Carpal Tunnel Syndrome

Carpal Tunnel Syndrome - ClinicalKey https://udca.elogim.com:2774/#!/content/clinical_overview/67-s2.0-c0...
CLINICAL OVERVIEW
Carpal Tunnel Syndrome

Elsevier Point of Care (ver detalles)
Actualizado May , . Copyright Elsevier BV. All rights reserved.
Synopsis
Urgent Action
Acute, severe carpal tunnel syndrome occurs very rarely (eg, aer a wrist injury); in such
cases, immediate surgery may be the best option for symptomatic relief
Key Points
Carpal tunnel syndrome is a group of symptoms related to median nerve compression at the
wrist caused by increased carpal tunnel pressure
Classic symptoms include pain, paresis, and/or paresthesia of palm side of thumb, second nger,
third nger, and radial side of fourth nger; symptoms sometimes radiate into forearm
Symptoms are oen worse at night and can awaken the patient
Most cases are idiopathic; oen caused by repetitive strain or overuse of the hand or wrist,
and prolonged, improper positioning (typically work-related)
Common risk factors include obesity, pregnancy, hypothyroidism, diabetes, and fracture
History and physical examination form the basis of the diagnostic evaluation; include
provocative testing (eg, Phalen test, Tinel sign) in the diagnostic evaluation
Obtain needle EMG and nerve conduction studies when physical examination and/or
1 de 19 11/3/2024, 14:10
Obtain needle EMG and nerve conduction studies when physical examination and/or provocative
test results are positive and surgical management is being considered, in patients with thenar
atrophy and/or persistent numbness (to document more severe nerve injury), and to exclude
dierential diagnoses
Initially, use conservative therapy (eg, splinting, local steroid injection) in patients with mild to
moderate carpal tunnel syndrome
If rst line conservative treatment methods fail to resolve symptoms in to weeks, implement
alternative nonoperative or surgical treatment options
Surgical release is recommended when symptoms do not respond to conservative treatment
Generally, carpal tunnel syndrome is a progressive condition that can lead to permanent
median nerve damage; it may be reversible in the early stages, so early treatment is
recommended
Prevented through avoidance of repetitive movements and overuse activities, particularly in

certain occupations; ergonomic interventions can mitigate physiologic stresses
Pitfalls
Patients with more severe or prolonged carpal tunnel syndrome may not benet from
prolonged, nonoperative treatment
It is important to consider the location of the median nerve when performing injections and
surgery; the median nerve is the most supercial structure in the carpal tunnel
Symptoms that develop during pregnancy oen resolve spontaneously within several months
aer delivery
Terminology
Clinical Clarication
Carpal tunnel syndrome is a group of symptoms related to median nerve compression at the
wrist caused by increased carpal tunnel pressure
2 de 19 11/3/2024, 14:10
Median nerve is compressed where it passes, along with the exor tendons, beneath the
Median nerve is compressed where it passes, along with the exor tendons, beneath the volar
ligament of the carpus (ie, transverse carpal ligament or exor retinaculum of hand)
Diagnosis
Clinical Presentation
History
Classic symptoms include pain, paresis, and/or paresthesia of
palm side of thumb, second nger, third nger, and radial side of
fourth nger; symptoms sometimes radiate into forearm and,
less commonly, into upper arm and shoulder
Decreased grip strength, resulting in loss of dexterity; patient
may complain of dropping things and having Carpal tunnel syndrome: relevant diculty with
opening jars anatomy.
Sensation of swelling or tightness in the absence of edema in

the aected hand(s)
Sensation of extreme temperature in the aected hand(s)
Symptoms sometimes appear intermittently and during performance of specic manual

