Carpal Tunnel Syndrome

dr. Su Djie To Rante, M.Biomed, Sp.OT

FAKULTAS KEDOKTERAN
UNIVERSITAS NUSA CENDANA
 Carpal Tunnel Syndrome
• A group of symptoms associated with
compression of median nerve at the
wrist
• The Most common nerve compression
condition in the upper extremity
• Anything causing diminution of size of
CT (inflammation, arthritis, hypothyrorids,
tenosynovitis, old fractures, Idiopathic)
• one of the most commonly performed
procedures in the United State
 Epidemiology
• In Netherland
715 subjects (33% men) aged 25-74 years,
confirmed 5.8% in women and 0.6% in men
• In Sweden
From 2466 subjects, confirmed clinically 3.8%,
NCS confirmed 2.7%, women 9.4%, men 4.9%

• Caucasians has the highest risk of CTS compared

other races
• Women suffer more CTS than men (3:1)
• 45–60 years are the peak prevalence
 Why ??
• The only nerve that travel through the
Median Nerve tunnel along with the Tendons

Transverse • A Very strong ligament connect the

Carpal Ligament arch of the carpal bones

• Nine tiny but tough tendons, each in its

lubricating lining or sheath
Flexor Tendons
• As the muscles of the hand and fingers
move
Eight small bones form a “U” at
Carpal Bones
the base the palm
 The Carpal Tunnel
• Is a space bounded by the
carpal bones dorsally
– The trapezium & scaphoid
radially
– The hook of hamate ulnarly
– The transfers carpal ligament
palmarly
• Contains:
– Median nerve
– Nine digital flexor tendons
– With tenosynovium
 anatomy

Variations of Median nerve Branches

Kaplan Cardinal Line

 Risk Factor
• Most cases are idiopathic
• Associated w/ any condition that cause
pressure on the median nerve at the wrist
Ex: - Obesity - Parvovirus
- Oral contraceptives - Double crush syndrome
- Hypothyroidism - Acromegaly
- Arthritis - Amyloidosis
- Diabetes - Pregnancy
- Trauma - Work related
- Benign tumors, eg: lipoma, ganglion - Myxoedema
 Sign and
Symptoms
Symptoms of Syndrome:

1. Pain
2. Paresthesias
3. Numbness
4. Nocturnal waking
in median nerve distribution of the hand
– Aching in thenar eminens
– Weakness & atrophy of Thenar muscles
 PAIN WEAKNESS

PARAESTHESIA

CTS CLUMSINESS

THENAR
TINGLING WASTING
SENSATION
 The physical examinations
• Includes the neck and shoulder girdle
• Supraclavicular, axillary area, elbow and
forearm
• Important to palpate the course of the nerve
• Elicit Tinnel sign along the course of
– Paracervical
– Brachial plexus
– Median
– Ulnar and
– Radial nerves
LOOK:
In late cases, we can find wasting in thenar muscles
 Special test
The Tinnel sign
• Mechanical external
stimulus threshold for
depolarization-
repolarization
• Subjective finding of
Radicular pain
• Anatomic distribution
 Phalen’s sign
• Wrist flexion decreases
the anatomic volume of
the carpal canal
• Raises pressure in
patients in CTS
• There’s pain sensation
and sensory dulling
• The pattern of paresthesia
can be important
- Manual Carpal Compression Test (mCCT)/
Durkan test can elicit the symptoms

Showed greater sensitivity and specificity than

other test In the clinical diagnosis of carpal tunnel
syndrome
MOVE:

In late cases, we often find:

- clumsiness and weakness movement which

requiring fine manipulation, eg: fastening
buttons

- weakness of thumb abduction

 Imaging and Other Diagnostic
Studies
• Radiographs are not mandatory
• If there is any possibility of wrist pathology, these
studies should be obtained
• Other imaging studies are not indicated in
routine cases
• Electrodiagnostics : NCS and EMG are Important
 Further Investigations

• The diagnosis of CTS can be verified

objectively by using electrodiagnostic testing
• The test includes EMG/NCV
• very sensitive shows very mild CTS
Electrodiagnostic test parameters for normal testing are:
1. Median distal sensory latency < 3.6 ms
2. Median ulnar mixed nerve latency difference < 0.4 ms
3. Sensory amplitude >20μV
CTS can be graded based on NCS and
EMG findings
• Increased sensory or
motor distal latency
MILD • May see decreased
amplitude
• Increased nerve conduction
MODERATE velocity
• EMG shows sign of chronic
denervation
• Positive fibrillations
SEVERE • Sharp waves, or unobtainable
recordings on the electrodes to the
innervated muscles
 CTS can be DD/ with:

