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Patients suffering from carpal tunnel syndrome (CTS) actively search for medical information on the Internet. The World Wide Web represents the main source of patient information. The aim of this study was to systematically assess the quality of patient information about CTS in the Internet. A qualitative and quantitative assessment of websites was performed with the modified Ensuring Quality Information for Patients (EQIP) tool that contains 36 standardized items. Five hundred websites with information on CTS treatment options were identified through Google, Bing, Yahoo, Ask.com and AOL. Duplicates and irrelevant websites were excluded. One hundred and ten websites were included. Only five websites addressed more than 20 items; quality scores were not significantly different between the various providing groups. A median of 15 EQIP items was found, with the top website addressing 26 out of 36 items. Major complications such as median nerve injury were reported in 27% of the websites and their treatment in only 3%. This analysis revealed several critical shortcomings in the quality of the information provided to patients suffering from CTS. There is a collective need to provide interactive, informative and educational websites for standard procedures in hand surgery. These websites should be compatible with international quality standards for hand surgery procedures. [ABSTRACT FROM AUTHOR]

Résumé: Nous rapportons la découverte d’une rupture subtotale du nerf médian par usure « sur chevalet » de celui-ci sur une séquelle de fracture du poignet datant de l’enfance. Cette observation inédite a été faite lors d’une chirurgie de reprise du canal carpien chez un patient de 80ans, pour qui l’indication de neurolyse avait été posée devant la récidive d’un syndrome sévère du canal carpien à 30ans d’une première intervention de neurolyse. Si les ruptures par usure des tendons fléchisseurs sont largement relatées dans la littérature, de même que la survenue de plaies nerveuses aiguës dans le cadre de traumatismes à haute énergie, la survenue d’une rupture secondaire d’un nerf par usure de celui-ci sur un relief osseux n’a, à notre connaissance, jamais été décrite. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Wounds on the palmar side of the wrist affecting the median or ulnar nerves are responsible for motor and sensory sequelae, severe pain and cold intolerance. Materials and methods: Thirty-nine patients with 40nerve sections were retrospectively reviewed with a mean follow up of 23months. The median nerve alone was affected 20times, the ulnar nerve seven times and both nerves simultaneously 13times. In 75% of the cases, there was an associated vascular injury (radial artery and/or ulnar artery). The average number of tendons cut was 4.25. Results: After repair of the median nerve, 71% of patients recovered antepulsion and opposition that was normal or possible against resistance. The strength was approximately 70% of the opposite side. The sensitive recovery was good (S3 in≥50% of cases) but it was accompanied by cold intolerance one out of two patients. After repair of the ulnar nerve, 29% of the cases had an ulnar claw hand, 71% of patients recovered sensitivity greater or equal to S3 but with cold intolerance in 42% of the cases. The combined median and ulnar sections had a poorer sensory-motor prognosis. Revision surgery was necessary in 12 of these cases. Conclusion: Sensory recovery after an isolated ulnar nerve lesion at the wrist is better than after an isolated median nerve lesion but there is no difference in the motor recovery. Combined median and ulnar lesions have an especially bad prognosis and may require secondary palliative surgery. The existence of nerve contusion and a high number of tendon injuries were factors associated with a poorer prognosis. [Copyright &y& Elsevier]

Abstract: Recurrence of carpal tunnel syndrome following surgery is not rare. The reported frequency of reoperation varies from 0.3 to 12%. We distinguish between persistent carpal tunnel syndrome, and recurrent carpal tunnel syndrome which we define as reappearance of the condition three months or more following surgery. More proximal nerve lesions or other erroneous diagnoses may cause either persistent or recurrent syndromes. In the cases of persistent syndromes, incomplete division of the flexor retinaculum is a frequent cause, but iatrogenic nerve lesions or active flexor tenosynovitis may also be to blame. In the cases of recurrent carpal tunnel syndrome, the problem is often due to perineural fibrosis. At the time of reoperation, except in those cases where an incomplete division of the flexor retinaculum is found, one must consider whether or not to combine the neurolysis with an additional procedure to prevent or diminish recurrent fibrosis. To achieve this goal, a number of measures have been proposed, including interposition of a biomaterial or raising a local flap to surround and protect the nerve. Others recommend early mobilization to diminish fibrous adhesions between the nerve and surrounding tissues. The results are at best modest, and may be counterproductive after several interventions. It is necessary to distinguish between improvement in symptoms that are due to local irritation, the priority for the patient, and improvement in neurologic function of the motor and sensory components of the nerve. According to the literature, from 43 to 90% of patients who undergo repeat operations continue to have symptoms, and one in five get no relief, while 80% of first operations for carpal tunnel syndrome give excellent results. These findings indicate that the first intervention must be performed with the most rigorous attention to technical detail. [Copyright &y& Elsevier]

