Carpal tunnel syndrome in children

Functional results after carpal tunnel release in mucopolysaccharidosis

BACKGROUND

Mucopolysaccharidosis consists of a group of diseases caused by the deficiency of lysosomal enzymes, which may lead to the compression of the median nerve in the carpal tunnel due to the accumulation of glycosaminoglycan, resulting in the hand disability. The study purpose is to present functional results of carpal tunnel release in mucopolysaccharidosis patients. Patients were selected from an enzyme replacement group in the Department of Pediatric Neurology. The legal guardians of the patients were informed about the likely functional change of the hands induced by compression of the median nerve. Clinical evaluation was performed in those patients who received their legal guardians' consent to participate and was included inspection, assessment of functional level, wrinkle test and the digital pinch function to manipulate small and large objects. Ultrasound and electromyography were performed to confirm the clinical median nerve compression. Bilateral extended opening technique was performed to access the carpal tunnel and analyze the anatomic findings of the median nerve and the flexed tendons of the fingers. After the surgical release of the carpal tunnel, the clinical evaluation was repeated. Subjective observations of the legal guardians were also considered.

RESULTS

Seven patients underwent bilateral surgical opening of the carpal tunnel; six boys, mean age of 9.5 (5 to 13), five of them presenting Type II mucopolysaccharidosis, 1 Type I and 1 Type VI. The average follow-up was 12 months (10-13 months). The functional results observed included the improvement in the handling of small and large objects in all children who underwent decompression of the median nerve. The comparison between the pre-operative and post-operative functional levels revealed that 2 patients evolved from Level II to IV, 3 from Level III to IV, 1 from Level IV to V and 1 patient remained in Level III. Tenosynovitis around the flexor tendons and severe compression of the median nerve in the fourteen carpal tunnels were observed during the surgical procedure. In 6 wrists, partial tenosynovitis was performed.

CONCLUSIONS

Despite the improvement in the overall function of the children' hands, we cannot conclude that only surgery was responsible for the benefit. Better designed studies are required.

Etiology of Carpal Tunnel Syndrome in a Large Cohort of Children

(1) Background: Carpal tunnel syndrome (CTS), a compressive mononeuropathy of the median nerve at the wrist, is rare in childhood and occurs most frequently due to secondary causes. (2) Methods: Medical history, electrodiagnostic findings, and imaging data of patients with CTS from two pediatric neuromuscular centers were analyzed retrospectively. The etiology of CTS was investigated and compared with the literature. (3) Results: We report on a cohort of 38 CTS patients (n = 22 females, n = 29 bilateral, mean age at diagnosis 9.8 years). Electrodiagnostic studies of all patients revealed slowing of the antidromic sensory or orthodromic mixed nerve conduction velocities across the carpal tunnel or lack of the sensory nerve action potential and/or prolonged distal motor latencies. Median nerve ultrasound was diagnostic for CTS and confirmed tumorous and vascular malformations. Etiology was secondary in most patients (n = 29; 76%), and mucopolysaccharidosis was the most frequent underlying condition (n = 14; 37%). Idiopathic CTS was rare in this pediatric cohort (n = 9; 24%). (4) Conclusion: Since CTS in childhood is predominantly caused by an underlying disorder, a thorough evaluation and search for a causative condition is recommended in this age group.

[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.

Early Recurrent Carpal Tunnel Syndrome in Patients with Mucopolysaccharidoses

Supplemental Digital Content is available in the text.

Early-onset carpal tunnel syndrome (CTS) is a well-known manifestation of mucopolysaccharidoses (MPS) due to excessive deposition of glycosaminoglycans in soft tissues. Standard treatment has been carpal tunnel release surgery, with the conventional technique of dividing the transverse carpal ligament. With advancement of treatments for MPS, these patients now have a longer life expectancy and are presenting with recurrent CTS. Management of recurrent CTS in these patients is not well studied. Here, we report 2 cases of recurrent CTS in MPS patients after a carpal tunnel release operation. We describe the findings on repeat operations and propose a unique technique for treating CTS in MPS patients to minimize recurrence during the initial CTS surgery. Our method involves resection of a portion of the transverse carpal ligament and use of a hypothenar fat pad flap over the median nerve.

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.

