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PMR Short Cases; Chapter-5: Wrist & Hand; Short case: Carpal Tunnel Syndrome

Authors:
  • Sher-E-Bangla Medical College

Abstract

Short case of Carpal tunnel syndrome
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Figure: Carpal tunnel syndrome1
Usual instruction: Examine the hand. What are your findings. What else do you want to see?
Carpal Tunnel Syndrome
Each patient carries his own doctor inside him Norman Cousin
Chapter
5
Wrist & Hand
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Wrist & Hand
EXAMINATION:
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Carpal Tunnel Syndrome
LOOK:
Look at palmar surface and then dorsal surface of the hand
Look for wasting
Generalized wasting: C8 & T1 lesion, MND
Thenar muscle wasting: Median nerve lesion2
Figure: Gross wasting of the thenar muscles in a CTS patient3
Hypothenar and other muscles (Except thenar) wasting: Ulnar nerve lesion
Wasting in dorsum of the hand with dorsal guttering: Ulnar nerve lesion, RA
Look for Ulcer, Infarction, Gangrene, Rash, Rheumatoid nodule, Palmar erythema, puckering of palm,
Garrod’s pads, Cut injury
Look for any visible swelling along the radial aspect and styloid process to exclude Dorsal ganglion
Look for any visible deformity
Flexion deformity and contracture:
PIP: Spindle shape swelling, Boutonniere deformity
DIP: Swan neck deformity
Z deformity of thumb
Ulnar deviation and dorsal subluxation of ulna at the carpal joint
FEEL:
Patient 
IP, MCP, Wrist joint Squeeze  tenderness 
Palmar surface and dorsal surface
Rheumatoid nodule 
Heberden’s node (In DIP for OA)
Bouchard’s node (In PIP for OA)
Palpate  elbow  medial epicondyle  ulnar nerve thickening 
Radial pulse 
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Figure:4 (A). Phalen Test (B) Tinel Test
MOVE:

(To see weakness and exclude Myotonia Distrophica)
 

Median nerve lesion

 
  
Ulnar nerve lesion

C8 & T1 lesion
Maneuver:
Tinel’s test:4
Method: Examiner lightly taps along median nerve at the wrist, proximal to distal
Condition measured: Paresthesia in response to position
Positive result: Numbness or tingling on radial side digits
Interpretation of positive result: Probable CTS
Phalen’s test:4
Method: Patient hold wrist in marked flexion for 30-60 seconds.
Condition measured: Site of nerve lesion
Positive result: Tingling response in fingers
Interpretation of positive result: Probable CTS if response is at the wrist
A two-point sensory discrimination test:5
Most sensitive of the bedside examination techniques.
This involves a comparison of the two-point discriminating sensory ability of the median
with that of the ulnar nerve distribution of the hand. Careful observation of the hands,
comparing the affected side with the unaffected side and comparing the thenar and
hypothenar eminences of the same hand, may reveal an increasing asymmetry
Finkelstein test for de’ Quervain Syndrome
Sensory:
Behind the thumb: Radial nerve
Index finger: Median nerve
Little finger: Ulnar nerve
Neck movement to exclude Cervical spondylosis
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Figure: Sensory examination6
Examiner 
CTS  primary cause  evidence 

?
?


