Thenar Crease Research Articles

Intraneural Lipoma of the Median Nerve Causing Carpal Tunnel Syndrome in a 57-year-old Filipino Female: A Case Report

A 57-year-old female presented with a history of a progressively enlarging palmar mass over three years, with associated numbness over the median nerve distribution and difficulty in gripping due to dimensions of the mass. Physical examination revealed a 4 x 5 cm, movable, non-tender mass over the thenar eminence and a 2 x 1 cm movable, non-tender mass over the center of the palm. Tinel’s sign was positive over the mass and the carpal tunnel. Excision of the mass was performed under intravenous regional anesthesia. A curvilinear incision made from the thenar crease distally to the midline of the wrist overlying the carpal tunnel, proximally. Dissection was carried down to the transverse carpal ligament which was transected to allow visualization of the mass and its attachment to the median nerve. The mass described in this present case report shares characteristics from cases in previously published literature. Its gross appearance was highly indicative of a lipoma and its close relationship with the median nerve suggested an epineural origin. Magnetic resonance imaging revealed a well-defined lesion, suggesting a mass that was more likely to be excised, potentially leading to better neurologic outcomes. Intraneural lipomas (within the epineurium) are rare soft-tissue tumors that predominantly occur in the hand and forearm. Most cases reported involve the median nerve, followed by the radial nerve, posterior interosseus nerve and more rarely the brachial plexus. Compression of peripheral nerves by benign adipose tumors is infrequently reported in literature, with most publications restricted to case reports or series of a few patients. To the author’s knowledge, this is the first article describing an intraneural lipoma in the Filipino population.

The Presence of Minor Physical Anomalies of a Hand in Patients with Mental Disorders.

Minor physical anomalies (MPA) are subtle morphological deviations with little to none clinical significance that are developed prenatally and therefore could be an indicator of structural changes in the brain developing at the same time. Aim of this study was to determine whether the MPA of the hand can distinguish psychotic patients from patients with non-psychotic diagnoses as well as from the healthy individuals. 100 consecutive patients from the University Hospital Center Zagreb, Department of psychiatry, were included in this case-control study along with 100 healthy control subjects. Investigators examined the dorsal and palmar side of the hand and were blind to the patient's diagnoses previous to the examination. Examined MPA included thenar crease, proximal transverse crease, proximal interphalangeal joint, eponychium of the middle digit, fingernail size and digital flexibility. Results showed significant differences in the quantity of MPA between the patients and the control group, as well as differences between patients with psychosis and the healthy subjects. Despite the fact that previous studies demonstrated characteristic distribution of specific MPA in schizophrenia, this study did not prove such results. Moreover, this study showed that all the MPA are equally common in both schizophrenia and other psychoses.

Mini-inciziona tehnika u zbrinjavanju sindroma karpalnog tunela

Introduction/Aim: Carpal tunnel syndrome (CST) is the most common cause of upper extremity compressive neuropathy. Until the introduction of endoscopy, the dominant surgical method was classic open surgery. The objective of the paper is to examine the efficacy, safety and economic value of the mini-open carpal tunnel release technique using a longitudinal 2 cm long incision in the carpal region. Methods: The diagnosis was made based on clinical examination, followed by an ENMG. The study includes only patients with idiopathic CTS, while those who have developed CTS as a result of secondary causes have been excluded from the study. All patients were operated on under local anaesthesia, WALANT, without the use of a tourniquet. A longitudinal incision 2 cm long is made in the line of the radial edge of the ring finger, 2-3 cm distal to the wrist flexion crease, immediately proximal of the Caplan cardinal line and ulnar to the thenar crease. Upon cutting through the skin and subcutaneous soft tissue, the superficial fascia is identified and then cut with the same scalpel in the same direction and the same length. The transversal ligament is then identified and carefully incised with a scalpel enough to allow further decompression with the use of scissors. Using standard surgical scissors for the hand, the ligament is cut proximally to the forearm fascia and then distally until a faint crackling sound is heard, which means that the ligament had been completely cut. This must be checked by inserting the Freer elevator proximally and distally to the edge of the ligament. Now it is possible to identify the nerve and accompanying hand flexor tendons. Sutures are placed only on the skin and a roll of gauze is fixed to the wound with an elastic bandage to provide compression. The first check-up is on the very next day and the patient is advised to start doing hand exercises. The sutures are removed 10-14 days after surgery. Results: From January 2018 to December 2019, 35 carpal tunnel decompressions were performed on 30 patients using the mini-open decompression technique and standard surgical scissors. The surgery was performed on 22 patients in the operating room and 8 patients in the infirmary. There were no intraoperative complications. All patients reported no night pain from the very first day after surgery. Pillar pain, incision pain and hand weakness were progressively becoming less pronounced during the next 12 weeks. At the final check-up, only one patient still had pronounced symptoms that required a reintervention. The rest of the patients had completely recovered. Even though the endoscopic procedure for carpal tunnel decompression is constantly evolving, the classic open method and newly developed mini-open carpal tunnel release technique remain the treatments of choice. Conclusion: Our research shows that the mini-open carpal tunnel release technique is a quick, efficient, safe and cheap surgical technique for treating carpal tunnel compressive neuropathy.

