Carpal Tunnel Syndrome No More
The carpal tunnel is formed by the carpal bones and the overlying flexor retinaculum. It is through this tunnel that most, but not all, of the forearm tendons and the median nerve pass. The flexor retinaculum is attached to four bony points the pisiform, the hook of the hamate, the scaphoid and the trapezium. The carpal tunnel is narrow and no arteries or veins are transmitted through it for risk of potential compression. The median nerve is however at risk of compression when the tunnel is narrowed for any reason. This is the carpal tunnel syndrome and results in signs of median nerve motor and sensory impairment. Note that the ulnar nerve and artery pass over the retinaculum and are thus outside the carpal tunnel.
The major disaster with the carpal tunnel approach is if the patient has a congenital abnormality of the motor branch to the thenar muscles that is not recognized, resulting in the branch being cut. This injury used to be called the million-dollar injury because of the size of the malpractice awards to compensate for the disability that results when the thenar muscles no longer function. Typically, the motor branch of the thenar muscles comes off the median nerve along the radial side just distal to the transverse carpal ligament and is, for the most part, out of the way if you are staying along the ulnar side of the canal. There are, however, multiple congenital abnormalities of this nerve that have been described and that put the branch at greater risk. Anything that is encountered coming through the transverse carpal ligament from its deep side should be very carefully dissected. There are typically no structures that penetrate the transverse carpal ligament.
Diabetic neuropathy rarely causes symptoms in the hands, and when it does the disease is already advanced in the feet and legs. Numbness and clumsiness of the fingers are thus very unusual and more likely to be due to some other neurological disorder. Impairment of sensation is, however, enough to prevent blind diabetics from reading braille. Paraesthesiae and numbness in the fingers, especially at night, are usually due to carpal tunnel syndrome, which is commoner than in non-diabetics. It is easily and effectively relieved by minor surgery performed under local anaesthetic without admission to hospital.
Delay in the relaxation phase of reflexes, dry skin, a husky voice, loss of the outer part of the eyebrows, and weight gain. In severe disease there is lethargy, bradycardia, hypothermia, and respiratory depression. Deposition of a mucinous substance causes thickening of the subcutaneous tissues producing a nonpitting oedema. Myxoedematous infiltration of the vocal cords and tongue can occur. Cardiovascular complications include ischaemic heart disease, bradycardia, pericardial effusion, and cardiac failure (Gomberg-Maitland & Frishman 1998). Neurological complications may involve carpal tunnel syndrome, polyneuritis, myopathy, and cerebellar syndrome.About 70 of patients have paraesthesia or sensory neuropathy. Psychiatric disturbances may predominate.
Atroshi R, Johnsson R, Ornstein R (1997) Endoscopic carpal tunnel release a prospective References assessment of 255 consecutive cases. J Hand Surg (Br) 22 42-47 Cseuz KA, Thomas JE, Lambert EH, et al (1966) Long term results of operation for carpal tunnel syndrome. Mayo Clin Proc 41 232-241 Rosenbaum RB, Ochoa JL (1993) Carpal Tunnel Syndrome and other disorders of the median nerve. Butterworth Heinemann, Boston Todnem K, Lundemo G (2000) Median nerve recovery in carpal tunnel syndrome. Muscle Nerve 23 1555-1560
FIGURE 6.3 (a) Thirty-eight-year-old male presenting with new onset headache, hand numbness, and visual changes, deteriorating to aphasia and right hemiparesis over 3 hours. This CT demonstrates a large left MCA infarct with hypoattenuation in the MCA territory, loss of normal gray-white matter differentiation, partial effacement of the frontal horn of the left lateral ventricle, and sulcal effacement within the left frontal and parietal lobes. (b) Postoperative CT after decompressive hemicraniectomy and left anterior temporal lobectomy. FIGURE 6.3 (a) Thirty-eight-year-old male presenting with new onset headache, hand numbness, and visual changes, deteriorating to aphasia and right hemiparesis over 3 hours. This CT demonstrates a large left MCA infarct with hypoattenuation in the MCA territory, loss of normal gray-white matter differentiation, partial effacement of the frontal horn of the left lateral ventricle, and sulcal effacement within the left frontal and parietal lobes. (b)...
