CARPAL TU N N EL

SYN D RO M E

D efi
nition

Carpal tunnel syndrome, the

most common focal peripheral

neuropathy, results from
compression of the median
nerve at the wrist.

Pathophysiology
Disturbed axoplasmic

flow
Endoneural edema
Impaired neural
circulation
Diminished nerve
elasticity

O ther risks factors

- Obesity
- Diabetes (prevalence 14%-30% with neuropathy)
- Pregnancy (~50% prevalence)
- Inflammatory arthritis
- Acromegaly
- Age (>50)

ClinicalFeatures
Pain
Numbness
Tingling
Symptoms are usually worse at night and

can awaken patients from sleep.

To relieve the symptoms, patients often
flick their wrist as if shaking down a
thermometer (flick sign).

ClinicalFeatures
Pain and paresthesias may radiate to the

forearm, elbow, and shoulder.

Decreased grip strength may result in loss of
dexterity, and thenar muscle atrophy may
develop if the syndrome is severe.

Atrophy

Physicalexam ination
Sensory & motor examination
Phalens maneuver (&reverse phalen)
Tinels sign
Durkhan test
Flick sign
weak thumb abduction.
two-point discrimination test

Phalens m aneuver

Reverse Phalen Test

Tinels sign

D urkan Com pression

Test

Gentle pressure directly over carpal tunnel

paresthesias in 30 seconds or less

Better for wrists with limited motion
Highest sensitivity/specificity of all physical
exam tests

Sum m ary ofTests

Test
Sensitivity
Specificity
Phalens
75%
62%
Tinels
64%
71%
Durkhan
87%
90%

D iagnostic
History
Physical examination
Nerve Conduction Study & EMG

D iagnostic
Lab: CBC, BG
X-ray of the wrist

D iff
erentialD iagnostics
Cervical radiculopathy
Tendonitis
Brachial plexopathy (trauma or non trauma)
Diabetic neuropathy
Compression of the Median nerve at the

elbow

Treatm ent
CONSERVATIVE TREATMENTS (non surgical)

GENERAL MEASURES
WRIST SPLINTS
ORAL MEDICATIONS
LOCAL INJECTION

SURGERY

G EN ERAL M EASU RES

Avoid repetitive wrist and hand motions that

may exacerbate symptoms or make

symptom relief difficult to achieve.
Ergonomic measures to relieve symptoms
depending on the motion that needs to be
minimized

W RIST SPLIN TS
Probably most

effective when it is
applied within
three months of
the onset of
symptoms
(Usually night
splint)

W RIST SPLIN TS

O RAL M ED ICATIO N S
Nonsteroidal anti-inflammatory drugs

(NSAIDs)
Orally administered corticosteroids
Prednisolone
20 mg per day for two weeks
followed by 10 mg per day for two weeks

LO CAL IN JECTIO N
A mixture of 10 to 20 mg of lidocaine

(Xylocaine) without epinephrine and 20 to 40

mg of methylprednisolone acetate (DepoMedrol) or similar corticosteroid preparation
is injected with a 25-gauge needle at the
distal wrist crease (or 1 cm proximal to it).

LO CAL IN JECTIO N

LO CAL IN JECTIO N

LO CAL IN JECTIO N
Splinting is generally recommended after

local corticosteroid injection.

If the first injection is successful, a repeat
injection can be considered after a few
months
Surgery should be considered if a patient
needs more than two injections

SU RG ERY
patients with symptoms that do not respond

to conservative measures
patients with severe nerve entrapment as
evidenced by nerve conduction studies,
thenar atrophy, or motor weakness.

Minimally-invasive Endoscopic Carpal

Tunnel release

THANK
YOU