Orthopedics Book


Carpal Tunnel Syndrome

Aka: Carpal Tunnel Syndrome, Median Neuropathy, Carpal Tunnel
  1. See Also
    1. Overuse Syndromes of the Hand and Wrist
    2. Peripheral Nerve Injury
  2. Epidemiology
    1. Most common Entrapment Neuropathy of the arm
      1. Incidence: 3% of U.S. general population
    2. Women outnumber men affected by 3 fold
    3. Bilateral in 50% of cases
    4. Associated with workplace repetitive hand activities
    5. Hand Paresthesias occur in 30% of computer users
      1. Only 10% of these meet criteria for Carpal Tunnel
      2. Only 3.5% of these have abnormal EMGs
      3. Stevens (2001) Neurology 56:1568-70 [PubMed]
  3. Pathophysiology
    1. Compression of Median Nerve
      1. Occurs between transverse carpal ligament and underlying Carpal Bones
      2. Median Nerve adjacent to 9 inflamed and enlarged synovial lining of flexor tendons
    2. Sensory deficits predominate
      1. Motor Nerves are much less susceptible than Sensory Nerves to compression
  4. Risk Factors
    1. Repetitive motion of hand and wrist
      1. Most common cause, and typically work related
      2. More common if significant force applied or hand-operated vibratory tool
    2. Local wrist or Hand Trauma
    3. Obesity
    4. Many associated conditions (see below)
  5. Associated Conditions
    1. Hypothyroidism
    2. Diabetes Mellitus
    3. Acromegaly
    4. Rheumatoid Arthritis
    5. Gouty Arthritis
    6. Lyme Disease
    7. Amyloidosis
    8. Multiple Myeloma
    9. Edematous condition
      1. Third trimester of Pregnancy
        1. Symptoms subside after delivery
      2. Congestive Heart Failure
      3. Renal Failure
    10. Aberrant or Anomalous Muscles in wrist
      1. Proximal lumbrical insertion
      2. Distal extension of flexor superficialis Muscle
      3. Persistent thrombosed median artery
      4. Abnormal palmaris longus tendon
      5. Ganglion Cyst
      6. Lipoma
    11. Double-Crush Syndrome
  6. Symptoms
    1. Image: Median Nerve Sensory Innervation
      1. NeuroMedianNerve.jpg
    2. Paresthesias along Median Nerve course (palmar surface)
      1. Electrical Sensation or Dysesthesias
      2. Commonly involves only palmar Index and Middle fingers
        1. May affect palmar aspect of all Median Nerve innervated 3.5 fingers (thumb to fourth finger)
    3. Pain in distal, palmar surface of wrist or arm
      1. Distal radiation into thumb, index and middle finger
    4. Radiation
      1. Proximal radiation into Forearm (may rarely radiate proximally into Shoulder and neck)
      2. May even present as Chest Pain (has resulted in ED Chest Pain cardiac work-ups)
    5. Gradually increasing night pain (95% of patients)
      1. Increase in wrist swelling with inactivity
      2. Wrist flexion at night (may awaken patient)
    6. Numbness
      1. Describes "poor circulation" and "Stiffness"
      2. Despite which hand feels warm
    7. Weakness and Clumsiness of hand
      1. Decreased grip strength
    8. Timing
      1. Spontaneous onset
    9. Provocative of Sensory and Motor Symptoms
      1. Repetitive wrist flexion or hand elevation
      2. Precipitated by Typing, holding phone, driving, painting, and wrist motion
    10. Palliative
      1. Shaking or moving hand
      2. Allow hand to hang down
      3. Flick Sign
        1. Flicking wrist as if shaking down Thermometer (often after night-time awakening)
        2. Test Sensitivity 93%, Test Specificity 96%
  7. Signs
    1. Precautions
      1. In addition to wrist and Hand Exam, also examine elbow, Shoulder and neck for referred pain source
    2. Observation
      1. Square-shaped wrist (depth dimensions approaches wrist width, esp in Obesity, OR 4.56)
        1. Shiri (2015) Muscle Nerve 52(5): 709-13 [PubMed]
    3. Modifying factors
      1. Pain not worse with resisted motion
      2. Flick Test (see above)
      3. Carpal Compression Test (64-90% sensitive, 83-90% specific)
        1. Direct pressure applied over the transverse carpal ligament for 30 seconds
        2. Positive for sensory symptoms within first 30 seconds
