A 28-year-old dentist consults her physician, complaining ...



Musculoskeletal Case: carpal tunnel syndrome

A 28-year-old dentist consults her physician, complaining that she feels tingling and slight pain in her right hand. The symptoms are localized to her thumb, index, middle and lateral side of her ring finger. The sensations are more intense at night or if she overworks. Recently, she has experienced some weakness in her grasp and finds it more difficult to hold her instruments. Also, movements of her right thumb are not as strong as before.

On examination, there is loss of power on certain movements of the thumb. She has impaired appreciation of light touch and pin pricks to the thumb, index, middle and lateral side of her ring finger, but sensation to her palm is not affected. Pressure and tapping over the flexor retinaculum causes tingling. After a complete examination, the patient is diagnosed with carpal tunnel syndrome.

Questions to consider:

1. What is the carpal tunnel? What is contained in it?

2. Two muscles that are affected by carpal tunnel syndrome are the abductor pollicis brevis and the opponens pollicis. How would you test their function?

3. Physicians used to think this kind of pain was caused by a deficiency in the brachial plexus. If this was the case, what roots or trunks would have to be involved and why is this unlikely to be the cause of the problem? (Consider both sensory and motor deficiencies that this patient has.)

4. What causes the symptoms of carpal tunnel syndrome?

5. Although this patient recovered with rest and physical therapy, some patients do not improve with conservative treatment and opt for surgery. What structures might be endangered by surgery and need to be avoided?

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