High-resolution ultrasonography of the carpal tunnel

Twenty-eight wrists of 25 patients with carpal tunnel syndrome (CTS) and 28 wrists of 14 normal control subjects were studied with high-frequency real-time ultrasonography. Three general findings could be observed in CTS, regardless of its cause: swelling of the median nerve at the entrance of the carpal tunnel; flattening of the median nerve in the distal carpal tunnel; and increased palmar flexion of the transverse carpal ligament. Quantitative analysis proved these findings to be significant. We conclude that high-resolution sonography is able to diagnose median nerve compression in the carpal tunnel syndrome and to detect some of its potential causes.     

Ulnar nerve involvement in carpal tunnel syndrome

This is a retrospective study of the involvement of the ulnar nerve in patients with electrodiagnostic evidence of carpal tunnel syndrome as defined by median sensory nerve action potential (SNAP) greater than 3.6msec at the wrist and/or motor distal latency in excess of 4.3msec. The study included 248 patients, 63 (25%) with unilateral and 185 (75%) with bilateral carpal tunnel syndrome. The electrodiagnostic criteria for ulnar nerve involvement was a SNAP peak latency greater than 3.7msec and/or motor distal latency in excess of 4.2msec. One hundred fourteen patients (46%) had delayed ulnar SNAP peak at the wrist; of these, 100 cases had bilateral ulnar nerve involvement and 14 had unilateral abnormalities. Slowing of the motor nerve conduction velocity for the elbow-wrist segment was noted in 24% and 15% of the study group for the median and ulnar nerves, respectively. An incidental finding was the presence of "double crush syndrome" in 35 patients (14%). The results of this study suggest the frequent association of ulnar nerve involvement at the wrist for sensory fibers and carpal tunnel syndrome.     

Subjective swelling: a new sign for carpal tunnel syndrome

This single-blinded, randomized cohort study of 186 patients was conducted to determine whether the subjective complaint of swelling of the hand or wrist is associated with the diagnosis and/or prognosis of carpal tunnel syndrome. All patients were referred for splinting with a presenting clinical diagnosis of carpal tunnel syndrome from outpatient specialty clinics, including orthopedics, rheumatology, and neurology. Patients were assessed before splinting for the complaint of subjective swelling and underwent a clinical examination including Phalen testing and carpal compression testing. In addition, 211 of the 290 joints underwent electrodiagnostic testing by the end of this study. Among the 211 joints for which electrodiagnosis was used, a chi2 analysis was performed to determine the correlation among subjective swelling, the Phalen and carpal compression tests, and the electrodiagnostically verified carpal tunnel syndrome. Two weeks after splinting, an assessment was made of the subjective response to splinting. Chi2 analysis was then performed to assess the correlation among the Phalen test, carpal compression test, and nerve conduction study results and the symptom of subjective swelling at presentation with that of response to splinting. Subjective swelling of the hand showed a trend toward association with electrodiagnostic results (although this finding was not statistically significant) and proved to be significantly correlated with a poor clinical response to splinting. Positive electrodiagnostic findings were significantly, though positively, correlated with pain relief from splinting. This study, therefore, introduces the complaint of subjective swelling of the affected hand as an important diagnostic and prognostic symptom for the assessment and treatment of carpal tunnel syndrome.     

高频超声对ECTR术后神经解剖学参数的动态评估价值

目的 探讨高频超声对关节镜下腕管松解术后神经解剖学参数的动态评估价值。方法 随访31例（44腕）腕管综合症患者术前3天,术后2周、4周、3月、6月、1年正中神经卡压近端水肿范围、腕管入口正中神经直径及横截面积,并根据横截面积绘制高频超声诊断腕管综合征ROC曲线。结果 术后各神经解剖学参数逐步改善,术后1个月至3个月各解剖学参数改善最明显。高频超声对CTS具有较高的诊断效能。结论 高频超声能够对关节镜下腕管松解术后神经解剖学参数进行有效地的动态评估。     

Persistent median artery in the carpal tunnel: color Doppler ultrasonographic findings.

