Carpal Tunnel Carpal Tunnel SyndromeSyndrome

By: Dr. Masoud Shayesteh AzarBy: Dr. Masoud Shayesteh Azar

Associate Professor, Orthopaedic Department, Associate Professor, Orthopaedic Department, Mazandaran UniversityMazandaran University

DefinitionDefinition

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

Described in 1854 by Sir James PagetDescribed in 1854 by Sir James Paget

anatomyanatomy

The median nerveThe median nerve

travels from thetravels from the

forearm into yourforearm into your

hand through ahand through a

““tunnel” in your wristtunnel” in your wrist . .

AnatomyAnatomyhook of the hamatehook of the hamatetriquetrum and triquetrum and pisiform mediallypisiform medially

scaphoid trapezium scaphoid trapezium and fibroosseous and fibroosseous F.c.r. sheath laterallyF.c.r. sheath laterally..

Carpal tunnel syndromeCarpal tunnel syndrome

Pressure on the median nerve can result in; Pressure on the median nerve can result in; sensations of numbness, tingling, pain and sensations of numbness, tingling, pain and clumsiness of the handclumsiness of the hand.( typical median N. distribution .( typical median N. distribution in the radial three and one – half digits). in the radial three and one – half digits).

The combination of these symptoms is called The combination of these symptoms is called carpal tunnel syndromecarpal tunnel syndrome

Carpal tunnel syndromeCarpal tunnel syndrome

Most often 30 -60 years oldMost often 30 -60 years old

Five times more common in womenFive times more common in women

Older, overweight, and physically inactive Older, overweight, and physically inactive peoplepeople

Carpal tunnel syndromeCarpal tunnel syndrome

Carpal tunnel syndromeCarpal tunnel syndrome

EtiologyEtiology 11--primery or Idiopathicprimery or Idiopathic

22 - -secondarysecondary A: Local etiology A: Local etiology I: Anatomical malformation I: Anatomical malformation

II: TumorsII: Tumors III: InfectionsIII: Infections

IV: Bone prominenceIV: Bone prominence

B: Systemic etiologyB: Systemic etiology obesity, diabetes mellitus, thyroidobesity, diabetes mellitus, thyroid

dysfunction, R.Adysfunction, R.A

Computer Related Health HazardsComputer Related Health Hazards

Research TopicsResearch Topics

Repetitive Strain InjuriesRepetitive Strain Injuries

Carpal Tunnel SyndromeCarpal Tunnel SyndromeEye Strains and Computer Vision SyndromeEye Strains and Computer Vision Syndrome

Internet AddictionInternet Addiction

Stress and DepressionStress and Depression

RadiationRadiation

Clinical findingClinical finding

History often is more important than the physical History often is more important than the physical examination in making the diagnosis of CTSexamination in making the diagnosis of CTSNumbness and tinglingNumbness and tingling

hands fall asleep or things slip from the fingers without hands fall asleep or things slip from the fingers without the person's noticing (loss of grip, dropping things), as the person's noticing (loss of grip, dropping things), as well as numbness and tinglingwell as numbness and tinglingSymptoms are usually intermittent and are associated Symptoms are usually intermittent and are associated with certain activities (i.e., driving, reading the with certain activities (i.e., driving, reading the newspaper, crocheting, painting)newspaper, crocheting, painting)Nocturnal symptoms that wake the individual are more Nocturnal symptoms that wake the individual are more specific of CTS, especially if the patient relieves specific of CTS, especially if the patient relieves symptoms by shaking the hand/wristsymptoms by shaking the hand/wrist

Clinical findingClinical finding

If pressure continues- thenar muscles can weaken and atrophy

diagnosisdiagnosis

HistoryHistory

Clinical examinationClinical examination I: I: Tinel'sTinel's nerve percussion test nerve percussion test

II: II: Phalen'sPhalen's wrist flexion test wrist flexion test

III: Tourniquet testIII: Tourniquet test

IV: Carpal compression testIV: Carpal compression test

V: Tethered median nerve stress testV: Tethered median nerve stress test

Para clinical examinationPara clinical examination

diagnosisdiagnosis

Reverse Phalen TestReverse Phalen Test

Electrodes are placed on the forearm and a mild Electrodes are placed on the forearm and a mild

electrical current is passed through the armelectrical current is passed through the arm..

diagnosisdiagnosisElectromyographyElectromyography

90%90% sensitive and 60% specificsensitive and 60% specific

Measurement of how fast & how well the Measurement of how fast & how well the median nerve responds indicates if there median nerve responds indicates if there is damage to the nerveis damage to the nerve..

