Carpal Tunnel Syndrome
Upcoming SlideShare
Loading in...5

Like this? Share it with your network


Carpal Tunnel Syndrome

Uploaded on

This is a powerpoint slide show with information for patients and allied personnel about carpal tunnel syndrome

This is a powerpoint slide show with information for patients and allied personnel about carpal tunnel syndrome

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads


Total Views
On Slideshare
From Embeds
Number of Embeds



Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

    No notes for slide


  • 1. Carpal Tunnel SyndromeGershon Zinger MD MSHadassah Medical OrganizationJerusalem, Israel
  • 2. Gershon Zinger MD MS Grad School MIT – mechanical eng Medical School UCLA Residency USC – orthopedic surgery Fellowship UCLA – hand & micro Work Private practice Denver, Colorado Current Hadassah Medical Organization Jerusalem, Israel
  • 3. Definition Carpal comes from the Greek word Karpos – means wrist ! Carpal tunnel syndrome means wrist tunnel syndrome Syndrome – “A set of symptoms which occur together” (from Dorland’s Medical Dictionary) (AKA – we don’t really understand it !)
  • 4. Anatomy Wrist tunnel formed by bone on bottom and ligament on top There are 9 tendons and one nerve in the tunnel Analogous to 4 lanes of traffic going to 2 lanes then back to 4 !
  • 5. Who Gets CTS Women more often affected (ratio 3:1) Historically more common in retired people Associated with repetitive activity Can be associated with medical diseases  Diabetes  Rheumatoid Arthritis  Thyroid Disease
  • 6. Diagnosis of CTS History Physical Exam Nerve Conduction Study/EMG
  • 7. Nerve Exam Sensory Motor Irritability
  • 8. Nerve Exam - Sensory Pattern peripheral or radicular Check for altered sensation, numbness on palmar and dorsal sides Middle finger is median n. Small finger is ulnar n. First dorsal webspace is radial nerve innervated
  • 9. Median Nerve The median nerve provides feeling to the thumb, index, middle and part of the ring fingers Sometimes people complain of numbness in the little finger that may or may not be CTS
  • 10. Nerve Exam Sensory Numbness over first dorsal web space may indicate cervical origin Numbness glove- stocking may indicate general neuropathy Numbness in non anatomic distribution may indicate trigger points
  • 11. Nerve Exam Sensory 2 point discrimination is an objective test of sensibility  Use large, not small paper clip  As points get closer together, it feels like one instead of two  6 mm or less is normal
  • 12. Nerve Exam Motor – Carpal Tunnel Look for atrophy of thenar muscles  May be secondary to thumb arthritis Test strength for opposition (median)
  • 13. Nerve Exam Irritability - Carpal Tunnel Local CompressionPhalen Test (up to 60 seconds) Tinel’s Sign
  • 14. Other sources of nerve irritation Cervical Cervical testing  Reproduction of symptoms with extension+rotation Numbness that extends to shoulder level very suspicious for proximal origin
  • 15. Double-Crush Phenomenon A compression point at one location may lower the threshold at another location
  • 16. Other sources of nerve irritationThoracic Outlet Syndrome 90 degree abduction-external rotation test (AER) – neither too far forward nor too far back
  • 17. Other sources of nerve irritation Thoracic Outlet Syndrome Examiner’s thumb over anterior scalene muscle
  • 18. Other sources of nerve irritation Trigger Points Palpation of parascapular trigger points may cause local pain but also reproduce tingling and numbness distal into hand  Trapezius  Rhomboid  Latissimus  Posterior arm
  • 19. Nerve Conduction + EMG Nerve Conduction  EMG Study  Needles into muscles  Test speed of signal looking for defibrillation down the nerve
  • 20. Nerve anatomy A nerve carries electricity in two directions Axons in bundles or fascicles Micro-circulation affected by pressure
  • 21. Saltatory ConductionNode of Ranvier
  • 22. Seddon Classification Neuropraxia  Interruption in conduction  Nerve elements normal  Recovery full  Recovery can take 6-8 weeks Axontmesis Neurotmesis
  • 23. Seddon Classification Neuropraxia Axontmesis  Loss of axon continuity  EMG 2-3 weeks later may show denervation and fibrillation potentials  Epineurium preserved  Axon may regenerate at rate of 1mm/day  Incomplete recovery  Final result at one year Neurotmesis
  • 24. Seddon Classification Neuropraxia Axontmesis Neurotmesis  neurotmesis (neuro as in never as in fahgedaboutit)  Complete loss of nerve function  May include loss or scarring of all neural elements  Surgery can still help w/pain
  • 25. Remember: Nerve is brain tissue – limited ability to recover Numbness may go away after 1 day, months, a year or never ! Numbness may be permanent if nerve already damaged beyond recovery
  • 26. Treatment of CTS JBJS 1980 – Steroid Injection + splint  Prospective, one year, 50 hands  Overall, only 22% of hands were sx-free  In mild category, 40% hand were sx-free J of Hand Surg 1994 – Steroid injection + splint  Prospective, 76 hands, f/up 1 yr, avg age 38 yo, excluded DM, thyroid dz, RA, preg and “severe dz”  Overall only 13% of hands were sx-free JAMA 2002 – surgery vs splint  Prospective, 147 patients, excluded DM  At 18 months, 90% success surgery group vs 37% for splint group
  • 27. Surgery - CTR Under the skin lies palmar fascia There are muscles on both sides – thenar and hypothenar consisting of 3 muscles each
  • 28. Surgery - CTR Under fascia lies the transverse carpal ligament This ligament is cut and springs apart Ligament later heals leaving the tunnel larger
  • 29. Open versus endoscopic Open theoretically safer Endoscopic theoretically has faster recovery
  • 30. Injuries J of Hand Surgery* – May 1999  Survey of members of ASSH  Endoscopic – 455 major injuries  Open – 283 major injuries * Palmer & Toivonen
  • 31. Postoperative Nurse visit at about 10 days for suture removal and nerve gliding exercise Need to avoid heavy or repetitive for one month then gradual return to activities Palm may be sore 2-4 months
  • 32. Thank You !