Carpal Tunnel Syndrome
Jill C. Cash
Definition
A.Carpal tunnel syndrome (CTS) is a nerve entrapment condition of the median nerve of the wrist.
Incidence
A.CTS occurs in approximately 1% of the general population. It is primarily seen in 30- to 60-year-old adults. Women and older adults are more likely to develop this condition.
Pathogenesis
A.CTS occurs from compression of the median nerve in the carpal canal. Compression occurs due to swelling of the flexor tenosynovium; the pressure blocks the nerve fibers, which produces numbness and discomfort in the digits/hands. Repetitive flexion and extension of the wrists create increased pressure in the carpal canal.
B.Potential causes of CTS include blunt trauma or structural changes; tumors; systemic diseases, such as rheumatoid disorders, diabetes mellitus (DM), thyroid disorders, endocrine diseases, and so forth; mechanical overuse syndrome; and infectious diseases, such as tuberculosis (TB) and leprosy. Consider multifactorial causes of CTS. Heredity is likely an important factor as the carpal tunnel may be smaller in some people or anatomic differences change the amount of space of the nerve; therefore, this trait can run in families.
Predisposing Factors
A.Women.
B.Hobbies or jobs that require repetitive wrist or hand movement and the use of vibratory tools.
C.Pregnancy.
D.Heredity.
Common Complaints
A.Pain.
B.Tingling/numbness sensation in the wrists, hands, and fingers that radiates up into the forearm.
Other Signs and Symptoms
A.Paresthesia in wrists, hands, and fingers.
B.Localized pain of radial three digits of the hand.
C.Weakness with grasp.
D.Decreased dexterity.
E.Night pain in wrists.
F.Referred pain to elbow and/or shoulder.
G.Long-term pressure in the carpus can produce ischemic changes and may lead to axonal death, muscular atrophy, and pain. Long-term nerve compression may produce irreversible changes.
Subjective Data
A.Determine onset, duration, and course of presenting symptoms.
B.Note the progression of symptoms since the initial occurrence.
C.Assess whether the symptoms increase with hand or wrist activity and decrease with the joint at rest.
D.Identify factors that precipitate symptoms, that make symptoms worse, and that alleviate symptoms.
E.Inquire whether the patient awakens at night with numbness and tingling sensations.
F.Have the patient describe the pain, and note if radiation is present. Are symptoms bilateral?
G.Note the patient’s occupation, hobby, and/or daily routines that require hand or wrist use.
H.Identify what treatment and/or relief measures have been used, and note results.
Physical Examination
A.Inspect: Inspect the hands for deformities. Note wasting or atrophy.
B.Palpate: Perform sensory motor evaluation of the hand and arm:
1.Perform Tinel’s test: Tap over transverse carpal ligament; result is positive if tingling in fingers is noted.
2.Perform Phalen’s test: Have patient place elbows on flat surface and hold forearms in vertical position, then flex wrists; result is positive if pain, numbness, or tingling is noted within the next 60 seconds.
Diagnostic Tests
A.Electromyographic (EMG).
B.Nerve conduction velocity (NCV) studies.
C.If an underlying systemic illness or condition exists, consider the following:
1.Erythrocyte sedimentation rate (ESR).
2.Blood glucose.
3.Thyroid profile.
4.Inflammatory disease studies.
Differential Diagnoses
A.CTS.
B.Peripheral neuropathy.
C.Cervical spondylosis and cervical disk herniation.
D.Brachial plexus lesion.
E.Trauma.
F.Thenar atrophy and neuropathy.
G.Osteoarthritis.
H.Neurologic disorders: Polyneuritis, multiple sclerosis (MS), tumors, and so on.
Plan
A.General interventions:
1.Help the patient identify causative agents, eliminate activity if possible, decrease repetitive use, or use alternative methods to accomplish the same task.
2.Advise resting arms and wrists as much as possible.
3.Encourage performing daily stretching exercises.
4.Give instructions on applying wrist splints, especially at bedtime, while sleeping.
B.Patient teaching:
1.Instruct the patient on splinting wrists.
2.Demonstrate stretching exercises.
3.Stress the importance of rest and elimination of the causative activity.
C.Pharmaceutical therapy:
1.Nonsteroidal anti-inflammatory drugs (NSAIDs) as needed. Ibuprofen (Motrin) 600 to 800 mg by mouth three times daily or naproxen (Naprosyn) 500 mg by mouth twice a day unless contraindicated.
2.Vitamin B6 100 mg/d.
3.Consider corticosteroid injections in carpal canal (40 mg/mL with 1% lidocaine 1 mL).
Follow-Up
A.Depending on treatment, consider follow-up in 1 month to evaluate status.
Consultation/Referral
A.Refer the patient to a physician for severe cases requiring evaluation for surgery.
B.Refer the patient to a surgeon for severe symptoms that could require carpal tunnel release.
C.Consider occupational therapy consult.
D.Consider physical therapy consult.
Individual Considerations
A.Pregnancy: CTS is the most frequent complaint during pregnancy. About 15% of the cases will progress and continue several months postpartum.