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By Dr.Anushka Heerah
Median nerve
The median
nerve supplies
most if the feeling
of the hand,
particularly to the
thumb, index and
middle fingers, the
thumb half of the
palm, and the
outer side of the
hand.
Pathology:
1. In acute compression a severe deforming force
(traumatic dislocation of the carpal bones) cause
mechanical deformation of the carpal tunnel and
ischemic changes of the median nerve.
2. Chronic compressive compression:
Stage I: Progressive obstruction of the venous
return causing circulatory slowing in the epineural
and intrafunicular tissues,which leads to impairs
the nerve fibers nutrition. The hypoxic nerve
become
hyperexcitable
and
discharge
spontaneously. Pain and parethesia result from the
imbalance of fiber activity and fiber dissociation.
Nocturnal paresthesia and pain are caused by
impeded venous return from distal part of the
thumb. At this stage, the structural changes may
be corrected by treatment that eliminates or
reduce pressure in the carpal tunnel.
Stage III:
Nerve fibers undergo
Wallerian degeneration with loss of
axons available for regeneration.
The compressed nerve become a
Fibrous cord.
Patient Complaints:
1-Pain
2-Weakness
3-Occasional burning shoulder pain
4-Stage I chronic compression is indicated
by
nocturnal pain and diminished
sensation in the
distribution of the
median nerve.
5-Stage II is indicated by burning pain and
referred to the shoulder.
6-Stage III is indicated by pain subsidence
or it become more severe.
7-Acute compression is indicated by
numbness or severe pain.
Evaluation:
1. Diminished sensation in the thumb, index,
long and radial aspect of Ring fingers.
2. Atrophy of thenar muscles
3. A positive tinel's sign
4. Positive phalen's sign
5. visual inspection of the hand for pseudomotor changes in the skin
6. X- ray views of the carpal tunnel
7. Electromyography and nerve conduction
8. Hand grip dynamometer
9. To relieve the symptoms, patients often
flick their wrist as if shaking down a
thermometer (flick sign).
Tinel sign
The examiner taps the
hand from the fingertips
proximally to the palm.
The patient is asked to
report any "electric
shocks" or tingling when
percussed. tinel's sign is
often "positive" causing
tingling in the thumb,index,
middle fingerand the radial
half of the fourth digit. Tinel's
sign is sometimes referred to
as "distal tingling on
percussion" orDTP
Phalen sign
The patient is
asked to report
any sensory
changes in the
median nerve
innervated area
after holding his
wrists flexed for
1 minute.
electromyography
Tendon
gliding
exercises
a straight palm...then a hooked fist..
...now make a "straight' fist ...and a full
fist
Surgical methods
Surgical technique.In most cases, carpal tunnel surgery is
done on an outpatient basis under local anesthesia.
During surgery, a cut is made in your palm. The roof
(transverse carpal ligament) of the carpal tunnel is divided.
This increases the size of the tunnel and decreases pressure
on the nerve.
Once the skin is closed, the ligament begins to heal and grow
across the division. The new growth heals the ligament, and
allows more space for the nerve and flexor tendons.
Endoscopic method.Some surgeons make a smaller skin
incision and use a small camera, called an endoscope, to cut
the ligament from the inside of the carpal tunnel. This may
speed up recovery.
complications
Complications after surgery may include the following:
Nerve damage with tingling and numbness (usually temporary)
Infection
Scarring
Pain
Stiffness
Loss of some wrist strength is a complication that affects 10 - 30% of patients.
Some patients who have jobs requiring significant hand and wrist strength may
not be able to perform them after surgery. These workers may also have
problems in other parts of the upper body, including the elbows and shoulders.
These problems do not go away with surgery and can persist. Studies indicate
that 10 - 15% of patients change jobs after a CTS operation.
If pain and symptoms return, the release procedure may be repeated.
Reasons for procedure failure include:
Incomplete release of the ligament
Extensive scarring
Recurrence of the disorder due to underlying medical conditions
Patients who had open release surgery appear more likely to require repeat
operations compared with those who have had endoscopic surgery.