Carpal Tunnel

Syndrome
 DEFINITION
A common disorder characterized by
pain, burning , and tingling of the
palmar surface of the hand, resulting
from compression of the median
nerve between the carpal ligament
and other structures within the carpal
tunnel (entrapment neuropathy).
 Floor and walls = bony carpus
Roof = flexor retinaculum /transverse carpal
ligament
Radial attachment = tubercle of scaphoid +
ridge of trapezium
Ulnar attachment = hook of hamate + pisiform
Contents:
FPL
Median Nerve
FDS
FDP
PALMAR VIEW CROSS SECTION
Position Carpal tunnel pressures
(mmHg)
Normal 2,5
Maximum flexion < 32
Maximum extension < 32
 Pathogenesis

The tendons of the hands are wrapped with a

lining that produce a slippery fluid (synovium)
which in turn, lubricates the tendons
With repetitive movement of the hand, the
lubrication system may malfunction
This reduction in lubrication results in
inflammation and swelling of the tendon area
Repeated episodes of swelling cause thick
tissue to form and prevents tendon movement
 Two basic categories of
causes
Work related causes
- Grabbing and tagging cloth
- Handling objects on conveyor belt
- Hand weeding
- Using spray gun
- Knitting
- Turning keys
- Typing
Non Work Related causes
- Arthritis
- Diabetic
- Thyroid Gland inbalance
- Gout
- Broken or dislocation bones of the wrist
- Hormonal changes associated with
menopause
- Pregnancy
 SYMPTOMS AND CLINICAL
FINDINGS
Tingling of the thumb, index, middle
& ring fingers.
Especially at night & after using
hands
Relieved by shaking, hanging or
massaging your hands
Dropping objects, inability to keep or
count change with the affected hand
Tinels Test:
is performed
applying
repeated digital
percussion over
the median
nerve in a
proximodistal Positive electric tingling
response in fingers.
direction.
 Phalens Test:
is a provocation test
done through
maximal wrist
flexion maintained
for approximately
60 second. This
increases pressure
on the median
Positive Numbness or tingling on radial
digits within 60 second. nerve.
 Durkan Carpal
Compression Test:
considered positive
when patient
symptoms are
reproduced applying
a direct digital
pressure for
approximately 30
Positive Paresthesia within second.
30 second
 Electromyography
Electrodes are
placed on the
forearm and a
mild electrical
current is passed
through the arm.
Measurement of
how fast & how
well the median
nerve responds
indicates if there
is damage to the
nerve.
TREATMENT
MILD CASE :
Splint (usually worn at
night) to prevent the
wrist from bending.
Relieves swelling
through rest.
Medications: Oral anti-
inflammatories. The
swollen membranes are
reduced
 TREATMENT
SEVERE CASE
Cortisone injection: Medication
surrounds the swollen membranes
& tendon, shrinking them
(effective when diagnosis is made
early)
Surgery: under local anesthetic.
Relieves pressure on the median
nerve.
 SURGERY TREATMENT
Signs and symptoms are persistent and
progressive, especially if they include
thenar atrophy
Open-Incision
Most common
Small incision made on palm of hand (< 2in)
Cut through palmar fascia and carpal ligament
Stitch skin together
Leave TCL separated
 SURGERY TREATMENT (cont)
Endoscopic CT release
Newer procedure
Smaller incision
Some surgeons make 2 incisions (see picture)
Single incision is becoming more popular

Fiber optic TV camera

Still release TCL
A. Transverse incision proximal to anterior wrist crease
between flexor carpi ulnaris and flexor carpi radialis
tendons. Distal longitudinal incision made between
proximal palmar crease and 1 cm distal to hamate hook
in line with radial border of ring finger.
B. Incision used for minimal-incision approach.
 Relative position of the flexor
retinaculum and superficial palmar
arch in relation to topographic
markings.
(a) Proximal palmar crease of hand;
(b) Superficial arch;
(c) distal extent of flexor
retinaculum;
(d) Hook of hamate;
(e) distal flexor crease of wrist;
(f) site of entry of recurrent branch
of median nerve into
thenarmuscles.
Clarpal Tunnel syndrome, R. Luchetti
SURGERY TREATMENT (cont)
Open Carpal Tunnel Release