Abstract: Introduction. – There is currently little consensus regarding the appropriate surgical approach to treatment of cubital tunnel syndrome (CubTS), and few studies have reported long-term follow-up of patients who have received surgical treatment for ulnar nerve compression at the elbow. Method. – Seventy-four patients with a total of 102 cases of CubTS treated with simple decompression of the ulnar nerve were examined 1.0–12.4 years postoperatively. Ulnar nerve conduction studies (slowest conducting 5 cm segment of ulnar nerve motor fibers measured at the elbow) were performed both pre- and postoperatively. The primary clinical outcome was percentage relief of symptoms, divided into “excellent” outcome group or less (≥90% improvement or <90% improvement). Results. – Ulnar nerve conduction improved pre- to postoperatively, but clinical improvement was not related to changes in velocity. Women reported greater clinical improvement than men, and weight gain in men (but not women) predicted less improvement. Relief of cubital tunnel symptoms was greatest for those arms receiving carpal tunnel release surgery simultaneous or subsequent to cubital tunnel release. Discussion. – Simple decompression may offer excellent intermediate and long-term relief of symptoms associated with CubTS. Although improvement in ulnar motor nerve conduction velocity occurs following treatment of CubTS, it may not be a consistent marker of perceived symptom relief. Finally, these findings suggest that less complete relief of symptoms following ulnar nerve decompression may be related to unrecognized carpal tunnel syndrome or weight gain. [Copyright &y& Elsevier]

Abstract: Carpal tunnel syndrome presenting as a trophic disorder in the hand is unusual. We report the case of a 66 year old man in whom nerve conduction tests confirmed compression of the median nerve in the carpal tunnel, and vasospasm in the corresponding area was demonstrated by arteriography for, we believe, the first time. Simple decompression of the carpal tunnel brought about total recovery. The mechanism of the autonomic disorders found in carpal tunnel syndrome remains controversial. The clinical case that we report objectively demonstrates the vasospasm caused by the compression of the autonomic fibres of the median nerve. [Copyright &y& Elsevier]

Extranodal manifestations of lymphoma are well described in the literature and occur in 20 to 30% of patients. Skeletal muscle involvement is rare. We describe the case of a patient with non-Hodgkin's lymphoma in a forearm muscle. At the age of 86, the featured patient started experiencing continuous, progressive and high intensity pain that was more frequent at night and localized in the right dominant hand. It was associated with paresthesia and hypoesthesia, primarily in the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to the diagnosis of carpal tunnel syndrome. The patient underwent carpal tunnel release at a private hand center. The progression was unfavorable. Additional clinical examination and electrodiagnosis showed compression of the anterior interosseous nerve (double crush syndrome). The patient was referred to our university hand center for further management. Magnetic resonance imaging showed a large mass of about 20cm occupying the entire anterior compartment of the forearm and enclosing the median nerve. Biopsies were performed and revealed a diffuse large B-cell primary non-Hodgkin's lymphoma. The patient underwent chemotherapy and radiotherapy. Six months later, the patient was in complete remission. Muscular involvement during lymphoma is rare. Biopsy is mandatory; needless radical surgery can be avoided because lymphoma is primarily a non-surgical disease. The key points of the treatment process are reviewed., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Abstract: Carpal tunnel syndrome is the most frequent among entrapment neuropathies at the upper limb. The usual etiology is idiopathic, but its origin can also be anatomic, traumatic, endocrine, rheumatismal or tumoral. Even though the clinical presentation is often typical, an electromyographic examination is useful for confirmation of the diagnosis, assessment of nerve lesions and detection of associated neuropathies. A medical treatment can be indicated in moderate cases. A surgical treatment is necessary in severe cases or after failure of the medical treatment. The basic procedure consists in opening of the transverse carpal ligament, achieved by open or endoscopic technique. The use of endocscopy leads to a faster postoperative recovery of hand strength and function. Other surgical procedures can be associated to carpal tunnel release depending on the etiology of the compression. [Copyright &y& Elsevier]

