SlideShare une entreprise Scribd logo
1  sur  41
Télécharger pour lire hors ligne
Carpal tunnel
Carpal Tunnel Syndrome
Definition
• Sign and symptoms secondary to compression
  of the median nerve in the carpal tunnel
History
• CTS First described by
   Sir James Paget 1854
• First CTR performed
   Sir James Learmonth 1933
• Popularised by Phalen in the 1950s with a series of
  articles
• Introduction of endoscopic release 1985-1987
   – Dr Agee, Dr Chow, Dr Okutsu
Anatomy - median nerve
Attachment of the transverse carpal ligament
Content of the carpal tunnel
Relationship with the Guyon’s tunnel
Anatomy - Carpal Tunnel
•   The bony borders are: radially, the tubercle of the scaphoid and the
    tubercle of the trapezium; ulnarly the triquetrum, pisiform and hook of
    the hamate. The lunate lies in the floor of the tunnel.
•   Nine tendons run through the tunnel: the 4 FDS, the 4 FDP, and FPL. FCR
    runs in a separate fascial compartment on the radial side of the tunnel.
    The middle and ring FDS tendons are superficial to the index and little
    finger FDS tendons. The FDS and FDP tendons all share a common sheath;
    the tendons appear to be invaginated into the sheath from the radial side.
     The FPL tendon has its own synovial sheath.
•   The recurrent motor branch can be extraligamentous; subligamentous;
    transligamentous. Rarely, it can take origin from the ulnar side of the
    median nerve, and it can come to lie on top of the transverse carpal
    ligament.
Anatomy - PCB median nerve
Sub-ligamentous
Extra-ligamentous
                     The recurrent motor branch
                     of the median nerve




                    Trans-ligamentous
Microstructure of the median nerve in the
              carpal tunnel

• The nerve is composed of 6-40 fascicles with
  an average of 24. Epineurial tissue makes up
  around 42% of the nerve.
• Sensory fibres outnumber motor fibres 9:1.
  The motor nerve fibres are situated anteriorly.
Physiology
• Excursion of the nerve
   – with flexion/extension is 7-14mm at the wrist
   – 5-7mm at the elbow.
• Resting pressure in normal patients is 2.5mmHg.
   – Full flexion or extension increases the pressure to 30mmHg in normal
     patients
   – 90-100mmHg in patients with CTS
   – Contraction of finger and thumb flexors may increase pressure 3-6
     times above resting values.
• Reduced epineural blood flow is the earliest manifestation of
  nerve compression
   – and may occur at a pressure of 20-30mmHg.
   – Reduced axoplasmic transport occurs at pressures of 30mmHg.
Pathophysiology of CTS
• Night numbness is caused by a number of factors:
• Horizontal position results in a redistribution of fluid
  to the upper limbs
• Drainage by the action of the muscle pump is
  diminished
• There is a tendency towards wrist flexion at night
• The blood pressure drops during late night and early
  morning, resulting in decreased perfusion pressure
Epidemiology
• Carpal tunnel syndrome is the most common
  compression neuropathy.
• Median age is 51.
• Women are affected 4:1
• More common in industrialized societies.
• High rate of bilateral compression.
• More common in the dominant arm.
• 50% associated with Raynaud’s phenomenon.
Aetiology
• Reduction in the size of the carpal tunnel:
   – Trauma
   – Acromegaly
   – osteoarthritis
• Increase in the volume of the contents of the carpal tunnel:
   – Inflammation: Nonspecific tenosynovitis of the flexor
     tendons; RA; gout; amyloid.
   – Swellings: ie. Ganglia; lipoma; tumour.
   – Endocrine abnormalities: ie. Pregnancy; diabetes; thyroid
     disease.
• Congenital developmental conditions
   – Persistent median artery
   – Abnormal muscle bellies - eg. FDS, palmaris profundus
   – Proximal or hypertrophied lumbricals
Symptoms
• Nocturnal numbness and paraesthesias almost
  pathoneumonic
   – This is because of redistribution of blood from the legs
     while the patient is recumbent, with dilation of blood
     vessels in the carpal tunnel.
   – Shaking the hand gets the blood out of the dilated vessels.
• The pain should radiate only to the elbow.
• The patient may complain of dropping things.
Signs
•   Numbness doesn’t have to be exactly anatomical but there should be a
    big difference between the thumb and little finger.
     – Numbness often affects the middle finger first then the thumb and
        index.
     – The palmar sensory branch should be spared so there should be
        normal sensation over the thenar eminence.
•   Thenar wasting is a late sign and implies you have missed the boat.
•   Phalen’s sign may be positive with either volar flexion (Phalen’s volar test)
    or dorsiflexion (Phalen’s dorsal test). Overall sensitivity of 75%, specificity
    of 0.47.
•   Tinel’s sign has a sensitivity of 0.60 and a specificity of 0.67.
•   Durkan’s direct median nerve compression test is the most sensitive
    (0.87) and specific (0.90).
Phalen’s Test
Durkan’s Test
Nerve Conduction Studies
• The main benefit of NCS is to provide objective evidence for
  the diagnosis.
• False negative rate of 8%. (These patients have symptoms
  and respond to carpal tunnel release but have normal NCS).
• EMG evidence of denervation of the thenar muscles provides
  evidence of the severity of compression.
• Discrepancy between clinical findings and NCS
   – Interestingly, no consensus could be reached regarding
     the patient with classic/probable symptoms without
     abnormal NCS findings. This is the group where diagnosis
     is often debated between hand surgeons and neurologists.
Carpal tunnel
DDx