The surgeon makes a 2-5 inch incision in the lower palm and wrist area.
The carpal ligament is opened. This frees the median nerve. The incision is
closed with stitches. A bulky bandage is applied to the wound, with care
taken to ensure that digit movement is NOT restricted.
Endoscopic Carpal Tunnel Release

A tiny, -inch incision is made on the palm side of the

wrist. A miniature fiber optic camera is passed through. This
camera allows the surgeon to view the inside of the carpal
tunnel. Another tiny incision is made. Surgical tools are
passed in. While looking at the monitor, these instruments
are used to release the carpal ligament and free the median
nerve. After the camera and instruments are removed, a
few stitches are necessary to close the incisions. A bulky
bandage is placed over the wounds.
 AFTER THE SURGERY
It may have to wear a brace or splint
for several weeks after surgery.
Complete recovery may take 4-6
weeks or longer.
The numbness or tingling in hand and
fingers usually improves rather quickly.
Grasp strength will very slowly begin to
improve.
Physiotherapy needed
Exercises
Post Surgery
Physical activities can
be resumed only after
a few weeks & for
some a few months
Exercises will be given
in order to build muscle

strength, joint flexibility

of hand and wrist
Q-6: The recurrent motor branch of the
median nerve innervates which of the
following muscles?

1. Abductor pollicis brevis, first dorsal interosseous, opponens

pollicis.
2. Abductor pollicis brevis, flexor pollicis brevis, opponens
pollicis.
3. Adductor pollicis, first dorsal interosseous, opponens pollicis.
4. Adductor pollicis, flexor pollicis brevis (deep and superficial
heads)
5. Adductor pollicis, flexor pollicis brevis, opponens pollicis.
PREFERRED RESPONSE : 2

DISCUSSION : The recurrent branch of the median nerve supplies the thenar
muscles (abductor pollicis brevis, flexor pollicis brevis and opponens pollicis)
that are primarily responsible for thumb opposition. The nerve can be injured
in carpal tunnel release. A branch of the nerve also supplies the tne first
lumbrical. The adductor pollicis and the interossei are supplied by the ulnar
nerve.

REFERENCES : Last RJ: Anatomy: Regional and Applied, ed 6. London, England, Churchill
Livingstone, 1978, p 109.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach.
Philadelphia,,
PA, JB Lipincott, 1984, p 170.
Q-15: In the early stage of carpal tunnel syndrome,
Semmes-Weinstein monofilament testing is
considered more sensitive than static two-point
discrimination testing in assessing median nerve
dysfunction because it measures the :

1. innervation density of slowly adapting fibers

2. innervation density of quickly adapting fibers
3. threshold of quickly adapting fibers
4. threshold of slowly adapting fibers
5. conduction velocity of sensory fibers
PREFERRED RESPONSE : 4

DISCUSSION : A threshold test measures the function of a single nerve fiber

innervating a group of receptors, whereas an innervation density test measures
numerous overlapping receptor fields. Therefore, threshold tests such as Semmes-
Weinstein monofilament testing and vibration testing are more likely to show a
gradual change in nerver function. Semmes-Weinstein monofilament testing reflects
the function of slowly adapting touch fibers (Group-A beta), and vibration testing
measures the quickly adapting fibers. Static and moving two-point discrimination
testing both measure innervation density and are more a reflection of complex
cortical organization. Therefore, they are most useful in assessing functional nerver
regeneration after nerver repair. Conduction velocity is a useful measure of nerver
dysfunction in compressive neuropathies but can be measured only with
electrodiagnostic equipment.

REFERENCES : Gelberman RH: Operative Nerve Repair and Reconstruction. Philadelphia, PA,
JB Lippincott, 1991, pp 158-162.
MacKinnon SE, Dellon AL: surgery of the Peripheral Nerve. New York, NY, Thieme, 1998, pp
217-219.