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Background The purpose of the study was to examine the coverage of thenar and hypothenar muscles on the transverse carpal ligament (TCL) in the radioulnar direction through in vivo ultrasound imaging of the carpal tunnel. We hypothesized that the TCL distance covered by the thenar muscle would be greater than that by the hypothenar muscle, and that total muscle coverage on the TCL would be greater than the TCL-alone region. Methods Ultrasound videos of human wrist were collected on 20 healthy subjects. Automated algorithms were used to extract the distal cross-sectional image of the trapezium-hamate level. Manual tracing of the anatomical features was conducted. Results Thenar muscles covered a significantly larger distance (11.9 ± 1.8 mm) as compared with hypothenar muscles (1.7 ± 0.8 mm) (p Conclusions More than 50% of the TCL at the distal carpal tunnel is covered by thenar and hypothenar muscles. Knowledge of muscular attachments to the TCL improves our understanding of carpal tunnel syndrome etiology and can guide carpal tunnel release surgery.

Background. The surgical therapy modalities for carpal tunnel syndrome, vary from open transverse carpal ligament release TCLR, to different surgical treatment options, Minimal invasive release, endoscopic release, and sonographically guided release, with no consensus about any of them. Aim of the work. To evaluate the end results and efficacy after minimally invasive carpal tunnel syndrome. Patient and methods, Twenty patients with severe carpal tunnel syndromes, were treated at Al-Azhar University Hospitals between 2015-2017, with percutaneous technique, will be described in detail. There were 2 males and 18 females, 45.9 years of age on average with an average follow-up of about 12 months. Results. All patients were satisfied except three patients. two of them suffered from recurrence and one from scar formation. There was no difficulty with this technique for all patients except for one female patient with marked obesity. In our study, we will compare our results to the open technique. No adjacent structures were damaged Conclusion. This study demonstrated that minimal invasive carpal tunnel release is potentially a safe, secure, quick, and effective procedure to transect the transverse carpal ligament and may be an alternative option to traditional surgical treatment of carpal tunnel syndrome and need more accurate knowledge of district anatomy and more experience.

Objective Carpal tunnel syndrome (CTS), the compression of the median nerve under the carpal ligament, is the most common peripheral nerve entrapment of the upper extremity. While conservative treatment is used for patients with mild and moderate symptoms, surgical treatment is preferred for severe symptoms. The aim of the study is to evaluate the difference between transverse and longitudinal incision by comparing postoperative pain and recurrence rates. Methods The patients were divided into two groups according to the surgical incision type. Surgical intervention was applied to patients in group T (transverse incision) and group L (longitudinal incision) by the same two surgeons in each group. All patients were followed-up with electromyography (EMG) and performance scale before and after surgical treatment. If the postoperative EMG result was similar to the preoperative EMG result, it was accepted as recurrent CTS. Results A total of 418 patients were included to the study. Six patients in the group T with transverse incision, and 18 patients in the group L with longitudinal incision, were reoperated for an average of 6 ± 2 months after the primary surgery. Conclusion Complications are less, and recurrent nerve compression is less in longitudinal approach, since surgical intervention is performed by seeing the median nerve directly.

Background and objective: There are different methods and incisions to release the transverse carpal ligament in carpal tunnel syndrome. This study aimed to compare the surgical outcome of the conventional extended incision with the limited mid palmar one. Methods: The study was a prospective comparative one. Patients with carpal tunnel syndrome were divided into two groups: Group 1 was patients operated on by the conventional extended incision, Group 2 with a limited mid palmar incision. Results: The patients included were 79 with 89 hands. The age mean was 41 years. Group 1 included 47, and Group 2 included 42 hands. The differences between both groups were statistically significant regarding the operative data (the incision length and the operative time) and the post-operative data (the duration of analgesia needed, the date of starting to use the hand in daily life activities, and return to work). However, the date of improvement of the sensory symptoms from the fingers showed no significant differences. The sum of the overall complications that occurred for the cases of Group 2 was about a third of that occurred for Group 1. The highly significant difference was in the scar tenderness in the third month of the post-operative period. Conclusion: The limited mid palmar incision to release the entrapment of median nerve in carpal tunnel syndrome offers a shorter operative time, less analgesia needed post-operatively, less complication rate, less scar tenderness, earlier use of the hand in daily life activities, and return to work in a shorter period. Keywords: Carpal tunnel syndrome; Surgical treatment; Incision.

Introduction This study aimed to assess the carpal arch dynamics during active finger and wrist motion following carpal tunnel release using four-dimensional computed tomography (4D-CT). Materials and Methods Four patients who diagnosed with bilateral carpal tunnel syndrome and underwent unilateral carpal tunnel release were prospectively included. 4D-CT of the bilateral wrists during active finger and wrist motion was performed for 10 seconds at five frames per second. The distances between the tip of tuberosity of the scaphoid and the volar ridge of the pisiform (S–P distance) and volar ridge of trapezium and the tip of hook of hamate (T–H distance) were measured at each position and the values of S–P and T–H distances were compared between the postoperative and contralateral wrists. Results During finger motion, the S–P and T–H distances were not different at any position between the postoperative side and contralateral side. Conversely, S–P and T–H distances gradually increased in the postoperative wrists. The differences between the sides of S–P distance were significant, with >0 degrees of wrist extension, and differences of T–H distance were significant with >15 degrees of wrist extension. Conclusion This study demonstrated the carpal arch dynamics using 4D-CT and revealed that the carpal arch was widened with the wrist in extension after carpal tunnel release. This study suggests that the transverse carpal ligament plays an important role in maintaining carpal arch stability.

