Carpal Tunnel Syndrome

Carpal Tunnel SyndromeDr. Amith Kamath MBBS

Definition

Compression neuropathy of the median nerve in wrist area ( tardy median nerve palsy)

Described in 1854 by Sir James Paget

The median nerve travels from the forearm into your hand through a tunnel in the wrist.

Anatomy

Etiology1- Primary or Idiopathic2- Secondary A: Local etiology I: Anatomical malformation II: Tumors III: Infections IV: Bone prominence B: Systemic Etiology Obesity, Diabetes Mellitus, Thyroid Dysfunction ,R.A ,DM, Pregnancy

MNEMONICPRAGMATICP-PREGNANCYR-RHEUMATOID ARTHRITISA-ATHRITIS DEGENERATIVEG-GROWTH HORMONE EXCESS i.e. ACROMEGALYM-METABOLIC i.e. GOUTA-ALCOHOLISMT-TUMORSI-IDIOPATHICC-CONNECTIVE TISSUE DISORDER i.e. AMYLOIDOSIS

Clinical stagesStage 1 Pain Morning stiffness of hand

Stage 2-localised to supply of median nervePainTinglingNumbnessParaesthesia

Stage 3Clumsiness of hand Impairment of digital function

Stage 4Sensory loss in the area of median nerve distribution obvious wasting of thenar muscles

Thenar muscle wasting due to continued pressure

Diagnosis History Clinical examination I: Median nerve percussion test II: Phalen's wrist flexion test III: Tourniquet test IV: Median nerve compression test Others2 point discrimination testElectrodiagnostic test

Phalens testPatients is asked to actively place the wrist in complete but forced flexion+ve if tingling and numbness is produced in 60 sec.Sensitive and specific in 80%

Median nerve percussion testExaminer gently taps over the median nerve at the wrist+ve numbness n paraesthesia

Tourniquet testBP cuff tied proximal to elbow and inflated higher than patients Systolic BP. +ve if numbness and paraesthesia

Median nerve compression testDirect pressure is exerted over both wrist 1st phase time taken for symptoms appear(15-20sec)2nd phase-time taken for symptoms to disappear after release of pressure

Treatment1- Non surgical treatment2- Surgical treatment Endoscopic release 1- Age over 50 2- Duration longer than 10 months 3- Constant paraesthesia4- Stenosing flexor tenosynovitis5- Positive Phalens test less than 30 seconds

NSAIDsSteroids- Prednisolone for 8days, 40mg for 2days n taper by 10mg for next 2days

Carpal tunnel splint

Injection-infusion of cortisone with splinting for 3weeks

Surgical treatment

Open or endoscopic (similar success)

Consists of division of flexor retinaculum and transverse carpal ligament

Surgical Complication 1- Infection2- Nerve injury 3- Reflex Sympathetic Dystrophy4- Painful scar 5- Bowstringing6- Muscle weakness7- Skin necrosis

Dupuytrens Contracture

Dupuytrens contracture is defined as proliferative fibroplasia of subcutaneous palmar tissue, forming nodules and cords along its ulnar border.

This fibroplasia results in finger contracture, thinning of subcutaneous fat, pitting of skin, and knuckle pads on dorsum of proximal inter phalangeal joint

Etiology

HereditaryTrauma chronic & repetitive in natureOccupational-rock drillingMore in malesWhitesEpileptics and alcoholics

Structures Involved

Palmar fasciaPretendinous bandsSuperficial transverse ligamentSpiral bandNatatory ligamentLateral digital sheathGraysons ligamentCleelands ligament

Clinical Features

Grades

TreatmentObservation-consists of no Rx with observation being done at every 3 months

Radiotherapy-only during fibroblastic phase

Surgical-Depends on degree of contracture

Surgical Methods

Subcutaneous Fasciotomy-in elderly,arthiritisPartial Selective Fasciotomy-when 2 fingers are involvedComplete Fasciotomy- rareHematoma, Joint stiffnessFasciotomy with skin grafting-young people with epilepsyResection and arthrodesis-severe contracture of Proximal Inter Phalengeal JointAmputation

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