Utility and practice of electrodiagnostic testing in the pediatric population: An AANEM consensus statement

Nerve conduction studies and needle electromyography, collectively known as electrodiagnostic (EDX) studies, have been available for pediatric patients for decades, but the accessibility of this diagnostic modality and the approach to testing vary significantly depending on the physician and institution. The maturation of molecular diagnostic approaches and other diagnostic technologies such as neuromuscular ultrasound indicate that an analysis of current needs and practices for EDX studies in the pediatric population is warranted. The American Association of Neuromuscular & Electrodiagnostic Medicine convened a consensus panel to perform literature searches, share collective experiences, and develop a consensus statement. The panel found that electrodiagnostic studies continue to have high utility for the diagnosis of numerous childhood neuromuscular disorders, and that standardized approaches along with the use of high-quality reference values are important to maximize the diagnostic yield of these tests in infants, children, and adolescents.

Strengthening the association of lipomatosis of nerve and nerve-territory overgrowth: a systematic review

OBJECTIVE

Lipomatosis of nerve (LN) is a massive enlargement of a nerve due to abundant proliferation of adipose and fibrotic tissue within the epineurium—part of the spectrum of adipose lesions of nerves, including intra- and extraneural lipomas. LN has been frequently associated with soft-tissue and/or osseous overgrowth. Unfortunately, much confusion exists since many names have been used for LN (e.g., fibrolipomatous hamartoma, macrodystrophia lipomatosa, and so on). To better understand this condition and to evaluate its association with nerve-territory overgrowth, the authors attempted to compile the world’s literature on published LN cases.

METHODS

PubMed and Google Scholar databases were searched to identify published articles on LN cases, using a variety of terms. Publications in all languages were assessed. All publications with cases determined likely to be LN were read. Cases that provided clear clinicopathological and/or radiological evidence of LN were labeled as “definite” and cases that demonstrated features of LN (e.g., nerve-territory overgrowth) but lacked definite proof of nerve involvement were labeled as “probable.”

RESULTS

Initial screening revealed a total of 2465 papers. After exclusions, 281 publications reported cases with a definite diagnosis of LN and 120 articles reported cases with a probable diagnosis of LN. The authors identified 618 definite and 407 probable cases of LN. Sex distribution was balanced (51% female). Early diagnosis was common, with two-thirds of patients having symptoms in the 1st decade of life. The most commonly affected nerve was the median nerve (n = 391). Nerve-territory overgrowth was common (62% definite LN; 78% combined cases); overgrowth was exclusive to the territory of the affected nerve in all cases but 5.

CONCLUSIONS

The authors present a comprehensive review and analysis of the literature of LN cases. One of the main findings was the nerve-territory overgrowth was associated with LN, especially when present earlier in life. The authors believe that all cases of LN associated with overgrowth can be explained on anatomical grounds, even in the few reported cases in which this is not immediately obvious.

Carpal tunnel syndrome and associated nail changes: Review and examples from the author's practice

Carpal tunnel syndrome (CTS) is commonly seen by general practitioners and often presents with neurologic symptoms of nocturnal pain and paresthesia along the median nerve distribution. Approximately 20% of patients also present with cutaneous findings (ulcerations, blistering, sclerodactyly, nail dystrophy) characterizing a severe form called necrotic CTS. Necrotic CTS can also be associated with bone changes (acro-osteolysis). In the author's practice, combined nail and skin findings are not an uncommon presentation of CTS, although this form remains overlooked and underreported in the dermatological textbooks and studies. This manuscript aims to review the literature on CTS cases, with a specific focus on using associated nail findings as diagnostic clues. The literature review along with a few additional recent cases from the author's practice demonstrate that CTS is frequently accompanied by a variety of nail changes including koilonychia, longitudinal fissuring, Beau's lines, onychomadesis, melanonychia, nail thickening, hyperkeratosis, and ischemic ulcerations with paronychia. Furthermore, when these changes are limited to the second and third fingernails, they should prompt the diagnosis of CTS. Once suspected, diagnostic evaluation is not difficult and surgical management can resolve cutaneous findings and prevent irreversible changes such as acro-osteolysis.

Diagnosis and Management of Carpal Tunnel Syndrome in Children with Mucopolysaccharidosis: A 10 Year Experience

INTRODUCTION

Mucopolysaccharidoses (MPS) are rare and clinically heterogeneous lysosomal storage disorders. Carpal tunnel syndrome (CTS) is a frequent complication in MPS types I, II, VI, and VII. CTS symptoms are difficult to recognize in these children, and often there is a lack of appropriate investigations.

