OSCE Orthopedics: Carpal Tunnel Syndrome (CTS) and Rule out Cervical Radiculopathy (Cervical Spinal Nerve Roots Syndrome)

Carpal Tunnel Syndrome (CTS)

1. Patient Introduction and Communication (10 points)

1. Introduce Yourself: Politely introduce yourself to the patient and state your role.
2. Confirm Patient’s Identity: Ask for the patient’s name to confirm identity.
3. Explain the Examination Process: Briefly explain that you will be performing a physical examination to assess hand and wrist function and will be testing for carpal tunnel syndrome.

2. Physical Examination (85 points total)

Inspection (10 points)

• Thenar Atrophy: Look for signs of muscle wasting in the thenar eminence, which is a common sign of advanced CTS due to median nerve compression.
• Deformity or Swelling: Observe for any hand or wrist deformity, swelling, or color changes that might indicate inflammation or an alternative pathology.

Palpation (5 points)

• Temperature and Swelling: Palpate the wrist and hand, particularly over the carpal tunnel region, to assess for warmth and swelling, which may indicate inflammation.

Movement Assessment (5 points)

• Range of Motion (ROM): Test the range of motion in the wrist and each digit joint (MCP, PIP, DIP) to rule out limitations caused by pain or stiffness.

Motor Function (20 points)

• Median Nerve:
  • Abductor Pollicis Brevis (APB) Testing: Test motor power by asking the patient to abduct the thumb against resistance. Weakness is common in CTS.
• Ulnar Nerve:
  • First Dorsal Interosseous and Abductor Digiti Minimi Testing: Ask the patient to spread the fingers apart against resistance (tests for ulnar nerve innervation).
• Radial Nerve:
  • Wrist Extension Strength: Test wrist extension strength against resistance, as the radial nerve innervates the extensors.

Sensory Examination (20 points)

• Median Nerve Distribution: Use a 2-point discrimination test or Semmes-Weinstein monofilament test over the palmar surface of the thumb, index, and middle fingers.
• Ulnar Nerve Distribution: Test sensation over the ring and little fingers.
• Radial Nerve Distribution: Test sensation on the dorsum of the hand, particularly the thumb’s back side.

Circulation (10 points)

• Pulse Check: Check the radial pulse on both hands to assess circulation.
• Capillary Refill Time (CRT): Perform CRT by pressing the nail bed and observing the time for color return (normal is <2 seconds).

Reflex Testing (5 points)

• Biceps Reflex (C5-C6): Test the biceps reflex as part of the brachial plexus assessment.
• Triceps Reflex (C7): Test the triceps reflex, which could be informative if there is suspected cervical involvement.

3. Special Tests for Carpal Tunnel Syndrome (30 points)

• Tinel’s Sign: Tap over the carpal tunnel. A positive sign reproduces tingling or pain in the median nerve distribution.
• Phalen’s Test: Ask the patient to press the backs of their hands together in full flexion. A positive result reproduces symptoms within 60 seconds.
• Median Nerve Compression: Apply pressure over the carpal tunnel region to check if this produces numbness or tingling.

4. Differential Diagnosis Tests (20 points)

• Pronator Teres Syndrome: Test for resistance to forearm pronation, which can reproduce median nerve symptoms proximal to the wrist.
• Thoracic Outlet Syndrome: Perform Adson’s maneuver; a positive test indicates reduced radial pulse or symptom reproduction due to neurovascular compression.
• Cervical Radiculopathy: Use the Spurling maneuver; cervical radiculopathy can cause radiating pain or weakness similar to CTS.

5. Diagnosis (15 points)

• Diagnosis of CTS: Based on examination findings (e.g., positive Phalen’s and Tinel’s signs, thenar atrophy), make a diagnosis of CTS and specify the affected side.

Differential Diagnoses and Comparative Features

1. Pronator Teres Syndrome:
   • Key Test: Resisting forearm pronation causes pain.
   • Differences: Symptoms are typically in the median nerve area but may not worsen at night like CTS.
2. Thoracic Outlet Syndrome:
   • Key Test: Adson’s maneuver; symptom reproduction or pulse reduction.
   • Differences: Involves neurovascular symptoms; can affect the whole arm.
3. Cervical Radiculopathy:
   • Key Test: Spurling’s maneuver; may involve more extensive dermatome areas than CTS.
   • Differences: Symptoms can include pain radiating from the neck, affecting upper limb dermatomes beyond the median nerve.
4. Other Considerations:
   • Cubital Tunnel Syndrome: Numbness in the ulnar distribution.
   • De Quervain’s Tenosynovitis: Radial wrist pain; positive Finkelstein’s test.
   • Basal Thumb Arthritis: Pain at thumb base, positive grind test for arthritis.

By following this structured approach and ensuring completeness in each step, this format will maximize both accuracy and scoring in a Carpal Tunnel Syndrome OSCE assessment.

---

Cervical Radiculopathy (Cervical Spinal Nerve Roots Syndrome) 1. Patient Introduction and Communication (10 points)

1. Introduce Yourself: Greet the patient, introduce yourself, and explain your role.
2. Confirm Patient Identity: Confirm the patient’s name for correct identification.
3. Explain the Examination: Inform the patient that you’ll perform a physical exam of the neck and arms to assess any nerve-related pain or weakness.

