eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Carpal Tunnel Syndrome: Differential Diagnoses & Workup

Author: Jeffrey G Norvell, MD, Clinical Assistant Professor of Emergency Medicine, University of Kansas School of Medicine
Coauthor(s): Mark Steele, MD, Associate Dean for Truman Medical Center Programs, Professor, Department of Emergency Medicine, University of Missouri-Kansas City
Contributor Information and Disclosures

Updated: Sep 10, 2009

Differential Diagnoses

Tendonitis
Tenosynovitis

Other Problems to Be Considered

Compressive neuropathies of the nerve roots and brachial plexus
Proximal median neuropathy
Polyneuropathy

Workup

Imaging Studies

  • Currently, there is no universally accepted criterion standard for the diagnosis of carpal tunnel syndrome (CTS). The diagnosis of CTS is made from the ED presumptively. The clinician who follows the patient after the acute presentation usually orders the imaging studies and other tests discussed below.
    • Magnetic resonance imaging (MRI) is reasonably accurate in diagnosing CTS. Currently, this imaging modality is only recommended when the clinical picture is confusing or when nerve conduction studies are equivocal or contradictory. Dynamic MRI imaging may be useful in identifying dynamic CTS (CTS symptoms brought on only by repetitive wrist motion).9 MRI may also identify causative lesions in carpal tunnel.10


Carpal tunnel syndrome. Axial fast spin-echo T2-w...

Carpal tunnel syndrome. Axial fast spin-echo T2-weighted MRI with fat saturation. Note the increased T2-weighted signal within the median nerve (arrow). A slightly increased cross sectional area of the nerve is noted but the nerve architecture is preserved, consistent with early or mild inflammation.

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Carpal tunnel syndrome. Axial fast spin-echo T2-w...

Carpal tunnel syndrome. Axial fast spin-echo T2-weighted MRI with fat saturation. Note the increased T2-weighted signal within the median nerve (arrow). A slightly increased cross sectional area of the nerve is noted but the nerve architecture is preserved, consistent with early or mild inflammation.



Carpal tunnel syndrome. Fast spin-echo T2-weighte...

Carpal tunnel syndrome. Fast spin-echo T2-weighted MRI illustrates more pronounced increased signal within the median nerve (arrow). Note the small amount of fluid within the carpal tunnel, a secondary sign of inflammation. Slightly less optimal fat saturation is noted than on other images, which is a common occurrence.

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Carpal tunnel syndrome. Fast spin-echo T2-weighte...

Carpal tunnel syndrome. Fast spin-echo T2-weighted MRI illustrates more pronounced increased signal within the median nerve (arrow). Note the small amount of fluid within the carpal tunnel, a secondary sign of inflammation. Slightly less optimal fat saturation is noted than on other images, which is a common occurrence.



Carpal tunnel syndrome. Axial fast spin-echo T2-w...

Carpal tunnel syndrome. Axial fast spin-echo T2-weighted MRI with greater increase in signal and loss of definition within the nerve (arrow). Inflammatory change is noted within the carpal tunnel, adjacent to the flexor digitorum superficialis tendons. The appearance is consistent with pronounced inflammatory change within the carpal tunnel.

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Carpal tunnel syndrome. Axial fast spin-echo T2-w...

Carpal tunnel syndrome. Axial fast spin-echo T2-weighted MRI with greater increase in signal and loss of definition within the nerve (arrow). Inflammatory change is noted within the carpal tunnel, adjacent to the flexor digitorum superficialis tendons. The appearance is consistent with pronounced inflammatory change within the carpal tunnel.

    • Plain radiography is low-yield.11
    • High-resolution ultrasonography (US) has received increased attention in the evaluation of CTS. US as a modality is more widely available than electrodiagnostic studies and is noninvasive and has lower costs. Recent US studies have shown that patients with CTS have an increased cross-sectional area of the median nerve in the carpal tunnel than controls. Ultrasonography may be useful as an alternative to nerve conduction studies for an initial diagnostic test for CTS.12 One study concluded that sonography is not accurate enough to replace nerve conduction studies for diagnosing CTS.13

Other Tests

  • Electromyographic (EMG) and nerve conduction studies
    • EMG and nerve conduction studies help to confirm the diagnosis of CTS.
    • They are most helpful in the determination of the site and severity of nerve compression.
    • Electrodiagnostic testing has been found to have an 85% sensitivity and specificity greater than 95% for diagnosing CTS.14
    • Clinically symptomatic CTS may have normal nerve conduction findings.15

More on Carpal Tunnel Syndrome

Overview: Carpal Tunnel Syndrome
Differential Diagnoses & Workup: Carpal Tunnel Syndrome
Treatment & Medication: Carpal Tunnel Syndrome
Follow-up: Carpal Tunnel Syndrome
Multimedia: Carpal Tunnel Syndrome
References
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References

  1. Papanicolaou GD, McCabe SJ, Firrell J. The prevalence and characteristics of nerve compression symptoms in the general population. J Hand Surg Am. May 2001;26(3):460-6. [Medline].

