Tips on using my ppt.
1. You can freely download, edit, modify and put your
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
6. Good for self study also.
7. See notes for bibliography.
Introduction & History.
• Carpal tunnel syndrome (CTS) is a
collection of characteristic symptoms and
signs that occurs following compression of
the median nerve within the carpal tunnel.
• Until the advent of electrophysiologic
testing in the 1940s, carpal tunnel syndrome
(CTS) commonly was thought to be the
result of compression of the brachial plexus
by cervical ribs and other structures in the
anterior neck region (so-called thoracic
• The carpal tunnel is an osteofibrous canal
situated in the volar wrist.
• The boundaries are the carpal bones and
the flexor retinaculum.
• Structures passing
– Median nerve,
– Nine tendons: the flexor pollicis longus, the
four flexor digitorum superficialis and the four
flexor digitorum profundus
• Ulnar N. passes superficial to flexor
• The median nerve innervates the skin of
the palmar (volar) side of the index finger,
thumb, middle finger, and half the ring
finger, and the nail bed.
• The radial aspect of he palm is supplied by
the palmar cutaneous branch of the median
nerve, which leaves the nerve proximal to
the wrist creases.
• median nerve is damaged within the rigid
confines of the carpal tunnel,
• initially undergoing demyelination
• followed by axonal degeneration.
• Sensory fibers often are affected first
• followed by motor fibers.
• Autonomic nerve fibers carried in the
median nerve also may be affected.
• abnormally high carpal tunnel pressures
exist in patients with CTS. This pressure
causes obstruction to venous outflow, back
pressure, edema formation, and ultimately,
ischemia in the nerve.
• Mild -numbness and tingling in the
distribution of the median nerve without
motor or sensory losses. The patient's sleep
does not suffer disruption, and there are no
changes to the activities of daily living.
• Moderate - symptoms of mild carpal tunnel
syndrome with sensory loss in the median
nerve distribution and sleep becomes
disrupted; there can also be some changes to
• Severe carpal tunnel syndrome includes
symptoms of mild and moderate carpal
tunnel syndrome weakness in the median
nerve distribution and changes to the
activities of daily living.
• Incidence & Prevalence
• Geographical distribution.
• Socioeconomic status
• Temporal behaviour
• In US 1-3 cases per 1000 subjects per year;
prevalence is approximately 50 cases per 1000.
• CTS is almost unheard of in some developing
countries (e.g., among non-white South Africans
• Whites are probably at highest risk.
• The female-to-male ratio for carpal tunnel
syndrome is 3-10:1.
• The peak age range for development of carpal
tunnel syndrome (CTS) is 45-60 years. Only 10%
of patients with CTS are younger than 31 years.
• Increasing age
• Female sex
• Increased body mass index (BMI), especially a
• Square-shaped wrist
• Short stature
• Dominant hand
• Race (white)
• Usual symptoms include numbness,
paresthesias, and pain in the median nerve
• hands fall asleep or that things slip from
their fingers without their noticing (loss of
grip, dropping things)
• numbness and tingling
• Symptoms are usually intermittent and are
associated with certain activities (eg,
driving, reading the newspaper, crocheting,
• Night-time symptoms that wake the individual are
more specific to CTS, especially if the patient
relieves symptoms by shaking the hand/wrist
• Bilateral CTS is common, although the dominant
hand is usually affected first and more severely
than the other hand.
• Complaints should be localized to the palmar
aspect of the first to the fourth fingers and the
distal palm (ie, the sensory distribution of the
median nerve at the wrist).
• Numbness existing predominantly in the fifth
finger or extending to the thenar eminence or
dorsum of the hand should suggest other
• A surprising number of CTS patients are unable to
localize their symptoms further (eg, whole
hand/arm feeling dead). This generalized
numbness may indicate autonomic fiber
involvement and does not exclude CTS from the
• Aching sensation over the ventral aspect of the
wrist. This pain can radiate distally to the palm
and fingers or, more commonly, extend
proximally along the ventral forearm.
• Pain in the epicondylar region of the elbow, upper
arm, shoulder, or neck is more likely to be due to
other musculoskeletal diagnoses (eg,
epicondylitis) with which CTS commonly is
associated. This more proximal pain also should
prompt a careful search for other neurologic
diagnoses (eg, cervical radiculopathy)
• tight or swollen feeling in the hands and/or
temperature changes (eg, hands being cold/hot all
• sensitivity to changes in temperature (particularly
cold) and a difference in skin color. In rare cases,
there are complaints of changes in sweating. In all
likelihood, these symptoms are due to autonomic
nerve fiber involvement (the median nerve carries
most of the autonomic fibers to the hand).
