This document summarizes carpal tunnel syndrome (CTS), including its anatomy, pathogenesis, etiology, symptoms, clinical tests, treatments, and other related topics. It describes how CTS is caused by compression of the median nerve as it passes through the carpal tunnel. Common causes include repetitive hand motions, anatomical abnormalities, medical conditions like diabetes or hypothyroidism. Clinical tests for diagnosing CTS include Phalen's test and Tinel's sign. Treatments may involve splinting, corticosteroid injections, surgery such as open or endoscopic carpal tunnel release. De Quervain's tenosynovitis and tuberculous tenosynovitis are also summarized.

1. CARPAL TUNNEL
SYNDROME

2. • Original description of median nerve compressive neuropathy was reported by
PAGET in 1854.
• MOERSCH was first to coin the term ‘carpal tunnel syndrome’

3. ANATOMY
• Formed by transverse carpal ligament(TCL) or flexor retinaculum is quadrangular
spanning the concave carpal arch and contains flexor tendons and median nerve.
• TCL is attached to triquetrum and hamate on ulnar aspect and to tubercles of
trapezium and scaphoid on radial aspect.
• Roughly has a hour glass shape.
• At the distal end of TCL median nerve divides to recurrent motor branch to thenar
muscles and into sensory branches.

7. PATHOGENESIS
• Onset of compression of median nerve triggers a breakdown of the blood-nerve
barrier which produces endoneurial edema resulting in perineural fibrosis.
• Sustained compression then leads to localised demyelination which then
becomes diffuse resulting in features of classic CTS.

8. ETIOLOGY
• Normal pressure -2.5 mm of hg
• This can reach upto 30 mm or even in flexion extention of notmal hands.
• Causes can be divided into five main categories
1. Idiopathic- 80 percent
2. Factors increasing the volume of carpal tunnel
1. Factors outside the nerve
2. Factors within the nerve
3. Extrinsic factor that alter contour of tunnel
4. Exertional/overuse conditions
5. Neuropathic factors

9. 1. Increasing the volume –
OUTSIDE THE NERVE – conditions altering the fluid balance – hypothyroidism,pregnancy,renal failure
- inflammatory conditions-Rhematoid arthritis,gout,amyloidosis,tubercular
tenosynovitis
- tumors and swellings like ganglion ,lipoma and fibroma
-Anatomical anomilies like aneurysm of median nerve
-Hematological conditions :Hemophilia,Von willebrand’s disease,acute leukemia
-Post –traumatic: traction neuropathies high pressure injection injuries
WITHIN THE NERVE –Tumor and Tumor like lesion: Schwannoma,neurofibroma,synovial sarcoma
2. Extrinsic factors that alter the contour
-distal radius fractures (acute and malunited)
3. Exertional and overuse
4. Neuropathic factors – diabetes,myeloma,alcoholism,nutritional deficiency.

10. SYMPTOMS
• Dull aching pain in hand ,forearm or upper arm.
• Paresthesia in hand
• Weakness or clumsiness of hand
• Dry skin, swelling or color changes in hand
• Occurrence of any of above in median distribution
• Provocation of symptoms in
1. Sustained hand or arm positions
2. Repetitive actions of hand or wrist.
3. Sudden change of hand posture or shaking the wrist.

11. CLINICAL TESTS
PROVOCATIVE TESTS
1. Phalen test – Forearm vertical and wrist in flexion for one minute- tingling and
numbness in median nerve area.
2. Reverse phalen-wrist and fingers actively extended fir 2 minutes-tingling and
numbness in median nerve area.
3. Tinel sign – Examiner percusses over median nerve at wrist lightly-shock like
sensation
4. Durkan test- press the carpal tunnel for 30 seconds produces tingling and
numbness
5. Gilliat test- tourniquet inflated to systolic pressure around arm for 60 seconds

12. SENSORY EVALUATION
1. Static two point discrimination
2. Moving two point discrimination
3. Tuning fork test

13. QUESTIONNAIRES
1. Katz – patient asked to fill questionnaires.
2. Boston questionnaire.

14. ELECTRODIAGNOSTIC STUDIES
• Criteria for diagnosis in Electro myography- two or more
1. prolonged conduction velocity of median nerve across wrist-normal 10-18 msec
2. Increased duration of action potential
3. Polyphasic contour - normally biphasic

16. SENSORY NERVE CONDUCTION VELOCITY
• More sensitive test
• Nerve conduction velocity between finger and wrist is normally 2-4msec
• Time prolonged two to three times.
• Amplitude (normal-10-30) is reduced.

17. RADIOLOGICAL INVESTIGATIONS
1. X-rays –
• Reflect bony causes like perilunate injury or malunited distal radius which alters shape
of carpal tunnel.
• Carpal tunnel view-palm kept on cassette and wrist hyperextended, xray beam along
volar aspect to a point 2.5 cm distal to base of forth metacarpal at an angle 25-30
degree to long axis.

19. USG AND MRI
• USG can be used as a screening tool along with MRI.
• In MRI we look for cross sectional area of median nerve in carpal tunnel and a
ratio of cross sectional area of median nerve at level of pisiform and distal radius
are used.
• The area at inlet for diagnosis is taken as less than 10.7 square mm.

20. TREATMENT- NON OPERATIVE
KAPLAN,GLICKEL AND EATON -331 patients
Gave 5 important factors in determining success of non operative 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.

