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The aim of this study was to determine the significance of limited portal carpal tunnel release compared to the classic open approach. We present a retrospective comparative clinical trial including 161 patients (105 open release and 56 limited portal release). Special interest was directed towards postoperative functionality, disorders and quality of life. Significant advantages could be demonstrated for the limited portal carpal tunnel release: rapid ability to return to work as well as to routine tasks of daily living and high patient satisfaction. In the hands of trained surgeons, limited portal carpal tunnel release represents a rewarding alternative to the classic open release.

An expert opinion on occupational disability insurance is not a common occurrence and because of this represents a challenge for the appointed specialist. The peculiarities of the eligibility requirements for this type of insurance are described in detail in this article, including case examples. Besides the medical considerations, there are detailed, specific occupational aspects which must be considered in order to reach an expert judgment which is comprehensible for both, the contracting party and the claimant.

The carpal tunnel is the pathway between the flexor compartment of the distal forearm and the midpalmar space of the hand. It contains all the long finger and thumb flexor tendons including the median nerve. In cases of a discrepancy between the volume of the carpal tunnel in relation to its contents, high pressures in this region can result. There is a risk that the median nerve will be sustained by compression. The carpal tunnel is covered by the flexor retinaculum. Length and width of the retinaculum correspond to the extension of the tunnel. Radial und ulnar osseous walls can narrow the tunnel diameter as well as an prominent capitate bone at the floor. The median nerve normally courses the tunnel radially near the middle of the flexor retinaculum far reaching straight to the midpalmar region. Several deviations of its tunnel course, atypical divisions, accessory branches and variations of the ramification of the thenar branch of the median nerve are described.

Background: Multiple recurrences of carpal tunnel syndrome and increased malfunction of the hand caused by tendopathies and arthropathies occur in long-term (20 - 30 years) haemodialysis and are mainly influenced by beta2-microglobulin amyloidosis., Method and Clinical Material: 18 patients undergoing haemodialysis for an average of 29 years had been operated on 96 times for bilateral CTS and recurrent CTS during a mean observation period of 12.6 years. In nine patients (12 hands), removal of the thickened flexor digitorum superficialis tendons III and IV had been performed. All but two patients suffered from amyloidosis, 17 of them suffered from additional tendo- and 13 from additional arthropathies. All procedures were performed under local anaesthesia, and in half of them a tourniquet was used. The outcome was evaluated both clinically and with nerve conduction studies., Results: 77 procedures for CTS-recurrences were performed. The first recurrence was observed after an average of 6.1 years (SD 2.8), the second after 4.6 (SD 3.1) and the third after 3.8 (SD 1.9) years. Whereas in case of a first (occasionally second or extremely seldom in a third) recurrence, another re-opening of the carpal tunnel with or without synovectomy, was sufficient to improve symptoms in the majority of patients, this was occasionally the case with a second but rarely with the third recurrence. In these latter patients, only resection of thickened superficial flexor tendon bundles, showing marked amyloid-deposits histologically, resulted in improvement of pain, as well as finger mobility in one third of the patients. The distal motor latency of the median nerve recovered after the primary operation in 86 %, and after the second (first recurrence) only in 53 %. After the third operation (second recurrence), the results after tendon removal were better than in cases after synovectomy alone., Conclusion: In long-term (more than 20 - 30 years) haemodialysis patients suffering from arthropathies, tendopathies and recurrent carpal tunnel syndrome, removal of the flexor digitorum superficial tendons should be considered for the second recurrence to improve pain and finger mobility.

Silicone synovitis is an important clinical entity recognized in rheumatoid patients after arthroplasties with silicone implants. It is a foreign body reaction to particulate material (silicone elastomer) characterized clinically by the re-occurrence of pain, stiffness and swelling at the site of arthroplasty after initial relief of symptoms. Whereas silicone synovitis is a rare complication in metacarpophalangeal implants, it is an important one in the wrist implant. Long-term follow-up studies have revealed that the rates of fracture and subsidence are high and that the implants deteriorate with time necessitating operative revisions in up to 50% of cases. Indications should therefore be restricted to a painful wrist in the elderly, very low demand patient with insufficient bone stock to permit total wrist arthroplasty with a metal-on-plastic design. Severe preoperative deformity and the need for use of ambulatory aids may further limit the indication. The unusual case of direct perforation of silicone particles from the wrist into the tendon sheath of the M. flexor pollicis longus inducing a tumor-like synovitis and a secondary carpal tunnel syndrome is presented. The importance of silicone synovitis and the indication at present for implantation of a silicone wrist spacer in the rheumatoid patient are discussed.

