carpal tunnel syndrome (median neuropathy)
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Introduction
Entrapment of the median nerve at the carpal tunnel (wrist).
Etiology
- idiopathic
- occupational
- pregnancy
- hypothyroidism
- rheumatoid arthritis
- injury (Colles fracture)
- amyloidosis
- acromegaly
- multiple myeloma
- T-cell lymphoma[17]
- diabetes mellitus[8]
- obesity
Epidemiology
- 3% of U.S. population
- more common in females[23]
Pathology
- nerve impingement syndrome due to compression of the median nerve as it passes through the carpal tunnel
- thickening from tendinitis or other swelling can narrow the carpal tunnel & causes the median nerve to be compressed
Genetics
- associated with defects in transthyretin (type 1)
Clinical manifestations
- pain & paresthesias, especially at night
- often relieved by shaking affected wrist/hand[23]
- wrist pain & numbness that worsens with repetitive activity
- sensory abnormalities on palmar surface of radial 3 & 1/2 fingers (includes thumb)[4]
- Tinel's sign (limited discrimination utility)[4]
- Phalen's sign (limited discrimination utility)[4]
- Durkan maneuver (64% sensitive, 83% specific)
- pain may refer to the forearm or shoulder
- thenar atrophy & muscle weakness occurs with more severe cases[13]
- loss of thumb opposition,
- impaired flexion of the thumb, index, & middle finger
Laboratory
- thyroid function tests
- erythrocyte sedimentation rate
- complete blood count
- fasting serum glucose
- serum protein electrophoresis, urine protein electrophoresis if multiple myeloma suspected
Diagnostic procedures
- EMG, nerve conduction study if surgery contemplated
- slowed impulse conduction in the median nerve
- include entire upper extremity in study
- more proximal nerve entrapment may produce similar symptoms
- active denervation is an indication for surgical decompression
- ultrasound, neuromuscular
- measurement of median nerve cross-sectional area[9]
Radiology
- magnetic resonance imaging of unclear value[4]
Complications
Differential diagnosis
- C6, C7 radiculopathy
- tenosynovitis & osteoarthritis
- polyneuropathy
- proximal median nerve injury (at elbow)
- brachial plexus lesion
- radial nerve palsy
- wrist drop (inability to extend the wrist)
- loss of finger extension at the metacarpophalangeal joints
- weakness of thumb extension & abduction
- sensory loss typically involves the dorsal aspect of the hand Complication:
- increased risk of later amyloidosis (0.10% vs 0.006%)[20]
- increased risk of later heart failure (5.3% vs 3.2%)[20]
Management
- avoidance of repetitive motions (activity modification)
- wrist splint that holds wrist straight or extended not greater than 15 degrees (at night)
- first line treatment of constant bilateral carpal tunnel syndrome symptoms including in pregnancy (MKSAP20)[4]
- occupational therapy[4]
- anti-inflammatory agents
- prednisone 20 mg PO QD for 1 week, then 10 mg QD for 1 week
- NSAIDs as needed
- glucocorticoid injection[5]
- more effective than oral glucocorticoid
- 0.25 mg of Kenalog (40 mg/mL) + 0.75 mL of 1% lidocaine
- injection into flexor retinaculum adjacent to median nerve or just proximal to the carpal tunnel[3]
- outcomes are better when carpal tunnel injection is performed under ultrasound guidance[16]
- relief of symptoms strongly supports diagnosis
- early improvement in symptoms, but most patients still opt for surgery[10]
- intermediate-term outcomes similar for glucorticoid injection vs slinting but glucorticoid injection resulted in fewer lost work days[19]
- ultrasound-guided perineural injection with D5W superior to glucocorticoid injection[18]
- ice pack to the palm side of the wrist
- splinting[19]
- surgical decompression[5]
- release of transverse carpal ligament[15]
- prevent irreversible muscle weakness[4]
- indications:
- active denervation on nerve conduction studies
- muscle weakness & muscle atrophy (thenar atrophy)[4]
- intolerable pain[4]
- not responsive to conservative measures[4]
- useful for patients without denervation[7]
- superior to medical management[21]
- initial surgical decompression superior to glucocorticoid injection at 18 months. (61% vs 45%)[24]
- improve control of comorbidities
- 50 mg of vitamin B6 BID may be of benefit
- indications for follow-up
- severe pain not relieved by rest, ice, & anti-inflammatory agents
- hand grip becomes weak
- numbness persisting more than one month
- prognosis
- thenar atrophy & weakness of pinch or opposition strength are late motor signs that may respond poorly to surgical or medical management
- better symptom relief with steroid injection than surgery in 1st few months; no difference at 6 months[5]
More general terms
- entrapment neuropathy; nerve entrapment syndrome; pinched nerve
- median neuropathy
- repetitive strain disorder
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 803-805, 1016-18
- ↑ DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 872
- ↑ 3.0 3.1 Journal Watch vol 19 #22, pg 177, Nov 15, 1999
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018.
Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025 - ↑ 5.0 5.1 5.2 5.3 Journal Watch 25(6):52, 2005 Ly-Pen D, Andreu JL, de Blas G, Sanchez-Olaso A, Millan I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. 2005 Feb;52(2):612-9. PMID: https://pubmed.ncbi.nlm.nih.gov/15692981
- ↑ Jarvik JG et al Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial The Lancet 2009, 374:1074-1081 PMID: https://pubmed.ncbi.nlm.nih.gov/19782873
Atroshi I and Gummesson C Non-surgical treatment in carpal tunnel syndrome The Lancet 2009, 74:1042-1044 PMID: https://pubmed.ncbi.nlm.nih.gov/19782855 - ↑ 7.0 7.1 Jarvik JG et al. Surgery versus non-surgical therapy for carpal tunnel syndrome: A randomised parallel-group trial. Lancet 2009 Sep 26; 374:1074. PMID: https://pubmed.ncbi.nlm.nih.gov/19782873
- ↑ 8.0 8.1 Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
- ↑ 9.0 9.1 Cartwright MS et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve 2012 Aug;46(2):287-93 PMID: https://pubmed.ncbi.nlm.nih.gov/22806381
- ↑ 10.0 10.1 Atroshi I et al Methylprednisolone Injections for the Carpal Tunnel Syndrome: A Randomized, Placebo-Controlled Trial. Ann Intern Med. 2013;159(5):309-317 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/24026316 <Internet> http://annals.org/article.aspx?articleid=1733275
- ↑ D'Arcy CA, McGee S. Clinical diagnosis of carpal tunnel syndrome JAMA. 2000 Oct 18;284(15):1924-5. No abstract available. PMID: https://pubmed.ncbi.nlm.nih.gov/11035885
D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome? JAMA. 2000 Jun 21;283(23):3110-7. Review. PMID: https://pubmed.ncbi.nlm.nih.gov/10865306 - ↑ Huisstede BM, Hoogvliet P, Randsdorp MS et al Carpal tunnel syndrome. Part I: effectiveness of nonsurgical treatments--a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):981-1004. PMID: https://pubmed.ncbi.nlm.nih.gov/20599038
Huisstede BM, Randsdorp MS, Coert JH et al Carpal tunnel syndrome. Part II: effectiveness of surgical treatments--a systematic review. Arch Phys Med Rehabil. 2010 Jul;91(7):1005-24 PMID: https://pubmed.ncbi.nlm.nih.gov/20599039 - ↑ 13.0 13.1 The NNT: Carpal Tunnel Syndrome http://www.thennt.com/lr/carpal-tunnel-syndrome/
- ↑ Alfonso C, Jann S, Massa R, Torreggiani A. Diagnosis, treatment and follow-up of the carpal tunnel syndrome: a review. Neurol Sci. 2010 Jun;31(3):243-52 PMID: https://pubmed.ncbi.nlm.nih.gov/20145967
- ↑ 15.0 15.1 15.2 Young K, Sofair A, Chavey WE Carpal Tunnel Syndrome Guidelines Published Physician's First Watch, March 4, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org
Guideline on the Treatment of Carpal Tunnel Syndrome American Association of Orthopedic Surgeons (AAOS) http://www.aaos.org/Research/guidelines/CTStreatmentguide.asp
