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Carpal tunnel syndrome

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This article is about the medical condition. For the anatomical structure, see Carpal tunnel.
For the Fall Out Boy song, see The Carpal Tunnel of Love. For the Kid Koala album, see
Carpal Tunnel Syndrome (album).

Carpal tunnel syndrome


Classification and external resources

Transverse section at the wrist. The median nerve is


colored yellow. The carpal tunnel consists of the
bones and flexor retinaculum.
ICD-10
G56.0
ICD-9
354.0
OMIM
115430
DiseasesDB
2156
MedlinePlus
000433
orthoped/455 pmr/21 emerg/83
eMedicine
radio/135
MeSH
D002349
Carpal tunnel syndrome (CTS) is a median entrapment neuropathy, that causes paresthesia,
pain, numbness, and other symptoms in the distribution of the median nerve due to its
compression at the wrist in the carpal tunnel. The pathophysiology is not completely
understood but can be considered compression of the median nerve traveling through the
carpal tunnel.[1] It appears to be caused by a combination of genetic and environmental
factors.[2] Some of the predisposing factors include: diabetes, obesity, pregnancy,
hypothyroidism, and heavy manual work or work with vibrating tools but not lighter work
even if repetitive.[2]
The main symptom of CTS is intermittent numbness of the thumb, index, long and radial half
of the ring finger.[3] The numbness often occurs at night, with the hypothesis that the wrists
are held flexed during sleep. Recent literature suggests that sleep positioning, such as
sleeping on one's side, might be an associated factor.[4] It can be relieved by wearing a wrist
splint that prevents flexion.[5] Long-standing CTS leads to permanent nerve damage with
constant numbness, atrophy of some of the muscles of the thenar eminence, and weakness of
palmar abduction.[6]

Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one
from sleep. Pain in electrophysiologically verified CTS is associated with misinterpretation of
nociception and depression.[7]
Conservative treatments include use of night splints and corticosteroid injection. The only
scientifically established disease modifying treatment is surgery to cut the transverse carpal
ligament.[8]

Contents

1 Signs and symptoms

2 Causes
o 2.1 Work related
o 2.2 Associated conditions

3 Diagnosis
o 3.1 Differential diagnosis

4 Pathophysiology

5 Prevention

6 Treatment
o 6.1 Splints
o 6.2 Corticosteroids
o 6.3 Surgery
o 6.4 Physiotherapy therapy

7 Prognosis

8 Epidemiology

9 History

10 Notable cases

11 References

12 External links

Signs and symptoms

Untreated carpal tunnel syndrome


People with CTS experience numbness, tingling, or burning sensations in the thumb and
fingers, in particular the index, middle fingers, and radial half of the ring fingers, which are
innervated by the median nerve. Less-specific symptoms may include pain in the wrists or
hands and loss of grip strength[9] (both of which are more characteristic of painful conditions
such as arthritis).
Some posit that median nerve symptoms can arise from compression at the level of the
thoracic outlet or the area where the median nerve passes between the two heads of the
pronator teres in the forearm,[10] but this is highly debatable. This line of thinking is an
attempt to explain pain and other symptoms not characteristic of carpal tunnel syndrome.[11]
Carpal tunnel syndrome is a common diagnosis with an objective, reliable, verifiable
pathophysiology, whereas thoracic outlet syndrome and pronator syndrome are defined by a
lack of verifiable pathophysiology and are usually applied in the context of nonspecific upper
extremity pain.
Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic
symptoms (NS) of carpal tunnel entrapment syndrome. Weakness and atrophy of the thenar
muscles may occur if the condition remains untreated.[12]