Summary. During cadaver dissections of 34 adult human hands (fixed in formaldehyd solution), we examined a fibrous complex at the distal end of the flexor retinaculum. This fibrous complex was first mentioned by Legueu and Juvara (1892). It is located always ulno-dorsally to the attachment of the palmaris longus tendon into the palmar aponeurosis. Measurements of this special connective tissue show a mean length of 18.6 mm, a mean height of 4.3 mm and a mean width of 3.1 mm.Also, we looked for the fibrous complex in six adult plastinated transverse sections and in 12 fetal hands where it occurred in a constant way. We also found a very close topographic relationship between these oblique criss-crossed fibers and the palmar cutaneous branch of the median nerve. This nerve regularly gives some ulnar branches to the fibrous complex. The clinical relevance of the fibrous complex is discussed in relationship to a carpal tunnel syndrome. The described transverse fibers of the connective tissue complex are in danger as well as the ulnar branches of the palmar cutaneous nerve when releasing the flexor retinaculum during operation.

In our study, we present the data of eleven patients suffering from scarring of the median nerve, predominantly after open decompression of the carpal tunnel. Dysaesthesia in the palmar region and loss of grip strength prevented performing normal daily activities. All patients except one were relieved of the palmar discomfort and experienced an increase of grip strength allowing their return to work. The hypothenar fat flap has been shown to be a reliable source of local tissue to cover the median nerve. The sprouting of nerve fibers to the skin is prevented as well as median nerve readherence. We believe that the hypothenar fat flap provides sufficient regenerative conditions and coverage of the median nerve within the carpal tunnel in the surgical treatment of abundant scarring.

The morphological correlation of the phenomenon of increased pressure in the carpal tunnel during wrist flexion and extension--as has been proved though measurements using wick-catheters--was studied in healthy subjects (n = 15) and symptomatic patients with carpal tunnel syndrome (n = 15). Our own measurements using magnetic resonance imaging (MRI) showed that there is a significant reproducible decrease in carpal tunnel diameter when the wrist is held in position of either flexion or extension. During flexion the diameter is decreased at the pisiformes and hamate level as well as it is lowered during extension at the pisiformes level. This might explain the rise in carpal tunnel pressure and thus the consecutive negative influence on the median nerve. Proximal swelling, distal flattening and increased signal intensity of the median nerve as well as the palmar bulging of the flexor retinaculum at the level of the hook of the hamate and at the level of the pisiformes were significantly higher in patients with carpal tunnel syndrome than in normal volunteers (from p < 0.05 to p < 0.001). In post-operative follow-up examinations of 13 patients with no clinic symptoms the distal flattening of the median nerve normalized in 94% within 3 months. The increased signal of the median nerve on T2-weighted images decreased postoperatively in 2/3 of the patients, whereas the motor latency of the median nerve recovered only in 39% of our patients who had 100% partial or complete clinical benefit. These findings imply that postoperative imaging may be helpful for evaluating the success or failure of surgical treatment.

Osteopoikilosis (Osteopathia condensans disseminata) is a rare and usually asymptomatic sclerosing bone dysplasia of unknown origin. Familial clustering suggests a dominant inheritance. The observation of a 47-year-old woman lead to differential diagnostic considerations in view of the literature on about 350 cases. For 2 years the patient has been complaining about pain and stiffness of both hands with swelling of the fingers. Additionally, she remarked about bilateral paresthesias corresponding to the sensory innervation of the median nerve. Clinical examination revealed a sensory carpal tunnel syndrome and mild synovitis of the proximal interphalangeal joints with skin induration and limited flexion of the fingers. In addition, some finger and toe nails showed pitting and most fingers had scar-like linear skin alterations. Radiologic findings showed symmetric, well-defined, homogeneous sclerosing areas in spongy bone. The combination of symmetrical sclerosing bone densities, hereditary character, and associated skin and joint manifestations suggests the existence of a general connective tissue disease.

