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Carpal Tunnel Syndrome

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Presentation on theme: "Carpal Tunnel Syndrome"— Presentation transcript:

1 Carpal Tunnel Syndrome
Department of Osteopathic Manipulative Medicine University of North Texas Health Science Center Texas College of Osteopathic Medicine

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3 Case Presentation A 42-year-old Caucasian female presents to your office complaining of numbness and tingling in her right hand for approximately one year. The sensation is on the palmar surface of the thumb, index, and middle fingers, and ring finger. She states that sometimes it feels like her hand is “asleep,” while other times it feels like “pins and needles.” The symptoms occur at night and the only relief is “flicking” of the wrist.

4 Case Presentation Occasionally, the pain is referred to the forearm and shoulder, but only during an acute flare-up. The patient has worked as a secretary at UNTHSC for the past 15 years. Physical examination: overweight female in NAD. Sensation full & = bilat; DTR’s 2+ & = bilat; slight atrophy and weakness of the thenar muscle and grip strength on the Rt.; decreased ROM of Rt. wrist compared to Lt.; positive Tinel’s and Phalen’s

5 Differential Diagnosis
Cervical radiculopathy Cervical disc herniation Thoracic outlet syndrome Diabetes mellitus Fracture/Dislocation Carpal tunnel syndrome

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7 What is Carpal Tunnel Syndrome?
This condition is most commonly described as an entrapment neuropathy of the median nerve at the wrist in the carpal tunnel The tunnel is formed by the carpal bones and the transverse carpal ligament Contents of the tunnel include the flexor tendons and the median nerve

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15 ANATOMY Carpal Tunnel:
space on the volar aspect of the wrist formed by the carpal bones and the transverse carpal ligament (flexor retinaculum).

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17 ANATOMY Boney Landmarks Proximal: Distal: pisiform bone - medially
scaphoid bone - laterally Distal: hook of the hamate - medial trapezium bone - laterally

18 Right Hand- Carpal Bones

19 CONTENTS OF CARPAL TUNNEL
I. Median nerve II. 2 synovial sheathes 1st sheath 8 flexor digitorum profundi and superficialis tendons. 2nd sheath flexor pollicis longus tendon.

20 Cross Section Outside Canal: palmaris longus tendon:
begins at the medial epicondyle of the humerus fans out to become the palmar aponeurosis ulnar nerve and artery: “canal of Guyon”

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23 Carpal Tunnel Anatomy Posterior Border Anterior Border Boundaries
Carpal bones Anterior Border Transverse carpal ligament Boundaries Proximally – pisiform and tubercle of navicular Distally – hook of hamate and tubercle of trapezium Contents Flexor digitorum superficialis Flexor digitorum profundus Flexor pollicis longus Median nerve

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28 Median Nerve Sensory fibers. Motor fibers.

29 Clinical Presentation Cutaneous Innervation
Median nerve cutaneous sensory distribution Palmar surfaces of Thumb Index Middle Lateral ½ of ring finger

30 How does one get carpal tunnel syndrome?
1. Increase pressure within the canal. 2. Compromise space within the canal.

31 Pressure is increased in the carpal tunnel by:
Both flexion and extension of the wrist.

32 Space is compromised in the carpal tunnel by:
Thickening of the tendon sheaths. Encroachment from other structures.

33 Secondary Etiologies Systemic diseases Pregnancy Carpal Tunnel Mass
Diabetes mellitus Thyroid disorders Rheumatoid arthritis Paget’s bone disease Gout Myxedema Multiple myeloma Acromegaly Hepatic disease Dialysis patients Leukemia Sx are frequently bilaterally with systemic diseases Pregnancy Carpal Tunnel Mass Ganglion cyst Lipoma Dislocation Misc. mass effect

34 SPECIFIC ETIOLOGIES *Nonspecific tenosynovitis Amyloidosis
Rheumatoid arthritis Hypothyroidism Boney deformities from fractures Osteoarthritis Pregnancy Tumor

35 Other Etiologies Dislocation of lunate bone.
Malunited Colle’s fracture. Certain scaphoid fractures. Soft tissue masses lipoma ganglion Hypertrophy of the volar ligament No etiology.

36 Pathophysiology of Carpal Tunnel Syndrome
1. Decreasing the volume of the tunnel. 2. Increasing the volume of the contents of the tunnel.