Causes
Most cases of CTS are of unknown causes, or idiopathic.[13] Carpal Tunnel Syndrome can be
associated with any condition that causes pressure on the median nerve at the wrist. Some
common conditions that can lead to CTS include obesity, oral contraceptives,
hypothyroidism, arthritis, diabetes, prediabetes (impaired glucose tolerance), and trauma.[14]
Carpal tunnel is also a feature of a form of Charcot-Marie-Tooth syndrome type 1 called
hereditary neuropathy with liability to pressure palsies.
Other causes of this condition include intrinsic factors that exert pressure within the tunnel,
and extrinsic factors (pressure exerted from outside the tunnel), which include benign tumors
such as lipomas, ganglion, and vascular malformation.[15] Carpal tunnel syndrome often is a
symptom of transthyretin amyloidosis-associated polyneuropathy and prior carpal tunnel

syndrome surgery is very common in individuals who later present with transthyretin
amyloid-associated cardiomyopathy, suggesting that transthyretin amyloid deposition may
cause carpal tunnel syndrome.[16][17][18][19][20][21][22]

Work related
The international debate regarding the relationship between CTS and repetitive motion in
work is ongoing. The Occupational Safety and Health Administration (OSHA) has adopted
rules and regulations regarding cumulative trauma disorders. Occupational risk factors of
repetitive tasks, force, posture, and vibration have been cited. However, the American Society
for Surgery of the Hand (ASSH) has issued a statement claiming that the current literature
does not support a causal relationship between specific work activities and the development
of diseases such as CTS.[23]
The relationship between work and CTS is controversial; in many locations, workers
diagnosed with carpal tunnel syndrome are entitled to time off and compensation.[24] In the
USA, carpal tunnel syndrome results in an average of $30,000 in lifetime costs (medical bills
and lost time from work).[25]
Some speculate that carpal tunnel syndrome is provoked by repetitive movement and
manipulating activities and that the exposure can be cumulative. It has also been stated that
symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in
industrial occupations,[26] but it is unclear as to whether this refers to pain (which may not be
due to carpal tunnel syndrome) or the more typical numbness symptoms.[27]
A review of available scientific data by the National Institute for Occupational Safety and
Health (NIOSH) indicated that job tasks that involve highly repetitive manual acts or specific
wrist postures were associated with incidents of CTS, but causation was not established, and
the distinction from work-related arm pains that are not carpal tunnel syndrome was not clear.
It has been proposed that repetitive use of the arm can affect the biomechanics of the upper
limb or cause damage to tissues. It has also been proposed that postural and spinal assessment
along with ergonomic assessments should be included in the overall determination of the
condition. Addressing these factors has been found to improve comfort in some studies.[28]
Speculation that CTS is work-related is based on claims such as CTS being found mostly in
the working adult population, though evidence is lacking for this. For instance, in one recent
representative series of a consecutive experience, most patients were older and not working.
[29]
Based on the claimed increased incidence in the workplace, arm use is implicated, but the
weight of evidence suggests that this is an inherent, genetic, slowly but inevitably progressive
idiopathic peripheral mononeuropathy.[30]

Associated conditions
A variety of patient factors can lead to CTS, including heredity, size of the carpal tunnel,
associated local and systematic diseases, and certain habits.[1] Non-traumatic causes generally
happen over a period of time, and are not triggered by one certain event. Many of these
factors are manifestations of physiologic aging.[31]
Examples include:

Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons.

With hypothyroidism, generalized myxedema causes deposition of


mucopolysaccharides within both the perineurium of the median nerve, as well as the
tendons passing through the carpal tunnel.

During pregnancy women experience CTS due to hormonal changes (high


progesterone levels) and water retention (which swells the synovium), which are
common during pregnancy.

Previous injuries including fractures of the wrist.

Medical disorders that lead to fluid retention or are associated with inflammation such
as: inflammatory arthritis, Colles' fracture, amyloidosis, hypothyroidism, diabetes
mellitus, acromegaly, and use of corticosteroids and estrogens.

Carpal tunnel syndrome is also associated with repetitive activities of the hand and
wrist, in particular with a combination of forceful and repetitive activities[14]

Acromegaly causes excessive growth hormones. This causes the soft tissues and
bones around the carpel tunnel to grow and compress the median nerve.[32]

Tumors (usually benign), such as a ganglion or a lipoma, can protrude into the carpal
tunnel, reducing the amount of space. This is exceedingly rare (less than 1%).

