Carpal tunnel syndrome: Difference between revisions
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==Background== | ==Background== | ||
*Also known as "Median Mononeuropathy" | |||
*Most common focal mononeuropathy | *Most common focal mononeuropathy | ||
*Results from compression of median nerve at wrist where it traverses the carpal tunnel | *Results from compression of median nerve at wrist where it traverses the carpal tunnel | ||
*Median nerve provides sensation to the palmar aspect digits 1-3 and radial side of 4th | *Median nerve provides sensation to the palmar aspect digits 1-3 and radial side of 4th | ||
*Etiology: repetitive wrist flexion/extension, trauma, edema | *Etiology: repetitive wrist flexion/extension, trauma, edema | ||
===Risk factors=== | |||
*[[Diabetes mellitus]] | |||
*[[Amyloidosis]] | |||
*[[The Obese Patient|Obesity]] | |||
*[[Pregnancy]] | |||
*[[Hypothyroidism]] | |||
==Clinical Features== | ==Clinical Features== | ||
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*Pain, paresthesia, and numbness in distribution of median nerve | *Pain, paresthesia, and numbness in distribution of median nerve | ||
**Palmar aspect of thumb, index, middle, and radial aspect of ring finger | **Palmar aspect of thumb, index, middle, and radial aspect of ring finger | ||
*Awakening at night | *Awakening at night with burning pain and tingling in hand | ||
===Physical=== | ===Physical=== | ||
*Tinel sign | *Sensation testing | ||
**Most specific - splitting of 4th digit in which medial aspect of 4th digit normal and lateral aspect abnormal | |||
**Most sensitive - abnormal sensation of distal palmar tip of 2nd digit | |||
*'''LOAF''' muscle weakness as compared to other hand - '''L'''umbricals, with thumb '''O'''pposition, '''A'''bduction, '''F'''lexion | |||
*Tinel sign - poorly sensitive and specific | |||
**Tapping on palmar aspect of wrist reuslts in electric shock sensation shooting into hand | **Tapping on palmar aspect of wrist reuslts in electric shock sensation shooting into hand | ||
**SN 0.50 and SP 0.77<ref>MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.</ref> | **SN 0.50 and SP 0.77<ref>MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.</ref> | ||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
===Proximal Lesion=== | ===By Type of Lestion=== | ||
====Proximal Lesion==== | |||
*[[Spinal cord compression (non-traumatic)|Spinal cord lesion]] | *[[Spinal cord compression (non-traumatic)|Spinal cord lesion]] | ||
*[[Neck pain|Cervical redicular pain]] | *[[Neck pain|Cervical redicular pain]] | ||
*Thoracic outlet syndrome | *Thoracic outlet syndrome | ||
*[[Multiple Sclerosis (MS)]] | *[[Multiple Sclerosis (MS)]] | ||
===Distal Lesion=== | ====Distal Lesion==== | ||
*Ulna neuropathy | *Ulna neuropathy | ||
===Systemic condition=== | ====Systemic condition==== | ||
*Raynaud syndrome | *Raynaud syndrome | ||
*[[Pregnancy (Main)]] | *[[Pregnancy (Main)]] | ||
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*[[Hypothyroidism]] | *[[Hypothyroidism]] | ||
*[[Hypocalcemia]] | *[[Hypocalcemia]] | ||
{{Upper extremity peripheral nerve syndromes}} | |||
==Management== | ==Management== | ||
*See this American Academy of Orthopedic Surgeons clinical decision tool for treatment options and disposition - [http://www.orthoguidelines.org/go/auc/auc.cfm?auc_id=224989 CTS guidelines] | |||
*Behavioral modification | *Behavioral modification | ||
*Wrist splint | *Wrist splint with wrist in neutral position | ||
*NSAIDs (although not clearly effective) | *[[NSAIDs]] (although not clearly effective) | ||
*Diuretics (if edema is significant contributor to | *[[Diuretics]] (if edema is significant contributor to patient's symptoms) | ||
==Disposition== | |||
*Discharge | |||
==See Also== | ==See Also== | ||
*[[Radial neuropathy at the spiral groove]] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Neurology]] [[Category:Orthopedics]] |
Revision as of 23:19, 17 October 2018
Background
- Also known as "Median Mononeuropathy"
- Most common focal mononeuropathy
- Results from compression of median nerve at wrist where it traverses the carpal tunnel
- Median nerve provides sensation to the palmar aspect digits 1-3 and radial side of 4th
- Etiology: repetitive wrist flexion/extension, trauma, edema
Risk factors
Clinical Features
History
- Pain, paresthesia, and numbness in distribution of median nerve
- Palmar aspect of thumb, index, middle, and radial aspect of ring finger
- Awakening at night with burning pain and tingling in hand
Physical
- Sensation testing
- Most specific - splitting of 4th digit in which medial aspect of 4th digit normal and lateral aspect abnormal
- Most sensitive - abnormal sensation of distal palmar tip of 2nd digit
- LOAF muscle weakness as compared to other hand - Lumbricals, with thumb Opposition, Abduction, Flexion
- Tinel sign - poorly sensitive and specific
- Tapping on palmar aspect of wrist reuslts in electric shock sensation shooting into hand
- SN 0.50 and SP 0.77[1]
- Phalen maneuver
- Holding wrists in flexion for 60 seconds evokes or worsens symptoms
- SN 0.68 and SP 0.73[2]
- Durkan sign
- Manual compression of carpal tunnel reproduces symptoms after 30 seconds
- SN 0.64 and SP 0.83
- More sensitive and specific than Tinel and Phalen in earlier studies[3]
Differential Diagnosis
By Type of Lestion
Proximal Lesion
- Spinal cord lesion
- Cervical redicular pain
- Thoracic outlet syndrome
- Multiple Sclerosis (MS)
Distal Lesion
- Ulna neuropathy
Systemic condition
- Raynaud syndrome
- Pregnancy (Main)
- B12 deficiency
- Diabetic neuropathy
- Hypothyroidism
- Hypocalcemia
Upper extremity peripheral nerve syndromes
Median Nerve Syndromes
Ulnar Nerve Syndromes
Radial Nerve Syndromes
- Radial neuropathy at the spiral groove (ie. "Saturday night palsy")
- Posterior interosseous neuropathy
Proximal Neuropathies
- Suprascapular neuropathy
- Long thoracic neuropathy
- Axillary neuropathy
- Spinal accessory neuropathy
- Musculocutaneous neuropathy
Other
Management
- See this American Academy of Orthopedic Surgeons clinical decision tool for treatment options and disposition - CTS guidelines
- Behavioral modification
- Wrist splint with wrist in neutral position
- NSAIDs (although not clearly effective)
- Diuretics (if edema is significant contributor to patient's symptoms)
Disposition
- Discharge
See Also
References
- ↑ MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.
- ↑ MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.
- ↑ Durkan, JA. A new diagnostic test for carpal tunnel syndrome, The Journal of Bone and Joint Surgery. 1991; 73(4):535–538.