Carpal canals and their contents. Carpal tunnel syndrome - causes and risk factors

Wrist grips First, let's clarify that not all techniques in this category are based on the use of weak points in the carpal joint. Sometimes the opponent's wrist is bent in order to use his hand as a lever to twist the forearm. Pain

In the area of ​​the wrist joint there are three channels, resulting from the presence here retinaculum flexorum.

Throwing in the form of a bridge from eminentia carpi ulnaris to eminentia carpi radialis, it turns a gutter between the named hills, sulcus carpi, into the channel canalis carpalis, and bifurcating into the radial and ulnar sides, forms, respectively canalis carpi radialis and canalis carpi unlaris.

In the cubital canal are the ulnar nerve and vessels, which continue here from the sulcus ulnaris of the forearm. IN canalis carpi radialis lies tendon m. flexor carpi radialis, surrounded by a synovial sheath.

Finally, in canalis carpalis are 2 separate synovial sheaths: 1) for tendons mm. flexores digitorum superficialis et profundus and 2) for tendon m. flexoris pollicis longus.

First vag. synovialis communis mm. flexorum represents a medially located voluminous sac covering 8 tendons of the deep and superficial flexors of the fingers. At the top, it protrudes 1–2 cm proximal to the retinaculum flexorum, and at the bottom it reaches the middle of the palm. Only on the side of the little finger does it continue along the tendons of the long muscles that flex it, surrounding them and reaching with them the base of the distal phalanx of the fifth finger.

Second vagina, vag. tendinis m. flexoris pollicis longi, located laterally, it represents a long and narrow canal, in which the tendon of the long flexor of the thumb is enclosed. At the top, the vagina also protrudes 1-2 cm proximal to the retinaculum flexorum, and below it continues along the tendon to the base of the distal phalanx of the first finger.

Rest 3 fingers have separate vaginas, vag. synoviales tendinum digitorum (manus) covering the flexor tendons of the corresponding finger. These sheaths extend from the line of the metacarpophalangeal articulation to the base of the nail phalanges. Consequently, II-IV fingers on the palmar side have isolated sheaths for the tendons of their common flexors, and on the segment corresponding to the distal halves of the metacarpal bones, they are completely devoid of them.

Vagina synovialis communis mm. flexorum, covering the tendons of the V finger, at the same time does not surround the tendons of the II-IV fingers on all sides; it is believed that it forms three protrusions, one of which is located in front of the tendons of the superficial flexors, the other is between them and the tendons of the deep flexor, and the third is behind these tendons. Thus, the ulnar synovial sheath is a true synovial sheath only for the tendons of the fifth finger.

The tendon sheaths on the palmar side of the fingers are covered with a dense fibrous plate, which, adhering to the scallops along the edges of the phalanges, forms a bone-fibrous canal on each finger that surrounds the tendons along with their sheath. The fibrous walls of the canal are very dense in the area of ​​the bodies of the phalangeal bones, where they form transverse thickenings, pars annularis vaginae fibrosae.

In the area of ​​​​the joints, they are much weaker and are reinforced by obliquely intersecting connective tissue bundles, pars cruciformis vaginae fibrosae. The tendons inside the vagina are connected to their walls through thin mesentery, mesotendineum, which carry blood vessels and nerves.

Training video anatomy of the synovial sheaths of the tendons of the hand

Borders: proximal - a horizontal line drawn one transverse finger proximal to the styloid process of the radius; distal - a horizontal line drawn distal to the pisiform bone, corresponding to the distal transverse folds of the wrist. Vertical lines drawn through the styloid processes of the radius and ulna separate the anterior region of the wrist from the posterior region of the wrist.

Layers:

Front surface

Leather thin, mobile, has three transverse folds of the wrist - proximal, middle and distal.

PC adipose tissue is poorly developed. Near the borders with the back of the wrist, the following formations pass in fatty deposits:

From the elbow side - v. basilica and n. cutaneus antebrachii medialis.

On the radial side -v. cephalica and n. cutaneus antebrachii lateralis.

In the middle - r. palmaris n. mediani.

own fascia forearm at the transition to the wrist thickens and forms a retinaculum flexorum.

Channels containing tendons, vessels and nerves form in the openings of the flexor retinaculum and behind it.

Lateral to the pisiform bone in the flexor retinaculum is located canalis carpi ulnaris , through which the ulnar vessels and nerve ( vasa ulnaria et n. ulnaris ) pass to the brush.

Medial to the trapezius bone in the flexor retinaculum is located canalis carpi radialis , in which the tendons of the t. flexor carpi radialis pass. Lateral to the tendon of the radial flexor of the wrist is the radial artery (a. radialis), which, under the tendons of the long muscle that abducts the thumb and the short extensor of the thumb, passes into the radial fossa located in the back of the wrist.

Between the flexor retinaculum and the bones of the wrist is formed canaliscarpi, through which the flexor tendons of the superficial and deep flexors of the fingers, surrounded by a common synovial sheath, pass. In its own synovial sheath, the tendon of the long flexor of the thumb, as well as the median nerve and artery accompanying the median nerve, pass through the carpal canal, projecting onto a line drawn in the middle of the wrist.

Wrist bones.

Back surface

Leather thin, mobile, has a hairline, more pronounced in men.

fatty deposits are more pronounced than in the anterior region of the wrist. In the fat deposits of the lateral part of the region there are tributaries v. cephalica And r . superficialis P. radialis . In the fatty deposits of the medial part of the region, there are tributaries of the medial saphenous vein of the arm v. basilica and dorsal branch of the ulnar nerve r . dorsalis ulnaris .

own fascia the forearm thickens at the transition to the wrist and forms the extensor retinaculum , which is thrown between the styloid processes of the radius and ulna, gives off spurs to the radius, dividing the space under the extensor retinaculum into 6 channels.

The tendons of the muscles of the posterior group of the forearm, surrounded by synovial sheaths, pass through the channels of the posterior region of the wrist. The synovial sheaths start from the proximal edge of the extensor retinaculum and reach the base of the metacarpals.

The first channel is m. abductor pollicis longus and m. extensor pollicis brevis.

The second channel is t. extensor carpi radialis brevis et m. extensor carpi radialis longus.

The third channel is t. extensor pollicis longus.

The fourth channel is t. extensor digitoni et t. extensor indicis.

The fifth channel is t. extensor digiti minimi.

The sixth channel is t. extensor carpi ulnaris.

Stenosing ligamentitis of the retinaculum extensorum (extensor retinaculum). Among ligamentites of retinaculum extensorum, stenosis of the I canal (de Quervain's disease) is of practical importance.

De Quervain's disease is also a polyetiological disease, but more often occurs after overexertion of the hand, mainly in women against the background of age-related diseases. The disease sometimes begins acutely, immediately, with the exact localization of pain in a strictly limited area of ​​\u200b\u200bthe wrist, corresponding to zone I of the dorsal canal (see Fig. 51). Then, extension and abduction of the thumb, adduction of the hand, flexion and opposition of the thumb to the base of the little finger become painful. When feeling in this area, a painful compaction of soft tissues is determined. An x-ray examination first noted compaction of soft tissues, subsequently osteoporosis, and later sclerosis of the cortical layer of the styloid process of the radius.

Surgical treatment: before anesthesia, the course of the skin incision is outlined with blue. The operation is performed under local infiltration or regional anesthesia with 0.5 or 1% novocaine solution in an amount of 30 to 50 ml, without bleeding. An oblique or transverse incision is made over the painful protrusion. Immediately under the skin lies the venous network and a little deeper, in loose fiber - the superficial branch of the radial nerve. They need to be carefully taken with a blunt hook to the rear, open the fascia. Then the retinaculum extensorum is exposed and the I channel is examined; the movement of the thumb (extension and abduction) checks the degree of canal stenosis. If possible, a grooved probe is inserted between the tendon sheath and the ligament, with careful sawing movements the ligament is dissected, lifted, and part of it is excised. After that, the tendons are completely exposed and one can judge the variant of the canal structure and pathological changes. Unbending, adducting and retracting the first finger, you need to make sure that the tendon is completely free to slide. Occasionally, with an advanced scleropathic process and aseptic inflammation, adhesions are observed that fix the tendons to the posterior wall of the vagina and periosteum. In such cases, adhesions that prevent the tendons from sliding are excised. The operation ends with a thorough hemostasis, then 2-3 catgut thin sutures are applied to the subcutaneous tissue and fascia, sutures to the skin, aseptic dressing to the wound; the hand is placed on the scarf. The sutures are removed on the 8-10th day, and depending on the specialty of the patient, on the 14th day he can start working.

carpal tunnel syndrome.

At the same time, compression neuropathy of the median nerve develops, passing in the carpal tunnel along with the tendons.