OBJECTIVE: To describe the ultrasonographic and color Doppler ultrasonographic findings in 2 patients with carpal tunnel syndrome associated with a persistent median artery and to report the frequency of this anatomic variation in healthy volunteers. METHODS: Two patients with the clinical appearance of carpal tunnel syndrome and 100 wrists and distal forearms of 50 asymptomatic volunteers were examined with ultrasonography and color Doppler ultrasonography. The frequency and size of a persistent median artery and its relationship to median nerve anatomy in the carpal tunnel were evaluated. RESULTS: A large persistent median artery of 3 mm in diameter was found in the affected hands in both patients with carpal tunnel syndrome. Findings were confirmed at surgery. Among the asymptomatic volunteers, a persistent median artery could be found in 13 (26%, 10 [20%] unilateral and 3 [6%] bilateral), with a mean diameter of 1.1 mm (range, 0.5-1.7 mm). In 10 (63%) of 16 hands, the persistent median artery was associated with high division of the median nerve or a bifid nerve configuration in the carpal tunnel. CONCLUSIONS: A persistent median artery is a common condition in healthy individuals and in most cases is related to median nerve variations such as high division or a bifid nerve. Because a persistent median artery has a superficial course close to the transverse carpal ligament, preoperative diagnosis of this anatomic variation may be of clinical importance.     

感觉神经传导检查比较法在诊断轻度腕管综合征中的应用

目的寻找诊断轻度腕管综合征（CTS）敏感的神经电生理指标。方法回顾性分析经吉林大学第一医院手外科医生临床诊断,并经手术治疗疗效确实,但常规电生理检查提示拇短展肌复合肌肉动作电位的潜伏期（CAMP）及示、中指感觉神经传导检查正常的患者80人,共92例手的腕管综合征患者进行神经电生理分析,采用顺向法记录掌腕正中、尺神经混合神经电位潜伏期时差和环指腕正中、尺神经感觉神经电位潜伏期时差,以潜伏期时差差值≥0．4ms为阳性指标,计算其阳性符合率,并进行统计学分析。结果掌腕正中、尺神经混合神经电位潜伏期时差≥0．4ms为64例,阳性率为69．56％;环指腕正中、尺神经感觉神经电位潜伏期时差≥0．4ms为83例,阳性率为90．21％。其中两种方法均为阳性的62例,均为阴性的7例。结论环指腕正中、尺神经感觉神经电位潜伏期时差在诊断轻度腕管综合征时具有较高的诊断价值。     

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.     

Value of the lumbrical-interosseous technique in carpal tunnel syndrome

OBJECTIVE: To determine whether the second lumbrical-interosseous technique has comparable sensitivity with the median-ulnar transcarpal mixed nerve technique (palmdiff). DESIGN: A prospective series of consecutive patients with median distribution paresthesias were evaluated with electrodiagnostic testing. Outpatient veterans referred by a heterogeneous group of specialists and generalists to the Portland Veterans Affairs Medical Center electrodiagnostic laboratory. A total of 129 consecutive veterans referred for evaluation of median distribution paresthesias were assessed with two electrodiagnostic tests. RESULTS: The second lumbrical-interosseous technique performed with equal sensitivity (60.5%) to the palmdiff technique, with the added unique feature of its being uniformly obtainable. CONCLUSIONS: The second lumbrical-interosseous technique is characterized by performance equal to the palmdiff in categorizing carpal tunnel syndrome. It is also characterized by being nearly uniformly obtainable, even in severe carpal tunnel syndrome. These features suggest a wider role for the second lumbrical-interosseous technique than currently accepted.     

