Thenar Muscle Atrophy Research Articles

Multiple etiologies of trigger wrist

Trigger wrist, a relatively unusual condition, is a triggering at the wrist produced by wrist or finger motion. The clinical manifestations and surgical results of trigger wrist with multiple etiologies were evaluated. From October 2008 to December 2012, this study retrospectively reviewed 15 patients diagnosed with trigger wrist. The patients comprised six men and nine women with a mean age of 44.8 years (range, 29-86 years). The mean follow-up period was 16.2 months (range, 11-30 months). The causes of trigger wrist were an anomalous muscle belly of the flexor digitorum superficialis (n=5), severe tenosynovitis of the flexor tendon (n=4), fibroma around the flexor tendon sheath (n=2), a rheumatoid nodule (n=1), both anomalous muscle belly and tenosynovitis (n=1), a ganglion (n=1), and pigmented villonodular synovitis (n=1). Mild-to-moderate symptoms of median neuropathy without thenar muscle atrophy were present in all patients. Postoperatively, all patients recovered well with resolution of median nerve symptoms, and the wrist triggering was absent. Trigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. To avoid inadequate and ineffective treatment of patients with trigger wrist, careful examination and proper diagnosis are vital. Therapeutic/IV.

Postoperative Follow-Up of Extreme Carpal Tunnel Syndrome: How Long Does It Take to Recover Thumb Opposition?: Level 3 Evidence

In extreme carpal tunnel syndrome (CTS), thumb opposition is impossible due to thenar muscle atrophy. Affected patients demonstrate undetectable compound muscle action potentials of the abductor pollicis brevis (APB-CMAP) following stimulation of the median nerve at the wrist. At the ASSH 2012 Annual Meeting, the authors reported that thumb opposition recovered in more than half of extreme CTS patients one year or longer after carpal tunnel release. This study investigated the length of time required to recover thumb opposition and at what time after surgery recovery could be predicted.

Thumb opposition in severe carpal tunnel syndrome with undetectable APB-CMAP.

Thumb opposition does not always represent the function of the median nerve due to variations in thenar muscle innervation. One hundred and thirty hands of 109 idiopathic carpal tunnel syndrome (CTS) patients with an undetectable compound muscle action potential of the abductor pollicis brevis (APB-CMAP) were classified into one of four groups; Type 1 (86.2%) had thenar muscle atrophy and could not perform thumb opposition; Type 2 (10.8%) had thenar muscle atrophy but could perform thumb opposition; Type 3 (2.3%) did not have thenar muscle atrophy and could perform thumb opposition, but needle electromyography of the APB showed neurogenic changes and Type 4 (0.8%) had no thenar muscle atrophy, could perform thumb opposition, and needle electromyography showed no neurogenic changes. Over 10% of severe CTS patients have mild or no muscle atrophy and intact thumb opposition. The purpose of this study was to investigate the variations in thenar muscle innervation in patients with severe CTS.

An unsuspected case of relapsed multibacillary leprosy.

