Carpal tunnel syndrome
Carpal Tunnel Syndrome or CTS is a common presentation in Primary Care. This review of CTS on A4Medicine presents the clinician with pathophysiology with relevant anatomy displayed for easy reference. CTS is the commonest compression neuropathy of the upper limb. Presentation of carpal tunnel syndrome and examination is discussed – specific tests as the Phalen’s, Tinel’s and Durkan test are described. The differential diagnosis of CTS is mentioned and the clinician should exclude other causes as cervical radiculopathy and vibration white finger or hand arm vibration syndrome. The management of CTS is discussed and the role of interventions as lifestyle modification, physiotherapy, corticosteroid injections have been mentioned. Referral to trauma and orthopaedics should be considered if surgery is being contemplated. Visual diagrams of CTS, Phalen’s test and Durkan’s test have been shown to aid understanding.
Symptomatic compression neuropathy of the median nerve at the level of the wrist. Anatomical compartment bounded on three sides by carpal bones and on palmar side by transverse carpal ligament Contains ○ 9 tendons with synovial sheaths and ○ the Medial nerve- divides into recurrent branch and palmar digital nerves ( once passes through the carpal tunnel ) Median nerve contains fibers from all five roots C5-T1 Anything that causes a ○ reduction in the volume of this compartment or ○ ↑↑ the pressure within the compartment Ischaemia of the median nerve and impaired nerve conduction Symptoms of carpal tunnel syndrome
Epidemiology-Commonest compression neuropathy of the upper limb Reported prevalence is between 1% and 7% in European population studies Much more rare in developing countries Three times ↑ common in women High BMI Occupation – repetitive movements Familial and psychosocial factors
Presentation-Intermittent tingling , numbness or altered sensation and burning –> distribution of medial nerve Symptoms often worse at night- can wake patient up Pain in hand , wrist or forearm radiating as far proximally as the shoulder Can be uni or bilateral Reduced grip strength Clumsiness or ↓↓ manual dexterity Trophic ulcers – tips of thumb , index finger or middle finger Severe disease ○ unremitting sensory symptoms ○ weakness ○ thenar mucle wasting Exacerbating factors eg ○ sleep ○ sustained hand or arm positions ○ repetitive hand or wrist movements Ask about relieving factors as changing hand posture or shaking / flicking the wrist Effect on function and activities
Examination-Examine both hands Check for sensory loss – Median N distribution Atrophy of muscles -> thenar eminence Thumb- reduced strength thumb abduction Evidence of trophic ulcer -> dry skin thumb , index & middle fingers Tests ○ Phalen’s – flex wrist + 60 sec’s can produce symptoms ○ Tinel’s – tapping lightly over the median N ○ Durkan’s or carpal tunnel compression test Direct compression of median nerve at the carpal tunnel ○ Hand diagram – patient marks site of pain or altered sensation on hand diagram Examine cervical spine Neurological & musculoskeletal examination of upper limbs
Other possible causes- Cervical radiculopathy Diabetes Hypothyroidism Osteoarthritis Inflammatory arthropathy Stroke Lateral epicondylitis De Quervains tenosynovitis Amyotrophic lateral sclerosis MND Vibration white finger or hand-arm-vibration syndrome Peripheral neuropathy – any cause Raynaud’s phenomenon Motor neurone disease ( no sensory component ) Ulnar N compression Rotator cuff tendinopathies
Management-Optimize any underlying condition Lifestyle modifications may help- eg ○ avoidance of repetitive movements ○ break from tasks that precipitate symptoms ○ workplace adaptation ( if work related ) ○ check if eligible for Industrial Disablement Benefit Physiotherapy Wrist splinting in neutral position -> particularly for night time symptoms ( can be used first line ) Steroid injections -> if expertise available + splinting considered safe and effective Do not suggest NSAIDs ,diuretics , magnets , vitamins or acupuncture Surgery ○ carpal tunnel decompression well established treatment ○ day case ○ good evidence of good outcome and patient satisfaction ○ possible complications ( usually rare ) ♦ scar tenderness ( may persist up to 2 yrs ) ♦ persistent symptoms ♦ N/V injury ♦ wound complications ♦ bleeding ♦ pillar pain → deep aching pain at base of thenar eminence and across the wrist ( may persist upto 2 yrs ) Decompression can also be achieved endoscopically
