Carpal tunnel Carpal tunnel syndromesyndrome

Carpal tunnel Carpal tunnel syndromesyndrome

Dr Zameer AliDr Zameer Ali

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Carpal tunnel syndrome

• Described in 1854 by Sir James Paget,

• However term was first coined by Moerisch

• Also called (tardy median palsy)

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• Carpal tunnel syndrome is the most common clinical entity seen by the hand surgeon, with some reporting that the condition affects up to 10% of the general population (u.s)

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• This syndrome consists of motor ,sensory ,vasomotor and trophic symptoms in hand caused by compression of median nerve in carpal tunnel

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Motor changes• Motor changes ; ape thumb

deformity • Loss of opposition of thumb• Index and middle finger lag

behind while making fist

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Motor changes• Vasomotor changes• The skin area with sensory loss is

warmer due to arteriolar dilatation • And also drier due to loss of

sympathetic supply

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• Trophic changes• Long standing cases of paralysis

lead to dry and scaly skin • Nails crack easily with atrophy of

pulp of fingers

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• 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).

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Carpal tunnel • A cylindrical cavity connecting the

volar forearm with the palm, • 9 tendons and one nerve passes

through this tunnel

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boundaries• Carpal tunnel is bounded by bones

from 3 sides and ligament on one side

• Floor is formed by osseous arch and roof is formed by transverse carpal ligament

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Boundaries• Carpal tunnel is bounded by the

transverse arch of the carpal bones dorsally,

• medially, by hook of the hamate, triquetrum, and pisiform

• Laterally by scaphoid, trapezium, and fibroosseous flexor carpi radialis sheath

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Boundaries 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

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Boundaries• The most ventral (palmar)

structure in the carpal tunnel is the median nerve

• Lying dorsal (deep) to the median nerve in the carpal tunnel are the nine flexor tendons to the fingers and thumb

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Risk factors• Risk factors for the condition include female,• diabetes,• hypothyroidism,• obesity,• pregnancy,• rheumatoid arthritis, • gout,•

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Risk factors• precious trauma,• acromegaly, • smoking,• old age,• peripheral neuropathy occupational vibrational exposure,

and renal disease.

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symptoms• Pain, described as deep, aching, or

throbbing, occurs diffusely in the hand and radiates up the forearm.

• Thenar atrophy usually is seen later in the course of the nerve compression.

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symptoms• The classic complaint from the

patient bothered by carpal tunnel syndrome is paresthesias at night.

• Paresthesias are typically tingling or numbness in the median nerve distribution of the hand.

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symptoms• Secondary symptoms include

paresthesias encountered while holding a book or newspaper (“reading paresthesias”)

• or paresthesias encountered while driving (“driving paresthesias”). Other complaints vary from “clumsiness” of the hands, such that objects are often dropped and fine digital tasks are difficult

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• When carpal tunnel syndrome occurs in pregnant women, the symptoms usually resolve after delivery

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diagnosis• The diagnosis of carpal tunnel

syndrome is based on information gathered from the history,

• physical examination,• and electrodiagnostic studies

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Tinel sign• The Tinel sign also may be

demonstrated in most patients by percussing the median nerve at the wrist.

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Phalen test• Acute flexion of the wrist for 60

seconds in some but not all patients or strenuous use of the hand increases the paresthesia.

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Venous engorgement• Application of a blood pressure

cuff on the upper arm sufficient to produce venous distention may initiate the symptoms.

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Findings by Gellman et al.

• The most sensitive test was the wrist flexion test, whereas nerve percussion was the most specific and the least sensitive.

• Tourniquet test: Because of its insensitivity and nonspecificity, the tourniquet test was not recommended

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Pressure changes in different wrist positions• wrist in neutral position, the mean

pressure within the carpal tunnel in patients patients with carpal tunnel syndrome usually >30 mmhg. ( normal 25mmhg)

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• Volar Flexion till 90 degree: 99mmhg (normal 30mmhg)

• Extension till 90 degree :110 mmhg (normal 30 mmhg)

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• It has been established that venous blood flow and axonal transport within the median nerve is compromised with carpal tunnel pressures of 30 mm Hg.

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Pressures in excess of 30 m Hg have been shown in the patient who frequently flexes and extends the wrist, pronates and supinates the forearm, or repeatedly grasps objects

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• The consequence of chronic compression causes damage to the epineural covering of the median nerve resulting in diminished conduction velocity.

