НА РАКАТА КАЈ ВОЗРАСНИ ПАЦИЕНТИ ПОВРЗАНИ СО СИНДРОМ НА КАРПАЛЕН ТУНЕЛ THE MOST COMMON DISORDERS OF THE HAND ASSOCIATED WITH CARPAL TUNNEL SYNDROME IN ADULTS

Carpal tunnel (CTS) is one of the most common peripheral neuropathies caused by chronic compression of the median nerve in the area of the carpal tunnel and its etiology is multifactorial. Trigger fingers and de Quervain’s disease are common disorders of the hand related to CTS in adults. The aim of this study was to present the most common disorders of the hand such as stenosing tenosynovitis in adults with surgically treated CTS and to evaluate their demographic data. Material and methods: A total of 116 surgically treated patients with established diagnosis of CTS (clinically and by electrophysiological examination) were included in this prospective study, which was conducted at the University Clinic for Orthopedic Diseases in Skopje. Demographic data, findings of history of the disease and clinical examination were recorded and analyzed. Results: Participants with CTS included in the study were with a mean age of 55.41 ± 10.7 years (age range 29-75). 75% of them were female. 63.8% of participants suffered from one or more comorbid chronic diseases. On admission to hospital, disorders such as trigger fingers and de Quervain’s disease were concomitantly diagnosed in 15.51% on ipsilateral hand with CTS. All disorders were surgically treated following open carpal tunnel release, as “one stage procedure”, under local anesthesia. Conclusion: Our findings have determined concomitant existence of CTS and stenosing tenosynovitis (trigger fingers and de Quervain’s disease) on ipsilateral hand, which suggests common etiological factors. Female gender and age range 40-60 years are major common factors related to these three disorders. Abstract


Introduction
Carpal tunnel syndrome (CTS) is one of the most common non-traumatic disorders of the hand in adult patients and the most common reason for visiting orthopaedic surgeons. This syndrome is often associated with trigger fingers and de Quervain's disease in adults. These disorders might exist separately, but also might be concomitantly present on the same hand or appear after surgical procedures of one of them.
Carpal tunnel syndrome (CTS) is a peripheral neuropathy caused by chronic compression of the median nerve in the area of the carpal tunnel and its etiology is multifactorial.
The clinical picture depends on the duration and intensity of pressure on median nerve, which is a mixed type of nerve with sensitive and motor nerve fibers. At the beginning, the discomfort is in the form of sensory disturbances (numbness, paresthesia and/or pain in the fingers -from the thumb to the radial side of the ring finger, tingling and burning pain even radiating to the elbow or shoulder, nocturnal pains). Later, in more severe cases, when motor component of the median nerve is involved, clumsiness during everyday activities and hypotrophy of tenor muscles, are observed. 1 Nocturnal pains are typical due to the additional pressure on median nerve because of the prolonged flexion position of the wrist during sleeping. Shaking of the hand during nights is a typical act in patients with CTS in order to relieve pain.
The exact incidence and prevalence vary depending on the diagnostic criterion. The highest incidence is in patients aged 50-60 years and more often in females. 2 The exact prevalence of people with complaints is from 13.0% to 15.8% in the general population, and according to the clinical picture and confirmed by ENMG examinations varies from 2.7% to 5.8%. 3 Surgical carpal tunnel release is a treatment of choice in cases where conservative therapy for CTS failed.
Trigger finger is a disorder characterized by an impaired smooth sliding of the flexor tendons of the fingers due to the mechanical entrapment usually at the level of the first annular pulley, caused by multifactorial etiology. Chronic discrepancy between the flexor tendons with tenosynovitis and the first annular pulley is the cause of morphological and functional disorders. According to the Green classification, complaints might be pain and discomfort, painful tenderness on palpation at the level of the metacarpophalangeal joint on palmar side, locking of fingers in flexion/ extension or inability of passive extension of fingers due to flexion contracture of proximal interphalangeal joint. 4  Occupations that include repetitive movements, packing, counting money, clothing industry, use of vibrating machines are main risk factors for development of these disorders. 8 Although the etiology is multifactorial, coexistence of several diseases (diabetes, rheumatoid arthritis, and hypothyroidism, overweight) in the same person is noticeable. 9 The aim of this paper was to present the most commonly associated disorders of the hand in surgically treated adult patients with CTS and by evaluating the demographic data of these patients to identify possible risk factors for the coexistence of these three disorders.

