Dr Stuart Myers

Ligament

Carpal Tunnel Syndrome in Pregnancy

Carpal Tunnel Syndrome in Pregnancy

Dr Stuart J.D. Myers
MB. B.S. Hons (UNSW), F.R.A.C.S. (Orth), FA (Orth) A


WHAT IS CARPAL TUNNEL SYNDROME (C.T.S.)?

It is a painful disorder of the hand caused by excess pressure on the Median nerve as it passes through a tunnel at the wrist.

The tunnel is formed by a tough membrane (Flexor Retinaculum) that makes a "roof' to a natural arch produced by the carpal (wrist) bones.

The Flexor retinaculum keeps the tendons and nerves that pass under it in place & provides protection for the nerve.


If structures in or around the tunnel swell then excess pressure on the nerve may cause nerve dysfunction. It is very common in the late stages of pregnancy.

      
             Cross Section of the Wrist

WHAT CAUSES CTS?

Often many factors play a role but the major issue in pregnancy is fluid retention.
One may have many predisposing factors but no symptoms of the condition.
Fluid retention may therefore act as “the final straw”.


- Genetic - often mum also had CTS.
- Age – More common with older mothers
- Obesity – best predictor of developing CTS
- Diabetes or Family history of Diabetes
- Fluid retention
- Hormones – eg under-active Thyroid

WHAT ARE THE SYMPTOMS?

               


The symptoms typically include tingling and numbness in the hand which wakes you from sleep.


Pain may shoot up the arm from the wrist.

The fingers may feel swollen.

It may be relieved by shaking the hands or hanging them over the side of the bed.

Later – “Constant” Symptoms
- Numbness all day
- Weakness
- Dropping things
- Difficulty picking up small objects.


DIAGNOSIS:

The diagnosis is usually straight forward and is made after eliciting a typical history (as above) and an examination.
Nerve conduction tests are rarely required.

WHAT ARE THE RISKS?

It is usually not a serious problem and often settles when the baby is born. 

If the symptoms develop early in pregnancy eg at 20 weeks then it may cause permanent nerve damage.

If the numbness is constant ie present night and day then it may take 12 months to recover.

If you have Gestational Carpal Tunnel Syndrome which settles once the baby is born you have an increased risk of developing CTS later in life.

WHAT IS THE TREATMENT?

-Night Splints (Grenace wrist brace holds wrist straight & opens up the tunnel). Can be obtained from the physiotherapist or from a chemist)


- Oedema Gloves ( control the swelling in the hand)


- Raising bed head to reduce the fluid shift from the legs to the hands at night ( Brick under bedhead)


- Controlling weight gain during pregnancy


-Aerobic Fitness training – You need to be very fit to have a baby. It is the hardest thing you will ever do!


-Cortisone injections
– are safe in pregnancy
- May control symptoms for 4 – 6 weeks
- Will not relieve Constant numbness – only “variable” symptoms


-Surgery

– Not Common


BUT – has been required more frequently in recent years due to:


1. Older mothers
2. Increased incidence of gestational Diabetes.
3. Onset of symptoms earlier in pregnancy


It is indicated when: The risk of permanent nerve damage is high:


1. Early onset in Pregnancy eg before 20 weeks
2. Diabetics
3. Severe symptoms where non-operative treatment is failing

 

                   

 
Endoscopic release - involves cutting the membrane (Flexor retinaculum) to create more space in the tunnel for the nerve.


- See separate Information Sheet on this procedure


- The operation is undertaken in close consultation with your obstetrician.


- The operation is performed under local anaesthetic & sedation as a day only procedure.


- It may be less "Bad" to have surgery when pregnant than when you are dealing with a new baby.


- It is desirable to perform surgery before 30 weeks of pregnancy so you have time to recover before the baby arrives.


- Surgery is effective in relieving the symptoms of carpal tunnel syndrome in over 95% of cases.


- Recovery periods are variable but you can use the hand after surgery as Pain permits. You are NOT doing damage by using it.


- Note - If the numbness is constant it is likely to take 9 - 12 months for the nerve to recover.

