Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel at the wrist. It is often associated with repetitive hand motions or conditions that cause swelling. Symptoms include numbness, tingling, and pain in the hand and fingers. Diagnosis involves physical exam maneuvers like Tinel's sign and Phalen's test as well as nerve conduction studies. Conservative treatment involves splinting, anti-inflammatories, and corticosteroid injections. Surgery to cut the transverse carpal ligament is considered if conservative measures fail. Endoscopic surgery is an option but has limitations including risk of injury compared to open surgery.
2. Carpal tunnel syndrome
• Described in 1854 by Sir James
Paget,
• However term was first coined by
Moerisch
• Also called (tardy median palsy)
2
3. Carpal Tunnel
• The carpal tunnel is
formed between the
carpal bones of the
wrist and the
transverse carpal
ligament.
• The ligament is an
unyielding thick
fibrous tissue which
does not allow for
changes in volume
within the carpal
tunnel.
5. • This syndrome consists of motor
,sensory ,vasomotor and trophic
symptoms in hand caused by
compression of median nerve in
carpal tunnel
5
6. Motor changes
• Motor changes ; ape thumb deformity
• Loss of opposition of thumb
• Index and middle finger lag behind
while making fist
6
7. Motor changes
• Vasomotor changes
• The skin area with sensory loss is
warmer due to arteriolar dilatation
• And also drier due to loss of
sympathetic supply
7
8. • Trophic changes
• Long standing cases of paralysis lead
to dry and scaly skin
• Nails crack easily with atrophy of
pulp of fingers
8
9. • The syndrome consists predominantly
of tingling and numbness in the
typical median nerve distribution in
the radial three and one-half digits
(thumb, index, long, radial side of
ring).
9
10. Carpal tunnel
• A cylindrical cavity connecting the
volar forearm with the palm,
• 9 tendons and one nerve passes
through this tunnel
10
11. boundaries
• Carpal tunnel is bounded by bones
from 3 sides and ligament on one
side
• Floor is formed by osseous arch and
roof is formed by transverse carpal
ligament
11
12. Boundaries
• The most ventral (palmar) structure
in the carpal tunnel is the median
nerve
• Lying dorsal (deep) to the median
nerve in the carpal tunnel are the
nine flexor tendons to the fingers
and thumb
12
13. Risk factors
• Risk factors for the condition include female,
• diabetes,
• hypothyroidism,
• obesity,
• pregnancy,
• rheumatoid arthritis,
• gout,
•
13
15. Work Related
Repetitive Task Profession
Grabbing & tugging cloth Tailor, sewer
Handling objects on conveyor belt Assembly-line worker
Hand weeding Gardener
Using spray gun Painter
Knitting Homemaker
Turning keys Locksmith
Typing Clerical worker
Using scanner at checkout counter Cashier
Scrubbing Janitor
Stringed instruments Musician
16. Non-Work Related
Arthritis
Diabetes
Thyroid gland imbalance
Gout
Broken or dislocated bones of the wrist
Hormonal changes associated with menopause
Oral use of contraceptives
Pregnancy
Wrist cysts
Gynecological surgery
17. Pathophysiology
The tendons of the hands are wrapped with a lining that
produce a synovium fluid which lubricates the tendons
With repetitive movement of the hand, the lubrication
system may malfunction
This reduction in lubrication results in inflammation and
swelling of the tendon area
Abnormally high carpal tunnel pressures exist in patients
with CTS.
This pressure causes obstruction to venous outflow, back
pressure, edema formation, and ultimately, ischemia in
the nerve.
18. symptoms
• Pain, described as deep, aching, or
throbbing, occurs diffusely in the
hand and radiates up the forearm.
• Thenar atrophy usually is seen later
in the course of the nerve
compression.
18
19. symptoms
• The classic complaint from the
patient bothered by carpal tunnel
syndrome is paresthesias at night.
• Paresthesias are typically tingling or
numbness in the median nerve
distribution of the hand.
