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Summary A Percheron mare was presented for acute, severe lameness and marked swelling of the right forelimb after being cast. The mare was initially diagnosed with cellulitis of the forelimb but as her condition improved and the affected limb was able to bear more weight it became apparent that the limb was hyperextended at the level of the carpus. Widening of the palmar aspect of the middle carpal joint was observed radiographically. During ultrasonographic examination, excessive fluid in the carpal sheath and perithecal swelling were noted and tearing of the palmar carpal ligament was suspected. A dynamic brace was fabricated to prevent hyperextension of the carpus. After discontinuation of systemic antibiotics, the mare became febrile and forelimb lameness worsened. Cytology of fluid from the middle carpal joint confirmed joint sepsis and the mare was anaesthetised for arthroscopic examination. A tear in the palmar carpal ligament, characterised by focal fibre disruption and fibrillation, was identified during arthroscopic and tenoscopic examination. Communication between the carpal flexor tendon sheath and middle carpal joint was identified during these procedures. Both the middle carpal joint and carpal flexor tendon sheath were lavaged with physiological saline solution. Post operatively, swelling and lameness slowly resolved. Four months after discharge, the mare was sufficiently sound to be maintained at pasture. Viewed from its lateral aspect, the limb no longer appeared to be hyperextended from the carpus.

Introduction The C-Trac splint has been designed to mechanically stretch the transverse carpal ligament and is advertised as an alternative to surgical Carpal Tunnel Decompression. The purpose of the study is to compare the effectiveness of the C-Trac splint with standard splinting in mild to moderate idiopathic carpal tunnel syndrome. Methods This is a pilot parallel randomised controlled trial. Forty-nine patients with clinically and neurophysiologically proven carpal tunnel syndrome were randomised into the two treatment groups, C-Trac and Beta Wrist Brace, and reassessed clinically for one year. Results Patients were generally satisfied with both splints, but two out of the 24 C-Trac patients developed problematic side effects possibly due to using the splint: De Quervains tenosynovitis and basal joint arthritic pain. There was no clinically relevant or statistically significant difference in the success and failure rates of the two splints by eight weeks, six months or at one year. Three of the 25 C-Trac splints (costing £130 each) used during the one-year study required replacement, compared with eight of the Beta Wrist Braces (costing approximately £10 each). Conclusions These results suggest that C-Trac splint is not dissimilar in efficacy to a resting Beta Wrist Brace. The reported side effects raise questions as to the wisdom of its unregulated use.

Purpose This study aimed to identify technical difficulties encountered during 2-portal endoscopic carpal tunnel release (ECTR) and to determine their incidence. Furthermore, we assessed the possibility of preoperatively predicting such technical difficulties. Methods We retrospectively reviewed the records of 311 hands of 311 patients with idiopathic carpal tunnel syndrome who underwent ECTR with our modified Chow 2-portal technique. Any technical difficulties during the procedure were reviewed and correlated with preoperative physical findings, nerve conduction studies, and magnetic resonance imaging findings, by use of the t test, χ 2 test, and binary regression analysis. Results One or more difficulties were encountered in 139 of 311 hands (44.7%), whereas surgery in the remaining 172 hands (55.3%) was performed without any difficulties. Technical difficulties encountered were as follows: tight access in 61 hands, difficulty in identifying the distal part of the transverse carpal ligament through the exit portal in 35 hands, synovial tissue being caught at the cannula tip when pulling it out of the carpal tunnel in 39 hands, steep angle of the cannula assembly with difficulty in emerging from the exit portal in 29 hands, and other difficulties. Postoperative worsening of symptoms was observed in 8 hands (2.6%), in all of which technical difficulties were encountered. Tight access was noted in younger patients and those with a small cross-sectional area at the hook-of-hamate level. The entire ECTR procedure for older female patients was more likely to be easily performed. Conclusions The surgeon may face a variety of technical difficulties during ECTR. Technical difficulties were most often encountered during introduction of the cannula assembly into the carpal tunnel and pulling it out of the exit portal. Older female patients may be the best candidates for 2-portal ECTR. Level of Evidence Level IV, therapeutic case series.

The objective of this study was to evaluate the cross-sectional area of the median nerve by ultrasonography before and after release of the transverse carpal ligament in patients with carpal tunnel syndrome. An additional goal was to correlate the cross-sectional area following surgery with clinical symptoms. Eighteen patients and 22 wrists were evaluated. All patients underwent Paine’s surgical technique for release of the transverse ligament. Cross-sectional area was calculated from sonograms taken at the pisiform bone level pre- and postsurgery. Postsurgical measurements were made at 4, 8, 12, and 96 weeks. Before surgery, the mean cross-sectional area was 19.7 mm2. The results following surgery were as follows: 4 weeks, 20.1 mm2; 8 weeks, 17.4 mm2; 12 weeks, 15.5 mm2; and 96 weeks, 13.5 mm2. Three patients remained clinically symptomatic at the time of their last follow-up visit. Cross-sectional area of the median nerve tends to increase 4 weeks after surgery for carpal tunnel syndrome, compared with the measurements taken prior to surgery, and then progressively decreases. There was no evidence of postprocedure correlation between the cross-sectional area of the median nerve and clinical symptoms.

