Carpal tunnel syndromeCarpal tunnel syndrome

Dr F Pato

History History

•49 years old, male patient. •Two months hx painful and swollen right hand along the wrist joint. •The pain started as a tingling sensation in the hand. •Radiates up the arm and stops midway in arm. •The hand feels as if it is on fire. •He cannot flex his hand at the wrist and unable to make a fist.

• Nil Previous medical history • Nil Previous surgical history• Self employed welder

Examination • General systems intact• Minimal swelling at wrist joint• Unable to flex wrist joint • Can only flex metacarpo phalyngeal joints• Extension of wrist joint also impaired• Decreased apposition of fingers• Movement associated with pain• Loss of sensation sparing the thenar eminence on

dorsal aspect of hand. • Tinel test positive

• Assessment• Carpal tunnel syndrome• Ulnar nerve entrapment• Arthritis

Xray wrist jointNormal

Assessment • Assessment• Carpal tunnel syndrome

• Three stage assessment

• Subjective • Arthritis• Muscle sprain• Bone fracture

• Objective • Overuse injury• Carpal tunnel syndrome

• Contextual • Ability to function normally after surgery• Loss of income due to inability to work

Management

• Management• Referral to occupational therapy for night

splints• Referral to hand surgery for carpal tunnel

release• Brufen

• Review– Confirmed diagnosis– Carpal tunnel release booked– Using splints

Discussion

• Carpal tunnel syndrome• Compression of the median nerve in the

carpal tunnel characterized by pain and paraesthesia

• Most commonly diagnosed neuropathy in the upper limb7

Anatomy

• The carpal tunnel houses the median nerve together with the flexor tendons of the hand (FDP, FDS, FPL).

• The flexor retinaculum and the carpal bones form a tunnel.

• Extension of the flexor retinaculum • Anterior prominences of the outer carpal bones• Anterior concavity is converted into a tunnel. • Very small space• Conditions that can result in the decrease of the space – compression of the nerve.

AnatomyAnatomy

Movement at wrist joint

•

Pathology

• Reduction in the size of the carpal tunnel– Inflammation – Swelling of the tendons– Infection– Fluid retention

• Excessive exercise – swelling of the tendon or their synovial sheaths.

• The median nerve is the most affected• Most common amongst arthritis patients and

pregnant women, postmenopausal women2.

• The kind of activity that is associated with increased risk for development of carpal tunnel syndrome is the ones where there is – constant pressure on the volar aspect of the hand

eg. Wheelchair users, cycling – associated with constant flexion and extension of

the wrist joint eg tennis– use of vibrating equipment • (highly repetitive or forceful exertions of the hand and

the wrist)

• Other conditions associated with carpal tunnel syndrome are: arthritic conditions, pregnancy and rheumatoid conditions, occupational2, 7.

• The pain occurs during resting periods – decreased blood flow through the limb – median nerve being more irritated.4 – The pain and the numbness wake the patient up

at night. • Shaking the arm results in increased blood

flow to the arm – relief of the irritation of the median nerve and

thus the pain and the numbness is decreased4.

• During the normal conditions• Blood flow is variable depending on the

activity level. • Increase in activity– blood flow can increase up to ten times– more capillaries open up and admit more blood. – asymptomatic during activity.4

Signs and symptoms

• Paresthesia• Hypoesthesia • Burning volar wrist pain • Along the distribution of the median nerve in the

hand – (thumb, middle finger, index finger, radial side of ring

finger)• Can extend up to the shoulder • Pain usually wakes the patient up at night 2,3,4,7.

• Pain worsened by activities that require recurrent repetitive movement of the wrist joint and where the arms are kept immobile.

• The pain is poorly locaised7.• It can radiate to the forearm, elbow and

shoulder. • There is a progressive loss of coordination and

strength in the thumb also with wasting of the thenar muscles.

• There is impairment in the thumb opposition or it cannot be performed.

• Affects the dominant hand or both hands

Diagnosis

• The diagnosis can be made based on the history and clinical examination.

• With examination: – positive Tinel test– reproduction of the symptoms2

(compression of the arm with a Blood pressure cuff or holding the wrist in full palmar flexion for a minute).

• Electrical studies are used to confirm the diagnosis, not for diagnosis purposes2,7

• more important in those with significant motor loss or those with atypical signs or symptoms7.

