Nerve conduction affections of the hand.

1. Dr. Angelo Smith M.D
WHPL
CARPAL TUNNEL
SYNDROME

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

3. FEATURES • Nerve Entrapment
• Middle or Advanced age
• > 40 yrs (>80%)
• 2x in women
• ? Occupational Disease

9. MEDIAN NERVE – MOTOR INNERVATION:
1st
and the 2nd
lumbricals
Muscles of thenar eminence:
1. Opponens pollicis brevis
2. 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.

10. 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).

11. 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).

12. Finger lag when making a fist
Ape thumb

14. 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.

15. 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.

16. 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.

17. • 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.

18. 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.

20. 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.

21. 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.

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

24. MANAGEMENT
IMMOBILISING BRACES / SPLINT
Stretching 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 pressure
Orally administered diuretics ("water pills") can decrease swelling.

26. 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).

27. 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

28. 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

29. Open Release Endoscopic Release

30. OPEN SURGERY

31. OPEN SURGERY

34. 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

35. 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.