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REVIEW OF ANATOMY UNDERLYING CARPAL TUNNEL SYNDROME.

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Presentation on theme: "REVIEW OF ANATOMY UNDERLYING CARPAL TUNNEL SYNDROME."— Presentation transcript:

1 REVIEW OF ANATOMY UNDERLYING CARPAL TUNNEL SYNDROME

2 CARPAL TUNNEL SYNDROME Carpal tunnel syndrome is one of the most common workplace injuries. It results from compression of the median nerve as it passes into the hand and can be treated surgically by opening the carpal tunnel (decompression). Knowledge of the anatomy of the upper extremity and hand is essential in the diagnosis and treatment of carpal tunnel syndrome. MEDIAN NERVE

3 Clavicle Scapula Humerus Radius Ulna Carpal bones Metacarpals Phalanges BONES OF UPPER EXTREMITY CARPAL BONES ARE LOCATED IN THE PROXIMAL PART OF THE HAND

4 Styloid process of Ulna Sesamoid bones Distal phalanges Middle phalanges Proximal phalanges Metacarpal bones Styloid process of Radius Hook of hamate AP RADIOGRAPH OF RIGHT HAND CARPAL BONES Wrist Joint

5 THUMB CARPAL BONES FORM A 'TUNNEL' FOR PASSAGE OF STRUCTURES INTO THE HAND TWO ROWS OF BONES: Order (lateral to medial) Proximal Row - Scaphoid, Lunate, Triquetrum, Pisiform Distal Row - Trapezium, Trapezoid, Capitate, Hamate ANTERIOR VIEW OF LEFT HAND MNEMONIC: SOME LOVERS TRY POSITIONS THAT THEY CAN'T HANDLE Trapezium Pisiform Hook of Hamate Trapezoid Capitate Hamate Scaphoid Lunate Triquetrum

6 Trapezium Pisiform Ulnar Styloid Process Hook of Hamate Radial Styloid Process Trapezoid Capitate Hamate Scaphoid Lunate Triquetrum Radius Ulna First Metacarpal AP RADIOGRAPH OF WRIST OF LEFT HAND THUMB

7 FLEXION AT WRIST, FINGERS SUPINATION = PALM UP (FORWARD) MOVEMENTS OF FOREARM, HAND EXTENSION/FLEXIONSUPINATION/PRONATION PRONATION= PALM DOWN (BACK) EXTENSION AT WRIST, FINGERS

8 MANY MUSCLES THAT MOVE THE HAND AND FINGERS ARE LOCATED IN THE FOREARM FLEXION AT WRIST EXTENSION AT WRIST EXTENSOR/SUPINATORS POSTERIOR FOREARM: WRIST, FINGER EXTENSORS ANTERIOR FOREARM: WRIST, FINGER FLEXORS FLEXOR/PRONATORS SUPERFICIAL DEEP Large muscles in forearm can produce powerful grip with the hand

9 TENDONS OF LONG FLEXOR MUSCLES PASS INTO THE HAND UNDER THE FLEXOR RETINACULUM - prevents bowstringing of tendons INSERT - MIDDLE PHALANGES DIGITS 2-5 INSERT - DISTAL PHALANX OF THUMB FLEXOR DIGITORUM SUPERFICIALIS ORIGIN - RADIUS, HUMERUS (MEDIAL EPICONDYLE), ULNA FLEXOR POLLICIS LONGUS ORIGIN - RADIUS, INTEROSSEUS MEMBRANE FLEXOR DIGITORUM PROFUNDUS ORIGIN - ULNA, INTEROSSEUS MEMBRANE INSERT - DISTAL PHALANGES DIGITS 2-5 FLEXOR RETINACULUM = TRANSVERSE CARPAL LIGAMENT SUPERIFICIAL LAYER DEEP LAYER

10 FLEXOR RETINACULUM (TRANSVERSE CARPAL LIGAMENT) ATTACHES TO CARPAL BONES FLEXOR RETINACULUM - attaches CARPAL BONES DO NOT LIE FLAT BUT ARE ARCHED AND CREATE A TUNNEL HAMATE laterally to SCAPHOID, TRAPEZIUM plane of cut medially to PISIFORM, HOOK OF HAMATE FLEXOR RETINACULUM FLEXOR TENDONS IN CARPAL TUNNEL MEDIAN NERVE THUMB

11 COMMON SYNOVIAL SHEATH FOR FLEXOR DIGITORUM SUPERFICIALIS AND PROFUNDUS; EXTENDS UNDER FLEXOR RETINACULUM SYNOVIAL SHEATH FOR FLEXOR POLLICIS LONGUS DIGITAL SYNOVIAL SHEATH IN FINGERS FIBROUS DIGITAL SHEATH SURROUNDS SYNOVIAL SHEATH SYNOVIAL SHEATHS SURROUND FLEXOR TENDONS - SYNOVIAL SHEATHS SECRETE SYNOVIAL FLUID - ACTS AS LUBRICANT - REDUCES FRICTION WHEN TENDONS MOVE UNDER FLEXOR RETINACULUM SYNOVIAL SHEATHS CAN BECOME INFLAMED AND SWOLLEN WITH REPETITIVE MOVEMENTS

