Difference between revisions of "Carpal tunnel syndrome"

 
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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==
 
===History===
 
===History===
*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 with 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 radicular 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’s disease|Raynaud syndrome]]
 
*[[Pregnancy (Main)]]
 
*[[Pregnancy (Main)]]
 
*[[Anemia|B12 deficiency]]
 
*[[Anemia|B12 deficiency]]
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*[[Hypothyroidism]]
 
*[[Hypothyroidism]]
 
*[[Hypocalcemia]]
 
*[[Hypocalcemia]]
 +
 +
{{Upper extremity peripheral nerve syndromes}}
  
 
==Management==
 
==Management==
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*Behavioral modification
 
*Behavioral modification
 
*Wrist splint with 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 patient's symptoms)
+
*[[Diuretics]] (if edema is significant contributor to patient's symptoms)
  
 
==Disposition==
 
==Disposition==
Out-patient
+
*Discharge
  
 
==See Also==
 
==See Also==

Latest revision as of 14:28, 19 October 2019

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.