Bifid Median Nerve Research Articles

A Rare Case of Carpal Tunnel Syndrome with Bifid Median Nerve and Palmaris Profundus Muscle

Summary: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. We report an extremely rare case of CTS associated with a bifid median nerve and palmaris profundus muscle. A 68-year-old man presented with numbness and pain in the right hand. Intraoperatively, a bifid median nerve was identified, with the ulnar branch severely compressed by the palmaris profundus muscle. The muscle was resected, leading to symptom resolution. Anatomical variations of the median nerve and anomalous muscles should be considered in CTS. Preoperative imaging and open carpal tunnel release are recommended to identify and address such variations.

Satisfactory treatment outcome of a middle-aged woman with carpal tunnel syndrome caused by bifid median nerve: A case report

Satisfactory treatment outcome of a middle-aged woman with carpal tunnel syndrome caused by bifid median nerve: A case report

Scoping review of the palmaris profundus muscle: anatomy of a rare variant and its role in carpal tunnel syndrome.

The palmaris profundus muscle is a rare anatomical variation of the forearm muscles. It has been described in both cadaveric and clinical studies as a possible cause of carpal tunnel syndrome. We observed three cases of this variant in recent years and decided to perform a scoping review of this uncommon anatomical entity. Major databases were searched to identify all relevant clinical and anatomical studies containing anatomical descriptions of the muscle, including its origin, insertion, and concomitant presence of the proper palmaris longus muscle or the bifid median nerve. In clinical cases, we studied the surgical approach. Sixty-four articles met our inclusion criteria and contained 88 cases of palmaris profundus muscle. The most common origin was the ventral aspect of the radius in the area of insertion of the pronator teres muscle observed in 11 cases (12.5 %). We found 65 cases (73.3%) in which the tendon was inserted into the palmar aponeurosis or palmar fascia after entering the carpal canal. The concomitant presence of the proper palmaris longus muscle was described in 47 cases (53.4%). We identified 10 cases (10.8%) of the bifid median nerve. In 49 of 69 clinical cases (71%), the surgical approach was to resect the variant muscle. The importance of this variant should not be underestimated due to its potential to compress the median nerve. We found a significant disparity in the muscle origin sites, but uniformity of muscle insertion. In cases where the muscle is found during carpal canal surgery, it should be partially resected to ensure complete nerve decompression.

Median artery persistence in coexistence with a bifid median nerve and interconnections of the median with the ulnar nerve and vice versa

PurposeThis report describes a bilateral persistent median artery (PMA) originating from the ulnar artery and terminating at different levels of the upper limb. The PMA coexisted with a bilateral bifid median nerve (MN) and two bilateral interconnections (ICs characterized with the symbol -) of the MN with the ulnar nerve (UN) (MN-UN) and a unilateral reverse IC (UN-MN). Emphasis was given to the artery’s developmental background.MethodsThe PMA was identified in an 80-year-old formalin-embalmed donated male cadaver.ResultsThe right-sided PMA terminated at the wrist, posterior to the palmar aponeurosis. Two neural ICs were identified: the UN joined the MN deep branch (UN-MN), at the forearm’s upper third, and the MN deep stem joined the UN palmar branch (MN-UN), at the lower third (9.7 cm distally to the 1st IC). The left-sided PMA ended in the palm giving off the 3rd and 4th proper palmar digital arteries. An incomplete superficial palmar arch was identified by the contribution of the PMA, radial, and ulnar arteries. After the MN bifurcation into superficial and deep branches, the deep branches formed a loop, that was penetrated by the PMA. The MN deep branch communicated with the UN palmar branch (MN-UN).ConclusionsThe PMA should be evaluated as a causative factor of carpal tunnel syndrome. The modified Allen's test and the Doppler ultrasound may detect the arterial flow and the angiography may depict the vessel thrombosis in complex cases. PMA could also be a "salvage" vessel for the hand supply, in radial and ulnar artery trauma.

Pilot Cadaveric Study of Anatomical Variations of the Median Nerve at the Wrist in the Lithuanian Population.

