An unusual cause of acute carpal tunnel syndrome

Acute carpal tunnel syndrome following anticoagulation is uncommon. We describe a case in which the diagnosis was missed on three previous presentations by several clinicians. Although the presentation is typical, lack of awareness of this complication, inability to notice subtle signs and failure to do INR may lead to missing the diagnosis.     

An unusual cause of carpal tunnel syndrome. Case report.

A 38 year old woman with carpal tunnel syndrome of the right hand was treated with operative decompression, initially successfully. Subsequently, she developed a compartment syndrome after an injury. On re-exploration, an accessory palmaris longus muscle was encasing the median nerve at the distal forearm and passing through the flexor sheath, underneath the flexor retinaculum, inserted into the deep palmar fascia.     

Perineural tumour spread: an unusual cause of carpal tunnel syndrome

We describe the development of the carpal tunnel syndrome in a 58-year-old man, from perineural spread of a previously-excised cutaneous malignancy.     

Periosteal chondroma: another cause of carpal tunnel syndrome

Periosteal chondroma has not been previously described as a cause of carpal tunnel syndrome. This report describes a case of periosteal chondroma developing in the floor of the carpal canal and presenting as carpal tunnel syndrome.     

Amyloidosis as a cause of carpal tunnel syndrome in haemodialysis patients

Over a five-year period (1981–1985), nine patients on haemodialysis developed carpal tunnel syndrome. Five patients, following biopsy of synovium in the carpal tunnel or biopsy of thickened epineurium of the median nerve, were found to have amyloid deposits in the soft tissues. The relationship between this condition, dialysis arthropathy and long-term haemodialysis is reviewed. In addition, in this small group of patients no relationship to the side of the fistula has been demonstrated and two patients developed recurrent problems despite initial open decompression of the carpal tunnel.     

Unusual cause of carpal tunnel syndrome: a case report.

An unusual case of compression of median nerve at the wrist is described due to a foreign body. In unusual presentation of carpal tunnel syndrome, ultrasonography of the wrist is recommended to rule out a foreign body in the region.     

Rare cause of acute carpal tunnel syndrome: acute metacarpal osteomyelitis

Acute carpal tunnel syndrome resulting from acute metacarpal osteomyelitis is an exceptional etiopathogenic entity. A 6-year-old boy developed an acute carpal tunnel syndrome on the left four days after trauma. The carpal tunnel was opened in an emergency setting and exploration revealed a pale median nerve with infiltration of neighboring tissue. After release, pus issued from the depth of the tunnel. A posterior approach disclosed the collection and a total loss of the 4th metacarpal periosteum, leading to the diagnosis of acute osteomyelitis. Edema and pain regressed rapidly with antibiotic therapy. A pathologic fracture of the 4th metacarpal discovered three months later was treated conservatively. At 10 months, the child has a very good functional result despite persistence of a short 4th metacarpal after healing. There was no motor or sensitive neurological deficit and thumb opposition was complete. We have been unable to find any other report of acute metacarpal osteomyelitis leading to acute carpal tunnel syndrome. Emergency treatment is crucial. Opening the annular ligament is the only way to achieve complete nerve recovery.     

Post-traumatic carpal tunnel syndrome

In the course of a ten months study on 508 patients with CTS a trauma as a possible causal factor was observed in 22 cases. In none of these cases did the other hand show normal electroneurographic parameters. The mean values of distal motor latency were among 5.5 ms (3.7-9.2 ms) on the injured side and 4.6 (3.5-6.7 ms) on the other. The relatively seldom occurrence of CTS in connection with a trauma requires therefore strict criteria for the evaluation of the casual context. A traumatic etiology can only be recognised if a close temporal relation exists (beginning of the symptomatology during immobilisation or after removal of the cast) or a special tendency to swelling or a dislocation as well as a clear difference in electroneurographic values of the two sides can be observed. Depending on the degree of this difference in latency one can maintain criteria for evaluating the question of causality or of transient or permanent deterioration. Finally in case of CTS the treatment should be given primary importance ahead of reimbursement for the injury.     

Acute carpal tunnel syndrome

Carpal tunnel syndrome is considered the most common of the chronic compressive neuropathies. Its cause is generally unknown. Acute carpal tunnel syndrome, which is much less common, is more often directly related to fractures and fracture-dislocations about the wrist, hemorrhagic conditions, and vascular disorders involving the wrist. Many rare and unusual causes have been described, including chronic conditions that may be associated with acute carpal tunnel syndrome, such as rheumatologic disorders and anomalous anatomy. In contrast to the more common chronic idiopathic form, the acute form of carpal tunnel syndrome requires urgent surgical intervention to avoid or diminish serious sequelae.     

Congenital carpal tunnel syndrome

A case of congenital carpal tunnel syndrome associated with melorheostosis is described. The symptoms were lack of use of the hand since birth, hypotrophy of the fingers innervated by the median nerve, and severe atrophy of the thenar muscles. The total degeneration of the nerve in the carpal tunnel was successfully treated with a sural nerve graft.     

Recurrent carpal tunnel syndrome

Recurrence of carpal tunnel syndrome following surgery is not rare. The reported frequency of reoperation varies from 0.3 to 12%. We distinguish between persistent carpal tunnel syndrome, and recurrent carpal tunnel syndrome which we define as reappearance of the condition three months or more following surgery. More proximal nerve lesions or other erroneous diagnoses may cause either persistent or recurrent syndromes. In the cases of persistent syndromes, incomplete division of the flexor retinaculum is a frequent cause, but iatrogenic nerve lesions or active flexor tenosynovitis may also be to blame. In the cases of recurrent carpal tunnel syndrome, the problem is often due to perineural fibrosis. At the time of reoperation, except in those cases where an incomplete division of the flexor retinaculum is found, one must consider whether or not to combine the neurolysis with an additional procedure to prevent or diminish recurrent fibrosis. To achieve this goal, a number of measures have been proposed, including interposition of a biomaterial or raising a local flap to surround and protect the nerve. Others recommend early mobilization to diminish fibrous adhesions between the nerve and surrounding tissues. The results are at best modest, and may be counterproductive after several interventions. It is necessary to distinguish between improvement in symptoms that are due to local irritation, the priority for the patient, and improvement in neurologic function of the motor and sensory components of the nerve. According to the literature, from 43 to 90% of patients who undergo repeat operations continue to have symptoms, and one in five get no relief, while 80% of first operations for carpal tunnel syndrome give excellent results. These findings indicate that the first intervention must be performed with the most rigorous attention to technical detail.