Carpal Tunnel Syndrome

Contents
• Description
• Causes
• Signs, symptoms, complications
• Diagnostic test (Examinations)
• Treatment
Carpal Tunnel Syndrome (CTS)
• Nerve compression syndrome where the median nerve get
compressed at the wrist
• CTS is the most well-known and frequent form of median nerve
entrapment, and accounts for 90% of all entrapment neuropathies
• The American Academy of Orthopaedic Surgeons (AAOS) Clinical
Guidelines on the Diagnosis of CTS defines it as a symptomatic
compression neuropathy of the median nerve at the level of the wrist
• Carpal tunnel syndrome (CTS) is the most common entrapment
neuropathy caused by compression of the median nerve at the wrist,
• Can causing sensory and motor loss.
Carpal Tunnel
• Carpal tunnel is a narrow passageway on the palmar side of the wrist.
• The median nerve, formed by contributions from the lateral (C6–C7
fibers) and medial cords (C8–T1 fibers), enters the wrist, along with
nine finger flexor tendons, through the carpal tunnel to the fingers
and thumb. The floor and sides of the tunnel are composed of carpal
bones, while the transverse carpal ligament forms its roof.
• Doing flexion will narrowing this passageway or tunnel, because
during flexion these 9 tendons with the tone of the forearm muscles
is pushing bending the median nerve over the flexor retinaculum.
Causes
The most common causes for Carpal tunnel syndrome is Idiopathic.
Oedema and fibrosis of tenosynovium. Not inflammatory.

But in general everything that compress the median nerve at the carpal
tunnel can be the causes of Carpal tunnel syndrome.
• Repetitive motion causing the thickening of the transverse
retinalucum ligament and it will compress the median nerve
Risk Factors
Alterations in the balance of body fluids:
1. Obesity
2. Pregnancy
3. Thyroid Hormone Disorder

Nerve Damaging Inflammatory

Conditions: conditions:
• Diabetes • RA
• Alcoholism • Te n d o n i t i s
Risk Factors
• Smoking. Why? It could impair the vascular supply of the median
nerve, making it more susceptible to physical workloads.
• Advanced Age. Why?
• Obesity. Obese people usually have problem with the blood
circulation, the blood have problem coming back from the distal of
hand to the heart. This will causing oedema and might compress the
median nerve at the carpal tunnel.
• Repetitive motion. What kind of repetitive motion?
• Certain athletic activities such as typing, throwing, tennis, cycling, driving,
reading the newspaper, crocheting, and painting may cause the carpal tunnel
syndrome.
Risk Factors
• Alterations in the balance of body fluids: certain conditions such as
pregnancy, obesity, thyroid hormone disorders and kidney failure can affect
the level of the fluid in your body. Fluid retention can common during
pregnancy and can increase the pressure inside the carpal tunnel.
• Nerve-damaging conditions: some chronic illness, such as diabetes and
alcoholism, increase your risk of nerve damage, including the damage to
your median nerve.
• Inflammatory conditions: Inflammation, such as RA or an infection, can
affect the tendons in your wrist, exerting pressure on your median nerve.
• Anatomic factors: A wrist fracture or dislocations that alters the space
within the carpal tunnel can create the extraneous pressure on the median
nerve.
Sign and Symptoms
• Numbness, tingling, burning, or pain in the radial 3 ½ digits. Numbness should be less
at the thenar area of the palm. Reffered pain into the Forearm, Arm and Shoulder.
• Freuqent awakening at night due to Pain and parethesia (nocturnal pain). And is
relieved by shaking the hand away. Parethesia is tingling sensation associated with injury
or irritation the nerve.
• Clumsiness and weakness: Loss of power in the hand (particularly for precision grips
involving the thumb) does occur. However, compared to the loss of motor power, the most
important causes are loss of sensory feedback and pain.
• Athropy of Thenar Muscle (?)
• Swollen fingers.

[Why nocturnal pain? Because during sleeping usually we dont realize in what position our hands are, and
usually the hands would be curling up at night during sleep. This flexion position is a fital position because
this flexion will causing the narrowing of the tunnel and the nerve being compressed by the tendons to the
flexor retinaculum ligaments then causing pain]
CTS Classification
Mild: Only sensory Moderate: both Severe: both
conduction is sensory and motor sensory, motor and
affected are affected needle finding in
• Numbness and • Symptoms will EMG
tingling at night appear • Weakness and
• No weakness throughout the athropy
• Diagnosis is usually day
by medical history • Provocative test
• Physical findings are positive
not presents
 Examinations
1. Flick Sign/Maneuver
• How to Perform? Vigorously shake the hands. Positive test is if there’s resolution of the parasthesia symptoms
associated with carpal tunnel syndrome during or following administration of flicking of the waist.
2. Phalen test
• How to perform? Wrist volar flexion for approximately 60 seconds produced symptoms
3. Tinnel’s sign
• How to perform? By Tapping on the median nerve over the volar carpal tunnel
4. Durkan’s Test
• Carpal tunnel compression test (most sensitive test to diagnose Carpal Tunnel Syndrome).
• How to perform? Pressing the thumb over the carpal tunnel and holding the pressure for 30 seconds
• The positive sign: The pain and parethesia in the median nerve distribution within 30 seconds. Additional
investigation should be performed (electromyography or EMG)
5. Semmes – Weinstein testing
• Most sensitive sensory test for detecting early syndrome. The nerve is damaged, causing the sensory and
proprioception problems so this kind of testing would be help
Electrodiagnostic Testing
• Nerves and muscles create electrical signals that deliver messages to and from
your brain. Sensory nerves deliver information about your surroundings to the
brain. Motor nerves deliver signals from the brain to activate your muscles.
• Injuries or diseases that affect nerves and muscles can slow the movement of
these electrical signals. If you have pain, weakness or numbness in your back,
neck or hands, measuring the speed and degree of electrical activity in your
muscles and nerves can help doctor make a proper diagnosis. Two tests are
commonly used:
• Electromyography (EMG)
• Nerve conduction studies (NCS)
• These tests are usually administered by a neurologist (a doctor who specializes
in the study of the nerves) or a physiatrist (a specialist in rehabilitation medicine).
The tests can be done in less than an hour.
Treatment
1. Conservative: Exercise and Orthoses
2. Non Conservative treatment: Surgical
Conservative Treatment

