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carpal tunnel syndrome

Carpal tunnel syndrome is compression of the median nerve at the wrist, causing numbness and tingling in the hand and fingers. It is typically diagnosed based on symptoms and physical exam findings. Conservative treatment includes splinting, corticosteroid injections, and lifestyle changes. If conservative treatment fails, surgical release of the transverse carpal ligament is performed, either via open or endoscopic technique. Care must be taken during surgery to avoid injuring nearby structures like nerves and blood vessels.

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SRI SIDDHARTHA MEDICAL COLLEGE TUMKUR Topic :- Carpal Tunnel Syndrome CHAIRPERSON PROF. & HOD:- Dr. Kiran Kalaiah MODERATOR:- Prof Dr. Veeranna H.D PRESENTER:- Dr. K. Anudeep kumar Date-10/05/2018 SUBJECT SEMINAR Department of Orthopaedics
Definition: Carpal tunnel syndrome (Tardy median nerve palsy) is compression of the median nerve at the wrist, which may result in numbness, tingling, weakness, or muscle damage in the hand and fingers. In 1854 it was described by James Paget. Moersch was the first to coin the term carpal tunnel syndrome The incidence in the general population is about 1 percent . It occurs more often in women, (F>M) in a ratio of 5:1. The common age at onset is 40 to 50yr, although a person of any age may be affected. Most commonly dominant limb is involved.
• CTS is typically a clinical diagnosis based on the classical symptoms of tingling ,numbness , and ocassional pain in the hand with definitive physical findings. • The onset of compression triggers a breakdown of the blood-nerve barrier which produces endo neurial edema resulting eventually in perineural fibrosis. • Sustained compression then leads to localized demyelination which then becomes diffuse resulting in the features of CTS. • The normal interstitial pressure with in the carpal tunnel is about 2.5mm Hg.this can reach above 30mm or more in maximal wrist flexion extension even in normal hands.pressure above 30mmhg have been found to result in nerve dysfunction.
Anatomy of wrist and palm after removal of skin and superficial fascia: • Diagram shows triangular shaped palmar aponeurosis, which is thickened deep fascia. Its apex is directed proximally. • Palmar aponeurosis is continuous with tendon of palmaris longus. It is regarded as degenerated tendon of palmaris longus. Lateral to palmar aponeurosis thenar muscles are situated. • Medial to palmar aponeuroses superficial muscle palmaris brevis is situated. • Deep to proximal part of aponeurosis Flexor retinaculum is present. It keeps the flexor tendons in place. It is a strong band of fascia stretching across the ventral aspect of carpus.
• Flexor retinaculum is attached medially to pisiform bone & to hook of hamate bone. Laterally it splits into superficial & deep layer. Superficial layer is attached to tubercle of scaphoid & tubercle of trapezium. • Deep layer is attached to the trapezium posterior to the groove for flexor carpi radialis. The space between retinaculum and carpal bones is called CARPAL TUNNEL.
• Carpal tunnel is an inelastic cylindrical cavity connecting the volar forearm with the palm. Boundaries • It is bounded by bones on 3 sides and flexor retinaculum on one side. • >Floor : formed by transverse arch of carpal bones • >Medially : hook of hamate, triquetrum, pisiform • >Laterally : Scaphoid, trapezium, fibro osseous flexor carpi radialis sheath Roof: flexor retinaculum • >Deep forearm fascia proximally -Transverse carpal ligament over wrist -Aponeurosis between thenar and hypothenar Muscles'
CONTENTS : > Tendons of flexor digitorum superficialis and flexor digitorum profundus in a common sheath. > Flexor pollicis longus tendon in an independent sheath. > Median nerve
ETIOLOGY OF CARPAL TUNNEL SYNDROME 1. Idiopathic 2. Factors increasing the volume of carpal tunnel A. Factors outside the nerve a. Conditions altering fluid balance: Thyroid disorders (especially hypothyroidism); Pregnancy; Renal failure; Myxedema; Acromegaly b. Inflammatory conditions: Rheumatoid arthritis; Gout; Systemic Lupus erythematosus; Scleroderma; Amyloidosis; Nonspecific tenosynovitis c. Tumors and Tumor like swellings: Ganglions; Pigmented villonodular synovitis; Lipoma; Fibroma d. Anatomical anomalies: Anomalous muscles Eg. Palmaris profundus, aneurysm of median artery e. Hematological conditions: Hemophilia, Von Willebrand Disease, Acute lukemias f. Post traumatic: traction neuropathy, high pressure injection injuries, roll over injuries B. Factors within the nerve a. Tumors and Tumor like lesions: Schwannoma, neurofibroma, Sotta-Dejerine syndrome, lipomas, hemangiomas, synoviosarcoma
3. Extrinsic factors that could alter the counter of the tunnel A.Acute wrist, distal radius fractures B. Acute fracture dislocations, complex carpal injuries C. Chronic wrist injuries D.Malunited distal radius fractures, smith fractures. 4. Exertional/Over use conditions 5. Neuropathic factors: Diabetes mellitus, alcoholism, nutritional deficiency, vitamin toxicity, hand arm vibration syndrome 6. Idiopathic etiology is most common associated with 80 percent of cases . 7. External forces like direct pressure, vibration.
