CARPEL TUNNEL SYNDROME

CAUSE AND EFFECT THE

CONFUSION

RICHARD RADECKI MDMEDICAL REHABILITATION CENTER OF NM

1. EVIDENCE BASED MEDICINE = CONSCIENTIOUS, EXPLICIT, AND JUDICIOUS USE OF CURRENT BEST EVIDENCE IN MAKING DECISIONS ABOUT CARE OF INDIVIDUAL PATIENTS

2. EPIDEMIOLOGY = BIOMEDICAL DISCIPLINE FOCUSED ON THE DISTRIBUTION AND DETERMINANTS OF DISEASE IN GROUPS OF PEOPLE WHO HAPPEN TO HAVE SOME CHARACTERISTICS, EXPOSURE, OR DISEASE IN COMMON

DEFINITIONS

3. CAUSE = AN EVENT, CONDITION OR CHARACTERISTIC THAT PLAYS AN ESSENTIAL ROLE IN PRODUCING AN OCCURRENCE OF THE DISEASE

4 RISK = THE PROBABLITY THAT AN EVENT WILL OCCUR

5. RISK FACTOR = ENVIROMENTAL, BEHAVIORAL, OR BIOLOGIC FACTOR CONFIRMED BY TEMPORAL SEQUENCE, THAT IF PRESENT, DIRECTLY INCREASES THE PROBABILITY A DISEASE WILL OR WILL NOT OCCUR

DEFINITIONS

KEYBOARD ACTIVITIES COLD ENVIRONMENT LENGTH OF EMPLOYMENT DOMINANT HAND AWKWARD POSTURE BLUNT WRIST TRAUMA REPETITIVE WORK ALONE OR COMBINIATION

OF FACTORS SMOKING

INSUFFICIENT EVIDENCE

AGE = AGING BMI (BODY MASS INDEX) SEX - FEMALE ETHNICITY FAMILIAL PERSONNEL FACTORS

STRONG EVIDENCE

THE INDUSTRIAL COMMITTEE OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND

CONFIRMATION OF CARPEL TUNNEL SYNDROME PER ELECTRODIAGNOSTIC CRITERIA

“REPETITIVE” ACTIVITY – “AWKWARD POSTURE” DIAGNOSTIC TECHNIQUE FOR “ABNORMAL”

NO CAUSUAL RELATIONSHIP

OBJECTIVE CONFIRMATION OF MEDIAN NERVE SLOWING WITH AT LEAST SOME NONSPECIFIC SYMPTOMS OF CTS

PATIENT MAY OR MAY NOT BE SYMPTOMATIC ONLY MEDIAN CONDUCTION STUDIES PROVIDE

OBJECTIVE DIAGNOSIS WITH LOCALIZATION AND QUANTIFICATION

IS “ABNORMAL” ABNORMAL COMPARISON BETWEEN OTHER NERVES STUDIED GIVES

STRONGER DIAGNOSTIC WIEGHT TO “ABNORMAL”

CARPEL TUNNEL DEFINITION

MEN – MAYO CLINIC 22 % 1961-1980 CHINA – MEN = 16% SOUTH AFRICA – PRIMARY/TERTIARY CLINIC

DIAGNOSED 26 BLACK MEN WITH CTS OUT OF 6 MILLION NON-WHITE PATIENTS

0% WAS WORK RELATED OR IDIOPATHIC

2 FRACTURE, 2 INFECTIONS,1 GANGLION

GENDER AND ETHNICITY

PHALEN STATED, “MANY PATIENT SAY THEIR PARENTS AND GRANDPARENTS HAD SIMILAR COMPLAINTS”

PROSPECTIVE STUDY FOUND◦ A 4 GENERATION FAMILY WITH CTS◦ IDENTICAL TWINS WITH CTS◦ 115/421 PATIENTS WITH MEDIAN NERVE SLOWING

