What’s in the web for family physicians – Carpal tunnel syndrome

Wilbert WB Wong 王維斌，Alfred KY Tang 鄧權恩

HK Pract 2020;42:58-59

Carpal tunnel syndrome is the most common neuropathy relating to nerve entrapment. It affects 0.1% of the population but can be up to 5% for those in certain occupations. ¹ Risk factors involved include repetitive maneuvers, trauma, diabetes, hypothyroidism, rheumatoid arthritis and pregnancy.

Symptoms are due to compression of the median nerve, which may result in pain and numbness of the hand.

Physical examination findings include positive Tinel test and Phalen's Test. A classic or probable pattern on hand symptom diagram is usually helpful in confirming the diagnosis. ²

Nerve conduction studies can resolve diagnostic uncertainties and can be used to quantify and stratify disease severity.

Treatment options depend on disease severity. Lifestyle modifications, avoiding repetitive movements of the wrist and the use of ergonomic devices have been advocated but the effectiveness lacks convincing evidence.

Cock-up and neutral wrist splints and oral corticosteroids are considered first-line therapies, with local corticosteroid injections used for refractory symptoms. Effectiveness of nonsteroidal anti-inflammatory drugs, diuretics, and pyridoxine (vitamin B6) are still controversial. ³

Conservative treatment usually provide short-term symptom relief, with little evidence on sustainable long-term benefits. Patients with moderate to severe disease should be considered for open or endoscopic surgical approach.

Overview of Immunotherapy for Cancer treatment

This Clinical Practice Guideline was developed in 2016 by the American Academy of Orthopaedic Surgeons. It was based on system reviews of the current scientific and clinical information and accepted approaches on treatment and diagnosis. This clinical practice guideline evaluates the effectiveness of different modes of treatment for carpal tunnel syndrome. The full version of guidelines can be downloaded from the website, it covers evidence on history, physical examination, diagnostic investigation, conservative treatments, oral medications, injections and surgical interventions.

Interactive orthopaedic guidelines for management of carpal tunnel syndrome

The American Academy of Orthopaedic Surgeons developed Appropriate Use Criteria in 2011 as an evidence-based Clinical Practice Guidelines. Appropriate Use Criteria are created with an aim to determine who are best candidates for a procedure. This involves using clinician expertise and experience, in conjunction with the relevant evidence, to rate the appropriateness of various treatments in a set of hypothetical, but clinically realistic, patient scenarios. This website provides guidelines for various orthopaedic problems including carpal tunnel syndrome. By answering different clinical questions like the likelihood of carpal tunnel syndrome under physical examination, the result of electrodiagnostic testing, clinical severity and response to previous treatment, the system will generate suggested management options to the clinicians.

Clinical anatomy of carpal tunnel syndrome

Developed by University of Warwick in United Kingdom, this video in their health channel on Youtube introduces the complex anatomy related to Carpal Tunnel Syndrome. It explains how the median nerve is being compressed, and shows where the median nerve is located in relationship to other structures in the carpal tunnel. The video provides a better understanding of the pathophysiology of Carpal Tunnel Syndrome and prepares the practitioner on the anatomical landmarks for injection.

Effects of taping therapy for carpal space expansion on electrophysiological change in patients with carpal tunnel syndrome

Taping therapy is one of the most popular and safe modes of conservative treatment for Carpal Tunnel Syndrome (CTS). This article evaluates the effects of taping therapy for carpal space expansion on electrophysiological changes with CTS. There were significant differences between distal motor latency (DML) and sensory nerve conduction velocity (SNCV), but no difference between compound muscle action potential and sensory nerve action potential (SNAP) after 4 weeks taping treatment. The taping methods used in the study are explained with illustrations in the article.

Corticosteroid injection technique for the treatment of carpal tunnel syndrome

This article shows the landmark guided corticosteroid injection technique for the treatment of carpal tunnel syndrome. Increasing evidence supports local carpal tunnel corticosteroid injection as an effective treatment for carpal tunnel syndrome. ⁴ Evidence does not support one injection technique over another or a particular steroid formulation. However, ultrasound-guided injection may be more effective than blind injection and allows for direct visualisation to ensure accurate and safe needle placement. Although injection is generally safe, there is risk of median nerve injury and tendon rupture. A repeat injection in the same wrist may be offered after six months. If symptoms recur after two injections, other treatment modality or surgery should be considered.

Median nerve anatomy and US-guided injection

This video clip from The American Family Physician provides a review of the anatomy of the median nerve at the wrist under ultrasound. The video illustrates its relationship with flexor retinaculum and other essential structures of the wrist. It also provides demonstration of two methods of US-guided median nerve injection of the median, namely the out of plane and in plane technique.

Therapeutic exercise program for carpal tunnel syndrome

This exercise program is designed by the experts of the American Academy of Orthopaedic Surgeons. Exercises may help reduce the pressure on the median nerve at the wrist. They may be incorporated with bracing or splinting, medication, and activity changes to relieve symptoms. Some patients may benefit from specific exercises that help the median nerve move more freely within the carpal tunnel. In addition, exercises to help tendons glide through the carpal tunnel can help improve joint range of motion and hand function. This exercise program for carpal tunnel syndrome should be continued for 3 to 4 weeks, and can be continued as a maintenance program.

Carpal tunnel release operations

This website by John Hopkins University provides information to patients about different types of surgery for carpal tunnel syndrome, mainly the open and laporoscopic surgery.

Animated video clips are available to explain the indications, process, risk and complications of the procedures

Most people who have had surgery for carpal tunnel syndrome have improved symptoms of pain and numbness in their hand after surgery. ⁵ The risk and complication rates for endoscopic surgery are very low. Major problems such as nerve damage happen in fewer than 1 out of 100 surgeries (less than 1%). ⁶