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Carpal Tunnel Syndrome

For further information, see CMDT Part 41-04: Upper Extremity Musculoskeletal Injuries

Key Features

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

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

eTable 41–2.Wrist examination.
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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 ...

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