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Carpal Tunnel Syndrome

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Other Names

  • Median Neuropathy
  • CTS

Background


Pathophysiology

  • Compressive neuropathy occurs as either a result decrease in size of the carpal tunnel and/or diseases increasing the contents of the carpal tunnel
    • Decrease in carpal tunnel size
    • Increase in carpal tunnel contents
      • Masses
      • Deposition of pathologic material
      • Synovial hypertrophy or inflammation (most common)
  • Epidemiology
    • Most common nerve entrapment syndrome, affecting 3-6% of adults[1][2]
    • Up to 15% incidence
    • Associated with significant morbidity, and disability
  • Dominant hand most commonly affected, however bilateral approximately 30% of the time

Risk Factors

  • Mnemonic: MEDIAN TRAP
  • General
    • Ages 30s-60s
    • Women > Men
    • Obesity
    • Pregnancy
    • Hypothyroidism
    • Rheumatoid Arthritis
    • Chronic Renal Failure
    • Tobacco Use
    • Alcohol Use
    • Repetitive activities
    • Mucopolysaccharidosis
    • Mucolipidosis
    • Leukemia
    • Multiple Myeloma
  • Sports
    • Throwing sports
    • Tennis
    • Cycling

Differential Diagnosis

Differential Diagnosis Wrist Pain

Differential Diagnosis Hand Pain

Other Considerations


Clinical Features

  • History
    • Symptoms in distribution of median nerve
    • Patients typically report nocturnal pain ascending from the wrist (brachialgia paraesthetica nocturna)
    • Sensory symptoms affect first 3 and 1/2 digits (radial side)
    • Symptoms may radiate into forearm
    • Flick Sign: Patient 'flicks' wrist and hand similar to shaking a thermometer
  • Physical Exam: Physical Examination Wrist
    • Typically reassuring
    • Motor weakness is a late symptom
    • Thenar atrophy
  • Special Tests
    • Tinels Test: Parasthesias by tapping median nerve
    • Phalens Test: Parasthesias by exaggerated flexion
    • Durkans Test: Parasthesias by applying direct pressure over the carpal tunnel
    • Self Administered Hand Diagram: Specific for CTS (need citation)
    • Square Wrist Sign: Ratio of wrist thickness to wrist width is greater than 0.7
    • Closed Fist Sign: Reproduction of symptoms with clenched fist for 60 seconds
    • Reverse Phalens Test: Parasthesia reproduced by exaggerated extension (prayer position)

Evaluation

Radiographs

Ultrasound

  • A normal cross sectional area is between 10-13mm
  • A cross sectional area >13mm is consistent with carpal tunnel syndrome
  • You can also visualize flattening of the median nerve at the hamate.
  • Palmer bowing of the flexor retinaculum [3]
  • Engorgement or enlargement of the nerve proximal to the retinaculum

MRI

  • Palmer bowing of flexor retinaculum
  • Elargement of median nerve
  • Flattening of median nerve

Diagnostic Criteria

  • Numbness, tingling in median nerve distribution
  • Weakness/atrophy of thenar musculature
  • Nocturnal symptoms
  • Positive tinel or phalen test
  • Loss of 2PV

EMG/NCS

  • Most objective diagnostic modality and thus gold standard
  • Not needed to diagnose, helpful in refractory cases or uncertainty in diagnosis
  • Useful to confirm if surgical management being considered
  • NCS: Prolonged latencies, slower conduction velocities
  • EMG: sharp waves, fibrillations, fasciulations, complex repetitive changes

Classification

Disease Classification in Carpal Tunnel Syndrome

Classification Duration Two-Point Discrimination Weakness Atrophy EMG NCS
Mild Less than 1 year Normal Absent Absent Non deneveration No-to-mild velocity decrease
Moderate Shorter or longer than 1 year Possible abnormality Minimal presence Minimal presence No-to-mild deneveration No-to-mild velocity decrease
Severe Longer than 1 year Marked abnormality Marked presence Marked presence Marked deneveration Marked velocity decrease

Management

Nonoperative

  • Indications
    • First line treatment for all atraumatic cases
  • Splints
    • Neutral or Cock Up Splint: Reduction in symptoms[4]
    • Wearing full time is superior to night time only [5]
  • Activity modification[6]
    • Avoiding repetitive motions
    • Use ergonomic equipment (e.g., wrist rest, mouse pad)
    • Take breaks
    • Using keyboard alternatives (e.g., digital pen, voice recognition and dictation software)
    • Alternative job functions
  • Physical Therapy
    • Ultrasound Therapy: Superior to sham treatment[7]
  • Corticosteroid Injection
    • Transient improvement often for only 1-2 months, only 20% or so symptom free at 1 year[8]
    • Lack of response is poor prognostic indicator for surgery
  • Platelet Rich Plasma
    • In a single arm, prospective study, 70% of patients reported positive outcomes ≥2 years post-injection[9]
  • Medications

Operative

  • Carpal tunnel release
    • Failure of conservative management
    • Acute median neuropathy following trauma
  • Revision of carpal tunnel release
    • Most commonly due to incomplete primary release

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Depends on patient tolerance and ability to play
  • In surgical cases, at discretion of surgeon

Complications & Prognosis

Prognosis

  • Favorable prognostic indicators (need citation
    • Good response to corticosteroid injection
    • Night pain

Complications

  • Chronic pain
  • Weakness
  • Inability to perform job

See Also


References

  1. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–158.
  2. Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol. 2010;195 (3): 585-94. AJR Am J Roentgenol (full text) - doi:10.2214/AJR.10.4817
  3. https://radiopaedia.org/articles/carpal-tunnel-syndrome-1?lang=us
  4. Brininger TL, Rogers JC, Holm MB, Baker NA, Li ZM, Goitz RJ. Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(11):1429–1435.
  5. Walker WC, Metzler M, Cifu DX, Swartz Z. Neutral wrist splinting in carpal tunnel syndrome: a comparison of night-only versus full-time wear instructions. Arch Phys Med Rehabil. 2000;81(4):424–429.
  6. https://www.aafp.org/afp/2011/0415/p952.html#afp20110415p952-b6
  7. Ebenbichler GR, Resch KL, Nicolakis P, Wiesinger GF, Uhl F, Ghanem AH, et al. Ultrasound treatment for treating the carpal tunnel syndrome: randomised “sham” controlled trial. BMJ. 1998;316:731–5.
  8. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(2):CD001554.
  9. Lai CY, Li TY, Lam KHS, Chou YC, Hueng DY, Chen LC, Wu YT. The long-term analgesic effectiveness of platelet-rich plasma injection for carpal tunnel syndrome: a cross-sectional cohort study. Pain Med. 2022 Jan 19:pnac011. doi: 10.1093/pm/pnac011. Epub ahead of print. PMID: 35043941.
  10. Spooner GR, Desai HB, Angel JF, Reeder BA, Donat JR. Using pyridoxine to treat carpal tunnel syndrome. Randomized control trial. Can Fam Physician. 1993;39:2122–7.
  11. Chang MH, Chiang HT, Lee SS, Ger LP, Lo YK. Oral drug of choice in carpal tunnel syndrome. Neurology. 1998;51:390–3.
  12. Pal B, Mangion P, Hossain MA, Wallace AS, Diffey BL. Should diuretics be prescribed for idiopathic carpal tunnel syndrome? Results of a controlled trial. Clin Rehabil. 1988;2:299–301.
Created by:
John Kiel on 14 June 2019 08:38:10
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Last edited:
13 April 2022 11:40:38
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