Osteosynthesis of the radius in a typical place with a plate. Surgical treatment of distal fractures of the radius

Carpal tunnel syndrome is a condition that develops when the median nerve is pinched or injured within the carpal tunnel of the hand. In this case, the movements and sensitivity of the fingers are disturbed (the first three and part of the fourth fingers are affected).

Carpal tunnel syndrome is considered an occupational disease, since it most often develops in people of certain professions, whose activities are associated with monotonous flexion and extension of the hand. For example, musicians, tailors, secretaries (they work with a computer mouse and keyboard).

Carpal tunnel syndrome has two more names: carpal tunnel syndrome and tunnel syndrome. Although the latter name is not entirely correct, since there are other tunnel syndromes (for example, the syndrome of compression of the deep branch of the ulnar nerve).

Statistics

According to various sources, carpal tunnel syndrome is 3-10 times more common in women than in men.

The peak of the onset of the disease occurs between the ages of 40 and 60 years. However, this does not mean at all that young people are not prone to this disease: according to statistics, 10% of all cases are under 30 years old.

It is believed that people who work daily and long hours on the computer are most susceptible to developing carpal tunnel syndrome. According to one study, every sixth examined has it. Users who, while working with a keyboard and a computer mouse, have their hand extended by 20° or more in relation to their forearms are most at risk. Carpal tunnel syndrome is a relatively "young" disease. For the first time, a disease similar to carpal tunnel syndrome was described by the English surgeon Sir James Paget in 1854 in a patient with a fracture of the radius at the level of the wrist.

A little later it turned out that the disease can develop in workers performing monotonous movements.

Well, in our time, when a personal computer has firmly entered the life of a modern person, carpal syndrome has almost become an epidemic. However, science does not stand still. Therefore, there is great news for active users of a personal computer: a special platform and a flying computer mouse with a magnetic ring have been developed that can withstand the weight of a human hand. A stylish novelty can be used both for the treatment of carpal tunnel syndrome and for the prevention of its development.

Structure and function of nerves

The processes extending from the nerve cells come together and form bundles - nerves.

Together, all nerves form the peripheral nervous system, the task of which is to transmit impulses from the brain and spinal cord organs and tissues. Moreover, each nerve is responsible for its own area or organ.

The structure of a nerve cell (neuron)

Body nerve cell contains a core, and outside it is limited by a wall, which consists of two layers of fats. Due to this, only substances that dissolve in fats (for example, oxygen) enter the cell.

Neurons have different shape(spherical, fusiform, stellate and others), as well as the number of processes. Depending on the function performed, neurons are sensitive (they receive impulses from organs and transmit them to the central nervous system), motor (send commands from the central nervous system to organs and tissues), and intercalary (carry out communication between sensory and motor neurons).

body of the nerve cell incapable of reproduction (division) and recovery in case of damage. However, when the axon or dendrite is cut, the cell ensures the restoration of the dead section of the process (growth).


axon and dendrites

axon- a long process of a nerve cell that transmits excitation and information from a neuron to an executive organ or tissues (for example, muscles).

Most nerve cells have only one axon. However, it can divide into several branches that connect with other cells: muscle, nerve or glandular. This connection of an axon with a target cell is called a synapse. Between the axon and the cell is the synoptic cleft.

At the end of each branch of the axon there is a thickening, in which there are vesicles with a special substance - a mediator. Until a certain point, he is in a "sleeping" state.

Outside, most axons are covered with Schwann cells (perform a supporting and nourishing function), which form the myelin (pulp) sheath. Between the Schwann cells there are nodes of Ranvier - the area where myelin sheath. However, some axons lack Schwann cells - unmyelinated fibers.

Myelin fibers are characteristic of the peripheral nervous system.

Dendrites- short branched processes of a neuron, with the help of which it receives information from body cells and other nerve cells.

The structure of the nerve

Outside, the nerve is covered with three layers:

1. Endoneurium, in which pass the capillaries (small vessels) that feed the nerve fibers.
2. Perineurium, "dressing" bundles of nerve fibers, since it contains collagen (a protein - the basis of connective tissue), which performs a supporting function.
3. The epineurium is an outer layer of dense connective tissue that surrounds a nerve.

Nerves carry out the transmission of impulses from the brain, as well as the spinal cord to the cells of the organs and tissues of the body.

How is a nerve impulse transmitted?

How is momentum transmitted?

Normally, the axon is at rest and does not conduct impulses. Therefore, potassium ions move inside the axon body, and sodium ions move out (approximately, as if a fresh cell is placed in a saline solution).

However, when an impulse arrives at the axon from the dendrite, the situation changes: sodium moves inside the axon, and potassium goes outside. As a result, the internal environment of the axon acquires a positive charge for a short period, leading to the cessation of the influx of sodium into the cell. But at the same time, potassium continues to leave the axon.

Meanwhile, sodium ions inside the cell spread to other parts of the axon, changing the permeability of its membrane, thus contributing to further dissemination impulse. When it passes through a certain point in the axon, the body of the nerve cell receives a “command” to relax, so it returns to a state of rest.

Such impulse transmission is quite slow (for example, the signal sent by the brain will reach the hand in a minute). However, thanks to the myelin sheaths, it speeds up as it "jumps" over Ranvier's intervals.

However, the impulse must hit the neighboring cell. To do this, having reached a thickening at the end of the neuron, it promotes the release of mediators from the vesicles, which enter the synoptic gap. Further, mediators are connected to special receptors on the cell of the target organ (muscles, glands, and others). As a result, an action occurs: movement of the hand, fingers, turning of the head, and so on.

