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Carpal Tunnel Syndrome CTS for ortho.pptx

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Carpal Tunnel Syndrome CTS Lukman Hakim
The carpal tunnel is bound by 1. the carpal bones arching dorsally; 2. the hook of the hamate and the pisiform medially; 3. the scaphoid tubercle and trapezial ridge laterally. 4. The palmar aspect, or “roof,” of the carpal tunnel is formed by the flexor retinaculum, .
The palmar aspect, or “roof,” of the carpal tunnel is formed by the flexor retinaculum flexor retinaculum consisting of • deep forearm fascia proximally, • transverse carpal ligament over the wrist, and • aponeurosis between the thenar and hypothenar muscles distally.
• most palmar structure in the carpal tunnel is the median nerve. • Lying dorsal (deep) to the median nerve in the carpal tunnel are the nine long finger and thumb flexor tendons.
Carpal tunnel syndrome • affect 1% to 10% of the population. • in 30 to 60 years old • women = 3men. more likely to develop carpal tunnel syndrome, • Older, • overweight, • physically inactive individuals carpal tunnel risk factors in industrial workers • female sex, • obesity, • cigarette smoking, • vibrations with job tasks.
pathophysiology: • Elevation of carpal tunnel pressures of more than 20 to 30 mm Hg impedes epineurial blood flow, and nerve function is impaired. • Reduction in cross-sectional area along the length of the carpal tunnel
Carpal tunnel syndrome is primarily a clinical diagnosis, • tingling and numbness • in median nerve distribution • Pain, • deep, • aching, or throbbing, • diffusely in the hand • may radiate up the forearm. • Thenar muscle atrophy • in late-stage nerve compression.
DIAGNOSIS Clinical: symptoms in the median nerve distribution 1. numbness, 2. pain, 3. paresthesia • Paresthesia is the most frequent symptom, • often awakening patients with burning and numbness of the hand • is relieved by exercise.
DIAGNOSIS Clinical: signs Tinel sign • in most patients • percussing the median nerve at the wrist. Atrophy of the median-innervated thenar muscles • in half of patients .
DIAGNOSIS Explain TEST Percussion Test (Tinel Test) HOW PERFORMED Lightly tap along median nerve from proximal to distal CONDITION TESTED Site of nerve lesion POSITIVE RESULT “Electric” tingling response in fingers INTERPRETATION OF POSITIVE RESULT Probable CTS if Positive at the wrist (Sensitivity 0,60, specificity 0,67)
DIAGNOSIS Clinical: signs Phalen test: Acute flexion of the wrist for 60 seconds • increases the paresthesia • in some but not all patients
DIAGNOSIS Clinical: signs Durkan test OR carpal compression test direct compression is applied to the median nerve for 30 seconds with the thumbs Explain TEST Carpal Tunnel compression Test (Dukan) HOW PERFORMED Direct compression of median nerve at carpal tunnel CONDITION TESTED Paresthesia in response to compression POSITIVE RESULT Parasthesia within 30 s INTERPRETATION OF POSITIVE RESULT Probable CTS (Sensitivity 0,87, specificity 0,90)
Explain TEST Static two – point discrimination HOW PERFORMED Determine minimal separation of two distinct points when applied to palmar fingertip CONDITION TESTED Innervation density of slow- adapting fibers POSITIVE RESULT Failure to determine separation of at least 5 mm INTERPRETATION OF POSITIVE RESULT Advanced nerve dysfunction Explain TEST Moving two – point discrimination HOW PERFORMED As above, with movement of the points CONDITION TESTED Innervation density of fast - adapting fibers POSITIVE RESULT Failure to determine separation of at least 4 mm INTERPRETATION OF POSITIVE RESULT Advanced nerve dysfunction
Explain TEST Semmes – Weinstein monofilaments HOW PERFORMED Monofilaments of increasing diameter touched to palmar side of digiti until patient can determine which digiti is taouched CONDITION TESTED Threshold of slowly adapting fibers POSITIVE RESULT Value > 2.83 INTERPRETATION OF POSITIVE RESULT Median nerve impairment (sensitivity 0,83) Sensibility testing Semmes-Weinstein monofilament pressure testing was the most accurate in determining early nerve compression. combination with wrist flexion test 82% sensitivity and 86% specificity.
Explain TEST Hand Diagram HOW PERFORMED Patient marks site of pain or altered sensation on outlined hand diagram CONDITION TESTED Patient’s perception of symtoms POSITIVE RESULT Markings on palmar side of radial digits, without marking in palm INTERPRETATION OF POSITIVE RESULT Probable CTS ( Sensitivity 0,96, specificity 0,73, negative predictive value 0,91
DIAGNOSIS Clinical: signs mean pressure within the carpal tunnel NORMAL: • 25 mm Hg with the wrist in neutral position, • 31 mm Hg with the wrist in flexion, • 30 mm Hg with the wrist in extension. in CTS • 32 mm Hg. with wrist in neutral position, • 99 mm Hg with 90 degrees of wrist flexion • 110 mm Hg with the wrist at 90 degrees of extension.
