Carpal Tunnel Syndrome

The five Minute Orthopedic Consult, Rohit Robert Dhir BA Damien Doute MD A. Jay Khanna MD

Hasmiyanti C 111 06 034 Supervisor dr. Jainal Arifin, M.Kes, Sp. OT

Carpal Tunnel Syndrome

CTS is a neuropathy caused by compression of the median nerve within the carpal tunnel. The floor of the tunnel is formed by the volar radiocarpal and intercarpal ligaments. The transverse carpal ligament forms the roof of the tunnel. 9 long flexors of the wrist and fingers and 1 nerve (median) run within this spatially limited and relatively rigid tunnel. Thus, any increase in pressure within the tunnel compresses the injury-prone median nerve. A decrease in thenar muscle strength occurs, along with a numbness or a decrease in the sensibility of the palmar surface of the radial 3 1/2 digits, especially the middle and index fingers.

Incidens
50% of cases are reported to occur in patients 40-60 years old; average age at carpal tunnel release is 54 years. CTS occurs predominantly in females (70%), although the number of males with CTS may be underestimated.

Prevalence
The prevalence of CTS has been reported to vary between 0.6% and 61% in different occupational groups. It is the most commonly diagnosed site of nerve compression in the upper extremity.

Risk Factors
Repetitive hand work Endocrine imbalance History of neuropathy Associated conditions Rheumatoid arthritis Pregnancy Thyroid myxedema Acromegaly Amyloidosis Multiple myeloma Diabetes Trauma Alcoholism Gout

Pathophysiology
Internal fibrosis of the median nerve Epineural scarring and constriction Reduced nerve conduction velocity

Diagnosis
CTS can be diagnosed accurately by careful history and physical examination, inspection for thenar atrophy, and detection of sensory disturbance via light touch or a pinwheel. Provocative tests, such as the Phalen test (which consists of placing the affected wrist in hyperflexion in an attempt to reproduce the numbness in the hand) or tapping over the course of the nerve in the tunnel to elicit a Tinel sign, also serve to confirm the diagnosis.

Signs and Symptoms

These symptoms can be aggravated with use of the affected hand:
Paresthesia in the median nerve distribution in the hand Weakness or clumsiness in the hand Pain in the hand, wrist, or distal forearm Awakening from sleep with pain or numbness in the hand Tinel sign: Tapping the median nerve over the carpal tunnel with resultant paresthesias in the radial 3 fingers Phalen sign: Paresthesias in the median nerve distribution with full flexion for at least 1 minute

Physical Exam
The hand should be examined to detect thenar muscle atrophy. 2-point discrimination should be checked at the tips of the fingers on the radial and ulnar borders (should be <5-6 mm). Provocative tests such as the Phalen and Tinel tests should be performed.

Tests
The following basic tests should be ordered to rule out systemic causes of CTS:
Sedimentation rate Serum glucose concentration Serum uric acid level Thyroid function test Electromyography/nerve conduction velocity can confirm diagnosis and help determine severity.

Imaging
Radiography
Plain radiographs of the wrist in patients with previous trauma or in patients with a long history of inflammatory disease should be performed.

Electromyographic studies can help rule out proximal injury to the median nerve or identify peripheral neuropathy.

Differential Diagnosis
Compression of the lower cervical roots by cervical degenerative disc disease or tumors

Treatment
General Measures Nonoperative intervention:
Modalities: Cockup wrist splinting, NSAIDs (not proven effective), diuretics, and cortisone injections (which must be performed by an experienced physician to avoid direct injury to the median nerve) The patient should wear a wrist splint during sleep.

Activity modification in work-related CTS is recommended. Surgical release of the transverse carpal ligament is performed when nonoperative measures have failed or in patients with constant numbness, motor weakness, or increased distal median nerve motor latency noted on electromyography.

 Special Therapy Physical Therapy Occupational or physical therapy should be consulted for activity modification teaching or for nerve gliding exercises that might decrease symptoms of nerve compression. Postoperative therapy is aimed at minimizing the development of painful scars and increasing ROM and strength.

 Medication (Drugs) No effective medication specifically to treat CTS has been described. Corticosteroid injection into the carpal tunnel is indicated when the median nerve compression is predicted to be temporary, as in pregnancy or when the patient's activity can be modified.
Injections must be done with great care to avoid injury to the median nerve.

Prognosis
Most patients with CTS associated with the repetitive trauma commonly seen in the workplace respond to a combination of splinting, cortisone injection into the carpal tunnel, and activity modification. If job modification is not in the patient's nonoperative treatment program, splinting and cortisone injections may provide only temporary relief. The maximum return of strength after carpal tunnel release can take 6 months or longer.

Complications
Iatrogenic injuries to the median nerve or its branches may occur with open or endoscopic release. Painful surgical scars may ruin the results of a successful decompression procedure. Flexion tendon bowstringing may occur in a few patients.

Patient Monitoring
To obtain maximal beneficial results, the splint should be worn full-time for at least 3-4 months, after which time use of the splint can be discontinued gradually. If symptoms return with removal of the splint, the patient becomes a surgical candidate.
The patient usually experiences immediate pain relief after carpal tunnel release, whereas numbness gradually improves over the next several months.

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