Idiopathic carpal tunnel syndrome in children and adolescents

First Case of Combined Carpal and Cubital Tunnel Syndromes in an Adolescent: A Case Report and Literature Review

Carpal and cubital tunnel syndromes are the two most common compressive neuropathies, but both carpal and cubital tunnel syndromes are extremely rare in children. Therefore, the combination of carpal and cubital tunnel syndrome in the pediatric population is even more uncommon. These neuropathies have multiple causes, with the three main categories being mechanical injury, metabolic, and idiopathic. Here, we present the unique case of a 15-year-old female with no known genetic or physical risk factors who was diagnosed with atraumatic combined carpal and cubital tunnel syndrome with severe, chronic nerve entrapment and damage. After nearly two years of conservative management, the patient had a cubital tunnel and carpal tunnel release simultaneously. The transverse carpal ligament was grossly thickened intraoperatively, leading to difficulty in the identification of the median nerve. The ulnar nerve was severely compressed and flattened. Following decompression, both nerves continued to be erythematous and inflamed. After surgery, the patient had barriers to getting appropriate postoperative care. Specifically, the patient was unable to attend physical and hand therapy appointments, possibly leading to continued weakness, numbness, and intermittent pain. In our patient, the preoperative workup did not illuminate the severity of the median and ulnar nerve damage, possibly delaying surgical intervention. In addition to our case, we utilized the TriNetX database (TriNetX, Inc., Cambridge, Massachusetts, United States) to investigate the rate and treatment of compressive neuropathies in the pediatric population. The database was queried for pediatric patients who underwent carpal tunnel release, cubital tunnel release, and pediatric patients with both carpal and cubital tunnel syndrome diagnoses in childhood. We found that there were 20,819,207 pediatric patients on the TriNetX database, of whom 503 (0.002%) were diagnosed with both carpal and cubital tunnel syndrome. Based on our case and the current literature, a thorough history of pediatric patients with suspected carpal or cubital tunnel syndrome should include an evaluation of family history and activity level for pertinent risk factors. Widening the scope of the patient history could allow for more timely surgical intervention and improve long-term outcomes for the pediatric population. When evaluating children for either carpal tunnel or cubital tunnel syndrome, we recommend that healthcare providers evaluate both neuropathies simultaneously.

Coexistence of anomalous muscle, persistent median artery, bifid median nerve causing carpal tunnel syndrome: A case report and literature review

Carpal tunnel syndrome (CTS) is an upper extremity median nerve entrapment disorder that is rare in children and adolescents. Anatomical variations of the wrist, such as anomalous muscles, persistent median artery (PMA), and bifid median nerves (BMN), are rare etiology of CTS. Coexistence of all three variants combined with CTS in adolescents has been rarely reported. Case description: A 16-year-old right-hand dominant male presented to our clinic with several years of bilateral thenar muscle atrophy and weakness but no paresthesia or pain in his both hands. Ultrasonography showed that the right median nerve become significantly thinner, and the left median nerve was split into two branches by PMA. Magnetic resonance imaging (MRI) revealed that anomalous muscles in the bilateral wrist extending to the carpal tunnel, causing compression of the median nerve. Considering the possibility of CTS clinically, the patient underwent bilateral open carpal tunnel release without resection of anomalous muscles and PMA. The patient has no discomfort after 2 years. This suggests that anatomical variations of the carpal tunnel may contribute to CTS, which can be confirmed by preoperative ultrasonography and MRI, and the possibility of carpal tunnel anatomical variations should be considered when CTS occurs in adolescents. Open carpal tunnel release is an effective treatment for juvenile CTS without the need to resect abnormal muscle and PMA during the operation.

[Median nerve compression in the carpal tunnel in children - a delayed diagnosis. About 20 clinical cases]

OBJECTIVES

The carpal tunnel syndrome is rare in children. We performed a retrospective study of 10 children. The aim is to show that the diagnosis of carpal tunnel syndrome is difficult in children.

PATIENTS AND METHODS

We identified all children with median nerve compression in the carpal tunnel between 2010 at 2020, managed in our service.

