Greenhand

Carpal Tunnel Syndrome - information for patients

What is carpal tunnel syndrome?

The carpal tunnel is a narrow passage in your wrist made up of small bones which lie below a tough band of tissue above. Carpal tunnel syndrome (CTS) is a condition where the median nerve is compressed as it passes through this short tunnel at the wrist. The tunnel contains the flexor tendons that bend the fingers and thumb as well as the nerve.

CTS can occur with pregnancy, diabetes, thyroid problems and rheumatoid arthritis. It may also be associated with swelling in the tunnel caused by inflammation of the tendons, a fracture of the wrist, wrist arthritis and other less common conditions. However, in most cases, no cause is found

What are the symptoms?

The main symptom is altered feeling in the hand, affecting the thumb, index, middle and ring fingers; it is unusual for the little finger to be involved. Many people describe the altered feeling as tingling. Tingling and numbness are often worse at night or first thing in the morning. It may be provoked by activities that involve gripping an object, for example a mobile telephone or newspaper, especially if the hand is elevated.

In the early stages, numbness and tingling are intermittent and sensation will return to normal. If the condition worsens, the altered feeling may become continuous, with numbness in the fingers and thumb together with weakness and wasting of the muscles at the base of the thumb. People often describe a feeling of clumsiness, dropping objects easily. CTS may also be associated with pain in the wrist and radiating up the forearm.

How is it diagnosed?

Usually CTS is able to be diagnosed from the symptoms and by examination. In some cases, nerve conduction tests are needed to confirm the diagnosis. Blood tests and x-rays are sometimes required to see if there is an underlying cause.

What can be done to improve the symptoms?

Treating associated medical conditions

Sometimes treating an underactive thyroid gland may improve the CTS symptoms. CTS associated with pregnancy often resolves once the baby is born.

Altering Exacerbating Activities

Some activities may increase the severity of your symptoms and where possible, altering these may reduce your symptoms. Other alterations include reviewing your workplace set up and posture to avoid extreme positions of the wrist, using tools with a thicker and softer handles and minimising the duration of aggravating activities.

Splinting

The median nerve is under more pressure when the wrist is bent. This can bring on the symptoms if this position is held for a long time, such as while sleeping. Therefore wearing a splint at night may help CTS symptoms. It can take several weeks before you start to notice an improvement in your symptoms, therefore it is best to try wearing splints at night for at least 8-12 weeks, if possible.

Exercises

Median nerve gliding exercises can be demonstrated by a physiotherapist and can help your symptoms by moving the nerve within the tunnel and the tendons within the tunnel. This can help reduce swelling.

Injections

Steroid injection is used to treat CTS due to its anti-inflammatory effects. It reduces inflammation in the carpal tunnel and thus relieve compression of the median nerve. Injections are not suitable if you have continuous loss of feeling or muscle wastage. However, for most other patients they are very helpful in reducing symptoms. It is difficult to predict exactly how effective they will be and how long they will last but they are safe and generally recommended before surgery as some patients will find their symptoms do not recur for several years.

Carpal Tunnel Decompression

When troublesome symptoms persist despite non-operative management, a Carpal Tunnel Decompression (CTD) should be considered. The operation involves opening the roof of the tunnel to relieve the pressure on the nerve.

The procedure is generally performed under local anaesthetic by numbing the skin in the palm. Rarely there may be a need for a patient to have a regional anaesthetic (numbing the arm) or general anaesthetic (going to sleep).

Surgery generally relieves the pain and tingling and intermittent numbness very well, especially the night-time symptoms. Continuous numbness can improve but sometimes does not. It often takes many months for the nerve to finishing recovering when the nerve has been severely compressed.

As with all surgery, there is a small chance of complications. These are explained below. Please take time to read these.

Pain

It is normal for the scar to be painful and tender. This is most troublesome when pushing up or gripping. This gradually reduces and is usually gone by 3 months, though it can be more.

Sometimes the scar is not tender but there is pain either side of the scar. This is known as pillar pain because the two pillars of bone on each side of the carpal tunnel are here. This is much less common than scar tenderness but also generally settles in a few months.

Swelling

There will be swelling around the scar. This doesn’t cause a problem but often takes several months to resolve.