      4. Classic exam findings have individual poor predictive value (but combined 80% sensitivity, 92% Specificity)
        1. Tinel's sign (44-70% sensitive, 94% specific)
        2. Phalen's Maneuver (70-80% sensitive, 80% specific)
      5. Hand elevation test
        1. Hands raised overhead for one minute
        2. Positive test if symptoms are reproduced in the first minute
        3. Ahn (2001) Ann Plast Surg 46(2): 120-4 [PubMed]
      6. Tourniquet Test (not recommended as not sensitive and not specific)
        1. Inflate Blood Pressure Cuff on upper arm above systolic Blood Pressure
        2. Positive if Paresthesias and Numbness after inflation in first 60 seconds
    4. Sensory deficit over Median Nerve
      1. Sensory deficit predominates as Sensory Nerves are more susceptible to compression than Motor Nerves
      2. Hypalgesia in classic Median Nerve distribution has high Likelihood Ratio
        1. Patient draws areas of pain or numbness on hand diagram
      3. Two Point Discrimination <6 mm with caliper (33% Sensitive, 100% Specific)
      4. Resolution of pain with persistent numbness suggests permanent sensory loss
    5. Motor deficits (late finding in severe Median Neuropathy)
      1. Weak thumb abduction and weakness
        1. Weak on grasping items, opening jars, buttoning clothing
      2. Thenar Muscle atrophy
        1. Associated with decreased grip strength
        2. Only present in severe, long-standing disease
        3. Other hand and wrist neuropathies will cause this as well
      3. Abductor pollicis brevis weakness
        1. Abduct thumb perpendicular to palm against examiner's resistance
    6. Findings suggestive of alternative diagnosis
      1. Wrist and hand with reduced range of motion (ROM should be unaffected in Carpal Tunnel)
      2. Thenar eminence with reduced Sensation
        1. Innervated by Median Nerve's palmar cutaneous branch (origin is proximal to Median Nerve)
        2. Suggests a Median Nerve injury in the neck or proximal arm
  8. Diagnosis
    1. Findings with highest predictive value
      1. Classic hand symptoms in median distribution
      2. Decreased Pain Sensation at index palmar surface
      3. Weak thumb abduction
    2. References
      1. D'Arcy (2000) JAMA 283:3110-7 [PubMed]
  9. Differential Diagnosis
    1. Tenosynovitis
      1. Flexor carpi radialis Tenosynovitis
        1. Extends from proximal 1st Metacarpal to medial epicondyle
      2. De Quervain's Tenosynovitis
        1. Affects extensor pollicis brevis, abductor pollicis longus
    2. Other Neuropathy
      1. Cervical Radiculopathy (C6 nerve)
      2. Median Nerve compression at elbow (Pronator Syndrome)
      3. Ulnar Tunnel (or Cubital Tunnel)
      4. Peripheral Neuropathy (e.g. Diabetes Mellitus)
    3. Degenerative Joint Disease
      1. Wrist Osteoarthritis
      2. Thumb carpometacarpal Osteoarthritis
    4. Vascular conditions
      1. Raynaud Syndrome
      2. Vibration white finger (occurs with vibratory hand tools)
  10. Radiology: Wrist XRay
    1. Evaluate for local bony abnormality
  11. Diagnostics
    1. Nerve Conduction Studies (Electromyography, EMG)
      1. Indicated in unclear cases or in pre-surgical assessment of severity
      2. Delayed electrical conduction across wrist at the Median Nerve
      3. Efficacy: 56-85% sensitive, 94-99% specific
      4. Normal in up to one third of patients with mild Carpal Tunnel
    2. Ultrasound
      1. See Median Nerve Measurement on Ultrasound
      2. Highest efficacy when wrist Median Nerve cross sectional area is compared with Forearm measurement
      3. Noninvasive, painless test with high efficacy (for experienced operators) and evaluates other wrist structures
    3. Other diagnostic studies (CT, MRI, XRay)
      1. Not typically indicated
      2. Consider Wrist XRay if bone or joint disorders are suspected
  12. Management: General Measures (Conservative)
    1. Efficacy
      1. Spontaneous resolution with Placebo: 50%
        1. Goodyear-Smith (2004) Ann Fam Med 2:267-73 [PubMed]
      2. Short-term: 80% respond
      3. Long-term: 80% of responders recur after one year
