Subacute Nerve Compressions after Trauma and Surgery of the Hand

Management of Acute Carpal Tunnel Syndrome: A Systematic Review

Purpose

This review aims to compare recovery outcomes of conservative, early operative, and a combination of conservative and operative management for acute carpal tunnel syndrome (ACTS).

Methods

A literature search of PubMed, Scopus, and CINAHL from 1970 to 2022 was conducted using the keywords carpal tunnel syndrome and acute nerve compression. ACTS was defined as a case within 12 weeks of symptom onset. Primary data extracted included causes (traumatic or atraumatic), symptom duration (<1 day, 1-7 days, or 8-84 days), intervention (surgical, conservative, or conservative then surgical), follow-up duration, and outcome (full recovery or non-full recovery). Logistic regression analyses and χ2 tests were performed to investigate associations among these variables.

Results

A total of 197 patients involving 127 (64.5%) traumatic and 70 (35.3%) atraumatic cases were included. Forty-seven percent of patients were managed conservatively followed by surgery, 30% conservative only, and 23% surgery only. The traumatic group was associated with better recovery than the atraumatic group. Recovery outcomes were not associated with symptom duration or follow-up time. The choice of intervention was not associated with traumatic or atraumatic etiology, nor did it affect recovery outcomes in either group.

Conclusions

Traumatic ACTS is associated with better recovery outcomes than atraumatic etiologies. Surgical intervention was not found to be associated with better outcomes than conservative management, regardless of the etiologies. Further prospective studies are warranted to compare surgical versus conservative management.

Clinical Relevance

Currently, there are no guidelines for the best management of ACTS, and it is not known if early or delayed surgical treatment is optimal. This review compiles the current evidence and identifies gaps in the literature, highlighting the need for further investigation to provide the best clinical practice.

Concomitant Total Shoulder Arthroplasty and Ipsilateral Carpal Tunnel Release: Is it Safe?

PURPOSE

Symptomatic carpal tunnel syndrome in patients with advanced ipsilateral glenohumeral arthritis requiring total shoulder arthroplasty (TSA) may be easily overlooked. Even when diagnosed beforehand, most upper extremity surgeons have historically chosen to perform TSA and carpal tunnel release (CTR) separately. We hypothesized that combined single-stage TSA and CTR is feasible and yields results comparable with those when the 2 procedures are performed separately, while avoiding 2 surgeries.

METHODS

This was a retrospective review of patients who underwent single-stage primary TSA and ipsilateral CTR between 2015 and 2019. The shoulder outcomes included pain, range of motion, and validated quality of life (QoL) questionnaires: Veterans RAND 12-Item Health Survey (VR-12) and Penn Shoulder Score. The CTR outcomes included pain, grip, pinch, VR-12, shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH), and Boston Carpal Tunnel Questionnaire. The time to the initiation of rehabilitation and complications were also analyzed. The comparison group consisted of patients who underwent independent TSA or CTR during the same period.

RESULTS

Forty-one patients underwent concomitant TSA and CTR, 248 underwent isolated TSA, and 154 underwent isolated CTR. The shoulder outcomes of patients who underwent the combined procedure were similar to those of patients who underwent isolated TSA in terms of pain, range of motion, general QoL (VR-12), and shoulder-specific QoL (Penn Shoulder Score). The outcomes of patients who underwent the combined procedure were similar to those of patients who underwent isolated CTR in terms of pain, grip and pinch, general QoL (VR-12), QuickDASH, and Boston Carpal Tunnel Questionnaire. The time to the initiation of rehabilitation was also comparable.

CONCLUSIONS

Concomitant CTR and TSA are feasible. The functional outcomes and QoL of patients who underwent the concomitant treatment were comparable with those of patients who underwent the 2 procedures separately.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Acute Superficial Vein Thrombosis of the Upper Extremity: A Case Report

Superficial vein thrombosis has traditionally been considered a disease of the lower extremity. Less frequently it can affect the breast, chest wall, penis, or upper extremity. Cases involving upper extremities are usually associated with intravascular access, and the vast majority remain self-limiting. This case report presents a 63-year-old patient who had acute extensive thrombosis of cephalic and basilic venous systems following resection of a desmoid tumor from the flank. This was likely related to intraoperative positioning and resulted in severe symptoms mimicking deep vein thrombosis and carpal tunnel syndrome. Additionally, diagnostic tools available to the hand surgeon that allow prompt diagnosis, management, and prevention are discussed.

Volar fracture dislocation of the 2nd metacarpal base associated with acute carpal tunnel syndrome: A case report

Posttraumatic acute carpal tunnel syndrome is a not a usual complication in traumatic hand injuries but requires more urgent and aggressive management. Compression of the median nerve should be systematically sought when there is a major and painful swelling of the hand, associated with one or several hand and wrist fractures. In rare case, a single metacarpal fracture or dislocation can be the only cause of median nerve compression and requires urgent diagnosis. If missed or neglected irreversible damage could occur to the median nerve. If surgery is perform in a timely manner outcomes are excellent, with complete recovery in most of the cases. We present the case of a 24-year-old man with an acute compression of the median nerve due to an intra-articular fracture of the 2nd metacarpal base. A bony fragment shifting from the base of 2nd metacarpal was found in the carpal tunnel participating, at least in part, in the compression of the median nerve.

Neurologic complications in common wrist and hand surgical procedures

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

Acute carpal tunnel syndrome

Acute carpal tunnel syndrome is characterized by rapid onset of median neuropathy caused by sudden increases in carpal tunnel pressures, which leads to ischemia of the median nerve. The most common cause is traumatic injury, although atraumatic sources should also be recognized. Patients generally complain of pain, lose two-point discrimination, and may demonstrate elevated compartment pressure on measurement. Prompt recognition and surgical decompression are imperative to spare median nerve viability.

