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PMR SHORT CASES
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Carpal Tunnel Syndrome
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
Israt Hasan, MD
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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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Carpal Tunnel Syndrome
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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Carpal Tunnel Syndrome
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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17. Martin S. Carpal tunnel syndrome: a job-related risk. Am Pharm. 1991;31:21–24.
18. Nathan PA, Meadows KD, Doyle LS. Occupation as a risk factor for impaired sensory conduction of the
median nerve at the carpal tunnel. J Hand Surg Br. 1988;13:167–170.
19. Pelmear PL, Taylor W. Carpal tunnel syndrome and hand-arm vibration syndrome. A diagnostic enigma.
Arch Neurol. 1994;51:416–420
20. Tung W-L, Zhou C, Yoshi Y, et al. A comparative study of carpal tunnel compliance in the human, dog,
rabbit and rat. J Orthop Res. 2010; 28:652–656.
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2021. p. 849.
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24. Cartwright MS, Hobson-Webb LD, Boon AJ, et al. Evidence-based guideline: neuromuscular ultrasound
for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012;46:287–293.
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nonsurgical treatments—a systemic review. Arch Phys Med Rehabil. 2010; 91:981–1004.
29. Walker WC, Metzler M, Cifu DX, et al. Neutral wrist splinting in carpal tunnel syndrome: a comparison
of night-only versus full-time wear instruction. Arch Phys Med Rehabil. 2000; 81:424–429.
30. Hasan MI, Tasnim M, Ahmed SM, Morshed T, Deowan SA. 3D printing technology in the management
of carpal tunnel syndrome: A case report. Bangabandhu Sheikh Mujib Medical University Journal
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31. Hasan MI, Emran M, Newaz F, Md Atiquzzaman, Morshed T, Banik A, Sadeque AZ, Sharmin S.
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37. Hasan MI, Emran M, Atiquzzaman M, Morshed T, Ahmed SM, Hasan AM, Chowdhury ZR. Bangla
Version of the Boston Carpal Tunnel Questionnaire: Translation, Cross-Cultural Adaptation, Validation
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