Clinical Notes : Orthopedics

54. Carpal Tunnel Syndrome



  • Hand pain

  • Numbness & tingling in the distribution of the median nerve

  • Reduction in hand grip and function


Associated with

  • Anatomic factors.

    • A wrist fracture or dislocation, or arthritis that deforms the small bones in the wrist, can alter the space within the carpal tunnel and put pressure on the median nerve.

  • People with smaller carpal tunnels

    • may be more likely to have carpal tunnel syndrome.

  • Sex.

    • more common in women, because the carpal tunnel area is relatively smaller in women than in men.

    • women who have carpal tunnel syndrome may also have smaller carpal tunnels than women who don't have the condition.

  • Nerve-damaging conditions.

    • Some chronic illnesses, such as diabetes, increase the risk of nerve damage, including damage to the median nerve.

  • Inflammatory conditions.

    • e.g. rheumatoid arthritis, can affect the tendon sheaths in the wrist and put pressure on your median nerve.

  • Obesity.

    • is a significant risk factor for carpal tunnel syndrome.

  • Alterations in the balance of body fluids.

    • Fluid retention may increase the pressure within the carpal tunnel, irritating the median nerve. This is common during pregnancy and menopause. Carpal tunnel syndrome associated with pregnancy generally resolves on its own after pregnancy.

  • Other medical conditions.

    • menopause, obesity, thyroid disorders and kidney failure

  • Workplace factors.

    • working with vibrating tools or on an assembly line that requires prolonged or repetitive flexing of the wrist may create harmful pressure on the median nerve or worsen existing nerve damage

carpal tunnel 2.png


Where numbness or tingling in your wrist, hand or fingers is present, ask the following


  • Do your symptoms spare your little finger?

  • Are the symptoms worse at night?

  • Do the symptoms wake you up at night?

  • Have you noticed your hand is weak e.g. dropping things?

  • Do you find shaking your hand, holding it or running it under warm water improves your symptoms?

  • Are the symptoms made worse by activities such as driving, holding a telephone, using vibrating tools or typing?

  • Have splints or injections helped with the pain in the past?


  • If ≥3 positive CTS diagnosed

  • If ≥2 positive, CTS diagnosed if Phalen’s test (forced flexion of wrist) is also positive.

  • If <2 positive, consider alternative diagnosis (e.g. cervical radiculopathy, peripheral neuropathy, wrist arthrosis, tendonitis/tenosynovitis)

EMG and nerve conduction studies may be considered if the diagnosis is uncertain



  • Lifestyle advice & reassurance that 1/3 spontaneously resolve within 10-15 months

  • NSAIDs or diuretics should not be routinely recommended

  • There is limited evidence to support night splinting and steroid injections in mild to moderate cases (absence of weakness or wasting of thenar musculature)

  • Refer for consideration of decompression surgery if symptoms are severe or constant, progressive motor or sensory deficit evident, or no improvement after 3 months of conservative management

carpal tunnel 3.jpg
BMJ Best Practice.png

Diagnosing and Managing Carpal Tunnel Syndrome in Primary Care

Burton C, Chesterton LS, Davenport G

Br J Gen Pract 2014; 64 (622): 262-263.



Carpal Tunnel Syndrome: A Review of the Recent Literature

Ibrahim I, Khan WS, Goddard N, Smitham P

Open Orthop J. 2012; 6: 69–76. Suppl 1.

Published online 2012 Feb 23.


Diagnosis and therapy of carpal tunnel syndrome--guideline of the German Societies of Handsurgery, Neurosurgery, Neurology, Orthopaedics, Clinical Neurophysiology and Functional Imaging, Plastic, Reconstructive and Aesthetic Surgery, and Surgery for Traumatology

Assmus H et al.

Handchir Mikrochir Plast Chir. 2007 Aug;39(4):276-88.



Management of carpal tunnel syndrome evidence-based clinical practice guideline

American Academy of Orthopaedic Surgeons

February 2016.


Carpal tunnel syndrome

BMJ Best Practice

Last reviewed: February 2019

Last updated: December  2017


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