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Carpal Tunnel Syndrome
azharia@mums.ac.ir
dr.aminazhari@gmail.com
Introduction
Definition
- There is a tight space between the fibrous band and the wrist bone called the carpal tunnel
- The median nerve passes through the carpal tunnel & receive sensation from the thumb
- Carpal tunnel syndrome is pressure on the median nerve at this space
Epidemiology
- Female to male ratio is 3-10/1
- The peak age range for developement of CTS is 45-60 years. Only 10% of patients with CTS are younger than 31 years
Syptomes
In the hand & fingers
Syptomes
Carpal tunnel syndrome can lead to
- Pain
- Numbness
- Tingling
- weakness or muscle damage
Symptomes are usually worse at night
and can awaken patients from sleep
To relieve the symptomes, patients
often shake their wrist (flick sign)
Causes
Usually the cause is unknown
Causes
- Osteoartthritis can narrow the tunnel
- Posture: Keeping the wrist bent for long periods of time
- Diabetes mellitus
- Rheumatoid arthritis
- Fluid retention during pregnancy
- Thyroid conditions (Hypothyroidism)
- Repititive wrist movements
- Joint dislocations & fractures
Diagnosis
- Carpal tunnel syndrome is a clinical diagnosis.
- No good clinical test exists to support the diagnosis of CTS.
Diagnosis
Special tests
Phalen's Maneuver
Phalen' s Maneuver
Tingling in the median nerve distribution is induced by full flexion (or full extension for reverse Phalen) of the wrists for up
to 60 seconds
Tinel sign
Tinel sign: is a way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve
Durkan Compression Test
Durkan Compression test
This test involves applying firm pressure directly over the carpal tunnel, usually with the thumbs, for up to 30 seconds to reproduce symptoms.
Electrodiagnosis
( EMG- NCS)
ED tests can help:
– Identify peripheral neuropathy
– locate other sites of compression
– Establish severity
Treatment
The goal of treatment for CTS is to reduce the swelling and pressure on the median nerve.
Ergonomics
- Avoid inadequate posture and repetitive wrist movement
- Keyboard and mouse support
Wrist brace
- Wrist splints are recommended for use either at night, or both day and night although they get in the way when doing daily activities.
- These help to keep wrist straight and reduce pressure on the compressed nerve.
- Most individuals with mild-to-moderate carpal tunnel syndrome respond to conservative management, usually consisting of splinting the wrist at nighttime for a minimum of 3 weeks
Wrist Brace
Pharmacotherapy
- Vitamin B6 (Pyridoxine) - 200mg po daily for 90 days may relieve numbness and tingling
- Short (1-2 wk) courses of regular NSAIDs
- A short course of a mild diuretic may be of benefit.
- The local injection and oral cortisone are used to relieve pressure (inflammation) on the median nerve and provide immediate, temporary relief to persons with mild or intermittent symptoms.
Exercises
Median Nerve Gliding Exercises
Carpal Tunnel Stretch
Exercises
Surgery
- Patients whose condition does not improve following conservative treatment
- Patients who initially are in the severe carpal tunnel syndrome should be considered for surgery
There are 2 types of surgery
Open Carpal Tunnel Release
Open Carpal Tunnel Release
Endoscopic Carpal Tunnel Release
Endoscopic Carpal Tunnel Release
Rehabilitation After Surgery
- Gentle massage for the scar tissue desensitize the incision
- Modalities to decrease pain, inflammation and swelling (heat, cold, e-stim)
- Progressively exercises to strengthen and stabilize the muscles and joints in the hand.
- Exercises to improve fine motor controland dexterity.
Rehabilitation After Surgery
Complication & prognosis
- Carpal tunnel syndrome appears to be progressive over time and can lead to permanent median nerve damage.
- Whether any conservative management can prevent progression is unclear.
• Even with surgical release, it appears that the syndrome recurs to some degree in a significant number of cases possibly in up to one third after 5 years.
• Initially, approximately 90% of mild to moderate CTS cases respond to conservative management. Over time, however, a number of patients progress to requiring surgery