Carpal Tunnel Syndrome

By A. A. Sagung Mas Cahyandari

Definition
Carpal Tunnel Syndrome (CTS), or median neuropathy at the wrist, is a medical condition in which the median nerve is compressed at the wrist, leading to paresthesia, numbness and muscle weakness in the hand.

Anatomy

Symptoms
The first symptoms of CTS may appear when sleeping and typically include numbness and paresthesia (a burning and tingling sensation) in the thumb, index, and middle finger In chronic cases, there may be wasting of the thenar muscles, weakness of palmar abduction of the thumb.

Ethiology

Idiopathic Secondary (tumor in median nerve) Carpal canal stenosis (deformity congenital or acquired) Collagen and autoimmune diseases (tenovaginitis, rheumatoid arthritis, scleroderma, rheumatic polymyalgia, LES, gout, chondrocalcinosis, others) Endocrinopathy (diabetes mellitus, thyroid diseases, estrogen, progesterone, gonadotropin, growth hormone) Amyloidosis Polyneuropathy Infection

 Carpal canal anomaly (cysts, tumors, muscles anomalies, median artery persistence) Obesity Primary and secondary hand edema Acute form (fracture, crushing hand injury, hemorrhage, burn, median artery thrombosis, infection, pregnancy) Congenital diseases (mucopolysaccharidosis, mucolipidosis) Consequential forms occurring from pharmaceuticals (oral contraceptives, anticoagulants, lack of vitamin B6 or excessive intake of B6, etc.)

Pathophysiology
The damage of median nerve between the rigid confines of the carpal tunnel abnormally high carpal tunnel pressures exist in patients with CTS causes obstruction to venous outflow, back pressure, edema formation, and ultimately, ischemia in the nerve The risk of development of CTS appears to be associated including genetic, medical, social, vocational and demographic.

Incidence
Frequency : Incidence is 1-3 /1000 subjects / year Sex: The female-to-male ratio is 3-10:1. Age: 45-60 years.

Risk factor
- structural and biological Carpal tunnel - The strongest is genetic predisposition

Diagnose
Historical : - The patient's history often is more important than the physical examination in making the diagnosis of CTS. - Usual symptoms include numbness, paresthesia, and pain in the median nerve distribution - Hobbies and sports activities Examinations : - Sensory examination : on the palmar aspect of the first 3 digits and radial one half of the fourth digit. - Motor examination : Wasting and weakness of the median-innervated hand muscles (LOAF muscles) may be detectable.

 Special tests : - prayer test - Tinel sign - Phalen sign - The carpal compression test
Work Up : - Electrodiagnosis studies, including electromyography (EMG) and nerve - conductions studies (NCS), are the first-line investigations in suggested CTS. - Ultrasound - MRI

Prevention
* Take frequent breaks from repetitive movement such as computer keyboard usage or use of browser-based games that encourage the user for excessive finger movement. * Reduce your force and relax your grip. * Take frequent breaks. Every 15 to 20 minutes give your hands and wrists a break by gently stretching and bending them. * Watch your form. Avoid bending your wrist all the way up or down. A relaxed middle position is best. * Improve your posture. * Keep your hands warm.

Treatment
Conservative Care treatment Activity / Ergonomic Modification Splinting Exercise / Modalities Oral Medications Corticosteroid Injections Surgical Treatment

I. DATA BASE, October 14th, 2009 Identity Name : Mrs. W Sex : female Age : 67 years Race : Java Address : Surabaya Job : Housewife Referred From Neurology Outpatient with Carpal Tunnel Syndrome Dextra-Sinistra Chief Complain : Rasa kesemutan di kedua tangan

History of present illness

She felt numbness and tingling sensation on the both hand since 1 year ago, The site of tingling and numbness on hand especially at index, middle and partial ring finger. Every night she feel pain at her both hand, pain was decrease if she shake her hand. At the morning she get pain on wrist and fell like stiffness on her finger before daily activity, during activity pain and stiffness was reduce, at night pain can come again Due to her unpleasant fell on both hand she was disturbed for cooking, washing ,dressing and working, in particular when she take little thing.

History of past illness She get diabetes and no traumatic accident. Physical examination General state : CM, ambulation independent, normal gait, right handed Vital sign : BP : 120/70 mmHg , HR 84 x/m, RR: 16 x/m , BW=60 kg, BH: 150 cm, Head and neck : not anemic /icteric /cyanosis Thorax : symmetrical - Heart : normal sound, no murmur - Lung : vesicular sound both side Abdomen : flat, normal bowel sound - Hepar : unpalpable - Lien : unpalpable Extremity : warm and red

Musculoskeletal Examinations
Cervical Flexion Extension Lateral Flexion Rotation Trunk Flexion Extension Lateral Flexion Rotation ROM F (0-450) F (0-450) F/F (0-450) F/F (0-600) ROM F (0-800) F (0-300) F/F (0-350) F/F (0-450) MMT 5 5 5/5 5/5 MMT 5 5 5/5 5/5

