Carpal Tunnel Syndrome

Pregnant, early middle-aged female with h/o obesity, DM, hypothyroidism, rheumatoid arthritis presents with pain and paresthesias in distribution of median nerve. Pain often awakens patient from sleep and is reduced by shaking hand (flick sign). Square shaped-wrist with loss of two-point discrimination, positive Phalen/Tinnel/median nerve compression tests on exam.

• Obtain HbA1c, TSH

• Consider obtaining rheumatoid factor, anti-CCP antibodies

• Ultrasound showing median nerve cross-sectional area < 9mm

• Treatment

  • Consider median nerve glide exercises, yoga

  • Start neutral wrist splint

  • No improvement after 6 weeks of conservative therapy

    • Consider prednisone 20 mg x 10 days

    • Consider 80 mg methylprednisolone local injection

  • Failure of conservative management after 4-6 months: Refer for nerve conduction studies/needle electromyography and consider surgical intervention

Notes

• More common in women

• Flick sign

  • Patient experiences relief s/p shaking hand

  • 93% sensitive and 96% specific for carpal tunnel syndrome

• Pathophysiology and physical exam

  • Median nerve distribution: Palmar aspect of thumb/index/middle fingers and radial half of ring finger

  • Sensory nerves are more susceptible to compression that motor nerve fibers

  • Two point discrimination: Inability to distinguish between points less than 6 mm apart

• Treatment

  • Ineffective therapies: NSAIDs, vitamin B6

  • Oral corticosteroids can improve pain for up to 8 weeks

  • Corticosteroid injection

    • Can reduce pain for 1 month and delay need for surgery at 1 year

    • Risks include median nerve injury and tendon rupture

  • Avoid routine physical therapy referral after surgery