Carpal Tunnel Syndrome
Orthopedic
First 5 Minutes
- Thorough history – including occupation and activities, and physical exam of the wrist joint, and joints above and below.
- Do not miss: ischemic strokes, motor neuron disease such as ALS, forearm/hand compartment syndrome, septic joint.
Context
- The carpal tunnel is a narrow passageway of ligament and bones at the base of your hand. It contains nerve and tendons.
- Carpal tunnel syndrome describes a compressive neuropathy of the median nerve at the level of the wrist. The flexor retinaculum is a strong ligament that bridges the anterior concavity of the carpal bones, thus creating a “tunnel”.
- Common condition, affecting 1-5% of population.
- Most common causes of nerve compression include:
- Idiopathic CTS (due to inflamed synovium).
- Repetitive motions in patient with normal anatomy.
- Space occupying lesions.
- Treatment is generally conservative with night splints and injections with carpal tunnel release reserved for refractory cases.
Diagnostic Process
- Diagnosis is made by clinical signs and symptoms. EMG and NCV can provide objective evidence of a compressive neuropathy and help discriminate severity of CTS, but are not required to make a diagnosis.
- Night pain.
- Hand weakness.
- Numbness/paresthesia in median nerve distribution – the radial 3.5 digits.
- Positive provocative tests:
- Tinel’s test: provocative test performed by tapping the median nerve over the volar carpal tunnel, positive test reproduces symptoms.
- Phalen’s test: wrist volar flexion against gravity for about 60 seconds produces symptoms.
- Durkan’s test (aka Carpal Tunnel Compression Test): most sensitive test to diagnose carpal tunnels syndrome. Performed by pressing thumbs over the carpal tunnel and holding pressure for 30 seconds. Onset of pain or paresthesia in the median nerve distribution within 30 seconds is a positive result.
Recommended Treatment
- Non-operative
- Acetaminophen, NSAIDs, night and/or occupational splints, activity modifications.
- Steroid injections may be used as an adjunctive treatment in some cases.
- Operative
- Carpal tunnel release (open or endoscopic), when there is failure of nonoperative treatment (including steroid injections).
Criteria For Hospital Admission
No requirement for hospital admission.
Criteria For Transfer To Another Facility
No indications for transfer.
Criteria For Close Observation And/or Consult
Consider consultation with plastic surgery as an outpatient with refractory cases.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
There is high quality evidence for local corticosteroid treatment in delaying need for surgery, and for endoscopic and open carpal tunnel release are equally effective, long-lasting treatments for carpal tunnel syndrome.
Weak evidence, approach to diagnosis and treatment are largely based on observational studies and clinical experience.
Related Information
Reference List
Elwyn G, Kerrigan C, Warhold L, Reinke TR. Carpal tunnel syndrome: treatment options [Internet]. Choosing Wisely Canada. 2016 [cited 2022Nov24]. Available from: https://choosingwiselycanada.org/wp-content/uploads/2017/06/Carpal-tunnel-syndrome.pdf
Kothari MJ. Carpal tunnel syndrome: Clinical manifestations and diagnosis [Internet]. UpToDate. 2022 [cited 2022Nov24]. Available from: https://www.uptodate.com/contents/carpal-tunnel-syndrome-clinical-manifestations-and-diagnosis?search=carpal+tunnel+&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Kothari MJ. Carpal tunnel syndrome: Treatment and prognosis [Internet]. UpToDate. 2022 [cited 2022Nov24]. Available from: https://www.uptodate.com/contents/carpal-tunnel-syndrome-treatment-and-prognosis?search=carpal+tunnel+&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Peters B, Giuffre JL. Canadian trends in carpal tunnel surgery. The Journal of Hand Surgery. 2018Mar17;43(11).
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Dec 16, 2022
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