Neurology chapter 11 carpal tunnel syndrome Flashcards
1
Q
Carpal Tunnel Syndrome
Description
A
- Entrapment neuropathy of the median nerve at the wrist that causes mechanical compression, local ischemia and damage to the median nerve.
- also known as “wake and shake syndrome”
2
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CTS
Etiology
A
- median nerve is entrapped or compressed as it passes through a tunnel composed of the carpal bones and the transverse carpal ligament.
- any condition that results in edema may precipitate CTS.
3
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CTS
incidence
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- affects 1.3 per 1,000 patients
- women > men 3-10:1
- predominant age is 40-60 years
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CTS
Risk factors
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- repetitive flexion, pronation, and supination of the wrist.
- tenosynovitis of the flexor tendons of the fingers.
- local trauma
- prolonged improper positioning
- weight gain, obesity
- pregnancy or premenstrual edema
- arthritis
- hyperthyroidism
- diabetes
- metabolic conditions
- space-occupying lesions
- fractures
- tumors
- inflammatory diseases
5
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CTS
Assessment findings
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- median paresthesias affecting the thumb, index finger, middle finger, and radial side of the ring finger.
- nocturnal paresthesias.
- bilateral presentation common at first, but may be unilateral.
- Positive Phalen’s, and Tinel’s test
- dull, aching sensation in hand, wrist, forearm, or upper arm.
weakness and sensory loss; dropping objects from affected hand - affected hand may be cool to touch, pale in color, with dry skin.
- atrophy of thenar muscle
Blood pressure cuff inflated on the arm may precipitate symptoms.
6
Q
Phalen’s test
A
- hold flexed fingers against each other with wrists flexed at a 90 degree angle for 60 seconds.
- considered positive if paresthesia occurs.
- high specificity, low sensitivity
7
Q
Tinel’s test
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- percuss over the median nerve on the volar aspect of the wrist.
- considered positive if paresthesia occurs.
- high specificity, low sensitivity.
8
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CTS
Differential diagnosis
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- De Quervain’s syndrome
- cervical radiculopathy
- lesion of the brachial plexus
- peripheral neuropathy
- thoracic outlet syndrome
- multiple sclerosis
- CVA
9
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CTS
Diagnostic studies
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- nerve conduction studies of the median nerve: delayed latency across the wrist confirms the diagnosis.
- consider EMG, especially if nerve conduction studies are negative.
10
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CTS
Prevention
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- frequent rest periods when repetitive wrist motions are performed
- proper hand/wrist positioning
- avoidance of risk factors
11
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CTS
Nonpharmacologic management
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- correct underlying disorder
- avoid aggravating factors
- limit full extension and flexion of the wrist
- reduce heavy work activities
- avoid repetitive movements
- splinting of wrists in neutral position with fingers free: wear for 4-12 weeks, mostly at night, may wear in day for activities that may aggravate the condition, consider adding steroid treatment if no relief after 1 month.
- surgical decompression of the carpal tunnel with release of the transverse carpal ligament and debridement.
12
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Pharmacologic management
A
- NSAID’s in doses sufficient for anti-inflammatory effect.
- combined nonsurgical and pharmacologic interventions may be most effective.
- Intermediate-acting corticosteroid injection. Maximum three injections in 2 to 3 month intervals: inject with or without local anesthetic.
13
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CTS
Pregnancy / lactation considerations
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- pregnancy is a risk factor due to edema.
- local injection of anesthetic and hydrocortisone useful during pregnancy.
14
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CTS
Consultation / Referral
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- surgeon if severe or persistent despite conservative therapy.
15
Q
CTS follow-up
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- evaluate effect of conservative therapy (splints, NSAIDs, and cortisone injections)
- postoperative evaluation by surgeon
