CARPAL TUNNEL SYNDROME - DNB Orthopaedics MS Orthopedics MRCS Exam GUIDE -

DNB Orthopaedics  MS Orthopedics  MRCS Exam GUIDE -

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Saturday 19 May 2018



  • MC entrapment neuropathy of U/L, compression of median N in carpal tunnel
  • fibro osseous canal bound by carpal bones and roofed by transverse carpal ligament
  • ligament attached to scaphoid and trapezium radially, hook of hamate on ulnar side
  • middle of distal carpal row bones – 10mm – narrowest point
  • extends from distal wrist crease to mid palm – 5cm
  • contains median N, nine Flexor tendon (FDP, FDS, FPL)
  • median N gives of palmar branch to skin of palm and thenar eminence before entering canal – 5cm proximal to wrist – radial side of median n
  • in canal branch to radial and ulnar br – radial br gives sensory to palmar surface of thumb and index, motor to APB, FPB(sup.head), Opp pollicis – ulnar br sensory to palmar surface of II, III, radial side of IV fingers

  • increase in carpal tunnel pressure >20-30mm Hg – impedes epineural blood flow – nerve function impaired
  • Anatomical factors
    • decreased size of canal
      • bony abnormalities of canal
      • acromegaly
      • flexion/ extension of wrist
    • increased canal contents
      • wrist # (colles, scaphoid)
      • dislocations, subluxations
      • post traumatic arthritis (osteophytes)
      • aberrant muscles
      • local tumors (neuroma, lipoma, ganglion)
      • persistent medial artery
      • hypertrophic synovium
      • hematoma ( hemophilia, anticoagulation therapy)
  • Physiological factors
    • neuropathic
      • DM – alcoholism
    • inflammatory
      • RA – gout – infection – nonspecific tenosynovitis
    • fluid balance alterations
      • pregnancy – menopause – ecclampsia – hypothyroidism – renal failure – obesity – long term hemodialysis – SLE – scleroderma – amyloidosis – Paget's disease
    • external factors
      • vibration – external pressure
  • in children – macrodactyly, lysosomal storage disorders, family h/o
Clinical features
  • numbness (MC) – paraesthesia – pain – burning sensation along median nerve
  • increased at night , relieved by hanging down position
  • atrophy of thenar muscles, weakness of hand muscles
Clinical tests
  • Phalen's test
    • elbow on table – forearm vertical – wrist flexed – 60 sec – numbness and tingling on radial digits
    • sensitive > specific
  • Percussion test (Tinel's sign)
    • light tap- proximal to distal – along median N – tingling response in fingers
    • probable CTS if + at wrist
  • Durkan's compression test
    • direct compression of median nerve at carpal tunnel – 30sec- paraesthesia
    • most sensitive and specific
  • Hand diagram
    • patient marks site of pain and altered sensation on a hand diagram – finds patients perception of symptom
    • markings on palmar side of radial digits
  • Hand volume stress test
    • hand volume measured by displacement- repeated after 7 min stress test and 10min rest
    • increase of >/= 10ml
  • direct carpal tunnel pressure measurement
    • wick or infusion catheter placed in carpal tunnel – hydrostatic pressure in resting and provocative positioning
    • >25 mm Hg resting pressure
  • Reverse Phalen's test (Wormer test)
    • elbow on table – forearm vertical – wrist extension – 60 sec
  • Static 2 point discrimination
    • failure to determined minimum 5mm separation – suggest advanced nerve dysfunction
  • Moving 2 point discrimination
    • minimal separation of 2 moving points applied to palmar finger tip
    • normal = 4mm. <4mm – severe nerve dysfunction
  • Vibrometry
    • vibrometer on palmar side of digit – amplitude at 120Hz – increased to threshold of perception – compare median to ulnar b/l – asymmetry with contralateral hand or median to ulnar asymmetry of same hand
  • Semme Weinstein mono filament
    • monofilaments of increased diameter – touched to palmar side of digits – until patient determine which digit is touched
    • nl – 2.83 or less - >2.83 indicates impairment
  • Digital sensory latency and conduction velocity
    • orthodromic stimulation and recording across wrist
    • latency >3.5ms or asymmetry of velocity >0.5 m/s to opposite side suggestive
  • Motor latency and conduction velocity
    • latency >4.5ms or asymmetry of conduction velocity >1millisec
  • EMG
    • fibrillation potential, sharp waves, increased exertional activity
  • Imaging
    • X ray at 300 to extended wrist – visualized carpal tunnel
    • CT – bony abnormalities
    • MRI – soft tissue abnormalities
    • USG
Differential diagnosis
  • cervical disc herniation
  • thoracic outlet syndrome
  • pronator syndrome
  • Non surgical
    • change of work pattern
    • splint
    • cause treatment like RA, DM
    • NSAIDS, diuretics
    • local steroid injections
      • needle entry – slightly proximal to distal wrist crease – ulnar to PL to avoid median N – 1cm radial to FCU to avoid entering Guyon's canal
      • needle 450 – beneath the proximal margin of TCL and directed in line with ring finger – flush of fluid into canal felt distally in mid palm
  • Surgical treatment
    • classic approach
    • limited approaches
      • double incision of Wilson
      • minimal incision of Bromleg
    • carpal tunnel tone through small palmar incision – Strickland
    • endoscopic CTS release – single portal(Agee)– double portal (chow)
After treatment
  • compression dressing and volar splint
  • hand activity as soon as possible
  • splint continued for comfort 2.3 wks
Unrelieved and recurrent CTS
  • incomplete ligament release
  • reformation of flexor retinaculum
    • both needs re exploration and re release of TCL
  • fibrosis or painful scar
    • epineurolysis
    • local muscle flaps
    • local or remote free fat grafts
    • excision or Z plasty of scar
    • nerve wrapping or inter position materials (silicone sheet, vein wrap)
  • recurrent tenosynovitis
    • tenosynovectomy
    • appropriate medical management ( antibiotics)
  • medial or palmar cutaneous neuroma
  • double crush syndrome
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