Diagnosing carpal tunnel syndrome

Median Nerve Recovery and Morphological Change on MRI at 24 Months after Open Carpal Tunnel Release

Background: This study aimed to investigate the relationship between postoperative clinical results and long-term morphological changes in patients with carpal tunnel syndrome (CTS) as observed on magnetic resonance imaging (MRI) before and after open carpal tunnel release (OCTR). Methods: We retrospectively analysed data for 28 hands that had undergone OCTR with at least 24 months of follow-up data. Two-point discrimination (2PD) test results were examined for the first three fingers, as were the distal motor latency (DML) and sensory conduction velocity (SCV) of the median nerve. We also calculated the cross-sectional area (CSA) of the carpal tunnel and the distance from the median nerve to the volar carpal bone at the hamate and the pisiform levels using MRI images. Variables were compared before and 24 months after OCTR. Results: Significant improvements in all variables were observed, including average 2PD scores (Finger I: 13.1 ± 6.2 vs. 7.7 ± 4.3, p < 0.01, Finger II: 11.9 ± 6.6 vs. 7.0 ± 3.5, p < 0.01, Finger III: 13.6 ± 6.1 vs. 7.8 ± 4.5, p < 0.01), average DML (8.3 ± 3.3 vs. 4.3 ± 0.6 m/s, p < 0.01), average SCV (30.8 ± 11.0 vs. 41.3 ± 5.3 m/s, p < 0.01), CSA of the carpal tunnel (hamate level: 194.9 ± 30.6 vs. 254.2 ± 47.6 mm2, p < 0.01, pisiform level: 244.2 ± 46.5 vs. 274.7 ± 75.1 mm2, p = 0.01) and the distance between the median nerve and volar carpal bone (hamate level: 8.7 ± 1.4 vs. 11.2 ± 1.6 mm, p < 0.01, pisiform level: 11.8 ± 1.7 vs. 13.8 ± 2.5 mm, p < 0.01). Conclusions: Our results demonstrate that OCTR is successful in achieving long-term decompression and recovery of the median nerve in patients with CTS. Level of Evidence: Level III (Therapeutic).

Carpal Tunnel Syndrome in Patients with Psoriatic Arthritis: Ultrasonography and Magnetic Resonance Imaging Findings

Objective

The aim of the present study is to assess carpal tunnel syndrome's (CTS's) ultrasonography (US) and magnetic resonance imaging (MRI) findings in patients with psoriatic arthritis (PsA) and compare them with healthy controls.

Methods

Thirty-nine PsA and twenty-eight healthy volunteers were examined in this study. Demographic and clinical features were recorded. CTS-6, a diagnostic algorithm, was used to estimate the probability of CTS. Electrodiagnostic study (EDS) was applied to all wrists included in the report, where the diagnosis of CTS was made by EDS. The cross-sectional area (CSA) of the median nerve was measured at pisiform bone level by US and MRI.

Results

Regarding to the demographic characteristics, no statistically significant difference was found between the groups. Twelve of 39 (30.76%) PsA patients had CTS, whereas CTS was not detected in the control group (p=0.001). US and MRI showed increased median nerve CSA in PsA patients compared to healthy controls (p=0.005, p<0.001; respectively). Also, US and MRI showed increased median nerve CSA in CTS patients compared to others (p=0.002, p<0.001; respectively). The Pearson correlation coefficient between MRI and US measurements of the CSA was 0.85 (p<0.001).

Conclusion

CTS frequency in PsA patients is found higher than healthy controls. The relationship between CTS diagnosed by EDS and CSA measured by both US and MRI was observed in PsA patients.

Predictive factors and clinical effects of diabetic hand: A prospective study with 1-year follow-up

AIMS

Diabetes mellitus is considered an etiological factor for hand-related conditions that are grouped under the term "diabetic hand" (DH), which includes limited joint mobility, Dupuytren's contracture, carpal tunnel syndrome, and trigger finger. This study aimed to identify predictive factors and the clinical effects of DH development among patients with diabetes.