Anatomy of the hand, wrist and forearm

All bones of the hand are interconnected by joints, ligaments and muscles. Due to this, movements in the hand, which are controlled by the nervous system, become possible.

forearm - the part of the human hand that is made up of two tubular bones(length prevails over width): radial and ulnar. From the top it is limited elbow joint, and from below - the wrist.

The structure and functions of the median nerve

The median nerve originates in the shoulder region from branches formed by fibers spinal nerves(sixth-eighth cervical and first chest). Then it goes to the hand, but does not give any branches at the level of the shoulder and cubital fossa.

Having reached the region of the forearm (from the elbow to the hand), the median nerve gives off several branches. Then it passes in the carpal tunnel under the transverse ligament of the wrist and branches into terminal branches.

In its course, the median nerve innervates the following muscles:

• Superficial and deep flexor of the fingers, which are responsible for bending the II-V fingers
• The muscle that promotes flexion and rotation of the forearm is the pronator teres
• Flexor wrist muscle - flexes and abducts the hand
• Muscle that flexes the nail phalanx of the first finger
• The long palmar muscle that flexes the hand and strains the palmar aponeurosis (a wide tendon plate that covers the muscles of the hand from the palmar surface)
• The quadratus muscle, which is responsible for the rotation of the hand and forearm
• Muscle that abducts the thumb
• The muscle that opposes the thumb of the hand to all the rest
• Muscle that flexes the thumb
• Muscles that bend II-III fingers.

Based on the areas of innervation, the median nerve is involved in flexion and abduction of the hand during inside, flexion of the fingers, bringing the elevation of the first finger to the rest of the fingers, rotation of the hand and forearm.

Also, the median nerve innervates the skin on the palmar surface of the hand of the first, index and middle fingers, as well as parts of the ring fingers, and on the back surface of the hand, the skin of the terminal phalanges of the index and middle fingers.

Thus, the median nerve provides both movement and sensation to the hand.

Causes of damage to the median nerve

Prolonged work at the computer (using a computer mouse and keyboard)

However, studies have shown that not all frequent PC users develop carpal tunnel syndrome. Certain conditions are necessary for its occurrence. For example, people who are most often at risk are those who have III-IV degrees of obesity (due to fat, the lumen of the carpal tunnel narrows), female sex (anatomically narrower carpal tunnel) and some other factors.

Arthritis: rheumatoid, psoriatic or gouty arthritis, as well as other rheumatic diseases affecting the joints

Further, over time, as the course of the underlying disease worsens, aging of the articular cartilage occurs. Therefore, they lose their elasticity, cracks appear on them. As a result, the cartilage gradually begins to wear out, and in some places so much that the bone is exposed. Such changes lead to the death of cartilage and the fusion of articular surfaces. Therefore, deformations occur, as a result of which the normal anatomical structure hand and carpal tunnel.

Acute wrist injuries

However, systemic corticosteroids are more side effects(for example, sleep disturbance, the formation of ulcers in the stomach and intestines). Therefore, they are used with caution, especially in certain diseases (for example, diabetes mellitus). In addition, they inhibit the activity immune system therefore, in the presence of infections, they are not prescribed.
There is one more unpleasant moment: after the abolition of corticosteroids, the “rebound” syndrome may develop: all symptoms quickly return again.

Local treatment

The introduction of medicinal mixtures

A drug mixture of an anesthetic (Lidocaine or Novocaine) with a corticosteroid hormone (Diprospan or hydrocortisone) is injected into the carpal tunnel using a special long needle. As a rule, after the introduction of drugs into the cavity of the carpal tunnel, pain and other symptoms of the disease disappear after some time. However, in some cases, the pain may increase, but after 24-48 hours it gradually decreases.

With this method of treatment, after the first injection, the condition of patients improves. If the symptoms do not disappear completely, then two more procedures are performed with a two-week interval between them.

With a relapse of the disease (the appearance of symptoms again), the course of treatment is repeated.

Local compresses with a complex composition

One of the composition options:

• Dimexide - 50 ml
• Lidocaine solution 10% - 2 ml, or Novocaine 2% - 30 ml
• Hydrocortisone solution - 1 ampoule
• Water - 30 ml

The prepared composition can be stored in a cool place and used for several days.

Carpal Tunnel Syndrome: Surgery

The purpose of the intervention is to reduce pressure on the median nerve by expanding the lumen of the carpal tunnel.

There are two types of surgery that are performed under local anesthesia:

After the operation, a plaster bandage is applied to the wrist area for several days. As rehabilitation treatment physiotherapy and physiotherapy(finger movements should be carried out with a fixed wrist).

3 months after the operation, the function of the hand is restored by 70-80%, and after 6 months - completely.

After recovery, the patient can return to their usual activities. However, if you do not change the working conditions (proper arrangement of the workplace, the use of cuts), there is a high risk of relapse (return of symptoms of the disease)

Non-drug treatment

With hypothyroidism hormone replacement therapy is prescribed: L-thyroxine, Euthyrox.

With menopause physiological or artificial (removal of the ovaries) for replacement therapy appointed hormonal preparations containing estrogen (female sex hormone). However, such treatment is possible only if the woman's last menstruation was no later than 10 years ago, and she is under 60 years old.

If a menstruating woman taking hormonal contraceptives, developed carpal tunnel syndrome, then they are canceled or changed to another drug.

Treatment of diabetes aimed at preventing jumps in sugar levels during the day. Since it is in this case that the in large numbers substances that damage neurons. However, treatment has its own characteristics depending on the type of disease.

Type I diabetes is treated with insulin (short-, long-, or intermediate-acting). The dosage and scheme of application is individual, depending on the severity of the disease and the level of sugar in the blood.

