carpal tunnel syndrome · de quervain’stendonitis by: rodney a. miller md wooster orthopaedics...
TRANSCRIPT
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Carpal Tunnel Syndrome
Trigger Finger
De Quervain’s Tendonitis
by:
Rodney A. Miller MD
Wooster Orthopaedics &
Sports Medicine
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Carpal Tunnel Syndrome
• Definition
• History
• Causes
• Diagnosis
• Treatment/prevention
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Carpal Tunnel Syndrome
(CTS) refers to a constellation of symptoms
resulting from compression of the median
nerve at the wrist
definition
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History of CTS
• 1854 - Sir James Paget - post fracture
• 1880 - James Putnam - idiopathic
• 1893 - Franz Schultz - “acroparesthesia”
• 1906 - Farquhar Buzzard - corporeal rib
• 1909 - James Ramsey Hunt - motor branch
• 1913 - Pierre Marie & Charles Foix -
median nerve under annular ligament
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history
• 1933 - Sir James Learmonth - 1st surgical
release of TCL - post-traumatic
• 1938 F.P. Moersch - spont comp in CT
• 1946 - Cannon & Love - 1st surgical release
of TCL for spont median n comp
• 1947 - Brain, Wilkinson, & Wright - 1st
paper describing CTS & op release of TCL
• 1950 - George Phalen - popularized CTS
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Causes
• Anatomy of the carpal tunnel
• Underlying systemic or physiological
disorders
• Patterns of use
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Anatomy
• CT is an inelastic structure bounded by the
arch of the carpal bones & the transverse
carpal ligament
• Not a closed compartment, but often
functions as a confined space
• CT transmits 9 tendons & median nerve
• Median n compression results from a
discrepancy : canal size vs contents
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Carpal Tunnel Syndrome
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Carpal Tunnel associated
diagnosis
• Diabetes
• Rheumatoid arthritis
• Hypothyroidism
• Pregnancy
• Fractures
• Obesity
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Carpal Tunnel associated patterns
of use
• Repetitive motion of the fingers/wrist
• Repetitive squeezing/torsion of a tool
• Vibration exposure
• Prolonged wrist flexion or extension
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Diagnosis of CTS
• History of chief complaint
• Past medical history
• Review of systems
• Physical exam
• Special tests
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History
• Pain or burning & numbness in the hand
• Night symptoms frequent
• Paresthesias in the radial three and one-half
digits which may increase with actvities
• A sense of fullness or swelling along with
cramping
• Weakness or clumsiness +/- muscle
wasting
diagnosis
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Physical exam
• Cervical spine
• Examine both upper extremities
• Neurovascular exam
• Special tests
diagnosis
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Electrodiagnostic studies
• Adjunct to clinical examination in the
objective eval of disorders of periph n
• Help isolate the segment of n that is injured
• Assess severity of neuropathy
• However, nearly 10% incidence of false-
negatives
diagnosis
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diagnosis
• Nerve conduction studies are more helpful
in establishing the diagnosis
• Electromyographic studies are useful in
determining the prognosis
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Special tests
• Compartment pressure
• X-ray
• CT
• MRI
• Thermography
• Ultrasound
diagnosis
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Classification of
CTS
• Acute
• Chronic
* mild (early)
* moderate (intermediate)
* severe (advanced)
diagnosis
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Prevention in workplace
• Keep wrists straight
• Avoid fast, continuous, repetitive
movements
• Use whole hand to grasp hand tool of
appropriate size in good condition
• Modify work station
• Rotate job tasks
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Prevention in office
• Good posture, spine against back of chair
• Wrist straight and at same level as elbow
• Rest wrist lightly on pad while typing
• Typing material and screen at eye level
• Short rest period or alternate tasks
• Exercise to improve posture, strengthen
muscles, and improve circulation
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Treatment of CTS
Conservative
• patient education
• activity modification
• splint
• NSAIDs
• Vit B6
• inject
Surgery
• classic open release
• small palmar incision
• endoscopic CTR
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Classic open release
Pros
• “classic”
• full visualization of
TCL
• contents of CT
accessible
• anomalous muscle
&/or nerves
Cons
• excessive tissue
trauma
* prolonged recovery
* more scar & pillar
pain
* persistent weakness
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Carpal Tunnel Surgery
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Carpal Tunnel Surgery
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Results of CT surgery
Classic open
• MRI: mean increase in CT volume of 24%
• up to 96 % patient satisfaction & sx improv
• up to 84 % return to original job
• pinch & grip strength return to nl at 6 & 12
weeks
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Complications
• Injection into nerve
• Incorrect diagnosis
• Hypertrophic scar
• Severance of palmar cutaneous branch
• Severance of recurrent motor branch
• Incomplete decompression
• Median nerve injury from ECTR
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Complications
• Median nerve injury from neurolysis
• Ulnar nerve injury from ECTR
• Distal neurovascular injury from ECTR
• Subcutaneous tender nerve
• Adherence of nerve to skin
• Adherence of nerve to flexor tendons &
restricted tendon movement
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Complications
• Hematoma
• Bowstringing of flexor tendons
• Reflex sympathetic dystrophy
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In conclusion:
• Common problem
• Early intervention helpful
• Chronic, severe cases have less optimal
results
• Most people very happy with surgical
outcome
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Trigger Finger
• Pain, locking, grinding in palm at base of
digit
• Caused by tight A1 pulley over flexor
tendon
• Related to CTS
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TriggerFinger
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Trigger Finger
Non op treatment:
• Ice
• Splint
• NSAID, PO steroid
• Injection
• OT
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Trigger Finger
Op Treatment:
Open release of
A1 pulley
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De Quervain’s Tendonitis
• Pain over radial side (thumb side) of wrist
• Possibly grinding or grating
• Possible swelling
• Caused by pressure over 1st dorsal wrist
compartment
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De Quervain’s Tendonitis
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De Quevain’s Tendonitis
Non op treatment:
• Ice
• Splint
• NSAID, PO steroid
• Injection
• OT
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De Quervain’s Tendonitis
• Op Treatment
Open release of
1st Dorsal wrist
compartment
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Thank You!
• Questions?