Alterations of the spatial geometry of the carpal tunnel and its contents during dynamic stress situations of the wrist are of importance in clarifying morphological causes of a carpal tunnel syndrome. In order to demonstrate the changes occurring in the form of the carpal tunnel and the location of its contents during wrist movement, casts of the carpal tunnel were produced from the hands of cadavers in flexed and extended positions. The casts were then morphometrically analyzed and the movements of the median nerve and the flexor tendons were examined radiologically. The investigation showed that a delicate equilibrium exists between the capacity of the carpal tunnel--whose hourglass shape typically changes to suit dynamic stress situations--and the volume of its contents. Spatial processes extending from the carpal tunnel wall or emanating from the structures contained within the carpal tunnel may exceed the system's ability to compensate for extreme positioning of the wrist and thus induce compression symptoms of the median nerve.

Carpal tunnel release used to be the standard treatment for carpal tunnel syndrome. However, some authors now prefer reconstruction of the transverse carpal ligament, due to suspected palmar dislocation of the median nerve in wrist flexion after simple ligament release. In this retrospective study the topographic location of the median nerve after release is investigated and an attempt made to find a correlation with the postoperative clinical outcome. In computed tomography no palmar subluxation of the nerve was found, even in a patient with a poor clinical result.

This paper presents the results of histologic studies conducted in the context of tenosynovectomy of the flexor tendons to treat carpal tunnel syndrome. The most common findings were inflammatory changes of the synovial sheath, vascular pathology and fibrous changes of the connective tissue.

The present paper, based on intraoperative findings in 1420 primary operations for carpal tunnel syndrome demonstrates the frequency of rare causes of median nerve compression in the carpal canal. Some previously unpublished anatomical and pathological variants will be presented.

Histological examination of surgical specimens from 98 patients with carpal tunnel syndrome revealed amyloid deposits in 12% of the cases. Amyloid was located in the flexor retinaculum and to the same extent in the tenosynovium. Serial sections of the material containing amyloid deposits demonstrated that examination of only one level would detect solely 90% of the amyloid-positive cases. In one single case amyloid deposits were considered extensive enough to cause compression of the median nerve and thus could have played a role in the pathogenesis of the carpal tunnel syndrome. In 8 of the 12 cases the patients' histories proved no correlation to preexisting diseases. In our opinion, an individual disposition may promote amyloid deposits as a response to local and chronic irritation. It is noteworthy that the mean age in the amyloid-positive group (70 years) is significantly higher than in the amyloid-negative cases (55 years).

An anatomic variation of the median nerve is demonstrated in a female patient suffering from carpal tunnel syndrome subsequent to a distal radius fracture with malalignment and reflex sympathetic dystrophy. The median nerve coursed anterior to the superficial flexor tendons from proximal ulnar toward the distal radial region of the distal forearm, giving off an ulnar branch just 2.5 cm proximal to the flexor retinaculum. This case proves that in the distal forearm, branches of the median nerve can be found both radial and ulnar to the midline.

The authors present a follow-up of thirty five patients with carpal tunnel syndrome, who had undergone surgical treatment including synovialectomy of the flexor tendons. Beyond the clinical findings, pre- and postoperative comparison of the electromyograms, conduction velocities and an exact analysis of the lipid disorders were studied. These findings and the results of the histological analysis of the tenosynovial membrane are evaluated with special regard to the etiology of the carpal tunnel syndrome.

In the case of combination of osteopoikilosis with dermal alterations we wanted to know if the hereby discussed general mesenchymal lesions are the cause of the additional entrapment syndromes of peripheral nerves present in our case. For this purpose we recorded the pressure at the distal median and ulnar nerves within and out of the entrapment location. The results of the pressure recording of not point to a primary nerve lesion by a elevated pressure susceptibility or a pressure elevation at the peripheral nerve out of a defined entrapment location e.g. by an increase of connective tissue. Because of a hypertrophic scar formation in this case it should be paid attention to the wound healing of all patients with osteopoikilosis. The histologically verified nevoid mesenchymal alterations of the connective tissue found in this case, are to be delineated from the disseminated lenticular dermatofibrosis of the Buschke-Ollendorff syndrome.

beta 2-microglobulin amyloidosis is a major complication in chronic hemodialysis patients. Destructive arthropathy, spondylarthropathy, and carpal tunnel syndrome are clinical manifestations of beta 2M amyloid depositions within the joints, intervertebral discs, and tendon sheets. We have investigated the prevalence of beta 2M amyloidosis associated radiological joint lesions in a population of 175 patients on chronic hemodialysis. In 32 of 175 patients the diagnosis of amyloidosis arthropathy and spondylarthropathy was made by radiomorphological criteria. These 32 patients were asked about rheumatic symptoms (localisation and character of pain, synovitis, carpal tunnel syndrome, influence of dialysis membrane on pain) and examined clinically. Bilateral pain of the shoulders or wrists was complained by most of the patients. 24 of the 32 patients had signs of secondary hyperparathyroidism besides beta 2M-amyloidosis. 29 patients had a carpal tunnel syndrome, 23 of whom had to be operated. beta 2M-amyloid was histochemically demonstrated in all of these 23 cases. Renal transplantation led to immediate pain relief in 3 out of 3 patients, a change of the dialysis membrane (high-flux membrane) improved chronic pain in the majority of patients.