In type II diabetes, hypoglycemic drugs (Glucophage, Metformin) are prescribed, which increase the sensitivity of cell walls to insulin, improving the intake of glucose. In addition, they reduce the formation of glucose in the liver, as well as its absorption in the intestine.

While maintaining the partial function of the pancreas, drugs are used that stimulate the production of insulin by its cells. These are sulfonylurea derivatives: Chlorpropamide, Gliquidone and others.

Regardless of the type of diabetes, thioctic acid preparations (Thiogamma, Berlition) are prescribed to improve tissue nutrition. They improve the uptake of glucose by tissues, bind free radicals (unstable molecules that damage other normal cells in the body), especially the cells of the nervous system.

With chronic kidney failure treatment is aimed at improving the function and blood circulation in the kidneys, removing excess fluid from the body and the end products of protein metabolism.

For this, drugs that thin the blood and improve blood circulation in small vessels (for example, Warfarin, Angioflux) are used.

Sometimes diuretics are prescribed (depending on the degree of preservation of kidney function).

Sorbents (Polysorb, Enterosgel and others) are used to remove the end products of protein metabolism.

With high blood pressure, drugs are used that regulate it: ACE inhibitors(Diroton, Captopril), calcium antagonists (Verapamil) and others.

In case of severe renal insufficiency (stages III-IV), the patient is connected to an artificial kidney apparatus.

Physiotherapy procedures

However, despite their effectiveness, they are not suitable for everyone.

General contraindications for physiotherapy procedures

• Tumor processes
• Pregnancy
• Severe III degree of heart failure
• Any infectious viral diseases in the acute period (presence of elevated body temperature)
• Severe diabetes mellitus (high sugar numbers)
• Increased arterial pressure- temporary contraindication. After its normalization, the procedure can be carried out.
• Presence of a pacemaker
• Epilepsy with frequent seizures, hysteria and psychosis
• Decreased blood clotting and tendency to bleed
• Severe cardiac arrhythmia: severe atrial fibrillation (contraction of the ventricles and atria is not synchronous) and severe extrasystole (in this disease, the heartbeat)
• The presence of pustular inflammation on the skin (the site of exposure to the device)

Ultraphonophoresis

During the procedure, the impact on the body is carried out with the help of ultrasonic vibrations, which contribute to the penetration of drugs into the cells.

In addition, the effect of ultrasound itself is therapeutic: it dilates blood vessels and accelerates blood flow in the capillaries. Due to this, pain decreases or disappears, swelling decreases and hematomas resolve.

Dimexide, painkillers, hormones and other drugs are used as medicines. The exception is some medications that ultrasound destroys: novocaine, B vitamins, ascorbic acid and other substances.

Goals - reducing pain and inflammation, accelerating tissue repair.

Indications

• Diseases of the musculoskeletal system: osteochondrosis, arthrosis, arthritis, (vascular disease)
• Active pulmonary tuberculosis
• Individual intolerance to drugs for ultraphonophoresis

First, the medical officer wipes the skin area to be treated with a disinfectant solution. Next, apply to the skin medicine, then applies an apparatus to the site of exposure, which delivers ultrasonic waves.

The duration of one procedure is from 10 to 30 minutes. Course - 8-12 sessions. After a few months, if necessary, the course of treatment is repeated.

shock wave therapy

As a result, blood circulation in the affected area improves, pain decreases, and sensitivity is restored. Moreover, after several procedures, bone growths begin to disintegrate, and new vessels grow at the site of the lesion.

The method is so effective that with the timely start of treatment, it is equated with the result that is available after the operation.

Goals

Treatment of acute and chronic pain caused by trauma, diseases of the musculoskeletal system (osteochondrosis, arthritis, and others) and the nervous system.

Indications

• Arthrosis, arthritis, osteochondrosis, hernia and protrusion of the intervertebral discs, heel spur
• Stones in the gallbladder and kidneys
• Slow healing of fractures
• Soft tissue injuries: muscles, ligaments, tendons
• Cicatricial contraction of muscles, tendons and ligaments, therefore, free movements (flexion, extension) in the limb are limited
• Pain with bruises, fractures, sprains
• Burns and trophic ulcers
• Chronic muscle pain due to prolonged and frequent overwork

(addition to general)

Age up to 18 years, since the waves act on the growth zones of the bones. Whereas when they are damaged, irreversible changes develop that adversely affect the development of the child's skeleton.

Methodology

The medical officer helps the patient to get comfortable on the couch, then wipes the skin area, disinfecting and degreasing it. Then he adjusts the device depending on the field of application and the disease (there are several programs). Next, he applies a special gel to the skin, after which he applies a sensor to the site of exposure, which sends healing impulses.

The course of treatment is 5-7 procedures, each of which lasts 20-30 minutes. Procedures are carried out with an interval of 3-7 days. After treatment, about 90% of patients have a significant improvement in their condition. If necessary, the course of treatment is repeated after a few months.

On a note

It is impossible to act with shock waves on the area of ​​​​the head, intestines, large blood vessels and lungs.

Prevention of carpal tunnel syndrome

So, what to do based on the mechanism of the development of the disease?

Arrange your workplace
Select the height of the computer desk so that the armrests of the chair are at the level of its surface. In this position, during work (typing or computer mouse movements), the forearms lie quietly on the table or armrests, and are not in a suspended state. Therefore, the hands are relaxed during work, and the hand in the wrist area does not bend. At the same time, there is no additional load on the canal and the median nerve is not clamped.

In addition, while working, try to ensure that the lower back in relation to the hips is located at an angle of 90 °, and the angle between the shoulder and forearm is also 90 °.

Try not to strain or pinch. Make sure that the head does not retract between the shoulders.

