GPAtlas🧭 When to suspect
Carpal tunnel syndrome (CTS) is compression of the median nerve as it passes through the carpal tunnel at the wrist, and it is the commonest entrapment neuropathy seen in general practice. Suspect it in any patient describing numbness, tingling or pain in the thumb, index, middle and radial half of the ring finger – the little finger is characteristically spared, because it is supplied by the ulnar nerve, and this single point is one of the most useful discriminators at the bedside.
The hallmark is nocturnal paraesthesia that wakes the patient from sleep and is relieved by shaking the hand (the “flick sign”). Symptoms are bilateral in over half of cases, and pain may radiate proximally up the forearm. As compression advances, intermittent tingling gives way to constant numbness and, eventually, weakness and wasting of the thumb muscles.
The diagnosis is made clinically from this history. The key primary-care task is to grade severity, screen selectively for treatable associations, and decide between a conservative pathway and surgical referral – bearing in mind that up to a third of cases settle spontaneously.
| Severity | Typical features | Action |
|---|---|---|
| Mild | Intermittent tingling/pain; symptoms come and go; no sensory loss or weakness | Conservative – nocturnal splint, activity modification |
| Moderate | More frequent or persistent symptoms, some by day; possible mild sensory blunting; no significant weakness | Conservative ± corticosteroid injection; refer if no benefit by ~3 months |
| Severe | Constant numbness, definite sensory loss, or thumb (thenar) weakness/wasting | Refer for surgical decompression – do not delay |
Source: BSSH · BJGP
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