On Pins and Needles: Diagnosing and Treating Hand Numbness & Tingling


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There can be a number of causes for abnormal sensations in the hands and other extremities. Whatever the reasons, one thing is certain—these feelings of numbness or tingling can be incredibly uncomfortable—and may be a cause for concern. Please join Dr. Jianjun Ma, specialist in Hand, Upper Extremity & Microsurgery with the Orthopedic Group at Springfield Clinic, discusses the various causes and treatments for numbness and tingling in the hands—including carpal tunnel—and how to known when this nuisance may require medical attention.

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On Pins and Needles: Diagnosing and Treating Hand Numbness & Tingling

  1. 1. Treatment of Hand Numbness &Tingling Carpal vs Cubital TunnelSyndromeJianjun Ma, MDDepartment of Orthopedic Surgery
  2. 2. www.SpringfieldClinic.com
  3. 3. Case40 year old male, professional guitar player.Numbness and tingling in the right small finger for one month.Questions:1.Is this carpal tunnel syndrome?2.Can I wait for a few months to see doctors?3.What kind of treatment will I need?
  4. 4. Hand numbness and tingling1. Peripheral nerves connect our brain/spinal cord to the other parts of your body.2. A peripheral nerve injury can interfere with brains ability to communicate with your hands.3. Abnormal sensations caused by peripheral nerve dysfunction, common in nerve compression.
  5. 5. Peripheral Nerve Fiber typesThree types of nerve fibers:Sensory: Sensation.Motor: Muscle strength.Autonomic: Involuntary activity, such as sweating etc. Sensory fibers Motor fibers Autonomic fibers
  6. 6. Histology of Peripheral Nerve G 50 µm 10 µm
  7. 7. Peripheral Nerve Injury Peripheral nerves are fragile and easily damaged. Peripheral nerves follow a path from the spinal cord to the hand where they can be pinched. Sensory fibers: small, susceptible to nerve compression injury Motor fibers: large, not susceptible to nerve compression injury
  8. 8. Acute versus Chronic Peripheral Nerve InjuryAcute injury: Chronic injury:Sensation loss Numbness and tinglingMuscle atrophy Sensation loss and muscle atrophy
  9. 9. Pathophysiologyic classification of nerve compressionSeverity Pathophysiology ClinicalMild Blood-nerve barrier Symptoms, no breakdown signs on examModerate Demyelination Symptoms, Abnormal signs, and/or threshold of weaknessSevere Axonal loss Symptoms, Decreased signs, and innervation muscle wasting
  10. 10. Sensory Nerve Innervation in the HandMedian nerve: Thumb, index, long, and radial side of the ring finger.Ulnar nerve: Small finger and ulnar aspect of the ring finger.Radial nerve:The radial aspect of the dorsum of the hand and thumb, index,and long finger.
  11. 11. Median N. Sensation in the Hand Median N.Ulnar N. Radial N. Ulnar N. Radial N.
  12. 12. Nerve Compression Syndromes of the Hand Median nerveCarpal tunnel syndrome ----------------- Most commonPronator syndromeAnterior interosseous syndrome Ulnar nerveCubital tunnel syndrome --------------- Second most commonGuyon canal syndrome Radial nerveRadial tunnel syndromePosterior interosseous syndromeSuperficial radial nerve syndrome
  13. 13. Systemic Diseases Predisposing to Nerve Compression in the US 1. Diabetes 2. Thyroid disease 3. Collagen vascular disease (vasculitis) most common: RA, SLE, MS. 4. Chemotherapy-induced neuropathy 5. Alcoholism 6. Vitamin deficiency (folate, B12, B6) 7. Heavy metal toxicity 8. Lyme disease 9. Multiple myeloma 10. AIDS
  14. 14. Carpal Tunnel versus Cubital Tunnel Syndrome Carpal tunnel syndrome Most common
  15. 15. Demographics of Carpal Tunnel Syndrome1. Incidence: 1-3 per 1000 subjects per year.2. Prevalence: ≈ 5 per 100 subjects in general population. 14 per 100 in diabetics 30 per 100 in diabetics with neuropathy3. Women are three times more likely than men to develop CTS.4. The dominant hand is usually affected first.5. The estimated lifetime risk: 10% of adults.
  16. 16. What is carpal tunnel?1. A narrow passageway on the palm side of the wrist.2. Made up of bone, tendons, and ligaments.3. Cross section area: 134.9 ± 23.6 mm2.4. One nerve, nine tendons, and synovium.5. Size of median nerve: ≈10 mm2.6. Number of nerve fiber: 7,457-27,190.7. With repetitive wrist movement or constant pressure, the canal can become inflamed. ↑ carpal tunnel pressure → median nerve compression→ carpal tunnel syndrome
  17. 17. Symptoms of Carpal Tunnel Syndrome1. Numbness/tingling in the index and middle fingers, followed by thumb, uncommon in the ring finger.2. Night time awakening (Wrist flexion).3. Thenar muscle wasting: classic but rare.4. Dropping objects and weakness.