Infection

There is approximately a 1% chance of a wound infection. Usually this causes swelling, redness and discharge. It generally responds very well to antibiotic tablets. It is very rare to need further surgery.

Bleeding

Bleeding will occur during surgery but is usually straightforward to control and you don’t normally need to stop blood thinning tablets. Rarely (<1%) there may be some bleeding after the surgery which requires urgent treatment to drain the collection of blood.

Nerve injury

Structures such as nerves, blood vessels and tendons may be damaged during surgery. Additional surgery may be necessary should this problem occur. Injury to associated structures may be temporary or permanent.

The median nerve itself can be injured during surgery. This is very rare as we take great care to protect the nerve but it is a risk that comes with all surgery. If it were injured there would be permanent numbness in the thumb, index and middle fingers, weakness of some of the thumb muscles and probably pain.

Complex Regional Pain Syndrome

This is an unusual syndrome than can occur after any hand operation or injury. There is a wide range of severity; it can be mild and shortlived or rarely, severe and permanent. Symptoms are mainly pain, stiffness and reduced hand function that continues long after one would expect. Treatment with special painkillers and physiotherapy is usually helpful but it usually takes years to recover and extremely rarely there may be permanent loss of hand function.

Lack of improvement

Symptoms may continue despite the operation. This is usually if there is continuous numbness before the operation and there is nothing than can be done but wait and see if the nerve recovers.

Rarely, it might also be due to an inadequate release of the nerve, which can usually be dealt with by doing the procedure again.

Recurrence of symptoms

Occasionally (1%) the symptoms improve well for a few months but recur. This can be due to tightness from scarring around the nerve and can be treated by further surgery though the results are less predictable.

It is uncommon but symptoms can also recur after many years, due to further tightness building up in the carpal tunnel. This can usually be dealt with fairly easily by doing the same operation again.

Generally being worse off

As with any operation, it is possible that one of the above complications may make your hand worse than it was before the operation. Usually people are worse off from the scar tenderness but the carpal tunnel symptoms are relieved. Mostly people find this is acceptable and, in any case, the pain settles in due course.

Extremely rarely, one or more of the complications can make you worse off permanently. However, it is worth remembering that the vast majority of patients (>95%) are completely or much better within a few weeks.

Greenhand - Information for patients

What is GreenHand?

GreenHand is an initiative jointly led by the Research and Innovation Department and the Musculoskeletal Service in Gloucestershire Royal Hospital, who have received funding to develop a new way of managing a common hand condition called Carpal Tunnel Syndrome (CTS)

The aim of the project is to reduce the environmental impact of care at all stages from the first point of contact to the last. Other benefits include reduced cost to the NHS and less inconvenience for patients.

Normally all patients referred to the NHS with carpal tunnel syndrome are seen in a clinic several weeks later. If surgery is recommended, patients return for surgery on another day, which is usually several months later.

GreenHand makes this process much faster and improves patient experience and convenience by combining the assessment and surgery into one appointment for those patients who are suitable. Initial and follow up care is also provided remotely where safe and practical to minimise transport and maximise convenience.

If you choose to be seen in the GreenHand clinic you will be offered a clinic appointment in Gloucestershire Royal Hospital. If, as we expect, surgery is confirmed to be appropriate for you this will take place at that appointment in a Minor Operating Procedure Room. This is known as the one-stop pathway.

Who is suitable for GreenHand?

We expect that most of the patients who we see with CTS will be suitable for GreenHand.

Patients taking warfarin and pregnant women are not suitable for Greenhand. Patients on all other blood thinning medications are suitable.

Carpal tunnel syndrome can be diagnosed fairly reliably using a questionnaire. You can take this questionnaire here (it takes about 15-20 minutes). If you score more than 70% you almost certainly have carpal tunnel syndrome and are suitable for GreenHand. When you complete this questionnaire, you will be given a 6 digit number. Please make a note of this as you will need to inform us.

We ask that all patients who would like to have same day surgery with GreenHand read some general information about carpal tunnel syndrome here as well as the following information about GreenHand. Once you have done that, you can sign up for GreenHand by completing this online consent form here.