Choose a comfortable keyboard and computer mouse
If the position of the hands is correct during work, then the hands lie calmly above the working surface, so the movements in them are free. However, if the keyboard is located high, then you have to keep your hands above it in a suspended position. In this position, the load on the carpal tunnel increases. Therefore, it is better to purchase a special hand mat or a tilted keyboard.

Pick up a computer mouse so that it "lies" in the palm of your hand while you work. So the hand gets tired less and relaxed. For people who have already developed carpal tunnel syndrome, special computer mice have been developed that are shaped like a joystick. When working with them, the carpal tunnel is practically not loaded.

In addition, there are special mouse pads that have a roller (it is better to choose with a helium filler) at the level of the wrist. In this position, during operation, the carpal tunnel is in a straightened state and is loaded minimally.

The position of the brushes at work

Adjust the angle and height of the monitor

So that during operation the text is at eye level. Since if the monitor is low, then you have to constantly tilt your head down, if it is high, then raise it up. With such movements, blood circulation in the cervical region spine and arms.

Among neurological disorders various kinds of neuropathies associated with ischemic, inflammatory or compression (tunnel) damage to the nerve fiber are often diagnosed. Median nerve neuropathy is a common pathology in modern people. This is due to a certain lifestyle and predominantly manual labor without the concomitant development of muscle groups. upper limb. We are talking about professions related to the use of computer technology.

If the median nerve of the hand is damaged, then a segmental disturbance of sensitivity occurs in the area of ​​\u200b\u200bthe palm and non-fast fingers of the hand. Anatomically n. Medianus is responsible for providing motor activity and skin sensitivity in the region of the first three fingers of the hand. With neuropathy of the median nerve of the hand, an inflammatory reaction may occur in the area of ​​​​the carpal joint, motor activity is impaired thumb brushes.

The anatomical features of this plexus of axons are that they are formed by two groups of bundles at once, extending in the form of radicular nerves from the spinal cord. The C5-Th1 segment gives rise to two pairs of radicular nerves: ventral and dorsal. The former are responsible for movement, the latter for skin sensitivity. If the inflammation or lesion begins at the level intervertebral disc C5-Th1, then there may be a "loss" of only one function of the median nerve. With compression, ischemia, or inflammation of the median nerve in the forearm, shoulder, or wrist, a combination occurs clinical symptoms neurological and motor dysfunction.

Damage to the nerve fiber can be observed along the entire length of its path to the hand. First, the median nerve descends into the armpit and passes to the onset humerus. Here, injury can occur by wearing tight and uncomfortable clothing. On the forearm, the nerve passes deep into the thickness of the muscle and layer and is reliably protected from injury. The next dangerous area is the carpal carpal tunnel, which can be deformed. Compression of the median nerve in this anatomical node occurs in almost 80% of programmers and representatives of other professions associated with manual labor based on the performance of monotonous movements of the same type.

Causes of damage and inflammation of the median nerve

Damage to the median nerve can be associated not only with the performance of professional duties. There are pathogenic causes that can provoke inflammation of the median nerve, among them it is worth noting the following factors:

• traumatic impact on the areas through which the innervation passes (fractures of the shoulder and forearm, the beam in a typical place, the bones of the wrist);
• stretching of the muscle and tendon tissue in the area of ​​the carpal canal - lead to the formation of coarse connective tissue in the form of scar bands, which significantly impairs the canal's patency and has a compressive effect on the structure of the nerve fiber;
• deformation of the structural tissues of the carpal joint due to arthritis or arthrosis, rheumatoid manifestations or gout;
• tumor processes;
• the formation of hematomas after bruises and ruptures of soft tissues without violating the integrity of the epidermis;
• endocrine pathologies associated with a deterioration in the blood supply to the soft tissues of the upper extremities (diabetic angiopathy, narrowing of the capillary bed in hypothyroidism or its stretching in acromegaly);
• atherosclerosis, capillary and arterial insufficiency of blood supply;
• violation of the integrity of large main blood vessels;
• syndrome of prolonged limb compression with soft tissue atrophy.

In addition, pathology can be provoked by mechanical factors of influence. For example, some people have a habit of holding their hands long time in an unnatural twisted position. The habit of not paying attention to inconveniences when organizing your workplace and choosing tools can also play a cruel joke. If the implementation of professional duties associated with the use of the brush causes pain and a feeling of stiff tissues, then you should think about changing the tool or workplace.

Compression ischemic syndrome can be caused by the anatomical features of the development of the carpal tunnel. Signs of this may appear for the first time at the age of 10 - 13 years. A teenager may begin to complain of pulling sensations in the wrist area, pain in the first three fingers brushes. In most cases, this pathology resolves on its own by the age of 14-15.

However, approximately 20% of patients have persistent anatomical defects in the carpal tunnel. This provokes squeezing of blood vessels and nerve fibers. In this case, there are two types of negative influence on the median nerve of the hand. He suffers from mechanical pressure and from a lack of nutrition against the background of improper blood supply.

Neuropathy of the median nerve, which is formed by the type of tunnel syndrome, is an officially recognized occupational disease. According to the medical classification, representatives of such processions as musicians, plasterers, painters, massage therapists, builders and carpenters, hairdressers and tilers, tennis players and packers are subject to such injuries.

Syndrome of pinching of the median nerve of the hand in the carpal tunnel

As mentioned above, the median nerve of the hand passes through the carpal tunnel, where it can be subjected to compression and ischemia. Tunnel syndrome of the median nerve leads to the development of a severe pain syndrome, the appearance of characteristic features inflammatory reaction (redness and swelling, impaired mobility, deterioration of sensitivity).

In order to provide first aid, it is necessary to eliminate the pinching of the median nerve, and this must be done in such a way as not to violate the integrity of the surrounding tissues.