    2. Eliminate cause and modify work conditions
      1. Avoid repetitive Trauma
      2. Avoid the extremes of wrist flexion or extension
      3. Avoid vibratory tool use
      4. Employ ergonomics (wrist rest, adjust chair/desk, voice recognition software)
    3. Wrist Splint or Wrist brace (neutral position)
      1. Polypropylene occupational Wrist Splint
      2. Maintains wrist in neutral position
        1. Avoid cock-up (hyperextension) brace
      3. Most effective if started early (within 3 months)
      4. Wear during both day and night (best results)
        1. Burke (1994) Arch Phys Med Rehabil 75:1241-4 [PubMed]
        2. Sevim (2004) Neurol Sci 25:48-52 [PubMed]
    4. Wrist and Hand Exercises
      1. Brief (1 minute) Exercise performed intermittently (e.g. during or after work)
        1. May be taught by physical therapy, hand therapy or by online video
      2. Nerve glide Exercises (repeat each 10-15 repetitions)
        1. May theoretically untether a compressed Median Nerve
        2. Hyperextend hand against wall
        3. Wrist rotation against wall
        4. Repeat wrist rotation with neck lateral bending to either side
        5. Alternate finger extension with clenched fist
        6. https://www.youtube.com/watch?v=B5goXA9MqCA
    5. Local or Systemic Corticosteroid
      1. Carpal Tunnel Steroid Injection (preferred)
        1. Risk of Median Nerve injury, tendon rupture
        2. May repeat injection after 6 months
        3. As effective as surgery with benefits lasting more than 10 weeks (often >1 year)
          1. Ly-Pen (2005) Arthritis Rheum 52:612-9 [PubMed]
      2. Consider Systemic Corticosteroids
        1. Less effective and more adverse effects than with local injection
        2. First: Prednisone 20 mg PO qd for 14 days
        3. Next: Prednisone 10 mg PO qd for 14 days
        4. Chang (1998) Neurology 51:390-3 [PubMed]
    6. Local Ultrasound
      1. Six weeks of therapy provides up to 6 months relief
      2. Reference
        1. Ebenbickler (1998) BMJ 316:731-5 [PubMed]
    7. NSAIDs (e.g. Ibuprofen)
      1. Variable efficacy (unlikely to offer benefit beyond transient pain relief)
    8. Pyridoxine may be indicated in pregnancy
      1. Dose: Pyridoxine 25-50 mg PO tid
      2. Unproven benefit
      3. Reference
        1. (1993) Can Fam Physician, 39:2122-7 [PubMed]
  13. Management: Surgical release transverse carpal ligament
    1. Indications
      1. Early surgery for moderate to severe Median Nerve injury
      2. Persistent symptoms refractory to conservative therapy after 3-4 months
      3. Progressive or persistent motor weakness (grip strength) or thenar Muscle atrophy
    2. Efficacy
      1. Results in prompt, permanent pain relief
      2. Very effective in 66% of patients (some studies report 70-90% of cases)
      3. May be effective even if EMG normal
      4. Earlier return to work by 8 days with endoscopic repair (but equivalent longterm outcomes to open repair)
      5. References
        1. Katz (2001) Arthritis Rheum 44:1184-93 [PubMed]
        2. Gerritsen (2001) Br J Surg 88:1285-95 [PubMed]
    3. Course
      1. Sensory, Motor function improvement may take months
      2. Post-operative Splinting is not recommended
        1. Results in increased stiffness and does not improve outcomes
    4. Adverse affects
      1. No Disability from sectioning transverse ligament
      2. Residual discomfort may continue from Tenosynovitis
    5. Complications
      1. Median Nerve branch injury
      2. Hypertrophic, painful scar
      3. Superficial Palmar ArchLaceration
      4. Pillar pain adjacent to ligament release
  14. References
    1. D'Arcy (2000) JAMA 283(23): 3110-7 [PubMed]
    2. Katz (1994) Am Fam Physician 49(6):1371-9 [PubMed]
    3. Keith (2009) J Am Acad Orthop Surg 17(6): 389-96 [PubMed]
    4. Keith (2009) J Am Acad Orthop Surg 17(6): 397-405 [PubMed]
    5. LeBlanc (2011) Am Fam Physician 83(8): 952-8 [PubMed]
    6. Silver (2021) Am Fam Physician 103(5): 275-85 [PubMed]
    7. Viera (2003) Am Fam Physician 68(2):265-72 [PubMed]
    8. Wipperman (2016) Am Fam Physician 94(12): 993-9 [PubMed]

