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Introduction: A supracondylar process is a bony spur on the distal anteromedial surface of the humerus, and it is considered an anatomical variant with a prevalence of 0.4-2.7% according to anatomical studies. In almost all cases, it is associated with a fibrous, sometimes ossified ligament, which extends from the supracondylar process to the medial epicondyle. This ligament is known in the literature as the ligament of Struthers, named after the Scottish anatomist who first described it in detail in 1854. In rare cases, the supracondylar process can be a clinically relevant finding as a cause of nerve compression syndrome. The median and ulnar nerve can be trapped by the ring-shaped structure formed by the ligament of Struthers and the supracondylar process., Case Report: A 59-year-old patient with symptoms of a cubital tunnel syndrome and additional ipsilateral sensory deficits in his thumb was referred to our clinic. Electroneurography showed no signs of an additional carpal tunnel syndrome. Preoperative x-ray and CT scans of the upper arm revealed a supracondylar process, which led us to suspect an associated entrapment of the median nerve. An MRI scan of the upper arm showed a ligament of Struthers and signs of a related median nerve compression as we initially assumed. We performed a surgical decompression of the median nerve in the distal upper arm and of the ulnar nerve in the cubital tunnel. Intraoperatively, there was evidence of compression of the median nerve due to the supracondylar process and the ligament of Struthers. The latter was cleaved and then resected along with the supracondylar process. Three months after surgery, the patient had no motor or sensory deficits., Summary: The ring-shaped structure formed by the supracondylar process and ligament of Struthers represents a rare cause of compression syndrome of the median and ulnar nerve. Its incidence remains unknown so far. This anatomical variant should be considered a differential diagnosis in case of possibly related nerve entrapment symptoms after ruling out other, more frequent nerve compression causes. Moreover, the supracondylar process should be completely resected including the periosteum during surgery to minimise the risk of recurrence., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Carpal tunnel syndrome (CTS) is one of the most common compression neuropathies. The therapeutic concept should be tailored to each patient individually, with initial non-surgical treatment being the standard of care for early CTS. Primary surgical intervention should be considered in more advanced diseases stages, in case of concomitant pathologies (including space-occupying lesions, complex regional pain syndrome or diabetic neuropathy), if non-surgical strategies have failed or in pregnancy-related CTS. This work aims to discuss common surgical approaches, their clinical application as well as benefits and disadvantages in a pragmatic style. Further, we highlight surgical strategies to address recurrent CTS following failed primary surgery. In view of the recently updated S3 guidelines "Diagnosis and Therapy of Carpal Tunnel Syndrome", this topic is timely and relevant for hand and nerve surgeons., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: Post-operative pain in the palm and scar area is the most common complication after carpal tunnel release and injury to the terminal branches of the palmar cutaneous nerve is generally considered one of the causes for this complication. The Authors performed an intraoperative study preserving the terminal branches of the palmar cutaneous branch of the median nerve and verifying the frequency, location and direction of the branches that cross an interthenar incision., Method and Material: Eighty-five consecutive patients (57 F - 28 M, mean age 66 y) underwent carpal tunnel release between February and June 2021. The cutaneous branches crossing the incision were identified and preserved by careful dissection. Subsequently they were counted and classified by their direction and distance from the proximal border of the transverse carpal ligament., Results: Sensory branches were found in 40 % of cases (34/85) and their origin was observed at an average of 1.05 cm (0-1.8 cm) distal from the proximal border of the carpal tunnel. A total of 44 branches were observed of which 23 branches crossed the incision with a transverse course and 21 with an oblique, generally proximal-distal radio-ulnar course. The subcutaneous layer overlying the distal third of the transverse carpal ligament was found to be devoid of sensory branches, therefore it can be considered a relatively safe area., Conclusion: Isolation and protection of palmar sensory branches is important for improving carpal tunnel release results. This goal can be more easily achieved by locating the skin incision on the distal third of the transverse carpal ligament, where the sensory branches have a lower frequency, possibly associated with a second proximal incision (biportal technique) to better visualize the proximal portion of the ligament and antebrachial fascia., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Purpose: This study analyses the correlation between the constriction in the substance of the median nerve in the carpal tunnel and distal motor latency, gender and age of patients with a carpal tunnel syndrome., Patients and Methods: In 82 patients (59 women and 23 men with an average age of 66.6 (41-89) years) with an electrophysiologically verified carpal tunnel syndrome undergoing open carpal tunnel release, the diameter of the median nerve was measured at the narrowest point of the nerve at the level of the constriction and the widest point of the nerve proximal to the constriction. The grade of nerve constriction was the ratio between the diameter at the level of the constriction and the widest diameter proximal to the constriction. Additionally, the distance from the distal wrist crease to the beginning of the constriction was measured. The grade of constriction was correlated with the patients' distal motor latency, gender and age., Results: The diameter of the median nerve at the narrowest point of the constriction averaged 6.0 (SD 1.1) mm; the diameter at the widest point proximal to the constriction was 7.6 (SD 1.5) mm. The distance from the distal wrist crease to the beginning of the constriction averaged 17.6 (SD 3.7) mm. Grade of nerve constriction did not correlate with distal motor latency. However, there was a correlation between patient age and distal motor latency., Conclusion: The grade of nerve constriction cannot be estimated based on the severity of prolongation of distal motor latency. There is a positive correlation between the age of patients with a carpal tunnel syndrome and distal motor latency., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose:  Outcomes of surgery for carpal tunnel syndrome may differ in relation to certain factors like age, duration of symptoms, clinical and electrophysiological severity. The objective of this study was an investigation into the hypothesis that several factors are predictive of results of surgical treatment of the condition., Methods:  The pre- and postoperative records of 1,117 patients: 909 women (81 %) and 208 men (19 %) with a mean age of 63 years were analysed. Outcomes recorded in the sensory and functional severity scores of the Levine questionnaire were dichotomized into achieving or not-achieving a minimally clinically important difference. The effect of selected variables: sex, age, duration of symptoms, clinical and electrophysiological severity of and presence of comorbidities on outcomes of surgery at 6 months was investigated., Results:  Univariate and multivariate analysis of covariates based on sex, age, duration of the disease and its clinical severity showed female gender and worse baseline symptom severity scores to be significant predictors for an improvement following carpal tunnel syndrome surgery. It showed also younger age, shorter duration of symptoms and higher baseline symptom severity scores to be predictive of a greater improvement of total grip strength, and younger age to be predictive of a greater pain cessation following surgery., Conclusion:  Of all considered patient's and disease related factors, the baseline clinical severity expressed in the Levine symptom severity scores had appeared to be the strongest predictor of better outcomes of surgery for carpal tunnel syndrome., Competing Interests: The authors declare that they have no conflict of interest, (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht.