The median nerve of the carpal tunnel can be released using osteopathic techniques and manual therapy. Therefore, if you have pain in the wrist area and there is a violation of sensation in the palm, some fingers, we recommend that you make an appointment for a free appointment at our manual therapy clinic. Here, an experienced doctor will conduct an examination, make a diagnosis and tell you what can be done to alleviate the condition right now, and what will need to be done for a full recovery.

Damage to the median nerve of the forearm

Another common pathology is damage to the median nerve of the forearm, associated with traumatic effects in the form of fractures, bruises and sprains of the ligamentous apparatus. These lesions are typical for people engaged in heavy physical labor and who are fond of sports associated with lifting weights (weightlifting).

The median nerve of the forearm is quite well protected by muscle tissue and fascia from mechanical stress. Therefore, traumatic compression injuries are likely here. The clinic of this process is that shortly after the injury, swelling of the carpal tunnel develops, the sensitivity of the first three fingers and the palmar part of the hand is disturbed.

Detailed symptoms may also accompany deforming osteoarthritis of the shoulder, elbow and carpal joints. At the same time, the clinic of cartilage and bone tissue deformation comes to the fore. After some time, signs of impaired innervation join.

Compression and ischemic neuropathy of the median nerve: symptoms of neuropathy

In the practice of a neurologist, compression neuropathy of the median nerve is more common than manifestations of an ischemic process against the background of impaired capillary blood supply to the soft tissues of the upper limb. Among the potential patients, one can note people who are in the prime of life and professional opportunities. This age category is from 25 to 45 years. It is her representatives who are most often diagnosed with compression neuropathy of the median nerve associated with professional activity or misplaced physical activity during sports.

The disease is more often referred to in the specialized literature as carpal tunnel syndrome. Treatment is possible only with the help of manual therapy. In difficult cases, when precious time is lost and the pathology has passed into the final stage, a surgical operation will be required.

Ischemic neuropathy of the median nerve can also result from narrowing of the carpal tunnel. But more often ischemia is observed in persons with impaired blood circulation. This may be a consequence of cardiovascular or endocrine pathology. In most cases, ischemic neuropathy of the median nerve accompanies diabetes, hypothyroidism and gout.

Clinical symptoms of neuropathy of the median nerve of the hand may include the following manifestations:

• severe pain in the wrist, passing to the palm, the first three fingers of the hand;
• discoloration of the soft outer tissues (redness or, conversely, an unnatural pale and bluish tint);
• limitation of motor activity (the patient cannot clench his hand into a fist, take his thumb to the side);
• over time, there is a noticeable dystrophy of some muscle groups of the palmar zone with a loss of their turgor, elasticity and volume;
• sensitivity suffers (the patient cannot distinguish between hot and cold, hard and soft).

Diagnosis can be made using X-ray, MRI, CT and ultrasound. It is important for the doctor to establish the place where the infringement or violation of the patency of the median nerve occurs. For exclusion cervical osteochondrosis as a potential cause this disease X-rays of this part of the spine should be taken.

Treatment of neuropathy (neuropathy) of the median nerve

Treatment of the median nerve of the hand begins with an examination. The doctor must determine the cause of the negative effect on nerve fiber. After that, the treatment of neuropathy of the median nerve begins by eliminating this cause. If the pathology is provoked by the narrowing of the carpal tunnel, then techniques and techniques of osteopathy can be used to expand it and remove all obstacles along the path of the nerve fiber.

Manual therapy for the treatment of median nerve neuropathy offers various techniques:

• massage aimed at improving blood supply to soft tissues and relaxing muscle groups;
• osteopathy, which allows you to eliminate muscle spasms, spasms of the bloodstream and other clamps;
• therapeutic gymnastics and reflexology;
• electromyostimulation and kinesitherapy.

The choice of appropriate methods of therapy is carried out by the doctor after examining the patient and making the correct diagnosis.

17701 0

The two most frequent places compression of the median nerve:

• at the wrist with the transverse carpal tunnel ligament: carpal tunnel syndrome
• in the upper part of the forearm with a round pronator: pronator round syndrome

Anatomy

The median nerve contains fibers from the C5-T1 segments. In the upper part of the forearm, it passes between the two heads of the round pronator and innervates this muscle. Immediately below this point, it divides to form a purely motor anterior interosseous nerve that innervates all but 2 of the muscles of the fingers and the flexors of the hand. It descends, located between the superficial flexor of the fingers ( PSP) (top) and deep flexor of the fingers (bottom). Near the wrist, it comes out from under the lateral edge of the PSP, is located more superficially, lies medially to the tendon of the radial flexor of the wrist, immediately lateral and partially under the tendon of the long flexor of the palm. It passes under the transverse carpal ligament ( CCD) through carpal tunnel, which also contains the tendons of the deep and superficial flexors of the fingers, located deeper than a nerve. The motor branch departs deeper than the CCD, but in abnormal cases it can pierce the CCD. It supplies the 1st and 2nd worm-like muscles, the muscle that opposes the 1st finger, the muscle that removes the 1st finger and the short flexor of the 1st finger.

The CCD inserts medially to the pisiform and the hook of the hamate, and laterally to the trapezoid and tubercles of the scaphoid. The CCD continues proximally into the fascia covering the PSP and the forearm fascia, and distally into flexion anoneurosis. In the distal direction, the CCD continues into the hand for≈3 cm below the distal carpal crease. The tendon of the long palmar muscle is partially attached to the CCD, which may be absent in 10% of the population.

The palmar cutaneous branch of the median nerve departs from the radial side of the median nerve to≈5.5 cm proximal to the styloid process of the radius under the superficial flexor of the 3rd finger. She crosses the wrist above CCD and provides sensitive innervation of the base of the eminence of the thumb (thenar).