PATIENTS AND METHODS

In this retrospective study, all MPS patients were referred to the electrodiagnostic (EDX) laboratory of a single academic center during a 10-year period. Forty-eight children underwent serial EDX studies for CTS diagnosis and follow-up after surgery. Forty-two patients were diagnosed with CTS. Sensory nerve conduction velocity (SNCV), distal motor latency (DML), and motor nerve conduction velocity through the wrist (MNCV-W) of the median nerve were reviewed and analyzed.

RESULTS

One-hundred-three EDX examinations were performed on 48 patients. The median age at disease diagnosis was 2.1 years versus 4.9 years for CTS diagnosis. Analysis of the series revealed that electrophysiological abnormalities of CTS could have started much earlier (before the age of 2 years or at diagnosis of MPS). Diagnosis was based on SNCV and DML results, and MNCV-W was taken into consideration. Bilateral CTS was frequent (88%) in the types of MPS studied in our population and was observed from the first year of life, and may not have be associated with obvious clinical symptoms. EDX studies also helped in the follow-up and detection of CTS relapses, thus leading to an early intervention allowing a better recovery.

CONCLUSION

EDX studies should be performed promptly and regularly in these patients. Prospective studies are required in order to understand the effect of disease-specific therapies in preventing the development of CTS in these patients.

SYNOPSIS

EDX studies should be performed in MPS patients soon after diagnosis and during routine follow-up, before and after surgical decompression.

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.

The carpal tunnel syndrome in children

INTRODUCTION

Carpal tunnel syndrome (CTS) in children represents a complex challenge for the hand surgeon because of its rarity, poor patient cooperation, frequently associated malformation syndromes and mental retard, atypical symptoms and nuanced and poor sensitivity of instrumental tests. The most frequently associated causes with the CTS in children are rare congenital malformations and diseases, requiring an overall assessment of the young patient and a high degree of suspicion for the potentially associated canalicular syndrome. On the other hand, the associated syndromes may be the main ally for a diagnosis that starts from the knowledge of the literature and the surgeon's suspicion by observing the child wailing. Early diagnosis and decompression treatment is mandatory.

MATERIALS AND METHODS

The authors report a case series of 26 children and analyze the etiology and diagnostic algorithms. Patient assessment was based on complete clinical examination and medical history collection of these young patients with the involvement of the family and educators.

RESULTS

In all 26 patients treated, along an average period of 23 months (minimum 12, maximum 30), no signs of recurrence or persistence of median nerve disturbances were recorded.

CONCLUSIONS

In conclusion, we believe that anamnesis, a careful physical examination and analysis of instrumental examinations, should be accompanied by a thorough knowledge of rare diseases in the context of congenital malformations. The carpal tunnel syndrome, while well known and treated by each orthopedic surgeon, reveals a mysterious aspect in the context of the "fabulous" world of childhood illnesses, even more difficult than rare congenital diseases.

Prevalence of Mucopolysaccharidosis Types I, II, and VI in the Pediatric and Adult Population with Carpal Tunnel Syndrome (CTS). Retrospective and Prospective Analysis of Patients Treated for CTS

BACKGROUND

We wanted to investigate whether the prevalence of mucopolysaccharidoses (MPS) I, II, and VI was higher than expected in a selected cohort of patients with carpal tunnel syndrome (CTS). CTS is a common finding in patients with MPS, and therefore we screened patients who had undergone surgery for CTS for undiagnosed MPS.

PATIENTS AND METHODS

Patients who had been operated for CTS were found in databases from two hospitals. Furthermore, patients who had undergone surgery for CTS when under the age of 18 were retrieved from the National Patient Registry. All included patients had a filter paper blood spot sample taken that was subsequently analyzed enzymatically for MPS I, II, and VI.

RESULTS

425 patients were included. 402 patients tested negative in the first test. 23 had inconclusive result whereof 18 was negative in a second test. The remaining five patients had two inconclusive tests each and were referred for further examination at the Center for Inherited Metabolic Diseases where the diagnosis was excluded. Thus, all included patients were negative for both MPS I, II and VI.

DISCUSSION/CONCLUSION

Though our sample size is relatively small, results indicate that MPS is not prevalent in a cohort of adult patients with monosymptomatic CTS, and that screening is not indicated in this setting.

