Carpal tunnel syndrome caused by a giant cell tumour of the flexor tendon sheath

Abstract

A 76-year-old woman developed right carpal tunnel syndrome after being conservatively treated for tenosynovitis of the flexor tendons with associated mild carpal tunnel syndrome. A magnetic resonance imaging scan showed a tumour in the carpal tunnel. Re-exploration showed that the median nerve was being compressed by a giant cell tumour of the flexor tendon sheaths. Appropriate imaging is advised in patients with additional findings (such as swelling) or in patients with secondary carpal tunnel syndrome and incomplete response to conservative treatment, to exclude a space-occupying lesion.     

结核性腱鞘滑膜炎所致腕管综合征的手术治疗

目的 总结腱鞘结核所致的腕管综合征的临床表现,观察手术治疗的效果.方法 对11例术前不能明确病因的腕管综合征患者行手术治疗,广泛切除腱鞘滑膜上病灶组织,经病检确诊为结核性腱鞘滑膜炎,术后行抗痨治疗.通过随访观察症状的改善、神经肌电图的变化来评估手术疗效.结果 11例随访6～18个月,9例术后1周神经症状缓解,1个月后麻木症状消失.术后6个月临床症状和神经传导较术前明显改善,结核未复发,手指功能恢复良好,未产生并发症.结论 结核性腱鞘滑膜炎好发于腕部屈肌腱,是引起腕管综合征病因之一.手术切除病灶,加上抗痨治疗和早期功能锻炼,疗效满意.     

Thickening of the synovium of the digital flexor tendons: cause or consequence of the carpal tunnel syndrome?

Using a monofilament wire suture, the radial and ulnar edges of the flexor retinaculum were approximated in 14 white New Zealand rabbits. As a result, the volume of the carpal tunnel was diminished, and "carpal tunnel syndrome" was produced. At various intervals after this procedure the animals were sacrificed. The median nerve and all the digital flexor tendons passing through the carpal tunnel were excised "en bloc", and sent for histological examination. Vascular proliferation with perivascular round cell infiltration and oedema, and large areas of fibroblastic activity were observed around the digital flexor tendons. This was probably due to increased vascular permeability secondary to ischaemic endothelial damage. These findings are similar to those observed in the synovium of patients operated on for carpal tunnel syndrome.     

Case report. Initial manifestation of gout after carpal tunnel release.

A carpal tunnel release was performed on a patient with recurrent carpal tunnel syndrome and asymptomatic hyperuricaemia with no prior history of gouty arthritis. Intraoperatively, the patient was found to have tenosynovitis without crystals or tophaceous deposits in the carpal tunnel. Postoperatively, the patient developed an acutely inflamed hand, which responded dramatically to anti-gout medications. We report this patient as an initial attack of gout after a carpal tunnel release.     

Current concepts of carpal tunnel syndrome: pathophysiology, treatment, and evaluation

The current concepts of carpal tunnel syndrome (CTS) with respect to its pathophysiology, treatment, and evaluation are discussed. With regard to the pathophysiology of idiopathic CTS, biomechanical studies to determine the kinematics of the flexor tendon, and the median nerve inside the carpal tunnel may provide valuable insights. Different degrees of excursion between the flexor tendons and the median nerve could cause strain and microdamage to the synovial tissue; this has been microscopically observed. A biomechanical approach for elucidating the events that trigger the development of CTS seems interesting; however, there are limitations to its applications. Endoscopic carpal tunnel release (ECTR) is a useful technique for achieving median nerve decompression. However, it is not considered superior to conventional open carpal tunnel release in terms of fast recovery of hand function. Unless the effect of inserting a cannula into the diseased carpal tunnel on the median nerve function is quantitatively elucidated, ECTR will not be regarded as a standard procedure for relieving the median nerve from chronic compression. The treatment of CTS should be evaluated on the basis of patient-oriented questionnaires as well as conventional instruments because these questionnaires have been validated and found to be highly responsive to the treatment. It should be noted that nerve conduction studies exclusively evaluate the function of the median nerve, whereas patient-oriented questionnaires take into account not only the symptoms of CTS but other accompanying pathologies as well, such as flexor tenosynovitis. In Japan, the number of CTS patients is expected to rise; this may be attributed to a general increase in the life-span of the Japanese and increase in the number of diabetic patients. Thus, more efforts should be directed toward elucidating the pathophysiology of so-called idiopathic CTS, so that new treatment strategies can be established for CTS of different pathologies.     

