Carpal Tunnel Syndrome in Emergency Medicine Treatment & Management

Updated: Nov 12, 2019
  • Author: Jonathan E Dangers, MD, MPH; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Emergency Department Care

In the emergency department setting, the mainstay of treatment for carpal tunnel syndrome (CTS) is rest, wrist immobilization with a splint, and nonsteroidal anti-inflammatory drugs (NSAIDs). For some individuals with CTS, nonsurgical management is curative; however, more than 50% of patients undergoing nonsurgical management progress to surgery within 1 year. [15]

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. [32, 33, 34]

No data support that NSAIDs are superior to placebo in the treatment of CTS. [33] However, in the 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. [32, 33]

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. [35, 36] Local injections have been shown to be superior to systemic corticosteroids. [32] Steroid injection combined with splinting has been shown to be superior to splinting alone. [37]  Single corticosteroid injection has been shown to be superior to night splinting at 6 months. [38]  Ultrasound-guided injections have been shown to be more effective than blind injections. [39]

Diuretics have not been shown to be superior to placebo in the treatment of CTS. [33]

Ultrasound has been proposed as a treatment for carpal tunnel syndrome, though evidence is conflicting. A recent randomized controlled trial showed no benefit for therapeutic ultrasound, while a systematic review of extracorporeal shockwave therapy showed improvement in symptoms, function, and electrodiagnostic study results when to corticosteroid injection. [40, 41] Evidence is limited for newer modalities such as manual techniques, transcutaneous electrical nerve stimulation (TENS), and laser therapy [42] .

Surgery

Definitive therapy consists of surgical release of the transverse carpal ligament. Surgery for CTS has a long-term success rate of greater than 75%. The surgical approach may be open or endoscopic. [43]  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. [44] 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. 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. [33, 34, 35, 45, 46]