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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.
orthoped/455 pmr/21 emerg/83
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]

[7] Conservative treatments include use of night splints and corticosteroid injection.1 Differential diagnosis  4 Pathophysiology  5 Prevention  6 Treatment o 6.1 Work related o 2.1 Splints o 6. Pain in electrophysiologically verified CTS is associated with misinterpretation of nociception and depression.3 Surgery o 6.2 Associated conditions  3 Diagnosis o 3.2 Corticosteroids o 6.4 Physiotherapy therapy  7 Prognosis  8 Epidemiology  9 History  10 Notable cases  11 References .Pain in carpal tunnel syndrome is primarily numbness that is so intense that it wakes one from sleep.[8] Contents  1 Signs and symptoms  2 Causes o 2. The only scientifically established disease modifying treatment is surgery to cut the transverse carpal ligament.

ganglion. Weakness and atrophy of the thenar muscles may occur if the condition remains untreated. diabetes. and trauma. hypothyroidism. arthritis.[11] Carpal tunnel syndrome is a common diagnosis with an objective. in particular the index. verifiable pathophysiology.[10] but this is highly debatable. or burning sensations in the thumb and fingers. 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. 12 External links Signs and symptoms Untreated carpal tunnel syndrome People with CTS experience numbness.[13] Carpal Tunnel Syndrome can be associated with any condition that causes pressure on the median nerve at the wrist. prediabetes (impaired glucose tolerance). and radial half of the ring fingers. which are innervated by the median nerve.[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. which include benign tumors such as lipomas. Some common conditions that can lead to CTS include obesity.[15] Carpal tunnel syndrome often is a symptom of transthyretin amyloidosis-associated polyneuropathy and prior carpal tunnel . and vascular malformation. oral contraceptives. 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). reliable. 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. tingling. or idiopathic. Numbness and paresthesias in the median nerve distribution are the hallmark neuropathic symptoms (NS) of carpal tunnel entrapment syndrome. and extrinsic factors (pressure exerted from outside the tunnel). middle fingers. Other causes of this condition include intrinsic factors that exert pressure within the tunnel.[12] Causes Most cases of CTS are of unknown causes. This line of thinking is an attempt to explain pain and other symptoms not characteristic of carpal tunnel syndrome.

Addressing these factors has been found to improve comfort in some studies.[24] In the USA.[28] Speculation that CTS is work-related is based on claims such as CTS being found mostly in the working adult population. and certain habits.[25] Some speculate that carpal tunnel syndrome is provoked by repetitive movement and manipulating activities and that the exposure can be cumulative.000 in lifetime costs (medical bills and lost time from work). genetic. [29] Based on the claimed increased incidence in the workplace. The Occupational Safety and Health Administration (OSHA) has adopted rules and regulations regarding cumulative trauma disorders. force. suggesting that transthyretin amyloid deposition may cause carpal tunnel syndrome. and are not triggered by one certain event. 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. It has been proposed that repetitive use of the arm can affect the biomechanics of the upper limb or cause damage to tissues. size of the carpal tunnel. associated local and systematic diseases. though evidence is lacking for this. in one recent representative series of a consecutive experience.[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. slowly but inevitably progressive idiopathic peripheral mononeuropathy.[30] Associated conditions A variety of patient factors can lead to CTS. in many locations. carpal tunnel syndrome results in an average of $30. Many of these factors are manifestations of physiologic aging. It has also been proposed that postural and spinal assessment along with ergonomic assessments should be included in the overall determination of the condition. workers diagnosed with carpal tunnel syndrome are entitled to time off and compensation. However. posture.[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.[23] The relationship between work and CTS is controversial. Occupational risk factors of repetitive tasks. and the distinction from work-related arm pains that are not carpal tunnel syndrome was not clear. For instance. but the weight of evidence suggests that this is an inherent. and vibration have been cited.[31] Examples include: . It has also been stated that symptoms are commonly exacerbated by forceful and repetitive use of the hand and wrists in industrial occupations. but causation was not established.syndrome surgery is very common in individuals who later present with transthyretin amyloid-associated cardiomyopathy. arm use is implicated. including heredity.[16][17][18][19][20][21][22] Work related The international debate regarding the relationship between CTS and repetitive motion in work is ongoing. most patients were older and not working.[1] Non-traumatic causes generally happen over a period of time.