21. NON OPERATIVE
1. Splinting
2. Corticosteroid injection
3. NSAID’s and pregabalin
4. Nerve gliding exercises

24. SURGERY
• MINI PALM OPEN CARPAL TUNNEL RELEASE
• EXTENDED OPEN CARPAL TUNNEL
• ENDOSCOPIC RELEASE

25. MINI PALM OPEN RELEASE

27. DE QUERVAIN’S TENOSYNOVITIS
• Fritz De Quervain initially described the condition in 1895.Also known as
washerwoman’s sprain.
• Basically a tenosynovitis involving the abductor pollicis longus and extensor
policis brevis.
• Repetitive wrist movements has been proposed as a causative factor.

28. CLINICAL FEATURES
• Pain and swelling are classical symptom.
• Persistent swelling may cause thickening of the tendons and may give rise to a
locking phenomenon.
• Finkelstein’s test – It is performed by grasping the patient’s thumb and quickly
deviating the hand and wrist ulnarly.
• Eichoff’s maneuver – pain that is exacerbated by passive wrist ulnar deviation
while the thumb is flexed and the fingers curled around it.This is more specific.

29. DIFFERENTIAL DIAGNOSIS
• 1st carpometacarpal joint arthritis
• Kienbock’s disease
• Scaphoid fracture
• Radioscaphoid arthritis

30. TREATMENT
• Initial treatment is by splinting the forearm in a volar splint.
• Corticosteroid injections into tendon sheath if it fails to respond to a trial of splinting and
analgesics.Repeated corticosteroid injections are avoided since it may produce skin
depigmentation and fat atrophy.
• Resistant cases: slitting the tendon sheath .
1. Transverse insicion /longitudnal/oblique incision along the skin crease is used.
2. Care is taken to protect the superficial branch of radial nerve(damage can cause a painful
neuroma)
3. The abductor pollicis longus and extensor pollicis brevis tendon is identified and divided.
4. Slitting of the tendon sheath should be done on ulnar side to prevent volar subluxation of
tendons(Burton and Litter)

31. COMPLICATIONS OF SURGICAL RELEASE
• Injury to superficial branch of radial nerve,volar subluxation of first dorsal
compartment muscles and hypertrophic scar formation.
• Persistent pain from inadequate decompression often represents failure to
recognise and release an additional compartment ,most commonly that of
extensor pollicis brevis.

32. COMPOUND PALMAR GANGLION (ACREL IN 1977)
• Extrapulmonary tuberculous involvement of the musculoskeletal system is uncommon,
accounting for only 10% of tuberculosis (TB) cases.
• Although the tendon sheaths constitute an uncommon target of extra-articular TB, it
remains the leading cause of chronic tendon sheath infection.
• The diagnosis of tuberculous synovitis is usually delayed as it mimics many other
conditions , which can lead to complications.
• Many complications of tuberculous tenosynovitis have been reported in the
literature due to delayed presentation and diagnosis.

34. DEFINITIONS
• Tenosynovitis- It is an inflammation of synovial sheath that encloses the tendon.
• Tendinosis-
• It is chronic degenerative changes in the tendons without clinical or histopathologic
sign of inflammation within the tendon .
• Tendinitis-
• Inflammation of the tendon is called as tendinitis.
• Peritendinitis-
• In peritendinitis the inflammation takes place in
the paratendon, the layer of connective tissue that wraps around the tendon in the absence of
a synovial sheath

35. INCIDENCE
Mycobacterium tuberculosis remains a top-10 cause of death worldwide, with greater than
2 billion active cases occurring mostly in developing countries.
•Tuberculous tenosynovitis is a rare complication of the primary tuberculosis.
•Isolated tuberculous disease of synovial sheaths or bursa occur rarely.

36. PRECIPITATING FACTORS
1.Trauma
2.Overuse of the joint
3.Old age
4.Low socioeconomicstatus
5.Malnutrition
6.Alcoholism
7.Immunosuppression
8.Steroid injection

37. CLINICAL FEATURES
1.Progressive swelling,the swelling is doughy with semifluctuation, creaking or crepitations are palpable on movement/fluctuation.
2.Mild pain
3.Diminished range of motion
4.Local warmth
5.Mild tenderness
6.Local sinus tract formation
7.Cold abcess
8.Regional lymphadenitis
9.Paresthesia due to median nerve compression
10. Associated history of fever, loss of weight or appetite, night sweats, malaise or fatigue may be present.

38. DIAGNOSIS
Diagnosis in early stage may be difficult.
1.History
2.General examination
3.Local examination
4.Systemic examination
5.Investigation-1. ESR ,CRP
1.USG
2.PLAIN XRAY
3.MRI
4.FNAC
5.BIOPSY AND HISTOPATHOLOGICALEXAMINATION
AND CULTURE OF ORGANISM-CONFIRMATORY TEST

39. XRAY CHANGES
Soft tissue swelling with or without calcification.
•Osteopenia may be observed, indicating areas of hyperemia.
• In chronic cases, joint space narrowing and osseous erosions may be seen.

40. TREATMENT
Conservative management
1. Immobilisation in functioning position
2. Intermittent exercise
3. Antitubercular drug for 9 to 12 months.
4. In the presnce of large fluid ,aspiration and instillation of
streptomycin combined with isoniazid is useful.

41. • Surgical debridement

42. • Thank you