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: DM, amyloidosis, obesity, pregnancy, hypothyroidism
 
===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 w/ burning pain and tingling in hand
*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 w/ wrist in neutral position
*Wrist splint with wrist in neutral position
*NSAIDs (although not clearly effective)
*[[NSAIDs]] (although not clearly effective)
*Diuretics (if edema is significant contributor to pt's symptoms)
*[[Diuretics]] (if edema is significant contributor to patient's symptoms)
 
==Disposition==
*Discharge


==See Also==
==See Also==
*[[Radial neuropathy at the spiral groove]]


==Source==
==References==
*Tintinalli
*Marx, John A. et al. "Wrist and Forearm." Rosen's Emergency Medicine: Concepts and Clinical Practice. Eighth ed. Vol. 1. Elsevier, 2014. 588-589.
<references/>
<references/>


[[Category:Neuro]] [[Category:Ortho]]
[[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

Distal Lesion

  • Ulna neuropathy

Systemic condition

Upper extremity peripheral nerve syndromes

Median Nerve Syndromes

Ulnar Nerve Syndromes

Radial Nerve Syndromes

Proximal Neuropathies

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

  1. MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.
  2. MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.
  3. Durkan, JA. A new diagnostic test for carpal tunnel syndrome, The Journal of Bone and Joint Surgery. 1991; 73(4):535–538.