Online Module:

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome (CTS)
 By far the most common entrapment
neuropathy, especially of the upper extremity.
 Caused by compression of the Median Nerve at
the wrist by the Transverse Carpal Ligament.
 “Classic” patient is a 40-something y/o female
complaining of dominant-hand weakness,
clumsiness, or stiffness with nocturnal
dysesthesias (waking up at night due to painful
hand numbness).
 CTS statistics
 As many as 1 in 10 Americans will experience
CTS at some point in their lives.
 Female to Male ration = 4:1
 More than 50% of patients with CTS have
bilateral involvement, though symptoms are
usually worse in dominant hand.
 Associated with repetitive wrist/hand motions.
 Secretaries, computer use, writers, shop workers, etc.
 CTS
 It is important to have a high degree of
suspicion for CTS because…
 if caught early, non-operative management is
usually very successful in bringing patients relief.
 If conservative management fails, surgical options
carry a very high success rate and have low risk of
complications.
 Overall, patients should not have to suffer with
undiagnosed CTS!
 CTS signs/symptoms
 Nocturnal dysesthesia: Patients will complain
of waking up due to “painful numbness” of
their hand. They will “shake it out,” or run
water over it, or rub hands together to try to
relieve the symptoms.
 Subjective complaints regularly include
involvement of the underside of the forearm,
and can even radiate proximal to the elbow!
 Onset usually insidious, present for months.
 CTS signs/symptoms
 Complaints of hand weakness are common;
may include “stiffness,” “clumsiness,” and
difficulty with gripping/holding things in
affected hand.
 Pain, numbness, burning, loss of sensation in a
median nerve-distribution of the palm.
 Subjective complaints involving any of the first
three fingers carries an 80% sensitivity!!!
 CTS signs/symptoms
 Most CTS complaints are secondary to sensation
changes; even fine motor skill loss is usually
more due to loss of sensation than motor
weakness.
 Muscle atrophy is classically appreciated in the
“APB,” Abductor Pollicis Brevis muscle, which
provides bulk to the thenar emenince.
 Muscle wasting, however, is a LATE finding of CTS.
Therefore, just because a patient’s thenar eminence
and/or motor exam is normal, does not r/o CTS!
 Median Nerve Supply
 A cool pneumonic to remember the palmar
muscles that are innervated by the Median
Nerve: Meat-LOAF
 Meat – Median nerve
 L – lumbricals 1 and 2

 O – opponens pollicis

 A – abductor pollicis brevis

 F – flexor pollicis brevis

 Phalen’s Test
 Performed by maximally flexing the wrist;
between 30 seconds to 1 minute of this will
worsen or reproduce pain or tingling in 80% of
cases of CTS.
 It is POSITIVE if symptoms are worsened or
reproduced.
 It is NEGATIVE, of course, if they are not.
 Tinel’s Sign
 Test for by percussing over the carpal tunnel.
 Tinel’s sign is PRESENT if paresthesias or
pain in median nerve distribution are produced
by this action.
 The sign is ABSENT if not.
 CTS
 In most cases, a diagnosis of CTS can be
reasonably arrived at through a thorough
history and physical exam. Even so, there are
diagnostic tests which are used to help confirm
the diagnosis and rule out other possible
diagnoses.
 EMG and NCV in CTS
 Electromyography (EMG) looks at the
electrical activity of muscles, both at rest and
during contraction.
 EMG is abnormal in ~ 70% of cases of CTS.
 Nerve Conduction Velocities (NCV) measure
the speed and efficiency with which nerves are
transmitting electrical signals.
 NCV is abnormal in ~75-85% of CTS cases.
 Differential Diagnoses that can
mimic CTS
 Cervical radiculopathy
 Thoracic Outlet Syndrome
 Pronator Teres Syndrome
 Reflex Sympathetic Dystrophy
 Diabetic neuropathy
Conditions that have been associated
with CTS
 Multiple Myeloma
 Rheumatoid Arthritis
 Pregnancy
 Amyloidosis
 A/V dialysis shunts
 Endocrine/Pituitary abnormalities
 Hypothyroidism
 acromegaly
 “Abnormal” CTS
 The presentation of CTS is usually fairly
typical, in that it is with the previously-
described symptomology in a middle-aged or
older adult who has a history of repetitive hand
motions or some type of activity which can be
associated with disturbing the median nerve at
the wrist.
 Occasionally, though, there are “odd”
presentations of CTS which warrant further
work-up.
 “Abnormal” CTS
 Young individuals, especially with no history of
repetitive hand/wrist motions, should receive
w/u including laboratory studies considering
conditions associated with CTS (prev. slide).
 “Acute” CTS – abrupt onset of CTS-like
symptoms, usually after trauma or precipitating
event.
 Median artery thrombosis
 TCL hematoma
 CTS treatment
 Most cases of CTS can be adequately treated with
conservative (i.e. non-surgical) management.
 Rest
 NSAIDs, steroid injections
 Neutral-position splints

 Surgical management is generally reserved for:

 CTS refractory to conservative management.
 CTS with severe sensory loss and/or thenar atrophy.
 Surgical treatment of CTS
 Surgery for CTS involves either open or
endoscopic approach with the same goal:
surgical division of the Transverse Carpal
Ligament.
 Approximately 90% of surgically-treated
patients report satisfactory results, with either
improvement or resolution of symptoms of
CTS.
 Complication rate ~ 2%
 Summary
 Carpal Tunnel Syndrome is a common,
debilitating condition for which there is an
excellent prognosis, provided that the
condition is recognized and the patients
receive appropriate attention and treatment.