CLINICAL FEATURES Symptoms >Paroxysms of pain, paresthesias and numbness occur in the areas of distribution of median nerve particularily at night >Patient is awakened after few hours of sleep by pain which is burning, aching or pricking of pins and needles and numbness in one or both hands >Pain may radiate to inner aspect of forearm or even up to shoulder >Uselessness of wrist and swelling of the fingers >Acute attack subsides within few mins to an hour and relieved by dangling the arm over the side of the bed, shaking the arm or rubbing the hand >Tingling may develop during day often precipitated by certain manual activities >Sensory impairment in distribution of median nerve >Wasting of thenar muscles and decreased grip strength
Maneuvers for diagnosing Carpal Tunnel syndrome • PHALEN TEST(wrist flexion test)- (provocative test) • The elbows are placed on a table with forearm vertical and wrist flexed by gravity or by examiner for 1 minute • Response- tingling and numbness in median nerve area
REVERSE PHALEN TEST • Wrist and fingers are actively extended for 2 mins • Response: Tingling and numbness in median nerve area GILLIAT TEST (Tourniquet test) • Tourniquet is infiltrated around the arm to the systolic pressure for 60secs • Response: Tingling and numbness in median nerve area
SENSORY EVALUATION STATIC TWO POINT DISCRIMINATION • Paper clips of different prong distances touched over the pulp • Response: 2PD>5mm over the median nerve distribution (or less than ulnar and radial nerve areas) MOVING TWO POINT DISCRIMINATION TEST • Prongs of varying distance run over the fingers • Response: 2PD>5mm over the median nerve distribution (or less than ulnar and radial nerve areas) TUNING FORK TEST • A vibrating tuning fork (256 cps) is pressed over the finger tips • Altered perception in median nerve distribution
SEMMES-WEINSTEIN MONOFILAMENT TEST • Monofilaments of varing thickness pressed over the had till filaments bend • Response: Inability to discern below 2.83 monofilament over median distribution
• Hand volume stress test : hand volume measured by displacement , repeat after 7 minutes stress test and10 minutes rest . • Positive result hand volume is increased by >10 ml.
DIAGRAMS AND QUESTIONNAIRES KATZ HAND DIAGRAM • Patient asked to fill a questionnaire • Response: Sensory loss in median nerve area BOSTON CARPAL TUNNEL QUESTIONNAIRE • Patient asked to fill a questionnaire • Response: Sensory loss in median nerve area
DIFFERENTIAL DIAGNOSIS: 1)Tendinitis 2)Tenosynovitis 3)Nerve compression by cervical disc herniation 4)Thoracic outlet syndrome
IMAGING STUDIES: X-RAY • They reflect the bony cause such as lunate lying in the carpal tunnel following a perilunate injury or mal-united distal radius fracture which alters the shape of the carpal tunnel. • Special view carpal tunnel view is taken with the hand placed on the cassette and the wrist hyperextended by the patient. • The x-ray beam is angled along the volar aspect of the carpal tunnel to a point 2.5 cm distal to the base of 4th metacarpal at an angle of 25-30 degrees ULTRASONOGRAPHY and MRI : • USG is being used an ancillary aid in diagnosis of CTS, especially as a screening tool with MRI. • An increase in cross sectional area of the median nerve in the carpal tunnel and a ratio of csa of median nerve at the level of pisiform and distal radius( swelling ratio )are used.
• The CSA cutoff value for diagnosis is 10.7mmsquare with a sensitivity and specificity nearing 63percent.
• EMG and nerve conduction studies: They help to confirm the diagnosis mostly helpful in determination of site and severity of nerve compression. • It can detect 84% of cases. A distal motor latency of more than 4.5 ms and a sensory latency of more than 3.5 ms are considered abnormal. Electromyography may show signs of nerve damage, including increased insertional activity, positive sharp waves, fibrillations at rest, decreased motor recruitment, and complex repetitive discharges. These studies occasionally are normal, however, when clinical signs of carpal runnel syndrome are present, and they may be abnormal in asymptomatic patients. Nerve conduction studies are reported to be 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome. • They also are helpful in evaluating the upper extremity for nerve compression at the elbow, axilla, and cervical spine, and for showing changes of peripheral neuropathy. Braun and Jackson showed that electrodiagnostic testing provided no significant data for prediction of functional recovery or reemployment after carpal tunnel release.
CONSERVATIVE TREATMENT: * If mild symptoms have been present, and there is no thenar muscle atrophy, the use of night splints has been useful. * Injection of cortisone preparations into the carpal tunnel may provide temporary relief Care should be taken not to inject directly into the nerve. Injection also can be used as a diagnostic tool in patients without osteophytes or tumors in the canal. Most of these cases are probably caused by a nonspecific synovial edema, and these seem to respond more favorably to injection. * Nasaids and other measures early treatment with nasaids , diuretics ,B6 supplements and pregabalin has been said to have some symptomatic relief in some patients . * Nerve gliding excercises and hatha yoga is beneficial in mild stages. * On the basis of experimental and clinical observations, 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. Patients with intermediate and advanced (chronic) syndromes responded to carpal tunnel release. * Treatment of acute carpal tunnel syndrome should be individualized, depending on its cause. For carpal tunnel syndrome caused by an acute increase in carpal tunnel pressure (e.g., 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.
Surgical Release of Carpal Tunnel Limited approaches, such as >the "double incision" of Wilson >the "minimal incision" of Bromley offer the rapid recovery described to the endoscopic technique and less risk.
TECHNIQUE > Make a curved incision ulnar to and paralleling the thenar crease. Avoid making the incision in the thenar crease if the crease is deep to minimize the skin maceration with postoperative drainage of edema fluid.  Extend the incision proximally to the flexor crease of the wrist, where it can be continued further proximally if necessary.  Angle the incision toward the ulnar side of the wrist to avoid crossing the flexor creases at a right angle, but especially to avoid cutting the palmar sensory branch of the median nerve, which lies in the interval between the palmaris longus and the flexor carpi radial is tendons.  Maintain longitudinal orientation so that the incision is generally to the ulnar side of the long finger axis or aligned with the palmaris longus.  When severed, the palmar sensory branch frequently causes a painful neuroma that may later require excision from the scar. Should this nerve be severed, do not attempt to repair it, but section it at its origin.
* Incise and reflect the skin and subcutaneous tissue. * Identify the deep fascia of the forearm proximal to the carpal tunnel by subcutaneous blunt dissection proximally, and incise the fascia, avoiding the median nerve beneath it. * Place a blunt dissector beneath the fascia to dissect the carpal tunnel contents from the transverse carpal ligament. * Identify the distal end of the transverse carpal ligament, and carefully divide the transverse carpal ligament along its ulnar border to avoid damage to the median nerve and its recurrent branch, which may perforate the distal border of the ligament and may leave the median nerve on the volar side .The strong fibers of the transverse carpal ligament extend distally farther than is generally expected .
