Carpal Tunnel Syndrome


Article Author:
Justin Sevy


Article Editor:
Matthew Varacallo


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
4/23/2019 11:52:18 PM

Introduction

Carpal tunnel syndrome (CTS) is an entrapment neuropathy caused by compression of the median nerve as it travels through the wrist's carpal tunnel. It is the most common nerve entrapment neuropathy, accounting for 90% of all neuropathies. Early symptoms of carpal tunnel syndrome include pain, numbness, and paresthesias. These symptoms typically present, with some variability, in the thumb, index finger, middle finger, and the radial half (thumb side) of the ring finger. Pain also can radiate up the affected arm. With further progression, hand weakness, decreased fine motor coordination, clumsiness, and thenar atrophy can occur.

In the early presentation of the disease, symptoms most often present at night when lying down and are relieved during the day. With further progression of the disease, symptoms will also be present during the day, especially with certain repetitive activities, such as when drawing, typing, or playing video games. In more advanced disease, symptoms can be constant.

Typical occupations of patients with carpal tunnel syndrome include those who use computers for extended periods of time, those who use equipment that has vibration such as construction workers, and any other occupation requiring frequent, repetitive movement. [1] [2] [3]

Etiology

Carpal tunnel syndrome results from increased pressure carpal tunnel pressure and subsequent compression of the median nerve. The most common causes of carpal tunnel syndrome include genetic predisposition, history of repetitive wrist movements such as typing, or machine work as well as obesity, autoimmune disorders such as rheumatoid arthritis, and pregnancy. [4]

Epidemiology

In the United States, carpal tunnel syndrome has an incidence of 1 to 3 persons per 1000 per year, with a prevalence of 50 per 1000, with similar incidence and prevalence in most developed countries. It most commonly affects whites, has up to a 10 to 1 predominance in females, and has a peak age of 46 to 60.  [5]

Pathophysiology

Carpal tunnel syndrome (CTS) is multifactorial, and often results from multiple patient-specific, occupational, social, and environmental risk factors.  A single, specific cause is not always determined unless there is, for example, a space-occupying lesion that can be attributable to patient-reported symptoms.  While this can be appreciated in select medical conditions (e.g., gout), these relatively straightforward clinical presentations are relatively uncommon in comparison to most presentations of CTS. 

In general, the pathophysiology of CTS results from a combination of compression and traction mechanisms.  The compressive element of the pathophysiology includes a detrimental cycle of increased pressure, obstruction of overall venous outflow, increasing local edema, and compromise to the median nerve's intraneural microcirculation.  Nerve dysfunction becomes compromised, and the structural integrity of the nerve itself further propagates the dysfunctional environment-- the myelin sheath and axon develop lesions, and the surrounding connective tissues become inflamed and lose normal physiologic protective and supportive function.  Repetitive traction and wrist motion exacerbates the negative environment, further injuring the nerve.  In addition,  any of the nine flexor tendons traveling through the carpal tunnel can become inflamed and compress the median nerve. [6]

History and Physical

Patients often report numbness, tingling, and pain that increase at night. Weakness, clumsiness, and temperature changes also are common complaints. The thumb, digits 2 and 3, and the radial half of digit 4 are typically affected. Patients with carpal tunnel syndrome often will have a positive "flick sign," meaning that symptoms improve when they flick their hand and wrist. Patients often find some relief with ice, rest if provoked by repetitive activity, and night splints.

Evaluation

Electromyography and nerve conduction studies are the basis for carpal tunnel syndrome diagnosis. Other clinical or special exams do not confirm carpal tunnel syndrome but do assist in ruling out other diagnoses. These findings can prompt electromyography and nerve conduction studies.

The clinical physical exam may include testing for sensory and motor deficits and evidence of thenar wasting. There are several special tests with varying degrees of sensitivities and specificities. 

  • The best of these include the carpal compression test. This is done by applying firm pressure directly over the carpal tunnel for 30 seconds. The test is positive when paresthesias, pain, or other symptoms are reproduced.
  • The square sign test is an evaluation to determine the risk of developing carpal tunnel syndrome. The test is positive if the ratio of the thickness of the wrist divided by the width of the wrist is great than 0.7.
  • Another test is a palpatory diagnosis. In this test, the health care provider examines soft tissue over the median nerve for mechanical restriction.
  • The Phalen's test or ‘reverse prayer’ is performed by having the patient fully flex their wrists by placing dorsal surfaces of both hands for one minute. A positive test is when symptoms (numbness, tingling, pain) are reproduced.
  • The reverse Phalen's, or ‘prayer test,’ is done by having the patient extend both of their wrists by placing palmar surfaces of both hands together for 1 minute (as if praying). Again a positive test is with reproduction of symptoms.
  • Although a low sensitivity and specificity, the Hoffmann-Tinel sign is another test commonly performed. In this test the healthcare professional taps immediately over the carpal tunnel to stimulate the median nerve. Like the above tests, a positive test is when symptoms are reproduced.

