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SNDROME DE

TUNEL DEL CARPO


Andrs Esteban
Rivera Lpez
Cirujano Plstico maxilofacial y de la mano.

PERSPECTIVA HISTRICA

Sir James Paget 1854


Putnam 1880
Shultz 1893
Pierre Marie y Charles Foix 1913
Learmonth 1933
Cannon y Love 1946

Carpal tunnel syndrome: a historical perspective. Sam L. Loa, Kevin Raskin, MDb, Harriet Lester, MDc, Benisse
Lester. HAND CLINICS 2002
Paget J. Lectures on Surgical Pathology. Philadelphia: Lindsay & Blakiston, 1854.

ANATOMA

Definicin
Lmites
Medidas
Estructuras

Practical anatomy of the carpal tunnell Mitchell B. Rotman, MDa,*, James P. Donovan, MS(R)b. HAND CLINICS 2002

ANATOMA
LIGAMENTO TRANSVERSO DEL
CARPO(LTC)
Origen
Medidas
Secciones

Cobb T, Dalley B, Posteraro R, Lewis R. Anatomyof the flexor retinaculum. J HandSurg 1993;18:919.
Practical anatomy of the carpal tunnell Mitchell B. Rotman, MDa,*, James P. Donovan, MS(R)b. HAND CLINICS 2002

ANATOMA

NERVIO MEDIANO
Tipo de nervio
Origen
Recorrido
Terminales .

Color Atlas of Anatomy. Rohen_ Yokochi - 4th Ed


Practical anatomy of the carpal tunnell Mitchell B. Rotman, MDa,*, James P. Donovan, MS(R)b. HAND CLINICS 2002

ANATOMA
Lanz estudio 246 manos
Grupo O: extraligamentosa 46%.
Grupo I:

subligamentoso (IA): 31%.

Transligamentoso (IB) 23% . **

Ulnar (IC).

Supraligamentoso (ID):
Grupo II: 7%
Grupo III: 3%

IIIA: ausente

IIIB: a. mediana

IIIC: lumbrical
Grupo IV: 1.6%

IVA:

IVB:

Demircay E, et al: Anatomic Variations of the Median Nerve. Turkish Neurosurgery 2011, Vol: 21, No: 3, 388-396
Lanz U. 1977. Anatomical variations of the median nerve of the carpal tunnel. J Hand Surg [Am] 2:4453.

ANATOMA
COMUNICACIONES ENTRE EL ULNAR Y MEDIANO

Demircay E, et al: Anatomic Variations of the Median Nerve. Turkish Neurosurgery 2011, Vol: 21, No: 3, 388-396

ANATOMA

Luchetti, R.; Amadio, P,, Carpal Tunnel Syndrome2002

MARCAS TOPOGRFICAS

Luchetti, R.; Amadio, P,, Carpal Tunnel Syndrome2002

FISIOPATOLOGA
FALLO DELA BARRERA
HEMATONEURAL

DEGENERACION AXONAL

EDEMA ENDONEURAL

DESMIELINIZACIN DIFUSA

ENGROSAMIENTO DEL TEJIDO


CONECTIVO

DESMIELINIZACIN LOCALIZADA
Upton AR, McComas AJ (1973) The double crush in thenerve entrapment syndromes. Lancet 2: 359
Lundborg G (1970) Ischemic nerve injury. Experimentalstudies on intraneural Microvascular pathophysiology and nerve function in a limb
sujected to temporary circulatory arrest. Scand J Plast Reconstr Surg, Suppl 6

EPIDEMIOLOGA
Neuropata compresiva ms comn.
prevalencia de 0.1% a 10%.
Incidencia : 95-148/100000.
Relacin hombre : mujer 1:3.
Bilateralidad de 65% a 84% .
Edad 40 a 60 aos.
Prdida laboral 25 das por ao.
500.000 cirugas al ao.
2 billones al ao

Hales TR, Bernard BP. Epidemiology of work-related musculoskeletal disorders. Ortho Clin N Amer 27(4):679-709, 1996.
Hagberg M et al. Impact of occupations and job tasks on the prevalence of carpal tunnel syndrome. Scand J Work Environ Health 18:337-45, 1992.

ETIOLOGA Y CLASIFICACON
Idioptico

40-50 aos

Mujeres en mano dominante


Sistmico

Afeccin balance de lquidos

Condiciones inflamatorias

Condiciones hemorrgicas

Neuropatas

Infeccin
Anatmico

Anomalas

Tumores

Trauma

Ocupacional (Vibraciones )
Agudo
Crnico

Luchetti, R.; Amadio, P,, Carpal Tunnel Sydrome2002

Etiopathogenesis of carpal tunnel syndrome.

