Carpal Tunnel Syndrome

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Carpal Tunnel Syndrome

  1. 1. Carpal Tunnel SyndromeGershon Zinger MD MSHadassah Medical OrganizationJerusalem, Israel
  2. 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. 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. 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. 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. 6. Diagnosis of CTS History Physical Exam Nerve Conduction Study/EMG
  7. 7. Nerve Exam Sensory Motor Irritability
  8. 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. 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. 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. 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. 12. Nerve Exam Motor – Carpal Tunnel Look for atrophy of thenar muscles  May be secondary to thumb arthritis Test strength for opposition (median)
  13. 13. Nerve Exam Irritability - Carpal Tunnel Local CompressionPhalen Test (up to 60 seconds) Tinel’s Sign
  14. 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. 15. Double-Crush Phenomenon A compression point at one location may lower the threshold at another location
  16. 16. Other sources of nerve irritationThoracic Outlet Syndrome 90 degree abduction-external rotation test (AER) – neither too far forward nor too far back
  17. 17. Other sources of nerve irritation Thoracic Outlet Syndrome Examiner’s thumb over anterior scalene muscle
  18. 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. 19. Nerve Conduction + EMG Nerve Conduction  EMG Study  Needles into muscles  Test speed of signal looking for defibrillation down the nerve
  20. 20. Nerve anatomy A nerve carries electricity in two directions Axons in bundles or fascicles Micro-circulation affected by pressure
  21. 21. Saltatory ConductionNode of Ranvier
  22. 22. Seddon Classification Neuropraxia  Interruption in conduction  Nerve elements normal  Recovery full  Recovery can take 6-8 weeks Axontmesis Neurotmesis
  23. 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. 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. 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. 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. 27. Surgery - CTR Under the skin lies palmar fascia There are muscles on both sides – thenar and hypothenar consisting of 3 muscles each
  28. 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. 29. Open versus endoscopic Open theoretically safer Endoscopic theoretically has faster recovery
  30. 30. Injuries J of Hand Surgery* – May 1999  Survey of members of ASSH  Endoscopic – 455 major injuries  Open – 283 major injuries * Palmer & Toivonen
  31. 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. 32. Thank You !

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