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CARPAL TUNNEL SYNDROME

By Dr.Anushka Heerah

It is a compression of the median nerve


at the level of the carpal tunnel as it
passes beneath the flexor retinaculum
Causes:
1- Trauma: Fracture and dislocation
2- Increase in volume of tunnel contents
secondary to:
a)Tenosynovitis
b)Thickening of the transverse carpal
ligament
3- Tumour.
4-Systemic etiology :obesity, diabetes
mellitus, thyroid
dysfunction, R.A

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 ll: The capillary circulation


slows so severely, that anoxia
damages the endoneurim. Edema
occurs as protein leaks into the
surrounding
tissue.
Within
the
funiculi,
endoneural
tissue
accumulates
protein,
which
interferes with the nutrition and
metabolism of the nerve fibers.
Protein
exudates
promote
the
proliferation of fibroblasts and the
formation
of
constrictive
endoneurial connective tissue.

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).

Thenar muscle atrophy

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

Non operative management


1) Initial treatment by a physician may
include local steroid injection, oral
NSAIDs.
2) Splinting by the volar wrist cock up
splint, the wrist in 10 to 20 degrees
of extension . It is wearied
continuously for 4 to 6 weeks, and
decrease use of splint over the
subsequent 4 weeks .

Local steroid injection

Volar wrist cock up splint

The custom-design volar wristextension


splint can be used during work activities.
The patient is taught how to maintain flexor
muscle relaxation while wearing the splint.

3. Instruction to avoid certain wrist and hand postures


(Figure 4). These includes:
. Gripping or pinching objects while flexing the wrist
. Performing repetitive wrist flexion extension motion
. Gripping a tool by ulnar deviating hand.
Examples:
.Computer keyboard typing
.Driving long distances
.Use of tools that produce vibrations in the hand, such
as:
hammers, saws, drills, and jack-hammers
.Repetitive assembly line work
.Folding materials such as laundry and paper products
.Knitting and sewing
4. Control inflammation through ice packs, tendon
gliding exercises performed 5 times each, 5 times
daily, and elevated activities

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.

Post surgical management:


Goals for the first 3 weeks postoperative:
Control edema
Maintenance of ROM
Restriction of adhesion formation
Protected use of the hand
Methods:
1-Constant elevation of the involved hand , and
retrograde massage.
2-Tendon gliding exercise: 10 repetitions, 3 times
daily.
3-Shoulder exercises are performed 3 times daily
in all directions.
4-After one week the volar cast is removed and
another thermoplastic splint is fabricated to be
worn during sleep and strenuous activities

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.

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