WHAT IS INVOLVED

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Median Nerve at the wrist


LOCATION

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The Carpal Tunnel, at the wrist


COMMON SYMPTOMS

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- Worse in the dominant hand

- Dropping objects

- Numbness tingling, hand/wrist ----> Thumb, Index and/or Middle finger

- May radiate up the arm, occasionally to the shoulder

- Symptoms primarily at night. Patient wakes up and shake their hands to obtain relief

- Frequently bilateral, although may only be symptomatic on one side


ONSET

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Usually slow, insidious over months/years


RISK FACTORS

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- Women more than Men, Diabetes or family history, Pregnancy, weight gain, trauma, HIV infection

- Working with hands a lot, secretaries, homemakers, operating machinery, computer joysticks, factory workers in assembly jobs, manual laborers


EXAM

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- Look for hand Abductor Pollicis Brevis (APB) flattening

- Test the APB strength (push thumb upwards against resistance)

- Positive Tinel sign (tingling upon tapping nerve) at the wrist usually with appropriate radiation to finger(s) with symptoms


EMG

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Nerve Conductions Workup:
- Median sensory and Motor studies with F-waves on both sides, disease is frequently bilateral

- Ulnar sensory and Motor studies with F-waves. Do other side if the symptomatic side is abnormal

Findings:
- Prolonged Median Sensory/Motor distal latencies (make sure both sides are tested)

- If Median and Ulnar Conductions are abnormal, test Lower Extremity to rule out Peripheral Neuropathy

- Active/Chronic denervation in the APB on Needle Examination

Suggested Treatment:
- Mild ------> Wrist splints, wear mostly at night

- Moderate ------> Wrist splints/Steroid Injection (contraindicated in Diabetics)

- Severe or active denervation in APB ------> Surgery


RECOMMENDATIONS

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- Stop/address cause of problem

- Treat Diabetes if present, address weight gain problems

- Wrist splints (both sides) mostly at night for mild to moderate carpal tunnel (see above)

- Steroid Injections, Surgery for moderate to severe cases (see above)

- Surgery may be indicated if mild to moderate but symptoms intolerable or interfere with job


WHAT ELSE COULD IT BE?

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- Repetitive stress injury with joint, tendon, myofascial symptoms (not carpal tunnel) in musicians, computer/machinery operators

- Cervical root lesion

- Thoracic outlet syndrome (very rare)