TO HAVE ONE OR MORE FAMILY MEMBERS WITH CTS OR HISTORY OF MEDIAN NERVE DECOMPRESSION

◦ = 40% PREVALENCE OF CTS IN PATIENTS WITH PRIOR MEDIAN NERVE SURGERY

HEREDITY

POTENTIAL HERITABLE PERSONAL CHARACTERISTICS

BASAL MASS INDEX (BMI) GREATER THEN AVERAGE WRIST DEPTH VS WIDTH

(INCREASE WRIST RATIO) THICKER THEN NORMAL CARPEL TUNNEL LIGAMENT CERTAIN FAMILIAL CASE REPORTS SHOW 100 %

INCIDENCE OF CTS IN THE FAMILY. FAMILY AGE GROUPS AFFECT 4 Y.O. TO MIDDLE AGES

HEREDITY

LESS THEN 30 Y.O INCIDENCE = 3.9-12 % LESS THEN 40 Y.O. INCIDENCE = 12.5-22.7% 946 WOMEN AGE FACTOR MORE SPECIFIC

REGARDLESS OF WORK-RELATEDNESS OF PATIENTS COMPLAINTS

AGE MORE SIGNIFICANT THEN DURATION OF EMPLOYMENT

IE. POULTRY INDUSTRY

4462 ARMY PERSONNEL SENSORY MEDIAN .127M/SEC/YR MOTOR MEDIAN .108 M/SEC/YR

AGE = AGING PROCESS

OBESITY, SHORTER STATURE, WEIGHT GAIN MALE PATIENTS OF NORMAL BMI (SLENDER)

=0% CTS NONPATIENT POPULATION (ASYMPTOMATIC)

FOUND HIGH CORRELATION IN 427 PATIENTS WITH MEDIAN NERVE SLOWING

MEDIAN – ULNAR SENSORY LATENCY HAS STRONG CORRELATION TO BMI

PATIENTS WITH HIGHEST BMI HAD 100% PRESENCE OF MEDIAN NERVE SLOWING (15 TO 60KG/m2)

BODY MASS INDEX (BMI)

STRONG POSITIVE COORELATION BETWEEN MEDIAN MOTOR LATENCY AND THE WRIST RATIO( LONGER LATENCY WITH HIGHER RATIO) ADJUSTING FOR AGE AND SEX

1472 PATIENTS STRONG ASSOCIATION (P< .0001) WEATHER OR NOT WORK RELATED

WRIST DEPTH DIVIDED BY WIDTH (1983) SIGNIFICANT IN BOTH ASYMPTOMATIC AND PATIENTS

AUTO WORKERS WRIST RATIO X> OR = .7 OR GREATER HAD MEDIAN NERVE SLOWING (WITHIN 4-12 MONTHS OF EMPLOYMENT) 29/39 = 74 %, ADJUSTED FOR AGE AND SEX

JOHNSON WRIST RATIO

0 % INCIDENCE WITH RECTANGULAR WRIST TO NEARLY 100% INCIDENCE WITH HIGH RATIOS REGARDLESS OF OCCUPATION

ANOTHER STUDY STUDENTS, WORKERS, AND PATIENTS FOUND WRIST RATIO ONE OF 3 PERSONAL FACTORS EXCEEDING ANY OCCUPATIONAL FACTORS FOR MEDIAN LATENCY VARIATION

JOHNSON WRIST RATIO

DISTAL FOREARM, WRIST, HAND ? DID TRAUMA CAUSE AGRAVATION OF PRE-

EXISTING CTS / ASYMPTOMATIC (92 WITH COLLES’S FRACTURE;80 WOMEN)

1961 -1980 3/79 SAME DAY 56/79 DAY 2 AND 2 YEARS (59/79 = 74%) FOR BLUNT TRAUMA WITHOUT FRACTURE 8/1016 (.7%)

TRAUMA, WRIST FRACTURES AND FALLS

FORMULA IS UNEFFECTED BY OCCUPATOIN UTILIZING GENDER, HANDEDNESS, LACK OF

MAJOR WRIST TRAUMA IE. FRACTURES THE “EXPECTED”LATENCY DIFFERENCE =

-4.463+5.644 X RIGHT WRIST RATIO+.O23 X BMI / .011 X AGE

PREDICTS THE EXPECTED PALMAR LATENCY DIFFERENCE BETWEEN THE MEDIAN AND ULNAR NERVE LATENCIES IN RIGHT – HAND – DOMINANT WOMAN

PREDICTED PALMAR LATENCY DIFFERENCE OF .2 MSEC OR LESS (N=24) LACKED ACTUAL MEDIAN NERVES SLOWNESS

PREDICTED MEDIAN PALMAR LATENCY DIFFERENCE >1 34/35 HAD PALMAR LATENCY DIFFERENCE .4MSEC

CTS EQUATION

QUESTIONS

THANK –YOU HAVE A HAPPY THANKSGIVING