1.   Pronator syndrome:
     –   compression by the ligament of Struthers, supracondylar process, bicipital
         aponeurosis, within pronator teres and under FDS arch. Hand numbness and
         nocturnal pain and numbness is rare.
1.   Anterior interosseous syndrome
2.   Brachial neuritis
3.   Thoracic outlet syndrome
4.   Cervical radiculopathy
5.   RSD
6.   Raynaud’s phenomenon
7.   TIA
Treatment: Non-surgical
• Only if no sign of motor damage.
• Reduce oedema with diuretic or steroid.
• Splint to reduce nocturnal flexion – splint in
  neutral.
Steroid Injection
•   Transient relief occurs in 80% of patients after steroid injection
•   But only 22% of patients with steroid injections are pain free at 12 months
    (These patients were also splinted).
     – It is most useful early in the disease, when there has been less than 1
        yr of symptoms
     – there is no weakness or thenar atrophy
     – less than 2ms prolongation of distal motor and sensory latencies.
•   Technique of injection:
     – a 22-gauge needle is introduced between FCR and PL
     – angled dorsally and distally at 45 degrees
     – It is advanced until it reaches the floor of the tunnel, and then
        withdrawn 5mm
     – A water soluble preparation is used
          • e.g. dexamethasone acetate plus lignocaine
          • if any immediate paraesthesias occur the injection is stopped.
Non-surgical treatment (other than steroid
      injection) for carpal tunnel syndrome
                        [Review] Volume (1), 2006, [no page #]
            The Cochrane Library, Copyright 2006, The Cochrane Collaboration
                     O'Connor, D; Marshall, S; Massy-Westropp, N
                     Date of Most Recent Update: 15-August-2005



Implications for practice:
• Moderate evidence shows significant short-term benefit from
  oral steroids.
• Limited evidence shows significant short-term benefit from
  splinting
• yoga and carpal bone mobilization do not produce significant
  benefit.
Surgical Treatment
• Open Carpal Tunnel Release
  – Open technique
  – Limited incision technique
• Endoscopic Carpal Tunnel Release(1985)
  – Two incision technique Dr James Chow (Southern Illinois)
  – Distal single incision technique Dr Michael Murphy (John
    Hopkins Univ, Baltimore)
  – Proximal single incision technique Dr John Agee
    (Sacramento, California)
Open Carpal Tunnel Release
-Surgical Landmarks
Open carpal tunnel
    release
-Structures to avoid
1. Palmar cutaneous
    br of median nerve
2. Superficial palmar
    arch
Open Carpal Tunnel Release
Postoperative course and results for Open
                  CTR
• Grip strength returns to normal in 3 months.
• Surgery is most successful when done early; Patients with
  intermittent numbness do better than patients with constant
  numbness.
• Overall excellent results in 80% (Mayo clinic). 5% have
  worsened function.
• MRI shows a 20-30% increase in the carpal tunnel volume
  after surgery. MRI also shows that Guyon’s canal enlarges
  after carpal tunnel release.
• Measurement of pressures within the carpal tunnel before
  and after release demonstrate marked decreases in resting
  pressures after release of the ligament.
Endoscopic Techniques - CTR
• Two incisions
• Distal one incisions
• Proximal one incisions
Two incisions technique by James Chow
Slotted tube technique
Adv: Visualise the distal and proximal margin of TCL
Disadv: Two portals. One portal in the palm
Single distal portal endoscopic technique
Advantage: Visualise the superficial arch and the distal margin of TCL
Disadvantage: the incision is in the palm
Single distal portal endoscopic technique
single proximal
portal technique
-John Agee from
Sacrimento
California
-The equipmenmt is
manufactured by Microaire
Pty Ltd.
Endoscopic carpal
tunnel release
-single portal
technique
Outcome:
Endoscopic vs Open
The Cochrane Database of Systematic Reviews
Surgical treatment options for carpal tunnel syndrome [Review]
Volume (1), 2006, [no page #]
Scholten, R; Bouter, LM; Gerritsen, A; Uitdehaag, BM; de Vet,
HCW; van Geldere,
D
Date of Most Recent Update: 17-August-2005

Cochrane Neuromuscular Disease Group.
Dr. Rob Scholten, Director, Dutch Cochrane Centre, Academic Medical Center, Room
J1B - 108-1, P.O. Box 22700, AMSTERDAM, 1100 DE, NETHERLANDS. Phone: +31 20 566
5602, Fax: +31 20 691 2683, E-mail: cochrane@amc.uva.nl, N
Background: Carpal tunnel syndrome is a common disorder, for which several
surgical treatment options are available.

Objectives: To compare the efficacy of the various surgical techniques in
relieving symptoms and promoting return to work and/or activities of daily
                                                                                   -Reviewed 23 studies RCT
living and to compare the occurrence of side-effects and complications, in
patients suffering from carpal tunnel syndrome.                                    -Good methodology
Search strategy: We updated the searches in 2003. We conducted computer-aided
searches of the trials register of the Cochrane Neuromuscular Disease Group        -Pooling of results was not possible
(searched in July 2003), the Cochrane Central Register of Controlled Trials (The
Cochrane Library, Issue 2, 2003), MEDLINE (January 1966 to August 2003), EMBASE
(January 1980 to August 2003) and tracked references in bibliographies.
                                                                                   because of differing outcome
Selection criteria: Randomised controlled trials comparing various surgical        measures
techniques for the treatment of carpal tunnel syndrome.