19
20. symptoms
• Secondary symptoms include
paresthesias encountered while
holding a book or newspaper (“reading
paresthesias”)
• or paresthesias encountered while
driving (“driving paresthesias”).
Other complaints vary from
“clumsiness” of the hands, such that
objects are often dropped and fine
digital tasks are difficult
20
21. • When carpal tunnel syndrome occurs
in pregnant women, the symptoms
usually resolve after delivery
21
22. diagnosis
• The diagnosis of carpal tunnel
syndrome is based on information
gathered from the history,
• physical examination,
• and electrodiagnostic studies
22
23. Tinel sign
• The Tinel sign also may be
demonstrated in most patients by
percussing the median nerve at the
wrist.
23
24. Phalen test
• Acute flexion of the wrist for 60
seconds in some but not all patients
or strenuous use of the hand
increases the paresthesia.
24
25. Venous engorgement
• Application of a blood pressure cuff
on the upper arm sufficient to
produce venous distention may
initiate the symptoms.
25
26. Findings by Gellman et al.
• The most sensitive test was the
wrist flexion test, whereas nerve
percussion was the most specific and
the least sensitive.
• Tourniquet test: Because of its
insensitivity and nonspecificity, the
tourniquet test was not
recommended 26
27. Pressure changes in
different wrist positions
• wrist in neutral position, the mean
pressure within the carpal tunnel in
patients patients with carpal tunnel
syndrome usually >30 mmhg. ( normal
25mmhg)
27
29. • It has been established that venous
blood flow and axonal transport
within the median nerve is
compromised with carpal tunnel
pressures of 30 mm Hg.
29
30. Pressures in excess of 30 m Hg have
been shown in the patient who
frequently flexes and extends the
wrist, pronates and supinates the
forearm, or repeatedly grasps
objects
30
31. • The consequence of chronic
compression causes damage to the
epineural covering of the median
nerve resulting in diminished
conduction velocity.
31
32. Durkan test
• carpal compression test in which
direct compression is applied to the
median nerve for 30 seconds with the
thumbs . Patients with carpal tunnel
syndrome usually have symptoms of
numbness, pain, or paresthesia in the
median nerve distribution.
32
33. compared with the Tinel nerve
percussion and Phalen wrist flexion
tests, the carpal compression test is
more specific (90%) and more
sensitive (87%) than either of these
tests
33
34. Hand diagram
• Patient marks site of pain or altered
sensation on outlined hand diagram
• Positive result marking on palmar site
of radial digits without marking on
palm
• Sensitivity .96
• Specificity .73
34
35. Direct measurement of
C.T pressure
• Infusion catheter placed in carpal
tunnel
• Hydrostatic pressure in resting
phase >25
35
36. static 2 point
discrimination
• Determine minimal separation of 2
distinct points when applied to
palmar finger tip
• Failure to determine seperation of
at least 5 mm
• Tests advanced nerve dysfunction
36
38. Vibrometry
• Vibrometer placed on palmer side of
digit
• Amplitude at 120 Hz ,increased to
perception
• Results ;asymmetry compared with
contra lateral hand
38
39. Semmes –Weinstein mono
filament
• Monofilaments of increased diameter
touched to palmer side of digit until
patient can determine which digit is
touched
• Positive result value of >2.83
39
40. • Distal sensory and latency conduction
velocity
• Distal motor and latency conduction
velocity
40
41. Electro diagnostic tests
• Electro diagnostic tests include the
nerve conduction velocity (NCV)
measurements and the
electromyogram (EMG).
41
42. • The NCV is considered positive for
carpal tunnel syndrome when the
median motor distal latency is >4.5
ms or the distal sensory latency is
>3.5 ms
• In more advanced cases, diminished
action potential may also be seen
42
43. • Nerve conduction studies are
reported to be as high as 90%
sensitive and 60% specific for the
diagnosis of carpal tunnel syndrome
43
44. Electro myography
• Needle electrodes placed in muscle
• Positive results : fibrillation potential
,sharp waves, increased insert ional
activity
• Interpretation advanced motor
median nerve palsy
44
45. • On the EMG portion of the study,
the presence of positive sharp waves,
increased insertional activity,
decreased muscle recruitment, or
polyphasic activity is indicative of
substantial nerve dysfunction.
