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