activities; can vary day to day
Dominant hand can be aected initially and/or with greater severity, but bilateral carpal tunnel
syndrome occurs frequently
Symptoms are oen worse at night and can wake the patient
Patients sometimes report icking or shaking their wrist in an attempt to relieve symptoms
(ick sign)
3 de 19 11/3/2024, 14:10
Evidence supports not using ick sign as an independent factor for diagnosis, because this
sign alone has only weak association with ruling in or ruling out carpal tunnel syndrome
Physical examination
Decreased sensation on palm side of thumb, second nger, third nger, and radial side of fourth
nger; other areas of the hand should demonstrate normal sensation
Evidence supports not using this test as an independent physical examination maneuver for
diagnosis, because this symptom alone in these areas has only weak association with ruling in
or ruling out carpal tunnel syndrome
Thenar atrophy may be observable, usually in more severe cases
Strong evidence supports thenar atrophy as strongly associated with ruling in carpal tunnel
syndrome but only weakly associated with ruling it out
Weakness of abductor pollicis brevis is demonstrated when the patient raises the aected
thumb perpendicular to the palm when downward pressure is applied on the distal phalanx
by the examiner (demonstrates weakness of abduction and opposition)
diagnosis, because this nding alone has only weak association with ruling in or ruling out
carpal tunnel syndrome
Measure pinch and grip strength on both hands either manually or by using a dynamometer;
weakness is commonly demonstrated
In more severe cases, a -point discrimination test with calipers will demonstrate inability to
discriminate points less than mm apart in volar pads of aected ngers
diagnosis, because this nding alone has only weak association with ruling in or ruling out
carpal tunnel syndrome
Ecchymosis or abrasions on hands and wrists may be present in cases caused by acute injury
4 de 19 11/3/2024, 14:10
Causes and Risk Factors
Causes
Idiopathic (most common)
Repetitive strain or overuse of the hand or wrist, and prolonged, improper positioning
(typically work-related)
Risk factors and/or associations
Age
More common in people older than years
Sex
More common in women
Genetics
Rarely familial; these cases are caused by a congenitally small carpal tunnel
Other risk factors/associations

Repetitive movements
Oen associated with computer use and occupations involving vibrating machinery, assembly
on a production line, and construction
Flexor tenosynovitis
Obesity
Pregnancy
Arthritis
5 de 19 11/3/2024, 14:10
Hypothyroidism
Diabetes mellitus
Fracture or acute injury of the wrist
Mass lesions (eg, ganglion cyst, lipoma)
Amyloidosis
Sarcoidosis Obtain needle EMG and

nerve conduction
Multiple myeloma studies in the
following situations:
Leukemia
Physical examination
Acromegaly Gout ndings are suggestive
and/
or provocative test
results are positive,
Diagnostic Procedures and surgical
management is
Primary diagnostic tools under consideration
History and physical examination form the basis of Presence of thenar

diagnostic evaluation atrophy and/or
persistent numbness
Duration of symptoms and examination ndings does (to document more
not always correlate with degree of nerve injury or severe nerve injury)
treatment outcomes
Include provocative testing (eg, Phalen test, Tinel sign)

in the diagnostic evaluation; however, none of the
provocative tests have been established as a gold
standard
Evidence supports not using such tests as independent

physical examination methods for diagnosis, because,
on their own, each has only weak association with
ruling in or ruling out carpal tunnel syndrome The Tinel sign for carpal tunnel
syndrome.
6 de 19 11/3/2024, 14:10
Phalen test. - ( A ) performed properly
( le ) and improperly ( right ). The le
image illustrates independent testing
of each carpal tunnel. The right image
illustrates a common shortcut
examination technique, which is a
good general screening for nerve
compression, but not specic to the
carpal tunnel because it also
challenges the
thoracic outlet (therefore
Exclusion of di erential diagnoses misleading if it evokes
symptoms). ( B ) The Phalen
test combined with carpal compression test—examiner
Imaging maintains wrist simultaneously applying exion whilerm

pressure directly over the carpal
canal. This maneuver is typically
Functional testing held for up to seconds and less

than minute.
Procedures
The carpal compression test.
Dierential Diagnosis
Most common
Pronator teres syndrome
Median nerve compression in the forearm

