1. Carpal Tunnel Syndrome

2. Anatomy

3. Distribution

4. Signs & Symptoms Pain – Worse at night Paraesthesia – Sparing the Thenar Eminence Weakness and Atrophy of Thenar Muscles

5. Aetiology Intermittent or sustained high tissue pressure in the Carpal tunnel impairs microvascular circulation in the median nerve and leads to spurious generation of action potential, local demyelination, and ultimately axonal loss. Various underlying causes

6. Risk Factors and Associated Features Genetic predisposition Caucasian Age >30 Female High BMI Tunnel Structure Arthritis Pregnancy Trauma/ Fractures Overuse injuries Diabetes Dialysis Use of Mobility Aids Hypothyroidism Amyloidosis Acromegaly

7. Diagnosis Clinical Tinel’s Phalen’s Nerve Conduction Studies Additional Investigations

8. Management Conservative Medication Surgical

9. Conservative ‘Lifestyle’ Rest Hand-splints TENS Physiotherapy

10. Medication Corticosteroid/ Local Anaesthetic Injection Non-Steroidal Anti-Inflammatory Drugs Underlying causes/ issues Eg. Hydrochlorothiazide 25-200mg/day orally for 2/52 course

11. Surgical Carpal Tunnel Release For failure of medical therapy For severe ENG findings

12. Brachial Plexus Crush Syndrome Damage in one area increases the likelihood of damage elsewhere along the nerve Carpal Tunnel + Bellies of Pronator Terries Carpal Tunnel + Cervical Radiculopathy

13. Bland JDP. Carpal Tunnel Syndrome. British Medical Journal. 335 (7615): 343-346. 2007. De Rijk MC, et al. Does Carpal tunnel syndrome predict an underlying cause? Journal of Neurology, Neurosurgery & Psychiatry. 78 (6): 635-637. 2007. Van Dijk MA, et al. Indications for requesting laboratory tests for concurrent diseases in patients with carpal tunnel syndrome: a systematic review. Clin Chem. 2003. BMJ Best Practice. Last updated 2014 Aug 11. Viewed 2014 September 30. http://bestpractice.bmj.com/best-practice/monograph/380.html Kumar P, Clark M (Ed.). Kumar & Clark’s Clinical Medicine. 7 th Edn. Saunders Elsevier. 2009. East Kent Hospital Foundation. NHS Trust. Double Crush Syndrome. Carpal-Tunnel.net. Revised 2012 Feb 24. Viewed 2014 September 30. http://www.carpal-tunnel.net/about-cts/doublecrushhttp://www.carpal-tunnel.net/about-cts/doublecrush Osterman AL. The double crush syndrome. Orthop Clin North Am. 19 (1): 147-155. 1988. Flak M, et al. Double Crush Syndrome Evaluation in the Median Nerve in Clinical, Radiological and Electrophysiological Examination. Studies Health Technology Information. 123 (5): 435-441. 2006.

14. Thankyou