Carpal tunnel syndrome (CTS) is known as one of the most common neurological disorders in the human body.Nowadays, the prevalence in the general population ranges between 1% and 5%. Due to its high prevalence and increasing incidence of carpal tunnel surgery, the anatomical variations of the median nerve at the wrist are important to know to avoid iatrogenic injury of the nerve. The objective of this study was to evaluate the anatomical variation of the median nerve at the level of the wrist in the Lithuanian population with a focus onits thenar motor branch based on the classifications of Lanz. A cadaveric study was performed, and 30 wrists of 15 adult Lithuanian cadavers ranging from 70 to 89 years of age were dissected and examined. Eight female and seven male cadavers were included in the study. Any anatomical finding was documented, and the results were compared with the classification of Lanz as well as with the data found in the literature. All hands showed different patterns in comparison to the standard anatomical variation Lanz type 0. The most common result was dedicated to Lanz group 4A. Nineteen out of 30 hands(63%, p<0.01) had an accessory branch proximal to the carpal tunnel, while one of these hands showed a third thenar motor branch. Five hands (16%) were dedicated to Lanz group 2 with an accessory branch distal to the carpal tunnel. One hand (3%) showed a variation close to Lanz group 2, but in this case, the thenar motor branch had its origin under the flexor retinaculum instead of proximal to it. Two hands each (6%) were classified by Lanz groups 1B and 3A.Additionally, one variation showed a pattern of a combination of Lanz types 3A and 3B. The bifid median nerve had a connecting branch in between which started distal to the flexor retinaculum. Two anatomical variations (6%) were not described by the classification of Lanz.

Bifid median nerve causing carpal tunnel syndrome in association with persistent and thrombosed median artery in a young adult: A rare case report

Abstract Carpal tunnel syndrome is a commonly encountered entrapment neuropathy of the median nerve under the flexor retinaculum. Course of median nerve is associated with several anatomical abnormalities. Various anomalies of the median nerve are frequently associated with carpal tunnel syndrome. Various radiological and electrophysiological modalities assist clinical examination in reaching to accurate diagnosis. We present a case of a young male with carpal tunnel syndrome with a bifid median nerve with persistent thrombosed median artery.

Electromyoneurography in the diagnostics of rare causes of carpal tunnel syndrome

Introduction. The paper points to the problem of electromyoneurography of the bifid median nerve as a rare cause of carpal tunnel syndrome. Carpal tunnel syndrome represents a set of symptoms caused by compression of the distal portion of the median nerve. It is important in clinical practice as it significantly effects the functionality and the quality of daily activities. One of the predisposing factors for the carpal tunnel syndrome is the bifid median nerve. Electromyoneurography is still the gold standard for the verification of the carpal tunnel syndrome. Case Report. A 48-year-old patient, after a clinical suspicion of carpal tunnel syndrome, has been confirm by ultrasonography to be suffering from moderate carpal tunnel syndrome, with a detection of ?incomplete? bifid median nerve in the carpal tunnel. Electromyoneurography also confirmed a mild level of carpal tunnel syndrome. However, as difficulties were exclusively present in the innervation area of the median nerve internal branch, and there was a possibility of incomplete correlation of electromyoneurography results, the lumbrical muscles and dorsal interossei muscles were examined, and confirmed a moderate degree of carpal tunnel syndrome. Discussion. The bifid median nerve can be the cause of the above insufficient sensitivity of this method, which is why it is necessary to apply optional electromyoneurographic techniques. Conclusion. The final practical significance lies in the fact that the presence of the diagnosed bifid median nerve could affect the choice and efficiency of certain therapeutical options.