7 de 19 11/3/2024, 14:10
Causes sensory alteration in the median nerve distribution of the hand and the palmar
cutaneous distribution of the thenar eminence Also causes aching in the forearm and
hand weakness Dierentiated by physical examination:
Symptoms occur with resisted pronation of the forearm and wrist exion, or with direct
pressure on the leading edge of the pronator while the forearm is in maximum
supination and the wrist is in a neutral position
Pronator compression test demonstrates development of paresthesia in the hand

within seconds of manual compression of the median nerve at or near the within
seconds of manual compression of the median nerve at or near the pronator muscle
Cervical radiculopathy
Neck pain with associated radiation to upper extremity in a specic dermatomal

distribution
Can cause numbness, weakness, and decreased reexes in upper extremities
Positive result on Spurling test (foraminal compression test) conrms diagnosis
Dierentiated by:
Cervical MRI scan (imaging method of choice) shows disk herniation
Cervical radiograph shows disk space narrowing, sclerosis, and osteophyte

formation
Ulnar neuropathy
Ulnar nerve compression at the cubital tunnel on the medial elbow or the ulnar side of
the wrist
Symptoms can occasionally aect the third nger, and weakness is a common nding; sensory
symptoms aect the fourth and h ngers
Dierentiated by EMG, which reveals abnormalities of the ulnar nerve
Raynaud phenomenon
8 de 19 11/3/2024, 14:10
Recurrent vasospasm of ngers and toes; usually occurs in response to stress or cold
exposure
Numbness and pain occur in aected area
Aected area also demonstrates at least color changes: white (pallor), blue
(cyanosis), and red (hyperemia)
Dierentiated by history and physical examination
Osteoarthritis
Primary osteoarthritis occurs because of articular cartilage degeneration in wrist
Secondary osteoarthritis can result from fractures and dislocations
Results in severe pain and restricted movement of wrist
Dierentiated by plain radiographs of wrist (posteroanterior and lateral views)

demonstrating degenerative changes
Diabetic neuropathy (Related: Diabetic Peripheral Neuropathy)
Distal polyneuropathy caused by chronic prolonged hyperglycemia
Frequently bilateral; causes tingling and numbness in a stocking-and-glove

distribution
Dierentiated by elevated levels of hemoglobin AC and fasting plasma glucose
Treatment
Goals
Relieve symptoms and prevent further nerve compression
9 de 19 11/3/2024, 14:10
Disposition
Recommendations for specialist referral

Refer patients requiring surgical carpal tunnel release to an orthopedic specialist
Treatment Options
It is important that the patient stop repetitive movements and overuse activities to avoid
exacerbating symptoms
Ergonomic interventions, such as using wrist supports with computer keyboards, can help
relieve symptoms
Initially, use conservative therapy in patients with mild to moderate carpal tunnel syndrome;
methods include:
Splinting (eg, neutral or cock-up wrist splints)
Local steroid injection (if unresponsive to splinting and symptoms lasting at least weeks )
If rst injection provides relief, second injection can be considered aer a few months
Consider surgery if more than injections are needed
Oral steroids or therapeutic ultrasound
Optional; may be less eective than other treatments
If rst line conservative treatment methods fail to resolve symptoms within to weeks,
implement alternative nonoperative or surgical treatment options
Patients with more severe or prolonged carpal tunnel syndrome may not benet from
prolonged, nonoperative treatment
Surgical release of exor retinaculum is eective treatment of carpal tunnel syndrome
Strong evidence supports that surgical release of transverse carpal ligament should relieve
symptoms and improve function
10 de 19 11/3/2024, 14:10
Recommended when symptoms do not respond to conservative treatment
Early surgery is an option with clinical evidence of median nerve denervation or if patient
elects to proceed directly to surgery
Acute, severe carpal tunnel syndrome occurs very rarely (eg, aer a wrist injury); in such
cases, immediate surgery may be the best option for symptomatic relief
Drug therapy
Injected corticosteroids
Recommended initial conservative therapy; if condition is unresponsive to splinting and

