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Carpal Tunnel Syndrome

View profile for Kimmo Boote
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This is an image that the actress Brooke Shields posted of herself on Instagram – following surgery to both hands for Carpal Tunnel Syndrome.

Carpal tunnel syndrome (CTS) is a common condition that causes a tingling sensation, numbness and sometimes pain in the hand and fingers. These sensations usually develop gradually and start off being worse during the night. They tend to affect the thumb, index finger and middle finger.

Other symptoms of carpal tunnel syndrome include:

  • Pins and needles (paraesthesia)
  • Thumb weakness and a dull ache in the hand or arm

CTS is caused by the compression of the median nerve; the nerve passes underneath a fibrous band just before the wrist into the hand on its palmar side. The nerve supplies sensation to the palm side of the thumb and the adjacent index finger and middle finger. 

Treatments usually consist of prescribing medication, though occasionally some cases need surgical intervention.

Medical treatments

Patients may wake at night with tingling sensations in the fingers which is very uncomfortable. Splints are used to keep the hand in a position (the neutral position) so that the nerve is not compressed by the wrist flexing, i.e. the palm going backwards towards the forearm. The wrist splint is applied at night time with symptoms often improving within 4 weeks of application.  Direct steroid injections into the area before the wrist (deep into the fibrous band) are used - but repeated injections may be needed.

The indications for surgery include:

  • Failure of medical treatment for 6 months
  • Any evidence of nerve damage
  • Continuous loss of sensation in the fingers/thumb
  • Decreased strength of the fingers/thumb

Surgical options

The most common solution is to relieve pressure on the median nerve by dividing the transverse carpal ligament. This can be done by either an open approach (i.e. making an incision at the wrist) or by the use of keyhole surgery (called endoscopic carpal tunnel release surgery).

The open approach means that there will be a residual scar and healing may take longer as there is more tissue damage. The success rate is however better than with keyhole surgery.

Many patients have their surgery done as ‘day case,’ with local anaesthesia being sufficient. After the operation, the wrist is bandaged and kept in a sling to reduce swelling. Gentle exercise is recommended to stop the wrist becoming stiff.

Outcomes

A survey of 6,000 patients treated by surgery found that 50% found complete relief with another 25% having significant improvement of their symptoms.

Complications

  • Incomplete division of the carpal tunnel ligament
  • Damage to the median nerve
  • Bleeding at the operative site
  • Infection following surgery
  • Scarring and disfiguring cosmetic appearance

Uncommon complications

  • Recurrence of carpal tunnel syndrome
  • Complex regional pain syndrome 

MEDICOLEGAL ASPECTS

When considering a case of possible negligence the following features should be looked for:

  • Is it clear from the history that medical treatments had been tried and failed, or were the indications for surgery present, as listed above?
  • Was the patient advised as to the potential complications?
  • If there is recurrence, how does that compare with the symptoms and signs prior to the operation?
  • Where and how was the procedure carried out – a sterile technique is essential to reduce the possibility of infection.
  • Some patients have a tendency to increased scarring such as keloid- this must be taken into account for whatever the type of surgery that is used.
  • The features of decreased power and sensation in the fingers/thumb are marked indications of failure of the procedure.

If you want further information about this particular topic, or wish to discuss the possibility of bringing a claim for Clinical Negligence - or indeed any other type of injury, please contact the Dutton Gregory Clinical Negligence Team on (01202) 315005, or email k.marden@duttongregory.co.uk  

NB This article does not constitute legal advice and should not be relied on as such. No responsibility for the accuracy and/or correctness of the information and commentary set out in the article, or for any consequences of relying on it, is assumed or accepted by any member of Dutton Gregory LLP.