CTS is more common in orthopedic clinic. In some cases, surgery is needed In this presentation, from diagnosis to treatment is explained

1. CARPAL TUNNEL SYNDROME
Hamidreza zafari
Resident of Orthopedic Surgery at Tehran university Medical scince
Imam khomeyni Hospital center

2.  45-year-old female that comes to the clinic with a history of pain
with tingling and numbness in the right hand with thumb, index and
middle finger involvement that started 2 years ago while he was at
work.
 The patient describes the pain as “needles and pins”. The discomfort
gets exacerbated as he does repetitive computer work and gets
mildly relieved with handshaking and change of positions.
 Atrophy of the tenar muscles is seen on examination

3.  CARPAL TUNNEL SYNDROME is the most common upper
extremity compression neuropathy and results from median
nerve compression within the carpal tunnel
 Carpal tunnel syndrome is primarily a clinical diagnosis

4. Pisifprm
Flexor retinacolum
Trapezium
Scaphoid
Hamete

6. Risk factors
 Age : 30-60 years
 Female > male
 Overweight
 physically inactive
 Cigarette smoking
 DM
 Hypothyroidy
 RA
 pregnancy
 Jobs

7.  Distal radial fracture immobilization with the wrist in
marked flexion and ulnar deviation

8.  in most patients is idiopathic
 its direct association with work is difficult to substantiate
 involvement of the nondominant hand is frequent

9.  In children, carpal tunnel syndrome is unusual.
 predisposing factors in children:
 Macrodactyly
 lysosomal storage diseases
 strong family history
 Symptoms in children may be confusing and include
decreased dexterity and diffuse pain

10. DIAGNOSIS

11. Sensory disturbance
Weakness in thumb
abduction
Thenar atrophy

12. Physical examination
 Phalens maneuver
 Tinels sign
 Hand Elevation test
 Durkan compression test
 Two point discrimination

13.  Gentle pressure directly over carpal tunnel
paresthesias in 30 seconds or less
Better for wrists with limited motion
Highest sensitivity/specificity of all physical exam tests

14. •( > 5 mm)
•Abnormal = severe nerve compression

15. Test Sensitivity Specificity
Phalen’s 75% 62%
Tinel’s 64% 90%
Compression 87% 90%
S-W monofilament 65% 42%

16.  nerve conduction velocity (NCV) test :
measurement of the speed of conduction of an
electrical impulse through a nerve.
NCS can determine nerve damage and destruction.
Sensory latencies (DSL)>3.2ms (most sensitive)
-motor latencies(DML)>4.2ms.

17. IMAGING :
 MRI
 Sonography

18. TREATMENT

19. Non operative :
 GENERAL MEASURES
 WRIST SPLINTS
 ORAL MEDICATIONS
 LOCAL INJECTION

21. factors in determining the success of nonoperative
treatment :
1. Age older than 50 years
2. duration longer than 10 months
3. constant paresthesia
4. stenosing flexor tenosynovitis
5. positive Phalen test result in less than 30 seconds
:

22. Operative treatment

23.  The results of surgery are good in most instances
 Maximal improvement is seen in the first 6 months after carpal
tunnel release.
 thenar atrophy may disappear, it resolves slowly.
 Surgical release might not achieve complete relief of all
symptoms for patients older than 70 years or those with
advanced nerve compression.

24.  endoscopic release :
 earlier return to work
 improved strength during the early postoperative period.
 lower risk of scar tenderness compared with open release
 greater risk of nerve injury

25. Contraindications to endoscopic carpal tunnel release
include the following:
 neurolysis, tenosynovectomy, decompression of the Guyon canal
Anatomic variation in the median nerve
 localized infection or severe hand edema, or the vascular status of the
upper extremities is tenuous
 revision surgery or recurrent carpal tunnel syndrome
 previous tendon surgery or flexor injury that would cause scarring in
the carpal tunnel

26. SURGICAL RELEASE

31.  A light compression dressing and a volar splint may be
applied.
 The hand is actively used as soon as possible after surgery,
but the dependent position is avoided.
 Usually the dressing and splint can be removed in clinic 1
week after the surgery
 The sutures are removed after 14 to 21 days.
POSTOPERATIVE CARE

32.  Findings reported at reoperation include :
 incomplete release of the transverse carpal ligament
 re-formation of the flexor retinaculum
 scarring in the carpal tunnel or hypertrophic scar in the skin
 median or palmar cutaneous neuroma
 palmar cutaneous nerve entrapment
 recurrent granulomatous or inflammatory tenosynovitis

33.  Recurrent carpal tunnel syndrome was demonstrated more
often in patients with diabetes :
 incomplete release of the flexor retinaculum
 scarring of the median nerve
were common intraoperative findings in all patients