Entrapment Neuropathies with basic focus on Carpal Tunnel Syndrome

1. Presented by:
Anish Dhakal
24th May, 2019
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2. Introduction
 Also known as nerve compression syndrome
 Compression of peripheral nerve
 When nerve traverse fibro-osseous tunnel, risk of
entrapment and compression
 Nerve compression
 impairs epineural blood flow and axonal conduction 
giving rise to symptoms

3. Introduction
 Symptoms
 Numbness
 Paraesthesia
 Muscle weakness
 Prolonged or severe compression
 Segmental demyelination
 Target muscle atrophy
 Nerve fibrosis

4. Entrapment Neuropathies
 Median Neuropathy
 Ulnar Neuropathy
 Radial Neuropathy
 Common peroneal Neuropathy
 Proximal Femoral Neuropathy
 Lateral Femoral Neuropathy
 Posterior tibial neuropathy

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6. Carpal Tunnel Syndrome
 Most common entrapment neuropathy
 Compression of the median nerve at the wrist
 Swelling  Compression  Ischemia of nerve
 More common in women
 Age group: 40–50 years

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8. Causes
Inflammatory causes Rheumatoid arthritis
Wrist osteoarthritis
Post-traumatic causes Bone thickening after a
Colles' fracture
Endocrine causes Diabetes
Myxoedema
Acromegaly
Hypothyroidism
Pregnancy
Idiopathic commonest cause

9. Clinical Features
 Pain and paraesthesia in the distribution of median
nerve in hand
 Burning pain, tingling and numbness causing
patient to wake up at night
 Relieving factor: hanging the arm over the side of
the bed or shaking the arm

10. sensory lossMedian nerve distribution

11. Diagnosis
 History
 Motor examination
 Wasting and weakness of the median- innervated hand
muscles (LOAF muscles)
 L - First and second lumbricals
 O - Opponens pollicis
 A - Abductor pollicis brevis
 F - Flexor pollicis brevis

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13. Special Test
 Tinel’s nerve percussion test
 Gentle tapping over the median nerve in the carpal
tunnel region elicits tingling in the nerve distribution
 Phalen’s wrist flexion test
 Full flexion of the wrists for up to 60 seconds induce
tingling sensation
 Electromyography

14. Tinel’s sign
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15. Phalen’s test
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17. Wrist Splints & Physiotherapy
 Light splints that prevent wrist flexion help those
with night pain or with pregnancy-related symptoms
 Most effective when it is applied within three months
of the onset of symptoms

18. Oral medication
 Nonsteroidal anti-inflammatory drugs (NSAIDs)
 Orally administered corticosteroids
 Prednisolone 20 mg per day for two weeks followed by
10 mg per day for two weeks

19. Failure of conservative therapy:
 Long duration of symptoms (>10 months)
 Age greater than 50
 Constant paresthesias
 Impaired two-point discrimination (>6 mm)
 Positive Phalen's sign <30 seconds
 Prolonged motor and sensory latencies demonstrated by
electrodiagnostic testing

20. Treatment
 Oral glucocorticoid or injections: 10 to 20 mg of
lidocaine without epinephrine + 20 to 40 mg of
methylprednisolone acetate
 Surgical: carpel tunnel release

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22. Local Injection
 Steroid injection into the carpal canal provides
temporary relief
 Splinting is generally recommended after local
corticosteroid injection
 If the first injection is successful, a repeat injection can be
considered after a few months
 Surgery should be considered if a patient needs more
than two injections

23. Surgery
 Partial or complete surgical division of flexor
retinaculum Carpal tunnel release
 If symptoms are refractory to conservative measures or if
nerve conduction studies show severe entrapment
 Relieves both compression and resulting symptoms

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25. References
 Harrison’s Principle of Internal Medicine, 19th edition
 Apley’s System of Orthepedics & Fractures, 9th edition
 Maheshwari J, Essentials orthopedics, 4th edition

26. Thank You