Combined ulnar and carpal tunnel syndrome caused by pigmented villo-nodular tenosynovitis: a rare case

Pigmented villo-nodular synovitis/tenosynovitis (PVNS) is a rare cause of combined ulnar and median nerve compression neuropathy at the wrist. In our case, a 53-year-old house-wife had sensorial and motor complaints at her left hand. In clinical examination, painless soft tissue mass was palpated at her wrist and both the tenar and hypotenar muscles were atrophic. Electromyography showed prolonged distal latencies for median and ulnar nerve. A space-occupying soft tissue lesion was revealed in magnetic resonance imaging. Carpal tunnel and Guyon canal were released and lesion was excised. PVNS was confirmed by histopathological examination. If compression neuropathy of medial and ulnar nerves together is caused by a space-occupying lesion, PVNS should be considered in etiology.     

Post-traumatic cyst of the scaphoid--a case report]

Carpal bone cysts are very uncommon and they are usually occasionally diagnosed during radiological examination of the wrist after trauma. Some carpal bone cysts are symptomatic and then they are revealed on routine X-ray investigation. We present a case of 14 years old boy, in whom a scaphoid bone cyst developed around the foreign body (a splinter), stacked into the wrist when he fell on the wooden board. Because of pain, swelling and reduction of active range of motion of the wrist occurred at the load of the hand and lasted 3 months, patient was given radiological examination which was negative, and eventually CT scanning revealed a scaphoid bone cyst. Patient underwent operation: curettage of the lesion followed by filling of the bone defect with prepared allogenic bone. Histopathological examination of the contents of the cyst showed presence of wood piece, surrounded with granulomatic tissue and necrotic trabecular bone. This suggested a splinter stacked in the wrist at the primary injury to be a cause of cyst formation. Surgery resulted in complete recovery in 6 months.     

Fibro-osseous pseudotumor of the digits: a rare tumor in an unusual location

Fibro-osseous pseudotumor of the digits (FOPT) is a rare benign lesion of the hand. When FOPT originates in an unusual anatomic region (other than the digits), it can imitate a malignant neoplasm, and consequently surgical treatment can be improper. This report describes a case of FOPT that developed in an unusual anatomic region: the first dorsal-extensor compartment of the wrist.     

Correction to: A Clinical Approach to Diagnosing Trigger Wrist

BackgroundTrigger wrist is a relatively unusual condition, produced by wrist or finger motion. The various causes of trigger wrist can originate from flexor tendon, extensor tendon, bones, or tumour. A proper clinical approach is required to diagnose and manage patients with trigger wrist.MethodsA keyword search was performed across Google Scholar and PubMed. Articles describing trigger wrist conditions were analysed. Based on the information obtain from the articles, the clinical manifestations and approach to diagnosing the cause of trigger wrist is discussed.ResultsA detailed history alone may lead to a reasonably accurate diagnosis. Patients can present with trigger wrist occurring during movement of the fingers or with wrist movements. Presence of tenderness around A1 pulley suggest trigger finger. Absence of tenderness over the A1 pulley may suggest trigger wrist. The wrist should be examined for any swelling or malunion around the wrist joint. Palpate for any bony prominence, clicking, or crepitus with the movement of the wrist. Examination for the presence of carpal tunnel syndrome should be performed. A simple radiograph of the wrist joint is needed to see any possible bony pathology such as malunion, instability or arthritis of the carpal bone. For soft tissue assessment ultrasound would be a good choice and can be done during finger or wrist movement. MRI is useful for further assessment of space occupying lesion within the carpal tunnel and is useful for surgical planning. Nerve conduction study is indicated for patients with median nerve compression symptoms. During the initial stage, the patient should be advised for activity modification to reduce the wrist and finger movements. Surgical treatment will depend on the causative factor. Surgery done under local anaesthesia has the advantage of reconfirming with the patient, resolution of triggering during surgery by asking the patient to actively move the fingers or wrist. ConclusionsTrigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital.     

Traumatic dislocation of the hamate and pisiform: a case report and review of the literature

Isolated dislocation of the hamate bone and pisiform bone is rare. We describe the simultaneous complete dislocation of both the hamate and pisiform bones in a 27-year-old man who crushed his right hand in a rolling press. An open reduction and internal fixation with Kirschner wires was performed. Four weeks later, the Kirschner wires were removed and rehabilitation was started. At 6 months follow-up, the patient had minimal pain and full range of motion in the affected wrist joint and fingers. However, grip strength was 50% compared to his unaffected left hand, and sensation of the ulnar nerve area was reduced to almost 30% of that of his left hand. It appears that the ulnar nerve injury was the largest contributing factor to the poor outcome of our patient. Evaluation of soft-tissue injuries, especially nerve injury, is important in the treatment of complex carpal dislocations.     

