What is involved:

Median Nerve at the wrist

Location:

The Carpal Tunnel, at the wrist

Common symptoms:

	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:

Usually slow, insidious over months/years

Risk factors:

	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:

	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:

	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:

	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:

	Repetitive stress injury with joint, tendon, myofascial symptoms (not carpal tunnel) in musicians, computer/machinery operators
	Cervical root lesion
	Thoracic outlet syndrome (very rare)