Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 41-04: Upper Extremity Musculoskeletal Injuries + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Pain, burning, and tingling in the distribution of the median nerve Initially, most bothersome during sleep Late weakness or atrophy, especially of the thenar eminence Can be caused by repetitive activities using the wrist Commonly seen during pregnancy and in patients with diabetes mellitus or rheumatoid arthritis +++ General Considerations ++ May occur due to fluid retention of pregnancy, in individuals with a history of repetitive use of the hands, or following injuries of the wrists Caused by compression of the median nerve between the carpal ligament and other structures within the carpal tunnel The contents of the tunnel can be compressed by Synovitis of the tendon sheaths or carpal joints Recent or malhealed fractures Tumors Tissue infiltration Congenital syndromes (eg, mucopolysaccharidoses) There is a familial type in which no etiologic factor can be identified Can also be a feature of many systemic diseases, such as Rheumatoid arthritis and other rheumatic disorders (inflammatory tenosynovitis) Myxedema Amyloidosis Sarcoidosis Leukemia Acromegaly Hyperparathyroidism + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Pain, burning, and tingling in the distribution of the median nerve; it is most bothersome at night A Tinel or Phalen sign may be positive (eTable 41–2) A Tinel sign is tingling or shock-like pain on volar wrist percussion The Phalen sign is pain or paresthesia in the distribution of the median nerve when the patient flexes both wrists to 90 degrees for 60 seconds The carpal compression test, in which numbness and tingling are induced by the direct application of pressure over the carpal tunnel, may be more sensitive and specific than the Tinel and Phalen tests (eTable 41–2) Muscle weakness or atrophy, especially of the thenar eminence, can appear later than sensory disturbances as compression of the nerve worsens ++Table Graphic Jump LocationeTable 41–2.Wrist examination.View Table||Download (.pdf)eTable 41–2. Wrist examination. Maneuver Description Inspection Examine for the alignment of the wrist and fingers SEADS. Palpation Include important landmarks: scaphoid “snuff box,” distal radius, scapholunate ligament, hook of hamate, ulnar joint line, distal radioulnar joint. Range of motion testing Check range of motion actively (patient performs) and passively (clinician performs) especially with flexion and extension of the wrist. Ulnar and radial deviation and circumduction of the wrist can be screened. Neurovascular examination Check motor strength and dermatomal sensation in the fingers in the radial (thumb), median (3rd finger) and ulnar distribution (5th finger). Check capillary refill to digits as well as radial pulse. Tinel sign Tingling or shock-like pain on volar wrist percussion. The carpal compression test, in which numbness and tingling are induced by the direct application of pressure over the carpal tunnel, may be more sensitive and specific than the Tinel and Phalen tests. Phalen sign Pain or paresthesia in the distribution of the median nerve when the patient flexes both wrists to 90 degrees for 60 seconds. Carpel compression test Performed by applying direct application of pressure over the carpal tunnel. SEADS, swelling, erythema, atrophy, deformity, and (surgical) scars. +++ Differential Diagnosis ++ Cervicobrachial pain syndromes Compression syndromes of the median nerve in the forearm or arm Mononeuritis multiplex Angina pectoris (when pain is left sided) + Diagnosis Download Section PDF Listen +++ +++ Imaging ++ Ultrasound Can demonstrate flattening of the median nerve beneath the flexor retinaculum Sensitivity is estimated to be between 54% and 98% +++ Diagnostic Procedures ++ Electromyography and nerve conduction studies show evidence of sensory conduction delay before motor delay, which can occur in severe cases Electrodiagnosis can provide information on focal median mononeuropathy at the wrist and can classify carpal tunnel syndrome from mild to severe + Treatment Download Section PDF Listen +++ +++ Conservative measures ++ Hand activities should be modified and the affected wrist splinted in the neutral position for up to 3 months When a causative lesion is discovered, it should be treated appropriately +++ Medications ++ Oral corticosteroids or nonsteroidal anti-inflammatory drugs can be tried +++ Surgery ++ Carpal tunnel release Indications Positive electrodiagnostic test At least moderate symptoms High clinical probability Unsuccessful nonoperative treatment Symptoms lasting longer than 12 months + Outcome Download Section PDF Listen +++ +++ Prognosis ++ Both corticosteroid injection and surgery resolved symptoms but only decompressive surgery allows resolution of neurophysiologic changes Decompression with the use of vascularized flap coverage appears to have a higher success rate over simple repeated decompression +++ When to Refer ++ If symptoms persist > 3 months despite conservative treatment, including the use of a wrist splint If thenar muscle (eg, abductor pollicis brevis) weakness or atrophy develops + References Download Section PDF Listen +++ + +Huisstede BM et al. Carpal tunnel syndrome: effectiveness of physical therapy and electrophysical modalities. An updated systematic review of randomized controlled trials. Arch Phys Med Rehabil. 2018 Aug;99(8):1623–34. [PubMed: 28942118] + +Huisstede BM et al. Effectiveness of surgical and postsurgical interventions for carpal tunnel syndrome—a systematic review. Arch Phys Med Rehabil. 2018 Aug;99(8):1660–80. [PubMed: 28577858] + +Petrover D et al. Ultrasound-guided surgery for carpal tunnel syndrome: a new interventional procedure. Semin Intervent Radiol. 2018 Oct;35(4):248–54. [PubMed: 30402007] + +Urits I et al. Recent advances in the understanding and management of carpal tunnel syndrome: a comprehensive review. Curr Pain Headache Rep. 2019 Aug 1;23(10):70. [PubMed: 31372847] + +Wang L. Guiding treatment for carpal tunnel syndrome. Phys Med Rehabil Clin N Am. 2018 Nov;29(4):751–60. [PubMed: 30293628] + +Zhang D et al. Evaluation and management of unsuccessful carpal tunnel release. J Hand Surg Am. 2019 Sep;44(9):779–86. [PubMed: 31300226]