By preparing a new experimental model for the carpal tunnel syndrome, the authors evaluated the differences of the human and rabbit carpal tunnels using a comparative anatomical study. A nearly identical situation-regarding the osseous and connective tissue formations in the carpal channel--was found. Therefore, the carpal tunnel of the rabbit is recommended for a model of chronic nerve compression, which is now planned by the authors.

A 61 year old female patient with diffuse scleroderma, complicated by carpal tunnel syndrome, is reported. The coexistence of carpal tunnel syndrome with dermatomyositis and lupus erythematodes is reviewed.

In the advanced stage of the carpal tunnel syndrome with apparently "irreversible" loss of motor function and sensibility, epineural and interfascicular neurolysis has been recommended as an idjunct to the conventional decompression of the median nerve. Nevertheless the literature is lacking in data concerning recovery of motor function after operation. In addition to clinical examination, histological and electromyographic data are proveded to demonstrate the histo-pathological changes and the late results after neurolysis. Indications for the technique of this more radical operative procedure as well as late results are described.

The diagnosis of a carpal tunnel syndrome constitutes a frequent indication for surgery. The need for the operation should be underscored by a neurological investigation with measurement of distal motor latency and the sensory conduction rate in the median nerve. According to an evaluation of 3,816 cases treated surgically, the main cause of the carpal tunnel syndrome is a histologically demonstrated fibrous hyperplasia of the flexor tendon sheaths.

A number of locally defined as well as generalised diseases of the peripheral nervous system is manifested in the shoulderarm region besides lesions of individual nerves through traumas or as a result of pressure. Radicular syndromes are particularly frequent. These are based on prolapsed disks or degenerative changes of the cervical vertebral column. We must differentiate between these syndromes and the often rather unknown neuralgic amytrophy of the shoulder. Our experience has shown that in too many cases, paralysis of the plexus cervico-brachialis is assumed, although this occurs almost exclusively on the basis of traumatic violence, much rarer due to pressure. In such cases, the physician should look for the scalenus syndrome, the costoclavicular syndrome, and the hyperabduction syndrome. As a rule, pain is the most prominent symptom in plexus pareses through new growths, eg Pancoast's tumour. In such cases, a clear distinction must be made against bursitis of the shoulder (periarthritis humeroscapularis), in which there are no neurogenic changes, but only myogenic changes manifested in the electromyogram. If the sudden pain is accompanied by swelling and weakness of the arm, there is every likelihood of the existence of Paget-von Schrötter's syndrome. A remarkably painless deformation of the shoulder joint should also suggest neurogenic arthropathy in syringomyelia. The physician should also consider disturbances of distant origin, for example in the region of the carpal tunnel, with pain radiating to the shoulder in the manner of brachialgia paraesthetica. Finally, any noticeable weakness or muscular atrophy in the shoulder region should suggest a disease of the neuromuscular system, mainly progressive muscular dystrophy or the rare shoulder girdle type of amyotrophic lateral sclerosis.

The genesis of a carpal tunnel syndrome not described before is reported. The case in question is a 45-year-old patient with a four weeks history and increasing complaints (pain on motion and at rest, positive Hoffmann-Tinel's sign, positive extension and flexion test, considerable delay in the speed of nerve conduction). During the operation a thrombosed epineural vessel was found. Histologically, it could not be stated with certainty whether this had been a thrombosed artery or vein.

Tuberculosis of the flexor tendon sheaths in western industrial countries is rare. The author presents a case with an exceptional course and an unexpected outcome. A sixty-five year old woman suffered from tuberculosis of the flexor tendon sheath of her little finger. Appropriate tuberculostatic treatment was impossible due to damage of liver cells by chronic hepatitis. An open wound with positive cultures of mycobacterium tuberculosis persisted over eight months despite local and systemic treatment. It was only after an incidental streptococcal infection of the wound--resembling an erysipelas--that the tuberculous germs disappeared. The result was rapid healing with return of limited but useful function of the hand.

