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Patient Case: Carpal Tunnel Syndrome

Patient Case: Carpal Tunnel Syndrome

Discussion

A 47-year-old office worker presents to the neurology clinic with a six-month history of numbness, tingling, and occasional burning pain in his right hand, particularly affecting the thumb, index, and middle fingers. The symptoms are worse at night and sometimes wake him from sleep. He also reports weakness in his grip, making it difficult to hold objects like a coffee mug or a pen.

On examination, there is mild thenar muscle atrophy and a positive Tinel’s sign and Phalen’s test at the wrist. Sensation is reduced in the distribution of the median nerve, but there is no involvement of the little finger. Reflexes and arm strength are otherwise normal.

Nerve conduction studies confirm median nerve compression at the carpal tunnel, consistent with carpal tunnel syndrome (CTS). He is advised on wrist splinting at night, ergonomic modifications at work, and a trial of nonsteroidal anti-inflammatory drugs (NSAIDs). If symptoms persist, corticosteroid injection or surgical decompression may be considered.

Questions
1. What is the most likely diagnosis in this patient presenting with numbness and tingling in the thumb, index, and middle fingers?

A) Ulnar neuropathy

B) Cervical radiculopathy

C) Carpal tunnel syndrome (CTS)

D) Peripheral polyneuropathy

2. Which clinical test is most useful in diagnosing carpal tunnel syndrome?

A) Straight leg raise test

B) Phalen’s test

C) Finkelstein’s test

D) McMurray’s test

3. What is the initial conservative management for carpal tunnel syndrome?

A) Surgical decompression

B) Nighttime wrist splinting and ergonomic adjustments

C) High-dose corticosteroids

D) Complete immobilization of the wrist

4. Which nerve is compressed in carpal tunnel syndrome?

A) Ulnar nerve

B) Median nerve

C) Radial nerve

D) Axillary nerve

Reveal answers

Answers

1 - C) Carpal tunnel syndrome (CTS)

CTS is caused by compression of the median nerve at the wrist, leading to numbness and tingling in the thumb, index, and middle fingers. The sparing of the little finger helps differentiate it from ulnar neuropathy.

2 - B) Phalen’s test

Phalen’s test involves flexing the wrist for 60 seconds, which reproduces CTS symptoms due to increased pressure on the median nerve. Tinel’s sign, which elicits tingling upon tapping the wrist, is also helpful in diagnosis.

3 - B) Nighttime wrist splinting and ergonomic adjustments

Initial treatment includes wrist splinting, especially at night, to prevent excessive flexion. Ergonomic modifications at work, such as adjusting keyboard height, can also help alleviate symptoms.

4 - B) Median nerve

The median nerve passes through the carpal tunnel and provides sensation to the thumb, index, middle, and half of the ring finger. Compression results in sensory disturbances and, in severe cases, thenar muscle atrophy.