CARPAL TUNNEL

SYNDROME(CTS)

INTRODUCTION
MUHAMMAD HAIKAL BIN MOHD
HARIS
012011100096

WHAT IS CARPAL TUNNEL

SYNDROME?
1. Carpal tunnel syndrome is a set of symptoms caused
by compression of the median nerve in the carpal
tunnel.
The symptoms :
I. Pain
II. Numbness
III. Weakness
IV. Pins and needles sensation

CARPAL TUNNEL
I. A narrow passageway on the palmar side of the wrist
made of bones and ligaments

CONTENT OF CARPAL TUNNEL

I. 9 flexor tendon
.Flexor pollicis longus (FPL)
.Flexor digitorum profundus (FDP)
.Flexor digitorum superficialis (FDS)

FP
L

FD
P

FDS

Cont..
II. 1 median nerve

PALMAR CUTANEOUS BRANCH

OF MEDIAN NERVE
I. The palmar cutaneous branch of median nerve arises
from the radiopalmar part of the nerve 5cm proximal
to volar wrist crease

Palmar
cutaneous
branch of
median nerve

Supply
thenar
eminen
ce

Branches of median nerve

Recurrent motor branch of median

nerve innervates:
1. Abductor pollicis brevis
2. Flexor pollicis brevis
3. Opponens pollicis muscles

PATHOPHYSIOLOGY
AND ETIOLOGY OF
CARPAL TUNNEL
SYNDROME
Vaishini A/P Thanabalam

PATHOPHYSIOLOGY
Compressive syndrome combines the
phenomenon of compression and tension.
Pressure from swelling in tunnel and
compress on median nerve.
Nerve compression & traction create
problem relating to intraneural blood
microcirculation, lesion at myelin shealth,
at axonal level & changes to the supporting
connective tissue.

Tendons are
wrapped by
synovium fluid for
lubrication

With repetitive
movement, the
lubrication system
may malfunction

Causing
inflammation and
swelling
surrounding the
tendon (synovium
sheath)

High pressure in
carpal tunnel

This pressure
cause obstruction
to venous outflow,
back pressure,
edema formation

Ischemia in the
nerve

Idiopat Second
ary
hic
Etiolo
gy
Exposure to
Dynami
vibration
(rare)
c

IDIOPATHIC

Female (65 80 %)
Age (between 40 and 60 years)-50-60% bilateral
Hereditary
Smoking
Obesity

SECONDARY
Abnormalities in
container

Abnormalities in content

Shape / position of carpal

bone:
Dislocation or subluxation of
carpal

Tenosynovial hypertrophy

Shape of the distal

extremities of radius:
Fracture (translation >35%)

Inflammatory tenosynovitis,
inflammatory rheumatism, lupus
and infection

Joint:
Wrist arthrisis, inflammatory
arthritis, infectious arthritis,
rhizharthrosis

Metabolic tenosynovitis:
Diabetes mellitus, primary or
secondary amyloidosis, gout

Acromegaly

Abnormalities of fluid
distribution: Pregnancy (3rd
trimester), hypothyroidism, chronic
kidney disease (arteriovenous
fistula)

DYNAMIC
Occupational pathological condition.
Repetitive extension & flexion of wrist, along with
flexion of finger and supination of forearm

REFERENCE
Elsevier Orthopedia

History Taking
Law Koon Lum
012011100188

To ask:
Main complaints: (Lateral palmar aspect mainly Median n.)
1. Pain
Night Awakening ( Burning hands wake you up )
Relieved by shaking hands of
Only hand (CTS)
With ( Proximal ) upper arm, shoulder, neck
MSK ddx (Epicondylitis/ tennis elbow & Cervical radiculopathy, C6 & C7)

2. Numbness / Paraesthesia and tingling

Swelling and tightness at wrist

3. Weakness
Gripping fails ( spending money without noticing it )
Precision loss
Money on the floor also dont want to take. ( more flexion and
compression over wrist)

4. Autonomic
Hand feel hot / cold all the time
Sweating

Risk factor
1. Bilateral : ( Medical disease )
mneumonics MEDIAN TRAP
Commonly dominant hand afected first
40 to 50 years menopausal women
Women > Men

2. Unilateral / Bilateral : ( Mechanical )

Using walking stick, Wheelchair Driving
Improper way / height

Wrist fracture ( Colles #)

In Cotton-Loder position immobilisation
Palmer flexion and Ulnar deviation

Cyclist (handlebar pressure)

Lunate dislocation (football player fall down)
Keyboard warriors (long hours)

 Reference:
1. Apley And Solomons Concise System Of Orthopaedics
And Trauma, Fourth Edition
2. http://emedicine.medscape.com/article/327330-clinical

Physical Examination
Maisaratul Firzanah bt Khidzir

Sensory Examination
sensory deficits usually occur late
Involve median innervated area,
but spare the thenar eminence

Motor Examination
Atrophy and weakness of
thenar muscle
weakness of thumb abduction
and thumb opposition