RESULTS

Ten children with 20 hands included. There was different etiologies of carpal tunnel syndrome: 5 lysosomal storage diseases, 4 idiopathic carpal tunnel syndrome, 1 genodermatose, 1 Byler syndrome and 1 VACTERL syndrome. Common presenting symptoms were pain (five patients) and under use of fingers (five patients). Two children had opposition deficit of the thumb. We operated 19 hands. Median age at diagnosis was 4 years and 7 months. One children or 2 hands had a reanimation of opposition by tendinous transfer of flexor digitorum superficialis tendon of the ring finger. All children had a complete regression of the painful symptoms, a use improvement of fingers and recovery of the opposition of the thumb.

CONCLUSION

The diagnosis of carpal tunnel syndrome is difficult in children. It is common to be confronted with an advanced clinical symptoms. The atypical symptoms may cause diagnostic delay. Due to the quality of the clinical results obtained, we recommend open carpal tunnel release even when the diagnosis seems delayed.

LEVEL OF EVIDENCE

IV.

Outcomes of Pediatric and Adolescent Carpal Tunnel Release

PURPOSE

To investigate carpal tunnel syndrome (CTS) presentation and long-term outcomes of carpal tunnel release (CTR) in children and adolescents.

METHODS

All pediatric and adolescent patients who underwent CTR between February 2003 and June 2018 were identified. Patients were grouped by etiology: lysosomal storage disease (11 hands), idiopathic (6 hands), acute traumatic (7 hands), delayed traumatic (5 hands) and tumorous (2 hands). Medical records were reviewed for presenting symptoms and preoperative treatments. Final outcomes were assessed via phone interviews, chart review, the Boston Carpal Tunnel Questionnaire (BCTQ), and Patient-Reported Outcomes Measurement Information System (PROMIS) scores.

RESULTS

All 25 patients (31 hands) identified were included in the study; median age at surgery was 12.7 years (range, 2.5-23.3 years). Eighteen patients completed surveys at a median of 4.7 years after surgery (range, 8 months-16 years). Common presenting symptoms in lysosomal storage disease were numbness/tingling (7 hands); pain was only reported in 1 hand. The most frequent indication for acute traumatic CTR (7 hands) was palmar hand swelling at the carpal tunnel (4 hands). Delayed traumatic and idiopathic CTS most often presented with numbness/tingling (4 hands and 6 hands, respectively) and pain (3 hands, 4 hands, respectively). Of the original 4 lysosomal storage disease surgeries included in long-term follow-up, all experienced gradual recurrence of symptoms after years of relief (range, 3-14 years). Two patients underwent revision CTR and were symptom-free at follow-up. All patients with acute traumatic and tumorous etiologies had full resolution of symptoms. Delayed traumatic and idiopathic etiologies frequently experienced recurrent or recalcitrant symptoms (4 of 5 and 3 of 6 surgeries, respectively).

CONCLUSIONS

Carpal tunnel release often alleviates symptoms in children with lysosomal storage disease for years to decades. Carpal tunnel release successfully relieves symptoms in acute traumatic cases, but is not always sufficient to relieve symptoms associated with delayed traumatic etiologies. Approximately half of patients with idiopathic CTS experience recalcitrant or recurrent symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Upper Extremity Compressive Neuropathies in the Pediatric and Adolescent Populations

PURPOSE OF REVIEW

Although somewhat rare, upper extremity compressive neuropathies can occur in the pediatric and adolescent populations due to various etiologies. Some of the most common conditions seen include thoracic outlet syndrome, supracondylar process syndrome, cubital tunnel syndrome with subluxation of the ulnar nerve, and carpal tunnel syndrome. This review will focus on these diagnoses and how to address them in the pediatric and adolescent populations.

RECENT FINDINGS

Due to the rarity of upper extremity compressive neuropathies in the pediatric and adolescent populations, substantial advancement in the literature does not routinely occur. However, recent literature has found a difference in the rate of various subtypes of thoracic outlet syndrome in children versus adults. Additionally, cubital tunnel syndrome associated with ulnar nerve subluxation/instability has recently been found to have better outcomes following surgical decompression of the ulnar nerve and transposition than those with stable ulnar nerves. In summary, this review provides the most recent knowledge surrounding upper extremity compressive and entrapment neuropathies in the pediatric and adolescent populations.

Peripheral Nerve Compression Syndromes in Children

Nontraumatic neuropathies of the upper limb are rare in children. In this paper, we present the latest updates in this field and also critically review the diagnosis and treatment of nerve compression syndromes in children. This review describes the most common manifestations including idiopathic carpal tunnel syndrome (CTS), CTS occurring as a component of lysosomal storage diseases (mucopolysaccharidosis) and hereditary neuropathies, ulnar nerve neuropathy, and atraumatic radial nerve neuropathies.

