eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Carpal Tunnel Syndrome: Treatment & Medication

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

Treatment

Emergency Department Care

  • The mainstay of treatment for carpal tunnel syndrome (CTS) is rest, wrist immobilization with a splint, and nonsteroidal anti-inflammatory drugs (NSAIDs). Corticosteroid injections, oral steroids, and diuretics are other treatment modalities that have been used. 
    • A volar splint should be placed in neutral position because flexion and extension of the wrist increases carpal intracanal pressure. Splinting has been shown to have a statistically significant decrease in symptoms compared with controls. Studies comparing nocturnal only splinting to full-time splinting have not revealed a clear difference, although the studies may have been underpowered.16,17  
    • No data support that NSAIDs are superior to placebo in the treatment of CTS.17 However, in absence of contraindications, a trial of NSAIDs may be appropriate.
    • Oral steroids have been shown to have an advantage in treating CTS over placebo. The benefit appears short lived, and the studies do not assess the long-term effectiveness or complications of oral steroids used in treating CTS.16,17
    • Although not typically performed in the emergency department, corticosteroid injections have been shown to have a statistically significant benefit in CTS at 1 month compared with placebo. The effects of corticosteroid injection appear to be time limited, and the benefit beyond 1 month is unclear. Two steroid injections do not appear to add significant clinical benefit to one injection.18 Local injections have been shown to be superior to systemic corticosteroids.16 Steroid injection combined with splinting has been shown to be superior to splinting alone.19  
    • Diuretics have not been shown to be superior to placebo in the treatment of CTS.17
  • Surgery
    • Definitive therapy consists of surgical release of the transverse carpal ligament.
    • The surgical approach may be open or endoscopic. Both approaches have similar efficacy. A randomized controlled trial showed that patients who underwent endoscopic surgery for carpal tunnel syndrome had less postoperative pain than patients who underwent open surgery; however, the difference was small.20  The authors of this study extended the follow-up period to 5 years, and it demonstrated an equivalent improvement in CTS symptoms between an open and an endoscopic carpal tunnel release.21 An article in the Cochrane Database of Systematic Reviews states that endoscopic surgery allows an earlier return to work and fewer wound problems, but possible disadvantages may be higher complication rates and cost.22
    • Surgery for CTS has a long-term success rate of greater than 75%.23

Consultations

Referral to a hand specialist (plastic surgeon or orthopedic surgeon) for follow-up care is recommended.

Medication

The goal of therapy is to reduce inflammation and prevent complications.

Nonsteroidal anti-inflammatory agents

Most commonly are used for the relief of mild-to-moderate pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen usually is the DOC for the initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.


Flurbiprofen (Ansaid)

May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Adult

200-300 mg/d PO divided bid/qid

Pediatric

Not established

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion, risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug


Ketoprofen (Actron, Orudis, Oruvail)

For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease.
Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy


Ibuprofen (Ibuprin, Advil, Motrin)

Usually the DOC for the treatment of mild-to-moderate pain if no contraindications exist.
Inhibits inflammatory reactions and pain, probably by decreasing the activity of cyclooxygenase enzyme, which results in the inhibition of prostaglandin synthesis.
Taking medication with at least 4 oz of water may minimize adverse effects.

Adult

400 mg PO q4-6h; or 600 mg PO q6h; or 800 mg PO q8h; not to exceed 2400 mg/d

Pediatric

<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid or qid
>12 years: Administer as in adults

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy


Naproxen (Anaprox, Naprelan, Naprosyn, Aleve)

Used for the relief of mild-to-moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase enzyme, which results in a decrease of prostaglandin synthesis. Inexpensive and effective.

Adult

250 mg PO q6-8h; or 500 mg PO q12h; not to exceed 1 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Documented hypersensitivity; peptic ulcer disease; diathesis; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

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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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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