Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a medical condi- 1 Signs and symptoms

tion due to compression of the median nerve as it travels
through the wrist at the carpal tunnel.[1] The main symp-
toms are pain, numbness, and tingling, in the thumb, in-
dex nger, middle nger, and the thumb side of the ring
ngers.[1] Symptoms typically start gradually and during
the night.[2] Pain may extend up the arm.[2] Weak grip
strength may occur and after a long period of time the
muscles at the base of the thumb may waste away.[2] In
more than half of cases both sides are aected.[1]
Risk factors include obesity, repetitive wrist work,
pregnancy, and rheumatoid arthritis.[3][4] There is tenta-
tive evidence that hypothyroidism increases the risk.[5] It
is unclear if diabetes plays a role. The use of birth control
pills does not aect the risk. Types of work that are asso-
ciated include computer work, work with vibrating tools,
and work that requires a strong grip.[3] Diagnosis is sus-
pected based on signs, symptoms, and specic physical Untreated carpal tunnel syndrome, showing how the muscles at
tests and may be conrmed with electrodiagnostic tests.[2] the base of the thumb have wasted away.
If muscle wasting at the base of the thumb is present, the
People with CTS experience numbness, tingling, or burn-
diagnosis is likely.[3]
ing sensations in the thumb and ngers, in particular the
Being physically active can decrease the risk of develop- index and middle ngers and radial half of the ring n-
ing CTS. Symptoms can be improved by wearing a wrist ger, because these receive their sensory and motor func-
splint or with corticosteroid injections. Taking NSAIDs tion (muscle control) from the median nerve. Ache and
or gabapentin does not appear to be useful. Surgery to discomfort can possibly be felt more proximally in the
cut the transverse carpal ligament is eective with better forearm or even the upper arm.[8] Less-specic symp-
results at a year compared to non surgical options. Fur- toms may include pain in the wrists or hands, loss of grip
ther splinting after surgery is not needed. Evidence does strength,[9] and loss of manual dexterity.[10]
not support magnet therapy.[3]
Some suggest that median nerve symptoms can arise from
About 5% of people in the United States have carpal compression at the level of the thoracic outlet or the area
tunnel syndrome.[6] It usually begins in adulthood and where the median nerve passes between the two heads
women are more commonly aected than men.[2] Up to of the pronator teres in the forearm,[11] although this is
33% of people may improve without specic treatment debated.
over approximately a year.[1] Carpal tunnel syndrome was
Numbness and paresthesias in the median nerve dis-
rst fully described after World War II.[7]
tribution are the hallmark neuropathic symptoms (NS)
of carpal tunnel entrapment syndrome. Weakness and
atrophy of the thumb muscles may occur if the condition
remains untreated, because the muscles are not receiv-
ing sucient nerve stimulation.[12] Discomfort is usually
worse at night and in the morning.[13]

2 Causes
Most cases of CTS are of unknown cause.[14] Carpal tun-
nel syndrome can be associated with any condition that
Video explanation causes pressure on the median nerve at the wrist. Some
common conditions that can lead to CTS include obe-