symptoms have lasted at least weeks
It is important to consider the location of the median nerve when performing injections
and surgery; the median nerve is the most supercial structure in the carpal tunnel
Methylprednisolone Acetate Suspension for injection; Adults: to mg as a single injection

adjacent to the carpal tunnel as conservative treatment. Reassess at to weeks. To avoid
median-nerve injury, use specialized administration techniques. Use of weeks. To avoid
median-nerve injury, use specialized administration techniques. Use of or more repeat
injections is not advised; local tendon damage may occur.
Oral corticosteroids
Optional conservative therapy
Prednisolone Oral tablet; Adults: mg PO once daily for weeks, then mg PO once
daily for weeks, has provided relief. NOTE: The denitive treatment for median-nerve
entrapment is surgery. Corticosteroids are temporary measures; patients who have
intermittent pain and paresthesias without any xed motor-sensory decits may respond to
conservative therapy.
Nondrug and supportive care

Ergonomic interventions, such as using wrist supports with computer keyboards, can help
relieve symptoms
Splinting
11 de 19 11/3/2024, 14:10
Initial conservative therapy for those with mild to moderate symptoms
Wrist splints support the wrist in neutral or slightly dorsiexed position
Worn nightly or full-time; optimal splinting duration has not been established, but to
weeks is suggested
Procedures
Therapeutic ultrasound or short wave diathermy
General explanation
Energy is delivered via short wave radio frequencies or ultrasonic waves to produce heat
deep in the body, relieving pain and improving hand function
Exact mechanism and ecacy of this treatment are uncertain
Indication
Optional conservative therapy for patients with mild to moderate symptoms
Optional conservative therapy for patients with mild to moderate symptoms
Contraindications
Implanted metal devices
Cancer
Reduced skin sensation
Peripheral vascular disease
Surgical carpal tunnel release
General explanation
12 de 19 11/3/2024, 14:10
Outpatient procedure reduces pressure on the median nerve by completely releasing the
transverse carpal ligament (exor retinaculum of hand); patient receives regional anesthesia
methods are used: open release of the carpal tunnel (interthenar incision and release of
the transverse carpal ligament) and endoscopic release (minimally invasive technique with
use of an endoscope to release the ligament without incision of interthenar skin) Both
options have similar ecacy
Postoperative wrist immobilization or hand therapy is not recommended
Strong evidence supports that surgical release of this ligament should relieve symptoms
and improve function
Early surgery is an option with clinical evidence of median nerve denervation or if patient
elects to proceed directly to surgery
It is important to consider the location of the median nerve when performing injections and
surgery; the median nerve is the most supercial structure in the carpal tunnel
Indication
Condition not responding to other treatments
Severe symptoms
Severe symptoms
Contraindications
Endoscopic release method
Rheumatoid arthritis
Mass lesions
Repeated surgery
Open release method
Infection
13 de 19 11/3/2024, 14:10
Complications
Median nerve damage resulting in pain, permanent loss of sensation, denervation of thenar
muscles with loss of thumb opposition and abduction, and diculty moving thumb
Hypertrophic scarring
Laceration of supercial palmar arch
Tendon adhesion and stiness
Arterial injury and hematoma
Reex sympathetic dystrophy
A systematic review found that endoscopic release has a higher incidence of transient
nerve injury
Comorbidities
Generalized neuropathy
Surgical carpal tunnel release oers less favorable results
Special populations
Pregnant women
Pregnant women
Symptoms that develop during pregnancy oen resolve spontaneously within several
months aer delivery; therefore, conservative therapy is recommended
Monitoring
Regular follow-up examinations are recommended to ensure that condition is responding to
treatment
Reevaluate to weeks aer surgery, then every to months for at least year
14 de 19 11/3/2024, 14:10
Complications and Prognosis
Complications
Untreated carpal tunnel syndrome can result in permanent atrophy of the thenar muscles
and related grip weakness with diculty performing some activities of daily living, such as
opening jars
Prognosis
Generally, carpal tunnel syndrome is a progressive condition that can lead to permanent
median nerve damage
Spontaneous resolution occurs in some patients when predisposing factors are avoided
Disease course
Can be reversible in the early stages, so early treatment is recommended
In later stages, permanent nerve damage may occur owing to chronic nerve
compression
Severity
In mild to moderate cases, surgical release results in success in most cases, with complete
recovery in patients who do not respond to initial conservative treatment methods
In severe cases, complete recovery is unlikely, but most patients experience at least
In severe cases, complete recovery is unlikely, but most patients experience at least partial
recovery
Patients with an underlying condition (eg, diabetes, trauma) oen have poorer prognosis
Screening and Prevention
15 de 19 11/3/2024, 14:10
Prevention
Manage underlying disorders that can be risk factors (eg, diabetes, hypothyroidism)
Avoid repetitive movements and overuse activities, particularly in certain occupations;