>As emphasized by Cobb et al., the flexor retinaculum includes the distal deep fascia of the forearm proximally, the transverse carpal ligament at the true carpal tunnel, and the thick aponeurosis between the thenar and hypothenar muscles. Release all components of the flexor retinaculum. >Be aware of anomalous connections between the flexor pollicis longus and the index flexor digitorum profundus; anomalous flexor digitorum superficialis muscle bellies; and anomalies in the palmaris longus, hypothenar muscles, lumbrical muscles, and median and ulnar nerves. >Avoid injury to the superficial palmar arterial arch, about 5 to 8 mm distal to the distal margin of the transverse carpal ligament. >Inspect the flexor tenosynovium.
AFTER TREATMENT • A compression dressing and a volar splint are applied. The hand is actively used as soon as possible after surgery, but the dependent position is avoided. A smaller dressing can be applied after 1 week, and gradual resumption of normal use of the hand is encouraged. The sutures are removed after 10 to 14 days. The splint is continued for comfort as needed for 14 to 21 days.
Endoscopic Release of Carpal Tunnel • Advocates of endoscopic carpal tunnel release, including Okutsu et al., Chow, Agee et al., and Trumble et al., cite the advantages of less palmar scarring and ulnar "pillar" pain, rapid and complete return of strength, and return to work and activities at least 2 weeks sooner than for open release. • Prospective studies by Ferdinand and MacLean and by Macdermid et al. comparing open and endoscopic carpal tunnel release found no significant differences in function. Immediate postoperative advantages of the endoscopic technique in grip strength and pain relief disappeared after 12 weeks
• Anecdotal reports of intraoperative injury to flexor tendons; to median, ulnar, and digital nerves; and to the superficial palmar arterial arch emphasize the need to exercise great care and caution when performing the endoscopic procedure. • Cadaver studies have shown the close proximity of the median and ulnar nerves, superficial palmar arterial arch, and flexor tendons to the endoscopic instruments
• Agee, McCarroll, and North developed the following • 10 guidelines for the single-incision endoscopic technique to • prevent injury to the carpal tunnel structures: • 1. Know the anatomy. • 2. Never overcommit to the procedure. • 3. Ascertain that the equipment is working properly. • 4. If scope insertion is obstructed, abort the procedure. • 5. Ascertain that the blade assembly is in the carpal tunnel • and not in the Guyon canal. • 6. If a clear view cannot be obtained, abort the procedure. • 7. Do not explore the carpal canal with the scope. • 8. If the view is not normal, abort the procedure. • 9. Stay in line with the ring finger. • 10. “When in doubt, get out.
Although there are variations, the two methods in use are the 1) Agee single portal" 2) Chow "two portal" techniques. According to Chow, contraindications to endoscopic carpal tunnel release include the following: * the patient requires neurolysis, tenosynovectomy, Z-plasty of the transverse carpal ligament, or decompression of the Guyon canal * the surgeon suspects a space-occupying lesion or other severe abnormality of the muscles, tendons, or vessels in the carpal tunnel * the patient has localized infection or severe hand edema, or the vascular status of the upper extremities is tenuous. Fischer and Hastings added the following contraindications to the use of endoscopic technique
* Revision surgery for unresolved or recurrent carpal tunnel syndrome; * Anatomical variation in the median nerve, suggested by clinical findings of wasting in the abductor pollicis brevis without significant median sensory changes; * 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. * Before any surgeon attempts endoscopic carpal tunnel release, thorough familiarization with the technique through participation in "hands-on" laboratory practice sessions is recommended.
Endoscopic carpal tunnel release through a single incision agree. * Ascertain that the operating room setup is satisfactory . Ensure that there is an unobstructed view of the patient's hand and the television monitor. * Use general or regional anesthesia. Although the procedure can be done safely using local anesthesia, the increase in tissue fluid can compromise endoscopic viewing. Exsanguinate the limb with an elastic wrap, and inflate a pneumatic tourniquet applied over adequate padding. Leave the arm exposed distal to the tourniquet. >In a patient with two or more wrist flexion creases, make the incision in the more proximal crease between the tendons of the flexor carpi radialis and flexor carpi ulnaris. > Use longitudinal blunt dissection to protect the subcutaneous nerves and expose the forearm fascia.
* Incise and elevate a U-shaped, distally based flap of forearm fascia , and retract it palmar ward to facilitate dissection of the synovium from the deep surface of the ligament, creating a mouth like opening at the proximal end of the carpal tunnel. * When using the tunneling tools and the endoscopic blade assembly, keep them aligned with the ring finger, hug the hook of the hamate, and keep the tools snugly apposed to the deep surface of the transverse carpal ligament, maintaining a path between the median and ulnar nerves for the instruments. * Use the synovium elevator to scrape the synovium from the deep surface of the transverse carpal ligament. Extend the wrist slightly; insert the blade assembly to the carpal tunnel, pressing the viewing window snugly against the deep surface of the transverse carpal ligament . * While advancing the blade assembly distally, maintain alignment with the ring finger, and hug the hook of the hamate, staying to the ulnar side. Make several proximal-to-distal passes to define the distal edge of the transverse carpal ligament with the fat overlying it.
* Define the distal edge of the transverse carpal ligament by viewing the video picture, ballottement, and light transilluminated through the skin. Correctly position the blade assembly, and touch the distal end of the ligament with the partially elevated blade to judge its entry point for ligament division. Elevate the blade and withdraw the device, incising the ligament. > Fat from the proximal palm may compromise endoscopic viewing by protruding through the divided proximal half of the ligament, leaving an oil layer on the Jens.Avoid this by first releasing only the distal one half to two thirds other ligament.Using the unobstructed path for reinsertion of the instrument, accurately complete the distal ligament division with good viewing. Complete proximal ligament division with a final proximal pass of the elevated blade. * Assess the completeness of ligament division using the following endoscopic observations.