PATIENTS AND METHODS

Consecutive Japanese adults with diabetes were prospectively recruited at a single outpatient center. We assessed the presence of DH at baseline and at the 1-year follow-up, which was considered present if the patient exhibited one or more of the hand disorders at either examination.

RESULTS

The 590 eligible subjects had a mean age of 57 years and included 155 patients (26%) with DH. Binary logistic regression analysis revealed that DH was significantly associated with older age, longer diabetes duration, and higher body mass index. Patients with DH had significantly lower hand function and quality of life (QOL) scores. We assessed 476 patients at the 1-year follow-up, including 96 patients (20%) who had DH at baseline. Although 25 of the 96 patients (26%) experienced resolution of DH without specific treatment, 83 of 380 patients (22%) without DH at baseline had developed new DH-related conditions. At the 1-year follow-up, the group with DH was significantly older than that without DH.

CONCLUSION

Older age and prolonged duration of diabetes predicted the development of DH. Patients who are not old and do not have a prolonged duration of diabetes may experience DH resolution without specific treatment.

Diagnostic modalities and physical therapy in patients with Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) represents one of the most common compressive peripheral neuropathies on the upper extremities, and is characterized by compression of the medial nerve on its way through the carpal tunnel area. The first changes experienced by patients with CTS are sensory and occur mainly at night, and if they are not recognized and treated in time, they progress and become continuously present. Prolonged compression of the medial nerve in the region of the carpal tunnel can lead to permanent damage to this nerve, which can result in the patient losing the ability to distinguish between hot and cold, as well as atrophy of the thenar muscles and difficulty in palmar abduction of the thumb. The diagnosis of CTS is generally made based on the patient's symptoms, clinical history and anamnesis, as well as electrodiagnostic tests. In addition to these methods, provocative tests, nuclear magnetic resonance (NMR) and ultrasound examinations are used in the evaluation of CTS. In patients with CTS, a large number of treatment methods, both surgical and non-surgical, are used in clinical practice. Myofascial massage, ultrasound, interference currents, continuous short-wave diathermy, extracorporeal shock wave therapy (ESWT) have been shown to be beneficial in reducing pain and symptoms or improving function in patients with CTS in the short and medium term. It was also pointed out that there are no firm conclusions about optimal doses and therapeutic parameters. A better understanding of the etiology and pathophysiological mechanisms of CTS, as well as the effects of certain therapeutic modalities in the treatment of this condition, will contribute to further understanding of the origin and progression of CTS, as well as the possibilities of prevention and treatment of these patients in order to improve the quality of their life and the functionality of the affected limb.

Virtual orthopedic assessment: Main principles and specific regions

Telemedicine was originally created as a way to treat patients who were located in remote places far away from local health facilities or in areas with shortages of medical professionals. Telemedicine is still used today to address those problems, and is increasingly becoming a tool for convenient medical care. With the emergence of pandemics, telemedicine became almost a mandatory and valuable option for continuing to provide medical care in various specialties. As the threat of pandemic progress has continued for months and may continue for years, it is essential to validate existing tools to maintain clinical assessment and patient treatment to avoid negative consequences of the lack of medical follow-up. Therefore, the establishment of a virtual assessment technique that can be conducted effectively is of outmost importance as a way of adapting to the current situation. This study evaluated the role of telemedicine in the assessment of various orthopedic pathologies by means of a systematic virtual evaluation.

The rate and associated risk factors for acute carpal tunnel syndrome complicating a fracture of the distal radius

Background

Acute carpal tunnel syndrome (ACTS) is a known complication of distal radius fractures. This study aimed to document the demographics, range of presenting symptoms and risk factors of patients who develop ACTS following a fracture of the distal radius.

Methods

A retrospective review of 1189 patients with an acute distal radius fracture treated in the study centre over a one-year period were identified. Demographic and clinical variables were collected and compared between controls (did not develop ACTS) and those patients who did develop ACTS to identify factors associated with developing ACS.

Results

There were 51 (4.3%) distal radius fractures complicated by ACTS. The mean age of patients who developed ACTS was 56 years (range, 16–89) and 73% were female. The median time of onset post-injury was one week (range, 1–12). There was no association between patient background and comorbidities with the development of ACTS. AO-OTA Type C fractures had significantly increased rates of developing ACTS.

