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.
Key red flags
Rapidly progressive thumb-abduction weakness, finger-abduction weakness, constant dense sensory loss or visible wasting warrants expedited surgical assessment.
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.
Median symptoms are intermittent or mild and objective motor loss is absent.
Key medicines
Carpal-tunnel corticosteroid injectionUnder a trained local protocol, inject one dose such as triamcinolone acetonide 10–20 mg into the carpal tunnel using safe landmark or ultrasound-guided technique, keeping clear of the median nerve and reviewing response before any repeat.
Simple analgesia for associated painIf needed, use paracetamol 500–1000 mg orally at intervals of at least 4–6 hours, maximum 4 g in 24 hours, with a lower maximum in low body weight, frailty, malnutrition or liver risk.