The Thenar Crease Skin Graft: A Novel Addition to "Camouflage" Grafts of the Hand.

Palmar skin defects of the hand are common. When wound conditions are favorable, glabrous skin grafting provides ideal resurfacing-simple, predictable, and excellent esthetic outcome. Glabrous skin grafts are however confined to small sizes from limited donor sites. We present a novel technique of harvesting full-thickness skin grafts from the thenar crease and report the outcome of our cases. We provide further insights to adapt the technique to a variety of clinical scenarios-degloving injuries and shaving injuries of the finger including subcomplete pulp skin loss. Graft size is up to 75 mm by 10 mm, with tension-free donor site closure. We further report the operative experience, functional and esthetic outcome. The technique is fast, versatile, and provides large surface areas of good quality glabrous skin in a single-stage procedure. It will sit well in the armamentarium of the hand surgeon.

Injury of ulnar branch of palmar cutaneous branch of median nerve: an important cause of pillar pain after surgical treatment for carpal tunnel syndrome

Objective To find out the possible causes of pillar pain after surgical treatment for carpal tunnel syndrome through anatomical and clinical study. Methods Through the anatomical study of the surgical area of carpal tunnel syndrome in 6 cadavers (12 sides), the distribution rule of the nerve branches in this area was found. According to this rule, the incision design and entry route were improved and applied to the clinic, and the occurrence of pillar pain was analyzed. A statistical comparison was made between the occurrence of pillar pain in routine surgical and modified surgical in order to find out the possible causes of the occurrence of pillar pain. Results The nerve innervation in the surgical area of carpal tunnel syndrome was derived from the palmar cutaneous branch of the median nerve. The palmar cutaneous branch of the median nerve emerged off the palmar fascia 8.1 mm at the distal side to the zero point. There were 3 types of main branch including 16.7% in single branch, 33.3% in double branches and 50% in three branches. The nerve trunk of the single and double branches walked in the radial side of the thenar crease with several irregular fine branches to the ulnar side. The ulnar branch of the three branches went from the main trunk to the ulnar side at the site to zero point averaging 11.2 mm and crossed the thenar crease at the site to zero point averaging 14.6 mm. According to this, the operative method was designed: the incision was located at 0.5 cm of the ulnar side of the thenar crease. The incision was about 3.0 cm long, and the proximal end of the incision was at least 2.0 cm to zero point. After incision, only the transverse carpal ligament was cut to protect the palmar aponeurosis at the proximal end of the incision to zero point and avoid the injury of the ulnar branch of palmar cutaneous branch. 102 patients were performed with the improved surgery while 110 cases were treated by routine surgery. The incidence of pillar pain in the improved group was 12.7%, and that in the control group was 34.5% one month after the operation. The incidence of pillar pain in the improved group was 14.7%, and that in the control group was 41.0% 3 months after the operation. The two groups had significant differences (P<0.05). There was no significant differences between the two groups 6 months after the operation, and the pillar pain disappeared in all the patients one year after the operation. Conclusion The injury of the ulnar branch of the palmar cutaneous branch of median nerve may be an important cause of pillar pain after surgical treatment for carpal tunnel syndrome. Key words: Carpal tunnel syndrome; Anatomy; Palmar cutaneous branch; Pillar pain

The Effect of Distal Location of the Volar Short Arm Splint on the Metacarpophalangeal Joint Motion.

