Detailed CTS Management

2. carpal tunnel syndromecarpal tunnel syndrome
(tardy median palsy)(tardy median palsy)
• 1854 -Sir James Paget
• Carpal tunnel syndrome (tardy
median palsy) results from
compression of the median nerve
within the carpal tunnel.
• A cylindrical cavity connecting the
volar forearm with the palm.

3. • The carpal tunnel is bounded by the transverse
arch of the carpal bones dorsally, the hook of the
hamate, triquetrum, and pisiform medially, and
the scaphoid, trapezium, and fibroosseous flexor
carpi radialis sheath laterally.
• The ventral (palmar) aspect, or "roof" of the
carpal tunnel is formed by the flexor retinaculum,
consisting of the deep forearm fascia proximally,
the transverse carpal ligament over the wrist, and
the aponeurosis between the thenar and
hypothenar muscles distally.

4. Flexor retinaculumFlexor retinaculum

5. • The most ventral
(palmar) structure
in the carpal tunnel
is the median
nerve.
• Lying dorsal to the
median nerve in
the carpal tunnel
are the nine flexor
tendons to the
fingers and thumb.

6. • 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)

7. CARPAL TUNNELCARPAL TUNNEL
SYNDROMESYNDROME
.
• It occurs most often in
patients between 30 and
60 years old .
• Five times more common
in women than in men.
• Older, overweight, and
physically inactive people
are more likely to develop
carpal tunnel syndrome.
• Thenar atrophy usually is
seen later in the course of
the nerve compression

8. CARPAL TUNNELCARPAL TUNNEL
SYNDROMESYNDROME
• PREDISPOSING FACTORS.
• A malaligned Colles fracture .
• Odema from infection or trauma .
• Tumors or tumorous conditions such as a
ganglion, lipoma, or xanthoma are among the
more common.
• In the treatment of a Colles fracture,
immobilizing the wrist in marked flexion and ulnar
deviation can cause acute compression of the
median nerve within the carpal tunnel
immediately after reduction.

9. CARPAL TUNNELCARPAL TUNNEL
SYNDROMESYNDROME
• Systemic conditions such as obesity, diabetes mellitus,
thyroid dysfunction, amyloidosis, and Raynaud disease are
sometimes associated with the syndrome.
• Habitual sleeping posture at night in which the wrist is
kept acutely flexed.
• Trauma caused by repetitive hand motions has been
identified as a possible aggravating factor, especially in
patients whose work requires repeated forceful finger and
wrist flexion and extension.
• Laborers using vibrating machinery are at risk, as are
office workers, especially typists and data entry clerks, if
they spend long hours with the wrists flexed

11. CARPAL TUNNEL SYNDROMECARPAL TUNNEL SYNDROME

12. CARPAL TUNNEL SYNDROMECARPAL TUNNEL SYNDROME

13. CARPAL TUNNELCARPAL TUNNEL
SYNDROMESYNDROME
• The syndrome frequently is associated with
nonspecific tenosynovial edema and rheumatoid
tenosynovitis, as are trigger finger and de
Quervain disease..
• A biopsy specimens of the flexor tendon
synovium were typical of a connective tissue
undergoing degeneration under repeated
mechanical stress
• Kerr et al. reported that 96% of flexor synovial
biopsy specimens from 625 patients with
idiopathic carpal tunnel syndrome had benign
fibrous tissue without inflammatory changes

14. CARPAL TUNNELCARPAL TUNNEL
SYNDROMESYNDROME
• Paresthesia over the sensory
distribution of the median nerve is
the most frequent symptom;
• It occurs more often in women.
• Frequently causes the patient to
awaken several hours after getting to
sleep with burning and numbness of
the hand that is relieved by exercise
• Atrophy of thenar muscles

16. Phalen testPhalen test
• Acute flexion of the
wrist for 60
seconds in some
but not all patients
or strenuous use of
the hand increases
the paresthesia.

