Carpal Tunnel Syndrome in Emergency Medicine Clinical Presentation

Updated: Sep 08, 2016
  • Author: Jeffrey G Norvell, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Presentation

History

Patients typically complain of an intermittent "pins-and-needles" paresthesia in the median nerve distribution of the hand. Pain is generally worse at night than during the day. Patients may awaken with a burning pain or tingling that may be relieved with shaking their hands. Classic carpal tunnel syndrome (CTS) is associated with symptoms that affect at least 2 of the first through third digits; symptoms affecting the fourth and fifth digits, wrist pain, and radiation of pain proximal to the wrist may also occur, but classic CTS is not associated with symptoms on the palm or dorsum of the hand. [12]

Symptoms of probable CTS are the same as classic CTS except palmar symptoms may be present, unless confined solely to the ulnar aspect. Possible CTS involves symptoms in at least one of the first 3 digits. The sensitivity of classic or probable CTS symptoms for diagnosing CTS is 80%. CTS is unlikely if no symptoms are present in any of the first 3 digits. [12]

  • Symptoms are most often bilateral, insidious in onset, and progressive in nature.
  • With advanced nerve compression, an aching sensation is persistent and static and may radiate to the forearm and elbow.
  • Inquire with regard to repetitive strain risk, such as waitperson, assembly packing, computer keyboard work, playing a musical instrument, or craftwork.
  • Determine if any significant trauma has occurred.
  • Inquire with regard to presence of any other predisposing factors listed below under Causes.
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Physical

Weakness of resisted thumb abduction (ie, movement of the thumb at right angles to the palm) is helpful in determining which patients will have an electrodiagnosis of CTS. [13]

Sensory hypalgesia as demonstrated by diminished ability to perceive painful stimuli applied along the palmar aspect of the index finger when compared with the ipsilateral little finger also is associated with the electrodiagnosis of CTS. [13]

Hyperflexion of the wrist for 60 seconds may elicit paresthesia in the median nerve distribution (ie, Phalen sign). A literature review showed the average sensitivity and specificity of the Phalen sign to be 68% and 73%, respectively. [3]

Tapping the volar wrist over the median nerve (ie, Tinel sign) may produce paresthesia in the median distribution of the hand. Pooled data show the sensitivity and specificity of the Tinel sign to be 50% and 77%, respectively. [3]

Shaking or flicking one's hands for relief during maximal symptoms (ie, Flick sign) has been shown to have a sensitivity of 47% and specificity of 62%. [3]

The loss of 2-point discrimination in the median nerve distribution or abductor pollicis brevis atrophy has a high specificity (>90%) but low sensitivity (< 25%). [3]

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Causes

Causes include the following:

  • Inflammation of the flexor tendon sheath caused by activities involving repetitive wrist flexion (eg, assembly packing, computer keyboard work, playing a musical instrument, craftwork)
  • Edema from trauma of any type (eg, fractures), which can compress the median nerve
  • Compression of the median nerve from pregnancy [14] or oral contraceptive-related edema
  • Strong association between being overweight or obese and the presence of CTS
  • Renal failure and hemodialysis
  • Has been associated with diabetes mellitus
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