Dear Editor: Leprosy, a chronic granulomatous infection caused by Mycobacterium leprae, commonly affects the skin and nerves. Because of its many different manifestations, leprosy can be easily misdiagnosed as syphilis, sarcoidosis, lymphoma, leishmaniasis, and cutaneous tuberculosis1. Since multidrug therapy (MDT), the prevalence of leprosy has decreased to <1 in 10,000. However, there are still newly diagnosed and relapsed cases. We report an unsuspected case of relapsed multibacillary leprosy. A 63-year-old Korean man visited a neurologist because of tingling sensations in his hands and arms for 8 months. His medical history revealed congenital syphilis, claw hand deformity, uveitis, hypertension, and diabetes mellitus. Additionally, he was found to have prurigo 1 year before his visit, presenting as generalized pruritic nodules; however, these were not present at his visit. Neurologic examination revealed thenar/hypothenar muscle atrophy, ankle/knee jerk areflexia, hypoesthesia, and motor weakness in the fingers. Provisional diagnosis included neurosarcoidosis, polyneuropathy from diabetes mellitus, and tabes dorsalis. The laboratory findings were within the reference ranges, except for increased angiotensin-converting enzyme (ACE, 85.8 U/L; reference range, 18~55 U/L). His chest radiograph and cerebrospinal fluid were normal. Nerve conduction results showed distal, symmetric, sensorimotor polyneuropathy. He was referred to us for a newly developed single erythematous nodule on the right upper arm (Fig. 1). A punch biopsy was done to rule out sarcoidosis. Histopathologic examination revealed foamy histiocytes throughout the dermis, with perivascular lymphocytic infiltration (Fig. 2A, B). Acid-fast staining revealed many bacilli (Fig. 2C). Only then did the patient mention that he had developed lepromatous leprosy in 1973. The Korean Hansen Welfare Association was contacted, which stated that he had been treated for a year, remained disease-free, and was lost to follow-up in 1995. Finally, his condition was diagnosed as relapsed multibacillary leprosy. Previous cutaneous lesions, diagnosed as prurigo, could not be differentiated from manifestations of relapsed leprosy because biopsies and clinical photographs were missing. He is being treated with MDT (rifampicin, dapsone, and clofazimine) for another year. Fig. 1 An erythematous firm nodule on the right upper arm. Fig. 2 (A) Histopathologic findings showed Grenz zone and cell infiltration in a nested and perivascular pattern throughout the dermis (H&E, ×50). (B) Foamy macrophages clustered in the dermis (H&E, ×400). (C) Acid-fast bacilli ... Typical skin lesions of relapsed multibacillary leprosy are multiple, soft, shiny, pink papules or nodules on the forehead, lower back, dorsa of hands and feet, posterior arms, thighs, and buttocks2. Like sarcoidosis, ACE frequently increases in leprosy, indicating extensive macrophage activity3. Modern clinicians with little experience of leprosy may not recall the disease even when circumstantial evidences including claw hand deformity, thenar and hypothenar muscle atrophy, and tingling sensation indicate leprosy, as in this case. As patients may hide their medical history, suspicion for leprosy is needed. An early and accurate diagnosis is important to start MDT, reduce the risk of transmission, and minimize permanent damage. Proper treatment is important in relapsed cases as relapse usually occurs because of reinfection or growth of persistent organisms4. We report this case from an educational point of view because young dermatologists may impede the diagnosis of leprosy at first. Additionally, because of the increase in global travel and immigration, doctors even in nonendemic areas need to know how to identify leprosy so that no case will be missed.

Trapeziometacarpal osteoarthrosis: Clinical results and sonographic evaluation of the interposed tissue after trapeziectomy and first metacarpal suspension by external minifixation at a minimal two-year follow-up

Among the surgical options to treat trapeziometacarpal osteoarthrosis, trapeziectomy has been criticized as unable to prevent postoperative collapse of the thumb, causing painful scapho-metacarpal impingement. The implantation of an external minifixator between the first and the second metacarpals for sufficient time has been proposed to maintain the postoperative space created by the bone resection to allow the development of a resistant interposed fibrous tissue. Nineteen patients (16 women, 3 men, mean age 64.5 years) were evaluated at 3.3 years of follow-up after an unilateral trapeziectomy and first metacarpal suspension by external minifixation. Eighty-four percent of the patients were very satisfied with the operation. The mean DASH score was 27.7%, the pain 1.7/10 (Visual Analogue Scale), the opening angle of the first web 58.3° and the Kapandji opposition score 9.5/10. Sonography demonstrated the existence of a strong fibrotic interposed tissue, preventing scapho-metacarpal impingement. The mean height of the trapeziectomy space (8.4mm) was maintained upon active pinch and maximal traction on the thumb. A significant atrophy of thenar muscles was also demonstrated, except for the Abductor pollicis brevis. In conclusion, total trapeziectomy with external minifixation provides acceptable clinical results, stabilizes the base of the thumb and prevents scapho-metacarpal impingement. The study brings also important new information about the nature of the interposed tissue in the trapezial space and about the state of the thenar muscles after trapeziectomy.