Compression of the deep branch of the ulnar nerve in Guyon’s canal by a ganglion: two cases

INTRODUCTION: Ulnar nerve compression at the wrist can be caused by a variety of intrinsic and extrinsic factors. Isolated compression of only the deep branch of ulnar nerve by a ganglion is very uncommon. Ultrasound examination can clearly show the cystic lesion compressing the nerves. MATERIALS AND METHODS: We present two cases of compression of deep branch of ulnar nerve by a ganglion in the Guyon's canal. Two male patients presented with history of progressive weakness and paraesthesia in the medial 1(1/2) digits of the non-dominant hand. Interestingly, both the patients noticed sudden onset and rapid progress of the symptoms and signs. Clinical examination revealed typical symptoms of ulnar nerve (deep branch) palsy. Nerve conduction studies showed severe denervation of the deep branch of the ulnar nerves in both the patients and ultrasound confirmed the diagnosis. Surgical decompression led to complete recovery. RESULTS AND DISCUSSION: Whilst compression by a ganglion in the Guyon's canal is rare but well recognized, a feature of both of our cases was the rapid progression and severe nature of the compressive symptoms and signs. This is in contrast to the more typical features of compressive neuropathy and should alert the clinician to the possible underlying cause of compression. Early decompression has the potential to promote a complete recovery.     

Tenodesis extension splinting for radial nerve palsy

Injuries to the radial nerve or posterior interosseous nerve can lead to significant functional limitation. Inability to extend the wrist and/or digits prevents the hand from being positioned properly for functional tasks. Therapy after radial nerve injury is geared toward maintaining passive extension of the wrist and digits. Sensory reeducation can also be performed but often not necessary since the distribution of the nerve distally is on the dorsoradial surface of the hand. Since nerve regeneration is often a lengthy process and the extent of recovery is variable, splinting the involved extremity is used to prevent contractures and maximize function. This article introduces a new splint that allows patients to extend the fingers and thumb via a tenodesis effect at the wrist. In early trials, it has produced excellent results for enhancing functional use of the injured extremity while nerve regeneration occurs or until tendon transfers have been performed.     

A possible cause of misdiagnosis in tumors of the axilla: schwannoma of the brachial plexus

The Authors report a rare case of a 57 years old man affected by a left radial nerve schwannoma that occurred as an asymptomatic lesion of the axilla. At clinical examination the lump was undistinguishable from the most common axillary lymphadenopathy. A lymphoadenopathy was erroneously diagnosed with ultrasonography (US). This mistake was due to the low specificity of the instrumental methodology and to the rarity of an asymptomatic schwannoma of the infraclavicular brachial plexus. The neoplasia was excised without using the microscope. In the early post-operative follow up, a "falling" attitude of the wrist, the hand and the fingers appeared, peculiar for a lesion of the radial nerve. Furthermore a hypoaesthesia of the skin of first finger and of the first interosseus space was associated. The sensitive and motor electromyography showed a radial nerve suffering. The "stupor" of the nerve trunk was treated with steroid therapy for 7 days and the patient underwent to some series of neuro-rehabilitative physical therapy for 12 weeks. The postoperative total body CT, showed that the lesion was unique: therefore it was possible to exclude the diagnosis of neurofibromatosis. After 28 months electromyography and axillary US were performed showing the complete resolution of the motor and sensitive deficit and the absence of local recurrence.     

Rice bodies, millet seeds, and melon seeds in tuberculous tenosynovitis of the hand and wrist

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. Operative findings of "rice bodies, millet seeds, or melon seeds" are highly suggestive of tuberculous tenosynovitis. Six patients with TB of the hand and wrist at various stages of disease with characteristic operative findings are reviewed. Four patients had underlying immunosuppression. One patient had previous pulmonary TB, whereas 3 patients had radiographic evidence of previously undiagnosed pulmonary TB. The interval to presentation ranged from 1 week to 2 years. Two patients had median nerve irritation, 3 patients had osteomyelitis, and 1 patient had flexor tendon rupture. Mycobacterial cultures were positive in 4 patients; acid-fast bacilli stain, and polymerase chain reaction were positive in remaining 1 patient; and both stain and culture were negative in the last patient who had history of pulmonary TB. All 6 patients were managed with combination therapy comprising antituberculous chemotherapy and at least 1 debulking tenosynovectomy. Two patients had 2 debridements. Of these 2 patients, 1 underwent wrist arthrodesis during the second procedure. Mean follow-up was 4 years. There were no recurrences after the most recent debridement. The diagnosis of TB of the hand and wrist is often missed. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia. Combination therapy comprising thorough excisional debridement and antituberculous chemotherapy will minimize recurrence of this difficult-to-treat disease.     

