Authors: Laura Manfield, DO Mark Thomas, MD Se Won Lee, MD
Ultrasound
Affiliations: From the Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
CASE REPORT
Correspondence: All correspondence and requests for reprints should be addressed to: Se Won Lee, MD, Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, 110 East 210th St, Bronx, NY 10467.
Flexor Pollicis Longus Tenosynovitis in Patients with Carpal Tunnel Syndrome
Disclosures:
ABSTRACT
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
Manfield L, Thomas M, Lee SW: Flexor pollicis longus tenosynovitis in patients with carpal tunnel syndrome. Am J Phys Med Rehabil 2014;93:524Y527.
0894-9115/14/9306-0524 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000010
Carpal tunnel syndrome is typically diagnosed from history and physical examination then confirmed with electrodiagnosis. Electrodiagnosis provides only limited anatomic information and evaluation of space-occupying lesions. The authors present two cases in which demonstrated flexor pollicis longus tenosynovitis coexistent with carpal tunnel syndrome was diagnosed with ultrasonography. Ultrasonography is an effective modality that enhances the investigation of diseases in the soft tissues of the wrist and the hand. It can be useful in directing specific treatment by increasing diagnostic accuracy. Key Words:
Carpal Tunnel Syndrome, Flexor Pollicis Longus Tenosynovitis, Ultrasonography
C
arpal tunnel syndrome (CTS) is the most common entrapment neuropathy and a common reason for referral for the electromyographic (EMG) test. It accounted for 0.2% of all United States ambulatory care visits in 2006.1,2 CTS prevalence in the general population is approximately 5%, and women are affected two to three times more often than men are depending on the age group.3,4 CTS is characterized by motor and sensory impairments resulting in numbness and tingling in the median nerve distribution, thumb weakness, and atrophy of the thenar musculature in advanced cases. The diagnosis of CTS is usually made clinically on the basis of the history and physical examination and subsequently confirmed with electrodiagnosis.5 Electrodiagnosis provides only limited anatomic information and evaluation of space-occupying lesions.6 In the last decade, ultrasonography (US) has been increasingly used in the diagnosis of CTS as an effective supplement to electrodiagnostic studies.7 The main application of US to CTS has been diagnostic, with demonstration of focal enlargement of the median nerve at the carpal tunnel. However, the use of US in the differential diagnosis of space-occupying lesions such as tenosynovitis has been limited. The authors present two cases of CTS in which US identified a concomitant flexor pollicis longus (FPL) tenosynovitis. Because of the location of tenosynovitis within the carpal tunnel, it can contribute to the CTS by increasing intracarpal tunnel pressure.8
524
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 6, June 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CASE DESCRIPTIONS Case 1 A 17-yr-old right-handYdominant adolescent girl presented with a 6-mo history of progressively worsening right-hand pain, numbness, paresthesias, and weakness. She indicated that the pain began gradually without any trauma or injury. Her pain was located in the radiovolar aspect of the wrist, radiating primarily to the thumb. She also complained of pain and paresthesias in the second and third digits. Physical examination revealed mild bulging at the level of the volar wrist crease. Tenderness was noted on the ulnar side of the flexor carpi radialis tendon and over the thenar eminence. Resisted first interphalangeal flexion aggravated her pain in the hand and the wrist. Otherwise, the motor and the sensory examination of the bilateral upper extremities were unremarkable. The result of the Phalen test was positive. Electrodiagnostic findings were in the borderline range for CTS. US revealed a slight increase in cross-sectional diameter (17 mm2) of the median nerve at the entrance to the carpal tunnel (at the level of the pisiform-scaphoid bones). No gross synovial thickening was noted in the flexor carpi radialis tendon. There was anechoic synovial thickening around the FPL tendon, producing the characteristic Target sign corresponding to a thickened synovial membrane (Figs. 1 AYC).
Case 2 A 65-yr-old right-handYdominant woman with a medical history of diabetes presented with pain, numbness, tingling, and pins-and-needles paresthesia in the right hand and the fingers. The symptoms started gradually a few years ago with progressive worsening. The pain was described as cramping. She denied any weakness.
