CTS

Introduction:
It is the most common upper extrimity entrapment neuropathy
Compression of median nerve in carpal tunnel causes a syndrome that is
called carpal tunnel syndrome. This syndrome consists of characterized
motor, sensory, vasomotor and trophic changes in hand.

Anatomy:
Carpal tunnel
 A cylindrical cavity connecting
the volar forearm with the palm
 Boundaries
1. Floor – formed by
osseus arch of carpal bones
(bounded in 3 side)
2. Roof – formed by
transverse carpal ligament (Flexor
retinaculum)
 Contents:
9 tendons and 1 nerve passes
through
1. FDS and FDP in a common
Causes:
sheath
P – Pregnancy
R – RA
A – Arthritis degenerative (OA)
G – Growth hormone abnormality (Acromegaly)
M – Metabolic (Gout, DM, Myxeodema)
A – Alcoholism
T – Tumor
I – Iatrogenic (malunited # - colles’ fracture), Idiopathic
C – Connective tissue disorder (SLE, Scleroderma, Raynouds)

Incidence:
Age – 30 -60 years
Sex – F > M (2 or 3 times greater)

Clinical presentation:
1. Classic complain is paraesthesia at night
typically tingling or numbness in the median nerve
distribution of the hand.
2. Pain is deep, aching or throbbing sometime characterized by
“pins and needles,” or
burning. May radiate upto forearm
Symptoms relieved by
Hanging the arm over the side of the bed,
or shaking the arm,
3, In advanced cases there may be clumsiness and weakness,
O/E
Look - In long standing cases
1. Wasting of thenar muscle
2. Ape thumb deformity
3. skin – dry and scaly
4. nails – crack easily
5. pulp of finger – atrophid
 Feel –
1. warm – due to arteriolar dilation
2. dry – due to loss of sympathetic supply
3. Sensory loss – over radial 3 ½ digit of palmer aspect

Move -
1. loss of oppsition of thumb
2. index and middle finger lag behind while making fist

Special test for CTS

A. Provocative test:
1. Phalen test – 60 sec
2. Tinnel sign
3. Durkan compression test – 30 sec
4. Tourniquet test – usually not done
B. 2 point discrimination test
1. Static
2. Dynamic
C. Hand diagram
D. Hand volume stress test

Investigation:
Diagnosis is usually clinical
1. Electrodiagnostic test
NCT – Atypical symptom
EMG
2. X-Ray to see any malunited fracture
3. CT –
4. MRI – space occupying lesion ganglion, tumor
5. Angiogram – Aneurysm of arteries

D/D
Cervical spondylosis – X ray cervical spine
Pronator syndrome – Phalens test negative, NCV - ve

Treatment:
Conservative –
1. NSAIDS
2. Night splint to prevent wrist flexion
3. Steroid
a. Oral – Prednisolone – initially 40 mg /day for 2 day then
tapering to 10 mg /day for 2 day
b. Injection – locally – respond well in mild symptom
Surgical treatment
If conseravative treatment fail – at least 3month of course
Absolute indications
Constant paresthesias,
Thenar atrophy, and
Space occupying lesion
Decompression by transecting transverse carpal ligament
 Alternatively by endoscopic release of the ligament

The consequence of chronic compression is damage to the epineural covering of the

median nerve resulting in diminished conduction velocity.

Pressure in wrist
Normal person CTS
Neutral 25 mm of Hg 32 mm of Hg
90 degree flexion 31 mm of Hg 99 mm of Hg
90 degree extension 30 mm of Hg 110 mm of Hg

Motor changes –
6. Ape thumb deformity
7. loss of oppsition of thumb
8. index and middle finger lag behind while making fist

Vasomotor changes –
4. warm – due to arteriolar dilation
5. dry – due to loss of sympathetic supply

Trophic changes –
1. skin – dry and scaly (long standing cases of paralysis)
2. nails – crack easily
3. pulp of finger – atrophid

Sensory
1. tingling and numbness in the typical median nerve distribution in the radial 3
and one half digit

Kaplan, Glickel, and Eaton identified five important factors in determining the success of
nonoperative treatment:
(1) age older than 50 years,
(2) duration longer than 10 months,
(3) constant paresthesia,
(4) stenosing flexor tenosynovitis, and
(5) a positive Phalen test result in less than 30 seconds.
2/3 rd of patients were cured by medical treatment when none of these factors was present