treatmenttreatment11 - -Non surgical treatmentNon surgical treatment

22 - -Surgical treatmentSurgical treatment

Endoscopic releaseEndoscopic release

11--age over 50age over 50

22--duration longer than 10 monthsduration longer than 10 months

33--constant paresthesiaconstant paresthesia

44 - -stenosing flexor tenosynovitisstenosing flexor tenosynovitis

55--positive phalen test less than 30 secondspositive phalen test less than 30 seconds

treatmenttreatment

SteroidsSteroids by local injection by local injection SplintsSplints, especially if worn full, especially if worn full

timetime NSAIDs, diuretics, yoga, laserNSAIDs, diuretics, yoga, laser

& & ultrasoundultrasound

Non surgical treatmentNon surgical treatment

Local steroid injection for moderately severe Local steroid injection for moderately severe idiopathic carpal tunnel syndromeidiopathic carpal tunnel syndrome

BMC BMC Musculoskelet Disord.Musculoskelet Disord. 2010 2010

Published online 2010 AprilPublished online 2010 April

Department of Orthopedics, Hässleholm and Department of Orthopedics, Hässleholm and Kristianstad Hospitals, SE-28125 Hässleholm, SwedenKristianstad Hospitals, SE-28125 Hässleholm, Sweden

Non surgical treatmentNon surgical treatment

randomized double-blind placebo-controlled trialrandomized double-blind placebo-controlled trial

A total of 120 patients will be randomized to A total of 120 patients will be randomized to injection of 80 mg Methylprednisolone, 40 mg injection of 80 mg Methylprednisolone, 40 mg Methylprednisolone, or normal saline, each Methylprednisolone, or normal saline, each also containing 10 mg Lidocaine. Evaluation at also containing 10 mg Lidocaine. Evaluation at baseline and at 5, 10, 24 and 52 weeks after baseline and at 5, 10, 24 and 52 weeks after

injection includes validatedinjection includes validated

Non surgical treatmentNon surgical treatment

Non surgical treatmentNon surgical treatment

Surgical treatmentSurgical treatment

Surgical DecompressionSurgical Decompression

Open or endoscopic (similar success)Open or endoscopic (similar success)

Only means of definitive cure (American Only means of definitive cure (American Academy of Neurologists)Academy of Neurologists)

Up to 86% improvement in painUp to 86% improvement in pain

Complication 1-2% (higher in endoscopic)Complication 1-2% (higher in endoscopic)

Wilson JK, Sevier TL. A review of treatment for carpal tunnel syndrome. Clinical Rehabilitation. 2003; 25:3:113-119.

Surgical complicationSurgical complication

11 - -InfectionInfection22 - -Nerve injuryNerve injury

33 - -Reflex Sympathetic DystrophyReflex Sympathetic Dystrophy44 - -Painful scarPainful scar 55 - -BowstringingBowstringing

66 - -Muscle weaknessMuscle weakness77 - -Skin necrosisSkin necrosis

RecurrenceRecurrence

In 1000 case 20% recurrence reportedIn 1000 case 20% recurrence reported

Causes: 1- AdhesionCauses: 1- Adhesion

22 - -Anatomical abnormalityAnatomical abnormality

Study Study -1-1

8989 patient operated in Sari Emam hospital patient operated in Sari Emam hospital between 1386 -1388between 1386 -1388

All of them open surgeryAll of them open surgery

1515 male (17%)male (17%)

7474 female (83%)female (83%)

StudyStudy-2-2

Rt. Hand 54 case (60%)Rt. Hand 54 case (60%)

Lt. hand 36 case (40%)Lt. hand 36 case (40%)

Total age average 46/44 +/-11/45Total age average 46/44 +/-11/45

Male age average 48/26 +/-14/19Male age average 48/26 +/-14/19

Female age average 46/08 +/-10/89Female age average 46/08 +/-10/89

StudyStudy-3-3

Age minimum 22y.oldAge minimum 22y.old

Age maximum 77y.oldAge maximum 77y.old

Mode 53 y. oldMode 53 y. old

Complication Complication after 2 years follow after 2 years follow upup

11-- Recurrence Recurrence 11 case11 case (12.3%) (12.3%)

22 - -Pain full scar Pain full scar 5 case5 case (5.6%) (5.6%)

33--sympathetic dystrophy sympathetic dystrophy 4 case4 case (4.4%) (4.4%)

44--palmar coetaneous N. injury palmar coetaneous N. injury 2 case2 case (2.2%) (2.2%)

55 - -thenar branch N. injury thenar branch N. injury 1 case1 case (1.1%) (1.1%)

Thank you for your attentionThank you for your attention