ergonomic interventions can mitigate physiologic stresses
Consider consultation with an industrial hygienist for ergonomic evaluation of workplace
Referencias
. American Academy of Orthopaedic Surgeons: Management of Carpal Tunnel Syndrome: EvidenceBased

Clinical Practice Guideline. AAOS website. Updated February , . Accessed March , .
https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/
guidelines/CTS%CPG_...pdf
Ver en el Artículo (https://udca.elogim.com:/!/content/clinical_overview/-s.-ce-c--adddainline-reference-) |
Referencia cruzada (https://www.aaos.org/uploadedFiles/
PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%CPG_...pdf )
. Graham B et al: The American Academy of Orthopaedic Surgeons evidence-based clinical practice
guideline on: management of carpal tunnel syndrome [guideline summary]. J Bone Joint Surg Am.
():-,
Referencia cruzada (https://udca.elogim.com:/)
. LeBlanc KE et al: Carpal tunnel syndrome. Am Fam Physician. ():-,

. Viera AJ: Management of carpal tunnel syndrome. Am Fam Physician. ():-,

. Cranford CS et al: Carpal tunnel syndrome. J Am Acad Orthop Surg. ():-,

. D'Arcy CA et al: The rational clinical examination: does this patient have carpal tunnel syndrome?
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JAMA. ():-,
. Goodyear-Smith F et al: What can family physicians oer patients with carpal tunnel syndrome other than
surgery? A systematic review of nonsurgical management. Ann Fam Med. ():-,
. Armstrong T et al: Risk factors for carpal tunnel syndrome and median neuropathy in a working
population. J Occup Environ Med. ():-,
. Shiri R: Arthritis as a risk factor for carpal tunnel syndrome: a meta-analysis. Scand J Rheumatol.
():-,
. Deniz FE et al: Comparison of the diagnostic utility of electromyography, ultrasonography, computed

tomography, and magnetic resonance imaging in idiopathic carpal tunnel syndrome determined by
clinical ndings. Neurosurgery. ():-,
. González del Pino J et al: Value of the carpal compression test in the diagnosis of carpal tunnel syndrome.
J Hand Surg Br. ():-,
. Lee HJ et al: Intraoperative dynamic pressure measurements in carpal tunnel syndrome: correlations with
clinical signs. Clin Neurol Neurosurg. :-,
. Calandruccio JH et al: Carpal tunnel syndrome: making evidence-based treatment decisions. Orthop .
Calandruccio JH et al: Carpal tunnel syndrome: making evidence-based treatment decisions. Orthop
Clin North Am. ():-,
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. Hegmann KT: Upper extremity disorders. In: Occupational Medicine Practice Guidelines. Evaluation and
Management of Common Health Problems and Functional Recovery in Workers. rd ed. American
College of Occupational and Environmental Medicine; :-
Ver en el Artículo (https://udca.elogim.com:/!/content/clinical_overview/-s.-ce-c--adddainline-reference-)
. Page MJ et al: Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev. :CD,
. Page MJ et al: Therapeutic ultrasound for carpal tunnel syndrome. Cochrane Database Syst Rev. :CD,
. Incebiyik S et al: Short-term eectiveness of short-wave diathermy treatment on pain, clinical symptoms,
and hand function in patients with mild or moderate idiopathic carpal tunnel syndrome. J Back
Musculoskelet Rehabil. ():-,
. Vasiliadis HS et al: Endoscopic release for carpal tunnel syndrome. Cochrane Database Syst Rev. :CD,
. Faucher GK et al: Complications of surgical release of carpal tunnel syndrome: a systematic review. J Surg
Orthop Adv. ():-,
. Verdugo RJ et al: Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane Database
Syst Rev. :CD,
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Carpal Tunnel Syndrome - ClinicalKey https://udca.elogim.com:2774/#!/content/clinical_overview/67-s2.0-c0...

