اوجاع وتنمل اليد the carpal tunnelsyndrom

2007/09/28
اوجاع وتنمل اليد the carpal tunnelsyndrom
هي اوجاع من نوع التنمل او الشعور بوخز ابر وكأن اليد نائمة , وقد تشمل اليد كلها او جزء من اليد والاصابع الجانبية الثلاتة ونصف الاصبع الرابع .
قد يشعر المريض بان اليد متورمة وتصاحب بارتفاع في درجة حرارتها عن باقي الجسموتصعب بها الحركه ويكون المريض غير قادر على استعمال اليد وقد يلاحظ المريض استمرار وصعود الوجع الى كامل الطرف العلوي ثم الرقبة .
ان ماسبق يدل ويُشير الي مسار الوجع وهدا يتطابق مع مسار العصب الاوسط بالطرف العلوي –themedian nerve- .

## نظرة تشريحية the anatomy سريعة لمسار العصب الاوسط :
1. في الذراع يكون العصب الاوسط مصاحب بالشريان الاوسط ويمران خلال ممر خاص بين العضلات في الطريق الي كف اليد .
2. يمر العصب الاوسط تحت الجلد مباشرة ثم يمر تحت رباط قوي عند مفصل الرسغ the transverse ligament والتي تكون نفق مفصل الرسغ the carpale tunnel .
3. توجد مجموعة من العضلات تفصل العصب الاوسط عن عظمتي المعصم خلقها الله لحماية العصب من كسور عظمتي المفصل الكثيرة الحدوث مثل Colle,s fracture .
4. قٌبيل مرور العصب تحت هدا الرباط يعطي العصب الاوسط فرع عصبي حسي لتغدية اليد وكدلك يمر هدا الفرع من خلال نفق مفصل الرسغ .
5. عند دخول العصب الاوسط لكف اليد يتفرع الي فرعين تعطي تفرعات عصبية حركيةوحسية لليد والاصابع الجانبية الثلاته ونصف الاصبع الرابع .
6. العصب الاوسط يحمل معه الاعصاب السيمباتوية لليد the sympatatic branches .

## الصورة المرضية clinical picture

1. الشعور بتنمل اليد لعدة اشهر قبل حدوث الاوجاع الشديدة .
2. حدوث نوبات اوجاع شديدة باليد وبالمناطق التي يغديها العصب الاوسط .
3. يصحو المريض من النوم على نوبات الاوجاع باليد مع الشعور بوخز ابروتورم باليد .
4. الشعور بوجع على طول مسار العصب من اليد الى الرقبة .
5. شعور المريض بعدم القدرة على تحريك اليد او استعمالها .
6. قد تصاب احدى اليدين وخاصة اليد السائدة او كليهما .
7. تكون الاوجاع محدودة بالاصابعالثلات الجانبية ونصف الاصبع الرابع .

## الامراض المشابهه D.D
فثق غرضروفي بالرقبة .
. تشوهات. خلقية بالرقبة مثل وجود ضلع بالرقبةCervical rib .
. تشوهات عظام مفصل الرسغ ما بعد الكسور
• التأم كسركوليس في وضع معيب .
• امراض عظيمات مفصل الرسغ .
• تورمات الغشاء السينوفي والتهابها synovitis .
• التهابات الاغشية حول الاربطة peritendinitis .

# # التشخيص Diagnosis
1. صور الاشعة لمفصل الرسغ والرقبة
2. اختبارات الاعصاب مثل الحقنالموضعية للتخدير وتخطيط الاعصاب .
3. قد نحتاج الي تصوير مغناطيسي للرقبة .
4. اجراء منظار للرسغ تشخيصي\علاجي .

## العلاج :
1. يجب كشف الاسباب التي من المحتمل ان تكون في مفصل الرسغ وعلاجها مثل :
. تشوهات العظام ما بعد الكسور .
• الاورام مثل : اكياس الرسغ gangleon , ترسبات الكالسيوم , عقد مرض النقرس
• الامراض المزمنة مثل الروماثويد .
2- يجب وضع اليد في وضعية مريحة لثلاتة اسابيع في الجبس .
3- في حالة فشل العلاج التحفظي يجب العلاج الجراحي سواء فالجراحة العادية او بالمنظار.
وبالعمل الجراحي يتم التخلص من الاوجاع مباشرة وبدون مضاعفات تدكر .