Objective: To evaluate the outcomes of endoscopic release of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS) using the Chow dual-portal technique between January 2006 and December 2015. Materials and Methods: Study population consisted of 217 cases of idiopathic CTS, in 179 patients, 145 females (81%) (31 bilateral cases) and 34 males (19%) (7 bilateral cases), with an average age of 48.2 years (range, 32-68) and an average follow-up of 97.9 months. The symptom severity and functional evaluations were performed using the Boston Carpal Tunnel Questionnaire Symptoms Severity Scale (BCTQ-SSS)and the Functional Status Scale (BCTQ-FSS). Results: The average BCTQ-SSS was 3.20+0.26 in the preoperative period, which improved to 1.30+0.12 at the 6-month postoperative follow-up and remained at 1.25+0.11 in the long-term. The average BCTQ-FSS was 2.57+0.29 in the preoperative period, which improved to 1.28+0.12 at the 6-month postoperative follow-up and remained at 1.20+0.09 in the long-term. There were 7 cases (3.2%) of transient postoperative neurapraxia. No patient required to be converted to open technique. Conclusion: The endoscopic carpal tunnel release with Chow technique is an effective and safe surgical method for the treatment of idiopathic CTS. Key words: Carpal tunnel syndrome; Chow dual-portal technique; endoscopic release; neural compression; median nerve. Level of Evidence: III

Objectives Round Acupuncture having blunt end has developed from acupotomy. This case report is to find out that Round Acupuncture is effective in treating patients with recurrent carpal tunnel syndrome (CTS), which has not improved by steroid injection or acupotomy. Methods Round Acupuncture was inserted into the distal fibers of transverse carpal ligament and released toward the proximal fibers. Treatment was performed three times in total. T ingling, numbn ess, night pain and swelling sensation were assessed, and provocative maneuvers were also used. Results After treat ment, all symptoms completely disappeared and the patient had no recurrence until 3 months after treatment. Conclusion Round Acupuncture co uld be an effective treatment for recurrent CTS.

Percutaneous carpal tunnel release (CTR) is a new surgical technique allowing to cut the transverse carpal ligament under sonography, without skin incision. The technique is safe, offers good functional results and early return to daily activities. This study investigates if percutaneous CTR is also cost-effective. Percutaneous CTR presents many advantages and may be safer than open and endoscopic CTR. This study could not demonstrate that it allows also cheaper surgery, at least as compared to open CTR. However, if it allows earlier return to work, percutaneous CTR could offer a major economic advantage over other techniques, particularly open surgery.

Carpal tunnel syndrome is a common condition causing hand pain, numbness, and disability. Release of the transverse carpal ligament is the most commonly performed upper extremity procedure. This chapter focuses on the endoscopic (minimally invasive) technique to accomplish this. Current outcomes data are reviewed as well as relevant anatomic points of interest. Pearls and Pitfalls of the technical aspects of the procedure are discussed in detail to assist surgeons in the safe and effective performance of this procedure.

Carpal tunnel syndrome is the most common peripheral entrapment neuropathy. Surgical options include open or endoscopic release of the transverse carpal ligament. Most endoscopic techniques involve placing an endoscope deep to the transverse carpal ligament from either a proximal incision or a proximal and distal approach. This chapter describes a superficial (supraretinacular) endoscopic approach that permits visualization of the transverse carpal ligament and the median nerve throughout the entire procedure.

The aim of this study was to evaluate whether recurrent carpal tunnel syndrome (CTS) after complete and sufficient division of the transverse ligament really exists. Another goal was to analyze the underlying reasons for recurrent CTS operated on in our department. Over an observation period of eleven years, 156 patients underwent surgical intervention due to CTS. The records of each patient were analyzed with respect to baseline data (age, gender, affected hand), as were clinical signs and symptoms pre- and postoperatively. To assess long-term results, standardized telephone interviews were performed using a structured questionnaire in which the patients were questioned about persisting symptoms, if any. Of the 156 patients, 128 underwent first surgical intervention due to CTS in our department. In long-term follow-up, two-thirds of these patients had no symptoms at all, one-third of the patients described mild persisting numbness. None of the patients experienced a recurrence of CTS. The 28 patients who received their first operation outside of our department were operated on for recurrent CTS. The cause of recurrence was incomplete division of the distal part of the transverse carpal ligament in all cases. The results suggest that recurrent CTS after complete and sufficient division of the transverse ligament is very unlikely.

This study investigated the biomechanical effects of thenar muscles (abductor pollicis brevis (APB), superficial head of flexor pollicis brevis (sFPB), opponens pollicis (OPP)) on the transverse carpal ligament formed carpal arch under force application by individual or combined muscles (APB, sFPB, OPP, APB-sFPB, sFPB-OPP, APB-OPP, and APB-sFPB-OPP). In ten cadaveric hands, thenar muscles were loaded under 15% of their respective maximal force capacity, and ultrasound images of the cross section of the distal carpal tunnel were collected for morphometric analyses of the carpal arch. The carpal arch height and area were significantly dependent on the loading condition (p

Carpal tunnel decompression is commonly performed open or endoscopically. Carpal tunnel release using the KnifeLight instrument (Stryker, Kalamazoo, MI) is an alternative method established in 2000. The instrument has a cutting blade placed between two blunt flat tips with an integrated light source which helps to locate the tool blade by transillumination through the tissues. The instrument is inserted into an opening made in the wrist crease and transverse carpal ligament and used to divide the ligament. This is a simple, efficient, and reproducible alternative for carpal tunnel decompression.

