Short report letter Journal of Hand Surgery (European Volume) 0(0) 1–2 journals.sagepub.com/home/jhs
Development of carpal tunnel syndrome after repair of the median nerve in the distal forearm Dear Sir, A 55-year-old woman presented with a neglected injury of the median nerve in the distal forearm. The injury was self-inflicted and had occurred 16 months previously. At presentation, there was no sensation in the radial four digits, in the radial part of the palm including the skin of the thenar eminence (filament test: touch with orange 300 g filament), incomplete thumb opposition and weaker grip (16 kg, 65% of the other hand). The thenar muscles were slightly atrophic (Figure 1). Ultrasound imaging showed disruption of the median nerve with a 1.5-cm gap between the stumps. During surgery, the divided nerve was exposed and both stumps were sectioned until normal bundles were seen, the gap between the stumps after scar excision being 1.5 cm. After mobilization of the distal and proximal stumps, the nerve ends were coapted and sutured with 8/0 nylon,
without tension. After the operation, the wrist was immobilized for three weeks. At three-month follow-up, the patient reported improvement of sensation in the proximal palm, suggesting progression of nerve regeneration; the Tinel sign was also present at the level of proximal palm. Four months after the operation the patient developed numbness and paraesthesia in the radial four digits and pain in the hand, radiating to the elbow. The symptoms occurred mostly at night, awakening the patient. She denied any such symptoms in the past, before the median nerve injury. Ultrasonography showed enlargement of the median nerve at the inlet of the carpal tunnel (cross-sectional area 17 mm2) and thinness within the tunnel. Electrophysiological tests revealed no response from the radial three digits after antidromic stimulation of sensory fibres and recovery of innervation of the abductor pollicis brevis muscle, confirming that regeneration of the nerve had reached and passed the carpal tunnel. The clinical signs and sonographic imaging suggested development of carpal tunnel syndrome and a decision was made to
Figure 1. Appearance of the hand and forearm after carpal tunnel release. The dotted line indicates the level of the initial median nerve section. The scar marked 1 is after median nerve reconstruction and the scar marked 2 is after carpal tunnel release.
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Journal of Hand Surgery (Eur) 0(0)
Figure 2. Appearance of the hand three months after carpal tunnel release with the recovery of sensation indicated, according to the colours of the Semmes Weinstein filaments.
decompress the carpal tunnel. The operation was done five months after the median nerve repair, under local anaesthesia and with a tourniquet. The flexor retinaculum was sectioned via a 2-cm incision in the proximal palm. Four months later, the patient reported no pain and paraesthesia in the operated hand and further progression of the recovery of sensation in the palm (Figure 2). We have not found a report of any similar case of carpal tunnel syndrome developing in the course of regeneration of the median nerve. The symptoms appeared four months after the nerve reconstruction, when sprouting fibres had passed the carpal tunnel and reached the proximal palm level. One can speculate whether the symptoms would have developed in this patient without nerve injury, or in other words,
whether the nerve trauma had any relationship to the occurrence of the syndrome. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Andrzej Z_ yluk*, Piotr Puchalski and Zbigniew Szlosser Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Poland *Corresponding author: [email protected]
ß The Author(s), 2017. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193417729588 available online at http://jhs.sagepub.com
Development of carpal tunnel syndrome after repair of the median nerve in the distal forearm Dear Sir, A 55-year-old woman presented with a neglected injury of the median nerve in the distal forearm. The injury was self-inflicted and had occurred 16 months previously. At presentation, there was no sensation in the radial four digits, in the radial part of the palm including the skin of the thenar eminence (filament test: touch with orange 300 g filament), incomplete thumb opposition and weaker grip (16 kg, 65% of the other hand). The thenar muscles were slightly atrophic (Figure 1). Ultrasound imaging showed disruption of the median nerve with a 1.5-cm gap between the stumps. During surgery, the divided nerve was exposed and both stumps were sectioned until normal bundles were seen, the gap between the stumps after scar excision being 1.5 cm. After mobilization of the distal and proximal stumps, the nerve ends were coapted and sutured with 8/0 nylon,
without tension. After the operation, the wrist was immobilized for three weeks. At three-month follow-up, the patient reported improvement of sensation in the proximal palm, suggesting progression of nerve regeneration; the Tinel sign was also present at the level of proximal palm. Four months after the operation the patient developed numbness and paraesthesia in the radial four digits and pain in the hand, radiating to the elbow. The symptoms occurred mostly at night, awakening the patient. She denied any such symptoms in the past, before the median nerve injury. Ultrasonography showed enlargement of the median nerve at the inlet of the carpal tunnel (cross-sectional area 17 mm2) and thinness within the tunnel. Electrophysiological tests revealed no response from the radial three digits after antidromic stimulation of sensory fibres and recovery of innervation of the abductor pollicis brevis muscle, confirming that regeneration of the nerve had reached and passed the carpal tunnel. The clinical signs and sonographic imaging suggested development of carpal tunnel syndrome and a decision was made to
Figure 1. Appearance of the hand and forearm after carpal tunnel release. The dotted line indicates the level of the initial median nerve section. The scar marked 1 is after median nerve reconstruction and the scar marked 2 is after carpal tunnel release.
2
Journal of Hand Surgery (Eur) 0(0)
Figure 2. Appearance of the hand three months after carpal tunnel release with the recovery of sensation indicated, according to the colours of the Semmes Weinstein filaments.
decompress the carpal tunnel. The operation was done five months after the median nerve repair, under local anaesthesia and with a tourniquet. The flexor retinaculum was sectioned via a 2-cm incision in the proximal palm. Four months later, the patient reported no pain and paraesthesia in the operated hand and further progression of the recovery of sensation in the palm (Figure 2). We have not found a report of any similar case of carpal tunnel syndrome developing in the course of regeneration of the median nerve. The symptoms appeared four months after the nerve reconstruction, when sprouting fibres had passed the carpal tunnel and reached the proximal palm level. One can speculate whether the symptoms would have developed in this patient without nerve injury, or in other words,
whether the nerve trauma had any relationship to the occurrence of the syndrome. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Andrzej Z_ yluk*, Piotr Puchalski and Zbigniew Szlosser Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Poland *Corresponding author: [email protected]
ß The Author(s), 2017. Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav doi: 10.1177/1753193417729588 available online at http://jhs.sagepub.com
