The wrists are almost always involved in rheumatoid arthritis, and carpal tunnel syndrome, which affects the wrists, is often the first symptom of the disease. RA patients can develop carpal tunnel syndrome at any time, however.

The carpal tunnel is the space between the wrist bone and a band of fibrous tissue that surrounds the wrist, providing support. The median nerve passes through the carpal tunnel, providing feeling to the thumb and first three fingers, and function to the thumb muscles. Any condition that affects the tissue in the carpal tunnel can put pressure on the median nerve, creating the condition known as carpal tunnel syndrome. In rheumatoid arthritis, the tissues of the wrists become inflamed and swollen, exerting pressure on the median nerve.

Carpal tunnel syndrome can have many causes. Repetitive movements such as typing, frequent use of vibrating hand tools, pregnancy and other diseases like diabetes or leukemia can also cause carpal tunnel syndrome. RA, however, is the most common cause of carpal tunnel syndrome.

Compression of the median nerve slows the transmission of nerve impulses through the carpal tunnel. This is experienced as pain, numbness and tingling in the hand, wrist, thumb, index, middle and ring fingers. (The little finger is not served by the median nerve). There may be increased sensitivity to cold and a weakening of the grip, evidenced by a tendency to drop things. Pain increases when the hand is used. Pain is sometimes greatest at night and may awaken patients from sleep. Nighttime pain may increase because a prone position encourages the accumulation of fluid around the wrist, or perhaps because the wrist remains in a flexed position during sleep.

If carpal tunnel syndrome is allowed to progress untreated, symptoms may include burning sensations, cramping and sharp, shooting pains in the forearm.

Diagnosis is made on the basis of the patient's reported symptoms, a physical examination of the wrist, and a nerve conduction test.

The wrist is examined for signs of swelling, tenderness, warmth or other abnormalities. The doctor may tap on the front of the wrist over the median nerve. If tapping causes the patient to experience pain or a shock-like sensation, this is known as Tinel's sign of carpal tunnel syndrome. The doctor may also ask the patient to bend the wrist forward for one minute, a test known as Phalen's maneuver, to see if symptoms are produced.

The final diagnostic step is a nerve conduction test. In this test, electrical impulses are timed as they travel through the carpal tunnel. If impulses travel at a rate slower than normal, it is likely that the patient has carpal tunnel syndrome.

In rheumatoid arthritis patients, carpal tunnel syndrome is primarily treated by addressing the underlying disease, which is causing the inflammation around the median nerve. When RA improves, it is likely that carpal tunnel syndrome will also improve.

To obtain immediate relief, however, any of these treatments may be recommended:

Splinting the wrist to immobilize it

Corticosteroids, either by mouth or by injection into the carpal tunnel

Nonsteroidal anti-inflammatory medication, such as ibuprofen

Resting the wrist for two weeks or more

Sometimes carpal tunnel syndrome does not respond to treatments and can only be resolved through surgery. If symptoms do not subside within four to six months, surgery may be indicated. The goal of surgery is to relieve pressure on he median nerve. This is accomplished by cutting the carpal ligament free from the median nerve, which lies under it.

References

First published September 1, 1999
Last updated December 16, 2002
Copyright © 1999 Accordant Health Services, Inc. All Rights Reserved.

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