  2. Gelfman R, Melton LJ 3rd, Yawn BP, Wollan PC, Amadio PC, Stevens JC. Long-term trends in carpal tunnel syndrome. Neurology. Jan 6 2009;72(1):33-41. [Medline].

  3. Atroshi I, Gummesson C, Johnsson R, et al. Prevalence of carpal tunnel syndrome in a general population. JAMA. Jul 14 1999;282(2):153-8. [Medline].

  4. Bland JD. Carpal tunnel syndrome. Curr Opin Neurol. Oct 2005;18(5):581-5. [Medline].

  5. Katz JN, Stirrat CR. A self-administered hand diagram for the diagnosis of carpal tunnel syndrome. J Hand Surg [Am]. Mar 1990;15(2):360-3. [Medline].

  6. D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel syndrome?. JAMA. Jun 21 2000;283(23):3110-7. [Medline].

  7. MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. Apr-Jun 2004;17(2):309-19. [Medline].

  8. Smith MW, Marcus PS, Wurtz LD. Orthopedic issues in pregnancy. Obstet Gynecol Surv. Feb 2008;63(2):103-11. [Medline].

  9. Brahme SK, Hodler J, Braun RM. Dynamic MR imaging of carpal tunnel syndrome. Skeletal Radiol. Aug 1997;26(8):482-7. [Medline].

  10. Kim S, Choi JY, Huh YM, Song HT, Lee SA, Kim SM, et al. Role of magnetic resonance imaging in entrapment and compressive neuropathy--what, where, and how to see the peripheral nerves on the musculoskeletal magnetic resonance image: part 2. Upper extremity. Eur Radiol. Feb 2007;17(2):509-22. [Medline].

  11. Bindra RR, Evanoff BA, Chough LY, Cole RJ, Chow JC, Gelberman RH. The use of routine wrist radiography in the evaluation of patients with carpal tunnel syndrome. J Hand Surg [Am]. Jan 1997;22(1):115-9. [Medline].

  12. Moran L, Perez M, Esteban A, Bellon J, Arranz B, del Cerro M. Sonographic measurement of cross-sectional area of the median nerve in the diagnosis of carpal tunnel syndrome: correlation with nerve conduction studies. J Clin Ultrasound. Mar-Apr 2009;37(3):125-31. [Medline].

  13. Kwon BC, Jung KI, Baek GH. Comparison of sonography and electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Hand Surg Am. Jan 2008;33(1):65-71. [Medline].

  14. Jablecki CK, Andary MT, Floeter MK. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. Jun 11 2002;58(11):1589-92. [Medline].

  15. Witt JC, Hentz JG, Stevens JC. Carpal tunnel syndrome with normal nerve conduction studies. Muscle & Nerve. Apr 2004;29(4):515-22. [Medline].

  16. Graham B. Nonsurgical treatment of carpal tunnel syndrome. J Hand Surg Am. Mar 2009;34(3):531-4. [Medline].

  17. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database Syst Rev. 2003;CD003219. [Medline].

  18. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev. Apr 18 2007;CD001554. [Medline].

  19. Ucan H, Yagci I, Yilmaz L, Yagmurlu F, Keskin D, Bodur H. Comparison of splinting, splinting plus local steroid injection and open carpal tunnel release outcomes in idiopathic carpal tunnel syndrome. Rheumatol Int. Nov 2006;27(1):45-51. [Medline].

  20. [Best Evidence] Atroshi I, Larsson GU, Ornstein E, Hofer M, Johnsson R, Ranstam J. Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial. BMJ. Jun 24 2006;332(7556):1473. [Medline].

  21. [Best Evidence] Atroshi I, Hofer M, Larsson GU, Ornstein E, Johnsson R, Ranstam J. Open compared with 2-portal endoscopic carpal tunnel release: a 5-year follow-up of a randomized controlled trial. J Hand Surg Am. Feb 2009;34(2):266-72. [Medline].

  22. [Best Evidence] Scholten RJ, Mink van der Molen A, Uitdehaag BM, Bouter LM, de Vet HC. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev. Oct 17 2007;CD003905. [Medline].

  23. Bland JD. Carpal tunnel syndrome. BMJ. Aug 18 2007;335(7615):343-6. [Medline].

  24. Anto C, Aradhya P. Clinical diagnosis of peripheral nerve compression in the upper extremity. Orthop Clin North Am. Apr 1996;27(2):227-36. [Medline].

  25. Atroshi I, Gummesson C, Johnsson R, et al. Severe carpal tunnel syndrome potentially needing surgical treatment in a general population (1). J Hand Surg [Am]. Jul 2003;28(4):639-44. [Medline].

  26. Chen P, Maklad N, Redwine M, et al. Dynamic high-resolution sonography of the carpal tunnel. AJR Am J Roentgenol. Feb 1997;168(2):533-7. [Medline].

  27. de Araujo MP. Electrodiagnosis in compression neuropathies of the upper extremities. Orthop Clin North Am. Apr 1996;27(2):237-44. [Medline].