The new wave of Carpal Tunnel Syndrome (CTS) Surgery

Carpal tunnel syndrome (CTS) is the most common hand disease. The clinical prevalence in the general popula- 1 tion is 3.8%. From a study of Australian population, peo- ple younger than 25 had a 2.4% prevalence compared to an ex- tremely high prevalence in 45 to 65 year-olds who had a 45.5% prevalence.2 In all carpal tunnel syndrome cases, in patients who developed numbness, and experienced symptoms for more than 6 months or did not receive adequate conservative treatment needed further treatment of surgery (Figure 1). The incidence of surgery is high: up to 31% to 40% of patients with carpal tunnel syndrome.3,4 If the patients had severe compression and develop thenar muscle atrophy, the treatment has to be performed and ur- gent decompression is necessary to enable potential full recovery.5 Because carpal tunnel syndrome is the most common hand disease with the highest functional recovery of treatments, patients need to know and look for an update on treatment information. Nowa- days, surgical treatment had been in continuous development in terms of minimal invasive surgery. There has been a great para- digm shift from standard large open surgery to minimal invasive surgery based on patients benet and recovery. Also CTS is one of the benecial changes with the concept of minimal incision because of minimal dissection of highly sensitive numerous nerve areas, minimal trauma, rapid recovery and less complications.

CARPAL TUNNEL SYNDROME IN PATIENT WITH HEMIHYPERTROPHY: CASE REPORT

Carpal tunnel syndrome is a common condition; however, it has not been previously reported in patients with hemihypertrophy. A 67-year-old woman with left-sided hemihypertrophy presented with carpal tunnel syndrome of the left hand. Magnetic resonance imaging showed enlargement of the median nerve proximal to the transverse carpal ligament. Carpal tunnel decompression was performed, and pain was immediately relieved by decompression of the carpal tunnel. At the six-month follow-up examination, the patient experienced relief from numbness and improvement in thenar muscle atrophy was noted.

Speckled lentiginous nevus syndrome with median nerve paresis: A rare syndrome with a new association

Speckled lentiginous nevus (SLN) represents a mosaic phenotype which consists of café au lait macule superimposed by melanocytic nevi. Recently, SLN syndrome has been characterized where ipsilateral neurological abnormalities have been reported in association with SLN with papular type of melanocytic nevi only. This case describes the presence of ipsilateral thenar muscle atrophy with median nerve paresis in nevus spilus which had melanocytic nevi of the macular type alone, thus delineating a new association in SLN syndrome, hitherto unreported.

Clinical and histopathological study of Charcot-Marie-Tooth neuropathy with a novel S90W mutation in BSCL2

The objective of the study was to investigate the disease-causing mutation in an autosomal dominant Charcot-Marie-Tooth disease type 2 family and examine the clinical and histopathological evaluation. We enrolled a family of Korean origin with axonal Charcot-Marie-Tooth disease neuropathy (FC305; 13 males, six females) and applied genome-wide linkage analysis. Whole exome sequencing was performed for two patients. In addition, sural nerve biopsies were obtained from two patients. Through whole exome sequencing, we identified an average of 20,336 coding variants from two patients. We also found evidence of linkage mapped to chromosome 11p11-11q13.3 (LOD score of 3.6). Among these variants in the linkage region, we detected a novel p.S90W mutation in the Berardinelli-Seip congenital lipodystrophy 2 (BSCL2) gene, after filtering 31 Korean control exomes. Our p.S90W patients had frequent sensory disturbances, pyramidal tract signs, and predominant right thenar muscle atrophy in comparison with reported p.S90L patients. The phenotypic spectra were wide and demonstrated intrafamilial variability. Two patients with different clinical features underwent sural nerve biopsies; the myelinated fiber densities were increased slightly in both patients, which differed from two previous case reports of BSCL2 mutations (p.S90L and p.N88S). This report expands the variability of the clinical spectrum associated with the BSCL2 gene and describes the first family with the p.S90W mutation.