• Can also be used to determine the severity of the motor loss in order to determine the prognosis.

• Ultrasound can also be used to diagnose carpal tunnel syndrome9.

Investigations

Tinel testNerve conduction studies

Differential diagnosis

• Rheumatic conditions• Cervical disc disease (Cervical spondylosis, C6

and C7)• Proximal entrapment of the median nerve• Thoracic outlet syndrome

Management

•Conservative or surgical•The aim of treatment is aimed at both resolving the symptoms and fastest restitution of the hand and compressed nerve functions– nerve stability, conductivity, condition and

strength8. •The choice of management depends on the duration and the severity of the condition8.

Conservative • Preferably for the not so severe conditions

and those who do not want surgical treatment.

• Symptoms usually disappear after nine month in 50% of the patients4 with 22% continuing to have symptoms after 8years4.

• Night splints (prevents wrist flexion)• NSAIDS

• Single dose steroid injection3,8

• reduce the inflammatory process• reduction in the swelling – nerve compression.

• Improvement of symptoms. • More effective in the earlier course of the

disease. • Can be reserved for those in which

conservative therapy shows no improvement in symptoms after 6 months2,4 .

• Changing the activity type4. • Ischaemic compression therapy (newer

modality). Elimination of the trigger points along the course of the median nerve. Symptoms improve without change in the median nerve itself 4.

• Gabapentin6, effects thereof in the treatment of symptoms of carpal tunnel syndrome were looked at based on its efficacy in the treatment of neurologic pain.

Surgical

• Endoscopic versus open surgery• If symptoms remain pronounced • decline in motor and sensory functions4.• Carpal tunnel release necessary for complete

relief of symptoms, either partial or complete division of flexor retinaculum.

• Loss of relief of symptoms from surgery occurs in about a third of patients after about 2years4.

• Pain in the scar tissue and weakening hand have also been reported4.

Rehabilitation

• Occupational therapy and physiotherapy referral

• post-operative for hand rehabilitation. • Yield in a faster return to activity

Prevention

• Padded gloves, protect the ulnar surface of the wrist

• Adjusting technique• Occupational, adjusting

the weight and duration of activity

• Maintaining wheelchairs in good condition10

Take home message• The interventional options will depend on the

level of activity participation and the type of activity.

• Rehabilitation post therapy is important in the maintanace of hand function, retaining of sport specific hand function and early return to play

References • Moore and Dalley, Clinically Orientated Anatomy, 4th edition; 1999: 680,

774-776• Appley and Solomon, Conscise Systems of Orthopaedics and fractures,

2nd edition; 2001:138• Brukner and Khan, Clinical Sports Medicine, revised 3rd Edition;2009:325• Hains et al. A randomized control trial (intervention) of ischemic

compression therapy for chronic carpal tunnel syndrome. Journal of Canadian Chiropractor Association.2010;54(3);155-163

• Il-Jung Park et al. Opponensplasty using palmaris longus tendon and flexor retinaculum pulley in patients with severe carpal tunnel syndrome. Archives of Orthopedic Trauma Surgery. 2010;130:829-834

• Hui et al. Gabapentin for the treatment of carpal tunnel syndrome: a randomized control trial. European Journal of Neurology 2011;18:726-730

• Fabio Jennings et al. Rheumatic disease presenting as sport-related injuries. Sports medicine Journal. 2008:38(11):917-930

• Nenad Stepic et al. effects of perineural steroid injections on median nerve conduction during the carpal tunnel release. Military Medical and Pharmaceutical Journal of Serbia and Montegerro. 2008;65(11):825-829

• Ultrasonographic evaluation of median nerve in tennis training athletes.

• Olympic textbook of sportsmedicine , M schwellnus 2008;439• Roquelaure Y et al. Occupational and personal risk factors for carpal

tunnel syndrome in industrial workers. Scandanavian Journal of Work Environmental Health1997;23(5):364-369

• Prevalence and incidence of carpal tunnel• syndrome in a meat packing plant• Ron G Gorsche, J Preston Wiley, Ralph F Renger, Rollin F Brant, Tara

Y Gemer,• Treny M Sasyniuk• Occup Environ Med 1999;56:417–422