Physical examination revealed normal motor strength including thumb abduction. There was decreased light-touch sensation in the second digit compared with the fifth digit. The results of the Tinel and the Phalen sign were positive. Electrodiagnostic findings were consistent with moderate CTS in the right side. Ultrasound evaluation of the carpal tunnel revealed anechoic tenosynovial thickening in the FPL tendon within the carpal tunnel (Figs. 2A, B). The cross-sectional diameter of the median nerve was 9 mm2 at the scaphoid-pisiform level.
DISCUSSION These cases illustrate the application of musculoskeletal US in the diagnosis of FPL tenosynovitis in patients with CTS. When there is inconsistency between symptoms and electrodiagnostic findings in some mild CTS cases, other supplementary diagnostic tests can be useful. US has been increasingly used for the evaluation of CTS because it is often available and is noninvasive. The characteristic US findings of CTS are focal hypoechoic swelling of the median nerve and an increased nerve cross-sectional area.9 Although there has been controversy setting cross-sectional area thresholds (ranging from 9 to 15 mm2),10 a recent meta-analysis focused on the diagnostic test accuracy of US for CTS found that a cutoff point of 9 mm2 provided the greatest diagnostic accuracy.11 Other characteristics include flattening of the median nerve in the carpal tunnel and bowing of the flexor retinaculum.12 US evaluation is also valuable for detecting anatomic variations, such as bifid median nerves and persistent median arteries.13 US has also been used for the evaluation of extrinsic and intrinsic causes of CTS. These are broad and include space-occupying lesions, such as tenosynovitis, anomalous muscles, ganglion cysts, bony pathologic lesions, and tumors. Although a
FIGURE 1 A hypoechoic/anechoic effusion in the FPL tenosynovium on transverse view at the proximal wrist crease (A) and at the level of the first metacarpophalangeal joint (B). Longitudinal view of the FPL tendon and the tenosynovium at the wrist (C). www.ajpmr.com
Tenosynovitis in Carpal Tunnel Syndrome Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
525
FIGURE 2 Increased thickness of the FPL tenosynovium with irregular margin radial to the median nerve on transverse view (A) and longitudinal view (B) at the distal wrist crease.
few retrospective studies have examined flexor tendon pathology in patients with CTS,6,14 isolated FPL tenosynovitis has been scarcely reported. Because of the proximity of the FPL to the median nerve in the carpal tunnel, tenderness on the FPL tendon can be interpreted as a positive provocative test for CTS. Resisted flexion of the first interphalangeal joint can reproduce the symptom caused by FPL tenosynovitis. US identifies the synovial sheath as a thin, hypoechoic rim, usually less than 1-mm thick. In tenosynovitis, an increased amount of synovial fluid appears as a hypoechoic or an anechoic collection surrounding a hyperechogenic tendon with irregular margins.15 Other flexor muscle pathologic lesions that have been reported in patients with CTS include accessory muscle bellies and anomalous tendon between the FPL and the flexor digitorum profundus index and middle fingers,16 the Gantzer muscle, and the accessory flexor digitorum profundus and lumbricalis muscles.17 Giant-cell tumors of the flexor tendon sheath have been reported as a rare cause of CTS,18 and it appears as a hypoechoic solid mass with well-defined margins lacking the posterior acoustic enhancement. Ventral ganglion cyst, which originates from the carpal joint or the flexor tendon, may compress the median nerve. The ganglion cyst appears as a well-defined anechoic structure with posterior acoustic enhancement.19 Fractures, especially of the distal radius and the scaphoid, are high on the differential list if there is a history of trauma.20 US has been used for diagnosis when plain x-ray misses a fracture at a very early stage.21 Most peripheral nerve tumors of the hand and the wrist involve the median nerve and therefore can present as CTS. The tumors have a nonspecific appearance as oval hypoechoic solid masses with well-defined margins.19 Lipofibromatous hamartomas can be seen on US as a relatively mobile mass of intermixed echogenicity.19
526
Manfield et al.
