A Prospective Study of the Forensic Implications of Carpal Tunnel Syndrome in Relation to Radiological and Orthopaedic Evaluation

Abstract

Background: The most prevalent entrapment neuropathy of the upper limb is Carpal tunnel syndrome (CTS) which is a prominent source of hand pain, numbness disorder, impaired functions and occupational disability. Clinical examination and objective investigations should be combined to obtain an accurate diagnosis especially in the patients who are being evaluated due to a disability and in medico-legal assessment. Radiological imaging and electrodiagnostic tests are becoming crucial in the diagnosis confirmation, identification of disease severity and scope of functional deficit. To determine the forensic relevance of carpal tunnel syndrome by comparing the orthopaedic examination data with the radiological and electrodiagnostic data among individuals who present with clinically suspected CTS.

Methods: This observational prospective study was done in the Orthopaedic surgery, Radiology, physical medicine and rehabilitation and forensic medicine departments of the Lahore general hospital, Lahore, over the course of 12 months. A consecutive non-probability sampling was used to enroll 120 consecutive patients, with a clinical suspicion of CTS. The patients were all subjected to extensive clinical examination conducted as Phalen test, Tinel sign, Durkan compression test, motor and sensory examination, and nerve conduction test. All patients were subjected to radiological assessment with plain radiography of the wrists and high-resolution ultrasonography, and magnetic resonance imaging (MRI) in some complicated cases. The analysis of data has been performed with SPSS 26. Continuous variables were in the form of mean + SD and categorical variables were in the form of frequencies and percentages. When appropriate, one-way analysis of variance (ANOVA), Chi-square and correlation analysis were used. A p-value of less than 0.05 was deemed as statistically significant.

Results: Of 120 patients, 74 (61.7%) were women and that of 40-49 years was the largest (36.7%). Repetitive manual work (35.0%) and clerical/computer work (28.3%) were the most common occupations. The most common presenting symptoms were nocturnal paresthesia (85.0%), numbness of the median nerve area (80.0%), and pain at the wrist (78.3%). The compression test, conducted by Durkan, was the most positive (82.5%), followed by the test conducted by Phalen (78.3%), and the sign of Tinel (73.3%). In 33.4 percent of the patients who received ultrasonography, there was a median nerve cross-sectional area of ≥15 mm 2 whereas palmar bowing and high flattening ratio was observed in 58.3 percent and 53.3 percent respectively. Electrodiagnostic severity significantly correlated positively with the duration of symptoms, cross-sectional area of the median nerve, thenar weakness, radiographic changes and work-related disability (all p<0.001). Medico-legal concordance between clinical observations, electrodiagnostic, and imaging studies was found to be high (65.0% in patients) and probable permanent partial impairment was (21.7) found in patients.

Conclusion: Multidisciplinary assessment involving orthopaedic examination, electrodiagnostic testing and radiological imaging is a reliable and objective methods of diagnosing carpal tunnel syndrome and severity measurement of the disease. Ultrasonography was found to be closely correlated with results of electrodiagnostic, and the radiological test was also valuable as further evidence of structural abnormalities to consider in the context of secondary CTS. The high scores of correspondence between the clinical, electrophysiological, and imaging findings support the application of integrated assessment to the discrimination of disability and medico-legal practice. This practice is more effective in enhancing accuracy of diagnosis, objective assessment of impairment of functional activity, and in boosting forensic judgment in patients with suspected carpal tunnel syndrome.