The approximate zone of cutaneous innervation of the median nerve is shown in Fig. rice. 17-5.

Rice. 17-5

carpal tunnel syndrome

carpal tunnel syndrome ( SZK) is the most common neuropathy resulting from compression on the arm. The median nerve is compressed in the carpal tunnel just distal to the carpal crease.

Usually seen in middle-aged patients. 8 : % =4:1. In more than half of the cases it is bilateral, but more pronounced on the dominant hand.

Common Causes

In most cases, no specific cause can be identified. CTS is very common in the elderly. In younger patients, the following causes are possible:

1. "classic" SZK: chronic course, usually months or years

A.trauma: often work-related (or hobby)

1. repeated movements of the hand or wrist

2. repeated strong gripping of the hand or holding tools or any other objects

3. awkward hand and/or wrist positions, including wrist extension, ulnar abduction of the hand, and particularly strong wrist flexion

4. direct pressure on the carpal tunnel

5. working with vibrating hand tools

b.general conditions: in addition to common reasons causing neuropathy upon compression indicated on (especially RA and DM): obesity

1. local trauma

2. may appear temporarily during pregnancy

3. mucopolysaccharidosis V

4. TB tenosynovitis

C.Patients with AV shunts in the forearm for dialysis have an increased incidence of CTS, possibly of ischemic origin or as a result of existing kidney disease

2. "Acute" CTS: A rare condition in which symptoms appear suddenly, severely, usually after some type of exercise or injury. The reasons:

1. median artery thrombosis: persistent median artery occurs in<10% населения

2. hemorrhage or hematoma of the CCD

Complaints and symptoms

Clinical examination in CTS is usually uninformative.

Possible complaints and symptoms:

1. dysesthesia:

A.typically, when patients wake up at night with painful numbness in the arm, which is subjectively felt as a lack of blood supply. In order to relieve pain, patients shake their hands, clench and unclench their fists, rub their fingers, put their hands under hot or cold water, and walk around the room. Pain may radiate up the arm, sometimes all the way to the shoulder

b.typical situations in which pain may occur during the daytime: when the patient is holding a book or newspaper, a telephone handset, or while driving a car

C.spread of symptoms

1. radial side of the palm in the area of ​​3.5 fingers (palmar side of the 1st finger, 2nd, 3rd and radial side of the 4th fingers)

2. the back side of the same fingers distal to the proximal interphalangeal joints

3. radial side of the palm

4. often a subjective feeling of involvement of the 5th finger

2. weakness of the hand, especially clenching into a fist. It can be combined with thenar atrophy (it is a late sign, now, due to the high awareness of most doctors about CTS, severe atrophy is rare). Occasionally, patients may present with severe atrophy without any indication of prior pain.

3. clumsiness of the hand and difficulty with precise movements: mainly caused by numbness, not movement disorders. It often manifests itself as difficulty in fastening buttons, etc.

4. hyperesthesia in the zone of innervation of the median nerve: usually most pronounced in tips fingers, a more accurate test may be a violation of discrimination sensitivity

5. Phalen test: squeezing the hand into a fist for 30-60 seconds leads to the reproduction of pain and tingling. Positive in 80% of cases

6. Tinel's symptomon the wrist: gentle tapping over the carpal tunnel causes paresthesia and pain in the median nerve area. Positive in 60% of cases. It can also be seen in other diseases. Inverse symptom of Tinel: the occurrence of pain radiating up the forearm at different distances

7. ischemic test: inflation of the blood pressure cuff on the forearm for 30-60 seconds leads to the reproduction of CTS pain

Differential Diagnosis

DD includes (with changes):

1. cervical radiculopathy: seen in 70% of patients with neuropathies of the median or ulnar nerves (C6 neuropathy may resemble CTS). Usually, rest brings relief, and the pain is aggravated by movement of the neck. Sensory disturbances have a dermatomal distribution. It has been found that compression of the cervical root can interrupt the plasma flow along the axon and be a predisposing factor for distal compression injury (the term has been proposed to describe this condition double damage syndrome). Although the existence of such conditions is disputed, but it has not been refuted

2. chest outlet syndrome: a decrease in the volume of other muscles of the hand except for the tenar. Sensory disturbances on the ulnar side of the hand and forearm

3. pronator teres syndrome: pain in the palm is more pronounced than in CTS (cutaneous palmar branch of the median nerve does not pass through the carpal tunnel)

4. de Quervain's syndrome : Tenosynovitis of the tendons of the abductor thumb and extensor pollicis brevis muscles. Often caused by repeated hand movements. Pain and soreness in the wrist around the 1st finger. In 25% of cases, onset during pregnancy and in many cases within 1 year after delivery. Splints and/or steroid injections usually help. SNP should be normal. Finkelstein test: passive abduction of the 1st finger with simultaneous palpation of the muscles that abduct the 1st finger; is considered positive if the pain is aggravated

5. reflex sympathetic dystrophy: possible relief from sympathetic blockade

6. tenosynovitis of any of the flexor ligaments: sometimes seen with TB or fungal infection. Usually there is a slow, gradual course. May have fluid buildup

Greenberg. Neurosurgery

Carpal tunnel syndrome is a condition that develops as a result of injury or compression of the median nerve located in the carpal tunnel. Sometimes this syndrome is called tunnel syndrome, but this is not quite the right term, because there are other tunnel syndromes. With the development of this disease, there is a violation of the sensitivity and movements of the first three and part of the fourth finger.

