CARPAL TUNNEL

SYNDROME
A 42 year old women,typist by occupation comes to
hospital with cheif complaints of burning pain ,
tingling sensation and numbness of palmar aspect
of right hand in thumb, index and middle fingers,
and radial half of the ring finger. Tinling sensation
worsen at night.Patients often awaken with
symptoms and shake out their hand to provide
relief.There was associated wasting of the thenar
muscles.There was no painful thumb and wrist
movements,neck pain,fever,trauma,no associated
swelling of finger joints,no hlo DM,thyroid diseases.
 ANATOMY

● The wrist is surrounded by a band of fibrous tissue, called flexor

retinaculum.
● Tight space between the fibrous band and the wrist is called carpal tunnel
through which median nerve passes.
● The carpal tunnel is bordered superiorly by the transverse carpal ligament
and inferiorly by the carpal bones, through which the median nerve and
nine flexor tendons of the forearm pass. Increased pressure in the carpal
tunnel leads to compression and damage of the median nerve.
Median nerve - motor and sensory supply of hand
 CAUSES
● idiopathic -most common
● General conditions
○ Inflammatory—wrist osteoarthritis, rheumatoid arthritis
○ Endocrine—hypothyroidism, diabetes mellitus, menopause, pregnancy,
acromegaly,obesity
Other-amyloid,raynaud phenomenon,gout
Local causes-These cause crowding of the space.
○ Malunited Colles’ fracture

○ ganglion in the carpal region

○ osteo arthritis of the carpal bone

○ wrist contusion, hematoma

○ Lipoma

○ Synovitis of wrist
 CLINICAL -symptoms and signs

● pain and paresthesias in the distribution of the median nerve which includes
the palmar aspect of the Thumb, index and middle fingers, and radial half of the ring
finger.
● Tingling sensation and pain worsen at night
● Patients often awaken with symptoms and shake out their hand to provide relief -
flick sign
● Clumsiness in carrying out fine hand movements-Patients may describe difficulty
holding objects, opening jars, or buttoning a shirt.
● Severe disease-decreased sensation to pain on palmar aspect ,atrophy of
thenar muscles,weakness in thumb abduction
● Sensation over thenar eminence should be normal- palmar cutaneous branch of
median nerve
 Clinical Stages or Features

● Stage I: In this stage, pain is usually the presenting complaint and the patient
complains of characteristic discomfort in the hand, but there is no precise
localization to the median nerve. There may be history of morning stiffess
in the hand.

● Stage II: In this stage, symptoms of tingling and numbness, pain,

paresthesia, etc. are localized to areas supplied by the median nerve.

● Stage III: Here, the patient complains of clumsiness in the hand and
impairment of digital functions, etc.

● Stage IV: In this stage, sensory loss in the median nerve distribution area
can be elicited and there is obvious wasting of the thenar eminence.
 Clinical Tests
1.Phalen’s test-Flex the patient’s wrist 90 degrees with the elbow in full extension; pain or paresthesias in
the fingers innervated by the median nerve within 60 seconds are a positive result

2.Dukran's or direct compression test-Apply direct pressure over the transverse carpal ligament; sensory
symptoms within 30 seconds are a positive result

3.Tinel’s sign-Repeatedly tap the volar surface of the patient’s wrist over the transverse carpal ligament;
pain or paresthesias in the fingers innervated by the median nerve are a positive result

4.Pen test-Ask the patient to lay his hand flat on tablewith palm facing ceiling, raise the thumb perpendicular
to the palm, a pen is held above thumb and ask to touch pen with thumb

5.Reverse Phalen test - The reverse Phalen, or ‘prayer test,’ is done by having the patient extend both of
their wrists by placing palmar surfaces of both hands together for one minute (as if praying). Again a positive
test is with the reproduction of symptoms

6.The square wrist sign - The square sign test is an evaluation to determine the risk of developing carpal
tunnel syndrome. The test is positive if the ratio of the thickness of the wrist divided by the width of the wrist
is great than 0.7.

7.torniquet test-pneumatic blood pressure cuff is applied proximal to the elbow and inflated higher
than the patient’s systolic blood pressure. The test is positive if there is paresthesia or numbness in
the region of median nerve distribution of the hand. It is less reliable and is specificity in 65 percent of
 Investigations
1.Electromyography and Nerve Conduction Studies-
Abnormalities on electrophysiologic testing, in association with specific
symptoms and signs, are considered the gold standard for CTS diagnosis.
Electrophysiologic testing also can assess the severity of the damage to the
nerve and also determine prognosis. CTS is usually divided into mild,
moderate, and severe. In mild CTS patients have sensory abnormalities alone
on electrophysiologic testing, and in moderate CTS patients have sensory plus
motor abnormalities.

2.Ultrasonography potentially can identify space-occupying lesions in the

carpal tunnel. It can also detect abnormalities in the median nerve like an
increased cross-sectional area that can be diagnostic of CTS.
Ultrasonography can also help to guide steroid injections into the carpal tunnel

3. MRI of the carpal tunnel is particularly useful preoperatively if a space-

occupying lesion in the carpal tunnel is suggested.
Other -
1.Plain radiography-structural abnormalities, such as bone or joint disease,
are suspected.
2.Laboratory testing for comorbidities, such as diabetes or hypothyroidism
 Treatment

● Non-operative methods -mild to moderate

○ NSAIDS
○ Oral steroids- oral prednisolone
○ Physiotherapy- nerve gliding exercises,carpal bone mobilization, therapeutic ultrasound
○ Carpal tunnel splint -Splinting is a first-line treatment for mild to moderate CTS because
of its simplicity, low cost, and tolerability

● Injection Treatment
○ a single infusion of cortisone with splinting for 3 weeks

● Surgery- severe cases

○ this consists of division of flexor retinaculum and transverse carpal ligament and is
indicated in failed nonoperative treatment, thenar atrophy, sensory loss, etc.
 Surgery-

Avdantages of endoscopic release- faster rehabilitation (6-8days back to work),faster functional

recovery,short term pain and less scarring
Disadvantage- cost ,operative time ,chance of injury to median nerve
Complications due to Carpal Tunnel Syndrome

● Carpal tunnel syndrome may cause irreversible median nerve damage,

leading to permanent impairment and disability.
● Chronic wrist and hand pain with or without reflex sympathetic dystrophy.
● CTS can cause atrophy and weakness of the muscles at the base of the
thumb in the palm of the hand. This can lead to a lack of dexterity of the
affected fingers.

Complications due to Carpal Tunnel Surger

● neuroma of the palmar cutaneous branch of the median nerve.
● Hypertrophic scars
● Dysesthesias after multiple procedures to release the carpal tunnel
● Wrist Joint stiffness
● Failure to relieve symptoms
Thank you