Both patients underwent US-guided steroid injection to the carpal tunnel with good relief. Local corticosteroid injection at the carpal tunnel is widely used as the nonsurgical treatment of choice for CTS in addition to splinting and activity modification.22 A recent study found that the EMG severity of CTS was an important prognostic factor for the long-term effect of a local steroid injection because the group with mild CTS, as determined by EMG, responded better to local corticosteroid injection than did the group with moderate or severe CTS.23 Therefore, local steroid injection for a patient with borderline EMG findings such as case 1 and moderate CTS on EMG such as case 2 argued against the other treatment options such as splinting only and surgical release. Steroid injection was favored in these cases because it has been shown to be an effective firstline therapy for flexor tenosynovitis of the hand.24 The treatment of FPL tenosynovitis provides relief of the symptoms by decreasing intracarpal pressure.8 A cock-up splint is typically prescribed in CTS; however, it can aggravate the symptoms of concomitant FPL tenosynovitis by allowing free thumb movement. A splint extending to the thumb such as a thumbspica splint can be considered for instances of coexistent FPL tenosynovitis.25 In addition, patient education with the modification of thumb activities such as pinching, gripping, lifting, and twisting is useful.25 Improved accuracy in the diagnosis of a coexistent pathologic lesion allows construction of more specific and efficient treatment plans. In summary, these case reports illustrate FPL tenosynovitis in two patients with CTS who were diagnosed with musculoskeletal US. Most cases of CTS are idiopathic, but there are specific conditions that can contribute to median nerve compression. Concomitant conditions can be evaluated by US. This management of symptoms is facilitated with greater diagnostic accuracy. US is a very
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 6, June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
effective modality to enhance the investigation of diseases in the soft tissues of the wrist and the hand and should be considered to supplement electrodiagnostic evaluations of CTS.
REFERENCES 1. Schappert SM, Rechtsteiner A: Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report 2008:1Y29 2. Cullen KA, Hall MJ, Golosinskiy A: Ambulatory surgery in the United States, 2006. Natl Health Stat Report 2009:1Y25 3. Atroshi I, Englund M, Turkiewicz A, et al: Incidence of physician-diagnosed carpal tunnel syndrome in the general population. Arch Intern Med 2011;171:943Y4 4. da Costa BR, Vieira ER: Risk factors for work-related musculoskeletal disorders: A systematic review of recent longitudinal studies. Am J Ind Med 2010; 53:285Y323 5. Werner RA, Andary M: Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve 2011;44: 597Y607 6. Chen CH, Wu T, Sun JS, et al: Unusual causes of carpal tunnel syndrome: Space occupying lesions. J Hand Surg Eur Vol 2012;37:14Y9 7. Cartwright MS, Hobson-Webb LD, Boon AJ, et al: Evidence-based guideline: Neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve 2012;46:287Y93 8. Gelberman RH, Hergenroeder PT, Hargens AR, et al: The carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am 1981;63:380Y3 9. Jacobson JA: Fundamentals of Musculoskeletal Ultrasound. Philadelphia, Saunders, 2007 10. Roll SC, Case-Smith J, Evans KD: Diagnostic accuracy of ultrasonography vs. electromyography in carpal tunnel syndrome: A systematic review of literature. Ultrasound Med Biol 2011;37:1539Y53 11. Tai TW, Wu CY, Su FC, et al: Ultrasonography for diagnosing carpal tunnel syndrome: A meta-analysis of diagnostic test accuracy. Ultrasound Med Biol 2012: 38:1121Y8
www.ajpmr.com