CTS may improve spontaneously in up to 1/3rd of patients over a period of 10-15 months
Investigations-Electrophysiological studies- EMG Debate about its use BMJ review suggests ○ not required to make an initial diagnosis or to initiate Rx in primary care ○ assessment in specialist environment- patient selection for surgery and for evaluation of complex cases , relapse of symptoms or recurrence Ultrasound MRI
Referral-Diagnosis not clear Severe symptoms or functional ability is reduced Symptoms recur following surgery Patient request Conservative management has not worked Serious underlying cause suspected as ○ neurological dis ○ inflammatory joint disease ○ peripheral limb ischaemia ○ cervical n root entrapment
LINKS AND RESOURCES
A brief 1 page PIL from American College of Rheumatology https://www.rheumatology.org/Portals/0/Files/Carpal-Tunnel-Syndrome-Fact-Sheet.pdf
For patients who wish to learn more American College of Rheumatology has a useful online section (has useful information for a whole range of MSK conditions ) https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Carpal-Tunnel-Syndrome
Exercises and information from Arthritis Research Foundation is here https://www.csp.org.uk/system/files/2_carpal_tunnel.pdf
OthoInfo AAOS has a comprehensive section for patients on CTS https://orthoinfo.aaos.org/en/diseases–conditions/carpal-tunnel-syndrome/
Physiotherapy and exercise for CTS from NHS York Teaching Hospital with video instructions https://www.yourphysio.org.uk/condition-directory/carpal-tunnel-syndrome/
Carpal Tunnel Release Surgery– a useful section on this from BUPA https://www.bupa.co.uk/health-information/muscles-bones-joints/carpal-tunnel-release-surgery
Royal College of Surgeons has a section with downloadable information on CTS https://www.rcseng.ac.uk/search/#SearchTerm=carpal%20tunnel
RCS – full guideline can be downloaded from this https://www.rcseng.ac.uk/-/media/files/rcs/standards-and-research/commissioning/boa–carpal-tunnel-syndrome-guide-2017.pdf
American Academy of Orthopaedic Surgeons – Management of Carpal Tunnel Syndrome Evidence Based Clinical Practice Guideline 2016 can be found here https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%20CPG_2.29.16.pdf
Questionnaires on CTS
Boston CTS Questionnaire https://journals.plos.org/plosone/article/file?id=info:doi/10.1371/journal.pone.0129918.s002&type=supplementary
DASH Questionnaire https://www.orthopaedicscore.com/scorepages/disabilities_of_arm_shoulder_hand_score_dash.html
References
- Carpal tunnel syndrome Clinical Review BMJ 2007:335:343
- Carpal tunnel syndrome BMJ 2014;349:g6437
- CKS NHS Carpal tunnel syndrome https://cks.nice.org.uk/carpal-tunnel-syndrome
- Diagnosing and managing carpal tunnel syndrome in primary care Br J Gen Pract 2014 ;64 (622 ):262-263 https://bjgp.org/content/64/622/262
- Campbell’s Operative Orthopaedics , Thirteenth Edition Azar.Frederick M., MD Elsevier , Inc
- Carpal Tunnel Syndrome : Diagnosis and Management Am Fam Physician .2016 Dec 15;94 (12):993-999
- Carpal Tunnel Syndrome and Median Nerve Lesions Patient UK
- Treatment of Carpal Tunnel Syndrome Commissioning guide Royal College of Surgeons January 2016
- BMJ Best Practice – Carpal tunnel syndrome
- Risk factors in carpal tunnel syndrome The Journal of Hand Surgery : British & European Volume , 29 , Issue 4 , August 2004 , Pages 315-320 ( Abstract )
- The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome ( INSTINCTS trial ) : an open-label parallel group , randomised controlled trial The Lancet , Volume 392 , Issue 10156 , 20-26 October 2018 , Pages 1423-1433 ( Abstract )
- Dale, Ann Marie et al. “Prevalence and incidence of carpal tunnel syndrome in US working populations: pooled analysis of six prospective studies.” Scandinavian journal of work, environment & health vol. 39,5 (2013): 495-505. doi:10.5271/sjweh.3351
- Sevy JO, Varacallo M. Carpal Tunnel Syndrome. [Updated 2020 Mar 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448179/
- Carpal Tunnel Syndrome: A Review of the Recent Literature I Ibrahim et al https://openorthopaedicsjournal.com/VOLUME/6/PAGE/69/FULLTEXT/#
- Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I. Prevalence of Carpal Tunnel Syndrome in a General Population. JAMA. 1999;282(2):153–158. doi:10.1001/jama.282.2.153 ( Abstract )