Background

u Carpal tunnel syndrome represents compression of the median nerve in the

carpal tunnel
u In the hand, the median nerve supplies the LOAF muscles:
u Lateral 2 lumbricals
u Opponens policis

Carpal tunnel syndrome u Abductor policis brevis

u Flexor policis brevis

u The signs of median nerve compression can be explained by an increase in

antagonistic muscle groups to these muscles.

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Presentation Clinical examination

u Usually presents as burning/tingling/numbness in the distribution of the u Motor

median nerve
u Worse at night patient has to wake up and shake hand for symptoms to
go away
u Risk factors diabetes, fluid overload states, hypothyroidism, obesity,
pregnancy, hand trauma, rheumatoid arthritis
u Note role of repetitive wrist use in the workplace is controversial
u Wasting of thenar eminence due to de-inervation of LOAF muscles.
u Weakness of thumb abduction and opposition can be clinically tested.
u Loss of thumb opposition can lead to the simian or ape hand over time with the thumb moving to
the same plane as the fingers.
u Clawing of first 2 digits: the lumbrical muscles facilitate flexion at the MCP joints and
extension at the DIP/PIP joints. If these are lost, then overtime, extension will occur at the
MCP joint and flexion at the DIP/PIP joints, due to dominance of the antagonist muscles.
u Sensory
u Loss over palmar aspect of thumb, index, middle and half of ring finger.
u Sparing of part of the thenar eminence as the palmar cutaneous branch is given off
before the median nerve enters the carpal tunnel

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Clinical examination Differential diagnosis

u Tinnels tap test u Brachial plexus lesions these can given similar claw hands (e.g. Klumpkes
u Tapping on the flexor retinaculum reproduces symptoms palsy).
u Phalens test u Cervical myelopathy compression of nerve roots e.g. C6 nerve root.
u Both wrists are forcibly held in flexion for at least 30 seconds
u Reproduces symptoms u Median nerve compression at the forearm this will result in more extensive
neurology, as the median nerve innervates most of the wrist flexors.
u Ulnar nerve palsy sensory and motor loss are different. Clawing is usually of
the ring and little finger.
u Glove and stocking distribution peripheral neuropathy pattern associated
with diabetes.

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 Investigations Treatment

u Not everybody needs investigations, especially in the GP setting.
u Electrodiagnostics
u Nerve conduction studies may show conduction blocks, slowed conduction velocity.
u EMG - may show fibrillation potentials evidence of de-enervation of muscle groups;
the role of EMG is mainly to rule out other neuromuscular conditions.
u Imaging
u MRI C-spine may be warranted to rule out central lesions, especially if bilateral
symptoms are present.
u Wrist ultrasound scans/MRI may be undertaken, especially if a structural cause is
suspected e.g. lunate bone dislocation.
u Nerve conduction studies can help define the level of nerve dysfunction.
u Non-operative treatments are appropriate for mild dysfunction/recent
onset symptoms that could be corrected.
u Splint keeps wrist in neutral position, good 1st line treatment for pregnancy
u Glucocorticoid injections temporarily reduce inflammation
u Analgesics limited evidence of efficacy
u Operative intervention should be undertaken with severe nerve
dysfunction/prolonged symptoms.
u Other indications loss of 2 point discrimination (indicator of severe dysfunction),
failure of conservative methods.

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Surgery carpal tunnel release Surgery complications

u Set-up tourniquet to minimise bleeding, local analgesia with conscious sedation. u Neurovascular damage
u Palmar cutaneous branch of median nerve can result in a neuroma, so should
u Skin incision 2-4cm incision in the plane of a longitudinal in line drawn proximally
from the web space of middle/ring fingers, 2mm ulnar to the thenar crease. be removed from its proximal attachment if injured
u Median nerve
u Dissection and release Retractors are placed perpendicular to incision. u Ulnar nerve
Subcutaneous fat and palmar fascia are carefully dissected. This exposes the u Ulnar artery
transverse carpal ligament (aka flexor retinaculum) which can be dissected from
distal to proximal. u Complex regional pain syndrome
u Closure irrigation, haemostasis and wound closure completes the procedure. u Hypertrophic scar formation
u Postoperative care encourage early finger mobilisation and hand use. u Pillar pain pain adjacent to scar

Further detail: Rodner CM, Katarincic J. Open Carpal Tunnel Release. Techniques in Orthopaedics. 2006. 21(1):311

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Further reading

u Rodner CM, Katarincic J. Open Carpal Tunnel Release. Techniques in

Orthopaedics. 2006. 21(1):311.

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