Data collection and analysis: Two reviewers performed study selection,
                                                                                   -alternatives to open CTR does not
assessment of methodological quality and data abstraction independently of each
other.                                                                             offer better relief of symptoms
Main results:
                                                                                   -Result of early return to work with
                                                                                   endoscopic mean is conflicting
Twenty-three studies were included in the review. The methodological quality of
the trials was fair to good. However, the application of allocation concealment
was mentioned explicitly in only one trial. Many studies failed to present the
results in sufficient detail to enable statistical pooling. Pooling was also
impeded by the vast variety of outcome measures that were applied in the various   Conclusion: No evidence to
studies.

None of the existing alternatives to standard open carpal tunnel release seem to
                                                                                   support replacement of open CTR
offer better relief from symptoms in the short- or long-term. There was
conflicting evidence about whether endoscopic carpal tunnel release resulted in
earlier return to work and/or activities of daily living than open carpal tunnel
release.

Conclusions: There is no strong evidence supporting the need for replacement of
standard open carpal tunnel release by existing alternative surgical procedures
A Systematic Review of Reviews Comparing
                      the Effectiveness of Endoscopic and Open
                            Carpal Tunnel Decompression
   Achilleas Thoma, M.D., M.Sc., Karen Veltri, M.Sc., Ph.D., Ted Haines, M.D., M.Sc.,
                                 and Eric Duku, M.Sc.
                               Hamilton, Ontario, Canada
                       (Plast. Reconstr. Surg. 113: 1184, 2004.)
Controversy persists regarding the benefit of endoscopic
carpal tunnel release compared with open carpal
tunnel release for pain, numbness, strength, return to
work and function, scar tenderness, and complications.
For surgeons, a recommended first source of information           Controversy between the two techniques
on treatment effectiveness is a review of high-methodologic-
quality articles. This review of reviews was undertaken
to answer this clinical question regarding these outcomes.
                                                                  Reviewed articles from 1989-2002
Cochrane, MEDLINE, EMBASE, CINAHL, and Health-
STAR databases were searched using the key words “endoscopic      48 articles on the topic
carpal tunnel,” with limits “review or overview”
and dates from 1989 to present. Five key journals were
hand-searched. Any review with a reference to at least one
                                                                  7 articles are pertinent to the question
randomized controlled trial that compared endoscopic
carpal tunnel release to open carpal tunnel release was to        3 of high quality methodology
be included. Two reviewers independently scanned titles
and abstracts for potential relevance. Selection as relevant
was confirmed through a review of full texts. Disagreements
                                                                  -both techniques relief symptoms
were resolved through discussion and consensus.
The selected reviews were assessed for methodologic quality
                                                                  -conflicting result regarding return to work
on the basis of the scale of Hoving et al. Of 48 articles
initially identified, seven pertinent reviews were selected.
Of these seven, three reviews of high methodologic quality
                                                                  and function
concurred that there is no difference between the two
techniques in symptom relief and that the evidence is
                                                                  -no difference in the risk of median n. injury
conflicting for return to work and function. The risk of
permanent median nerve injury does not differ between
the techniques. The reviews indicated that the endoscopic
                                                                  -endoscopic has worse reversible nerve
carpal tunnel release technique is worse in terms of reversible
nerve injury but superior in terms of grip strength
                                                                  injury
and scar tenderness, at least in short-term follow-up. Several
trials have not been incorporated in these reviews and            -Endoscopic has superior grip strength and
statistical pooling has not been conducted. Further systematic
review with meta-analysis may permit more definitive
conclusions about the relative effectiveness of these
                                                                  and less scar tenderness
two techniques, particularly with regard to return to work
and function.
Point for discussion
• ECTR & OCTR ONLY relieve the mechanical
  component of the pathology
• i.e. that they do not address the biochemical,
  pathophysiology, endocrine or hormonal
  aspects of the disease
• i.e. we can perform a brilliant CTR but if the
  nerve has more than a mechanical problem
  then the pt will not get a full relief.
Point for discussion
• When Durkan’s, Phalen’s & Tinel’s tests are all
  negative, that the nerve is "no longer able to
  be irritated"
• ie that it has undergone some pathological
  change, such as intra-neural fibrosis or other,
  that prevents a positive response.
Complications
•   Early
     – Transection of the median nerve or the superficial arch
     – Haematoma
     – Pain, swelling and stiffness
     – Recurrent Branch injury
     – Infection
•   Late
     – RSD
     – Hypertrophic scar
     – Median nerve neuritis
     – Palmar fasciitis
     – Fibrosis of carpal tunnel
     – Recurrence
•   Revision carpal tunnel release
     – Only 25% of patients have complete relief of symptoms. 25% have no relief.
        The rest have partial relief.