Obesity also increases the risk of CTS: individuals classified as obese (BMI > 29) are
2.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS.
[33]

Double-crush syndrome is a debated hypothesis that compression or irritation of nerve


branches contributing to the median nerve in the neck, or anywhere above the wrist,
increases sensitivity of the nerve to compression in the wrist. There is little evidence,
however, that this syndrome really exists.[34]

Heterozygous mutations in the gene SH3TC2, associated with Charcot-Marie-Tooth,


confer susceptibility to neuropathy, including the carpal tunnel syndrome.[35]

Diagnosis
There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. A
combination of described symptoms, clinical findings, and electrophysiological testing is
used by a majority of hand surgeons. Numbness in the distribution of the median nerve,
nocturnal symptoms, thenar muscle weakness/atrophy, positive Tinel's sign at the carpal
tunnel, and abnormal sensory testing such as two-point discrimination have been standardized
as clinical diagnostic criteria by consensus panels of experts.[36][37] A predominance of pain
rather than numbness is unlikely to be caused by carpal tunnel syndrome no matter what the
result of electrophysiological testing.

Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively


verify the median nerve dysfunction. If these tests are normal, carpal tunnel syndrome is
either absent or very, very mild.
Clinical assessment by history taking and physical examination can support a diagnosis of
CTS.

Phalen's maneuver is performed by flexing the wrist gently as far as possible, then
holding this position and awaiting symptoms.[38] A positive test is one that results in
numbness in the median nerve distribution when holding the wrist in acute flexion
position within 60 seconds. The quicker the numbness starts, the more advanced the
condition. Phalen's sign is defined as pain and/or paresthesias in the medianinnervated fingers with one minute of wrist flexion. Only this test has been shown to
correlate with CTS severity when studied prospectively.[1]

Tinel's sign, a classic though less sensitive - test is a way to detect irritated nerves.
Tinel's is performed by lightly tapping the skin over the flexor retinaculum to elicit a
sensation of tingling or "pins and needles" in the nerve distribution. Tinel's sign (pain
and/or paresthesias of the median-innervated fingers with percussion over the median
nerve) is less sensitive, but slightly more specific than Phalens sign.[1]

Durkan test, carpal compression test, or applying firm pressure to the palm over the
nerve for up to 30 seconds to elicit symptoms has also been proposed.[39][40]

As a note, a patient with true carpal tunnel syndrome (entrapment of the median nerve within
the carpal tunnel) will not have any sensory loss over the thenar eminence (bulge of muscles
in the palm of hand and at the base of the thumb). This is because the palmar branch of the
median nerve, which innervates that area of the palm, branches off of the median nerve and
passes over the carpal tunnel.[41] This feature of the median nerve can help separate carpal
tunnel syndrome from thoracic outlet syndrome, or pronator teres syndrome.
Other conditions may also be misdiagnosed as carpal tunnel syndrome. Thus, if history and
physical examination suggest CTS, patients will sometimes be tested electrodiagnostically
with nerve conduction studies and electromyography. The goal of electrodiagnostic testing is
to compare the speed of conduction in the median nerve with conduction in other nerves
supplying the hand. When the median nerve is compressed, as in CTS, it will conduct more
slowly than normal and more slowly than other nerves. There are many electrodiagnostic
tests used to make a diagnosis of CTS, but the most sensitive, specific, and reliable test is the
Combined Sensory Index (also known as Robinson index).[42] Electrodiagnosis rests upon
demonstrating impaired median nerve conduction across the carpal tunnel in context of
normal conduction elsewhere. Compression results in damage to the myelin sheath and
manifests as delayed latencies and slowed conduction velocities [1] However, normal
electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome, as a
threshold of nerve injury must be reached before study results become abnormal and cut-off
values for abnormality are variable.[37] Carpal tunnel syndrome with normal electrodiagnostic
tests is very, very mild at worst.
The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear.
[43][44][45]

Differential diagnosis
There are some who believe that carpal tunnel syndrome is simply a universal label applied to
anyone suffering from pain, numbness, swelling, and/or burning in the radial side of the
hands and/or wrists. When pain is the primary symptom, carpal tunnel syndrome is unlikely
to be the source of the symptoms.[27] As a whole, the medical community is not currently
embracing or accepting trigger point theories due to lack of scientific evidence supporting
their effectiveness.