Treatment / Management

If carpal tunnel syndrome is identified early, conservative treatment is recommended. Initially, the patient should be instructed in modifying symptom provoking wrist movement. This can be through proper hand ergonomics such as placing the keyboard at a proper height and minimizing flexion, extension, abduction, and adduction of the hand when typing. It should be recommended to decrease repetitive activities if possible. Counseling on weight loss and increasing aerobic activity also can be beneficial. A properly fitted nighttime wrist splint can be offered. An occupational therapist trained in hand therapy also may be a beneficial referral. Combined therapy may be more beneficial than any single treatment. A short course of nonsteroidal anti-inflammatory medication can relieve symptoms but some do not feel it of adequate benefit.

If conservative treatments are not successful, an oral or local glucocorticoid could be offered. The definitive treatment for persistent carpal tunnel syndrome is surgical intervention with carpal tunnel release after nerve conduction studies showing significant axonal degeneration. Carpal tunnel release typically is performed by an orthopedic surgeon or hand surgeon. This procedure can be performed either open or endoscopically. Carpal tunnel release is considered a minor surgery in which the transverse carpal ligament or flexor retinaculum is cut, opening more space in the carpal tunnel and decreasing pressure on the median nerve. It does not typically require overnight hospitalization. [7] [8] [9]

Pearls and Other Issues

The carpal tunnel includes the median nerve and nine flexor tendons. The flexor tendons include the four tendons from the flexor digitorum profundus, four tendons from the flexor digitorum superficialis, and one tendon from the flexor pollicis longus. The transverse carpal ligament (flexor retinaculum) makes up the superior boundary, and the carpal bones form the inferior border.

Enhancing Healthcare Team Outcomes

The diagnosis and management of carpal tunnel syndrome is done with a multidisciplinary team that includes the primary caregiver, nurse practitioner, physical therapist, orthopedic surgeon, and the emergency department physician. The initial treatment is usually conservative combined with limiting repetitive activities.  A properly fitted nighttime wrist splint can be offered. An occupational therapist trained in hand therapy also may be a beneficial referral. Combined therapy may be more beneficial than any single treatment. A short course of nonsteroidal anti-inflammatory medication can relieve symptoms but some do not feel it of adequate benefit. 

Many other treatments are available to treat carpal tunnel syndrome including surgery. While surgery can relieve symptoms, recurrence is not uncommon. The patient must be fully educated about the potential complications of surgery which should only be undertaken after conservative treatments have failed.[10][11] (Level V)


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Carpal Tunnel Syndrome - Questions

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Which disease often presents with Tinel sign?



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Which of the following is true about carpal tunnel syndrome?



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Which of the following findings on physical examination points toward carpal tunnel syndrome?



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Once carpal tunnel syndrome has been diagnosed, what is the best treatment for a long-term outcome?



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A medical transcriptionist has had several weeks of progressive pain in the right thenar eminences and forearm. She is awakened at night due to the pain. She also complains of numbness, and today she dropped a can of soda. The patient has a history of obesity and hypothyroidism. What is the most likely diagnosis?



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A patient presents with a one-month history of numbness, tingling, and pain in the right hand and forearm. Phalen and Tinel signs are positive. What should be the next step in the management of this patient?



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Which of the following is the most appropriate initial treatment for carpal tunnel syndrome?



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Which of the following is associated with a positive Tinel sign?



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A 45-year-old teller complains of numbness of her hands after being at work for a few hours. The symptoms have been worsening with time. Which of the following would be consistent with advanced disease?



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Carpal tunnel syndrome can paralyze which of the following muscles?



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Which of the following will help to diagnose carpal tunnel syndrome?



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Median nerve compression causes which of the following syndromes?



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A positive Tinel sign in the setting of hand pain and atrophy of the thenar eminence suggests which diagnosis?



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What is the first step in a patient with carpal tunnel syndrome complaining of paresthesia?



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Which of the following muscles can be paralyzed in patients with carpal tunnel syndrome?



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A patient presents with tingling and pain in the right thumb and wrist which is worsened by her work. On physical exam, she has a positive Tinel sign. What is first line treatment for this patient?



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Where is the median nerve entrapped in carpal tunnel syndrome?



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A patient who works in a restaurant has carpal tunnel syndrome. Which of the following recommendations would be most important?



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When examining a patient with possible carpal tunnel syndrome, where should one tap to elicit Tinel sign?



