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Carpal tunnel syndrome - Management
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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.

Basis for recommendation

  • These recommendations are based on guidelines from the American Academy of Neurology [Quality Standards Subcommittee of the American Academy of Neurology, 1993] and expert opinion in review articles [Katz and Simmons, 2002; Barnardo, 2004; MacDermid and Wessel, 2004; Bland, 2007].
  • There is no gold standard for the diagnosis of carpal tunnel syndrome. Clinical diagnosis depends on specified symptoms and signs, and sometimes on the results of electrodiagnostic tests [Jordan et al, 2002].
  • The authors of a systematic review did not recommend electrodiagnostic testing if the symptoms of carpal tunnel syndrome are well defined [Jordan et al, 2002]. The authors cited a systematic review [Jablecki et al, 1993] which found that electrodiagnostic testing had a high specificity (95%) so few people without carpal tunnel syndrome would have an abnormal result. However the sensitivity was low (between 49% and 84%) so many people with positive clinical symptoms would have a negative result. Although electrodiagnostic testing is not recommended routinely in primary care it may be helpful where there is diagnostic doubt, before surgery [Bland, 2007], and in ruling out neuropathy and other nerve entrapments [Katz and Simmons, 2002]. The sensitivity of nerve conduction studies has improved with modern techniques and the false negative rate is now probably around 5–10% [Bland, 2007].
  • High resolution ultrasonography measures the diameter of the median nerve and has been compared with nerve conduction studies in a prospective cohort study of people (n = 120) suspected of having carpal tunnel syndrome. Figures for sensitivity and specificity are not clear as the authors optimized the ultrasound measurement cut off values to achieve specificity rates of 65% and sensitivity rates of 95% and also there were no absolute diagnostic standards for comparison [Wong et al, 2004]. Ultrasonography may also show relevant structural abnormalities such as bifid median nerves or space occupying lesions in the carpal tunnel but these are rare [Bland, 2007].

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