A 28-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office due to burning pain in her right hand. The pain is mild and intermittent but worse at night and is felt mainly over the first, second, and third digits. Shaking the hands or letting them hang down briefly relieves the pain. There is no associated neck or forearm pain. Her pregnancy has otherwise been uncomplicated. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Fetal heart tones are 160/min. On examination, there is no thenar or hypothenar atrophy, and thumb opposition is normal. Percussion over the volar aspect of the wrist reproduces the pain. Which of the following is the best next step in management of this patient?

Question

A 28-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office due to burning pain in her right hand.  The pain is mild and intermittent but worse at night and is felt mainly over the first, second, and third digits.  Shaking the hands or letting them hang down briefly relieves the pain.  There is no associated neck or forearm pain.  Her pregnancy has otherwise been uncomplicated.  The patient does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Fetal heart tones are 160/min.  On examination, there is no thenar or hypothenar atrophy, and thumb opposition is normal.  Percussion over the volar aspect of the wrist reproduces the pain.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

. 11ec25c8_d2b7_5598_bc81_819aa7e0c7f6_MD0003_00 This patient has hand pain in the distribution of the median nerve consistent with carpal tunnel syndrome (CTS). CTS is caused by compression of the median nerve where it passes under the transverse carpal ligament (flexor retinaculum) in the wrist, and is common in the third trimester of pregnancy due to hormonal changes and edema in the tunnel. The diagnosis is typically made on clinical grounds; maneuvers that increase compression of the nerve (eg, Phalen test, Tinel sign) can reproduce the symptoms and clarify the diagnosis. Phalen test, Tinel sign Most patients with mild CTS respond to conservative measures, including nocturnal wrist splinting. Splinting holds the wrist in a neutral position and prevents excessive flexion during sleep, lowering pressure within the tunnel. In most cases, CTS resolves spontaneously after childbirth, and additional treatment is often not necessary. (Choice A) Acetaminophen is safe for use in pregnancy and may provide transient relief of pain. However, it would not address the underlying pathology of the disorder or provide long-term relief. Nonsteroidal anti-inflammatory drugs (eg, ibuprofen) at best provide only transient relief and are generally avoided in pregnancy. (Choices B and C) Local glucocorticoid injection is safe and effective in pregnancy but is not required if splinting is effective (oral glucocorticoids are less effective and generally avoided in pregnancy). Surgical intervention can be considered during pregnancy for patients with severe symptoms (eg, motor weakness, thenar atrophy); it is not indicated for patients with mild to moderate symptoms that can be managed with conservative measures and will likely resolve after delivery. (Choice D) Wrist splinting is safe and effective during pregnancy, and is unlikely to cause fetal harm; treatment need not be delayed until after delivery. Educational objective: Carpal tunnel syndrome is common in pregnancy. Most patients with mild symptoms respond to nocturnal wrist splinting, which holds the wrist in a neutral position and prevents excessive flexion during sleep. In most cases, symptoms resolve spontaneously after childbirth. References: Long-term result and patient reported outcome of wrist splint treatment for carpal tunnel syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/24032598) Carpal tunnel syndrome in pregnancy: a review. (http://www.ncbi.nlm.nih.gov/pubmed/24104526)

A 28-Year-Old Woman, Gravida 1 Para 0, at 30 Weeks