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


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