Abstract: The medicolegal issues are often found in entrapment neuropathies of the upper limb and in particular, carpal tunnel syndrome. Due to an acquired knowledge and personal expertise on this subject, the pre-, peri- and postoperative precautions are considered in order to provide the best possible, prevention. of complications for the surgeon. [Copyright &y& Elsevier]

Abstract: Treatment of the post-surgical complications of carpal tunnel syndrome. Carpal tunnel surgery is the most frequently performed operative procedure in hand surgery centers. Surgical teatment for complications is more and more frequent. Among these complications we distiguish : complications after a lésion of a major anatomical stucture, complications secondary to flexor retinaculum section, incomplet release or recurrent syndrome, at least non specific complications. Nerve, vessel and tendon injuries must be treated without delay. Deffered surgery is more difficult and results are worse. In some cases of median nerve laceration an opponensplasty can be performed to improve hand fonction. Pillar pain is a frequent post-operative complication, about 30% of the cases. The cause of pillar pain remains elusive : alterations of the carpal arch, ligaments, muscles or nerves. Some complications can be considered as secondary effect of flexor retinaculum section : strenght’s decrease, trigger fingers, flexor tendons luxation and ulnar nerve compression at the Guyon tunnel. Persistence or recurrence of the clinical signs of carpal tunnel syndrome are the most frequent causes of surgical reexploration. Incomplete release of the flexor retinaculum and median nerve “neurodesis” are respectively in cause. The diagnostic must be confirmed, the surgical procedure consits in a complete retinacular section, neurolysis and in the majority of the cases an interposition vascularised flap. [Copyright &y& Elsevier]

Abstract: Median nerve compression around the elbow is much less frequent than carpal tunnel syndrome. Nevertheless, its diagnosis is a challenge for the clinician who must differentiate between these entrapment syndromes and try to further define the compression cite, in case of proximal compression. Median nerve compression around the elbow takes the form either of pronator syndrome or anterior interosseous nerve palsy. These syndromes, different in their theoretical description, are sometimes superimposed in their clinical appearance and electrophysiological profile. This is expected from the fact that compression factors are more or less common between these syndromes and that median and anterior interosseous nerves follow a common path in the proximal forearm. Apart from extrinsic compression, two other afflictions may show motor deficits in the same territory: Parsonage and Turner’s neuralgic amyotrophy and fascicular hourglass-like constrictions into the median nerve, the latter being a form of intrinsic compression. Clinical evaluation, nerve conduction and electromyographic studies of the whole upper limb as well as some specific clinical tests may help to define the nerve territory implied and the compressing factor. Conservative treatment stays the first choice for median nerve compression either in the form of pronator or anterior interosseous nerve syndrome. Nonetheless, in our opinion, the presence of motor deficits is an indication for surgical treatment in case of no amelioration in 3–5 months. This is also valid for pain refractory to conservative treatment. In case of exploration, every potential cause of compression should be treated, as it is sometimes impossible to exactly locate the site of compression with certainty and furthermore there might be multiple compression sites. Results after surgical treatment are generally good but frequently imperfect. The patient must also be warned that skin healing in this region may reserve unpleasant surprises. [Copyright &y& Elsevier]

