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Carpel tunnel syndrome
- 1. CARPEL TUNNEL SYNDROME DR. GOVIND GAIKWAD
- 2. DEFINITION AN entrapment neuropathy is defined as a pressure or pressure induced injury bto to a segment of a segment of peripheral nerve secondary to anatomic or pathologic structure. prevalence- men-2% , women- 3% Earliest description - sir James Paget 1854, 1880 Putnam- 30 patients series Surgical treatment- 1993
- 3. pathophysiology Increased pressure within the canal Decreased space Increased contents Pressure @30mmhg- Impair Axonal transport @30-40mmhg- paraesthesia @50mmhg- Axonal block @60mmhg-complete intraneural block ischaemia, sensory, motor block
- 4. Anatomy of carpel tunnel Definition - A fibro-osseous tunnel in the anterior aspect of the wrist that is formed by the carpel bones and flexor retinaculum (carpel tunnel ligament) Floor -volar radiocarpel ligament and other bridging ligaments Attachments- Medial-pisiform and hook of hamet Lateral -tubercle of scaphoid Roof- transverse carpel ligament Attachments -medial-pisiform and hook of hamet Lateral- tubercle of scaphoid
- 5. Length-4-6cm Thickness-2.5-3.5cm Width- 3-4cm Contents - Median nerve and its vascular bundle 9 tendons FDS-4, FDP-4, FPL-1
- 6. MEDIAN NERVE ORIGIN- Median and lateral cord Course Arm - Medial aspect with BA and BV Cubital fossa -MBBT Forearm - between Two head of prpnater teres Deep surface of FDS Sublimusbridge @CT- Superficial to FDS Deep to PL tendon
- 7. Branches of median nerve Medial palmar cutaneous nerve- 5cm proximal to the TCL Recurrent motor branch- Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis Digital palmar branches Lateral two lumbricals Sensory to palmar surface and distal dorsal surface of index, middle n lat ½ ring finger
- 8. Entrapment sites Arm - struther’s ligament Bicipital aponeurosis Forearm - pronaters teres - sublimus bridge Hand - carpel tunnel
- 9. Conditions a/w CTS METABOLIC-DM, Pregnancy, hypothyroidism, acromegaly, B6 deficiency, renal failure AUTOIMMUNE/INFLAMMATORY-RA,Sarcoidosis, amyloidosis, tenosynovits ANATOMIC -persistent median artery, anomalous tendon or muscle,congenital stenosis, #/dislocation @wrist INFECTIONS-septic arthritis, Lymes disease, TB, Histoplasma NEOPLASM- Ganlion cyst, nerve sheath tumors
- 10. CLINICAL PRESENTATION Pain and paraesthesia Nocturnal burning pain Predisposing factors Wheel chair athletes , bicyclers, archers, bodybuilders, wrestlers, golfers,football players Alcoholism Familial CTS
- 11. EXAMINATIONS INSPECTION- Entire shoulder and limb Asymmetry and atrophy Palpation- Entire length of nerve Point of tenderness Bony abnormality
- 13. HAND MUSCLES- LOAF muscles Lumbricals 1,2 Opponans pollicis APB FPB
- 14. SENSORY EXAMINATION SW filaments Vibrations testing
- 15. Provocative maneuvers Tinels sign Phalens test Reverse phalens test Pressure provocation test Durlhan compression test Gilliat torniquet test Ultrasonic stimulations test
- 16. Electrophysiological testing NCS Palamr sensory latency Distal motor latency Sensory Nerve action potential SNAP EMG -APB Spontaneous fibrillation potential Positive sharp waves MUP
- 17. IMAGING X RAYS -#, Dislocation, SCP. USG- Nerve cross section >10mm @pisiform MRI- STIR MRN
- 18. MEDICAL MANAGEMENT WRIST SPLINTING PHYSICAL THERAPY LIFESTYLE MODIFICATIONS US THERAPY DIURETICS NSAIDS STEROIDS LASER THERAPY
- 19. SURGICAL MANAGEMENT OPEN TECHNIQUE Goal- complete division of TCL Preservation of motor and sensory branch AX Position Incision -3-4cm starting @distal skin crease to @ point intercepting a imaginary line drawn from distal bank of extended thumb to pisiform prominence Layers - skin, subcut fat, Palmar fascia DIVISION @ MIDPOINT OF TCL
- 20. ENDOSCOPIC CTR UNIPORT-Agee and Okutsu BIPORT- CHOW and BROWN