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European Journal of Orthopaedic Surgery... Oct 2023Carpal tunnel (CT) syndrome continues to be a commonly treated hand pathology. We aimed to evaluate several CT injection techniques for (1) spatial accuracy within the...
PURPOSE
Carpal tunnel (CT) syndrome continues to be a commonly treated hand pathology. We aimed to evaluate several CT injection techniques for (1) spatial accuracy within the CT and (2) risk of median nerve (MN) injury. Our purpose was to evaluate for any significant differences in accuracy of needle placement within the carpal tunnel and final distance between the needle tip and the MN with each technique.
METHODS
Fifteen fresh frozen cadaveric arms were used for this study. Six different injection techniques for CT injection were performed on each specimen, including palmaris longus, ulnar to flexor carpi radialis, trans-flexor carpi radialis, volar radial, volar ulnar, and direct through the palm techniques. After needle placement, a standard open CT release was performed to assess for accuracy of placement within the CT and measure needle position in relation to the MN and other anatomic structures.
RESULTS
Accurate intra-CT needle placement was seen in 91% of injections. While there was no significant difference between injection techniques for distance to nearest tendon (p = 0.1531), the trans-flexor carpi radialis (tFCR), volar radial (VR), and volar ulnar (VU) techniques consistently provided the greatest intra-CT distance from needle tip to median nerve (p = 0.0019). The least incidence of intraneural needle placement was found with the tFCR and VR approaches.
CONCLUSION
All six injection techniques reliably enter the CT space. The lowest risk to the MN was found with tFCR and VR techniques, and we recommend these techniques for safe and effective needle placement to avoid iatrogenic intraneural injection.
LEVEL OF EVIDENCE
Level V: Cadaveric Study.
Topics: Humans; Median Nerve; Carpal Tunnel Syndrome; Wrist; Forearm; Cadaver
PubMed: 36934360
DOI: 10.1007/s00590-023-03515-z -
Journal of Hand Therapy : Official... 2017Systematic review. (Review)
Review
STUDY DESIGN
Systematic review.
INTRODUCTION
Median nerve mobilization is one of the interventions used in the treatment of carpal tunnel syndrome (CTS). However, it is uncertain how many types of mobilization techniques are described in the current literature or the relative effectiveness of these techniques in treating CTS.
PURPOSE OF THE STUDY
The aim of this review was to describe the types and effectiveness of median nerve mobilization techniques studied in the CTS literature.
METHODS
Electronic searches of 5 databases and manual searches of references lists located randomized controlled trials studies published between 2000 and April 2015. Quality appraisal for each study was conducted using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields by 2 independent reviewers.
RESULTS
Nine randomized controlled trial studies describing various median nerve mobilization techniques used in the treatment of CTS were included. All studies were rated as of "adequate", "good", or "strong" quality for the Standard Quality Assessment Criteria. Three techniques of median nerve mobilization were described. Treatment outcomes included measures of electrodiagnostic testing, functional performance, pain, physical examination, sensation, and strength. Standardized mean differences for the treatment outcomes ranged from very small to large (0.05-1.71).
CONCLUSION
The findings are inconclusive regarding the effectiveness of each mobilization technique due to methodological limitations in the current body of research. Therefore, there is a clear need for high-quality controlled studies to examine various approaches to median nerve mobilization techniques in the treatment of CTS.
LEVEL OF EVIDENCE
2a.
Topics: Carpal Tunnel Syndrome; Decompression, Surgical; Female; Humans; Male; Median Nerve; Pain Measurement; Prognosis; Randomized Controlled Trials as Topic; Severity of Illness Index; Treatment Outcome
PubMed: 28764878
DOI: 10.1016/j.jht.2017.06.019 -
Lumbrical Muscles Neural Branching Patterns: A Cadaveric Study With Potential Clinical Implications.Hand (New York, N.Y.) Sep 2022Lumbrical muscles originate in the palm from the 4 tendons of the flexor digitorum profundus and course distally along the radial side of the corresponding...
BACKGROUND
Lumbrical muscles originate in the palm from the 4 tendons of the flexor digitorum profundus and course distally along the radial side of the corresponding metacarpophalangeal joints, in front of the deep transverse metacarpal ligament. The first and second lumbrical muscles are typically innervated by the median nerve, and third and fourth by the ulnar nerve. A plethora of lumbrical muscle variants has been described, ranging from muscles' absence to reduction in their number or presence of accessory slips. The current cadaveric study highlights typical and variable neural supply of lumbrical muscles.
