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Carpal Tunnel Syndrome: Risk Factors, Symptoms & Treatment-physioscare

Carpal tunnel syndrome was first described by Sir James Paget3 in 1854, but the term was coined by Moerisch.

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Anatomy 
Bones bound the carpal tunnel on three sides and a ligament on one side. The floor is an osseous arch formed by the carpal bones and the transverse carpal ligament forms the roof.

Contents 
Tendons of flexor digitorum superficialis and profundus in a common sheath, tendon of flexor pollicis longus in an independent sheath and the median nerve. Synovitis of the above tendons can generate pressure on the nerve.

Causes 
General Inflammatory—e.g. rheumatoid arthritis. Endocrine—hypothyroidism, diabetes mellitus, menopause, pregnancy, etc. are some of the important endocrine causes. 

Metabolic cause—gout.

Local 
These cause crowding of the space. Malunited Colles’ fracture, ganglion in the carpal region, osteoarthritis of the carpal bones, and wrist contusion, hematoma, etc. are some of the important local causes.

Clinical Stages or Features

Stage I: In this stage, pain is usually the presenting complaint and the patient complains of characteristic discomfort in the hand, but there is no precise localization to the median nerve. There may be history of morning stiffness in the hand. 

Stage II: In this stage, symptoms of tingling and numbness, pain, paresthesia, etc. are localized to areas supplied by the median nerve. 

Stage III: Here, the patient complains of clumsiness in the hand and impairment of digital functions, etc. 

Stage IV: In this stage, sensory loss in the median nerve distribution area can be elicited and there is obvious wasting of the thenar eminence.

Clinical Tests 
These are provocative tests and act as important screening methods and as an adjunct to the electrophysiological testing.

Wrist flexion (Phalen’s test): The patient is asked to actively place the wrist in complete but unforced flexion. If tingling and numbness are produced in the median nerve distribution of the hand within 60 seconds, the test is positive. It is the most sensitive provocative test. It has a specificity of 80 percent. 

Tourniquet test: A pneumatic blood pressure cuff is applied proximal to the elbow and inflated higher than the patient’s systolic blood pressure. The test is positive if there is paresthesia or numbness in the region of median nerve distribution of the hand. It is less reliable and is specific in 65 percent of cases only. 

Median nerve percussion test: The examiner gently taps the median nerve at the wrist. The test is positive if there is tingling sensation. Seen only in 45 percent of cases. 

Median nerve compression test: Direct pressure is exerted equally over both wrists by the examiner. The first phase of the test is the time taken for symptoms to appear (15 sec to 2 min). The second phase is the time taken for the symptoms to disappear after release of pressure.

Other Tests 
Two-point discrimination test: This test is positive in about one-third cases. Electrodiagnostic tests are not very infallible with 10 percent individuals having normal values.

Treatment 
Nonoperative methods: In the initial stages, nonsteroidal anti-inflammatory drugs NSAIDs are given. If it is unsuccessful, steroids like prednisolone for 8 days starting with 40 mg for 2 days and tapering by 10 mg every 2 days are tried. Use of carpal tunnel splint is also advocated.

Injection treatment: This is indicated in patients with intermittent symptoms, duration of complaints less than one year and if there is no sensory deficits, no marked thenar wasting, etc.In the injection therapy, a single infusion of cortisone with splinting for 3 weeks is tried. 

Surgery: This consists of division of flexor retinaculum and transverse carpal ligament and is indicated in failed nonoperative treatment, thenar atrophy, sensory loss, etc. 

What is new in the treatment of carpal tunnel? 
Chow’s technique This is an endoscopic release of the carpal ligament. It is a reliable alternative for the open procedure and has a success rate of 93.3 percent.


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