University of Louisville Lunch & Learn

1. University of LouisvilleLunch & Learn Carpal Tunnel Syndrome: A Common Problem with Sometimes Unusual Symptoms Michael D. Weaver, DO Physical Medicine & Rehabilitation Sports Medicine October 16, 2013

2. Objectives • Become familiar with the basic anatomy of the wrist and causes of carpal tunnel syndrome {CTS}. • Obtain a better understanding of the signs and symptoms associated with CTS. • Become familiar with some of the various testing and treatments for CTS.

3. Background • Entrapment of the median nerve at the carpal tunnel is the most common and best characterized peripheral compression neuropathy • Prevalence: 2% Male & 3% Female • 0.1% to 10% of the population • Higher rates reported in those individuals involved in repetitive wrist motion activities • No concrete data supporting cumulative trauma • 50% of patients have bilateral CTS • ~38% are asymptomatic in ‘uninvolved’ hand

4. Risk Factors • Likely play a role by either increasing pressure within the CT or increasing susceptibility of the median nerve to pressure, however CTS is largely idiopathic • Normal – 2.5mm Hg (neutral) • CTS – 32mm Hg increased to 94-110mm Hg with wrist flexion/extension • Neuronal changes in < 2 hours • Contributing Factors: • Pregnancy, thyroid disorders, chronic kidney disease, acromegaly, diabetes, obesity, smoking, alcohol abuse, inflammatory arthritis, genetics

5. Pathophysiology • Chronic compression of nerve inhibits axonal transport and epidural blood flow which results in intraneural edema, myelin thinning, nerve fiber degeneration and fibrosis. • Impaired nerve circulation • Diminished nerve elasticity • Decreased nerve gliding

7. Nerve Compression

8. Anatomy • Median nerve travels beneath transverse carpal ligament along with 9 tendons • Flexor Digitorum Profundus {FDP} – 4 • Flexor Digitorum Superficialis {FDS} – 4 • Flexor Pollicis Longus {FPL} • Provides motor and sensory input to a portion of the hand

10. Median Neuropathy • Clinical Features • Pain, numbness, tingling in digits I-III • Sparing of sensation to thenar eminence {palm} • Palmar cutaneous sensory branch • More commonly c/o entire hand and vague complaints of pain in the shoulder and sharp shooting pains up the forearm • 50% of patients reliably localize • Neck pain is NOT an associated symptom

11. Carpal Tunnel Syndrome

12. CTS Symptoms • Usually worsen at night and can awaken patients from sleep • + flick sign • Exacerbated when driving or talking on the phone • Frequently dropping objects, weak grip • Fatigues with repetitive activity

13. Physical Examination • Visual Inspection • Asymmetry • Skin Changes • Strength • Sensation • Light touch/Pinprick • Vibration • 2 point discrimination • Provocative Maneuvers

14. Physical Examination • Tinel’s sign • Phalen Maneuver • Reverse Phalen • Carpal Compression • Durkan’s

15. Provocative Maneuvers

17. Masqueraders • Pronator Syndrome • Compression of the median nerve as it passes through the pronator teres muscle at the elbow • Double Crush Syndrome • Concomitant involvement of a pinched cervical nerve root in the neck • C6 and C7 • Thorough history and physical examination

18. Diagnosis • Truly a clinical diagnosis • Constellation of symptoms • Use of diagnostic tools • Ultrasound • Electrodiagnostic Studies

19. Ultrasound • Noninvasive • Allow for real-time visualization of nerve • Assist in guided injections

20. Electrodiagnosis • Nerve Conduction Studies • Electromyography

21. Treatment • Conservative • Activity modification • Wrist splints • Corticosteroid injection • US therapy • Nerve gliding • Medications • Vitamin B6 • NSAIDs v oral steroids • Surgical • Open v Endoscopic carpal tunnel release {CTR}

24. Referral Information • University of Louisville Physicians • Physical Medicine & Rehabilitation • Frazier Rehab Institute & Neuroscience Center • 502.584.3377

25. Thank You!