12. Buchberger W, Schon G, Strasser K, et al: Highresolution ultrasonography of the carpal tunnel. J Ultrasound Med 1991;10:531Y7 13. Karadag YS, Karadag O, Cicekli E, et al: Severity of carpal tunnel syndrome assessed with high frequency ultrasonography. Rheumatol Int 2010;30:761Y5 14. Kang HJ, Jung SH, Yoon HK, et al: Carpal tunnel syndrome caused by space occupying lesions. Yonsei Med J 2009;50:257Y61 15. Filippucci E, Gabba A, Di Geso L, et al: Hand tendon involvement in rheumatoid arthritis: An ultrasound study. Semin Arthritis Rheum 2012;41:752Y60 16. Slater RR: Flexor tendon anomalies in a patient with carpal tunnel syndrome. J Hand Surg Br 2001; 26:373Y6 17. Nayak SR, Ramanathan L, Prabhu LV, et al: Additional flexor muscles of the forearm: Case report and clinical significance. Singapore Med J 2007;48:e231Y3 18. Meek MF, Sheikh ZA, Quinton DN: Carpal tunnel syndrome caused by a giant cell tumour of the flexor tendon sheath. J Plast Surg Hand Surg 2013; PMID: 23692165 19. Bianchi S, Martinoli C, Abdelwahab IF: High frequency ultrasound examination of the wrist and hand. Skeletal Radiol 1999;28:121Y9 20. Bauman TD, Gelberman RH, Mubarak SJ, et al: The acute carpal tunnel syndrome. Clin Orthop Relat Res 1981;156:151Y6 21. Hodgkinson DW, Nicholson DA, Stewart G, et al: Scaphoid fracture: A new method of assessment. Clin Radiol 1993;48:398Y401 22. Bland JD: Treatment of carpal tunnel syndrome. Muscle Nerve 2007;36:167Y71 23. Visser LH, Ngo Q, Groeneweg SJ, et al: Long term effect of local corticosteroid injection for carpal tunnel syndrome: A relation with electrodiagnostic severity. Clin Neurophysiol 2012;123:838Y41 24. Graham JB, Hulkower SD, Bosworth M, et al: Clinical inquiries. Are steroid injections effective for tenosynovitis of the hand? J Fam Pract 2007;56:1045Y7 25. Yao J, Park MJ: Early treatment of degenerative arthritis of the thumb carpometacarpal joint. Hand Clin 2008;24:251Y61
Tenosynovitis in Carpal Tunnel Syndrome Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
527
Ultrasound
Affiliations: From the Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
CASE REPORT
Correspondence: All correspondence and requests for reprints should be addressed to: Se Won Lee, MD, Department of Physical Medicine and Rehabilitation, Montefiore Medical Center, Albert Einstein College of Medicine, 110 East 210th St, Bronx, NY 10467.
Flexor Pollicis Longus Tenosynovitis in Patients with Carpal Tunnel Syndrome
Disclosures:
ABSTRACT
Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.
Manfield L, Thomas M, Lee SW: Flexor pollicis longus tenosynovitis in patients with carpal tunnel syndrome. Am J Phys Med Rehabil 2014;93:524Y527.
0894-9115/14/9306-0524 American Journal of Physical Medicine & Rehabilitation Copyright * 2013 by Lippincott Williams & Wilkins DOI: 10.1097/PHM.0000000000000010
Carpal tunnel syndrome is typically diagnosed from history and physical examination then confirmed with electrodiagnosis. Electrodiagnosis provides only limited anatomic information and evaluation of space-occupying lesions. The authors present two cases in which demonstrated flexor pollicis longus tenosynovitis coexistent with carpal tunnel syndrome was diagnosed with ultrasonography. Ultrasonography is an effective modality that enhances the investigation of diseases in the soft tissues of the wrist and the hand. It can be useful in directing specific treatment by increasing diagnostic accuracy. Key Words:
Carpal Tunnel Syndrome, Flexor Pollicis Longus Tenosynovitis, Ultrasonography
C
arpal tunnel syndrome (CTS) is the most common entrapment neuropathy and a common reason for referral for the electromyographic (EMG) test. It accounted for 0.2% of all United States ambulatory care visits in 2006.1,2 CTS prevalence in the general population is approximately 5%, and women are affected two to three times more often than men are depending on the age group.3,4 CTS is characterized by motor and sensory impairments resulting in numbness and tingling in the median nerve distribution, thumb weakness, and atrophy of the thenar musculature in advanced cases. The diagnosis of CTS is usually made clinically on the basis of the history and physical examination and subsequently confirmed with electrodiagnosis.5 Electrodiagnosis provides only limited anatomic information and evaluation of space-occupying lesions.6 In the last decade, ultrasonography (US) has been increasingly used in the diagnosis of CTS as an effective supplement to electrodiagnostic studies.7 The main application of US to CTS has been diagnostic, with demonstration of focal enlargement of the median nerve at the carpal tunnel. However, the use of US in the differential diagnosis of space-occupying lesions such as tenosynovitis has been limited. The authors present two cases of CTS in which US identified a concomitant flexor pollicis longus (FPL) tenosynovitis. Because of the location of tenosynovitis within the carpal tunnel, it can contribute to the CTS by increasing intracarpal tunnel pressure.8