Carpal ligaments are commonly injured and may lead to pain and disability. These ligaments are very difficult to repair, and the results are unpredictable; as a result, treatment options abound. A novel approach is presented here using a polyester suture, aiming to substitute these ligaments' function, rather than to repair them.

We have searched for a synthetic substitute for the carpal ligaments, which would be widely available and easy to use. Four loops of 2-0 polyester fiber suture (Mersilene) were found to exceed the ultimate tensile strength of the scapholunate interosseous ligament. This construct approximates a normal ligament stress/strain curve and can theoretically facilitate fibrous tissue ingrowth. It is readily available, easy to handle, and inexpensive. Based on these findings, we recommend the use of polyester suture in the reconstruction of carpal and other ligaments.

The transverse carpal ligament (TCL) serves as the origin of the thenar muscles and is integral to thenar muscle contraction anatomically and biomechanically. TCL hypertrophy has been observed in patients with carpal tunnel syndrome and is potentially caused by repetitive hand use. The purpose of this study was to investigate the biomechanical interaction between the TCL and the thenar muscles. Specifically, the morphological changes of the carpal arch, formed by the TCL, in response to thenar muscle contractions were examined during isometric tip pinch between the thumb and index finger. Ultrasound videos of the carpal tunnel were recorded from 13 healthy subjects and were synchronized with the forces measured by a pinch dynamometer. The thenar muscles' ulnar point, trapezium, and hamate were tracked by a pattern-matching program. The pinch force significantly affected the carpal arch height, width, and area ( P < 0.005). As the pinch force increased from 0 to 100% maximum voluntary contraction force, the carpal arch height increased from 1.8 ± 1.0 to 2.3 ± 1.3 mm, the carpal arch width decreased from 23.9 ± 2.4 to 23.1 ± 2.4 mm, and the carpal arch area increased from 22.2 ± 13.6 to 27.3 ± 16.3 mm2. The TCL was pulled volarly during thenar muscle contractions, providing evidence for the biomechanical interaction between the ligament and muscles. Repetitive biomechanical stimulation on the TCL from thenar muscle contractions could lead to tissue remodeling and then TCL hypertrophy. This study sheds light on the potential cause of TCL hypertrophy, which may be an etiological factor for carpal tunnel syndrome.

OBJECTIVE:To compare between selected post-operatives physical therapy modalities after transverse carpal ligament release. DESIGN: Double blind, randomized controlled trial. SETTING: Health insurance hospital outpatient clinic in Cairo, Egypt SUBJECTS: Forty-five female patients aged 25–45 years, following transverse carpal ligament release of the dominant hand, referred to the physical therapy outpatient clinic of a health insurance hospital, Egypt. INTERVENTION: Patients were randomly allocated to three equal groups of 15: Ultrasonic group received continuous ultrasound with nerve and tendon gliding exercises, Laser group received laser therapy and the same exercises, Exercise group received the same exercises only. Treatment duration was six weeks, three times per week. MAINMEASURE: Visual analogue scale for pain intensity, pinch dynamometer for muscle strength, motor and sensory distal latencies for median nerve. RESULTS: There was significant improvement after treatment in all groups, with no significant difference between the Ultrasonic group and the Laser group; there was a highly significant difference between the Ultrasonic group and the Exercise group, and a significant difference between the Laser group and the Exercise group. CONCLUSION: Continuous ultrasound accompanied with nerve and tendon gliding exercises is considered more effective in the post-operative treatment of transverse carpal ligament release, giving best results and percentage of improvements when compared either to Laser therapy with nerve and tendon gliding exercises or nerve and tendon gliding exercises only.

The purpose of this study was to compare the stiffness of the transverse carpal ligament (TCL) between healthy volunteers and carpal tunnel syndrome (CTS) patients using sonoelastography. We studied 17 healthy volunteers (four men, 13 women; range 37–84 years) and 18 hands of 13 patients with CTS (three men, ten women; range 41–79 years). Thickness and elasticity of the TCL were evaluated by sonoelastography. Elasticity was estimated by strain ratio of an acoustic coupler, which has a standardized elasticity as a reference medium, to the TCL (AC/T strain ratio). The AC/T strain ratios of the healthy volunteers and the CTS patients were 6.0 and 8.1, respectively (p = 0.030). The AC/T strain ratio showed a positive correlation with the duration of symptoms in the CTS patients (p = 0.035, r = 0.50). We concluded that increased stiffness of the TCL could be one of the causes for CTS.

