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Carpal Tunnel Syndrome PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Carpal Tunnel Syndrome” by Wren V. McCallister, MD.

This medical PowerPoint presentation is about Carpal Tunnel Syndrome (CTS), a medical condition that affects the hand and wrist. It is caused by the compression of the median nerve as it passes through the carpal tunnel, which is a narrow passageway in the wrist made up of bones and ligaments. The median nerve is responsible for providing sensation to the palm, thumb, index finger, middle finger, and ring finger. It also controls some of the muscles in the hand.

The symptoms of CTS usually start gradually and can include pain, numbness, and tingling in the affected hand and fingers, particularly the thumb, index, and middle fingers. Some people may also experience weakness in the hand and difficulty gripping or holding objects. Symptoms are often worse at night and can interfere with sleep.

There are several risk factors for developing CTS, including repetitive hand movements, certain medical conditions such as diabetes and hypothyroidism, pregnancy, and obesity. Treatment for CTS may include wrist splints, medication, physical therapy, or surgery in severe cases. It is important to consult a healthcare professional if you suspect you may have CTS, as early diagnosis and treatment can help prevent permanent nerve damage and improve symptoms.

Tags : Carpal Tunnel Syndrome, Orthopaedic Surgery, Orthopaedic Surgery PowerPoint presentation

Published on : Jun 20, 2023 | Views : 1401 | Downloads : 6

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Slide 1-

Carpal Tunnel Syndrome Wren V. McCallister, MD Surgery of the Hand & Upper Extremity
Slide 2-

Paget 1854 Lectures on Surgical Pathology Paget J. Lectures on Surgical Pathology. Philadelphia: Lindsay & Blakiston, 1854. “…the median nerve, where it passes under the annular ligament, is enlarged with adhesions to all the adjacent tissues, and induration of both it and them (sic)” “He had ulcerations of the thumb, fore, and middle fingers, which resisted various treatment”
Slide 3-

Paget (continued) “…and was cured only by so binding the wrist that the parts on the palmar aspect being relaxed, the pressure on the nerve became and remained well, but as soon as the man was allowed to use his hand, the pressure on the nerve was renewed, and the ulcerations of the parts supplied by them returned”
Slide 4-

Putnam (1880) 37 patients with nocturnal or early am numbness First description of cardinal symptom of CTS Treatments ? Outcome galvanism strychnine cannabis indica …felt “electrified” stopped ALL symptoms just hungry all the time
Slide 5-

Marie and Foix (1913) “hourglass” configuration of nerve nodular thickening, then constriction at the annular ligament Recommended: if diagnosed early, surgical ”…transection of the ligament could stop the development of these phenomena”
Slide 6-

Learmonth (1933) “The median nerve was exposed at the wrist joint. It was compressed between the anterior annular ligament and the arthritic outgrowths of the carpal bones. Scissors were passed under the skin so that one blade was superficial and the other deep to the annular ligament, which was then divided completely.”
Slide 7-

Epidemiology of CTS Incidence of 99 to 148 per 100,0001 Prevalence from 1% to 10%2 occupational prevalence: 17% to 61%3 butchers, grinders, grocery-store workers, frozen-food factory workers (forceful repetitive hand motions, vibration) 1 Palmer DH, Hanrahan LP. Social and economic costs of carpal tunnel surgery. In Jackson DW (ed): Instructional Course Lectures. American Academy of Orthopaedic Surgeons, St, Louis, Mosby 1995, 167-72. 2 Spinner RJ et al. The many faces of carpal tunnel syndrome. Mayo Clin Proc 64:829-36, 1989. 3 Hagberg M et al. Impact of occupations and job tasks on the prevalence of carpal tunnel syndrome. Scand J Work Environ Health 18:337-45, 1992.
Slide 8-

4th-5th decade (82% > 40yo) Female:Male 3:1 ~50% have bilateral CTS up to 38% contralateral wrists: Asx with abnormal NCV ~400,000-500,000 CTR per annum (USA)1 economic cost ~ $2 billion worker’s comp cost 3X other workers worker’s comp cost 5X non-workers 1 Palmer DH, Hanrahan LP. Social and economic costs of carpal tunnel surgery. In Jackson DW (ed): Instructional Course Lectures. American Academy of Orthopaedic Surgeons, St, Louis, Mosby 1995, 167-72.
Slide 9-