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Durkan test• carpal compression test in which

direct compression is applied to the median nerve for 30 seconds with the thumbs . Patients with carpal tunnel syndrome usually have symptoms of numbness, pain, or paresthesia in the median nerve distribution.

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compared with the Tinel nerve percussion and Phalen wrist flexion tests, the carpal compression test is more specific (90%) and more sensitive (87%) than either of these tests

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Hand diagram• Patient marks site of pain or altered

sensation on outlined hand diagram • Positive result marking on palmar

site of radial digits without marking on palm

• Sensitivity .96• Specificity .73

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Direct measurement of C.T pressure

• Infusion catheter placed in carpal tunnel

• Hydrostatic pressure in resting phase >25

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static 2 point discrimination

• Determine minimal separation of 2 distinct points when applied to palmar finger tip

• Failure to determine seperation of at least 5 mm

• Tests advanced nerve dysfunction

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Moving two point discrimination

• Failure to determine seperation of at least 4 mm

• Tests advanced nerve dysfunction

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Vibrometry • Vibrometer placed on palmer side

of digit • Amplitude at 120 Hz ,increased to

perception • Results ;asymmetry compared

with contra lateral hand

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Semmes –Weinstein mono filament

• Monofilaments of increased diameter touched to palmer side of digit until patient can determine which digit is touched

• Positive result value of >2.83

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• Distal sensory and latency conduction velocity

• Distal motor and latency conduction velocity

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Electro diagnostic tests• Electro diagnostic tests include the

nerve conduction velocity (NCV) measurements and the electromyogram (EMG).

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• The NCV is considered positive for carpal tunnel syndrome when the median motor distal latency is >4.5 ms or the distal sensory latency is >3.5 ms

• In more advanced cases, diminished action potential may also be seen

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• Nerve conduction studies are reported to be as high as 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome

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Electro myography • Needle electrodes placed in

muscle • Positive results : fibrillation

potential ,sharp waves, increased insert ional activity

• Interpretation advanced motor median nerve palsy

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• On the EMG portion of the study, the presence of positive sharp waves, increased insertional activity, decreased muscle recruitment, or polyphasic activity is indicative of substantial nerve dysfunction.

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• According to some authors, electro diagnostic studies 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.

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Ct scan• Computed tomographic scanning

displays the bony structures clearly but does not define the soft tissues accurately

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Ultrasonography• Ultrasonography has been used to

show the movement of the flexor tendons within the carpal tunnel, but it does not clearly show soft tissue planes.

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MRI• Early reports of magnetic

resonance imaging (MRI) in carpal tunnel syndrome are promising. A major advantage of MRI is its high soft tissue contrast, which gives detailed images of both bones and soft tissues.

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treatment• Conservative • Operative

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A study of 331 pt• Kaplan, Glickel, and Eaton identified

five important factors in determining the success of nonoperative treatment:

• (1) age over 50 years,• (2) duration longer than 10 months,•

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• (3) constant paresthesia,• (4) stenosing flexor tenosynovitis,

and • (5) a positive Phalen test result in

less than 30 seconds

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• No patient with four or five factors was cured by medical management

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• Gelberman et al. proposed that carpal tunnel syndrome be divided into early, intermediate, advanced, and acute stages. Patients with early carpal tunnel syndrome and mild symptoms responded to steroid injection.

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• Those with intermediate and advanced (chronic) syndromes responded to carpal tunnel release.

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• Treatment of acute carpal tunnel syndrome should be individualized, depending on its cause.

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• For carpal tunnel syndrome caused by an acute increase in carpal tunnel pressure (such as after a Colles fracture treated with flexed wrist immobilization), relief may be obtained by a change in wrist position without surgical release of the tunnel.

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treatment• The mainstay of non operative

management is nocturnal splinting, • particularly for mild or moderate

carpal tunnel syndrome. When consistently used for a period of 4 to 6 weeks, permanent relief of symptoms can ensue.

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• Other non operative measures include non steroidal anti-inflammatory agents (NSAIDs),

• carpal tunnel injections, • ultrasound, phonophoresis,• nerve gliding or stretching, • and vitamin B6.

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Carpal tunnel injections• If mild symptoms have been

present and there is no thenar muscle atrophy, the injection of hydrocortisone into the carpal tunnel may afford relief.

