Unilateral carpal tunnel syndrome and space-occupying lesions

Carpal tunnel syndrome caused by an interosseous ganglion of the lunate

We present a case of a 29-year-old woman with diffuse, unilateral wrist pain and carpal tunnel syndrome secondary to an interosseous ganglion of the lunate and aim to highlight uncommon aetiologies when assessing patients with atypical carpal tunnel symptoms.

Is Carpal Tunnel Release Necessary in High-Energy Distal Fractures of the Radius?

Purpose This study aimed to compare the clinical outcomes of patients who underwent volar plate osteosynthesis for high-energy distal radius fracture (DRFx) and carpal tunnel release (CTR) for acute or subacute carpal tunnel syndrome (CTS) with patients who did not undergo CTR. Methods This study is a retrospective evaluation of all high-energy DRFx treated with volar plate osteosynthesis in a regional hospital between January 2021 and January 2023. All adult patients (≥18 years) who underwent open reduction and internal fixation were included in the study after obtaining approval from the internal review board of our institution. Only patients who underwent plate osteosynthesis of the volar aspect through a modified Henry incision and patients who underwent CTR through a classic separate incision were included in the study. Clinical results include hand dynamometry, visual analog scale (VAS) scores, and physical examination findings of patients who underwent volar plate osteosynthesis because of high-energy DRFx and CTR due to CTS in the acute and subacute periods were retrospectively examined. Results Among the patients who underwent volar plate osteosynthesis because of high-energy DRFx, no statistically significant difference was detected between the hand grip strength and VAS scores of patients who underwent CTR because of acute CTS and subacute CTS at the sixth postoperative week (p>0.05). Conclusion Prophylactic CTR may be performed in the same session in selected cases, such as DRFx caused by a high-energy injury, to establish a scale for DRFx at a high risk of CTS and avoid delays in treatment. CTR for transient CTS detected in the subacute period during outpatient follow-up does not improve clinical outcomes.

Radiological diagnosis of median nerve lipoma: A case report from Palestine

Lipomas are benign neoplasms that develop from adipocyte-rich adipose tissue. They affect up to 2% of the population and make up about 50% of all soft-tissue neoplasms. The most common locations for them to appear asymptomatically are the neck, upper back, proximal limbs, and chest. They typically start off as single, distinct, movable lumps. A 50-year-old man who had pain and edema in his right wrist came to our hospital. The patient's history dates back to 9 years ago, when he first began to complain of swelling in his wrist rest but no discomfort. According to a clinical examination, he has a soft, non-painful bump in his right wrist. After being monitored for 9 years with no change in the size of the tumor on his right wrist, the patient started to experience right hand pain and a weak right grasp. Magnetic resonance imaging is the preferred visualization method for examining hand tumors; it is advised to perform a preoperative complementary ultrasound or magnetic resonance imaging investigation in cases of atypical findings or nonfrequent locations of nerve compression, which are clinically interpreted as idiopathic compression.

Clinical Relevance of Ultrasonographic and Electrophysiological Findings of the Median Nerve in Unilateral Carpal Tunnel Syndrome Patients

Few studies have compared the unaffected and affected sides in the same carpal tunnel syndrome (CTS) patients using ultrasonography and electrophysiological tests. We focused on unilateral idiopathic CTS patients to investigate whether clinical test results differ between the unaffected and affected sides. The bilateral wrist joints of 61 unilateral idiopathic CTS patients were evaluated. The median nerve cross-sectional area of ultrasound image, and latencies of the compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) were measured. The values obtained were compared between the affected and unaffected sides. The diagnostic accuracies of each parameter were assessed, and cut-off values were defined. Significant differences were observed in all parameters between the affected and unaffected sides (p < 0.01). Area under the curve (AUC) values were 0.74, 0.88, and 0.73 for the cross-sectional area, CMAP distal latency, and SNAP distal latency, respectively. Cut-off values were 11.9 mm2, 5.1 ms, and 3.1 ms for the cross-sectional area, CMAP distal latency, and SNAP distal latency, respectively. The most reliable parameter that reflected clinical symptoms was the distal latency of CMAP. Cut-off values for each parameter are considered to be an index for the onset of the clinical symptoms of CTS.

Evaluation of the Transverse Carpal Ligament in Carpal Tunnel Syndrome by Shear Wave Elastography: A Non-Invasive Approach of Diagnosis and Management

OBJECTIVES

The goal of this work is to determine the clinical value of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS) for guiding subsequent treatment.

METHODS

This study analyzed patients who underwent median nerve (MN) ultrasound (US) examination of the wrist from April 2020 to April 2021. The cross-sectional area and anteroposterior diameter of the MN, as well as the TCL thickness and stiffness, were measured from images. The intra-group and intra-patient subgroup differences were compared using a t-test and a rank test. We also utilized receiver operating characteristic (ROC) curves to diagnose CTS and evaluate the severity.