Provocative Maneuvers
Phalens Test

Sensitivity 68%
Specificity 73%

Pain,
Paraesthesia

30-60 secs

 Tinnels Test

Sensitivity 50%
Specificity 77%

Pain/Paraesthe
sia

 Manual Carpal Compression aka Durkan Test

Apply pressure on transverse carpal
ligament

Sensitivity 64%
Specificity 83%

Paraesthe
sia

30
secs

Pain,
paraesthesi
a

Hand Elevation Test

1 min

Sensitivity 75%
Specificity 98%

References:
Apley's System of Orthopaedics and Fractures, Ninth
Edition
Up to date
http://elibrary.ptpl.edu.my:2062/contents/carpal-tunnelsyndrome-clinical-manifestations-and-diagnosis?
source=search_result&search=carpal+tunnel+syndrom
e&selectedTitle=2~132

Investigations
WONG KAI TIN
021011100101

1. Blood test
.Diabetes
.Rhemathoid arthritis
.hypothyroidism

2.X-ray
Usually only to aid in the diagnosis of fractures and
other disorder such as rheumatoid arthritis

3.Ultrasound scan
---fully developed cases, a triad of:
palmar bowing of the flexor retinaculum (>2 mm
beyond a line connecting the pisiform and the scaphoid)
distal flattening of the nerve
enlargement of the nerve proximal to the flexor
retinaculum

This is measurement of median nerve

20mmsq in cross section. (Normal range:911mmsq)

4.Nerve conduction study

A nerve conduction study is a test that measures how
fast signals are transmitted through your nerves.
During the test, electrodes are placed on your hand and
wrist and a small electrical current is used to stimulate
the nerves in the finger, wrist and, sometimes, elbow.
The results from the test indicate how much damage
there is to your nerves.

5. Electromyography
Provides useful information about how well are the
muscles are able to respond when a nerve is stimulated,
indicating any nerve damage.
During thetest,fine needles are inserted into your
muscles. The needles detect any natural electrical
activity given of by your muscles.

References
http://www.nhs.uk/Conditions/Carpal-tunnel-syndrome/P
ages/Diagnosis.aspx
http://radiopaedia.org/articles/carpal-tunnel-syndrome-1

TREATMENTS & PROGNOSIS OF

CARPAL TUNNEL SYNDROME
SITI NURLIANA BINTI ZULKEFLI

TREATMENTS
MILD

MODERATE-SEVERE

NON SURGICAL
1. Wrist splint/ braces
2. NSAIDS diuretics
3. Glucocorticoid injection :
a. Triamcinolone Acetonide 10-20mg
b. Methylprednisolone Acetate 10-20mg
4. Oral glucocorticoid : prednisone 20 mg daily for 10 to 14 days
5. Modify hand activities
%FAILURE
Long duration of symptoms (>10
months)
Age greater than 50 years
Constant paresthesia
Impaired two-point discrimination
(>6 mm)
Positive Phalen sign <30 seconds
Prolonged motor and sensory
latencies demonstrated by
electrodiagnostic testing

TREATMENTS
MILD

MODERATE-SEVERE

SURGICAL
1. open carpal tunnel release
2. endoscopic carpal tunnel release

Less pain & fast recovery

Need experience surgeon

POST-OP CARE
the wrist is splinted in neutral or slight extension; this avoids anterior
displacement of median nerve
Early motion (within
hypersensitivity

days

after

surgery)

may

promote

prolonged

keeping the wrist in a night splint may prevent the median nerve from
adhering to the anterior scar
encourage digit motion to prevent adhesions, but do not allow simultaneous
wrist and finger flexion

COMPLICATIONS POST- OP
1. Nerve laceration : Injuries palmar cutaneous or recurrent motor branch of
median nerve
2. Arterial injury
3. Tendon laceration
4. Tendon adhesion
5. Hypertrophic scarring
6. Postoperative infection
7. Hematoma
8. Stifness of joint
9. Incomplete release (endoscopic carpal tunnel release)

PROGNOSIS
Progressive over time permanent median nerve damage
Can recurs
Patients with CTS secondary to underlying pathology (eg:
diabetes, wrist fracture) tend to have a less favorable prognosis
than do those with no apparent underlying cause

REFERENCES
Uptodate.com
Emedicine
Wheeless' Textbook of Orthopaedics

TRIGGER FINGER
(STENOSING TENOSYNOVITIS)
LAVANNYA A/P RANGAS PARAN
012011100129

INTRODUCTION
is a painful condition caused by the inflammation
(tenosynovitis) and progressive restriction of the
superficial and deep flexors fibrous tendon sheath
adjacent to the A1 pulley at a metacarpal head.
usually involve the ring or middle finger,
sometimes of the thumb.
The flexor tendon causes painful popping or
snapping as the patient flexes and extend the digit.

Digital fibrous sheath

A strong fibrous sheath which covers the anterior
surface of the fingers and attached to the sides of
the phalanges
The sheath with the anterior surfaces of the
phalanges and interphalangeal joints form an
osteofibrous blind tunnel
For the long flexor tendons of the fingers

Synovial fluid
Secreted by synovial sheath
Act as lubricant
Reduces friction when tendons move under flexor
retinaculum

PULLEY SYSTEM
BAVANI KANNAIAH
012011100196

 There are two pulley system in the fingers :

a) Annular pulley (A)
b) Cruciate pulley ( C)
) Function is to keep tendon from excursion during
flexion of fingers.