Trigger wrist is a rare disorder affecting the wrist and should not be confused with trigger finger. A detailed preoperative evaluation includes a good Clinico-radiological evaluation and tests for median nerve compression. Surgical release of transverse carpal ligament along with excision of the offending mass relieves the symptoms. This report is a case of triggering at the wrist along with median nerve compression in a 28 years old female. After detailed pre-operative evaluation surgical treatment was done and the patient got relieved of the condition.

Introduction: Carpal tunnel syndrome is the most common compression neuropathy in clinical practice and is also the most extensively studied. In Mini-open carpal tunnel release, the transverse carpal ligament is transected using a small open cut at the volar aspect of the proximal palm. The objectives of this study were to determine the functional outcome of mini-open carpal tunnel release procedure, to use the Boston Questionnaire to determine the functional outcome following mini open carpal tunnel release which includes pain, numbness, weakness and fine hand activities. Methods: This descriptive cross-sectional was conducted in National After informed consent, the cases who meet the informed criteria were examined and relevant details were filled up in the proforma preoperatively and two weeks post-operatively. Assessment of the patient’s symptom severity and functional status was done with the Boston questionnaire. Results: CTS was most common in the age group of 25-29 years (36.36%) and was predominant in housewives (18.20%). Mean symptom severity scores per person improved from 3.11 pre-operatively to 1.12 post-operatively. Mean functional status scores per person improved from 2.65 pre-operatively to 1.03 post-operatively. There was a statistically significant improvement in postoperative outcomes in our population. Conclusions: The findings in this study indicate that mini-open carpal tunnel release has a good functional outcome. Keywords: carpal tunnel syndrome; compression neuropathy; transverse carpal ligament.

A clinical case, described in this study, demonstrates a successful combined treatment of posttraumatic neuropathy of the medial and radial nerves in a patient after the closed comminuted fracture of the distal metaepiphysis of the left radial bone with a fragment displacement. One of the most serious complications of such injuries is the development of carpal tunnel syndrome [1]. Osteopathic physicians were involved in the process of treatment and rehabilitation. According to the data of various authors [1, 2], it is necessary to use complex surgical aids such as decompression of the medial nerve by dissecting the carpal ligament with the scar, as well as nerve transposition if the conservative methods are not effective. Unfortunately, surgical treatment does not always lead to a positive result [4]. Invalidization of patients is significant — 5–7%. It is known that early complex pathogenetic treatment allows to fight against the developing carpal tunnel syndrome in patients with severe bone trauma much more successfully. In order to prevent scar changes of the carpal ligament and maintain adequate trophicity in the injured limb, it is necessary to implement measures aimed at stabilizing microcirculatory disorders in the distal parts of the injured forearm as soon as possible. In order to make the treatment of this pathology even more effective, an integrated approach to solving this complex and socially significant problem is needed, as well as the search for new advanced and relatively safe treatment tactics, these include osteopathic correction too.

Purpose The purpose of this study was to identify associations between the clinical manifestations of carpal tunnel syndrome (CTS) and the sonographic measurements of the median nerve in the carpal tunnel. We hypothesized that sonographic changes in the median nerve from proximal to distal along the carpal tunnel would be associated with symptom severity scores. Methods We report on 38 patients with clinical signs and symptoms of CTS in a prospective investigation. Subjects underwent sonographic evaluation with measurement of median nerve cross-sectional area (CSA) at 3 locations: the level of the pronator quadratus, pisiform, and hamate. In addition, we measured dimensions of the carpal tunnel at the levels of the pisiform (inlet) and hamate (outlet). Finally, we recorded maximal thickness of the transverse carpal ligament (TCL). Patients underwent routine clinical evaluation and 31 patients had electrodiagnostic examination. Patients completed the Levine Katz Questionnaire (LKQ) to characterize severity of clinical symptoms. Each clinician was blinded to symptom severity scores. Pearson correlation coefficients were calculated to measure the relationship between LKQ score and sonographic measures. Results Median nerve CSA decreased over the course of the carpal tunnel from proximal to distal in 30 of 38 wrists. A greater absolute change in CSA of the median nerve over the course of the carpal tunnel between the pisiform and the hamate as well as between the pronator quadratus and the hamate correlated with increased severity of clinical symptoms. Increased thickening of the TCL also correlated with greater symptom severity scores. Conclusions Changes in CSA of the median nerve as well as thickening of the TCL correlate with CTS severity. Type of study/level of evidence Diagnostic II.