 

The major problem with the surgery is persistent weakness or aching pain in the base of the hand when you lean on your hand or make a forceful grip ("Pillar pain").
See Hand Surgery Information  and Hand Surgery Risks Handouts.

Recurrent carpal tunnel syndrome is possible but extremely uncommon.

14 / 5/ 2020

Childrens Hand Fractures

 Childrens Hand Fractures

Dr Stuart J.D. Myers
MB BS Hons (NSW), FRACS, FA(Orth)A
www.myhand.com.au

General


         

        Many people think that a “fracture” is different from a  "break”, but they are the same.

Effect on the hand

The forces causing a fracture may also injure other structures such as muscles, tendons & ligaments and in children the finger nail.

When a bone breaks there is bleeding from the bone ends. Bleeding leads to scarring which results in stiffness particularly in the fingers. While this is a common problem in adults it is not common in children.

Childrens fractures can be immobilised in a splint for 3 – 6 weeks and they often regain range of motion very rapidly when the splint is removed.
If a fracture involves the joint surface then arthritis may develop later in life.

In children’s bones the “weak link” is the growth plate. This is formed from cartilage and appears as a dark line on the xray. The cartilage multiplies and is then converted into bone. In this way the bone increases in length.


       

 

Growth plate injuries are subdivided according to the Salter – Harris Classification. The higher the number the greater the risk of damage to the growth plate and the greater risk of problems. In reality a “growth arrest” is VERY uncommon.

       

Consequences of Growth plate injury:

1.    Shortening – If the entire growth plate is damaged.    ( ~50% Salter 5 fractures) rare in others
2.    Progressive bending of a bone if part of the growth plate “arrests” but the remaining growth plate continues to grow.
3.    Joint surface irregularity - if a Salter 3 or 4 fracture
 

Fracture Issues


There are many issues to take into consideration in the management of these fractures.

Age

Time remaining before growth ceases

Dominant Hand    Non Dominant Hand

Stable    Unstable

Undisplaced    Displaced

Acceptable    Unacceptable  deformity

Displacement  -  Rotation

                    -  Shortening
                    -  Bent

Joint involvement    - Step    ___  -----

                            - Gap     ___   ___              

Bone quality - Osteoporosis


Number bone fragments - comminution

Growth Plate   involved    Not involved

Other injuries  eg nerve, tendons, ligaments

Acceptable    Unacceptable

Risks of Surgery  v  Risks of No surgery

             Fixable                       Not Fixable

    

Need for  Xray monitoring        No Follow up

 

Treatment Principles:
 
1.    Reduce Swelling  - ice packs,
                                 - elevation
                                 - Coban bandage


2.    Control Pain  - splint, pain killers

3.    Prevent Stiffness - early movement if the fracture is stable (even before the fracture has healed)

4.    Stabilise the unstable

5.    Correct Deformity - Rotation
                                   - Angulation
                                   - Shortening
                                   - Joint step -   prevent arthritis

Options:

-    Coban bandage / Buddy strapping / Early movement

 


-    Closed Reduction & Splint - pulling on the bones under an anaesthetic to realign the fracture

   
-    K Wires

     
-    Plates & Screws ( Rare)
-    Xray monitoring - a growth arrest may only reveal itself over time and so monitoring may be required for a year or 2.




Reduction” means pulling the bones back into place. This can be done “Closed"  in which no cut is made & a plaster or splint is applied or “ Open” where a cut is performed &
the bones are directly repositioned .An open reduction often requires the use of wires, plates & screws.

Results

-    Perfect alignment of the bone on X-ray is not always necessary to get an excellent result. A bony lump may appear at the fracture site as the bone heals & is known as “fracture callus”. This is a normal part of the healing process & usually gets smaller over time.



-    The growth plate has the potential to correct deformity in the plane of movement of the finger. Ie the growth plate may grow on the crushed side of the bone quicker than the opposite side and thus correct malalignment.

It will not correct deformity from side to side or malrotation.

            

-    Occasionally loss of bone alignment occurs & additional treatment may be required

-    In general it takes 3 - 6 weeks for a hand fracture to heal depending on the age. The younger the faster a bone heals.
 


Revised  10 / 9 / 18

 

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Revised 27/5/2020