CASE PRESENTATION IN ENGLISH: (suppose all findings are on the left side)
Examination of the left hand of this middle-aged woman reveals that:
There is severe wasting in left thenar muscle
Abduction and opposition of thumb is weak
Sensory diminished in the median nerve territory
Phalen and Tinel test is positive
So, my….
Diagnosis is Carpal Tunnel Syndrome of left wrist
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RELATED QUESTIONS:
Q-What is Carpal Tunnel Syndrome?
Answer: Carpal tunnel syndrome is the most common form of entrapment neuropathy caused by the compression
of the median nerve as it passes through the carpal tunnel.7
Q-What are the causes of Carpal Tunnel Syndrome?
Answer: They are:
1. Pregnancy10,15
2. Diabetes8,11
3. RA8,15
4. Hypothyroidism8,12
5. OA of carpal bone
6. Ganglion at wrist10
7. Neurofibroma at wrist10
8. Acute trauma10
9. Obesity9,13,14
10. Exposure to vibration16,17,18,19
Q-What are your D/Ds?
Answer: They are as follows:
C/S with radiculopathy
Pronator syndrome
MND
PN
TOS
Q-How Carpal tunnel formed?
Answer: Formation of Carpal Tunnel: The carpal tunnel is a rigid, confined fibro-osseous space that
physiologically acts as a “closed compartment.”20
Medially: Pisiform, Hook of the hamate
Laterally: Tubercle of scaphoid, Crest of trapezium
Structures passing:
Superficial:
Tendon of palmaris longus
Palmar cutaneous branch of median nerve
Palmar cutaneous branch of ulnar nerve
Ulnar vessels
Ulnar nerve
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Figure: Formation of carpal tunnel21,22
Deep:
Median nerve
FDS tendon
FDP tendon
FPL tendon
Ulnar & radial bursa
Q-What are the root value, branches and muscles supplied by median nerve?
Answer: They are summarized in the following schematic diagram:21
Figure: Schematic diagram of Median nerve
Q-What is the “Gold standard test” of CTS?
Answer: Nerve conduction study.23
Q-What is the good alternative of EDX?
Answer: USG study:24
Show flattening of the nerve within the tunnel &
Enlargement of the nerve proximal and distal to the tunnel.
Q-What are the limitations of USG study?
Answer: Limitations of Ultrasound study is:2,25
Examiner’s experience
Dependent intra-rater reliability in measurement of the median nerve and
A lack of consensus in diagnostic thresholds and ideal locations for ultrasound measurement
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Q-What are your D/Ds?
Answer: D/Ds:4,23
TOS
Cervical radiculopathy
Brachial plexopathy
Pronator syndrome
Q-What are the treatment options?
Answer: Treatment of CTS:
NSAIDs
Oral steroid:32
Prednisone in doses of 20 mg daily for the first week and 10 mg daily for the second week26
Prednisolone at 25 mg daily for 10 days27
Night splint2,7,28,29,30
Figure: Wrist orthosis for CTS34
Physical Therapy:
UST7,31
Intralesional corticosteroid injection7,27,31,33
Q-What are the surgical options?
Answer: Open carpal tunnel release35
Figure: Open carpal tunnel release4
Q-Is there any validated patient reported outcome measure (PROM) for assessment of CTS available in
Bangladesh?
Answer: Yes. Bangla version of Boston Carpal Tunnel Questionnaire (B-BCTQ) is available in public domain.37
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REFERENCES:
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16. Chell J, Stevens A, Davis TR. Work practices and histopathological changes in the tenosynovium and
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ResearchGate has not been able to resolve any citations for this publication.
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A 35-year-old individual with carpal tunnel syndrome presented with tingling and numbness in the left thumb, index, and middle finger. A 3D printed CTS splint was crafted to immobilize the affected wrist joint, aiding pharmacotherapy. At six weeks, evaluations included the Boston Carpal Tunnel Questionnaire (BCTQ), Visual Analogue Scale (VAS) for pain, and Evaluation of Satisfaction with assistive Technology (QUEST) version 2.0.9. Substantial improvements were observed in Bangla-BCTQ scores (symptom severity scale: 3.68 vs. 1.27; functional status scale: 2.74 vs. 1.31), VAS (70 vs. 30), and QUEST scores. 3D printing technology may contribute to better personalized musculoskeletal care enhancing quality of life.
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Background: The aim of this study was to compare the outcomes of transverse mini-incision and traditional mini-palm incision for Carpal tunnel release. Methods: A case-control study was done at Kurmitola General Hospital, Dhaka, and at US Bangla Medical College Hospital, Narayangonj between January 2019 to December 2021. A total of 42 patients diagnosed with idiopathic CTS were equally allocated in the transverse mini-incision group (case) and traditional mini-palm incision group (control). Results: Patients operated with transverse mini-incision returned to their work significantly earlier (10.3±2.1 days) than patients operated with traditional mini-palm incision (18.7±2.3 days). No significant difference was found between group I and group II McGill pain score improvement (P=0.16) and BCTQ symptom severity score and functional severity score (P=0.61 and P=0.43 respectively). Conclusion: We conclude that no significant difference was found regarding pain, symptom, and functional outcome between the two groups. Hence, patients in group I returned early to work.
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Article
471 industrial employees from 27 occupations in four industries were surveyed to evaluate the role of occupational hand activity as a risk factor for slowing of sensory conduction of the median nerve at the carpal tunnel. After age-adjusting the latency values, slowing of the sensory fibres of the median nerve was found in 39% of the subjects and in 26% of the hands. No consistent association was found between the type and the level of occupational hand activity and the prevalence or the severity of slowing. In addition, the prevalence of bilateral slowing of conduction of the median nerve was not associated with bimanual occupational hand activity, and the length of employment of the subjects in the current industry did not influence the occurrence of impaired sensory conduction of the median nerve at the carpal tunnel.
Chapter
Carpal tunnel syndrome is the most common entrapment neuropathy in the upper extremity.
Chapter
This chapter provides a guide for prescribing and outlines the basic principles for using upper limb orthotic devices, commonly known as splints or braces. The goal is to cover the principles of upper extremity orthoses and make the indications for when to use them very clear and easy to learn. A multitude of different diagnoses are covered in detail, with a rationale for how the orthosis will correct the pathophysiology of the disease process.