DIAGNOSIS Clinical: signs highest sensitivity • Durkan nerve compression, • hand diagram score, • night pain, • Semmes-Weinstein testing after a Phalen test had the. The most specific tests • hand diagram • Tinel sign.
DIAGNOSIS Clinical: signs a patient with 1. abnormal hand diagram, 2. positive Durkan test, 3. abnormal Semmes-Weinstein sensibility testing, 4. night pain had a very high probability of having carpal tunnel syndrome. if all four tests were normal, the probability of CTS was very low.
DIAGNOSIS Clinical: signs IN provocative tests, • wrist flexion, the most sensitive test • nerve percussion, the most specific and the least sensitive. • Durkan test more specific (90%) and more sensitive (87%) than either the Tinel or Phalen test
DIAGNOSIS electrodiagnostic studies Abnormal: • A distal motor latency of more than 4.5 milliseconds (ms) • a sensory latency of more than 3.5 ms • positive sharp waves, • fibrillations at rest, • decreased motor recruitment, • complex repetitive discharges indicative of nerve damage.
DIAGNOSIS Nerve conduction studies are • 90% sensitive • 60% specific • are reliable confirmatory tests. • occasionally normal, in patients with classic clinical signs and symptoms • may be abnormal in asymptomatic patients.
DIAGNOSIS LIMITS: to determine treatment. • no significant data for prediction of functional recovery or reemployment after carpal tunnel release, • Nor does it increase the diagnostic value of the four commonly used tests • abnormal hand diagram, • abnormal Semmes-Weinstein testing, • positive Durkan compression, • night pain • false-negative rates of 10%, Postoperative electrodiagnostic testing may help assess recurrent symptoms
DIAGNOSIS MRI • not routinely used for diagnosis. major advantage • high soft-tissue contrast, • detailed images of bones and soft tissues. Ultrasound • sensitivity over 97% when the median nerve diameter is greater than 10 mm2 at the level of the pisiform
the diagnosis of carpal tunnel syndrome should be based on clinical acumen and physical examination in the vast majority of patients ancillary tests should be reserved for patients without clear presentations.
TREATMENT NON OP: •mild symptoms •no thenar atrophy, • night splints • injection of cortisone preparations into tunnel • long-term benefit 10%
TREATMENT response to injection faster in • men • older than 40 • not to inject directly into the nerve. • Injection as a diagnostic tool in patients without osteophytes or tumors in the canal. • Injection also helps to eliminate the possibility of other syndromes, especially cervical disc or TOS.
TREATMENT factors in determining the failure /success of nonoperative treatment: 1. age older than 50 years, 2. duration longer than 10 months, 3. constant paresthesia, 4. stenosing flexor tenosynovitis, 5. a positive Phalen test result in less than 30 seconds. • none of these factors 2/3 cure • one factor 59.6% cure • two factors 17% • three factors, 7% • five factors 0%
TREATMENT intermediate and advanced (chronic) syndromes early carpal tunnel release. • Extensive neurolysis no significant effect. • Internal neurolysis does not improve the motor or sensory outcome of carpal tunnel release. • epineurotomy no clinical benefit to carpal tunnel release.
TREATMENT Treatment of acute carpal tunnel syndrome should be individualized acute increase in carpal tunnel pressure (e.g., after a Colles fracture), change in wrist position without release not improved surgery usually is indicated.
TREATMENT florid tenosynovitis caused by rheumatoid arthritis or other inflammatory conditions tenosynovectomy + carpal tunnel release. thenar muscle wasting, palmaris longus opponensplasty (Camitz)
TREATMENT signs and symptoms persistent and progressive, carpal tunnel release • results are good • benefits to last • Maximal improvement in the first 6 months • After 6 months, there is no significant improvement but thenar atrophy may disappear, • not achieve complete relief in • older than 70 years or • advanced nerve compression.
TREATMENT release in idiopathic CTS with intermittent symptoms •uniformly successful; • release in diabetic and nondiabetic patients was • follow-up period of 6 months. • similarly beneficial • for long-term (10 years), • diabetes had worse outcomes
TREATMENT metabolic syndrome • a delay in the recovery process. • more severe grade of carpal tunnel syndrome • delayed functional recovery at up to 6 months’ follow-up,
TREATMENT moderate disease (prolonged sensory and motor latencies) • complete resolution of pain and paresthesias at 3 months after surgery, severe disease (prolonged sensory or motor latencies plus either absent sensory or mixed nerve action potential or low amplitude or absent compound motor action potential), • incomplete symptom reduction at 1 year after carpal tunnel release
TREATMENT surgical technique surgeon’s expertise. minimally invasive techniques • earlier return to work • less postoperative discomfort, • outcomes are similar at 6 months.