腕关节骨内腱鞘囊肿的诊断与治疗

目的 探讨腕关节骨内腱鞘囊肿的临床特点和治疗方法。方法 1993年6月-2002年3月，收治11例腕关节骨内肿物患者，经手术证实为骨内腱鞘囊肿。总结该病的临床状及影像就特点，并回顾性分析性别、年龄及生长部位等因素与发病的关系。所有患者术后均获得随访，随访时间3-62个月，平均38个月。结果 腕关节骨内腱鞘囊肿好发于青壮年，男友比例为3:8，多为优势手发病，占72.7%。主要症状为腕关节疼痛，病程2-84个月。X线特点为腕骨内出现密度减低区，周围有硬化缘。CT及MR检查提示病灶内为密度均匀的液体。11例患者均接受手术治疗，术后8例疼痛消失，2例有轻度疼痛，但功能正常，另外1例无明显改善。结论 腕关节骨内腱鞘囊肿的诊断依赖于临床症状及影像学表现，确诊须依据术中所见及病理结果。手术治疗效果满意。     

Benign and malignant cartilage tumors of the hand

Primary bone tumors of the hand and wrist are unusual but if present are frequently chondrogenic in origin. Enchondroma is the most common primary bone tumor of the hand and can be treated by curettage and bone grafting. Chondrosarcoma is rare and most likely the result of malignant degeneration of a pre-existing lesion. Wide en bloc resection is appropriate for chondrosarcoma and typically involves ray resection or partial hand amputation.     

Reconstruction of the triangular fibrocartilage complex after surgery for treatment of synovial osteochondromatosis of the distal radioulnar joint

Synovial osteochondromatosis of the hand is uncommon, except for tenosynovial chondromatosis of the digits. It is even more rare in the wrist joint. A patient with synovial osteochondromatosis of the distal radioulnar joint that involved the triangular fibrocartilage complex is described. At operation, synovectomy, excision of osteochondral bodies, and removal of the entire triangular fibrocartilage complex was done. The triangular fibrocartilage complex was reconstructed using part of the extensor carpi ulnaris tendon. One year after operation, the patient had regained almost full range of motion and is without pain.     

Acute carpal tunnel syndrome due to a hemangioma of the median nerve

Hemangioma of the median nerve presenting as acute carpal tunnel syndrome is unusual A-18- year old male presented with severe incapacitating pain of sudden onset of left forearm and hand after manual field work. There was swelling on volar aspect of forearm, with hyperalgesia in the median nerve distribution. The fingers and wrist were inmarked flexion and the patient did not allow wrist and finger extension. X-rays were within normal limits. An emergency volar carpal ligament release revealed, haematoma about 100 ml with numerous vessels encircling the median nerve. Histopathology of lesion turned out to be a cavernous hemangioma. Post operatively patient had full recovery.     

Eosinophilic granuloma of the hand

The first reported case of eosinophilic granuloma of the hand is presented. A slowly expanding lesion of the right third metacarpal shaft was treated by biopsy and curettage. Histological examination confirmed the presence of eosinophilic granuloma. A bone scan showed that it was a solitary lesion. There has been no evidence of recurrence of the lesion during follow-up. Eosinophilic granuloma is a rare disease of the mononuclear phagocyte system, representing one of the clinical manifestations of Langerhans-cell histiocytosis. The lesions are usually associated with the skull, femur, mandible and ribs; this condition has not been previously reported in the hand.     