BackgroundThe goals of this study were to compare maximal metacarpophalangeal joint (MCPJ) flexion angles after application of a volar short arm splint at 3 different locations and verify the relations between the three different physical and radiological locations.MethodsForty dominant hands of healthy subjects were analyzed in the study. We defined a transverse skin folding line as a line drawn from the radial aspect of the thenar crease to the ulnar aspect of the distal transverse palmar crease. The distal end of the volar short arm splint was applied on 3 parallel locations to this line. Location A was on this transverse skin folding line; location B was 1 cm proximal to location A; and location C was 1 cm distal to location A. Two orthopedic surgeons measured the maximal MCPJ flexion angles of each finger except the thumb with the application of a volar short arm splint at 3 different locations as well as without a splint as a control. Radiological locations of the 3 different distal ends of the volar short arm splint were also assessed by anteroposterior radiographs of the wrist.ResultsWhen the splint was applied at location A and C, the maximal MCPJ flexion angle decreased to a mean of 83° (91% of control value) and 56° (62% of control value), respectively (compared to the control, p < 0.001). At location B, the maximal MCPJ flexion angle was a mean of 90° (99% of control value); no significant difference was observed compared to the control or without the splint (p = 0.103). On radiography, the average length from the metacarpal head to the distal end of the splint at all fingers decreased in the order of location B, A, and C (29 mm, 19 mm, and 10 mm, respectively; p < 0.001).ConclusionsWe recommend applying the distal end of a volar short arm splint at proximal 1 cm to the transverse skin folding line to preserve MCPJ motion perfectly, which is located at distal 44% of the whole metacarpal bone length radiologically.

A rare case report of traumatic foreign body insertion in the wrist of a young child

We report a case of a 10-year-old male child admitted to the emergency department with a large foreign body inserted deep into his right wrist. The iron rod was all corroded and rusted, around 10-cm long and inserted deep into the wrist. It was decided to operate the child and general anaesthetic call was taken. An incision was made, extending from the volar aspect of the wrist just above iron body to the thenar crease, and the foreign body was removed with utmost care. Even in the cases of no obvious clinical signs of injury, blind removal of foreign bodies embedded deep in the wrist is inappropriate and may potentially cause more injury to the underlying structures or delay and compromise the operative exploration. During exploration, planning of the incision is crucial and the incision should be made so as to maximise the exposure to the potentially injured areas.

Can palmar creases serve as landmarks for the deeper neuro-vascular structures?

Purpose The aim of this study was the examination of the superficial anatomy of palmar creases and their relation to deeper neuro-vascular structures.MethodsFour creases: distal wrist flexion crease, thenar crease, proximal palmar crease and distal palmar crease were evaluated with reference to the following structures: palmar cutaneous branch of median nerve, palmar cutaneous branch of ulnar nerve, the nerve of Henle, transverse palmar branches from ulnar nerve, recurrent motor branch of median nerve, radial proper palmar digital nerve to the index and the ulnar proper palmar digital nerve to the thumb, Berrettini’s communicating branch, ulnar nerve and artery, superficial palmar arch. We performed dissections of 20 cadaveric upper limbs derived from a homogenous Caucasian group. In our study we measured the location of surgically important structures with reference to palmar skin creases.Results Among the other observations we noticed that the palmar cutaneous branches of the median and ulnar nerves were located at least 0.5 cm away from the thenar crease. The superficial palmar arch was found between the thenar and proximal palmar crease and never crossed the proximal or distal palmar creases.ConclusionsThese anatomical dissections will provide reference material for further ultrasound studies on the arrangements of neuro-vascular structures in reference to superficial palmar creases.