* Through the endoscope, note that the partially divided ligament separates on the deep surface, creating a V-shaped defect . * Make subsequent cuts viewing the trapezoidal defect created by complete division as the two halves of the ligament spring apart. Through this defect, observe the transverse fibers of the palmar fascia intermingled with fat and muscle. Force these structures to protrude by pressing on the palmar skin. * Confirm complete division by rotating the blade assembly in radial and ulnar directions, noting that the edges of the ligament abruptly "flop" into the window, obstructing the view. * Palpate the palmar skin over the blade assembly window, observing motion between the divided transverse carpal ligament and the more superficial palmar fascia, fat, and muscle.
> Ensure complete median nerve decompression by releasing the forearm fascia with tenotomy scissors. * Use small right-angle retractors to view the fascia directly, avoiding nerve and tendon injury . * Close the incision with subcuticular or simple stitches. > Apply a nonadhering dressing. Apply a well-padded volar splint, or, in selected patients, leave the wrist unsplinted. AFTERTREATMENT The splint and sutures are removed at about 10 to 14 days if the wound has healed suitably. Active finger motion is allowed early in the postoperative period. Forceful pulling with wrist flexion is discouraged for about 4 to 6 weeks to allow maturation of soft-tissue healing. Progression of light activities of daily living is allowed at about 2 to 3 weeks, and more strenuous activities are gradually added in the next 4 to 6 weeks.
Chow technique Endoscopic carpal tunnel release through two incisions chow * Perform the procedure using the anesthetic believed most appropriate by the patient and the anesthesiologist, usually a regional block or, as preferred by Chow, local anesthetic infiltration supplemented with intravenous midazolam hydrochloride (Versed) and alfentanil hydrochloride (Alfenta). * With the patient supine, place the hand and wrist on a hand table. The surgeon should be on the axillary side of the upper extremity, and an assistant should be on the cephalad side. * Apply a well-padded pneumatic tourniquet to use if needed. * At least one television monitor should be placed on the side of the extremity opposite the surgeon (toward the head of the table), or, as preferred by Chow, two monitors should be used, one for the surgeon and the other for the assistant.
* With a skin pencil, mark the entry and exit portals. Begin at the pisiform and, depending on the size of the hand, draw a line extending 1 to 1.5 cm radially. From the end of this line, extend a second line 0.5 cm proximally. From the end of the second line, draw a third line extending about 1 cm radially. * The third line is the entry portal. Passively, fully abduct the thumb. Draw a line along the distal border of the fully abducted thumb across the palm toward the ulnar border of the hand. * Draw another line extending proximally from the web space between the long finger and the ring finger, intersecting the line drawn from the thumb. About 1 cm proximal to the intersection of these lines, draw a third line about 0.5 cm long transverse to the long axis of the hand. * Make an incision in the previously marked entry portal, and bluntly dissect to explore the fascia and make a longitudinal incision through the fascia. Identify the proximal edge of the transverse carpal ligament.
* Gently lift the distal edge of the entry portal incision with a small right-angle retractor, revealing the small space between the transverse carpal ligament and the ulnar bursa. Bluntly dissect and develop the space between the transverse carpal ligament and the ulnar bursa. * Use the curved dissector obturator-slotted cannula assembly with the pointed side toward the transverse carpal ligament to enter the space and to push the ulnar bursa free from the deep surface of the transverse carpal ligament. * Avoid entering the ulnar bursa (the "extrabursal" approach). * Use the curved dissector to feel the curved shape of the deep surface of the transverse carpal ligament. Move the dissector back and forth to feel the "washboard" effect of the transverse fibers of the transverse carpal ligament. * Apply a lifting force to the dissector to test the tightness of the ligament and to ensure that the dissector is deep to the ligament, rather than in the tissues superficial to the ligament. * Ensure that the dissector and trocar are oriented in the longitudinal axis of the forearm.
• Touch the hook of the hamate with the tip of the assembly; lift the patient's hand above the table, extending the wrist and fingers over the hand holder. Gently advance the slotted cannula assembly distally, and direct toward the exit portal. Palpate the tip of the assembly in the palm. • Make a second small incision as marked for the exit portal in the palm. Pass the assembly through the exit portal, and secure the hand to the hand holder. * Insert the endoscope at the proximal opening of the tube. * Examine the entire length of the slotted cannula opening to ensure that there is no other tissue between the slotted cannula and the transverse carpal ligament. If there is any doubt, remove the tube and reinsert.
* With the endoscope, having been inserted from the proximal direction, remaining in the tube, insert a probe distally, and identify the distal edge of the transverse carpal ligament. * Use the probe knife to cut from distal i6 proximal to release the distal edge of the ligament . * Insert the triangle knife to cut through the midsection of the transverse carpal ligament. * Insert the retrograde knife, and position it in the second cut. Draw the retrograde knife distally to join the first cut, completely releasing the distal half of the ligament . * Remove the endoscope from the proximal opening of the open tube, and insert the endoscope into the distal opening. * Insert the instruments from the proximal opening.
• Identify the uncut proximal section of the ligament, and use the probe knife to release the proximal edge. Draw the retrograde knife proximally to complete the release of the ligament. * Choose the proper knife to make additional cuts to complete transection of the ligament as needed. * Reinsert the trocar, and remove the slotted cannula from the hand. * If a tourniquet is used, deflate it, and ascertain hemostasis and that there is no pulsatile or excessive bleeding. • > Suture the incisions with nonabsorbable suture; apply a soft dressing.
AFTER TREATMENT Active movement is encouraged immediately after surgery. The sutures are removed at 7 to 10 days, wound healing permitting. Direct pressure to the palm area and heavy lifting should be avoided for 2 to 3 weeks or until discomfort disappears Unrelieved or Recurrent Carpal Tunnel Syndrome Procedures for recurrent problems after carpal tunnel release as follows: * Incomplete ligament release—reexploration, re- release of transverse carpal ligament, excision, release of reformed retinaculum * 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) * Recurrent tenosynovitis—tenosynovectomy, appropriate medical management (appropriate antibiotics in patient with infectious granulomatous tenosynovitis from fungi or mycobacteria)
THANK YOU

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carpal tunnel syndrome

  • 1.
