Carpal tunnel syndrome

carpal tunnel syndrome

1. Carpal tunnel syndromE

2. Original description of median nerve compressive neuropathy was reported by PAGET in 1854. MOERSCH was first to coin the term ‘carpal tunnel syndrome’

3. Anatomy Formed by transverse carpal ligament(TCL) or flexor retinaculum is quadrangular spanning the concave carpal arch and contains flexor tendons and median nerve. TCL is attached to triquetrum and hamate on ulnar aspect and to tubercles of trapezium and scaphoid on radial aspect. Roughly has a hour glass shape. At the distal end of TCL median nerve divides to recurrent motor branch to thenar muscles and into sensory branches.

4. Pathogenesis Onset of compression of median nerve triggers a breakdown of the blood-nerve barrier which produces endoneurial edema resulting in perineural fibrosis. Sustained compression then leads to localised demyelination which then becomes diffuse resulting in features of classic CTS.

5. Etiology Normal pressure -2.5 mm of hg This can reach upto 30 mm or even in flexion extention of notmal hands. Causes can be divided into five main categories Idiopathic- 80 percent Factors increasing the volume of carpal tunnel Factors outside the nerve Factors within the nerve Extrinsic factor that alter contour of tunnel Exertional /overuse conditions Neuropathic factors

6. Increasing the volume – OUTSIDE THE NERVE – conditions altering the fluid balance – hypothyroidism,pregnancy,renal failure - inflammatory conditions-Rhematoid arthritis,gout,amyloidosis,tubercular tenosynovitis - tumors and swellings like ganglion ,lipoma and fibroma -Anatomical anomilies like aneurysm of median nerve - Hematological conditions : Hemophilia,Von willebrand’s disease,acute leukemia -Post –traumatic: traction neuropathies high pressure injection injuries WITHIN THE NERVE –Tumor and Tumor like lesion: Schwannoma,neurofibroma,synovial sarcoma Extrinsic factors that alter the contour -distal radius fractures (acute and malunited ) Exertional and overuse Neuropathic factors – diabetes,myeloma,alcoholism,nutritional deficiency.

7. Symptoms Dull aching pain in hand ,forearm or upper arm. Paresthesia in hand Weakness or clumsiness of hand Dry skin, swelling or color changes in hand Occurrence of any of above in median distribution Provocation of symptoms in Sustained hand or arm positions Repetitive actions of hand or wrist. Sudden change of hand posture or shaking the wrist.

8. Clinical tests PROVOCATIVE TESTS Phalen test – Forearm vertical and wrist in flexion for one minute- tingling and numbness in median nerve area. Reverse phalen-wrist and fingers actively extended fir 2 minutes-tingling and numbness in median nerve area. Tinel sign – Examiner percusses over median nerve at wrist lightly-shock like sensation Durkan test- press the carpal tunnel for 30 seconds produces tingling and numbness Gilliat test- tourniquet inflated to systolic pressure around arm for 60 seconds

9. Sensory evaluation Static two point discrimination Moving two point discrimination Tuning fork test

10. Questionnaires Katz – patient asked to fill questionnaires. Boston questionnaire.

11. Electrodiagnostic studies Criteria for diagnosis in Electro myography - two or more prolonged conduction velocity of median nerve across wrist-normal 10-18 msec Increased duration of action potential Polyphasic contour - normally biphasic

12. Sensory nerve conduction velocity More sensitive test Nerve conduction velocity between finger and wrist is normally 2-4msec Time prolonged two to three times. Amplitude (normal-10-30) is reduced.

13. Radiological investigations X-rays – Reflect bony causes like perilunate injury or malunited distal radius which alters shape of carpal tunnel. Carpal tunnel view-palm kept on cassette and wrist hyperextended, xray beam along volar aspect to a point 2.5 cm distal to base of forth metacarpal at an angle 25-30 degree to long axis.

14. Usg and mri USG can be used as a screening tool along with MRI. In MRI we look for cross sectional area of median nerve in carpal tunnel and a ratio of cross sectional area of median nerve at level of pisiform and distal radius are used. The area at inlet for diagnosis is taken as less than 10.7 square mm.

15. Treatment- non operative KAPLAN,GLICKEL AND EATON -331 patients Gave 5 important factors in determining success of non operative treatment Age older than 50 years Duration longer than 10 months Constant paresthesia Stenosing flexor tenosynovitis Positive phalen test result in less than 30 seconds.