Carpal Tunnel Syndrome in an Adolescent With Obesity

PURPOSE

Carpal tunnel syndrome (CTS) is typically found in adults and may be associated with a variety of metabolic conditions including obesity. Obesity is a growing problem among today's youth, and adult diseases often associated with obesity are now being found in a younger population. This case study describes a young adolescent girl with obesity and CTS.

SUMMARY OF KEY POINTS

A history and examination were completed before electrophysiologic testing, and the patient had no evidence of any contributory pathology.

STATEMENT OF CONCLUSIONS

There was electrophysiologic evidence of bilateral median nerve compromise at the wrist. The patient's diagnosis of CTS may be obesity related.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Management of patients with obesity and CTS should also include education about weight management in addition to traditional interventions. This may be even more important for a child or adolescent with obesity and CTS.

Idiopathic carpal tunnel syndrome in children and adolescents

PURPOSE

A retrospective review of a single institution's experience with idiopathic carpal tunnel syndrome (CTS) in children and adolescents was performed to evaluate management and outcomes in an effort to establish a treatment protocol.

METHODS

All patients diagnosed with idiopathic CTS from ages 1 to 16 years of age between 1983 and 2013 were reviewed. The results of diagnostic testing and efficacy of therapeutic interventions were analyzed. The Boston Carpal Tunnel Questionnaire was sent to all patients following medical or surgical management.

RESULTS

A total of 20 patients with 31 involved wrists met criteria for entrance into the study. The mean age at diagnosis was 14.4 years. Orthosis fabrication was used as the initial treatment in 30 of 31 wrists and was successful in completely alleviating symptoms in 9 of 30 wrists. A steroid injection was performed in 11 of 31 wrists, completely relieving symptoms in 5 of 11 wrists. Carpal tunnel release was performed in 10 of 31 wrists. Following surgery, patients had complete relief of symptoms in 5 of 10 wrists and partial relief of symptoms in 5 of 10 wrists. Questionnaire response incidence was 55% (11 of 20), with an average long-term follow-up of 17.6 years. Eight questionnaire respondents continued to have mild to moderate symptoms while performing activities of daily living.

CONCLUSIONS

Once metabolic, anatomical, and hereditary causes of pediatric CTS are ruled out, a reasonable treatment course should follow that of adults with orthosis fabrication, followed by injection, and then surgery for those that are refractory to nonsurgical treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Idiopathic bilateral carpal tunnel syndrome in a 9-month-old infant presenting as a pseudo-dystonia

BACKGROUND

Carpal tunnel syndrome is the most common focal peripheral neuropathy seen in most electrophysiological laboratories. Although the incidence of carpal tunnel syndrome in adults is 50 to 150 cases per 100,000 people, it is rare in children. There are less than 200 case reports of carpal tunnel syndrome in children, with mucopolysaccharides and mucolipidosis being the most frequent cause. Idiopathic carpal tunnel syndrome with childhood onset occurs in less than 0.2% of cases.

PATIENT

We describe a 9-month-old infant who presented with intermittent abnormal posturing movement of both hands.

RESULTS

The clinical presentation and the electrophysiological studies confirmed the diagnosis of carpal tunnel syndrome. His dystonic posturing had disappeared completely 3 weeks after surgical release of both flexor retinaculi.

CONCLUSION

We are not only reporting the youngest child with carpal tunnel syndrome, but we also report a new cause of abnormal movement disorder in children.

Necrotic carpal tunnel syndrome in a child

Median nerve entrapment at the wrist level causes carpal tunnel syndrome (CTS). Although frequent in adults, CTS is a rare entity in children. Bouvier described an exceptional necrotic variant in 1979 in which skin, nail, and bone lesions are typical. We report the case of a 10-year-old child with necrotic CTS secondary to trauma. To our knowledge, this is the first case reported in a child.

Carpal tunnel syndrome in children

Carpal tunnel syndrome rarely occurs in children. We retrospectively analyzed clinical data of 11 patients aged 5-17 diagnosed with carpal tunnel syndrome at a single pediatric neuromuscular center. Nerve conduction studies were performed according to the American Association of Electrodiagnostic Medicine recommendations. Additional imaging tests of the wrist were performed in 10 patients. In our group of 11 children, carpal tunnel syndrome was idiopathic in only 1 case. In the remaining subjects, it was secondary to congenital bone anomaly (6), hypothyroidism (2), or myopathic contractures (1). In 1 case, metabolic workup revealed an underlying mucopolysaccharidosis. Our results confirm that idiopathic carpal tunnel syndrome is rare in children. Hand clumsiness and thenar hypoplasia rather than sensory complaints are the presenting symptoms. Whenever carpal tunnel syndrome is diagnosed in a child, a thorough differential diagnosis should be made because of the secondary nature of this disease in most pediatric patients.