  18. 18. Tests and Diagnosis History Pattern of signs and symptoms Timing of the symptoms Physical exam Sensation Muscle strength Tinel’s sign Durkan test Phalen test Durkan test Tinel’s sign
  19. 19. Tests X-ray Rule out arthritis or a fracture. Electromyogram1. To measure electrical discharges produced in muscles.2. To determine if muscle damage has occurred. Nerve conduction study1. To measure if electrical impulses are slowed in the carpal tunnel.2. To rule out other condition in the neck.
  20. 20. Risk Factors1. Anatomic factors. 1. a wrist fracture or dislocation; 2. smaller carpal tunnel in women.2. Nerve-damaging conditions. Diabetes and alcoholism: ↑ risk of nerve damage.3. Inflammatory conditions. RA or infection can affect the tendons and exert pressure on median N.4. Alterations in the balance of body fluids. Certain conditions (pregnancy, menopause, obesity, thyroid disorders, or kidney failure) → fluid retention → pressure increase within carpal tunnel.5. Workplace factors. Vibrating tools/ work requiring prolonged or repetitive flexing of the wrist → pressure increase within carpal tunnel.
  21. 21. Risk factorsof carpal tunnel syndrome
  22. 22. Job tasks and occupations associated with CTSJob Tasks OccupationsGrasping and tugging fabric, pulling Production sewer, tailor, garmentcloth worker/stitcherMilking cows FarmerHandling objects on conveyor belts Assembly-line workerPushing down ratchet, using MechanicscrewdriverHand weeding GardenerKeyboarding / mouse use Office workersKnitting HomemakerScrubbing JanitorPlaying stringed instruments with bow MusicianUsing laser scanner at checkout CashierAssembling small parts Electronic industry workerPressing tool into palm Painter, carpenter, stablehandUsing air-powered hand tools Assembly worker
  23. 23. Nonsurgical Treatment1. Activity modification 2. Nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Wrist splinting 4. Corticosteroids Steroid injection Oral steroid
  24. 24. Surgical TreatmentThe goal of carpal tunnel surgery:To relieve pressure on the mediannerve by cutting the ligament pressingon the nerve.Open surgerySurgery involves making an incisionin the palm of the hand over thecarpal tunnel and cutting through theligament to free the nerve.Endoscopic surgeryA small incision in the wrist . Highercomplication rate.
  25. 25. Postoperative Care1. Elevate your hand above your heart for 2-3 days after surgery.2. Dressing off three to four days after surgery.3. Keep the incision clean and dry.4. Move your fingers.5. Light daily activity such as eating, brushing your teeth, etc.6. Take prescribed medications for pain as indicated and necessary.7. Do not drive until evaluated.8. Do not lift anything over 1-2 pounds until evaluated.9. Expected recovery time and release to work depends on the job and healing time.
  26. 26. Postoperative Therapy1-2 weeks Postop:Gentle exercise and light use of the hand and isolatedtendon glide exercises for all digits2-6 weeks Postop:Active Range of motion exercises of the wristEdema controlScar massage/desensitization6-12 weeks Postop:Progressive strengthening exercises
  27. 27. Prevention1. Take quick breaks from repetitive activities.2. Rotate your wrists and stretch your palms/fingers.3. Take a NSAID pain reliever.4. Wearing a wrist splint at night.5. Avoid sleeping on your hands.
  28. 28. Prevention of carpal tunnel syndrome
  29. 29. Carpal Tunnel versus Cubital Tunnel Syndrome Cubital tunnel syndrome Second most common
  30. 30. Demographics of Cubital Tunnel Syndrome1. Incidence: 24.7 cases/100,000 person years. 1) USA: 75,000 cases annually 2) World-wide: 1.5 million cases2. Prevalence: 2.8% to 6.8% in occupations requiring repetitive work.3. Affects men 3-8 times as often as women.4. Employees working with flexed elbows and direct pressure on the ulnar nerve are at risk.