Objective: The aim of this study was to sonographically evaluate the anatomy of the transverse carpal ligament (TCL) after open surgical release in the treatment of carpal tunnel syndrome (CTS) and to establish new ultrasonographic criteria for the completeness of TCL release. Methods: Thirty-six patients who underwent open surgical release for CTS were recruited prospectively. Patients were evaluated with physical examination and ultrasonography before and after the operation. Results: All patients’ symptoms resolved after surgery. TCL was found to be diffusely thickened and to have lost its smooth form after surgery. Postoperative TCL thickness showed a statistically significant increase when compared with preoperative values (p

Carpal tunnel syndrome is the most common peripheral nerve compression syndrome. Treatment options include wrist-neutral bracing, corticosteroid injections, operative release of the transverse carpal ligament, and symptom-relief options. Endoscopic carpal tunnel release may give patients a faster recovery compared with traditional open release, but there are no ultimate differences in outcome among the various surgical options.

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy,1,2 with a lifetime incidence estimated at up to 10%.3 The pathophysiology of CTS is thought to be due to compression of the median nerve in the region of the carpal tunnel.4,5 When symptoms are recalcitrant to conservative management, surgical intervention is indicated. The goal of surgery is to decompress the median nerve in the carpal tunnel by transecting the deep transverse carpal ligament (TCL).

Carpal tunnel syndrome (CTS) was first described by Sir James Paget in 1854. Today, it is recognized as the most common upper extremity compressive neuropathy, occurring under the transverse carpal ligament of the wrist and causing median nerve symptoms. The compression can be idiopathic or can result from trauma or systemic illness.

Objectives: Carpal tunnel release (CTR) is one of the most frequently used surgical procedures of hand surgery. Endoscopic CTR is a new alternative technique of the standard open transverse carpal ligament release. In this study we present the effectiveness and complications of two-portal endoscopic CTR. Methods: Between August 2000 and October 2001, we performed two portal (modified Chow technique) endoscopic CTR to the 19 hands of 17 patients. Fifteen of these were female, two were male and mean age was 54.6 (range: 38-62) years. Mean follow up period was 8 (range: 4-21) months. Clinical evaluation was confirmed with positive ENMG values. Patients were evaluated with the postoperative pain, numbness, scar sensation, returning to daily activities, and complications. Results: All the patients were satisfied with the relief of pain. They all returned to daily activities within two weeks after the operation. There was no hypersensitive scar formation. Numbness didn't change at the six patients. In four patients, complication due to 3-4 common digital nerves injury occurred. Two of them explorated and interfascicular nerve repair was performed. Conclusion: For many years, conventional open technique transverse carpal ligament release was used as the standard surgical procedure of carpal tunnel syndrome. Nowadays, endoscopic CTR has become popular because of the minimal perioperative morbidity, short hospitalisation, early rehabilitation of the hand, less postoperative pain and less scarring. Our experience is the same agreement with those advantages. But unacceptable digital nerve complications were more frequent then the open technique. Especially at the learning period the surgeon should be more careful for the complications. [Hand Microsurg 2012; 1(2.000): 49-52]

Introduction Iatrogenic laceration of the median nerve motor branch during carpal tunnel release is a devastating complication that has been reported with both open and endoscopic techniques. The purpose of this study is to highlight a previously underreported relationship between an aberrant course of the median nerve motor branch and an anomalous thenar muscle that places the motor branch at high risk. Materials and methods This was a two part study. The first part was a retrospective review of over 500 cases of carpal tunnel release over a 7 year period. There were 530 carpal tunnel releases performed and 20/530 cases were found to have a characteristic anomalous thenar muscle associated with a consistent aberrant course of the motor branch of the median nerve. Part two was an anatomic study in which 42 cadaveric wrists were dissected to determine median nerve branching patterns, dimensions of the transverse carpal ligament, and thenar musculature dimensions. Results Twenty patients (3.8%) in the clinical arm were found to have anomalous musculature. In each case, the characteristics of the muscle were similar; the muscle was triangular in shape, was distal to the FPB, and had minimal fascial covering. In 100% of the cases the motor branch was found to be more anterior/central or ulnar in its take-off. In the anatomic study, two hands (5%) had aberrant musculature extending distal to the transverse carpal ligament (TCL). Both were associated with an anterior/central or ulnar median motor branch take-off with recurrent course. Larger thenar musculature dimensions and anomalous thenar muscle were associated with more anterior and ulnar motor branch take-off. Conclusion There appears to be a high association between anomalous thenar musculature and an aberrant course of the motor branch of the median nerve placing it a greater potential risk for iatrogenic injury. Lourie GM, Gaston RG, Peljovich AE, Marshall JJ, Patterson L. Anomalous Thenar Musculature Associated with Aberrant Median Nerve Motor Branch Take-off: An Anatomic and Clinical Study. The Duke Orthop J 2012;2(1):18-22.