A compression syndrome of the median nerve was caused by an atypical M. flexor digiti indicis in the palmar area and carpal tunnel. Apart from its anomalous anatomy, this muscle showed an abnormal histological structure. A persistent median artery was also seen in the carpal canal.

The structure of the peri- and epineurium of the median nerve in the carpal tunnel syndrome was studied by light and transmission electron microscopy. Electron microscopy confirms the flattened lamellar arrangement of the perineurial cells, but in contrast to the normal architecture the perineurial component of the median nerve in carpal tunnel syndrome consists of 20-25 layers of ramified squamous-type cells, each layer being separated from the adjacent one by a wide space containing thick bundles of collagen fibrils. The perineurial cells are bounded on both sides by a basement membrane which is of substantial thickness. A prominent feature is the occurrence of multiple pinocytotic vesicles and caveolae opening on both the internal and external aspects of the flattened cells. They also contain bundles of closely aggregated filaments. In the spaces between the perineurial cells we find, in some places, extremely disoriented and individually abnormal fibrils and fine filaments arranged in form of a spider web. Matrix vesicles can also be seen. The epineurium of the median nerve in the carpal tunnel syndrome is also considerably thickened, and the attachment is solid, so that the median nerve is relatively immobile constricted like an hourglass. The thick collagen fibers are orientated predominantly parallel to the axis of the nerve, but circular fibers can also be seen. Apart from fibroblasts, the outer layer of the epineurium contains mast cells and vasa nervorum as well as myelinated nervi nervorum. Variable quantities of fat are also present, particularly in the surrounding loose connective tissue.

Thus far, muscle anomalies in the carpal canal causing carpal tunnel syndrome have been reported for single cases only. The authors describe nine muscle anomalies of seven patients with the symptoms of carpal tunnel syndrome. Considering the existing literature and the own cases, they attempt to predict the incidence of muscle anomalies appearing in carpal tunnel syndrome and comment on the adequate treatment.

The dermatoglyphics are genetically determined as well as anatomical variations are unique in every person. The following paper coordinates some variations in furrows of the hand with anatomical situations that can be found when operating a Carpal tunnel syndrome. In 166 patients the preoperative handprint was compared to the anatomy found. Some anatomical variations were found to have their expression in certain furrows.

Numerous investigations of the carpal tunnel were performed in 60 human hands of adults. In detail we determined the length, width, and thickness of the flexor retinaculum. Furthermore the dimensions of the carpal tunnel and the proximal, middle and distal cross-section areas were calculated. We found that the middle region is the narrowest portion of the carpal tunnel. The median nerve increases constantly in width from proximal to distal in the carpal tunnel whereas its thickness decreases. In 43.3% the nerve passes radially from the middle of the tunnel to the palm. In 21.7% the median nerve is located exactly under the middle of the flexor retinaculum and only in 1.7% is it shifted to the more ulnar side. The median nerve shows a winding course in the remaining cases.

Among the non-traumatic lesions of peripheral nerves the compression syndromes occupy a numerically leading position. After mentioning the common characteristics the individual compression syndromes of the brachial plexus and peripheral nerves of the upper extremity are described: the compression of the brachial plexus in the posterior triangle of the neck, in the costoclavicular passage and on hyperabduction. The suprascapular notch syndrome ist mentioned. The distal compression syndrome of the median nerve, the carpal tunnel syndrome is described in detail as the most common of the compression syndromes. The proximal compression syndrome of the ulnar nerve, the cubital tunnel syndrome, ist also described as are the distal compression syndrome of this nerve, Guyon's recess syndrome and the ramus profundus nervi ulnaris lesion. The supinator recess syndrome of the radial nerve is briefly mentioned.

Morphometric measurements of the carpal bones were carried out in 32 patients with carpal tunnel syndrome (CTS) and in 47 normal persons, using high resolution CT. Measurements of distances and areas were carried out at the entry of each carpal tunnel and at its narrowest point. In idiopathic CTS there were no significant differences in these measurements from normal carpal measurements. The situation was different in ten patients with nonidiopathic CTS; in these CT showed the cause of median compression reliably. Our results suggest that there are no indications for performing CT of the wrist in idiopathic CTS, but that valuable information may be expected from CT in cases of nonidiopathic CTS.