 Carpal tunnel syndrome is also associated with repetitive activities of the hand and wrist.5 times more likely than slender individuals (BMI < 20) to be diagnosed with CTS. and electrophysiological testing is used by a majority of hand surgeons. reducing the amount of space. increases sensitivity of the nerve to compression in the wrist.[32]  Tumors (usually benign). however. A combination of described symptoms. .[34]  Heterozygous mutations in the gene SH3TC2. acromegaly.  Obesity also increases the risk of CTS: individuals classified as obese (BMI > 29) are 2. and use of corticosteroids and estrogens. which are common during pregnancy.  With hypothyroidism. positive Tinel's sign at the carpal tunnel. [33]  Double-crush syndrome is a debated hypothesis that compression or irritation of nerve branches contributing to the median nerve in the neck.  Medical disorders that lead to fluid retention or are associated with inflammation such as: inflammatory arthritis. generalized myxedema causes deposition of mucopolysaccharides within both the perineurium of the median nerve. confer susceptibility to neuropathy. This is exceedingly rare (less than 1%). or anywhere above the wrist. Rheumatoid arthritis and other diseases that cause inflammation of the flexor tendons. including the carpal tunnel syndrome. clinical findings. diabetes mellitus. thenar muscle weakness/atrophy. Numbness in the distribution of the median nerve. as well as the tendons passing through the carpal tunnel. amyloidosis. that this syndrome really exists. This causes the soft tissues and bones around the carpel tunnel to grow and compress the median nerve. in particular with a combination of forceful and repetitive activities[14]  Acromegaly causes excessive growth hormones. hypothyroidism. nocturnal symptoms. such as a ganglion or a lipoma. Colles' fracture.  During pregnancy women experience CTS due to hormonal changes (high progesterone levels) and water retention (which swells the synovium). There is little evidence. 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.  Previous injuries including fractures of the wrist.[35] Diagnosis There is no consensus reference standard for the diagnosis of carpal tunnel syndrome. associated with Charcot-Marie-Tooth. can protrude into the carpal tunnel.

specific.  Phalen's maneuver is performed by flexing the wrist gently as far as possible. if history and physical examination suggest CTS. very mild at worst. Thus. it will conduct more slowly than normal and more slowly than other nerves. The quicker the numbness starts. 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. This is because the palmar branch of the median nerve. [43][44][45] . very mild. 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. carpal tunnel syndrome is either absent or very. Phalen's sign is defined as pain and/or paresthesias in the medianinnervated fingers with one minute of wrist flexion.[42] Electrodiagnosis rests upon demonstrating impaired median nerve conduction across the carpal tunnel in context of normal conduction elsewhere. branches off of the median nerve and passes over the carpal tunnel. as a threshold of nerve injury must be reached before study results become abnormal and cut-off values for abnormality are variable. and reliable test is the Combined Sensory Index (also known as Robinson index). patients will sometimes be tested electrodiagnostically with nerve conduction studies and electromyography. There are many electrodiagnostic tests used to make a diagnosis of CTS. which innervates that area of the palm. Clinical assessment by history taking and physical examination can support a diagnosis of CTS.[39][40] As a note. Only this test has been shown to correlate with CTS severity when studied prospectively. Tinel's sign (pain and/or paresthesias of the median-innervated fingers with percussion over the median nerve) is less sensitive. normal electrodiagnostic studies do not preclude the presence of carpal tunnel syndrome.[1]  Tinel's sign. as in CTS. or pronator teres syndrome. the more advanced the condition. a classic — though less sensitive . but slightly more specific than Phalen’s sign.Electrodiagnostic testing (electromyography and nerve conduction velocity) can objectively verify the median nerve dysfunction.[37] Carpal tunnel syndrome with normal electrodiagnostic tests is very. but the most sensitive. then holding this position and awaiting symptoms.[41] This feature of the median nerve can help separate carpal tunnel syndrome from thoracic outlet syndrome. When the median nerve is compressed.[1]  Durkan test. The goal of electrodiagnostic testing is to compare the speed of conduction in the median nerve with conduction in other nerves supplying the hand. Other conditions may also be misdiagnosed as carpal tunnel syndrome. Compression results in damage to the myelin sheath and manifests as delayed latencies and slowed conduction velocities [1] However. If these tests are normal. The role of MRI or ultrasound imaging in the diagnosis of carpal tunnel syndrome is unclear. 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).[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.test is a way to detect irritated nerves.

