IME,Inc.
211 Beaumont
Williamsburg,
Michigan MI 49690
Tel: (800)
968-4637
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Carpal Tunnel Syndrome I. Background Carpal Tunnel Syndrome, also known as tardy
median nerve palsy,
is believed to be caused by local impairment of the median nerve at
the carpal canal in the wrist
secondary to narrowing or crowding of the nerve in the
carpal tunnel. The condition may have multiple causes including 1) space-occupying
lesions such as the residual of
a wrist fracture, infections, local edema, tumors, flexor tenosynovitis
(non-specific as well as that associated with rheumatoid
arthritis), foreign bodies, or aberrant muscles; 2) systemic conditions
such as pregnancy, obesity, diabetes mellitus, thyroid dysfunction,
arthritis, or amyloidosis; 3) overuse of hand and wrist,
work-related trauma and repetitive movements, constricting bandages
around the wrist, or improper postural habits regarding the wrist
joint; or 4) it may have a spontaneous or idiopathic onset. The
condition can occur at any age but is most often encountered in
patients over 30 years in age. It occurs three to five times more
frequently in women than men. II. Diagnostic Criteria A.
Pertinent
Historical and Physical Findings Patients
complain of paresthesias and numbness in all or part of the
sensory distribution pattern of the median nerve in the hand,
which often worsen at night when lying in bed. These sensations
are occasionally associated with pain that may radiate
proximally to the shoulder area. The most characteristic history
involves nocturnal paresthesias, described frequently as
sensations of burning or numbness that may be relieved by shaking
or holding the affected arm in the dependent position.
Weakness of grip, hypohydrosis, clumsiness and proximal pain
migration may be accompanying complaints. Wrist pal-mar flexion
may aggravate the symptoms, and the patient may note difficulty
manipulating small objects. Occasionally, patients may complain
of circulatory disturbances in the fingers. Symptoms
may be reproduced by hand and wrist motions, such as forced
flexion and extension of the wrist, that con-strict the carpal
canal. This tendency forms the physiologic basis for the Phalen
test, which may be positive in the presence of median nerve
compression at the wrist. The patient may exhibit dryness of the
skin on the hand and fingers, thenar muscle atrophy or
fasciculations, and decreased pinch or grip strength. There may be
increased median nerve two-point discrimination. Tinel's sign may
be positive. These tests are strongly corroborative, but their
absence does not exclude this diagnosis. B.
Appropriate Diagnostic Tests and Examinations 1.
Radiographs
of wrist 2.
Electromyogram
and nerve conduction studies 3.
Hematologic,
serologic, and endocrinologic studies if symptoms suggest an
underlying systemic disease 4.
Response
to steroid injection into carpal canal 5.
Anteroposterior
and lateral oblique radiographs of cervical spine if symptoms
suggest origin in the cervical spine 6.
Chest
radiograph, if there is concern about brachial plexus or apex of
lung C.
Evolving Diagnostic Tests and Examinations 1.
Carpal
tunnel pressure measurements 2.
Measurement
of sensibility and vibration perception D.
Supporting Evidence The electromyographic and nerve conduction tests are
helpful when positive but can be negative in some patients with
this disorder. They are useful in atypical patients or in
patients in whom secondary gain may be a motive. The most
difficult differentiation involves patients with diabetes
mellitus and suspected carpal tunnel syndrome. Some patients with
neuropathies may be difficult to assess. Electrodiagnostic
studies may facilitate the assessment of patients with both
neuropathy and suspected carpal tunnel syndrome. In patients with
suspected double-crush syndrome, electrodiagnostic tests may be
helpful in determining the relative contributions of each site of
compression. III. Treatment A.
Outpatient Treatment 1.
Nonoperative treatment a.
Indications 1)
Mild
symptoms 2)
Pregnancy 3)
If
constricting bindings or positional abnormalities are causative b.
Treatment Options 1)
Neutral
position wrist splint, especially at night 2)
Steroid
injections 3)
Diuretic
agents 4)
Nonsteroidal
anti-inflammatory drugs 5)
Activity
modification 6)
Treatment
of underlying systemic disease 7)
Removal
of constricting bindings or bandages c.
Rehabilitation 1)
Hand
and wrist exercises 2)
Grip
strengthening exercises 3)
Modification
of activities of daily living and job d.
Supporting evidence consists of favorable response to steroid
injections and to the use of a wrist splint in the absence of
objective evidence of denervation. 2.
Ambulatory Surgery a.
Indications 1)
Failure
to respond to nonoperative treatment 2)
Presence
of thenar atrophy or weakness or 3)
Progressive
symptoms 4)
Presence
of space-occupying lesion in carpal canal b. Treatment options 1)
Release
of transverse carpal ligament, either under local or regional
block, or general anesthesia 2)
Tenosynovectomy
at the wrist 3)
Opponensplasty c.
Home health care may be necessary in selected cases such as in
opposite-hand dysfunction. d. Rehabilitation 1)
Elevation
of hand and exercise of fingers and
shoulder 2)
Wrist
splint in position of slight extension for two to three weeks
postoperatively e. Supporting Evidence Carpal
tunnel release may provide partial or complete
relief of symptoms in over 85% of patients. Pain is
relieved more often than numbness, particularly in older
patients with severe numbness or in those patients with associated
diabetes mellitus. Patients who have sustained worker's
compensation-related injuries or patients with diabetes mellitus
seem to be more refractory to treatment efforts. Complications are
not frequent, but prolonged tenderness in the region of the
surgical incision is not unusual. f. Controversial treatment 1)
median
nerve internal neurolysis 2)
concurrent
routine release of the ulnar nerve at Guyon's canal 3)
flexor
tenosynovectomy B. Inpatient Treatment 1.
Nonoperative
inpatient treatment is not indicated. 2.
Operative
treatment a. Indications for Admission 1)
Bilateral
surgical release 2)
Impaired
function in opposite upper extremity 3)
Concurrent
systemic disease increasing surgical risk 4)
Presence
of compartment syndrome or extensive injury to the forearm and
wrist b. Treatment options 1)
Release
of transverse carpal ligament, either under
local or regional block, or general anesthesia 2)
External
or internal neurolysis of median nerve and/or
its branches 3)
Tenosynovectomy
at the wrist 4)
Opponensplasty c. Indications for discharge 1)
Uncomplicated cases in which the patient's 2)
Complicated a)
Resolved
wound complication b)
Medical
instability of patient well-controlled d.
Home
Health Care: same as III, A, 2, c e.
Rehabilitation:
same as III, A, 2, d C.
Estimated duration of care 1.
Nonoperative
treatment - two to, three months 2.
Operative
treatment - two to six months (Note:
These periods will be longer in patients with severe preoperative
numbness or significant thenaratrophy.) D.
Anticipated outcomes 1.
Pain
reduction 2.
Improvement
of sensation and/or motor function 3. 3.
Reduction
of paresthesias (note: in some elderly patients or those with
severe preoperative compression, postoperative dysesthesias may be
associated with the recovering preoperative neuropraxia.) 4.
Improved
dexterity and grip strength 5.
Improved
vasomotor function 6.
Prevention
of further deterioration in nerve function. E.
Evolving therapeutic procedures 1.
Ergometric
studies to improve workplace situations 2.
Arthroscopic
release F.
Modifiers (age, sex, and co-morbidity) Pregnant
women may have a transitory carpal tunnel syndrome that usually
resolves itself after delivery. Occasionally,
a pregnant patient may prove refractory to non-operative
treatment. Persisting symptoms may be severe enough to require
surgical release of the carpal canal during the pregnancy or after
delivery.
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