1
2 2 CAUSES

2.1 Work related

The international debate regarding the relationship be-

tween CTS and repetitive motion in work is ongo-
ing. The Occupational Safety and Health Administra-
tion (OSHA) has adopted rules and regulations regard-
ing cumulative trauma disorders. Occupational risk fac-
tors of repetitive tasks, force, posture, and vibration have
been cited. The relationship between work and CTS
is controversial; in many locations, workers diagnosed
with carpal tunnel syndrome are entitled to time o and
compensation.[28][29]
Some speculate that carpal tunnel syndrome is pro-
voked by repetitive movement and manipulating activi-
ties and that the exposure can be cumulative. It has also
been stated that symptoms are commonly exacerbated by
forceful and repetitive use of the hand and wrists in in-
dustrial occupations,[30] but it is unclear as to whether this
Anatomy of the carpal tunnel showing the median nerve passing refers to pain (which may not be due to carpal tunnel syn-
through the tight space it shares with the nger tendons. drome) or the more typical numbness symptoms.[31]
A review of available scientic data by the National In-
stitute for Occupational Safety and Health (NIOSH) in-
dicated that job tasks that involve highly repetitive man-
ual acts or specic wrist postures were associated with
incidents of CTS, but causation was not established,
sity, hypothyroidism, arthritis, diabetes, prediabetes (im- and the distinction from work-related arm pains that are
paired glucose tolerance), and trauma.[15] Genetics play a not carpal tunnel syndrome was not clear. It has been
role.[16] The use of birth control pills does not aect the proposed that repetitive use of the arm can aect the
risk.[3] Carpal tunnel is a feature of a form of Charcot- biomechanics of the upper limb or cause damage to tis-
Marie-Tooth syndrome type 1 called hereditary neuropa- sues. It has also been proposed that postural and spinal
thy with liability to pressure palsies. assessment along with ergonomic assessments should be
included in the overall determination of the condition.
Other causes of this condition include intrinsic factors Addressing these factors has been found to improve com-
that exert pressure within the tunnel, and extrinsic fac- fort in some studies.[32] A 2010 survey by NIOSH showed
tors (pressure exerted from outside the tunnel), which that 2/3 of the 5 million carpal tunnel cases in the US that
include benign tumors such as lipomas, ganglion, and year were related to work.[33] Women have more work-
vascular malformation.[17] Carpal tunnel syndrome of- related carpal tunnel syndrome than men.[34]
ten is a symptom of transthyretin amyloidosis-associated
polyneuropathy and prior carpal tunnel syndrome surgery Speculation that CTS is work-related is based on claims
is very common in individuals who later present with such as CTS being found mostly in the working adult
transthyretin amyloid-associated cardiomyopathy, sug- population, though evidence is lacking for this. For
gesting that transthyretin amyloid deposition may cause instance, in one recent representative series of a con-
carpal tunnel syndrome.[18][19][20][21][22][23][24] secutive experience, most patients were older and not
working.[35] Based on the claimed increased incidence
The median nerve can usually move up to 9.6 mm in the workplace, arm use is implicated, but the weight
to allow the wrist to ex, and to a lesser extent dur- of evidence suggests that this is an inherent, genetic,
ing extension.[25] Long-term compression of the median slowly but inevitably progressive idiopathic peripheral
nerve can inhibit nerve gliding, which may lead to injury mononeuropathy.[36]
and scarring. When scarring occurs, the nerve will adhere
to the tissue around it and become locked into a xed po-
sition, so that less movement is apparent.[26] 2.2 Associated conditions
Normal pressure of the carpal tunnel has been dened
as a range of 210 mm, and wrist exion increases this A variety of patient factors can lead to CTS, including
pressure 8-fold, while extension increases it 10-fold.[25] heredity, size of the carpal tunnel, associated local and
Repetitive exion and extension in the wrist signicantly systematic diseases, and certain habits.[37] Non-traumatic
increase the uid pressure in the tunnel through thicken- causes generally happen over a period of time, and are not
ing of the synovial tissue that lines the tendons within the triggered by one certain event. Many of these factors are
carpal tunnel.[27] manifestations of physiologic aging.[38]
 3

