Wrist & Hand: Carpal Tunnel Syndrome

Question 1

what is carpal tunnel syndrome?

Answer 1

compression of the median nerve within the carpal tunnel of the wrist due to raised pressure in the compartment

Question 2

what are the symptoms of carpal tunnel syndrome?

Answer 2

pain, numbness and paresthesia of the lateral 3 1/2 digits

Question 3

is carpal tunnel syndrome more common in women or men?

Answer 3

women

Question 4

what is the peak age of incidence for carpal tunnel syndrome?

Answer 4

45-60 years

Question 5

what are the risk factors for carpal tunnel syndrome?

Answer 5

female
increasing age
pregnancy 
obesity 
previous wrist injury 
occupations involving repetitive hand or wrist movements

Question 6

what other conditions is carpal tunnel syndrome associated with?

Answer 6

diabetes mellitus, RA and hypothyroidism

Question 7

what are the clinical features of carpal tunnel syndrome?

Answer 7

pain, numbness and/or paraesthesia throughout median nerve distribution
palm is often spared

Question 8

what is the palm often spared in carpal tunnel syndrome?

Answer 8

palmar cutaneous branch of the median nerve branching proximal to the flexor retinaculum and passing over the carpal tunnel

Question 9

when is the pain typically worse in carpal tunnel syndrome?

Answer 9

worse during night and symptoms can often be temporarily relieved by hanging the affected arm over the side of the bed or by shaking back and fourth

Question 10

what is seen on examination of carpal tunnel syndrome?

Answer 10

often no visible findings during early stages
symptoms can be reproduced by either percussing over the median nerve (Tinel’s Test) or holding the wrist in full flexion for 1 minute (Phalen’s Test)

Question 11

what can often be seen in the later stages of carpal tunnel syndrome?

Answer 11

weakness of thumb abduction due to denervation atrophy of the thenar muscles and/or wasting of the thenar eminence

Question 12

DDx for carpal tunnel syndrome?

Answer 12

cervical radiculopathy - likely to have element of neck pain or symptoms involving the arm
pronator teres syndrome - symptoms will extend to proximal forearm and sensation to palm will be reduced
flexor carpi radialis tenosynovitis - tenderness at the base of the thumb

Question 13

how is carpal tunnel syndrome investigated?

Answer 13

clinical diagnosis - evident pathology in most cases from Hx and examination
uncertain cases - nerve conduction studies may be useful to confirm median nerve damage (normal median nerve conduction does not rule out CTS)

Question 14

how is carpal tunnel syndrome managed?

Answer 14

conservatively - wrist splinting - prevents wrist flexion and hols wrist as to not exacerbate the tingling pain
physiotherapy and various exercises
corticosteroid injections can be trialled
surgical treatment

Question 15

outline corticosteroid treatment in carpal tunnel syndrome

Answer 15

can be trialled
administered directly into carpal tunnel to reduce swelling and in turn reduce the symptoms
NSAIDs may be used in an attempt to further reduce swelling - limited evidence in routine use

Question 16

outline the surgical management of carpal tunnel syndrome

Answer 16

severely limiting cases where previous treatment has failed
carpal tunnel release surgery - decompress the carpal tunnel involving cutting through the flexor retinaculum which release the pressure on the median nerve - local anaesthetic and done as a day case
90% report improved symptoms

Question 17

what are the complications of carpal tunnel surgery?

Answer 17

persistent CTS symtoms
infection 
scar formation 
nerve damage 
trigger thumb

Question 18

what are the long term complications of untreated carpal tunnel syndrome?

Answer 18

permanent neurological impairment that surgery will not improve