In the absence of the effect of conservative therapy and a protracted course of the disease, surgery is recommended. The operation is performed under intraosseous, intravenous - regional anesthesia with exsanguination. A transverse or patchwork L-shaped incision at the base of the palm along the carpal skin fold 4-5 cm long provides the necessary access. Farabeuf's hooks open the wound, dissect the aponeurosis and expose the retinaculum flexorum. The dissection is done along the Kocher probe or over Buyalsky's scapula carefully, under the control of the eye, since a branch of the median nerve passes here to the muscles of the elevation of the thumb, the superficial branch of the radial artery and the sheath of the flexor tendons. The operation ends with excision of the strip from the retinaculum flexorum. After excision, synovial bags are examined, then the condition of the ulnar nerve is checked. Scars and adhesions are eliminated. Careful hemostasis, the imposition of two or three catgut sutures on the fascia and tissue, a deaf wound suture.

35. Topographic anatomy of the palmar surface of the hand. Borders, layers, fascial beds, vessels and nerves, synovial bags. Ways of distribution of purulent processes. Technique of opening and drainage of superficial and deep phlegmons of the hand. Phlegmon of the Pirogov-Paron space.

Border: horiz. flat drawn 1 transverse finger above the styloid process of the ray. There are 3 parts: wrist, metacarpus, fingers.

FASCIA BRUSH

Fascia manus propria consists of 2 parts: palmar and dorsal. Palmar (f.palmaris) is divided into 2 plates: superficial and deep. The superficial fusion with the superficial fascia forms an aponeurosis (aponeurosis palmaris). the superficial plate in the region of tener and hypotener is less pronounced. The deep plate is the interosseous fascia.

The fascia of the forearm, passing to the wrist, thickens and forms the flexor and extensor retainers.

The flexor retinaculum distally passes into the proper fascia of the palm, which covers the muscles of the eminences of the thumb and little finger with a thin plate, and in the center of the palm is represented by a dense palmar aponeurosis (aponeurosis palmaris), which consists of longitudinal and transverse bundles.

Longitudinal bundles - a continuation of the tendon of the long palmar muscle, located superficially, fan-shaped. Longitudinal bundles are divided into four parts, passing to the palmar surface II-V fingers and involved in the formation of fibrous sheaths of the fingers (vag. fibrosae digitorum manus).

The transverse bundles are located behind the longitudinal ones. The distal edge of the transverse bundles limits three commissural openings that connect the subgaleal tissue with the subcutaneous layer at the interdigital folds.

From the lateral edge of the palmar aponeurosis, the lateral intermuscular septum departs, which goes around the tendons of the superficial and deep flexors of the fingers and is attached to W metacarpal bone. From the medial edge of the palmar aponeurosis to the fifth metacarpal bone, the medial intermuscular septum extends. The lateral and medial intermuscular septa form three fascial beds in the palm of the hand: the lateral one, containing tener muscles, the middle one, in which the tendons of the superficial and deep flexors of the fingers are located, and the medial one, containing the hypotener.

The deep plate of the fascia of the hand lines the interosseous muscles and separates them from the tendons of the flexors of the fingers, limiting the middle fascial bed from behind.

In the formation of fibrous sheaths of the fingers, in addition to the longitudinal bundles of the palmar aponeurosis, transverse bundles take part - the annular part of the fibrous sheath (pars annularis vag. fibrosae), decussated bundles - the cruciform part of the fibrous sheath (pars cruciformis vag. fibrosae).

MUSCLES OF THE HAND

In the palmar region of the hand, there are own muscles and tendons that penetrate the hand from the forearm. The intrinsic muscles of the hand are divided into three groups: the muscles of the eminence of the thumb, the muscles of the elevation of the little finger, and the middle group of muscles of the hand.

Muscles of the thumb

In the formation of the eminence of the thumb (eminentia thenaris) four muscles are involved.

Short abductor thumb (T.abductor pollicis brevis) ;

Short thumb flexor (m. flexor pollicis brevis) 2 heads: superficial - from retinaculum flexorum; deep - from lig.carpi radiatum & os trpezoideum. attached to the proximal phalanx of the thumb from the lateral side.

M. opposing thumb (m. opponens pollicis)

Muscle adductor thumb (m. adductor pollicis brevis) 2 heads: transverse - from the 3rd metacarpal bone; oblique - from lig. carpi radiatum & os capitatum. attached to the proximal phalanx of the 1st finger.

Muscles of the little finger elevation

Short palmar muscle (m.palmaris brevis) in the subcutaneous fat of the hypotener from retinaculum flexorum to the skin of honey. brush edges.

Muscle that abducts the little finger (T. abductor digiti minimi ), starts from the pisiform bone and is attached to the base of the proximal phalanx of the little finger; withdraws the little finger.

Short little finger flexor (T. flexor digiti minimi brevis ) adjacent to the previous muscle from the ulnar side; starts from the flexor retinaculum { retinaculum flexorum ) and is attached to the base of the proximal phalanx of the little finger, which it flexes.

Muscle that opposes the little finger (T. opponens digiti minimi ), located under the two previous muscles; starts from the flexor retinaculum { retinaculum flexorum ) and is attached to the medial edge of the fifth metacarpal bone. The muscle opposes the little finger to the thumb.

All four muscles of the little finger elevation are innervated by the ulnar nerve.

Middle group of muscles of the hand

Four lumbrical muscles (tt. lumbricales ) originate from the deep flexor tendons on the palmar side of the hand. The vermiform muscles on the radial side go around the metacarpophalangeal joints, heading to the dorsal surface of the fingers, where they attach to the bases of the proximal phalanges and are woven into the lateral bundles of the extensor tendon tendon of the fingers, which are attached to the dorsal surfaces of the distal phalanges. Muscles provide flexion in the metacarpophalangeal and extension in the interphalangeal joints.

Three palmar interosseous muscles (tt. interossei palmares ) located in the interosseous spaces of the II-V metacarpal bones. The first palmar interosseous muscle originates from the ulnar side of the second metacarpal bone and is attached to the ulnar side of the base of the proximal phalanx of the second finger. The second and third palmar interosseous muscles start from the radial side of the IV and V metacarpal bones and are attached, respectively, to the radial side of the proximal phalanges of the IV and V fingers. The palmar interosseous muscles bring the fingers to the middle finger and simultaneously bend their first phalanges; innervated by the ulnar nerve.

Dorsal interosseous muscles (tt. interossei dorsales ) start from the surfaces of the metacarpal bones facing each other and occupy all four spaces between them. The first and second dorsal interosseous muscles are attached to the radial sides of the proximal phalanges of the index and middle fingers, respectively, the third and fourth dorsal interosseous muscles are attached to the ulnar side of the proximal phalanges of the middle and ring fingers, respectively. The dorsal interosseous muscles abduct the index and ring fingers from the middle; innervated by the ulnar nerve.

Topography of the synovial sheaths and tendons of the flexors of the fingers

Synovial sheaths provide a reduction in friction during the passage of tendons in the bone-fibrous canals.

Tendons of the superficial and deep flexors of the fingers, surrounded by a common synovial flexor sheath ( vag . synovialis communis mm . flexorum ), penetrate the hand under the flexor retainer ( retinaculum flexorum ) in the carpal tunnel ( canalis carpi ). extends proximally 3-4 cm above the flexor retinaculum (limits space in front Pirogea-Parona), distally, the border is the middle of the metacarpal bones for the tendons of the II-IV fingers, and only the tendons of the fifth finger are covered to the base of the distal phalanx.

The tendon of the long flexor of the thumb, surrounded by the synovial sheath, passes through the carpal canal. It starts 2 cm above the flexor retinaculum and reaches the distal phalanx. The proximal part of the sheath of the tendon of the long flexor of the thumb, as well as the common synovial sheath of the flexors, limits the space in front Pirogov - Parona.

Brush channels:

Retinaculum flexorum, spreading over the groove of the wrist, is fixed on the eminentia carpi radialis et ulnaris, forming:

1. Canalis carpi - the bone-fibrous canal passes through: the common synovial sheath of the deep and superficial flexors of the fingers, the sheath of the tendon of the long flexor of the thumb and the median nerve.

2. Canalis carpi radialis: the tendon of the radial flexor of the wrist passes.

3. Canalis carpi ulnaris: ulnar nerve, ulnar artery and veins.

The palmar aponeurosis forms 4 fascial spaces: 1) tenor 2) hypotenor 3) production for the tendons of the flexors of the fingers and worms. muscles 4) interosseous muscles

INERVATION

median nerve(P. medicinus ) through the carpal tunnel.

Muscular branches depart ( rami musculares ), innervates the short muscle that abducts the thumb (T. abductor pollicis brevis ), muscle that opposes the thumb (T. opponents pollicis ), superficial head of flexor pollicis brevis ( caput superficiale m. flexoris pollicis longi), as well as two worm-like muscles 1 and 2 (tt.lumbricales)

3 common palmar digital nerves, in the area of ​​\u200b\u200bthe heads of the metacarpal bones, are divided into their own palmar digital nerves. The skin of the 1st, 2nd, 3rd and radial half of the 4th finger is innervated.

