Carpal%20Tunnel%20Syndrome

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Carpal Tunnel Syndrome

• Presented
• By
• NathaëlF Hyppolite RIII MF

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Objectives

• How to evaluate the patient clinically
• How to treat the patient effectively
• When to treat surgically

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Plan

• Definition
• Epidemiology
• Etiology
• Clinical Features
• Physical examination
• Diagnostic
• Differential Diagnostics
• Treatment

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Definition

• Carpal tunnel syndrome, the most common focal
  peripheral neuropathy, results from compression
  of the median nerve at the wrist.

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epidemiology

• Affects an estimated 3 percent of adult Americans
• Three times more common in women than in men
• High prevalence rates have been reported in
  persons who perform certain repetitive wrist
  motions (frequent computer users)
• 30? hand paresthesias
• 10? clinical criteria for carpal tunnel
  syndrome
• 3.5? abnormal nerve conduction studies

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Clinical Features

• Pain
• Numbness
• Tingling
• Symptoms are usually worse at night and can
  awaken patients from sleep.
• To relieve the symptoms, patients often flick
  their wrist as if shaking down a thermometer
  (flick sign).

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Clinical Features

• Pain and paresthesias may radiate to the forearm,
  elbow, and shoulder.
• Decreased grip strength may result in loss of
  dexterity, and thenar muscle atrophy may develop
  if the syndrome is severe.

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Atrophy
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Physical examination

• Phalens maneuver
• Tinels sign
• weak thumb abduction.
• two-point discrimination

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Phalens maneuver
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Tinels sign
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Diagnostic

• History
• Physical examination
• Nerve Conduction Study

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Differential Diagnostics

• Tendonitis
• Tenosynovitis
• Diabetic neuropathy
• Kienbock's disease
• Compression of the Median nerve at the elbow

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Treatment

• CONSERVATIVE TREATMENTS
• GENERAL MEASURES
• WRIST SPLINTS
• ORAL MEDICATIONS
• LOCAL INJECTION
• ULTRASOUND THERAPY
• Predicting the Outcome of Conservative Treatment
• SURGERY

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GENERAL MEASURES

• Avoid repetitive wrist and hand motions that may
  exacerbate symptoms or make symptom relief
  difficult to achieve.
• Not use vibratory tools
• Ergonomic measures to relieve symptoms depending
  on the motion that needs to be minimized

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WRIST SPLINTS

• Probably most effective when it is applied within
  three months of the onset of symptoms
• Optimal splinting regimen ?

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WRIST SPLINTS
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ORAL MEDICATIONS

• Diuretics
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• pyridoxine (vitamin B6)
• Orally administered corticosteroids
• Prednisolone
• 20 mg per day for two weeks
• followed by 10 mg per day for two weeks

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LOCAL INJECTION

• A mixture of 10 to 20 mg of lidocaine (Xylocaine)
  without epinephrine and 20 to 40 mg of
  methylprednisolone acetate (Depo-Medrol) or
  similar corticosteroid preparation is injected
  with a 25-gauge needle at the distal wrist crease
  (or 1 cm proximal to it).

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LOCAL INJECTION
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LOCAL INJECTION
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LOCAL INJECTION

• 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

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ULTRASOUND THERAPY

• May be beneficial in the
• long term management
• More studies are needed
• to confirm its usefulness

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SURGERY

• Should be considered in patients with symptoms
  that do not respond to conservative measures and
  in patients with severe nerve entrapment as
  evidenced by nerve conduction studies,thenar
  atrophy, or motor weakness.
• It is important to note that surgery may be
  effective even if a patient has normal nerve
  conduction studies

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SURGERY

• Complications of surgery
• Injury to the palmar cutaneous or recurrent motor
  branch of the median nerve
• Hypertrophic scarring
• laceration of the superficial palmar arch
• tendon adhesion
• Postoperative infection
• Hematoma
• arterial injury
• stiffness

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SURGERY
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PREGNANCY

• Alterations in fluid balance may predispose some
  pregnant women to develop carpal tunnel syndrome.
  
• Symptoms are typically bilateral and first noted
  during the third trimester.
• Conservative measures are appropriate, because
  symptoms resolve after delivery in most women
  with pregnancy-related carpal tunnel syndrome.

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Conclusion

• Most common focal peripheral neuropathy
• Pain and paresthesias in the distribution of the
  median nerve are the classic symptoms.
• While Tinels sign and a positive Phalens
  maneuver are classic clinical signs of the
  syndrome, hypalgesia and weak thumb abduction are
  more predictive of abnormal nerve conduction
  studies.

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Conclusion

• Conservative treatment options include splinting
  the wrist in a neutral position and ultrasound
  therapy
• Orally administered corticosteroids can be
  effective for short-term management (two to four
  weeks), but local corticosteroid injections may
  improve symptoms for a longer period.
• If symptoms are refractory to conservative
  measures or if nerve conduction studies show
  severe entrapment, open or endoscopic carpal
  tunnel release may be necessary.

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bibliography

• American family physician july 15 2003
• www.aafp.org/afp
• Essantials of musculoskeletal care
• C.Cabrol anatmie tome 1