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Carpal tunnel syndrome. 1.

Carpal tunnel syndromecarpal tunnel syndrome (tardy median palsy)(tardy median palsy). 1854 -Sir James Paget. Carpal tunnel syndrome (tardy median palsy) results from compression of the median nerve within the carpal tunnel. A cylindrical cavity connecting the volar forearm with the palm. The carpal tunnel is bounded by the transverse arch of the carpal bones dorsally, the hook of the hamate, triquetrum, and pisiform medially, and the scaphoid, trapezium, and fibroosseous flexor carpi radialis sheath laterally. The ventral (palmar) aspect, or 'roof' of the carpal tunnel is formed by the flexor retinaculum, consisting of the deep forearm fascia proximally, the transverse carpal ligament over the wrist, and the aponeurosis between the thenar and hypothenar muscles distally.

Flexor retinaculumFlexor retinaculum. The most ventral (palmar) structure in the carpal tunnel is the median nerve. Lying dorsal to the median nerve in the carpal tunnel are the nine flexor tendons to the fingers and thumb. The syndrome consists predominantly of tingling and numbness in the typical median nerve distribution in the radial three and one-half digits (thumb, index, long, radial side of ring). CARPAL TUNNELCARPAL TUNNEL SYNDROMESYNDROME.

It occurs most often in patients between 30 and 60 years old. Five times more common in women than in men. Older, overweight, and physically inactive people are more likely to develop carpal tunnel syndrome. Thenar atrophy usually is seen later in the course of the nerve compression. CARPAL TUNNELCARPAL TUNNEL SYNDROMESYNDROME. PREDISPOSING FACTORS. A malaligned Colles fracture.

Odema from infection or trauma. Tumors or tumorous conditions such as a ganglion, lipoma, or xanthoma are among the more common. In the treatment of a Colles fracture, immobilizing the wrist in marked flexion and ulnar deviation can cause acute compression of the median nerve within the carpal tunnel immediately after reduction. CARPAL TUNNELCARPAL TUNNEL SYNDROMESYNDROME. Systemic conditions such as obesity, diabetes mellitus, thyroid dysfunction, amyloidosis, and Raynaud disease are sometimes associated with the syndrome. Habitual sleeping posture at night in which the wrist is kept acutely flexed. Trauma caused by repetitive hand motions has been identified as a possible aggravating factor, especially in patients whose work requires repeated forceful finger and wrist flexion and extension.

Laborers using vibrating machinery are at risk, as are office workers, especially typists and data entry clerks, if they spend long hours with the wrists flexed. CARPAL TUNNEL SYNDROMECARPAL TUNNEL SYNDROME. CARPAL TUNNEL SYNDROMECARPAL TUNNEL SYNDROME. CARPAL TUNNELCARPAL TUNNEL SYNDROMESYNDROME. The syndrome frequently is associated with nonspecific tenosynovial edema and rheumatoid tenosynovitis, as are trigger finger and de Quervain disease. A biopsy specimens of the flexor tendon synovium were typical of a connective tissue undergoing degeneration under repeated mechanical stress. Kerr et al.

Reported that 96% of flexor synovial biopsy specimens from 625 patients with idiopathic carpal tunnel syndrome had benign fibrous tissue without inflammatory changes. CARPAL TUNNELCARPAL TUNNEL SYNDROMESYNDROME. Paresthesia over the sensory distribution of the median nerve is the most frequent symptom;. It occurs more often in women. Frequently causes the patient to awaken several hours after getting to sleep with burning and numbness of the hand that is relieved by exercise. Atrophy of thenar muscles.

Phalen testPhalen test. Acute flexion of the wrist for 60 seconds in some but not all patients or strenuous use of the hand increases the paresthesia. Tourniquet test,Tourniquet test,. Application of a blood pressure cuff on the upper arm sufficient to produce venous distention may initiate the symptoms.

Because of its insensitivity and nonspecificity, the tourniquet test was not recommended. The wrist in neutral position, the mean pressure within the carpal tunnel with carpal tunnel syndrome was 32 mm Hg.

This pressure increased to 99 mm Hg with 90 degrees of wrist flexion and to 110 mm Hg with the wrist at 90 degrees of extension. The pressures in the control subjects with the wrist in neutral position were 25 mm Hg, 31 mm Hg with the wrist in flexion, and 30 mm Hg with the wrist in extension. Durkan carpal compressionDurkan carpal compression testtest. Durkan described a 'new' carpal compression test in which direct compression over median nerve for 30 seconds with the thumbs or an atomizer bulb attached to a manometer. Patients with carpal tunnel syndrome usually have symptoms of numbness, pain, or paresthesia in the median nerve distribution. Compared with the Tinel nerve percussion and Phalen wrist flexion tests,the carpal compression test was more specific (90%) and more sensitive (87%).

