Carpal Tunnel Syndrome Disease

BASICS

DESCRIPTION

This is the most common cause of peripheral nerve compression. The median nerve is compressed as it traverses the carpal tunnel in the wrist and hand. The tunnel is composed of the carpal bones dorsally and the transverse carpal ligament ventrally. It contains flexor tendons and the median nerve. Symptoms tend to affect the dominant hand but over half the patients experience bilateral symptoms.

System(s) affected: Musculoskeletal, Nervous
Genetics: Unknown, however a familial type has been reported
Incidence/Prevalence in USA: Most common entrapment neuropathy
Predominant age: 40 to 60
Predominant sex: Female > Male (3-6:1)

SIGNS AND SYMPTOMS

The symptoms characteristically are relieved by shaking or rubbing the hands. During waking hours symptoms occur when driving the car, reading the newspaper and occasionally when using the hands for repetitive maneuvers. The altered sensation is characteristically confined to the thumb, index and middle finger but many patients do not distinguish this localization and feel the entire hand is affected

Tingling or prickling sensations in the fingers
Burning pain in the fingers particularly at night (acroparesthesias)
Arm pain
Finger sensory loss
Positive Tinel's sign
Positive Phalen's sign
Wasting of the thenar and hypothenar muscles is a late sign
Weakness of the hand, however, for such tasks as opening jars is often noted by the patient early in the disorder

CAUSES

Disorders affecting the musculoskeletal system in the region of the wrist including trauma or Colles' fracture, degenerative joint disease, rheumatoid arthritis, ganglion cyst, scleroderma
Hypothyroidism and diabetes are frequently associated with this condition which also occurs with increased frequency during pregnancy
Other miscellaneous causes include acromegaly, lupus erythematosus, leukemia, pyogenic infections, sarcoidosis, primary amyloidosis and Paget's disease
Hyperparathyroidism, hypocalcemia

RISK FACTORS

Repetitive flexion and extension of the wrist may influence the development of carpal tunnel syndrome. Occupation as a seamstress or computer operator may aggravate carpal tunnel syndrome. There is, however, no universal agreement that carpal tunnel syndrome is job related.

DIAGNOSIS

LABORATORY

No one laboratory test is diagnostic
Normal thyroid function studies and normal glucose metabolism studies may be helpful in excluding these conditions which may be associated with CTS

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

Electromyography will be abnormal in more than 85% of cases; prolonged distal latency of the median motor nerves; the most sensitive indicator is the median sensory distal latency which is prolonged. Furthermore the sensory nerve action potential may be reduced or unobtainable.
Stimulation of the ulnar nerve should be done as well to exclude generalized polyneuropathy

IMAGING

Special x-ray views of the carpal tunnel may be obtained. These are of limited usefulness unless heterotopic calcification can be identified.

DIAGNOSTIC PROCEDURES

Tinel's sign - tapping of the wrist proximal to the carpal tunnel may produce electric sensation perceived by the patient, a sign of nerve compression
Phalen's sign - holding the wrist flexed for 60 seconds may precipitate the paresthesias experienced by the patient
A blood pressure tourniquet to cut off circulation to the arm may precipitate symptoms promptly

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient
Outpatient surgery

GENERAL MEASURES

Splinting of the wrist in extension may provide significant relief of symptoms. Prolonged use of splinting if possible may allow some symptoms to resolve.
Injection of the carpal tunnel with hydrocortisone (Medrol 40 mg/mL). 1 mL + 1% lidocaine (1 mL) may provide significant temporary relief. This is particularly useful during pregnancy.

SURGICAL MEASURES

Surgical decompression of the carpal tunnel by dividing the transverse carpal ligament completely provides almost complete relief of symptoms in over 95% of patients
Surgical decompression usually done as an outpatient under local anesthesia
Healing of the incision generally takes two weeks; an additional two weeks of recuperation may be required before the hand can be fully utilized for tasks requiring strength

ACTIVITY

As tolerated

DIET

No special diet

PATIENT EDUCATION

Carpal Tunnel Syndrome Foundation. For patient education materials favorably reviewed on this topic, contact: American Academy of Family Physicians Foundation, P.O. Box 8418, Kansas City, MO 64114, (800)274-2237, ext.4400

FOLLOW UP

PREVENTION/AVOIDANCE

Take a break once an hour when doing repetitive work involving hands

POSSIBLE COMPLICATIONS

Post-op infection (rare)
Injury to recurrent branch of the nerve

EXPECTED COURSE AND PROGNOSIS

Untreated the condition can be expected to lead to numbness and weakness in the hand with atrophy of hand muscles and permanent loss function of the extremity

MISCELLANEOUS

ASSOCIATED CONDITIONS

Diabetes
Obesity
Pregnancy

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: N/A
Others: N/A

PREGNANCY

May occur in pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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