Carpal tunnel syndrome in rheumatoid arthritis patients: the role of combined ultrasonographic and electrophysiological assessment

BackgroundCarpal tunnel syndrome (CTS) is known as one of the most common neurological extra-articular manifestations in rheumatoid arthritis (RA) patients. Studies on CTS in RA depend mostly on electrophysiological assessment. Few studies have used ultrasonography for evaluation of the local causes with much focus on wrist arthritis and tenosynovitis as the main cause of entrapment neuropathy of the median nerve in RA. The aim of our study is to assess the local causes of carpal tunnel syndrome in rheumatoid arthritis patients by ultrasonography and whether inflammatory or anomalous variations could affect decision-making and patient management.ResultsCarpal tunnel syndrome was diagnosed in 71 out of 74 examined RA wrists by nerve conduction studies (NCSs) and was categorized from minimal to severe according to Padua et al.’s (Ital J Neurol Sci 18:145–50, 1997) grading criteria. Median nerve CSA at the level of the carpal tunnel inlet and flattening ratio showed statistically significant relation with CTS severity. Bifid MN was found in 20 wrists (10 mild CTS wrists and 10 moderate CTS wrists), a persistent median artery was found in 4 wrists with moderate CTS, and an accessory muscle bundle was present in 3 wrists (2 mild CTS and 1 moderate CTS). The majority of the examined hands (85.1%) showed flexor tendon tenosynovitis at the wrist level and radio-carpal joint synovitis. The US7-joint score using GSUS7 & PDUS7 for synovitis, tenosynovitis and erosions showed significant relation with patients’ disease activity by DAS28 score. Significant relations between CTS severity and the following nerve conduction studies’ parameters, median nerve distal motor latency (DML), motor/sensory NCV, peak sensory latency, amplitude of SNAP, and median-radial latency difference test, were observed.ConclusionSynovial inflammation and local causes of median nerve compression such as bifid median nerve, persistent median artery, and accessory muscle bundle are collectively contributing factors in the etiology of carpal tunnel syndrome in rheumatoid arthritis patients. Ultrasonographic visualization of these inflammatory and anomalous variations enables early detection of CTS and highlights the possibility of non-arthritic-related causes. Using the 7-joint ultrasound (US7) score for assessment of synovitis, tenosynovitis, and erosions in rheumatoid arthritis patients is of valuable role in reflecting inflammation and its relation to the development of CTS in RA patients.

Trigger Wrist with Carpal Tunnel Syndrome Accompanied with Trifid Median Nerve: A Case Report and Literature Review.

Trigger wrist, characterized by a clicking or snapping sensation around the wrist joint during finger or wrist motion, and bifid or trifid median nerve, which occurs in carpal tunnel syndrome along with anatomical variation of median nerve, are rare conditions. We report the case of a patient with a thickened tendon caused by severe tenosynovitis and flexor tendon subluxation to the hamate hook due to bowing of the flexor retinaculum, thereby resulting in trigger wrist as well as an anatomical median nerve variation (bifid median nerve in the right wrist and trifid median nerve in the left wrist). A 59-year-old housewife visited our hospital with bilateral fingertip numbness, tingling sensation, and aggravated severe night cramping that began 2 months ago. She also complained about trigger wrist during small finger flexion. Based on magnetic resonance imaging, ultrasonography, and nerve conduction study, trifid median nerve and bilateral severe median nerve neuropathy of the wrist were diagnosed; therefore, transverse carpal tunnel release and exploration under wide-awake anesthesia were planned. Intraoperative findings showed trifid and bifid median nerves in left and right wrists, respectively. Additionally, bowing of flexor retinaculum and severe flexor tendon tenosynovitis were observed. Tenosynovitis with thickened flexor sheath resulted in subluxation of the small finger flexor tendon above the hamate hook. After transverse carpal ligament release with antebrachial fascia release and tenosynovectomy, subluxation of the flexor tendon was resolved. At 6 months postoperatively, the tingling and dullness in fingertips also resolved, and no trigger wrist or any other complications were noted.

