Login

Carpal Tunnel Syndrome

 

Introduction

The majority of cases of carpal tunnel syndrome are idiopathic.  Possible risk factors include pregnancy, hypothyroidism, diabetes mellitus, osteoarthritis of the thumb MCPJ, rheumatoid arthritis and high repetition hand and/or wrist activities.  Symptoms may spontaneously resolve in some people.


In scope             Carpal Tunnel Syndrome


Not in scope     Other orthopaedic and neurological conditions including fractures

  


Red Flag Features

Recent fracture

Onset of numbness or paraesthesiae after an injury

Nerve tumour or other lump in the carpal tunnel region

Symptoms associated with a lump in the carpal tunnel region

Fixed neurological deficit (such as permanent numbness and/or paraesthesiae, thenar muscle wasting)

Sudden progression of symptoms

*This list is non exhaustive 


 

Investigations required prior to referral

Blood tests are only considered if history and/or examination suggest a systemic cause such as Diabetes, Hypothyroidism, Rheumatoid arthritis

Nerve conduction studies are not usually required, unless there is:

  • Diagnostic uncertainty
  • Recurrence of symptoms after surgery
  • Concurrent cubital tunnel symptoms

Consider if there is:

  • Vibratory exposure
  • Neuropathy
  • Diabetes

 


Management optimisation

Consider a shared decision making approach with the patient1 NHS_Carpal_Tunnel_decision_tool

Optimise management of any underlying condition1

Address any work related factors, consider Occupational Health assessment or direct to Work Well if needed

Night splints are suitable for:

Short history of symptoms with a definable cause that is likely to remit

Predominantly night symptoms

Patient not fit or willing for surgery

 

Splints can be accessed from:

Readily available online for patients to buy themselves

RCHT Appliance Department – specify small/medium/large/X large/Left/right

Local physiotherapy department

 

Steroid injection in-house or inter-practice referral

Useful for symptom relief and confirming diagnosis

Trial of 1 injection prior to referral for surgery

Subsequent injection may be appropriate if patient does not want surgery or wishes to postpone surgery

 

Practices that are unable to provide an ‘in-house’ MSK steroid injection are able to refer to other practices for the MSK steroid injections under the Direct Enhanced Scheme Musculoskeletal Corticosteroid Injection

 


Advice and Guidance

No advice and guidance currently available


 

Referral

Urgent referral criteria

Refer to Hand Trauma clinic if:

  • The carpal tunnel symptoms and/or signs are associated with a recent fracture
  • The onset of numbness and/or paraesthesiae are after an injury

Refer direct to Hand Trauma clinic, not via RMS

 

Refer to Orthopaedics at first presentation if there is a:

  • Nerve tumour, lump or symptoms associated with a lump in the carpal tunnel region
  • Fixed neurological deficit (such as permanent numbness and/or paraesthesiae, thenar muscle wasting)
  • Sudden progression of symptoms
  • Symptoms deteriorate after carpal tunnel surgery
  • If there is complex regional pain syndrome following surgery that does not resolve by 2 weeks, make an urgent referral to Hand Therapy

 

Urgent referral criteria to other specialties:

An underlying neurological disorder other than compression is suspected

Peripheral limb ischaemia (thoracic outlet syndrome or Raynaud’s disease)

Cervical nerve root entrapment

Active inflammatory joint disease

 

Routine referral criteria

  • Primary care management has failed OR there is significant functional impairment* AND
    Symptoms are more than 6 months duration

*Significant functional impairment is defined as a loss or absence of an

individual’s capacity to meet personal, social or occupational demands.  Please

provide examples of the impairment the individual is experiencing.

  • Recurrent or persistent symptoms after decompression 3 months or more post surgery

 


Supporting Information

For professionals

Carpal tunnel syndrome | Health topics A to Z | CKS | NICE

For patients

Patient.info.  Carpal Tunnel Information Leaflet Carpal Tunnel Syndrome: Causes, Symptoms, and Treatment

 

Royal College of Surgeons of England.  Carpal Tunnel Release.  Download the Leaflet — Royal College of Surgeons

References

National Institute Of Clinical Excellence.  Clinical Knowledge Summaries Carpal Tunnel Syndrome; August 2022

 

Page Review Information

 

Review date

6 December 2024

Next review date

6 December 2026

Clinical editor

Dr Rebecca Hopkins

Contributors

Miss Dunlop, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust

Mr Poulter, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust