carpal tunnel syndrome Flashcards
what is carpal tunnel syndrome?
Carpal tunnel syndrome (CTS) is an entrapment neuropathy caused by compression of the median nerve as it travels through the wrist’s carpal tunnel.
most common nerve entrapment neuropathy?
carpal tunnel syndrome (90%)
Early symptoms of carpal tunnel syndrome
pain, numbness, and paresthesias.
Symptoms typically present?
in the thumb, index finger, middle finger, and the radial half (thumb side) of the ring finger.
radiate?
Pain also can radiate up the affected arm. With further progression, hand weakness, decreased fine motor coordination, clumsiness, and thenar atrophy can occur
Clinically Relevant Anatomy
carpal tunnel is the fibro osseous canal formed between three carpal bone (scaphoid,trapezoid and hamate) and the transverse carpal ligament.
the median nerve & eight tendon of the digital flexors & flexors pollicis longus pass through this 2-2.5 cm tunnel.
Etiology
occupational overuse of the wrist joints eg computer keyboard
malunited colles fracture rheumatoid osteoarthritis ganglia or haemotoma at the wrist connective tissue disorder endocrine disorder such as dm hypothyroidism menopause metabolic causes such as gout growth hormone abnormality (acromegaly ) pregnancy
Epidemiology
The prevalence of carpal tunnel syndrome is estimated to be 2.7-5.8% of the general adult population, with a lifetime incidence of 10-15%, depending on occupational risk 4.
Carpal tunnel syndrome usually occurs between ages 36 and 60 and is more common in women, with a female-to-male ratio of 2-5:1.[4]
Clinical Presentation
CTS onset is generally gradual with tingling or numbness in the median nerve distribution of the affected hand. Fig.3. [9] [10] [11]
Patients may notice aggravation of symptoms with static gripping of objects such as a phone or steering wheel but also at night or early in the morning. [10] [11] Many patients will report an improvement of symptoms following shaking or flicking of their hand.
As the disorder progresses, the feeling of tingling or numbness may become constant and patients may complain of burning pain. [10]
The final symptoms are weakness and atrophy of muscles of the thenar eminence. These combined effects of sensory deprivation and weakness may result in a complaint of clumsiness and loss of grip and pinch strength or dropping things, [10]
Differential Diagnosis
other median nerve entrapment syndromes pronator teres syndrome anterior interosseous nerve syndrome an injury of nerve digitales in the palm. cervicobrachial syndrome.[4]
Outcome Measures
Boston Carpal Tunnel Questionnaire (BCTQ)
Disability of Hand and Shoulder (DASH) Questionnaire
Physical Therapy Management
Patients with mild to moderate symptoms can be effectively treated in a primary care environment .
pt education:
Physical therapists should give advice on modifications of activities and the workplace (ergonomic modifications)task modification, For example, taking sufficient rest and variation of movements.
Often simple obvious alterations to the working practice can be beneficial in controlling milder symptoms of CTS.
Manual therapy techniques include mobilisation of
Soft tissue
Carpal bone
Median nerve[19]
Other modalities include: ultrasound and electromagnetic field therapy and splinting.
A simple splint that blocks movement at the wrist is adequate to avoid compressive stretches to carpal tunnel
pain free relaxed passive or speedy active movements are encouraged in the pain free range by removing the splint
cryotherapy
Research findings (varies)
Physiotherapy modalities (TENS and ultrasound) have little useful effects on hand sensory discomfort.[21] The evidence of the effectiveness of the exercise and mobilization interventions is limited and very low in quality.[19]. Evidence about post-operative rehabilitation is also limited. None of them seems to have a prevailing benefit[22].
special tets
phalen tets
reverse phalen test
modified phalan’a test
c/f
Numbness and tingling
Among the most common complaints, patients will reveal that their hands fall asleep or that things slip from their fingers without their noticing (loss of grip, dropping things); numbness and tingling also are commonly described.
Symptoms are usually intermittent and are associated with certain activities (eg, driving, reading the newspaper, crocheting, painting). Nighttime symptoms that wake the individual are more specific to CTS, especially if the patient relieves symptoms by shaking the hand/wrist. Bilateral CTS is common, although the dominant hand is usually affected first and more severely than the other hand.
Complaints should be localized to the palmar aspect of the first to the fourth fingers and the distal palm (ie, the sensory distribution of the median nerve at the wrist). Numbness existing predominantly in the fifth finger or extending to the thenar eminence or dorsum of the hand should suggest other diagnoses. A surprising number of CTS patients are unable to localize their symptoms further (eg, whole hand/arm feeling dead). This generalized numbness may indicate autonomic fiber involvement and does not exclude CTS from the diagnosis.
Pain
The sensory symptoms above commonly are accompanied by an aching sensation over the ventral aspect of the wrist. This pain can radiate distally to the palm and fingers or, more commonly, extend proximally along the ventral forearm.
Pain in the epicondylar region of the elbow, upper arm, shoulder, or neck is more likely to be due to other musculoskeletal diagnoses (eg, epicondylitis) with which CTS commonly is associated. This more proximal pain also should prompt a careful search for other neurologic diagnoses (eg, cervical radiculopathy).
Autonomic symptoms
Not infrequently, patients report symptoms in the whole hand. Many patients with CTS also complain of a tight or swollen feeling in the hands and/or temperature changes (eg, hands being cold/hot all the time).
Many patients also report sensitivity to changes in temperature (particularly cold) and a difference in skin color. In rare cases, there are complaints of changes in sweating. In all likelihood, these symptoms are due to autonomic nerve fiber involvement (the median nerve carries most of the autonomic fibers to the hand).
Weakness/clumsiness - Loss of power in the hand (particularly for precision grips involving the thumb) does occur; in practice, however, loss of sensory feedback and pain is often a more important cause of weakness and clumsiness than is loss of motor power per se.