What about Work? 22 epidemiologic studies to identify risk factors OR from 1.7 to 34 consistent evidence to support association repetitive motion and forceful motion non-neutral wrist postures, vibration cold temperatures did not control for force/repetitive motion synergy for > 2 risk factors dose-response (suggested but not proven) No established cause and effect Hales TR, Bernard BP. Epidemiology of work-related musculoskeletal disorders. Ortho Clin N Amer 27(4):679-709, 1996.
Slide 10-

Stevens, Neurology 2001 No causal relationship Rates ~ general population
Slide 11-

Other risk factors Obesity Hypothyroidism Diabetes (prevalence 14%-30% with neuropathy) Pregnancy (~50% prevalence) Renal disease Inflammatory arthritis Acromegaly Mucopolysaccharidosis Genetics (twin study) Age (>50) Smoking
Slide 12-

Anatomy of the Carpal Tunnel FCR FPL FDS ----- FDP
Slide 13-

Carpal Tunnel Topography Proximal border = palmar wrist crease Distal border = Kaplan + ring finger axis Superficial palmar arch Kaplan’s cardinal line: distal TCL thenar branch superficial arch Thenar motor branch
Slide 14-

Median Nerve Originates lateral and medial cords of brachial plexus Contributions from C6, C7, C8 & T1 (± C5) Motor fascicles (radially oriented) Thenar branch variations
Slide 15-

Pathophysiology Disturbed axoplasmic flow Endoneural edema Impaired neural circulation Diminished nerve elasticity Decreased gliding
Slide 16-

Chronic CTS Classification Early mild sx (night, activity) < 1 year duration no gross morphologic changes in nerve Intermediate numbness, paresthesias (min. thenar atrophy) chronic changes in median nerve (edema) reversible with decompression
Slide 17-

Chronic CTS Advanced marked sensory changes thenar motor weakness chronic pathologic changes in median nerve endonerual edema, intraneural fibrosis, partial demyelination, axonal degeneration some changes irreversible
Slide 18-

Pathophysiology Clinical stages: magnitude and duration of compression Normal subjects carpal tunnel pressure = 2.5mmHg (neutral) CTS subjects carpal tunnel pressure = 32mm Hg (neutral) 94-110mmHg with wrist flexion/extension epineural edema (<2 h), endoneural edema
Slide 19-

Pathophysiology Symptom relief after decompression Immediate restore intraneural blood flow in normal nerve Days-weeks decreased intraneural edema Months remyelination and axonal regeneration
Slide 20-

History Common presentation intermittent pain and paresthesias in the median nerve distribution nocturnal paresthesias (cardinal Sx) with time, thenar atrophy weak grip, fatigue with repetitive activity sensory-sparing CTS can be clumsiness/weakness of hands “shake test”
Slide 21-

Differential Diagnosis C6, C7 radiculopathy Thoracic outlet syndrome Proximal median nerve entrapment Traumatic injury at the level of the wrist handcuff neuropathy Double crush syndrome Upton, McComas (Lancet 1973) 81/115 patients with median/ulnar nerve sx also had cervical nerve root lesion
Slide 22-

Physical Exam Clinical findings wasting of thenar eminence weakness of APB (most sensitive motor sign) palmar abduction / thumb supination weakness of opponens pollicis Skin examination ulcerative, necrotic or bullous lesions digital anhydrosis, alopecia, nail change (rare)
Slide 23-

Physical Exam - Sensory Threshold testing Semmes-Weinstein monofilament or vibrometry Preferred method of testing sensibility Vibrometry more sensitive, less practical Innervation density testing Static two-point discrimination “slow” adapting fibers Moving two-point discrimination “fast” adapting fibers
Slide 24-

Two-point discrimination Moberg 1958 Static (nl < 6mm) and Moving (nl = < 3mm) Abnormal = severe nerve compression
Slide 25-

Semmes-Weinstein Von Frey hairs (1898) Five selected thresholds: normal (2.83),  light touch (3.61),  protective (4.31), loss of protective (4.56), loss of deep pressure (6.56) Abnormal > 2.83 (eyes closed)
Slide 26-

Vibrometry Dellon 1980 Biothesiometer (shown) Evaluates “fast” adapting fibers More expensive, cumbersome than monofilament testing
Slide 27-

Ten Test “10 test” (Strauch, Plast Rec Surg 1997) Patient ranks moving LT from 0-10 compared to normal contralateral area Useful adjunct for serial examinations Correlates with SW monofilament testing
Slide 28-

