Carpal tunnel syndrome results from median nerve compression in the carpal tunnel of the wrist. It is caused by narrowing of the tunnel or swelling of its contents. Symptoms include numbness, tingling and pain in the hand and fingers. Conservative treatments include splinting and steroid injections while surgery involves cutting the transverse carpal ligament to relieve pressure on the median nerve. Recurrence after surgery can occur due to incomplete release, scarring or persistent swelling.

2. BY Dr. VEER ABHISHEK GOUD
MS ORTHO

3. DEFINITION
Carpal tunnel syndrome is a nerve disorder of the
hand resulting due to compression of the median
nerve within the carpal tunnel.
Entrapment neuropathy
Tardy median nerve palsy

5. ANATOMY-CARPAL TUNNEL
 Dorsally - Transverse arch of the carpal bones.
 Medially- Hook of the hamate, triquetrum, & pisiform.
 Laterally- Scaphoid, trapezium, & fibro-osseous flexor
carpi radialis sheath.
 Roof- Flexor retinaculum.
 Contents – median nerve(most ventral structure) & the
nine flexor tendons of the fingers & the thumb.

7. FLEXOR RETINACULUM
Proximally – deep forearm fascia
Distally –aponeurosis b/w the thenar & hypothenar
muscles
Over the wrist- the transverse carpal ligament

9. MEDIAN NERVE
 Root- C5,6,7,8 and T1.
 Along with the ulnar artery passes beneath fibrous arch of flexor
digitorum superficialis and runs deep to this muscle on the surface
of flexor digitorum profundus.
 About 5 cm above flexor retinaculum it becomes superficial and
lies between tendons of flexor carpi radialis and flexor digitorum
superficialis.
 Median nerve enters the palm by passing deep to flexor
retinaculum (through carpal tunnel).

11. MEDIAN NERVE
 Muscular branches to all superficial flexors except flexor
carpi ulnaris.
 Ant interosseus branch – flexor pollicis longus, lat half of
flexor digitorum profundus and pronator quadratus. Also
supplies distal radioulnar and wrist joints.
 Palmar cutaneous branch – skin over thenar eminence,
central part of the palm.

12. In the hand:
Divides into lateral and medial branches
Lateral division-
Muscular branch to the thenar muscles
Three digital branches, 2 for the thumb and one for the
lateral side of the index finger which also supplies the 1st
lumbrical.
Medial division-
Digital branches for the second and third interdigital
clefts, the latter also supplies the 2nd lumbrical.
MEDIAN NERVE

16. MUSCLES EXAMINED:
FLEXOR POLLICIS LONGUS:

17. OCHSNERS CLASPING TEST:

18. FLEXOR CARI RADIALIS

19. MUSCLES OF THENAR EMINENCE:
PEN TEST:
OPPONENS POLLICIS:
 Brings the tip of the thumb towards tip of the other fingers.
 Count the fingers.

20. Carpal Tunnel Syndrome

21. PATHOLOGY
• Results From Conduction Block In Medial Nerve.
• Both Ischemia And Mechanical Block Have Been Implicated.
• Initial Lesion Is Intra Funicular Anoxia.
• Due To Venous Obstruction From Pressure.

23. FACTORS INVOLVED IN THE PATHOGENESIS OF CARPAL TUNNEL SYNDROME
Anatomy:
Decrease in Size of Carpal Tunnel
 Bony abnormalities of the carpal
bones
 Acromegaly
 Flexion or extension of wrist

24. Increase in Contents of Canal
 Forearm and wrist fractures (Colles fracture, scaphoid fracture)
 Dislocations and subluxations (scaphoid rotary subluxation, lunate volar dislocation)
Posttraumatic arthritis (osteophytes)
 Musculotendinous variants
 Aberrant muscles (lumbrical, palmaris longus, palmaris profundus)
 Local tumors (neuroma, lipoma, multiple myeloma, ganglion cysts)
 Persistent medial artery (thrombosed or patent)
 Hypertrophic synovium
 Hematoma (hemophilia, anticoagulation therapy, trauma)

25. Neuropathic Conditions
 Diabetes mellitus, Alcoholism
 Double-crush syndrome
 Exposure to industrial solvents

26. Inflammatory Conditions
 Rheumatoid arthritis
 Gout
 Nonspecific tenosynovitis
 Infection

27. Alterations of Fluid Balance
 Pregnancy
 Menopause
 Eclampsia
 Thyroid disorders (especially hypothyroidism)
 Renal failure
 Long-term hemodialysis

28.  Raynaud disease
 Obesity
 Lupus erythematosus
 Scleroderma
 Amyloidosis
 Paget disease

29. CLINICAL FEATURES
 Symptoms:
 Tingling or numbness in part of the hand, relieved by shaking hand
repeatedly.
 Sharp pains that shoot from the wrist up the arm, especially at
night.
 Burning sensations in the fingers.
 Morning stiffness or cramping of hands
 Thumb weakness.
 Frequent dropping of objects.
 Inability to make a fist.
 Shiny, dry skin on the hand.

