Question
A 58 year old woman presents with numbness in her hand and difficulty with fine tasks such as doing up buttons.
- What is the diagnosis?
- What are the classic examination findings?
- How would you manage this problem?
Answer
Diagnosis
- Thenar wasting of the left hand from long standing, severe carpal tunnel syndrome
- Median nerve compression at the wrist with axonal loss
Examination findings
- Wasting of abductor pollicis brevis and opponens pollicis with weak thumb abduction
- Sensory loss over the radial three and a half digits, sparing the thenar eminence because the palmar cutaneous branch arises proximal to the tunnel
- Positive Tinel sign over the carpal tunnel, Phalen test and Durkan carpal compression test
- Two point discrimination over 6 mm indicates advanced disease
- Examine the neck and forearm to exclude cervical radiculopathy, pronator syndrome and double crush
- Look for diabetes, hypothyroidism, rheumatoid arthritis, pregnancy and previous wrist fracture
Investigations
- Nerve conduction studies confirm the diagnosis and grade severity
- Ultrasound shows an enlarged median nerve or a space occupying lesion
Management
- Thenar wasting indicates axonal loss, so surgical release is advised without delay
- Open carpal tunnel release, dividing the transverse carpal ligament on its ulnar side and protecting the recurrent motor branch
- Endoscopic release is an alternative with faster return to work
- Night symptoms settle quickly, but motor recovery is often incomplete with established wasting
- Opponensplasty, such as the Camitz palmaris longus transfer, for persistent loss of opposition
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.