PROLOTHERAPY PERINEURAL INJECTION IN CARPAL TUNNEL SYNDROME WITH BIFID MEDIAN NERVE: A CASE REPORT

Background: Carpal tunnel syndrome (CTS) is a common neuropathy condition caused by entrapment of the median nerve. Perineural injection therapy with 5% dextrose or prolotherapy becoming a common method for treating carpal tunnel syndrome. Although it is effective, some anatomical variaton of the median nerve could effect the outcome of the prolotherapy in CTS. Case Report: A 43-year-old woman suffered from diurnal, nocturnal numbness and paraesthesia of the first, second, third and radial surface in the fourth finger of the right hand. She also complained pain in the same area with the VAS score of 8, and muscle weakness. Physical examination showed positive Tinel’s sign, Phalen’s sign and Durkan’s compression test. The Boston questionnare score showed a symptom average of 3.27 and a difficulty average of 3.25. USG examination showed that the patient had a bifid median nerve anatomy variaton. Discussion: Variation of median nerve branches has been reported as one of the prevalence of median nerve entraptment. In this case, a bifid median nerve variation was found through the USG imaging. Prolotherapy has been reported to be an effective method to treat carpal tunnel syndrome. But the bifid median nerve could affect the effectiveness of prolotherapy injection. Conclusion: In the case of a bifid median nerve, it is necessary to modify the injection technique so it would be more able to reach the whole of the bifid median nerve.

A Prospective Evaluation of the Prevalence of Persistent Median Artery in Patients with Carpal Tunnel Syndrome.

The median artery is an embryonic structure that typically regresses during gestation. Occasionally, the artery remains and is then termed a persistent median artery (PMA). A PMA can be associated with other anatomic anomalies, and has been known to contribute to carpal tunnel syndrome (CTS). Recent literature has observed an increase in PMA prevalence, speculated to indicate microevolutionary change. We performed a prospective observational study to investigate the current prevalence rate of PMA in patients undergoing carpal tunnel release (CTR). Institutional review board approval was obtained. From October 2020 to January 2021, patients ≥18 years old undergoing open CTR by 9 orthopaedic hand surgeons were included in analysis. Patients undergoing endoscopic CTR were excluded. Intraoperatively, the carpal tunnel was evaluated for the presence of a PMA, median nerve anomalies, or any other anatomic anomalies. If a patient underwent bilateral CTR during the study, only one side was included in analysis as determined randomly. Three hundred and sixty open CTRs in 327 patients were performed during the study. Twenty-seven PMAs were identified, for an overall prevalence rate of 8.3%. The average age of patients with a PMA was 63.6 years (SD 13.3 years), consisting of 15 men and 12 women. There were no statistical differences in age, gender, or laterality between patients that did and did not have a PMA. Thirty-three patients underwent bilateral CTR during the study, with 3 being found to have a PMA unilaterally, and zero having a PMA bilaterally. Two bifid median nerves (0.6%) were also identified. This study represents the highest prevalence rate of PMA directly observed in CTR patients reported to date (8.3%). A PMA is not a rare finding, and it should be recognized and protected during CTR. Occasionally, a PMA can be the cause of an acute presentation of CTS.

Bifid median nerve as an anatomical risk factor for carpal tunnel syndrome: A meta-analysis.

As the median nerve enters the carpal tunnel, it is a single nerve that soon bifurcates into lateral and medial branches into the hand. If the bifurcation is proximal to the carpel tunnel, a bifid median nerve (BMN) results. Carpal tunnel syndrome is often associated with a BMN with or without a persistent median artery. Individual keywords and MeSH phrases were searched in the Google Scholar, SCOPUS, and PubMed databases. Full texts were then collected and assessed for suitability. The prevalence of BMN at the wrist joint in normal and carpal tunnel syndrome wrists (precanal part) and the mean difference between groups were recorded. Only human data were used to test the findings. The pooled odds ratio (with minimal heterogeneity) was 1.50 [1.17-1.93, 95% CI]. The BMN cross-sectional area (CSA) was significantly greater than that of a solitary median nerve in normal wrists. The mean difference in CSA between the two was 1.50 mm2 [0.56-2.45 mm2 , 95% CI] without heterogeneity (i2 =0). Sex and laterality distributions scarcely differed between the two types of wrists. Owing to the insufficiency of data, the relationships with mean height and weight were not examined. There was a 50% greater incidence of bifid median nerves in carpal tunnel syndrome patients than in normal subjects. A bifid median nerve increases the mean CSA at the wrist joint by 1.5 mm2 . These findings indicate that the bifid median nerve is an anatomical risk factor for carpal tunnel syndrome.

Palmaris profundus and carpal tunnel syndrome: is it really a palmaris muscle?