Background: Open carpal tunnel release typically requires several weeks of recovery. A less invasive, ultrasound-guided percutaneous technique of releasing the transverse carpal ligament using a thread (thread carpal tunnel release [TCTR]) has been described. To date, its clinical effectiveness and safety have been evaluated exclusively by the group that developed the technique, using a single outcome measure without a control comparison. The objective of this study was to independently evaluate the safety and effectiveness of TCTR using multiple outcome measures and a control comparison. Methods: A convenience sample of 20 participants with refractory moderate or severe carpal tunnel syndrome underwent TCTR of their most symptomatic hand. Outcome measures included pre-TCTR and 1-, 3-, and 6-month post-TCTR Boston questionnaire; pre-, 3-, and 6-month post-TCTR monofilament sensibility, strength, ultrasound, and electrodiagnostic testing; weekly post-TCTR phone interviews for 1 month; and satisfaction surveys at 3 and 6 months post-TCTR. Results: No complications were reported. During the month post-TCTR, significant prompt improvements in hand pain and dysfunction occurred. The following significant improvements were demonstrated in the treated versus control hand: Boston Questionnaire scores, median nerve distal motor latency, transcarpal tunnel motor and sensory conduction velocities and sensory nerve action potential amplitudes. No significant differences in sensibility, pinch or grip strength, median nerve cross-sectional area (CSA) at the carpal tunnel inlet, or wrist: forearm median nerve CSA ratio were documented between TCTR and control sides. Satisfaction with the TCTR procedure was high (85%-90%). Conclusions: This study supports previous reports that the TCTR procedure is safe and effective.

Background: Ultrasound can provide evaluation of the anatomy of the carpal tunnel in a convenient, noninvasive office setting. This study is intended to determine the accuracy and diagnostic performance of ultrasound, used by surgeons, for the evaluation of completeness of carpal tunnel release (CTR). Methods: Ten cadaver arms underwent randomized sectioning of 0%, 25%, 50%, 75%, or 100% of the transverse carpal ligament. Following a brief training session, a blinded observer used ultrasound to evaluate the percentage of the transverse carpal ligament release. The release amount was then confirmed with an open exposure of the transverse carpal ligament. Results: Cronbach α and Pearson correlation coefficients were 0.92 and 0.87, demonstrating excellent reliability and validity of the technique. Diagnostic performance including sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 75%, 86%, and 100%, respectively, for the diagnosis of incomplete release of the transverse carpal ligament by a novice sonographer orthopedic surgeon. Conclusions: The ultrasound is a highly accurate tool for the diagnosis of incomplete transverse carpal ligament release and requires a minimal amount of training to use for this purpose. It provides a rapid means of diagnosing incomplete release of the transverse carpal ligament following CTR.

Although various techniques exist for pulley reconstruction, none are useful for all patients. We performed flexor pulley reconstruction using a transverse carpal ligament which has the advantages of a useful gliding surface, sufficient width and thickness, anatomical similarity to the pulley, and adequate durability. Cosmetically, all the surgical scars are on the volar side while functionally, we can avoid invasion to both the flexion and extension sides.

Established endoscopic carpal tunnel release (ECTR) techniques carry a not entirely eludible risk of iatrogenic complications, mainly because of incomplete view of the cutting blade and intraoperative pressure increase inside the carpal tunnel (CT). We describe a novel single-portal ECTR method, conceived to reduce these risks, by optimizing visual control and avoiding dilatation of the CT. After incising the well exposed proximal third of the transverse carpal ligament (TCL), transection of the remainder is completed using a pediatric urethrotome. This small caliber instrument is moved in the plane of the TCL, without invading the tunnel, and provides detailed view of the TCL and any crossing anatomical structures at any given moment. We present the technique and the results of a retrospective case series of 33 patients with CT syndrome who underwent the procedure, after failing to respond to conservative treatment. Because of improved view and the avoidance of intraoperative pressure trauma to structures passing through the CT, the described approach may contribute to prevent iatrogenic complications and represent a valid improvement over conventional ECTR procedures.

Carpal stability depends on the integrity of both intra-articular and intracapsular carpal ligaments. In this review, the role of the radial-sided and ulnar-sided extrinsic and intrinsic ligaments is described, as well as their advanced imaging using magnetic resonance arthrography (MRA) and contrast-enhanced magnetic resonance imaging (MRI) with three-dimensional (3D) scapholunate complex sequences and thin slices. In the last decade, the new concept of a so-called “scapholunate complex” has emerged among hand surgeons, just as the triangular ligament became known as the triangular fibrocartilage complex (TFCC).The scapholunate ligament complex comprises the intrinsic scapholunate (SL), the extrinsic palmar radiocarpal: radioscaphocapitate (RSC), long radiolunate (LRL), short radiolunate (SRL) ligaments, the extrinsic dorsal radiocarpal (DRC) ligament, the dorsal intercarpal (DIC) ligament, as well as the dorsal capsular scapholunate septum (DCSS), a more recently described anatomical structure, and the intrinsic palmar midcarpal scaphotrapeziotrapezoid (STT) ligament complex. The scapholunate (SL) ligament complex is one of the most involved in wrist injuries. Its stability depends on primary (SL ligament) and secondary (RSC, DRC, DIC, STT ligaments) stabilizers.The gold standard for carpal ligament assessment is still diagnostic arthroscopy for many hand surgeons. To avoid surgery as a diagnostic procedure, advanced MRI is needed to detect associated lesions (sprains, midsubstance tears, avulsions and chronic fibrous infiltrations) of the extrinsic, midcarpal and intrinsic wrist ligaments, which are demonstrated in this article using 3D and two-dimensional sequences with thin slices (0.4 and 2 mm thick, respectively).