سلام
د.ناصر حبارات
You're working at your desk,trying to ignore the tingling or numbness you've had for months in your handand wrist. Suddenly, a sharp, piercing pain shoots through the wrist and upyour arm. Just a passing cramp? More likely you have carpal tunnel syndrome, apainful progressive condition caused by compression of a key nerve in thewrist.
Whatis carpal tunnel syndrome?
Carpal tunnel syndrome occurswhen the median nerve, which runs from the forearm into the hand, becomespressed or squeezed at the wrist. The median nerve controls sensations to thepalm side of the thumb and fingers (although not the little finger), as well asimpulses to some small muscles in the hand that allow the fingers and thumb tomove. The carpal tunnel - a narrow, rigid passageway of ligament and bones atthe base of the hand ¾ houses the median nerve and tendons. Sometimes,thickening from irritated tendons or other swelling narrows the tunnel andcauses the median nerve to be compressed. The result may be pain, weakness, ornumbness in the hand and wrist, radiating up the arm. Although painful sensationsmay indicate other conditions, carpal tunnel syndrome is the most common andwidely known of the entrapment neuropathies in which the body's peripheralnerves are compressed or traumatized.
Whatare the symptoms of carpal tunnel syndrome?

Symptoms usually start gradually, with frequent burning,tingling, or itching numbness in the palm of the hand and the fingers,especially the thumb and the index and middle fingers. Some carpal tunnelsufferers say their fingers feel useless and swollen, even though little or noswelling is apparent. The symptoms often first appear in one or both handsduring the night, since many people sleep with flexed wrists. A person withcarpal tunnel syndrome may wake up feeling the need to "shake out"the hand or wrist. As symptoms worsen, people might feel tingling during theday. Decreased grip strength may make it difficult to form a fist, grasp smallobjects, or perform other manual tasks. In chronic and/or untreated cases, themuscles at the base of the thumb may waste away. Some people are unable to tellbetween hot and cold by touch.
Whatare the causes of carpal tunnel syndrome?
Carpal tunnel syndrome isoften the result of a combination of factors that increase pressure on themedian nerve and tendons in the carpal tunnel, rather than a problem with thenerve itself. Most likely the disorder is due to a congenital predisposition -the carpal tunnel is simply smaller in some people than in others. Othercontributing factors include trauma or injury to the wrist that cause swelling,such as sprain or fracture; overactivity of the pituitary gland;hypothyroidism; rheumatoid arthritis; mechanical problems in the wrist joint;work stress; repeated use of vibrating hand tools; fluid retention duringpregnancy or menopause; or the development of a cyst or tumor in the canal. Insome cases no cause can be identified.
There is little clinical datato prove whether repetitive and forceful movements of the hand and wrist duringwork or leisure activities can cause carpal tunnel syndrome. Repeated motionsperformed in the course of normal work or other daily activities can result inrepetitive motion disorders such as bursitis and tendonitis. Writer's cramp - acondition in which a lack of fine motor skill coordination and ache andpressure in the fingers, wrist, or forearm is brought on by repetitive activity- is not a symptom of carpal tunnel syndrome.
Whois at risk of developing carpal tunnel syndrome?
Women are three times morelikely than men to develop carpal tunnel syndrome, perhaps because the carpaltunnel itself may be smaller in women than in men. The dominant hand is usuallyaffected first and produces the most severe pain. Persons with diabetes orother metabolic disorders that directly affect the body's nerves and make themmore susceptible to compression are also at high risk. Carpal tunnel syndromeusually occurs only in adults.
The risk of developing carpaltunnel syndrome is not confined to people in a single industry or job, but isespecially common in those performing assembly line work - manufacturing,sewing, finishing, cleaning, and meat, poultry, or fish packing. In fact,carpal tunnel syndrome is three times more common among assemblers than amongdata-entry personnel. A 2001 study by the Mayo Clinic found heavy computer use(up to 7 hours a day) did not increase a person's risk of developing carpaltunnel syndrome.
During 1998, an estimatedthree of every 10,000 workers lost time from work because of carpal tunnelsyndrome. Half of these workers missed more than 10 days of work. The averagelifetime cost of carpal tunnel syndrome, including medical bills and lost timefrom work, is estimated to be about $30,000 for each injured worker.
Howis carpal tunnel syndrome diagnosed?
Early diagnosis and treatmentare important to avoid permanent damage to the median nerve. A physicalexamination of the hands, arms, shoulders, and neck can help determine if thepatient's complaints are related to daily activities or to an underlyingdisorder, and can rule out other painful conditions that mimic carpal tunnelsyndrome. The wrist is examined for tenderness, swelling, warmth, anddiscoloration. Each finger should be tested for sensation, and the muscles atthe base of the hand should be examined for strength and signs of atrophy.Routine laboratory tests and X-rays can reveal diabetes, arthritis, andfractures.
Physicians can use specifictests to try to produce the symptoms of carpal tunnel syndrome. In the Tineltest, the doctor taps on or presses on the median nerve in the patient's wrist.The test is positive when tingling in the fingers or a resultant shock-likesensation occurs. The Phalen, or wrist-flexion, test involves having thepatient hold his or her forearms upright by pointing the fingers down and pressingthe backs of the hands together. The presence of carpal tunnel syndrome issuggested if one or more symptoms, such as tingling or increasing numbness, isfelt in the fingers within 1 minute. Doctors may also ask patients to try tomake a movement that brings on symptoms.
