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Carpal tunnel syndrome.pptx

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Carpal tunnel syndrome.pptx

  1. 1. Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.
  2. 2. Learning Objectives
  3. 3. Learning Objectives 1. Introduction & History 2. Relevant Anatomy, Physiology 3. Aetiology 4. Pathophysiology 5. Pathology 6. Classification 7. Clinical Features 8. Investigations 9. Management 10. Prevention 11. Guidelines 12. Take home messages
  4. 4. Introduction & History. •
  5. 5. Introduction & History. • Carpal tunnel syndrome (CTS) is a collection of characteristic symptoms and signs that occurs following compression of the median nerve within the carpal tunnel. • Until the advent of electrophysiologic testing in the 1940s, carpal tunnel syndrome (CTS) commonly was thought to be the result of compression of the brachial plexus by cervical ribs and other structures in the anterior neck region (so-called thoracic outlet syndrome).
  6. 6. Relevant Anatomy •
  7. 7. Anatomy • The carpal tunnel is an osteofibrous canal situated in the volar wrist. • The boundaries are the carpal bones and the flexor retinaculum. • Structures passing – Median nerve, – Nine tendons: the flexor pollicis longus, the four flexor digitorum superficialis and the four flexor digitorum profundus • Ulnar N. passes superficial to flexor retinaculum
  8. 8. Anatomy • The median nerve innervates the skin of the palmar (volar) side of the index finger, thumb, middle finger, and half the ring finger, and the nail bed. • The radial aspect of he palm is supplied by the palmar cutaneous branch of the median nerve, which leaves the nerve proximal to the wrist creases.
  9. 9. Anatomy: Motor Supply
  10. 10. Anatomy: Motor Supply LOAF muscles • L - First and second lumbricals • O - Opponens pollicis • A - Abductor pollicis brevis • F - Flexor pollicis brevis
  11. 11. • palmar the index finger, thumb, middle finger, and half the ring finger, and the nail bed. The radial aspect of the palm
  12. 12. Relevant Physiology •
  13. 13. Aetiology • Idiopathic • Congenital/ Genetic • Nutritional Deficiency/excess • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative / lifestyle • Iatrogenic • Psychosomatic • Poisoning/ Toxins/ Drug induced
  14. 14. Aetiology • Idiopathic • Congenital/Genetic • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative • Iatrogenic
  15. 15. Aetiology of Aetiology •
  16. 16. Aetiology of Aetiology • Idiopathic • Congenital/ Genetic • Nutritional Deficiency/excess • Traumatic • Infections /Infestation • Autoimmune • Neoplastic (Benign/Malignant) • Degenerative / lifestyle • Iatrogenic • Psychosomatic • Poisoning/ Toxins/ Drug induced
  17. 17. Pathophysiology
  18. 18. Pathophysiology • median nerve is damaged within the rigid confines of the carpal tunnel, • initially undergoing demyelination • followed by axonal degeneration. • Sensory fibers often are affected first • followed by motor fibers. • Autonomic nerve fibers carried in the median nerve also may be affected.
  19. 19. Pathophysiology • abnormally high carpal tunnel pressures exist in patients with CTS. This pressure causes obstruction to venous outflow, back pressure, edema formation, and ultimately, ischemia in the nerve.
  20. 20. Classification
  21. 21. Classification • Mild -numbness and tingling in the distribution of the median nerve without motor or sensory losses. The patient's sleep does not suffer disruption, and there are no changes to the activities of daily living. • Moderate - symptoms of mild carpal tunnel syndrome with sensory loss in the median nerve distribution and sleep becomes disrupted; there can also be some changes to hand function.
  22. 22. Classification • Severe carpal tunnel syndrome includes symptoms of mild and moderate carpal tunnel syndrome weakness in the median nerve distribution and changes to the activities of daily living.