17. Tourniquet test,Tourniquet test,
• Application of a blood pressure cuff
on the upper arm sufficient to
produce venous distention may
initiate the symptoms.
• Because of its insensitivity and
nonspecificity, the tourniquet test
was not recommended .

18. • The wrist in neutral position, the mean
pressure within the carpal tunnel with
carpal tunnel syndrome was 32 mm Hg.
• This pressure increased to 99 mm Hg with
90 degrees of wrist flexion and to 110 mm
Hg with the wrist at 90 degrees of
extension.
• The pressures in the control subjects with
the wrist in neutral position were 25 mm
Hg, 31 mm Hg with the wrist in flexion,
and 30 mm Hg with the wrist in extension.

19. Durkan carpal compressionDurkan carpal compression
testtest
• Durkan described a "new" carpal compression
test in which direct compression over median
nerve for 30 seconds with the thumbs or an
atomizer bulb attached to a manometer.
• Patients with carpal tunnel syndrome usually
have symptoms of numbness, pain, or
paresthesia in the median nerve distribution
• Compared with the Tinel nerve percussion and
Phalen wrist flexion tests,the carpal compression
test was more specific (90%) and more sensitive
(87%).

20. • The hand diagram score,
• Semmes-Weinstein testing after a Phalen
test had the highest sensitivity.
• electrodiagnostic studies - EMG & NCV
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.

21. Electrodiagnostic studiesElectrodiagnostic studies
• Nerve conduction studies are reported to
be as high as 90% sensitive and 60%
specific for the diagnosis of carpal tunnel
syndrome.
• They also are helpful in evaluating the
upper extremity for nerve compression in
other areas, that is, the elbow, axilla, and
cervical spine, and for demonstrating
changes of peripheral neuropathy.

22. • Computed tomography displays the bony
structures clearly but not define the soft
tissues accurately
• . Ultrasonography has been used to show
the movement of the flexor tendons within
the carpal tunnel, but not clearly show soft
tissue planes.
• MRI-A major advantage of MRI is its high
soft tissue contrast, which gives detailed
images of both bones and soft tissues.

23. DIFFERNTIAL DIOGNOSISDIFFERNTIAL DIOGNOSIS
Care should be taken not to confuse
this syndrome with nerve
compression caused by
• cervical disc herniation,
• Thoracic outlet structures,
• Median nerve compression
proximally in the forearm and at the
elbow
• Peripherar neuropathy

24. TREATMENTTREATMENT
• Gelberman. proposed
that carpal tunnel
syndrome be divided
into early,
intermediate,
advanced, and acute
stages. Patients with
early carpal tunnel
syndrome without
thiner atropy and mild
symptoms responded
to steroid injection &
splinting.

25. TREATMENTTREATMENT
• Those with intermediate and
advanced (chronic) syndromes
responded to carpal tunnel release.
• Treatment of acute carpal tunnel
syndrome should be individualized,
depending on its cause.

26. • Kaplan, and Eaton identified five important
factors in determining the success of
nonoperative treatment:
• 1) age over 50 years,
• (2) duration longer than 10 months,
• (3) constant paresthesia,
• (4) stenosing flexor tenosynovitis,
• (5) a positive Phalen test result in less than 30
seconds. Two thirds of patients were cured by
medical treatment when none of these factors
was present, 59.6% with one factor, and 83.3%
with two factors; 93.2% with three factors did
not improve. No patient with four or five factors
was cured by medical management.

27. Surgical Release of CarpalSurgical Release of Carpal
TunnelTunnel
• Make a curved incision
ulnar to and paralleling the
thenar crease. Extend this
proximally to the flexor
crease of the wrist,. Angle
the incision toward the
ulnar side of the wrist to
avoid crossing the flexor
creases at a right angle
but especially to avoid
cutting the palmar sensory
branch of the median
nerve,
• Maintain longitudinal
orientation so that the
incision is generally to the
ulnar side of the long
finger axis or aligned with
the palmaris longus.