524
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 6, June 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
CASE DESCRIPTIONS Case 1 A 17-yr-old right-handYdominant adolescent girl presented with a 6-mo history of progressively worsening right-hand pain, numbness, paresthesias, and weakness. She indicated that the pain began gradually without any trauma or injury. Her pain was located in the radiovolar aspect of the wrist, radiating primarily to the thumb. She also complained of pain and paresthesias in the second and third digits. Physical examination revealed mild bulging at the level of the volar wrist crease. Tenderness was noted on the ulnar side of the flexor carpi radialis tendon and over the thenar eminence. Resisted first interphalangeal flexion aggravated her pain in the hand and the wrist. Otherwise, the motor and the sensory examination of the bilateral upper extremities were unremarkable. The result of the Phalen test was positive. Electrodiagnostic findings were in the borderline range for CTS. US revealed a slight increase in cross-sectional diameter (17 mm2) of the median nerve at the entrance to the carpal tunnel (at the level of the pisiform-scaphoid bones). No gross synovial thickening was noted in the flexor carpi radialis tendon. There was anechoic synovial thickening around the FPL tendon, producing the characteristic Target sign corresponding to a thickened synovial membrane (Figs. 1 AYC).
Case 2 A 65-yr-old right-handYdominant woman with a medical history of diabetes presented with pain, numbness, tingling, and pins-and-needles paresthesia in the right hand and the fingers. The symptoms started gradually a few years ago with progressive worsening. The pain was described as cramping. She denied any weakness.
Physical examination revealed normal motor strength including thumb abduction. There was decreased light-touch sensation in the second digit compared with the fifth digit. The results of the Tinel and the Phalen sign were positive. Electrodiagnostic findings were consistent with moderate CTS in the right side. Ultrasound evaluation of the carpal tunnel revealed anechoic tenosynovial thickening in the FPL tendon within the carpal tunnel (Figs. 2A, B). The cross-sectional diameter of the median nerve was 9 mm2 at the scaphoid-pisiform level.
DISCUSSION These cases illustrate the application of musculoskeletal US in the diagnosis of FPL tenosynovitis in patients with CTS. When there is inconsistency between symptoms and electrodiagnostic findings in some mild CTS cases, other supplementary diagnostic tests can be useful. US has been increasingly used for the evaluation of CTS because it is often available and is noninvasive. The characteristic US findings of CTS are focal hypoechoic swelling of the median nerve and an increased nerve cross-sectional area.9 Although there has been controversy setting cross-sectional area thresholds (ranging from 9 to 15 mm2),10 a recent meta-analysis focused on the diagnostic test accuracy of US for CTS found that a cutoff point of 9 mm2 provided the greatest diagnostic accuracy.11 Other characteristics include flattening of the median nerve in the carpal tunnel and bowing of the flexor retinaculum.12 US evaluation is also valuable for detecting anatomic variations, such as bifid median nerves and persistent median arteries.13 US has also been used for the evaluation of extrinsic and intrinsic causes of CTS. These are broad and include space-occupying lesions, such as tenosynovitis, anomalous muscles, ganglion cysts, bony pathologic lesions, and tumors. Although a
FIGURE 1 A hypoechoic/anechoic effusion in the FPL tenosynovium on transverse view at the proximal wrist crease (A) and at the level of the first metacarpophalangeal joint (B). Longitudinal view of the FPL tendon and the tenosynovium at the wrist (C). www.ajpmr.com
Tenosynovitis in Carpal Tunnel Syndrome Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
525
FIGURE 2 Increased thickness of the FPL tenosynovium with irregular margin radial to the median nerve on transverse view (A) and longitudinal view (B) at the distal wrist crease.