    SRI SIDDHARTHA MEDICALCOLLEGE TUMKUR Topic :- Carpal Tunnel Syndrome CHAIRPERSON PROF. & HOD:- Dr. Kiran Kalaiah MODERATOR:- Prof Dr. Veeranna H.D PRESENTER:- Dr. K. Anudeep kumar Date-10/05/2018 SUBJECT SEMINAR Department of Orthopaedics
  • 2.
    Definition: Carpal tunnel syndrome(Tardy median nerve palsy) is compression of the median nerve at the wrist, which may result in numbness, tingling, weakness, or muscle damage in the hand and fingers. In 1854 it was described by James Paget. Moersch was the first to coin the term carpal tunnel syndrome The incidence in the general population is about 1 percent . It occurs more often in women, (F>M) in a ratio of 5:1. The common age at onset is 40 to 50yr, although a person of any age may be affected. Most commonly dominant limb is involved.
  • 3.
    • CTS istypically a clinical diagnosis based on the classical symptoms of tingling ,numbness , and ocassional pain in the hand with definitive physical findings. • The onset of compression triggers a breakdown of the blood-nerve barrier which produces endo neurial edema resulting eventually in perineural fibrosis. • Sustained compression then leads to localized demyelination which then becomes diffuse resulting in the features of CTS. • The normal interstitial pressure with in the carpal tunnel is about 2.5mm Hg.this can reach above 30mm or more in maximal wrist flexion extension even in normal hands.pressure above 30mmhg have been found to result in nerve dysfunction.
  • 5.
    Anatomy of wristand palm after removal of skin and superficial fascia: • Diagram shows triangular shaped palmar aponeurosis, which is thickened deep fascia. Its apex is directed proximally. • Palmar aponeurosis is continuous with tendon of palmaris longus. It is regarded as degenerated tendon of palmaris longus. Lateral to palmar aponeurosis thenar muscles are situated. • Medial to palmar aponeuroses superficial muscle palmaris brevis is situated. • Deep to proximal part of aponeurosis Flexor retinaculum is present. It keeps the flexor tendons in place. It is a strong band of fascia stretching across the ventral aspect of carpus.
  • 6.
    • Flexor retinaculumis attached medially to pisiform bone & to hook of hamate bone. Laterally it splits into superficial & deep layer. Superficial layer is attached to tubercle of scaphoid & tubercle of trapezium. • Deep layer is attached to the trapezium posterior to the groove for flexor carpi radialis. The space between retinaculum and carpal bones is called CARPAL TUNNEL.
  • 8.
    • Carpal tunnelis an inelastic cylindrical cavity connecting the volar forearm with the palm. Boundaries • It is bounded by bones on 3 sides and flexor retinaculum on one side. • >Floor : formed by transverse arch of carpal bones • >Medially : hook of hamate, triquetrum, pisiform • >Laterally : Scaphoid, trapezium, fibro osseous flexor carpi radialis sheath Roof: flexor retinaculum • >Deep forearm fascia proximally -Transverse carpal ligament over wrist -Aponeurosis between thenar and hypothenar Muscles'
  • 9.
    CONTENTS : > Tendonsof flexor digitorum superficialis and flexor digitorum profundus in a common sheath. > Flexor pollicis longus tendon in an independent sheath. > Median nerve
  • 12.
    ETIOLOGY OF CARPALTUNNEL SYNDROME 1. Idiopathic 2. Factors increasing the volume of carpal tunnel A. Factors outside the nerve a. Conditions altering fluid balance: Thyroid disorders (especially hypothyroidism); Pregnancy; Renal failure; Myxedema; Acromegaly b. Inflammatory conditions: Rheumatoid arthritis; Gout; Systemic Lupus erythematosus; Scleroderma; Amyloidosis; Nonspecific tenosynovitis c. Tumors and Tumor like swellings: Ganglions; Pigmented villonodular synovitis; Lipoma; Fibroma d. Anatomical anomalies: Anomalous muscles Eg. Palmaris profundus, aneurysm of median artery e. Hematological conditions: Hemophilia, Von Willebrand Disease, Acute lukemias f. Post traumatic: traction neuropathy, high pressure injection injuries, roll over injuries B. Factors within the nerve a. Tumors and Tumor like lesions: Schwannoma, neurofibroma, Sotta-Dejerine syndrome, lipomas, hemangiomas, synoviosarcoma
  • 13.
    3. Extrinsic factorsthat could alter the counter of the tunnel A.Acute wrist, distal radius fractures B. Acute fracture dislocations, complex carpal injuries C. Chronic wrist injuries D.Malunited distal radius fractures, smith fractures. 4. Exertional/Over use conditions 5. Neuropathic factors: Diabetes mellitus, alcoholism, nutritional deficiency, vitamin toxicity, hand arm vibration syndrome 6. Idiopathic etiology is most common associated with 80 percent of cases . 7. External forces like direct pressure, vibration.
  • 14.
    CLINICAL FEATURES Symptoms >Paroxysms ofpain, paresthesias and numbness occur in the areas of distribution of median nerve particularily at night >Patient is awakened after few hours of sleep by pain which is burning, aching or pricking of pins and needles and numbness in one or both hands >Pain may radiate to inner aspect of forearm or even up to shoulder >Uselessness of wrist and swelling of the fingers >Acute attack subsides within few mins to an hour and relieved by dangling the arm over the side of the bed, shaking the arm or rubbing the hand >Tingling may develop during day often precipitated by certain manual activities >Sensory impairment in distribution of median nerve >Wasting of thenar muscles and decreased grip strength
  • 15.
    Maneuvers for diagnosingCarpal Tunnel syndrome • PHALEN TEST(wrist flexion test)- (provocative test) • The elbows are placed on a table with forearm vertical and wrist flexed by gravity or by examiner for 1 minute • Response- tingling and numbness in median nerve area
  • 17.
    REVERSE PHALEN TEST •Wrist and fingers are actively extended for 2 mins • Response: Tingling and numbness in median nerve area GILLIAT TEST (Tourniquet test) • Tourniquet is infiltrated around the arm to the systolic pressure for 60secs • Response: Tingling and numbness in median nerve area
  • 19.
