Carpal tunnel syndrome, Causes, Clinical features, Clinical tests, Treatment.

 Compression of the median nerve as it passes beneath the flexor retinaculum.

Causes:-
General -
Inflammatory due to joint disease - eg., rheumatoid arthritis.
Endocrine - hypothyroidism, diabetes mellitus, menopause, pregnancy, etc.,
Metabolic - Gout
Local causes - Crowding of the space, Malunited Colles' fracture, ganglion in the carpal region, Osteoarthritis of the carpal bones, and wrist contusions, haematoma, etc.,

Clinical features:-
  • Stage 1 In this stage, pain is usually the presenting complain and the patient complains of 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 2 In this stage, symptoms of tingling and numbness, pain paraesthesia, etc., are localized to areas supplied by the median nerve.
  • Stage 3 Here the patient complains of clumsiness in the hand and impairment of digital function, etc.,
  • Stage 4 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:- 
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 hand within 60sec, the test is positive. It is the most sensitive provocative test It has a specificity of 80%.
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 paraesthesia or numbness in the region of median nerve distribution of hand. It is less reliable and is specific in 65% 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% 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(15sec to 2min), The second phase is the time taken for the symptoms to disappear after release of pressure.


Treatment:-
Non - operative methods:- In the initial stages non-steroid anti-inflammatory drugs(NSAIDS) are given. If it is unsuccessful steroid like prednisolone for 8 days starting with 40 mg for 2 days are tapering by 10mg every 2 days are tried. Use of carpal tunnel splint is also advocated
Physiotherapy measures:-
  • Thermotherapy Using ultrasound, SWD helps to relieve pain.
  • Exercises Gentle relaxed passive movements, active assisted and active movements of the wrist and fingers area indicated. Treatment of the underlying disease is of utmost importance.
  • Splints Carpal tunnel splint helps.
Injection treatment:-This is indicated in  patients with intermittent symptoms, duration of complaints less than one year and if there is no sensory deficit, 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 non-operative treatment, thenar atrophy, sensory loss, etc.,

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