Surgical release is recommended when symptoms do not respond to conservative treatment

Prevented through avoidance of repetitive movements and overuse activities, particularly in

Decreased grip strength, resulting in loss of dexterity; patient

Sensation of swelling or tightness in the absence of edema in

Sensation of extreme temperature in the aected hand(s)

Symptoms sometimes appear intermittently and during performance of specic manual

Thenar atrophy may be observable, usually in more severe cases

Causes and Risk Factors

Risk factors and/or associations

Other risk factors/associations

Fracture or acute injury of the wrist

Mass lesions (eg, ganglion cyst, lipoma)

Sarcoidosis Obtain needle EMG and

History and physical examination form the basis of Presence of thenar

Include provocative testing (eg, Phalen test, Tinel sign)

Evidence supports not using such tests as independent

Imaging maintains wrist simultaneously applying exion whilerm

Functional testing held for up to seconds and less

Median nerve compression in the forearm

hand weakness Dierentiated by physical examination:

Pronator compression test demonstrates development of paresthesia in the hand

Neck pain with associated radiation to upper extremity in a specic dermatomal

Can cause numbness, weakness, and decreased reexes in upper extremities

Positive result on Spurling test (foraminal compression test) conrms diagnosis

Cervical MRI scan (imaging method of choice) shows disk herniation

Cervical radiograph shows disk space narrowing, sclerosis, and osteophyte

Dierentiated by EMG, which reveals abnormalities of the ulnar nerve

Numbness and pain occur in aected area

Dierentiated by history and physical examination

Primary osteoarthritis occurs because of articular cartilage degeneration in wrist

Secondary osteoarthritis can result from fractures and dislocations

Results in severe pain and restricted movement of wrist

Dierentiated by plain radiographs of wrist (posteroanterior and lateral views)

Diabetic neuropathy (Related: Diabetic Peripheral Neuropathy)

Distal polyneuropathy caused by chronic prolonged hyperglycemia

Frequently bilateral; causes tingling and numbness in a stocking-and-glove

Dierentiated by elevated levels of hemoglobin AC and fasting plasma glucose

Recommendations for specialist referral

Splinting (eg, neutral or cock-up wrist splints)

Consider surgery if more than injections are needed

Oral steroids or therapeutic ultrasound

Optional; may be less eective than other treatments

Surgical release of exor retinaculum is eective treatment of carpal tunnel syndrome

Recommended initial conservative therapy; if condition is unresponsive to splinting and

Methylprednisolone Acetate Suspension for injection; Adults: to mg as a single injection

Optional conservative therapy

Nondrug and supportive care

Wrist splints support the wrist in neutral or slightly dorsiexed position

Therapeutic ultrasound or short wave diathermy

Exact mechanism and ecacy of this treatment are uncertain

Optional conservative therapy for patients with mild to moderate symptoms

Implanted metal devices

Reduced skin sensation

Peripheral vascular disease

Surgical carpal tunnel release

Postoperative wrist immobilization or hand therapy is not recommended

Condition not responding to other treatments

Endoscopic release method

Open release method

Laceration of supercial palmar arch

Tendon adhesion and stiness