Correction of contracture and recurrence rates of Dupuytren contracture following invasive treatment: the importance of clear definitions

PURPOSE

To call attention to the wide variety of definitions for recurrence that have been employed in studies of different invasive procedures for the treatment of Dupuytren contracture and how this important limitation has contributed to the wide range of reported results.

METHODS

This study reviewed definitions and rates of contracture correction and recurrence in patients undergoing invasive treatment of Dupuytren contracture. A literature search was carried out in January 2011 using the terms "Dupuytren" AND ("fasciectomy" OR "fasciotomy" OR "dermofasciectomy" OR "aponeurotomy" OR "aponeurectomy") and limited to studies in English.

RESULTS

The search returned 218 studies, of which 21 had definitions, quantitative results for contracture correction and recurrence, and a sample size of at least 20 patients. Definitions for correction of contracture and recurrence varied greatly among articles and were almost always qualitative. Percentages of patients who achieved correction of contracture (ie, responder rate) when evaluated at various times after completion of surgery ranged from 15% to 96% for fasciectomy/aponeurectomy. Responder rates were not reported for fasciotomy/aponeurotomy. Recurrence rates ranged from 12% to 73% for patients treated with fasciectomy/aponeurectomy and from 33% to 100% for fasciotomy/aponeurotomy. Review of these reports underscored the difficulty involved in comparing correction of contracture and recurrence rates for different surgical interventions because of differences in definition and duration of follow-up.

CONCLUSIONS

Clearly defined objective definitions for correction of contracture and for recurrence are needed for more meaningful comparisons of results achieved with different surgical interventions.

CLINICAL RELEVANCE

Recurrence after surgical intervention for Dupuytren contracture is common. This study, which evaluated reported rates of recurrence following surgical treatment of Dupuytren contracture, provides clinicians with practical information regarding expected long-term outcomes of surgical treatment choices.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and decision analysis III.

[Special considerations in breast cancer treatment of an augmented breast]

Breast augmentation surgery involving the use of implants has been one of the most popular plastic surgical procedures for decades. As the multi-million female population who received breast implants ages, the risk of cancer is increasing rapidly, therefore the incidence of malignant disease in association with breast implants will increase as well. Although there is no relationship between tumor development and implants, these cases require special considerations in diagnostics, therapy and follow-up methods. Appropriate multidisciplinary treatment of tumors in augmented breasts corresponding with modern oncoplastic principles can only be accomplished based on adequate oncological, breast and plastic surgical knowledge. Supposing a possible increase of this condition in Hungary, too, authors provide a wide review of the literature on the special oncological and esthetic considerations, for the first time in Hungarian language.

A rare cause of carpal tunnel syndrome in childhood: Benign recurrent intrahepatic cholestasis

Carpal tunnel syndrome and benign recurrent intrahepatic cholestasis are rare conditions in childhood. Benign intrahepatic cholestasis is characterized by repeated self-limited attacks of cholestasis that can start at any age and last from weeks to months. The patients are asymptomatic between these attacks. We report a 16 year-old male patient with benign recurrent intrahepatic cholestasis who developed carpal tunnel syndrome during a cholestatic attack. He was admitted with complaints of jaundice, pruritus and pain, tingling and muscle weakness in both hands for 15 days. Nerve conduction studies revealed findings compatible with carpal tunnel syndrome. He was started on ursodeoxycholic acid, fat soluble vitamins and cholestyramine and cholestasis regressed after four weeks of therapy. With the improvement of cholestasis, the symptoms of carpal tunnel syndrome also disappeared. In conclusion, benign recurrent intrahepatic cholestasis can be a rare cause of carpal tunnel syndrome in childhood. We also advocate treating the underlying disease as an appropriate conservative treatment before surgery.

Relief of the pain of neuromas-in-continuity and scarred median and ulnar nerves in the distal forearm and wrist by neurolysis, wrapping in vascularized forearm fascial flaps and adjunctive procedures

This prospective study reports treatment by neurolysis then wrapping the nerves in vascularized forearm fascia and, when necessary, adjunctive procedures of twelve median and two ulnar nerves in continuity in the distal forearm with neurogenic pain. Preoperatively, all 14 patients had severe pain in at least one of the five modalities of pain analysed. There was complete resolution of all modalities of pain in eight of 14 patients following neurolysis and fascial nerve wrap surgery and two more patients had only mild pain in one or two modalities. After the addition of wrist pinning or arthrodesis alone or in conjunction with selective division of flexor tendons in four patients, there was complete resolution of all modalities of pain in nine of 14 patients. A further three patients had mild pain in three or less modalities and only one patient continued to have severe pain in one modality.

The triad of multiple metacarpal fractures and/or dislocations of the fingers, severe hand swelling and clinical evidence of acute median nerve dysfunction

Twenty-five cases of crush injury to the hand resulting in the triad of multiple finger metacarpal fractures/dislocations of the fingers, a balloon hand appearance due to severe swelling and clinical evidence of acute median nerve dysfunction were retrospectively reviewed. All were men with a mean age of 33 (range 20-45) years. All injuries occurred following industrial or major car accidents. The fracture site included metacarpal head/neck fractures, metacarpal shaft fractures and carpometacarpal joint fracture-dislocations. All patients underwent fasciotomies, open carpal tunnel release and fixation of displaced fractures, followed by immediate mobilisation of the fingers. At a mean final follow-up of 7 (range 6-8) months, full recovery of median nerve function was seen in all patients. The final mean total active motion of the fingers was 243 degrees , 230 degrees and 250 degrees in displaced distal, middle and proximal impact fractures, respectively. All patients were able to return back to work.