Diferencia entre revisiones de «Carpal tunnel syndrome»

(Added Durkan sign)
 
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==Background==
==Background==
[[File:Carpal Tunnel Syndrome.png|thumb|Anatomy of the carpal tunnel, showing the median nerve passing through the tight space it shares with the other tendons.]]
[[File:Carpal-Tunnel.png|thumb|Transverse section at the wrist. The median nerve is colored yellow. The carpal tunnel consists of the bones and transverse carpal ligament.]]
[[File:Nerves of the left upper extremity.gif |thumb|Nerves of the left upper extremity showing the median nerve distribution. Area of nerve compression is at wrist.]]
*Also known as "Median Mononeuropathy"
*Most common focal mononeuropathy
*Most common focal mononeuropathy
*Results from compression of median nerve at wrist where it traverses the carpal tunnel
*Results from compression of median nerve at wrist where it traverses the carpal tunnel
*Etiology:
*Median nerve provides sensation to the palmar aspect digits 1-3 and radial side of 4th
**Repetitive wrist flexion/extension, DM, amyloidosis, trauma, edema
*Etiology: repetitive wrist flexion/extension, trauma, edema
 
==Risk factors==
*Female sex<ref>Kothari MJ. Carpal tunnel syndrome: Etiology and epidemiology. Post TW, ed. UpToDate. UpToDate Inc. Accessed May 21, 2020.</ref>
*[[Rheumatoid arthritis]] and other connective tissue diseases
*[[Diabetes mellitus]]
*[[Amyloidosis]]
*[[The Obese Patient|Obesity]]
*[[Pregnancy]]
*[[Hypothyroidism]]


==Clinical Features==
==Clinical Features==
*Pain, paresthesia, and numbness in distribution of median nerve
===History===
*Pain, [[paresthesia]], and [[numbness]] in distribution of median nerve
**Palmar aspect of thumb, index, middle, and radial aspect of ring finger
**Palmar aspect of thumb, index, middle, and radial aspect of ring finger
*Awakening at night w/ burning pain and tingling in hand
*Awakening at night with burning pain and tingling in hand
*Tinel sign
===Physical===
*Sensation testing
**Most specific - splitting of 4th digit in which medial aspect of 4th digit normal and lateral aspect abnormal
**Most sensitive - abnormal sensation of distal palmar tip of 2nd digit
*'''LOAF''' muscle weakness as compared to other hand - '''L'''umbricals, with thumb '''O'''pposition, '''A'''bduction, '''F'''lexion
*Tinel sign - poorly sensitive and specific
**Tapping on palmar aspect of wrist reuslts in electric shock sensation shooting into hand
**Tapping on palmar aspect of wrist reuslts in electric shock sensation shooting into hand
**SN 0.50 and SP 0.77<ref>MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.</ref>
*Phalen maneuver
*Phalen maneuver
**Holding wrists in flexion for 60 seconds evokes or worsens symptoms
**Holding wrists in flexion for 60 seconds evokes or worsens symptoms
*Durkan sign (more sensitive)
**SN 0.68 and SP 0.73<ref>MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.</ref>
**Manual compression of carpal tunnel reproduces symptoms
*Durkan sign
**Manual compression of carpal tunnel reproduces symptoms after 30 seconds
**SN 0.64 and SP 0.83
**More sensitive and specific than Tinel and Phalen in earlier studies<ref>Durkan, JA. A new diagnostic test for carpal tunnel syndrome, The Journal of Bone and Joint Surgery. 1991; 73(4):535–538.</ref>
*Hand Elevation Test
**Performed by having patient elevated both hands above the head
**Positive if paresthesia, numbness, or dull pain felt within two minutes
**SN 0.87 and SP 0.89<ref>Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472</ref>
*May see atrophy of thenar eminence in advanced cases
[[File: Untreated_Carpal_Tunnel_Syndrome.JPG|thumb|Severe atrophy of the bilateral thenar eminences from untreated carpal tunnel syndrome]]
 
==Differential Diagnosis==
===By Type of Lesion===
====Proximal Lesion====
*[[Spinal cord compression (non-traumatic)|Spinal cord lesion]]
*[[Neck pain|Cervical radicular pain]]
*[[Thoracic outlet syndrome]]
*[[Multiple Sclerosis (MS)]]
====Distal Lesion====
*Ulna neuropathy
====Systemic condition====
*[[Raynaud’s disease|Raynaud syndrome]]
*[[Pregnancy (Main)]]
*[[Anemia|B12 deficiency]]
*[[Diabetes Mellitus (Main)|Diabetic neuropathy]]
*[[Hypothyroidism]]
*[[Hypocalcemia]]
 
