Treatment of Carpal Tunnel Syndrome

A 45 year old woman who works as a professional baker, with a specialty in birthday and wedding cakes, is diagnosed today with carpal tunnel syndrome. Her history of present illness include a four month history of numbness and tingling of the thumb, index and middle finger of her dominant hand. Physical exam reveals normal grip strength and decreased sensation along the median nerve distribution. Thenar atrophy is absent. 

Which of the following is the most appropriate next step?

A. referral for carpal tunnel surgical decompression

B. arranging for carpal tunnel corticosteroid injection

C. advice on the use of neutral position wrist splinting

D. obtain a TSH and an A1C

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Transcript

Voiceover: Welcome to NP Certification Q&Apresented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.

Margaret Fitzgerald: 45 year-old woman who works as a professional baker with a specialty in birthday and wedding cakes is diagnosed today with carpal tunnel syndrome. Her history of present illness include a 4-month history of numbness and tingling of the thumb, index, and middle finger of her dominant hand. Physical exam reveals normal grip strength and decreased sensation along the median nerve distribution. Thear atrophy is absent. Which of the following is the most appropriate next step? 

A. Referral for carpal tunnel surgical decompression. 
B. Arranging for a carpal tunnel corticosteroid injection. 
C. Advice on the use of neutral position wrist splinting. 
D. Obtain a TSH and an A1C. 

Correct answer is C. Advice on the use of neutral position wrist splinting.

Where should you go with this question? First, of course, determine what kind of a question it is. We're given the patient's diagnosis. then asked for next steps. So this is a question centered on planning. 

Some background information. CTS is a painful condition caused by compression of the median nerve between the carpal ligament and other structures within the carpal tunnel. The compression leads to an entrapment neuropathy causing symptoms in the distribution of the median nerve. The resulting symptoms are likely due to nerve ischemia rather than nerve damage. And I have another podcast that goes over physical exam findings in carpal tunnel syndrome and I would encourage you to listen to that as well. 

The most common CTS risk factor is repetitive motion. The condition is common in workers such as cake decorators. That's what we have here. And people who do soldering as a business who must constantly grip a small object. Of course, it's quite common in people who use keyboards, which is pretty much all of us. In this case, usually CTS is bilateral as they're using both hands to do this work and a patient like this who is a cake decorator, she's no doubt using her dominant hand for the most part. And you'll see with her, it's a unilateral issue. In the exam room, whenever I see somebody who I suspect has CTS, I always ask them to demonstrate with their hand or hands what they do for work. And it is so insightful because it gives you an idea of what caused the condition to develop. Truth be told, in almost any orthopedic issue that is not directly related to like an acute event like somebody who comes in with a short sore shoulder and tells you they fell down a flight of stairs a few days ago. Okay, that's not going to be helpful in that. But let's say that somebody comes in and says, "My shoulder is always sore and I work in a professional laundry." and then tell them, "Show me what you do with your arms and shoulders during your workday." And very often, immediately, you can see what the origin of their shoulder pain is. So, it works with a myriad of different orthopedic issues. And CTS can also be part of a manifestation of systemic disease like rheumatoid arthritis or sarcoidosis. That's unlikely to pop up on boards because that's uncommon. And last but certainly not least, CTS can be noted tangentially as well in people who are generally lower risk for developing it. In other words, it's quite common towards the end of pregnancy, tends to be bilateral and this is associated with the increased fluid retention that is often noted in very late pregnancy when the circulating volume increases tremendously. And often times you'll have just miserably uncomfortable people in late pregnancy. I remember having one woman in the exam room who was sobbing saying, "How am I going to take care of a baby with these numb hands?" And she was, you know, very legitimately concerned about this. The same intervention works during pregnancy as we have here with the wrist splinting. But the other part is reassurance, reassurance, reassurance, reassurance. It usually self-resolves in the first few weeks postpartum. The other time you can see transient CTS in a lower risk individual is during a person who was just diagnosed with hypothyroidism. Um, and then once their TSH gets more into normal range, the CTS goes away. And one more time with the CTS triggered by hypothyroidism. Usually it is bilateral. 

As with the diagnosis of many conditions, the clinician should be aware of what signs and symptoms occur earlier and later in the disease and which are most consistent with the diagnosis. I covered that in the physical exam of CTS in another podcast. 

So let's get back to this patient here. 45-year-old woman who works as a professional baker with a specialty in birth date and wedding cakes is diagnosed today with carpal tunnel syndrome. Her HPI include a 4-month history of numbness and tingling of the thumb, index, and middle finger of her dominant hand. Physical exam reveals a normal grip strength and decreased sensation along the median nerve distribution. Thear atrophy is absent. Which of the following represents the most appropriate next step? 

So, keep in mind what her physical exam findings are. Are we talking earlier or later disease? Option A, referral for carpal tunnel surgical decompression. You know, this person has had CTS for symptoms for a relatively short period of time, four months. I'm not minimizing how miserable and how concerned she might be. However, it's only four months and she has intact hand strength and no thenar atrophy. These findings are consistent with earlier milder disease. Surgical intervention is usually reserved in situations where more conservative therapy have failed and clinical findings are more consistent with severe disease. Evidence of severe disease include reduced hand strength, thenar atrophy and persistent symptoms in the presence of conservative therapy such as splinting. 

B. Arranging for a carpal tunnel corticosteroid injection. As mentioned, this is not the correct answer, but she has milder disease and has not had a trial of conservative therapy. Carpal tunnel corticosteroid injection is usually reserved when there has been a failure of first line therapy and it's always important to keep in mind we generally start with something more conservative and then go to something more aggressive with orthopedic conditions like this. 

C. Advice on the use of neutral position rest splinting. Obviously this is the correct answer. Firstline therapy in earlier CTS without evidence of severe disease includes the use of neutral positioning rest splinting particularly during the nonwork hours in overnight. The splints help relieve pressure within the carpal tunnel and generally a 6 to 8 week trial is done and then the patient is reassessed to see how they are doing. Something to also consider. Remember this is how this woman makes her living. Occupational therapists are to my thought a tremendously underutilized and underappreciated part of the health care team and they this is what they do. An OT referral might be exactly what this woman needs in addition to doing the splinting because what OT can do is teach her how to do her job a little bit differently so that she is able to preserve function and stay employed which is very important. 

D obtaining a TSH and an A1C. Well, this is a example of one of those yeah, but answers. Can carpal tunnel syndrome be secondary to or worsened by poorly controlled diabetes, untreated or undertreated hypothyroidism? Absolutely. However, in this question, what we're given is an occupational reason for her carpal tunnel syndrome. Well, to be honest with you, if I was seeing this woman in the exam room, I probably would check an A1C and a TSH on her. She's a middle-aged person, higher risk time for the development of diabetes and/or hypothyroidism. And that could be contributing to her CTS symptoms. But on the other hand, she is telling you, I'm a cake decorator. She's giving you a reason for her to have this. So this is a maybe in real life we would do this but it is one more time. It is technically a correct answer but it is not the best answer. It is not the best answer. 

Key takeaway recognizing earlier disease and earlier interventions in diseases commonly encountered in primary care is important to clinical practice and NP board success.

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