Purpose: The primary aim of the study was to analyze whether there is and - if so - how far a correlation between the clinical findings after carpal tunnel release (CTR) for carpal tunnel syndrome (CTS) and the Wrist-to-Forearm-Ratio (WFR) of the median nerve in ultrasound to answer is question whether the WFR can be used in controlling the operative result., Patients and Methods: In a prospective study the clinical, electrophysiological, and sonographic data of 40 patients with CTR for CTS were collected preoperative and 3 and 9 months postoperative. The data of 21 patients with 23 operated hands completing the study were analyzed. There were 5 men and 16 women with an average age of 58 years., Results: Neither a correlation between the clinical findings postoperative and the WFR nor the electrophysiological findings postoperative was found., Conclusion: Concerning the Wrist-to-Forearm-Ration of the Median nerve ultrasound is not a suitable method for assessing the success of a carpal tunnel release., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Records were analysed from the institutional database, including 943 patients (1089 hands) with CTS who were operated on in the authors' department over a period of four years (2012 to 2015). The diagnosis of CTS was made solely on the basis of clinical findings in 551 patients (58 %); 392 patients (42 %) also had electrodiagnostic tests performed, for various reasons. Patients were followed-up at 1 and 6 months with assessments that included the Levine scores, filament tests, grip and pinch strength. No significant differences in Levine scores were found at the 1 and 6 month assessments. Statistically significant differences were noted in 3-point pinch strength and sensation: however, these were not clinically meaningful. The results of the study show that the results of carpal tunnel release in patients with typical symptoms are no better after electrodiagnostic tests., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Ziel der vorliegenden Arbeit war es, unter Berücksichtigung der in Pubmed und Medline veröffentlichten Ergebnisse nach Eingriffen am Karpalkanal zu ermitteln, inwieweit ausgewählte Faktoren wie das Patientenalter, die Dauer der Symptome, die Ausprägung der klinischen und elektrophysiologischen Befunde, das Vorliegen von Begleiterkrankungen und medikolegale Momente die Ergebnisse beeinflussen. Letztlich konnte für keinen der zahlreichen untersuchten Faktoren ein signifikanter Einfluss auf das Langzeitergebnis nachgewiesen werden. Bestehen die Beschwerden länger, sind die klinischen und elektrophysiologischen Befunde ausgeprägter und liegen Begleiterkrankungen vor, so fallen die Ergebnisse weniger gut aus, was darauf hindeutet, dass die betroffenen Patienten etwas weniger von der Operation profitieren. Nur bei Vorliegen von medikolegalen Faktoren wie Rechtsstreit oder Schadenersatzansprüchen lässt sich definitiv ein schlechtes Ergebnis voraussagen., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: In the current literature, there are reports of associations between complex regional pain syndromes (CRPS) and carpal tunnel syndromes (CTS). The aim of this study was to determine the prevalence of both disease patterns in hand rehabilitation patients and to investigate whether there is a correlation between CTS and CRPS. Furthermore, differences in the healing process of patients with and without additional CTS, and the effectiveness of the rehabilitative therapy for both diseases, were investigated., Patients and Methods: The computerised medical records of 791 patients in the years 2009-2015 who had been in hand rehabilitation were retrospectively analysed. At the beginning and end of rehabilitation, measurements were made of pain by visual analogue scales (VAS, 0-10), grip strength and finger mobility (mean distance from finger pulp to palmar D2-D5). The clinical course was statistically analysed. CRPS diagnosis was confirmed clinically by a pain therapist, CTS diagnosis was confirmed by neurological and neurophysiological examination. Surgical therapy was performed despite CRPS diagnosis., Results: The prevalence of CRPS was 161/1000 and of CTS 62/1000; the co-prevalence of the 2 diagnoses was 24/1000 (p<0.0001). In the CRPS group, after a mean of 8 (1-21) weeks of rehabilitative therapy, mean pain was reduced from 5 (1-10) to 3 (0-9), grip strength improved from 10 (0-39)kg to 18.5 (2.5-45.5)kg and finger mobility increased from 2.9 (0-7.6)cm to 1.8 (0-7.8)cm. In the CRPS+CTS group, after a mean of 6.8 (3-23) weeks of rehabilitative therapy, mean pain was reduced from 5 (0-8) to 2.6 (0-5), grip strength improved from 9.7 (2.4-25.5)kg to 17.4 (0.9-47.4)kg and finger mobility increased from 2.7 (0-5.3)cm to 1.7 (0-5.3)cm. Improvement over the period of rehabilitation was significant in both groups, though the period of therapy was significantly shorter in the CRPS+CTS group., Conclusion: CRPS and CTS are often associated. Rehabilitative therapy was effective for CRPS- and CRPS+CTS patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

We report on a carpal tunnel syndrome in a 50-year-old woman, presumably caused in part by a 35-year-old asymptomatic capitate non-union. The carpal tunnel was released and a large exostosis removed. 3 weeks after the operation the patient was free of symptoms., (© Georg Thieme Verlag KG Stuttgart · New York.)