31. Signs:
 Tests for Nerve compression
 Phalen maneuver

32. Percussion test (Tinel sign)

33. Carpal tunnel compression test (Durkan)

34. Static 2-point discrimination
Determine minimal separation of two distinct points when applied to
palmar finger tip
 Failure to determine separation of at least 5 mm

35. Semmes Weinstein monofilaments-
 Monofilaments of increasing diameter touched to palmar side of digit until
patient can determine which digit is touched

36. Electromyography (EMG)
 Needle electrodes placed in muscle
 Fibrillation potentials, sharp waves, increased insertional activity

37. Thenar muscles atrophy

38. DIFFERENTIAL DIAGNOSIS:
 Tendonitis
 Tenosynovitis
 Nerve compression by cervical disc herniation
 Thoracic outlet syndrome

39. IMAGING STUDIES
X-ray and MRI
 X-ray: check for arthritis or fractured bones; not useful for detecting CTS
 MRI: to estimate severity of CTS: not used routinely but is capable of detecting
abnormalities indicative of CTS.
 CT scan- Displays bony structures but not soft tissues properly
 Ultrasonography – shows movement of flexor tendon but not soft tissues

40. NERVE CONDUCTION TEST
 90% sensitive & 60% specific
 Median nerve stimulated just proximal to the wrist & the start of muscle
AP in abductor pollicis brevis is noted
 Sensory nerve fiber conduction velocity b/w finger & the wrist is more
sensitive .
 Criteria – prolonged conduction velocity, increased duration of AP
 Criteria – motor latency >4.5 ms and sensory latency >3.5 ms
 Surface electrodes on hand and wrist
 Small elec. shocks applied to nerves in fingers, wrist, and forearm
(measure speed of conduction)

41. TREATMENT
Gelberman divided into 4 stages –
 Early
 Intermediate
 Advanced
 Acute

42. Early stage (mild symptoms, no thenar atrophy) – steroid injection into
the carpal tunnel, splinting.
TREATMENT

43.  Injection of cortisone preparations into the carpal tunnel may provide temporary
relief, Care should be taken not to inject directly into the nerve. Injection also can
be used as a diagnostic tool in patients without osteophytes or tumors in the canal.
Most of these cases are probably caused by a nonspecific synovial edema, and
these seem to respond more favorably to injection.

44. Conservative
 Rest, Ice, Heat
 Brace
 Drugs
 NSAIDS (Ibuprofen Naproxen, Aspirin):
Recommended EARLY In The Inflammation Cycle
 Corticosteroids : Decrease In Tendon Strength &
Mass Over Time

45.  Intermediate & the advanced stage – carpal tunnel
release.
 Acute stage- seen in Cole's # with flexed wrist
immobilization – relieved by the change in wrist
position / if symptoms still persisting then division of
transverse carpal ligament.

46. SURGERY
Open technique
 Limited approach – Double incision of Wilson & the
minimal incision of Bromley
Endoscopic release –
 Agee’s single portal &
 the Chow’s two portal technique

47. OCTR ECTR LIT
Prox 1 portal 2 portal
Agee Chow Bromley
1 incis.
Carpal tunnel release - techniques

48. OPEN TECHNIQUE
 Curved incision ulnar to & paralleling the
thenar crease
 Extending proximally to the flexor crease of
the wrist
 Angle the incision towards the ulnar side of
the wrist to avoid palmar sensory branch of
median nerve

49. Classical incision

50. Procedure
 Dissect proximally identify deep fascia of forearm, incise avoiding median
nerve beneath.
 Divide transverse carpal ligament along its ulnar border to avoid damage
to the median nerve.
 Release all components of the flexor retinaculum.
 Avoid injury to the palmar arterial arch which is 5 to 8 cms distal to the
distal margin of the transverse carpal ligament.
 Only skin closure.

51. WILSON’S DOUBLE INCISION
 Transverse incision proximal to the ant
wrist crease b/w FCU & FCR tendon
 Distal longitudinal incision b/w proximal
palmar crease & 1 cm distal to hamate hook
in line with radial border of ring finger

52. POSTOP TREATMENT
 Compression dressing
 Volar splint- 2 weeks
 Immediate hand & finger movements
 Suture removal – after 10-14 days
 Light daily activities- 2 to 3 weeks
 Gradual initiation of strenuous activities- next 4 to 6 weeks

53. ENDOSCOPIC RELEASE
Advantages
Small incision
Single
suture
Fast rehabilitation Better cosmetic result

54. Disadvantages
 Technically demanding
 Limited visual field
 Vulnerability of the median nerve, flexor tendons &
superficial palmar arterial arch
 Inability to control bleeding

55. Contraindications for ECTR
 Patient who requires additional procedure- neurolysis,
tenosynovectomy.
 Space occupying lesion.
 Localized infection or hand edema.
 Recurrent carpal tunnel syndrome.
 Anatomical variations in the median nerve.
 Scarred tunnel due to previous tendon surgery or flexor injury.

56. AGEE’S TECHNIQUE
Single portal:
Incision over the proximal wrist flexion crease between the tendons of
flexor carpi ulnaris and flexor carpi radialis.

57. CHOW’S TECHNIQUE

58. RECURRENT CARPAL TUNNEL SYNDROME
 Good results seen in 50%
 Fair results in 1/3rd
 Complications and failures between 3% and 19%
 Symptoms may lead to reoperation in 12%

59. RECURRENCE-FACTORS
 Incomplete release of transverse carpal ligament
 Reformation of flexor retinaculum
 Scarring in the carpal tunnel
 Recurrent tenosynovitis

60. TREATMENT OF RECURRENCE
 Incomplete ligament release- re-explore & re-release of ligament
 Excision and release of flexor retinaculum
 For fibrosis or painful scar-epineurolysis, local muscle flaps, free fat grafts
 Excision & Z plasty of painful scar
 Recurrent tenosynovitis- tenosynovectomy, appropriate medical
management