Modified Camitz Opponensplasty Using Transverse Carpal Ligament Loop Pulley in Patients with Advanced Carpal Tunnel Syndrome

Sir:FigureThumb opposition is a key factor in providing motion and strength for both prehension and grasp. In advanced carpal tunnel syndrome, severe thenar muscle atrophy precludes effective opposition. The recovery of thenar muscle atrophy is unpredictable even after carpal tunnel release.1,2 Camitz described palmaris longus transfer as augmenting thumb opposition in carpal tunnel syndrome with severe thenar muscle atrophy.3 However, his transfer restored palmar abduction rather than true opposition because of the inefficient line of pulling. In this study, we introduce a modification of the Camitz procedure using the ulnar-based transverse carpal ligament loop pulley and report the results of our early series. Under general anesthesia or an axillary block, a curved palmar incision was made from the distal palmar crease to 1 inch proximal to the distal wrist crease. The palmaris longus tendon was elevated in continuity with the third ray pretendinous band and was reflected proximally. By dividing the proximal third of the transverse carpal ligament near the radial attachment and ulnarward extension, a transverse carpal ligament flap was elevated (Fig. 1). The transverse carpal ligament flap was reflected ulnarward and sutured to itself near its pisiform attachment site with two or three nonabsorbable polypropylene stitches, which resulted in the ulnar-based transverse carpal ligament loop pulley. The remaining distal portion of the transverse carpal ligament was released to decompress the median nerve. After passing through the loop pulley and subcutaneous tunnel, the previously elevated palmaris longus with its fascial extension was secured to the abductor pollicis brevis insertion with appropriate tension (Fig. 1). Postoperatively, a thumb spica plaster splint immobilization was kept for 4 weeks. Gentle active range-of-motion exercise of the thumb and wrist was permitted from the fifth week after the operation.Fig. 1: (Above) After elevation and proximal reflection of palmaris longus-pretendinous band (arrowheads), the ulnar-based proximal one-third transverse carpal ligament flap (arrow) was created. (Below) The palmaris longus tendon with its fascial extension was passed through the transverse carpal ligament loop pulley (arrow) and was secured to the abductor pollicis brevis insertion and dorsoradial expansion hood of the first metacarpophalangeal joint (arrowhead).From March of 2006, nine wrists in eight patients with advanced carpal tunnel syndrome accompanied by severe thenar muscle atrophy underwent open carpal tunnel release and opponensplasty using our modified method and were followed for more than 1 year. At an average 24-month (range, 14 to 46 months) follow-up, the average maximal palmar abduction4 was 90.1 percent and the average Kapandji tip opposition score was 92.4 percent that of the opposite sides. The mean grip strength and key pinch strength were 92.1 percent and 93.9 percent, respectively. The functional outcome based on the Boston questionnaire revealed that the mean symptom score was 1.24 and the mean sign score was 1.22. The subjective gradings of the overall functional outcome by patients were four “complete cure” and five “much better” (Table 1). No postoperative complications were noted related to transverse carpal ligament loop pulley.Table 1: Summary of Cases with a Modified Camitz OpponensplastyCompared with other reports1,2,5 of simple carpal tunnel release or palmaris longus transfers in advanced carpal tunnel syndrome, the overall functional outcome of our series was quite encouraging. The transfer directed toward the pisiform with the combination of a stable pulley can provide the efficient line of pull and power for opposition (Fig. 2). Even though the number of cases is small, our simple modification of the original Camitz procedure using an ulnar-based transverse carpal ligament loop pulley revealed improved opposition, grip, and pinch powers; functional scores; and patient satisfaction, without major complications.Fig. 2: (Above) A 64-year-old woman presented with severe thenar muscle atrophy and an inability to perform thumb abduction and opposition of the right hand (case 7). (Below) At 20-month follow-up, she had uncollapsed tip-to-tip opposition with recovered abduction and pronation of the thumb (arrow).Soo-Whan Kang, M.D. Yang-Guk Chung, M.D. Joo-Yup Lee, M.D. Woo-Lam Jo, M.D. Department of Orthopedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea DISCLOSURE The authors have no financial relationships to disclose. ACKNOWLEDGMENT This study was supported by Seoul St. Mary's Clinical Medicine Research Program year of 2011 through The Catholic University of Korea.

