Dr. Angelo Smith M.DWHPL

CARPAL TUNNEL SYNDROME

DEFINITION

• Carpal tunnel syndrome, the most common focal peripheral neuropathy, results from compression of the median nerve at the wrist.

FEATURES • Nerve Entrapment

• Middle or Advanced age

• > 40 yrs (>80%)

• 2x in women

• ? Occupational Disease

MEDIAN NERVE – MOTOR INNERVATION:

1st and the 2nd lumbricals

Muscles of thenar eminence: 1. Opponens pollicis brevis2. Flexor pollicis brevis

SENSORY INNERVATION:

Skin of the palmar side of the thumb, index and middle finger.

Half the ring finger and nail bed of these fingers.

SIGNS AND SYMPTOMS

• Tingling• Numbness or discomfort in

the lateral 31/2 fingers• Intermittent pain in the

distribution of the median nerve

• Symptoms gets aggravated at night.

• To relieve the symptoms, patients often “flick” their wrist as if shaking down a thermometer (flick sign).

MOTOR CHANGES:

Apelike thumb deformity

Loss of opposition of thumb

Index and middle finger lag behind when making the fist.

SENSORY CHANGES:

Loss of sensation of lateral 3 1/2 digits including the nail bed and distal phalanges on dorsum of hand (An important point to remember for Carpal tunnel syndrome is that there is no sensory loss over the thenar eminence in Carpal tunnel syndrome because the branch of median nerve that innervates it (palmar cutaneous branch) passes superficial to Carpal tunnel and not through it).

Finger lag when making a fist

Ape thumb

VASOMOTOR CHANGES:

• Skin area with sensory loss is warmer

• Dry skin

TROPHIC CHANGES:

• Long standing cases leads to dry and scaly skin

• Nail crack easily

• Atrophy of the pulp of the fingers.

DIAGNOSIS

Physical Assessment Tests:

• Less sensitivity to pain where the median nerve runs to the fingers

• Thumb weakness

• Inability to tell the difference between one and two sharp points on the fingertips

• Flick Signal. The patient is asked, "What do you do when your symptoms are worse?"

If the patient responds with a motion that resembles shaking a thermometer, the doctor can strongly suspect carpal tunnel.

PHALEN’S TEST:

The patient rests the elbows on a table The wrists dangle( flexion) with fingers pointing down and the backs of the hands pressed together.

POSITIVE: If symptoms develop within a minute, CTS is indicated.

• TINEL’S SIGN TEST:

In the Tinel's sign test, the doctor taps over the median nerve to produce a tingling or mild shock sensation.

o DURKAN TEST:

The doctor presses over the carpal tunnel for 30 seconds to produce tingling or shock in the median nerve.

o HAND ELEVATION TEST:

The patient raises his or her hand overhead for 2 minutes to produce symptoms of CTS.

ELECTRODIAGNOSTIC TEST:

Help detect median nerve compression in the carpal tunnel.

Nerve Conduction Studies:

To perform nerve conduction studies, surface electrodes are first fastened to the hand and wrist. Small electric shocks are then applied to the nerves in the fingers, wrist, and forearm to measure how fast a signal travels through the nerves that control movement and sensation.

Electromyography:

To perform electromyography, a thin, sterile wire electrode is inserted briefly into a muscle, and the electrical activity is displayed on a viewing screen. Electromyography can be painful and is less accurate than nerve conduction.

• Cervical Spondylosis• Compartment Syndrome• Diabetic Neuropathy• Ischemic Monomelic Neuropathy• Lateral Epicondylitis• Lyme Disease• Multiple Sclerosis• Overuse Injury• Tumatic Brachial Plexopathy• Tendonitis

DIFFERENTIAL DIAGNOSIS

MANAGEMENTIMMOBILISING BRACES / SPLINTStretching and strengthening exercises can be helpful in people

whose symptoms have abated

Non surgical:ANALGESICS LIKE NSAID(like aspirin, ibuprofen,and other pain

killers)Corticosteroids (such as prednisone) or the drug lidocaine injected

directly to the wrist to relieve the pressureOrally administered diuretics ("water pills") can decrease swelling.

LOCAL INJECTION

• A mixture of 10 to 20 mg of lidocaine (Xylocaine) without epinephrine and 20 to 40 mg of methylprednisolone acetate (Depo-Medrol) or similar corticosteroid preparation is injected with a 25-gauge needle at the distal wrist crease (or 1 cm proximal to it).

LOCAL INJECTION

• Splinting is generally recommended after local corticosteroid injection.

• If the first injection is successful, a repeat injection can be considered after a few months

• Surgery should be considered if a patient needs more than two injections

Surgical:• Generally recommended if symptoms last for 6 months,

surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve.

TWO TYPES OF CTS RELEASE SURGERY:

Open release surgery

Endoscopic surgery

Open Release Endoscopic Release

OPEN SURGERY

OPEN SURGERY

Complications of surgery• Injury to the palmar cutaneous or recurrent motor

branch of the median nerve• Hypertrophic scarring• laceration of the superficial palmar arch• tendon adhesion• Postoperative infection• Hematoma• arterial injury• stiffness

PREGNANCY

• Alterations in fluid balance may predispose some pregnant women to develop carpal tunnel syndrome.

• Symptoms are typically bilateral and first noted during the third trimester.

• Conservative measures are appropriate, because symptoms resolve after delivery in most women with pregnancy-related carpal tunnel syndrome.