MATERIALS
Eight (3 right and 5 left) fresh frozen cadaveric hands of 3 males and 5 females of unknown age were dissected. From the palmar wrist crease, the median and ulnar nerve followed distally to their terminal branches. The ulnar nerve deep branch was dissected and lumbrical muscle innervation patterns were noted.
RESULTS
The frequency of typical innervations of lumbrical muscles is confirmed. The second lumbrical nerve had a double composition from both the median and ulnar nerves, in 12.5% of the hands. The thickest branch (1.38 mm) originated from the ulnar nerve and supplied the third lumbrical muscle, and the thinnest one (0.67 mm) from the ulnar nerve and supplied the fourth lumbrical muscle. In 54.5%, lumbrical nerve bifurcation was identified.
CONCLUSION
The complex innervation pattern and the peculiar anatomy of branching to different thirds of the muscle bellies are pointed out. These findings are important in dealing with complex and deep injuries in the palmar region, including transmetacarpal amputations.
Topics: Cadaver; Female; Hand; Humans; Male; Median Nerve; Muscle, Skeletal; Ulnar Nerve
PubMed: 33349041
DOI: 10.1177/1558944720963881 -
Ultrasound in Medicine & Biology Nov 2019Nerve movement is decreased in patients with carpal tunnel syndrome and can be assessed with ultrasound. In addition to morphologic features, this study describes a...
Nerve movement is decreased in patients with carpal tunnel syndrome and can be assessed with ultrasound. In addition to morphologic features, this study describes a novel approach in which nerve movement and the association with short-term patient-reported outcome are assessed. Ultrasound images at the carpal tunnel inlet were acquired during finger and wrist flexion. Linear regression models were used with the Boston Carpal Tunnel Questionnaire as main outcome. Eighty-five patients were included; 93% completed the 3-mo follow-up. Pre-surgical mean nerve area was 14.5 ± 4.2 mm and decreased to 13.3 ± 3.8 mm (p < 0.001). Displacement in dorsal direction with wrist flexion increased from 1.9 ± 1.3 to 2.4 ± 1.3 mm (p < 0.01). A pre-surgical larger nerve area was associated with more functional improvement (β = -0.024, p = 0.02), but baseline mobility was not. Change in excursion with finger flexion was associated with symptomatic improvement, but with a small effect (β = -0.05, p = 0.01). This indicates that there is limited prognostic potential for dynamic transverse ultrasound in carpal tunnel syndrome.
Topics: Adult; Aged; Aged, 80 and over; Carpal Tunnel Syndrome; Female; Humans; Male; Median Nerve; Middle Aged; Prognosis; Prospective Studies; Surveys and Questionnaires; Ultrasonography
PubMed: 31488311
DOI: 10.1016/j.ultrasmedbio.2019.06.422 -
Clinical Rheumatology Dec 2021
Topics: Carpal Tunnel Syndrome; Humans; Median Nerve; Ultrasonography
PubMed: 34247290
DOI: 10.1007/s10067-021-05851-z -
Orphanet Journal of Rare Diseases Sep 2021Mucopolysaccharidosis consists of a group of diseases caused by the deficiency of lysosomal enzymes, which may lead to the compression of the median nerve in the carpal...
BACKGROUND
Mucopolysaccharidosis consists of a group of diseases caused by the deficiency of lysosomal enzymes, which may lead to the compression of the median nerve in the carpal tunnel due to the accumulation of glycosaminoglycan, resulting in the hand disability. The study purpose is to present functional results of carpal tunnel release in mucopolysaccharidosis patients. Patients were selected from an enzyme replacement group in the Department of Pediatric Neurology. The legal guardians of the patients were informed about the likely functional change of the hands induced by compression of the median nerve. Clinical evaluation was performed in those patients who received their legal guardians' consent to participate and was included inspection, assessment of functional level, wrinkle test and the digital pinch function to manipulate small and large objects. Ultrasound and electromyography were performed to confirm the clinical median nerve compression. Bilateral extended opening technique was performed to access the carpal tunnel and analyze the anatomic findings of the median nerve and the flexed tendons of the fingers. After the surgical release of the carpal tunnel, the clinical evaluation was repeated. Subjective observations of the legal guardians were also considered.