Pathophysiology
Main article: Carpal tunnel
The carpal tunnel is an anatomical compartment located at the base of the palm. Nine flexor
tendons and the median nerve pass through the carpal tunnel that is surrounded on three sides
by the carpal bones that form an arch. The median nerve provides feeling or sensation to the
thumb, index finger, long finger, and half of the ring finger. At the level of the wrist, the
median nerve supplies the muscles at the base of the thumb that allow it to abduct, or move
away from the fingers, out of the plane of the palm. The carpal tunnel is located at the middle
third of the base of the palm, bounded by the bony prominence of the scaphoid tubercle and
trapezium at the base of the thumb, and the hamate hook that can be palpated along the axis
of the ring finger. The proximal boundary is the distal wrist skin crease, and the distal
boundary is approximated by a line known as Kaplan's cardinal line.[46] This line uses surface
landmarks, and is drawn between the apex of the skin fold between the thumb and index
finger to the palpated hamate hook.[47] The median nerve can be compressed by a decrease in
the size of the canal, an increase in the size of the contents (such as the swelling of
lubrication tissue around the flexor tendons), or both.[48] Simply flexing the wrist to 90
degrees will decrease the size of the canal.
Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL)
causes atrophy of the thenar eminence, weakness of the flexor pollicis brevis, opponens
pollicis, abductor pollicis brevis, as well as sensory loss in the digits supplied by the median
nerve. The superficial sensory branch of the median nerve, which provides sensation to the
base of the palm, branches proximal to the TCL and travels superficial to it. Thus, this branch
spared in carpal tunnel syndrome, and there is no loss of palmar sensation.[49]

Prevention
Suggested healthy habits such as avoiding repetitive stress, work modification through use of
ergonomic equipment (wrist rest, mouse pad), taking proper breaks, using keyboard
alternatives (digital pen, voice recognition, and dictation), and employing early treatments
such as taking turmeric (anti-inflammatory), omega-3 fatty acids, and B vitamins have been
proposed as methods to help prevent carpal tunnel syndrome. The potential role of Bvitamins in preventing or treating carpal tunnel syndrome has not been proven.[50][51] There is
little or no data to support the concept that activity adjustment prevents carpal tunnel
syndrome.[52]
Biological factors such as genetic predisposition and anthropometrics had significantly
stronger causal association with carpal tunnel syndrome than occupational/environmental

factors such as repetitive hand use and stressful manual work.[52] This suggests that carpal
tunnel syndrome might not be preventable simply by avoiding certain activities or types of
work/activities.

Treatment
Generally accepted treatments include: steroids either orally or injected locally, splinting, and
surgical release of the transverse carpal ligament.[53] There is no or insufficient evidence for
ultrasound, yoga, lasers, B6, and exercise therapy.[53]
Early surgery with carpal tunnel release is indicated where there is clinical evidence of
median nerve denervation or a person elects to proceed directly to surgical treatment.[54] The
treatment should be switched when the current treatment fails to resolve the symptoms within
2 to 7 weeks. However, these recommendations have sufficient evidence for carpal tunnel
syndrome when found in association with the following conditions: diabetes mellitus,
coexistent cervical radiculopathy, hypothyroidism, polyneuropathy, pregnancy, rheumatoid
arthritis, and carpal tunnel syndrome in the workplace.[54]

