Carpal Tunnel Syndrome (CTS)

Definition

Carpal Tunnel Syndrome (CTS) is a common peripheral nerve entrapment disorder caused by compression of the median nerve as it travels through the carpal tunnel in the wrist. This compression results in symptoms affecting the hand and fingers.

Aetiology

CTS can be caused by various factors, including:

• Repetitive hand movements or activities (e.g., typing, assembly line work)
• Wrist injuries or fractures
• Inflammatory conditions (e.g., rheumatoid arthritis)
• Fluid retention during pregnancy or menopause
• Diabetes
• Obesity
• Genetic predisposition (smaller carpal tunnel)

Pathophysiology

CTS occurs when the median nerve is compressed within the carpal tunnel, a narrow passageway in the wrist formed by bones and ligaments. This compression can result from swelling of the surrounding tendons or other structures, leading to reduced blood flow and nerve function, causing pain and sensory disturbances.

Risk Factors

• Repetitive hand or wrist movements
• Wrist anatomy (e.g., smaller carpal tunnel)
• Gender (more common in women)
• Age (more common in adults)
• Medical conditions (e.g., diabetes, rheumatoid arthritis)
• Pregnancy
• Obesity

Signs and Symptoms

• Numbness or tingling in the thumb, index, middle, and ring fingers
• Hand pain, particularly at night
• Weakness in the hand and difficulty gripping objects
• Clumsiness or a tendency to drop things
• Swelling or discomfort in the wrist

Investigations

• Clinical history and physical examination (e.g., Tinel's sign, Phalen's test)
• Nerve conduction studies to assess the function of the median nerve
• Electromyography (EMG) to evaluate muscle activity and nerve conduction
• Ultrasound or MRI to visualise the carpal tunnel and surrounding structures

Management

Primary Care Management

• Initial assessment and diagnosis based on clinical history and physical examination
• Conservative treatments such as wrist splinting, particularly at night
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief
• Education on activity modification and ergonomic adjustments
• Referral to a specialist if symptoms persist or worsen

Specialist Management

• Advanced diagnostic testing (e.g., nerve conduction studies, EMG)
• Corticosteroid injections to reduce inflammation and pain
• Surgical intervention (carpal tunnel release) in severe or refractory cases
• Post-surgical rehabilitation and physical therapy
• Occupational therapy to improve hand function and prevent recurrence

Example Management for Carpal Tunnel Syndrome

A patient presenting with mild to moderate carpal tunnel syndrome may initially be managed with nocturnal wrist splinting and NSAIDs to reduce inflammation and pain. If symptoms persist after several weeks, referral to a specialist for further evaluation and possible corticosteroid injections or surgical intervention may be necessary. Post-surgical rehabilitation should include physical and occupational therapy to restore hand function and prevent recurrence.

References

1. NICE. (2024). Carpal Tunnel Syndrome: Diagnosis and Management. Retrieved from NICE
2. NHS. (2023). Carpal Tunnel Syndrome. Retrieved from NHS
3. American Academy of Orthopaedic Surgeons. (2022). Carpal Tunnel Syndrome. Retrieved from AAOS
4. MacDermid, J. C., & Wessel, J. (2004). Clinical Diagnosis of Carpal Tunnel Syndrome: A Systematic Review. Journal of Hand Therapy.
5. Stevens, J. C. (1997). The Electrodiagnosis of Carpal Tunnel Syndrome. Muscle & Nerve.