This is a powerpoint slide show with information for patients and allied personnel about carpal tunnel syndrome

1. Carpal Tunnel Syndrome
Gershon Zinger MD MS
Hadassah Medical Organization
Jerusalem, Israel

2. Gershon Zinger MD MS
 Grad School MIT – mechanical eng
 Medical School UCLA
 Residency USC – orthopedic surgery
 Fellowship UCLA – hand & micro
 Work Private practice Denver, Colorado
 Current Hadassah Medical Organization
Jerusalem, Israel

3. Definition
 Carpal comes from the Greek word Karpos –
means wrist !
 Carpal tunnel syndrome means wrist tunnel
syndrome
 Syndrome – “A set of symptoms which occur
together” (from Dorland’s Medical Dictionary)
(AKA – we don’t really understand it !)

4. Anatomy
 Wrist tunnel formed by
bone on bottom and
ligament on top
 There are 9 tendons
and one nerve in the
tunnel
 Analogous to 4 lanes
of traffic going to 2
lanes then back to 4 !

5. Who Gets CTS
 Women more often affected (ratio 3:1)
 Historically more common in retired people
 Associated with repetitive activity
 Can be associated with medical diseases
 Diabetes
 Rheumatoid Arthritis
 Thyroid Disease

6. Diagnosis of CTS
 History
 Physical Exam
 Nerve Conduction
Study/EMG

7. Nerve Exam
 Sensory
 Motor
 Irritability

8. Nerve Exam - Sensory
Pattern peripheral or radicular
 Check for altered
sensation, numbness on
palmar and dorsal sides
 Middle finger is median n.
 Small finger is ulnar n.
 First dorsal webspace is
radial nerve innervated

9. Median Nerve
 The median nerve
provides feeling to the
thumb, index, middle
and part of the ring
fingers
 Sometimes people
complain of numbness
in the little finger that
may or may not be
CTS

10. Nerve Exam
Sensory
 Numbness over first
dorsal web space may
indicate cervical origin
 Numbness glove-
stocking may indicate
general neuropathy
 Numbness in non
anatomic distribution
may indicate trigger
points

11. Nerve Exam
Sensory
 2 point discrimination
is an objective test of
sensibility
 Use large, not small
paper clip
 As points get closer
together, it feels like
one instead of two
 6 mm or less is normal

12. Nerve Exam
Motor – Carpal Tunnel
 Look for atrophy of
thenar muscles
 May be secondary to
thumb arthritis
 Test strength for
opposition (median)

13. Nerve Exam
Irritability - Carpal Tunnel
Local Compression
Phalen Test (up to 60 seconds)
Tinel’s Sign

14. Other sources of nerve irritation
Cervical
 Cervical testing
 Reproduction of
symptoms with
extension+rotation
 Numbness that
extends to shoulder
level very suspicious
for proximal origin

15. Double-Crush Phenomenon
 A compression point
at one location may
lower the threshold at
another location

16. Other sources of nerve irritation
Thoracic Outlet Syndrome
90 degree abduction-external
rotation test (AER) – neither
too far forward nor too far back

17. Other sources of nerve irritation
Thoracic Outlet Syndrome
 Examiner’s thumb
over anterior scalene
muscle

18. Other sources of nerve irritation
Trigger Points
 Palpation of
parascapular trigger
points may cause local
pain but also reproduce
tingling and numbness
distal into hand
 Trapezius
 Rhomboid
 Latissimus
 Posterior arm

19. Nerve Conduction + EMG
 Nerve Conduction  EMG
Study  Needles into muscles
 Test speed of signal looking for defibrillation
down the nerve

20. Nerve anatomy
 A nerve carries
electricity in two
directions
 Axons in bundles or
fascicles
 Micro-circulation
affected by
pressure

21. Saltatory Conduction
Node of Ranvier

22. Seddon Classification
 Neuropraxia
 Interruption in
conduction
 Nerve elements normal
 Recovery full
 Recovery can take 6-8
weeks
 Axontmesis
 Neurotmesis

23. Seddon Classification
 Neuropraxia
 Axontmesis
 Loss of axon continuity
 EMG 2-3 weeks later may
show denervation and
fibrillation potentials
 Epineurium preserved
 Axon may regenerate at
rate of 1mm/day
 Incomplete recovery
 Final result at one year
 Neurotmesis

24. Seddon Classification
 Neuropraxia
 Axontmesis
 Neurotmesis
 neurotmesis (neuro as in
never as in fahgedaboutit)
 Complete loss of nerve
function
 May include loss or
scarring of all neural
elements
 Surgery can still help
w/pain

25. Remember:
 Nerve is brain tissue – limited ability to
recover
 Numbness may go away after 1 day,
months, a year or never !
 Numbness may be permanent if nerve
already damaged beyond recovery

26. Treatment of CTS
 JBJS 1980 – Steroid Injection + splint
 Prospective, one year, 50 hands
 Overall, only 22% of hands were sx-free
 In mild category, 40% hand were sx-free
 J of Hand Surg 1994 – Steroid injection + splint
 Prospective, 76 hands, f/up 1 yr, avg age 38 yo, excluded
DM, thyroid dz, RA, preg and “severe dz”
 Overall only 13% of hands were sx-free
 JAMA 2002 – surgery vs splint
 Prospective, 147 patients, excluded DM
 At 18 months, 90% success surgery group vs 37% for splint
group

27. Surgery - CTR
 Under the skin lies
palmar fascia
 There are muscles on
both sides – thenar
and hypothenar
consisting of 3
muscles each

28. Surgery - CTR
 Under fascia lies
the transverse
carpal ligament
 This ligament is cut
and springs apart
 Ligament later
heals leaving the
tunnel larger

29. Open versus endoscopic
 Open theoretically
safer
 Endoscopic
theoretically has faster
recovery

30. Injuries
 J of Hand Surgery* – May 1999
 Survey of members of ASSH
 Endoscopic – 455 major injuries
 Open – 283 major injuries
* Palmer & Toivonen

31. Postoperative
 Nurse visit at about 10
days for suture
removal and nerve
gliding exercise
 Need to avoid heavy
or repetitive for one
month then gradual
return to activities
 Palm may be sore 2-4
months

32. Thank You !