  23. 23. Clinical Features •
  24. 24. Clinical Features • Demography • Symptoms • Signs • Prognosis • Complications
  25. 25. Demography
  26. 26. Demography • Incidence & Prevalence • Geographical distribution. • Race • Age • Sex • Socioeconomic status • Temporal behaviour
  27. 27. Demography • In US 1-3 cases per 1000 subjects per year; prevalence is approximately 50 cases per 1000. • CTS is almost unheard of in some developing countries (e.g., among non-white South Africans • Whites are probably at highest risk. • The female-to-male ratio for carpal tunnel syndrome is 3-10:1. • The peak age range for development of carpal tunnel syndrome (CTS) is 45-60 years. Only 10% of patients with CTS are younger than 31 years.
  28. 28. Demography • Increasing age • Female sex • Increased body mass index (BMI), especially a recent increase • Square-shaped wrist • Short stature • Dominant hand • Race (white)
  29. 29. Demography • Incidence & Prevalence-
  30. 30. Demography • Geographical distribution.
  31. 31. Demography • Race.
  32. 32. Demography • Age
  33. 33. Demography • Sex
  34. 34. Demography • Socioeconomic status
  35. 35. Demography • Temporal behaviour
  36. 36. Symptoms
  37. 37. Symptoms • Usual symptoms include numbness, paresthesias, and pain in the median nerve distribution. • hands fall asleep or that things slip from their fingers without their noticing (loss of grip, dropping things) • numbness and tingling • Symptoms are usually intermittent and are associated with certain activities (eg, driving, reading the newspaper, crocheting, painting)
  38. 38. Symptoms • Night-time symptoms that wake the individual are more specific to CTS, especially if the patient relieves symptoms by shaking the hand/wrist • Bilateral CTS is common, although the dominant hand is usually affected first and more severely than the other hand. • Complaints should be localized to the palmar aspect of the first to the fourth fingers and the distal palm (ie, the sensory distribution of the median nerve at the wrist).
  39. 39. Symptoms • Numbness existing predominantly in the fifth finger or extending to the thenar eminence or dorsum of the hand should suggest other diagnoses. • A surprising number of CTS patients are unable to localize their symptoms further (eg, whole hand/arm feeling dead). This generalized numbness may indicate autonomic fiber involvement and does not exclude CTS from the diagnosis.
  40. 40. Symptoms Pain • Aching sensation over the ventral aspect of the wrist. This pain can radiate distally to the palm and fingers or, more commonly, extend proximally along the ventral forearm. • Pain in the epicondylar region of the elbow, upper arm, shoulder, or neck is more likely to be due to other musculoskeletal diagnoses (eg, epicondylitis) with which CTS commonly is associated. This more proximal pain also should prompt a careful search for other neurologic diagnoses (eg, cervical radiculopathy)
  41. 41. Symptoms Autonomic symptoms • tight or swollen feeling in the hands and/or temperature changes (eg, hands being cold/hot all the time). • sensitivity to changes in temperature (particularly cold) and a difference in skin color. In rare cases, there are complaints of changes in sweating. In all likelihood, these symptoms are due to autonomic nerve fiber involvement (the median nerve carries most of the autonomic fibers to the hand).
  42. 42. Weakness/clumsiness • Loss of power in the hand (particularly for precision grips involving the thumb) does occur; in practice, however, loss of sensory feedback and pain is often a more important cause of weakness and clumsiness than is loss of motor power per se.
  43. 43. Signs
  44. 44. Signs • These symptoms may or may not be accompanied by objective changes in sensation and strength of median-innervated structures in the hand. • Clinical examination is important to rule out other neurologic and musculoskeletal diagnoses; however, the examination often contributes little to the confirmation of the diagnosis
  45. 45. Physical Examination
  46. 46. Physical Examination • Sensory examination is most useful in confirming that areas outside the distal median nerve territory are normal (eg, thenar eminence, hypothenar eminence, dorsum of first web space). – Semmes-Weinstein monofilament testing or 2- point discrimination • Motor examination - Wasting and weakness of the median-innervated hand muscles (LOAF muscles) may be detectable.