RESULTS

The final cohort consisted of 120 wrists (bilateral) from 60 samples, evenly balanced across the patient and control groups according to their CTS diagnosis. In the unilateral positive patient subgroup, the MN and TCL of the positive hand were significantly thicker and stiffer than the negative counterparts (both, p < 0.05). The values from the right were also thicker and stiffer than the left (both, p < 0.05) in patients with bilateral CTS. The MN and TCL of the patient group were also significantly thicker and stiffer than those of the control group (both, p < 0.001). For diagnosing CTS, the area under the curve (AUC) of TCL thickness and stiffness at the distal carpal tunnel (DCT) ranged between 0.925 and 0.967. For evaluating CTS severity, we found that the optimal TCL stiffness is sufficient for diagnosing mild and non-mild patient cases (AUC: Emean = 0.757, Emax = 0.779).

CONCLUSIONS

Shear wave elastography is therefore an effective method for CTS diagnosis and management.

Neuromuscular ultrasound findings in carpal tunnel syndrome with symptoms mainly in the nondominant hand

BACKGROUND

Carpal tunnel syndrome (CTS) may be associated with structural lesions or anatomical variations at the wrist, especially in patients whose symptoms are more severe in, or limited to, the nondominant hand. The aims of this study were to identify the type and frequency of structural abnormalities and anatomical variations, and to demonstrate the contribution of ultrasound in this subgroup of CTS patients.

METHODS

A retrospective chart review was performed on all patients referred to the electromyography laboratory who fulfilled the diagnostic criteria for CTS and who underwent neuromuscular ultrasound.

RESULTS

Of 114 CTS patients with symptoms mainly in nondominant hand, 51 (44.7%) had structural abnormalities or anatomical variations detected by ultrasound. In multivariable analysis, symptoms mainly in the nondominant hand and a body mass index (BMI) <30 kg/m² were the only independent variables significantly associated with structural findings, odds ratios 2.3 (P < .001) and 1.9 (P = .006), respectively.

CONCLUSIONS

Neuromuscular ultrasound, in addition to electrodiagnostic studies, should be considered in all CTS patients with symptoms more severe in nondominant hand as a significant number have abnormal structural abnormalities or anatomical variations that may be causative or change the therapeutic approach.

Ultrasound Findings in Less Frequent Causes of Carpal Tunnel Syndrome

The most common etiology of carpal tunnel syndrome (CTS) is idiopathic. However, secondary causes of CTS should be considered when symptoms are unilateral, or electrodiagnostic studies are discrepant with the clinical presentation. Imaging of the carpal tunnel should be performed when secondary causes of CTS are suspected. An ultrasound evaluation of the carpal tunnel can assess for pathologic changes of the median nerve, detect secondary causes of CTS, and aid in surgical planning.

Unilateral carpal tunnel syndrome: an unusual presentation of nodular fasciitis

Nodular fasciitis is a benign, self-limiting proliferative disorder of fibroblast of uncertain aetiology, occurs frequently in the forearm. Nodular fasciitis in hand inducing carpal tunnel syndrome is exceptional. There are four cases of non-intraneural nodular fasciitis causing peripheral neuropathy that has been reported previously. We present the case of a 38-year-old man with features of unilateral carpal tunnel syndrome. Decompression of the median nerve performed subsequently along with excision of the lesion in a piecemeal fashion. Histopathological and immunohistochemical findings were consistent with nodular fasciitis. There were complete resolution of symptoms and no sign of recurrence at the end of 1 year after surgery.

Cross-sectional Area Just Proximal to the Carpal Tunnel According to the Ulnar Variances: Positive Ulnar Variance and Carpal Tunnel Syndrome

PURPOSE

We evaluated the relationship between the area around the distal radioulnar joint according to the ulnar variances and the cross-sectional area using magnetic resonance imaging (MRI) scans in this prospective study of patients with carpal tunnel syndrome (CTS).

METHODS

From among a total of 243 patients who had been diagnosed with CTS between March 2012 and February 2017 at our hospital, 41 patients with positive ulnar variance were enrolled in group 1. As control groups, 39 healthy volunteers who underwent MRI evaluations were included in group 2 (neutral ulnar variance) and group 3 (negative variance). Basic demographic data, including age, sex, and body mass index, were recorded for all 3 groups. An area encompassing the contents of carpal tunnel (nerves/tendons) was designated as area "A," and the area just beneath the subcutaneous fat was designated as area "B" at the levels of the lunate (L) and pisiform (P) on axial MRI. Ratios of these areas ("A/B at L" and "A/B at P") were evaluated in terms of their correlations with ulnar variance.

RESULTS

Mean age, sex, and body mass index were not statistically different among the groups, respectively. Within each group, there was no difference between "A/B at L" and "A/B at P," respectively. When comparing the 3 groups, "A/B at L" and "A/B at P" were all significantly decreased in group 1 than in other groups. Regardless of the group, ulnar length negatively correlated with both "A/B at L" and "A/B at P" ratios.

CONCLUSIONS

We found a positive relationship between decreased cross-sectional area around the distal radioulnar joint and positive ulnar variance on radiologic investigation. These findings show the importance of variance in the positive ulna variance to the development of CTS.

Carpal tunnel syndrome caused by a vascular malformation in a 48-year-old woman

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Vascular malformation can present nerve compression syndrome in a middle age because of slow growth, though it appeared in childhood.

