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Carpal Tunnel Syndrome
From WikiSM
Contents
Other Names
- Median Neuropathy
- CTS
Background
- This page refers to carpal tunnel syndrome, a compression neuropathy of the median nerve at the carpal tunnel of the wrist
History
Epidemiology
Introduction
General
- Compressive Neuropathy of the median nerve
- Associated with significant morbidity, and disability
- Dominant hand most commonly affected, however bilateral approximately 30% of the time
- 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
- Overuse
- Osteoarthritis
- Trauma
- Acromegaly
Increase in carpal tunnel contents
- Masses
- Deposition of pathologic material
- Synovial hypertrophy or inflammation (most common)
Anatomy
- Carpal tunnel anatomic borders
- Radial: Scaphoid tubercle, Trapezium
- Ulnar: Hook of Hamate, Pisiform
- Floor: Proximal carpal row (as above)
- Roof: Transverse Carpal Ligament
- Median Nerve
- Contributions from C5 to T1
- innervates multiple muscles of the hand and wrist primarily responsible for flexion activities
- Sensory of the palmar aspects of digits 1-3, half of 4 as well as dorsal side of the fingertips
Risk Factors
- Mnemonic: MEDIAN TRAP
- M: Myxedema
- E: Edema
- D: Diabetes Mellitus
- I: idiopathic
- A: Acromegaly
- N: Neoplasm
- T: Trauma
- R: Rheumatoid Arthritis
- A: Amyloidosis
- P: Pregnancy
- 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
- Fractures
- Dislocations
- Wrist Dislocation (Radiocarpal and/or Ulnocarpal)
- Carpometacarpal Joint Dislocation
- Distal Radioulnar Joint Dislocation
- Lunate Dislocation
- Perilunate Dislocation
- Instability & Degenerative
- Tendinopathies & Ligaments
- Neuropathies
- Pediatric Considerations
- Distal Radial Epiphysitis (Gymnast's Wrist)
- Torus Fracture
- Arthropathies
- Cartilage
- Vascular
- Other
Differential Diagnosis Hand Pain
- Fractures
- Dislocations
- Tendinopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Nail Bed Injuries
- Pediatric Considerations
- Other
Other Considerations
- Cervical Radiculopathy
- Median Nerve Compression at the Elbow
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)
- Hand Elevation Test: Hold hands over head for up to 2 minutes
Evaluation
Radiographs
- Standard Radiographs Wrist
- Typically normal
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
- NSAIDS: No more effective than placebo
- Neuropathy pain medications including Gabapentin, Pregabalin (evidence?)
- Pyridoxine: Superior to placebo [10]
- Corticosteroids: Oral corticosteroids superior to placebo for short term pain relief[11]
- Diuretic: No more effective then placebo [12]
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/Work
- Depends on patient tolerance and ability to play
- In surgical cases, at discretion of surgeon
Prognosis and Complications
Prognosis
- Favorable prognostic indicators (need citation)
- Good response to corticosteroid injection
- Night pain
Complications
- Chronic pain
- Weakness
- Inability to perform job
See Also
- Hand and Wrist Anatomy (Main)
- Hand Pain (Main)
- Wrist Pain (Main)
- Forearm Pain (Main)
- Physical Exam Wrist
External
- Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/
- Sports Medicine Review Wrist Pain: https://www.sportsmedreview.com/by-joint/wrist/
References
- ↑ 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.
- ↑ 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
- ↑ https://radiopaedia.org/articles/carpal-tunnel-syndrome-1?lang=us
- ↑ 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.
- ↑ 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.
- ↑ https://www.aafp.org/afp/2011/0415/p952.html#afp20110415p952-b6
- ↑ 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.
- ↑ Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(2):CD001554.
- ↑ 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.
- ↑ 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.
- ↑ Chang MH, Chiang HT, Lee SS, Ger LP, Lo YK. Oral drug of choice in carpal tunnel syndrome. Neurology. 1998;51:390–3.
- ↑ 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:
14 June 2023 00:17:47
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