Trigger wrist caused by a tumor of the tendon sheath in a teenager

Triggering of the flexor tendons at the wrist is a rare phenomenon. It usually occurs in adult patients, and the manifestations and etiology can vary. We present a teenager with triggering and symptoms of carpal tunnel syndrome caused by a fibroma of the tendon sheath originating from the flexor tendons in the carpal canal.     

Tendinous sheath fibroma causing "trigger wrist" and carpal tunnel syndrome

There are few cases described of fibroma of tendon sheath located to the hand and the wrist. A case of fibroma of tendon sheath of lumbrical muscle of the index finger has been described. The tumor was responsible of a peculiar phenomenon of "triggering" of the wrist during the movements of flexion and extension of the index finger, and caused compression of the median nerve at the carpal tunnel. The intervention has brought to an early and long lasting relief of symptoms. Moreover, the histological aspect has been described and the relatively high possibility of recurrence of this lesion is underlined.     

"Trigger finger at the wrist" due to anomalous flexor digitorum superficialis muscle belly within the carpal tunnel

"Triggering of the fingers at the wrist" is a relatively unusual condition. It consists in a triggering at the wrist produced by finger motion. Its etiology and presentation may vary. This condition should be clearly differentiated from the other clinical entity called "trigger wrist", occurring on wrist movement. In the present article, we report the case of an anomalous flexor digitorum superficialis muscle belly, arising from the right ring finger at the carpal tunnel, in a 47-year old female patient, causing triggering of the right ring finger at the wrist and a carpal tunnel syndrome. Surgical excision of the muscle mass and carpal tunnel release relieved patient's symptoms and has led to the disappearance of the triggering phenomenon. To date, few cases of trigger finger at the wrist have been reported in the literature. These reported cases were reviewed. The clinical entity of "true trigger wrist" and its etiology are also discussed.     

Syndrome du canal carpien et poignet à ressaut révélant un fibrome de la gaine des fléchisseurs

The tendinous sheath fibroma (TSF) is a rare benign tumor, exceptionally responsible for carpal tunnel syndrome and “trigger” wrist: we found this association less than ten times in the English and French literature. We report the case of a 63-year-old right-handed carpenter who featured a triggering phenomenon of the right wrist during the flexion-extension movements and compression of the median nerve at the carpal tunnel, secondary to a TSF of the flexor digitorum superficialis. The diagnosis was suspected at the sonography and MRI, the tumor was excised and proven histologically to be a TSF. One year later, the patient remained free of symptoms.     

Clicking at the wrist due to fibroma in an anomalous lumbrical muscle: a case report and review of literature

A 33-year-old man had clicking at the wrist and symptoms that were characteristic of carpal tunnel syndrome, which were secondary to a fibroma arising from an anomalous lumbrical muscle in the carpal tunnel. Carpal tunnel release and excision of the fibroma relieved both of the conditions.     

Flexor tendon lengthening by tenotomy at the musculotendinous junction

The author presents his experience with an established technique of flexor tendon lengthening by tenotomy at the musculotendinous junction. This technique can be used for digital stiffness of forearm origin when active extension is possible on flexion of the wrist. There must not be adherence in the carpal tunnel or in the digital sheath, and active flexion must be preserved. It can also be used for digital stiffness in addition to other techniques. This kind of lengthening has some advantages: there are no sutures in the tendon itself, and it allows early reeducation in association with dynamic extension splinting. Active flexion is preserved immediately and there is good tendon healing. It is possible to lengthen selectively the superficial flexor or the deep flexor and in some cases both. Results are presented according to cause.     

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.     

Anomalous flexor digitorum superficialis muscle transposition for vascular coverage of the median nerve in recurrent carpal tunnel syndrome

Recurrent carpal tunnel syndrome is uncommon yet troublesome. Significant adhesions and scarring around the median nerve can render it relatively ischemic. A number of vascular flaps have been described to provide vascular coverage in attempts to decrease further cicatricial adhesions and to improve local blood supply around the median nerve. A rare case of an anomalous muscle in the distal forearm used as tissue to provide good vascularized coverage of the median nerve that was severely scarred in its bed is reported. The anomalous muscle was distal to the flexor digitorum superficialis tendon and inserted in the palmar fascia on the ulnar aspect of the hand. Referring branches from the ulnar artery provided vascular supply to the anomalous muscle. The muscle on these vascular pedicles was transposed over the median nerve, providing good, stable, unscarred coverage. The patient had an excellent result with resolution of the carpal tunnel symptoms. The redundant anomalous muscle provided a unique vascularized source for coverage of the median nerve in recurrent carpal tunnel syndrome.     

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.     

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.     

Trigger wrist phenomenon in rheumatoid arthritis

Flexor tendon synovitis in patients with rheumatoid arthritis commonly presents with a carpal tunnel syndrome and a concomitant trigger finger. Triggering at the wrist joint is in this disease an uncommon additional feature. In the two cases reported, histological examination of the tissue has indicated that, as well as chronic synovitis, there was a true rheumatoid nodule present at the wrist joint, either pedunculated or fusiform. The passage of the nodule, with a 'Click' from the proximal side of the transverse carpal ligament to the distal aspect, when the fingers are flexed, creates the sensation, signs and symptoms of a trigger wrist.     

Trigger digits-associated carpal tunnel syndrome: relationship between carpal tunnel release and trigger digits.