Splints

A rigid splint can keep the wrist straight


The importance of wrist braces and splints in the carpal tunnel syndrome therapy is known,
but many people are unwilling to use braces. In 1993, The American Academy of Neurology
recommend a non-invasive treatment for the CTS at the beginning (except for sensitive or
motor deficit or grave report at EMG/ENG): a therapy using splints was indicated for light
and moderate pathology.[55] Current recommendations generally don't suggest immobilizing
braces, but instead activity modification and non-steroidal anti-inflammatory drugs as initial
therapy, followed by more aggressive options or specialist referral if symptoms do not
improve.[56][57]
Many health professionals suggest that, for best results, one should wear braces at night and,
if possible, during the activity primarily causing stress on the wrists.[58][59]

Corticosteroids
Corticosteroid injections can be effective for temporary relief from symptoms while a person
develops a longterm strategy that fits their lifestyle.[60] This treatment is not appropriate for
extended periods, however. In general, local steroid injections are only used until other
treatment options can be identified. For most surgery is the only option that will provide
permanent relief.[61]

Surgery
Main article: Carpal tunnel surgery

Scars from carpal tunnel release surgery. Two different techniques were used. The left scar is
6 weeks old, the right scar is 2 weeks old. Also note the muscular atrophy of the thenar
eminence in the left hand, a common sign of advanced CTS

Carpal Tunnel Syndrome Operation


Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. It is
recommended when there is static (constant, not just intermittent) numbness, muscle
weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms.[62]
In general, milder cases can be controlled for months to years, but severe cases are
unrelenting symptomatically and are likely to result in surgical treatment.[63]

Physiotherapy therapy
One review of the evidence found good evidence for splinting, ultrasound, nerve gliding
exercises, carpal bone mobilization, magnetic therapy, and yoga for people with carpal tunnel
syndrome.[64] However, a recent evidence based guideline produced by the American
Academy of Orthopedic Surgeons assigned lower grades to most of these treatments.[65]
Again, some claim that pro-active ways to reduce stress on the wrists, which alleviates wrist
pain and strain, involve adopting a more ergonomic work and life environment. For example,
some have claimed that switching from a QWERTY computer keyboard layout to a more
optimised ergonomic layout such as Dvorak was commonly cited as beneficial in early CTS
studies[citation needed], however some meta-analyses of these studies claim that the evidence that
they present is limited.[66][67]

Prognosis
Most people relieved of their carpal tunnel symptoms with conservative or surgical
management find minimal residual or "nerve damage".[68] Long-term chronic carpal tunnel

syndrome (typically seen in the elderly) can result in permanent "nerve damage", i.e.
irreversible numbness, muscle wasting, and weakness. Those that undergo a carpal tunnel
release are nearly twice as likely as those not having surgery to develop trigger thumb in the
months following the procedure.[69]
While outcomes are generally good, certain factors can contribute to poorer results that have
little to do with nerves, anatomy, or surgery type. One study showed that mental status
parameters or alcohol use yields much poorer overall results of treatment.[70]
Recurrence of carpal tunnel syndrome after successful surgery is rare.[71] If a person has hand
pain after surgery, it is most likely not caused by carpal tunnel syndrome. It may be the case
that the illness of a person with hand pain after carpal tunnel release was diagnosed
incorrectly, such that the carpal tunnel release has had no positive effect upon the patient's
symptoms.[citation needed]

Epidemiology
Carpal tunnel syndrome can affect anyone. In the U.S., roughly 1 out of 20 people will suffer
from the effects of carpal tunnel syndrome. Caucasians have the highest risk of CTS
compared with other races such as non-white South Africans.[72] Women suffer more from
CTS than men with a ratio of 3:1 between the ages of 4560 years. Only 10% of reported
cases of CTS are younger than 30 years.[72] Increasing age is a risk factor. CTS is also
common in pregnancy.