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The less invasive operative treatment of carpal tunnel release is effective to reduce pain for the large size vascular malformation.

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The carpal tunnel release has advantage of improving the complaint without damaging the tumor.

Introduction

Case presentation

Discussion

Conclusion

Prospective Evaluation of Median Nerve Dysfunctions in Patients with a Distal Radius Fracture Treated with Volar Locking Plating

Background: The aim of this study was to identify the risk factors for median nerve dysfunctions after volar locking plate (VLP) fixation for distal radius fracture (DRF). Methods: We prospectively assessed the incidence of median nerve symptoms (MNS) such as numbness, pain, paresthesia, or hypesthesia in the area innervated by the median nerve and evaluated post-operative nerve conduction (NC) in 91 hands of 121 patients after VLP fixation for DRF. Multivariate logistic regression analysis was conducted to identify factors independently associated with MNS and abnormal NC in the injured wrist. Results: There were 18 cases (20%) of MNS on the injured side, 9 hands (10%) of both MNS and abnormal NC, 11 hands (12%) with only abnormal NC, and 9 hands with only MNS. Sensitivity, specificity, and diagnostic accuracy of abnormal NC for diagnosing MNS were 50%, 86%, and 78%, respectively. Four cases did not respond to conservative treatment and received carpal tunnel release concomitantly with plate removal. Logistic regression examination revealed that volar placement of the plate and short stature were significant independent predictors of MNS, while patient age was the sole independent predictor of abnormal NC. Conclusions: Our study demonstrated that plate prominence, short stature, and age were significant independent risk factors for median nerve dysfunctions after VLP fixation for DRF.

Solitary Calcified Nodules as the Cause of Carpal Tunnel Syndrome: Two Case Reports and Literature Reviews

Solitary calcified nodule-related carpal tunnel syndrome (CTS) is rare and easy to be misdiagnosed owing to the high incidence of primary CTS. Release of the transverse carpal ligament without removal of the mass leads to persistence of the symptoms and subsequent complications like wasting of the thenar muscles. Here, we report two cases of solitary calcified nodule-related CTS and discuss the role of ultrasound in preventing misdiagnosis. Both patients reported persistent numbness over the lateral side of their palm and weakness of the right wrist with thenar muscle atrophy. One patient had undergone transverse carpal ligament release 2 years previously, and the other had received a local injection of lidocaine at the clinic. Neither patient experienced symptom relief. X-ray revealed a similar finding of nodule lesions in front of the capitate–hamate region. Solitary calcified nodule-related CTS was diagnosed, and the patients underwent nodule removal with/without transverse ligament release. The first patient was a typical case of misdiagnosed solitary calcified nodule-related CTS. The second patient had a definitive clinical sonographic diagnosis before surgery. The accurate diagnosis of secondary CTS is paramount for performing effective surgery. Thus, ultrasonography is an easy, convenient, safe, and effective method in screening for secondary CTS.

Carpal tunnel syndrome due to hibernoma of the wrist: Case report

Carpal tunnel syndrome (CTS) is the most frequent among entrapment neuropathies. The usual etiology is idiopathic, but can be caused by space-occupying lesions, a relatively rare condition. This condition becomes exceptional when the space-occupying lesion corresponds to a rare tumor whose location is atypical. The authors report the case of a 36-year-old woman with CTS due to hibernoma of the wrist.

Carpal Tunnel Syndrome Caused by Intraneural Lipoma of the Median Nerve and Arteriovenous Malformation

Carpal tunnel syndrome can be the result of a wide variety of etiologic factors. Compressive causes are rare and tumors causing compression are even rarer. We present a case with a carpal tunnel syndrome caused by an intraneural lipoma and an arteriovenous malformation concomitantly. The lesions were excised, and the patient recovered with full hand function and entire disappearance of acroparesthesia. To our knowledge, this is the first case report of carpal tunnel syndrome caused by an intraneural lipoma and an arteriovenous malformation concomitantly.

Determination of Electrophysiologically Moderate and Severe Carpal Tunnel Syndrome: Ultrasonographic Measurement of Median Nerve at the Wrist

OBJECTIVE

To establish the cutoff value of cross-sectional area (CSA) of the median nerve at the wrist, for determination of electrophysiologically moderate and severe carpal tunnel syndrome (CTS).

METHODS

The prospective study was conducted among patients suspected of having CTS. A total of 106 patients (185 symptomatic wrists) received nerve conduction study (NCS) and ultrasonography. To establish a cutoff value, various diagnostic properties were calculated across a range of the CSA.

RESULTS

A mean±standard deviation of CSA of the median nerve of normal and mild, moderate and severe CTS was 9.4±2.1, 12.0±2.7, 13.8±4.7, and 15.4±4.1 mm², respectively. The positive relationship between CTS severities and CSA was observed (rs=0.56). A 14 mm² CSA had sufficient power to rule in moderate and severe CTS, with a specificity of 91.4% and sensitivity of 42.3%. In addition, it showed a post-test probability (positive predictive value) of 86.3% as against a pre-test probability of 56.2%.