37 Clinical Presentation
Compression of median nerve in carpal tunnel Anesthesia Paresthesia Pain Muscle weakness Decreased ROM Night-time symptoms “Flick Sign”

38 Workers involved in specialized tasks:
1. Require repetitive use of the hand and wrist while held in forced flexion. 2. Carpal tunnel becomes tighter when wrist held in forced flexion.

39 Pathophysiology Frequently associated with repeated or sustained activity of the fingers and hands (over-use injury) i.e. typing, repeated use of tools such as a screwdriver or socket wrench, etc. Repeated activity and/or inflammation leads to compressive effect in carpal tunnel First effect → obstruction of venous return from the nerve Leads to increased capillary distension and further increases in intratunnel pressure. Cyclic, self-amplifying impairment of nutrition to the nerve

40 Pathophysiology As the condition worsens, capillary circulation is sufficiently slowed → endoneurial edema, epineural edema, and intratunnel edema In final stages → arterial insufficiency and increasing mechanical deformation which cause nerve fiber destruction and fibrous replacement “Two Hit” theory The nerve must be compressed in two different areas along its length to produce symptoms CTS patients tend to have other musculoskeletal involvement at the wrist, elbow, shoulder, or neck

41 Other proposed causes of Carpal Tunnel Syndrome:
1. “Double Crush” theory: nerve impairment occurs when single axons that are compressed in one region become especially susceptible to damage in another. 2. Decreased blood supply to median n. 3. Lymphatic or venous congestion. 4. Upper thoracic dysfunction. 5. Cervical dysfunctions - DJD

42 SIGNS AND SYMPTOMS Early - compression of sensory portion of median nerve decreased or lost sensation in the tips of the first 3 1/2 digits. “pins and needles” sensation of the digits paresthesias increase with hand and wrist in forced flexion paresthesias may awaken patient - shake wrist

43 Later Symptoms - Motor Changes
Thenar atrophy - flattening on the radial side (atrophy of abductor pollicis brevis mm.) Subjective: weak grip weak thumb abduction loss of fine motor skills decreased pinch strength

44 Physical Examination 1. Tinel’s sign 2. Phalen’s sign
a. lightly tapping over volar aspect of wrist b. + sign- tingling distally of 1st 3 1/2 digits. 2. Phalen’s sign A. George Phalen - hand surgeon of Cleveland clinic. B.Hyperflex both wrists against dorsal surface of each hand. C. + test- numbness in approx. 30 sec.

45 Special Tests Phalen’s & Tinel’s Tests
Wrist flexion to maximum for 60 sec Tinel’s Tapping over transverse carpal ligament Symptoms Pain Anesthesia Paresthesia

46 Diagnostic Tests Nerve Conduction Studies Electromyography
help differentiate CTS from: lesions of proximal median nerve brachial plexus C6-C7 radiculopathy

47 Electrophysiologic Studies
Can separate CTS into: 1. Median nerve demyelination conservative management. 2. Axonal degeneration- may require surgical intervention.

48 Magnetic Resonance Imaging
Excellent noninvasive modality. Flattening of median nerve. Volar bowing or bulging of the flexor retinaculum. Increased T2 signal density: swollen median nerve.

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50 CTS is still a clinical diagnosis.
*History *Physical Exam Both still very important.

51 Differential Diagnosis
Cervical radiculopathy Transient Ischemic Attack Diffuse peripheral neuropathy Thoracic Outlet Syndrome. Nerve entrapment affecting brachial plexus at level of cervicobrachial junction. (Check scalenes, pectoralis minor.)

52 Treatment of Carpal Tunnel Syndrome
Conservative Surgical

53 Conservative Treatments
Wrist splinting Ultrasound Anti-inflammatory medications Stretching exercises Local injection Acupuncture Osteopathic manipulation

54 Current Therapies Education NSAIDs Physical medicine
PT/OT Prevention of re-injury Stretching Injections of the tendons within the carpal tunnel Lidocaine, Marcaine, etc.. Steroids Transcarpal ligament surgical resection OMT

55 Surgical Treatment Open carpal tunnel release (OCTR).
Endoscopic carpal tunnel release (ECTR). 10% failure rate Patient may have co-existing conditions.

