Carpal tunnel syndrome: Difference between revisions
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==Background== | ==Background== | ||
[[File:Carpal Tunnel Syndrome.png|thumb|Anatomy of the carpal tunnel, showing the median nerve passing through the tight space it shares with the other tendons.]] | |||
[[File:Carpal-Tunnel.png|thumb|Transverse section at the wrist. The median nerve is colored yellow. The carpal tunnel consists of the bones and transverse carpal ligament.]] | |||
[[File:Nerves of the left upper extremity.gif |thumb|Nerves of the left upper extremity showing the median nerve distribution. Area of nerve compression is at wrist.]] | |||
*Also known as "Median Mononeuropathy" | *Also known as "Median Mononeuropathy" | ||
*Most common focal mononeuropathy | *Most common focal mononeuropathy | ||
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*Etiology: repetitive wrist flexion/extension, trauma, edema | *Etiology: repetitive wrist flexion/extension, trauma, edema | ||
==Risk factors== | |||
*Female sex<ref>Kothari MJ. Carpal tunnel syndrome: Etiology and epidemiology. Post TW, ed. UpToDate. UpToDate Inc. Accessed May 21, 2020.</ref> | |||
*[[Rheumatoid arthritis]] and other connective tissue diseases | |||
*[[Diabetes mellitus]] | *[[Diabetes mellitus]] | ||
*[[Amyloidosis]] | *[[Amyloidosis]] | ||
*Obesity | *[[The Obese Patient|Obesity]] | ||
*[[Pregnancy]] | *[[Pregnancy]] | ||
*[[Hypothyroidism]] | *[[Hypothyroidism]] | ||
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==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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**SN 0.64 and SP 0.83 | **SN 0.64 and SP 0.83 | ||
**More sensitive and specific than Tinel and Phalen in earlier studies<ref>Durkan, JA. A new diagnostic test for carpal tunnel syndrome, The Journal of Bone and Joint Surgery. 1991; 73(4):535–538.</ref> | **More sensitive and specific than Tinel and Phalen in earlier studies<ref>Durkan, JA. A new diagnostic test for carpal tunnel syndrome, The Journal of Bone and Joint Surgery. 1991; 73(4):535–538.</ref> | ||
*Hand Elevation Test | |||
**Performed by having patient elevated both hands above the head | |||
**Positive if paresthesia, numbness, or dull pain felt within two minutes | |||
**SN 0.87 and SP 0.89<ref>Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472</ref> | |||
*May see atrophy of thenar eminence in advanced cases | |||
[[File: Untreated_Carpal_Tunnel_Syndrome.JPG|thumb|Severe atrophy of the bilateral thenar eminences from untreated carpal tunnel syndrome]] | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
===Proximal Lesion=== | ===By Type of Lesion=== | ||
====Proximal Lesion==== | |||
*[[Spinal cord compression (non-traumatic)|Spinal cord lesion]] | *[[Spinal cord compression (non-traumatic)|Spinal cord lesion]] | ||
*[[Neck pain|Cervical | *[[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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*[[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) | ||
[[File: splint.jpg|thumb|Splint in neutral position]] | |||
==Disposition== | ==Disposition== | ||
*Discharge | |||
==See Also== | ==See Also== | ||
Latest revision as of 14:28, 5 February 2022
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
- Female sex[1]
- Rheumatoid arthritis and other connective tissue diseases
- Diabetes mellitus
- Amyloidosis
- Obesity
- Pregnancy
- Hypothyroidism
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[2]
- Phalen maneuver
- Holding wrists in flexion for 60 seconds evokes or worsens symptoms
- SN 0.68 and SP 0.73[3]
- 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[4]
- Hand Elevation Test
- Performed by having patient elevated both hands above the head
- Positive if paresthesia, numbness, or dull pain felt within two minutes
- SN 0.87 and SP 0.89[5]
- May see atrophy of thenar eminence in advanced cases
Differential Diagnosis
By Type of Lesion
Proximal Lesion
Distal Lesion
- Ulna neuropathy
Systemic condition
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
- ↑ Kothari MJ. Carpal tunnel syndrome: Etiology and epidemiology. Post TW, ed. UpToDate. UpToDate Inc. Accessed May 21, 2020.
- ↑ 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.
- ↑ Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472