Carpal Tunnel Syndrome (C0007286)

Definition (MEDLINEPLUS)

You're working at your desk, trying to ignore the tingling or numbness you've had for some time in your hand and wrist. Suddenly, a sharp, piercing pain shoots through the wrist and up your arm. Just a passing cramp? It could be carpal tunnel syndrome.

The carpal tunnel is a narrow passageway of ligament and bones at the base of your hand. It contains nerve and tendons. Sometimes, thickening from irritated tendons or other swelling narrows the tunnel and causes the nerve to be compressed. Symptoms usually start gradually. As they worsen, grasping objects can become difficult.

Often, the cause is having a smaller carpal tunnel than other people do. Other causes include performing assembly line work, wrist injury, or swelling due to certain diseases, such as rheumatoid arthritis. Women are three times more likely to have carpal tunnel syndrome than men.

Early diagnosis and treatment are important to prevent permanent nerve damage. Your doctor diagnoses carpal tunnel syndrome with a physical exam and special nerve tests. Treatment includes resting your hand, splints, pain and anti-inflammatory medicines, and sometimes surgery.

NIH: National Institute of Neurological Disorders and Stroke

Definition (NCI) Entrapment of the median nerve in the wrist that is characterized by numbness, tingling and painful movement.
Definition (MSH) Entrapment of the MEDIAN NERVE in the carpal tunnel, which is formed by the flexor retinaculum and the CARPAL BONES. This syndrome may be associated with repetitive occupational trauma (CUMULATIVE TRAUMA DISORDERS); wrist injuries; AMYLOID NEUROPATHIES; rheumatoid arthritis (see ARTHRITIS, RHEUMATOID); ACROMEGALY; PREGNANCY; and other conditions. Symptoms include burning pain and paresthesias involving the ventral surface of the hand and fingers which may radiate proximally. Impairment of sensation in the distribution of the median nerve and thenar muscle atrophy may occur. (Joynt, Clinical Neurology, 1995, Ch51, p45)
Definition (CSP) entrapment of the median nerve in the carpal tunnel, which is formed by the flexor retinaculum and the carpal bones; this syndrome may be associated with repetitive occupational trauma, wrist injuries, amyloid neuropathies, rheumatoid arthritis, acromegaly, pregnancy, and other conditions; symptoms include burning pain and paresthesias involving the ventral surface of the hand and fingers which may radiate proximally; impairment of sensation in the distribution of the median nerve and thenar muscle atrophy may occur.
Concepts Disease or Syndrome (T047)
MSH D002349
ICD9 354.0
ICD10 G56.0, G56.00
SnomedCT 155073007, 193126005, 57406009, 246611002
English Carpal Tunnel Syndromes, Syndromes, Carpal Tunnel, Syndrome, Carpal Tunnel, AMYOTROPHY, THENAR, OF CARPAL ORIGIN, CTS1, CARPAL TUNNEL SYNDROME, CTS, CTS (carpal tunnel syndrome), carpal tunnel syndrome, carpal tunnel syndrome (diagnosis), Compression Neuropathy, Carpal Tunnel, Entrapment Neuropathy, Carpal Tunnel, Median Neuropathy, Carpal Tunnel, Carpal Tunnel Syndrome [Disease/Finding], median nerve entrapment, carpal tunnel syndrome (CTS), Carpal tunnel syndrome, unspecified upper limb, Amyotrophy, Thenar, Of Carpal Origin, Carpal canal, Carpal tunnel, Carpal tunnel syndrome, Median nerve entrapment, Median nerve compression, CTS - Carpal tunnel syndrome, Carpal tunnel syndrome (disorder), Median nerve entrapment (disorder), Carpal Tunnel Syndrome, carpal tunnel; syndrome, compression; median nerve (in carpal tunnel), entrapment; neuropathic, nerve, median, n.medianus; compression (in carpal tunnel), neuropathy; entrapment, nerve, median, syndrome; carpal tunnel, carpal tunnel median neuropathy, Carpel tunnel syndrome, Syndrome carpel tunnel
German Syndrom, Karpaltunnel, CARPALTUNNELSYNDROM, Karpaltunnel-Syndrom, Karpaltunnelsyndrom, Druckneuropathie, Karpaltunnel, Nervenkompressionssyndrom, Karpaltunnel
Portuguese Síndrome do túnel cárpico, SINDROME DO TUNEL CARPICO, Síndrome do Túnel do Carpo, Síndrome do Túnel Cárpico, Síndrome do Túnel Carpiano, Síndrome do canal cárpico, Neuropatia de Aprisionamento do Túnel Carpal, Neuropatia de Compressão do Túnel Carpal, Síndrome do Túnel Carpal
Swedish Karpaltunnelsyndrom
Japanese シュコンカンショウコウグン, 手根管圧迫症候群, 手根管症候群, 手根トンネル症候群
Finnish Rannekanavaoireyhtymä
Spanish SINDROME TUNEL CARPIANO, compresión de nervio mediano, compresión de nervio mediano (trastorno), atrapamiento del nervio mediano (trastorno), atrapamiento del nervio mediano, síndrome del túnel carpiano (trastorno), síndrome del túnel carpiano, Síndrome del túnel carpiano, Neuropatía por Atrapamiento del Túnel Carpiano, Neuropatía por Compresión del Túnel Carpiano, Síndrome del Túnel Carpiano
French SYNDROME DU CANAL CARPIEN, Syndrome du canal carpien, Neuropathie de compression du nerf médian dans le canal carpien, SCC (Syndrome du Canal Carpien)
Czech Syndrom karpálního tunelu, karpální tunelový syndrom, syndrom karpálního tunelu
Italian STC, Neuropatia da compressione del nervo mediano nel tunnel carpale, Neuropatia da compressione nel tunnel carpale, Neuropatia da intrappolamento nel tunnel carpale, Sindrome del tunnel carpale
Korean 팔목 터널 증후군
Polish Zespół cieśni nadgarstka, Zespół ciasnoty kanału nadgarstka, Zespół tunelowy nadgarstka
Hungarian Carpalis alagút-syndroma, Carpalis alagút syndroma, Carpalis alagút tünetegyüttes
Norwegian Karpaltunnelsyndrom
Dutch Carpale tunnelsyndroom, carpale tunnel; syndroom, compressie; nervus medianus (in carpale tunnel), inklemming; neuropathie, nervus, medianus, n.medianus; compressie (in carpale tunnel), neuropathie; inklemming, nervus, medianus, syndroom; carpale tunnel, carpaletunnelsyndroom, Carpale-tunnelsyndroom, Compressieneuropathie van de carpale tunnel, Syndroom, carpale-tunnel-
Derived from the NIH UMLS (Unified Medical Language System)