Palmar branch, (ramus palmaris nervi mediani) - Skin of the lateral side of the palmar surface of the hand

Ulnar nerve-h-h ulnar canal, divided into atop. and deep branches.

Surface: nn. digitales palmaris propii - skin 5 and honey side 4 fingers

Deep: muscle branches to the honey group of the hand, 3 and 4 vermiform muscles, interosseous, m. Adductor thumb, deep head of the flexor thumb.

BLOOD SUPPLY:

Arterial blood supply

Ulnar artery ( a . ulnaris ) on the wrist gives off the palmar carpal branch ( ramus carpeus palmaris ), which behind the flexor tendons is directed laterally, where it anastomoses with the eponymous branch of the radial - palmar network of the wrist.

Further penetrates the brush through the cubital canal , located at the lateral border of the pisiform bone ( os pisiform ae), where ripple can be found.

Distal to the pisiform bone, a deep palmar branch arises from the ulnar artery (G. palmaris profundus ), anastomoses with a deep palmar arch ( arcus palmaris profundus ) .

Further, the trunk of the ulnar artery bends laterally, forming a superficial palmar arch ( arcuspalmarissupetflcialis ) . The superficial palmar arch is located on the common synovial sheath of the flexor tendons of the fingers under the palmar aponeurosis; the arc is projected onto the skin of the palm along a transverse line running along the lower edge of the elevation of the thumb in the position of its maximum abduction. Four common palmar digital arteries arise from the superficial palmar arch. (ah. digitalis palmares communes ), three of which go to the three interdigital spaces of the II-V fingers, and the fourth goes to the ulnar side of the little finger. The common palmar digital arteries merge with the palmar metacarpal arteries (ah. metacarpea epalmares ) - branches of the deep palmar arch. Each of the common palmar digital arteries at the level of the heads of the metacarpal bones divides into two proper digital arteries (ah. digitales palmares propriae ), passing along the sides of the P-V fingers facing each other.

radial artery ( a . radialis ) along the lateral canal of the forearm ( canalis antebrachii lateralis ) penetrates the wrist and gives off the palmar carpal and superficial palmar branches.

Palmar carpal branch (G. carpeus palmaris ) anastomoses with the eponymous branch of the ulnar artery.

Superficial palmar branch (G. palmaris superficialis ) anastomoses with the superficial palmar arch ( arcus palmaris superficialis ). Further, at the level of the styloid process of the radius, the radial artery passes into the radial fossa ( foveola radialis ), bounded laterally by the tendons of the abductor pollicis longus muscle (T. abductorpollicis longus ), medially - the tendon of the long extensor of the thumb (T. extensorpollicis longus ). The dorsal carpal branch departs there (r. carpeus dorsalis ), which gives off the dorsal metacarpal arteries. Each of the dorsal metacarpal arteries at the level of the metacarpophalangeal joints divides into the dorsal digital arteries (ah. digitales dorsates ).

Under the tendon of the long extensor of the thumb, the radial artery gives off the first dorsal metacarpal artery, which supplies blood to the back surface of the sides of the thumb and forefinger facing each other.

Further, the radial artery passes between the I and II metacarpal bones through the first dorsal interosseous muscle, gives off the artery of the thumb of the hand ( a . princeps pollicis ) and radial artery of the index finger ( a . radialis indicis ), then on the anterior surface of the interosseous muscles forms a deep palmar arch ( arcus palmaris profundus ), anastomosing with the deep palmar branch of the ulnar artery. The deep palmar arch is located at the level of the base of the II-IV metacarpal bones, its projection is the transverse line, drawn through the middleosh thumb. The palmar metacarpal arteries arise from the deep palmar arch. (ah. metacarpeae palmares ), anastomosing with common digital arteries ( a . digitales palmares communes ) - branches of the superficial palmar arch. The artery of the thumb divides into two branches - the own palmar digital arteries (ah. digitales palmares propriae ) , running along the sides of the thumb.

Each finger is supplied with blood by its own palmar digital arteries passing along the sides, and on the back of the hand near the lateral surfaces of the fingers - by the dorsal digital arteries.

Phlegmon brush

Superficial phlegmon of the palmar space. It is opened with a cut in the central part of the palm along its middle line. Dissect the skin and aponeurosis (necrotic aponeurosis excised within healthy tissues)

Deep phlegmons of the median palmar space (tendon) are opened in a similar way. After dissection of the palmar aponeurosis, manipulations must be carried out in a blunt way, fearing damage to the palmar arterial arches. If necessary, I w o resort to ligation of vessels with catgut.

Method Izlena

Distal interdigital incisions for phlegmon of the median palmar space recommends using Islen .

The disadvantage of distal incisions is the lack of sufficient conditions for the outflow of purulent discharge, especially when the necrotic focus is localized in the proximal part of the palm.

Method Voino-Yaseneshkogo

V.F. Voyno-Yasenetsky recommended opening the phlegmon of the median palmar space with an incision connecting the middle of the wrist with the radial edge of the metacarpophalangeal joint of the second finger (see Fig. 4-123, a). With a finger inserted into the wound under the first worm-like muscle and tendon, they easily penetrate into the deep median space and, for the purpose of revision, onto the back side of the first intermetacarpal space, bypassing the free edge of the interosseous muscle.

With severe phlegmon of the median palmar space, complicated by a breakthrough of pus on the forearm through the carpal tunnels, a zigzag incision is recommended, which allows not only to drain purulent streaks in the median palmar space, but also to evacuate pus from the space Pirogov-Paron after dissection of the palmar transverse ligament of the wrist.

Elevation phlegmon of the fifth finger

Phlegmons of the fascial-cellular space of the eminence of the fifth finger, with an appropriate clinical picture, should be opened with a linear incision in the place of the most pronounced fluctuation and hyperemia. After emptying the purulent-necrotic cavity, it must be drained.

Elevation phlegmon of the first finger

When opening the phlegmon of the elevation of the first finger, it is necessary to beware of damage to the branch of the median nerve, the intersection of which will significantly limit the function of the hand.

interdigital fold. After dissection of the skin and tissue in a blunt way, they carefully penetrate the interosseous muscle into the space of the elevation of the first finger, the abscess is emptied and drained. The hand is fixed in a functionally advantageous position with some abduction of the first finger. The disadvantages of this method include the formation of coarse scar tissue in the first interdigital space with subsequent limitation of hand function due to impaired abduction of the first finger.

By method Canavella the phlegmon of the elevation of the first finger is opened with an incision made somewhat outward from the skin fold that delimits the elevation of the first finger from the middle part of the palm. The length of the incision depends on the zone of pronounced fluctuation, thinning and skin changes. Usually the lower border of the incision does not reach 2-3 cm to the distal transverse skin fold of the wrist. After dissection of the skin and fiber, further manipulations are carried out in a blunt way. Carefully penetrating deep into the finger, eliminate all purulent streaks and pockets.

U-shaped phlegmon brush

With a U-shaped phlegmon of the hand with a breakthrough of pus into space Pirogov-Paron drain the tendon sheaths of the I and V fingers and the space Pirogov-Paron .

Commissural phlegmon

The inflammatory process occurs and is localized in the commissural spaces, the projection of which corresponds to the pads of the distal palm. These phlegmons are opened with linear cuts of the corresponding interosseous spaces. An incision about 2-3 cm long is made parallel to the axis of the hand. If necessary, an additional incision should be made in the adjacent commissural space.

In cases where the inflammatory process spreads through the commissural spaces to the back surface of the hand, it is necessary to drain purulent streaks through an additional incision on the back of the hand.

When pus breaks into the median palmar space, it is necessary to continue the incision in the proximal direction, dissect the aponeurosis and eliminate purulent streaks.

Commissural phlegmon mo w o open and drain also with semi-arc incisions in the distal part of the palm at the base of the finger in the corresponding commissural space.

36. Topographic anatomy of the fingers. synovial sheaths. The concept of panaritium. Types of panaritium. Methods of surgical treatment of various types of panaritium.

LAYERED TOPOGRAPHY OF THE PALM SURFACE OF THE FINGERS (Fig. 2-77)

1) Skin (cutis) the palmar surface of the finger is dense, has a large number of sweat glands, there are no sebaceous glands and hair follicles.

2) Fat deposits (panniculus adiposus) have a large thickness and density, penetrated by connective tissue jumpers stretching from the skin to the fibrous sheath of the finger. As a result, the purulent process in the fatty deposits on the palmar surface of the finger usually spreads in depth.

The palmar digital arteries pass through the fatty deposits on the sides of the finger. (ah.digitales palmarespropriae), which on the distal phalanges form an arterial network.

Palmar digital nerves (pp.digitales palmares) - branches of the median and ulnar nerves; passing along with the palmar digital arteries, they innervate the palmar surface of the proximal and middle phalanges, as well as the palmar and dorsal surfaces of the distal phalanx.