If you would like to participate in GreenHand but would prefer to have the information and consent form on paper please email ghn-tr.greenhand@nhs.net with your address so we can send this to you. You would still need to complete the Carpal-Tunnel.net  questionnaire online.

Before the Procedure

You will be seen as usual by a surgeon in clinic. They will take a history and examine you to confirm surgery is appropriate. If so you can ask any further questions about the operation. If you are happy to proceed, you will then be asked to sign a consent form and the correct side marked.

You may need to wait for an hour or so before your procedure that afternoon but you will be able to eat and drink in the meantime. While waiting for surgery you will be asked to complete a questionnaire so we can measure both the outcome of your surgery and its environmental impact. It is a good idea to bring something else to do. You will not be able to drive home after surgery so will need to make arrangements whether to travel on public transport or be driven from hospital.

You do not need to change out of your clothes for the procedure but please wear a short-sleeved top or vest.

If you are on any medication you should continue to take this as normal. This includes any blood thinning medications. When you return for your procedure, you will be greeted by a nurse who will ask some questions and perform some routine observations such as blood pressure.

Around 30 minutes before you go in for your procedure, the surgeon or surgical assistant will numb the skin of your palm. This needs a small injection, but people find this is much less painful than they had expected. Your fingers usually don’t go numb – it is just the skin around the incision that needs to be numb.

The Procedure

A second nurse will show you into the procedure room. There will be a surgical assistant as well as the surgeon you have already met. You will be asked to lie down with your arm out on a table to the side and some more routine checks will take place. Your hand will be cleaned and the area protected with drapes.

The procedure will take about 10 minutes. You will feel things happening to your hand but shouldn’t feel any pain. If you do feel any pain, let the surgeon know and they will give some more local anaesthetic.

What can I do afterwards? How should I look after my wound?

The skin is closed with stitches which will dissolve after 2-3 weeks. The wound is covered with a small sticky dressing with a bulky bandage over the top. It is advisable to keep the bandage on for comfort and padding until it feels comfortable to remove it, which is normally after a few days. This can be done yourself at home, leaving the sticky dressing only. You can replace this yourself if necessary, but it should stay in place for 2 weeks or until the wound is dry and comfortable. After 2 weeks, you should massage the scar with your other thumb to help make it more comfortable and supple.

You will be given a sling to keep the hand higher than your heart to avoid swelling of the fingers. You only need to wear this for the first 2 days when you are sitting on standing.

You can have a shower but it is best to keep the dressing dry (eg. with a bag over your hand) as if it gets wet it should be changed. You should move your fingers and thumb fully and can use your hand for light activities (e.g. typing) but should avoid any moderate activities (e.g. cooking).

You can drive when you feel safe to do so. This varies greatly depending on many things (the type of car, which hand it is, how much pain you experience) but it is usually between 1-3 weeks before people return to driving.

Going Home

After the procedure you will sit for up to 30 minutes in an area where you can be monitored before going home.

Normally pain after the procedure is controlled by paracetamol and/or ibuprofen. It is recommended that you take these early on, ideally before the numbness wears off as the pain relief is better.

What follow up care do I receive?

We will ask you to complete two more online questionnaires to monitor your symptoms 1 and 6 months after your procedure. It is expected that almost all patients will recover well and the CTS symptoms will settle down well. We therefore don’t need to make a routine appointment to see you again but if you have any concerns about your recovery at all you can contact your consultant’s secretary by phone or email. These contact details will be found on a letter written to you which you should receive soon after your visit, however, if you have any urgent problems, you can also contact the Trauma Assessment Unit on 03004 226726 (8am-7pm) or ghn-tr.traumaassessmentunit@nhs.net If you have any non-urgent questions, please contact the GreenHand team on ghn-tr.greenhand@nhs.net

Confidentiality

All information you provide will be kept confidential. Your name and other directly identifiable information will not be linked to your responses. When we report the findings of this project, the data will be presented in an anonymized and aggregated format, so individual participants cannot be identified. The data will be stored securely on password-protected NHS computers and servers.

Voluntary Participation and Right to Withdraw

Your participation in this project is entirely voluntary. You have the right to refuse to participate, and if you choose to participate, you can withdraw at any time without giving a reason and without it affecting your current or future medical care.