The potential role of Bvitamins in preventing or treating carpal tunnel syndrome has not been proven. mouse pad). numbness.[50][51] There is little or no data to support the concept that activity adjustment prevents carpal tunnel syndrome. or move away from the fingers. Compression of the median nerve as it runs deep to the transverse carpal ligament (TCL) causes atrophy of the thenar eminence. swelling. index finger. using keyboard alternatives (digital pen. and the distal boundary is approximated by a line known as Kaplan's cardinal line. or both. 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. and B vitamins have been proposed as methods to help prevent carpal tunnel syndrome. the median nerve supplies the muscles at the base of the thumb that allow it to abduct. taking proper breaks. The carpal tunnel is located at the middle third of the base of the palm. this branch spared in carpal tunnel syndrome.Differential diagnosis There are some who believe that carpal tunnel syndrome is simply a universal label applied to anyone suffering from pain. carpal tunnel syndrome is unlikely to be the source of the symptoms. and there is no loss of palmar sensation.[48] Simply flexing the wrist to 90 degrees will decrease the size of the canal. and is drawn between the apex of the skin fold between the thumb and index finger to the palpated hamate hook.[49] Prevention Suggested healthy habits such as avoiding repetitive stress. bounded by the bony prominence of the scaphoid tubercle and trapezium at the base of the thumb. and employing early treatments such as taking turmeric (anti-inflammatory).[47] The median nerve can be compressed by a decrease in the size of the canal. opponens pollicis. omega-3 fatty acids. as well as sensory loss in the digits supplied by the median nerve. When pain is the primary symptom. weakness of the flexor pollicis brevis. and half of the ring finger. which provides sensation to the base of the palm.[27] As a whole. The median nerve provides feeling or sensation to the thumb. and the hamate hook that can be palpated along the axis of the ring finger. The superficial sensory branch of the median nerve. the medical community is not currently embracing or accepting trigger point theories due to lack of scientific evidence supporting their effectiveness. abductor pollicis brevis. voice recognition. and dictation). Thus. and/or burning in the radial side of the hands and/or wrists. The proximal boundary is the distal wrist skin crease.[52] Biological factors such as genetic predisposition and anthropometrics had significantly stronger causal association with carpal tunnel syndrome than occupational/environmental . out of the plane of the palm. branches proximal to the TCL and travels superficial to it. long finger.[46] This line uses surface landmarks. work modification through use of ergonomic equipment (wrist rest. Pathophysiology Main article: Carpal tunnel The carpal tunnel is an anatomical compartment located at the base of the palm. At the level of the wrist. an increase in the size of the contents (such as the swelling of lubrication tissue around the flexor tendons).

For most surgery is the only option that will provide permanent relief. yoga. these recommendations have sufficient evidence for carpal tunnel syndrome when found in association with the following conditions: diabetes mellitus. during the activity primarily causing stress on the wrists. and surgical release of the transverse carpal ligament. one should wear braces at night and. In 1993.[60] This treatment is not appropriate for extended periods.[52] This suggests that carpal tunnel syndrome might not be preventable simply by avoiding certain activities or types of work/activities.[56][57] Many health professionals suggest that. However. followed by more aggressive options or specialist referral if symptoms do not improve.[54] The treatment should be switched when the current treatment fails to resolve the symptoms within 2 to 7 weeks. Treatment Generally accepted treatments include: steroids either orally or injected locally. coexistent cervical radiculopathy.factors such as repetitive hand use and stressful manual work. rheumatoid arthritis. and exercise therapy. In general. 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.[61] . splinting.[58][59] Corticosteroids Corticosteroid injections can be effective for temporary relief from symptoms while a person develops a longterm strategy that fits their lifestyle.[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. lasers. hypothyroidism.[55] Current recommendations generally don't suggest immobilizing braces.[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. however. B6. and carpal tunnel syndrome in the workplace. pregnancy. if possible. but many people are unwilling to use braces. for best results. but instead activity modification and non-steroidal anti-inflammatory drugs as initial therapy. local steroid injections are only used until other treatment options can be identified.[53] There is no or insufficient evidence for ultrasound. polyneuropathy.