  47. 47. Physical Examination • Hoffmann-Tinel sign – Gentle tapping over the median nerve in the carpal tunnel region elicits tingling in the nerve's distribution. • Phalen sign – Tingling in the median nerve distribution is induced by full flexion (or full extension for reverse Phalen) of the wrists for up to 60 seconds
  48. 48. Physical Examination • The carpal compression test – This test involves applying firm pressure directly over the carpal tunnel, usually with the thumbs, for up to 30 seconds to reproduce symptoms. • Palpatory diagnosis – This test involves examining the soft tissues directly overlying the median nerve at the wrist for mechanical restriction.
  49. 49. Physical Examination • A flick sign occurs when a patient is awoken from sleep with symptoms of carpal tunnel syndrome and need to flick their hands to relieve the symptoms • Hand elevation tests can be completed with the patient lifting their hand above their heads for one minute, recreating symptoms of carpal tunnel syndrome.
  50. 50. • severe thenar muscle (abductor pollicis brevis, opponens pollicis) wasting of the right hand, .
  51. 51. Personal History
  52. 52. Personal History • Lack of aerobic exercise • Pregnancy and breastfeeding • Use of wheelchairs and/or walking aids
  53. 53. Genetics
  54. 54. Genetics • A strong family susceptibility exists and is probably related to multiple inherited characteristics (e.g., square wrist, thickened transverse ligament, stature). • A number of inherited medical conditions also are associated with CTS (e.g., diabetes, thyroid disease, hereditary neuropathy with liability to pressure palsies).
  55. 55. Medical Conditions
  56. 56. Medical Conditions • Wrist fracture (Colles) • Acute, severe flexion/extension injury of wrist • Space-occupying lesions within the carpal tunnel (e.g., flexor tenosynovitis, ganglions, hemorrhage, aneurysms, anomalous muscles, various tumors, edema)
  57. 57. Medical Conditions • Diabetes mellitus. • Thyroid disorders (usually myxedema) • Rheumatoid arthritis and other inflammatory arthritides of the wrist • Recent menopause (including post- oophorectomy) [20] • Renal dialysis • Acromegaly • Amyloidosis
  58. 58. Signs
  59. 59. Signs • General Examination • Systemic Examination • Local Examination
  60. 60. Signs • General Examination
  61. 61. Signs • Systemic Examination
  62. 62. Signs • Local Examination
  63. 63. Prognosis
  64. 64. Prognosis • Morbidity • Mortality rate • 5 year survival in Malignancy
  65. 65. Investigations
  66. 66. Investigations • Laboratory Studies – Routine – Special • Imaging Studies • Tissue diagnosis – Cytology • FNAC – Histology – Germ line Testing and Molecular Analysis • Diagnostic Laparotomy.
  67. 67. Investigations • Laboratory Studies – Routine – Special • Imaging Studies • Tissue diagnosis – Cytology • FNAC – Histology
  68. 68. Investigations in Malignancy •
  69. 69. Investigations in Malignancy • For diagnosis • For staging • For Screening • For Monitoring
  70. 70. Diagnostic Studies
  71. 71. Diagnostic Studies Imaging Studies • X-Ray • USG • CT • Angiography • MRI • Endoscopy • Nuclear scan
  72. 72. Diagnostic Studies • Electrophysiologic studies. • Imaging Studies.
  73. 73. Diagnostic Studies • Electrophysiologic studies, • Electromyography (EMG) • Nerve conductions studies (NCS), are the first-line investigations
  74. 74. Diagnostic Studies Ultrasonography • Ultrasonography as an adjunct to electrodiagnostic studies. • Potentially can identify space-occupying lesions in and around the median nerve • confirm abnormalities in the median nerve (eg, increased cross-sectional area) that can be diagnostic of CTS, and help to guide steroid injections into the carpal tunnel.
