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200
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Anatomy

Upper Limb

Question 71 of 239

A patient presents to ED complaining of pins and needles over the lateral three and a half digits. You suspect carpal tunnel syndrome. Which of the following clinical features would you most expect to see on examination:

Answer:

Compression of the median nerve in the carpal tunnel will result in weakness and atrophy of the thenar muscles - resulting in weakness of opposition, abduction and flexion of the thumb at the metacarpophalangeal joint and anaesthesia or paraesthesia over the distribution of the palmar digital branch of the median nerve (skin over the palmar surface and fingertips of the lateral three and a half digits). The adductor pollicis muscle is innervated by the ulnar nerve, and abduction of the fingers is produced by the interossei, also innervated by the ulnar nerve. Flexion of the interphalangeal joint of the thumb is produced by the flexor pollicis longus, and flexion of the distal interphalangeal joint of the index finger is produced by the flexor digitorum profundus. Median nerve injury at the wrist will not affect the long flexors of the forearm as these are innervated by the anterior interosseous nerve which arises in the proximal forearm.

Carpal Tunnel Syndrome

Anatomy / Upper Limb / Wrist and Hand

Last Updated: 16th August 2020

Carpal tunnel syndrome (CTS) is caused by compression of the median nerve within the carpal tunnel at the wrist.

Aetiology

  • In most people the cause of carpal tunnel syndrome is not known
  • Factors that have strong evidence supporting an increased risk of CTS include:
    • Activities with high hand/wrist repetition rate
    • Obesity

Clinical Features

  • Symptoms
    • Numbness, tingling and pain in distribution of the median nerve (palmar surface and fingertips of lateral three and a half digits - lateral palm is typically spared as the palmar cutaneous branch of the median nerve does not pass through the carpal tunnel)
    • Symptoms often worse at night
    • May be unilateral or bilateral
    • Pain may radiate up forearm
    • Loss of grip strength, clumsiness and reduced manual dexterity
  • Signs
    • Sensory loss in distribution of the median nerve
    • Atrophy of thenar muscles
    • Reduced strength of thumb abduction
    • Positive Tinel's test (tapping lightly over the nerve at the wrist elicits symptoms in the median nerve distribution
    • Positive Phalen's test (holding the wrist in flexion for 60s elicits symptoms in the median nerve distribution)
    • Positive carpal tunnel compression test (pressure over the proximal end of the carpal ligament (proximal wrist crease) with the thumbs elicits symptoms in the median nerve distribution)

Untreated Carpal Tunnel Syndrome. (Image by Dr. Harry Gouvas, MD, PhD [Public domain], via Wikimedia Commons)

Management

  • Lifestyle modifications
  • Wrist splinting in neutral position
  • Corticosteroid injections
  • Carpal tunnel decompression surgery

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  • Biochemistry
  • Blood Gases
  • Haematology
Biochemistry Normal Value
Sodium 135 – 145 mmol/l
Potassium 3.0 – 4.5 mmol/l
Urea 2.5 – 7.5 mmol/l
Glucose 3.5 – 5.0 mmol/l
Creatinine 35 – 135 μmol/l
Alanine Aminotransferase (ALT) 5 – 35 U/l
Gamma-glutamyl Transferase (GGT) < 65 U/l
Alkaline Phosphatase (ALP) 30 – 135 U/l
Aspartate Aminotransferase (AST) < 40 U/l
Total Protein 60 – 80 g/l
Albumin 35 – 50 g/l
Globulin 2.4 – 3.5 g/dl
Amylase < 70 U/l
Total Bilirubin 3 – 17 μmol/l
Calcium 2.1 – 2.5 mmol/l
Chloride 95 – 105 mmol/l
Phosphate 0.8 – 1.4 mmol/l
Haematology Normal Value
Haemoglobin 11.5 – 16.6 g/dl
White Blood Cells 4.0 – 11.0 x 109/l
Platelets 150 – 450 x 109/l
MCV 80 – 96 fl
MCHC 32 – 36 g/dl
Neutrophils 2.0 – 7.5 x 109/l
Lymphocytes 1.5 – 4.0 x 109/l
Monocytes 0.3 – 1.0 x 109/l
Eosinophils 0.1 – 0.5 x 109/l
Basophils < 0.2 x 109/l
Reticulocytes < 2%
Haematocrit 0.35 – 0.49
Red Cell Distribution Width 11 – 15%
Blood Gases Normal Value
pH 7.35 – 7.45
pO2 11 – 14 kPa
pCO2 4.5 – 6.0 kPa
Base Excess -2 – +2 mmol/l
Bicarbonate 24 – 30 mmol/l
Lactate < 2 mmol/l

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