A Patient Presenting With Carpal Tunnel Syndrome

Carpal tunnel syndrome

Carpal tunnel syndrome usually presents with tingling and numbness mainly of the lateral three and a half fingers. There may be associated pain which may radiate towards the elbow. The symptoms are worse at night and the symptoms are partially relieved if the hands are held upwards to reduce oedema. The diagnosis should always be kept in mind if the patient

  • middle-aged female
  • has obesity or hypothyroidism
  • has history of osteoarthritis
  • during pregnancy

Other associated conditions are acromegaly, amyloidosis. There may be a history of trauma in the past. As cervical spondylosis is a common accompaniment, it is frequently misdiagnosed as cervical radiculopathy. Early NCV study will settle the issue.

Examination reveals positive Tinel’s sign (tapping of the volar aspect of the wrist with a hammer causes tingling in the lateral 31/2 fingers) and a positive Phalen’s sign (forced flexion of the wrist for 60 seconds will reproduce the symptoms of carpal tunnel compression). In long-standing cases, there may be wastina Of the thenar eminence muscles. There may also be sensory impairment of the lateral 31/2 fingers. Thumb abduction may be impaired.

Diagnosis

It is confirmed by nerve conduction velocity study which differentiates from other causes like cervical radiculopathy or polyneuropathy.

Management

In mild cases simple wrist splint or hand brace during working might provide symptomatic benefit. NSAID and diuretics also help in relieving symptoms but oral steroids are more effective. Even more effective is local injection of steroid (1 cm proximal to the distal flexion crease of the wrist between palmaris longus and flexor carpi radialis). However, the process is blind and exact location of the target is not guaranteed. It is usually given where CTS is transient as in pregnancy. Short acting steroids (e.g. hydrocortisone) are nowadays preferred to long-acting ones (triamcinolone) to avoid long-term side effects.

The treatment of choice in persistent CTS is surgical decompression with a success rate of 95% in expert hands. Nowadays in certain centres, endoscopic decompression is being practiced. The success rate is more or less same but the procedure is less painful and return to work is earlier. Whichever procedure is chosen, it should be properly timed as permanent damage to the nerves would render the operation a failure. In bilateral involvement, the operation should be done sequentially with a gap of few months to ensure good recovery from the first procedure.

The patient mentioned above underwent surgical decompression (sequential) of her CTS. She was also treated with thyroxin and at one year follow up she was doing very well.

Causes of Carpal tunnel syndrome

  • Osteoarthritis
  • Hypothyroidism
  • Obesity
  • Amyloidosis
  • Inflammatory arthropathy

Diagnosis: Re De Quervains’ tenosynovitis in a hyperuricaemia and diabetic patient.

Hand pain and shoulder pain are a very common presentation in clinical practice am in majority of cases they present to the internists who with careful clinical examination may make a definitive diagnosis and offer successful treatment.

Common causes of hand pain:

  • Trauma
  • Infection
  • Osteoarthritis – distal PIP joints and commonly involved 1st MCP joints
  • Uric acid related problems
  • Inflammatory arthropathy – MCP joints commonly involved
  • carpal tunnel syndrome – discussed

Tenosynovitis of different tendons around the wrist joints main associated causes are-over use, diabetic mellitus, high uric acid, gonococcal infection.

Main Points

  • CTS is a common presentation in clinical practice.
  • It is frequently misdiagnosed as osteoarthritis or cervical spondylosis.
  • Careful history taking clinical examination and early NCV test will detect the condition earlier.
  • Surgical decompression is the treatment of choice with adequate symptomatic relief.
  • Underlying causes like hypothyroidism should be ruled out.

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