(See also Overview and Evaluation of Hand Disorders Overview and Evaluation of Hand Disorders Common hand disorders include a variety of deformities, ganglia, infections, Kienböck disease, nerve compression syndromes, noninfectious tenosynovitis, and osteoarthritis. (See also complex... read more .)
Carpal tunnel syndrome is very common and most often occurs in women aged 30 to 50. Risk factors include rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more or other wrist arthritis (sometimes the presenting manifestation), diabetes mellitus Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , hypothyroidism Hypothyroidism Hypothyroidism is thyroid hormone deficiency. Symptoms include cold intolerance, fatigue, and weight gain. Signs may include a typical facial appearance, hoarse slow speech, and dry skin. Diagnosis... read more , acromegaly Gigantism and Acromegaly Gigantism and acromegaly are syndromes of excessive secretion of growth hormone (hypersomatotropism) that are nearly always due to a pituitary adenoma. Before closure of the epiphyses, the result... read more , primary, cardiac or dialysis-associated amyloidosis Amyloidosis Amyloidosis is any of a group of disparate conditions characterized by extracellular deposition of insoluble fibrils composed of misaggregated proteins. These proteins may accumulate locally... read more , and pregnancy-induced edema in the carpal tunnel. Activities or jobs that require repetitive flexion and extension of the wrist may contribute, but rarely. Most cases are idiopathic.
Symptoms and Signs of Carpal Tunnel Syndrome
Symptoms of carpal tunnel syndrome include pain of the hand and wrist with tingling and numbness, classically distributed along the median nerve (the palmar side of the thumb, the index and middle fingers, and the radial half of the ring finger) but possibly involving the entire hand. Typically, the patient wakes at night with burning or aching pain and with numbness and tingling and shakes the hand to obtain relief and restore sensation. Thenar atrophy and weakness of thumb opposition and abduction may develop late.
Diagnosis of Carpal Tunnel Syndrome
Sometimes nerve conduction testing
The diagnosis of carpal tunnel syndrome is strongly suggested by the Tinel sign, in which median nerve paresthesias are reproduced by tapping at the volar surface of the wrist over the site of the median nerve in the carpal tunnel. Reproduction of tingling with wrist flexion (Phalen sign) or with direct pressure on the nerve at the wrist in a neutral position (median nerve compression test) is also suggestive. The median nerve compression test is positive if symptoms develop within 30 seconds. The six-item carpal tunnel syndrome symptom scale (CTS-6) is a diagnostic aid that uses 6 clinical criteria. A score ≥ 12 correlates with a high probability of carpal tunnel syndrome.
However, clinical differentiation from other types of peripheral neuropathy may sometimes be difficult.
If symptoms are severe or the diagnosis is uncertain, nerve conduction testing Nerve conduction studies When determining whether weakness is due to a nerve, muscle, or neuromuscular junction disorder is clinically difficult, these studies can identify the affected nerves and muscles. In electromyography... read more should be done on the affected arm for diagnosis and to exclude a separate or coexistent more proximal neuropathy.
Treatment of Carpal Tunnel Syndrome
Treatment of underlying disorders
Sometimes corticosteroid/anesthetic injection
Sometimes surgical decompression
Changing the position of computer keyboards and making other ergonomic corrections may occasionally provide relief. Otherwise, treatment of carpal tunnel syndrome includes wearing a lightweight neutral wrist splint, especially at night, and taking mild analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs).
Treating any underlying disorders (eg, diabetes Diabetes Mellitus (DM) Diabetes mellitus is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia... read more , rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis is a chronic systemic autoimmune disease that primarily involves the joints. Rheumatoid arthritis causes damage mediated by cytokines, chemokines, and metalloproteases.... read more , hypothyroidism Hypothyroidism Hypothyroidism is thyroid hormone deficiency. Symptoms include cold intolerance, fatigue, and weight gain. Signs may include a typical facial appearance, hoarse slow speech, and dry skin. Diagnosis... read more ) may help relieve symptoms.
If these measures do not control symptoms, a mixture of an anesthetic and a corticosteroid (eg, 1.5 mL of a 4-mg/mL dexamethasone solution mixed with 1.5 mL of 1% lidocaine) may be injected into the carpal tunnel at a site just ulnar to the palmaris longus tendon and proximal to the distal crease at the wrist. This is more often effective for milder or pregnancy-related carpal tunnel syndrome.
If bothersome symptoms persist or recur or if hand weakness and thenar wasting develop, the carpal tunnel can be surgically decompressed by using an open or endoscopic technique.
Neutral wrist splint
Although carpal tunnel syndrome has many risk factors, most cases are idiopathic.
Typical symptoms include wrist and hand pain with tingling and numbness along the palmar side of the thumb, the index and middle fingers, and the radial half of the ring finger.
Reproducing symptoms with wrist flexion or pressure over the median nerve can provide helpful diagnostic clues.
Treat first with ergonomic corrections, then try splinting and analgesics, corticosteroid injection, and, for weakness, muscle wasting, and/or severe unresponsive symptoms, surgical decompression.
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