    SENSORY EVALUATION STATIC TWOPOINT DISCRIMINATION • Paper clips of different prong distances touched over the pulp • Response: 2PD>5mm over the median nerve distribution (or less than ulnar and radial nerve areas) MOVING TWO POINT DISCRIMINATION TEST • Prongs of varying distance run over the fingers • Response: 2PD>5mm over the median nerve distribution (or less than ulnar and radial nerve areas) TUNING FORK TEST • A vibrating tuning fork (256 cps) is pressed over the finger tips • Altered perception in median nerve distribution
  • 20.
    SEMMES-WEINSTEIN MONOFILAMENT TEST • Monofilamentsof varing thickness pressed over the had till filaments bend • Response: Inability to discern below 2.83 monofilament over median distribution
  • 21.
    • Hand volumestress test : hand volume measured by displacement , repeat after 7 minutes stress test and10 minutes rest . • Positive result hand volume is increased by >10 ml.
  • 22.
    DIAGRAMS AND QUESTIONNAIRES KATZHAND DIAGRAM • Patient asked to fill a questionnaire • Response: Sensory loss in median nerve area BOSTON CARPAL TUNNEL QUESTIONNAIRE • Patient asked to fill a questionnaire • Response: Sensory loss in median nerve area
  • 23.
    DIFFERENTIAL DIAGNOSIS: 1)Tendinitis 2)Tenosynovitis 3)Nerve compressionby cervical disc herniation 4)Thoracic outlet syndrome
  • 24.
    IMAGING STUDIES: X-RAY • Theyreflect the bony cause such as lunate lying in the carpal tunnel following a perilunate injury or mal-united distal radius fracture which alters the shape of the carpal tunnel. • Special view carpal tunnel view is taken with the hand placed on the cassette and the wrist hyperextended by the patient. • The x-ray beam is angled along the volar aspect of the carpal tunnel to a point 2.5 cm distal to the base of 4th metacarpal at an angle of 25-30 degrees ULTRASONOGRAPHY and MRI : • USG is being used an ancillary aid in diagnosis of CTS, especially as a screening tool with MRI. • An increase in cross sectional area of the median nerve in the carpal tunnel and a ratio of csa of median nerve at the level of pisiform and distal radius( swelling ratio )are used.
  • 25.
    • The CSAcutoff value for diagnosis is 10.7mmsquare with a sensitivity and specificity nearing 63percent.
  • 26.
    • EMG andnerve conduction studies: They help to confirm the diagnosis mostly helpful in determination of site and severity of nerve compression. • It can detect 84% of cases. A distal motor latency of more than 4.5 ms and a sensory latency of more than 3.5 ms are considered abnormal. Electromyography may show signs of nerve damage, including increased insertional activity, positive sharp waves, fibrillations at rest, decreased motor recruitment, and complex repetitive discharges. These studies occasionally are normal, however, when clinical signs of carpal runnel syndrome are present, and they may be abnormal in asymptomatic patients. Nerve conduction studies are reported to be 90% sensitive and 60% specific for the diagnosis of carpal tunnel syndrome. • They also are helpful in evaluating the upper extremity for nerve compression at the elbow, axilla, and cervical spine, and for showing changes of peripheral neuropathy. Braun and Jackson showed that electrodiagnostic testing provided no significant data for prediction of functional recovery or reemployment after carpal tunnel release.
  • 27.
    CONSERVATIVE TREATMENT: * Ifmild symptoms have been present, and there is no thenar muscle atrophy, the use of night splints has been useful. * Injection of cortisone preparations into the carpal tunnel may provide temporary relief Care should be taken not to inject directly into the nerve. Injection also can be used as a diagnostic tool in patients without osteophytes or tumors in the canal. Most of these cases are probably caused by a nonspecific synovial edema, and these seem to respond more favorably to injection. * Nasaids and other measures early treatment with nasaids , diuretics ,B6 supplements and pregabalin has been said to have some symptomatic relief in some patients . * Nerve gliding excercises and hatha yoga is beneficial in mild stages. * On the basis of experimental and clinical observations, 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. Patients with intermediate and advanced (chronic) syndromes responded to carpal tunnel release. * Treatment of acute carpal tunnel syndrome should be individualized, depending on its cause. For carpal tunnel syndrome caused by an acute increase in carpal tunnel pressure (e.g., 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.
  • 28.
    Surgical Release ofCarpal Tunnel Limited approaches, such as >the "double incision" of Wilson >the "minimal incision" of Bromley offer the rapid recovery described to the endoscopic technique and less risk.
  • 31.
    TECHNIQUE > Make acurved incision ulnar to and paralleling the thenar crease. Avoid making the incision in the thenar crease if the crease is deep to minimize the skin maceration with postoperative drainage of edema fluid.  Extend the incision proximally to the flexor crease of the wrist, where it can be continued further proximally if necessary.  Angle the incision toward the ulnar side of the wrist to avoid crossing the flexor creases at a right angle, but especially to avoid cutting the palmar sensory branch of the median nerve, which lies in the interval between the palmaris longus and the flexor carpi radial is tendons.  Maintain longitudinal orientation so that the incision is generally to the ulnar side of the long finger axis or aligned with the palmaris longus.  When severed, the palmar sensory branch frequently causes a painful neuroma that may later require excision from the scar. Should this nerve be severed, do not attempt to repair it, but section it at its origin.
  • 32.
    * Incise andreflect the skin and subcutaneous tissue. * Identify the deep fascia of the forearm proximal to the carpal tunnel by subcutaneous blunt dissection proximally, and incise the fascia, avoiding the median nerve beneath it. * Place a blunt dissector beneath the fascia to dissect the carpal tunnel contents from the transverse carpal ligament. * Identify the distal end of the transverse carpal ligament, and carefully divide the transverse carpal ligament along its ulnar border to avoid damage to the median nerve and its recurrent branch, which may perforate the distal border of the ligament and may leave the median nerve on the volar side .The strong fibers of the transverse carpal ligament extend distally farther than is generally expected .
  • 33.