Unlabelled: Defects of the median, ulnar or radial nerves in the forearm, can be treated by conventional nerve grafts, or by interposing a synthetic guide such as nerve conduits. Wounds without nerve loss treated with simple suture may be supplemented by sleeving to prevent the nerve irritation symptoms using a nerve conduit or a vein sleeve. We studied the results of nerve conduits in both cases in a single-center retrospective study., Patients and Methods: Four patients underwent surgery with placement of a nerve conduit in the forearm, between May 2007 and January 2011. All patients were reviewed by the same examiner. Pain, tenderness, motor (Medical Research Council classification, MRC), time to return to work and self-evaluation by the patient were measured. The averages of these data were calculated and compared with results of other studies in the literature, the nerve grafts for defects and the Socket joints for venous ulcers., Results: The decrease is on average 30 months (2 years). The defect never exceeds 40mm and is 22mm on average. According to the classification MRC, sensitivity found after inserting nerve conduits in the forearm after a defect is excellent (S4) for two of three patients and good (S3) for the third. Motor results were very good (M4 and M3 for one patient) andM2 for the other. As for the insertion of a nerve conduit as a sleeve, the result is good in terms of sensitivity (S3) and excellent in terms of motor (M5) for our case in the study. For our small group of patients with neuroma we obtained, results similar to those published in the literature with conventional techniques., Conclusion: The nerve conduits seem to give results similar to conventional techniques, in situations of defects or neuromasin the forearm, with a diameter greater than 2mm, but defects of less than 30mm., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

The authors reviewed 52 patients who underwent Bier's block, as supplementary anesthesia for insufficient axillary block in upper extremity surgical procedures. Prior to proceeding to the Bier's block, the mean value of pain using the visual optical analogue scale (VAS) was 7.0. In 48 of the patients supplementation with the Bier's block was sufficient (mean VAS score of 1.0) and all patients were comfortable throughout the procedure. In the remaining four patients supplementation with narcotics and sedatives via the other i.v. line was required. Intraoperative Bier's block provides a safe and effective alternative way of successfully compensating for an insufficient axillary block in upper extremity surgical procedures.

Introduction: Nerve injuries of the upper limb can cause serious damage: primary repair has improved the results but the prognosis for recovery remains uncertain. We present the results of primary repair of 24 median nerve injuries at the level of the wrist., Materials and Methods: Between 1990-1998, we repaired 57 median nerve injuries at the wrist. Only 24 patients were included in this retrospective study. The average age of the patients was 25 years (range: 18-60 years). Seventeen patients were men and seven were women. All the patients were operated within 12 h after the accident. In all the cases, epiperineural suture was performed followed by immobilisation in a cast for 3 weeks. No specific rehabilitation programme was employed., Results: At review with a mean follow-up of 3 years, 46% of the patients obtained good or very good results according to Chanson's scoring system. The sensory recovery was between S4-S2 with the Weber test in 75% of patients. Fifty-eight percent of patients recovered a motor function between M3-M2., Discussion: In most papers, very good and good results averaged 60%. The results in our series did not achieve this level. We believe that this is due to two factors: firstly, the age distribution of our patients and secondly the lack of a specific program of sensory rehabilitation.

Introduction: Following an anatomical study on the vascular supply of the upper limb, we propose a new adipo-fascial flap at the wrist. The fat pad of pronator quadratus lies over the muscle and is vascularised by a recurrent branch arising from the anastomotic "cross-road" of the anterior interosseous, radial and ulnar arteries, at the radio-carpal joint. The peripheral extensions of the adipose tissue have to be anchored to the palmar fascia of the muscle in order to hoist the flap as a "square sail". The flap is then distally rotated in order to cover the traumatized median nerve segment at the wrist, for 2.5-3 cm of length., Methods: The authors present a review of the clinical applications (1995-2001) on painful neuromas of the median nerve at the wrist, where traumatic and iatrogenic injuries frequently occur. The surgical procedure consists of external neurolysis followed by coverage of the nerve using this vascularised flap., Results: The results confirm the usefulness of vascularised fat flaps in creating an optimal perineural environment in terms of biological and mechanical quality. The advantage offered by this particular local flap is that it can be speedily raised. Because of its limited length the flap is only able to cover the median nerve at the level of the carpal tunnel: its indications are therefore very selective but not rare, due to the frequency of median nerve injuries at this level., Discussion: Clinical results were very satisfactory: in the twenty cases reviewed, resolution of the symptoms of algodystrophy and causalgia was consistently observed, sometimes to an extraordinary degree, and associated with an improvement in the neurological deficit.