In this article, we will introduce you to the causes, symptoms, and treatments for carpal tunnel syndrome. This information will help you make a timely decision about the need for its treatment, and you can prevent the development of irreversible damage to the median nerve.

In the world, carpal tunnel syndrome is detected in 1.5-3% of the population and in half of the cases patients are active computer users. This disease is considered professional, because it is much more common for people who, due to their professional activities, are forced to make frequent and monotonous flexion and extension movements of the hand (for example, office workers who work at a computer for a long time, tailors, musicians, etc. ).

This syndrome is more often observed in people 40-60 years old, but can also develop at a younger age. According to statistics, in 10% of cases the disease is detected in people under 30 years of age.

Experts believe that those people who work at the computer for a long time are most susceptible to the development of this syndrome. According to one of the numerous studies, it is detected in every sixth active PC user. According to various sources, the syndrome is 3-10 times more likely to develop in women.

The reasons

The main cause of carpal tunnel syndrome is compression of the median nerve as it passes through the tunnel formed by the transverse ligament and carpal bones. Compression is caused by inflammation and swelling of the joint, tendons, and muscles in the joint itself or inside the carpal tunnel. In most cases, the cause of such damage to the median nerve is work that requires frequent and repetitive movements.

In addition to professional factors, the development of carpal tunnel syndrome can be triggered by other diseases and conditions:

1. . With bruises or sprains, swelling of the ligaments and muscles of the hand occurs, which causes compression of the nerve. Dislocations or fractures, in addition to swelling of the soft tissues, may be accompanied by displacement of the bones. Such damage compresses the nerve. With proper treatment of a dislocation or fracture, compression is eliminated, but with bone deformity or muscle contractures, joint disorders can become irreversible.
2. and other rheumatic joint disorders. The inflammation and swelling that occurs with these diseases cause compression of the nerve by the soft tissues of the carpal tunnel. With prolonged progression of the syndrome, the cartilaginous tissue of the joint ages, loses its elasticity and wears out. Wear and tear of cartilage leads to fusion of joint surfaces and their deformation.
3. Tenosynovitis (inflammation of the tendons). Tendons are affected by pathogenic bacteria and become inflamed. The tissues in the wrist area swell and compress the nerve. The sources of infection can be: purulent wounds on the hands, panaritium, etc. In addition, inflammation of the tendon tissues can be non-bacterial and be caused by chronic stress injuries: frequent movements of the hand and arm, prolonged exercise, exposure to cold.
4. Diseases and conditions accompanied by fluid retention in the body. Swelling of soft tissues (including in the carpal tunnel) can be observed when taking oral contraceptives, pregnancy, or kidney pathologies.
5. tumor of the median nerve. Such neoplasms are rare. These can be schwannomas, neurofibromas, perineuromas, and malignant tumors of the nerve sheaths. Their growth causes displacement and compression of the nerve.
6. Diabetes. The course of this disease is accompanied by the accumulation of fructose and sorbitol in nerve tissues. When they are activated by the enzyme protein kinase C, damage to neurons and their processes occurs. In addition, metabolic disorders lead to insufficient blood flow to the nerves and a decrease in their nutrition. All these consequences cause non-infectious inflammation of the nerves (including the median one). Nerves become swollen and can be compressed in narrow areas such as the carpal tunnel.
7. . This disease develops for a long time and is accompanied by growth to a disproportionate size of the bones of the face and limbs. In addition to bone changes, soft tissue proliferation is observed. Enlargement of the carpal bones causes a narrowing of the lumen of the carpal tunnel, and the median nerve is infringed.
8. genetic predisposition. Compression of the median nerve can be observed with such anatomical features of the hand as a "square wrist", congenital insufficiency in the production of tendon sheaths of lubrication, or congenital thick transverse carpal ligament.

Symptoms

Carpal tunnel syndrome develops gradually. In most cases, one hand is affected, i.e. "working" (for right-handers - the right, for left-handers - the left). Sometimes nerve compression is observed in both hands (for example, with endocrine disorders or pregnancy).

Paresthesia

Tingling and numbness of the fingers is the first sign of the syndrome. Paresthesias are felt by the patient immediately after awakening, but are completely eliminated by noon. With the development of the syndrome, they begin to appear at night, and then during the day. As a result, the patient cannot hold the hand on weight for a long time (when applying the phone to the ear, holding the handrail in public transport, etc.). When trying to perform such holdings, paresthesias intensify and the person changes his hand to perform the action (shifts the phone to the other hand, changes its position, etc.).

Pain

Initially, the patient develops pains of a burning or tingling nature. Arising at night, they disturb sleep, and a person has to wake up in order to put his hand down or shake his hand. Such actions contribute to the normalization of blood circulation in the fingers, and pain is eliminated.

Pain does not occur in certain joints, but is widespread. They capture the entire finger - from the base to the tip. In the absence of treatment, pain begins to appear during the day. Any movement of the hand causes their strengthening, and the patient cannot fully work. In severe cases of the syndrome, pain can capture the entire palm and spread up to the elbow, making it difficult to diagnose.

Clumsy hand movements and loss of strength

With the aggravation of the syndrome, the patient develops weakness in the arm, and he cannot perform precise movements. It is difficult for him to hold small objects (a needle, a button, a pen, etc.), and such actions are accompanied by a feeling that they themselves fall out of his hand.

In some cases, there is a decrease in the strength of opposition of the thumb to the rest. It is difficult for the patient to take it away from the palm and actively grasp objects.

Desensitization

This symptom appears with a significant lesion of the median nerve. A third of patients complain of a reaction to a sudden change in temperature or cold: a burning sensation or painful numbness is felt in the arm. Depending on the severity of the disease, the patient may not feel a light touch on the hand or prick with a pin.