CONCLUSION

Patients who had ≥14 mm² of median nerve CSA had very high probability of moderate to severe CTS.

Benign tumors affecting the median nerve. Case series report of diagnostic and surgical strategies

Objective

The aim of this study was to describe the strategies adopted in this institution to diagnose and treat patients with benign tumors affecting the median nerve.

Methods

A retrospective chart review study of all patients operated on between 2010 and 2015. Histology, symptoms, complementary exams, surgical techniques performed, and demographic characteristics were analyzed.

Results

Fifty-four patients were included in the study. There were three neurofibromas, six schwannomas, 15 lipofibromatous hamartomas, three hemangiomas, 12 lipomas, one benign fibrohistiocytoma, and 14 synovial cysts. Complete tumoral resection was performed in 32 cases, partial resection in five, segmented nerve resection in one, nerve decompression in eight, and amputation for macrodactyly in eight.

Conclusions

The most important recommendations on treating benign tumors of the median nerve are related to the clinical symptoms, tumoral growth, and tumoral nature. The surgical approach resulted in good function for 60% of the patients. However, lipofibromatous hamartomas, hemangiomas, and neurofibromas were associated with preoperative functional deficit. It may be inferred that the diagnosis and treatment of these tumors should be performed earlier.

Fibroma sinovial como causa atípica de síndrome de túnel del carpo: presentación de 2 casos clínicos

El fibroma sinovial (FS) es una tumoración benigna que puede encontrarse en la mano, teniendo predilección por las vainas flexoras. Esta lesión puede comportarse como una lesión ocupante de espacio (LOE), la cual puede llegar a comprimir nervios, como en el túnel del carpo, provocando un síndrome del túnel del carpo (STC). Este hecho solo ha sido descrito en 9 ocasiones. Cuando el STC se presenta de manera unilateral debemos descartar una LOE, entre las cuales el FS debería ser considerado como diagnóstico diferencial, especialmente frente al tumor de células gigantes, del cual solo es diferenciable microscópicamente, por lo que la resección de la masa es imprescindible. Los 2 casos aquí descritos tuvieron diferentes presentaciones clínicas pero sin complicaciones tras la resección.

Peripheral nerve lipoma: Case report of an intraneural lipoma of the median nerve and literature review

Adipose lesions rarely affect the peripheral nerves. This can occur in two different ways: Direct compression by an extraneural lipoma, or by a lipoma originated from the adipose cells located inside the nerve. Since its first description, many terms have been used in the literature to mention intraneural lipomatous lesions. In this article, the authors report a case of a 62-year-old female who presented with an intraneural median nerve lipoma and review the literature concerning the classification of adipose lesions of the nerve, radiological diagnosis and treatment.

Carpal Tunnel Syndrome Caused by Tumoral Calcinosis

We present a case of carpal tunnel syndrome caused by systemic tumoral calcinosis. A 54-year-old woman experienced hand numbness that persisted for nine months. She had no family history or medical problem. A plain radiograph of her right wrist showed a calcified mass on the volar side of the wrist joint. The patient also experienced pain in her contralateral wrist joint and both right and left shoulders, which had calcification on radiography around the joint. Her condition was diagnosed as carpal tunnel syndrome caused by systemic tumoral calcinosis and a resection biopsy was performed. Histopathological analysis of the biopsied specimen showed basophile deposition inside the fibrous connective tissue. At 14 months after the treatment, she no longer had pain or numbness in her fingers and there was no recurrence of the mass. This patient's condition is considered as a case of nonfamilial, systemic primary tumoral calcinosis. Since incomplete resection leads to a recurrence of the lesion, a follow-up radiography examination is needed to monitor symptom recurrence.

Neglected lunate dislocation presenting as carpal tunnel syndrome

Most of carpal tunnel syndrome cases are idiopathic, and secondary causes are so rare that can be easily missed. We present a patient with neglected undiagnosed lunate dislocation compressing on median nerve causing its signs and symptoms.

Unilateral carpal tunnel syndrome caused by an occult ganglion in the carpal tunnel: a report of two cases

Carpal tunnel syndrome (CTS) usually presents bilaterally and a secondary nature should be suspected in patients with unilateral symptoms, especially those with a long-standing history, and when the symptomatic hand shows severe neurophysiologic impairment, while the contralateral hand is neurophysiologically intact. Space-occupying lesions are known to cause CTS and the incidence of space-occupying lesions in unilateral CTS is higher than that of bilateral CTS. It is easy to detect a mass when it is palpable; however, occult lesions are usually overlooked. Whenever a patient presents with unilateral symptoms and unilateral neurophysiologic impairment, the possibility of a space-occupying lesion compressing the median nerve should be kept in mind in the differential diagnosis. This study presents two cases with an occult ganglion in the carpal tunnel compressing the median nerve and causing unilateral symptoms of CTS. We stress on the importance of imaging studies in patients with unilateral symptoms that are usually not used in CTS. The reported patients were evaluated and magnetic resonance images revealed an intratunnel space-occupying lesion.

