Provide a brief description of Carpal Tunnel Syndrome, noting the chief complaints, examination findings (including signs, wigns and symptoms); and treatment options.
Carpal Tunnel Syndrome (CTS) is an entrapment neuropathy due to compression of the median nerve as it passes through the carpal tunnel. The tunnel is at the base of the palm, right above the wrist. It has four sides: 3 of which are carpal bones and the 4th side/top of structure being the transverse carpal ligament.
The key clinical point is based on the anatomy: the signs and symptoms must be in the median nerve only; and they need to be related to targets of the median nerve distal to the tunnel itself. That is, objective median nerve function in the forearm should not be affected.
Carpal Tunnel Syndrome occurs most commonly in patients between 30-60 years of age; more common in females.
Risk/causative factors: POSITIONAL (this may be why typing a lot causes symptoms); increases in contents of canal ( fractures synovitis); neuropathic conditions (DM); inflammatory conditions (RA, gout); alterations of fluid balance (pregnancy, menopause, , thyroid disorders); and external forces (jackhammer?).
The chief complaints are numbness and paresthesias in the anatomic distribution of the median nerve: radial 3 ½ fingers (thumb, index, middle, and radial side of ring). Patients may experience pain radiation proximally into the forearm.
A common early complaint is awakening in the night due to numbness or pain in these fingers (night-time worsening). Patients may also complain of swelling in the hands, dry skin, and cold hands (less common symptoms).
Later, patients may report constant numbness, motor disturbances, and decreased strength (tendency to drop objects)
Exam findings: the exam may show: Nothing; Weakness of the thenar intrinsic muscles (clinically tested by abduction of thumb against resistance) Diminished sensation to pin prick in the median nerve distribution; a Positive Phalen test or Tinel’s test (not “sign”); or any combination thereof.
EMG would likely show focal slowing of conduction velocity in median nerve across carpal tunnel
(A note to the interested student: the accuracy/sensitivity/specificity of various diagnostic maneuvers or tests is hard to define: What is the reference standard? If all are compared to, say, “positive EMG” we have a problem, as there people without any Carpal Tunnel symptoms who have a positive EMG; likewise there are some with normal EMGs who seem to have the syndrome… Recall, the word “syndrome” means that the condition is somewhat ill-defined. As treating doctors, we don’t necessarily want to know what the patient has, we want to know what to do with them therapeutically (or what to say regarding prognosis) . So the reference question should be “What percentage of patients with a positive Phalen’s test, say, get relief from surgery?” But that is not only an assessment of the test, but also the patients in the study and the surgeon doing the work…)
There are many treatment options for individuals with CTS, and the treatment choice depends on the severity of the nerve dysfunction, patient preference, and availability. Non-operative treatment options include: rest, wrist splinting, NSAISDs, and oral steroids or corticosteroid injections.
In patients who do not respond to more conservative treatment modalities or in patients with signs of atrophy or muscle weakness, carpal tunnel release–cutting the transverse carpal ligament –can be considered. This surgery is performed to decrease pressure on the median nerve.
Obviously if there is a precipitating cause (like a wrist fracture) that cause should be addressed expeditiously