Supplemental Digital Content is available in the text., Summary: Early-onset carpal tunnel syndrome (CTS) is a well-known manifestation of mucopolysaccharidoses (MPS) due to excessive deposition of glycosaminoglycans in soft tissues. Standard treatment has been carpal tunnel release surgery, with the conventional technique of dividing the transverse carpal ligament. With advancement of treatments for MPS, these patients now have a longer life expectancy and are presenting with recurrent CTS. Management of recurrent CTS in these patients is not well studied. Here, we report 2 cases of recurrent CTS in MPS patients after a carpal tunnel release operation. We describe the findings on repeat operations and propose a unique technique for treating CTS in MPS patients to minimize recurrence during the initial CTS surgery. Our method involves resection of a portion of the transverse carpal ligament and use of a hypothenar fat pad flap over the median nerve.

Purpose We sought to determine surgeon-pathologist agreement with respect to distinguishing between a previously undivided transverse carpal ligament (TCL) and scar during revision carpal tunnel release (CTR). Additionally, we aimed to describe the histologic findings of the TCL and flexor tenosynovium during revision CTR. Methods All patients undergoing revision CTR for persistent or recurrent CTS by a single surgeon between 2013 and 2019 were included. An intraoperative assessment was made as to the presence of scar versus a previously undivided TCL by the surgeon. Two pathology specimens (1 consisting of flexor retinaculum and 1 consisting of tenosynovium) were sent for histopathological analysis with hematoxylin-eosin staining. The pathologist’s assessment of the flexor retinaculum specimen was categorized as either “ligamentous” if a previously undivided TCL was identified or “nonligamentous” if scar or any other tissue was identified. The surgeon’s intraoperative assessment served as the reference standard when comparing the histologic assessment. Results A total of 40 patients underwent 46 revision CTRs. The histologic assessment agreed with the surgeon’s intraoperative assessment of a previously undivided TCL versus a scar in 30 of 46 (65%) cases. In 12 of 46 (26%) revision cases, the surgeon determined that there was a previously undivided TCL. In these 12 cases, the pathologist identified a ligament 17% of the time. Conclusions Surgeon-pathologist agreement is low with respect to determining previously undivided TCLs versus nonligamentous tissue in the setting of revision CTR. The results of this investigation suggest that pathologists (with limited clinical information) have difficulty confirming the clinical diagnosis of persistent CTS with previously unreleased TCL when using routine hematoxylin-eosin staining. Routine biopsy of the TCL during revision CTR may be of limited clinical utility, as it does not alter the diagnosis or management in these cases. Type of study/level of evidence Diagnostic III.

Radiocarpal dislocations are rare, but serious injuries. The shearing and rotation forces associated with these injuries lead to extrinsic carpal ligament damage and associated fractures of the distal radius and carpus. Prompt reduction and stabilization via surgical repair are critical to providing satisfactory outcomes. These injuries are often complex and are associated with variable injury patterns of osseous, ligamentous, and soft tissues. Knowledge and comfort with multiple surgical approaches and repair techniques can help the surgeon achieve better outcomes.

Purpose The main cause of carpal tunnel syndrome (CTS) is pathological changes in the flexor synovium, which is a known cause of pressure elevation in the carpal tunnel. The importance of the transverse carpal ligament (TCL) in the pathogenesis of CTS has hitherto been overlooked. However, the TCL significantly affects carpal biomechanics; the TCL is known to affect the carpal bone to a greater extent when intra carpal tunnel pressure is high. In addition, the effect of TCL properties on the progression course of idiopathic CTS is unknown.Therefore, we hypothesized that TCL thickness, measured using ultrasonography, would influence the results of conservative treatment for CTS patients with mild to moderate symptoms. We aimed to investigate the relationship between the ultrasound-measured TCL thickness and idiopathic carpal tunnel conservative treatment surgery rate. Materials and methods We analyzed the wrists of 127 patients with mild to moderate symptoms of CTS. The patients were diagnosed on the basis of electrophysiological assessment outcomes, median nerve cross-sectional area in the carpal tunnel, and clinical symptoms. The Boston carpal tunnel questionnaire score was also measured. Patients with a TCL thinner than 1.5 mm were classified into group A (n = 62), and those with a TCL thicker than 1.5 mm were classified into group B (n = 65). Patients with severe symptoms or other diseases were excluded. The patients were initially treated with night splinting after diagnosis. If symptoms were not ameliorated, steroid injection and surgical treatment were performed consecutively. The procedures were determined by a single surgeon. Results The mean TCL thickness was 1.51 mm: 0.98 mm in group A and 2.28 mm in group B. The percentages of patients who underwent surgery were 43.0% in group A and 67.7% in group B. Group B was 1.77 times more likely to have surgery, and the interval between diagnosis and surgery and/or steroid injection was shorter. The TCL thickness in group B was also related to cross-sectional area and symptom duration. Conclusions Transverse carpal ligament thickness affects disease progression and may affect treatment efficacy, depending on the treatment method. Transverse carpal ligament thickness may be a criterion for deciding between surgical and conservative treatments based on a thickness threshold of 1.5 mm.

