Carpal Tunnel Syndrome Anty

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Carpal Tunnel Syndrome

The five Minute Orthopedic Consult, Rohit Robert Dhir BA

Damien Doute MD

A. Jay Khanna MD

HasmiyantiC 111 06 034

Supervisor

dr. Jainal Arifin, M.Kes, Sp. OT


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Carpal Tunnel Syndrome

CTS is a neuropathy caused by compression of the mediannerve within the carpal tunnel.

The floor of the tunnel is formed by the volar radiocarpaland intercarpal ligaments.

The transverse carpal ligament forms the roof of the tunnel.

9 long flexors of the wrist and fingers and 1 nerve (median)run within this spatially limited and relatively rigid tunnel.

Thus, any increase in pressure within the tunnelcompresses the injury-prone median nerve.

A decrease in thenar muscle strength occurs, along with anumbness or a decrease in the sensibility of the palmarsurface of the radial 3 1/2 digits, especially the middle andindex fingers.


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Incidens

50% of cases are reported to occur in patients

40-60 years old; average age at carpal tunnel

release is 54 years.

CTS occurs predominantly in females (70%),

although the number of males with CTS may

be underestimated.


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Prevalence

The prevalence of CTS has been reported to

vary between 0.6% and 61% in different

occupational groups.

It is the most commonly diagnosed site of

nerve compression in the upper extremity.


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Risk Factors

Repetitive hand work Endocrine imbalance

History of neuropathy

Associated conditions

Rheumatoid arthritis

Pregnancy

Thyroid myxedema Acromegaly

Amyloidosis

Multiple myeloma

Diabetes

Trauma

Alcoholism

Gout


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Pathophysiology

Internal fibrosis of the median nerve

Epineural scarring and constriction

Reduced nerve conduction velocity


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Diagnosis

CTS can be diagnosed accurately by carefulhistory and physical examination, inspection forthenar atrophy, and detection of sensory

disturbance via light touch or a pinwheel. Provocative tests, such as the Phalen test (which

consists of placing the affected wrist inhyperflexion in an attempt to reproduce the

numbness in the hand) or tapping over thecourse of the nerve in the tunnel to elicit a Tinelsign, also serve to confirm the diagnosis.


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Signs and Symptoms

These symptoms can be aggravated with use of theaffected hand:

Paresthesia in the median nerve distribution in the hand

Weakness or clumsiness in the hand

Pain in the hand, wrist, or distal forearm

Awakening from sleep with pain or numbness in the hand

Tinel sign: Tapping the median nerve over the carpaltunnel with resultant paresthesias in the radial 3 fingers

Phalen sign: Paresthesias in the median nerve distributionwith full flexion for at least 1 minute


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Physical Exam

The hand should be examined to detect

thenar muscle atrophy.

2-point discrimination should be checked at

the tips of the fingers on the radial and ulnar

borders (should be


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Tests

The following basic tests should be ordered to

rule out systemic causes of CTS:

Sedimentation rate

Serum glucose concentration

Serum uric acid level

Thyroid function test

Electromyography/nerve conduction velocity can

confirm diagnosis and help determine severity.


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Imaging

Radiography

Plain radiographs of the wrist in patients with

previous trauma or in patients with a long history

of inflammatory disease should be performed.

Electromyographic studies can help rule out

proximal injury to the median nerve or

identify peripheral neuropathy.


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Differential Diagnosis

Compression of the lower cervical roots by

cervical degenerative disc disease or tumors


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Treatment General Measures

Nonoperative intervention: Modalities: Cockup wrist splinting, NSAIDs (not proven

effective), diuretics, and cortisone injections (which must beperformed by an experienced physician to avoid direct injury tothe median nerve)

The patient should wear a wrist splint during sleep.

Activity modification in work-related CTS is recommended.

Surgical release of the transverse carpal ligament is

performed when nonoperative measures have failed or inpatients with constant numbness, motor weakness, orincreased distal median nerve motor latency noted onelectromyography.


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Special Therapy

Physical Therapy

Occupational or physical therapy should be

consulted for activity modification teaching or

for nerve gliding exercises that might decrease

symptoms of nerve compression.

Postoperative therapy is aimed at minimizing

the development of painful scars and

increasing ROM and strength.


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Medication (Drugs)

No effective medication specifically to treatCTS has been described.

Corticosteroid injection into the carpal tunnel

is indicated when the median nervecompression is predicted to be temporary, as

in pregnancy or when the patient's activity

can be modified.

Injections must be done with great care to avoid

injury to the median nerve.


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Prognosis

Most patients with CTS associated with therepetitive trauma commonly seen in theworkplace respond to a combination of splinting,cortisone injection into the carpal tunnel, and

activity modification. If job modification is not in the patient's

nonoperative treatment program, splinting andcortisone injections may provide only temporary

relief. The maximum return of strength after carpal

tunnel release can take 6 months or longer.


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Complications

Iatrogenic injuries to the median nerve or its

branches may occur with open or endoscopic

release.

Painful surgical scars may ruin the results of a

successful decompression procedure.

Flexion tendon bowstringing may occur in a

few patients.


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Patient Monitoring

To obtain maximal beneficial results, the splintshould be worn full-time for at least 3-4months, after which time use of the splint can

be discontinued gradually. If symptoms return with removal of the splint,

the patient becomes a surgical candidate.

The patient usually experiences immediate painrelief after carpal tunnel release, whereasnumbness gradually improves over the nextseveral months.


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THANK YOU

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Carpal Tunnel Syndrome Anty