Carpal Tunnel Syndrome
Aetiology
- Pregnancy
- Obesity
- Diabetes Mellitus
- Hypothyroidism
- Acute fluid retention
- Connective tissue diseases
- Rheumatoid arthritis
- Local abnormalities/lesions involving the wrist, including previous fractures
Differential Diagnosis
- Cervical radicular pain (C6 or C7): Neck pain, positive Spurlings test
- First Carpometacarpal Joint Osteoarthritis : Painful thumb motion, positive grind test, radiographic findings
- De Quervain Tendinopathy: Tenderness distal radial styloid
- Polyneuropathy: History of diabetes mellitus, bilateral, lower extremity involvement.
- Thoracic Outlet Syndrome: ulnar sided symptoms, positive EAST and ULTT.
- Pronator teres syndrome (median nerve compression at the elbow): Forearm pain; sensory loss over the thenar eminence; weakness with thumb flexion, wrist extension, and forearm pronation
- Ulnar neuropathy: Paresthesias of the ring and little fingers, positive Tinel sign and compression tests at the elbow or wrist (Guyon canal)
- Radial neuropathy
- Raynaud syndrome:Symptoms related to cold exposure, typical color changes
- Vibration white finger:Use of vibratory hand power tools, symptoms of Raynaud phenomenon
- Wrist osteoarthritis: painful wrist motion, radiographic findings
- Inflammatory arthropathy
- Peripheral nerve tumour
- Multiple sclerosis
- Amyotrophic lateral sclerosis
- Acute compression syndromes (eg, Saturday night palsy)
Assessment
- Symptoms are often variable but classically include pain or paraesthesia in the median nerve distribution.
- Neurological examination
- Provocative tests
| Test Name | LR+ | LR- | Sens | Spec | Kappa |
|---|---|---|---|---|---|
| Flick sign | 21 | 0.1 | 93% | 96% | |
| Closed fist sign | 7.3 | 0.4 | 61% | 92% | |
| Hypalgesia | 3.1 | 0.7 | 39% | 88% | |
| Square wrist sign | 2.7 | 0.6 | 53% | 80% | |
| Classic or probable Katz hand diagram | 2.4 | 0.5 | 64% | 73% | |
| Weak thumb adduction | 1.8 | 0.5 | 65% | 65% | |
| Thenar atrophy | 1.6 | 0.9 | 16% | 90% | |
| Abnormal vibration | 1.6 | 0.8 | 36% | 77% | |
| Abnormal monofilament findings | 1.5 | 0.7 | 59% | 59% | |
| Bilateral symptoms | 1.4 | 0.7 | 61% | 58% | |
| Tinel sign | 1.4 | 0.8 | 36% | 75% | |
| Phalen sign | 1.3 | 0.7 | 57% | 58% | |
| Age > 40 years | 1.3 | 0.5 | 80% | 41% | |
| Nocturnal paresthesias | 1.2 | 0.7 | 70% | 43% | |
| 2-point discrimination | 1.2 | 1.0 | 20% | 83% |
Investigations
Not normally required, but can include nerve conduction studies or diagnostic ultrasound. These modalities cannot exclude the condition.
Treatment
Conservative treatment for mild and intermittent symptoms, or symptoms that are likely to resolve soon such as during pregnancy.
- Activity Modification
- Corticosteroid injection
See Carpal Tunnel Injection article.
- Splinting
A hand therapist can provide a custom thermoplastic or the patient can buy an off the shelf splints.
- Manual Therapy
In one study 120 women with carpal tunnel syndrome were randomised to hand therapy versus surgery with no significant differences in pain or function at 1 year and 4 years. The hand therapy group had three 30 minute weekly sessions of physical therapy (figure). The sessions included desensitisation techniques targeted at potential sites of median nerve entrapment, lateral glide mobilisation of the cervical spine, a tendon/nerve gliding exercise, and instructions for a home tendon/nerve gliding exercise. The potential anatomical sites were scalene, pectoralis minor, bicipital aponeurosis, pronator teres, transverse carpal ligament, palmar aponeurosis. At each of these sites the therapist evaluated for pain on palpation and reproduction of sensory or motor symptoms. The surgery group also received the same educational session for performing the tendon/nerve gliding exercises at home.[2][3]
- Surgery (Carpal tunnel release or decompression)
Consider conservative therapy first until severe pain or marked neurological signs. Access to surgery is variable across New Zealand. Surgery may not result in complete recovery of any neurological deficit but may prevent progression.
References
- ↑ D'Arcy & McGee. The rational clinical examination. Does this patient have carpal tunnel syndrome?. JAMA 2000. 283:3110-7. PMID: 10865306. DOI.
- ↑ Fernández-de-Las-Peñas et al.. Manual Therapy Versus Surgery for Carpal Tunnel Syndrome: 4-Year Follow-Up From a Randomized Controlled Trial. Physical therapy 2020. 100:1987-1996. PMID: 32766779. DOI.
- ↑ Fernández-de-Las Peñas et al.. Manual Physical Therapy Versus Surgery for Carpal Tunnel Syndrome: A Randomized Parallel-Group Trial. The journal of pain : official journal of the American Pain Society 2015. 16:1087-94. PMID: 26281946. DOI.
Literature Review
Literature Review
- Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf
- Articles from all years: PubMed search, Google Scholar search.
- TRIP Database: clinical publications about evidence-based medicine.
- Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,