The palmaris profundus (PP) is a variable muscle present in the flexor muscle region of the forearms. Its implication in the etiopathogenesis of carpal tunnel syndrome has been discussed in the literature. We present a case of a PP with a characteristic morphology, associated with a bifid median nerve (MN), found during surgery for a recurrence of carpal tunnel syndrome in a 51-year-old female patient. The PP muscle was first described with this morphology by Frohse in 1908. Initially, this muscle was considered an anatomical variation of the palmaris longus, but since 1984 the existence of both muscles has been observed in the same forearm, so the PP is considered an accessory muscle. Some authors associate the existence of a PP with compression of the median nerve in the carpal tunnel. Others, however, argue that it may be an aggravating factor but not the primary cause, or simply a casual finding during surgery. We believe that this tendon is not the primary cause of compression of the MN, but it can aggravate the situation in case of a reduced canal due to any other cause, so we recommend surgeons to resect it if it is found. Furthermore, based on the embryological origin of the forearm muscles, we believe that this PP could actually be the radio-carpal, radio-palmar or short radial forearm muscle described as early as the 19th century.

Welcome message from the Editor-in-chief

It is with much pleasure that I welcome you to volume 2 issue 2 of the Health Sciences Investigations Journal. The Journal remains committed to reaching the global community with open access publications from basic and clinical health sciences. According to the World Health Organization “Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”. Thus, our multi-disciplinary journal consistently provides an avenue for communication of research findings in health, the science of well-being. The current issue of the Journal contains a case study on the bifid median nerve, an anatomical variation that is caused by the early and proximal division of the nerve trunk preceding entry into the carpal tunnel. The bifid median nerve was identified in an adult male Wolof cadaver during dissection of the anterior region of the wrist. The nerve within the carpal tunnel had a cleavage at the superficial finger flexor muscles. his is a rare condition that hand surgeons must know to avoid the median nerve in carpal tunnel release operations. In this issue, we also present data on clinical features of 57 children (12-17 years) infected with the novel coronavirus disease (COVID-19) in the Accra Regional Hospital in Ghana. The most common symptom was a headache (50%) and this was followed by cough (35.7%). Two other articles in Child Health in this issue are multivariate analysis of risk factors associated with severe underweight among children under 5 years and screening for wasting and underweight in sick children (6-59 months). In the former study, both child and maternal risk factors were associated with being underweight, and these include multiple births, small size at birth, mother’s education and the number of children under 5 years. Improvement in maternal education, socio-economic status of families and family planning were considered key in resolving the challenge of child underweight. In the latter article, 4% (out of 199) of children were classified as being severely wasted by Mid Upper Arm Circumference Measurement, whereas 3% were diagnosed to have severe acute malnutrition. Analogous to the former study, determinants of wasting were the low level of maternal education and age of children (&lt;24 months). We highlight these publications because globally malnutrition constitutes a critical cause of the increase in mortality of children under 5 years of age. I am grateful to the hardworking Editorial Team and the Reviewers for their effort in ensuring that the Journal publishes good articles for our cherished readers. The Advisory Board, Authors and Publishers are also acknowledged for their contributions. I welcome suggestions, complaints, discussions, and thoughts from authors and readers to help us to maintain high standards. I look forward to receiving your high-quality manuscripts for publication. Thank you. Acknowledgements he University of Ghana College of Health Sciences, the copyright owner, the patron, and sponsor of HSI Journal has always shown a deep interest in the affairs of its constituent institutions. The Journal is indeed grateful to Professor Julius Fobil, the Provost of the University of Ghana College of Health Sciences, for his immense support and leadership

Bifid median nerve: a case report at the wrist

The median nerve is a terminal branch of the brachial plexus. It arises in the axilla and ends in the hand by dividing into three common palmar nerves after passing through the carpal tunnel deep to the flexor retinaculum at the wrist. The bifid median nerve corresponds to a bifurcation of the median nerve trunk inside the carpal tunnel. It is a rare variation that is often associated with the persistence of the wrist median artery. The authors report here a fortuitous discovery of a case of bifid median nerve during the wrist dissection of a cadaverous melanoderm belonging to the Wolof ethnic group in Senegal. The bifurcation started at about 14 cm distal and lateral to the medial bicipital groove with the medial trunk ending in the third interdigital space and the lateral trunk which gave four branches. There was neither the wrist median artery nor any other variations of the normal structures at the wrist. The bifid median nerve is rare but should be kept in mind. Being aware of this kind of variation is important to avoid nerve lesions during carpal tunnel surgery.