Tuberculous tenosynovitis of hand and wrist: a report of two cases

Tuberculous tenosynovitis of the wrist and hand is a rare condition that presents as chronic painless swelling, tenosynovitis and occasional compressive neuropathy. There is usually a striking lack of pulmonary symptoms. Two patients of tuberculous tenosynovitis of wrist and hand, who were managed at a tertiary health care centre, are presented. Both were young healthy adult males with isolated tenosynovitis of one hand each, without any associated systemic or pulmonary features. Both had been reviewed earlier at other tertiary referral centers without establishing the correct diagnosis. They presented with painful swelling in the wrist and palm. One patient also had features of ulnar nerve compressive neuropathy. Intra-operatively, both had thickened synovium of flexor tendons with "rice bodies" within the synovial fluid. Surgical management consisted of synovectomy and decompression of the nerves. Post-operatively, both were given full anti-tubercular treatment. On follow-up of over three years, they have remained free from recurrence. The slow progressive course of clinical symptoms and lack of radiological signs of tuberculosis leads to difficulties in establishing early diagnosis of this rare localized tuberculous infection. The functional outcome depends on early diagnosis and surgical intervention for symptomatic patients, thus emphasizing the importance of awareness of this rare entity.     

Ulnar nerve compression at the wrist. Ulnar tunnel syndrome.

Compression neuropathy of the ulnar nerve at the wrist can be caused by several lesions. The most common cause is a carpal ganglion followed by occupational repeated trauma to the hypothenar area. This process is in contrast to carpal tunnel syndrome in which the majority of the cases are idiopathic in nature with no local cause found except for synovitis of the flexor tendons. The site of the lesion will determine the clinical picture whether it is both motor and sensory abnormalities, only motor paralysis or only sensory abnormality. The latter is rare. If the abnormality is purely motor, then the compression is distal in the ulnar tunnel and the hypothenar muscles are usually spared. Carpal ganglia must be sought and removed. After an extensive search through the literature, I found only one report in which thickening of the volar carpal ligament was found to be the cause of ulnar nerve compression. I encourage the use of the term "ulnar tunnel syndrome" to discuss these lesions and the classification outlined by Shea to determine the site of the lesion. Patients with type 2 syndrome usually present late because of the lack of sensory changes. Average delay in obtaining a diagnosis of 5 months was found in my patients. The condition should be suspected if spontaneous clumsiness or awkwardness of the use of the hand occurs in a middle-aged patient.     

Neural fibrolipoma of a digital nerve of the index finger without macrodactyly

Abstract

We present a case of neural fibrolipoma arising from the digital nerve in the index finger of the right hand. A 31-year-old man was referred with a soft tissue mass in the ulnar aspect of the index finger of his right hand, which had gradually enlarged during the past seven years. Histological examination of an excisional biopsy specimen identified a neural fibrolipoma, which is a differential diagnosis of a lipomatous lesion of the digits.     

Enchondroma of the scaphoid bone

The scaphoid bone is a very rare location for enchondroma. The literature reports eight cases; five of them presented with pathologic fracture, and the youngest patient was 13 years old. This is a report of an 11-year-old patient with scaphoid enchondroma who presented with only mild pain in the left wrist. Magnetic resonance imaging demonstrated the lesion clearly.     

Acute carpal tunnel syndrome resulting from haemorrhage into the carpal tunnel in a patient on Warfarin

A case of acute compression neuropathy of the median nerve associated with haemorrhage into the carpal tunnel is presented. The condition occurred spontaneously in a patient on Warfarin for previous deep venous thrombosis. The signs and symptoms were those of acute tenosynovitis originating in the common flexor synovial sheath at the wrist with associated paraesthesia in the distribution area of the median nerve in the hand. The patient was afebrile and blood tests were normal.     

Fenton's syndrome or scapho-capitate fracture (a case report)

INTRODUCTION: Scapho-capitate fracture is a rare lesion and its mechanism is controversial. Forced extension seems to be the most frequent cause as this movement of the wrist induces scaphoid fracture by compression. Hyperextension of the wrist as a result of the scaphoid lesion, allows contact between the posterior margin of the radius and the neck of the capitate inducing a capitate fracture. MATERIALS AND METHODS: We report a case of Fenton's Syndrome, the patient was operated as an emergency by pining and immobilization of the carpus and thumb until bone consolidation had occurred. RESULTS: Consolidation was noted at 8 weeks with a good mobility of the wrist. DISCUSSION: Fenton's Syndrome is a rare lesion of the wrist. Analysis of our own case and a review of literature demonstrated extension as a causative mechanism, and the frequency of delayed diagnosis. Because of the presence of instability, scaphoid reduction and osteosynthesis is necessary. Immobilization of the carpus and thumb is essential until bony consolidation is obtained.