28. Surgical Release of CarpalSurgical Release of Carpal
TunnelTunnel
• Carefully divide the
transverse carpal
ligament along its
ulnar border to avoid
damage to the median
nerve and its
recurrent branch,
which may perforate
the distal border of
the ligament and may
leave the median
nerve on the volar
side

29. Take care to release all components of
the flexor retinaculum.

30. • Avoid injury to the
superficial palmar
arterial arch, about 5 to
8 mm distal to the
distal margin of the
transverse carpal
ligament.
• Inspect the flexor
tenosynovium.
Tenosynovectomy
occasionally may be
indicated, especially in
patients with
rheumatoid arthritis.
• Close only the skin and
drain the wound.

31. Surgical Release of CarpalSurgical Release of Carpal
TunnelTunnel
• Limited approaches, such
as 1-The "double incision"
of Wilson
2-The "minimal incision"
of Bromley
• , 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.

32. AFTERTREATMENT.AFTERTREATMENT.
• A compression dressing and a volar
splint are applied.
• The hand is actively used as soon as
possible after surgery, but the
dependent position is avoided.
• The splint should be maintained for
14 to 21 days.

33. Endoscopic Release ofEndoscopic Release of
Carpal TunnelCarpal Tunnel
Advantages
1)Less palmar scarring
2) Less ulnar "pillar" pain,
3)Rapid and complete return of
strength, and return to work and
activities at least 2 weeks sooner
than for open release

34. Endoscopic Release ofEndoscopic Release of
Carpal TunnelCarpal Tunnel
• 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.
• 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, (4) the
inability to control bleeding easily, and (5) the
limitations imposed by mechanical failure.

35. • Agee, McCarroll, and North developed the following 10 guidelines
to prevent injury to the carpal tunnel structures.
• Know the anatomy.
• Never overcommit to the procedure.
• Ascertain that the equipment is working properly.
• If scope insertion is obstructed, abort the single incision
procedure.
• Ascertain that the blade assembly is in the carpal tunnel and not
in the Guyon canal.
• If a clear view cannot be obtained, abort the single-incision
procedure.
• Do not explore the carpal canal with the scope.
• If the view is not normal, abort the single-incision procedure.
• Stay in line with the ring finger.
• "When in doubt, get out."

36. • The two methods
• 1-Agee "single portal"
• 2-Chow "two portal" techniques.

37. Contraindications toContraindications to
endoscopic carpal tunnelendoscopic carpal tunnel
releaserelease
• (1) The patient requires neurolysis,
tenosynovectomy, Z-plasty of the
transverse carpal ligament, or
decompression of the Guyon canal;
• (2) The surgeon suspects a space-
occupying lesion or other severe
abnormality of the muscles, tendons, or
vessels in the carpal tunnel;
• (3) The patient has localized infection or
severe hand edema, or the vascular status
of the upper extremities is tenuous

38. Contraindications toContraindications to
endoscopic carpal tunnelendoscopic carpal tunnel
releaserelease
• (4) Revision surgery for unresolved or
recurrent carpal tunnel syndrome;
• (5) Anatomical variation in the median
nerve, suggested by clinical findings of
wasting in the abductor pollicis brevis
without significant median sensory
changes; and
• (6) 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.

39. Endoscopic Carpal TunnelEndoscopic Carpal Tunnel
Release Through SingleRelease Through Single
IncisionIncision (Agee)(Agee)
• Operating room
setup is
satisfactory
• Use general or
regional
anesthesia.
Although the
procedure can be
done safely using
local anesthesia,

40. • Make the incision in the more
proximal crease between the
tendons of the flexor carpi
radialis and flexor carpi ulnaris.
• Expose the forearm fascia.
Incise and elevate a U-shaped,
distally based flap of forearm
fascia Retract this flap
palmarward to facilitate
dissection of the synovium
from the deep surface of the
ligament, creating a mouthlike
opening at the proximal end of
the carpal tunnel.