The transverse carpal ligament (TCL) influences carpal stability and carpal tunnel mechanics, yet little is known about its mechanical properties. We investigated the tissue properties of TCLs extracted from eight cadaver arms and divided into six tissue samples from the distal radial, distal middle, distal ulnar, proximal radial, proximal middle, and proximal ulnar regions. The 5% and 15% strains were applied biaxially to each sample at rates of 0.1, 0.25, 0.5, and 1%/s. Ligament thickness ranged from 1.22 to 2.90 mm. Samples from the middle of the TCL were thicker proximally than distally (p

Purpose To test the hypothesis that division of muscle fibers lying over or within the transverse carpal ligament (TCL) in an open carpal tunnel release does not have an effect on outcomes in patients with carpal tunnel syndrome (CTS). Methods A total of 152 patients with a mean age of 57 years (range, 31–83 y) diagnosed with CTS were enrolled for intraoperative observation of the muscles overlying or within the TCL as seen through a 3-cm incision. These muscles when present were incised layer by layer in line with division of the TCL. Patients were divided into 3 groups according to the extent of the muscles covering the TCL. We compared the 3 groups for outcomes of surgery at 6 months in terms of the Boston and Disabilities of the Arm, Shoulder, and Hand (DASH) scores, grip and pinch powers, and scar pain. Results Of the 152 patients, 75 had a purely ligamentous TCL (group 1), 52 had muscle fibers covering 50% or less of the incision length (group 2), and 25 had muscle fibers covering more than 50% of the incision length (group 3). There were no differences in the postoperative Boston symptom and function scores and the DASH scores among the groups. In addition, there were no differences in the grip and pinch strengths and scar pain. Conclusions Division of the muscles overlying or within the TCL in line with the third web space incision does not affect postoperative outcomes after carpal tunnel release in terms of the Boston and DASH scores, grip and pinch powers, and scar pain. Type of study/level of evidence Prognostic I.

Carpal tunnel mechanics is relevant to our understanding of median nerve compression in the tunnel. The compliant characteristics of the tunnel strongly influence its mechanical environment. We investigated the distensibility of the carpal tunnel in response to tunnel pressure. A custom balloon device was designed to apply controlled pressure. Tunnel cross sections were obtained using magnetic resonance imaging to derive the relationship between carpal tunnel pressure and morphological parameters at the hook of hamate. The results showed that the cross-sectional area (CSA) at the level of the hook of hamate increased, on average, by 9.2% and 14.8% at 100 and 200 mmHg, respectively. The increased CSA was attained by a shape change of the cross section, displaying increased circularity. The increase in CSA was mainly attributable to the increase of area in the carpal arch region formed by the transverse carpal ligament. The narrowing of the carpal arch width was associated with an increase in the carpal arch. We concluded that the carpal tunnel is compliant to accommodate physiological variations of the carpal tunnel pressure, and that the increase in tunnel CSA is achieved by increasing the circularity of the cross section. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29:1951–1956, 2011

Carpal tunnel syndrome is the most frequent among entrapment neuropathies. It is mainly due to entrapment of the median nerve at wrist level. The authors analyze conservative treatment options, which can be useful in the early stages of the disease. Afterward, they compare various surgical techniques. The goal of surgery is to reduce the pressure on the nerve by cutting the transverse carpal ligament. Surgery can be accomplished with open carpal tunnel release or endoscopic carpal tunnel release. Open techniques can, in rare cases, cause scar problems. On the other hand, endoscopic surgery techniques can cause iatrogenic problems.

Objective: The study aims to establish the normal range of all sonologic measurements of carpal tunnel (CT) structures in an asymptomatic population. Methods: Sonological evaluation of 150 wrists in 75 asymptomatic adults was performed. The cross-sectional area (CSA) of the median nerve at four levels, the flattening ratio (FR) at three levels, the antero-posterior (AP) diameter of the CT and the distance of the transverse carpal ligament (TCL) from the trapezium-hamate (TmH) line were measured. Results: The mean (standard deviation (SD)) CSA of the median nerve at the distal forearm, CT inlet, mid and outlet were 6.8 (1.3), 7.4 (1.1), 7.5 (1.0), 7.1 (1.0) mm2, respectively. The mean (SD) FR at the CT inlet, mid and outlet were 2.66 (0.54), 2.55 (0.54), 3.69 (0.82), respectively. The mean (SD) AP diameter of the CT was 10.4 mm (1.1). Volar bowing of the retinaculum was seen in 7.3% of normal wrists. Conclusions: The normal range at two SDs of the CSA of the median nerve at the inlet was 5.2–9.6 mm2. The upper limit of volar bowing of the flexor retinaculum was 0.8 mm. The FR overlaps with values obtained in other studies of patients with carpal tunnel syndrome. The mean AP diameter of the CT was 10.4 mm (SD 1.1). To the best of our knowledge, this is the largest study performed in an asymptomatic population assessing the different sonological parameters related to the CT.

