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Carpal and Guyon tunnel syndrome in burns at the wrist
Carpal and Guyon tunnel syndrome in burns at the wrist A series of 22 patients with burns of the upper extremities have been evaluated by clinical and electromyographic (EMG) studies. As suggested by others, a significantly higher incidence of carpal tunnel syndrome and sensory involvement of the ulnar nerve was discovered. Those findings suggest that we pay more attention to the median and ulnar nerves at the wrist level in burns and treat them when compression is demonstrated by clinical and EMG evaluation.
Jean Fissette, M.D., Andre Onkelinx, M.D., and Nasseredine Fandi, M.D., Liege, Belgium
Carpal tunnel syndrome and compression within the loge de Guyon in the burned patient has been pointed out, but we were unable to find any studies on this particular subject in the recent literature. 1, 2 In this study we reviewed 22 patients who had sustained a bum at the wrist level. Deep electrical and chemical burns involving the forearm, the wrist, or the hand were not included because of their direct damaging effect on the nerve. The time between the burn injury and the investigation ranged from 1 to 9 years. Five female and 17 male patients were evaluated. Their ages at the time of injury varied from 4 to 57 years. The investigation was conducted in the Department of Plastic Surgery of the Liege University and a total of 39 wrists were studied. The study consisted of a clinical examination, electromyographic (EMG), and nerve conduction velocity tests of the median and ulnar nerves at the levels of the forearm and wrist. It was sometimes difficult to discriminate symptoms of neurologic origin from those related to the various lesions in the soft tissues. Skin fragility and hypersensitivity, scar contractures, and periarticular involvement are very often present and superimposed on the symptoms of neurologic origin. Clinical evaluation was based on numbness and tingling of the fingers, thenar eminence atrophy, and Tinel's sign at the wrist. Weakness or inaccuracy of the From the University of Liege, Hopital de Baviere, 4020 Liege , Belgium. Received for publication March 29, 1980. Reprint requests: Jean Fissette, Service de Chirurgie Plastique, University of Liege, H6pital de Baviere, 66, Boulevard de la Constitution, 4020 Liege, Belgium.
0363-5023/811010013+03$00.3010
usual movements controlled by the median and ulnar nerves were noted as was pain in the nerve's territory of the hand with or without irradiation above the wrist level. We suspected nerve damage when at least two of those clinical signs were present. Electrical evaluation was a more objective test. We used the following method of investigation: Neurogenic findings were recorded while the muscles were at rest and during maximal activity; the flexor carpi radialis, flexor carpi ulnaris, abductor digiti quinti, abductor pollicis brevis, and sometimes the opponens pollicis were studied. Motor conduction velocities and distal latencies were measured after stimulation at the elbow and at the distal crease of the wrist. Motor evoked potentials were recorded in the abductor pollicis brevis for the median nerve and in the abductor digiti quinti for the ulnar nerve. Sensitive distal latencies were measured antidromically. In that way, we were able to rule out a possible total nerve lesion as it may happen in some systemic disease (e.g., diabetes) or in a more proximal traumatic involvement of the upper limb. EMG findings were considered pathologic when the distal motor latency exceeded 4 msec for the median nerve and 3 msec for the ulnar nerve. For the distal sensitive latency, a delay of more than 3 msec was considered abnormal for both median and ulnar nerves. Of 22 patients we examined, 14 accepted the EMG tests and eight refused. Table I summarizes those data, showing the numbers of bilateral and unilateral cases. A total of 39 burned wrists were examined. EMG tests were performed on 24. When the median nerve was tested in those 24
© 1981 American Society for Surgery of the Hand
THE JOURNAL OF HAND SURGERY
13
The Journal of
14
HAND SURGERY
Fissetfe, Onkelillx. alld Falldi
Table II. Positive clinical signs demonstrated in a series of 39 wrists
Table I. Number of patients studied with and without EMG tests
With EMG unilateral bilateral WithoutEMG unilateral bilateral Total
No. of patients
No. of wrists
4 10
4 20
7 22
14 39
Nerve clinically involved
With EMG unilateral bilateral WithoutEMG unilateral bilateral Total
No . of patients
No. of wrists
2 (4) 5 (10)
2 (4) 10 (20)
I (I) 3 (7) II (22)
I (I) 6 (14) 19 (39)
Table III. Clinical and EMG data in our 22 patients Median nerve
Vlnar nerve
EMG Left Pt . No.
Age
Sex
V nilat . or bilat.
2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 20 21 22
29 14 16 32 51 50 28 56 24 43 57 28 52 17 22 39 16 28 9 4 31 34
M M M M M M M M M M M M M M M M M F F F F F
LR R L R L L R L R L R L L R L R L R L L R L R L R LR LR L R L R L R R L R
Clin.
+ ++ +++ ++ +? ++ ++ ++ +
+ +
M*l 4.4 6.5 4.3 4.5 5.1
EMG Right
S*
M
Normal Normal Normal Normal 3.7 4.2 4.5 7.1 4 4.4 3.7 4.5 4.2 4.4
I
Left
S
Clin.