Gouty tenosynovitis of the wrist

A 56-year-old man presented with a mass of the right wrist limiting excursion of the digits. Operative exploration demonstrated gouty infiltration of the flexor tendons. The tendons were debrided of the urate crystalline material and the motion of the digits returned, preserving all tendon function. The patient later returned with symptoms of carpal tunnel in the contralateral wrist. Exploration of the carpal tunnel revealed similar infiltration of the flexor tendons. The tendons were debrided and the carpal tunnel syndrome resolved.     

Intrasynovial lipoma causing trigger wrist and carpal tunnel syndrome

Triggering of the flexor tendon at the wrist is rare. We report a case of intrasynovial lipoma that caused a trigger wrist. As far as we know it is unique in that the intrasynovial lipoma simultaneously caused carpal tunnel syndrome. The massive tenosynovitis and adhesion of flexors tendons after the locking of the intrasynovial lipoma may have resulted from inflammation caused by attrition within the carpal tunnel.     

Flexor tendon anomalies in a patient with carpal tunnel syndrome

A case of an anomalous interconnection between the tendons of the flexor pollicis longus and the flexor digitorum profundi to both the index and middle fingers at the wrist of a patient presenting with carpal tunnel syndrome is described. The contents of the carpal tunnel should be inspected carefully at the time of median nerve decompression in cases where preoperative clinical examination suggests associated pathologies.     

痛风石致腕管综合征的手术治疗

目的 探讨痛风石导致腕管综合征的临床特点及手术治疗效果.方法 回顾性分析2017年10月至2019年12月于复旦大学附属华山医院手外科接受手术治疗的16例(17侧)痛风石致腕管综合征病人的临床资料,痛风病程(7.68±5.48)年,腕管综合征病程(5.22±2.24)个月.术中7侧可见正中神经局部压痕,9侧痛风石广泛包...     

Gouty tenosynovitis in the hand

Gouty tenosynovitis can present as an infection, tendon rupture, nerve compression, or digital stiffness. In ten patients, extensive urate deposition was encountered in the extensor tendons at both the wrist and digital levels in addition to involvement of the flexor tendons in the carpal canal and digital theca. Direct nerve or muscle involvement was not observed in the hand. Medical therapy, which is now the cornerstone of treatment for most aspects of gout, may not be the best treatment for tophaceous deposits in the hand. Operative treatment may be required to debulk tophaceous deposits, improve tendon gliding, decompress nerves, allow increased range of motion of joints, and ameliorate pain.     

Clinical diagnosis of carpal tunnel syndrome: old tests-new concepts

BackgroundThe diagnosis of carpal tunnel syndrome (CTS) continues to be neurophysiologically and clinically controversial. Earlier data concluding that the higher prevalence of persons with symptoms suggestive of CTS but without evidence of median mononeuropathy highlights the need for a better understanding of the underlying pathophysiology and natural history of CTS to provide a less empirical foundation for diagnosis and clinical management.ObjectiveTo examine the relationship between the clinical manifestations of CTS with the outcome of the diagnostic tools (nerve conduction tests and ultrasonography), and its implication for clinical practice.MethodsTwo-hundred and thirty-two patients (69 male and 163 female, ages ranging between 20 and 91 years) with CTS manifestations and 182 controls were included in this study. Diagnosis of CTS was based on the American Academy of Neurology clinical diagnostic criteria. All patients and controls completed a patient oriented questionnaire, were subjected to clinical testing for provocative tests for carpal tunnel syndrome (Tinel's, Phalen's, Reverse Phalen's and carpal tunnel compression tests), blood check for secondary causes of carpal tunnel syndrome, nerve conduction testing as well ultrasonographic assessment of the carpal tunnel and median nerve.ResultsOne-hundred and seventy-seven out of 232 (76.3%) had abnormal nerve conduction studies. Forearm symptoms and tenosynovitis confirmed by US examination were found in 51.3% of cases. No significant difference was found on comparing anthropometric measures in the affected hands to the control group hands. A higher prevalence of positive Phalen's and CT compression were found in patients suffering from tenosynovitis regardless of their nerve conduction study results. Sensitivity of Tinel's, Phalen's, Reverse Phalen's and carpal tunnel compression tests was higher for the diagnosis of tenosynovitis than for the diagnosis of CTS (Tinel, 46% vs. 30%; Phalen's, 92% vs. 47%; Reverse Phalen's, 75% vs. 42%; carpal tunnel compression test, 95% vs. 46%). Similarly, higher specificity of these tests was found with tenosynovitis than CTS.ConclusionThe results of this study revealed that Tinel's, Phalen's, Reverse Phalen's and carpal tunnel compression tests are more sensitive, as well as being specific tests for the diagnosis of tenosynovitis of the flexor muscles of the hand, rather than being specific tests for carpal tunnel syndrome and can be used as an indicator for medical management of the condition.     