Often it is necessary toconfirm the diagnosis by use of electrodiagnostic tests. In a nerve conductionstudy, electrodes are placed on the hand and wrist. Small electric shocks areapplied and the speed with which nerves transmit impulses is measured. Inelectromyography, a fine needle is inserted into a muscle; electrical activityviewed on a screen can determine the severity of damage to the median nerve.Ultrasound imaging can show impaired movement of the median nerve. Magnetic resonanceimaging (MRI) can show the anatomy of the wrist but to date has not beenespecially useful in diagnosing carpal tunnel syndrome.
Howis carpal tunnel syndrome treated?
Treatments for carpal tunnelsyndrome should begin as early as possible, under a doctor's direction.Underlying causes such as diabetes or arthritis should be treated first.Initial treatment generally involves resting the affected hand and wrist for atleast 2 weeks, avoiding activities that may worsen symptoms, and immobilizingthe wrist in a splint to avoid further damage from twisting or bending. Ifthere is inflammation, applying cool packs can help reduce swelling.
Non-surgical treatments
Drugs - In specialcircumstances, various drugs can ease the pain and swelling associated withcarpal tunnel syndrome. Nonsteroidal anti-inflammatory drugs, such as aspirin,ibuprofen, and other nonpre ion pain relievers, may ease symptoms thathave been present for a short time or have been caused by strenuous activity.Orally administered diuretics ("water pills") can decreaseswelling. Corticosteroids (such as prednisone) or the drug lidocaine canbe injected directly into the wrist or taken by mouth (in the case ofprednisone) to relieve pressure on the median nerve and provide immediate,temporary relief to persons with mild or intermittent symptoms. (Caution:persons with diabetes and those who may be predisposed to diabetes should notethat prolonged use of corticosteroids can make it difficult to regulate insulinlevels. Corticosterioids should not be taken without a doctor's pre ion.)Additionally, some studies show that vitamin B6 (pyridoxine)supplements may ease the symptoms of carpal tunnel syndrome.
Exercise - Stretchingand strengthening exercises can be helpful in people whose symptoms haveabated. These exercises may be supervised by a physical therapist, who istrained to use exercises to treat physical impairments, or an occupationaltherapist, who is trained in evaluating people with physical impairments andhelping them build skills to improve their health and well-being.
Alternative therapies- Acupuncture and chiropractic care have benefited some patients but theireffectiveness remains unproved. An exception is yoga, which has been shown toreduce pain and improve grip strength among patients with carpal tunnelsyndrome.
Surgery
Carpal tunnel release is oneof the most common surgical procedures in the United States. Generallyrecommended if symptoms last for 6 months, surgery involves severing the bandof tissue around the wrist to reduce pressure on the median nerve. Surgery is doneunder local anesthesia and does not require an overnight hospital stay. Manypatients require surgery on both hands. The following are types of carpaltunnel release surgery:
Open release surgery,the traditional procedure used to correct carpal tunnel syndrome, consists ofmaking an incision up to 2 inches in the wrist and then cutting the carpalligament to enlarge the carpal tunnel. The procedure is generally done underlocal anesthesia on an outpatient basis, unless there are unusual medical considerations.
Endoscopic surgery mayallow faster functional recovery and less postoperative discomfort thantraditional open release surgery. The surgeon makes two incisions (about½" each) in the wrist and palm, inserts a camera attached to a tube,observes the tissue on a screen, and cuts the carpal ligament (the tissue thatholds joints together). This two-portal endoscopic surgery, generally performedunder local anesthesia, is effective and minimizes scarring and scartenderness, if any. One-portal endoscopic surgery for carpal tunnel syndrome isalso available.
Although symptoms may berelieved immediately after surgery, full recovery from carpal tunnel surgerycan take months. Some patients may have infection, nerve damage, stiffness, andpain at the scar. Occasionally the wrist loses strength because the carpalligament is cut. Patients should undergo physical therapy after surgery torestore wrist strength. Some patients may need to adjust job duties or evenchange jobs after recovery from surgery.
Recurrence of carpal tunnelsyndrome following treatment is rare. The majority of patients recovercompletely.
Howcan carpal tunnel syndrome be prevented?
At the workplace, workers cando on-the-job conditioning, perform stretching exercises, take frequent restbreaks, wear splints to keep wrists straight, and use correct posture and wristposition. Wearing fingerless gloves can help keep hands warm and flexible.Workstations, tools and tool handles, and tasks can be redesigned to enable theworker's wrist to maintain a natural position during work. Jobs can be rotatedamong workers. Employers can develop programs in ergonomics, the process ofadapting workplace conditions and job demands to the capabilities of workers.However, research has not conclusively shown that these workplace changesprevent the occurrence of carpal tunnel syndrome

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kaaan
2008/03/17
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