M
2.2 2.3 2.9 2.8 3.7 Imp. 3.9 3.7 3.6
+? ++ ++ ++
2.4 2.9 3.6
I
Right
S
M
2.9 2.7 3 2.4 2.8 2.7 3 2.3 Normal Normal 2.5 2.8 2.6 3.2 Imp. 3.1
I
S 3.5 3 3.4 3
3.3 2.7 4
++ ++ ++ +
4.2 3.5
++
3 .6 4.5 3.7 3.6 Normal Normal Normal
3.7 3.9
+ +
2 .7 2.4 2.5
++ 2.7
2.7 3.1 2.5 3.3 2.5 2.9 Normal 3.1 ?
3.6 3.3 3. 1 ?
No EMG data for patients Nos. 10 to 17. • M. Distal motor latency; S. distal sensitive latency.
wrists, an EMG test result was pathologic in 14 cases; when the ulnar nerve was evaluated, 15 showed an abnormal EMG response . Of 39 wrists evaluated, positive clinical signs were demonstrated in 19 . This is shown in Table II where, in addition, we have separated those patients who accepted the EMG tests and those who refused.
Table III shows the clinical data combined with the EMG results . The significant frequency of the clinical symptoms is noted , but the EMG findings appear to be more demonstrative when compared with a standard population . The median nerve appears to be the most severely injured and important motor and sensory involvement
Vol. 6, No . I January 1981
was found in 12 cases. A striking finding for the ulnar nerve was the higher incidence of pathologic EMG results (more than 60%); the damage, however, is lighter and more often involves the sensory component of the ulnar nerve. Because the frequency and the nature of the clinical symptoms were quite similar in those eight patients who refused the EMG studies , we suggest that the results would have been similar. Conclusions
A high incidence of clinical symptoms of median and/or ulnar nerve involvement is noticed following burns at the wrist level. This is confirmed by EMG findings where motor and sensory damage of the median nerve is present in more than 50% of the patients and a sensory involvement of the ulnar nerve in more than 60%. One patient presented a pathologic EMG test in the absence of clinical symptoms.
Carpal and Gllyon tllnnel syndrome
15
Because deep burns of the wrist, with their direct destroying effect on the nerve , were excluded in this study, we conclude that the lesions we found in our series are most likely due to edema and subsequent scar formation in the soft tissues. For the median nerve, we were unable to determine whether the lesion was located within the carpal tunnel or before its entry into the tunnel, where it is more superficial. Earlier clinical and EMG studies will hopefully help us to treat patients earlier and to ease the rehabilitation of the burned hands. REFERENCES I . Brown EZ Jr, Snyder CC: Carpal tunnel syndrome caused by hand injuries . Plast Reconstr Surg 56:41-3 , 1975 2. McClain EJ, Wissinger HA : The acute carpal tunnel syndrome: Nine case reports. J Trauma 16:75-8, 1976
Jean Fissette, M.D., Andre Onkelinx, M.D., and Nasseredine Fandi, M.D., Liege, Belgium
Carpal tunnel syndrome and compression within the loge de Guyon in the burned patient has been pointed out, but we were unable to find any studies on this particular subject in the recent literature. 1, 2 In this study we reviewed 22 patients who had sustained a bum at the wrist level. Deep electrical and chemical burns involving the forearm, the wrist, or the hand were not included because of their direct damaging effect on the nerve. The time between the burn injury and the investigation ranged from 1 to 9 years. Five female and 17 male patients were evaluated. Their ages at the time of injury varied from 4 to 57 years. The investigation was conducted in the Department of Plastic Surgery of the Liege University and a total of 39 wrists were studied. The study consisted of a clinical examination, electromyographic (EMG), and nerve conduction velocity tests of the median and ulnar nerves at the levels of the forearm and wrist. It was sometimes difficult to discriminate symptoms of neurologic origin from those related to the various lesions in the soft tissues. Skin fragility and hypersensitivity, scar contractures, and periarticular involvement are very often present and superimposed on the symptoms of neurologic origin. Clinical evaluation was based on numbness and tingling of the fingers, thenar eminence atrophy, and Tinel's sign at the wrist. Weakness or inaccuracy of the From the University of Liege, Hopital de Baviere, 4020 Liege , Belgium. Received for publication March 29, 1980. Reprint requests: Jean Fissette, Service de Chirurgie Plastique, University of Liege, H6pital de Baviere, 66, Boulevard de la Constitution, 4020 Liege, Belgium.