Median Neuropathy (C0751922)

Definition (MSH) Disease involving the median nerve, from its origin at the BRACHIAL PLEXUS to its termination in the hand. Clinical features include weakness of wrist and finger flexion, forearm pronation, thenar abduction, and loss of sensation over the lateral palm, first three fingers, and radial half of the ring finger. Common sites of injury include the elbow, where the nerve passes through the two heads of the pronator teres muscle (pronator syndrome) and in the carpal tunnel (CARPAL TUNNEL SYNDROME).
Concepts Disease or Syndrome (T047)
MSH D020423
SnomedCT 397828008, 29833009
English Median neuropathy (finding), MEDIAN NERVE DIS, Median nerve lesion, nerve palsy median, median nerve palsy, median nerve palsy (diagnosis), Median Nerve Disease, Median Nerve Diseases, Nerve Disease, Median, Nerve Diseases, Median, Median Neuropathies, Neuropathies, Median, Neuropathy, Median, Median Neuropathy [Disease/Finding], Median Neuropathy, median nerve lesion, lesions median nerve, median neuropathy, Median nerve palsy, Median neuropathy (disorder), Median neuropathy, disease (or disorder); median nerve
Swedish Medianneuropati
Spanish neuropatía del nervio mediano (hallazgo), neuropatía del nervio mediano (trastorno), neuropatía del nervio mediano, Enfermedades del Nervio Medio, Neuropatía Mediana
Finnish Keskihermon neuropatia
Croatian Not Translated[Median Neuropathy]
Polish Neuropatia nerwu pośrodkowego, Neuropatia pośrodkowa
Japanese 正中神経障害, 正中神経疾患, 正中神経麻痺
Norwegian Sykdommer i medianusnerven, Medianusnevropati, Sykdommer i nervus medianus
Czech neuropatie nervu medianus, nemoci nervu medianus, nervus medianus - neuropatie
Dutch aandoening; nervus medianus, Nervus-medianusneuropathie, Neuropathie van de nervus medianus, Neuropathie, nervus-medianus-
French Neuropathie du nerf médian
German Medianus-Neuropathie, Nervus-medianus-Krankheiten, Neuropathie, Nervus medianus
Italian Neuropatia del nervo mediano
Portuguese Doenças do Nervo Mediano, Neuropatia Mediana
Derived from the NIH UMLS (Unified Medical Language System)

Carpal tunnel space (C2332442)

Concepts Body Space or Junction (T030)
English Carpal tunnel space
Derived from the NIH UMLS (Unified Medical Language System)

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