We present the case of a 54-year-old woman with symptomatic coalition of scaphoid, trapezium and trapezoid as well as a coexisting ipsilateral hypoplasia of the thumb., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Recent studies have demonstrated ultrasonography as a valuable tool for confirming the diagnosis of carpal tunnel syndrome. The objective of this study was to investigate sonographic parameters of the median nerve in patients diagnosed clinically with carpal tunnel syndrome., Patients and Methods: 185 wrists in 185 patients, 149 women (81%) and 36 men (19%), with a mean age of 59 years, with the clinical diagnosis of carpal tunnel syndrome were examined sonographically. We measured cross-sectional area (CSA) of the median nerve at the forearm and at the carpal tunnel inlet, as well as the height (a-p dimension) of the nerve at the tunnel inlet and in the narrowest site in the carpal tunnel. Moreover, in all patients the severity of the disease was assessed by the Levine questionnaire., Results: A significant variability of sonographic data characterizing the median nerve was found: the mean CSA at the tunnel inlet was 17.6 mm2 (range: 7-36) and height of the nerve at the tunnel inlet was a mean of 2.7 mm (range: 1.3-4.5). No correlation was found between sonographic data and severity of the syndrome as expressed by the Levine scores., Conclusion: Sonography of the median nerve contributes little to the diagnosis of a clinically relevant carpal tunnel syndrome and its routine use is not justified., (© Georg Thieme Verlag KG Stuttgart · New York.)

In order to improve operating room efficiency in our institution, we introduced the wide-wake approach for carpal tunnel releases in 2012. This study examines the effect of this new anaesthetic technique on the work-flow and the duration of operation compared to the previously used axillary plexus anaesthesia.In this retrospective study, we reviewed the surgical case data of all patients in whom carpal tunnel releases had been performed as single procedures. 120 procedures of the year 2011, performed under axillary plexus anaesthesia, were compared to 153 procedures of the year 2012, performed as wide-awake surgery. We hypothesised that an earlier beginning of the first operation of the day with wide-awake surgery. Furthermore, we expected a shorter surgical time as well as a shorter interval between 2 carpal tunnel releases.By introduction of the wide-awake -approach, the first operation began a mean of 11 min earlier (p<0.001). While the surgical time did not change for the hand surgeon himself (10.7 vs. 10.2 min; p=0.478), the surgical time shortened significantly, when residents performed the operation (19.1 vs. 15.9 min, p<0.001). The interval between 2 carpal tunnel releases shortened from 19.8 to 17.7 min (p=0.009). Secure preparation was accomplished by the hypoperfused situs, when the wide-awake approach was applied, even though a tourniquet was not used. In the post-operative control, no complicated wound healings were noted.The wide-awake approach has proven to be reliable for the operating room -efficiency and, likewise, for patient safety. Therefore, we can recommend this technique without restrictions for carpal tunnel releases., (© Georg Thieme Verlag KG Stuttgart · New York.)

We report a case of an 80-year-old woman with an acute carpal tunnel syndrome. This was based on an acute episode of chondrocalcinoses and accompagnied by a prolaps of the median nerve into a gap of the forearm fascia as result of a cut injury in childhood., (© Georg Thieme Verlag KG Stuttgart · New York.)

Carpal tunnel syndrome is common in children with mucopolysaccharidosis type 1H (MPS type 1H). Clinical signs of carpal tunnel syndrome are frequently absent in these children and it is often very difficult to perform and interpret neurophysiological investigations. In this article we wish to present our experience and results regarding the diagnosis and postoperative results after decompression of the median nerve.In an interdisciplinary set-up we are currently treating 11 MPS type 1H children following blood stem cell transplantation. 7 patients were operated 12 times (5 bilateral operations) because of a carpal tunnel syndrome (age at the time of operation 83,3 months, (43-143 months), 2 male, 5 female). 6 patients had a follow up after 23,7 months (9-59 months). 6 patients had a histological analysis of the flexor retinaculum. Three patients had a postoperative neurophysiological investigation.Each of the operated patients had at least 1 preoperative clinical sign of a carpal tunnel syndrome. We found at least 1 pathological finding in motor and sensory nerve conduction studies in each patient. 6 of the 7 children operated on were symptom-free at postoperative follow-up. 1 of the 3 patients with a postoperative neurophysiological follow up showed a deterioration of the nerve conduction studies. This patient was free of symptoms postoperatively. Biopsy of the flexor retinaculum confirmed abundant proteoglycan deposition. We had neither postoperative complications nor were revisional operations necessary.The Diagnosis of a carpal tunnel syndrome in children with MPS Typ 1H needs a thorough medical history, the correct interpretation of the clinical symptoms and sophisticated nerve conduction studies. Wether the improvement of the postoperative clinical situation lasts has to be evaluated in a long term investigation especially because in one patient in our group we saw a deterioration of the nerve conduction studies postoperatively., (© Georg Thieme Verlag KG Stuttgart · New York.)

