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200
38

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Anatomy

Upper Limb

Question 201 of 239

A patient presents to ED complaining of pain and paraesthesia in her right hand which becomes worse at night. Her symptoms have been ongoing for about 6 months. You suspect carpal tunnel syndrome. Which of the following muscles would you most expect to be atrophied on examination:

Answer:

Carpal tunnel syndrome results from compression of the median nerve in the carpal tunnel. Typically there is pain and paraesthesia in the cutaneous 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), and weakness and wasting of the thenar muscles with weak thumb grip. Symptoms may be reproduced by performing Phalen's test (with sustained flexion of the wrist) or Tinel's test (by tapping lightly over the median nerve at the wrist). The hypothenar muscles, interossei and medial two lumbricals are all innervated by the ulnar nerve.

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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