Diagnostic and therapeutic injection of the wrist and hand region

Joint injection of the wrist and hand region is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures for carpal tunnel syndrome, de Quervain's tenosynovitis, osteoarthritis of the first carpometacarpal joint, wrist ganglion cysts, and digital flexor tenosynovitis (trigger finger) are reviewed. Indications for carpal tunnel syndrome injection include median nerve compression resulting from osteoarthritis, rheumatoid arthritis, diabetes mellitus, hypothyroidism, repetitive use injury, and other traumatic injuries to the area. For the first carpometacarpal joint, injection may be used to treat pain secondary to osteoarthritis and rheumatoid arthritis. Pain associated with de Quervain's tenosynovitis is treated effectively by therapeutic injection. If complicated by pain or paresthesias, wrist ganglion cysts respond to aspiration and injection. Painful limitation of motion occurring in trigger fingers of patients with diabetes or rheumatoid arthritis also improves with injection. The proper technique, choice and quantity of pharmaceuticals, and appropriate follow-up are essential for effective outcomes.     

Anterior interosseous/median nerve latency ratio

This report describes a new diagnostic technique for evaluating anterior interosseous nerve injuries (Kiloh Nevin syndrome). The resultant "AIM" (anterior interosseous/median nerve) score establishes a normal ratio of the pronator quadratus latency to the abductor pollicis brevis latency after one stimulus to the proximal median nerve and simultaneous recordings of the evoked response at the respective muscles. One hundred normal nerves were tested in 61 patients. The result was an AIM score of 0.60 (SD = 0.06). Five patients with Kiloh Nevin syndrome were evaluated. The average AIM score was 0.76 (SD = 0.04). Five patients with severe carpal tunnel syndrome were evaluated. The average AIM score was 0.38 (SD = 0.06). Ten patients with borderline carpal tunnel syndrome were evaluated. The average AIM score was 0.48 (SD = 0.06). Anterior interosseous nerve entrapment or compression injury remains a difficult clinical diagnosis because it is mainly a motor nerve and the syndrome is often mistaken for finger ligamentous injury. We describe an easily performed electrodiagnostic latency ratio technique to diagnose this injury. This technique may also be helpful as a screen for carpal tunnel syndrome when it is difficult to control for systemic illness.     

Treatment of carpal tunnel syndrome with vitamin B6: a double-blind study

We undertook a randomized, double-blind, placebo-controlled study to investigate the therapeutic effect of vitamin B6 on carpal tunnel syndrome. After ten weeks in the study, ten of 15 patients improved (this included patients given placebo and those given no treatment). Vitamin B6 seems to have no advantage over conservative therapy for carpal tunnel syndrome. This study also suggests that repeat electrodiagnostic testing is no more useful than clinical symptoms in deciding on surgical intervention after unsuccessful conservative therapy.     

Neurologic disorders masquerading as carpal tunnel syndrome: 12 cases of failed carpal tunnel release

We describe 12 patients with a diagnosis of carpal tunnel syndrome in whom carpal tunnel release was unsuccessful and another neurologic disorder was diagnosed subsequently. Final diagnoses included polyneuropathy, radiculopathy, motor neuron disease, spondylotic myelopathy, syringomyelia, and multiple sclerosis. Sources of error by the electromyographer and treating physician were identified. Care must be taken to avoid an inappropriate carpal tunnel operation when clinical or electrodiagnostic features are atypical.     

Median and radial sensory latencies to digit I: normal values and usefulness in carpal tunnel syndrome

Median and radial sensory latencies were recorded from digit I at a distance of 10cm in 78 neurologically healthy people aged 20 to 79 years. The mean median latency was 2.5 +/- 0.3ms, and mean radial latency was 2.4 +/- 0.2ms. Both were measured to the negative peak. Twenty individuals with carpal tunnel syndrome determined by traditional electrodiagnostic techniques had at least 1ms longer latency in median nerve than the median latency for the healthy control group. This technique is useful in diagnosis of carpal tunnel syndrome.     

