Synopsis
Localise median nerve compression at the wrist and ulnar nerve compression at the elbow, recognise progressive motor loss and proximal mimics, use electrodiagnosis for the right question, and escalate treatment before irreversible denervation.
- Carpal-tunnel syndrome causes nocturnal or activity-related paraesthesia in thumb, index, middle and radial ring finger, often relieved by shaking; thenar eminence sensation is usually spared.
- Cubital-tunnel syndrome affects the little and ulnar half of the ring finger and may worsen during sleep, telephone use, driving or leaning with the elbow flexed.
- Look for high-yield motor findings: weak abductor pollicis brevis or thumb opposition at the wrist, and weak first dorsal interosseous, finger abduction or key pinch at the elbow.
- First-line investigation is clinical localisation. Provocative tests support but do not rule in or rule out disease alone; always examine neck, reflexes and other nerve territories.
- Nerve-conduction studies with electromyography are the reference physiological tests for severity and localisation when diagnosis is uncertain, motor loss is present or surgery is planned, but urgent decline should not wait.
- First-line mild carpal treatment is a neutral wrist splint at night plus activity adjustment; a corticosteroid injection can provide temporary relief, while decompression is appropriate for severe or persistent disease.
- First-line mild cubital treatment is avoiding prolonged flexion and direct pressure, with night positioning or a towel wrap and nerve-friendly activity change; routine elbow steroid injection is not standard care.
- Refer urgently for progressive weakness, wasting, constant sensory loss or acute traumatic compression; delayed decompression can leave permanent axonal deficit.
Key red flags
Rapidly progressive thumb-abduction weakness, finger-abduction weakness, constant dense sensory loss or visible wasting warrants expedited surgical assessment.
Acute symptoms after wrist or elbow fracture, dislocation, bleeding, cast application or infection require urgent decompression and trauma evaluation.
Pain out of proportion, tense swelling, passive-stretch pain or deteriorating perfusion suggests compartment syndrome and demands emergency surgical review.
Bilateral hand symptoms with gait disturbance, hyperreflexia, sphincter change or widespread weakness raises cervical myelopathy or systemic neuropathy.
A neck-provoked dermatomal syndrome or motor deficit crossing several peripheral nerves requires cervical root or plexus localisation.
Investigation priorities
Map sensory territory and motor loss and distinguish median wrist from ulnar elbow, root, cord and polyneuropathy disease.
Management branches
Intermittent hand paraesthesia occurs without acute trauma, compartment features or rapidly progressive weakness.
- Map affected digits and palmar versus dorsal surfaces and identify provoking wrist, elbow or neck positions.
- Test abductor pollicis brevis, opposition, first dorsal interosseous, finger abduction, key pinch, reflexes and proximal power.
- Examine tunnel sites, thumb base, elbow stability and cervical spine and screen the feet for length-dependent neuropathy.
- Document constant sensory loss, wasting or functional dropping because these features accelerate investigation and referral.
Median symptoms are intermittent or mild and objective motor loss is absent.
- Fit a neutral wrist splint for night use and adjust prolonged wrist extremes or vibrating exposure.
- Review after six to twelve weeks using night waking, sensation and hand function rather than provocation tests alone.
- Consider one local corticosteroid injection for short-term relief when splinting fails, pregnancy creates a temporary driver or surgery is delayed.
- Refer for release if symptoms persist, electrodiagnosis is severe or constant numbness, weakness or wasting develops.