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Carpal tunnel syndrome ⁉️🤔

‫💥 عاوزك قبل ما تبدأ تقرأ الموضوع عاوزك تشوف الفديوز إللي هحطلك‬
‫لينكاتهم تحت االول هيكون فديو تشريح والتاني فديو توضيحي للموضوع‬
https://youtu.be/07DFZyulaYY
https://youtu.be/cEO5YG8Y554
💥Summary
✅Carpal Tunnel Syndrome is a compressive neuropathy of the
median nerve at the level of the wrist
✅Diagnosis is made by clinical signs and symptoms (night
pain, hand weakness/clumsiness, numbness in median nerve
distribution) and positive provocative tests (i.e Tinel's,
Durkan's)
✅Treatment is generally conservative with night splints and
injections with carpal tunnel release reserved for refractory
cases
💥Epidemiology:
💁Most common entrapment neuropathy (90% of all cases)
💁affects 0.1-10% of general population

💥Etiology:
💁CTS is caused by compression of the median nerve in the
carpal tunnel, under the transverse carpal ligament

💥Risk factors
💁Previous fracture of the wrist
💁Traumatic dislocation of the lunate
💁Manual work: increased risk in workers using vibrating tools
or prolonged, forceful, and repetitive flexion/extension of the
wrist
💁Rheumatoid arthritis and other types of chronic
inflammation of the tendon sheaths
💁Pregnancy and puerperium:Pregnant women are at
increased risk of synovitis and commonly develop CTS
💁Obesity , Osteoarthritis , Systemic amyloidosis
💁Renal failure and dialysis-associated deposition of amyloid
💁Diabetes mellitus , Hypothyroidism , Acromegaly

💥Pathophysiology:The carpal tunnel is a narrow fibro-

osseous structure at the level of the palmar aspect of the wrist,
delimited by the carpal bones and the transverse carpal
ligament, which contains flexor tendons and the median nerve
✅Pressure increase within the carpal tunnel → compression
of contained structures → impaired blood flow and altered
microvascular structure of the median nerve → inflammatory
reaction → edema and hypoxia → axonal degeneration

💥Clinical features:

💥Symptoms:
✅Develop in the areas innervated by the median nerve:
palmar surface of the thumb, index, and middle fingers, and
radial half of the ring finger
✅Paresthesia: burning sensation, tingling
✅Loss of sensation/numbness , pain
✅Typically worsen at night
Patients often report that symptoms improve by shaking the
hand (flick sign)👉93% sensitive and 96% specific for CTS.
Changing the resting position of the hands or massaging them
may also relieve symptoms
✅Severely affected patients may report:
💥Dropping objects and difficulty with fine motor skills (
buttoning up clothing) secondary to weakened finger pinch and
grip strength 👉Related to the involvement of the motor fibers
of the median nerve innervating the thenar muscles, such as
the abductor pollicis brevis, opponens pollicis, and superficial
head of the flexor pollicis brevis
💥Disappearance of pain 👉Advanced disease can cause
permanent sensory loss
🚫Motor deficits are typically only seen in severe disease

💥Examination findings:

✅Mild disease: Initial examination is often normal; symptoms

only develop with provocative tests for CTS
✅Severe disease: Findings of both sensory and motor deficits
may be seen
💥 Examination of the sensory system
✅May show decreased sensation in the area innervated by
the median nerve distal to the carpal tunnel👉 hypalgesia on
the palmar aspect of the index finger compared to the little
finger
✅Usually, there is no loss of sensation of the palmar surface
of the thenar eminence because it is innervated by the
superficial branch of the median nerve, which arises 5–7 cm
proximal to the carpal tunnel and is, therefore, not compressed
💥 Examination of the motor system:
✅may show weakness in thumb abduction and opposition as
well as thenar atrophy👉Thenar atrophy is rarely seen because
individuals have usually already sought treatment for less
severe manifestations
🚫Sensory innervation of the thenar eminence is not affected
in CTS
🚫The "pope's blessing" (inability to flex the first three digits
when making a fist) is not a symptom of CTS. It is only seen in
proximal lesions of the median nerve
💥 Diagnostics
💥 General principles
✅Usually a clinical diagnosis, based on classic clinical features
of CTS combined with positive provocative tests for CTS
👉Diagnostic questionnaires, e.g., hand symptom diagrams,
include elements of the history and physical examination and
may help to make a clinical diagnosis of CTS.
✅Consider additional testing (e.g., electrodiagnostic studies)
in: 👉Diagnostic uncertainty 👉Severe cases ( those that may
require surgical intervention)

💥 Provocative tests for CTS

✅Considered positive when sensory symptoms (e.g., pain,
paresthesias) are elicited along the distribution of the median
nerve distal to the carpal tunnel
✅Usually performed in combination as use of a single
provocative test has low sensitivity and specificity
👉Combining provocative tests and interpreting them in the
context of other examination findings can improve diagnostic
accuracy
💥 Commonly used provocation tests
💁Phalen test
https://youtu.be/TMAD-dhT9PM
💁Tinel sign
https://youtu.be/U8cPjPeZgFw
💁Hand elevation test
https://youtu.be/_6Bf_Rp_Vbk
💁Carpal compression test
https://youtu.be/OfDuo3CPX1o