Study of Flexion Creases and Ridges Patterns in Patients with Congenital Anomalies of Aplasia and Hypoplasia of Thumb

Present study was carried out on 120 hands in which 60 hands were anomalous having aplasia and hypoplasia of thumb as cases and 60 hands were normal hands as control were studied. Aim of this study was to find out any ridges abnormalities in anomalous hands as ridges differentiation is closely associated with embryogenesis of limbs. Second aim is to find out any specific association between aplasia and hypoplasia of thumb and formation of thenar crease because of close association between presence of thenar volar pad and thenar crease during development of hand. We evaluated fingertip patterns palmar pattern, position of axial triradius, and type of flexion creases either transverse type, transitional type normal type (having distal, proximal transverse and thenar creases) and presence or absence of thenar crease.Results of this study showed in aplasia of thumb there is increase in frequencies of unknown pattern, absence of axial triradius and absence of thenar crease while in hypoplasia of thumb there is increase in frequencies of arches pattern, shifting of axial triradius distally, some cases showed absence of thenar crease and some caseshaving poorly formed thenarcrease.Conclusion of this study shows development of anomalous hand influences development of epidermis and so ridges pattern and formation of thenar crease associated with presence of thenar volar pad In aplasia of thumb there is absence of thenar volar pad so there is no formation of thenar crease.

The Glabrous Palmar Flap

We devised a new flap using the palmar cutaneous branch of the superficial radial artery proximally and anastomosed with a cutaneous perforator of the superficial palmar arch distally. We named our flap "the volar glabrous palmar flap." The flap was used both as a free flap and as a reverse-flow island flap. Thirty-six patients with volar hand defects (24 digits, 7 palms, and 5 first web space) were reconstructed with this flap. The flap was used as a proximally based free flap in 15 patients and was used as a reverse-flow island flap based on distal communication in the remaining 21 patients. Free flaps were supplied by the palmar branch of the superficial radial artery and its fasciocutaneous extensions; reverse-flow island flaps were supplied by one of the perforating branches of the superficial palmar arch, which is connected to the proximal fasciocutaneous branches. Flaps extended from the wrist crease to the proximal palmar crease and were designed medially on the thenar crease, extending 2 to 2.5 cm laterally. Flap sizes ranged from 1.5 x 2.2 cm to 2.5 x 10 cm. The palmar cutaneous branch of the median nerve within the flap area was identified and then was sutured to the divided digital nerve in 6 cases of finger pulp defect. The donor sites were closed and repaired primarily in most cases. The postoperative course was uneventful, and all the flaps survived without major complications. Follow-up (minimum 6 mo, mean 24 mo) showed excellent functional and cosmetic results. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer for pulp defects. At the same time, we studied 6 cadaver hands to understand the vascular anatomy of the thenar area of the hand. We also revised several published anatomic papers to obtain a refined and scrutinized understanding of the palmar anatomy.

Multiple primary tumors associated with chromosome 9p deletion

Multiple primary tumors associated with chromosome 9p deletion

Clinical indicators of normal thumb length in adults

Purpose This study was undertaken to obtain clinical indicators of normal relative thumb length in adults. Methods Fifty two normal hands in 26 volunteers were analyzed. There were 10 women and 16 men. The average age was 34 years (range, 23–47 years). Eighteen of the volunteers (36 hands) were Chinese and 8 were Caucasian (16 hands). All the subjects were healthy with no history of trauma or disease affecting the hand. The relative distal extent of the tip of the thumb was measured against 2 parameters: the length of the proximal phalanx of the index finger and the distance between the proximal digital crease and proximal interphalangeal crease of the index finger. The obtained values were designated as the thumb-proximal phalanx (TPP) index and the thumb-digital crease (TDC) index, respectively. Results The TPP index was 0.69 (standard deviation = 0.09) and the TDC index was 0.41 (standard deviation = 0.15). There were no statistically significant differences between the right and left hands nor were there any between male and female hands. It was also noticed that when the thumb was adducted the thenar crease and thumb interphalangeal crease came into contact with one another in 90% of the hands. Consequently, an arc traced along the thenar crease could be extended smoothly into the interphalangeal crease of the thumb. This was termed the thenar arc. Positive or negative variances of the thenar arc correlated statistically with variations of the TPP and TDC indexes. Conclusions This study provides 3 simple clinical indicators of normal thumb length: the TPP index, the TDC index, and the thenar arc. Statistical analysis of the TPP and TDC indexes showed that the values are independent of gender, race, or laterality of the hands examined. These 3 indicators may help the clinician determine normal relative thumb length when reconstructing the thumb in adults.

