Summary
Definition
History and exam
Key diagnostic factors
- presence of risk factors
- numbness of hand(s)
- nighttime worsening
- numbness in median nerve distribution
- numbness confined to palmar aspect of the first 4 fingers
Other diagnostic factors
- symptoms are intermittent
- onset is gradual
- weakness of hand
- clumsiness
- aching and pain in arm
- weakness of thenar muscles (abductor pollicis brevis, or APB, in particular)
- normal reflexes
- finger stiffness
- cold sensitivity
- atrophy of thenar eminence
Risk factors
- age 40-60 years
- high BMI
- female sex
- fractured wrist/carpal bones
- square wrist
- rheumatoid arthritis
- diabetes
- pregnancy
- congenital carpal tunnel stenosis
- occupational exposure
- tobacco smoking
- thyroid disorders
- significant computer use
Diagnostic tests
1st tests to order
- electromyogram (EMG)
Tests to consider
- ultrasound of the wrist
- MRI of the wrist
Treatment algorithm
clinical diagnosis of carpal tunnel syndrome (CTS) without electromyogram (EMG) confirmation, or pregnant women
mild or moderate based on EMG findings (nonpregnant)
severe based on EMG findings (nonpregnant)
moderate based on EMG findings + failed splint and corticosteroid injection(s)
refractory to surgery
Contributors
Authors
Nigel Ashworth, MBChB, MSc, FRCP(Can)
Professor
Division of Physical Medicine & Rehabilitation
Faculty of Medicine & Dentistry
University of Alberta
Edmonton
Canada
Disclosures
NA is an author of a number of references cited in this topic.
Peer reviewers
Ines C. Lin , MD, MSEd
Associate Professor of Surgery
Division of Plastic Surgery, Department of Surgery, and Department of Orthopaedic Surgery
Perelman School of Medicine at the University of Pennsylvania
Philadelphia
PA
Disclosures
ICL declares that she has no competing interests.
Peter C. Amadio, MD
Dean for Research Academic Affairs
Lloyd A. and Barbara A. Amundson Professor of Orthopedic Surgery
Professor of Biomedical Engineering
Mayo Clinic
Rochester
MN
Disclosures
PCA declares that he has no competing interests.
Shawn Marshall, MD, MSc
Associate Professor
University of Ottawa
Ottawa
Ontario
Canada
Disclosures
SM declares that he has been primary author and co-author of Cochrane systematic reviews of nonsurgical interventions for treatment of carpal tunnel syndrome.
Tim J. Doherty, MD, PhD
Associate Professor
The University of Western Ontario
London
Ontario
Canada
Disclosures
TJD declares that he has no competing interests.
Michael Plant, MD, FRCP
Consultant Rheumatologist
The James Cook University Hospital
South Tees Hospitals NHS Foundation Trust
Middlesbrough
UK
Disclosures
MP declares that he has no competing interests.
References
Key articles
Cartwright MS, Hobson-Webb LD, Boon AJ, et al; American Association of Neuromuscular and Electrodiagnostic Medicine. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012 Aug;46(2):287-93. Abstract
Ashworth NL, Bland JDP, Chapman KM, et al. Local corticosteroid injection versus placebo for carpal tunnel syndrome. Cochrane Database Syst Rev. 2023 Feb 1;2(2):CD015148.Full text Abstract
Peters S, Page MJ, Coppieters MW, et al. Rehabilitation following carpal tunnel release. Cochrane Database Syst Rev. 2016 Feb 17;(2):CD004158.Full text Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
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