Carpal tunnel syndrome
DEFINITION
Carpal tunnel syndrome (CTS) refers to the symptom complex brought on by
compression of the median nerve in the carpal tunnel.
AE T IOLOGY
Compression of the median nerve within the carpal tunnel (formed by the
flexor retinaculum superiorly and the carpal bones inferiorly). Usually idiopathic (43%) but
may be secondary to:
Tenosynovitis: Overuse, rheumatoid arthritis, other inflammatory rheumatic disease.
Infiltrative diseases of the canal/increased soft tissue: Amyloidosis, myeloma myxoedema,
acromegaly.
Bone involvement in the wrist: Osteoarthritis, fracture, tumour.
Fluid retention states: Pregnancy, nephrotic syndrome.
Other: Obesity, menopause, diabetes, end-stage renal disease
E P IDEMIOLOGY
Overall prevalence 2.7%. Incidence in adults 0.1% per year. Lifetime
risk 10%.
H ISTORY
Tingling and pain in the hand and fingers (patients may be woken up at night).
Weakness and clumsiness of hand.
EXAMINA T I ON
Sensory impairment in median nerve distribution (first 31/2 fingers).
Weakness and wasting of the thenar eminence (abductor pollicis brevis and opponens)
Tinel’s sign: Tapping carpal tunnel triggers symptoms.
Phalen’s test: Maximal flexion of the wrist for 1 min may cause symptoms. Signs of the
underlying cause, e.g. hypothyroidism or acromegaly.
INVE S T I G A T IONS Blood: TFTs, ESR.
Nerve conduction study: Not always necessary. Shows impaired median nerve conduction
across the carpal tunnel in the context of normal conduction elsewhere.
MANAGEMENT
Mild to moderate CTS: Nocturnal wrist splinting in the neutral position.
If there is inadequate response: a single injection of methylprednisolone into the carpal
tunnel.
Referral to an occupational therapist/carpal bone mobilization.
Moderate to severe CTS refractory to conservative measures: Surgical decompression.
COM P L IC A T I ONS
Permanent motor and sensory impairment of the hand.
PROGNOSIS
Good. Majority of cases wax and wane over years. Secondary cases are more
likely to progress further.
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