Background Flexor retinaculum reconstruction techniques or simply Flexor Retinaculum Z-lengthening have been proposed to preserve Flexor Retinaculum continuity after carpal tunnel release. Their effectiveness is based solely on symptom relief. There has been no analysis of the effects on intra-carpal tunnel pressure of Flexor Retinaculum-lengthening techniques. Objective was to compare intra-carpal tunnel pressure outcomes between complete division and Z-lengthening of the Retinaculum in a cadaveric model of carpal tunnel release. Methods Experimental study of carpal tunnel pressure after surgical Flexor Retinaculum modification in 10 fresh-frozen forearm and hand cadaveric specimens. The Kyphon™ Balloon Kyphoplasty system was used to measure the pressure before and after infusing 1, 2, 3, 4 and 5 ml of saline solution when untreated (Flexor Retinaculum continuity stage I), when Z-lengthened (Flexor Retinaculum continuity stage II), and after complete Flexor Retinaculum division (Flexor Retinaculum continuity stage III). Finding Intra-carpal tunnel pressure increased with larger volume of infused saline solution, although mean pressures were lower after Z lengthening or complete division of the Retinaculum than at baseline. Analysis of linear regression coefficients indicated significant differences as a function of FR continuity stage (F(2,18) = 18.38, p 0.001), while the Bonferroni test revealed significant differences in slopes between stages I and III (p = 0.003), between stages I and II (p 0.02), but not between stages II and III (p 0.05). Interpretation The effectiveness of carpal tunnel release and the reduction in intra-carpal tunnel pressures obtained by Z-lengthening of the FR were similar to those observed after its complete division, while preserving FR continuity.

Accessory and atypical muscles of the upper limb are common, whereas symptomatic variations presenting with carpal tunnel syndrome (CTS) are rare. A rare unilateral accessory transverse carpal muscle located palmar to the transverse carpal ligament is described. The accessory muscle, associated with CTS clinical manifestations in a 38-year-old Greek male worker, can be quite problematic during CTS operation. The current case emphasizes the importance of meticulous knowledge of the variable anatomy of the carpal tunnel (CT) area, since the accessory muscles may be accompanied by ectopic motor branches and a high risk of iatrogenic injury. Recognition and careful evaluation of accessory muscles may enhance a surgeon’s ability to carry out a safer and successful CT approach.

The treatment of athletes with carpal ligament injuries provides many challenges. Our initial goals remain to make a timely and accurate diagnosis, provide treatment options, and create an environment for shared decision making. To optimize outcomes and facilitate return to play, early surgical intervention may be warranted. This article reviews common carpal ligament injury patterns in the athlete with a focus on both classic and newer surgical techniques.

Surgical treatment of carpal tunnel syndrome (CTS) was recently started in our department, and we noticed that the development of trigger finger (TF), with which neurosurgeons are generally unfamiliar, is not rare after such treatment. We summarized the clinical and pathogenetic aspects of TF and retrospectively analyzed the medical records of all 39 patients who underwent CTR in our department to investigate the occurrence of TF. In 39 patients with CTS, 46 surgical interventions were performed in our department. All surgical procedures were carried out by open release of the transverse carpal ligament under local anesthesia infiltration, but the distal forearm fascia was not released. The mean postoperative follow-up period was 21.1 ± 16.8 months. TF after CTR occurred in nine hands of eight patients (9 of 46 hands, 19.6%). The mean interval between CTR and TF onset was 5.3 ± 2.8 months. TF after surgical treatment of CTS is not rare; therefore, surgeons who treat CTS should understand the clinical features of TF and carefully assess affected patients, particulary at presentation and within 6 months postoperatively.

Objective: The purpose of this study was to investigate the effect of transverse carpal ligament (TCL) thickness and the size of carpal tunnel area on clinical findings and electrophysiological changes through the wrist magnetic resonance imaging (MRI). Methods: In this prospective study, the thickness of the TCL and the carpal tunnel areas of preoperative cases diagnosed with carpal tunnel syndrome (CTS) were measured via wrist MRI results. The effect of TCL thickness and carpal tunnel area on endocrinopathies such as diabetes mellitus (DM) and hypothyroidism and the effect of these variables on clinical findings and electrophysiologic changes were evaluated in the light of the literature. Results: TCL thickness and carpal tunnel area were not statistically significant among DM, hypothyroidism and electrophysiological changes (p>0.05). Conclusion: This study include one of the limited researches comparing the carpal tunnel area and TKL thickness in cases with and without endocrinopathy CTS. However, there is a need for further researches that have a greater number of cases, including multi-centered, differentwinged people.

The carpal tunnel is a semiannular tunnel surrounded by the carpal and transverse ligament of volar wrist. The carpal tunnel contains median nerve, flexor digitorum, superficial tendon, and flexor hallucis longus (Fig. 4.1).