A common reason for persisting or new complaints after carpal tunnel surgery is an incomplete release of the retinaculum flexorum. Traction neuropathy, a real recurrent carpal tunnel syndrome and iatrogenic nerve lesions occur less frequently. In the case of an incomplete release of the flexor retinaculum the clinical symptoms in most of the patients can be resolved with revision surgery. Electrodiagnostic testing can only support the indication for a reoperation if a preoperative examination exists but is not able to demonstrate the exact cause of a failed carpal tunnel surgery. The 4 cases presented here show that high resolution ultrasound provides valuable information in addition to electrodiagnostic testing before a reintervention., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The prohibition against the use of local anaesthetics in combination with adrenaline in hand surgery focused on publications of the past is lacking. Many recent publications show good results using adrenaline in hand surgery, especially no higher rate of skin necrosis was seen. Based on this, we started using the "wide awake approach" in elective outpatient hand surgery in 2008., Purpose: The goals of this retrospective study are twice, to evaluate a) whether the use of local anaesthesia with adrenalin in selected outpatient hand surgical procedures will not - as reported in the recent literature - lead to a high complication rate, and b) the patient?s satisfaction with the 'wide awake approach"., Patients and Methods: From 2/2008 to 1/2009 151 patients underwent carpal tunnel release, release of the first extensor compartment, and trigger finger release using the "wide awake approach" without use of a tourniquet. The mixture for local anaesthesia was lidocain 1% together with adrenaline (1:100 000). In spring 2009 the patients answered a questionnaire with items about pain (VAS), comfort and complications. In addition the patients were asked, whether they would choose the "wide awake approach" again., Results: We received 119 questionnaires (78.8%). Pain during injection of the local anaesthetics was on average 2.86 (0-10) at the VAS, and 0.88 (0-10) during the procedure itself. 12 patients (10%) needed a second shot of the local anaesthetics. 95 (79.9%) patients felt "extremely well" or ""well", 24 (20.1%) felt ""less well" or "extremely less well" during the operation. 83% of the patients would choose this form of anaesthesia again, if a further operation is necessary; 9% would prefer another form of anaesthesia., Conclusion: The so called "wide awake approach" with the use of local anaesthetics added with adrenaline in the elective hand surgery is a safe and comfortable anaesthesia method. There are no valid reasons to adhere to the prohibition against the use of local anaesthetics with adrenaline in hand surgery., (© Georg Thieme Verlag KG Stuttgart · New York.)

The objective of this study was to compare the 3 commonly used questionnaires DASH, PEM and Levine to assess which is the best as an outcome measure after carpal tunnel release. 50 patients (43 women and 7 men) with an average age of 56 years underwent minimally invasive carpal tunnel release. Patients were examined before the operation, and at 1 and 6 months after, according to the same protocol. They completed the DASH, PEM and Levine questionnaires and undertook total grip, key-pinch strengths, and sensation by filament tests. The results showed higher responsiveness to change in the Levine and the PEM, compared to the DASH at the 1- and 6-month-assessments. The Levine showed the highest validity as it correlated strongly with all functional measures, although all 3 questionnaires, including Levine, showed a discordance with total grip and key-pinch strength at the 1-month assessment. The instruments were characterized by various (excellent and poor) concurrent validity in the assumed periods of observation and all 3 showed high internal consistency., (© Georg Thieme Verlag KG Stuttgart · New York.)

Hand surgery is an interdisciplinary specialty in which the contents of further training in the individual fields differ widely. We have first investigated general quality criteria and then the further training programmes of the specialties general surgery, orthopaedic and trauma surgery as well as plastic and aesthetic surgery. On the basis of the treatment error statistics of the Chamber of Medicine of North Rhine-Westphalia from the years 2004-2008, the treatment error quotas for a period of 5 years were evaluated according to specialty and the presence of additional training in hand surgery. This revealed that treatment errors in hand surgery with 41.7% were markedly more frequent than the general average value of 31.1%. On individual evaluations, the error quota for qualified surgeons without additional training was 44% whereas that for surgeons with additional training was 26%. Most frequently treatment errors were reported for distal radius fractures, followed by soft-tissue and cut injuries, carpal tunnel syndrome and finger fractures. The largest difference in the error quotas for the groups with and without further training in hand surgery was found for soft-tissue injuries including tendon injuries, 13.3% as compared with 53.7%., (© Georg Thieme Verlag KG Stuttgart · New York.)

The aetiology of the carpal tunnel syndrome is unknown in most cases. Among our patients we found four with acute thrombosis occurring in a persistent median artery which led to acute carpal tunnel symptoms. The purpose of this study was to compare our cases with those from the literature and to show possible causes for the thrombosis. In conclusion, thrombosis of a persistent median artery as a cause of acute carpal tunnel syndrome is certainly very rare. Sudden onset of pain, local tenderness at the palm and decreased sensation in the median nerve distribution may provide clues for the diagnosis. Prior to surgery ultrasound can be performed to confirm the diagnosis.

There are typical causes for carpal tunnel syndromes as well as a series of rare causes. Furthermore, the clinical image can also be untypical. This report is about a 59-year-old female patient with an untypical clinical symptomatology and with a rare cause: there was no major pain during the night or in the morning, no paraesthesias and no impairment of the fine motor skills, nevertheless, there were rapid paraesthesias and pain in the first three fingers of the right hand immediately after hyperextension of the wrist. Although the discomforts had already existed for 2 years they were not recognised properly because they were untypical and incomplete and neurography was negative. 3 years later in a renewed examination X-ray pictures of the carpus were taken and a 4 x 6 x 8 mm big ossicle on the ground of the carpal canal was found, the computed tomography and the intraoperative situs confirmed the image. The histology gave the diagnosis of a loose osteochondral body. Postoperatively the patient was quickly was free of the symptoms.

