Carpal tunnel syndrome

Question 1

Definition

Answer 1

Median nerve compression at the wrist leading

to paresthesias of the radial three fingers and sometimes hand weakness

Question 2

Gender predominance

Answer 2

Women ++ 3:!

Question 3

What is tinel and phalen’s signs

Answer 3

Tinel->percussion +

Phalen->flexion +

Question 4

When is surgery indicated

Answer 4

Surgery is indicated for intractable symptoms that are refractory to medical
management

Question 5

Surgical approach

Answer 5

1. A tourniquet is used to exsanguinate the limb, 2. operative field is infiltrated with Xylocaine; in
   addition, intravenous sedation can be used.
2. The Palmer fascia and the ligament are
   divided vertically from the proximal end of the carpal tunnel to its most distal point,
   and a wide separation of the ends of the ligament is observed
3. The underlying median nerve is carefully protected.
4. A small tissue flap is left attached to
   the hook of the hamate, and the skin is closed.
5. Postoperatively, the wrist is splinted
   in slight extension for approximately 2 weeks

Question 6

Risk factors

Answer 6

Strong

age over 30 years
high BMI
female sex
alterations in carpal tunnel space
fractured wrist/carpal bones
square wrist
rheumatoid arthritis
diabetes
dialysis
pregnancy
congenital carpal tunnel stenosis
occupation involving exposure to repetitive bending, twisting, or vibration of the hands or wrists
mobility aids
Thyroid

Question 7

Clinical features

Answer 7

presence of risk factors (common)
numbness of hand(s) (common)
night-time worsening (common)
numbness in median nerve distribution (common)
numbness confined to palmar aspect of the first 4 fingers (uncommon)

Question 8

Investigations

Answer 8

Diagnosis is clinical

May consider EMG, USS, MRI depending on presentation

Question 9

Most common 3 causes of upper extremixity mononeuropathy

Answer 9

Carpal tunnel
Ulnar nerve neuropathy
Cervical radiculopathy

Question 10

Less common causes of upper extremity mononeuropathy

Answer 10

Uncommon
Ulnar neuropathy at the wrist/palm
Radial neuropathy at the spiral groove (Saturday night palsy)
Neurogenic thoracic outlet syndrome
Posterior interosseus syndrome
Anterior interosseus neuropathy
Brachial neuritis (brachial amyotrophy, Parsonage-Turner syndrome, idiopathic acute brachial neuropathy)
Amyotrophic lateral sclerosis
Metastatic cancer/nerve sheath tumours
Amyloidosis
Post-irradiation brachial plexopathy
Peripheral nerve vasculitis (mononeuritis multiplex)
Sarcoidosis
Multifocal chronic inflammatory demyelinating polyneuropathy
Hereditary neuropathy with liability to pressure palsies (HNPP)
Leprosy
CMV
HIV
Lyme disease

Question 11

Management

Answer 11

NSAIDs
Hydrochlorthiazide
Wrist spint
Ibuprofen

Second line is steroid injection
If failed medical management/severe->surgical release