TREATMENT In a RCT study: endoscopic release • earlier return to work • improved strength during the early postoperative period. • Results at 6 months or later were similar to open except • greater risk of nerve injury • lower risk of scar tenderness endoscopic release may appeal to patients who require an early return to work and activities,
TREATMENT SURGICAL RELEASE Limited approaches, 1. “double incision” of Wilson 2. “minimal incision” of Bromley offer rapid recovery as ascribed to the endoscopic techniques. “carpal tunnel tome” through a small palmar incision minimize the soft-tissue trauma and provides adequate exposure Regardless of the technique selected, all structures to be incised should be seen and identified and safety of the median nerve verified before carpal tunnel release
TREATMENT SURGICAL RELEASE Limited approaches for open carpal tunnel release “double incision” of Wilson Transverse incision proximal to anterior wrist crease between FCU and FCR Distal incision between proximal palmar crease and 1 cm distal to hamate hook in line with radial border of ring
TREATMENT SURGICAL RELEASE Limited approaches for open carpal tunnel release “minimal incision” of Bromley Incision used for minimal- incision approach.
TREATMENT SURGICAL RELEASE Mini-palm open release technique A. longitudinal incision begins just distal to the distal wrist flexion crease and slightly ulnar to the midline of the wrist and extends distally approximately 2.0 to 3.0 cm in line with the third web space
TREATMENT SURGICAL RELEASE Mini-palm open release technique B. Exposure of transverse carpal ligament (TCL) with parallel palmar fascia fibers and hypothenar fat retraction.
TREATMENT SURGICAL RELEASE Mini-palm open release technique C, After division of TCL, distal 2.0 cm of antebrachial fascia is divided with a Metzenbaum, The TCL division should be such that 3 to 4 mm of it is left attached to the hamate hook to avoid flexor tendon ulnar subluxation
TREATMENT SURGICAL RELEASE Mini-palm open release technique D. In this patient, median nerve is adherent to divided radial TCL leaf and was subsequently externally neurolyzed.
TREATMENT SURGICAL RELEASE Mini-palm open release technique E. Incision is closed F. Compressive dressing is applied
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS • palmar incisions should be well ulnar to it to avoid the median nerve palmar cutaneous branch. • A curved incision ulnar and parallel to the thenar crease is not advisable because the palmar cutaneous branch of the median nerve proximally may be more at risk of injury. • We prefer to use the incision described for the mini-palm technique : • longitudinal incision begins just distal to the distal wrist flexion crease and slightly ulnar to the midline of the wrist (center dot reference point) and extends distally approximately 2.0 to 3.0 cm in line with the third web space
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS continued proximally if necessary. Angle the incision toward the ulnar side of the wrist to avoid: 1. crossing the flexor creases at a right angle, 2. Cutting the palmar cutaneous sensory branch, lies in the interval between the PL and the FCR
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS When severed: • We do not attempt to repair • Section it more proximally to be covered by the middle finger sublimis muscle. • causes a painful neuroma • later require excision from the scar
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS Maintain longitudinal orientation so that the incision is generally to the • ulnar side of the long finger axis • radial border of the ring fourth ray.
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS Carefully divide TCL and avoid damage to the median nerve and its recurrent branch Incidence of extraligamentous, subligamentous, and transligamentous course of thenar branch.
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS Fibers of the transverse carpal ligament can extend distally farther than expected
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS A successful carpal tunnel release usually requires division of all THREE components
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS Be aware of potential anomalies: • connections between the FPL and the index flexor digitorum profundus • flexor digitorum superficialis; • palmaris longus, • hypothenar, • lumbrical muscle bellies; • median and ulnar nerve branches and interconnections
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS Avoid injury to the superficial palmar arterial arch, which is 5 to 8 mm distal to the distal margin of the transverse carpal ligament.
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS Inspect the flexor tenosynovium. Tenosynovectomy may occasionally be indicated, especially in patients with rheumatoid arthritis
TREATMENT EXTENDED OPEN CARPAL TUNNEL RELEAS POSTOPERATIVE CARE. • light compression dressing • volar splint for 14 to 21 days. • hand is actively used as soon as possible • dependent position is avoided. • dressing removed 2 or 3 days after the surgery, and then gentle washing and showering of the hand is permitted. • sutures are removed after 10 to 14 days.
UNRELIEVED OR RECURRENT CTS • The recurrence rate after primary carpal tunnel release is approximately 2% • Unrelieved symptoms may lead to a repeat operation in 12% of patients
UNRELIEVED OR RECURRENT CTS CAUSES: • incomplete release of the transverse carpal ligamen • re-formation of the flexor retinaculum • scarring in the carpal tunnel • median or palmar cutaneous neuroma • palmar cutaneous nerve entrapment • recurrent granulomatous or inflammatory tenosynovitis • hypertrophic scar in the skin
UNRELIEVED OR RECURRENT CTS Worse results in Patients with • normal preoperative electrodiagnosticstudies • patients who had filed for compensation • and patients with ulnar nerve symptoms
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