Purpose: The aim of this study was to assess the clinical results of revision surgery due to persistent neurological disturbances after carpal tunnel release., Patients and Method: In a previous study we showed the reasons for persisting neurological symptoms after carpal tunnel release on the basis of the intraoperative findings in 200 patients who underwent revision surgery in the years 2001 - 2003. We classified them into four groups (1: incomplete release of the retinaculum flexorum, 2: traction neuropathy, 3: real recurrent carpal tunnel syndrome, and 4: nerve lesions). 122 of these patients have been investigated regarding the clinical results using two questionnaires in the year 2004. We used the DASH questionnaire as well as an additional self-assessment questionnaire asking about remaining symptoms of median nerve irritation and the subjective results of revision surgery. The completely filled-out forms were assigned to the four groups, analysed and the results compared with each other., Results: Within group 1 (incomplete release), 78 % reported only one persistent neurological symptom, 89 % described a benefit from revision surgery and 84 % were satisfied with a median DASH score of 11. Within group 2 83 % complained about at least one persistent neurological problem and only 60 % reported on an improvement following revision surgery. The DASH score within group 2 averaged 30. 87 % of group 3 patients reported of an improvement following the revision operation (DASH score 24), whereas this was the case for only 55 % (DASH score 37) of group 4 patients., Conclusion: The incomplete release of the flexor retinaculum is the most common reason for revision surgery. In most of these patients the clinical symptoms can be resolved with revision surgery leading to a very high satisfaction of the patients. A similarly high satisfaction can be expected following revision surgery of a true recurrent carpal tunnel syndrome although in most patients a significant degree of functional deficit will remain. Revision surgery due to fibrotic adhesions of the median nerve, leading to a traction neuropathy, or iatrogenic nerve lesions during the primary surgery will definitely lead to unsatisfactory overall results.

Purpose: The aim of this study is to evaluate the results of fasciocutaneous posterior interosseous artery island flaps in the treatment of recurrent or persistent carpal tunnel compression syndrome (CTS)., Patients and Methods: From 1997 to 2006, 14 patients (8 women, 6 men, ages ranging from 26 to 77 years with a mean age of 55.7 years) have been operated for recurrent or persistent CTS, or for a neuropathic pain syndrome. All patients were treated with a posterior interosseous island flap following neurolysis of the scarred median nerve. The patients were evaluated pre- and postoperatively using a pain visual analogue scale and the DASH score. Sensibility, motor dysfunction, pain and success of the treatment were classified as good, better or bad., Results: Mean follow-up of the patients was 23.8 months (1.7 to 93.5 months). The pain evaluation showed a statistically significant improvement (p < 0.005) decreasing from a mean value of 6.7 to 1.5. The DASH score was also statistically significantly improved postoperatively (p < 0.005). The best results were observed in patients without extensive preliminary median nerve damage. The duration of symptoms before re-operation did not influence the outcome. Seven patients demonstrated good, five improved and two patients maintained poor results. The two patients with poor results suffered from extremely scarred and injured median nerves following previous carpal tunnel surgery., Conclusion: Protective coverage of the median nerve by use of a fasciocutaneous island flap after failure of carpal tunnel release provides a good gliding tissue cover and reduces the risk of adhesions between the nerve and the surrounding tissues after previous surgery. While this protection of the nerve can reduce painful symptoms it does not guarantee total pain relief in all patients. Pain relief and functional recovery strongly depend on the preexisting condition of the median nerve.

We report about the sudden onset of a median nerve neuropathy in an anticoagulated patient eight weeks after uneventful carpal tunnel release. Several differential diagnosis have to be considered: compression syndrome as well as iatrogenic damage of the median nerve due to the preliminary procedure or even concomitant disease can generate symptoms of peripheral neuropathy. We diagnosed an intraneural haematoma through surgical exploration. This rare complication of oral anticoagulation therapy occurred spontaneously and was treated successfully by interfascicular neurolysis.

Evidence-based supradisciplinary guideline that deals with the epidemiology, pathogenesis, symptoms, clinical and electrophysiological diagnosis, supplementary imaging investigations, differential diagnosis, conservative and surgical treatments, prognosis and course along with complications and revision surgery. The recommendations on investigation and treatment are based on a comprehensive literature search with critical evaluation and two consensus methods (expert group and Delphi technique) within the participating specialist societies. Besides this long version, a short version and a patient version can be viewed through the AWMF platform. The development of the guideline and the methodological foundations are documented in a method report. MAIN STATEMENTS: Apart from an accurate history and clinical neurological examination (including clinical tests), electrophysiological investigations (distal motor latency and sensory neurography) are particularly important. Radiography, MRI, high-resolution ultrasonography can be regarded as optional supplementary investigations. Among conservative treatment methods, treatment with a nocturnal splint and local infiltration of a corticosteroid preparation are effective. Oral steroids, splinting and ultrasound showed only short-term benefit. Surgical treatment is clearly superior to all other methods. Open and endoscopic procedures (when the endoscopic surgeon has sufficient experience) are equivalent. A routine epineurotomy and interfascicular neurolysis cannot be recommended. Early functional treatment postoperatively is important.

Background: The carpal tunnel syndrome is one of the most frequent peripheric nerve compression syndromes. Almost 15 years ago, the endoscopic surgery of the carpal tunnel was introduced, in order to reduce postoperative pain and to shorten the length of the postoperative inactivity period, especially work absence. In the literature the rate of complications due to the endoscopic carpal tunnel release surgery is reported differently in respect to number and severity. This paper summarizes all reinterventions after endoscopic surgery in a single specialized hand surgery department, which prefers the open approach even for first time interventions., Patients and Method: A retrospective analysis of all reoperations between 1998 and 2006 is presented. There were 22 reinterventions done on 21 patients. A reoperation was performed if the symptoms of the carpal tunnel syndrome persisted or new pain or sensomotor deficit appeared. There were 8 male and 14 female patients. The age span ranged from 28 to 86 years. The time distance between the first and the second surgery was between 19 days and 36 months., Results: Most of the intraoperative findings were incomplete releases of the retinaculum (n = 13). In three cases abundant adherences caused the clinical symptoms. Three times pathologies were found in carpal tunnel, which could not be recognized or treated endoscopically: severe bleeding in the synovia, massive synovialitis and a swannoma of the median nerve. In seven patients transsected nerves had to be treated: one complete transsection of the median nerve, two nerves with injured radial fascicles, two nerves with violated ulnar fascicles, one neuroma of the median nerve and one transsection of both branches of the ulnar nerve., Conclusion: In 22 cases the result of the endoscopic release of the carpal tunnel forced to redo the intervention. In seven patients there were important lesions of the neurovascular structures. Since the long-term result of the endoscopic and open surgery of the carpal tunnel is comparable, it should be discussed if endoscopic surgery is justified even with the risk of mutilant complications and which preoperative imaging procedure is required to discover pathologies and anatomical variants.

