Carpal Tunnel Syndrome

Question 1

What is carpal tunnel syndrome

Answer 1

Symptomatic compression neuropathy of the median nerve at the level of the wrist causing pain, numbness, tingling

Question 2

Causes of carpal tunnel syndrome

Answer 2

Idiopathic
Repetitive trauma e.g. occupational
Pregnancy
Diabetes, hypothyroidism, inflammatory arthropathy
Fracture
Overweight

Question 3

What gender/age is carpal tunnel syndrome most common in

Answer 3

Women > men
Middle aged and elderly

Question 4

Which part of the hand do pain/paraesthesia symptoms affect?

Answer 4

Median nerve distribution - radial 3 ½ digits
Can sometimes be felt in wrist and radiating up forearm

Question 5

What time of day are the symptoms of carpal tunnel syndrome typically worse?

Answer 5

Typically worse at night, waking patients from sleep.
May be present in the morning.

Question 6

What do patients with carpal tunnel syndrome typically do to relieve the pain/paraesthesia?

Answer 6

Shake their hand or dangle it out of bed

Question 7

Carpal tunnel symptoms may be provoked by activities that involve ___________ the wrists e.g., reading, driving.

Answer 7

Flexing or extending

Question 8

What might patients describe in terms of weakness symptoms in carpal tunnel syndrome?

Answer 8

May have weakness of hand grip, specifically with thumb abduction and pincer grip (may drop things, describe clumsy hands)

Question 9

Can carpal tunnel syndrome be bilateral?

Answer 9

Can be bilateral. Dominant hand usually affected first and more severely.

Question 10

Findings on examining sensation of hands in carpal tunnel

Answer 10

Reduced/absent pinprick over median nerve distribution

Question 11

In carpal tunnel syndrome sensory loss usually begins ______ and progresses _________

Answer 11

Begins distally in the fingertips and may progress proximally

Question 12

If sensory loss of thenar eminence and palm on exam this suggests __________

Answer 12

Median nerve loss proximal to the carpal tunnel

Question 13

When are weakness and wasting apparent on exam for carpal tunnel

Answer 13

Weakness and wasting of thenar eminence in advanced/severe carpal tunnel syndrome

Question 14

Special tests for carpal tunnel syndrome

Answer 14

Phalen’s test - wrist flexion (reverse prayer) maintained for 30-60s reproduces sx
Tinel’s sign - tapping over median nerve (midpoint) at wrist reproduces sx

Question 15

How useful are special tests for carpal tunnel syndrome?

Answer 15

May be useful, but neither is particularly sensitive or specific for carpal tunnel syndrome.

Question 16

Are investigations usually needed in diagnosis of carpal tunnel

Answer 16

Diagnosis usually clinical
Can check for associated/underlying conditions e.g. HbA1c, TSH, RF, CRP, ESR

Question 17

What investigation would be useful if unsure about the diagnosis

Answer 17

Nerve conduction studies (via ortho/neuro)

Question 18

When to refer to ortho if a patient has carpal tunnel syndrome

Answer 18

Thenar wasting or thumb weakness
Severe symptoms
Conservative treatment fails

Question 19

Management options for carpal tunnel

Answer 19

Treat underlying conditions
Conservative
Surgical

Question 20

When should you consider conservative treatment for carpal tunnel

Answer 20

If symptoms mild and intermittent

Question 21

What does conservative treatment of carpal tunnel syndrome involve

Answer 21

Education
Avoid intensive hand activities
Splinting
Hand therapy
Steroid injection if symptoms fail to settle with above

Question 22

What times/situations is splinting helpful in carpal tunnel

Answer 22

Night time
Intermittently during activity

Question 23

Management of carpal tunnel in pregnancy

Answer 23

Conservative, esp night splints can be used during pregnancy as it may resolve after delivery

Question 24

Is full time splinting or night splinting more effective

Answer 24

Full-time splinting has not been shown to improve symptoms compared to night-time splinting

Question 25

When to consider hand therapy

Answer 25

Barriers to recovery
Loss of strength, ROM, proprioception or function
Pain a key feature

Question 26

What can hand therapy offer in carpal tunnel management

Answer 26

Graded exercises and rehabilitation
Can provide customised splints

Question 27

How effective is hand therapy in the management of carpal tunnel

Answer 27

If good engagement → likely to reduce/postpone the need for surgery

Question 28

When are steroid injections most effective for treatment of carpal tunnel syndrome

Answer 28

Can be as effective as surgery for mild-moderate sx that have lasted <6 months

Question 29

Effectiveness of steroid injections if severe carpal tunnel syndrome or when symptoms have lasted for > 6 months

Answer 29

Less likely to be effective but may provide some temporary relief (up to 3 months)

Question 30

How is carpal tunnel surgery done?

Answer 30

Usually performed as an open operation, but occasionally endoscopically.
Under local anaesthetic as a day patient

Question 31

How effective is carpal tunnel surgery

Answer 31

Very high rate of complete and permanent cure

Question 32

How effective is carpal tunnel surgery if there is a neurological deficit

Answer 32

Surgery will prevent progression but may not result in complete recovery of the deficit

Question 33

When is it appropriate to file an ACC claim for carpal tunnel syndrome?

Answer 33

Following an acute injury e.g. distal radius fracture.
Most commonly - prolonged, work-related exposure to vibrating machinery

Question 34

Explain carpal tunnel to a patient

Answer 34

The carpal tunnel is a narrow passage in your wrist, through which your median nerve and the tendons to your thumb and fingers pass. If you have carpal tunnel syndrome, it means there is pressure on your median nerve. This causes symptoms like numbness or tingling in your thumb and fingers (but not normally your little finger), or the palm of your hand.