45
46. • According to some authors, electro
diagnostic studies are reliable
confirmatory tests. However, these
studies occasionally are normal when
clinical signs of carpal tunnel
syndrome are present, and they may
be abnormal in asymptomatic
patients.
46
47. Ct scan
• Computed tomographic scanning
displays the bony structures clearly
but does not define the soft tissues
accurately
47
48. Ultrasonography
• Ultrasonography has been used to
show the movement of the flexor
tendons within the carpal tunnel, but
it does not clearly show soft tissue
planes.
48
49. MRI
• Early reports of magnetic resonance
imaging (MRI) in carpal tunnel
syndrome are promising. A major
advantage of MRI is its high soft
tissue contrast, which gives detailed
images of both bones and soft
tissues.
49
51. • five important factors in determining
the success of nonoperative
treatment:
• (1) age over 50 years,
• (2) duration longer than 10 months,
51
52. • (3) constant paresthesia,
• (4) stenosing flexor tenosynovitis,
and
• (5) a positive Phalen test result in
less than 30 seconds
52
53. • No patient with four or five factors
was cured by medical management
53
54. • Gelberman et al. proposed that carpal
tunnel syndrome be divided into
early, intermediate, advanced, and
acute stages. Patients with early
carpal tunnel syndrome and mild
symptoms responded to steroid
injection.
54
55. • Those with intermediate and
advanced (chronic) syndromes
responded to carpal tunnel release.
55
56. • Treatment of acute carpal tunnel
syndrome should be individualized,
depending on its cause.
56
57. • For carpal tunnel syndrome caused by
an acute increase in carpal tunnel
pressure (such as after a Colles
fracture treated with flexed wrist
immobilization), relief may be
obtained by a change in wrist position
without surgical release of the
tunnel.
57
58. treatment
• The mainstay of non operative
management is nocturnal splinting,
• particularly for mild or moderate
carpal tunnel syndrome. When
consistently used for a period of 4 to
6 weeks, permanent relief of
symptoms can ensue.
58
59. • Other non operative measures
include non steroidal anti-
inflammatory agents (NSAIDs),
• carpal tunnel injections,
• ultrasound, phonophoresis,
• nerve gliding or stretching,
• and vitamin B6.
59
60. Carpal tunnel injections
• If mild symptoms have been present
and there is no thenar muscle
atrophy, the injection of
hydrocortisone into the carpal tunnel
may afford relief.
• Great care should be taken not to
inject directly into the nerve
60
61. • Injection also can be used as a
diagnostic tool in patients without
bony or tumorous blocking of the
canal; well over 65% of these cases
probably are caused by a non specific
synovial oedema, and these respond
to injection treatment
61
62. • Injection also helps to eliminate the
possibility of other syndromes,
especially cervical disc or thoracic
outlet syndrome
62
63. • Injection is indicated in patients with
• Disease duration of less than 1 year
• No sensory deficits
• No marked thenar wasting
63
64. • In injection therapy a single dose of
cortisone with splinting for 3 weeeks
is tried
64
65. Indications of operative
treatment
• Surgical treatment of carpal tunnel
syndrome is considered when two of
the following criteria are meet
following at least a 3-month course
of nonoperative care:
• persisting symptoms,
• positive physical examination,
• and positive electrodiagnostic
testing. 65
66. Absolute indications
• Absolute indications for surgery are
constant paresthesias,
• Thenar atrophy, and markedly
delayed median motor nerve
conduction velocity
• or abnormal EMG testing
66
67. • The surgical procedure consists of
increasing the volume of the carpal
canal by transecting the transverse
carpal ligament.
67
68. • An MRI study has shown that division
of the transverse carpal ligament
expands the volume of the carpal
canal by as much as 25%.