Ultrasonography of peripheral nerves

Over the last decade, neuromuscular ultrasonography has emerged as a useful tool for the diagnosis of peripheral nerve disorders. This article reviews sonographic findings of normal nerves, including key quantitative ultrasound measurements that are helpful in the evaluation of focal and possibly generalized peripheral neuropathies. It also discusses several recent articles outlining the evidence base for the use of this technology, as well as new findings in compressive, traumatic, and generalized neuropathies. Ultrasonography is well suited for use in electrodiagnostic laboratories, where physicians, experienced in both the clinical evaluation of patients and the application of hands-on technology, can integrate findings from the patient's history, physical examination, electrophysiological studies, and imaging for diagnosis and management.

Bifid median nerve causing carpal tunnel syndrome: MRI and surgical correlation

Carpal tunnel syndrome can be secondary in some patients, and vascular anomalies (usually a persistent median artery), median nerve variations, or both are among the etiologic factors. High division of the median nerve proximal to the carpal tunnel (known as a bifid median nerve) is a median nerve anomaly that has an incidence rate of 2.8%. This rare entity is often associated with various abnormalities that are clinically relevant, such as vascular malformations (persistent median artery), aberrant muscles, and carpal tunnel syndrome. The bifid median nerve is one cause of carpal tunnel syndrome because of its relatively higher cross-sectional area compared with a nonbifid median nerve. Obtaining magnetic resonance imaging and ultrasounds of bifid median nerves has helped surgeons avoid potential surgical hazards.This article describes 3 men with 4 bifid median nerves associated with a persistent median artery. Mean patient age was 38 years (range, 37-40 years). Mean follow-up was 7 years (range, 3-11 years). Patients were diagnosed with carpal tunnel syndrome and underwent open carpal tunnel release. To reveal a morphological etiology in patients in whom it the possibility of having idiopathic carpal tunnel syndrome is unlikely, preoperative imaging studies should be obtained. Bifid median nerves associated with a persistent median artery in the carpal tunnel are important to understand for their clinical and surgical significance. A secondary nature should be suspected in patients with unilateral symptoms, especially those with a history of symptoms and when the symptomatic hand shows severe neurophysiologic impairment but the contralateral hand is neurophysiologically intact. Inadvertent injury to the median nerve during carpal tunnel surgery can be minimized if the variations of the median nerve are recognized.

[Ultrasonography for the management of carpal tunnel syndrome]

Ultrasonography is useful for the management of carpal tunnel syndrome. It aids in the diagnosis of idiopathic cases, screening of local pathologies(space-occupying lesions, tenosynovitis, and bone and joint abnormalities), incomplete release, and anatomic variations, and performance of low-invasive surgery.

Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome

INTRODUCTION

The purpose of this study was to develop an evidence-based guideline for the use of neuromuscular ultrasound in the diagnosis of carpal tunnel syndrome (CTS).

METHODS

Two questions were asked: (1) What is the accuracy of median nerve cross-sectional area enlargement as measured with ultrasound for the diagnosis of CTS? (2) What added value, if any, does neuromuscular ultrasound provide over electrodiagnostic studies alone for the diagnosis of CTS? A systematic review was performed, and studies were classified according to American Academy of Neurology criteria for rating articles of diagnostic accuracy (question 1) and for screening articles (question 2).

RESULTS

Neuromuscular ultrasound measurement of median nerve cross-sectional area at the wrist is accurate and may be offered as a diagnostic test for CTS (Level A). Neuromuscular ultrasound probably adds value to electrodiagnostic studies when diagnosing CTS and should be considered in screening for structural abnormalities at the wrist in those with CTS (Level B).

Median nerve neuropathy in the forearm due to recurrence of anterior wrist ganglion that originates from the scaphotrapezial joint: Case Report

Background

Median nerve neuropathy caused by compression from a tumor in the forearm is rare. Cases with anterior wrist ganglion have high recurrence rates despite surgical treatment. Here, we report the recurrence of an anterior wrist ganglion that originated from the Scaphotrapezial joint due to incomplete resection and that caused median nerve neuropathy in the distal forearm.

Case presentation

A 47-year-old right-handed housewife noted the appearance of soft swelling on the volar aspect of her left distal forearm, and local resection surgery was performed twice at another hospital. One year after the last surgery, the swelling reappeared and was associated with numbness and pain in the radial volar aspect of the hand. Magnetic resonance imaging revealed that the multicystic lesion originated from the Scaphotrapezial joint and had expanded beyond the wrist. Exploration of the left median nerve showed that it was compressed by a large ovoid cystic lesion at the distal forearm near the proximal end of the carpal tunnel. We resected the cystic lesion to the Scaphotrapezial joint. Her symptoms disappeared 1 week after surgery, and complications or recurrent symptoms were absent 13 months after surgery.

Conclusions

A typical median nerve compression was caused by incomplete resection of an anterior wrist ganglion, which may have induced widening of the cyst. Cases with anterior wrist ganglion have high recurrence rates and require extra attention in their treatment.