12 C5 C6 C7 C8 T1 Clavicle 1. Ulnar n. 4. Radial n. 3. Musculocutaneous n. 2. Median n. Trunks Divisions Cords BRANCHES BRACHIAL PLEXUS - sensory and motor innervation of upper extremity - PROXIMAL PART OF BRACHIAL PLEXUS INNERVATES SHOULDER AND BACK - FOUR LARGE BRANCHES INNERVATE ARM AND HAND: MEDIAN, ULNAR, MUSCULOCUTANEOUS AND RADIAL NERVES

13 AXILLARY NERVE RADIAL NERVE MUSCULO- CUTANEOUS NERVE MEDIAN NERVE RADIAL NERVE ULNAR NERVE ULNAR NERVE BRANCHES OF BRACHIAL PLEXUS PROVIDE SENSORY INNERVATION TO SKIN OF ARM AND HAND DORSAL VENTRAL

14 MEDIAN NERVE INNERVATES MUSCLES OF FOREARM AND HAND, SENSORY TO SKIN OF HAND MEDIAN NERVE arises from medial and lateral cords (M of brachial plexus) MOTOR TO FLEXOR/ PRONATOR MUSCLES - innervates most muscles of anterior forearm MOTOR TO SOME, IMPORTANT MUSCLES OF HAND - Median nerve innervates muscles of thenar ( thumb ) eminence and first two lumbricals Passes under Flexor retinaculum to enter hand SENSORY innervation to lateral palm and lateral 3.5 digits PALMAR SIDE DORSAL SIDE

15 LUMBRICALS 1,2 MUSCLES OF THENAR EMINENCE - Flexor pollicis brevis Abductor pollicis brevis Opponens pollicis FLEX/EXTEND AB/ADDUCT OPPOSE IN HAND, MEDIAN NERVE INNERVATES MOST MUSCLES OF THE THUMB DAMAGE TO MEDIAN NERVE PRODUCES LOSS OF OPPOSITION OF THUMB

16 BRANCHES TO LUMBRICALS 1,2 RECURRENT BRANCH OF MEDIAN NERVE - TO MUSCLES OF THENAR EMINENCE - Flexor pollicis brevis, Abductor pollicis brevis Opponens pollics MOTOR BRANCHES OF MEDIAN NERVE TO MUSCLES OF HAND PASS THROUGH THE CARPAL TUNNEL FLEXOR RETINACULUM = TRANSVERSE CARPAL LIGAMENT

17 MOST SENSORY BRANCHES OF MEDIAN NERVE PASS THROUGH CARPAL TUNNEL Note: Palmar Cutaneous branch of Median Nerve does not pass through carpal tunnel Digital sensory branches of Median nerve pass through the carpal tunnel SENSORY innervation to lateral palm and lateral 3.5 digits (thumb to lateral side of ring finger); on dorsal side, skin over the distal phalanges of same digits PALMAR SIDE DORSAL SIDE

18 COMPRESSION OF MEDIAN NERVE IN CARPAL TUNNEL MEDIAN NERVE FLEXOR RETINACULUM FLEXOR TENDON SYNOVIAL SHEATH CARPAL BONES SWELLING OF SYNOVIAL SHEATHS PRODUCES COMPRESSION OF MEDIAN NERVE BECAUSE FLEXOR RETINACULUM AND CARPAL BONES ARE RIGID AND DO NOT STRETCH Ulnar nerve does not pass through carpal tunnel

19 SYMPTOMS OF CARPAL TUNNEL SYNDROME: MOTOR WEAKNESS OR PARALYSIS PARALYSIS OF MUSCLES OF THUMB - due to damage to Recurrent Branch of Median nerve Atrophy of muscles of thenar eminence - muscles at base thumb look flattened Loss of Opposition of Thumb OPPOSE

20 Note: Palmar Cutaneous branch of Median Nerve does not pass through carpal tunnel Digital sensory branches of Median nerve SYMPTOMS OF CARPAL TUNNEL SYNDROME: SENSORY LOSS SENSORY LOSS - anesthesia or numbness in distal part lateral palm; lateral 3.5 digits (thumb to lateral side of ring finger); on dorsal side, skin over the distal phalanges of same digits Note: Skin of proximal part of lateral palm may show no sensory loss (Palmar Cutaneous branch)

21 ULNAR NERVE IS NOT AFFECTED IN CARPAL TUNNEL SYNDROME ULNAR NERVES DOES NOT PASS THROUGH CARPAL TUNNEL Ulnar nerve innervates all other intrinsic muscles of hand (ex. interosseus muscles) Sensory innervation to medial palm and medial 1.5 digits MEDIAN NERVE ULNAR NERVE

22 RADIAL NERVE IS NOT AFFECTED IN CARPAL TUNNEL SYNDROME RADIAL NERVE - Innervates extensor muscles of arm and forearm (damage produces WRIST DROP) - Sensory innervation to dorsum of arm, forearm and hand In Hand: Radial nerve innervates no muscles - only sensory to dorsum of hand - does not pass through Carpal Tunnel RADIAL NERVE POSTERIOR ARM FOREARM: WRIST, FINGER EXTENSORS RADIAL NERVE IN SPIRAL GROOVE MOTOR SENSORY

23 3) Median nerve 2) Flexor carpi radialis tendon 6) Flexor carpi ulnaris tendon 5) Ulnar nerve and artery 1) Radial artery 4) Flexor digitorum superficialis and Palmaris longus tendons THUMB IS LATERAL ORDER OF STRUCTURES AT WRIST: LATERAL TO MEDIAL KNOW FOR SURGERY, REPAIR


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