In the fatty deposits of the finger there is an abundant network of lymphatic capillaries that carry lymph through the lymphatic vessels passing along the lateral surfaces of the fingers and in the area of ​​the metacarpophalangeal joints passing to the back of the hand.

3) Fibrous sheaths of fingers (vagg. flbrosae digitorum manus) begin at the level of the metacarpophalangeal joints and end at the base of the distal phalanx. At the level of the body of the phalanx, the fibrous sheath consists of strong transverse fibers -

vagina ( pars annularis vaginae flbrosae ), at the level of the joints consists of mutually intertwined oblique fibers - the cruciform part of the fibrous sheath ( pars cruciformis vaginae flbrosae ).

. Synovial sheaths of fingers ( vagg . synoviales digitorum manus ) contain the tendons of the superficial and deep flexors of the fingers.

4) The synovial sheath, covering the tendons from all sides, forms two sheets - parietal, called peritendinium ( peritendineum ), fixed to the walls of the bone-fibrous canals, and visceral, lining the tendon. These sheets pass one into another with the formation of a duplication called mesotendinium. ( mesotendineum ) , between the leaves of which the vessels are suitable for the tendon.

The tendon of the superficial flexor at the level of the metacarpophalangeal joint is divided into two legs, attached to the base of the middle phalanx. The deep flexor tendon passes between the pedicles of the superficial flexor tendon, making a decussation of the tendons ( chiasma tendinum ), and attaches to the base of the distal phalanx. Tendon ligaments fit the tendons of the superficial and deep flexors ( vinculo tendinum ), extending from the posterior wall of the synovial sheath and containing vessels that supply blood to the tendons.

5) Phalanges of the fingers, covered with periosteum, and interphalangeal joints.

LAYERS OF THE BACK OF THE FINGERS

1) Skin (cutis) on the back surface of the fingers is thinner and more mobile than on the palmar, has sebaceous glands and hairline.

Subcutaneous tissue ( panniculus adiposus ) It is represented by a thin, loose, almost devoid of fat layer, in which the dorsal digital arteries pass along the sides of the fingers. ( aa . digitales dorsales ) and dorsal digital nerves (pp. digitales dorsales ), reaching the distal interphalangeal joint. In the subcutaneous tissue of the rear of the finger, the formation of the venous network of the rear of the hand begins ( rete venosum dorsale manus ), from which along the interhead veins (w. intercapitales) outflow occurs in the dorsal metacarpal veins (w. metacarpeae dorsales).

2) Tendon sprain on the back of the finger (Fig. 2-78) is formed due to the fusion of the extensor tendon of the fingers with the tendons of the interosseous and worm-like muscles. The extensor tendon of the fingers forms the central leg of the tendon stretch and is attached to the base of the middle phalanx. Side n ozhk and tendon stretching are formed by the tendons of the interosseous and vermiform muscles and are attached to the base of the distal phalanx.

3) If the extensor tendon on the forearm and hand is damaged, extension in the metacarpophalangeal joint is impossible.

When the tendon sprain of the finger is torn off from the distal phalanx, extension in the distal interphalangeal joint is disturbed, which eventually leads to flexion contracture in it.

With isolated damage to the middle pedicle of the tendon sprain of the finger, extension in the proximal interphalangeal joint is impossible while maintaining extension in the distal one. Over time, the ego leads to the formation of a flexion contracture in the proximal and an extensor contracture in the distal interphalangeal joint.

Under the tendon stretch on the back of the finger are phalanges covered with periosteum and interphalangeal joints. To build a projection of the joint space of the metacarpophalangeal joint, a transverse line is drawn 8-10 mm distal to the bulge of the metacarpal head. The distal part of the line drawn in the middle of the lateral surface of the phalanx with the interphalangeal joint bent at a right angle corresponds to the projection of its joint space.

Blood supply and innervation - see the previous question.

Felon

purulent inflammation of the tissues of the finger. from localization:

periungual (paronychia)

subcutaneous

tendinous

articular

pandactylitis

Operations:

Incisions are not allowed: at the level of the interphalangeal folds and on the palmar surface.

Klyushkoobr incision with panaritium of the nails of the phalanx.

Tendon - Linear lateral incisions, drainage.

with paronychia - wedge-shaped, U-arr, paired lateral incisions.

Subungual - resection of the nail plate, trepanation, removal of the entire nail.

Bony - resection or complete removal of the phalanx

37. Topography of the hip joint: bag-ligamentous apparatus, blood supply. Joint puncture: indications, technique. Arthrotomy: indications, technique. Hip joint, art. coxae, formed from the side of the pelvic bone by a hemispherical acetabulum, acetabulum, more precisely facies lunata which includes the head of the femur. A fibrocartilaginous rim runs along the entire edge of the acetabulum, labium acetabulare, making the cavity even deeper, so that, together with the rim, its depth exceeds half the ball. This headband is over incisura acetabuli folds over in the form of a bridge, forming lig. transversum acetabuli. The acetabulum is covered with hyaline articular cartilage only throughout facies lunata, a fossa acetabuli occupied by loose adipose tissue and the base of the ligament of the femoral head. The articular surface of the femoral head articulating with the acetabulum is generally equal to two-thirds of the ball. It is covered with hyaline cartilage, except for the fovea capitis, where the head ligament is attached. The articular capsule of the hip joint is attached around the entire circumference of the acetabulum. Attachment of the articular capsule on the thigh in front goes along the entire length of the linea intertrochanterica, and behind it runs along the femoral neck in parallel crista intertrochanterica, retreating from it to the medial side. Due to the described location of the line of attachment of the capsule on the femur, most of the neck is lying in the joint cavity. Ligaments: extra- and intra-articular. Inside: 1. lig. transversum acetabuli, 2. lig. capitis femoris. It starts from the edges of the notch of the acetabulum and from lig. transversum acetabuli, attached to the apex of the fovea capitis femoris. The ligament of the head is covered with a synovial membrane, which rises to it from the bottom of the acetabulum. It is an elastic cushion that softens the shocks experienced by the joint, and also serves to guide the head of the femur a. lig. capitis femoris, extending from a. obturatoria. Outside: 1. Iliofemoral ligament, lig. iliofemorale, or bertini *, is located on the front side of the joint. With its apex, it is attached to the spina iliaca anterior inferior, and with an expanded base, to the linea intertrochanterica. Its width here reaches 7-8 cm, thickness - 7-8 mm. It inhibits extension and prevents the body from falling backwards when walking upright. This explains the greatest development of the Bertinian ligament in a person, in whom it becomes the most powerful of all the ligaments of the human body, withstanding a load of 300 kg. 2. Pubic-femoral ligament, lig. pubofemorale, is located on the lower medial side of the joint. Starting from the eminentia iliopubica and the lower horizontal branch of the pubis, it attaches to the lesser trochanter. The ligament delays abduction and inhibits outward rotation. 3. Ischiofemoral ligament, lig. ischiofemorale, strengthens the medial part of the joint capsule. It starts behind the joint from the edge of the acetabulum in the area of ​​the ischium, goes laterally and upwards above the femoral neck and, weaving into the bag, ends at the anterior edge of the greater trochanter. 4. circular zone, zona orbicularis, has the form of circular fibers that are embedded in the deep layers of the articular bag under the described longitudinal ligaments and form the basis of the fibrous layer of the articular capsule of the hip joint. The fibers of the zona orbicularis cover the femoral neck in the form of a loop, growing at the top to the bone under the spina iliaca anterior inferior

Joint blood supply: 1. R.acetabularis from a.obturatoria from a.iliaca int 2. R.acetabularis from a.circumflexa femoris med from a.profunda femoris from a.femoralis 3. Rr.musculares from a.circumflexa femoris med/lat from a.profunda femoris from a.femoralis

Puncture of the joint: Puncture of the hip joint can be performed from the front and side surfaces. The position of the patient on the back, the thigh is straightened, slightly retracted and rotated outwards. To determine the injection point, the established joint projection scheme is used. To do this, draw a straight line from the greater trochanter to the middle of the pupart ligament. The middle of this line corresponds to the head of the femur. In the point established in this way, the needle is injected, that is, the injection point during puncture from the outer surface is located above the top of the greater trochanter, which can be easily palpated (Fig. 180). At the established point, a needle is injected, which is carried out perpendicular to the plane of the thigh to a depth of 4-5 cm, until it reaches the femoral neck. Then the needle is turned somewhat inwards and further moving it deeper into the joint cavity. When puncturing from the front, the puncture point is located under the pupart ligament, somewhat retreating outward from the femoral artery, passing the needle perpendicular to the long axis of the thigh. As it penetrates the tissue, the needle rests against the femoral neck. Giving the needle a slightly cranial direction, they enter the joint. Arthrotomy: Indications: treatment of inflammatory processes (purulent arthritis, chronic synovitis, etc.); damage or consequences of injuries of the joints. The position of the patient: on a healthy side, the operated limb is bent at the hip and knee joints at an angle of 120°. Kocher access. The incision is made from the outer surface of the base of the greater trochanter upwards to the anterior edge of its apex and then continues angularly upwards and inwards, along the fibers of the gluteus maximus muscle. Dissect the skin, subcutaneous tissue and superficial fascia. Through the grooved probe, their own fascia is opened. The fibers of the gluteus maximus muscle are stratified in a blunt way, while exposing the greater trochanter. The gluteus medius and minimus muscles are dissected from the greater trochanter. The joint capsule is opened along the posterior surface with a linear incision. Completion of the operation: a drainage perforated PVC tube is inserted into the joint cavity, the free end of which is brought out through a separate puncture of the soft tissues in the gluteal region. Interrupted sutures and an aseptic bandage are applied in layers to the postoperative wound.