Unusual causes of carpal tunnel syndrome: space occupying lesions

Space occupying lesions found at surgery caused or contributed to carpal tunnel syndrome in 23 of 779 patients operated for carpal tunnel syndrome from January 1999 to December 2008. The mean age of these 23 patients was 52.9 years, and in patients who had a local swelling or palpable mass, ultrasonography or magnetic resonance imaging (MRI) was done. All had open release of the transverse carpal ligament and lesions were removed. Histopathology showed tophaceous gout in 10 men, tenosynovitis in seven patients and tumors in eight. The tumors included ganglion cysts in two, lipoma in three and fibroma of the tendon sheath in one. The neurological symptoms subsided after surgery in all. In patients with gout, one had an infected wound and another had recurrence of symptoms 1 year after later. Carpal tunnel syndrome caused by a space occupying lesion is rare and more complicated than idiopathic carpal tunnel syndrome.

Giant lipoma: an unusual cause of carpal tunnel syndrome

Carpal tunnel syndrome, in its idiopathic form, is an extremely common entrapment neuropathy in the clinical practice however secondary compressive causes are rare. Among secondary causes, tumors are even rarer. Although lipomas are the most common soft tissue tumor in the body, <5% of the benign tumors of the hand are lipomas. A 48-year old manual laborer man presented to us with a two-year history of numbness, tingling and burning pain in the palmar surface of the left hand and fingers along with a progressively increasing swelling in the hand and wrist. His medical history was unremarkable and no trauma episode was reported. According to the clinical examination and the result of median nerve conduction study (NCS) the diagnosis of carpal tunnel syndrome was established. Operative release of the transverse carpal ligament was subsequently performed along with excision of the lipoma using extensile open approach. Intraoperatively, median nerve and its digital branches were found to be stretched over the giant lipoma causing substantial compression to median nerve. Histopathological findings of the resected mass were consistent with lipoma. After two years the patient was pain-free without any sign of tumor recurrence. Lipomas are infrequently seen in hand and wrist, however giant lipoma as a cause of secondary carpal tunnel syndrome is even more rare, which makes this case interesting.

The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis

BACKGROUND

Carpal tunnel syndrome (CTS) is the most commonly diagnosed compression neuropathy of the upper extremity. Current AAOS recommendations are to obtain a confirmatory electrodiagnostic test in patients for whom surgery is being considered. Ultrasound has emerged as an alternative confirmatory test for CTS; however, its potential role is limited by lack of adequate data for sensitivity and specificity relative to electrodiagnostic testing.

QUESTIONS/PURPOSES

In this meta-analysis we determined the sensitivity and specificity of ultrasound in the diagnosis of CTS.

METHODS

A PubMed/MEDLINE search identified 323 articles for review. After applying exclusion criteria, 19 articles with a total sample size of 3131 wrists were included for meta-analysis. Three groups were created: a composite of all studies, studies using clinical diagnosis as the reference standard, and studies using electrodiagnostic testing as the reference standard.

RESULTS

The composite sensitivity and specificity of ultrasound for the diagnosis of CTS, using all studies, were 77.6% (95% CI 71.6-83.6%) and 86.8% (95% CI 78.9-94.8%), respectively.

CONCLUSIONS

The wide variations of sensitivities and specificities reported in the literature have prevented meaningful analysis of ultrasound as either a screening or confirmatory tool in the diagnosis of CTS. The sensitivity and specificity of ultrasound in the diagnosis of CTS are 77.6% and 86.8%, respectively. Although ultrasound may not replace electrodiagnostic testing as the most sensitive and specific test for the diagnosis of CTS given the values reported in this meta-analysis, it may be a feasible alternative to electrodiagnostic testing as the first-line confirmatory test.

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies. See Guidelines for Authors for a complete description of levels of evidence.

Differential onset patterns and causes of carpal tunnel syndrome after distal radius fracture: a retrospective study of 105 wrists

BACKGROUND

It is well known that carpal tunnel syndrome (CTS) can occur in a wide range of time periods after distal radius fracture (DRF). Few studies have evaluated in detail the relationship between fracture and electrophysiological finding characteristics and time to onset of CTS after DRF. To clarify the characteristics of CTS after DRF, we classified a large number of clinical cases based on the period from the injury to onset of CTS. These cases were analyzed retrospectively.

METHODS

We reviewed 105 wrists with CTS following DRF. Patients' ages ranged from 13 to 89 years. These 105 wrists were divided into three groups according to the period of post-fracture onset of CTS. Twenty-eight wrists were classified into the acute onset group (when the symptoms of CTS occurred within 1 week after fracture). Forty-seven wrists were classified into the subacute onset group (when symptoms of CTS occurred from 1 to 12 weeks after fracture). The remaining 30 wrists were classified into the delayed onset group (when symptoms of CTS occurred more than 12 weeks after fracture). Deformity of the distal radius on X-ray films was evaluated and distal motor latency (DML) of the median nerve was recorded to compare values among these three groups.

RESULTS

In the acute onset group, 68% had an AO C-type fracture and 46% were caused by a high-energy injury. The percentage of this fracture pattern and mechanism was significantly higher in the acute onset group than in the other groups (P < 0.05; Kruskal-Wallis test). In the subacute onset and delayed onset groups, 79% and 63% had an A-type fracture and more than 90% were caused by a low-energy injury. In the delayed onset group, the incidence of prolonged DML in the contralateral wrists was 71%, which was significantly higher than in the other two onset groups (P < 0.05; Kruskal- Wallis test).