  28. Franzblau A, Werner RA. What is carpal tunnel syndrome?. JAMA. Jul 14 1999;282(2):186-7. [Medline].

  29. Gerritsen AA, de Vet HC, Scholten RJ. Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA. Sep 11 2002;288(10):1245-51. [Medline].

  30. Gerritsen AA, Korthals-de Bos IB, Laboyrie PM. Splinting for carpal tunnel syndrome: prognostic indicators of success. J Neurol Neurosurg Psychiatry. Sep 2003;74(9):1342-4. [Medline].

  31. Graham RG, Hudson DA, Solomons M. A prospective study to assess the outcome of steroid injections and wrist splinting for the treatment of carpal tunnel syndrome. Plast Reconstr Surg. Feb 2004;113(2):550-6. [Medline].

  32. Hilburn JW. General principles and use of electrodiagnostic studies in carpal and cubital tunnel syndromes. With special, attention to pitfalls and interpretation. Hand Clin. May 1996;12(2):205-21. [Medline].

  33. Horch RE, Allmann KH, Laubenberger J, et al. Median nerve compression can be detected by magnetic resonance imaging of the carpal tunnel. Neurosurgery. Jul 1997;41(1):76-82; discussion 82-3. [Medline].

  34. [Best Evidence] Hui AC, Wong S, Leung CH. A randomized controlled trial of surgery vs steroid injection for carpal tunnel syndrome. Neurology. Jun 28 2005;64(12):2074-8. [Medline].

  35. Kaufman MA. Differential diagnosis and pitfalls in electrodiagnostic studies and special tests for diagnosing compressive neuropathies. Orthop Clin North Am. Apr 1996;27(2):245-52. [Medline].

  36. Kele H, Verheggen R, Bittermann HJ. The potential value of ultrasonography in the evaluation of carpal tunnel syndrome. Neurology. Aug 12 2003;61(3):389-91. [Medline].

  37. Keles I, Karagulle Kendi AT, Aydin G. Diagnostic precision of ultrasonography in patients with carpal tunnel syndrome. Am J Phys Med Rehabil. Jun 2005;84(6):443-50. [Medline].

  38. Kerwin G, Williams CS, Seiler JG 3rd. The pathophysiology of carpal tunnel syndrome. Hand Clin. May 1996;12(2):243-51. [Medline].

  39. Kulick RG. Carpal tunnel syndrome. Orthop Clin North Am. Apr 1996;27(2):345-54. [Medline].

  40. Lee CH, Kim TK, Yoon ES. Correlation of high-resolution ultrasonographic findings with the clinical symptoms and electrodiagnostic data in carpal tunnel syndrome. Ann Plast Surg. Jan 2005;54(1):20-3. [Medline].

  41. Mondelli M, Rossi S, Monti E, Aprile I, Caliandro P, Pazzaglia C, et al. Prospective study of positive factors for improvement of carpal tunnel syndrome in pregnant women. Muscle Nerve. Dec 2007;36(6):778-83. [Medline].

  42. Padua L, LoMonaco M, Aulisa L, Tamburrelli F, Valente EM, Padua R. Surgical prognosis in carpal tunnel syndrome: usefulness of a preoperative neurophysiological assessment. Acta Neurol Scand. Nov 1996;94(5):343-6. [Medline].

  43. Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet HC, Bouter LM. Surgical treatment options for carpal tunnel syndrome. Cochrane Database Syst Rev. 2004;(4):CD003905. [Medline].

  44. Stallings SP, Kasdan ML, Soergel TM, Corwin HM. A case-control study of obesity as a risk factor for carpal tunnel syndrome in a population of 600 patients presenting for independent medical examination. J Hand Surg [Am]. Mar 1997;22(2):211-5. [Medline].

  45. Sternbach G. The carpal tunnel syndrome. J Emerg Med. May-Jun 1999;17(3):519-23. [Medline].

  46. Tavares SP, Giddins GE. Nerve injury following steroid injection for carpal tunnel syndrome. A report of two cases. J Hand Surg [Br]. Apr 1996;21(2):208-9. [Medline].

  47. Wong SM, Griffith JF, Hui AC. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology. Jul 2004;232(1):93-9. [Medline].

  48. Wong SM, Hui AC, Tang A. Local vs systemic corticosteroids in the treatment of carpal tunnel syndrome. Neurology. Jun 12 2001;56(11):1565-7. [Medline].

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Further Reading

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Keywords

carpal tunnel syndrome, CTS, median nerve compression at the wrist, median neuropathy, nerve compression syndrome, carpal tunnel syndrome symptoms, carpal tunnel syndrome causes, compressive neuropathy, median nerve, peripheral compressive neuropathy, hand weakness, numbness in the hand, thenar atrophy, hand pain, wrist pain

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Contributor Information and Disclosures

Author

Jeffrey G Norvell, MD, Clinical Assistant Professor of Emergency Medicine, University of Kansas School of Medicine
Jeffrey G Norvell, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Mark Steele, MD, Associate Dean for Truman Medical Center Programs, Professor, Department of Emergency Medicine, University of Missouri-Kansas City
Mark Steele, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David FM Brown, MD, Assistant Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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