a person has an abnormal wrist structure, such as an unusually narrow carpal tunnel, or as a result of cysts, growths or swellings in the tendons or blood vessels that pass through the carpal tunnel.

Investigation Physical tests: Phalens, Reverse Phalens, Tinels sign , - TOS, Nomal pulses (medial and ulnar arteries do not pass through the tunnel ) Physical examination of the hands, arms, shoulders, neck and back

Other tests: (NHS, 2013) Blood tests (diabetes , rheumatoid arthritis, hypothyroidism), Nerve conduction study, Electromyography, X-ray. Exclude conditions that may be confused with carpal tunnel syndrome: Neurological: Fairly common: cervical radiculopathy (especially C6/7); ulnar neuropathy; generalized peripheral neuropathies. Rare: brachial plexopathy; motor neurone disease; syringomyelia; multiple sclerosis. Vascular: Raynaud's phenomenon; vibration white finger; cerebral infarction. Vascular or neurogenic thoracic outlet syndrome (rare). Osteoarthritis of the metacarpophalangeal joint of the thumb. Refer for electromyography and nerve conduction studies if the diagnosis is uncertain. High resolution ultrasonography may be available as a diagnostic tool in some areas. Factors to exclude: Inflammatory conditions: rheumatoid arthritis, gout, pseudogout, non-specific tenosynovitis of the flexor tendons, connective tissue disease (e.g. systemic lupus erythematosis). Metabolic causes: hypothyroidism, diabetes mellitus, acromegaly. Increased canal volume: congestive heart failure, oedema, pregnancy, obesity in younger people. Fractures: Colles' fracture; fracture dislocation of the radiocarpal, carpal, and carpometacarpal joints. Abnormal anatomy: ganglion, lipoma, haemangioma, neurofibromas, median artery aneurysm or arteriovenous malformation, xanthoma, congenitally small carpal canal. Tumours: of the median nerve. Amyloidosis: (e.g. secondary to renal failure). Infections: Lyme disease, mycobacterial infection, septic arthritis.

Management Non-surgical treatments *wrist splints *corticosteroid injections are often recommended. There is a lack of evidence to support the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for treating CTS, or for diuretics to help relieve fluid retention (NHS, 2013)

*Carpal tunnel release surgery: Surgery is usually only recommended for severe cases of CTS, when symptoms last for more than six months or other treatments have not been effective. During surgery the roof of the carpal tunnel, known as the carpal ligament, is cut to reduce pressure on the median nerve in the wrist (keyhole surgery > back to work in 2/3 days < open surgery >6 weeks recovery<) In a survey of more than 6,000 NHS carpal tunnel operations, 50% thought that the surgery had been completely successful, and a further 25% felt their symptoms were greatly improved. However, as with any form of surgery there is always a small risk of complications. Complications of CTS include: infection, failure during surgery to fully separate the roof of the carpal tunnel, usually resulting in persistent CTS symptoms, bleeding after the operation, nerve injury, scarring, persistent wrist pain, which may be different to the original symptoms , complex regional pain syndrome a rare but chronic (long-term) condition that causes a burning pain in one of the limbs Osteopathy care options Consider cervical spine dysfunction, Ergonomics, pronator teres Combination of gentle soft tissue and articulatory techniques coupled with advice, stretches and exercises. Acupuncture may be effective for pain relief in the short-term, although there is no therapeutic benefit.

Advise minimization of activities that exacerbate symptoms. Explain to people who work with computer keyboards that there is little evidence to suggest that modifications at their work place are likely to be of any help in relieving symptoms.

Do not recommend the use of nonsteroidal anti-inflammatory drugs or diuretic medication.

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