few retrospective studies have examined flexor tendon pathology in patients with CTS,6,14 isolated FPL tenosynovitis has been scarcely reported. Because of the proximity of the FPL to the median nerve in the carpal tunnel, tenderness on the FPL tendon can be interpreted as a positive provocative test for CTS. Resisted flexion of the first interphalangeal joint can reproduce the symptom caused by FPL tenosynovitis. US identifies the synovial sheath as a thin, hypoechoic rim, usually less than 1-mm thick. In tenosynovitis, an increased amount of synovial fluid appears as a hypoechoic or an anechoic collection surrounding a hyperechogenic tendon with irregular margins.15 Other flexor muscle pathologic lesions that have been reported in patients with CTS include accessory muscle bellies and anomalous tendon between the FPL and the flexor digitorum profundus index and middle fingers,16 the Gantzer muscle, and the accessory flexor digitorum profundus and lumbricalis muscles.17 Giant-cell tumors of the flexor tendon sheath have been reported as a rare cause of CTS,18 and it appears as a hypoechoic solid mass with well-defined margins lacking the posterior acoustic enhancement. Ventral ganglion cyst, which originates from the carpal joint or the flexor tendon, may compress the median nerve. The ganglion cyst appears as a well-defined anechoic structure with posterior acoustic enhancement.19 Fractures, especially of the distal radius and the scaphoid, are high on the differential list if there is a history of trauma.20 US has been used for diagnosis when plain x-ray misses a fracture at a very early stage.21 Most peripheral nerve tumors of the hand and the wrist involve the median nerve and therefore can present as CTS. The tumors have a nonspecific appearance as oval hypoechoic solid masses with well-defined margins.19 Lipofibromatous hamartomas can be seen on US as a relatively mobile mass of intermixed echogenicity.19
526
Manfield et al.
Both patients underwent US-guided steroid injection to the carpal tunnel with good relief. Local corticosteroid injection at the carpal tunnel is widely used as the nonsurgical treatment of choice for CTS in addition to splinting and activity modification.22 A recent study found that the EMG severity of CTS was an important prognostic factor for the long-term effect of a local steroid injection because the group with mild CTS, as determined by EMG, responded better to local corticosteroid injection than did the group with moderate or severe CTS.23 Therefore, local steroid injection for a patient with borderline EMG findings such as case 1 and moderate CTS on EMG such as case 2 argued against the other treatment options such as splinting only and surgical release. Steroid injection was favored in these cases because it has been shown to be an effective firstline therapy for flexor tenosynovitis of the hand.24 The treatment of FPL tenosynovitis provides relief of the symptoms by decreasing intracarpal pressure.8 A cock-up splint is typically prescribed in CTS; however, it can aggravate the symptoms of concomitant FPL tenosynovitis by allowing free thumb movement. A splint extending to the thumb such as a thumbspica splint can be considered for instances of coexistent FPL tenosynovitis.25 In addition, patient education with the modification of thumb activities such as pinching, gripping, lifting, and twisting is useful.25 Improved accuracy in the diagnosis of a coexistent pathologic lesion allows construction of more specific and efficient treatment plans. In summary, these case reports illustrate FPL tenosynovitis in two patients with CTS who were diagnosed with musculoskeletal US. Most cases of CTS are idiopathic, but there are specific conditions that can contribute to median nerve compression. Concomitant conditions can be evaluated by US. This management of symptoms is facilitated with greater diagnostic accuracy. US is a very
Am. J. Phys. Med. Rehabil. & Vol. 93, No. 6, June 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
effective modality to enhance the investigation of diseases in the soft tissues of the wrist and the hand and should be considered to supplement electrodiagnostic evaluations of CTS.