0363-5023/811010013+03$00.3010
usual movements controlled by the median and ulnar nerves were noted as was pain in the nerve's territory of the hand with or without irradiation above the wrist level. We suspected nerve damage when at least two of those clinical signs were present. Electrical evaluation was a more objective test. We used the following method of investigation: Neurogenic findings were recorded while the muscles were at rest and during maximal activity; the flexor carpi radialis, flexor carpi ulnaris, abductor digiti quinti, abductor pollicis brevis, and sometimes the opponens pollicis were studied. Motor conduction velocities and distal latencies were measured after stimulation at the elbow and at the distal crease of the wrist. Motor evoked potentials were recorded in the abductor pollicis brevis for the median nerve and in the abductor digiti quinti for the ulnar nerve. Sensitive distal latencies were measured antidromically. In that way, we were able to rule out a possible total nerve lesion as it may happen in some systemic disease (e.g., diabetes) or in a more proximal traumatic involvement of the upper limb. EMG findings were considered pathologic when the distal motor latency exceeded 4 msec for the median nerve and 3 msec for the ulnar nerve. For the distal sensitive latency, a delay of more than 3 msec was considered abnormal for both median and ulnar nerves. Of 22 patients we examined, 14 accepted the EMG tests and eight refused. Table I summarizes those data, showing the numbers of bilateral and unilateral cases. A total of 39 burned wrists were examined. EMG tests were performed on 24. When the median nerve was tested in those 24
© 1981 American Society for Surgery of the Hand
THE JOURNAL OF HAND SURGERY
13
The Journal of
14
HAND SURGERY
Fissetfe, Onkelillx. alld Falldi
Table II. Positive clinical signs demonstrated in a series of 39 wrists
Table I. Number of patients studied with and without EMG tests
With EMG unilateral bilateral WithoutEMG unilateral bilateral Total
No. of patients
No. of wrists
4 10
4 20
7 22
14 39
Nerve clinically involved
With EMG unilateral bilateral WithoutEMG unilateral bilateral Total
No . of patients
No. of wrists
2 (4) 5 (10)
2 (4) 10 (20)
I (I) 3 (7) II (22)
I (I) 6 (14) 19 (39)
Table III. Clinical and EMG data in our 22 patients Median nerve
Vlnar nerve
EMG Left Pt . No.
Age
Sex
V nilat . or bilat.
2 3 4 5 6 7 8 9 10 II 12 13 14 15 16 17 18 19 20 21 22
29 14 16 32 51 50 28 56 24 43 57 28 52 17 22 39 16 28 9 4 31 34
M M M M M M M M M M M M M M M M M F F F F F
LR R L R L L R L R L R L L R L R L R L L R L R L R LR LR L R L R L R R L R
Clin.
+ ++ +++ ++ +? ++ ++ ++ +
+ +
M*l 4.4 6.5 4.3 4.5 5.1
EMG Right
S*
M
Normal Normal Normal Normal 3.7 4.2 4.5 7.1 4 4.4 3.7 4.5 4.2 4.4
I
Left
S
Clin.
M
2.2 2.3 2.9 2.8 3.7 Imp. 3.9 3.7 3.6
+? ++ ++ ++
2.4 2.9 3.6
I
Right
S
M
2.9 2.7 3 2.4 2.8 2.7 3 2.3 Normal Normal 2.5 2.8 2.6 3.2 Imp. 3.1
I
S 3.5 3 3.4 3
3.3 2.7 4
++ ++ ++ +
4.2 3.5
++
3 .6 4.5 3.7 3.6 Normal Normal Normal
3.7 3.9
+ +
2 .7 2.4 2.5
++ 2.7
2.7 3.1 2.5 3.3 2.5 2.9 Normal 3.1 ?
3.6 3.3 3. 1 ?
No EMG data for patients Nos. 10 to 17. • M. Distal motor latency; S. distal sensitive latency.
wrists, an EMG test result was pathologic in 14 cases; when the ulnar nerve was evaluated, 15 showed an abnormal EMG response . Of 39 wrists evaluated, positive clinical signs were demonstrated in 19 . This is shown in Table II where, in addition, we have separated those patients who accepted the EMG tests and those who refused.
Table III shows the clinical data combined with the EMG results . The significant frequency of the clinical symptoms is noted , but the EMG findings appear to be more demonstrative when compared with a standard population . The median nerve appears to be the most severely injured and important motor and sensory involvement
Vol. 6, No . I January 1981
was found in 12 cases. A striking finding for the ulnar nerve was the higher incidence of pathologic EMG results (more than 60%); the damage, however, is lighter and more often involves the sensory component of the ulnar nerve. Because the frequency and the nature of the clinical symptoms were quite similar in those eight patients who refused the EMG studies , we suggest that the results would have been similar. Conclusions
A high incidence of clinical symptoms of median and/or ulnar nerve involvement is noticed following burns at the wrist level. This is confirmed by EMG findings where motor and sensory damage of the median nerve is present in more than 50% of the patients and a sensory involvement of the ulnar nerve in more than 60%. One patient presented a pathologic EMG test in the absence of clinical symptoms.
Carpal and Gllyon tllnnel syndrome
15
Because deep burns of the wrist, with their direct destroying effect on the nerve , were excluded in this study, we conclude that the lesions we found in our series are most likely due to edema and subsequent scar formation in the soft tissues. For the median nerve, we were unable to determine whether the lesion was located within the carpal tunnel or before its entry into the tunnel, where it is more superficial. Earlier clinical and EMG studies will hopefully help us to treat patients earlier and to ease the rehabilitation of the burned hands. REFERENCES I . Brown EZ Jr, Snyder CC: Carpal tunnel syndrome caused by hand injuries . Plast Reconstr Surg 56:41-3 , 1975 2. McClain EJ, Wissinger HA : The acute carpal tunnel syndrome: Nine case reports. J Trauma 16:75-8, 1976