Carpal tunnel syndrome treatment

Carpal tunnel syndrome, the most common peripheral neuropathy, results from compression of the median nerve at the wrist, and is a cause of pain, numbness and tingling in the upper extremities and an increasingly recognized cause of work disability. If carpal tunnel syndrome seems likely, conservative management with splinting should be initiated. Moreover, it has suggested that patients reduce activities at home and work that exacerbate symptoms. Pyridoxine and diuretics, since are largely utilised, are no more effective than placebo in relieving the symptoms. Non steroidal anti-inflammatory drugs and orally administered corticosteroids can be effective for short-term management (two to four weeks), but local corticosteroid injection may improve symptoms for a longer period. Injection is especially effective if there is no loss of sensibility or thenar-muscle atrophy and weakness, and if symptoms are intermittent rather than constant. If symptoms are refractory to conservative measures, the option of surgical therapy may be considered.

Laryngospasm as preceding symptom of amyotrophic lateral sclerosis

A 62-year-old man presented with paroxysmal sensation of suffocation, each time lasting for about 10 s. They were not triggered by body position, physical exercise, or sleep, and there was no associated dysphagia, dysphonia, cough, stridor, or pyrosis. Clinical examination was normal. A diagnosis of laryngospasm was evoked. Electromyography (EMG), including bulbar exploration, brain and cervical spine MRI, direct laryngoscopy (performed in absence of clinical symptoms), and esophagogastroscopy were normal. Laryngospasms persisted after gastric antisecretory medication. CAG repeat length in the androgen receptor gene, in search for Kennedy’s disease, was normal. One year after laryngospasm onset, progressive distal left arm weakness occurred. Clinical examination revealed left thenar, hypothenar, and interossei muscle weakness and atrophy, fasciculations in both upper limbs and tongue, generalized deep tendon hyperreflexia, left-sided Babinski sign, hypernasal voice, brisk jaw-jerk, and emotional lability. EMG showed reduced compound motor action potential amplitude in the left arm without conduction block on nerve conduction studies, with normal F-wave and sensory nerve conduction studies. Electromyographical exploration showed diffuse fibrillations and positive sharp waves at rest in the left upper limb, both lower limbs, and paravertebral muscles, together with large, long and polyphasic muscle unit potentials during muscle contraction. EMG of bulbar muscles was normal. Positron emission tomography with fludeoxyglucose F 18 showed a severe hypometabolism of bilateral temporal and frontal lobes and anterior cingular region. A diagnosis of amyotrophic lateral sclerosis (ALS) was made in presence of El Escorial criteria. Functional pulmonary exploration was normal. Frequency of laryngospasm remained stable the first year following ALS diagnosis. Laryngospasm is clinically defined as a sudden-onset sensation that air cannot be moved in or out, usually followed by inspiratory stridor, due to a rapid and forceful contraction of the laryngeal sphincter [1]. It sometimes results in loss of consciousness making urgent tracheostomy necessary [2]. A gastroesophageal reflux disease is found in 80% of patients with laryngospasm [3]. ALS is defined by progressive degeneration of upper and lower motor neurons. One-third of ALS patients present with bulbar symptoms [4]. In a large cohort of 44 ALS patients with initial bulbar symptoms, none had isolated laryngospasm [5]. Laryngospasm is reported in 2% of ALS patients in early clinical stage, but seems to be more frequent in later stages of the disease [6, 7]. Kennedy’s disease (KD) is characterized by lower motor neuron dysfunction with predominant bulbar involvement. Laryngospasms have been described in 47% in a series of 49 KD patients [6]. All of these patients had bulbar involvement and 65% had pyrosis. Laryngospasm was observed in all stages of KD and there was no increase in frequency of laryngospasm in later stages of the disease. In two-thirds of the patients with laryngospasm and associated pyrosis, laryngospasm was reduced by gastric antisecretory and prokinetic drugs. Our presented patient is the first case of laryngospasm preceding ALS diagnosis. Laryngospasm was probably related to ALS since there were no arguments for G. Fourcade (&) G. Castelnovo D. Renard P. Labauge Department of Neurology, CHU Nimes, Service des Explorations Fonctionnelles du Systeme Nerveux, Hopital Caremeau Place du Pr Debre, 30029 Nimes Cedex 9, France e-mail: n.fourcade@wanadoo.fr