RESULTS
Seven patients underwent bilateral surgical opening of the carpal tunnel; six boys, mean age of 9.5 (5 to 13), five of them presenting Type II mucopolysaccharidosis, 1 Type I and 1 Type VI. The average follow-up was 12 months (10-13 months). The functional results observed included the improvement in the handling of small and large objects in all children who underwent decompression of the median nerve. The comparison between the pre-operative and post-operative functional levels revealed that 2 patients evolved from Level II to IV, 3 from Level III to IV, 1 from Level IV to V and 1 patient remained in Level III. Tenosynovitis around the flexor tendons and severe compression of the median nerve in the fourteen carpal tunnels were observed during the surgical procedure. In 6 wrists, partial tenosynovitis was performed.
CONCLUSIONS
Despite the improvement in the overall function of the children' hands, we cannot conclude that only surgery was responsible for the benefit. Better designed studies are required.
Topics: Carpal Tunnel Syndrome; Child; Humans; Male; Median Nerve; Mucopolysaccharidoses; Tendons; Ultrasonography
PubMed: 34503540
DOI: 10.1186/s13023-021-01982-3 -
Journal of Orthopaedic Research :... Mar 2021Carpal tunnel syndrome (CTS) is a peripheral neuropathy resulting from chronic median nerve compression. Chronic compression leads to neurological changes that are...
Carpal tunnel syndrome (CTS) is a peripheral neuropathy resulting from chronic median nerve compression. Chronic compression leads to neurological changes that are quantified through nerve conduction studies (NCS). Although NCS represents the gold standard in CTS assessment, they provide limited prognostic value. Several studies have identified ultrasound as a tool in diagnosing and potentially predicting the progression of CTS in patients. The purpose of this study was to evaluate the predictive value of ultrasound examination in CTS patients. Twenty patients recruited at their first visit with the neurologist completed two NCS and ultrasound examinations approximately 6 months apart. Ultrasound examination consisted of B-mode, pulse-wave Doppler and colour Doppler ultrasound videos and images to quantify median nerve cross-sectional area, intraneural blood flow velocity in three wrist postures (15° flexion, neutral, and 30° extension), and displacement of the flexor digitorum superficialis (FDS) tendon and the adjacent subsynovial connective tissue (SSCT) of the middle finger during repetitive finger flexion-extension cycles. A questionnaire was administered to assess the work-relatedness of CTS. Linear regression analyses revealed that intraneural blood flow velocity (R = 0.36, p = .03), assessed in wrist flexion, and relative FDS-SSCT displacement (R = 0.27, p = .04) and shear strain index (R = 0.28, p = .04) were significant predictors of nerve sensory and motor changes at 6 months. Results suggest the possibility of using a battery of ultrasound measures as viable markers to predict median nerve functional changes within 6 months.
Topics: Adult; Aged; Blood Flow Velocity; Carpal Tunnel Syndrome; Disease Progression; Double-Blind Method; Female; Humans; Male; Median Nerve; Middle Aged; Predictive Value of Tests; Tendons; Ultrasonography
PubMed: 33098574
DOI: 10.1002/jor.24893 -
Clinical Biomechanics (Bristol, Avon) Jan 2020Carpal tunnel and median nerve dynamically change with wrist motion. The purpose of this study was to investigate the morphological changes and positional migration of...
BACKGROUND
Carpal tunnel and median nerve dynamically change with wrist motion. The purpose of this study was to investigate the morphological changes and positional migration of the carpal arch and median nerve, as well as nerve-arch positional relationship associated with wrist deviation in healthy volunteers.
METHODS
Twenty asymptomatic male volunteers performed wrist motion from neutral to deviated positions combining flexion-extension and radioulnar deviation. Ultrasound images of the carpal arch and median nerve at the distal carpal tunnel were collected during wrist motion. Morphological and positional parameters of the carpal arch and median nerve were derived from the ultrasound images.
FINDINGS
Carpal arch height, area, and palmar bowing of the transverse carpal ligament (TCL) increased with flexion related wrist motion and decreased with extension related motion (P < 0.05). Arch width increased with radial flexion and decreased with extension and ulnar extension (P < 0.05). Median nerve circularity increased with flexion and radial flexion but decreased with extension, ulnar extension, and ulnar deviation (P < 0.05). Nerve centroid displaced ulnarly with radial deviation, radial flexion, and radial extension and displaced radially with ulnar deviation, ulnar flexion, and ulnar extension (P < 0.05). Nerve centroid displaced in the dorsal direction with flexion and radial flexion, but in the palmar direction with extension (P < 0.05). Nerve-TCL distance increased with flexion related motion and decreased with extension relation motion (P < 0.05).