38. Topographic anatomy of the anterior thigh: borders, layers, femoral triangle, neurovascular bundle, projection line of the femoral artery (see 41) Topography of the adductor canal, the relationship of elements of the neurovascular bundle in the adductor canal. Ways of distribution of purulent processes. Technique of opening phlegmon of the anterior surface of the thigh. Upper border of the anterior thigh- a line connecting the spina iliaca anterior superior and the pubic tubercle (projection of the inguinal ligament); lateral border of the anterior thigh- a line drawn from this spine to the lateral epicondyle of the thigh; medial border of the anterior femur- a line running from the pubic symphysis to the medial epicondyle of the thigh; lower border of the anterior thigh- a transverse line drawn 6 cm above the patella.

Departments - hip tr-k, hip canal, obturator region, gunter's canal.

The skin is thin, mobile. PZhK, vessels - pudenda ext (2), epigastr superf, circumfl ilium superf, veins - respectively, flow into the saphenous magna or femoral. Under the inguinal ligament, the skin is innervated by n.lumboinguinalis, later pov - n cut fem lat, anterior - femora; is (r cut ant). LU - superficial inguinal, superficial inguinal, deep inguinal. Own fascia - two sheets - superficial and deep .. Surface - from 2 departments - the later is dense, the medial is loose. The triangle is bounded from above by the inguinal ligament, from the outside by the sartorius muscle, and from the inside by the long adductor muscle. The bottom of the triangle is mm. iliopsoas and pectineus. Muscles - superficial (tensor f lata, Sartorius, gracilis, adductor longus), deep (pectineus, ilipsoas)

Gaps - arcus iliopectineus divides into two holes. Outside the lacuna musculorum, m. iliopsoas and m. femoralis. Lacuna vasorum lies medially from the previous one. It contains a. femoralis (outside) and v. femoralis (inside). Medial to the femoral vein is the internal opening of the femoral canal. The femoral artery in the region of the femoral triangle is directed from the middle of the inguinal ligament to its apex. From the femoral artery, in addition to the above branches within this triangle, at a distance of 3-5 cm below the inguinal connection, a. femoris profunda. She gives aa. circumflexa femoris medialis et lateralis and ends with three aa. perforantes. The femoral vein is located under the inguinal ligament medially from the artery, and at the top of the femoral triangle - deeper than the artery. V flows into the femoral vein. saphena magna. Near the femoral vein, deep lymphatic vessels pass and, at the inguinal ligament, flow into 5-6 nodes that receive lymph from the deep layers of the lower limb. N. femoralis (from the lumbar plexus) goes to the thigh, located on the front surface of m. iliopsoas. At the base of the femoral triangle, the nerve is located outside the femoral artery, separated from it by a deep sheet of the wide fascia of the thigh and splits into muscle and skin branches. Only its long branch n. saphenus goes along with the vessels into the femoral-popliteal canal. Femoral canal - inner ring: in front - groin ligament, behind - Cooper's ligament, honey - lacunar, later - femoral vein. Superficial (outer) ring of the femoral canal is subcutaneous fissure, hiatus saphenus, a defect in the superficial layer of the fascia lata. The hole is closed by a cribriform fascia, fascia cribrosa. Walls - Anterior wall of the femoral canal formed by a superficial sheet of the broad fascia between the inguinal ligament and the upper horn of the subcutaneous fissure - cornu superius. Lateral wall of the femoral canal- medial semicircle of the femoral vein. Posterior wall of the femoral canal- a deep leaf of the broad fascia, which is also called fascia iliopectinea. The obturator canal is formed from the outside by the obturator bone groove of the pubic bone, and from the inside by the upper outer edge of the membrana obturatoria with muscles starting from it: from the side of the inlet - m. Obturatorius internus, from the side of the outlet - m. Obturatorius externus. The obturator artery with the same veins and the obturator nerve, surrounded by fiber, pass through the canal. More often, the nerve is located medially or anteriorly from the vessels. The afferent canal (gunter, femoral-popliteal) is in the lower third of the thigh, it contains an artery, vein, n.saphenus. Walls: external - septum intermusc mediale, vastus med; inside and back - adductor magnus; anterior - l.vastoadductoria. 3 openings - the upper one - the SNP enters through it, the lower - hiatus adductorius - the thigh vessels go to the back of the thigh and pass into the popliteal, the anterior one - into the lamina vastoadd, through it the n.saphenus and the branch of the femoral artery exit. (genus descendens) Distribution: 1 ) tissue of the femoral triangle along the course of the femoral vessels, through the vascular lacuna, it is connected with the subperitoneal floor of the pelvis; 2) along the superficial branches of the femoral vessels through holes in the cribriform fascia that fills the hiatus saphenus, it is connected with the subcutaneous tissue of the femoral triangle; 3) along the lateral circumflex artery of the femur, - with the gluteal region; 4) along the medial circumflex artery of the femur, - with a bed of adductor muscles; 5) along the femoral vessels- with a leading channel; 6) along the perforating branches of the deep femoral artery, aa. perforantes, - with the posterior fascial bed of the thigh. To open the anterior bed (4head m), incisions are made along the anterior-outer thigh. With deep phlegmon - cuts along the honey and lat edges of m. rectus femoris. Bed of adductor muscles - incisions along the anterior-medium of the thigh, 2-3 cm away from the projection line of the femoral snp.

39. Topographic anatomy of the posterior region of the thigh. Borders, layers, muscular-fascial sheaths, vessels and nerves. Ways of distribution of purulent processes. Technique of opening and drainage of phlegmon. Upper border of the posterior thigh- transverse gluteal fold, plica glutea, lower border of the posterior thigh- a circular line drawn 6 cm above the patella, medial border of the posterior femur- a line connecting the pubic symphysis with the medial epicondyle of the femur, lateral border of the posterior thigh- a line drawn from the spina iliaca anterior superior to the lateral epicondyle of the femur.

The skin is thin, easily mobile (innerv from the outside - cutaneus femoris lat, from the inside - genitofemoralis, fem, obtur, the rest - cut fem post). PZhK - well expressed. Superficial fascia - in the thickness of the pzhk. Wide f - 1 layer, septum intermusc post departs from it in the medial part (separates adductors and flexors). Muscles - flex the lower leg, 2 groups (semitendinosus. semimembranosus - medially, biceps - later). N.ischiadicus goes in the furrow between them, is divided into tibialis and peroneus communis.

Opening of phlegmon and streaks - longitudinal incisions along the lat edge of the biceps femoris muscle or along the semitendinosus m.

40. Exposure of the sciatic nerve in the gluteal region and upper third of the thigh. Projection line, access, blockade of the sciatic nerve.

Projection line: from the middle of the distance between the ischial tuberosity and the greater trochanter (from the border between the inner and middle third lines, connecting these points) to the middle of the popliteal fossa. Access: Roundabout? In the gluteal region: arcuate skin incision (outward bulge) starts from sp.iliaca post.sup. and to the outer part of the greater trochanter through the gluteal fold on the thigh. The gluteal fascia is cut at the upper and lower edges of m.glut.max and a finger is penetrated under this muscle. Under the protection of the finger (probe), its tendon is crossed. The leaf of the gluteal fascia is dissected deeply, the musculoskeletal flap is pulled upward and medially, the tissue covering m.piriformis is corroded with a swab, and n.ischiadicus is found at the lower edge of this muscle. (Hagen-Thorn access). In the thigh area - an incision medial to the projection of the nerve, along a line drawn from the middle of the distance between the ischial tuberosity and the greater trochanter to the middle of the fossa. Dissect the broad fascia, penetrate between the biceps and semitendinosus muscles, find the sciatic nerve.

The blockade of the sciatic nerve is carried out according to two possible methods. When using the first technique, the patient is laid on his side so that the limb to be blocked is on top, which is slightly bent at the knee and hip joints. The injection point of a long needle (12 cm) is marked 3-4 cm distal and perpendicular to the line connecting the greater tubercle and the posterior superior iliac spine. When using the second technique, the patient remains lying on his back on a hard surface. The knee joint is slightly bent (with the help of padded pads). The point for the injection of the needle is located 3 cm distal to the large tubercle. The needle is carried out in a horizontal plane to a depth of 6-7 cm.

