Hand CASE 40

CASE                               40                               

The patient is a 48-year-old, diabetic woman who presents with a 4 months history of numbness and paresthesias of bilateral thumbs, index, and middle fingers. She has had no prior workup for this problem. She reports that her symptoms have been progressive, and that they wake her up from sleep two or three times per week. On physical examination, the patient has grossly normal sensibility in all fingers, and has 5/5 strength to palmar abduction in bilateral thumbs.

What is the most likely diagnosis?

1. Diabetic peripheral neuropathy

2. Cubital tunnel syndrome

3. Pronator syndrome

4. Cervical radiculopathy

5. Carpal tunnel syndrome

 

Discussion

The correct answer is (E). Carpal tunnel syndrome is the most common compressive neuropathy in the extremity, and can manifest in many ways but often presents with numbness and paresthesias in the volar aspect of the thumb, index finger, middle finger and radial half of the ring finger. It is more common in patients with diabetes, and can result in symptoms that progress over time. This patient’s presentation is most consistent with carpal tunnel syndrome.

Which of the following is the most appropriate next step in workup of this patient’s symptoms?

1. X-rays of bilateral wrists and hands

2. MRI of bilateral wrists

3. EMG and nerve conduction studies

4. CBC, chemistries, liver function tests

5. TSH and Vitamin B6 levels

 

Discussion

The correct answer is (C). The most appropriate workup for this patient’s symptoms would include electromyography and nerve conduction studies. These tests can provide objective data to determine the presence and severity of the patient’s disease. X-rays and MRI are not typically useful in the workup of carpal tunnel syndrome unless other, more rare pathophysiology is suspected.

An EMG is performed which demonstrates mild carpal tunnel syndrome bilaterally, with slight prolongation of distal sensory latencies and no appreciable change in distal motor latencies. The patient is not interested in undergoing surgery.

What is the most appropriate initial management of this patient’s condition?

1. Percutaneous carpal tunnel release in the office using an 18 gauge needle

2. Bilateral wrist splints with wrists in 40 degrees of flexion

3. Semi-urgent open bilateral carpal tunnel release

4. Bilateral wrist splints with wrists in neutral position

5. Bilateral corticosteroid injection into the carpal tunnel with 40 cc total of triamcinolone 40 mg/cc mixed with 1% lidocaine with epinephrine

Discussion

The correct answer is (D). This patient has mild carpal tunnel syndrome by EMG. She is not currently interested in undergoing surgical release, and an appropriate first step would be the provision of bilateral wrist splints in neutral position. Studies investigating pressures within the carpal tunnel have demonstrated that the optimal position to splint the wrist are in neutral position or slight extension with slight ulnar deviation. Corticosteroid injections into the carpal tunnel can be effective but at a much lower dose than indicated in answer (E).

 

Objectives: Did you learn...?

 

 

Poinpoint the clinical presentation of carpal tunnel syndrome? Perform workup of carpal tunnel syndrome?

 

Initially manage carpal tunnel syndrome?