CONCLUSIONS

There were three onset patterns of CTS after DRF, and each CTS onset pattern had different etiologic mechanisms and different clinical features of CTS. In the acute onset group, a high-energy fracture pattern was associated with CTS. In the subacute and the delayed onset groups, lowenergy injury in elderly women was associated with CTS. Both deformity of the fracture and preexisting median nerve dysfunction were suggested as predisposing factor for CTS.

Percutaneous carpal tunnel release compared with mini-open release using ultrasonographic guidance for both techniques

PURPOSE

To compare the outcomes of percutaneous carpal tunnel release (PCTR) and mini-open carpal tunnel release (mini-OCTR) using ultrasonographic guidance for both techniques.

METHODS

We included 74 hands of 65 women with idiopathic carpal tunnel syndrome (age, 52-71 y; mean, 58 y). Thirty-five hands of 29 women had the PCTR (release with a device consisting of an angled blade, guide, and holder, along a line midway between the median nerve and ulnar artery (safe line) under ultrasonography (incision, 4 mm), and 39 hands of 36 women had the mini-OCTR (release along the safe line, distally under direct vision (incision, 1-1.5 cm) and proximally under ultrasonography, using a device consisting of a basket punch and outer tube.

RESULTS

Assessments at 3, 6, 13, 26, 52, and 104 weeks showed no significant differences in neurologic recovery between the groups (p > .05). The PCTR group had significantly less pain, greater grip and key-pinch strengths, and better satisfaction scores at 3 and 6 weeks (p < .05), and less scar sensitivity at 3, 6, and 13 weeks (p < .05). There were no complications.

CONCLUSIONS

The PCTR provides the same neurologic recovery as does the mini-OCTR. The former leads to less postoperative morbidity and earlier functional return and achievement of satisfaction.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Unilateral carpal tunnel syndrome caused by an occult palmar lipoma

Carpal tunnel syndrome usually presents bilaterally and space-occupying lesions should be suspected in patients with unilateral symptoms, especially with a long history and when the symptomatic hand shows severe neurophysiologic impairment, while the contralateral hand is neurophysiologically intact. Approximately half of patients with unilateral symptoms have positive electrodiagnostic test results in the asymptomatic, contralateral hand. Space-occupying lesions are known to cause carpal tunnel syndrome and the incidence of space-occupying lesions in unilateral carpal tunnel syndrome is higher than that of bilateral carpal tunnel syndrome. It is easy to detect a mass when it is palpable, but occult lesions may be overlooked easily. Whenever a patient presents with unilateral symptoms and unilateral neurophysiologic impairment, the possibility of a space-occupying lesion compressing the median nerve should be kept in mind in the differential diagnosis. This article presents 2 cases of patients with occult deep palmar lipomas compressing the median nerve and causing unilateral symptoms of carpal tunnel syndrome. We stress the importance of imaging studies in patients with unilateral symptoms that are usually not used in carpal tunnel syndrome. While both patients' symptomatic hands showed severe neurophysiologic impairment, the contralateral hands were totally intact, which is contradictory with a long history. The reported patients were evaluated and magnetic resonance images revealed intra-tunnel lesions. Although lipomas are the most common soft tissue tumor in the body, <5% of the benign tumors of the hand are lipomas. Since the thick palmar fascia is strong, a deep lipoma may not be recognized although nerve compression symptoms may be gross.

Myoepithelioma within the carpal tunnel: a case report and review of the literature

Myoepitheliomas of the extremity are rare and usually benign, while a minority display malignant features. This case demonstrates the diagnosis and management of myoepithelioma within the carpal tunnel. Clinical and radiological tumour features were evaluated. Hematoxylin and eosin stained tumour sections were examined, and immunohistochemistry was performed. Histology revealed a nodular mass of epithelioid cells in clusters within a myxoid/chondroid stroma. No mitoses were noted. Cytokeratins, neuron-specific enolase, synaptophysin, glial fibrillary acidic protein, and S100 were positive on immunohistochemistry. A literature review revealed very few prior reports of myoepithelioma in the wrist, and limited data concerning any relationship between recurrence and quality of surgical margins. In this case, wide local excision would have significantly compromised dominant hand function, and therefore a marginal excision was deemed appropriate in the context of bland histological features. Surgical margins noted in future case reports will aid clinical decision making.

Carpal tunnel syndrome caused by space occupying lesions

PURPOSE

To evaluate the diagnosis and treatment of the carpal tunnel syndrome (CTS) due to space occupying lesions (SOL).

MATERIALS AND METHODS

Eleven patients and 12 cases that underwent surgery for CTS due to SOL were studied retrospectively. We excluded SOL caused by bony lesions, such as malunion of distal radius fracture, volar lunate dislocation, etc. The average age was 51 years. There were 3 men and 8 women. Follow-up period was 12 to 40 months with an average of 18 months. The diagnosis of CTS was made clinically and electrophysiologically. In patients with swelling or tenderness on the area of wrist flexion creases, magnetic resonance imaging (MRI) and/or computed tomogram (CT) were additionally taken as well as the carpal tunnel view. We performed conventional open transverse carpal ligament release and removal of SOL.