DIAGNSTICO
Parestesias - Disestesias
nocturno o en la madrugada
actividades manuales.
Mejora de los sntomas con sacudir las manos.
Dolor
Diagrama de Katz y Stirrat.
Debilidad de la musculatura intrnseca

Wilder-Smith EP, Seet RC, Lim EC. Diagnosing carpal tunnel syndrome clinical criteria and ancillary tests. Nat Clin Pract Neurol
2006;2:36674.
Rempel D et al. Consensus Criteria for the Classification of Carpal Tunnel Syndrome in Epidemiologic Studies. Am J Public Health.
1998 Oct;88(10):1447-51

EXAMEN FSICO

SENSIBILIDAD.
Prueba de Weber
Prueba de Van Frey
Vibracin

Clinical Diagnosis of tunnel carpal syndrome.M. Ceruso, R. Angeloni, G. Lauri, G. Checcucci. 2002. JHS

EXAMEN FSICO
PRUEBAS DE
PROVOCACIN
Tinnel S: 64% E: 71%
Phalen S:75% E:62%
Combinados S: 90%

Durkan S 87% E 90%

Clinical Diagnosis of tunnel carpal syndrome.M. Ceruso, R. Angeloni, G. Lauri, G. Checcucci. 2002. JHS

EXAMEN FSICO
EVALUACIN MOTORA.

Clinical Diagnosis of tunnel carpal syndrome.M. Ceruso, R. Angeloni, G. Lauri, G. Checcucci. 2002. JHS

IMGENES DIAGNSTICAS

RADIOGRAFA
TOMOGRAFA
ECOGRAFA
RESONANCIA MAGNTICA

Diagnostic Imaging of carpal tunnel and aplications E. Cerofolini

Luchetti, R.; Amadio, P,, Carpal Tunnel Sydrome2002

ELECTRODIAGNSTICO
VELOCIDAD DE CONDUCCIN
S: 84 % E:95%
Sensitivas
Motoras
Mixtas
ELECTROMIOGRAFA
Relajacin, Insercin, contraccin
P. Fibrilacin Denervacin activa
P. M. polifsicos Denervacin con
reinervacin
D.C. repetitivas Denervacin crnica

Neurophysiological Assessment of Carpal Tunnel SyndromeR. Schoenhuber, L. Capone, R. Gentile, R. Pentore


Electrodiagnosis in carpal tunnel syndrome D.D. Kilmer, B.A. Davis / Hand Clin 18 (2002) 243255

TRATAMIENTO
Mdico
Frula
Medicacin oral
Corticosteroides
Otras modalidades:
- Cambios ergonmicos
- Ultrasonido
- Ejercicios
- Laser
- iontoforesis
Quirrgico
Abierto
Mnimamente invasiva

Endoscpico

C. Sabin Cranford, MD, et al. Journal of the American Academy of Orthopaedic Surgeons. Volume 15, Number 9, September
2007

FRULA

Posicin neutra
2+- 9extension
2 +- 6desviacin ulnar
80% mejoran

J.S. Brault .Conservative Care for Carpal Tunnel Syndrome 2002. JHS

MEDICACIN

AINES
DIURETICOS
PIRIDOXINA
CORTICOSTEROIDES

C. Sabin Cranford, MD, et al. Journal of the American Academy of Orthopaedic Surgeons. Volume 15, Number 9, September
2007

INFILTRACIN

Tradicionalmente
20 mg triamcinolona con o
sin lidocana
Aguja calibre 25
1,25
Dexametasona

C. Sabin Cranford, MD, et al. Journal of the American Academy of Orthopaedic Surgeons. Volume 15, Number 9, September
2007

LIBERACIN ABIERTA DEL TUNEL DEL


CARPO

Green's Operative Hand Surgery: 2-VolumeScott W. Wolfe, Robert N. Hotchkiss, William C.Pederson, Scott H. Kozin

C. Sabin Cranford, MD, et al. Journal of the American Academy of Orthopaedic Surgeons. Volume 15, Number 9, September
2007

LIBERACIN MNIMANETE INVASIVA


DEL TUNEL DEL CARPO

C. Sabin Cranford, MD, et al. Journal of the American Academy of Orthopaedic Surgeons. Volume 15, Number 9, September
2007

LIBERACIN MNIMANETE INVASIVA DEL TUNEL DEL


CARPO CON EL RETRACTOR FIBRO - PTICO DE
CONVERSE

P. Di Giuseppe. The Mini-Invasive Technique for Carpal Tunnel Release: Open Approach with Converse
Fiberoptic Light Retractor

LIBERACIN ENDOSCPICA

Chow JCY (1989) Endoscopic Release of the Carpal Ligament:A New Technique for Carpal Tunnel Syndrome;
Arthroscopy5:19-24

TRATAMIENTO

ABIERTO VS ENDOSCPICO

GRACIAS.