INTERPRETATION
The current study advances our understanding the effect of wrist motion on the carpal tunnel and its contents, which has implications for pathomorphological and pathokinematic changes associated with wrist disorders.
Topics: Adult; Carpal Bones; Female; Healthy Volunteers; Humans; Ligaments, Articular; Male; Median Nerve; Motion; Radius; Range of Motion, Articular; Ultrasonography; Wrist; Wrist Joint
PubMed: 31733628
DOI: 10.1016/j.clinbiomech.2019.10.024 -
Plastic and Reconstructive Surgery Jun 2021The objectivity of physical and electrodiagnostic tests is limited in detecting carpal tunnel syndrome and its recurrence. Predicting the median nerve blood supply using...
BACKGROUND
The objectivity of physical and electrodiagnostic tests is limited in detecting carpal tunnel syndrome and its recurrence. Predicting the median nerve blood supply using superb microvascular imaging will allow exact diagnosis and a good follow-up system. The aims of this study include using superb microvascular imaging to correlate with electromyographic diagnosis, and to determine the impact of surgery on improvement in superb microvascular imaging.
METHODS
Between July of 2019 and January of 2020, 32 wrists of 21 patients were evaluated prospectively. After preoperative electrodiagnostic studies and vascular index measurement with superb microvascular imaging, open carpal tunnel release was performed by a single surgeon, and 3 months later standardized superb microvascular imaging was performed. Preoperative vascular indexes were compared with the mild, moderate, and severe electrodiagnostic study results. Preoperative and postoperative vascular index results were compared.
RESULTS
The average of the preoperative and postoperative imaging groups was 2.77 and 1.48, respectively, and there was a statistically significant difference between the two groups (p < 0.05). Although no significant difference was found between preoperative and postoperative vascular index values in patients presenting with mild carpal tunnel syndrome (p > 0.05), there was a significant decrease in vascular index values in patients presenting with moderate and severe carpal tunnel syndrome after surgical decompression.
CONCLUSIONS
Superb microvascular imaging is emerging as a groundbreaking, new, and reliable technique. Evaluation of the median nerve blood supply is a reliable method that would be helpful for early diagnosis, planning treatment, determining the severity of carpal tunnel syndrome, and postoperative follow-up.
CLINICAL QUESTION/LEVEL OF EVIDENCE
Diagnostic, IV.
Topics: Adult; Aged; Aged, 80 and over; Carpal Tunnel Syndrome; Decompression, Surgical; Electrodiagnosis; Female; Humans; Male; Median Nerve; Microcirculation; Middle Aged; Ultrasonography, Doppler
PubMed: 33974590
DOI: 10.1097/PRS.0000000000007940 -
Clinical Anatomy (New York, N.Y.) May 2019Clinical and diagnostic variations may occur due to the variable presence of a connection between the median and ulnar nerves in the forearm (Martin-Gruber anastomosis)....
Clinical and diagnostic variations may occur due to the variable presence of a connection between the median and ulnar nerves in the forearm (Martin-Gruber anastomosis). This incidence has a wide range at 7%-40%. Most commonly, the connection between the nerves is considered to be composed of motor fibers; although, a sensory role has also been described. It is important to note that the number of axons, or the nature of the fibers in this connection, have not yet been elucidated. Fifty upper limbs were examined evaluating morphometric characteristics of the Martin Gruber connection, dissected out, sectioned, and immunohistochemically stained for choline acetyltransferase (ChAT) and analyzed with ImageJ . The connection was observed in 32% of all cases (16/50). The nerve connections were identified as those in Pattern 1 group (12%-type 1b, 19%-type 1a, and 69%-type 1c) and contained motor (ChAT positive) fibers (40.42 ± 10.5% per connection) with three to four fascicles in each. No statistically significant differences were found according to sex, side, or laterality. There were statistically significant differences in the percentages of ChAT positive fibers; however, this was dependent on the distribution being greater in those not distributed zonally. The presence of this connection is prevalent in almost a third of the cadavers dissected; the understanding of this complex composition in sensory and motor fibers allows for the optimization of diagnosis and treatment of certain median-ulnar nerve injuries. Clin. Anat. 32:501-508, 2019. © 2019 Wiley Periodicals, Inc.
Topics: Aged; Aged, 80 and over; Anatomic Variation; Female; Humans; Male; Median Nerve; Middle Aged; Ulnar Nerve
PubMed: 30664256
DOI: 10.1002/ca.23339