Carpal tunnel syndrome

Prepard by//
Dr. Ramzy Shokri
Anatomy of the carpal tunnel

• Borders:

• scaphoid tubercle and trapezium (radially)

• hook of hamate and pisiform (ulnarly)
• transverse carpal ligament palmarly (roof)
• proximal carpal row dorsally (floor)

• Carpal tunnel is narrowest at the level of the hook of the hamate

Anatomy
Anatomy

• Contents:
• nine flexor tendons (4 FDS,4 FDP and FPL)
• one nerve (median nerve)

• FPL is the most radial structure

Anatomy
Neuro hazards

• Branches of median nerve

• palmar cutaneous branch of median nerve

• lies between PL and FCR at level of the wrist flexion crease

• recurrent motor branch of median nerve: 

• 50% are extraligamentous with recurrent innervation
• 30% are subligamentous with recurrent innervation
• 20% are transligamentous with recurrent innervation
• cut transverse ligament far ulnar to avoid cutting if nerve is transligamentous
Carpal tunnel syndrome

• It is the compression of the median nerve in the carpal tunnel

• Most common compressive neuropathy
• affects 0.1-10% of general population

• precipitated by
• exposure to repetitive motions and vibrations
• certain athletic activities
• cycling
• tennis
• throwing
• compression may be due to
• repetitive motions in a patient with normal anatomy
• space occupying lesions (e.g., gout)
Risk factors

female sex

obesity

pregnancy

hypothyroidism

rheumatoid arthritis

advanced age
 chronic renal failure

smoking

alcoholism

repetitive motion activities

mucopolysaccharidosis

mucolipidosis
Prognosis

• good prognostic indicators include:

• night symptoms
• short incisions
• relief of symptoms with steroid injections
Landmarks for the classical incision

• kaplan’s cardinal line : from hook of hamate to the first web

space.

• Drawing a line from radial aspect of the ring finger.

• The point where these two lines meet is our incision site
Landmarks

• Drawing a line from radial aspect of the middle finger and the
point of intersection with the Kaplan’s line is app. The location of
the recurrent motor branch of the median nerve

• Hyperflexing the MCP joint of the ring finger past 90 degrees and
flexing the PIP and DIP joints to 90 degrees ( site of superficial
palmar arch)

• From there , the incision extends proximally about 2 cm.

Superficial dissection

• Incise skin and subcutaneous tissue to expose palmar facsia

• Incise palmar fascia and retract to expose transverse carpal
ligament (TCL)
DEEP DISSECTION

• Small sharp incision is made in the distal aspect of the TCL.

• Staying in line with the radial aspect of the ring finger to avoid
injury to the recurrent motor branch of the median nerve.
• Slide elevator into carpal tunnel beneath the TCL to protect the
underlying median nerve.
• Sharply incise the ligament while staying on top of the elevator to
expose median nerve and flexor tendons
• Using sharp scissors with tips pointed ulnarly to protect median
nerve , continue cutting distal to proximal, then distally
• Visualize recurrent motor branch as it enters thenar musculature
and superficial palmar arch to confirm they are intact
•Any questions ??
•Thank you for listening!