A 57-year-old woman comes to the office due to discomfort in her right hand. She reports that periodically her fingers "feel numb, with some tingling, sort of like they fell asleep." When the patient shakes her hands, normal sensation is partially restored. The symptoms are more often present at night but are occasionally experienced during the daytime as well. She has not had abnormalities of sensation on the dorsal surfaces of her hands, and she reports no shoulder or neck pain. There is no history of injury to the upper extremities. Medical history is notable for irritable bowel syndrome, mitral valve prolapse, degenerative knee arthritis, and hypertension controlled with lisinopril. She also takes an over-the-counter fiber supplement. The patient works as a bookkeeper. She does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 32 kg/m². Neurologic examination shows no sensory loss, muscle weakness, or muscle atrophy in the right upper extremity. Provocative testing reproduces the patient's symptoms. Which of the following is the most appropriate next step in management of this patient's condition?

Question

Quizplus · Accepted Answer

Explanation: Initial treatment of carpal tunnel syndrome (CTS) includes splints to hold the wrist in a neutral position. Splinting prevents excessive flexion or extension that could narrow the tunnel and worsen median nerve compression. Nighttime splinting is usually adequate, although patients may opt for full-time use. Splinting is most effective in patients with mild symptoms for <10 months. Surgery is more effective than splinting but is usually unnecessary; it is often reserved for patients with moderate to severe symptoms for at least 6 months that do not resolve with conservative measures or are associated with significant neurologic deficits (Choice D). (Choice A) Corticosteroid injection into the carpal tunnel usually provides only short-term relief and is associated with a risk of complications (eg, tendon rupture). For most patients, treatment should start with splinting, with corticosteroid injections later for those who fail initial treatment. (Choice C) Nonsteroidal anti-inflammatory drugs in CTS have shown no benefit compared with placebo and are generally not recommended. (Choice E) Median nerve compression may result in tethering and decreased mobility of the nerve. Physical therapy referral for tendon and nerve-gliding exercises theoretically may improve this complication, but studies are inconclusive. Educational objective: Initial treatment of carpal tunnel syndrome utilizes nighttime splinting to hold the wrist in a neutral position. Corticoid injections can provide short-term relief. Surgical decompression is effective but usually reserved for patients with more severe or chronic symptoms that fail conservative measures.

A 57-Year-Old Woman Comes to the Office Due to Discomfort