Electrodiagnosis of carpal tunnel syndrome

This article discusses the epidemiology and clinical presentation of carpal tunnel syndrome and the electrodiagnostic approach to evaluating patients with possible carpal tunnel syndrome. The selection of the best sensory testing protocol and use of motor conduction studies and needle electromyography are discussed. Interpretation requires care, particularly in light of the risks of false-positive testing results and possible technical errors.     

MRI对早期类风湿性关节炎手、腕部关节的诊断价值

目的 研究早期类风湿性关节炎（RA）手、腕部关节的MRI对早期RA的诊断及临床价值。方法 对40例早期RA患者行双手掌指关节及腕关节X线平片检查和MR扫描。对X线和MRI发现的骨侵蚀病灶分别进行计数，并对滑膜炎进行分级评分。同时搜集患者的临床资料包括症状、体征、实验室化验指标。统计并分析X线和MRI征象与临床检查之间的关系。结果 MRI见26例49只腕关节有184处明确的骨侵蚀改变，X线平片仅发现11例14只腕关节21处有骨侵蚀征象。21例患者掌指关节有32处MRI骨侵蚀改变，X线仅发现6处骨侵蚀征象。X线和MRI对早期RA患者的骨侵蚀病灶的检出上的差异有统计学意义。MRI所见40例RA患者均出现滑膜炎性改变，其中31例见明显强化，9例未见明显强化。对明显强化的滑膜炎进行分级评分，腕关节得分为2.5，掌指关节为2.8。腕关节滑膜强化组、无强化组与患者的临床检查的差异性有统计学意义，同时腕关节滑膜炎分级与骨侵蚀征象有较高相关性（r=0.91，P〈0.01）。另外，MRI还可显示早期RA的骨髓水肿、关节积液、肌腱炎等征象。结论 MRI能显示早期RA手腕部关节的病理改变，对骨侵蚀的检出明显优于传统X线检查。MRI可以对早期RA的滑膜炎进行半定量化分级评分，为早期RA滑膜炎的深入研究提供新的平台。早期滑膜炎、骨侵蚀病变对评价RA的活动性及预测疾病进程、预后方面有重要价值。     

Lack of utility of Semmes-Weinstein monofilament testing in suspected carpal tunnel syndrome

OBJECTIVE: To investigate the value of Semmes-Weinstein monofilament (SWM) testing in patients with electrodiagnostically confirmed carpal tunnel syndrome in a group of patients with symptoms compatible with carpal tunnel syndrome. DESIGN: A total of 119 consecutive patients with symptoms compatible with carpal tunnel syndrome were assessed. Blinded comparison of two Semmes-Weinstein monofilament testing protocols with orthodromic midpalm electrodiagnostic testing was performed. The electrodiagnostic test was considered the standard to which the results of the Semmes-Weinstein monofilament testing were measured. RESULTS: Fifty three percent of our patients had electrodiagnostically confirmed carpal tunnel syndrome. Using a conservative Semmes-Weinstein monofilament testing protocol the sensitivity was 98% and the specificity was 15%. The positive predictive value was 56% and the negative predictive value was 88%. Using a liberal Semmes-Weinstein monofilament testing protocol the sensitivity was 13% and the specificity was 88%. The positive predictive value was 53% and the negative predictive value was 47%. CONCLUSION: Semmes-Weinstein monofilament testing was not shown to have utility in diagnosing electrodiagnostically confirmed carpal tunnel syndrome in our population of predominantly male veterans.     

高频超声在腕管综合征病因学评价中的应用

目的探讨高频超声在评价腕管综合征病因中的作用。 方法选取2015年3月至2019年12月在解放军总医院经电生理检查诊断或手术证实腕管综合征的患者,首先对腕管进行灰阶超声检查,观察腕管内正中神经的位置、走向,神经受压情况、神经束结构、神经外膜回声以及神经周围结构的异常,横切面扫查腕管及正中神经时观察正中神经横截面情况、测量豌豆骨平面正中神经的横截面积以及观察神经周围结构的异常;应用能量多普勒超声以观察正中神经及腕管内其他结构的血流情况。采用独立样本t检验比较患侧腕和无症状侧腕豌豆骨平面正中神经横截面面积的差异。利用受试者操作特征（ROC）曲线分析豌豆骨平面正中神经的横截面面积的诊断价值并找出最佳的诊断界值。 结果腕管综合征患者63例,共95侧腕。腕管综合征患者高频超声表现为腕管内正中神经的卡压近端肿胀、增粗,神经束结构模糊,神经外膜增厚。能量多普勒超声显示正中神经内血流信号增加。患侧腕与无症状侧腕的豌豆骨平面正中神经横截面面积比较［（15.91±5.95）mm² vs（8.71±1.62）mm²］,差异具有统计学意义（t=-2.51,P＜0.001）,ROC曲线下面积为0.946,截断值为10.5 mm2时,敏感度为89.5%,特异度为83.9%。高频超声诊断为特发性腕管综合征者73侧腕（76.8%,73/95）,可明确诊断病因的共22侧腕（23.2%,22/95）,其中13侧腕（13.7%,13/95）为腕管内屈肌腱腱鞘炎,1侧腕（1.1%,1/95）为腕管内屈肌腱腱鞘积液,2侧腕（2.1%,2/95）为腕管内腱鞘囊肿,1侧腕（1.1%,1/95）为腕管内实性肿块,2侧腕（2.1%,2/95）为腕管内指浅屈肌肌腹过低,2侧腕（2.1%,2/95）为正中神经高位分叉伴永存正中动脉,1侧腕（1.1%,1/95）为桡骨远端术后瘢痕压迫正中神经。 结论高频超声可作为评估腕管综合征病因的一种手段。     

Carpal tunnel syndrome: the cause dictates the treatment

Mild carpal tunnel syndrome should be conservatively treated and severe carpal tunnel syndrome usually requires surgery; however, management of moderate carpal tunnel syndrome is more complex. Usually, the treatment is dictated by the cause, which may be occupational injury, acute trauma, systemic diseases such as diabetes, hypothyroidism, or rheumatoid arthritis, or other causes.     

Wrist dimensions: correlation with median sensory latencies

A serendipitous observation that many individuals with carpal tunnel syndrome have square wrists led to this study which correlates wrist dimensions with median sensory latencies. Results suggest that the squarer the wrist the longer the latencies.     

An MRI evaluation of carpal tunnel dimensions in healthy wrists: Implications for carpal tunnel syndrome

BACKGROUND: Deviated wrist postures and pinch grip use have been linked to the development of carpal tunnel syndrome and are likely related to the size and shape of the carpal tunnel. The purpose of this study was to quantify carpal tunnel dimensions with changes in wrist posture and pinch grip. METHODS: Eight healthy volunteers (4 male, 4 female) underwent magnetic resonance imaging of their dominant wrists under seven conditions which included: 30 degrees wrist extension, neutral and 30 degrees flexion (with and without a 10 N pinch force) and a fist with a neutral wrist. Cross-sectional area of the carpal tunnel and its contents were calculated at 3mm increments along the length of the tunnel and integrated to calculate volumes. Ratios were calculated between the contents of the tunnel to the tunnel itself for area and volume. FINDINGS: The use of a correction factor significantly reduced volume and distal carpal tunnel area in flexed and extended wrists. Carpal tunnel areas were largest in neutral and smallest at the distal end with wrist flexion. An extended wrist resulted in the smallest carpal tunnel and content volumes as well as the smallest carpal tunnel content volume to carpal tunnel volume ratios. While men had significantly larger areas and volumes than women for both the carpal tunnel and it contents, there were no differences in ratios between the contents and tunnel size. INTERPRETATION: A simple correction factor for non-perpendicular magnetic resonance images proved useful in relating volume changes to known pressure changes within the carpal tunnel. More inclusive and detailed evaluation of the carpal tunnel and its contents is required to fully understand mechanisms for median nerve compression in the carpal tunnel.