• Great care should be taken not to inject directly into the nerve

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• Injection also can be used as a diagnostic tool in patients without bony or tumorous blocking of the canal; well over 65% of these cases probably are caused by a non specific synovial oedema, and these respond to injection treatment

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• Injection also helps to eliminate the possibility of other syndromes, especially cervical disc or thoracic outlet syndrome

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• Injection is indicated in patients with

• Disease duration of less than 1 year

• No sensory deficits• No marked thenar wasting

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• In injection therapy a single dose of cortisone with splinting for 3 weeeks is tried

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Indications of operative treatment

• Surgical treatment of carpal tunnel syndrome is considered when two of the following criteria are meet following at least a 3-month course of nonoperative care:

• persisting symptoms,• positive physical examination,• and positive electrodiagnostic testing.

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Absolute indications• Absolute indications for surgery

are constant paresthesias,• Thenar atrophy, and markedly

delayed median motor nerve conduction velocity

• or abnormal EMG testing

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• The surgical procedure consists of increasing the volume of the carpal canal by transecting the transverse carpal ligament.

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• An MRI study has shown that division of the transverse carpal ligament expands the volume of the carpal canal by as much as

25%.

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Surgical release of carpal tunnel

Endoscopic release of carpal tunnelLimited approaches1 double incision" of Wilson 2 minimal incision" of Bromley

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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. B, Incision used for minimal-incision approach.

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Endoscopic Release of Carpal Tunnel

• Endoscopic carpal tunnel release is now being used by many surgeons to treat carpal tunnel syndrome.

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• . However, numerous anecdotal reports of 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

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Problems• 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,

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Problems with endoscopic release

• (4) the inability to control bleeding easily, and

• (5) the limitations imposed by mechanical failure.

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• Although Endoscopic technique has proved to be effective, it is doubtful that it should be used in every patient with carpal tunnel syndrome. Consideration always should be given to an open technique if endoscopic release cannot be accomplished safely.

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contraindications• contraindications to endoscopic carpal tunnel

release include• (1) the patient requires neurolysis,

tenosynovectomy, Z-plasty of the transverse carpal ligament; (2) the surgeon suspects a space-occupying lesion or other severe abnormality of the muscles, tendons, or vessels in the carpal tunnel; and

• (3) the patient has localized infection or severe hand edema, or the vascular status of the upper extremities is tenuous

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• . Fischer and Hastings add contraindications to the use of endoscopic technique as follows:

• (1) revision surgery for unresolved or recurrent carpal tunnel syndrome;

• (2) anatomical variation in the median nerve, suggested by clinical findings of wasting in the abductor pollicis brevis without significant median sensory changes; and

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• (3) previous tendon surgery or flexor injury that would cause scarring in the carpal tunnel, preventing the safe placement of the instruments for Endoscopic carpal tunnel release.

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UNRELIEVED, OR RECURRENT, CTS

• In a series of explorations of patients who had undergone previous carpal tunnel surgery, Langloh and Linscheid reported good results in one half and fair results in one third

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• They estimated a recurrence rate of 1.7% after primary carpal tunnel release. Complications and failures are estimated to be between 3% and 19%. Symptoms may lead to repeat operation in 12% of patients

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Causes of recurrent CTS

• incomplete release of the transverse carpal ligament,

• reformation of the flexor retinaculum, scarring in the carpal tunnel,

• median or palmar cutaneous neuroma,

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• palmar cutaneous nerve entrapment, recurrent granulomatous

• or inflammatory tenosynovitis, and hypertrophic scar in the skin

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treatment• Incomplete ligament release—

reexplore, re-release of transverse carpal ligament; excision, release of reformed retinaculum

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• Fibrosis or painful scar—epineurolysis, local muscle flaps, local or remote free fat grafts, excision, Z-plasty of painful scar, nerve wrapping or interposition materials (silicone sheet, vein wrap

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• Fibrosis or painful scar—epineurolysis, local muscle flaps, local or remote free fat grafts, excision, Z-plasty of painful scar, nerve wrapping or interposition materials (silicone sheet, vein wrap

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• Recurrent tenosynovitis—teno synovectomy, appropriate medical management (appropriate antibiotics in patient with infectious granulomatous tenosynovitis from fungi, or mycobacteria)

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• Thank you

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