The hand diagram score,. Semmes-Weinstein testing after a Phalen test had the highest sensitivity. electrodiagnostic studies - EMG & NCV are reliable confirmatory tests. However, these studies occasionally are normal when clinical signs of carpal tunnel syndrome are present, and they may be abnormal in asymptomatic patients. Electrodiagnostic studiesElectrodiagnostic studies. Nerve conduction studies are reported to be as high as 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome. They also are helpful in evaluating the upper extremity for nerve compression in other areas, that is, the elbow, axilla, and cervical spine, and for demonstrating changes of peripheral neuropathy.

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Computed tomography displays the bony structures clearly but not define the soft tissues accurately. Ultrasonography has been used to show the movement of the flexor tendons within the carpal tunnel, but not clearly show soft tissue planes. MRI-A major advantage of MRI is its high soft tissue contrast, which gives detailed images of both bones and soft tissues. DIFFERNTIAL DIOGNOSISDIFFERNTIAL DIOGNOSIS Care should be taken not to confuse this syndrome with nerve compression caused by. cervical disc herniation,. Thoracic outlet structures,. Median nerve compression proximally in the forearm and at the elbow.

Peripherar neuropathy. TREATMENTTREATMENT.

Gelberman. Proposed that carpal tunnel syndrome be divided into early, intermediate, advanced, and acute stages. Patients with early carpal tunnel syndrome without thiner atropy and mild symptoms responded to steroid injection & splinting. TREATMENTTREATMENT.

Those with intermediate and advanced (chronic) syndromes responded to carpal tunnel release. Treatment of acute carpal tunnel syndrome should be individualized, depending on its cause.

Kaplan, and Eaton identified five important factors in determining the success of nonoperative treatment:. 1) age over 50 years,. (2) duration longer than 10 months,. (3) constant paresthesia,. (4) stenosing flexor tenosynovitis,. (5) a positive Phalen test result in less than 30 seconds.

Two thirds of patients were cured by medical treatment when none of these factors was present, 59.6% with one factor, and 83.3% with two factors; 93.2% with three factors did not improve. No patient with four or five factors was cured by medical management. Surgical Release of CarpalSurgical Release of Carpal TunnelTunnel. Make a curved incision ulnar to and paralleling the thenar crease. Extend this proximally to the flexor crease of the wrist. Angle the incision toward the ulnar side of the wrist to avoid crossing the flexor creases at a right angle but especially to avoid cutting the palmar sensory branch of the median nerve,.

Maintain longitudinal orientation so that the incision is generally to the ulnar side of the long finger axis or aligned with the palmaris longus. Surgical Release of CarpalSurgical Release of Carpal TunnelTunnel. Carefully divide the transverse carpal ligament along its ulnar border to avoid damage to the median nerve and its recurrent branch, which may perforate the distal border of the ligament and may leave the median nerve on the volar side. Take care to release all components of the flexor retinaculum.

Avoid injury to the superficial palmar arterial arch, about 5 to 8 mm distal to the distal margin of the transverse carpal ligament. Inspect the flexor tenosynovium. Tenosynovectomy occasionally may be indicated, especially in patients with rheumatoid arthritis. Close only the skin and drain the wound. Surgical Release of CarpalSurgical Release of Carpal TunnelTunnel. Limited approaches, such as 1-The 'double incision' of Wilson 2-The 'minimal incision' of Bromley., Transverse incision proximal to the anterior wrist crease between flexor carpi ulnaris and flexor carpi radialis tendons. Distal longitudinal incision made between proximal palmar crease and 1 cm distal to hamate hook in line with radial border of ring finger.

AFTERTREATMENT.AFTERTREATMENT. A compression dressing and a volar splint are applied. The hand is actively used as soon as possible after surgery, but the dependent position is avoided.

The splint should be maintained for 14 to 21 days. Endoscopic Release ofEndoscopic Release of Carpal TunnelCarpal Tunnel Advantages 1)Less palmar scarring 2) Less ulnar 'pillar' pain, 3)Rapid and complete return of strength, and return to work and activities at least 2 weeks sooner than for open release. Endoscopic Release ofEndoscopic Release of Carpal TunnelCarpal Tunnel.

Intraoperative injury to flexor tendons, to median, ulnar, and digital nerves, and to the superficial palmar arterial arch raise concerns about the safety of this procedure. Problems related to endoscopic carpal tunnel release include (1) a technically demanding procedure, (2) a limited visual field that prevents inspection of other structures, (3) the vulnerability of the median nerve, flexor tendons, and superficial palmar arterial arch, (4) the inability to control bleeding easily, and (5) the limitations imposed by mechanical failure. Agee, McCarroll, and North developed the following 10 guidelines to prevent injury to the carpal tunnel structures. Know the anatomy. Never overcommit to the procedure. Ascertain that the equipment is working properly.

