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u Tinnels tap test u Brachial plexus lesions these can given similar claw hands (e.g. Klumpkes
u Tapping on the flexor retinaculum reproduces symptoms palsy).
u Phalens test u Cervical myelopathy compression of nerve roots e.g. C6 nerve root.
u Both wrists are forcibly held in flexion for at least 30 seconds
u Reproduces symptoms u Median nerve compression at the forearm this will result in more extensive
neurology, as the median nerve innervates most of the wrist flexors.
u Ulnar nerve palsy sensory and motor loss are different. Clawing is usually of
the ring and little finger.
u Glove and stocking distribution peripheral neuropathy pattern associated
with diabetes.
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Investigations Treatment
u Not everybody needs investigations, especially in the GP setting. u Nerve conduction studies can help define the level of nerve dysfunction.
u Electrodiagnostics u Non-operative treatments are appropriate for mild dysfunction/recent
u Nerve conduction studies may show conduction blocks, slowed conduction velocity.
u EMG - may show fibrillation potentials evidence of de-enervation of muscle groups; onset symptoms that could be corrected.
the role of EMG is mainly to rule out other neuromuscular conditions. u Splint keeps wrist in neutral position, good 1st line treatment for pregnancy
u Glucocorticoid injections temporarily reduce inflammation
u Imaging u Analgesics limited evidence of efficacy
u MRI C-spine may be warranted to rule out central lesions, especially if bilateral
symptoms are present. u Operative intervention should be undertaken with severe nerve
u Wrist ultrasound scans/MRI may be undertaken, especially if a structural cause is
dysfunction/prolonged symptoms.
suspected e.g. lunate bone dislocation. u Other indications loss of 2 point discrimination (indicator of severe dysfunction),
failure of conservative methods.
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u Set-up tourniquet to minimise bleeding, local analgesia with conscious sedation. u Neurovascular damage
u Palmar cutaneous branch of median nerve can result in a neuroma, so should
u Skin incision 2-4cm incision in the plane of a longitudinal in line drawn proximally
from the web space of middle/ring fingers, 2mm ulnar to the thenar crease. be removed from its proximal attachment if injured
u Median nerve
u Dissection and release Retractors are placed perpendicular to incision. u Ulnar nerve
Subcutaneous fat and palmar fascia are carefully dissected. This exposes the u Ulnar artery
transverse carpal ligament (aka flexor retinaculum) which can be dissected from
distal to proximal. u Complex regional pain syndrome
u Closure irrigation, haemostasis and wound closure completes the procedure. u Hypertrophic scar formation
u Postoperative care encourage early finger mobilisation and hand use. u Pillar pain pain adjacent to scar
Further detail: Rodner CM, Katarincic J. Open Carpal Tunnel Release. Techniques in Orthopaedics. 2006. 21(1):311
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Further reading
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