Material and methods
One handred and sixteen surgically treated patients with CTS were included in our prospective clinical study that was conducted at the University Clinic for Traumatology, Orthopedic Diseases, Anesthesiology, Reanimation and Intensive Care Medicine and Emergency Department, Clinical Center Mother Theresa, Skopje, RNM during a three-year-period. Patients were with clinical diagnosis of CTS and confirmed by electroneuromyographic examination (ENMG). Data from surgically treated hands were analyzed, and in cases with bilateral involvement, only data from the first treated hands were included.

CTS -carpal tunnel syndrome
The type and duration of the complaints and the clinical findings in the patients were examined. Table 2 presents the most common symptoms and duration of symptoms by gender.
The results obtained showed that  with tumor-like lesions and they were surgically treated 3 months after OCTR (Table 3).
p (Pearson Chi-square), CTS-carpal tunnel syndrome Discussion CTS, trigger fingers and de Quervain's disease are so called "disorders of entrapped nerves and tendons". They are a result of special anatomy of the hand adjusted for fulfillment of precisely coordinated movements. Special anatomy of tunnels with bone floors and soft-tissue roofs allows the passage and facilitates movements of nerves and tendons. Mutual existence of CTS and stenotic tenosynovitis (trigger finger and de Quervain's disease) with different times of occurrence refer to common etiological factors that act on a similar anatomical structure and lead to inadequacy of the space in the bone-fibrous tunnel and its contents (nerve and tendon), resulting in morphological and functional changes of both of them.
The clinical picture depends on the duration of chronic pressure on the median nerve or tendons. In the beginning symptoms are similar, while in later stages, when more changes develop due to prolonged pressure, the differentiation of these disorders becomes clearer.
Our results presented in Table 1 show that about 63% of patients with CTS had one or more comorbidities. 33% of respondents suffered from cardiovascular, metabolic and hormonal diseases, which are possible causes for the microvascular changes expressed mostly in nerves located in narrow bone-fibrous tunnels such as the median nerve. 10,11 Other comorbidities (rheumatic diseases, tenosynovitis, arthritic changes and chronic renal failure) may also be responsible for the increased chronic pressure of the median nerve at the level of the carpal tunnel. It is assumed that this leads to many alterations, especially intraneural circulation that cause morphological changes of the nerve in the form of swelling and change shape, with progressive demyelination, eventual axonal degeneration and fibrosis. 12 Histopathological studies of stenotic tenosynovitis have shown that noninflammatory hypertrophy and fibrosis of tendon sheath are biggest at the level of the first annular pulley and there is deposition of an abundant extracellular matrix with chondroid in the deep parts of the pulley. These changes lead to difficult movement, i.e. sliding of the flexor tendons in the inner lining. 13 A similar process develops in de Quervain's disease. Thickening of the tendon sheath due to mucopolysaccharide deposition and myxoid degeneration corresponding to chronic TLL-tumor-like lesions (1 Ganglioma, 2 benign giant-cell tumors of tendon sheet), CTS -carpal tunnel syndrome degenerative changes, rather than an inflammatory reaction, was demonstrated in a study conducted in England by examining histopathological specimens taken from 23 operatively treated patients with de Quervain's disease. 14 Some of the comorbidities listed in this paper were: diabetes, cardiovascular and metabolic diseases, hypothyroidism, chronic renal failure, rheumatic diseases. 15,16,17,18,19 The results obtained in our study have shown that majority of participants (75%) were of female gender. Female patients in our study were younger than male patients, but the mean age was not found to be statistically significant (p=0.16). This finding was consistent with other studies. 20,21 According to the results in Table 2, the duration of symptoms in female patients until surgery was shorter and the functional discomfort was smaller compared to male patients The symptoms (pain, insomnia, clumsiness and hypotrophy of thenar) as signs of more advanced damage of the median nerve were statistically more common (p=0.034) in males than in females, 55.2% vs 28.7%. The reason for delayed surgery was mostly due to the refusal of the operation, fear of it, reduced funds due to sick leаvе and the fear of losing а job (as obtained from our talks with the participants).