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Definition of concepts, terminology

Tunnel Syndromes

Tunnel syndromes (tunnel neuropathies) are a group of lesions of peripheral nerves due to prolonged compression and trauma in the musculoskeletal canals by chronically inflamed surrounding tissues. There are tunnel syndromes of damage to the nerves of the arms, legs, torso, neck.

Very often, "carpal tunnel syndrome" is called carpal tunnel syndrome, which is not entirely true - this is just one of the many tunnel syndromes that has received the greatest fame. Even in the wrist area, other tunnel syndromes are distinguished, for example, compression syndrome of the deep branch of the ulnar nerve.

carpal tunnel syndrome

The most common and well-known carpal tunnel syndrome is carpal tunnel syndrome (CTS). compression of the median nerve (Latin nervus medianus) under the transverse ligament of the wrist. Nerve compression occurs between three bony walls and a tight ligament that holds the tendons of the muscles that flex the fingers and hand.

Carpal tunnel syndrome is more common in women than in men (3-10 times according to various sources). The peak incidence occurs between the ages of 40 and 60 years (although the disease can occur at any age, only 10% of those suffering from this disease are under 31). The risk of developing carpal tunnel syndrome is about 10% in a lifetime, 0.1-0.3% per year in adults. The overall prevalence of the syndrome is up to 1.5-3%, and the prevalence among certain risk groups is up to 5%. The syndrome is more common in representatives of the Caucasian race, in some African countries it practically does not occur.

Chronic Repetitive Strain Injury (RSI)

In English texts, there is often an identification of the concept of "carpal tunnel syndrome" with the concept of "chronic injury from repetitive stress" (English repetitive strain injury, RSI; the term has many synonyms: repetitive stress disorder, cumulative trauma disorder, occupational overuse injury, etc.). In fact, RSI is a much broader group of diseases, and some authors even exclude carpal tunnel syndrome from it (eg Dennis L. Ettare).

Diseases of this group are found in many professions, including in such industries as construction, mining, engineering, and agriculture. They are caused by chronic functional overstrain, microtraumatization, performance of fast movements of the same type.
In particular, such diseases of a professional nature, in addition to the "acclaimed" carpal tunnel syndrome, include:

• myositis (inflammation of the muscles) and crepitant tendovaginitis (inflammation of the tendon sheaths with a characteristic crunch),
• stenosing tendovaginitis (de Quervain's disease),
• stenosing ligamentitis,
• snap finger,
• styloiditis (inflammation of the styloid process of the radius),
• bursitis (inflammation of the joint bags),
• epicondylitis of the shoulder (inflammation in the condyle of the humerus, often external, the so-called "tennis elbow"),
• deforming osteoarthritis of the joints of the hand (gradually increasing deformation of the bones and joints),
• periarthrosis of the shoulder joint (dystrophic changes in the soft tissues of the shoulder near the joint),
• osteochondrosis of the spine (damage to the intervertebral discs and other tissues of the spine),
• diseases of the nervous system from overexertion.

Professions in which chronic repetitive hand movements are observed are characterized by de Quervain's disease and stenosing ligamentitis.

Stenosing tendovaginitis

Chronic stenosing tendovaginitis (synonym: de Quervain's disease, French de Quervain, named after a Swiss surgeon) is a peculiar form of chronic inflammation of the tendon sheaths, which is characterized by damage to the tendons of the muscles of the thumb. In this case, the tendon sheath thickens, and the gap between the sheath and the tendon, filled with fluid to reduce friction (synovial cavity), narrows. This disease is characterized by pain during abduction and extension of the thumb, which can radiate to the forearm and shoulder, swelling along the affected tendons.

Stenosing ligamentitis

Close to de Quervain's disease in terms of clinical manifestations is stenosing ligamentitis of the fingers - a reactive inflammation of the ligamentous apparatus of the hand. It can occur both with repetitive trauma and with some infectious diseases (for example, with influenza). Ligaments between the phalanges of the fingers and near the joints connecting the fingers to the metacarpus are usually affected. This disease is characterized by inflammatory changes in the area of ​​the affected ligaments (pain on movement, swelling, swelling, redness and local increase in skin temperature). It is even possible necrosis of the ligaments with a violation of the sliding of the tendon and difficulty in flexing and unbending the finger with a characteristic clicking (the so-called "snapping finger"). Carpal tunnel syndrome in a large number of cases is also actually a ligamentitis, but in the area of ​​the wrist, and with a characteristic neurological picture.

carpal tunnel

The carpal tunnel is located at the base of the hand and is surrounded on three sides by the bones of the wrist, and in front by the transverse carpal ligament. The median nerve, flexor tendons of the fingers and hand, as well as the synovial membranes of these tendons, pass through this canal.

The synovial sheath of the tendon is a sheath of connective tissue that surrounds the tendon. In the gap between this sheath and the tendon, there is a small amount of lubricant to reduce friction (synovial fluid), which is produced by synovial cells (lining the sheath cavity from the inside).

Transverse carpal ligament

The transverse ligament of the wrist is a strong strand of dense connective tissue, which is attached on one side to the ulnar, and on the other - to the radial eminence of the wrist. This ligament also has a different name: "retainer of the tendons of the flexor muscles" (Latin retinaculum flexorum). It transforms the carpal sulcus into a carpal tunnel, in which the flexor tendons of the fingers and the median nerve pass.

median nerve

The median nerve (lat. nervus medianus) is one of the three main nerves of the hand (the other two are the radial and ulnar nerves). It comes from the brachial plexus. On the hand, this nerve leads sensory fibers to the skin of the tubercle of the thumb, the palmar surface of the thumb, index, middle and half of the ring fingers and fibers of internal sensitivity to some muscles of the hand (responsible for coordinating movements with these muscles), motor fibers to these muscles of the hand, as well as vegetative fibers to local arteries (affects vasoconstriction and expansion, for example, depending on temperature) and sweat glands.

Etiology and pathogenesis

Possible causes of carpal tunnel syndrome include:

• Activities that require repeated flexion/extension of the hand or are accompanied by exposure to vibration (for example, assembling machinery).
• Swelling or injury of any kind (such as fractures) that compresses the median nerve.
• Compression of the median nerve with edema in pregnant women or women taking contraceptives.
• There is a strong relationship between excessive body weight and the presence of carpal tunnel syndrome. In addition, people of short stature are more prone to the disease.
• Acromegaly, rheumatoid arthritis, gout, tuberculosis, kidney failure, decreased thyroid function, early post-menopause (and post-ovarian removal), amyloidosis, possible association with diabetes mellitus.
• The syndrome is characterized by a genetic predisposition, in part due to multiple inherited characteristics (eg, square wrist, transverse ligament thickness, build).

Carpal tunnel syndrome is caused mainly by compression of the median nerve at the wrist due to thickening or swelling of the synovium of the flexor muscles. As a result of chronic inflammation of the connective tissue due to constant repetitive stress, it becomes rougher, thicker, swollen, which increases pressure inside the carpal tunnel. Increased pressure causes venous congestion, edema, which leads to ischemia (impaired blood supply) to the nerve.

First, damage occurs to the sensory, and only then - to the motor fibers of the nerve. It is also possible damage to the fibers of the autonomic nervous system (responsible for sweating, expansion / narrowing of blood vessels, etc.).

Cold exposure plays a role in the development of carpal tunnel syndrome. According to Irenio Gomes et al., the frequency of diagnosis of carpal tunnel syndrome was significantly higher in the cold season.

Prolonged typing and carpal tunnel syndrome

Carpal tunnel syndrome has traditionally been considered an occupational disease for activities that require repeated flexion/extension or twisting of the hands, or accompanied by exposure to vibration. It is widely believed that prolonged daily computer work that requires constant use of the keyboard is a risk factor for developing carpal tunnel syndrome.

A number of scientific studies indicate the absence of significant differences in the incidence of this syndrome in the group of constantly working with the keyboard when compared with the general population. Simply put, carpal tunnel syndrome is not usually the result of prolonged keyboard work.

At the same time, Liu et al draw different conclusions based on their own research, and claim that carpal tunnel syndrome occurred in one in six computer users they examined. According to them, those users who, when working with the keyboard, are at greater risk of being extended by 20 ° or more in relation to the forearm.

Diagnostics

Clinical picture

As a rule, carpal tunnel syndrome is manifested by numbness, paresthesias (tingling, burning sensations, etc.) and pain in the region of innervation of the median nerve. These symptoms may or may not be accompanied by objective changes in the sensitivity and muscle strength of the tissues of the hand, the innervation of which is provided by the median nerve.

