Carpal tunnel syndrome 2018 Collected by PT Osama M. M. Mansour

1. CARPAL TUNNEL SYNDROME
PRESENTED BY :
OSAMA M. M. MANSOUR

2. Objectives
✔ How to evaluate the patient clinically
✔ How to treat the patient effectively
✔ When to treat surgically

3. Contents
Definitions
Epidemiology
Etiology
Clinical Features
Physical examination
Diagnostic
Differential Diagnostics
Treatment

4. Carpal tunnel syndrome is the most common entrapment
neuropathy, results from compression or squeeze of the
median nerve at the carpal tunnel of the wrist .
Carpal tunnel is a neuro-passage in the wrist , it is
formed by wrist bones in addition to tuff band of
connective tissue called transverse carpal ligament.
Definitions

9. Epidemiology
❖ Affects an estimated 3 percent of adult Americans
❖ Three times more common in women than in men
(3female:1male)
❖ High prevalence rates have been reported in persons who
perform certain repetitive wrist motions (frequent computer
users)
✔ 30%🡪 hand paresthesias
✔ 10%🡪 clinical criteria for carpal tunnel syndrome
✔ 3.5%🡪 abnormal nerve conduction studies

10. Risk factors of Carpal tunnel syndrome
Occupational risk factors
✔ Repetitive forceful hand work with wrist
extension
✔ Plus vibration or cold environment
✔ Aircraft engine workers and metal casting
workers
✔ Appliance and automobile manufacturers
✔ Construction workers and electronic and
forestry workers
✔ Dental hygienists
✔ Fish processing and cannery workers;
✔ Frozen food/meat workers
✔ Furniture factory, garment and textile
Non-Occupational risk factors
Female gender
Age
Pregnancy
Obesity
Wrist ratio*
Family history
Renal failure/dialysis
Amyloidosis
Lipid abnormalities
Drug treatment with
aromatase inhibitors
Diabetes
Hypothyroidism
Acromegaly
Previous wrist fracture
Collagen vascular disease
Osteoarthritis of the wrist

11. Clinical Features
✔ Pain
✔ Numbness
✔ Tingling
✔ Paresthesia
✔ Burning sensation
✔ Loss of sensation
✔ Weakness in fingers flexors

12. ✔ Symptoms are usually worse at night and can awaken patients
from sleep , to relieve the symptoms, patients often “flick”
their wrist as if shaking down a thermometer (flick sign).
✔ Muscle atrophy is classically appreciated in the Abductor
Pollicis Brevis muscle”APB”, which provides bulk to the
thenar eminence. however, muscle wasting is a LATE finding
of CTS
✔ Decreased grip strength may result in loss of dexterity, and
thenar muscle atrophy may develop if the syndrome is severe.
✔ Pain and paresthesias may radiate to the forearm, elbow, and
shoulder.

13. ⁂ Note that patients with carpal tunnel syndrome often have bilateral
symptoms , but one hand tends to be more significantly affected

14. Median Nerve Supply
۞ A cool pneumonic to remember the palmar muscles that are
innervated by the Median Nerve: Meat-LOAF
⁂ Meat – Median nerve
⁂ L – Lumbricals 1 and 2
⁂ O – Opponens pollicis
⁂ A – Abductor pollicis brevis
⁂ F – Flexor pollicis brevis

15. Diagnosis

16. Phalen’s sign
Performed by maximally flexing the wrist; between 30
seconds to 1 minute of this will worsen or reproduce
pain or tingling in 80% of cases of CTS
❑ Results
✔ POSITIVE if symptoms are worsened or reproduced.
✔ NEGATIVE, of course, if they are not.

17. Tinel’s sign
Test by tapping over the carpal tunnel.
❑ Results
✔ PRESENT if paresthesias or pain in median nerve
distribution are produced by this action.
X ABSENT if not.

18. Two points discriminations
Ask the patient to close his/her eyes and then uses small instruments , such as the tips of
two opened paper clips , to touch two points (fairly close together ) on the patient’s hand
or finger
If the two points are at least 0.5 cm apart .
✔ In normal or mild case of CTS ,The patient would feel separate touches .
✔ But in sever carpal tunnel syndrome , px may not be able to tell the difference
between the two touches , so it may feel as through only one place is being touched.

19. Other diagnostic tests which are used to help confirm the
diagnosis and rule out other possible diagnoses.
Electromyography (EMG) looks at the electrical activity of
muscles, both at rest and during contraction.
‣ EMG is abnormal in ~ 70% of cases of CTS.
Nerve Conduction Velocities (NCV) measure the speed and
efficiency with which nerves are transmitting electrical
signals.
‣ NCV is abnormal in ~75-85% of CTS cases.

20. Imaging studies useful to detect rare structural anomalies
Wrist x-ray
Cervical spine MRI
Chest x-ray and/or MRI of brachial plexus

21. Differential Diagnoses
Cervical radiculopathy
Thoracic Outlet Syndrome
Pronator Teres Syndrome
Reflex Sympathetic Dystrophy
Diabetic neuropathy
Tendonitis
Tenosynovitis
Kienbock's disease
Compression of the Median nerve at the elbow

22. Conditions that have been associated with CTS
Multiple Myeloma
Rheumatoid Arthritis
Pregnancy
Amyloidosis
A/V dialysis shunts
Endocrine/Pituitary abnormalities
Hypothyroidism
acromegaly

23. Carpal tunnel syndrome during pregnancy
During pregnancy, swelling of the pregnant women hands is caused by a collection of fluid in
the tissues ,This occur by fluid retention influenced by hormonal effect especially during
second and third trimester of pregnancy .
Some of this fluid can collect in the carpal tunnel, placing pressure on the median nerve,
compressing it and causing tingling , numbness and other CTS symptoms in the hands and
fingers.
60% (60 in every 100) of pregnant women may experience symptoms of carpal tunnel
syndrome.
Symptoms vary and can range from mild to very painful, and may affect one or both hands.

24. Management
Conservative
WRIST SPLINTS
ORAL MEDICATIONS
❑ NSAIDS.
❑ Diuretics.
❑ Single dose steroid injection.
Reduce the inflammatory process
Reduction in the swelling
Improvement of symptoms.
More effective in the earlier course of the disease.
Changing the activity type
Ischaemic compression therapy (newer modality). Elimination of the trigger points
along the course of the median nerve. Symptoms improve without change in the
median nerve itself
Gabapentin, effects thereof in the treatment of symptoms of carpal tunnel syndrome
were looked at based on its efficacy in the treatment of neurologic pain.
LOCAL INJECTION
ULTRASOUND THERAPY

25. Surgical