Diagnosis of the mucopolysaccharidoses

The mucopolysaccharidoses (MPSs) often present a diagnostic challenge, particularly for patients who have more slowly progressive disease phenotypes, as early disease manifestations can be subtle or non-specific. However, certain types of bone and joint involvement should always prompt consideration of an MPS diagnosis, such as early joint involvement without classic inflammatory features or erosive bone lesions, claw hand, spinal deformities or dysostosis multiplex. All such patients should be referred to a geneticist or metabolic specialist for diagnostic evaluation. The earlier the diagnosis is made, the better the potential outcome of treatment. Each type of MPS is associated both with deficient activity of a specific lysosomal enzyme that degrades specific glycosaminoglycans (GAGs) and with abnormalities in urinary GAG excretion. MPS patients usually excrete excess GAG in urine and/or have different relative proportions of types of GAG in urine as compared with age-matched normal subjects. Although urinary GAG analyses (both quantitative and qualitative) can suggest the most likely type of MPS, diagnosis must be confirmed by enzyme assay. Multiple assays may be necessary to identify the disease subtype. Correct identification of the MPS type is essential to guide treatment and management decisions.

Increased prevalence of carpal tunnel syndrome in albright hereditary osteodystrophy

CONTEXT

Albright hereditary osteodystrophy (AHO) is a rare genetic disorder characterized by phenotypic abnormalities including brachydactyly/brachymetacarpia, short stature, and sc ossifications. Carpal tunnel syndrome (CTS) is a chief complaint in many patients with AHO.

OBJECTIVE

The objective of the study was to investigate the prevalence of CTS in patients with AHO.

DESIGN

This was a cross-sectional study.

SETTING

The study was conducted at the Clinical Research Center (Institute of Clinical and Translational Medicine), Johns Hopkins University School of Medicine and Albright Clinic, Kennedy Krieger Institute.

PARTICIPANTS

Thirty-three subjects with a diagnosis of AHO participated in the study.

MAIN OUTCOME MEASURES

We assessed for the presence and location of hand tingling, numbness, pain, weakness, flick sign, difficulty with fine motor skills, severe hand or nail biting, and nocturnal symptoms in the setting of normocalcemia and a euthyroid state. Patients were considered to have CTS if they were positive for three of these symptoms. All subjects were analyzed for mutations in the GNAS gene.

RESULTS

Twenty-two subjects (67%) had a clinical diagnosis of CTS (95% confidence interval 0.48, 0.82). Twenty-eight of 33 subjects were confirmed to have mutations in GNAS, of whom 68% had CTS (95% confidence interval 0.48, 0.84). There were 14 children in this study; 36% had a clinical diagnosis of CTS. Body mass index, brachydactyly/brachymetacarpia, prior GH treatment, and specific GNAS mutations were not associated with CTS.

CONCLUSIONS

We report a high prevalence of CTS in both adults and children with AHO. The diagnosis of CTS should be considered when evaluating a patient with AHO because the intervention for CTS could improve overall function and quality of life in these patients.

Orthopaedic management of Hurler's disease after hematopoietic stem cell transplantation: a systematic review

OBJECTIVE

The introduction of hematopoietic stem cell transplantation (HSCT) has significantly improved the life-span of Hurler patients (mucopolysaccharidosis type I-H, MPS I-H). Yet, the musculoskeletal manifestations seem largely unresponsive to HSCT. In order to facilitate evidence based management, the aim of the current study was to give a systematic overview of the orthopaedic complications and motor functioning of Hurler's patients after HSCT.

METHODS

A systematic review was conducted of the medical literature published from January 1981 to June 2010. Two reviewers independently assessed all eligible citations, as identified from the Pubmed and Embase databases. A pre-developed data extraction form was used to systematically collect information on the prevalence of radiological and clinical signs, and on the orthopaedic treatments and outcomes.

RESULTS

A total of 32 studies, including 399 patient reports were identified. The most frequent musculoskeletal abnormalities were odontoid hypoplasia (72%), thoracolumbar kyphosis (81%), genu valgum (70%), hip dysplasia (90%) and carpal tunnel syndrome (63%), which were often treated surgically during the first decade of life. The overall complication rate of surgical interventions was 13.5%. Motor functioning was further hampered due to reduced joint mobility, hand dexterity, motor development and longitudinal growth.