REFERENCES 1. Schappert SM, Rechtsteiner A: Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report 2008:1Y29 2. Cullen KA, Hall MJ, Golosinskiy A: Ambulatory surgery in the United States, 2006. Natl Health Stat Report 2009:1Y25 3. Atroshi I, Englund M, Turkiewicz A, et al: Incidence of physician-diagnosed carpal tunnel syndrome in the general population. Arch Intern Med 2011;171:943Y4 4. da Costa BR, Vieira ER: Risk factors for work-related musculoskeletal disorders: A systematic review of recent longitudinal studies. Am J Ind Med 2010; 53:285Y323 5. Werner RA, Andary M: Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve 2011;44: 597Y607 6. Chen CH, Wu T, Sun JS, et al: Unusual causes of carpal tunnel syndrome: Space occupying lesions. J Hand Surg Eur Vol 2012;37:14Y9 7. Cartwright MS, Hobson-Webb LD, Boon AJ, et al: Evidence-based guideline: Neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve 2012;46:287Y93 8. Gelberman RH, Hergenroeder PT, Hargens AR, et al: The carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am 1981;63:380Y3 9. Jacobson JA: Fundamentals of Musculoskeletal Ultrasound. Philadelphia, Saunders, 2007 10. Roll SC, Case-Smith J, Evans KD: Diagnostic accuracy of ultrasonography vs. electromyography in carpal tunnel syndrome: A systematic review of literature. Ultrasound Med Biol 2011;37:1539Y53 11. Tai TW, Wu CY, Su FC, et al: Ultrasonography for diagnosing carpal tunnel syndrome: A meta-analysis of diagnostic test accuracy. Ultrasound Med Biol 2012: 38:1121Y8
www.ajpmr.com
12. Buchberger W, Schon G, Strasser K, et al: Highresolution ultrasonography of the carpal tunnel. J Ultrasound Med 1991;10:531Y7 13. Karadag YS, Karadag O, Cicekli E, et al: Severity of carpal tunnel syndrome assessed with high frequency ultrasonography. Rheumatol Int 2010;30:761Y5 14. Kang HJ, Jung SH, Yoon HK, et al: Carpal tunnel syndrome caused by space occupying lesions. Yonsei Med J 2009;50:257Y61 15. Filippucci E, Gabba A, Di Geso L, et al: Hand tendon involvement in rheumatoid arthritis: An ultrasound study. Semin Arthritis Rheum 2012;41:752Y60 16. Slater RR: Flexor tendon anomalies in a patient with carpal tunnel syndrome. J Hand Surg Br 2001; 26:373Y6 17. Nayak SR, Ramanathan L, Prabhu LV, et al: Additional flexor muscles of the forearm: Case report and clinical significance. Singapore Med J 2007;48:e231Y3 18. Meek MF, Sheikh ZA, Quinton DN: Carpal tunnel syndrome caused by a giant cell tumour of the flexor tendon sheath. J Plast Surg Hand Surg 2013; PMID: 23692165 19. Bianchi S, Martinoli C, Abdelwahab IF: High frequency ultrasound examination of the wrist and hand. Skeletal Radiol 1999;28:121Y9 20. Bauman TD, Gelberman RH, Mubarak SJ, et al: The acute carpal tunnel syndrome. Clin Orthop Relat Res 1981;156:151Y6 21. Hodgkinson DW, Nicholson DA, Stewart G, et al: Scaphoid fracture: A new method of assessment. Clin Radiol 1993;48:398Y401 22. Bland JD: Treatment of carpal tunnel syndrome. Muscle Nerve 2007;36:167Y71 23. Visser LH, Ngo Q, Groeneweg SJ, et al: Long term effect of local corticosteroid injection for carpal tunnel syndrome: A relation with electrodiagnostic severity. Clin Neurophysiol 2012;123:838Y41 24. Graham JB, Hulkower SD, Bosworth M, et al: Clinical inquiries. Are steroid injections effective for tenosynovitis of the hand? J Fam Pract 2007;56:1045Y7 25. Yao J, Park MJ: Early treatment of degenerative arthritis of the thumb carpometacarpal joint. Hand Clin 2008;24:251Y61
Tenosynovitis in Carpal Tunnel Syndrome Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
527