Variations in incisions and postoperative management in carpal tunnel surgery

This study examines the variations in incisions and postoperative protocol of open carpal tunnel release. A questionnaire was distributed to 65 hand surgeons. Respondents were asked to draw their preferred incision on original photocopies of the same palm. The results were measured against standard anatomical landmarks (thenar crease, vertical axis of the third web space, proximal palmar crease and the distal wrist crease). The participants were also asked to answer questions concerning their postoperative protocols. Demographics of the cohort, as well as the variations in incisions and postoperative management, were analyzed. Significant variations existed in the length and location of the incision in the palm. The differences in postoperative care in this cohort of surgeons were less significant.

直視下皮下手根管開放術の新しい手術器具の開発

Open twin incision has been performed for 200 cases of carpal tunnel syndrome since 1990. The operation is performed with twin skin incisions; a proximal incision is made on the distal wrist crease and a distal incision is made on the thenar crease. The proximal flexor retinaculum is excised and the proximal median nerve is explored. The distal flexor retinaculum is excised, and the superficial palmar artery, digital nerve, and thenar branch of the median nerve are exposed. The transverse carpal ligament is incised subcutaneously with our new device. The device has a round curved tip and long shaft with groove in order to prevent complications. The 200 cases who underwent the open twin incision technique with our new device were analyzed. There were no operative complications and residual symptoms disappeared within a month. We recommend our new device for the open twin incision technique for carpal tunnel syndrome.

Avoidance of transection of the palmar cutaneous branch of the median nerve in carpal tunnel release

The course of the palmar cutaneous branch of the median nerve (PCBMN) was studied in 25 fresh cadaveric upper extremities in order to identify its relation to local structures and commonly used incisions for carpal tunnel release. The PCBMN was found to closely underlie the thenar crease (average, 0-2 mm radial to crease; range, 6 mm ulnar to 6 mm radial to thenar crease), suggesting that an incision fashioned in the thenar crease would lead to frequent PCBMN injury. The PCBMN was also found to cross the axis of the ring finger when the axis was determined with the finger flexed into the palm. The axis of the ring finger, as drawn with the ring finger extended, projected in a more ulnar direction. The PCBMN was an average of 9 mm radial to this projection (range, 1-16 mm). An analysis of 100 human volunteer hands demonstrated that the deepest point between the thenar and hypothenar eminencies was a constant landmark in the proximal palm (interthenar depression). The PCBMN traveled an average of 5 mm radial to the interthenar depression (range, 0-12 mm radial). Thenar crease anatomy and ring finger projection were highly variable both in absolute location and configuration, providing a poor basis for incision placement. An incision placed approximately 5 mm ulnar to the interthenar depression, extending in the direction of the third web space, will decrease the incidence of injury to the PCBMN.

Congenital adducted thumb: Role of the index transposition flap

This study examines the results of a large length:width ratio transposition flap used for the correction of the congenitally adducted thumb. The flap is elevated from the radial side of the index finger and transposed into the palm parallel to the thenar crease. Long term analysis of flap results included the disappearance of a transverse palmar white line; length:width ratios; angle of abduction of thumb; sensation of flap; and functional assessment of thumb and index finger. There were 49 adducted thumbs operated on and 26 flaps were clinically examined with an average length:width ratio of 3.5:1, with some flaps having ratios of up to 6:1. All adducted thumbs were adequately released with no complications encountered.