❌Do not use a single provocative test to diagnose CTS; using a

combination of tests increases diagnostic accuracy

💥 Electrophysiological tests

💁Indications
💥Diagnostic uncertainty or atypical presentation
💥To rule out alternative diagnoses ( polyneuropathy,
radiculopathy)
💥Presurgical evaluation 👉For diagnostic confirmation and
assessment of severity
💁Modalities
💥Nerve conduction studies (confirmatory test): show
impaired median nerve conduction along the carpal tunnel
💥Prolonged sensory and distal motor latency
💥May be normal in patients with mild disease

💁Electromyogram : Usually ordered to rule out alternative

diagnoses , May show abnormal spontaneous activity (
fibrillation potentials) or altered action potential morphology
🔊lectrodiagnostic studies are not necessary to confirm a
clinical diagnosis of CTS but should be ordered when the
diagnosis is uncertain and for patients scheduled to have
surgery

⛔Differential diagnoses
💁Carpometacarpal arthritis of the thumb
💁Arthritis of the wrist
💁Cervical radiculopathy (C6)
💁De Quervain tendinopathy
💁Peripheral neuropathy
💁Pronator syndrome
💁Raynaud phenomenon
💁Ulnar neuropathy
💁Vibration white finger

🔊Treatment
Approach
👉Mild to moderate disease
👉Trial immobilization or glucocorticoid injection💁The
choice of first-line treatment is determined by patient
preference
👉No response after 6 weeks 💁Symptoms usually begin to
improve after 2–6 weeks with maximum improvement seen at
3 months.
👉Assess for adherence ، Trial alternate conservative methods
👉Severe or refractory disease: Refer to a hand specialist for
possible surgery

💥Conservative management
💁Treatment of underlying comorbidities
💁Immobilization: splinting of the wrist in a neutral position
🚫Traditionally, nighttime splinting has been recommended.
Patients may also use the splint throughout the day, but it is
unclear if this has any additional benefit over nighttime
splinting
💁Glucocorticoids : First-line: steroid injection
methylprednisolone ، Alternative: oral glucocorticoids
prednisone
🚫Oral glucocorticoids are less effective than glucocorticoid
injections for symptomatic relief in CTS

⛔🔊Physical therapy and exercise

✅nerve glide
https://youtu.be/UnkSHg0L4yM

✅exercises ( Stretch)
https://youtu.be/Q5G916yCyF0
https://youtu.be/d9t_fbCzsEM
https://youtu.be/dCpw1uTFfp8
https://youtu.be/noqq-QSG6w4

✅therapeutic ultrasound
https://youtu.be/Rs4odGvekDQ

✅ Electrical stimulation
https://youtu.be/U7V6wBYMT8A
https://youtu.be/DLrgmBlwa8E

✅ carpal bone mobilization

https://youtu.be/xciJJ9NZUdg
https://youtu.be/WGpNYLEG0ck
https://youtu.be/yGALtGVNlmQ
https://youtu.be/A2FTkoytWi8

🚫❌Oral analgesia ( NSAIDs, gabapentin) is not effective in

managing CTS
💥Surgery
https://youtu.be/BRyaEJf6SYk

💁Indications: severe disease or refractory symptoms

💁Method :Open or endoscopic release of the transverse
carpal ligament 👉Long-term outcomes are similar for both
methods, but recovery is often faster after endoscopic surgery
💁The transverse carpal ligament is divided to increase space
for the median nerve in the carpal tunnel

💥Complications
💁Recurrence of CTS is rare (0.5–3%)
👉Most commonly caused by incomplete division of the
ligament, which may occur after endoscopic release.
 Carpal tunnel syndrome in pregnancy

💁Epidemiology
💥 Most commonly seen entrapment neuropathy during
pregnancy
💥Occurs in up to 62% of pregnant women

💁Etiology
💥Hormone-mediated changes
💥Weight gain and fluid retention
💥Changes to the musculoskeletal system
💁The polypeptide hormone relaxin, which causes relaxation
of the pelvic joints, may also cause transverse carpal ligament
swelling and median nerve impingement
💥Edema of the wrist
💥Gestational diabetes , Gestational hypertension

💁Clinical features
💥Similar to the general population (see “Clinical features of
CTS”)
💥Patients commonly present in the third trimester (but can
present at any stage) , Often bilateral

✅Modifications to diagnostics of CTS: none

✅Modifications to treatment of CTS
1-Conservative management is recommended during
pregnancy as symptoms often resolve after delivery
2-Surgery may be required if symptoms persist postpartum
💁In some cases, symptoms can persist for up to three years
and require further treatment. Surgery is avoided when
possible in the postpartum period as restrictions on wrist
movement may make it challenging to care for the infant.

‫ محمود طلعت البدوي‬: ‫ د‬/‫🔊 إعداد‬

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