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Median neuropathy at the wrist or carpal tunnel syndrome (CTS) is the most common mononeuropathy There are multiple causes of median neuropathy at the wrist, although the vast majority are thought to be related to tenosynovitis of the exor tendons which also occupy the carpal tunnel along with the median nerve (Table 21 13)8,9 Some clinicians restrict the term CTS only to those median neuropathies at the wrist caused by tenosynovitis People with median neuropathy at the wrist usually complain of numbness and tingling of their ngers particularly at night or if they are doing activities with their hands Sometimes the numbness and tingling as well as the pain patients describe extend beyond the territory of the median nerve (eg, these may describe sensory symptoms in the little nger and aching in the forearm as well) The symptoms may be exacerbated by repetitive activity However, the discomfort often occurs at rest and frequently wakes people up at night The painful paresthesiae may be brie y alleviated by shaking the hands, the so-called ick sign 106 Clinical examination may reveal loss of sensation in the median nerve distribution to the ngers Motor function is generally spared unless the injury is severe at which point weakness of atrophy of the thenar muscles is appreciated Tapping over the wrist may elicit increased paresthesias in the ngers (Tinel sign), but this is not very speci c Having the persons maintain their wrists in the exed posture may also exacerbate the discomfort in the ngers (Phalen sign), and this is more speci c for CTS Sonography of the median nerve at the wrist may demonstrate attening of the median nerve at the wrist

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Figure 21 16 Sonograms of a patient with symptomatic carpal tunnel syndrome (A) The median nerve of normal size at the proximal level (7 mm2 ) (B) At the pisiform level the size of the median nerve was larger (12 mm2 ) compared with the proximal level (C) Increased attening of the median nerve at distal level (Reproduced with permission from Altinok T, Baysal O, Karakas HM, et al Ultrasonographic assessment of mild and moderate idiopathic carpal tunnel syndrome Clin Radiol 2004;59(10):916 925, Fig 6, p 923)

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