Clinical outcome of carpal tunnel release with and without opposition transfer

We studied the clinical outcome in 24 patients (25 hands) with carpal tunnel syndrome characterized by severe thenar muscle atrophy, who were treated by open carpal tunnel release alone (10 hands) or with simultaneous opposition transfer (15 hands). We also compared the surgical results in patients younger or older than 65 years. Pain and numbness improved after open carpal tunnel release but more so in younger patients. Activities of daily living also improved with and without opposition transfer; however, certain activities such as fastening hooks or buttons, using chopsticks and turning a key in a lock improved more with opposition transfer. Grip strength did not improve, with or without opposition transfer, regardless of the patients' ages. Pinch strength improved more with opposition transfer.

Local steroid injection for moderately severe idiopathic carpal tunnel syndrome: Protocol of a randomized double-blind placebo-controlled trial (NCT 00806871)

BackgroundPatients with idiopathic carpal tunnel syndrome (CTS) are commonly treated with steroid injection into or proximal to the carpal tunnel. However, evidence for its efficacy beyond one month has not been established in randomized placebo-controlled trials. The primary aim of this randomized trial is to assess the efficacy of steroid injection into the carpal tunnel in relieving symptoms of CTS in patients with symptoms of such severity to warrant surgical treatment but have not been treated with steroid injection.Methods/DesignThe study is a randomized double-blind placebo-controlled trial. Patients referred to one orthopedic department because of CTS are screened. Eligibility criteria are age 18 to 70 years, clinical diagnosis of primary idiopathic CTS and abnormal nerve conduction tests or clinical diagnosis made independently by two orthopedic surgeons, failed treatment with wrist splinting, symptom severity of such magnitude that the patient is willing to undergo surgery, no severe sensory loss or thenar muscle atrophy, and no previous steroid injection for CTS. A total of 120 patients will be randomized to injection of 80 mg Methylprednisolone, 40 mg Methylprednisolone, or normal saline, each also containing 10 mg Lidocaine. Evaluation at baseline and at 5, 10, 24 and 52 weeks after injection includes validated questionnaires (CTS symptom severity scale, QuickDASH and SF-6D), adverse events, physical examination by a blinded assessor, and nerve conduction tests. The primary outcome measures are change in the CTS symptom severity score at 10 weeks and the rate of surgery at 52 weeks. The secondary outcome measures are the score change in the CTS symptom severity scale at 52 weeks, time to surgery, and change in QuickDASH and SF-6D scores and patient satisfaction at 10 and 52 weeks. The primary analysis will be carried out using mixed model analysis of repeated measures.DiscussionThis paper describes the rationale and design of a double-blind, randomized placebo-controlled trial that aims to determine the efficacy of two different doses of steroid injected into the carpal tunnel in patients with moderately severe idiopathic CTS.Trial registrationClinicaltrials.gov identifier NCT00806871