    >As emphasized byCobb et al., the flexor retinaculum includes the distal deep fascia of the forearm proximally, the transverse carpal ligament at the true carpal tunnel, and the thick aponeurosis between the thenar and hypothenar muscles. Release all components of the flexor retinaculum. >Be aware of anomalous connections between the flexor pollicis longus and the index flexor digitorum profundus; anomalous flexor digitorum superficialis muscle bellies; and anomalies in the palmaris longus, hypothenar muscles, lumbrical muscles, and median and ulnar nerves. >Avoid injury to the superficial palmar arterial arch, about 5 to 8 mm distal to the distal margin of the transverse carpal ligament. >Inspect the flexor tenosynovium.
  • 34.
    AFTER TREATMENT • Acompression dressing and a volar splint are applied. The hand is actively used as soon as possible after surgery, but the dependent position is avoided. A smaller dressing can be applied after 1 week, and gradual resumption of normal use of the hand is encouraged. The sutures are removed after 10 to 14 days. The splint is continued for comfort as needed for 14 to 21 days.
  • 35.
    Endoscopic Release ofCarpal Tunnel • Advocates of endoscopic carpal tunnel release, including Okutsu et al., Chow, Agee et al., and Trumble et al., cite the advantages of less palmar scarring and ulnar "pillar" pain, rapid and complete return of strength, and return to work and activities at least 2 weeks sooner than for open release. • Prospective studies by Ferdinand and MacLean and by Macdermid et al. comparing open and endoscopic carpal tunnel release found no significant differences in function. Immediate postoperative advantages of the endoscopic technique in grip strength and pain relief disappeared after 12 weeks
  • 36.
    • Anecdotal reportsof intraoperative injury to flexor tendons; to median, ulnar, and digital nerves; and to the superficial palmar arterial arch emphasize the need to exercise great care and caution when performing the endoscopic procedure. • Cadaver studies have shown the close proximity of the median and ulnar nerves, superficial palmar arterial arch, and flexor tendons to the endoscopic instruments
  • 38.
    • Agee, McCarroll,and North developed the following • 10 guidelines for the single-incision endoscopic technique to • prevent injury to the carpal tunnel structures: • 1. Know the anatomy. • 2. Never overcommit to the procedure. • 3. Ascertain that the equipment is working properly. • 4. If scope insertion is obstructed, abort the procedure. • 5. Ascertain that the blade assembly is in the carpal tunnel • and not in the Guyon canal. • 6. If a clear view cannot be obtained, abort the procedure. • 7. Do not explore the carpal canal with the scope. • 8. If the view is not normal, abort the procedure. • 9. Stay in line with the ring finger. • 10. “When in doubt, get out.
  • 39.
    Although there arevariations, the two methods in use are the 1) Agee single portal" 2) Chow "two portal" techniques. According to Chow, contraindications to endoscopic carpal tunnel release include the following: * the patient requires neurolysis, tenosynovectomy, Z-plasty of the transverse carpal ligament, or decompression of the Guyon canal * the surgeon suspects a space-occupying lesion or other severe abnormality of the muscles, tendons, or vessels in the carpal tunnel * the patient has localized infection or severe hand edema, or the vascular status of the upper extremities is tenuous. Fischer and Hastings added the following contraindications to the use of endoscopic technique
  • 40.
    * Revision surgeryfor unresolved or recurrent carpal tunnel syndrome; * Anatomical variation in the median nerve, suggested by clinical findings of wasting in the abductor pollicis brevis without significant median sensory changes; * 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. * Before any surgeon attempts endoscopic carpal tunnel release, thorough familiarization with the technique through participation in "hands-on" laboratory practice sessions is recommended.
  • 41.
    Endoscopic carpal tunnelrelease through a single incision agree. * Ascertain that the operating room setup is satisfactory . Ensure that there is an unobstructed view of the patient's hand and the television monitor. * Use general or regional anesthesia. Although the procedure can be done safely using local anesthesia, the increase in tissue fluid can compromise endoscopic viewing. Exsanguinate the limb with an elastic wrap, and inflate a pneumatic tourniquet applied over adequate padding. Leave the arm exposed distal to the tourniquet. >In a patient with two or more wrist flexion creases, make the incision in the more proximal crease between the tendons of the flexor carpi radialis and flexor carpi ulnaris. > Use longitudinal blunt dissection to protect the subcutaneous nerves and expose the forearm fascia.
  • 42.
    * Incise andelevate a U-shaped, distally based flap of forearm fascia , and retract it palmar ward to facilitate dissection of the synovium from the deep surface of the ligament, creating a mouth like opening at the proximal end of the carpal tunnel. * When using the tunneling tools and the endoscopic blade assembly, keep them aligned with the ring finger, hug the hook of the hamate, and keep the tools snugly apposed to the deep surface of the transverse carpal ligament, maintaining a path between the median and ulnar nerves for the instruments. * Use the synovium elevator to scrape the synovium from the deep surface of the transverse carpal ligament. Extend the wrist slightly; insert the blade assembly to the carpal tunnel, pressing the viewing window snugly against the deep surface of the transverse carpal ligament . * While advancing the blade assembly distally, maintain alignment with the ring finger, and hug the hook of the hamate, staying to the ulnar side. Make several proximal-to-distal passes to define the distal edge of the transverse carpal ligament with the fat overlying it.
  • 43.
    * Define thedistal edge of the transverse carpal ligament by viewing the video picture, ballottement, and light transilluminated through the skin. Correctly position the blade assembly, and touch the distal end of the ligament with the partially elevated blade to judge its entry point for ligament division. Elevate the blade and withdraw the device, incising the ligament. > Fat from the proximal palm may compromise endoscopic viewing by protruding through the divided proximal half of the ligament, leaving an oil layer on the Jens.Avoid this by first releasing only the distal one half to two thirds other ligament.Using the unobstructed path for reinsertion of the instrument, accurately complete the distal ligament division with good viewing. Complete proximal ligament division with a final proximal pass of the elevated blade. * Assess the completeness of ligament division using the following endoscopic observations.
  • 44.