Examples include: The carpal tunnel is an anatomical compartment located

at the base of the palm. Nine exor tendons and the
Rheumatoid arthritis and other diseases that cause median nerve pass through the carpal tunnel that is sur-
inammation of the exor tendons. rounded on three sides by the carpal bones that form an
arch. The median nerve provides feeling or sensation to
With hypothyroidism, generalized myxedema the thumb, index nger, long nger, and half of the ring
causes deposition of mucopolysaccharides within nger. At the level of the wrist, the median nerve sup-
both the perineurium of the median nerve, as well plies the muscles at the base of the thumb that allow it
as the tendons passing through the carpal tunnel. to abduct, move away from the other four ngers, as well
as move out of the plane of the palm. The carpal tun-
During pregnancy women experience CTS due to nel is located at the middle third of the base of the palm,
hormonal changes (high progesterone levels) and bounded by the bony prominence of the scaphoid tubercle
water retention (which swells the synovium), which and trapezium at the base of the thumb, and the hamate
are common during pregnancy. hook that can be palpated along the axis of the ring nger.
From the anatomical position, the carpal tunnel is bor-
Previous injuries including fractures of the wrist. dered on the anterior surface by the transverse carpal lig-
Medical disorders that lead to uid retention or ament, also known as the exor retinaculum. The exor
are associated with inammation such as: inam- retinaculum is a strong, brous band that attaches to the
matory arthritis, Colles fracture, amyloidosis, hy- pisiform and the hamulus of the hamate. The proximal
pothyroidism, diabetes mellitus, acromegaly, and boundary is the distal wrist skin crease, and the distal
use of corticosteroids and estrogens. boundary is approximated by a line known as Kaplans
cardinal line.[43] This line uses surface landmarks, and
Carpal tunnel syndrome is also associated with is drawn between the apex of the skin fold between the
repetitive activities of the hand and wrist, in partic- thumb and index nger to the palpated hamate hook.[44]
ular with a combination of forceful and repetitive The median nerve can be compressed by a decrease in
activities[15] the size of the canal, an increase in the size of the con-
tents (such as the swelling of lubrication tissue around the
Acromegaly causes excessive growth hormones. exor tendons), or both.[45] Since the carpal tunnel is bor-
This causes the soft tissues and bones around the dered by carpal bones on one side and a ligament on the
carpel tunnel to grow and compress the median other, when the pressure builds up inside the tunnel, there
nerve.[39] is nowhere for it to escape and thus it ends up pressing up
against and damaging the median nerve. Simply exing
Tumors (usually benign), such as a ganglion or a the wrist to 90 degrees will decrease the size of the canal.
lipoma, can protrude into the carpal tunnel, reduc-
ing the amount of space. This is exceedingly rare Compression of the median nerve as it runs deep to the
(less than 1%). transverse carpal ligament (TCL) causes atrophy of the
thenar eminence, weakness of the exor pollicis brevis,
Obesity also increases the risk of CTS: individuals opponens pollicis, abductor pollicis brevis, as well as sen-
classied as obese (BMI > 29) are 2.5 times more sory loss in the digits supplied by the median nerve. The
likely than slender individuals (BMI < 20) to be di- supercial sensory branch of the median nerve, which
agnosed with CTS.[40] provides sensation to the base of the palm, branches prox-
imal to the TCL and travels supercial to it. Thus, this
Double-crush syndrome is a debated hypothesis that branch spared in carpal tunnel syndrome, and there is no
compression or irritation of nerve branches con- loss of palmar sensation.[46]
tributing to the median nerve in the neck, or any-
where above the wrist, increases sensitivity of the
nerve to compression in the wrist. There is little ev-
idence, however, that this syndrome really exists.[41] 4 Diagnosis

Heterozygous mutations in the gene SH3TC2, as-

sociated with Charcot-Marie-Tooth, confer suscep- There is no consensus reference standard for the di-
tibility to neuropathy, including the carpal tunnel agnosis of carpal tunnel syndrome. A combina-
syndrome. [42] tion of described symptoms, clinical ndings, and
electrophysiological testing may be used. CTS work up
is the most common referral to the electrodiagnostic lab.
Historically, diagnosis has been made with the combi-
3 Pathophysiology nation of a thorough history and physical examination
in conjunction with the use of electrodiagnostic (EDX)
Main article: Carpal tunnel testing for conrmation. Additionally, evolving technol-
ogy has included the use of ultrasonography in the diag-
4 4 DIAGNOSIS