Main complaints:

• Numbness and tingling. Most often, patients complain of hands "turning off" or that objects fall out of their hands unwillingly, as well as numbness and a "tingling" sensation on the skin of the hand, usually in the thumb, index, middle, and sometimes in the ring fingers of the hand. Symptoms tend to be intermittent and associated with certain activities (eg, driving, reading a newspaper, drawing). Due to the resulting numbness and pain, the patient sometimes cannot hold on to the upper handrails in public transport; talking on the phone for a long time, because of which he has to shift the phone to the other hand; hold the steering wheel of the car for more than 10 minutes while driving; read a book or newspaper, holding them in front of you, etc.
• Pain. The above sensitivity disorders are often accompanied by pain sensations of a burning nature on the palmar surface of the wrist and in 1-3 or 1-4 fingers. The pain may radiate ("radiate") towards the palm and fingers, or, more commonly, towards the palmar surface of the forearm. Pain in the area of ​​the epicondyles of the elbow joint, shoulder or neck is more often associated with other lesions of the musculoskeletal system, which are sometimes combined with carpal tunnel syndrome.
• The place where the symptoms are felt. Complaints usually concern the palmar surface of the first to fourth fingers and the palm adjacent to them (which corresponds to the zone of innervation of the palm by the median nerve). If the numbness occurs mainly in the little finger or extends to the back of the hand, this indicates another disease. In many patients, numbness spreads higher due to damage to the autonomic nerves.
• Night symptoms. Carpal tunnel syndrome is characterized by nocturnal onset of symptoms that may wake the patient, especially if the patient is able to relieve them by shaking the hand and wrist. The patient may be relieved by lowering and rubbing the hands, waving them in the lowered position. There may be a feeling of stiffness in the fingers of the hands in the morning.
• Side of defeat. Bilateral involvement is common, although the dominant hand (i.e., the right hand in a right-handed person, the left hand in a left-handed person) is usually affected earlier and more severely than the other hand.
• vegetative symptoms. Often, patients have complaints about the entire hand. Many patients with carpal tunnel syndrome also report a feeling of tightness and swelling in the hands and/or changes in temperature (i.e. persistently hot or cold hands). This is due to local dysregulation of vasoconstriction/dilation. A number of patients develop sensitivity to changes in ambient temperature (often at cold temperatures) and a change in skin color. In rare cases, there are local disorders of sweating. All these symptoms are associated with damage to the autonomic fibers (the median nerve carries the autonomic fibers for the entire hand).
• Weakness / inaccuracy of movements. Patients with carpal tunnel syndrome experience loss of hand muscle strength (particularly when gripping with the thumb); however, in practice, loss of feedback due to sensory impairment and pain are more important causes of weakness and inaccuracy of movement than loss of motor function per se. At the same time, the coordination of movements and the strength of the hand are disturbed ("everything falls out of hand").

Objective signs

Tinel's symptom - tapping over the passage of the nerve causes a sensation of tingling in the fingers.

Phalen's test - passive flexion and extension of the wrist in the wrist joint increases sensations of numbness, tingling and pain. Some authors express doubts about its diagnostic value.

Cuff test - when applying a cuff to measure blood pressure above the site of compression, inflating it to the level of normal systolic blood pressure and holding for 1 minute in the presence of carpal tunnel syndrome, paresthesias appear in the areas that supply this nerve.

"Square wrist" is an anatomical feature of the wrist that predisposes to the development of carpal tunnel syndrome. It represents an increase in the anteroposterior size of the wrist in relation to the medial-lateral (i.e., approaching the "square" cross-sectional shape).

An objective examination may show a violation of the abduction of the 1st finger of the hand and a decrease in pain sensitivity.

Additional research methods

Additional research methods are also used, in particular electromyography - the study of muscle contractions depending on the level of electrical stimulation. An electromyographic study allows you to objectively determine the localization of a nerve lesion, in particular, to identify another cause other than compression in the carpal tunnel.

Complications

Carpal tunnel syndrome, if left untreated, can lead to complete, irreversible damage to the median nerve, followed by severe impairment of hand function.

Prevention

Scientific research in the field of prevention

Lincoln et al. published a review article in 2000 of twenty-four primary prevention studies (i.e. prevention of occurrence) of carpal tunnel syndrome. They distinguish the following groups of methods for preventing the occurrence of this disease:

• engineering solutions (alternative designs of keyboards, computer mice, wrist rests, keyboard attachment systems, etc.);
• personal solutions (ergonomics training, wearing a support splint on the wrist, electromyographic feedback systems, exercises during work, etc.);
• multi-component solutions, or "ergonomic programs" (workplace redevelopment, accounting for ergonomics in the workflow, periodic change of activity within the position, ergonomic training and load limits).

Multicomponent programs have been associated with a reduction in the incidence of carpal tunnel syndrome, but the results are inconclusive because potential confounding factors have not been adequately considered. Some of the engineering solutions positively affected the risk factors associated with carpal tunnel syndrome, but these studies did not measure incidence. None of the "personalized" decisions were accompanied by significant changes in symptoms or risk factors. The authors concluded that none of the studies they reviewed had strong evidence that these solutions prevent carpal tunnel syndrome in workers.

Many popular sources on carpal tunnel syndrome contain various recommendations for the prevention of carpal tunnel syndrome. Usually these recommendations are based on "common sense" and ideas about the pathogenesis of the disease and do not refer to evidence-based studies. However, even if these tips are useless for the prevention of the disease in question, they are unlikely to bring any harm.

The main tips from the field of ergonomics and exercises can be classified into the following groups:

1. Correct hand position. These include: the direct position of the hand in relation to the forearm, avoiding the extensor position of the hand, the right angle of the bend of the arm at the elbow joint, the presence of an emphasis for the hand (the hand should lie on the table, and not be in a position suspended in the air).

2. Correct fit, posture and location of the workplace: there should be a right angle between the lower back and hips. Printed text should be at eye level to prevent neck bending during work (sometimes it is advised that the top edge of the monitor be at eye level, or no more than 15 centimeters lower). You should sit, leaning on the back of the chair, with relaxed shoulders. Feet should be firmly planted on the floor or on a footstool.

3. Periodic breaks in work. It is advised to take a break, for example, every 30-60 minutes for 3-5 minutes.

4. Exercises for the hands (for example, they can be performed during breaks): shaking the hands, clenching the hands into a fist for a few seconds, rotational movements of the fingers, massaging the fingers of the other hand, bringing the shoulder blades together, deep breathing, etc.

5. Tips for choosing furniture, keyboards, mice. It is recommended that the work chair be height-adjustable, have a comfortable backrest and armrests. Pressing the keyboard buttons should not require additional effort. Hands and wrists during work should remain relaxed. There are studies stating that the use of a mouse carries a greater risk for the occurrence of this disease, so some authors advise replacing the mouse with a trackball. It is advised to use all kinds of brush holders for the keyboard and mouse pad. Some people recommend keeping the mouse as close to the keyboard and torso as possible to minimize shoulder movement. While holding the mouse, the hand should be as relaxed as possible. Some people cut the mouse pad in half to restrict mouse movement. Various "alternative" ergonomic designs for keyboards and mice are often promoted.

Treatment

Treatment of carpal tunnel syndrome should be started as early as possible and under medical supervision. The underlying causes, such as diabetes or arthritis, should be treated first. Without treatment, the course of the disease tends to progress.

Drug therapy

In some cases, various medicines can relieve the pain and inflammation associated with carpal tunnel syndrome. Non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen, and other over-the-counter pain relievers can relieve symptoms that are recent or brought on by strenuous activity. Oral diuretics help reduce swelling. Corticosteroids (prednisone, hydrocortisone) or lidocaine (local anesthetic) may be given by injection directly into the wrist or (for corticosteroids) by mouth to reduce pressure on the median nerve and provide rapid temporary relief in individuals with mild or intermittent symptoms. (Caution: Individuals with diabetes, and those who may be predisposed to diabetes, should be aware that long-term use of corticosteroids makes it difficult to titrate insulin. Corticosteroids should not be taken without a doctor's prescription.) In addition, some studies show that drugs with vitamin B6 (pyridoxine) may relieve symptoms of carpal tunnel syndrome.

Non-drug conservative therapy

Initial treatment generally consists of limiting weight bearing on the affected hand and wrist for at least 2 weeks, avoiding activities that may aggravate symptoms, and immobilizing the wrist with a splint to prevent further damage from twisting or flexion. If an inflammatory reaction is present, ice packs may be used to relieve swelling.

Physical exercise

For those patients whose symptoms have improved, stretching and strengthening exercises may be helpful. Such exercises can be supervised by a physiotherapist who is trained in the use of exercises to treat physical injuries, or an occupational health professional who is trained in examining patients with physical injuries and helping them acquire skills to improve their own health and well-being.

Alternative Treatments

Some patients confirm that acupuncture, manual therapy, chiropractic helped them, but the effectiveness of these techniques remains unproven by scientific methods. An exception is yoga, which has been shown to reduce pain and improve grip strength in patients with carpal tunnel syndrome.