O-NU002. Spectrum of nerve and muscle anatomic variants detected during neuromuscular ultrasound examination: A retrospective study

Introduction . Neuromuscular ultrasound has become an important diagnostic tool for neuromuscular disorders. The sonographic scanning protocol varies according to the provisional diagnosis but there are basic elements to assess like nerve and muscle size, echotexture, vascularity, nerve mobility, dynamic muscle assessment, in addition to the assessment of surrounding structures and anatomic variants. Recognizing anatomic variants is important as it may impact treatment and diagnosis. The aim of this study was to retrospectively analyze the frequency and the spectrum of anatomic variants detected during neuromuscular ultrasound examination. Methods . The medical records of 339 patients who were referred for neuromuscular ultrasound examination during the period from December 2014 to June 2020 were reviewed. The neuromuscular ultrasound reports and images archive of the patients were analyzed for presence of nerve and/or muscle anatomic variants. The records which did not show anatomic variants in the report and images archives were excluded from further analysis. The ultrasound images which showed anatomic variants were furtherly analyzed for the type of the anatomic variant, its detailed description, and its diagnostic or therapeutic impact if such information is available. Results . Nerve and/or muscle variants were found in 61 of 339 patients (17.9%). The most common muscle anatomic variants were accessory flexor digitorum superficialis within the carpal tunnel, bifid median nerve, persistent median artery, and ulnar nerve subluxation/dislocation at the ulnar groove. Uncommon anatomic variants were encountered including abnormal traverse of median nerve within the pronator teres muscle, reversed palmaris longus, and atypical position of tibial nerve at the medial ankle. Conclusion . Various nerve and muscle variants were detected in 17.9% of patients who were referred for neuromuscular ultrasound examination. Putting the anatomic variants in consideration when performing neuromuscular ultrasound examination is important as it may impact diagnosis and treatment.

WS7.10. Neuromuscular ultrasound in focal neuropathies

Neuromuscular ultrasound is rapidly evolving as an excellent diagnostic tool in the evaluation of focal neuropathies. It can also be of use in understanding the underlying pathological mechanism of focal neuropathies. Unlike length-dependent polyneuropathies, focal neuropathies are more likely to be associated with structural abnormalities that can be easily recognized by imaging modalities. Point of care ultrasound helps with rapid examination of long segments of multiple nerves in the out-patient setting. This can result in early triaging of patients and rapid management decisions. Other advantages include easy patient tolerability when compared to nerve conduction studies and lower cost. The sonographic abnormalities that are commonly associated with focal neuropathies include focal enlargement, hour-glass constriction, change in neural architecture, decreased mobility of the nerve or increased vascularity. Neuromuscular ultrasound is particularly helpful with the correct localization of focal entrapment neuropathies. It can help also in the detection of dynamic compression. Its role as a diagnostic tool has extended beyond entrapment neuropathies to include traumatic neuropathies, infective and non-infective inflammatory neuropathies and peripheral nerve sheath tumors. It can also be of use in detecting extra-neural abnormalities like tenosynovitis, soft tissue tumors, entrapment or compression from metallic implants. Other lesser recognized uses include the detection of anatomical variants like bifid median nerves, persistent median artery, anomalous muscles and ulnar nerve subluxation at the elbow. Pathologies of the brachial plexus like inflammatory plexitis and thoracic outlet syndrome can also be detected by sonographic studies. The use of neuromuscular ultrasound can be complemented when used in conjunction with nerve conduction studies. Neural changes can be detected by sonographic studies very early into the disease at sites of focal pathologies like conduction block or temporal dispersion. Recent uses of ultrasound include its role as a tool in guiding with the therapeutic interventions for focal focal neuropathies. These include administration of steroids or local anesthetics in entrapment neuropathies or in those patients with neuralgic pain. The latter include carpal tunnel syndrome, meralgia paresthetica or other lesser known painful neuralgic disorders.