Introduction: Wounds involving the peripheral nerves cause serious damage in the upper limb. The prognosis for recovery remains uncertain despite microsurgery. It is commonly accepted that the results are far better in children than in adults. We sought to confirm this idea on the basis of objective recovery criteria, discriminating between peripheral axonal regeneration and the child's own capacity to adapt. In other words, do nerves regenerate better in children?, Materials and Methods: The clinical results of 25 nerve sutures of the wrist, in children under 15, were analysed with a minimum follow-up of 12 months. The subjects were reviewed clinically and had an electromyogram. The resulting data was compared to that for adults found in the literature., Results: Clinically, the overall function of the hand was always satisfactory. The sensory results were often excellent (S4 or S3+ in 23 cases/25). The mean value muscular testing was between M2 and M3. With respect to the EMG results, the values we recorded were rarely representative of the functional results. The motor recordings were mostly poor, demonstrating that the nerve supply was compensated by a phenomenon involving collateral innervation., Discussion: The poor results of peripheral nerve surgery are only due to the quality of the restored innervation. Dellon and Mackinnon demonstrated that they were also due to the incapacity of the nerve centres to integrate a change in the profile of sensory information. It would therefore seem that not only the quantity of nerve tissue repair is insufficient, but also the quality. Children have a superior cerebral capacity to adapt than adults and probably benefit from better cortical acquisition processes and are thus capable of putting the changes in the nerve messages to better use. The analysis of the clinical and EMG results also reveals a trend demonstrated partial nerve repair in children. We think that the functional results suggest that children have a better central capacity to adapt.

In huge median nerve losses and in some brachial plexus lesions, absence of sensation over the pulps of the index finger and the thumb preclude their use without visual control. Currently, end-to-side anastomosis is a new option available (when the ulnar nerve is intact) but we have reviewed the results of 7 cases of nerve anastomosis between the sensory branches of the radial nerve and the collateral nerves of the thumb (ulnar) and index finger (radial). Palmar translocation of the donor nerve, as classically performed, was used in two cases and the technique was subsequently modified to provide a better nerve suture by dorsal transfer of the collateral nerves of the thumb and index. Two sequellae of brachial plexus lesions and 5 cases of extensive defects of the median nerve were reviewed at a mean follow up of 5 years. With the classical technique the two point discrimination was 15 mm in one case and more in the other; with the modified technique, 4 patients achieved a thumb discriminaTion of 9 mm, 12 mm (2 cases) and 13 mm.

Since 1989, 13 consecutive cases of true recurrent carpal tunnel have been operated on. Average delay before reoperation was 20 months (3 to 60 months). Intraoperative findings were univocal: extensive fibrosis with nerve adhesion to the roof of the carpal tunnel and a lack of nerve gliding. Surgery performed was: extensive external neurolysis from distal forearm to distal to carpal tunnel to allow a complete freedom of the nerve. A vascularized flap was never performed. Mean follow-up was 27.5 months (range 4 to 74 months). Results were: complete relief of symptoms in 75%; improvement with complete disappearance of nocturnal symptoms but persistent dysesthesia in 17%; no improvement in one patient (Sudeck's dystrophy). Interests of this study are: homogeneous population (only true recurrence), no bias from work compensation, consecutive cases, one surgeon, standardized surgical procedure and one independent observer. Results suggest that main factor for true recurrent carpal tunnel syndrome is lack of normal gliding of the nerve and that an extensive neurolysis helps to restore this gliding.

Because of the loss of mobility, scarring of the median nerve in the carpal tunnel can lead to chronic pain syndrome of the wrist joint, with reduced sensation, muscular dystrophy and severe limitation of the use of the hand. This syndrome most often appears following open carpal tunnel release. Nine patients with scarring of the median nerve in the carpal tunnel were treated with a hypothenar fat-pad flap. Eight of them showed a significant reduction in pain, with improved sensation, trophism and strength. The procedure is suitable as a salvage procedure for restoring a sliding pathway and for cushioning the median nerve in the presence of recurrent lesions in the carpal tunnel.