Carpal Tunnel Syndrome After Ciprofloxacin-Induced Tendinitis

To the Editor: Different types of antibiotics can affect the peripheral nervous system and cause neuropathies, myopathies, and neuromuscular junction disorders by direct or indirect mechanisms.1 Fluoroquinolones may also cause seizures or encephalopathy, and a few cases of tendinitis have been reported as well.2-4 Tendinitis may occur as early as 2 hours after the first dose, and 50% of patients develop symptoms within 6 days of starting medication. Tenosynovitis has also been reported in association with recurrent carpal tunnel syndrome.5 We report a case of ciprofloxacin-related tendinitis leading to carpal tunnel syndrome A 77-year-old right-handed woman developed a urinary tract infection and was empirically treated with oral ciprofloxacin. Three days later, she developed bilateral hand pain and swelling, which improved after the medication was stopped and with a brief course of oral steroids and antihistamines. Symptoms were consistent with flexor tendinitis with focal tenderness and swelling. There was no history of diabetes, gout, rheumatoid arthritis, or of other autoimmune diseases. Because severe pain persisted waking her up, she was referred to a neurologist. At that time, 4 weeks after the onset and swelling resolved, the pain still involved the first three fingers, more severely on the left. She performed her daily activities independently, but pain got worse when these fingers were touched. She denied any neck or upper arm discomfort. On examination, she had slight atrophy and weakness of left thenar muscles (Medical Research Council 5-/5) with decreased sensation over distal aspects of the first three fingers on the left and left thenar allodynia. The remainder of the examination was normal. Electrodiagnostic testing was performed at 6 weeks after the onset and confirmed the diagnosis of bilateral distal median nerve entrapments (carpal tunnel syndrome) (Table 1), more severe on the left. Needle examination showed only few fibrillation potentials in the left abductor pollicis brevis muscle. The use of a wrist splint did not alleviate the symptoms. Repeat study 3 months later did not show significant improvement. Because symptoms persisted, she underwent bilateral sequential carpal tunnel releases resulting in resolution of her symptoms. Flexor tendinitis and inflammatory arthritis can precipitate median nerve entrapment in a confined space of carpal tunnel. Increased incidence of tendonitis has been described in elderly (older than 60 years of age) and with renal dysfunction or corticosteroid treatment.2-4 Most commonly, Achilles and patellar tendons are affected, but few cases of shoulder and hand tendinitis were reported. 2,3 Tendon rupture was reported in 5% of patients with quinolone-related tendinitis.2 Timely discontinuation of ciprofloxacin in our patient probably prevented tendon rupture and more significant nerve injury. Asymmetry of median nerve entrapments with more severe findings on the left in our case may be attributable to asymmetric tendinitis or possible pre-existing nerve entrapment aggravated by inflammation. Therefore, we should consider drug-induced tendinitis as a potential cause of musculoskeletal pain after institution of fluoroquinolone therapy. A recent report indicates that fluoroquinolones may also precipitate painful small fiber neuropathy expanding the spectrum of their toxicity.6 Early recognition of possible toxicity is crucial to stop the offending agent, avoid exercise, and hopefully reduce morbidity of fluoroquinolone-induced tendinitis.

Karpaltunnelsyndrom – moderne Diagnostik und Management

The carpal tunnel syndrome is the most common entrapment neuropathy (about 3% of the adults are affected). It is characterized by pain and paresthesia along the distribution of the median nerve. Thenar muscle atrophy with corresponding muscle weakness is a late manifestation of advanced disease. Electrophysiological tests are helpful in suggesting the diagnosis. An imaging with a magnetic resonance tomography may be used in the diagnosis of atypical cases. Ergonomic manoeuvres, oral steroids and steroidal injections may alleviate symptoms in mild cases. Surgical decompression of the carpal tunnel is the classical treatment of severe cases as well as for those who do not respond to conservative treatment. After surgery patients usually show excellent results. The following article discusses clinical aspects, diagnosis and current therapeutic options.

Opponensplasty using palmaris longus tendon and flexor retinaculum pulley in patients with severe carpal tunnel syndrome

Thenar muscle atrophy is a common finding in long-standing severe carpal tunnel syndrome (CTS). Combination of carpal tunnel release and Camitz opponensplasty has been used to treat severe CTS with thenar muscle atrophy. Camitz opponensplasty is beneficial for abduction, but provides little benefit to thumb flexion and pronation. This problem could be overcome by the use of a pulley. Twelve cases of long-standing CTS with severe thenar muscle atrophy in 11 patients were investigated. They were treated with the modified Camitz opponensplasty using a pulley at the ulnar side remnant of the flexor retinaculum at the time of carpal tunnel release. Outcome was assessed by clinical grade of thenar muscle atrophy, degree of thumb opposition and the patient's satisfaction. The average grade of thenar muscle atrophy improved from grade 3 pre-operatively to grade 0.83 at the last follow-up. Mean maximal palmar abduction improved from 3.6 to 6.8 cm, and spatial rotation improved from 54 degrees to 83 degrees . Kapandji tip opposition changed from 65 to 85% symmetry at the last follow-up. All 11 patients were 'very satisfied' or 'satisfied' with the outcome. Modified Camitz opponensplasty is a simple procedure that provides immediate improvement of thenar function. Palmar flexion and pronation can be further improved by addition of a pulley.