Contenu connexe

Tendances (20)

Intertrochanteric fracture
Intertrochanteric fractureIntertrochanteric fracture
Intertrochanteric fracture
 
Dupuytrens Contracture
Dupuytrens ContractureDupuytrens Contracture
Dupuytrens Contracture
 
Foot drop
Foot dropFoot drop
Foot drop
 
Claw Hand,Definition,Causes,Types,Symptoms and Management
Claw Hand,Definition,Causes,Types,Symptoms and ManagementClaw Hand,Definition,Causes,Types,Symptoms and Management
Claw Hand,Definition,Causes,Types,Symptoms and Management
 
Clinical examination of elbow joint
Clinical examination of elbow jointClinical examination of elbow joint
Clinical examination of elbow joint
 
Ctev.ppt by krr
Ctev.ppt by krrCtev.ppt by krr
Ctev.ppt by krr
 
The wrist joint
The wrist jointThe wrist joint
The wrist joint
 
Median nerve
Median nerveMedian nerve
Median nerve
 
Rotator cuff injuries
Rotator cuff injuriesRotator cuff injuries
Rotator cuff injuries
 
Knee Injuries In Detail
Knee Injuries In Detail Knee Injuries In Detail
Knee Injuries In Detail
 
Anatomy of median nerve
Anatomy of median nerveAnatomy of median nerve
Anatomy of median nerve
 
Carpal tunnel syndrome- short case
Carpal tunnel syndrome- short caseCarpal tunnel syndrome- short case
Carpal tunnel syndrome- short case
 
De quervain’s
De quervain’sDe quervain’s
De quervain’s
 
Median nerve palsy final
Median nerve palsy finalMedian nerve palsy final
Median nerve palsy final
 
Frozen shoulder 9.6.15
Frozen shoulder 9.6.15Frozen shoulder 9.6.15
Frozen shoulder 9.6.15
 
Sciatic nerve
Sciatic nerveSciatic nerve
Sciatic nerve
 
Knee examination
Knee examinationKnee examination
Knee examination
 
Mallet finger
Mallet fingerMallet finger
Mallet finger
 
Anatomy of Hand
Anatomy of HandAnatomy of Hand
Anatomy of Hand
 
Painful shoulder arc
Painful shoulder arcPainful shoulder arc
Painful shoulder arc
 

En vedette

Carpal Tunnel Syndrome.ppt
Carpal Tunnel Syndrome.pptCarpal Tunnel Syndrome.ppt
Carpal Tunnel Syndrome.pptShama
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndromeeystdotorg
 
Carpal tunnel syndrome CTS 2014
Carpal tunnel syndrome CTS 2014Carpal tunnel syndrome CTS 2014
Carpal tunnel syndrome CTS 2014Saber Lahmidi
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndromedralizameer
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndromemcorreamd
 
Acute back pain
Acute back painAcute back pain
Acute back painjehh87
 
Palmar arterial arches
Palmar  arterial archesPalmar  arterial arches
Palmar arterial archesMohana Sekar
 
Carpel tunnel syndrome presentation
Carpel tunnel syndrome  presentationCarpel tunnel syndrome  presentation
Carpel tunnel syndrome presentationRichard Radecki
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndromeGajanan Pandit
 
anatomy of Thyroid gland
 anatomy of Thyroid gland anatomy of Thyroid gland
anatomy of Thyroid glandddert
 
Anatomy of Submandibular Gland
Anatomy of Submandibular GlandAnatomy of Submandibular Gland
Anatomy of Submandibular GlandFuad Ridha Mahabot
 
Structures of the Hand PPT
Structures of the Hand PPTStructures of the Hand PPT
Structures of the Hand PPTStacey Turner
 
Inguinal hernia ppt
Inguinal hernia pptInguinal hernia ppt
Inguinal hernia pptViswa Kumar
 

En vedette (20)

Carpal Tunnel Syndrome.ppt
Carpal Tunnel Syndrome.pptCarpal Tunnel Syndrome.ppt
Carpal Tunnel Syndrome.ppt
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
 
Carpal tunnel syndrome CTS 2014
Carpal tunnel syndrome CTS 2014Carpal tunnel syndrome CTS 2014
Carpal tunnel syndrome CTS 2014
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndrome
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndrome
 
Acute back pain
Acute back painAcute back pain
Acute back pain
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndrome
 
Axilla
AxillaAxilla
Axilla
 
Palmar arterial arches
Palmar  arterial archesPalmar  arterial arches
Palmar arterial arches
 
Carpel tunnel syndrome presentation
Carpel tunnel syndrome  presentationCarpel tunnel syndrome  presentation
Carpel tunnel syndrome presentation
 
Pelvis By Dr. Fernandez
Pelvis By Dr. FernandezPelvis By Dr. Fernandez
Pelvis By Dr. Fernandez
 
Psoas Abscess
Psoas AbscessPsoas Abscess
Psoas Abscess
 
Psoas abscess
Psoas abscessPsoas abscess
Psoas abscess
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndrome
 
anatomy of Thyroid gland
 anatomy of Thyroid gland anatomy of Thyroid gland
anatomy of Thyroid gland
 
Anatomy of Submandibular Gland
Anatomy of Submandibular GlandAnatomy of Submandibular Gland
Anatomy of Submandibular Gland
 
Structures of the Hand PPT
Structures of the Hand PPTStructures of the Hand PPT
Structures of the Hand PPT
 
Hand anatomy
Hand anatomyHand anatomy
Hand anatomy
 
Inguinal hernia ppt
Inguinal hernia pptInguinal hernia ppt
Inguinal hernia ppt
 

Similaire à Carpal tunnel

carpal tunnel syndrome
carpal tunnel syndrome carpal tunnel syndrome
carpal tunnel syndrome Anudeep Korada
 
Carpal tunell syndrme
Carpal tunell syndrmeCarpal tunell syndrme
Carpal tunell syndrmeRam Mohan
 
Carpel tunnel syndrome
Carpel tunnel syndromeCarpel tunnel syndrome
Carpel tunnel syndromeShruti Shirke
 
