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University of Louisville Lunch & Learn. Carpal Tunnel Syndrome: A Common Problem with Sometimes Unusual Symptoms. Michael D. Weaver, DO Physical Medicine & Rehabilitation Sports Medicine October 16, 2013. Objectives. - PowerPoint PPT Presentation
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University of LouisvilleLunch & Learn
Carpal Tunnel Syndrome: A Common Problem with Sometimes Unusual
SymptomsMichael D. Weaver, DO
Physical Medicine & RehabilitationSports Medicine
October 16, 2013
Objectives Become familiar with the basic
anatomy of the wrist and causes of carpal tunnel syndrome {CTS}.
Obtain a better understanding of the signs and symptoms associated with CTS.
Become familiar with some of the various testing and treatments for CTS.
Background Entrapment of the median nerve at the
carpal tunnel is the most common and best characterized peripheral compression neuropathy› Prevalence: 2% Male & 3% Female
0.1% to 10% of the population Higher rates reported in those individuals
involved in repetitive wrist motion activities No concrete data supporting cumulative trauma
› 50% of patients have bilateral CTS ~38% are asymptomatic in ‘uninvolved’ hand
Risk Factors Likely play a role by either increasing
pressure within the CT or increasing susceptibility of the median nerve to pressure, however CTS is largely idiopathic› Normal – 2.5mm Hg (neutral)› CTS – 32mm Hg increased to 94-110mm Hg with
wrist flexion/extension Neuronal changes in < 2 hours
Contributing Factors:› Pregnancy, thyroid disorders, chronic kidney
disease, acromegaly, diabetes, obesity, smoking, alcohol abuse, inflammatory arthritis, genetics
Pathophysiology Chronic compression of nerve inhibits
axonal transport and epidural blood flow which results in intraneural edema, myelin thinning, nerve fiber degeneration and fibrosis.› Impaired nerve circulation› Diminished nerve elasticity› Decreased nerve gliding
Nerve Compression
Anatomy Median nerve travels beneath
transverse carpal ligament along with 9 tendons› Flexor Digitorum Profundus {FDP} – 4› Flexor Digitorum Superficialis {FDS} – 4› Flexor Pollicis Longus {FPL}
Provides motor and sensory input to a portion of the hand
Median Neuropathy Clinical Features
› Pain, numbness, tingling in digits I-III› Sparing of sensation to thenar eminence {palm}
Palmar cutaneous sensory branch› More commonly c/o entire hand and vague
complaints of pain in the shoulder and sharp shooting pains up the forearm 50% of patients reliably localize Neck pain is NOT an associated symptom
Carpal Tunnel Syndrome
CTS Symptoms Usually worsen at night and can
awaken patients from sleep› + flick sign
Exacerbated when driving or talking on the phone
Frequently dropping objects, weak grip Fatigues with repetitive activity
Physical Examination Visual Inspection
› Asymmetry› Skin Changes
Strength Sensation
› Light touch/Pinprick› Vibration› 2 point discrimination
Provocative Maneuvers
Physical Examination Tinel’s sign Phalen Maneuver
› Reverse Phalen Carpal Compression
› Durkan’s
Provocative Maneuvers
Masqueraders Pronator Syndrome
› Compression of the median nerve as it passes through the pronator teres muscle at the elbow
Double Crush Syndrome› Concomitant involvement of a pinched
cervical nerve root in the neck C6 and C7
› Thorough history and physical examination
Diagnosis Truly a clinical diagnosis Constellation of symptoms Use of diagnostic tools
› Ultrasound› Electrodiagnostic Studies
Ultrasound
Noninvasive Allow for real-time
visualization of nerve
Assist in guided injections
Electrodiagnosis Nerve Conduction Studies Electromyography
Treatment Conservative
› Activity modification› Wrist splints› Corticosteroid injection› US therapy› Nerve gliding› Medications
Vitamin B6 NSAIDs v oral steroids
Surgical› Open v Endoscopic carpal tunnel release {CTR}
Referral Information University of Louisville Physicians
› Physical Medicine & Rehabilitation› Frazier Rehab Institute & Neuroscience Center› 502.584.3377
Thank You!