Pseudo-anterior interosseous nerve syndrome: A case report

and patients with increased anesthetic risk can be treated safely. No local anesthetic is present at the incision site; this allows a more anatomic dissection without distorted tissues. The patient maintains use of the fingers and hand and can be released promptly from the day surgery area. The effects of the anesthetic last 6 to 8 hours, providing postoperative pain relief. A tourniquet can be placed on the distal forearm for the short time required for performance of the procedure. If desired, the tourniquet may be deflated without loss of anesthesia. The anesthetic can be administered in a preoperating room to expedite turnover time between operations. The potential for variation in nerve distribution to the palm must be remembered.’ This is the reason the anesthetic agent is placed above the fascia, allowing for more proximal branching of the median palmar cutaneous nerve as well as lateral and medial antebrachial cutaneous nerve distributions. The palmar cutaneous branch of the ulnar nerve is also anesthetized with this technique. If, for some reason, the block fails, the local anesthetic agent can still be injected at the incision site, since the amount of anesthetic used is far below the toxic level in adults. The most common area of persistent sensation is the thenar crease; an additional 5 ml of anesthetic may be injected subcutaneously in the palmar wrist crease near the flexor carpi radialis tendon to anesthetize this region. The risk of intravascular injection is remote. Only the ulnar artery is within the injection fields, and only a small amount of anesthetic is injected near the artery. As always, the surgeon who performs the block should be familiar with the pharmacology and side effects of local anesthetics, as well as possible complications and their treatment. This technique has also been used for other hand procedures, including palmar tenolysis, with excellent results.

MEDIAN NERVE COMPRESSION AT THE WRIST

Median nerve decompression at the wrist is one of the most common operative procedures performed by hand surgeons, yet studies report surgical failure rates of 7% to 20%. Symptoms must be coordinated with diagnostic studies. Initial paresthesias should be documented with delayed sensory conduction time. Threshold tests of sensibility, such as the Semmes-Weinstein monofilaments, are more consistent and reliable tests of decreased sensibility than innervation density tests, such as the Weber two-point discrimination test. Thenar atrophy should be documented with electromyographic studies. The median nerve should be evaluated from the fingertips to the cervical spine. Basic laboratory studies should test for collagen disease, thyroid or renal disorders, and diabetes mellitus. Appropriate roentgenograms must be obtained. Patients with normal laboratory and diagnostic studies should be offered nonoperative treatment. Factors that are important in predicting the patient's response to nonoperative treatment include: age over 50 years, constant paresthesias, intermittent paresthesias of more than 10 months duration, stenosing flexor tenosynovitis, and a wrist flexion test (Phalen) that is positive in less than 30 seconds. Fewer than 10% of patients with three or more of these factors present have been cured by nonoperative management. Surgical decompression of the carpal tunnel is done with tourniquet control and optical magnification. A longitudinal "zig-zag" incision is preferred that extends along the thenar crease, then proceeds ulnarly to reach the distal palmar crease at a point in line with the long axis of the ring finger, and then proceeds radially to the tendon of the palmaris longus. After release of the transverse carpal ligament, the motor branch should be explored and decompressed.(ABSTRACT TRUNCATED AT 250 WORDS)

The genetics of plamar creases: A study in the inheritance of liability estimated from the incidence among relatives

Six-hundred and fifty-nine Chinese children and 613 first degree relatives were studied with regard to four variations in the palmar creases: the simian crease, the Sydney line, the radial border termination of the thenar crease, and the distal border termination of the distal crease. With the exception of the Sydney line, these palmar crease variations were found to occur with significantly increased frequency in the parents of the propositi compared with 400 controls, indicating the presence of genetic factors in their embryogenesis. If the polygenic hypothesis is accepted, the very high heritability of liability (100%) to the radial border termination of the thenar crease is a further demonstration of the importance of the genetic contribution. Variations in the palmar creases thus cannot be totally explained away by early flexional folding in the skin of the developing hand.

Furrows and dermal ridges of the hand in patients with alcohol embryopathy.

Palmar creases and dermal ridge patterns of 34 patients with alcohol embryopathy are compared with 470 healthy individuals. In alcohol embryopathy several typical deviations were noted. Palmar Creases. The interdigital part of the distal palmar crease is generally sharply bent, the proximal transverse crease is hypoplastic or missing, the thenar crease is commonly well marked. Simian creases and bridged palmar creases are more common in patients with alcohol embryopathy than in healthy individuals. Ridge Patterns of the Palm. The main line D coming from triradius d in patients with alcohol embryopathy mostly shows a low type of ending in the fourth interdigital area; in this area loops are twice as common as in healthy individuals. Patterns of the Fingertips. No deviations were noted in the distribution of whorls and loops, but virtually no arches were observed in patients with alcohol embryopathy. These anomalies suggest embryonic damage in the twelfth week of gestation.