Median nerve deformation and displacement in the carpal tunnel during index finger and thumb motion

The purpose of this study was to investigate the deformation and displacement of the normal median nerve in the carpal tunnel during index finger and thumb motion, using ultrasound. Thirty wrists from 15 asymptomatic volunteers were evaluated. Cross‐sectional images during motion from full extension to flexion of the index finger and thumb were recorded. On the initial and final frames, the median nerve, flexor pollicis longus (FPL), and index finger flexor digitorum superficialis (FDS) tendons were outlined. Coordinate data were recorded and median nerve cross‐sectional area, perimeter, aspect ratio of the minimal‐enclosing rectangle, and circularity in extension and flexion positions were calculated. During index finger flexion, the tendon moves volarly while the nerve moves radially. With thumb flexion, the tendon moves volarly, but the median nerve moves toward the ulnar side. In both motions, the area and perimeter of the median nerve in flexion were smaller than in extension. Thus, during index finger or thumb flexion, the median nerve in a healthy human subject shifts away from the index finger FDS and FPL tendons while being compressed between the tendons and the flexor retinaculum in the carpal tunnel. We are planning to compare these data with measurements in patients with carpal tunnel syndrome (CTS) and believe that these parameters may be useful tools for the assessment of CTS and carpal tunnel mechanics with ultrasound in the future. Published by Wiley Periodicals, Inc. J Orthop Res 28:1387–1390, 2010     

Median innervated hypothenar muscle: anomalous branch of median nerve in the carpal tunnel

A hypothenar motor branch of the median nerve in the carpal tunnel was observed and its motor function was documented by direct intraoperative nerve stimulation in two patients having carpal tunnel releases. The hypothenar branch left the median nerve at the midcarpal tunnel area. It crossed the tunnel superficial to the flexor tendons and penetrated the transverse carpal ligament ulnarly to innervate the abductor digiti quinti. Such branching of the median nerve at this level has not been reported previously. Good visualization of the carpal tunnel and careful dissection of its content even in the so called safe zone ulnar to long axis of palmaris longus tendon is recommended.     

Digital avulsion injuries: the shish kebab effect of the fibrous flexor sheath

On debriding a hand from which four fingers with all their flexor tendons had been avulsed, a sizeable quantity of 'minced' muscle was found in the palm. Further cadaver investigations showed that the avulsed flexor tendons disrupted proximal to the musculo-tendon junction, and that a significant amount of devitalized forearm muscle tissue was left in the palm as the tendons passed through the proximal fibrous flexor sheath. A case of early development of carpal tunnel syndrome following avulsion injury of the little finger is illustrated in which later surgical exploration of the palm revealed detached muscle tissue compromising the median nerve. It is suggested that exploration of the palm is indicated in all cases of proximal avulsions of the flexor tendons.     

Gouty tenosynovitis and compression neuropathy of the median nerve

Two cases of gouty tenosynovitis were associated with carpal tunnel syndrome. Both patients had carpal tunnel release with good relief of symptoms. In one patient, gout was not suspected before operation; this patient developed wound dehiscence with tophaceous urate crystal drainage that eventually disappeared. Proper preoperative antigout therapy may have prevented this complication. Carpal tunnel syndrome associated with gout is rare. Preoperative investigations for gout may be indicated in patients with carpal tunnel syndrome.     