Unusual Triad of Bifid Median Nerve, Persistent Median Artery, and Aberrant Muscle Causing Carpal Tunnel Syndrome: A Case Report

CASE

A 15-year-old boy presented with intermittent pain, in the left nondominant hand, for the past 3 years. He recently developed numbness in the radial 3 and a half digits. Ultrasonography revealed a bifid median nerve (BMN) with a persistent median artery (PMA). An open carpal tunnel release was performed, which revealed an accessory lumbrical muscle in addition to the BMN and a PMA.

CONCLUSION

The surgeon should be aware of the possible coexistence of 3 anomalous structures while performing carpal tunnel release in a young patient.

Peripheral nerve injuries in the pediatric population: a review of the literature. Part II: entrapment neuropathies

INTRODUCTION

Entrapment neuropathies are infrequent in children, and therefore remain unrecognized. The incidence of radial, median, and cubital mononeuropathies are all similar. Despite the rarity of such cases, extensive, albeit scattered, literature has accumulated concerning entrapment neuropathies in children.

OBJECTIVE

To the literature concerning entrapment neuropathies in children.

METHODS

A systematic review of the existing literature has been made.

RESULTS

The management of chronic pediatric pain is very important in such patients to prevent youths from experiencing prolonged absences from school, sports, or other productive activities, and limit the psychological burden of chronic disease. Nonsurgical treatment of both cubital and carpal tunnel syndromes has been disappointing in pediatric patients, with only limited success; and, to date, there is no clear explanation for the outcome differences generated by nonsurgical management between adults and youths. Simple decompression of the ulnar nerve at the elbow also has much higher rates of failure in children than in adults.

CONCLUSIONS

The presence of an entrapment neuropathy (specially carpal tunnel syndrome) in a pediatric-age patient should alert medical care providers to the potential of some underlying genetic condition or syndrome.

Orthopaedic challenges for mucopolysaccharidoses

Mucopolysaccharidoses (MPS) are a group of diseases characterized by abnormal accumulation of glycosaminoglycans (GAGs). Although there are differences among the various disease types, the osteoarticular system is always involved. The aim of the present study was to establish a framework for MPS-related orthopaedic manifestations and for their treatment. The authors, affiliated to three different Italian Orthopaedic Centres, report data taken from the literature reviewed in light of their accumulated professional experience. Bone alterations make up what is known as dysostosis multiplex, involving the trunk and limbs and with typical radiological findings. Joints are affected by pathological tissue infiltrations. The cervical spinal cord is involved, with stenosis and cervical and occipitocervical instability. In MPS there is a much higher incidence of scoliosis compared with healthy subjects without any particular distinctive feature. Kyphosis of the spine is more frequent and also more severe because of its possible neurological complications, and it is localized at the thoracolumbar level with a malformed vertebra at the top of the deformity. Evolving forms, and those associated with neurological damage, require anteroposterior spine fusion. The hip is invariably involved, with dysplasia affecting the femoral neck (coxa valga), the femoral epiphysis (loss of sphericity, osteonecrosis), and the femoral acetabulum which is flared. All these features explain the tendency to progressive hip migration. Genu valgum is often found (a deviation of the physiological axis with an obtuse angle opening laterally). This deformity is often localized at the proximal tibial metaphysis; it causes functional limitations and leads to an irregular erosion of the articular cartilage. In young patients who still have the growth plate, it is possible to execute a medial hemiepiphysiodesis, a temporary inhibition of cartilage growth, with progressive axis correction. In this paper, the characterisation of clinical features and the review of treatments are divided into separate sections based on the part of the body involved. The conclusions of each section are presented as a summary. One section discusses the high risk of anaesthesia-related complications requiring the collaboration of specifically trained personnel.

Performing Hand Surgery Under Local Anesthesia Without a Tourniquet in China

In China, wide-awake surgeries are increasingly used by surgeons in a growing number of hospitals for hand and upper extremity surgeries. Experience suggests that wide-awake surgery is safe, economical, and patient-friendly, optimizing hospital resource allocation and increasing efficiency. This article discusses which procedures are most suitable, variations in procedures, departmental impacts, and future direction.