Carpal tunnel syndrome appropriate use criteria American Academy of Orthopaedic Surgeons (AAOS) http://www.orthoguidelines.org/go/auc/default.cfm?auc_id=224989&actionxm=Terms - ↑ 16.0 16.1 Evers S, Bryan AJ, Sanders TL, Selles RW, Gelfman R, Amadio PC. Effectiveness of ultrasound-guided compared to blind steroid injections in the treatment of carpal tunnel syndrome. Arthritis Care Res (Hoboken) 2017 Jul; 69:1060 PMID: https://pubmed.ncbi.nlm.nih.gov/27696773
- ↑ 17.0 17.1 Chevalier X, Hermine O, Authier FJ, Gaulard P, Gherardi RK. Carpal tunnel syndrome due to T cell lymphoma. Arthritis Rheum. 1995 Nov;38(11):1707-9. PMID: https://pubmed.ncbi.nlm.nih.gov/7488294
- ↑ 18.0 18.1 Wu YT, Ke MJ, Li TY. Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol 2018 Sep 5 PMID: https://pubmed.ncbi.nlm.nih.gov/30187524 https://onlinelibrary.wiley.com/doi/abs/10.1002/ana.25332
- ↑ 19.0 19.1 19.2 Chesterton LS et al. The clinical and cost-effectiveness of corticosteroid injection versus night splints for carpal tunnel syndrome (INSTINCTS trial): An open-label, parallel group, randomised controlled trial. Lancet 2018 Oct 20; 392:1423. PMID: https://pubmed.ncbi.nlm.nih.gov/30343858 Free PMC Article https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31572-1/fulltext
- ↑ 20.0 20.1 20.2 Fosbol EL, Rorth R, Leicht BP et al Association of Carpal Tunnel Syndrome With Amyloidosis, Heart Failure, and Adverse Cardiovascular Outcomes. J Am Coll Cardiol. Volume 74, Issue 1, July 2019 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/31272537 <Internet> http://www.onlinejacc.org/content/74/1/15
Ton VK, Patel S, Gottlieb SS Carpal Tunnel Syndrome and Future Amyloidosis. Time to Heed the Warning Sign. J Am Coll Cardiol. Volume 74, Issue 1, July 2019 <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/31272547 <Internet> http://www.onlinejacc.org/content/74/1/24 - ↑ 21.0 21.1 Blom AW, Donovan RL, Beswick AD et al. Common elective orthopaedic procedures and their clinical effectiveness: Umbrella review of level 1 evidence. BMJ 2021 Jul 7; 374:n1511 PMID: https://pubmed.ncbi.nlm.nih.gov/34233885 PMCID: PMC8262448 Free PMC article https://www.bmj.com/content/374/bmj.n1511
- ↑ Currie KB, Tadisina KK, Mackinnon SE Common Hand Conditions. A Review. JAMA. 2022;327(24):2434-2445. June 28 PMID: https://pubmed.ncbi.nlm.nih.gov/35762992 https://jamanetwork.com/journals/jama/fullarticle/2793654
- ↑ 23.0 23.1 23.2 23.3 NEJM Knowledge+ Neurology
- ↑ 24.0 24.1 Palmbergen WAC et al. Surgery versus corticosteroid injection for carpal tunnel syndrome (DISTRICTS): An open-label, multicentre, randomised controlled trial. Lancet 2025 Jun 14; 405:2153 PMID: https://pubmed.ncbi.nlm.nih.gov/40517008 Clinical Trial https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(25)00368-X/abstract
- ↑ NINDS Carpal Tunnel Syndrome Information Page https://www.ninds.nih.gov/disorders/all-disorders/carpal-tunnel-syndrome-information-page
Carpal Tunnel Syndrome Fact Sheet https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Carpal-Tunnel-Syndrome-Fact-Sheet
Patient information
carpal tunnel syndrome (median neuropathy) patient information