  31. 31. What is cubital tunnel?Cubital tunnel: fascia covers a gap of about 4  mmbetween the medial epicondyle and theolecranon.Number of nerve fiber: 10,365-22,690Size of ulnar nerve: ≈ 6 mm2
  32. 32. Cubital Tunnel SyndromeMechanisms1.The altered shape of the cubital tunnel.2.Traction and excursion of the ulnar nerve.3.Subluxation of the ulnar nerve: Constant friction. Susceptible to trauma.↑ cubital tunnel pressure → ulnar nerve compression→ cubital tunnel syndrome
  33. 33. Symptoms of Cubital Tunnel Syndrome 1. Altered sensation in the little and ring fingers 2. Sensory loss is the first symptom to be reported 3. Wasting of the ulnar-sided muscles of the forearm 4. Clumsiness in the hand 5. Wasting of the small muscles of the hand 6. Claw deformity
  34. 34. Risk Factors1. Elbow injury2. Rheumatoid arthritis3. Repetitive pulling4. Repetitive reaching5. Prolonged leaning on the elbow6. Overuse and stress injuries7. Using vibrating tools
  35. 35. Daily activity and cubital tunnel syndrome
  36. 36. Sleeping and cubital tunnel syndrome
  37. 37. Tests and Diagnosis History1. Numbness/tingling in the ring and little fingers.2. Timing of the symptoms. Physical exam• Sensory changes in ulnar nerve distribution (little+ring finger).• Intrinsic weakness.• Tinel’s sign at medial elbow.• Elbow flexion test (3 min @ 120° flexion reproduces symptoms).• Wartenberg’s sign.6. Fromment’s sign.
  38. 38. Tests X-ray Rule out arthritis or pre-existing trauma. Electromyogram1. To measure electrical discharges produced in muscles.2. To determine if muscle damage has occurred. Nerve conduction study1. To measure if electrical impulses are slowed in the cubital tunnel.2. Stage its severity.3. To rule out other condition in the neck.
  39. 39. Non Surgical Treatment1. Non-steroidal anti-inflammatory medication (NSAID).2. A splint or brace use while sleeping to keep the elbow from bending while you sleep.3. Watch and modify your posture during the day to avoid long periods of time with your elbow bent.4. Make more space between your work and your chest, so that your elbows are more straight.
  40. 40. Surgical Treatment The goal of surgery: to relieve the compression of the ulnar nerve within the cubital tunnel. Indication of surgery: Failure to non surgical treatment Timing of surgery: No prolonged waiting
  41. 41. Surgical Treatment In situ release Anterior ulnar nerve transposition
  42. 42. Anterior Ulnar Nerve Transposition The nerve can be placed underneath or within the forearm muscles that insert onto the bone at the inside of the elbow for protection. The bone which forms the bottom of the tunnel can be shaved and smoothed out, or a small portion removed if necessary.
  43. 43. Postoperative Care1. Keep the initial cast and incision clean and dry.2. Once the cast is removed (usually in 2-4 weeks), change the bandages as needed.3. Keep the fingers moving.4. Avoid bending the wrist forward for 4 weeks after surgery to let the muscles heal.5. Begin gently bending and straightening the elbow after splint removal.6. Scar massage.7. Gradual strengthening at 6 weeks post-surgery.
  44. 44. Postoperative Therapy1. Protective splinting with the wrist neutral.2. Elbow sleeve to protect the healing area from re-injury and for comfort.3. Scar management including silicone gel sheeting, ultrasound.4. Swelling reduction techniques.5. Desensitization techniques for a sensitive scar.6. Active motion including tendon and nerve gliding exercises.7. Work conditioning activities at 6 weeks after surgery.
  45. 45. Postoperative Recovery1. A large portion of the numbness/tingling is relieved.2. The pain radiating up the arm into the shoulder/neck is often relieved.3. The inside edge of the elbow will likely be tender for 4- 6 months after surgery.4. Numbness/tingling on the back side of elbow.5. Rate of peripheral nerve regeneration: 1mm/day.6. Hand muscle atrophy unlikely to be recovered.
  46. 46. Prevention1. Avoid leaning on the inside edge of the elbow.2. Avoid holding the elbow in flexion for prolong time.3. Minimize repetition and periodically rest the arms.4. Slow down the activity.5. Use the lightest grip possible.6. Use the least amount of force during the activity.7. Use ergonomically designed tools if available.8. Alternate work activities between hands.
  47. 47. Prevention of cubital tunnel syndrome
  48. 48. Case Analysis40 year old male, professional guitar player.Numbness and tingling in the right hand small finger for one month.Diagnosis: Right cubital tunnel syndromeTreatment:1.Activity modification.2.Elbow brace at night.3.Posture modification.3 month follow up: Normal.
  49. 49. Hand Numbness and Tingling carpal/cubital tunnel syndrome only? Very common. Carpal tunnel syndrome or/and cubital tunnel syndrome likely. However, some other conditions to be ruled out.
  50. 50. Hand Numbness and Tingling Differential diagnosisDiabetic Neuropathy Cardiac ischemiaCervical Disc Disease Apical lung tumorCervical Spondylosis LeprosyThoracic Outlet Syndrome Lyme DiseaseLateral Epicondylitis Mononeuritis MultiplexMedial Epicondylitis Multiple SclerosisMyofascial Pain Posttraumatic SyringomyeliaMedial elbow instability Radiation-Induced BrachialCompartment Syndrome Plexopathy Traumatic Brachial Plexopathy
  51. 51. Hand Numbness and Tingling When to act As soon as possible Who to see Family physician or orthopedist  What to expect 1. Evaluated early 2. Treated early 3. Recover better
  52. 52. Thank you