Conclusion

Four percent of distal radius fractures were complicated by ACTS. There was no association between patient background and comorbidities with the development of ACTS. AO-OTA type C complete articular fractures had a significantly higher rate of ACTS. A suggested treatment algorithm for patients presenting with ACTS has been presented.

Level of evidence:

III.

Diagnostic accuracy of history taking, physical examination and imaging for non-chronic finger, hand and wrist ligament and tendon injuries: a systematic review update

OBJECTIVE

The diagnostic work-up for ligament and tendon injuries of the finger, hand and wrist consists of history taking, physical examination and imaging if needed, but the supporting evidence is limited. The main purpose of this study was to systematically update the literature for studies on the diagnostic accuracy of tests for detecting non-chronic ligament and tendon injuries of the finger, hand and wrist.

METHODS

Medline, Embase, Cochrane Library, Web of Science, Google Scholar ProQuest and Cinahl were searched from 2000 up to 6 February 2019 for identifying studies. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 checklist, and sensitivity (Se), specificity (Sp), accuracy, positive predictive value (PPV) and negative predictive value (NPV) were extracted.

RESULTS

None of the studies involved history taking. Physical examination, for diagnosing lesions of the triangular fibrocartilage complex (TFCC), showed Se, Sp, accuracy, PPV and NPV ranging from 58% to 90%, 20% to 69%, 56% to 73%, 53% to 71% and 55% to 65%, respectively. Physical examination in hand and finger injuries the Se, Sp, accuracy, PPV and NPV ranged from 88% to 99%, 75% to 100%, 34% to 88%, 91% to 100% and 75% to 95%, respectively. The accuracy of MRI with high-resolution (3 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 89% to 91% and 75% to 100%, respectively. The accuracy of MRI with low-resolution (1.5 T) techniques for TFCC and interosseous ligaments of the proximal carpal row ranged from 81% to 100% and 67% to 95%, respectively.

CONCLUSIONS

There is limited evidence on the diagnostic accuracy of history taking and physical examination for non-chronic finger, hand and wrist ligament and tendon injuries. Although some imaging modalities seemed to be acceptable for the diagnosis of ligament and tendon injuries in the wrist in patients presenting to secondary care, there is no evidence-based advise possible for the diagnosis of non-chronic finger, hand or wrist ligament and tendon injuries in primary care.

Chang CC. Carpal Tunnel Syndrome: Retrospective Analysis of 60 Consecutive Cases of Ambulatory Surgical Treatment With Local Anesthesia

Background: The purpose of this study was to evaluate the safety and efficacy of ambulatory open surgical treatment for carpal tunnel syndrome with local anesthesia and without tourniquet ischemia, sedation by an anesthesiologist, or hospitalization. Methods: A retrospective analysis of 60 consecutive cases performed during 1 year was conducted, excluding other compressive or noncompressive neuropathies. The criteria for treatment efficacy were improvements in symptoms and recurrence rates, and the safety criterion was the presence of complications. Results: The mean patient age was 53.39 years, with 91.7% of women and 8.3% of men. The right side was more frequently affected (65% of the cases). The anesthetic and surgical procedures were well tolerated by patients. No complications during the procedures or postsurgical recurrences were observed. Conclusions: Consistent with previous data, the results of this study corroborate that the proposed treatment is effective, safe, and of low cost, resulting in great savings and increased productivity for the public health system.

Recent Advances in the Understanding and Management of Carpal Tunnel Syndrome: a Comprehensive Review

PURPOSE OF REVIEW

Carpal tunnel syndrome (CTS) is an entrapment neuropathy that involves the compression of the median nerve at the wrist and is considered the most common of all focal entrapment mononeuropathies. CTS makes up 90% of all entrapment neuropathies diagnosed in the USA and affects millions of Americans.