1. Thoracic outlet syndrome

2. Brachial plexopathy
3. Pronator syndrome
4. Anterior Interosseus Nerve Syndrome
5. Cervial radiculopathy
6. Proximal median neuropathy
7. Peripheral neuropathty
8. “double crush syndrome”
 Pronator teres syndrome

- Compression neuropathy of
median nerve at the elbow
- Entrapment at 1 of 4 distinct sites
1. lig. Of Struthers
2. Lacertus fibrosis
3. Heads of pronator teres
4. FDS aponeurotic arch
Symptoms include:
1. Pain at prox. Volar of prox. arm and forearm
2. Decrease sensation in thumb, index, long fingers
3. Phalen’s test and Tinel’s sign (-)
4. Provocative test Resisted elbow flexion &
forearm supinated
 Anterior Interosseus Nerve Syndrome
- AIN is purely motor branch of
median nerve
- Compression results loss of motor
function without sensory
disturbance
- Weakness of FPL, FDP index finger,
PQ
- Unable to form “OK” sign
- Mild weakness of pronation (when
elbow flexed maximally)
 Non-operative Management
1. Any systemic conditions should
be identified and treated
2. Activity modification can be
attempted
3. Light splints
– Prevent wrist flexion
– Temporary relief
4. NSAID, injection
Corticosteroids
– Reduce inflammation at carpal tunnel
– Also temporary relief
Recommendations by AAOS Oct 2008
• Non-operative management first, Early
surgery if significant evidence
Denervations of median nerve
• Suggest other non-operative if 2-7 weeks
fails to resolve
• Local steroids and splinting before
considering surgery
• No recommendations for acupuncture,
diuretics, physical therapy, electric
stimulations, systemic injection CS
 Surgical Management
• The Goal CTR surgery
Decompress the median nerve at
carpal canal by complete
divisions of the TCL to allow the
carpal tunnel to expand

1. Open Carpal Tunnel Release

2. Single-Incision endoscopic CTR
3. Two-Incision Endoscopic CTR
4. Revision release for Recurrent CTS
 Open Carpal Tunnel
Release
- Open surgical division of transverse
carpal ligament
- Quick and simple cure
- Incision should be kept at ulnar side
of thenar crease  avoid injury to
palmar cutaneous and thenar motor
branches
Open CTR
• Performed with the arm
outstretched
• Pneumatic tourniquet
• Anesthesia can be by GA or
Regional anesthesia
• Using superficial landmarks
• The incision should be long enough
to allow full access to the proximal
to distal extent of the TCL
• Without having the incision extend
proximal to the wrist flexion crease
Qiyun Shi, JC Mac Dermot: Is surgical
intervention more effective than non-surgical
treatment for carpal tunnel syndrome? A
systemic review, J. of Orthopaedic S. and Research. 2011,
6:17
Surgical VS Non-surgical
superior benefit in symptoms and function
Were two time to have normal nerve conduction also
complication and side effect
Both had treatment benefit

• The LANCET, 2009 vol 374, issue 9695,1074-1081, sept

2009
– Surgical treatment led to better outcome than non-surgical
treatment
 Recommendations by AAOS Oct 2008
• Recommended Carpal tunnel release as treatment
CTS (complete divisions of TCL)
• Do not routinely use the following procedure;
– Epineurotomy
– Skin nerve preservations
• No recommendations use procedure :
– Internal neurolysis
– Tenosynovectomy
– Flexor retinaculum lengthening
– Ulnar bursa preservations
• Wrist not be immobilized post operatively after
routine CTR
 Endoscopic Treatment
• One of carpal tunnel
release method
• Functional outcomes
achieved more quickly
(compared open release
carpal tunnel)
• Greater rate of complications:
1. Transection of superficial palmar branch
2. Digital nerve contusion
3. Ulnar nerve neurapraxia
4. Wound hematoma
5. Transection of common digital nerve ring &
small finger
• Functional Outcome more Quickly
The different degrees of Tenderness of the scar
after 84th days posoperative
THANK YOU