Comparative Anatomy of the Subsynovial Connective Tissue in the Carpal Tunnel of the Rat, Rabbit, Dog, Baboon, and Human

The tenosynovium in the human carpal tunnel is connected to the flexor tendons and the median nerve by the subsynovial connective tissue (SSCT). The most common histological finding in carpal tunnel syndrome (CTS), a compression neuropathy of the median nerve, is noninflammatory fibrosis of the SSCT. The relationship, if any, between the fibrosis and nerve pathology is unknown, although some have speculated that a change in the SSCT volume or stiffness might be the source of the compression. Yet, while animal models have been used to study the physiology of nerve compression, so far none have been used to study the relationship of the SSCT pathology to the neurophysiological abnormalities. The purpose of this study was to identify animal models that might be appropriate to study the interaction of SSCT and nerve function in the development of CTS. The front paws of a rat, rabbit, dog, and baboon were dissected. The carpal tunnel anatomy and SSCT of these animals were also examined by light and scanning microscopy and compared to the relevant human anatomy and ultrastructure. The carpal tunnel anatomy and contents of the baboon and rabbit are similar to humans. The canine carpal tunnel lacks the superficial flexor tendons and the rat carpal tunnel is very small. The human, baboon, and rabbit specimens had very similar organization of the SSCT, and content of the carpal canal. We conclude that, while both the baboon and rabbit would be good animal models to study the relationship of the SSCT to CTS, the rabbit is likely to be more practical, in terms of cost and animal care concerns.     

DIGITAL AVULSION INJURIES: THE SHISH KEBAB EFFECT OF THE FIBROUS FLEXOR SHEATH*

On debriding a hand from which four fingers with all their flexor tendons had been avulsed, a sizeable quantity of ‘minced’ muscle was found in the palm. Further cadaver investigations showed that the avulsed flexor tendons disrupted proximal to the musculc-tendon junction, and that a significant amount of devitalized forearm muscle tissue was left in the palm as the tendons passed through the proximal fibrous flexor sheath. A case of early development of carpal tunnel syndrome following avulsion injury of the little finger is illustrated in which later surgical exploration of the palm revealed detached muscle tissue compromising the median nerve. It is suggested that exploration of the palm is indicated in all cases of proximal avulsions of the flexor tendons.     

MRI evaluation of carpal tunnel morphology after carpal tunnel release by a retinaculum lengthening technique

AIM: The benefits of maintaining the pulley function of the flexor retinaculum in carpal tunnel release by lengthening or reconstructing it have been described. Quantitative MR imaging was used to investigate the morphological changes after open carpal tunnel release by such a retinaculum lengthening technique. METHOD: Ten patients had bilateral carpal tunnel MRI pre- and postoperatively. The MRI examinations were performed with a 1.5 Tesla imaging system and wrist coils. Carpal tunnel volume, carpal arch width, median nerve position and flexor tendon position in relation to the hamate-trapezial axis were recorded . RESULTS: Like other methods of carpal tunnel release with complete division of the flexor retinaculum, the retinaculum lengthening technique showed a significant postoperative increase of carpal tunnel volume. Carpal arch width increased only slightly. There was a significant palmar displacement of the median nerve but not of the flexor tendons. CONCLUSION: The findings support the hypothesis that maintenance of the pulley function of the retinaculum may lead to an early postoperative recovery of grip strength. In spite of some difficulties in application quantitative MR imaging may be a useful tool in evaluating the carpal tunnel morphology.     

Découverte inédite d’une rupture par usure du nerf médian lors d’une reprise de canal carpien

We report the finding of a subtotal rupture of the median nerve caused by a “bridge” or“easel” erosion due to a sequela of childhood wrist fracture. This unpublished observation was made during a carpal tunnel release procedure on an 80-year-old patient who was operated on for recurrence of a severe carpal tunnel syndrome 30 years after a previous neurolysis. If the flexor tendon ruptures are widely described, as well as nerve sections following high energy trauma, the median nerve rupture caused by its erosion over a bony projection has never been published at the best of our knowledge.     

Persistent median artery as a cause of pronator syndrome

Pronator syndrome may be caused by a persistent median artery that passes completely through the proximal median nerve and then gives origin to a vascular leash to the flexor muscles that compresses the nerve. A "double crush" compression of the median nerve caused by persistent median artery producing first a carpal tunnel syndrome and then a pronator syndrome is described.