 Pulley system of the thumb

a) Two annular pulley
b) One oblique pulley

 Oblique pulley
originates at proximal half of proximal phalanx
most important pulley in thumb
facilitates full excursion of flexor pollicis longus
prevents bowstringing of flexor pollicis longus

Annular pulleys
A1 pulley

at the level of the volar plate at the MCP

joint
6mm in length
A2 pulley

contributes least to arc of motion of

thumb

PATHOPHYSIO
LOGY
DALVINDER SINGH
012011100186

Normally, the tendons of the finger

flexors glide back and forth under a
restraining pulley
Thickening of the flexor tendon
sheath restricts the normal gliding
mechanism.
Result from enlargement of the
tendon itself or narrowing of the first
(A1) pulley.
no longer able to glide freely and may
swell forming a nodular thickening at
the point where it tries to pass into
the tunnel.
During forceful bending of the finger
or thumb, the enlarged portion of the
tendon is dragged
through the constricted opening.

Causing painful snap as the

swollen part of the tendon
passes back through the
sheath.
Straightening the finger or
thumb may require using the
other hand to pull the finger
out straight

The finger or thumb may

become locked in a bent
position.
This motion is often
accompanied by a painful
click.

CAUSES
Usually repetitive injury to the tendon or the fibrous sheath .
There are factors that put people at greater risk for
developing it :
1. More common in women than men.
2. People who are between the ages of 40 and 60 years of age.
3. More common in people with certain medical problems, such
as diabetes and rheumatoid arthritis. Other conditions like,
gout, carpal turner syndrome, Dupuytrens contracture.
4. May occur after repetitive activities that strain the hand like
using the keyboard or using the hp to key in words.

Presentation &
Classification...

Presentation
Symptoms
1. Stifness of the digits in the morning
2. Pain at distal palm near A1 pulley
(MCPJ)
3. Swelling and redness
4. Finger clicking
5. Finger becoming catching/locking in
flexed position
Physical
exam
1. Tenderness to palpation over A1
pulley
2. Palpable bump

GREEN CLASSIFICATION
H/o catching + tenderness at A-1
Grade I
pulley
Catching but can actively extent
Grade II
the digits
Locked and need to passively
Grade III
extent the digits
Grade IV Locked flexion contracture

INVESTIGATION
AND
CONSERVATIVE MANAGEMENT
PAVEETRAN BATHMANATHAN
012011100174

INVESTIGATION
Trigger finger is CLINICAL DIAGNOSIS
On examination :
- Nodule in tendon
- Audible click

Radiography are rarely indicated in trigger

finger

 Hand radiographs are performed only if abnormal

pathology are suspected :
- abnormal sesamoids
- loose bodies in the metacarpophalangeal joint
- osteoarthritic spurs on the metacarpal head
- avulsion injuries of collateral ligaments

Helpful to exclude :
-

osteoarthritis
fracture malunion
foreign body
large sesamoid bone that is affecting interphalangeal (IP)
joint motion.

MANAGEMENT
Principle of management
- Reduce swelling
- Reduce pain
- Allow smooth gliding of the tendon
thus allowing normal extension of
the fingers (MCPJ)

Types of management
- Conservative (non surgical)
- Surgical

Conservative management
Resting
Splinting
Activity modification
Physiotherapy
-maintain movement of the joints

-starting with gentle movement

Soaking in warm water

-5

to 10 minutes in the morning

-can help reduce severity of catching sensation
throughout the day

NSAIDS
-reduce swelling and inflammation

Local steroid injection

Commonly used: Prednisolone,
dexamethasone and triamcinolone
Symptoms does not resolved
immediately
After 6 weeks if there is no
improvement, 2nd injection can
be given
Symptoms persist after 2nd
injection considered as failure of
treatment thus surgical
intervention are needed

Operative Treatment &

Prognosis of Trigger Finger
Syahirah bt. Azizi
012011100132

Operative treatment
Indications :a) Fail conservative management
b) Multiple digit involvement
c) Infantile trigger finger
d) Irreducibly locked trigger finger

Percutaneous release of A1
pulley
Pulleys

Tendons
of FDP
and FDS
Synovial tendon sheath

Post-Operative Care
a) Encourage active movement on the day of
surgery.
b) Anti-inflammatory drugs and elevation are
advised for a period of 2-3 days following surgery.
c) Sutures are removed on day 10 to 14 , following
the procedure.
d) As pain tolerable, start with slow and gentle
movement and increase the intensity of the
movement gradually until patient can do normal
activities.

Prognosis
Very good prognosis.
Most patients respond to corticosteroid
injection with or without associated
splinting.
Patients who need surgical release
generally have a very good outcome.
Poor prognosis usually associated with
other medical condition.

References
Apleys
System of Orthopaedics and Fractures 9th
Edition by Solomon Warwick Nayagam
http://emedicine.medscape.com/article/1
244693-treatment
http://orthoinfo.aaos.org/topic.cfm?topic
=a00024

THANK YOU