Introduction. The standard open technique for carpal tunnel surgery has wound problems and complications significantly more than minimally invasive surgery using the Wongsiri technique with MiniSURE Kit® (Surgical Innovation Healthcare Co., Ltd, Bangkok, Thailand) and in particular, the open technique surgery requires a longer time for return to work. CTR surgery with endoscopic devices improves the results with fewer wound problems when compared with the commonly used open technique; however, nerve complications and injury are more prevalent with endoscopic surgery than with the open technique. The Wongsiri technique produces good results with new medical devices such as the MiniSURE View, for improved vision and line-of-sight, and the MiniSURE Cut for improved and complete cutting via the supraretinacular technique that may reduce the nerve problems associated with endoscopic tooling in the carpal tunnel. Purpose. To evaluate the results of the operation and postoperative outcomes of the Wongsiri technique with a MiniSURE Kit®. Methods. 20 patients underwent carpal tunnel release using the Wongsiri technique and a MiniSURE Kit® with a five-step surgery: MIS starts when the surgeon makes a 1.5–1.8 cm incision, creates a working space, inserts the visual tube of MiniSURE View, inserts the freer, and then cuts the transverse carpal ligament by using the MiniSURE Cut. Results. All 20 successes of the Wongsiri technique and MiniSURE Kit® surgery occurred within 6.8 minutes operative time and a 12 mm wound size. A single outlier, in one case (6.7%), the patient experienced pillar pain which abated within one month. Patients can return to work in 7.3 days. Conclusions. The Wongsiri technique with the MiniSURE Kit® demonstrated good outcomes similar to the endoscope. By contrast with the endoscopic surgery, the Wongsiri technique with the MiniSURE Kit® reduced preop, operating, and postop time, many resources, and significant costs and resulted in no nerve problems or complications.

Different techniques are available for carpal tunnel release such as classical surgical operations or minimally invasive procedures. A minimally invasive approach and the relevant regional anatomy are reported in this pilot study which was conducted with bodies from a body donation program. The method described here uses a hook knife to cut through the transverse carpal ligament or flexor retinaculum under ultrasound guidance. The results are documented by means of magnetic resonance and ultrasound imaging as well as by anatomical dissection.

Temporary or long-lasting loss of grip force after open carpal tunnel release (CTR) in carpal tunnel syndrome (CTS) patients is well known and caused by changes in biomechanical conditions through sectioning of the transverse carpal ligament. We hypothesize to find predicting factors for loss of grip strength. We performed dynamometer testing of overall hand grip, tip pinch, and key pinch grip prior, 3 and 6 months after open CTR in 42 CTS subjects. Changes in these three main variables related to pre-operative grip, tip pinch and key pinch forces as well as gender and age were analyzed for significant results (t test, Pearson and Spearman correlations, descriptive statistics; 2-tailed p = .05). At 3-month post-CTR, overall hand grip force decreased significantly by 11.7% (p = .006), whereas key pinch and tip pinch only decreased by 5.6 and 3.5% (p

Feline carpal ligament injuries are often diagnosed indirectly using palpation and stress radiography to detect whether there is instability and widening of joint spaces. There are currently no reports describing normal feline carpal ligament anatomy and the magnetic resonance imaging (MRI) appearance of the carpal ligaments. The objective of this prospective, anatomic study was to describe normal feline carpal ligament anatomy using gross plastinated specimens and MRI. We hypothesized that MRI could be used to identify the carpal ligaments as previously described in the dog, and to identify species specific variations in the cat. The study was conducted using feline cadaver antebrachii that were radiographed prior to study inclusion. Three limbs were selected for MRI to confirm repeatability of anatomy between cats. The proton density weighted pulse sequence was used and images were acquired in transverse, dorsal, and sagittal planes. Following MRI, the limbs were plastinated and a collagen stain was used to aid in identification of carpal ligament anatomy. These limbs were sliced in sagittal section, and a further six paired limbs were included in the study and sliced in transverse and dorsal planes. Anatomic structures were initially described using MRI and then subjectively compared with gross plastinated specimens. Readers considered the transverse MRI plane to be most useful for visualizing the majority of the carpal ligaments. Findings indicated that MRI anatomy of the carpal ligaments was comparable to plastinated anatomy; therefore MRI appears to be a beneficial imaging modality for exploration of feline carpal pathology.

Background To compare the clinical effectiveness of ultrasound-guided needle release of the transverse carpal ligament (TCL) with and without corticosteroid injection in carpal tunnel syndrome (CTS). Methods From June 2016 to June 2017, 49 CTS patients (50 wrists) were included in this study. Twenty-five wrists were treated with ultrasound-guided needle release of the TCL plus corticosteroid injection (group A), and 25 wrists were treated with single ultrasound-guided needle release of the TCL (group B). The following parameters were assessed and compared including postprocedure results according to relief of symptoms, ultrasound parameters (cross-sectional area of the median nerve at the levels of pisiform, flattening ratio of median nerve at the levels of the hamate bone, and the thicknesses of TCL on the cross-section at the level of the hamate bone), and electrophysiological parameters (distal motor latency and sensory conduction velocity). Results Group A had higher overall excellent and good rate 3 months after the procedure than group B (84 vs 52%, P

A new minimally invasive technique is presented to improve the results and reduce the duration of treatment of patients with stenosing ligamentitis of dorsal carpal ligament (de Quervain’s disease). The high efficiency of the proposed method (on the Disabilities of the Arm, Shoulder, and Hand scales and Visual Analogue Scale) is established, comparable with de Quervain’s open ligamentotomy but with the reduction of rehabilitation period after the surgery from 16-21 days to3-4 days. Clinical approbation of minimally invasive ligamentotomy in all patients revealed excellent long-term results of treatment, with minimal risk of complications. Comparison of the results of treatment of patients of both groups showed the advantage of minimally invasive ligamentotomy before open ligamentotomy in the early postoperative period with the same long-term results, which allows patients to start their labor and professional duties in the early stages. The proposed method can be performed in an outpatient mode and does not require special post-operative treatment, as well as special instruments and equipment, which allows reducing the costs of both the patient and the medical institution.