nosis of CTS. However, it is well established that physi- by lightly tapping the skin over the exor retinac-
cal exam provocative maneuvers lack both sensitivity and ulum to elicit a sensation of tingling or pins and
specicity. Furthermore, EDX cannot fully exclude the needles in the nerve distribution. Tinels sign (pain
diagnosis of CTS due to the lack of sensitivity. A Joint and/or paresthesias of the median-innervated ngers
report published by the American Association of Neuro- with percussion over the median nerve) is less sensi-
muscular and Electrodiagostic Medicine (AANEM), the tive, but slightly more specic than Phalens sign.[37]
American Academy of Physical Medicine and Rehabili-
tation (AAPM&R) and the American Academy of Neu- Durkan test, carpal compression test, or applying
rology denes practice parameters, standards and guide- rm pressure to the palm over the nerve for up
lines for EDX studies of CTS based on an extensive crit- to 30 seconds to elicit symptoms has also been
ical literature review. This joint review concluded me- proposed.[50][51]
dian and sensory nerve conduction studies are valid and
reproducible in a clinical laboratory setting and a clinical
Hand elevation test The hand elevation test is per-
diagnosis of CTS can be made with a sensitivity greater
formed by lifting both hands above the head, and
than 85% and specicity greater than 95%. Given the key
if symptoms are reproduced in the median nerve
role of electrodiagnostic testing in the diagnosis of CTS,
distribution within 2 minutes, considered positive.
The American Association of Neuromuscular & Electro-
The hand elevation test has higher sensitivity and
diagnostic Medicine has issued evidence-based practice
specicity than Tinels test, Phalens test, and carpal
guidelines, both for the diagnosis of carpal tunnel syn-
compression test. Chi-square statistical analysis has
drome.
shown the hand elevation test to be as eective, if
Numbness in the distribution of the median nerve, noc- not better than, Tinels test, Phalens test, and carpal
turnal symptoms, thenar muscle weakness/atrophy, pos- compression test.[52]
itive Tinels sign at the carpal tunnel, and abnormal sen-
sory testing such as two-point discrimination have been
standardized as clinical diagnostic criteria by consensus As a note, a patient with true carpal tunnel syndrome
panels of experts.[47][48] Pain may also be a presenting (entrapment of the median nerve within the carpal tun-
symptom, although less common than sensory distur- nel) will not have any sensory loss over the thenar emi-
bances. nence (bulge of muscles in the palm of hand and at the
base of the thumb). This is because the palmar branch
Electrodiagnostic testing (electromyography and nerve of the median nerve, which innervates that area of the
conduction velocity) can objectively verify the median palm, branches o of the median nerve and passes over
nerve dysfunction. Normal nerve conduction studies, the carpal tunnel.[53] This feature of the median nerve can
however, do not exclude the diagnosis of CTS. Clinical help separate carpal tunnel syndrome from thoracic outlet
assessment by history taking and physical examination syndrome, or pronator teres syndrome.
can support a diagnosis of CTS. If clinical suspicion of
CTS is high, treatment should be initiated despite normal Other conditions may also be misdiagnosed as carpal
electrodiagnostic testing. tunnel syndrome. Thus, if history and physical exam-
ination suggest CTS, patients will sometimes be tested
electrodiagnostically with nerve conduction studies and
electromyography. The goal of electrodiagnostic test-
4.1 Physical exam
ing is to compare the speed of conduction in the me-
dian nerve with conduction in other nerves supplying the
The use of Phalen test, Tinel sign, Flick sign, or upper
hand. When the median nerve is compressed, as in CTS,
limb nerve test alone is not sucient for diagnosis.[3]
it will conduct more slowly than normal and more slowly
than other nerves. There are many electrodiagnostic tests
Phalens maneuver is performed by exing the wrist used to make a diagnosis of CTS, but the most sensi-
gently as far as possible, then holding this position tive, specic, and reliable test is the Combined Sensory
and awaiting symptoms.[49] A positive test is one that Index (also known as Robinson index).[54] Electrodiag-
results in numbness in the median nerve distribu- nosis rests upon demonstrating impaired median nerve
tion when holding the wrist in acute exion position conduction across the carpal tunnel in context of normal
within 60 seconds. The quicker the numbness starts, conduction elsewhere. Compression results in damage
the more advanced the condition. Phalens sign is to the myelin sheath and manifests as delayed latencies
dened as pain and/or paresthesias in the median- and slowed conduction velocities [37] However, normal
innervated ngers with one minute of wrist exion. electrodiagnostic studies do not preclude the presence of
Only this test has been shown to correlate with CTS carpal tunnel syndrome, as a threshold of nerve injury
severity when studied prospectively.[37] must be reached before study results become abnormal
and cut-o values for abnormality are variable.[48] Carpal
Tinels sign, a classic though less sensitive - test is tunnel syndrome with normal electrodiagnostic tests is
a way to detect irritated nerves. Tinels is performed very, very mild at worst.
 5

The role of MRI or ultrasound imaging in the diagnosis of Stretches and isometric exercises will aid in prevention
carpal tunnel syndrome is unclear.[55][56][57] Their routine for persons at risk. Stretching before the activity and dur-
use is not recommended.[3] ing breaks will aid in alleviating tension at the wrist.[62]
Place the hand rmly on a at surface and gently press for
a few seconds to stretch the wrist and ngers. An example
4.2 Dierential diagnosis for an isometric exercise of the wrist is done by clench-
ing the st tightly, releasing and fanning out ngers.[62]
Carpal tunnel syndrome is sometimes applied as a label None of these stretches or exercises should cause pain or
to anyone with pain, numbness, swelling, and/or burning discomfort.
in the radial side of the hands and/or wrists. When pain Biological factors such as genetic predisposition and an-
is the primary symptom, carpal tunnel syndrome is un- thropometric features had signicantly stronger causal
likely to be the source of the symptoms.[31] As a whole, association with carpal tunnel syndrome than occupa-
the medical community is not currently embracing or ac- tional/environmental factors such as repetitive hand use
cepting trigger point theories due to lack of scientic ev- and stressful manual work.[60] This suggests that carpal
idence supporting their eectiveness. tunnel syndrome might not be preventable simply by
avoiding certain activities or types of work/activities.