CONCLUSION

Stem cell transplantation does not halt the progression of a large range of disabling musculoskeletal abnormalities in Hurler's disease. Although prospective data on the quantification, progression and treatment of these deformities were very limited, early surgical intervention is often advocated. Prospective data collection will be mandatory to achieve better evidence on the effect of treatment strategies.

Carpal tunnel syndrome secondary to ganglion cyst in a child

Carpal tunnel syndrome is uncommon in children and is associated with an underlying etiology in the majority of cases. The diagnosis of the condition in childhood is dependent on a high degree of clinical suspicion, careful clinical examination, and judicious use of confirmatory investigations. The authors report a novel cause of carpal tunnel syndrome in a child, and discuss the investigation and management strategies in childhood carpal tunnel syndrome.

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.

Familial primary carpal tunnel syndrome with possible skipped generation

Carpal tunnel syndrome, an entrapment neuropathy of the median nerve, is rarely seen in childhood. Familial carpal tunnel syndrome, an even more exceptional entity, is frequently associated with inherited systemic disorders. Rarely it can be presented as a primary familial form with Mendelian autosomal dominant inheritance. We report the occurrence of carpal tunnel syndrome in two generations of a family in which the index case was a 6-year-old boy with bilateral hand pain and paresthesias. Our report demonstrates an interesting inheritance pattern of carpal tunnel syndrome in a family transmitted by an autosomal dominant gene with variable expressivity and reduced penetrance. To our knowledge, it is the first report of familial bilateral carpal tunnel syndrome in a family with possible skipped generation.

Neurophysiologic abnormalities in children with Charcot-Marie-Tooth disease type 1A

Although Charcot-Marie-Tooth disease type 1A (CMT1A) initially manifests in the first decade, there are no large studies describing its neurophysiologic features in childhood. We report neurophysiologic findings in 80 children aged 2-16 years with CMT1A who underwent median motor and sensory nerve conduction studies. Neurophysiologic abnormalities were present in all children. Median motor nerve conduction velocity was invariably less than 33 m/s (mean 18.7 m/s, range 9.0-32.9 m/s), with conduction velocities significantly slower in children aged 7-16 years compared with children aged 6 years and below. All children had prolonged distal motor latencies (mean 7.3 ms, range 4.0-12.3 ms). The compound muscle action potential (CMAP) amplitude was reduced from an early age (mean 7.1 mV, range 2.1-13.5 mV), and its normal increase with age was attenuated. Median sensory responses were present in only seven children, all aged less than 9 years and with slowed sensory conduction. Neurophysiologic abnormalities are present in all children with CMT1A from the age of 2 years. Motor conduction slowing progresses through the first 6 years of life and thereafter remains stable. CMAP amplitude is reduced from an early age, and the normal physiologic increase with age is attenuated. Median sensory responses may be recorded in younger children, and their presence does not exclude the diagnosis of CMT1A.

Carpal tunnel syndrome in lysosomal storage disorders: simple decompression or external neurolysis?

Thirty-two patients (61 limbs) with lysosomal storage disorders underwent surgery for 'carpal tunnel syndrome'. Twenty-two limbs underwent a simple decompression whereas 39 limbs underwent additional neurolysis and tenosynovectomy. Data were incomplete for six patients (12 limbs). The mean age at operation for the decompression group (11 patients) was 10.5 years and for the neurolysis group (15 patients), 6.9 years. Overall, using a neurophysiological rating system, 39% of limbs demonstrated sensory improvement and 47% motor improvement with no significant difference between the groups. Only in the neurolysis group was a decline in motor conduction (2/29 limbs) or sensory conduction (four limbs) noted. Using neurophysiological criteria, no added benefit from external neurolysis was identified.

Recurrent carpal tunnel syndrome in a child due to fibrolipomatous hamartoma of the median nerve successfully treated by limited excision and decompression

We present a case of recurrent carpal tunnel syndrome in a child caused by fibrolipomatous hamartoma of the median nerve which was successfully treated by limited excision of the fibrolipomatous tissue and decompression.

Carpal tunnel syndrome and flexion contracture of the digits in a child with familial hypercholesterolaemia

This paper presents a 9 year-old girl who had flexion contracture of digits, carpal tunnel syndrome and multiple xanthomas covering the extremities.