Entrapment neuropathies
Entrapment neuropathiesEntrapment neuropathies
Entrapment neuropathiesNeurologyKota
 
MEDIAN NERVE PRESENTATION (2).pptx
MEDIAN NERVE PRESENTATION (2).pptxMEDIAN NERVE PRESENTATION (2).pptx
MEDIAN NERVE PRESENTATION (2).pptxSalman Syed
 
Entrapment neuropathy
Entrapment neuropathyEntrapment neuropathy
Entrapment neuropathyHossam atef
 
carpal tunnel syndrome and dupuytren disease
carpal tunnel syndrome and dupuytren diseasecarpal tunnel syndrome and dupuytren disease
carpal tunnel syndrome and dupuytren diseaserohit raj
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel SyndromeHassan Rajab
 
Management of Peripheral Nerve Entrapment (Carpal Tunnel Syndrome).pptx
Management of Peripheral Nerve Entrapment  (Carpal Tunnel Syndrome).pptxManagement of Peripheral Nerve Entrapment  (Carpal Tunnel Syndrome).pptx
Management of Peripheral Nerve Entrapment (Carpal Tunnel Syndrome).pptxDr. Shahnawaz Alam
 
Carpal tunnel Syndrom Wesam Aljabali -1.pdf
Carpal tunnel Syndrom Wesam Aljabali -1.pdfCarpal tunnel Syndrom Wesam Aljabali -1.pdf
Carpal tunnel Syndrom Wesam Aljabali -1.pdfMsm_mo
 
THORACIC%20OUTLET%20SYNDROME.pptx
THORACIC%20OUTLET%20SYNDROME.pptxTHORACIC%20OUTLET%20SYNDROME.pptx
THORACIC%20OUTLET%20SYNDROME.pptxNEELESHCHOUDHARY4
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndromePratikDhabalia
 
CARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGS
CARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGSCARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGS
CARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGSSUMIT KUMAR
 
Pathology and management of compartment syndrome in orthopedics 1
Pathology and management of compartment syndrome in orthopedics 1Pathology and management of compartment syndrome in orthopedics 1
Pathology and management of compartment syndrome in orthopedics 1EnejoJoseph
 

Similaire à Carpal tunnel (20)

carpal tunnel syndrome
carpal tunnel syndrome carpal tunnel syndrome
carpal tunnel syndrome
 
Carpal tunell syndrme
Carpal tunell syndrmeCarpal tunell syndrme
Carpal tunell syndrme
 
Carpel tunnel syndrome
Carpel tunnel syndromeCarpel tunnel syndrome
Carpel tunnel syndrome
 
Entrapment neuropathies
Entrapment neuropathiesEntrapment neuropathies
Entrapment neuropathies
 
Entrapment neuropathy
Entrapment neuropathyEntrapment neuropathy
Entrapment neuropathy
 
MEDIAN NERVE PRESENTATION (2).pptx
MEDIAN NERVE PRESENTATION (2).pptxMEDIAN NERVE PRESENTATION (2).pptx
MEDIAN NERVE PRESENTATION (2).pptx
 
Entrapment neuropathy
Entrapment neuropathyEntrapment neuropathy
Entrapment neuropathy
 
carpal tunnel syndrome and dupuytren disease
carpal tunnel syndrome and dupuytren diseasecarpal tunnel syndrome and dupuytren disease
carpal tunnel syndrome and dupuytren disease
 
Entrapment syndromes
Entrapment syndromes Entrapment syndromes
Entrapment syndromes
 
Sympathectomy
SympathectomySympathectomy
Sympathectomy
 
Carpal Tunnel Syndrome
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Carpal Tunnel Syndrome
 
Entrapment neuropathies
Entrapment neuropathiesEntrapment neuropathies
Entrapment neuropathies
 
Management of Peripheral Nerve Entrapment (Carpal Tunnel Syndrome).pptx
Management of Peripheral Nerve Entrapment  (Carpal Tunnel Syndrome).pptxManagement of Peripheral Nerve Entrapment  (Carpal Tunnel Syndrome).pptx
Management of Peripheral Nerve Entrapment (Carpal Tunnel Syndrome).pptx
 
Carpal tunnel Syndrom Wesam Aljabali -1.pdf
Carpal tunnel Syndrom Wesam Aljabali -1.pdfCarpal tunnel Syndrom Wesam Aljabali -1.pdf
Carpal tunnel Syndrom Wesam Aljabali -1.pdf
 
Thoracic outlet syndrome.
Thoracic outlet syndrome.Thoracic outlet syndrome.
Thoracic outlet syndrome.
 
THORACIC%20OUTLET%20SYNDROME.pptx
THORACIC%20OUTLET%20SYNDROME.pptxTHORACIC%20OUTLET%20SYNDROME.pptx
THORACIC%20OUTLET%20SYNDROME.pptx
 
Carpal tunnel syndrome
Carpal tunnel syndromeCarpal tunnel syndrome
Carpal tunnel syndrome
 
CARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGS
CARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGSCARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGS
CARPAL TUNNEL SYNDROME ANATOMY AND RADIOLOGY IMAGING FINDINGS
 
Pathology and management of compartment syndrome in orthopedics 1
Pathology and management of compartment syndrome in orthopedics 1Pathology and management of compartment syndrome in orthopedics 1
Pathology and management of compartment syndrome in orthopedics 1
 