OBJECTIVE: To compare two incisions used for the surgical treatment of CTS: the classic longitudinal incision, over the transverse carpal ligament (TCL), and the mini-incision, at the wrist crease and near the proximal border of the TCL. METHODS: 47 patients from the Hand Surgery Outpatient Clinic of the Clinwica Traumato - Ortopedica Madureira are evaluated. Group 1 consisted of 24 patients (28 hands) treated by the classic incision. Group 2 consisted of 23 patients (28 hands), treated by the transverse mini-incision technique. Both groups were compared in relation to discomfort of the scar, presence or absence of "pillar" pain, and time elapsed before returning to daily activities or unrestricted work. RESULTS: There was prevalence of females (87.5% in Group 1; 91.3% in Group 2) and of electromyographic bilateral syndrome in both groups (75% patients of Group 1; 86% patients of Group 2). Scar discomfort and "pillar" pain were more frequent in Group 1, but there was no difference in the time elapsed before returning to work or daily activities between the groups. CONCLUSION: The mini-incision technique is a less invasive alternative, and enables complete release of the carpal tunnel, with less morbidity than classic longitudinal incision. Level of Evidence II, Therapeutic.

Schwannomas are common, benign nerve tumors originating from the sheath of peripheral nerves. In this article, a 54 year old woman suffered from sudden onset motor and sensory deficit at her first radial three fingers on her right hand. Radiological investigations were normal. Electromyography diagnosed a median nerve entrapment neuropathy and urgent surgery was performed. Interestingly, a hemorrhaged mass was detected in the median nevre at the proximal end of the carpal ligament and was resected totally. Histopathological diagnosis was Schwannoma. The patient maintained a healthy status for five years.

Carpal tunnel syndrome has been surgically treated by release of the transverse carpal ligament (flexor retinaculum of the hand) using a blind procedure since 1930 or by an open procedure since 1946. The blind procedure has the possibility of unreliable results and ensuing complications, hence, the open procedure was developed. The open procedure, however, also resulted in various complications as reported in the 1970s. At the end of the 1970s, I had many questions regarding accepted surgical procedures for treatment of carpal tunnel syndrome. These included: "Why should any healthy tissue be injured?"; "How can I make operations as minimally invasive as possible?"; and "How can I shorten postoperative fixation periods that cause declines in activities of daily living?" This paper describes how I developed the world's first evidence-based endoscopic management procedure for carpal tunnel syndrome using local anaesthesia without a pneumatic tourniquet on an outpatient basis.

Median nerve compression is a well-known cause of carpal tunnel syndrome (CTS). Yet, reasons why the most common idiopathic form of CTS develops in certain individuals are not well understood. To further understand the compressive mechanisms at work in CTS development, the authors used ultrasonographic imaging of the median nerve to evaluate 2 patients with CTS. Findings were compared to those of 2 control subjects who did not have CTS. In the patients who had CTS, the transverse carpal ligament was pulled taut by thenar muscle contraction as the flexor tendons tightened, compressing the median nerve between the ligament and tendons. No such compression was observed with the control subjects. Thus, a pathologic mechanism of median nerve compression was confirmed in the patients with CTS. Demonstration of such pathologic mechanisms during prehensile hand movement may improve understanding of how to treat patients with CTS and prevent nerve injury.

The carpal tunnel syndrome - compression of the median nerve by the transverse ligament of the wrist - is a serious disease of the human hand. The electrophysiological changes in the median nerve can be easily followed by electroneurography (ENG). The degenerative changes in the collagen structures of the carpal ligament cause shrinking of the ligament and compression of the nerve.

Open release of the transverse carpal ligament (TCL) has been the gold standard surgical treatment for patients with carpal tunnel syndrome over the past 50 years. Transecting the TCL with a scalpel under direct vision produces reliable symptom relief in the vast majority of cases. However, despite the clinical success of this technique, transient post-operative “pillar pain,” scar tenderness, or weakness are known to occur in some patients.

Made available in DSpace on 2019-09-12T16:53:35Z (GMT). No. of bitstreams: 0 Previous issue date: 2007 AIM: To evaluate the cross-sectional. area of the median nerve using ultrasound in carpal tunnel syndrome patients before and after endoscopic intervention. MATERIAL AND METHODS: Twenty patients with carpal tunnel syndrome (15 women and five men; mean age 55 years) were prospectively evaluated. Informed consent was obtained from all. participants. The study was approved by our Institutional Review Board (IRB). Median nerve cross-sectional area was evaluated at the proximal level before and at 4, 8, and 12 weeks after endoscopic release of the transverse ligament. In the present study, the median nerve cross-sectional area cut-off point was 10 mm(2). Repeated measures analysis of variance test (ANOVA) was applied to compare the reproducibility of ultrasound measurements before and after intervention. RESULTS: The mean cross-sectional. area of the median nerve was 15 mm(2) (SD +/- 2.1) before surgery; and 11.1 mm(2) (SD +/- 3); 9.2 mm(2) (SD +/- 2); and 8.6 mm(2) (SD +/- 1.6) at 4, 8, and 12 weeks after surgery. Repeated measures analyses of variance were found to be statistically significant (p < 0.001). CONCLUSION: The results of the present study demonstrated that there was a decrease in the cross-sectional. area of the median nerve after the release of the transverse carpal ligament. (c) 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. Univ Sao Paulo, Dept Radiol, BR-05403001 Sao Paulo, Brazil; Universidade de Taubaté (Unitau), Dept Orthoped Surg, Sao Paulo, Brazil; Univ Nebraska, Med Ctr, Dept Radiol, Lincoln, NE 68583 USA; Hop La Pitie Salpetriere, Dept Radiol, Paris, France; Clin Lilas, Paris, France