RECENT FINDINGS

Age and gender likely play a role in the development of CTS, but additional studies may further elucidate these associations. Of known associated risk factors, diabetes mellitus seems to have the greatest association with CTS. One of the most commonly reported symptoms in CTS is a "pins-and-needles" sensation in the first three fingers and nocturnal burning pain that is relieved with activity upon waking. Treatment for CTS is variable depending on the severity of symptoms. Conservative management of CTS is usually considered first-line therapy. In cases of severe sensory or motor deficit, injection therapy or ultimately surgery may then be considered. Still CTS is often difficult to treat and may be reoccurring. Novel treatment modalities such as laser and shockwave therapy have demonstrated variable efficacy though further studies are needed to assess for safety and effect. Given the unknown and potentially complex etiology of CTS, further studies are needed to explore combinations of diagnostic and therapeutic modalities.

Correlation of ultrasound cross-sectional area of the median nerve, nerve conduction studies and 2-point discrimination

INTRODUCTION

The purpose of this study was to determine the correlation between a measure of physical performance, a measure of physiology and a measure of anatomy in the setting of carpal tunnel syndrome (CTS).

METHODS

A retrospective review of 215 consecutive patients with suspected CTS was conducted. All patients were evaluated with static 2-point discrimination (2PD), ultrasound (US) measurement of the median nerve cross-sectional area (CSA), and nerve conduction studies (NCS). Correlations between 2PD and US and NCS parameters were calculated. The ability of US/NCS to predict 2PD was evaluated.

RESULTS

Analysis failed to prove a statistically significant correlation between 2PD and median nerve CSA. A weak correlation was detected between 2PD and NCS parameters. When 2PD was used as a reference standard, NCS parameters combined had the greatest sensitivity, followed by US.

CONCLUSIONS

Currently used diagnostic tests (NCS and US) correlate poorly with 2PD. Muscle Nerve 000: 000-000, 2018 Muscle Nerve 59:236-239, 2019.

Compliance assessment and flip-angle measurement of the median nerve: sonographic tools for carpal tunnel syndrome assessment?

Objectives

To assess the diagnostic performance of median nerve (MN) flip-angle measurements, deformation during wrist flexion [transit deformation coefficient (TDC)], during compression [compression deformation coefficient (CDC)] and fascicular freedom to potentially identify fibrotic MN changes in patients with carpal tunnel syndrome (CTS).

Methods

This prospective study was performed with institutional review board approval; all participants provided oral and written informed consent. Wrists in 21 healthy participants and 29 patients with CTS were examined by ultrasound. MN movement during wrist flexion, MN deformation during transition over the flexor tendons (TDC) and during controlled compression (CDC) as well as fascicular freedom were assessed. Diagnostic properties of these parameters were calculated and compared to clinical findings and cross-section area measurements (ΔCSA).

Results

Low flip angles were associated with high ΔCSA at a receiver-operator characteristics area under the curve (AUC) of 0.62 (0.51-0.74). TDC [AUC, 0.83 (0.73-0.92), 76.3% (59.8-88.6%) sensitivity, 88.5% (76.6-95.7%) specificity], restricted fascicular movement [AUC, 0.86 (0.78-0.94), 89.5% (75.2-97.1%) sensitivity, 80.8% (67.5-90.4%) specificity] and compression-based CDC [AUC, 0.97 (0.94-1.00), 82.1% (66.5-92.5%) sensitivity, 94.2% (84.1-98.8%) specificity] demonstrated substantial diagnostic power (95% confidence intervals in parentheses).

Conclusions

Fascicular mobility, TDC and CDC show substantial diagnostic power and may offer insights into the underlying pathophysiology of CTS.

Key Points

• Dynamic ultrasonography during wrist flexion and compression enables median nerve deformability assessment.

• Overall, reduced median nerve deformability is highly indicative of CTS.

• Median nerve compressibility shows higher diagnostic power than conventional cross-section area measurements.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5555-3) contains supplementary material, which is available to authorized users.

It's All in the Wrist: Diagnosis and Management of Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy accounting for 90% of similar disorders, occurring in 3.8% of the population, common in adults aged 40-60 years, and is associated with an average 32 lost days of work and lost productivity. In addition to occupational exposure, there are several common chronic disorders that can preclude CTS, obesity, diabetes mellitus, rheumatoid arthritis, pregnancy, metabolic syndrome, and thyroid disorder, to name a few. Therefore, it is important for the primary care provider to have knowledge in this syndrome. The purpose of the article is to inform the provider about the etiology, presentation, diagnosis, and treatment of CTS, as well as the implications for job-associated CTS.