Spinal nerve root entrapment.pptx
Spinal nerve root entrapment.pptxSpinal nerve root entrapment.pptx
Spinal nerve root entrapment.pptx
 

Plus de drpouriamoradi (20)

Zplasty
ZplastyZplasty
Zplasty
 
Skin grafts
Skin graftsSkin grafts
Skin grafts
 
Scc
SccScc
Scc
 
Scaphoid fractures
Scaphoid fracturesScaphoid fractures
Scaphoid fractures
 
Radial nerve-palsy-tendon-transfers
Radial nerve-palsy-tendon-transfersRadial nerve-palsy-tendon-transfers
Radial nerve-palsy-tendon-transfers
 
Radial nerve-anatomy
Radial nerve-anatomyRadial nerve-anatomy
Radial nerve-anatomy
 
Principles of-tendon-transfers
Principles of-tendon-transfersPrinciples of-tendon-transfers
Principles of-tendon-transfers
 
Pipjw
PipjwPipjw
Pipjw
 
Perineal reconstruction
Perineal reconstructionPerineal reconstruction
Perineal reconstruction
 
Parotid gland
Parotid glandParotid gland
Parotid gland
 
Orbital fractures
Orbital fracturesOrbital fractures
Orbital fractures
 
Nsw speech-path-talk-flapvs-grafts
Nsw speech-path-talk-flapvs-graftsNsw speech-path-talk-flapvs-grafts
Nsw speech-path-talk-flapvs-grafts
 
Nsw plastic-nurses
Nsw plastic-nursesNsw plastic-nurses
Nsw plastic-nurses
 
Mucous cysts-dipjw
Mucous cysts-dipjwMucous cysts-dipjw
Mucous cysts-dipjw
 
Lower limb-guidelines
Lower limb-guidelinesLower limb-guidelines
Lower limb-guidelines
 
