Carpal Tunnel Syndrome

● carpal tunnel, formed by the concave anterior surface of the carpal bones and closed by the
flexor retinaculum, is tightly packed with the long flexor tendons of the fingers, with their
surrounding synovial sheaths, and with the median nerve [snell]
● The most common location of upper extremity nerve compression [schwartz]
● Commonly, the cause is increased the size of some of the nine structures or their coverings that
pass through it (e.g., inflammation of synovial sheaths). Fluid retention, injection, and excessive
exercise on the fingers may cause swelling of the tendons or their synovial sheaths
● Usually the cause eludes detection; however, common at the menopause, in rheumatoid
arthritis, pregnancy and myxoedema [trans]
● An estimated 53 per 10,000 working adults have evidence of CTS. The National Institute for
Occupational Safety and Health website asserts, “There is strong evidence of a positive
association between exposure to a combination of risk factors (e.g., force and repetition, force
and posture) and CTS.” [schwartz]

Evaluation
Initial evaluation of the patient consists of symptom inventory: location and character of the
symptoms, sleep disturbance due to symptoms, history of dropping objects, and difficulty manipulating
small objects such as buttons, coins, or jewelry clasps.

Physical examination should begin with inspection. Look for evidence of wasting of the thenar
muscles. Tinel’s sign should be tested over the median nerve from the volar wrist flexion crease to the
proximal palm, although this test has significant inter examiner variability. To check for Tinel's sign,
your doctor will lightly tap over the affected nerve. If the nerve is compressed or damaged, you'll feel a
tingling sensation that radiates outward. This sensation is also called paresthesia. The nerve that your
doctor tests will depend on what your symptoms suggest. Applying pressure over the carpal tunnel
while flexing the wrist has been shown in one series to have the highest sensitivity when compared to
Phalen’s and Tinel’s signs. Strength of the thumb in opposition should also be tested.

Clinical Findings
● Pain and paraesthesia occur in the distribution of the median nerve in the hand.
● The median nerve has two terminal sensory branches that supply the skin of the hand; hence,
paresthesia (tingling), hypoesthesia (diminished sensation), or anesthesia (absence of
sensation) may occur in the lateral three and a half digits. The palmar cutaneous branch of the
 median nerve arises proximal to, and does not pass through, the carpal tunnel; thus, sensation
in the central palm remains unaffected
● Progressive loss of coordination and strength of the thumb (owing to weakness of the APB and
opponens pollicis) may occur if the cause of compression is not alleviated. Individuals with
carpal tunnel syndrome are unable to oppose their thumbs
● Night after night the patient is woken with burning pain, “pins and needles” sensation or tingling
and numbness.
● Hanging the arm over the side of the bed, or shaking the arm, may relieve the symptoms.
● In advanced cases, there may be clumsiness and weakness, particularly with tasks requiring
fine manipulation such as fastening buttons.
● The condition is far more common in women than in men.
● The usual age group is 40–50 years
● In late cases there is wasting of the thenar muscles, weakness of thumb abduction and sensory
dulling in the median nerve territory.

Treatment
Early treatment of CTS consists of conservative management. The patient is given a splint to
keep the wrist at 20° extension worn at nighttime. Many patients can have years of symptom relief with
this management. As a treatment and diagnostic modality, corticosteroid injection of the carpal tunnel
is often employed. Mixing local anesthetic into the solution provides the benefit of early symptom relief
(corticosteroids often take 3–7 days to provide noticeable benefit), and the report of postinjection
anesthesia in the median nerve distribution confirms the injection went into the correct location.
Multiple authors have shown a strong correlation to relief of symptoms with corticosteroid injection and
good response to carpal tunnel release.

In a small number of patients, Yamanaka et al. showed that the main effect of triamcinolone
acetonide (TA) is antifibrotic and not anti-inflammatory when injected into the carpal tunnel of patients
who have clinically established CTS and they found no significant morphological changes in the carpal
tunnel. It could be that less fibrosis and reduced stiffness of tissues, as have been shown to happen in
response to steroids in other studies translate into more elasticity of the surrounding environment and
thus improved nerve function

When lesser measures fail or are no longer effective, carpal tunnel release is indicated. Open
carpal tunnel release is a time-tested procedure with documented long-term relief of symptoms. A
direct incision is made over the carpal tunnel, typically in line with where the ring finger pad touches the
proximal palm in flexion. Skin is divided followed by palmar fascia. The carpal tunnel contents are
visualized as they exit the carpal tunnel. The transverse carpal ligament is divided with the median
nerve visualized and protected at all times. Improvement in symptoms is typically noted by the first
postoperative visit, although symptom relief may be incomplete for patients with long-standing disease
or systemic nerve-affecting diseases such as diabetes.

Endoscopic carpal tunnel release offers an alternative with slightly quicker postoperative
rehabilitation; however, the complication rate is higher.