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

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

Flexor digitorum superficialis (FDS) FP L FD P FDS . 9 flexor tendon •.Flexor pollicis longus (FPL) •.CONTENT OF CARPAL TUNNEL I.Flexor digitorum profundus (FDP) •.

1 median nerve . II.Cont…..

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 .PALMAR CUTANEOUS BRANCH OF MEDIAN NERVE I.

Opponens pollicis muscles . Abductor pollicis brevis 2.Branches of median nerve Recurrent motor branch of median nerve innervates: 1. Flexor pollicis brevis 3.


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

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. edema formation Ischemia in the nerve . back pressure.

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 .

lupus and infection Joint: Wrist arthrisis. inflammatory arthritis.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. rhizharthrosis Metabolic tenosynovitis: Diabetes mellitus. primary or secondary amyloidosis. chronic kidney disease (arteriovenous fistula) . infectious arthritis. hypothyroidism. gout Acromegaly Abnormalities of fluid distribution: Pregnancy (3rd trimester).

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

REFERENCE • Elsevier Orthopedia .

History Taking Law Koon Lum 012011100188 .

Numbness / Paraesthesia and tingling • Swelling and tightness at wrist .) 1. shoulder. neck • MSK ddx (Epicondylitis/ tennis elbow & Cervical radiculopathy. C6 & C7) 2. Pain • Night Awakening ( Burning hands wake you up ) • Relieved by shaking hands of • Only hand (CTS) • With ( Proximal ) upper arm.To ask: • Main complaints: (Lateral palmar aspect mainly – Median n.

Autonomic • Hand feel hot / cold all the time • Sweating .3. Weakness • Gripping fails ( spending money without noticing it ) • Precision loss • Money on the floor also don’t want to take. ( more flexion and compression over wrist) 4.

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

Unilateral / Bilateral : ( Mechanical ) • Using walking stick.2. 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) .


medscape.• Reference: 1. Apley And Solomon’s Concise System Of Orthopaedics And Trauma. . Fourth Edition 2.

Physical Examination Maisaratul Firzanah bt Khidzir .

but spare the thenar eminence Motor Examination • Atrophy and weakness of thenar muscle •  weakness of thumb abduction and thumb opposition .Sensory Examination •  sensory deficits usually occur late • Involve median innervated area.

Paraesthesia 30-60 secs .Provocative Maneuvers • Phalen’s Test Sensitivity 68% Specificity 73% Pain.

• Tinnel’s 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 .

paraesthesi a • Hand Elevation Test 1 min Sensitivity 75% Specificity 98% .Pain.

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

Investigations WONG KAI TIN 021011100101 .

Rhemathoid arthritis •. Blood test •.1.Diabetes •.hypothyroidism .

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

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.Ultrasound scan ---fully developed cases.3. (Normal range:911mmsq) .

• The results from the test indicate how much damage there is to your nerves. electrodes are placed on your hand and wrist and a small electrical current is used to stimulate the nerves in the finger. • During the test.   . elbow. sometimes. wrist and.4.Nerve conduction study • A nerve conduction study is a test that measures how fast signals are transmitted through 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 the test, fine needles are inserted into your
muscles. The needles detect any natural electrical
activity given of by your muscles.



Triamcinolone Acetonide 10-20mg b. Oral glucocorticoid : prednisone 20 mg daily for 10 to 14 days 5. NSAIDS ± diuretics 3.TREATMENTS MILD MODERATE-SEVERE NON SURGICAL 1. Methylprednisolone Acetate 10-20mg 4. 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 . Glucocorticoid injection : a. Wrist splint/ braces 2.

endoscopic carpal tunnel release Less pain & fast recovery Need experience surgeon .TREATMENTS MILD MODERATE-SEVERE SURGICAL 1. open carpal tunnel release 2.

but do not allow simultaneous wrist and finger flexion . 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.POST-OP CARE the wrist is splinted in neutral or slight extension.

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

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

REFERENCES Emedicine Wheeless' Textbook of Orthopaedics .


• The flexor tendon causes painful popping or snapping as the patient flexes and extend the digit. sometimes of the thumb.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.






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 .


.• 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 .


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. During forceful bending of the finger or thumb. no longer able to glide freely and may swell forming a nodular thickening at the point where it tries to pass into the tunnel. the enlarged portion of the tendon is dragged through the constricted opening. This motion is often accompanied by a painful click. 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.Normally. Causing painful snap as the swollen part of the tendon passes back through the sheath. . Result from enlargement of the tendon itself or narrowing of the first (A1) pulley.


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

..Presentation & Classification..

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

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 .


Audible click • Radiography are rarely indicated in trigger finger .INVESTIGATION • Trigger finger is CLINICAL DIAGNOSIS • On examination : .Nodule in tendon .

• Hand radiographs are performed only if abnormal pathology are suspected : .avulsion injuries of collateral ligaments • Helpful to exclude : - osteoarthritis fracture malunion foreign body large sesamoid bone that is affecting interphalangeal (IP) joint motion.abnormal sesamoids . .loose bodies in the metacarpophalangeal joint .osteoarthritic spurs on the metacarpal head .

MANAGEMENT  Principle of management .Allow smooth gliding of the tendon thus allowing normal extension of the fingers (MCPJ)  Types of management .Surgical .Reduce swelling .Conservative (non surgical) .Reduce pain .

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

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 .




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

 Poor prognosis usually associated with other medical condition.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.

References  Apley’s System of Orthopaedics and Fractures 9th Edition by Solomon Warwick Nayagam  244693-treatment  http://orthoinfo.cfm?topic =a00024 .