Once you have cut the flexor retinaculum proximal to the wrist, you should palpate the transverse carpal ligament with a hemostat or other similar blunt instrument and feel the grittiness of the transverse fibers. You should also feel the hook of the hamate from inside the carpal canal and then start your transection with the nerve protected. Once you are deep to the superficial fat and the palmar fascia, any further fat that is encountered distally indicates you are already distal to the end of the ligament and are putting the superficial palmar arch at great risk. FIGURE 19 1 (Top Left) The general landmarks for surgical approaches to the hand. Kaplan's cardinal line proceeds from the ulnar border of the thumb proximal phalanx. The landmark is the deep palmar arch. At the intersection of Kaplan's line with a line following the ulnar border of the ring finger lies the hook of the hamate. At the intersection of Kaplan's line with a line extended along the radial border of the long...
Analysis of previously unexplained syndromes in patients with primary systemic amyloidosis at the time of diagnosis in an 11-year study at the Mayo Clinic. Nephrotic syndrome or renal failure was present in 28 of patients, congestive heart failure (CHF) in 17 , and carpal tunnel syndrome in 21 . Peripheral neuropathy and orthostatic hypotension also were common features. The possibility of primary systemic amyloidosis must be considered in every patient who has monoclonal protein in the serum or urine and who has unexplained nephrotic syndrome, CHF, sensorimotor peripheral neuropathy, carpal tunnel syndrome, hepatomegaly, or malabsorption. (Adapted from Kyle and Gertz 5 with permission.)
Radiograph showing carpal tunnel syndrome in a patient with dialysis-associated amyloidosis. Long-term hemodialysis often results in carpal tunnel syndrome with pain involving the shoulders, hands, wrists, hips, and knees. Cystic radiolucen-cies are common in the carpal bones. Pathologic fractures have occurred from large amyloid deposits. The major component of the amyloid is -microglobulin. (From Gertz and Kyle 3 with permission.)
Most patients experience the early warning symptoms of hypoglycaemia and can take sugar before more serious symptoms develop. These warning symptoms are well known and are described in the box. Tremulousness and sweating are by far the commonest symptoms, while circumoral paraesthesiae is the most specific. Many patients have highly individual symptoms of hypoglycaemia which range from quite inexplicable sensations to peripheral paraesthesiae. In three patients carpal tunnel compression resulted in tingling fingers when they were hypoglycaemic, representing their sole warning. Neuroglyopenic symptoms and diminished cognitive function follow if corrective action is not taken, with progressive confusion and eventually unconsciousness and occasionally convulsions. There is a prolonged debate as to whether recurrent hypoglycaemia causes long-term intellectual decline the evidence in general is unconvincing although major and recurrent episodes in childhood may have an adverse effect in...
The tendons are at risk, but they are usually large and apparent, and easy to avoid. One structure at risk that is less apparent is the terminal branch of the posterior interosseous nerve, which gives articular branches to the dorsal wrist capsule. This nerve runs deep to the extensor tendons at the radial side of the fourth compartment. Inadvertent injury to this nerve has been reported to result in painful neuroma and may be a cause of dorsal wrist pain.
Several important diagnostic tools are necessary for the proper evaluation of a patient with a suspected neuromuscular disorder. Each individual chapter in this book is headed by a tool bar , indicating the usefulness of various diagnostic tests for the particular condition discussed in the chapter. For example, genetic testing is necessary for the diagnosis of hereditary neuropathy and hereditary myopathy, while nerve conduction velocity (NCV) and electromyography (EMG) can be important but are less specific for these diseases. Conversely, NCV and EMG are the predominate diagnostic tools for a local entrapment neuropathy like carpal tunnel syndrome. Some conditions will require autonomic testing or laboratory tests.
Section at the distal end of the carpal tunnel. 1 Median nerve. 2 Ulnar nerve. 3 Deep ulnar nerve. 4 Flexor retinaculum. 5 Flexor tendons. 6 Flexor pollicis longus. 7 Abductor dig-iti minim) muscle Fig. 10. Acute carpal tunnel syndrome. A Local painful swelling of the left volar wrist, sensory loss in median nerve distribution. B After confirmation with ultrasound the median nerve was released. C Residual deficits were a sensory loss of the volar sides of the fingers (marked with a ball pen) Fig. 10. Acute carpal tunnel syndrome. A Local painful swelling of the left volar wrist, sensory loss in median nerve distribution. B After confirmation with ultrasound the median nerve was released. C Residual deficits were a sensory loss of the volar sides of the fingers (marked with a ball pen) Fig. 13. Carpal tunnel syndrome. Typical atrophy of the thenar eminence Fibers for the median nerve are found in the lateral and medial cord of the brachial plexus, C5-T1. The nerve runs along...
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