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Carpal tunnel syndrome - Management
How do I make a diagnosis?
- Carpal tunnel syndrome is characterized by tingling, numbness, or pain in the distribution of the median nerve (the thumb, index, and middle fingers, and half the ring finger) that is often worse at night and causes wakening.
- However some people present atypically (e.g. they may have sensory changes in all digits).
- The likelihood of the person having carpal tunnel syndrome increases with the number of standard symptoms and provocative factors:
- Dull, aching discomfort in the hand, forearm, or upper arm.
- Paraesthesia in the hand.
- Weakness (particularly of thumb grip causing the person to drop things) or clumsiness (especially fine finger function) of the hand.
- Occurrence of any of the above in the median nerve distribution.
- Provocation of symptoms by sleep, sustained hand or arm positions, or repetitive actions of the hand or wrist.
- Mitigation of symptoms by changing hand posture or shaking the wrist.
- Dry skin, swelling, or colour changes in the hand.
- The physical examination may be normal or the following may be present:
- Sensory loss in the median nerve distribution including loss of two-point discrimination.
- Weakness or atrophy of the thenar muscles.
- Dry skin of the thumb, index, and middle fingers.
- Positive Phalen's test — flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution.
- Positive Tinel's sign — tapping lightly over the median nerve at the wrist causes a distal lancinating paraesthesia in the median nerve distribution.
- Positive carpal tunnel compression test — pressure over the proximal edge of the carpal ligament (proximal wrist crease) with thumbs cause paraesthesia to develop or increase in the median nerve distribution.
- Exclude conditions that may be confused with carpal tunnel syndrome:
- Neurological:
- Fairly common: cervical radiculopathy (especially C6/7); ulnar neuropathy; generalized peripheral neuropathies.
- Rare: brachial plexopathy; motor neurone disease; syringomyelia; multiple sclerosis.
- Vascular: Raynaud's phenomenon; vibration white finger; cerebral infarction.
- Vascular or neurogenic thoracic outlet syndrome (rare).
- Osteoarthritis of the metacarpophalangeal joint of the thumb.
- Refer for electromyography and nerve conduction studies if the diagnosis is uncertain. High resolution ultrasonography may be available as a diagnostic tool in some areas.
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