RESULTS

The types of lesion confirmed by pathologic examination were; tuberculosis tenosynovitis in 3 cases, nonspecific tenosynovitis in 2 cases, and gout in one case. Other SOLs were tumorous condition in five cases, and abnormal palmaris longus hypertrophy in 1 case. Tumorous conditions were due to calcifying mass in 4 cases and ganglion in 1 case. Following surgery, all cases showed alleviation of symptom without recurrence or complications.

CONCLUSION

In cases with swelling or tenderness on the area of wrist flexion creases, it is important to obtain a carpal tunnel view, and MRI and/or CT should be supplemented in order to rule out SOLs around the carpal tunnel, if necessary.

Use of Sonography in Carpal Tunnel Syndrome Surgery-A Prospective Study-

The diagnosis of carpal tunnel syndrome (CTS) is mainly based on the characteristic symptoms and confirmed with nerve conduction studies. Sonography can provide measurements of the increased cross-sectional area of median nerve. The use of sonography was evaluated for the diagnosis and postoperative follow up of 48 wrists in 26 consecutive patients with CTS. Clinical evaluation and sonography were effective for the diagnosis in 40 wrists. Nerve conduction studies were needed in eight wrists, because of the decrease in cross-sectional area of the nerve as a result of degenerative changes. After 3 months, sonography detected statistically significant decreases in the cross-sectional areas of the median nerves. The sonographic studies were well tolerated by all patients. Sonography was both time-saving and cost-effective.

Ganglion cysts and other tumor related conditions of the hand and wrist

Most regard ganglion, giant cell tumor of tendon sheath and epidermal inclusion cysts as tumor-like conditions as opposed to true neoplasms. Ganglion cysts are the most common lesion of the hand and wrist, accounting for 50% to 70% of all masses identified. The majority of ganglion cysts can be treated nonoperatively but when surgery is performed a low recurrence rate can be anticipated. Giant cell tumor of the tendon sheath hand epidermoid cysts are also common hand lesions that require surgical excision in most instances. Of the three, giant cell tumor of tendon sheath have the most notable recurrence rates. This article reviews the clinical presentations of these lesions as well as their proposed pathophysiology.

Carpal tunnel syndrome due to heterotopic ossification

We report a rare case of carpal tunnel syndrome due to heterotopic ossification in the carpal tunnel in a 34-year-old woman without antecedents of neurological injury, musculoskeletal trauma, or metabolic disorder. To our knowledge, this is the first reported case. Incomplete excision of heterotopic ossification resulted in partial relief of symptoms.

Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature

Advances in ultrasound technology have made it possible to gain higher spatial resolution and even depict nerves with excellent visual quality. In this article, the literature concerning sonography in the diagnosis of carpal tunnel syndrome (CTS) is critically reviewed. We searched Medline for studies on sonography in the diagnosis of CTS and used the reference lists of the articles found. A total of seven studies on the diagnostic capabilities of sonography was found. There were considerable differences in study design. A reliable diagnosis of CTS could be made sonographically, mainly based on an increase in cross-sectional area of the median nerve at the level of the pisiform or hamate bone. However, most studies could not compare the diagnostic capabilities of sonography to those of electrodiagnostic studies, because the latter was applied as the gold standard. Several other reports on the possible extra value of sonography in CTS are mentioned (mass lesions, anatomical variants, rheumatological diseases, renal dialysis-related amyloidosis, surgery, corticosteroid injection). It is probable that sonography will not replace electrodiagnostic studies, but may serve as an additional investigation. To gain further insight into the possible additional value of sonography, it is necessary to examine subcategories of CTS patients in which electrodiagnostic studies are equivocal.

Ultrasonographic measurement of median nerve cross-sectional area in idiopathic carpal tunnel syndrome: Diagnostic accuracy

Severity-correlated enlargement of the median nerve occurs in idiopathic carpal tunnel syndrome (CTS). We determined whether measurement of the nerve cross-sectional area was useful in making the diagnosis of CTS. In 414 wrists of 275 patients with clinically diagnosed idiopathic CTS and 408 wrists of 408 controls, we made ultrasonographic measurements of the nerve area at the distal (distal edge of the flexor retinaculum), mid (hook of the hamate), and proximal carpal tunnel (wrist crease). Criteria based on the area at a single level yielded sensitivities of 43-57% and specificities of 96-97%. Use of the mean carpal nerve area (average of the areas at the three levels) improved the results (sensitivity, 67%; specificity, 97%), which was as sensitive as the nerve conduction studies (NCS). In the NCS, we obtained sensitivities of 66% for the distal motor nerve latency and 67% for the distal sensory nerve latency, with specificities of 97% for each. A combination of the mean carpal nerve area and NCS criteria yielded a sensitivity of 84% and a specificity of 94%. The clinical implications of these findings for the diagnosis of CTS are discussed.