5 Prevention
6 Treatment
Generally accepted treatments include: physiotherapy,
steroids either orally or injected locally, splinting, and
surgical release of the transverse carpal ligament.[63]
There is insucient evidence for ultrasound, yoga, lasers,
vitamin B6, and exercise.[63] Change in activity may in-
clude avoiding activities that worsen symptoms.[16]
The American Academy of Orthopedic Surgeons rec-
ommends proceeding conservatively with a course of
nonsurgical therapies tried before release surgery is
considered.[64] A dierent treatment should be tried if
the current treatment fails to resolve the symptoms within
2 to 7 weeks. Early surgery with carpal tunnel re-
lease is indicated where there is evidence of median
nerve denervation or a person elects to proceed directly
to surgical treatment.[64] Recommendations may dier
when carpal tunnel syndrome is found in association with
the following conditions: diabetes mellitus, coexistent
cervical radiculopathy, hypothyroidism, polyneuropathy,
pregnancy, rheumatoid arthritis, and carpal tunnel syn-
drome in the workplace.[64]

6.1 Splints
Carpal tunnel prevention stretch

Suggested healthy habits such as avoiding repetitive

stress, work modication through use of ergonomic
equipment (mouse pad, taking proper breaks, using key-
board alternatives (digital pen, voice recognition, and dic-
tation), and have been proposed as methods to help pre-
vent carpal tunnel syndrome. The potential role of B-
vitamins in preventing or treating carpal tunnel syndrome
has not been proven.[58][59]
There is little or no data to support the concept that activ-
ity adjustment prevents carpal tunnel syndrome.[60] The
evidence for wrist rest is debated.[61] A rigid splint can keep the wrist straight
6 7
A dierent type of rigid splint used in carpal tunnel syndrome.
The importance of wrist braces and splints in the carpal
tunnel syndrome therapy is known, but many people
are unwilling to use braces. In 1993, The American
Academy of Neurology recommend a non-invasive treat-
ment for the CTS at the beginning (except for sensitive
or motor decit or grave report at EMG/ENG): a ther-
apy using splints was indicated for light and moderate
pathology.[65] Current recommendations generally don't
suggest immobilizing braces, but instead activity modi-
cation and non-steroidal anti-inammatory drugs as ini-
tial therapy, followed by more aggressive options or spe-
cialist referral if symptoms do not improve.[66][67]
Many health professionals suggest that, for the best re-
sults, one should wear braces at night and, if possi-
ble, during the activity primarily causing stress on the
wrists.[68][69]
6.2 Corticosteroids
Corticosteroid injections can be eective for temporary
relief from symptoms while a person develops a long-
term strategy that ts their lifestyle.[70] The injections are
done under local ansthesia.[71][72] This treatment is not
appropriate for extended periods, however. In general,
local steroid injections are only used until other treatment
options can be identied.
6.3 Surgery
Main article: Carpal tunnel surgery
Release of the transverse carpal ligament is known
as carpal tunnel release surgery. It is recom-
mended when there is static (constant, not just in-
termittent) numbness, muscle weakness, or atrophy,
and when night-splinting or other conservative interven-
tions no longer control intermittent symptoms.[73] The
surgery may be done with local[74][75][76] or regional
anesthesia[77][78] with[79] or without[75] sedation, or un-
der general anesthesia.[76][78][80] In general, milder cases
can be controlled for months to years, but severe cases
are unrelenting symptomatically and are likely to result
in surgical treatment.[81]
PROGNOSIS
Carpal Tunnel Syndrome Operation
Surgery is more benecial in the short term to alleviate
symptoms (up to six months) than wearing an orthosis for
a minimum of 6 weeks. However, surgery and wearing a
brace resulted in similar symptom relief in the long term
(12-18 month outcomes).[82]
6.4 Physical therapy
A recent evidence based guideline produced by the
American Academy of Orthopedic Surgeons assigned
various grades of recommendation to physiotherapy
(also called physical therapy) and other nonsurgical
treatments.[83] One of the primary issues with physiother-
apy is that it attempts to reverse (often) years of pathology
inside the carpal tunnel. Practitioners caution that any
physiotherapy such as myofascial release may take weeks
of persistent application to eectively manage carpal tun-
nel syndrome.[84]