Shoulder Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation

Elbow Flexion Extension Forearm supination Forearm pronation

ROM F/F (0-1800) F/F (0-800) F/F (0-1800) F/F (0-450) F/F (0-450) F/F (0-550)
ROM F/F (0-1500) F/F (1500-0) F/F (0-800) F/F (0-800)

MMT 5/5 5/5 5/5 5/5 5/5 5/5

MMT 5/5 5/5 5/5 5/5

Wrist Flexion Extension Radial deviation Ulnar deviation

Fingers Flexion MCP PIP DIP Extension Abduction Adduction

ROM F/F (0-800) F/F (0-700) F/F (0-200) F/F (0-300)

ROM F/F (0-900) F/F (0-1000) F/F (0-900) F/F (0-450) F/F (0-200) F/F (200-0)

MMT 5/5 5/5 5/5 5/5

MMT 5/5 5/5 5/5 5/5 5/5 5/5

Thumb Flexion MCP IP Extension Abduction Adduction Opposition

Hip Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation

ROM
F/F (0-500) F/F (0-900) F/F (0-900) F (0-200) /F (0-500) F (200-0) /F (500-0)

MMT
5/5 5/5 5/5 5- (pain)/5 5- (pain)/5 5- (pain)/5 MMT 5/5 5/5 5/5 5/5 5/5 5/5

ROM F/F (0-1250) F/F (0-300) F/F (0-450) F/F (0-200) F/F (0-800) F/F (0-800)

Knee Flexion Extension Ankle Plantar Flexion Dorsi Flexion Inversion Eversion Toes Flexion MTP IP Extension Big Toe Flexion MTP IP Extension

ROM F/F (0-1350) F/F (1350-0) ROM F/F (0-450) F/F (0-300) F/F (0-350) F/F (0-250) ROM F/F (0-300) F/F (0-500) F/F (0-800) ROM F/F (0-250) F/F (0-250) F/F (0-800)

MMT 5/5 5/5 MMT 5/5 5/5 5/5 5/5 MMT 5/5 5/5 5/5 MMT 5/5 5/5 5/5

 Neurological Examination DTR : Biceps +2/+2 Knee +2/+2 Triceps +2/+2 Achiles +2/+2 Pathological reflex : Babinski -/-, Chaddock-/-, HT -/ Sensory (light touch): sensory deficit 50 % at palmar finger I,II,III, and radial side finger IV right hand and 30% at the left side

Locally state of the hand Inspection : Deformity: -/-, inflammatory sign -/ Atrophy tenar +/-, hipotenar -/ Palpation : Tender point : -/Hand Function : Grip Spherical Opposition Special test Prayer +/+ Phalen +/+ Tinel sign +/+

N/N N/N -/N

Pinch Cylindrical Hook

-/N N/N N/N

Diagnose Medical diagnose : Carpal Tunnel Syndrome bilateral

Functional diagnose: - Impairment : median nerve is compressed at the wrist, deficit sensoris dermatom n. Medianus, atrophy thenar Dextra, - Disability : cant take a small thing - Handicap : -

PROBLEM LIST
1. Medical :2. Surgical :3. Rehabilitation medicine: R1 (Mobilization) : R2 (ADL) : - cant take a small thing R3 (Communication) : R4 (Psychological) : - worried about her illness R5 (Social Economic) : R6 (Vocational) : R7 (Other) : - tingling, numbness and pain on both hand

III. PLANNING
Medical : Surgical : Rehabilitation medicine: Planning therapy :
- USD on flexor retinaculum wrist dextra/sinistra

(2 W/cm2 10 menit with tranducer 1 MHz gentle dinamis) - resensitisasi sensoris at area inervated n. medianus DS - hand function exercise for ADL - wrist splint D-S

Planning monitor : Patients complain Planning health education and home exercise : CTS exercise modification of ADL

IV. SUMMARY
It has been reported that female 67y.o, referred from neurology outpatient with CTS Dextrasinistra. Chief Complain: Rasa kesemutan di tangan kanan-kiri. History of present illness: Tingling and numbness on the both hand at index, middle and partial ring finger since 1 year ago, Due to her unpleasant fell on right hand she was disturbed for ADL, there was history of diabetes and no traumatic accident. Physical examination : Sensory (light touch) : sensory deficit 50 % at palmar finger I,II,III, and radial side finger IV right hand and 70 % at left one, Prayer test , Phalen test , Tinel sign positif on both hand.

Diagnose : Carpal Tunnel Syndrome dextrasinistra Planning therapy : - USD on flexor retinaculum wrist dextrasinistra, sensoris resensitisation at area innervated n. medianus D-S - hand function exercise for ADL Planning monitor : clinically Planning health education and home exercise : CTS exercise, modification of ADL