Case 61 Carpal Tunnel Syndrome
Paresthesias reported in the median nerve distribution of the right hand
Significant thenar atrophy of the hand relative to the contralateral side
Duration and evolution of symptoms
Prior treatments and their effectiveness
Pertinent symptoms consistent with nerve compression
Nocturnal pain, numbness, and tingling in the thumb and one or more radial fingers
Daytime paresthesias elicited with activities involving prolonged wrist flexion and/or extension
Need for shaking and wringing the hand to alleviate symptoms
Gritty sensation or numbness in fingers, grip and pinch weakness, and diminished finger dexterity with a history of dropping objects
Cold intolerance, dryness, and unusual textures in the radial digits
History of neck injuries or pain should be elicited (evaluate for more proximal issues)
61.2.2 Physical Examination
Tinel sign: Examiner percusses over the carpal tunnel. Tingling over distribution of the median nerve indicates positive result.
Phalen maneuver: Patient maintains full flexion of wrists for 30 to 60 seconds. Result is positive if tingling, burning, or numbness of the thumb, index, long, or ring finger is elicited.
Durkan’s (carpal compression) test: Examiner applies pressure with thumbs over the carpal tunnel for 30 seconds. Onset of pain/paresthesias in the median nerve distribution within 30 seconds is a positive result.
Diminished (increased) two-point discrimination compared to the ulnar nerve and contralateral hand. The normal distance is 4 to 6mm. Semmes-Weinstein monofilament testing or vibrometry.
Weakness and/or atrophy of the thenar musculature and radial lumbrical; atrophy and burning are later signs
Examination of soft tissues for skin and muscle atrophy, manual muscle strength testing, grip and pinch testing, percussion of all major peripheral nerves, assessment of deep tendon reflexes, and assessment of blood flow to each hand
Cervical spine and entire upper extremity examination to rule out cervical radiculopathy or thoracic outlet syndrome