questions 4

Carpal Tunnel Syndrome

Topic updated on 11/11/17 4:02pm

Snapshot
  • A 39-year-old woman presents to her primary care physician's office due to pain and numbness in her hand. The patient reports that the pain is worse at night and when her hand is outstretched; to relieve the pain she shakes her hand or places it under warm running water. She says her symptoms mainly affect the first 3 digits of her hand. She denies any recent injury to or pain in the hand or neck. On physical exam, she has normal range of motion of the neck and arm. She has 2+ bilateral biceps, triceps, and brachioradialis reflexes. She has a positive Phalen and Tinel test.
Introduction
  • Clinical definition
    • compressive median nerve neuropathy  
  • Epidemiology
    • demographics
      • bimodal distribution
        • 50-60 and 70-80 years of age
    • risk factors
      • female gender
      • obesity
      • pregnancy
      • hypothyroidism
      • rheumatoid arthritis
      • dialysis-related amyloidosis 
        dialysisrelated
        amyloidosis
      • repetitive use of the hand or wrist
  • Etiology
    • increased pressure within the carpal tunnel
  • Pathoanatomy
    • normal anatomy
      • the carpal tunnel contains
        • digital flexor tendons
        • flexor pollicis longus tendon
        • median nerve
    • pathology
      • synovial noninflammatory fibrosis and thickening leads to median nerve compression (most common)
      • compression leads to microvascular insufficiency causing ischemic damage to the nerve
  • Prognosis
    • in mild-to-moderate cases, there is spontaneous resolution or response to conservative therapy
Presentation
  • Symptoms
    • pain or paresthesia in the median nerve distribution
      • median nerve distribution
        • the first 3 digits and radial half of 4th digit
      • symptoms typically worse at night
    • weakness or hand clumsiness
  • Physical exam
    • provoking tests
      • Phalen test 
        • patients flexes palm at the wrist 
          • pain and/or paresthesia in the median nerve distribution is a positive test
      • Tinel test 
        • percussion over the course of the median nerve
          • pain and/or paresthesia in the median nerve distribution is a positive test
Studies
  • Making the diagnosis
    • the diagnosis can be clinically made; however, it is confirmed by nerve conduction studies 
  • Nerve conduction studies 
    • indication
      • may be used when contemplating surgical decompression
  • Electromyogram
    • indication
      • typically used to exclude other etiologies such as
        • polyneuropathy
        • plexopathy
        • radiculopathy
Differential
  • Cervical radiculopathy compressing C5-C6
    • distinguishing factor
      • patients have neck pain, worsening symptoms with head movement, and pain radiation to the shoulders and arm
      • patients also have reduced biceps, brachioradialis, and triceps reflex
Treatment
  • Conservative
    • splinting 
      • indication
        • to improve mild carpal tunnel syndrome symptoms
  • Medical
    • corticosteroid (oral or injection)
      • indication
        • to improve mild carpal tunnel syndrome symptoms
  • Operative
    • surgical decompression
      • indication
        • for severe median nerve injury
          • reflected by nerve conduction studies (e.g., severe axonal degeneration) or needle electromyography
Complications
  • Rare



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(M2.OR.5) A 44-year-old male factory worker presents with a 7-month history of pain and paresthesias involving the volar aspect of the right thumb, index finger, long finger, and the radial half of the ring finger. He has a history of anemia and obstructive sleep apnea. Percussion over the volar wrist crease produces electric sensation distally in the hand and wrist flexion with the elbow in extension produces thumb paresthesias. A sensory nerve conduction velocity test shows a distal sensory latency of 5.7 milliseconds. What is most likely diagnosis? Topic Review Topic

1. Carpal Tunnel Syndrome
2. Cubital Tunnel Syndrome
3. Cervical Myelopathy
4. Ulnar Tunnel Syndrome
5. Multiple Sclerosis

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