2. Physical Examination (85 points total)

Inspection (10 points)

• Postural Alignment: Observe the patient’s posture, including head and neck position. Note any tilting, guarding, or abnormal postures that might indicate nerve root irritation.
• Muscle Wasting: Check for muscle atrophy in the shoulders and upper arms, especially if symptoms have been chronic.

Palpation (5 points)

• Tenderness along Cervical Spine: Palpate the cervical spine from C3 to C7 for tenderness or spasm, which may indicate nerve root or joint inflammation.
• Paraspinal Muscle Spasm: Check for tightness or spasm along the cervical paraspinal muscles.

Range of Motion (ROM) Testing (5 points)

• Cervical Spine Movements: Test the neck's range of motion by asking the patient to flex, extend, rotate, and laterally bend the neck. Note any limitations or pain.

Motor and Sensory Function (20 points)

Motor Examination for Cervical Nerve Roots

• C5: Test shoulder abduction by asking the patient to raise their arm against resistance.
• C6: Test wrist extension strength.
• C7: Test elbow extension and wrist flexion.
• C8: Test finger flexion.
• T1: Test finger abduction.

Sensory Examination for Cervical Nerve Roots

• C5: Lateral shoulder (deltoid area).
• C6: Lateral forearm and thumb.
• C7: Middle finger.
• C8: Little finger and medial forearm.
• T1: Medial arm near the elbow.

Reflexes (10 points)

• C5-C6 (Biceps Reflex): Test the biceps reflex.
• C6 (Brachioradialis Reflex): Test the brachioradialis reflex.
• C7 (Triceps Reflex): Test the triceps reflex.

3. Special Tests for Cervical Radiculopathy (30 points)

Spurling’s Compression Test (15 points)

• Procedure: With the patient seated, ask them to extend, laterally bend, and rotate their neck toward the symptomatic side. Then apply downward pressure on the head.
• Interpretation: A positive Spurling’s test reproduces radicular pain, indicating nerve root compression.

Shoulder Abduction (Relief) Test (15 points)

• Procedure: Instruct the patient to place their hand on the top of their head. This maneuver often relieves symptoms of cervical radiculopathy by reducing nerve tension.
• Interpretation: A positive result is a reduction in symptoms, supporting the diagnosis of cervical radiculopathy.

4. Differential Diagnosis Tests (20 points)

1. Adson’s Test (Thoracic Outlet Syndrome): Ask the patient to extend their neck and turn the head toward the side of the symptoms while taking a deep breath. A positive test indicates decreased radial pulse or reproduction of symptoms due to compression.
2. Lhermitte’s Sign (Cervical Myelopathy): Ask the patient to flex the neck forward. A positive sign is an electric shock sensation down the spine or limbs, indicating possible cervical spinal cord compression.
3. Tinel’s Sign at the Elbow: Tap over the ulnar nerve at the elbow to assess for ulnar nerve compression (Cubital Tunnel Syndrome).

5. Diagnosis (15 points)

• Diagnosis of Cervical Radiculopathy: Make a diagnosis based on physical findings, such as a positive Spurling’s test, positive Shoulder Abduction Test, and consistent dermatomal sensory and motor findings. Specify the affected nerve root(s).

Differential Diagnoses and Comparative Features

1. Thoracic Outlet Syndrome (TOS):
   • Key Test: Positive Adson’s test with symptom reproduction.
   • Differences: TOS involves neurovascular compression, affecting the entire upper limb rather than specific dermatomes.
2. Cervical Myelopathy:
   • Key Test: Lhermitte’s sign; electric shock sensation upon neck flexion.
   • Differences: Involves spinal cord compression, leading to both upper and lower limb symptoms, unlike cervical radiculopathy.
3. Cubital Tunnel Syndrome:
   • Key Test: Positive Tinel’s sign at the elbow.
   • Differences: Involves ulnar nerve distribution (ring and little fingers), rather than the cervical dermatomes.
4. Carpal Tunnel Syndrome (CTS):
   • Key Test: Positive Phalen’s or Tinel’s sign at the wrist.
   • Differences: CTS affects the median nerve at the wrist, leading to sensory and motor deficits in the hand only.

Splinting in Cervical Radiculopathy

While cervical radiculopathy itself does not commonly require splinting, neck collars or soft cervical collars may be used temporarily in severe cases to reduce movement and alleviate symptoms. Here’s an outline for when and how to use a cervical collar:

1. Indications for Cervical Collar Use:
   • Acute neck pain with significant radicular symptoms.
   • Post-surgery or post-injury, as per physician instructions.
   • To limit neck movement temporarily in severe flare-ups.
2. Application and Guidelines:
   • Soft Cervical Collar: This type of collar provides mild support and restricts excessive motion. Instruct patients to wear it intermittently for short periods (e.g., a few hours per day) and only as needed.
   • Hard Collar (Philadelphia Collar): Used in cases where more substantial immobilization is needed, often post-surgery or after an injury. It is generally avoided for cervical radiculopathy unless recommended by a specialist.
3. Patient Education:
   • Emphasize that collar use is only a temporary measure.
   • Encourage gradual removal of the collar to prevent neck muscle weakening.
   • Educate patients on neck strengthening and posture exercises for long-term relief.