16. Non operative Splinting Corticosteroid injection NSAID’s and pregabalin Nerve gliding exercises

17. Surgery MINI PALM OPEN CARPAL TUNNEL RELEASE EXTENDED OPEN CARPAL TUNNEL ENDOSCOPIC RELEASE

18. Mini palm open release

19. De Quervain’s tenosynovitis Fritz De Quervain initially described the condition in 1895.Also known as washerwoman’s sprain. Basically a tenosynovitis involving the abductor pollicis longus and extensor policis brevis . Repetitive wrist movements has been proposed as a causative factor.

20. Clinical features Pain and swelling are classical symptom. Persistent swelling may cause thickening of the tendons and may give rise to a locking phenomenon. Finkelstein’s test – It is performed by grasping the patient’s thumb and quickly deviating the hand and wrist ulnarly . Eichoff’s maneuver – pain that is exacerbated by passive wrist ulnar deviation while the thumb is flexed and the fingers curled around it.This is more specific.

21. Differential diagnosis 1 st carpometacarpal joint arthritis Kienbock’s disease Scaphoid fracture Radioscaphoid arthritis

22. Treatment Initial treatment is by splinting the forearm in a volar splint. Corticosteroid injections into tendon sheath if it fails to respond to a trial of splinting and analgesics.Repeated corticosteroid injections are avoided since it may produce skin depigmentation and fat atrophy. Resistant cases: slitting the tendon sheath . Transverse insicion / longitudnal /oblique incision along the skin crease is used. Care is taken to protect the superficial branch of radial nerve(damage can cause a painful neuroma) The abductor pollicis longus and extensor pollicis brevis tendon is identified and divided. Slitting of the tendon sheath should be done on ulnar side to prevent volar subluxation of tendons(Burton and Litter)

23. Complications of surgical release Injury to superficial branch of radial nerve,volar subluxation of first dorsal compartment muscles and hypertrophic scar formation. Persistent pain from inadequate decompression often represents failure to recognise and release an additional compartment ,most commonly that of extensor pollicis brevis .

24. Compound palmar ganglion (ACREL IN 1977) Extrapulmonary tuberculous involvement of the musculoskeletal system is uncommon, accounting for only 10% of tuberculosis (TB) cases. Although the tendon sheaths constitute an uncommon target of extra-articular TB, it remains the leading cause of chronic tendon sheath infection. The diagnosis of tuberculous synovitis is usually delayed as it mimics many other conditions , which can lead to complications. Many complications of tuberculous tenosynovitis have been reported in the literature due to delayed presentation and diagnosis.

25. Definitions Tenosynovitis- It is an inflammation  of synovial sheath  that encloses the  tendon. Tendinosis - It is chronic degenerative changes in the tendons without  clinical or  histopathologic sign of inflammation within the  tendon . Tendinitis- Inflammation of the tendon is called as tendinitis. Peritendinitis - I n peritendinitis the inflammation takes place in the   paratendon , the layer of connective tissue that wraps  around the tendon in the absence of a synovial sheath

26. Incidence Mycobacterium tuberculosis  remains a top-10 cause of  death worldwide, with greater than 2 billion active cases  occurring mostly in developing countries. •Tuberculous tenosynovitis is a rare complication of the  primary tuberculosis. •Isolated tuberculous disease of synovial sheaths or bursa  occur rarely.

27. Precipitating factors 1. Trauma 2.Overuse of the joint 3.Old age 4.Low socioeconomicstatus 5.Malnutrition 6.Alcoholism 7.Immunosuppression 8.Steroid injection

28. Clinical features 1. Progressive  swelling,the swelling is doughy with   semifluctuation , creaking or crepitations are palpable on  movement/fluctuation. 2.Mild pain 3.Diminished range of motion 4.Local warmth 5.Mild tenderness 6.Local sinus tract formation 7.Cold  abcess 8.Regional lymphadenitis 9.Paresthesia  due to median nerve compression 10.    Associated history of fever, loss of weight or appetite, night  sweats, malaise or fatigue may be present.

29. Diagnosis Diagnosis in early stage may be difficult. 1.History 2.General examination 3.Local examination 4.Systemic examination 5.Investigation-1. ESR ,CRP 1.USG 2.PLAIN XRAY 3.MRI 4.FNAC 5.BIOPSY AND HISTOPATHOLOGICALEXAMINATION AND CULTURE OF ORGANISM-CONFIRMATORY TEST

30. Xray changes Soft tissue swelling with or without calcification. •Osteopenia may be observed, indicating areas of  hyperemia . •    In chronic cases, joint space narrowing and osseous erosions  may be seen.

31. Treatment Conservative management 1. Immobilisation in functioning position 2.  Intermittent exercise 3 . Antitubercular drug for 9 to 12 months. 4. In the  presnce of large fluid ,aspiration and instillation of streptomycin combined with isoniazid is useful.

32. Surgical debridement

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