Onchocerca eberhardi n. sp. from the sika deer, Cervus nippon , in Japan is described. Adult worms lived in the carpal ligament; infection reached high levels (up to 25 female and 16 male worms in a single carpal limb). Skin dwelling microfilariae were mainly found in the ears. Prevalence of infection was 81 % at the type locality, Mt. Sobo, in Kyushu. The new material was compared to the 31 species of Onchocerca presently known. Onchocerca eberhardi n. sp. females were characterized by a long slender anterior end and a thin esophagus ≤ 1 mm long with no or only a slight glandular region. The vulva was located near the level of the mid-esophagus and the cuticle had transverse external ridges and internal striae (two striae between adjoining ridges). The most similar species were O. stilesi (re-examined), O. lienalis , and to a lesser extent O. gutturosa, all from bovids (cattle). Two main lineages of Onchocerca are recognized in cervids with either primitive or with derived characteristics (as exemplified by the new species). The species in both lineages are not restricted to cervids but are also found in bovids in the Holarctic region, suggesting that the species diversified in the two host groups simultaneously, when these host groups lived in the same geographic area.

Purpose The purpose of this study was to determine whether the excursion of the scaphoid tuberosity and therefore scaphoid motion is minimized during a dart-throwing motion. Methods Scaphoid tuberosity excursion was studied as an indicator of scaphoid motion in 29 cadaver wrists as they were moved through wrist flexion-extension, radioulnar deviation, and a dart-throwing motion. Results Study results demonstrate that excursion was significantly less during the dart-throwing motion than during either wrist flexion-extension or radioulnar deviation. Conclusion If the goal of early wrist motion after carpal ligament or distal radius injury and reconstruction is to minimize loading of the healing structures, a wrist motion in which scaphoid motion is minimal should reduce length changes in associated ligamentous structures. Therefore, during rehabilitation, if a patient uses a dart-throwing motion that minimizes his or her scaphoid tuberosity excursion, there should be minimal changes in ligament loading while still allowing wrist motion. Study Design Bench research, biomechanics, and cross-sectional. Level of evidence Not applicable. The study was laboratory based.

This study examined whether the radiocarpal and dorsal capsular ligaments limit end-range wrist motion or remain strained during midrange wrist motion. Fibers of these ligaments were modeled in the wrists of 12 subjects over multiple wrist positions that reflect high demand tasks and the dart thrower's motion. We found that many of the volar and dorsal ligaments were within 5% of their maximum length throughout the range of wrist motion. Our finding of wrist ligament recruitment during midrange and end-range wrist motion helps to explain the complex but remarkably similar intersubject patterns of carpal motion.

Lipoma is a relatively frequent, benign soft-tissue tumor rarely located in the hand. A lipoma of the hand causing a carpal tunnel syndrome by compression of the median nerve is exceptional. We report the case of a 70-year-old female presenting with a carpal tunnel syndrome. A compression of the median nerve by a lipoma was discovered during surgery. Transverse carpal ligament release with lipoma excision and neurolysis of the median nerve were performed. Histopathological study of the resected mass was consistent with a lipoma. Two-month postoperatively, the patient recovered full hand function with entire disappearance of acroparesthesia. Carpal tunnel syndrome caused by space occupying lesions is rare. Diagnosis is difficult, usually based on the clinical study, electrophysiology and magnetic resonance imaging (MRI). Transverse carpal ligament release and excision of lipoma provides excellent functional recovery.Key words: Lipoma, carpal tunnel syndrome, median nerve, nerve compression

A fundamental understanding of the ligamentous anatomy of the wrist is critical for any physician attempting to treat carpal instability. The anatomy of the wrist is complex, not only because of the number of named structures and their geometry but also because of the inconsistencies in describing these ligaments. The complex anatomy of the wrist is described through a review of the carpal ligaments and their effect on normal carpal motion. Mastery of this topic facilitates the physician's understanding of the patterns of instability that are seen clinically.

