Orthopedics - Carpal and Cubital Tunnel Syndrome
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Carpal and Cubital
Pain, loss of strength or sensory changes (paresthesias)
in the distribution of the median or ulnar nerves not associated with neck
Initial Diagnosis and Management
- History and physical exam
(screen for associated conditions, i.e., diabetes, pregnancy, Rheumatoid
Arthritis, Systemic Lupus Erythematosus (SLE).
- Assessment with
provocative tests to include Tinel's and Phalen's sign tests of specific
- Plain radiographs are not
required (unless there was trauma); MRI/CT are not indicated.
- For Carpal Tunnel
Syndrome (CTS) symptoms prescribe a wrist splint (wrist in a neutral
position) to wear at night and during the day for aggravating activities
(take splint off every 2 hours and move wrist to prevent stiffness).
- For cubital tunnel
syndrome, educate the patient to avoid pressure on elbow.
- For both, try work
simplification techniques using ergonomic principles and activity
modification to decrease symptoms.
Ongoing Management and Objectives
- Expect resolution or
decreasing symptoms within two to four weeks.
- Consider confirming the
diagnosis with Electromyography/Nerve Conduction Velocity (EMG/NCV),
(PM&R or Neuro diagnostics) if symptoms have not resolved within 6 weeks
or if there has been no response to treatment.
- Continue NSAID and splint
Indications for Specialty Care Referral
- For cubital tunnel
syndrome refer to Occupational Therapy (OT) for night elbow splints.
- If the patient exhibits
no relief of pain, sensory changes, decreases in AROM or strength to the
upper extremity within 3-4 weeks, refer to OT for evaluation and treatment.
- Chronic CTS or cubital
tunnel syndrome with symptoms >6months can be referred to OT for evaluation
- If the patient has
completed a full course of treatment through OT and referred back to
primary care with no improvement, referral to Orthopedic Surgery is
- Orthopedic Hand Clinic
referral is indicated if a sensory (2 point discrimination >5mm) or motor
deficit is demonstrated in patients with CTS.
Criteria for Return to Primary Care
- Resolution of symptoms.
- Chronic condition that
can be managed at primary care level with intermittent specialty care
evaluation/intervention as needed.