Carpal Tunnel Syndrome: Causes, Epidemiology, Diagnosis and Management

This is a short presentation on one of the most common entrapment neuropathy carpal tunnel syndrome. This presentation also provides information on its causes, epidemiology,diagnosis and management of carpal tunnel syndrome.

Krishna Dr. A. Mohan Krishna, M.S. Ortho, MCh Orth(UK) is currently a consultant orthopedic surgeon at Apollo Hospitals, Jubilee Hills. He is part of the orthopedic team and he specializes in fracture management, arthroscopy, primary hip and knee arthroplasties, and paediatric orthopedics. He has presented papers in the orthopedic specialty.
Presentation used with permission from Dr. A. Mohan Krishna.

Presentation Transcript

  1. Dr. A.MOHAN KRISHNA M.S.ORTHO, MCh ORTH(U.K) Consultant Orthopaedic surgeon , Trauma, Arthroscopy, Arthroplasty Surgeon Apollo hospitals, Hyderabad Consultant Orthopaedic Surgeon at www.drmohankrishna.com www.healthyjointclub.com www.bonesandjointsclinic.com www.drmohankrishna.com www.healthyjointclub.com www.bonesandjointsclinic.com
  2. Carpal tunnel syndrome, the most common focal peripheral neuropathy, results from compression of the median nerve at the wrist.
  3. Boundaries of carpal tunnel: Volarly : transverse carpal ligament Dorsally : Carpal bones, deep volar carpal ligaments and volar interoseeous ligaments Laterally : scaphoid tuberosity & Trapezium Medially : Pisiform & hook of hamate Contents: 9 Tendons and median nerve Tendons: The tendon of Flexor pollicis longus 4 tendons of Flexor digitorum profundus 4 tendons of Flexor digitorum superficialis Transverse carpal Ligament : Flexor Retinaculum Thick fibrous band from the tuberosity of scaphoid & a portion of trapezium to the Pisiform & hook of hamate.
  4. Aberrant Anatomy - Anamalous flexor tendons - Congenitally small carpal canal - Ganglion cysts - Lipoma - Proximal lumbrical muscle insertion - Thrombosed artery Infections - Septic arthritis - Mycobacterial infections - Lyme disease Inflammatory conditions - Flexor tenosynovitis - Connective tissue diseases - Gout or pseudogout - Rheumatoid arthritis Meatabolic conditions - Acromegaly - Hypothyroidism - Amyloidosis - Diabetes Increased canal volume - Pregnancy - Obesity - Edema - Congestive heart failure
  5. Sensory disturbance Weakness in thumb abduction Thenar atrophy
  6. In this test the wrist is flexed upto 90 degrees for a period of one minute. Patient is then asked for the complaints of tingling, numbness an or pain in the first 3 fingers. This test can be quantified by noting the time taken for the symptoms to appear. There are several ways of positioning the wrist for eliciting the test.
  7. Elicitation: Tap over the median nerve as it passes through the carpal tunnel in the wrist. Positive response: a sensation of tingling in the distribution of the median nerve over the hand. Elicitation: Tap over the median nerve as it passes through the carpal tunnel in the wrist. Positive response: a sensation of tingling in the distribution of the median nerve over the hand.
  8. Gentle pressure directly over carpal tunnel  paresthesias in 30 seconds or less Better for wrists with limited motion Highest sensitivity/specificity of all physical exam tests Gentle pressure directly over carpal tunnel  paresthesias in 30 seconds or less Better for wrists with limited motion Highest sensitivity/specificity of all physical exam tests
  9. Moberg 1958 •Static (nl < 6mm) and Moving (nl = < 3mm) •Abnormal = severe nerve compression Moberg 1958 •Static (nl < 6mm) and Moving (nl = < 3mm) •Abnormal = severe nerve compression 10. Von Frey hairs (1898) Five selected thresholds: - normal (2.83), - light touch (3.61), - protective (4.31), - loss of protective (4.56), - loss of deep pressure (6.56) - Abnormal > 2.83 (eyes closed) Von Frey hairs (1898) Five selected thresholds: - normal (2.83), - light touch (3.61), - protective (4.31), - loss of protective (4.56), - loss of deep pressure (6.56) - Abnormal > 2.83 (eyes closed)
  10. Test Sensitivity Specificity Phalen’s 75% 62% Tinel’s 64% 90% Compression 87% 90% S-W monofilament 65% 42% Vibrometry 87% ?
  11. EMG/NCV criteria: -Sensory latencies (DSL)>3.2ms (most sensitive), -motor latencies(DML)>4.2ms. EMG conduction delay: -distal motor latency >4.5ms for 8cm study; -distal peak sensory latency >4.0ms for 14cm distance; -distal peak compound nerve latency >2.4ms for 8cm study. (AMA Guides 6th ed.) However: - 8-22% of patients with –ve Electrodiagnostics and +ve clinical signs improve with carpal tunnel release. - In some cases Electrodiagnostics + ve for asymptomatic and –ve for symtomatic EMG/NCV criteria: -Sensory latencies (DSL)>3.2ms (most sensitive), -motor latencies(DML)>4.2ms. EMG conduction delay: -distal motor latency >4.5ms for 8cm study; -distal peak sensory latency >4.0ms for 14cm distance; -distal peak compound nerve latency >2.4ms for 8cm study. (AMA Guides 6th ed.) However: - 8-22% of patients with –ve Electrodiagnostics and +ve clinical signs improve with carpal tunnel release. - In some cases Electrodiagnostics + ve for asymptomatic and –ve for symtomatic
  12. Consensus Statement (Am J Pub Health 1998) • (-) ED test, (+) classic sx = ? If CTS • (+) ED test, (-) symptoms  CTS Szabo 1999 •night pain, +ve SW, +ve Durkan’s, +ve Hand diagram = 86% probability of CTS •all test above -ve = 0.68% probability of CTS ED tests did not add to diagnostic power CTS is a clinical diagnosis ED tests can help: • identify peripheral neuropathy • locate other sites of compression • establish severity  •May be beneficial in the long term management •More studies are needed to confirm it’s usefulness
  13. JBJS Evidence-Based Orthopaedics* “Decompressive Surgery Was Better Than Steroid Injection for Symptomatic and Neurophysiologic Outcomes in Carpal Tunnel Syndrome ” PRCT, ED-proven CTS, 20wk f/u All injection patients had improvement of Pain, NCV better with surgery (not grip) McCallister, Trumble JBJS (Am) 2006
  14. Dr.A.MOHAN KRISHNA M.S.Ortho., MCh Ortho(U.K)., Consultant Orthopaedic Surgeon, Apollo Hospitals, Hyderabad. Appointments: Secretary : 09247258989 09441184590 08332936085 www.drmohankrishna.com www.healthyjointclub.com www.bonesandjointsclinic.com Email: bonesandjointsclinic@gmail.com
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