Lower limb-flaps
Lower limb-flapsLower limb-flaps
Lower limb-flaps
 
Intro to-plastics
Intro to-plasticsIntro to-plastics
Intro to-plastics
 
Hand tumours
Hand tumoursHand tumours
Hand tumours
 
Hand infections
Hand infectionsHand infections
Hand infections
 
Gps suture-workshop
Gps suture-workshopGps suture-workshop
Gps suture-workshop
 

Carpal tunnel

  • 3. Definition • Sign and symptoms secondary to compression of the median nerve in the carpal tunnel
  • 4. History • CTS First described by Sir James Paget 1854 • First CTR performed Sir James Learmonth 1933 • Popularised by Phalen in the 1950s with a series of articles • Introduction of endoscopic release 1985-1987 – Dr Agee, Dr Chow, Dr Okutsu
  • 6. Attachment of the transverse carpal ligament Content of the carpal tunnel Relationship with the Guyon’s tunnel
  • 7. Anatomy - Carpal Tunnel • The bony borders are: radially, the tubercle of the scaphoid and the tubercle of the trapezium; ulnarly the triquetrum, pisiform and hook of the hamate. The lunate lies in the floor of the tunnel. • Nine tendons run through the tunnel: the 4 FDS, the 4 FDP, and FPL. FCR runs in a separate fascial compartment on the radial side of the tunnel. The middle and ring FDS tendons are superficial to the index and little finger FDS tendons. The FDS and FDP tendons all share a common sheath; the tendons appear to be invaginated into the sheath from the radial side. The FPL tendon has its own synovial sheath. • The recurrent motor branch can be extraligamentous; subligamentous; transligamentous. Rarely, it can take origin from the ulnar side of the median nerve, and it can come to lie on top of the transverse carpal ligament.
  • 8. Anatomy - PCB median nerve
  • 9. Sub-ligamentous Extra-ligamentous The recurrent motor branch of the median nerve Trans-ligamentous
  • 10. Microstructure of the median nerve in the carpal tunnel • The nerve is composed of 6-40 fascicles with an average of 24. Epineurial tissue makes up around 42% of the nerve. • Sensory fibres outnumber motor fibres 9:1. The motor nerve fibres are situated anteriorly.
  • 11. Physiology • Excursion of the nerve – with flexion/extension is 7-14mm at the wrist – 5-7mm at the elbow. • Resting pressure in normal patients is 2.5mmHg. – Full flexion or extension increases the pressure to 30mmHg in normal patients – 90-100mmHg in patients with CTS – Contraction of finger and thumb flexors may increase pressure 3-6 times above resting values. • Reduced epineural blood flow is the earliest manifestation of nerve compression – and may occur at a pressure of 20-30mmHg. – Reduced axoplasmic transport occurs at pressures of 30mmHg.
  • 12. Pathophysiology of CTS • Night numbness is caused by a number of factors: • Horizontal position results in a redistribution of fluid to the upper limbs • Drainage by the action of the muscle pump is diminished • There is a tendency towards wrist flexion at night • The blood pressure drops during late night and early morning, resulting in decreased perfusion pressure
  • 13. Epidemiology • Carpal tunnel syndrome is the most common compression neuropathy. • Median age is 51. • Women are affected 4:1 • More common in industrialized societies. • High rate of bilateral compression. • More common in the dominant arm. • 50% associated with Raynaud’s phenomenon.
  • 14. Aetiology • Reduction in the size of the carpal tunnel: – Trauma – Acromegaly – osteoarthritis • Increase in the volume of the contents of the carpal tunnel: – Inflammation: Nonspecific tenosynovitis of the flexor tendons; RA; gout; amyloid. – Swellings: ie. Ganglia; lipoma; tumour. – Endocrine abnormalities: ie. Pregnancy; diabetes; thyroid disease. • Congenital developmental conditions – Persistent median artery – Abnormal muscle bellies - eg. FDS, palmaris profundus – Proximal or hypertrophied lumbricals
  • 15. Symptoms • Nocturnal numbness and paraesthesias almost pathoneumonic – This is because of redistribution of blood from the legs while the patient is recumbent, with dilation of blood vessels in the carpal tunnel. – Shaking the hand gets the blood out of the dilated vessels. • The pain should radiate only to the elbow. • The patient may complain of dropping things.
  • 16. Signs • Numbness doesn’t have to be exactly anatomical but there should be a big difference between the thumb and little finger. – Numbness often affects the middle finger first then the thumb and index. – The palmar sensory branch should be spared so there should be normal sensation over the thenar eminence. • Thenar wasting is a late sign and implies you have missed the boat. • Phalen’s sign may be positive with either volar flexion (Phalen’s volar test) or dorsiflexion (Phalen’s dorsal test). Overall sensitivity of 75%, specificity of 0.47. • Tinel’s sign has a sensitivity of 0.60 and a specificity of 0.67. • Durkan’s direct median nerve compression test is the most sensitive (0.87) and specific (0.90).
  • 19. Nerve Conduction Studies • The main benefit of NCS is to provide objective evidence for the diagnosis. • False negative rate of 8%. (These patients have symptoms and respond to carpal tunnel release but have normal NCS). • EMG evidence of denervation of the thenar muscles provides evidence of the severity of compression. • Discrepancy between clinical findings and NCS – Interestingly, no consensus could be reached regarding the patient with classic/probable symptoms without abnormal NCS findings. This is the group where diagnosis is often debated between hand surgeons and neurologists.
  • 21. DDx 1. Pronator syndrome: – compression by the ligament of Struthers, supracondylar process, bicipital aponeurosis, within pronator teres and under FDS arch. Hand numbness and nocturnal pain and numbness is rare. 1. Anterior interosseous syndrome 2. Brachial neuritis 3. Thoracic outlet syndrome 4. Cervical radiculopathy 5. RSD 6. Raynaud’s phenomenon 7. TIA
  • 22. Treatment: Non-surgical • Only if no sign of motor damage. • Reduce oedema with diuretic or steroid. • Splint to reduce nocturnal flexion – splint in neutral.
  • 23. Steroid Injection • Transient relief occurs in 80% of patients after steroid injection • But only 22% of patients with steroid injections are pain free at 12 months (These patients were also splinted). – It is most useful early in the disease, when there has been less than 1 yr of symptoms – there is no weakness or thenar atrophy – less than 2ms prolongation of distal motor and sensory latencies. • Technique of injection: – a 22-gauge needle is introduced between FCR and PL – angled dorsally and distally at 45 degrees – It is advanced until it reaches the floor of the tunnel, and then withdrawn 5mm – A water soluble preparation is used • e.g. dexamethasone acetate plus lignocaine • if any immediate paraesthesias occur the injection is stopped.
  • 24. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome [Review] Volume (1), 2006, [no page #] The Cochrane Library, Copyright 2006, The Cochrane Collaboration O'Connor, D; Marshall, S; Massy-Westropp, N Date of Most Recent Update: 15-August-2005 Implications for practice: • Moderate evidence shows significant short-term benefit from oral steroids. • Limited evidence shows significant short-term benefit from splinting • yoga and carpal bone mobilization do not produce significant benefit.
  • 25. Surgical Treatment • Open Carpal Tunnel Release – Open technique – Limited incision technique • Endoscopic Carpal Tunnel Release(1985) – Two incision technique Dr James Chow (Southern Illinois) – Distal single incision technique Dr Michael Murphy (John Hopkins Univ, Baltimore) – Proximal single incision technique Dr John Agee (Sacramento, California)
  • 26. Open Carpal Tunnel Release -Surgical Landmarks