• Loss of power in the hand (particularly for
precision grips involving the thumb) does occur;
in practice, however, loss of sensory feedback and
pain is often a more important cause of weakness
and clumsiness than is loss of motor power per se.
• These symptoms may or may not be
accompanied by objective changes in
sensation and strength of median-innervated
structures in the hand.
• Clinical examination is important to rule out
other neurologic and musculoskeletal
diagnoses; however, the examination often
contributes little to the confirmation of the
• Sensory examination is most useful in
confirming that areas outside the distal
median nerve territory are normal (eg,
thenar eminence, hypothenar eminence,
dorsum of first web space).
– Semmes-Weinstein monofilament testing or 2-
• Motor examination - Wasting and weakness
of the median-innervated hand muscles
(LOAF muscles) may be detectable.
• Hoffmann-Tinel sign
– Gentle tapping over the median nerve in the
carpal tunnel region elicits tingling in the
• Phalen sign
– Tingling in the median nerve distribution is
induced by full flexion (or full extension for
reverse Phalen) of the wrists for up to 60
• The carpal compression test
– This test involves applying firm pressure
directly over the carpal tunnel, usually with the
thumbs, for up to 30 seconds to reproduce
• Palpatory diagnosis
– This test involves examining the soft tissues
directly overlying the median nerve at the wrist
for mechanical restriction.
• A flick sign occurs when a patient is
awoken from sleep with symptoms of carpal
tunnel syndrome and need to flick their
hands to relieve the symptoms
• Hand elevation tests can be completed with
the patient lifting their hand above their
heads for one minute, recreating symptoms
of carpal tunnel syndrome.
• severe thenar muscle (abductor pollicis
brevis, opponens pollicis) wasting of the
right hand, .
• A strong family susceptibility exists and is
probably related to multiple inherited
characteristics (e.g., square wrist, thickened
transverse ligament, stature).
• A number of inherited medical conditions also are
associated with CTS (e.g., diabetes, thyroid
disease, hereditary neuropathy with liability to
• Electrophysiologic studies,
• Electromyography (EMG)
• Nerve conductions studies (NCS), are
the first-line investigations
• Ultrasonography as an adjunct to
• Potentially can identify space-occupying
lesions in and around the median nerve
• confirm abnormalities in the median nerve
(eg, increased cross-sectional area) that can
be diagnostic of CTS, and help to guide
steroid injections into the carpal tunnel.
• Magnetic resonance imaging (MRI) of the
carpal tunnel is particularly useful
preoperatively if a space-occupying lesion
in the carpal tunnel is suggested.
• Abnormalities on
electrophysiologic testing, in
association with specific symptoms
and signs, are considered the
criterion standard for diagnosis.
• Other neurologic diagnoses can be
excluded with these test results.
• Electrophysiologic testing also can
provide an accurate assessment of
how severe the damage to the
nerve is, thereby directing
management and providing
objective criteria for the
determination of prognosis.
• Pronator syndrome, or pronator teres syndrome,
occurs when the pronator teres compresses the
• Looks remarkably similar to carpal tunnel
• In pronator syndrome, patients often complain of
discomfort in their forearm with activity.
• An extended elbow and repetitive pronation can
often reproduce the symptoms of pronator
syndrome, numbness and tingling of the thumb,
and first two digits.
• Occurs typically in cyclists
• Loss of sensation over the thenar eminence.
distinguishes pronator syndrome from carpal
• The Phalen maneuver and the Tinel sign are also
often negative in pronator syndrome
• Given that CTS is associated with low
aerobic fitness and increased body mass
index (BMI) aerobic fitness and weight-loss
• Stationary biking, cycling, or any other
exercise that puts strain on the wrists
probably should be avoided.
Non Operative Therapy
• therapeutic ultrasound
• splinting the wrist at night-time for a
minimum of 3 weeks.
• Steroid injection into the carpal tunnel US
• local progesterone injection
• (NSAIDs) and/or diuretics
• The anticonvulsants gabapentin and
• Patients whose condition does not improve
following conservative treatment and
patients who initially are in the severe CTS
category should be considered for surgery.
• Carpal tunnel release (CTR) Surgical
release of the transverse ligament
• Minimize repetitive hand movements.
• Alternate between activities or tasks to reduce the
strain on your hands and wrists.
• Keep wrists straight or in a neutral position.
• Avoid holding an object the same way for long.
• If you work in an office, adjust your desk, chair,
and keyboard so that your forearms are level with
your work surface.
• Wear a splint at night to keep your wrist straight
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