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
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
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