Objective To determine if the thickness of the transverse carpal ligament measured by T2 axial magnetic resonance imaging actually influences the onset of carpal tunnel syndrome. Material and method 94 patients between January 2015 and June 2016, of whom 28 had carpal tunnel syndrome, underwent magnetic resonance imaging, 37 with discomfort in different carpus regions without symptoms of carpal tunnel and 29 healthy subjects. Two observers performed 3 measurements in 3 different levels, and in the 3 groups of patients. Results No statistically significant differences in transverse carpal ligament thickness measurements between the carpal tunnel syndrome group and the group without carpal tunnel involvement became apparent, but statistical differences between the control group and the carpal tunnel syndrome group, and between the control group and the group without involvement of the carpal tunnel were observed. In both these groups, the thickness of the transverse ligament was higher than in the control group. Discussion An increase in the thickness of the transverse ligament in was found in this study in subjects with involvement of carpal tunnel syndrome as evidenced by numerous studies in the literature. There is no certain causative factor, but rather a set of facts that make onset of the syndrome possible in a specific group of patients. Conclusion Carpal tunnel syndrome is multifactorial. The thickness of the transverse ligament does not directly affect the onset of symptoms.

Zusammenfassung Ziel Diese prospektiv randomisierte Studie untersucht den Einfluss von standardisierter Kälte- und Kompressionstherapie auf Schwellung, Schmerzhaftigkeit und das funktionelle Ergebnis nach Spaltung des Retinaculum flexorum bei Karpaltunnelsyndrom im Vergleich zu einer reinen Kühlung. Patienten und Methoden Fünfzig Patienten zur Spaltung des Retinaculum flexorum wurden in zwei Gruppen randomisiert. Für eine Woche führte Gruppe 1 postoperativ eine konventionelle Kühlungstherapie durch, Gruppe 2 eine standardisierte Kühlungs- u. Kompressionstherapie mit dem Cryo/Cuff™-System (3 × 10 min zweimal täglich). Nachuntersuchungen erfolgten am 1., 8. und 21. Tag nach der Operation. Ein Patient der Gruppe 1 und 3 Patienten der Gruppe 2 konnten nicht nachuntersucht werden. Die Untersuchungsparameter waren Schmerz, Schwellung, Beweglichkeit, Kraft, DASH- und MHQ-Score. Ergebnisse Bzgl. der untersuchten Parameter fanden sich zu keinem Untersuchungszeitpunkt signifikante Unterschiede zwischen beiden Gruppen. Schlussfolgerung Ein Vorteil der standardisierten kombinierten Kühlungs- und Kompressionstherapie mit dem Cryo/Cuff™-System gegenüber einer konventionellen Kühlung nach Spaltung des Retinaculum flexorum konnte in dieser Studie nicht nachgewiesen werden.

Carpal tunnel syndrome is caused by compression of the median nerve under the transverse carpal ligament. We present a description of an ultrasound-guided (USG) percutaneous technique of the transcarpal tunnel and provide a discussion to the evidence in utilizing a minimally invasive technique as an alternative to open and endoscopic carpal tunnel release. USG percutaneous transverse carpal ligament fenestration is a quick, and relatively simple office based treatment for carpal tunnel syndrome. The use of ultrasound provides satisfactory visualization for the procedure and requires very little time and effort for setup. Here, in this case series, we detail the procedure and the results from our follow-up. This report details a case series of 2 patients with confirmed electrodiagnostic findings of mild to severe median neuropathy at the wrist in a university hospital outpatient pain management center. USG percutaneous fenestration of the transcarpal ligament was performed under local anesthesia. Patients were followed up from 4 to 20 weeks. It was found in patient 1, a greater than 60% reduction in pain at 20 weeks follow-up, and patient 2 had at least 50% reduction in pain at 8 weeks follow-up. Both patients had a minimum of 50% improvement in pain and sensory disturbance and without any adverse events. The main advantage of USG transverse carpal ligament fenestration is that it is an office based procedure, requiring local anesthesia only. Minimally invasive USG transcarpal ligament fenestration, in select patients, may be an appropriate tool and even prove to be a surgery-sparing modality. The limitations of this study includes no case-control, small sample size, and the short term follow-up. In conclusion, this case series presents an alternative to a more invasive and costlier procedure including open and endoscopic carpal tunnel release, usually performed in a surgical suite. USG percutaneous transverse carpal ligament fenestration is a quick, and relatively simple office based treatment for carpal tunnel syndrome. The use of ultrasound provides satisfactory visualization for the procedure and requires very little time and effort for setup. Key words: Ultrasound guided, transverse carpal ligament, fenestration, carpal tunnel syndrome

We report a case of carpal tunnel syndrome and trigger wrist caused by localized amyloidosis. A 37-year-old man, who worked as a manufacturer, presented with a 5-month history of tingling sensation in the three radial fingers of the left hand and a painful click at the volar aspect of the wrist during digital motion. We divided the transverse carpal ligament and detected diffuse tenosynovitis that was especially severe around the flexor digitorum profundus tendons. Histological findings led to a diagnosis of amyloidosis. Localized amyloidosis could thus be a cause of trigger wrist. Systemic amyloidosis may develop in patients with localized amyloidosis; therefore, patients with trigger wrist caused by flexor tenosynovitis should be investigated for the existence of localized amyloidosis, with biopsy of the flexor tenosynovium.