41. • When using the
tunneling tools
and the
endoscopic blade
assembly, keep
them aligned with
the ring finger,
hug the hook of
the hamate, to
protect the ulnar
nerve

42. • Define the distal edge
of the transverse
carpal ligament by
viewing the video
picture, ballottement,
and the light
transilluminated
through the skin.
Correctly position the
blade assembly and
touch the distal end of
the ligament
• .

43. Elevate the blade and withdraw
the device, incising the ligament. first
release only the distal one half to two
thirds of the ligament. Using the
unobstructed path for reinsertion of the
instrument, accurately complete the distal
ligament division with good viewing.
Complete proximal ligament division with
a final proximal pass of the elevated
blade.

45. • Inspection of incised transverse carpal ligament in
which 1) View depicts incomplete release as V-
shaped defect, with superficial fibers of transverse
carpal ligament remaining intact.
• 2) Depicts complete release of ligament after
reinsertion of blade assembly. Fat and transverse
fibers of palmar fascia that remain palmar to
divided ligament can be noted.
• 3) Demonstrates that rotating blade assembly
approximately 20 degrees in either direction causes
separated cut edges of ligament to fall into window.

46. • Tenotomy scissors used to release forearm
fascia proximal to skin incision.

47. AFTERTREATMENT.AFTERTREATMENT.
• The splint and sutures are removed at
about 10 to 14 days
• Active finger motion is allowed early in the
postoperative period
• Progression of light activities of daily living
is allowed at about 2 to 3 weeks, and
gradually more strenuous activities are
added in the next 4 to 6 weeks.

48. Endoscopic CarpalEndoscopic Carpal
Tunnel ReleaseTunnel Release
Through TwoThrough Two
IncisionsIncisions (Chow)(Chow)

49. • With a skin pencil mark the entry and exit portals

50. • Make an incision in the previously marked
entry portal. Bluntly dissect to explore the
fascia and make a longitudinal incision
through the fascia. Identify the proximal
edge of the transverse carpal ligament.
• Bluntly dissect and develop the space
between the transverse carpal ligament
and the ulnar bursa.

51. • Use the curved dissector
obturator–slotted
cannula assembly with
the pointed side toward
the transverse carpal
ligament to enter the
space and to push the
ulnar bursa free from the
deep surface of the
transverse carpal ligament
("extrabursal" approach)

52. Use the curved dissector to feel
the curved shape of the deep surface
of the transverse carpal ligament.
Move the dissector back and forth to
feel the "washboard" effect of the
transverse fibers of the transverse
carpal ligament.

53. • Advance the slotted
cannula assembly
distally and direct
toward the exit
portal.. Make a second
small incision as
marked for the exit
portal in the palm.
Pass the assembly
through the exit portal

54. • With the endoscope, having been
inserted from the proximal direction,
remaining in the tube, insert a probe
distally and identify the distal edge
of the transverse carpal ligament Use
the probe knife to cut from distal to
proximal to release the distal edge of
the ligament

58. UNRELIEVED, ORUNRELIEVED, OR
RECURRENT, CARPALRECURRENT, CARPAL
TUNNEL SYNDROMETUNNEL SYNDROME
• Arecurrence 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
• Incomplete release of the transverse carpal
ligament, reformation of the flexor retinaculum,
scarring in the carpal tunnel, median or palmar
cutaneous neuroma, palmar cutaneous nerve
entrapment, recurrent granulomatous or
inflammatory tenosynovitis, and hypertrophic
scar in the skin.

59. • Incomplete ligament release—reexplore, re-release of
transverse carpal ligament; excision, release of reformed
retinaculum
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)
Recurrent tenosynovitis—tenosynovectomy, appropriate
medical management (appropriate antibiotics in patient
with infectious granulomatous tenosynovitis from fungi, or
mycobacteria)