milder cases can be controlled for months to years. carpal bone mobilization. involve adopting a more ergonomic work and life environment. some claim that pro-active ways to reduce stress on the wrists. the right scar is 2 weeks old.Surgery Main article: Carpal tunnel surgery Scars from carpal tunnel release surgery. a common sign of advanced CTS Carpal Tunnel Syndrome Operation Release of the transverse carpal ligament is known as "carpal tunnel release" surgery. a recent evidence based guideline produced by the American Academy of Orthopedic Surgeons assigned lower grades to most of these treatments. Also note the muscular atrophy of the thenar eminence in the left hand. but severe cases are unrelenting symptomatically and are likely to result in surgical treatment.[65] Again. and when night-splinting no longer controls intermittent symptoms. The left scar is 6 weeks old. or atrophy. Two different techniques were used. nerve gliding exercises.[68] Long-term chronic carpal tunnel . ultrasound. not just intermittent) numbness. It is recommended when there is static (constant.[66][67] Prognosis Most people relieved of their carpal tunnel symptoms with conservative or surgical management find minimal residual or "nerve damage". muscle weakness. 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]. and yoga for people with carpal tunnel syndrome.[62] In general. however some meta-analyses of these studies claim that the evidence that they present is limited.[63] Physiotherapy therapy One review of the evidence found good evidence for splinting. which alleviates wrist pain and strain.[64] However. For example. magnetic therapy.

George S.[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.S. Physician Dr. 2008 by misssssskiinnya .[70] Recurrence of carpal tunnel syndrome after successful surgery is rare. i.[74] Following the early 20th century there were various cases of median nerve compression underneath the transverse carpal ligament.[73] In 1854. anatomy.[72] Women suffer more from CTS than men with a ratio of 3:1 between the ages of 45–60 years.[73] Individuals who had suffered from this condition have been depicted in surgical literature for the mid-19th century. such that the carpal tunnel release has had no positive effect upon the patient's symptoms. 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. it is most likely not caused by carpal tunnel syndrome.[72] Increasing age is a risk factor. irreversible numbness. Sir James Paget was the first to report median nerve compression at the wrist in a distal radius fracture. muscle wasting. It may be the case that the illness of a person with hand pain after carpal tunnel release was diagnosed incorrectly. CTS is also common in pregnancy.[71] If a person has hand pain after surgery.[citation needed] Epidemiology Carpal tunnel syndrome can affect anyone. Phalen of the Cleveland Clinic identified the pathology after working with a group of patients in the 1950s and 1960s. One study showed that mental status parameters or alcohol use yields much poorer overall results of treatment.syndrome (typically seen in the elderly) can result in permanent "nerve damage". and weakness. Only 10% of reported cases of CTS are younger than 30 years.[69] While outcomes are generally good. Carpal Tunnel Syndrome October 27. or surgery type.e. 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. certain factors can contribute to poorer results that have little to do with nerves. 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. In the U.

waspadailah penyakit yang satu ini. 2. cukup banyak pasien carpal tunnel syndrome yang membaik dengan fisioterapi. . kebas. Tanda-tandanya antara lain seperti sering pegal dan atau nyeri pada bagian pergelangan tangan maupun juga jari tangan. Carpal Tunnel Syndrome adalah penyakit yang terjadi pada pergelangan tangan serta jari yang disebabkan oleh tekanan yang sering terjadi pada bagian tersebut.Jari tangan terasa tak enak. 3. agak kaku atau rasa janggal pada tangan dan pergelangan tangan. Dan biasanya sering diakibatkan karena terlalu sering memakai keyboard dan mouse. 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. memegang mouse komputer.Rasa lemah. Penyakit ini dapat disembuhkan bila cepat ditangani. 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.Penderita sering terbangun di malam hari karena tangan terasa nyeri dan sering disertai kesemutan. telunjuk dan jari tengah. Jika dibiarkan maka kekuatan otot akan berkurang dan lama-lama fungsi tangan akan hilang. terutama pada bagian ibu jari. telunjuk dan jari tengah. pengobatan sekarang telah mencapai kemajuan pesat. Bila sudah sangat parah benda yang dipegang tiba-tiba bisa terlepas begitu saja.Bagi anda yang sering menggunakan komputer baik untuk bekerja atau bermain. mati rasa atau kesemutan terutama pada ibu jari. . seperti. Gejala 1. yang sering disebut penyakit CPS (Carpal Tunnel Syndrome).

pembengkakan dan peradangan. Penderita diberi obat untuk meredakan rasa sakit. 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. Kemudian dilakukan fisioterapi yaitu menghangatkan peradangan dengan ultrasound. Pembedahan Pasien dengan CARPAL SINDROM Bagaimanapun. atau sinar laser. 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. Ada juga program latihan pergelangan tangan dan pemakaian wrist splint sejenis pembungkus untuk menetralkan posisi pergelangan tangan. namun kemajuan ortopedi sekarang amat pesat. Beberapa CTS memang memerlukan tindakan pembedahan.Terapi untuk penderita tahap ringan adalah terapi konservatif alias tanpa operasi. . beberapa pasien hanya dibuka kulitnya 1 cm sampai 2 cm saja.