History
The condition known as carpal tunnel syndrome had major appearances throughout the years
but it was most commonly heard of in the years following World War II.[73] Individuals who
had suffered from this condition have been depicted in surgical literature for the mid-19th
century.[73] In 1854, Sir James Paget was the first to report median nerve compression at the
wrist in a distal radius fracture.[74] Following the early 20th century there were various cases
of median nerve compression underneath the transverse carpal ligament.[74] Carpal Tunnel
Syndrome was most commonly noted in medical literature in the early 20th century but the
first use of the term was noted 1939. Physician Dr. George S. Phalen of the Cleveland Clinic
identified the pathology after working with a group of patients in the 1950s and 1960s.

Carpal Tunnel Syndrome


October 27, 2008 by misssssskiinnya

Bagi anda yang sering menggunakan komputer baik untuk bekerja atau bermain, waspadailah
penyakit yang satu ini, yang sering disebut penyakit CPS (Carpal Tunnel Syndrome).
Carpal Tunnel Syndrome adalah penyakit yang terjadi pada pergelangan tangan serta jari
yang disebabkan oleh tekanan yang sering terjadi pada bagian tersebut. Dan biasanya sering
diakibatkan karena terlalu sering memakai keyboard dan mouse.
Tanda-tandanya antara lain seperti sering pegal dan atau nyeri pada bagian pergelangan
tangan maupun juga jari tangan, terutama pada bagian ibu jari, telunjuk dan jari tengah.
Gejala itu disebabkan adanya pembengkakan saraf yang melewati terowongan karpal di
pergelangan tanganGangguan ini kerap mendera individu yang sering menggunakan
pergelangan tangan dalam jangka waktu lama, seperti; memegang mouse komputer.
Gejala
1.Rasa lemah, agak kaku atau rasa janggal pada tangan dan pergelangan tangan.
2.Jari tangan terasa tak enak, kebas, mati rasa atau kesemutan terutama pada ibu jari, telunjuk
dan jari tengah. Jika dibiarkan maka kekuatan otot akan berkurang dan lama-lama fungsi
tangan akan hilang.
3.Penderita sering terbangun di malam hari karena tangan terasa nyeri dan sering disertai
kesemutan. Bila sudah sangat parah benda yang dipegang tiba-tiba bisa terlepas begitu saja.
Hal terburuk yang mungkin terjadi?? jangan dianggap enteng dengan masalah CPS ini karena
bisa saja CPS mengakibatkan putusnya sendi pergelangan tangan sehingga tangan tidak dapat
berfungsi dengan sebagaimana mestinya bahkan mungkin tidak dapat digerakkan sama
sekali. . Penyakit ini dapat disembuhkan bila cepat ditangani.
pengobatan sekarang telah mencapai kemajuan pesat, cukup banyak pasien carpal tunnel
syndrome yang membaik dengan fisioterapi,

Terapi untuk penderita tahap ringan adalah terapi konservatif alias tanpa operasi. Penderita
diberi obat untuk meredakan rasa sakit, pembengkakan dan peradangan. Kemudian dilakukan
fisioterapi yaitu menghangatkan peradangan dengan ultrasound, atau sinar laser.
Ada juga program latihan pergelangan tangan dan pemakaian wrist splint sejenis
pembungkus untuk menetralkan posisi pergelangan tangan. Wrist split ada dua macam yang
pertama bentuknya agak kaku tapi bisa digunakan saat bekerja dan yang kedua lebih kaku
untuk dikenakan saat tidur karena saat tidur kita sering tanpa sadar membengkokan tangan.
Beberapa CTS memang memerlukan tindakan pembedahan, namun kemajuan ortopedi
sekarang amat pesat, beberapa pasien hanya dibuka kulitnya 1 cm sampai 2 cm saja.
Pembedahan Pasien dengan CARPAL SINDROM

Bagaimanapun, mencegah lebih baik daripada mengobati Salah satu cara untuk melakukan
pencegahan adalah dengan cara mengetahui bagaimana duduk yang benar dan baik serta
posisi tangan pada saat menggunakan keyboard atau mouse.

SENAM TANGAN untuk menghindari CARPAL SINDROM