56 OMT Treatment Plan Global Treatment Plan Transverse carpal ligament
Carpal bones IO membrane Radius & Ulna Pectoralis minor Clavicle 1st rib Supraclavicular fascia Shoulder Girdle Cervical spine Thoracic spine

57 OMT TREATMENT Transverse Carpal Ligament Carpal Bones
Interosseous Membrane

58 Osteopathic Treatment
Myofascial release Articulatory Muscle energy

59 OMT Techniques Opponen’s Roll Squeeze with Rapid Circumduction
Wrist & Interosseous Membrane Ligament

60 Myofascial Release 1. Pressure applied centrally from the dorsal surface of the carpal bones. 2. Simultaneously apply pressure to the edges of the carpal bones on the ventral surface of the wrist. (lateral and medial borders of the carpal tunnel.) 3. Simultaneously the D.O. catches the patient’s thumb and pulls it back into hyperextension with abduction treating the attachment of the abductor pollicis brevis muscle. 4. Digits and wrist are hyperextended (pulls flexor tendons into canal and distends canal from inside out.)

61 Opponens Roll Technique
Lateral axial rotation stretches the opponens pollicis muscle. Thenar abduction with extension and lateral rotation.

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64 Opponen’s Roll Grasp first digit (thenar emin.) and fifth digit (hypothenar emin.) with each hand Contact pisiform and scaphoid bones with thumbs Extend wrist, abduct and laterally rotate first digit with counterforce over hypothenar area Use thumbs to stretch at boney contact points the transverse carpal ligament in lateral/medial direction Provide stretch to transverse carpal ligament for 3-5 minutes Perform at each clinic visit and teach patient to perform technique at home on daily basis

65 Myofascial Release 1. Crisscross thumbs over medial and lateral borders of carpal tunnel. 2. Apply gentle traction. 3. Have patient abduct fingers and hold in abduction. 4. With abduction maintained, have patient slowly flex involved wrist over D.O.’s crisscrossed thumbs.

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73 Articulatory Technique
1. D.O. applies a squeeze between his/her hands, producing traction at the joint as the thenar and hypothenar eminences separate. 2. D.O. maintains the squeeze and applies the articulatory force as a circumduction of the patient’s wrist in a clockwise, then counterclockwise conical motion, carrying the dysfunction through the restrictive barrier.

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75 Squeeze with Rapid Circumduction
Place heel of both hands over radiocarpal region of carpal bones & interlace fingers Attempt to distract fingers while squeezing fingers together Causes the heel of each hand to squeeze together Circumduct wrist in circular or figure eight fashion Care should be taken to maintain capsular tension throughout the articulatory sweep Perform at each clinic visit

76 Ligamentous Articular Strain (Conrad Speece D.O.)
Strains of the interosseous membranes result in a loss of the normal degree carrying angle of the wrist.

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79 Muscle Energy (interosseous membrane)
1. D.O. thumbs are crossed over the anterior surface of the patient’s forearm with interosseous dysfunction between his/her thumbs. 2. The pad and tip of the thumb of the hand closest to the D.O. contacts the lateral side of the ulna. The thumb of the other hand contacts the medial side of the radius. 3. Have patient attempt to pronate palm and use isometric counterforce.

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81 Flexion with Posterior Carpal Glide
1. Flex wrist to balanced ligamentous tension. 2. Apply traction. 3. Move joint into extension to articulate through the restrictive barrier.

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83 Extension With Anterior Carpal Glide
1. Extend wrist to the point of balanced ligamentous tension. 2. Apply traction. 3. Move joint into flexion to articulate the joint through the restrictive barrier.

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85 Abduction with Medial carpal Glide
1. Wrist in abduction to balance ligamentous tension. 2. Apply traction. 3. Move the joint into adduction to articulate the joint through restrictive barrier.

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87 Adduction with Lateral Carpal Glide
1. Place wrist in adduction to the point of balanced ligamentous tension. 2. Apply traction. 3. Move the joint into abduction to articulate the joint through the restrictive barrier.

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89 Patient Stretches 1. Patient places palm of affected extremity against wall. 2. Patient “hooks” hypothenar region of opposite hand into thenar region of hand to be stretched. 3. Thumb of affected extremity is grasped and extended. 4. While holding thumb and thenar eminence, palm is placed against wall in extension. 5. Elbow is tucked into patient’s iliac crest to assist with the stretch.

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