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With warm weather finally arriving, you suspect that your Monday morning clinical sojourn in the community sports medicine clinic will be filled with weekend athletes and over-doers. Rodney is a physical therapy student with you that week shadowing you as you see patients.
Your first patient, Bridie Redmond is a 24 year old female sent over by her family physician for evaluation of pain and numbness in her right (dominant) hand.
She has a history of recent onset rheumatoid arthritis. Not surprisingly, you note a positive Phalen’s test and Tinel’s sign on exam. You tell her she probably has carpal tunnel syndrome. Her mother, who accompanied Bridie, asks you exactly what is this disorder?
Spoiler for Answer:
Carpal tunnel is the most common neuropathy in the upper extremity. The disorder was first described by Sir James Paget in 1854 and the pathology was noted in 1913. Phalen et al dubbed it a clinical syndrome in the 1950s. Reported causes of carpal tunnel syndrome (CTS) include inflammatory arthritidies, displaced scaphoid fractures, pregnancy, distal radius fractures, gout, acromegaly, amyloidosis, multiple myeloma, anamolous muscles, and mass lesions. A significant percentage have no known origin. MedicalMnemonics.com reminds us with the mnemonic
Bridie tells you she needs to get back to her job as a secretary – what can you tell her about treatment of this disorder?
Spoiler for Answer:
Patients who have mild symptoms, usually sensory symptoms without motor deficit, may be treated conservatively. This includes the use of splints, in neutral position, and nonsteroidal antiinflammatory drugs. Studies have shown that volar or dorsal flexion of the wrist can increase the pressure within the carpal canal. Therefore, the neutral position splint is preferred over the traditional "cock-up" splint. In patients with mild symptoms for less than one year, injection of corticosteroids in the carpal tunnel may benefit. The likelihood of success with injection and splinting is reduced if the patient does heavy labor. Kaplan et al reported that conservative measures have a success rate of 60% in patients who have only one risk factor (age >50, positive Phalen's test at 30 seconds, symptoms for >10 months, constant paresthesias, and associated trigger fingers). Those patients who have three risk factors had a failure rate of 93% and those with four or more had a 100% failure rate.
“What if Bridie needs surgery?” Rodney, your PT student asks after Bridie leaves the office in a neutral splint. What can you tell him about operative treatment?
Spoiler for Answer:
The goal of surgery, regardless of open or endoscopic release, is to decompress the median nerve in the carpal tunnel. This is achieved by releasing the transverse carpal ligament and the distal antebrachial fascia. Open release can be done through a 3-cm incision at the base of the palm in line with the ulnar border of the ring finger being cognizant of the variations in the take-off of the motor branch to the thenar muscle.
Although some surgeons still prefer neurolysis, it is no longer felt to be a crucial part of the procedure when cohorts are compared. A local tenosynovectomy may be necessary during carpal tunnel release when there is synovitis, a space-occupying lesion that increases pressure within the carpal tunnel.
Rodney asks you if there is they are still using an endoscopic procedure successfully for this condition?
Spoiler for Answer:
Over the past two decades endoscopic release has gained. The risks of iatrogenic injury with endoscopic procedures include transection of the median nerve, the digital nerves, and the superficial carpal arterial arch An extensive review of endoscopic carpal tunnel surgery in the literature was done by Jiminez et al., reviewing over 8.000 procedures.
The overall success rate was 96.52% with a complication rate of 2.67% and a failure rate of 2.61%. The return to work average was 17.8 days. A prospective randomized study compared two-portal endoscopic release with open release and found no significant difference in sick leave (19 versus 17 days) or in surgical results. Another prospective comparison of endoscopic release and a minimal open release showed no difference for the efficacy of symptom relief, complications, or return to work.
References
1. Levine, B.: Nerve Entrapements of the Upper Extremity. Neurology Clinics. 17(3). August 1999
2. MedicalMnemonics.com
I'd like to add one differential to the Median Trap nemonic, Leprosy! I don't know where the letter can fit in but I was amazed in a recent episode of House that the unilateral peripheral neuropathy characteristic of peripheral nerve destruction in leprosy can mimic carpal tunnel syndrome and one may even get surgery (to no avail) in an attempt to remove the affliction. Just thought I would add the info as an example of how television CAN be a good thing (only on DVD though).
Name a Surgical Sieve for diagnostic categories 
PBL: Carpal Tunnel Syndrome