    * Through theendoscope, note that the partially divided ligament separates on the deep surface, creating a V-shaped defect . * Make subsequent cuts viewing the trapezoidal defect created by complete division as the two halves of the ligament spring apart. Through this defect, observe the transverse fibers of the palmar fascia intermingled with fat and muscle. Force these structures to protrude by pressing on the palmar skin. * Confirm complete division by rotating the blade assembly in radial and ulnar directions, noting that the edges of the ligament abruptly "flop" into the window, obstructing the view. * Palpate the palmar skin over the blade assembly window, observing motion between the divided transverse carpal ligament and the more superficial palmar fascia, fat, and muscle.
  • 45.
    > Ensure completemedian nerve decompression by releasing the forearm fascia with tenotomy scissors. * Use small right-angle retractors to view the fascia directly, avoiding nerve and tendon injury . * Close the incision with subcuticular or simple stitches. > Apply a nonadhering dressing. Apply a well-padded volar splint, or, in selected patients, leave the wrist unsplinted. AFTERTREATMENT The splint and sutures are removed at about 10 to 14 days if the wound has healed suitably. Active finger motion is allowed early in the postoperative period. Forceful pulling with wrist flexion is discouraged for about 4 to 6 weeks to allow maturation of soft-tissue healing. Progression of light activities of daily living is allowed at about 2 to 3 weeks, and more strenuous activities are gradually added in the next 4 to 6 weeks.
  • 46.
    Chow technique Endoscopic carpaltunnel release through two incisions chow * Perform the procedure using the anesthetic believed most appropriate by the patient and the anesthesiologist, usually a regional block or, as preferred by Chow, local anesthetic infiltration supplemented with intravenous midazolam hydrochloride (Versed) and alfentanil hydrochloride (Alfenta). * With the patient supine, place the hand and wrist on a hand table. The surgeon should be on the axillary side of the upper extremity, and an assistant should be on the cephalad side. * Apply a well-padded pneumatic tourniquet to use if needed. * At least one television monitor should be placed on the side of the extremity opposite the surgeon (toward the head of the table), or, as preferred by Chow, two monitors should be used, one for the surgeon and the other for the assistant.
  • 50.
    * With askin pencil, mark the entry and exit portals. Begin at the pisiform and, depending on the size of the hand, draw a line extending 1 to 1.5 cm radially. From the end of this line, extend a second line 0.5 cm proximally. From the end of the second line, draw a third line extending about 1 cm radially. * The third line is the entry portal. Passively, fully abduct the thumb. Draw a line along the distal border of the fully abducted thumb across the palm toward the ulnar border of the hand. * Draw another line extending proximally from the web space between the long finger and the ring finger, intersecting the line drawn from the thumb. About 1 cm proximal to the intersection of these lines, draw a third line about 0.5 cm long transverse to the long axis of the hand. * Make an incision in the previously marked entry portal, and bluntly dissect to explore the fascia and make a longitudinal incision through the fascia. Identify the proximal edge of the transverse carpal ligament.
  • 51.
    * Gently liftthe distal edge of the entry portal incision with a small right-angle retractor, revealing the small space between the transverse carpal ligament and the ulnar bursa. Bluntly dissect and develop the space between the transverse carpal ligament and the ulnar bursa. * Use the curved dissector obturator-slotted cannula assembly with the pointed side toward the transverse carpal ligament to enter the space and to push the ulnar bursa free from the deep surface of the transverse carpal ligament. * Avoid entering the ulnar bursa (the "extrabursal" approach). * Use the curved dissector to feel the curved shape of the deep surface of the transverse carpal ligament. Move the dissector back and forth to feel the "washboard" effect of the transverse fibers of the transverse carpal ligament. * Apply a lifting force to the dissector to test the tightness of the ligament and to ensure that the dissector is deep to the ligament, rather than in the tissues superficial to the ligament. * Ensure that the dissector and trocar are oriented in the longitudinal axis of the forearm.
  • 52.
    • Touch thehook of the hamate with the tip of the assembly; lift the patient's hand above the table, extending the wrist and fingers over the hand holder. Gently advance the slotted cannula assembly distally, and direct toward the exit portal. Palpate the tip of the assembly in the palm. • Make a second small incision as marked for the exit portal in the palm. Pass the assembly through the exit portal, and secure the hand to the hand holder. * Insert the endoscope at the proximal opening of the tube. * Examine the entire length of the slotted cannula opening to ensure that there is no other tissue between the slotted cannula and the transverse carpal ligament. If there is any doubt, remove the tube and reinsert.
  • 53.
    * With theendoscope, having been inserted from the proximal direction, remaining in the tube, insert a probe distally, and identify the distal edge of the transverse carpal ligament. * Use the probe knife to cut from distal i6 proximal to release the distal edge of the ligament . * Insert the triangle knife to cut through the midsection of the transverse carpal ligament. * Insert the retrograde knife, and position it in the second cut. Draw the retrograde knife distally to join the first cut, completely releasing the distal half of the ligament . * Remove the endoscope from the proximal opening of the open tube, and insert the endoscope into the distal opening. * Insert the instruments from the proximal opening.
  • 54.
    • Identify theuncut proximal section of the ligament, and use the probe knife to release the proximal edge. Draw the retrograde knife proximally to complete the release of the ligament. * Choose the proper knife to make additional cuts to complete transection of the ligament as needed. * Reinsert the trocar, and remove the slotted cannula from the hand. * If a tourniquet is used, deflate it, and ascertain hemostasis and that there is no pulsatile or excessive bleeding. • > Suture the incisions with nonabsorbable suture; apply a soft dressing.
  • 55.
    AFTER TREATMENT Active movementis encouraged immediately after surgery. The sutures are removed at 7 to 10 days, wound healing permitting. Direct pressure to the palm area and heavy lifting should be avoided for 2 to 3 weeks or until discomfort disappears Unrelieved or Recurrent Carpal Tunnel Syndrome Procedures for recurrent problems after carpal tunnel release as follows: * Incomplete ligament release—reexploration, re- release of transverse carpal ligament, excision, release of reformed retinaculum * 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) * Recurrent tenosynovitis—tenosynovectomy, appropriate medical management (appropriate antibiotics in patient with infectious granulomatous tenosynovitis from fungi or mycobacteria)
  • 56.