68
69. Surgical release of carpal
tunnel
Endoscopic release of carpal tunnel
Limited approaches
1 double incision" of Wilson
2 minimal incision" of Bromley
69
71. Transverse incision proximal to the anterior
wrist crease between flexor carpi ulnaris
and flexor carpi radialis tendons. Distal
longitudinal incision made between
proximal palmar crease and 1 cm distal to
hamate hook in line with radial border of
ring finger. B, Incision used for minimal-
incision approach.
71
72. Endoscopic Release of
Carpal Tunnel
• Endoscopic carpal tunnel release is
now being used by many surgeons to
treat carpal tunnel syndrome.
72
73. • . However, numerous anecdotal
reports of intraoperative injury to
flexor tendons, to median, ulnar, and
digital nerves, and to the superficial
palmar arterial arch raise concerns
about the safety of this procedure
73
74. Problems
• Problems related to endoscopic carpal
tunnel release include
• (1) a technically demanding procedure,
• (2) a limited visual field that prevents
inspection of other structures,
• (3) the vulnerability of the median nerve,
flexor tendons, and superficial palmar
arterial arch,
•
74
75. Problems with endoscopic
release
• (4) the inability to control bleeding
easily, and
• (5) the limitations imposed by
mechanical failure.
75
76. • Although Endoscopic technique has
proved to be effective, it is doubtful
that it should be used in every
patient with carpal tunnel syndrome.
Consideration always should be given
to an open technique if endoscopic
release cannot be accomplished
safely.
76
77. contraindications
• contraindications to endoscopic carpal tunnel
release include
• (1) the patient requires neurolysis,
tenosynovectomy, Z-plasty of the transverse
carpal ligament; (2) the surgeon suspects a space-
occupying lesion or other severe abnormality of
the muscles, tendons, or vessels in the carpal
tunnel; and
• (3) the patient has localized infection or severe
hand edema, or the vascular status of the upper
extremities is tenuous
77
78. • . Fischer and Hastings add contraindications to
the use of endoscopic technique as follows:
• (1) revision surgery for unresolved or recurrent
carpal tunnel syndrome;
• (2) anatomical variation in the median nerve,
suggested by clinical findings of wasting in the
abductor pollicis brevis without significant median
sensory changes; and
78
79. • (3) previous tendon surgery or flexor
injury that would cause scarring in
the carpal tunnel, preventing the
safe placement of the instruments
for Endoscopic carpal tunnel release.
79
80. UNRELIEVED, OR
RECURRENT, CTS
• In a series of explorations of
patients who had undergone previous
carpal tunnel surgery, Langloh and
Linscheid reported good results in
one half and fair results in one third
80
81. • They estimated a recurrence rate of
1.7% after primary carpal tunnel
release. Complications and failures
are estimated to be between 3% and
19%. Symptoms may lead to repeat
operation in 12% of patients
81
82. Causes of recurrent CTS
• incomplete release of the transverse
carpal ligament,
• reformation of the flexor
retinaculum, scarring in the carpal
tunnel,
• median or palmar cutaneous neuroma,
82
83. • palmar cutaneous nerve entrapment,
recurrent granulomatous
• or inflammatory tenosynovitis, and
hypertrophic scar in the skin
83
84. treatment
• Incomplete ligament release—
reexplore, re-release of transverse
carpal ligament; excision, release of
reformed retinaculum
84
85. • Fibrosis or painful scar—
epineurolysis, local muscle flaps, local
or remote free fat grafts, excision,
Z-plasty of painful scar, nerve
wrapping or interposition materials
(silicone sheet, vein wrap
85
86. • Fibrosis or painful scar—
epineurolysis, local muscle flaps, local
or remote free fat grafts, excision,
Z-plasty of painful scar, nerve
wrapping or interposition materials
(silicone sheet, vein wrap
86
87. • Recurrent tenosynovitis—teno
synovectomy, appropriate medical
management (appropriate antibiotics
in patient with infectious
granulomatous tenosynovitis from
fungi, or mycobacteria)
87