  75. 75. Diagnostic Studies MRI • Magnetic resonance imaging (MRI) of the carpal tunnel is particularly useful preoperatively if a space-occupying lesion in the carpal tunnel is suggested.
  76. 76. Electrophysiologic studies,
  77. 77. Electrophysiologic studies, • Abnormalities on electrophysiologic testing, in association with specific symptoms and signs, are considered the criterion standard for diagnosis. • Other neurologic diagnoses can be excluded with these test results.
  78. 78. Electrophysiologic studies • Electrophysiologic testing also can provide an accurate assessment of how severe the damage to the nerve is, thereby directing management and providing objective criteria for the determination of prognosis.
  79. 79. Differential Diagnosis
  80. 80. Differential Diagnosis • Pronator syndrome, or pronator teres syndrome, occurs when the pronator teres compresses the median nerve. • Looks remarkably similar to carpal tunnel syndrome. • In pronator syndrome, patients often complain of discomfort in their forearm with activity. • An extended elbow and repetitive pronation can often reproduce the symptoms of pronator syndrome, numbness and tingling of the thumb, and first two digits.
  81. 81. Pronator syndrome
  82. 82. Pronator syndrome • Occurs typically in cyclists • Loss of sensation over the thenar eminence. distinguishes pronator syndrome from carpal tunnel syndrome. • The Phalen maneuver and the Tinel sign are also often negative in pronator syndrome
  83. 83. Differential Diagnosis • Acute Compartment Syndrome • Cervical Disc Disease • Cervical Myofascial Pain • Cervical Spondylosis • Diabetic Neuropathy • Ischemic Monomelic Neuropathy • Leprosy • Lyme Disease • Mononeuritis Multiplex • Multiple Sclerosis • Neoplastic Brachial Plexopathy • Overuse Injury • Physical Medicine and Rehabilitation for Epicondylitis • • Lateral Epicondylitis • Myofascial Pain • Posttraumatic Syringomyelia • Radiation-Induced Brachial Plexopathy • Reflex Sympathetic Dystrophy ( • Thoracic Outlet Syndrome • Traumatic Brachial Plexopathy
  84. 84. Management
  85. 85. Management • Given that CTS is associated with low aerobic fitness and increased body mass index (BMI) aerobic fitness and weight-loss program. • Stationary biking, cycling, or any other exercise that puts strain on the wrists probably should be avoided.
  86. 86. Non Operative Therapy
  87. 87. Non Operative Therapy • therapeutic ultrasound • splinting the wrist at night-time for a minimum of 3 weeks. • Steroid injection into the carpal tunnel US guided. • local progesterone injection • (NSAIDs) and/or diuretics • The anticonvulsants gabapentin and pregabalin
  88. 88. Minimally invasive Therapy
  89. 89. Minimally invasive Therapy • Endoscopic carpal tunnel release (ECTR)
  90. 90. Operative Therapy
  91. 91. Operative Therapy • Patients whose condition does not improve following conservative treatment and patients who initially are in the severe CTS category should be considered for surgery. • Carpal tunnel release (CTR) Surgical release of the transverse ligament
  92. 92. Prevention
  93. 93. Prevention • Screening • Risk reduction
  94. 94. Prevention • Minimize repetitive hand movements. • Alternate between activities or tasks to reduce the strain on your hands and wrists. • Keep wrists straight or in a neutral position. • Avoid holding an object the same way for long. • If you work in an office, adjust your desk, chair, and keyboard so that your forearms are level with your work surface. • Wear a splint at night to keep your wrist straight while sleeping.
  95. 95. Mythbusters Myths Facts
  96. 96. Guidelines
  97. 97. Get this ppt in mobile 1. Download Microsoft PowerPoint from play store. 2. Open Google assistant 3. Open Google lens. 4. Scan qr code from next slide.
  98. 98. Get this ppt in mobile
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