Michael D. Weaver, DO Physical Medicine & Rehabilitation Sports Medicine October 16, 2013

 Become familiar with the basic anatomy of the wrist and causes of carpal tunnel syndrome {CTS}.  Obtain a better understanding of the signs and symptoms associated with CTS.  Become familiar with some of the various testing and treatments for CTS.

 Entrapment of the median nerve at the carpal tunnel is the most common and best characterized peripheral compression neuropathy › Prevalence: 2% Male & 3% Female  0.1% to 10% of the population  Higher rates reported in those individuals involved in repetitive wrist motion activities  No concrete data supporting cumulative trauma › 50% of patients have bilateral CTS  ~38% are asymptomatic in ‘uninvolved’ hand

 Likely play a role by either increasing pressure within the CT or increasing susceptibility of the median nerve to pressure, however CTS is largely idiopathic › Normal – 2.5mm Hg (neutral) › CTS – 32mm Hg increased to mm Hg with wrist flexion/extension  Neuronal changes in < 2 hours  Contributing Factors: › Pregnancy, thyroid disorders, chronic kidney disease, acromegaly, diabetes, obesity, smoking, alcohol abuse, inflammatory arthritis, genetics

 Chronic compression of nerve inhibits axonal transport and epidural blood flow which results in intraneural edema, myelin thinning, nerve fiber degeneration and fibrosis. › Impaired nerve circulation › Diminished nerve elasticity › Decreased nerve gliding

 Median nerve travels beneath transverse carpal ligament along with 9 tendons › Flexor Digitorum Profundus {FDP} – 4 › Flexor Digitorum Superficialis {FDS} – 4 › Flexor Pollicis Longus {FPL}  Provides motor and sensory input to a portion of the hand

 Clinical Features › Pain, numbness, tingling in digits I-III › Sparing of sensation to thenar eminence {palm}  Palmar cutaneous sensory branch › More commonly c/o entire hand and vague complaints of pain in the shoulder and sharp shooting pains up the forearm  50% of patients reliably localize  Neck pain is NOT an associated symptom

 Usually worsen at night and can awaken patients from sleep › + flick sign  Exacerbated when driving or talking on the phone  Frequently dropping objects, weak grip  Fatigues with repetitive activity

 Visual Inspection › Asymmetry › Skin Changes  Strength  Sensation › Light touch/Pinprick › Vibration › 2 point discrimination  Provocative Maneuvers

 Tinel’s sign  Phalen Maneuver › Reverse Phalen  Carpal Compression › Durkan’s

 Pronator Syndrome › Compression of the median nerve as it passes through the pronator teres muscle at the elbow  Double Crush Syndrome › Concomitant involvement of a pinched cervical nerve root in the neck  C6 and C7 › Thorough history and physical examination

 Truly a clinical diagnosis  Constellation of symptoms  Use of diagnostic tools › Ultrasound › Electrodiagnostic Studies

 Noninvasive  Allow for real-time visualization of nerve  Assist in guided injections

 Nerve Conduction Studies  Electromyography

 Conservative › Activity modification › Wrist splints › Corticosteroid injection › US therapy › Nerve gliding › Medications  Vitamin B6  NSAIDs v oral steroids  Surgical › Open v Endoscopic carpal tunnel release {CTR}

 University of Louisville Physicians › Physical Medicine & Rehabilitation › Frazier Rehab Institute & Neuroscience Center ›