Despite advances in understanding the anatomy and biomechanics of wrist motion, intrinsic carpal ligament injuries are difficult to diagnose and treat. Even when an accurate diagnosis is made, there is no consensus on the most appropriate and reliable treatment. Injury predisposes to a progressive decline in wrist function and a predictable pattern of degenerative arthritis. To prevent inadequate outcomes, many treatment options exist, all having inherent benefits and complications. This article reviews the complications of intrinsic carpal ligament injuries and complications of their treatment. Methods to prevent and principles to manage the complications are discussed.

We report a new surgical technique of open carpal tunnel release with subneural reconstruction of the transverse carpal ligament and compare this with isolated open and endoscopic carpal tunnel release. Between December 2007 and October 2011, 213 patients with carpal tunnel syndrome (70 male, 143 female; mean age 45.6 years; 29 to 67) were recruited from three different centres and were randomly allocated to three groups: group A, open carpal tunnel release with subneural reconstruction of the transverse carpal ligament (n = 68); group B, isolated open carpal tunnel release (n = 92); and group C, endoscopic carpal tunnel release (n = 53). At a mean final follow-up of 24 months (22 to 26), we found no significant difference between the groups in terms of severity of symptoms or lateral grip strength. Compared with groups B and C, group A had significantly better functional status, cylindrical grip strength and pinch grip strength. There were significant differences in Michigan Hand Outcome scores between groups A and B, A and C, and B and C. Group A had the best functional status, cylindrical grip strength, pinch grip strength and Michigan Hand Outcome score. Subneural reconstruction of the transverse carpal ligament during carpal tunnel decompression maximises hand strength by stabilising the transverse carpal arch. Cite this article: Bone Joint J 2015;97-B:221–8

Purpose. The palmaris longus profundus has been documented throughout the literature as a cause of carpal tunnel syndrome. We present a case of palmaris profundus tendon removal during the revision of carpal tunnel release.Method. During a carpal tunnel release in a 66-year-old woman, palmaris profundus tendon was found inside the tunnel under the transverse carpal ligament, just above the median nerve, but it was left intact. The patient complained of pain in the hand at night and weakness of her hand one month after surgery. We decided on a revision of the carpal tunnel release. The palmaris profundus tendon was found and was removed.Results. The patient had a normal postoperative course. Two months later she returned to her normal activities and was asymptomatic.Conclusions. When a palmaris profundus muscle is located in carpal tunnel, we recommend its excision during carpal tunnel release. This excision will eliminate the possibility of recurrent compression over the median nerve.

Recurrent carpal tunnel syndrome occurs in up to 12% of cases after carpal tunnel release. Recurrent carpal tunnel syndrome is defined as recurrence of classic symptoms confirmed by electrodiagnostic studies after a symptom-free interval of a minimum of 6 months, as opposed to persistent carpal tunnel syndrome, where a symptom-free interval never occurs after carpal tunnel release, which is attributed to incomplete release of the transverse carpal ligament. The most common causes of recurrent carpal tunnel syndrome requiring reoperation are incomplete release of the transverse carpal ligament and scarring of the median nerve to the surrounding structures. Surgical exploration, release of the reconstituted transverse carpal ligament, and freeing of the median nerve from constricting scar will usually result in symptom relief. The authors describe an unusual presentation of recurrent carpal tunnel syndrome with healing of the transverse carpal ligament dorsal to the median nerve, trapping the median nerve in the subcutaneous tissue. Hand surgeons must be aware of this anomalous location when performing revision carpal tunnel release. The surgeon must locate the median nerve proximally in normal tissue before proceeding distally to avoid iatrogenic injury during revision carpal tunnel release. [ Orthopedics. 2015; 38(1):e72–e74.]

Purpose: Surgical release of the tunnel is very effective in relieving symptoms and remains to be the preferred choice of treatment in carpal tunnel syndrome. However, refractory symptoms following surgical release are not very rare. The purpose of this study was to determine the power of ultrasonography in presenting the potential causes of ongoing symptoms following surgical release of the carpal tunnel.Methods: Thirty-four patients were evaluated in this retrospective study.Results: In 25 patients (74.5%), ultrasonography detected a pathology related to the cause of the ongoing symptoms. The most common pathologic findings detected were median nerve swelling (70.6%), incomplete transection of transverse carpal ligament (23.5%) and perineural fibrosis (17.6%). However, in nine (26.5%) of the patients; ultrasonography was not capable of detecting any pathology which could explain the cause of the persistent symptoms.Conclusions: In the majority of the cases; ultrasonographic examination was capable of detecting the pathology related to the ongoing symptoms. This finding reveals that ultrasonography could be used as a complementary imaging method for identifying the causes of failure following carpal tunnel release surgery. Detection of an ongoing pathology might help the clinician in the management of the persistent disease, and aid in planning a re-exploration. DOI: 10.3944/AOTT.2015.14.0198This abstract belongs to the un-edited version of the article and is only for informative purposes. Published version may differ from the current version.

