Carpal Tunnel Syndrome Flashcards
What is carpal tunnel syndrome
-a condition that results from compression of the median nerve as it passes through the carpal tunnel at the wrist
-results in numbness and tingling in the median distribution: lateral three and one-half digits
Relevant Information:
-most common entrapment syndrome in arm
-related to highly repetitive flexion and extension actions of the wrist, which leads to numbness and tingling in the median nerve distribution
-aggravated by movement, which causes pain
-distinguishing feature of CTS is nocturnal symptoms that wake the person up
-as condition persists, thenar muscle wasting that can lead to weakness and clumsiness of thumb and fingers
The Carpal Tunnel
- located at the wrist just distal to wrist crease (n: nếp gấp)
-fibrous canal with the floor formed by the carpal bones and the roof formed by the flexor retinaculum (transverse carpal ligament)
-retinaculum is a dense, fibrous band, approx. 1 to 2mm thick to as much as 3.5mm thick
-attaches to pisiform and hook of hamate on ulnar side; on radial side, attaches to scaphoid tubercle and trapezium
Proximally, ligament lies at distal wrist crease and bends with fascia of distal flexor surface of forearm, distally it extends to base of metacarpals and into the palmar fascia (n: work forearm + hand)
-the median nerve becomes superficial as it approaches carpal tunnel; before passing through the tunnel, it gives off a branch called the palmar cutaneous branch; this branch travels superior to and not through the carpal tunnel; the palmar cutaneous branch supplies skin over the thenar eminence; if median nerve is compressed in the tunnel, sensation to thenar area is not affected
-normally at rest, with wrist in neutral, pressure within carpal tunnel is 2.5mmHg (n: F+E: 90 mmHg); when carpal tunnel syndrome present, pressure increases to 32mmHg
-compresse of the tune itse de creases through carpal tunnel generally occurs in two ways:
+ size of the tunnel itself decreases or
+size of the contents passing through the tunnel increases
-it is not unusual that both of these occur in combination
-condition is often unilateral, affecting dominant hand
-can be bilateral though often the non-dominant hand is asymptomatic and condition is discovered only after electrodiagnosis
Structures that Travel Through the Carpal Tunnel
-median nerve
-four tendons of flexor digitorum superficialis
-four tendons of flexor digitorum profundus
-tendon of flexor pollicis longus
Causes
*Causes leading to an increase in size of contents through tunnel (chronic in nature)
-repetitive actions of wrist (flex/ext) can lead to edema, chronic fibrosis and thickening of the tendons
-thickening of retinaculum due to scar tissue from repeated trauma
-systemic conditions that result in edema and fluid retention or connective tissue degeneration (diabetes, RA, pregnancy)
- Causes leading to decreased canal space (chronic in nature)
-bony callus development after fracture of carpal bone or distal radius
-space-coupying (chiếm) lesions such as ganglia (hạch), lipomas, cysts
-bony changes that occur with RA
*Causes that are acute in nature
-secondary to trauma (fracture or dislocation of lunate especially, or other carpal bones infection
-acute exacerbation of RA (flare up)
-new activity requiring repetitive wrist actions
-hematoma, which can occasionally occur in people with hemophilia ( bệnh ưa chảy máu ) or those on anticoagulants
Contributing Factors
-vitamin B6 deficiency
-familial tendency (Xu hướng)
Medical Treatment
-may include splinting of wrist, usually in neutral position but sometimes in slight extension for a 3-6 week period
-splint worn particularly at night to prevent person from sleeping with wrist flexed, which causes compression
in some cases, splint is worn all day
-oral anti-inflammatories and diuretics
-steroid injections in less extreme cases
-surgery is generally used in moderate to severe cases or if condition has lasted for more than one year or if muscle atrophy has occurred
-surgical procedure involves complete transection of flexor retinaculum; a longitudinal incision, in line with ring finger in order to avoid median and palmar cutaneous nerves; wrist is then splinted for several days
-takes up to 3 months for strength to return
-results vary with an average of 50-65% reporting total success
-problems that arise are usually because of misdiagnosis of original condition, an incomplete transection of retinaculum, thickening of the retinaculum from scar tissue, entrapment of the nerve in developing scar tissue and damage from surgery
-laser endoscopic surgery; only 1-2 small incisions of 1-1.5cm in length are made at wrist and on palm above retinaculum; when successful, relief from symptoms and shorter down-time from activities (2-3 weeks)
Pronator Teres Syndrome and Median Nerve Compression
(N: Sleeping w Wrist flexion doesn’t increase (P))
-the median nerve is compressed at the level of the proximal attachment of pronator teres
-compression is usually from the tendons of this muscle, which may be thickened, possibly as result of local trauma
-usually gradual, insidious onset
-aching (often described as heaviness or tiredness) in anterior forearm and numbness in thumb and index finger, with some weakness in thenar muscles
-dull, sharp pain in anterior forearm is experienced with repetitive elbow movement rather than wrist movement
-tenderness found at proximal attachment of pronator teres and pain is present with active resisted testing of pronation of forearms