Of 875 idiopathic carpal tunnel syndrome (CTS) cases, 101 (11.5%) required trigger digit release operations within three years before and/or after carpal tunnel release (CTR); these 101 cases were investigated, retrospectively. Trigger digit release (TDR) was performed most often after the CTR, especially within three months. Next most common was at the same time as the CTR. The TDR performance rate after CTR was 5.9%. The nerve conduction study (NCS) comparison between trigger digits-associated CTS and isolated CTS showed that pre-operative distal motor latency was significantly more delayed in trigger digits-associated CTS, while there was no evidence of any difference due to age or gender. The difference of operative method (open or endoscopic procedure) did not influence the incidence rate of trigger digits after the CTR. This study suggested that trigger digits-associated CTS has a previously developed wide-ranging narrowing of the flexor tendon sheath.     

The acute carpal tunnel syndrome: nine case reports.

Nine cases of acute carpal tunnel syndrome are reported. Etiologies include: bleeding secondary to chronic lymphatic leukemia; Colles' fracture of the wrist (2 cases); Epiphyseal fracture (Salter II) of the distal radius; Bleeding secondary to giant cell tumor of the tendon sheath; Unstable distal radio-ulnar joint; Displaced intra-articular fracture of the distal radius; Rheumatoid synovitis and vasculitis; Trans-scaphoid, perilunar fracture dislocation of the wrist. Early recognition of median nerve compression in the carpal tunnel is vital. The signs of median nerve compression should be looked for in all cases of wrist trauma. In our opinion, immediate surgical decompression is frequently indicated.     

Akutes Karpaltunnelsyndrom bei Marfan-Syndrom

Acute carpal tunnel syndrome (ACTS) is rare and is mostly the result of fractures of the distal radius or the carpal bones. This paper gives the first report of an ACTS following contusion of the wrist as the result of an extensive haematoma of the flexor tendon sheath, which did not appear until 50 hours after the injury was sustained but then developed rapidly. The patient suffers from Marfan syndrome. This disease is associated with pathologic changes to the major vessels, and especially the aorta, and of the smaller peripheral vessels. It is assumed that the haematoma arose from an aneurysm of such a small vessel. The treatment of choice in ACTS is emergency incision of the carpal tunnel.     

Operative findings in camptodactyly of the little finger.

In five of six cases of camptodactyly in which an abnormality of the flexor tendon was examined at operation, the flexor digitorum superficialis tendon was hypoplastic and there was no continuity of the normal tendon between the muscle belly and bony insertion. The proximal end of the flexor digitorum superficialis tendon was attached to the palmar aponeurosis and the flexor tendon sheath of the ring finger in two patients, to the palmar aponeurosis in one, to the undersurface of the transverse carpal ligament in one and to the flexor tendon sheath of the ring finger in one. The tenodesis effect of the abnormal tendon of the flexor digitorum superficialis is considered to play an important role in the cause and rapid increase of the deformity of camptodactyly.     

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.     

Primary flexor tendon ruptures of the little finger within the carpal tunnel. Proposed classification based on six clinical cases and review of the literature

Six cases of primary flexor tendon rupture of the little finger within the carpal tunnel are presented. All of them were attritional ruptures caused by a rough hook of the hamate. These ruptures are rare. They have their place among the flexor tendon ruptures of the wrist and the palm. Ultrasound may by helpful to determine the level of rupture. The surgical treatment consists of excision of the hook of the hamate and tendon repair.     

Prevalence of anatomic variations encountered in elective carpal tunnel release

PURPOSE: To determine the prevalence of aberrant or unexpected anatomic structures within one surgeon's elective experience of carpal tunnel releases and their association with pathologic compression. METHODS: A total of 31 anomalies of median nerve, muscle, and tendon, median artery persistence, and ulnar nerve were documented in 30 hands during the course of 526 elective carpal tunnel releases in one surgeon's practice. The data collected were reviewed retrospectively. All carpal tunnel releases were performed open, exposing the median nerve from the palmar arch to the proximal wrist crease. Anomalies were categorized into those involving the median nerve and its motor and sensory branches, the ulnar nerve, a persistent median artery, and anomalies of muscle/tendon units traversing the carpal tunnel area. RESULTS: Seven hands were noted to have aberrant muscle/tendon variations within the carpal tunnel region (1.3%). Anomalies of the median nerve or its palmar cutaneous or motor branches were observed in 5 hands (1.0%). An anomaly of the ulnar nerve with an aberrant branch crossing the carpal tunnel incision occurred in one hand. A persistent median artery (>or=1 mm) was noted in 18 hands (3.4%). One hand had 2 anomalies present. One anomaly was high bifurcation of the median nerve and the second anomaly was an anomalous muscle to the long finger superficialis. CONCLUSIONS: The specific anatomic variations described may be anticipated and more readily recognized by hand surgeons during such open surgery, thus increasing the efficacy and safety of this common procedure.     

Symptomatic restrictive thumb-index flexor tenosynovitis: incidence of musculotendinous anomalies and results of treatment

During a 5-year period, 33 patients with pain in the palmar aspect of the wrist and forearm with and without features of carpal tunnel syndrome were diagnosed as having restrictive thumb-index flexor tenosynovitis. The pathognomonic sign in this condition was the simultaneous flexion of the index finger with active flexion of the thumb across the palm. Treatment included either steroid injection into the tendon sheath of the flexor pollicis longus or surgical exploration of the palmar aspect of the distal forearm and wrist region. Twenty-six wrists in 24 patients were surgically explored, and all had hypertrophic tenosynovium between the flexor pollicis longus and index profundus tendons. More than half of the explored wrists had a tendinous connection between the flexor pollicis longus and the flexor profundus of the index digit. Of 17 wrists with follow-up of more than 6 months, 13 were improved by surgical management. Steroid injection did not have a long-term effect.