Treatment of intercarpal ligament injuries in the athlete requires special attention due to several practical and biomechanical considerations. Optimally, the athlete will maintain as much function and range of motion as possible with return to high-impact and load-bearing activity in a timely fashion. Several cutting-edge techniques have arisen in treatment. This article discusses injury patterns in the athlete with scapholunate injury, lunotriquetral injury, scaphotrapezial-trapezoidal injury, and extrinsic ligamentous injury, and the various approaches to addressing these injuries, with a review of the classic as well as newer, innovative techniques.

This article reviews the superficial, skeletal, and ligamentous anatomy of the wrist. Standard and alternative exposures of the wrist joint and the distal radioulnar joint are discussed, emphasizing the importance of avoiding nerve injury. Standard exposure of the wrist joint is used in the treatment of carpal ligament injuries, fractures, and dislocations. Case presentations illustrate these techniques.

The purposes of this study were to investigate the mechanical properties of the carpal tunnel and to examine carpal tunnel compliance as it related to gender difference. Twelve male and twelve female subjects without any neuromusculoskeletal disorders in the upper extremities participated in the study. Indentation testing was manually performed on the wrist volar to the transverse carpal ligament. Effective compliance was defined as the slope of the regression analyses of indentation force and displacement data. In the tested indentation force range (2.45–19.60 N), the displacement of females was 1.38 ± 0.25 mm, significantly smaller than that of the males, 1.82 ± 0.30 mm (p < 0.001). Regression analyses in the force range showed that the effective compliance for females, 0.075 ± 0.012 mm/N, was 26.3% lower than that for males, 0.101 ± 0.018 mm/N (p < 0.005). It was concluded that females have less compliant carpal tunnel than males. The gender difference in carpal tunnel mechanics may predispose females to detrimental compression of the median nerve and carpal tunnel syndrome.

Carpal tunnel syndrome is a common peripheral nerve disease, often requiring surgical intervention. After the first description of endoscopic carpal tunnel release 20 years ago, several endoscopic techniques have been described. The endoscopic procedure seems to have a better outcome in terms of time to return to work. A feared complication of endoscopic carpal tunnel release is injury to the median nerve or branches of the median nerve. We developed a new guiding cannula with raised borders, which will prevent accidental injury to the median nerve. A single-portal anterograde technique, to release the transverse carpal ligament, is described with the use of this new guiding device.

Complex injuries of the distal radius can be associated with articular comminution, severe soft tissue injury, large metaphyseal and/or diaphyseal bone defects, carpal ligament tears or its combinations. We recommend a standardized three step approach for the management of these severe injuries: external fixation as an emergency procedure; treatment of soft tissue damage and further diagnostics as needed; definitive adapted operative therapy after thorough analysis of the specific injury.

We report the case of a 15-year-old girl with a red, swollen, and painful right hand. She first developed symptoms when she was 7 years old. Numerous physicians evaluated her at various institutions but were able to classify her only with chronic pain syndrome. She continued with regular occupational therapy and had to use special aids to compensate throughout school. After 8 years of treatment with no improvement, she presented to our office, where we diagnosed carpal tunnel syndrome. Intraoperative findings revealed a large proximal muscle belly of the index lumbrical, a thickened transverse carpal ligament, and marked compression of the median nerve. Two weeks after the surgery, her symptoms cleared; at 5 months, she remained symptom free.

The abductor digiti minimi (ADM) opponensplasty is used widely as a standard technique of opponensplasty for congenital hypoplastic thumb. Functional results, however, are not always satisfactory in cases of marked laxity of the thumb metacarpophalangeal (MP) joint. The authors have developed a modified procedure of ADM opponensplasty to stabilize the thumb MP joint and to obtain appropriate opponens function. The first step of their modification is to retain the maximum length of transferred ADM muscle. The origin of the ADM is shifted radially and is reattached to the transverse carpal ligament. In our modification the ADM tendon is passed underneath the extensor pollicis longus tendon and is sutured to the adductor pollicis tendon at the ulnar side of the thumb MP joint. By this modified anchoring point the transferred ADM tendon runs across the ulnar side of the thumb MP joint and is expected to act as if it were an ulnar collateral ligament.

A total of 379 patients (416 hands) with clinically diagnosed and electromyographically confirmed carpal tunnel syndrome were enrolled in a prospective study to determine the influence of a modified open decompression technique on postoperative scar discomfort. The new technique used in 184 patients (200 hands) is presented. Special attention was focused on identification and preservation of macroscopically detectable subcutaneous nerves. After using this method, which permits complete visualization of the entire transverse carpal ligament, the incidence of postoperative scar discomfort was 2.5%. This was significantly lower compared with the group of 195 patients (216 hands) treated by standard open decompression technique, without preservation of subcutaneous nerves. Primary results regarding relieving symptoms were comparable in both groups. Five anatomic variations of subcutaneous innervation, at the site of the incision in the line with the radial border of the ring finger, are described. The etiology of scar discomfort is discussed. (J Hand Surg 2002;27A: 821– 827. Copyright © 2002 by the American Society for Surgery of the Hand.)