Surgery

Carpal tunnel release is one of the most common surgical procedures performed in the United States of America. Surgery is usually recommended if symptoms last more than 6 months, and surgery involves cutting the bundles of connective tissue surrounding the wrist to relieve pressure on the median nerve. The operation is performed under local anesthesia and does not require a long stay in the hospital (in the US it is performed on an outpatient basis). Many patients require surgery on both hands. There are two types of carpal tunnel opening surgery:

1. Open surgery, a traditional intervention used in the treatment of carpal tunnel syndrome. It consists in making an incision up to 5 cm long on the wrist, after which the carpal ligament is cut to increase the volume of the carpal tunnel. Typically, the operation is performed under local anesthesia on an outpatient basis, unless there are exceptional medical circumstances.

2. It is believed that endoscopic intervention allows to achieve a faster recovery of function and less postoperative discomfort compared to traditional open canal opening surgery. The surgeon makes two incisions (about 1-1.5 cm each) on the wrist and palm, inserts a camera connected to a special tube, and examines the tissue on the screen, after which it dissects the ligament of the wrist. This two-hole endoscopic surgery is usually performed under local anesthesia, is effective, and is associated with minimal or no scarring and little or no pain in the scar area. There are also methods for performing endoscopic intervention for carpal tunnel syndrome through a single puncture.

While symptoms may improve immediately after surgery, full recovery from carpal tunnel surgery can take months. Some patients may experience infection, nerve damage, stiffness, and pain in the area of ​​the scar. Sometimes, due to the dissection of the ligament of the wrist, there is a loss of strength. To restore strength, patients should undergo physiotherapy in the postoperative period. Some patients require a change in the type of work activity or even a change of place of work while recovering from surgery.

Recurrence of carpal tunnel syndrome after treatment is rare. Usually, 80-90% of patients completely get rid of the symptoms of the disease after dissection of the transverse carpal ligament. In some cases, during the operation, neurolysis is performed - excision of scarred and altered tissues around the nerve, as well as partial excision of the tendon sheaths.

Sometimes, with prolonged and severe compression of the nerve, irreversible damage occurs. In these cases, the symptoms of the disease may persist and even intensify after surgery. In some cases, annoying pain may be due to the presence of tendovaginitis or arthritis of the joints.

Controversial status as an occupational disease in several countries

In addition to the popularity of coverage of carpal tunnel syndrome as an occupational disease in the United States, similar movements are emerging in other countries. In Australia, in the early 1980s, regulations were passed establishing the status of carpal tunnel syndrome as an occupational pathology (in Australia, "repetitive strain injury" was commonly referred to - "chronic repetitive strain injury", abbreviated as RSI). Subsequently, from 1983 to 1986, an "epidemic" of RSI was noted. Growing skepticism about the accuracy of the diagnosis of RSI has led to widespread public debate regarding the influence of social and psychological factors on the occurrence and diagnosis. After the Supreme Court of Australia rejected the claims of the plaintiffs, finding no signs of RSI in a worker (Cooper vs Commonwealth of Australia), the frequency of detecting RSI decreased significantly. For example, the number of reported cases of RSI in South Australia dropped from 1000 cases in 1984-1985 to 600-700 in 1986-1987. Some attributed the decline to the mentioned court decision, while others attributed the decline to improvements in workplace ergonomics.

In the later years of the Clinton presidency, OSHA (Occupational Safety and Health Administration) proposed an ergonomics improvement program that was to cover 102 million jobs and made employers responsible for employees who applied for work-related problems. conditioned injuries of the musculoskeletal system, obliging employers to provide free medical care, workload restrictions, wage reimbursement and ergonomic modification of workplaces. This new ergonomic initiative has generated considerable controversy. The proposed standard was resisted by the business community; according to them, the new rule defined "production-caused lesions of the musculoskeletal system" too vaguely, creating the basis for fraud. Although the Clinton administration estimated the cost of the program at only US$4.5 billion, business lobbyists have argued that it would cost the budget more than US$100 billion to adopt the changes required by the ergonomics program. Intense business lobbying led to the proposed ergonomics program being rejected by Congress in March 2001.

Sources of information and links

1. Great Medical Encyclopedia 3rd ed., article "Tunnel Syndromes" (T. 25, p. 458); article "Tendovaginitis" (T. 24, p. 539).
2. Carpal tunnel syndrome, article in the English version of Wikipedia.
3. Carpal Tunnel Syndrome. Article by Jeffrey G. Novell, MD, Mark Steele, MD. The article contains a concise description of background clinical information about the disease, written by a medical specialist in emergency care.
4. Carpal Tunnel Syndrome. Article by Nigel L. Ashworth. Another help article on carpal tunnel syndrome written by a physiotherapist.
5. The frequency of carpal tunnel syndrome in computer users at a medical facility J. Clarke Stevens et al. Neurology 2001; 56:1568-1570. An article about the statistical indicators of the occurrence of the disease.
6. Computer Use and Carpal Tunnel Syndrome. A 1-Year Follow-up Study. Johan Hviid Andersen et al. Study of the relationship between carpal tunnel syndrome and computer work.
7. Relationship between carpal tunnel syndrome and wrist angle in computer workers. Liu CW et al. Kaohsiung J Med Sci. 2003 Dec;19(12):617-23. Study of factors contributing to the development of carpal tunnel syndrome when working on a computer.
8. Seasonal distribution and demographical characteristics of carpal tunnel syndrome in 1039 patients. Irenio Gomes et al. Arq. Neuro-Psiquiatr. vol.62 no.3a Sao Paulo Sept. 2004 Article about the study of the statistical patterns of the occurrence of the disease.
9. Association of occupational and non-occupational risk factors with the prevalence of self-reported carpal tunnel syndrome in a national survey of the working population. Shiro Tanaka et al. American Journal of Industrial Medicine, Volume 32, Issue 5 , Pages 550 - 556
Study of risk factors for the development of carpal tunnel syndrome.
10. Tunnel neuropathies. A review article on tunnel neuropathies, written in a fairly simple language, with illustrations.
11. Interventions for the primary prevention of work-related carpal tunnel syndrome. Lincoln LE et al. Am J Prev Med. 2000 May;18(4 Suppl):37-50. Study of the effectiveness of various methods for the prevention of carpal tunnel syndrome.
12. Carpal tunnel syndrome (CTS) or carpal tunnel syndrome (CTS). "Popular science" article about carpal tunnel syndrome. Includes advice on prevention.
13. Tunnel syndrome or carpal tunnel syndrome. Another popular science article with tips and exercises.
14. Carpal Tunnel Syndrome - Prevention. An overview of the prevention of carpal tunnel syndrome, including prolonged use of the computer.
15. Occupational diseases caused by overstrain of individual organs and systems. Brief descriptions of various types of diseases associated with chronic trauma.
16. "Computer" pain. An article about the harmfulness of the wrong posture and ergonomics in a popular science style (albeit with elements of advertising "own design").
17. Clinical study. Basic principles for diagnosing tunnel neuropathies. Review article on tunnel neuropathies.
18. Brachialgia. G. R. Tabeeva. A review article on the various causes of arm pain.
19. Carpal Tunnel Syndrome Fact Sheet. Useful information about carpal tunnel syndrome in questions and answers.
20. Diseases of the periarticular tissues of the hand area. A. G. Belenky. A review article on diseases of the tissues surrounding the joints of the hand.
21. Carpal Tunnel Syndrome As an Occupational Disease. Stephanie Y Kao. An article on the status of carpal tunnel syndrome as an occupational disease.

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 susceptible 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 to organs and tissues. Moreover, each nerve is responsible for its own area or organ.

The structure of a nerve cell (neuron)

Body The nerve cell contains a nucleus, 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 a different shape (spherical, spindle-shaped, 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 the myelin sheath is interrupted. 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 the further propagation of the 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 - part of the human hand, which consists of two tubular bones (length prevails over width): the radius and ulna. On the upper side, it is limited by the elbow joint, and from the bottom - by the wrist.

The structure and functions of the median nerve

The median nerve begins in the shoulder region from the branches formed by the fibers of the spinal nerves (the sixth-eighth cervical and the first thoracic). 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
• 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 to the 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 with III-IV degrees of obesity are most often at risk (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 of the hand and carpal tunnel is disturbed.

Acute wrist injuries

However, systemic corticosteroids have a large number of side effects (eg, sleep disturbance, ulceration in the stomach and intestines). Therefore, they are used with caution, especially in certain diseases (for example, diabetes mellitus). In addition, they suppress the activity of the immune system, so they are not prescribed in the presence of infections.
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 a restorative treatment, physiotherapy and therapeutic exercises are used (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, hormonal preparations containing estrogen (female sex hormone) are prescribed. 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 substances are formed in large quantities 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 renal 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)
• High blood pressure is a 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 arrhythmias: severe atrial fibrillation (asynchronous contraction of the ventricles and atria) and severe extrasystole (in this disease, the heart rhythm is disturbed)
• 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. An exception is some drugs 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, a drug is applied to the skin, then an apparatus is applied 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 moving a computer mouse), 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 spine and arms worsens.