Escharotomies are usually performed in patients with circumferential third degree burns of the extremities or anterior trunk. Fasciotomies are recommended for patients who sustained high voltage (or associated crush) injuries, with entrance or exit wounds in one or more extremities. Carpal tunnel release is practiced routinely in some services for cases of electrical injury. We have reviewed the literature which provides relatively little information as to when should these procedures actually be performed and what would happen if they were not done. We present a series of patients treated at our institution when an algorithm was used for surgical decision making as to when (or not) to operate (perform an escharotomy, a fasciotomy or a carpal tunnel release), based on clinical signs and monitoring alternatives, using the oximeter and the Doppler flowmeter. 13 938 burn patients were treated at our institution during the year of 2005. Of these, 571, with an average of 22.3 % TBSA, were treated as inpatients. Of these, 58 (10.3 %) had circumferential or electrical burns of one or more extremities. Patients were monitored hourly from admission and decision to operate was based on clinical signs and in absent or below 90 % oximetry, regardless of Doppler flow signs. 68 % were males, 6 (11.3 %) patients had immediate escharotomies, while 4 (7.5 %) had immediate fasciotomies. 2 of these patients were operated regardless of positive Doppler sign but no oximetry. All patients recovered oximetry over 90 % immediately after the operations. 3 patients had negative Doppler sign but oximetry > 90 % and were not operated. 3 patients had carpal tunnel releases based on oximetry < 90 % and symptoms of compression of the median nerve. Patients who were not operated fared well with no signs or symptoms of impairment of circulation or nerve damage up to their 3 and 6 months reevaluations.

In the last eight years we performed 63 re-interventions because of recurrent carpal tunnel syndromes. Intact parts of the retinaculum were the reason for persistent symptoms in 38 patients. 21 patients suffered from scar tethering, two patients from circumferential fibrosis of the nerve. In one patient a ganglion and in another patient a direct injury to the median nerve was detected. In 21 patients short incisions were performed in the primary procedures. Since the introduction of endoscopic carpal tunnel release, an open decompression via a short incision is recommended as an alternative. Since then we encounter an increase of necessary operative revisions after short incisions. Optical tools may increase the survey especially in short incisions. In extended teno-synovialitis of the flexor tendons, a longer incision over the wrist enables adequate conditions for a safe teno-synovialectomy. The length of the incision has to be chosen according to the pathologic-anatomic situation, the disposable equipment and the experience of the surgeon.

Purpose: The aim of the study is to present our experience with fascial or fasciocutaneous pedicle and island flaps in the treatment of recurrences of CTS with and without median nerve lesions., Material and Methods: From 1987 to 2006 we have operated on 25 patients (17 women and 8 men, ages ranging from 38 to 76 years with a mean age of 55 years) due to a recurrence of CTS. All the patients required nerve coverage using a local or distant flap. There were 19 hypothenar fat flaps; two forearm radial artery flaps, a forearm ulnar artery flap, an ulnar fascial-fat flap and a posterior interosseous flap. Patients were clinically and instrumentally evaluated before the operation. Assessments of the evaluation parameters were classified in excellent, good, fair and poor according to clinical and return to work criteria., Results: Patients were evaluated after a mean follow-up of 51 months (12 to 168 months). The pain evaluation showed an improvement passing from a mean value of 9 to 4. The best results were for those patients in whom the median nerve was undamaged (mean value of 1). Eleven patients obtained excellent results; good results were obtained in twelve cases; two patients demonstrated fair results due to partial median nerve injury. In these cases, a hypothenar fat flap and an ulnar fascial-fat flap were used, respectively., Conclusion: Protective coverage of the median nerve by using fascial or fasciocutaneous flaps after failure of CTR and/or unsuccessful re-operations is a good solution to furnish to the median nerve a gliding tissue to avoid adherences with the surrounding tissue of previous surgery. The protection of the nerve can reduce painful symptoms even if it does not permit a return to a painless condition. However, the clinical results in terms of median nerve functional recovery cannot be predicted: if the median nerve is damaged, protective coverage of it by flaps cannot give a favourable result in terms of recovery of both sensory and motor deficits.

Background: With an increasing number of operative procedures for CTS, the number of reoperations is increasing too. These procedures are not in general performed because of recurrence, other reasons may play a role for the failure of the initial operation or recurrent symptoms. METHODS AND CLINICAL MATERIAL: Revision procedures performed in 57 patients in the practice for peripheral neurosurgery from January to September 2004 were analyzed for incision, intraoperative findings, method of operation, electrophysiological findings, and revised diagnosis. Moreover, the data were compared with 185 revision procedures performed in the years from 1986 up to 1994., Results: 2.4 % of all CTS operations were revision procedures (in the former time period 1.5 %). In 59 % of revision operations (former 50 %) an incomplete release of the transverse ligament was found, in 27 % (former 31 %) typical recurrence, in 5 % (former 6 %) nerve lesions, and in 9 % (former 13 %) no abnormalities so that other reasons for complaints of mainly radicular lesions must be assumed. In cases of incomplete release of the transverse ligament, only in 16 % of the patients were normal skin incisions seen, but in 56.3 % there were small incisions (i.e., short or mini-incisions). Typical CTS recurrence occurred mainly in hemodialysis patients, nerve lesions were seen mainly when endoscopic procedures were performed., Conclusion: Diagnostic problems because of incomplete or misinterpreted ENG findings may lead to delayed or useless primary as well as revision operations. Too small incisions but also endoscopic procedures used by less experienced surgeons are accompanied with an increased risk for avoidable revisions and nerve lesions. Not only for forensic reasons but also in view of quality management, procedures for correction (of operative failure) should be distinguished from those for recurrence.