Again, some claim that pro-active ways to reduce stress
on the wrists, which alleviates wrist pain and strain, in-
volve adopting a more ergonomic work and life environ-
ment. For example, some have claimed that switching
from a QWERTY computer keyboard layout to a more
optimised ergonomic layout such as Dvorak was com-
monly cited as benecial in early CTS studies, however
some meta-analyses of these studies claim that the evi-
dence that they present is limited.[85][86]
7 Prognosis
Most people relieved of their carpal tunnel symptoms
with conservative or surgical management nd minimal
residual or nerve damage.[87] Long-term chronic carpal
tunnel syndrome (typically seen in the elderly) can result
in permanent nerve damage, i.e. irreversible numb-
ness, muscle wasting, and weakness. Those that undergo
a carpal tunnel release are nearly twice as likely as those
not having surgery to develop trigger thumb in the months
following the procedure.[88]
8.1 Occupational
Scars from carpal tunnel release surgery. Two dierent tech-
niques were used. The left scar is 6 weeks old, the right scar is
2 weeks old. Also note the muscular atrophy of the thenar emi-
nence in the left hand, a common sign of advanced CTS
While outcomes are generally good, certain factors can
contribute to poorer results that have little to do with
nerves, anatomy, or surgery type. One study showed
that mental status parameters or alcohol use yields much
poorer overall results of treatment.[89]
Recurrence of carpal tunnel syndrome after successful
surgery is rare.[90] If a person has hand pain after surgery,
it is most likely not caused by carpal tunnel syndrome.
It may be the case that the illness of a person with hand
pain after carpal tunnel release was diagnosed incorrectly,
such that the carpal tunnel release has had no positive ef-
fect upon the patients symptoms.
8 Epidemiology
Rates of carpal tunnel syndrome by ethnicity. CTS is much more
common in Caucasians.
Carpal tunnel syndrome can aect anyone. It accounts
for about 90% of all nerve compression syndromes.[91]
In the U.S., 5% of people have the eects of carpal
tunnel syndrome. Caucasians have the highest risk of
CTS compared with other races such as non-white South
Africans.[92] Women suer more from CTS than men
with a ratio of 3:1 between the ages of 4560 years.
Only 10% of reported cases of CTS are younger than 30
7
years.[92] Increasing age is a risk factor. CTS is also com-
mon in pregnancy.
8.1 Occupational
As of 2010, 8% of U.S. workers reported ever hav-
ing carpal tunnel syndrome and 4% reported carpal tun-
nel syndrome in the past 12 months. Prevalence rates
for carpal tunnel syndrome in the past 12 months were
higher among females than among males; among work-
ers aged 4564 than among those aged 1844. Overall,
67% of current carpal tunnel syndrome cases among cur-
rent/recent workers were reportedly attributed to work by
health professionals, indicating that the prevalence rate
of work-related carpal tunnel syndrome among workers
was 2%, and that there were approximately 3.1 million
cases of work-related carpal tunnel syndrome among U.S.
workers in 2010. Among current carpal tunnel syndrome
cases attributed to specic jobs, 24% were attributed to
jobs in the manufacturing industry, a proportion 2.5 times
higher than the proportion of current/recent workers em-
ployed in the manufacturing industry, suggesting that jobs
in this industry are associated with an increased risk of
work-related carpal tunnel syndrome.[93]
9 History
The condition known as carpal tunnel syndrome had ma-
jor appearances throughout the years but it was most
commonly heard of in the years following World War
II.[7] Individuals who had suered from this condition
have been depicted in surgical literature for the mid-19th
century.[7] In 1854, Sir James Paget was the rst to re-
port median nerve compression at the wrist in a distal ra-
dius fracture.[94] Following the early 20th century there
were various cases of median nerve compression under-
neath the transverse carpal ligament.[94] Carpal Tunnel
Syndrome was most commonly noted in medical litera-
ture in the early 20th century but the rst use of the term
was noted 1939. Physician Dr. George S. Phalen of the
Cleveland Clinic identied the pathology after working
with a group of patients in the 1950s and 1960s.
10 Notable cases
HRH Prince Philip, husband of Queen Elizabeth
II[95]
Mike Dirnt, bassist with the band Green Day[96]
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8 11
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