Overall, more women suffer CTS from than men and it has been reported in a large number of epidemiological studies. 22,23 In a retrospective study done in New Zealand including 2,313 patients who underwent CTR, 61% were female and 39% were male. 22 In another study conducted by Farioli et.al. in Italy between 1997 and 2000, an almost 4-fold increase in the risk of surgically treated CTS was observed in women compared to men among non-manual workers. 23 In a study of Nosewicz et al. 60.3% of 967 participants with CTS were females. 24 The mean age of female participants in our study was 54.6±10.4, implicating that they were in the reproductive and menopausal period and the hormonal changes during these periods might be responsible for the onset of tissue edema and an increased pressure on the median nerve and tendons. 25 Our clinical study confirmed a concomitant presence of CTS, trigger fingers and de Quervain's disease in 15.51% of patients at admittance for CTR. The majority of them were also females, which could be explained by increased work in postpartum period, repetitive movements in taking care of small children and during housework. 26 The research by Rottgers also showed concomitant presence of CTS and trigger fingers, even in higher percentage of 61% . 27 In other prospective study of 211 patients with trigger finger, 43% were diagnosed with CTS, too. 28 Many authors report an increased incidence of trigger fingers on the same hand following CTR. Lin et al. in a retrospective study conducted on 10,420 patients with CTS and 2,605 patients with CTR reported a 6.71% incidence of trigger fingers, while after open decompression of the median nerve, the overall risk of trigger fingers was 3.63 times higher in the operated patients in the first 6 months after the intervention. 29 In another study comprising patients with CTS, where 66.7% were female, prevalence of trigger fingers after CTR was 26.3%. 30 According to Acar et al., the incidence of occurrence of trigger fingers after open decompression of the median nerve was 13.9%, and if the distal fascia of the forearm was also released, the incidence was up to 31.3% in patients with more severe EMG findings. 31 The trigger thumb was the most common finger (9.48%), followed by ring and middle finger (5.17%) in our study. These findings are consistent with data from a study conducted on 497 patients with CTR, of which in 229 patients with postoperatively developed trigger fingers, the thumb was registered in 42.22% after 3.5 months of intervention, and the fourth and third trigger finger were registered in 46.66% after 7.5 months. 32 The thumb and the ring finger were the most common trigger fingers in another study. 33 Some authors explain the more common occurrence of trigger fingers after surgical decompression of the median nerve by the displacement of the tendons of the superficial flexors of the fingers towards the volar, which leads to a mechanical irritation of the tendon sheath and its hypertrophy, usually at the level of the A1 pulley. 34,35 However, the existence of trigger fingers without CTS or CTR suggests other, still unknown etiological factors.
Disadvantages of our clinical study were the small number of patients, their inhomogeneity in terms of occupation and comorbidities, and the lack of a control group.
The importance of this paper is that this is the first research in our country, according to the available data, which deals with the association of CTS with simultaneous coexistence of de Quervain's disease and trigger fingers according to precisely defined inclusion and exclusion criteria. The results determined the prevalence of the females at the age of 40-60 years. The research findings can be the basis for further investigation of other risk factors, and thus the detection of possible preventive measures and appropriate treatment.

Conclusion
Our study showed a simultaneous coexistence of CTS and stenotic tenosynovitis -trigger fingers and de Quervain's disease with different time of onset. Our results also indicated that common risk factors were the female gender in patients and the age of 40-60 years. It might be assumed that common etiological factors, which act on a similar anatomical structure and lead to inadequacy of the space in the bone-fibrous tunnel and its contents (nerve and tendon), result in morphological and functional changes. In order to conduct a more significant statistical analysis and reach valid statistical conclusions, it would be necessary to perform research in the future on large groups of patients with CTS according to certain inclusion criteria in terms of comorbidities, physiological conditions and occupation.