An Experimental Survey on the Effect of Using the CTS-6 Tool on the Diagnosis of Carpal Tunnel Syndrome by Hand Surgeons

BACKGROUND

This controlled randomized experiment tested the research hypothesis that providing the CTS-6 quantitative diagnostic information to hand surgeons affects the diagnosis of carpal tunnel syndrome.

METHODS

Surgeon members of American Association for Hand Surgery participated in an online survey. Demographic and practice pattern information was collected. Few surgeons routinely use diagnostic questionnaires or algorithms. Each member was given four clinical scenarios. The respondents were randomized, The experimental group was given the same scenarios as the control group plus the quantitative results of the CTS-6 diagnostic tool.

RESULTS

There were statistically significant differences between the groups in the diagnostic decisions. Using the CTS-6 quantitative diagnostic tool affected the diagnosis of carpal tunnel syndrome, especially for patients with the lowest number of findings associated with carpal tunnel syndrome.

CONCLUSIONS

While accurate diagnostic decisions are dependent on the incorporation of all of the pertinent information gathered during the history and physical exams, the results of the CTS-6 may help the clinician focus their thinking and revise their diagnostic probabilities.

Ultrasound measurement of median nerve cross-sectional area at the inlet and outlet of carpal tunnel after carpal tunnel release compared to electrodiagnostic findings

INTRODUCTION

Ultrasound measurement of the cross-sectional area (CSA) of the median nerve can give information about regeneration of the nerve after carpal tunnel release (CTR), but the changes at selected follow-up points up to 1 year compared to electrodiagnostic findings are not known. We postoperatively measured the CSA of the median nerve with ultrasound and compared the measurements with electrophysiological findings over 12 months after open CTR.

MATERIALS AND METHODS

In 21 hands that underwent open CTR, the CSA of the median nerve was measured at the inlet (proximal CSA) and outlet (distal CSA) of the carpal tunnel at 3- 6- and 12-month follow-up. The respective ratios [(CSA postoperatively/CSA preoperatively) × 100] were calculated and correlated with distal motor latency (DML) and sensory nerve conduction velocity (SCV).

RESULTS

The proximal CSA ratio was 88.9, 84.5, and 78.4 % at 3-, 6-, and 12-month follow-up, respectively. Each value was significantly lower than that before surgery. The distal CSA ratio was 104.3, 99.1, and 91.8 % at 3-, 6-, and 12-month follow-up, respectively. The values were not significantly different compared to preoperative values.

CONCLUSIONS

The proximal CSA of the median nerve decreased continuously over the time after CTR while the distal CSA increased up to 3 months before it decreased continuously, too.

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.

Carpal tunnel decompression in the super-elderly

There is conflicting evidence about the functional outcome and rate of satisfaction of super-elderly patients (≥ 80 years of age) after carpal tunnel decompression.

We compiled outcome data for 756 patients who underwent a carpal tunnel decompression over an eight-year study period, 97 of whom were super-elderly, and 659 patients who formed a younger control group (< 80 years old). There was no significant difference between the super-elderly patients and the younger control group in terms of functional outcome according to the mean (0 to 100) QuickDASH score (adjusted mean difference at one year 1.8; 95% confidence interval (CI) -3.4 to 7.0) and satisfaction rate (odds ratio (OR) 0.78; 95% CI 0.34 to 1.58). Super-elderly patients were, however, more likely to have thenar muscle atrophy at presentation (OR 9.2, 95% CI 5.8 to 14.6). When nerve conduction studies were obtained, super-elderly patients were more likely to have a severe conduction deficit (OR 12.4, 95% CI 3.0 to 51.3).

Super-elderly patients report functional outcome and satisfaction rates equal to those of their younger counterparts. They are more likely to have thenar muscle atrophy and a severe nerve conduction deficit at presentation, and may therefore warrant earlier decompression.

Cite this article: Bone Joint J 2014; 96-B:1234–8.