Hand surgeons and amyloidosis specialists warning: transthyretin-associated amyloidosis with bifid median nerve as a cause of bilateral carpal tunnel syndrome. A case report and literature review

Approximately 75% of patients with carpal tunnel syndrome (CTS) are diagnosed as idiopathic. Despite this, the presence of an underlying cause such as an anatomical variant or a systemic disease must always be suspected, especially in cases of bilateral presentation without an obvious cause, recurrence or complications. The anatomical variant known as the bifid median nerve (BMN) is a very rare abnormality that can occasionally lead to CTS. On the other hands, transthyretin-associated amyloidosis (ATTR) is one of the possible causes of bilateral CTS. We report a case where these two very rare pathologies converge as the cause of bilateral CTS and a review of the literature. We report a 71-year-old male with prior history of lumbar canal stenosis, bilateral trigger finger, rupture of the supraspinatus muscle tendon and of the long portion of the right biceps brachial. He also had 8-year-old bilateral CTS that recurred after CTS surgery. He was surgically re-intervened and was diagnosed incidentally with BMN and an ultrasound of the other hands also showed BMN. Because of all the prior musculoskeletal history, a biopsy of the transverse carpal ligament was taken showing ATTR deposits that led to the diagnosis of cardiac ATTR wild type. This case highlights the natural history of the multiple musculoskeletal manifestations related to ATTR and the importance of performing intraoperative biopsies in patients with CTS surgery as this can lead to early diagnosis of cardiac ATTR.

Electrodiagnostic, Sonographic, and Clinical Features of Carpal Tunnel Syndrome with Bifid Median Nerve.

PurposeA bifid median nerve (BMN) is not a rare variant. This study aimed to investigate the features of carpal tunnel syndrome (CTS) accompanied by BMN.Patients and MethodsIn this retrospective study, we defined a BMN group as CTS with BMN and a non-bifid median nerve (NMN) group as CTS without BMN. All hands were assigned to four severity grades according to the findings of electrodiagnosis (EDx): very mild, mild, moderate, and severe. The cross-sectional area (CSA) of the median nerve, palmar bowing of the flexor retinaculum, and persistent median artery (PMA) were assessed by ultrasonography. Numerical pain rating scale (NRS) and symptom duration were assessed as clinical variables.ResultsSixty-four hands (57 patients) and 442 hands (341 patients) were enrolled in the BMN and the NMN groups, respectively. BMN was prevalent in 12.6% of all CTS hands. The distribution of EDx severity grade was milder in the BMN group than in the NMN group (P<0.001). The CSA of the BMN group was 16.2±4.1 mm2, slightly larger than 15.1±4.2 mm2 in the NMN group (P=0.056). The BMN group showed higher NRS than the NMN group (5.5±1.5 and 4.4±1.7, respectively; P<0.001). In the subgroup analysis, NRS was significantly higher in the BMN group than in the NMN group at all EDx severity grades. In the BMN group, the PMA group showed greater EDx severity (P=0.037) and higher NRS (6.0 and 5.0, respectively; P=0.012) than the non-PMA group. The radial side branch’s CSA was larger than that of the ulnar side branch (10.0 mm2 and 6.0 mm2, respectively; P<0.001).ConclusionCTS with BMN presented more severe symptoms and relatively milder EDx severity. When assessing the severity of CTS with BMN, the clinical symptoms should primarily be considered, as well as we should complementarily evaluate the EDx and ultrasonography.

Unusual findings in ultrasound screening for carpal tunnel syndrome in a patient with acromegaly: Bifid median nerve and persistent median artery

AbstractCarpal tunnel syndrome (CTS) is a common complication in acromegaly and is often associated with enlargement of the median nerve. Morphological changes in the median nerve and surrounding tissues can be visualized easily by ultrasound (US) scanning in suspected patients. Ultrasonography also offers priceless contributions to visualization of anatomical variations and pathological conditions that may potentially be associated with CTS. We present the presence of bifid median nerve and persistent median artery, which are both unusual findings, during the US screening for CTS in a 36‐year‐old male patient with acromegaly.