If scope insertion is obstructed, abort the single incision procedure. Ascertain that the blade assembly is in the carpal tunnel and not in the Guyon canal.

If a clear view cannot be obtained, abort the single-incision procedure. Do not explore the carpal canal with the scope. If the view is not normal, abort the single-incision procedure. Stay in line with the ring finger.

'When in doubt, get out.' . The two methods. 1-Agee 'single portal'. 2-Chow 'two portal' techniques.

These are the notes i'm talking about in slide 6: De Quervain's tenosynovitis is inflammation of tendons on the side of the wrist at the base of the thumb. These tendons include the extensor pollicis brevis and the abductor pollicis longus tendons. Raynaud's disease (vaso cons. Of small blood vessle Supply muscle) Cervical disk syndrome, an abnormal condition characterized by compression or irritation of the cervical nerve roots in or near the intervertebral foramina before the roots divide into the anterior and posterior rami.

When it is caused by ruptured intervertebral disks. No notes for slide. (Just for reading, not included in the exam) De Quervain's tenosynovitis is inflammation of tendons on the side of the wrist at the base of the thumb. These tendons include the extensor pollicis brevis and the abductor pollicis longus tendons.

Raynaud's disease (vaso cons. Of small blood vessle Supply muscle) Cervical disk syndrome, an abnormal condition characterized by compression or irritation of the cervical nerve roots in or near the intervertebral foramina before the roots divide into the anterior and posterior rami. When it is caused by ruptured intervertebral disks. The 1st and 2nd risk factors are (bilateral).The 3rd and 4th risk factors are (unilateral).

The 1st and 2nd risk factors are (bilateral).The 3rd and 4th risk factors are (unilateral). Carpal Tunnel Syndrome.

1. Prepared by: medicine students in King AbdulAziz University. Carpal Tunnel Syndrome. Sara is 33 years old female patient.

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She was brought to the OPD clinic complaining of right hand numbness/pain of 6 months duration. The patient’s symptoms started during her last pregnancy where the numbness was severe enough to wake her up from sleep. She used to shake and rub her hand to improve the symptoms.

She was advised to wear a wrist splint during her pregnancy and to see a doctor 3 months following delivery if her symptoms persisted. On examination the patient described numbness involving her thumb, index and middle finger. Her motor examination of the hand muscles was normal. There was no evidence of cervical spine disease. Her blood results of the thyroid hormone were within normal range. Case study:. Objectives.

At the end of the presentation, the student must be able to: 1. List the differentialdiagnosis of hand numbness/pain. Describethedetailedanatomy of the carpal tunnel. At the end of the presentation, the student should be able to: 1. Describe thepathophysiology of carpal tunnelsyndrome. List withexplanation,the treatmentoptions of carpal tunnel syndrome. 1st Objective.

List the differential diagnosis ofhand numbness/pain. Numbness of handsis usuallycaused by irritationor compressionof branch of a nerve travelingto the hands or fingers. Symptoms may accompanynumbness: 1- tingling 3- weakness 2- burning 4- sharppain. Differential diagnosis of hand Numbness and pain: ¤Carpal tunnel syndrome (most common) ¤Cervical disc disease. ¤De Quervain’stenosynovitis. ¤Reynaud's diseases.Check the notes below. 2nd Objective Describe the detailed anatomy of the carpal tunnel 1-How carpal tunnelis formed?

2-Boundries 3-What passes insideand outside?. 1-How the carpal tunnel is formed? A-arch B-flexorretinaculum. 1-How is the carpal tunnel (C.T.) formed? ¤The anterior concave surface of the carpus is transformed into tunnel by the attachment of theflexor retinaculum. ¤It is the passageway on the palmer side of the wrist that connects the forearm to the palm of thehand. A-arch.

Thearch is formedof 8 carpal bones,madeupoftworows of 4 bones. Theproximalrow consist of (L:M)thescaphoid,lunate, triquetrum, andpisiformbones.

The distalrow consist of(L:M) thetrapezium, trapezoid, capitate, andhamatebones. Due to weak bloodsupply of the scaphoid bone, it has a bad healing(takes long time). B- flexor retinaculum. It is a thickeningof deep fascia, which keep the tendonsof flexor muscles. It stretches across the front of the wrist and converts the concave anteriorsurface of the hand intothe carpal tunnel. 2-boundries ¤ Dorsally ( posterior): Carpal bones. ¤ Palmary ( anterior): Thickflexor retinaculum.

¤ Radialmargin (lateral): The scaphoid, trapezium. ¤ Ulnarmargin (medial ): The hook of the hamate, triquetrum and pisiform.