-no nocturnal pattern to symptoms
Repetitive Strain Injury (RSI)
-current term used to describe cumulative (n: dồn lại) trauma suffered as a result of highly repetitive and forceful hand movements, often performed in biomechanically unsound positions
-more recent name for a combination of conditions that seem to affect white collar workers, associated with computer work
-condition includes tendinitis, tenosynovitis, CTS and TOS and trigger points
-can lead to chronic pain and disability
-if severe, may lead to some degree of permanent median nerve damage
Symptom Picture
-when CTS is unilateral, it is usually in the dominant hand; it is often bilateral however
-numbness and tingling in median nerve distribution
-nocturnal (n: sleeping) dysthesia, often waking the person up; dysthesia may be due to venous stasis or persistent compression from sleeping with wrists in flexed position
-symptoms accompanied by local pain, which also occurs with wrist activity; later stages, pain can be present not only locally in wrist and hand but in forearm, elbow and even shoulder
-movements of wrist limited by pain; space occupying lesions or bone cysts may also be present, resulting in limited ROM at wrist
-person will often shake, massage or exercise hand for relief of symptoms (n: → doesn’t help but the brain has time to figure out)
-frequently person is distressed over loss of function and loss of ability to work
-swelling may be present; it could be the cause of CTS as it increases pressure
-tissues of forearms may be boggy and fibrous from build-up of metabolic waste
-hypertonicity is common in forearm flexors from overuse and often from the presence of TP’s in these muscles and the hand
-adhesions can develop at attachment sites of flexor retinaculum as well as in tendons of forearm muscles that pass through the tunnel; can result in wear and tear due to overuse
-atrophy of thenar muscles occurs as condition progresses; leads to clumsy movements of thumb and index finger; often worse in morning
Health History Questions
Any history of a systemic disorder (Diabetes, RA)?
Is the patient pregnant?
Has the patient seen a doctor for diagnosis? What tests were performed?
What treatment was prescribed? is a splint being used?( not using it at home to Keep ROM & Strength)
Is the patient currently taking meds?
How long has patient been experiencing discomfort?
Can the patient describe the sensation experienced?
Where does the patient experience altered feelings, in the entire hand or a specific finger?
What are the patient’s work activities, hobbies, sleeping positions?
What relieves the discomfort?
(N: How do you sleep?
Steroid injection! → leave alone 1 week,it makes mm weak first, clean up, then build up, strenghthen)
Observations
-patient’s posture is observed as patient demonstrates actions that aggravate symptoms
-unilateral presentation is generally in the dominant hand
-splint may be worn
-edema may be local at hand and wrist, or more diffuse over hand and forearm
-later stages, thenar muscle atrophy occurs, accompanied by decreased tissue health
-in time, weakness of thenar muscles is revealed by patient’s difficulty with holding a pen and writing
Palpation
-possible signs of inflammation local to wrist; in chronic cases, ischemia may be present
-tenderness reported local to carpal tunnel at insertions at carpal bones and over median nerve
-tissue texture may be boggy local to wrist; forearm muscles often dense due to accumulation of metabolic waste
-HT, TP’s and fascial restrictions of forearm muscles due to overuse
-later stages, atrophy of thenar muscles
Testing
-AROM and PROM reveal decreased range in flexion and extension and possible ulnar deviation;
end feel is often empty (n: → painful)
-muscle testing of abductor pollicis brevis is positive for weakness if CTS is chronic
-Phalen’s and reverse Phalen’s tests are positive
-Tinel’s sign is positive with paresthesia in distribution of median nerve
Differentiating Sources of Wrist Pain
-ROOT: C6 and C7 radiculopathies and disc lesions cause sensory symptoms in thumb, middle and index fingers, which may radiate along lateral forearm; distinguished by motor weakness in muscles innervated by C6 (biceps) and C7 (triceps); deep tendon reflexes are decreased; pain is experienced in neck and with neck movements
-TOS: TOS results in positive results of some of the following tests: Adson’s, Travell’s variation, costoclavicular, Eden’s and Wright’s hyperabduction and ULTT’s; numbness and tingling are L experienced in medial forearm and in medial two digits; muscle wasting of hypothenar muscles occurs, specifically over ulnar border and over 4th and 5th fingers
-PTS: Pronator Teres Syndrome is indicated by pain in anterior forearm with elbow movement, not wrist movement; tenderness is palpated at attachments of pronator teres muscle; no nocturnal pain present
-DOUBLE CRUSH: any of the above conditions may exist together with CTS; their presence would cause an increase susceptibility to CTS; double crush syndrome would be used to describe the combined conditions
Contraindications
-frictions are not performed if CTS is the result of RA due to joint instability; also not performed if patient has decreased tissue health due to diabetes or if edema is present over the adhered area or if anti-inflammatories are being taken
-vigorous joint play is not used if RA has resulted in joint hypermobility or if patient is in 3rd trimester of pregnancy
-no local massage is performed until 10 days after corticosteroid injection
(n: No deep compression on the tunnel)
