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History
History
Her symptoms are most prominent at night, often waking her from sleep. They are also triggered by prolonged use of the hand, such as driving, holding the phone, or keyboarding and mouse use. She finds some relief in flicking her right hand. More recently she notices loss of dexterity in the right hand and has difficulty writing.
Physical Examination
Upon physical examination mild atrophy of the right thenar eminence and mild weakness of thumb abduction is noted. All other muscles are strong and reflexes are normal. Pinprick and vibratory sensations are reduced over the first three digits. Hand elevation test elicits tingling in the first three fingers after 30 seconds. Allen test indicates effective arterial supply.
Investigations
Due to chronic symptoms and lack of evidence for a space-occupying lesion, only an EMG is ordered. Nerve conduction studies confirm the clinical impression of CTS, showing a moderately severe, right median neuropathy at the wrist. The right median sensory latency is moderately prolonged and the sensory CV and amplitude are moderately reduced. The median distal motor latency is moderately prolonged. The right ulnar motor and sensory studies are normal. Needle EMG shows mild denervation in the abductor pollicis brevis muscle, while ulnar-innervated hand muscles and proximal arm muscles are normal.
Treatment
Because of the progressive neurologic deficits and electrodiagnostic findings, she is referred to a hand surgeon without a trial of conservative therapy. Right carpal tunnel release surgery is scheduled for 3 weeks time.
Follow-up
Her symptoms resolve after surgery and dexterity improves gradually over the following month. Pain localized to her scar resolves within two months.
Secondary Prevention