Orthopedic Surgery for Carpal Tunnel Syndrome Workup

  • Author: David A Fuller, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Sep 22, 2010
 

Imaging Studies

Radiographs

Wrist radiographs should not be routinely performed in patients with carpal tunnel syndrome (CTS) because too little useful information is obtained from these images.[22]

Only 0.4% of routine wrist radiographs for CTS have been demonstrated to provide therapeutically significant findings.[22]

Patients with a history of systemic disorders, wrist trauma, arthritis, or abnormal findings (eg, limited motion) on physical examination for CTS are much more likely to have radiographic findings; use in these patients may be indicated.

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Other Tests

A thorough physical examination of the neck and upper extremity should be performed. Clinical tests to evaluate for carpal tunnel syndrome (CTS) include sensory evaluations and provocative maneuvers that attempt to elicit signs or symptoms of median nerve compression at the wrist. The list below includes the more commonly used tests in the workup.

  • Sensory examinations - Threshold tests (Semmes-Weinstein pressure monofilaments and vibratory sensibility) reflect gradual decreases in nerve function, but the innervation density tests (2-point discrimination) can remain normal until nearly all sensory conduction has ceased.
    • Semmes-Weinstein pressure monofilaments - Monofilaments of increasing diameter are pressed perpendicularly against the palmar aspect of each finger until the monofilament bends to determine the sensory threshold for each finger. Values greater than 2.83 may be indicative of CTS.
    • Vibratory sensibility - A 256-cycle per second tuning fork is struck against an object, causing it to vibrate, and the fork's prong is then placed against the patient's fingertips. The median and ulnar fingers of both hands are tested. The test is considered positive if decreased sensation is perceived.
    • Static and moving 2-point discrimination - This is the minimum separation between 2 points (either static or moving) that can be perceived. Failure to discriminate more than 6 mm (static) or 5 mm (moving) is a positive finding.
  • Provocative tests[23]
    • Phalen wrist flexion test - The patient's elbows are placed on a table, with the forearms perpendicular to the table and the wrists flexed. This position is held for 60 seconds. The test is positive if numbness or paresthesia develops in radial-sided digits.
    • Tinel test - The examiner taps along the course of the median nerve on the volar aspect of the wrist. The test is positive if paresthesia is elicited in the median nerve distribution.
    • Carpal compression test - Direct application of pressure of 150 mm Hg or even pressure from both thumbs of the examiner is exerted on the patient's carpal canal and is maintained for 30 seconds. The test is positive if pain, numbness, or paresthesia develops in the radial-sided digits.
  • Electrophysiologic diagnostic studies - Nerve conduction[24]
    • Median motor and sensory latencies, as well as conduction velocities, are measured across the wrist. A sensory latency of greater than 3.5 milliseconds or a motor latency of greater than 4.5 milliseconds is considered an abnormal finding. Comparison with the contralateral hand, as well as with ulnar motor and sensory latencies and conduction velocities, can provide additional evidence supporting the diagnosis of CTS.
    • Distal compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) amplitudes may be decreased in persons with CTS.
    • Minimum F-wave latencies of the median nerve can be prolonged in individuals with CTS.
  • Electrophysiologic diagnostic studies - Electromyography
    • This study must be performed with a clinical differential diagnosis in mind; the abductor pollicis brevis is the key muscle to evaluate.
    • Positive findings in persons with CTS include sharp waves, fibrillation potentials, and increased insertional activity.
  • When interpreting electrophysiologic studies, remembering that CTS is a clinical diagnosis is important. CTS is a constellation of signs and symptoms caused by the compression and slowing of the median nerve at the wrist. Electrodiagnostic studies should not be used independently in making a diagnosis.[25]
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Diagnostic Procedures

Direct pressure measurement

A catheter is inserted directly into the carpal canal to measure pressure.

This test is typically used to evaluate acute carpal tunnel syndrome and can help to differentiate between median nerve contusion and compression.

The figure of 30 mm Hg is a guide used to determine if the pressure is critically elevated, but physical examination and patient-specific factors can modify the critical pressure.

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Contributor Information and Disclosures
Author

David A Fuller, MD  Assistant Professor of Surgery, Director of Hand Surgery, University of Medicine and Dentistry of New Jersey, Cooper University Hospital

David A Fuller, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, Pennsylvania Orthopaedic Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael S Clarke, MD  Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Arthroscopy Association of North America, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Thomas R Hunt III, MD  John D Sherrill Professor and Director of Orthopaedic Surgery, Surgeon in Chief of UAB Highlands Hospital, Director of Hand and Upper Extremity Fellowship, University of Alabama at Birmingham

Thomas R Hunt III, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, American Society for Surgery of the Hand, AO Foundation, Mid-America Orthopaedic Association, and Southern Orthopaedic Association

Disclosure: Tornier Consulting fee Review panel membership; Tornier Royalty None; Tornier Ownership interest None; Lippincott Royalty Independent contractor

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

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Cross sections of the carpal canal at the levels of the proximal and distal carpal rows are depicted. The transverse carpal ligament bridges the carpal tunnel and is under tension.
Surgical incision for an open carpal tunnel release is depicted. The incision can be extended proximally across the wrist flexion crease for a more extended exposure.
Surgical incisions for an endoscopic (1- and 2-incision) carpal tunnel release are depicted. Precise location of the incisions is critical and depends on individual anatomy.
 
 
 
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