  • 27. Open carpal tunnel release -Structures to avoid 1. Palmar cutaneous br of median nerve 2. Superficial palmar arch
  • 29. Postoperative course and results for Open CTR • Grip strength returns to normal in 3 months. • Surgery is most successful when done early; Patients with intermittent numbness do better than patients with constant numbness. • Overall excellent results in 80% (Mayo clinic). 5% have worsened function. • MRI shows a 20-30% increase in the carpal tunnel volume after surgery. MRI also shows that Guyon’s canal enlarges after carpal tunnel release. • Measurement of pressures within the carpal tunnel before and after release demonstrate marked decreases in resting pressures after release of the ligament.
  • 30. Endoscopic Techniques - CTR • Two incisions • Distal one incisions • Proximal one incisions
  • 31. Two incisions technique by James Chow Slotted tube technique Adv: Visualise the distal and proximal margin of TCL Disadv: Two portals. One portal in the palm
  • 32. Single distal portal endoscopic technique Advantage: Visualise the superficial arch and the distal margin of TCL Disadvantage: the incision is in the palm
  • 33. Single distal portal endoscopic technique
  • 34. single proximal portal technique -John Agee from Sacrimento California -The equipmenmt is manufactured by Microaire Pty Ltd.
  • 37. The Cochrane Database of Systematic Reviews Surgical treatment options for carpal tunnel syndrome [Review] Volume (1), 2006, [no page #] Scholten, R; Bouter, LM; Gerritsen, A; Uitdehaag, BM; de Vet, HCW; van Geldere, D Date of Most Recent Update: 17-August-2005 Cochrane Neuromuscular Disease Group. Dr. Rob Scholten, Director, Dutch Cochrane Centre, Academic Medical Center, Room J1B - 108-1, P.O. Box 22700, AMSTERDAM, 1100 DE, NETHERLANDS. Phone: +31 20 566 5602, Fax: +31 20 691 2683, E-mail: cochrane@amc.uva.nl, N Background: Carpal tunnel syndrome is a common disorder, for which several surgical treatment options are available. Objectives: To compare the efficacy of the various surgical techniques in relieving symptoms and promoting return to work and/or activities of daily -Reviewed 23 studies RCT living and to compare the occurrence of side-effects and complications, in patients suffering from carpal tunnel syndrome. -Good methodology Search strategy: We updated the searches in 2003. We conducted computer-aided searches of the trials register of the Cochrane Neuromuscular Disease Group -Pooling of results was not possible (searched in July 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (January 1966 to August 2003), EMBASE (January 1980 to August 2003) and tracked references in bibliographies. because of differing outcome Selection criteria: Randomised controlled trials comparing various surgical measures techniques for the treatment of carpal tunnel syndrome. Data collection and analysis: Two reviewers performed study selection, -alternatives to open CTR does not assessment of methodological quality and data abstraction independently of each other. offer better relief of symptoms Main results: -Result of early return to work with endoscopic mean is conflicting Twenty-three studies were included in the review. The methodological quality of the trials was fair to good. However, the application of allocation concealment was mentioned explicitly in only one trial. Many studies failed to present the results in sufficient detail to enable statistical pooling. Pooling was also impeded by the vast variety of outcome measures that were applied in the various Conclusion: No evidence to studies. None of the existing alternatives to standard open carpal tunnel release seem to support replacement of open CTR offer better relief from symptoms in the short- or long-term. There was conflicting evidence about whether endoscopic carpal tunnel release resulted in earlier return to work and/or activities of daily living than open carpal tunnel release. Conclusions: There is no strong evidence supporting the need for replacement of standard open carpal tunnel release by existing alternative surgical procedures
  • 38. A Systematic Review of Reviews Comparing the Effectiveness of Endoscopic and Open Carpal Tunnel Decompression Achilleas Thoma, M.D., M.Sc., Karen Veltri, M.Sc., Ph.D., Ted Haines, M.D., M.Sc., and Eric Duku, M.Sc. Hamilton, Ontario, Canada (Plast. Reconstr. Surg. 113: 1184, 2004.) Controversy persists regarding the benefit of endoscopic carpal tunnel release compared with open carpal tunnel release for pain, numbness, strength, return to work and function, scar tenderness, and complications. For surgeons, a recommended first source of information Controversy between the two techniques on treatment effectiveness is a review of high-methodologic- quality articles. This review of reviews was undertaken to answer this clinical question regarding these outcomes. Reviewed articles from 1989-2002 Cochrane, MEDLINE, EMBASE, CINAHL, and Health- STAR databases were searched using the key words “endoscopic 48 articles on the topic carpal tunnel,” with limits “review or overview” and dates from 1989 to present. Five key journals were hand-searched. Any review with a reference to at least one 7 articles are pertinent to the question randomized controlled trial that compared endoscopic carpal tunnel release to open carpal tunnel release was to 3 of high quality methodology be included. Two reviewers independently scanned titles and abstracts for potential relevance. Selection as relevant was confirmed through a review of full texts. Disagreements -both techniques relief symptoms were resolved through discussion and consensus. The selected reviews were assessed for methodologic quality -conflicting result regarding return to work on the basis of the scale of Hoving et al. Of 48 articles initially identified, seven pertinent reviews were selected. Of these seven, three reviews of high methodologic quality and function concurred that there is no difference between the two techniques in symptom relief and that the evidence is -no difference in the risk of median n. injury conflicting for return to work and function. The risk of permanent median nerve injury does not differ between the techniques. The reviews indicated that the endoscopic -endoscopic has worse reversible nerve carpal tunnel release technique is worse in terms of reversible nerve injury but superior in terms of grip strength injury and scar tenderness, at least in short-term follow-up. Several trials have not been incorporated in these reviews and -Endoscopic has superior grip strength and statistical pooling has not been conducted. Further systematic review with meta-analysis may permit more definitive conclusions about the relative effectiveness of these and less scar tenderness two techniques, particularly with regard to return to work and function.
  • 39. Point for discussion • ECTR & OCTR ONLY relieve the mechanical component of the pathology • i.e. that they do not address the biochemical, pathophysiology, endocrine or hormonal aspects of the disease • i.e. we can perform a brilliant CTR but if the nerve has more than a mechanical problem then the pt will not get a full relief.
  • 40. Point for discussion • When Durkan’s, Phalen’s & Tinel’s tests are all negative, that the nerve is "no longer able to be irritated" • ie that it has undergone some pathological change, such as intra-neural fibrosis or other, that prevents a positive response.
  • 41. Complications • Early – Transection of the median nerve or the superficial arch – Haematoma – Pain, swelling and stiffness – Recurrent Branch injury – Infection • Late – RSD – Hypertrophic scar – Median nerve neuritis – Palmar fasciitis – Fibrosis of carpal tunnel – Recurrence • Revision carpal tunnel release – Only 25% of patients have complete relief of symptoms. 25% have no relief. The rest have partial relief.