What are the treatment options for paresthesias in the palm of the right hand?

Paresthesias to Palm of Right Hand: Diagnostic and Treatment Approach

The most likely diagnosis is carpal tunnel syndrome, and you should immediately initiate conservative management with nighttime wrist splinting in neutral position combined with activity modification, while simultaneously conducting a focused clinical examination to confirm median nerve compression and rule out alternative diagnoses. 1

Immediate Clinical Assessment

Perform a targeted examination focusing on:

• Median nerve distribution: Confirm paresthesias involve the palmar aspect of the thumb, index, middle fingers, and radial half of the ring finger (sparing the dorsal hand and little finger) 1
• Flick sign: Ask if the patient shakes their hand to relieve symptoms—this is highly specific for carpal tunnel syndrome 1
• Phalen maneuver: Hold wrists in full flexion for 60 seconds; reproduction of symptoms within this time indicates median nerve compression 1
• Median nerve compression test: Apply direct pressure over the carpal tunnel for 30 seconds; symptom reproduction confirms the diagnosis 1
• Thenar muscle atrophy: Check for weakness or wasting of the thumb base muscles, indicating severe disease 1
• Nocturnal symptoms: Determine if paresthesias worsen at night or awaken the patient from sleep—this pattern strongly suggests carpal tunnel syndrome 1

Rule Out Alternative Diagnoses

Examine for red flags requiring urgent evaluation 2, 3:

• Proximal or bilateral symptoms: Suggests polyneuropathy rather than entrapment neuropathy 3
• Rapid progression over days: May indicate Guillain-Barré syndrome or vasculitis requiring immediate specialist referral 3
• Motor weakness predominance: Limb weakness with paresthesias suggests central nervous system pathology 3
• Other cranial nerve involvement: Facial weakness, visual changes, or dysautonomia indicate central pathology 2
• Cervical radiculopathy signs: Neck pain radiating to arm, positive Spurling test, or dermatomal pattern different from median nerve distribution 2

Diagnostic Testing Strategy

For typical carpal tunnel syndrome presentation (nocturnal paresthesias in median nerve distribution with positive Phalen/compression tests), no additional testing is required to initiate conservative treatment. 1

Consider electrodiagnostic studies only if 1:

• Clinical presentation is atypical or diagnosis uncertain
• Symptoms fail to improve after 4-6 months of conservative therapy
• Surgical decompression is being planned (to determine severity and prognosis)

Ultrasonography can confirm nerve entrapment by demonstrating median nerve enlargement, hypoechogenic appearance, and increased intraneural vascularity at the carpal tunnel 3

First-Line Conservative Treatment

Initiate immediately for mild to moderate carpal tunnel syndrome 1:

• Wrist splinting: Neutral position splint worn at night (most critical intervention) 1
• Activity modification: Reduce repetitive hand motions, forceful gripping, and prolonged wrist flexion/extension 1, 4
• Corticosteroid injection: Local injection provides relief for more than one month and delays surgery at one year; consider if symptoms persist beyond 2-4 weeks of splinting 1
• Physical therapy: May provide benefit through nerve gliding exercises and ergonomic training 1
• Therapeutic ultrasound: Some evidence supports its use as adjunctive therapy 1

Treatments to Avoid

Do not prescribe the following—they are ineffective for carpal tunnel syndrome 1:

• NSAIDs (ibuprofen, naproxen)
• Diuretics
• Vitamin B6 supplementation

Surgical Referral Criteria

Refer for surgical decompression if 1:

• Severe carpal tunnel syndrome: Thenar atrophy, constant numbness, or severe electrodiagnostic findings
• Failed conservative therapy: No improvement after 4-6 months of appropriate conservative treatment
• Patient preference: After informed discussion of risks and benefits

Endoscopic and open carpal tunnel release are equally effective, though patients return to work approximately one week earlier with endoscopic technique 1

Common Pitfalls

• Assuming all hand paresthesias are carpal tunnel syndrome: Always examine for cervical radiculopathy, polyneuropathy, or central causes, especially if symptoms are bilateral, proximal, or rapidly progressive 2, 3
• Ordering unnecessary tests: Electrodiagnostic studies are not needed for typical presentations and should be reserved for atypical cases or pre-surgical planning 1
• Prescribing ineffective medications: NSAIDs and vitamin B6 have no proven benefit and waste time and resources 1
• Delaying surgical referral: Patients with severe disease (thenar atrophy, constant numbness) should be referred promptly rather than attempting prolonged conservative therapy 1
• Missing systemic causes: In patients with bilateral symptoms or atypical features, check for diabetes, vitamin B12 deficiency, thyroid disease, or monoclonal gammopathy 3