The operative treatment of carpal tunnel syndrome is relatively simple and is carried out by doctors from various surgical specialities. In cases of persisting pain or postoperative worsening of the condition, the indication for the procedure could have been wrong or an iatrogenic complication may have to be taken into consideration. We have analysed 42 patients (48 hands) who underwent surgical treatment for carpal tunnel release from 1999 to 2003. We treated eight men and 34 women with an average age of 56 years in this way. Ten patients were initially operated upon by endoscopic release. We found an incompletely transected or even untouched retinaculum flexorum in 16 patients. In eight patients we found an iatrogenic nerve lesion and 24 patients developed serious scarring. Revision surgery should be undertaken only by a surgeon who is a specialist in hand surgery and has extensive experience in this field. In the same context, postoperative hand therapy is essential for a good result, which is performed by occupational therapists in our clinic.

An inadequate indication for a carpal tunnel revision procedure may be followed by disastrous sequelae for the patient. So it may be justified to talk of iatrogenic CTS. A patient suffering from bilateral CTS is presented who had been operated on six times in all. The following techniques had been used by an orthopedic surgeon, a neurologist, a neurosurgeon and a hand surgeon: microsurgical neurolysis, epineurectomy, neuroma resection, tenosynovectomy and finally a hypothenar fat flap. Initial cause for this fatal series was scar tenderness following lesion of the muscular and palmar branches of the median nerve in the first or second operation. Since sensory nerve conduction was normal after decompression had been performed, there would have been no indication for further surgery of the median nerve. Resection of the neuromas of the two injured branches was not followed by any relief for the patient nor did wrapping the nerve in a fat flap help. Such courses may lead to high costs in health care and occupational disability. They can be avoided by competent neurological and electrophysiological examination, correct interpretation of findings as well as critical consideration of the indication for revision procedures.

47 patients with a carpal tunnel syndrome were preoperatively examined not only by electrophysical studies (nerve velocity and distal motoric latency) and clinical tests (Phalen's sign, Tinel's sign) but also by measuring the strength of the M. abductor pollicis brevis with a specifically designed strength-testing unit. 30 patients agreed to participate in a voluntary postoperative examination. In the 45 degrees -measurement there was a relative strength loss of the injured hand's thumb of about 25 % in comparison with the healthy hand preoperatively. The postoperative strength disadvantage amounted to only 10 %. Measurement of the strength in the neutral zero method showed a relative strength loss of the injured hand's thumb of 8 % while postoperatively there was even a strength advantage of 9 % in comparison with the thumb of the healthy hand. Both methods showed a relevant and significant postoperative strength increase of the injured hand's thumb. We could prove a significant correlation (p = 0.03) of the neutral zero strength measurement and the distal motoric latency of the median nerve. Furthermore, we could show a trend for a correlation between the neutral zero strength measurement and the median motoric velocity. In conclusion, it can be said that the special strength measurement of the M. abductor pollicis brevis is an important parameter to objectively evaluate the motoric symptomatology in carpal tunnel syndrome patients.

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.

We report on a six-year-old girl with bilateral carpal tunnel syndrome with familial accumulation. Parents and one grandmother had positive history for CTS, treated by surgical decompression. Following neurologic and radiologic evaluation and after failed conservative treatment in a plaster cast, open carpal tunnel release was performed in a two-stage procedure. Postoperatively symptoms diminished and now six months after surgery, all complaints disappeared completely.

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.

Purpose/background: Along with arthropathies, carpal tunnel syndrome (CTS) may occur in patients on chronic haemodialysis, its incidence is correlating with the duration of the haemodialysis treatment. To evaluate clinical and electrophysiological findings, relation of the disease to the side of the arteriovenous shunt, gender ratio, and a concurrent tendovaginosis stenosans (TVS), 268 haemodialysis-patients with CTS or recurrent CTS were retrospectively analyzed. METHODS AND (CLINICAL) MATERIAL: Over a period of ten years (1994 - 2003), 268 haemodialysis patients presented to our peripheral neurosurgery practice with CTS or recurrent CTS. Diagnosis was confirmed with clinical and electrophysiological findings. The patients were divided into three groups based on their severity of disease as follows: Patients with only intermittent paraesthesias (CTS I degrees ), with persistent numbness in the area supplied by the median nerve (CTS II degrees ), and with paresis of the thenar muscles (CTS III degrees ). The average distal motor latency (DML), loss of sensory nerve action potentials (SNAP), and/or motor action potentials (MAP) were used as electrophysiological parameters., Results: During the above mentioned period, 395 primary CTS-operations were performed in 268 patients, and 83 operations of recurrent CTS in 53 patients, i.e. approximately 50 % of the patients had bilateral operations. A second recurrency of CTS was treated in 29 hands of 20 patients and a third recurrency in six hands of five patients. The ratio of women to men suffering from CTS was approximately 1 : 1. TVS occurred concurrent in 22 % of the patients in one hand and in 11.6 % in both hands. Decompression of the median nerve was performed more frequently on the shunt-side, or primarily on the shunt-side, if both hands were affected, as compared to the contralateral side. Recurrency of CTS, possibly a second or third recurrency, was found with increasing time of dialysis. The temporal interval from one operation to the other had a declining tendency. Whereas at the time of the primary operation in 27.4 % of the patients a CTS I degrees was found, patients suffered from CTS II degrees or III degrees in case of a second or third recurrency. Deterioration of clinical signs in CTS recurrency was reflected by the electrophysiological findings with an increasing loss of SNAP and MAP., Conclusion: CTS is a typical complication of chronic haemodialysis, and differs from idiopathic CTS by a gender ratio of 1 : 1, a high frequency of concurrent TVS, as well as a tendency to recur. Since compression of the median nerve was found preferentially on the shunt-side, haemodynamic factors may play a role in the pathogenesis of the disease in addition to amyloidosis. Haemodialysis patients complaining of paraesthesia in their hands should undergo electrophysiological examination, even if a successful CTS-operation was performed in the past.