Amyotrophy

This muscle change appears in the absence of treatment in the later stages of the syndrome. The patient has a visual decrease in muscle size. In advanced cases, the hand is deformed, and it becomes like a monkey's paw (the thumb is brought to a flat palm).

Change in skin color

Violation of the innervation of skin cells leads to a violation of their nutrition. As a result, the skin of the fingers and the area of ​​the hand innervated by the median nerve acquires a lighter shade.

Diagnostics

For the diagnosis of carpal tunnel syndrome, the patient needs to consult a neurologist. The patient examination plan includes special tests, instrumental and laboratory methods.

Tests for carpal tunnel syndrome:

1. Tinel test. Tapping from the side of the palm in the area of ​​​​the narrowest part of the carpal tunnel causes the appearance of tingling in the fingers.
2. Phalen test. The patient should bend the arm as much as possible in the wrist area and hold it like that for a minute. With carpal tunnel syndrome, there is an increase in paresthesia and pain.
3. Cuff test. Between the elbow and wrist is put on the cuff of the apparatus for measuring pressure. It is inflated with air to significant figures and left in this position for one minute. The syndrome manifests tingling and numbness in areas innervated by the median nerve.
4. Raised hands test. Hands are raised above the head and held for a minute. With the syndrome, after 30-40 seconds, the patient feels paresthesia in the fingers.

Such tests can be used for preliminary self-diagnosis at home. If during even one of them there are unpleasant sensations, then an appeal to the doctor is necessary.

To clarify the diagnosis, the patient is assigned the following instrumental methods of examination:

• electroneuromyography;
• radiography;

To identify the causes of carpal tunnel syndrome (for example, rheumatoid arthritis, diabetes mellitus, autoimmune diseases, hypothyroidism, etc.), the following laboratory diagnostic methods may be recommended to the patient:

• blood biochemistry;
• blood and urine tests for sugar;
• analysis for thyroid-stimulating hormones;
• clinical analysis of urine and blood;
• blood test for rheumatic tests (rheumatoid factor, C-reactive protein, antistreptolysin-O);
• blood test for CEC (circulating immune complexes);
• blood test for antistreptokinase.

Treatment

Treatment of carpal tunnel syndrome always begins with guarding to take the stress off the wrist. In the absence of such measures, therapy is ineffective.

Guard mode for carpal tunnel syndrome:

1. When the first signs of the syndrome appear, the hand should be fixed with a special fixative. Such an orthopedic product can be purchased at a pharmacy. It allows you to reduce the range of motion and prevent further tissue trauma.
2. Completely refrain from activities that cause or worsen symptoms for two weeks. To do this, it is necessary to temporarily change jobs and exclude movements that cause increased pain or paresthesia.
3. Apply cold for 2-3 minutes 2-3 times a day.

The further treatment plan for carpal tunnel syndrome depends on the severity of its symptoms. If necessary, it is supplemented with therapy for the underlying disease that causes compression of the median nerve (for example, rheumatoid arthritis, trauma, hypothyroidism, renal pathologies, diabetes mellitus, etc.).

Local treatment

This type of therapy allows you to quickly eliminate acute symptoms and discomfort that bother the patient.

Compresses

To perform compresses, various multicomponent compositions can be used to eliminate inflammation and swelling of the tissues of the carpal tunnel.

One of the composition options for compresses:

• Dimexide - 60 ml;
• Water - 6 ml;
• Hydrocortisone - 2 ampoules;
• Lidocaine 10% - 4 ml (or Novocain 2% - 60 ml).

Such compresses are performed daily. The duration of the procedure is about an hour. The resulting solution of drugs can be stored in the refrigerator for several days.

Injection of drugs into the carpal tunnel

The doctor, using a special long needle, introduces a mixture of local anesthetic solutions (Lidocaine or Novocaine) and glucocorticosteroid hormone (Hydrocortisone or Diprospan) into the carpal tunnel. After the introduction of such a composition, pain and other unpleasant sensations are eliminated. Sometimes they can increase in the first 24-48 hours, but after that they begin to gradually regress and disappear.

After the first administration of such a composition, the patient's condition improves significantly. If the symptoms of the syndrome return again after some time, then two more such procedures are performed. The interval between them should be at least 2 weeks.

Medical therapy

The choice of drugs, dosage and duration of their administration depend on the severity of the disease and comorbidities. The drug treatment plan for carpal tunnel syndrome may include the following:

• vitamins of group B (B1, B2, B5, B6, B7, B9 and B 12): Milgamma, Neurobion, Neurobeks, Doppelherz active, Benevron, etc .;
• non-steroidal anti-inflammatory drugs: Xefocam, Dicloberl, Aertal, Movalis, etc.;
• vasodilators: Pentylin, Nicotinic acid, Trental, Angioflux;
• : Hypothiazide, Furosemide, Diacarb and others;
• anticonvulsants: Gabapentin, Pregabalin;
• muscle relaxants (drugs for relaxing muscles): Sirdalud, Mydocalm;
• glucocorticosteroids: Metipred, Hydrocortisone, Prednisolone;
• antidepressants: duloxetine, venlafaxine.

Physiotherapy

Physiotherapeutic methods of treatment can be used against the background of drug therapy or for the rehabilitation of patients after surgery.

The following can be used to treat carpal tunnel syndrome:

• acupuncture;
• manual therapy techniques;
• ultraphonophoresis;
• shock wave therapy.

The appointment of physiotherapy procedures is possible only if there are no contraindications to them.

Surgery

Surgery for carpal tunnel syndrome is recommended if other methods of therapy are ineffective and the symptoms of the disease persist for six months. The purpose of such surgical interventions is to expand the lumen of the canal and relieve pressure on the median nerve.