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A patient has numbness of the radial three digits (i.e. thumb, index, and long finger) and progressive atrophy and weakness of the thenar muscles. There are no findings proximal to the wrist. Which nerve is most likely involved?



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Which of the following is not part of the occupational therapy intervention for carpal tunnel syndrome?



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What nerve is compressed in carpal tunnel syndrome?



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What wrist position is appropriate for a splint when treating carpal tunnel syndrome?



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Testing for neural provocation of the median nerve is to be done. Select the test that would best confirm the origin of symptoms.



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Which of the following is true of carpal tunnel syndrome?



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A 40-year-old male computer programmer presents with complaints of numbness and tingling in the right thumb and first two fingers, which is worsens at night and with activity. What disorder is present if the tingling can be reproduced with wrist flexion?



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Which is true regarding carpal tunnel syndrome?



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An MRI of a patient's wrist for carpal tunnel symptoms is being performed. Which of the following is the best orientation to show the carpal tunnel?



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What is the term for pain and disability of the wrist and hand secondary to the impingement of the median nerve?



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A 51-year-old left-handed female automobile assembly worker complains of left-handed numbness and tingling for the past several months of her thumb, index and middle fingers. She has been working the same job for 12 years. Her position requires working with her wrists in an extreme bent extension and she has been working overtime for the past 6 weeks. She is overweight with a BMI of 34. Medications include lisinopril, metformin, levothyroxine, and adalimumab. Exam reveals positive Tinel and Phalen maneuvers and decreased sensitivity to touch in left index and middle fingers. Which of this patient's risk factors for her symptoms is modifiable?



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Compression of a nerve deep to the flexor retinaculum causes a condition called Carpal Tunnel Syndrome. The nerve involved is the:



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Edema under the flexor retinaculum can give rise to a condition known as Carpal Tunnel Syndrome. The contents of the carpal tunnel are all but which of the following?



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A patient with a positive wrist flexion test might be expected to demonstrate all of the following except:



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During the exam of a patient with carpal tunnel syndrome, which motion are you unlikely to observe?



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An electrician presents with paresthesias and tingling in the thumb and middle three fingers. Over the last few weeks, he has had difficulty holding on to objects. He undergoes a surgical procedure shown in the image below. Which of the following are true of this condition? Select all that apply.

(Move Mouse on Image to Enlarge)
  • Image 6557 Not availableImage 6557 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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Carpal Tunnel Syndrome - References

References

Why do local corticosteroid injections work in carpal tunnel syndrome, but not in ulnar neuropathy at the elbow?, Mezian K,Bruthans J,, Muscle & nerve, 2016 May 3     [PubMed]
Neurological assessment., Maher AB,, International journal of orthopaedic and trauma nursing, 2016 Feb 26     [PubMed]
Utilization of Preoperative Electrodiagnostic Studies for Carpal Tunnel Syndrome: An Analysis of National Practice Patterns., Sears ED,Swiatek PR,Hou H,Chung KC,, The Journal of hand surgery, 2016 Apr 8     [PubMed]
Akhondi H,Varacallo M, Anterior Interosseous Syndrome null. 2018 Jan     [PubMed]
Sevy JO,Varacallo M, Carpal Tunnel Syndrome null. 2018 Jan     [PubMed]
Hegmann KT,Merryweather A,Thiese MS,Kendall R,Garg A,Kapellusch J,Foster J,Drury D,Wood EM,Melhorn JM, Median Nerve Symptoms, Signs, and Electrodiagnostic Abnormalities Among Working Adults. The Journal of the American Academy of Orthopaedic Surgeons. 2018 Aug 15     [PubMed]
Pester JM,Varacallo M, Nerve Block, Median null. 2018 Jan     [PubMed]
Mooar PA,Doherty WJ,Murray JN,Pezold R,Sevarino KS, Management of Carpal Tunnel Syndrome. The Journal of the American Academy of Orthopaedic Surgeons. 2018 Mar 15     [PubMed]
Raizman NM,Blazar PE, AAOS Appropriate Use Criteria: Management of Carpal Tunnel Syndrome. The Journal of the American Academy of Orthopaedic Surgeons. 2018 Mar 15     [PubMed]
Carmona A,Hidalgo Diaz JJ,Facca S,Igeta Y,Pizza C,Liverneaux P, Revision surgery in carpal tunnel syndrome: a retrospective study comparing the Canaletto® device alone versus a combination of Canaletto{sup}®{/sup} and Dynavisc{sup}®{/sup} gel. Hand surgery     [PubMed]
Eroğlu A,Sarı E,Topuz AK,Şimşek H,Pusat S, Recurrent carpal tunnel syndrome: Evaluation and treatment of the possible causes. World journal of clinical cases. 2018 Sep 26;     [PubMed]

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