University of LouisvilleLunch & Learn

Carpal Tunnel Syndrome: A Common Problem with Sometimes Unusual

SymptomsMichael D. Weaver, DO

Physical Medicine & RehabilitationSports Medicine

October 16, 2013

Objectives Become familiar with the basic

anatomy of the wrist and causes of carpal tunnel syndrome {CTS}.

Obtain a better understanding of the signs and symptoms associated with CTS.

Become familiar with some of the various testing and treatments for CTS.

Background Entrapment of the median nerve at the

carpal tunnel is the most common and best characterized peripheral compression neuropathy› Prevalence: 2% Male & 3% Female

0.1% to 10% of the population Higher rates reported in those individuals

involved in repetitive wrist motion activities No concrete data supporting cumulative trauma

› 50% of patients have bilateral CTS ~38% are asymptomatic in ‘uninvolved’ hand

Risk Factors Likely play a role by either increasing

pressure within the CT or increasing susceptibility of the median nerve to pressure, however CTS is largely idiopathic› Normal – 2.5mm Hg (neutral)› CTS – 32mm Hg increased to 94-110mm Hg with

wrist flexion/extension Neuronal changes in < 2 hours

Contributing Factors:› Pregnancy, thyroid disorders, chronic kidney

disease, acromegaly, diabetes, obesity, smoking, alcohol abuse, inflammatory arthritis, genetics

Pathophysiology Chronic compression of nerve inhibits

axonal transport and epidural blood flow which results in intraneural edema, myelin thinning, nerve fiber degeneration and fibrosis.› Impaired nerve circulation› Diminished nerve elasticity› Decreased nerve gliding

Nerve Compression

Anatomy Median nerve travels beneath

transverse carpal ligament along with 9 tendons› Flexor Digitorum Profundus {FDP} – 4› Flexor Digitorum Superficialis {FDS} – 4› Flexor Pollicis Longus {FPL}

Provides motor and sensory input to a portion of the hand

Median Neuropathy Clinical Features

› Pain, numbness, tingling in digits I-III› Sparing of sensation to thenar eminence {palm}

Palmar cutaneous sensory branch› More commonly c/o entire hand and vague

complaints of pain in the shoulder and sharp shooting pains up the forearm 50% of patients reliably localize Neck pain is NOT an associated symptom

Carpal Tunnel Syndrome

CTS Symptoms Usually worsen at night and can

awaken patients from sleep› + flick sign

Exacerbated when driving or talking on the phone

Frequently dropping objects, weak grip Fatigues with repetitive activity

Physical Examination Visual Inspection

› Asymmetry› Skin Changes

Strength Sensation

› Light touch/Pinprick› Vibration› 2 point discrimination

Provocative Maneuvers

Physical Examination Tinel’s sign Phalen Maneuver

› Reverse Phalen Carpal Compression

› Durkan’s

Provocative Maneuvers

Masqueraders Pronator Syndrome

› Compression of the median nerve as it passes through the pronator teres muscle at the elbow

Double Crush Syndrome› Concomitant involvement of a pinched

cervical nerve root in the neck C6 and C7

› Thorough history and physical examination

Diagnosis Truly a clinical diagnosis Constellation of symptoms Use of diagnostic tools

› Ultrasound› Electrodiagnostic Studies

Ultrasound

Noninvasive Allow for real-time

visualization of nerve

Assist in guided injections

Electrodiagnosis Nerve Conduction Studies Electromyography

Treatment Conservative

› Activity modification› Wrist splints› Corticosteroid injection› US therapy› Nerve gliding› Medications

Vitamin B6 NSAIDs v oral steroids

Surgical› Open v Endoscopic carpal tunnel release {CTR}

Referral Information University of Louisville Physicians

› Physical Medicine & Rehabilitation› Frazier Rehab Institute & Neuroscience Center› 502.584.3377

Thank You!