{{Upper extremity peripheral nerve syndromes}}
 
==Management==
*See this American Academy of Orthopedic Surgeons clinical decision tool for treatment options and disposition - [http://www.orthoguidelines.org/go/auc/auc.cfm?auc_id=224989 CTS guidelines]
*Behavioral modification
*Wrist splint with wrist in neutral position
*[[NSAIDs]] (although not clearly effective)
*[[Diuretics]] (if edema is significant contributor to patient's symptoms)
[[File: splint.jpg|thumb|Splint in neutral position]]
 
==Disposition==
*Discharge


==Treatment==
==See Also==
#Behavioral modification
*[[Radial neuropathy at the spiral groove]]
#Wrist splint w/ wrist in neutral position
#NSAIDs (although not clearly effective)
#Diuretics (if edema is significant contributor to pt's symptoms)


==Source==
==References==
Tintinalli
<references/>


[[Category:Neuro]]
[[Category:Neurology]] [[Category:Orthopedics]]

Revisión actual - 14:28 5 feb 2022

Background

Anatomy of the carpal tunnel, showing the median nerve passing through the tight space it shares with the other tendons.
Transverse section at the wrist. The median nerve is colored yellow. The carpal tunnel consists of the bones and transverse carpal ligament.
Nerves of the left upper extremity showing the median nerve distribution. Area of nerve compression is at wrist.
  • Also known as "Median Mononeuropathy"
  • Most common focal mononeuropathy
  • Results from compression of median nerve at wrist where it traverses the carpal tunnel
  • Median nerve provides sensation to the palmar aspect digits 1-3 and radial side of 4th
  • Etiology: repetitive wrist flexion/extension, trauma, edema

Risk factors

Clinical Features

History

  • Pain, paresthesia, and numbness in distribution of median nerve
    • Palmar aspect of thumb, index, middle, and radial aspect of ring finger
  • Awakening at night with burning pain and tingling in hand

Physical

  • Sensation testing
    • Most specific - splitting of 4th digit in which medial aspect of 4th digit normal and lateral aspect abnormal
    • Most sensitive - abnormal sensation of distal palmar tip of 2nd digit
  • LOAF muscle weakness as compared to other hand - Lumbricals, with thumb Opposition, Abduction, Flexion
  • Tinel sign - poorly sensitive and specific
    • Tapping on palmar aspect of wrist reuslts in electric shock sensation shooting into hand
    • SN 0.50 and SP 0.77[2]
  • Phalen maneuver
    • Holding wrists in flexion for 60 seconds evokes or worsens symptoms
    • SN 0.68 and SP 0.73[3]
  • Durkan sign
    • Manual compression of carpal tunnel reproduces symptoms after 30 seconds
    • SN 0.64 and SP 0.83
    • More sensitive and specific than Tinel and Phalen in earlier studies[4]
  • Hand Elevation Test
    • Performed by having patient elevated both hands above the head
    • Positive if paresthesia, numbness, or dull pain felt within two minutes
    • SN 0.87 and SP 0.89[5]
  • May see atrophy of thenar eminence in advanced cases
Severe atrophy of the bilateral thenar eminences from untreated carpal tunnel syndrome

Differential Diagnosis

By Type of Lesion

Proximal Lesion

Distal Lesion

  • Ulna neuropathy

Systemic condition

Upper extremity peripheral nerve syndromes

Median Nerve Syndromes

Ulnar Nerve Syndromes

Radial Nerve Syndromes

Proximal Neuropathies

Other

Management

  • See this American Academy of Orthopedic Surgeons clinical decision tool for treatment options and disposition - CTS guidelines
  • Behavioral modification
  • Wrist splint with wrist in neutral position
  • NSAIDs (although not clearly effective)
  • Diuretics (if edema is significant contributor to patient's symptoms)
Splint in neutral position

Disposition

  • Discharge

See Also

References

  1. ↑ Kothari MJ. Carpal tunnel syndrome: Etiology and epidemiology. Post TW, ed. UpToDate. UpToDate Inc. Accessed May 21, 2020.
  2. ↑ MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.
  3. ↑ MacDermid JC and Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther. 2004; 17(2):309.
  4. ↑ Durkan, JA. A new diagnostic test for carpal tunnel syndrome, The Journal of Bone and Joint Surgery. 1991; 73(4):535–538.
  5. ↑ Ma H, Kim I. The diagnostic assessment of hand elevation test in carpal tunnel syndrome. J Korean Neurosurg Soc. 2012;52(5):472-475. doi:10.3340/jkns.2012.52.5.472
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