Purpose: Following surgery for breast cancer, an increased risk is assumed for development or worsening of lymphedema following hand surgery procedures. The aim of this study was to find out whether surgery performed with exsanguination using a pneumatic tourniquet has any disadvantages under these circumstances. There might result consequences for patients' information of possible risks as well as for performance of hand surgical procedures., Method: 52 patients who had undergone mastectomy were included in the study. In 47 of these, axillar lymph node biopsy or dissection had been performed. 41 patients had been advised not to allow measurement of blood pressure, drawing of blood or surgery to that arm. Surgical release of the retinaculum flexorum by using local anesthesia and exsanguination for a maximum of ten minutes was performed at an average of 7.5 (range from 1 - 26) years after the breast operation., Results: Following release of the carpal ligament a temporary swelling of the arm or hand was found in four patients, which persisted for 2 - 3 months in one patient and disappeared within one week in the others. Three patients suffered from moderate lymphedema before surgery. It was unaffected by hand surgery in two patients and only temporarily worsened for several days in another patient. In all patients, neurological symptoms (paresthesia, numbness and pain) improved completely. Other complications, particularly infections, were not observed., Conclusions: 1. Exaggerated information of patients with breast surgery in their history does not seem to be indicated in minor hand surgical procedures. 2. The hand surgeon should inform the patients preoperatively that there may occur a transient swelling which can be avoided by loose dressings and early functional training. Using a pneumatic tourniquet has no adverse effect on existing lymphedema in short lasting procedures. 3. Since patients after mastectomy and/or axillary dissection often complain about arm pain and paraesthesia, not only brachial plexus pathology but also a carpal tunnel syndrome must be considered.

We report a case of bilateral carpal tunnel syndrome due to two distinct muscular anomalies coexisting with trigger finger deformity. Many muscular anomalies in association with carpal tunnel syndrome have been described so far. But such a unique case of bilateral carpal tunnel syndrome with two different muscular anomalies, flexor digitorum superficialis anomaly on one side and palmaris longus anomaly on the other side has not been described. Even rare, muscular anomalies should be considered in the aetiology of carpal tunnel syndrome.

This is a report about 1000 endoscopic carpal tunnel release procedures using a single-portal system. Not a single iatrogenic lesion was found out at the follow-up check. Under consideration of certain technical details there is no risk of lesions.

The goal of the presented carpal tunnel syndrome (CTS) follow-up study was to compare the clinical value of the Millesi hand function score with the "Pressure Specifying Sensory Device" (PSSD) introduced by A. L. Dellon using self-administered patient questionnaires. 25 patients (10 male, 15 female) with an electrodiagnostically confirmed CTS were enrolled in this study, performing one preoperative and five postoperative examinations over 24 weeks. 12 of the 25 patients underwent an "open" two-portal carpal tunnel release with two minimal incisions (group OT); the other 13 patients were treated with a two-portal endoscopic carpal tunnel release (group ET). Additionally, in eleven out of the twelve patients of group OT, an epineuriotomy of the median nerve was performed during the same session. Concerning preoperative data of the Millesi score and the PSSD, no statistically significant differences were found between group OT and ET. However, preoperative comparison with the contralateral hand demonstrated a reduction in hand function of 15% and an increase in the pressure perception threshold of 41% compared to normative data could be measured with the PSSD. The subjective functional value of the hand was objectively evacuated using the Levine score. In the second postoperative week, a significant decrease in hand function could be obtained with the Millesi score in group OT. In group ET, the decrease in hand function representing the operative trauma was significantly lower than in group OT. Data of the static one- and two-point pressure perception threshold revealed a statistically significant improvement of the sensibility in both groups. The results of the Millesi score recorded at the last examination in the 24th postoperative week showed an improvement in hand function in both groups compared to preoperative data. Concerning static one- and two-point measurements with the PSSD, distinct improvements compared to the preoperative data could also be detected in both groups although significant differences between group OT and ET were evident: Data of group OT regarding the whole postoperative course demonstrate a continuous improvement in sensibility of the index finger. In contrast, the analysis of the PSSD measurements in group ET revealed an increase in all the parameters starting in the sixth postoperative week and ending with significantly worse static one- and two-point threshold measurements than in group OT. On the other hand, data of self-administered patient questionnaires using the Levine Score revealed significant improvements in hand function and reduction in pain intensity in both groups compared to preoperative results. Differences between both groups at the end of the examination course were not evident. In conclusion, the Millesi hand score with its emphasis on the motor function proved to be a reliable method to record the severity of CTS preoperatively, the severity of the surgical trauma and changes in the course of rehabilitation of the affected hand. A good correlation was found between data obtained with the Millesi Score and the self-administered patient questionnaires according to Levine. But when compared with the PSSD, both methods could not directly document the preoperative status and postoperative changes of the median nerve. Preoperative static two-point pressure threshold measurements with the PSSD confirmed their status as a screening parameter as published by A. L. Dellon. In the postoperative course of group ET, a distinct worsening in the sensibility of the index and little finger could only be detected with the PSSD before the patients noticed the onset of related symptoms.