Physical exam Provocative testing ALWAYS, test sensibility first ! many described, all based on same concept stress a compromised median nerve to recreate Sx 3 most commonly used tests Phalen’s test, Tinel’s test, compression test Tourniquet test high false (+) rate
Slide 29-

Phalen’s test Described in 1951 Originally: rested elbows on table better without elbow flexion Median nerve trapped b/n proximal TCL and underlying flexor tendons & radius “reverse” Phalen’s maneuver Abnormal = reproduce Sx in 30-60 sec Limitations decreased wrist motion, severe CTS wide variation in reported sensitivity (10%-80%) and specificity (40%-100%)
Slide 30-

Tinel’s Sign Gently tapping along the median nerve at the wrist Abnormal = tingling in median nerve dist. Careful to tap “gently” Phalen reported 60%-73% of patients with CTS had a Tinel’s sign present Wide range of sensitivity (26%-79%) and specificity (40%-100%)
Slide 31-

Durkan Compression Test Gentle pressure directly over carpal tunnel  paresthesias in 30 seconds or less Better for wrists with limited motion Highest sensitivity/specificity of all physical exam tests
Slide 32-

Summary of Tests Test Sensitivity Specificity Phalen’s 75% 62% Tinel’s 64% 71% Compression 87% 90% S-W monofilament 65% 42% Vibrometry 87% ?
Slide 33-

Electrodiagnostic Tests NOT the gold standard Benchmark for validity testing in CTS how physical exam tests are evaluated for accuracy Diagnostic bias selection criteria for application of test different methods of performing tests patient selection differs from study to study Spectrum bias use of asymptomatic controls for sens/spec goal of test = identify those with disease in a pool of patients with symptoms c/w the disease
Slide 34-

Electrodiagnostic Tests Latency and conduction velocity reflect only the healthiest myelinated axons large fibers only (not pain / temperature) can be normal in early stages of compression dynamic ischemia EMG can distinguish functional symptoms normal study except for submaximal voluntary MUP recruitment
Slide 35-

Electrodiagnostic tests Abnormal = across the wrist: distal motor latency > 4.5ms sensory latency > 3.5ms However: 8-22% of patients with (-) electrodiagnostics and (+) clinical signs improve with CTR electrodiagnostics (+) for Asx, (-) for Sx
Slide 36-

Diagnosis of CTS Consensus Statement (Am J Pub Health 1998) (-) ED test, (+) classic sx = ? If CTS (+) ED test, (-) symptoms  CTS Szabo 1999 night pain, (+) SW, (+) Durkan’s, (+) Hand diagram = 86% probability of CTS all test above (-) = 0.68% probability of CTS ED tests did not add to diagnostic power CTS is a clinical diagnosis ED tests can help: identify peripheral neuropathy locate other sites of compression establish severity
Slide 37-

Non-operative Treatment Mild to moderate disease key is denervation of ABP Splinting (nocturnal, neutral) Oral agents NSAIDs, Vitamin B6 (?) Neither effective in isolation Steroid injection 80% relief short-term, ~10-20% @ 1.5 years (+) response predictive of success with surgery dexamethasone safest
Slide 38-

Non-operative Treatment JBJS Evidence-Based Orthopaedics* “Decompressive Surgery Was Better Than Steroid Injection for Symptomatic and Neurophysiologic Outcomes in Carpal Tunnel Syndrome” PRCT, ED-proven CTS, 20wk f/u All injection patients had improvement Pain, NCV better with surgery (not grip) *McCallister, Trumble JBJS (Am) 2006
Slide 39-

Non-operative Treatment Therapy iontophoresis + splint ? > NSAIDs + splint ultrasound is equivocal Activity/ergonomic modification Exercises aerobic exercise ? yoga ? short-term benefit tendon and nerve gliding* 43% failure versus 71% if not done @ 2y f/u *Rozmaryn et al, J Hand Ther 1998
Slide 40-

Non-operative Treatment No benefit: magnets laser acupuncture chiropractic
Slide 41-

Operative Treatment Indicated when non-operative treatment has failed or thenar motor denervation Minimally-invasive Endoscopic Carpal Tunnel release Evidence supports success of Endoscopic Carpal Tunnel release and suggests earlier return of function compared to open release
Slide 42-

Summary CTS is a clinical diagnosis ED are confirmatory, if not required (L&I) No cause and effect vis-à-vis work Non-operative treatment early Operative treatment if denervation of APB failure of non-operative treatment
Slide 43-

Thank you