Non-surgical treatment in carpal tunnel syndrome

Carpal tunnel syndrome is a common cause of disabling hand symptoms.1 Patients seeking treatment are offered surgery or various non-surgical therapies. In the UK, 31% of patients newly presenting in primary care with carpal tunnel syndrome in 2000 were treated surgically.2 In a US population, the annual incidence of carpal tunnel syndrome (2001–05) was 424 per 100 000 and, for carpal tunnel release surgery, 134 per 100 000.3 It is generally accepted that severe carpal tunnel syndrome, manifested by thenar muscle atrophy, severe sensory loss, or both, requires surgery.

Acupuncture in Patients With Carpal Tunnel Syndrome

To investigate the efficacy of acupuncture compared with steroid treatment in patients with mild-to-moderate carpal tunnel syndrome (CTS) as measured by objective changes in nerve conduction studies (NCS) and subjective symptoms assessment in a randomized, controlled study. A total of 77 consecutive and prospective CTS patients confirmed by NCS were enrolled in the study. Those who had fixed sensory complaint over the median nerve and thenar muscle atrophy were excluded. The CTS patients were randomly divided into 2 treatment arms: (1) 2 weeks of prednisolone 20 mg daily followed by 2 weeks of prednisolone 10 mg daily (n = 39), and (2) acupuncture administered in 8 sessions over 4 weeks (n = 38). A validated standard questionnaire as a subjective measurement was used to rate the 5 major symptoms (pain, numbness, paresthesia, weakness/clumsiness, and nocturnal awakening) on a scale from 0 (no symptoms) to 10 (very severe). The total score in each of the 5 categories was termed the global symptom score (GSS). Patients completed standard questionnaires at baseline and 2 and 4 weeks later. The changes in GSS were analyzed to evaluate the statistical significance. NCS were performed at baseline and repeated at the end of the study to assess improvement. All main analyses used intent-to-treat. A total of 77 patients who fulfilled the criteria for mild-to-moderate CTS were recruited in the study. There were 38 in the acupuncture group and 39 in the steroid group. The evaluation of GSS showed that there was a high percentage of improvement in both groups at weeks 2 and 4 (P < 0.01), though statistical significance was not demonstrated between the 2 groups (P = 0.15). Of the 5 main symptoms scores (pain, numbness, paresthesia, weakness/clumsiness, nocturnal awakening), only 1, nocturnal awakening, showed a significant decrease in acupuncture compared with the steroid group at week 4 (P = 0.03). Patients with acupuncture treatment had a significant decrease in distal motor latency compared with the steroid group at week 4 (P = 0.012). Acupuncture was well tolerated with minimal adverse effects. Short-term acupuncture treatment is as effective as short-term low-dose prednisolone for mild-to-moderate CTS. For those who do have an intolerance or contraindication for oral steroid or for those who do not opt for early surgery, acupuncture treatment provides an alternative choice.

A Child with Trigger Wrist Caused by Finger Flexion and Extension: A Case Report

A 9 year-old boy presented with a mass in the left wrist and motion-induced discomfort. The patient had a trigger phenomenon on the palmar side of his wrist caused by extension and flexion of the middle finger. The patient had no significant medical history. A 5-cm mass was visualized extending from the palm over the wrist. The patient did not have finger numbness, motor impairment, thenar muscle atrophy, or a Tinel-like sign of the wrist. X-ray imaging showed no abnormalities. A magnetic resonance image (MRI) showed a mass around a single flexor tendon, a lowintensity mass on T1-weighted images (Fig. 1), and a highintensity mass on T2-weighted images (Fig. 2). Accordingly, the mass was expected to be a ganglion or cyst. On sagittal images, the mass surrounded the flexor tendon. Because the symptoms did not improve, the patient underwent surgery 2 months after he noticed the mass. The mass was excised by opening the carpal tunnel. The flexor digitorum superficialis (FDS) of the middle finger adhering to the mass was enlarged (Fig. 3). Histological analysis showed cystic synovial tissue accompanied by thickened wall, papillary proliferation towards the lumen, fibrin deposition, and lymphocyte infiltration. (Fig. 4). Based on the above findings, the patient was diagnosed with a ganglion adhering to the FDS. One year after surgery, the patient had no discomfort, recurrence, or disturbance in daily living.