Medicine by Steroid
NSAIDS Injections

Orthotics
Exercise
Treatment

Activity
Modifications
Conservative Treatment
• NSAIDS
• To relief the pain
• Steroid injections
• The site of injections is 1 cm proximal and 1 cm ulnar to the intersection of
the palmaris longus tendon and the distal palmar crease
• Activity modification

• Exercise
 Surgical Treatment
• Indications for surgery
• Failure of non operative management: You still have symptoms after a long period of nonsurgical
treatment. In general, surgery is not considered until after several weeks to months of nonsurgical
treatment. But this assumes that you are having ongoing symptoms but no sign of nerve damage.
• Severe symptoms (such as persistent loss of feeling or coordination in the fingers or hand, or no
strength in the thumb) restrict your normal daily activities.
• There is damage to the median nerve (shown by nerve test results and loss of hand or finger function)
or a risk of damage to the nerve.
• Thenar weakness/atrophy

Surgical usually successful but there’s always a chance that the pain or numbness is not completely
relieved. Could be because the nerve is permanently damage, due to disease like neuropathy diabetes or
long-standing carpal tunnel.
Surgical Treatment

BY CARPAL TUNNEL RELEASE.

1. Endoscopic
2. Open surgery
Surgical Treatment

BY CARPAL TUNNEL RELEASE. Can be

1. Endoscopic
- Pillar pain for up to 3-4 months
- Dynamic symptoms (with wrist movement) resolve rapidly.
- Advantage: minimal pain and scarring due to small incision, a shortened recovery period and a
high level of patient satisfaction
- Disadvantage: if the release is incomplete, may cause injury to the nerve, artery, or tendon

• Endoscopic surgery uses a thin tube with a camera attached (endoscope). The
endoscope is guided through a small incision in the wrist (single-portal technique)
or at the wrist and palm (two-portal technique). The endoscope lets the doctor see
structures in the wrist, such as the transverse carpal ligament, without opening the
entire area with a large incision.
• The cutting tools used in endoscopic surgery are very tiny. They, also, are inserted
through the small incisions in the wrist or wrist and palm. In the single-portal
technique, one small tube contains both the camera and a cutting tool
- During endoscopic carpal tunnel release surgery the transverse carpal ligament is cut.
,

This releases pressure on the median nerve, relieving carpal tunnel syndrome symptoms.
 Surgical Treatment
2. Carpal Tunnel Release
With failure of the nonoperative treatments including steroid injections
- Important to cut the transverse carpall ligament far ulnarly to avoid cutting the recurrent
motor branch of the median nerve

3. Repeat Carpal Tunnel Release Syndrome For Recurrent Carpal Tunnel Syndrome
- Repeat is not as good as in primary carpal tunnel release and larger incision may be needed
in some patient
- Outcomes:
• Only 25% will have complete release
• 50% some relief
• 25% will have no relief
Orthotics Treatment
• Orthotics Goal: Decrease or eliminate the symptoms and prevent permanent nerve
damage.
• Control motion: Limit motion on the wrist joint.
• Alignment : Slightly extension or Neutral position. Because unlike flexion, the neutral
or slightly extension position doesn’t cause the narrowing of the carpal tunnel.
• Orthotics device: Wrist Hand Orthosis. Daytime or Night time custom-made splint
• Time using : There are no standard prescription guidelines for wearing the splints, can
be used during Day time or Night time.

1. Dorsal carpal tunnel splint. This limits wrist movement while still providing support to
the wrist and hand, and leaves the fingers free for normal grasping.
Keep the wrist joint in neutral, or can be also set in slightly extended
position. Can be a custom-made splint (made of soft-cast) or a
prefabricated splint (trademark Tricodur), which contains a metal strip
that can be adjusted to immobilize the wrist in a neutral position.
Complications
• Scar Tissue Formation
Excessive scar tissue buildup. The body attempts to heal the area but goes too far in the
process of supplying new cells. Too much scar tissue forms. When this happens the nearby
soft tissues can become bound together. The incision may appear raised. The nearby skin
may feel tight and restrict motion on the hand and wrist. Scar tissue can also bind the
flexor tendons and median nerve, preventing them from gliding smoothly within the carpal
tunnel. Pain and a loss of range of motion may occur. In severe cases, a second surgery may
be needed to remove the extra scar tissue.
• Nerve aggravation or injury (most commonly the palmar cutaneous branch of median
nerve)
• Pillar pain is a known complication following carpal tunnel release and can be causing
weakness, decrease in strength and delayed return to work/recreational activities. It is
defined as pain and tenderness localized to the prominences of the trapezial ridge,
scaphoid tubercle, pisiform or hook of the hamate
• Infections
References
• Goldberg, Bertram et al, ATLAS of Orthosis and Assistive Devices 3rd
Edition, 1997
• https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelin
es_and_Reviews/guidelines/CTS%20CPG_4.13.2017.pdf
• https://emedicine.medscape.com/article/327330-clinical
• https://www.webmd.com/pain-management/carpal-
tunnel/endoscopic-carpal-tunnel-surgery-for-carpal-tunnel-syndrome