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Acute carpal tunnel syndrome caused by fracture of the scaphoid and the 5th metacarpal bones
198
Injury(1984) 16, 198-199
Printedin
Great Britain
Acute carpal tunnel syndrome caused by fracture the scaphoid and the 5th metacarpal bones
of
Claes Olerud and Lennart Lbnquist University Hospital, Uppsala, Sweden Summary A case of acute carpal tunnel syndrome in a 19-year-old girl is described. She sustained undisplaced fractures of the right scaphoid and 5th metacarpal bones during a motorcycle collision with a deer. The carpal tunnel syndrome developed within 3 hours of the accident and the diagnosis was easily established since she developed intense pain in her wrist, together with paraesthesiae in the distribution of the median nerve. The carpal tunnel was decompressed within 1 hour of the onset of the symptoms, revealing a fracture haematoma under pressure. The pain disappeared immediately and the sensation was next to normal within 12 hours and completely normal within 3 weeks.
INTRODUCTION ACUTE compression of the median nerve in the carpal tunnel is a rare condition. It is usually associated with distal fractures of the radius and is considered to be due either to the position of the hand during immobilization or to bleeding or oedema produced by the injury. There are also occasional reports in the literature of other conditions in the wrist area that are associated with the syndrome, such as carpal fractures, infections and thrombosis of the median artery. The present report consists of one case of acute carpal tunnel syndrome after undisplaced fractures of the scaphoid and the base of the 5th metacarpal bones. CASE REPORT A 19-year-old girl who collided with a deer on her motorcycle injured her right arm. On admission 20 minutes after the accident she complained of pain in her right wrist. Examination revealed a slight swelling over the wrist and tenderness at the base of the 5th metacarpal bone and over the scaphoid bone. She had normal function of the hand. Radiography showed undisplaced fractures of the base of the 5th metacarpal bone and of the tuberosity of the scaphoid (Fig. 1). The forearm and hand were splinted in neutral position in a split, padded plaster cast. Three hours after the injury the girl started to develop severe pain in her wrist. The intensity of the pain increased in spite of the removal of the cast. Parallel to the onset of pain paraesthesia started to develop in the palmar aspects of the three radial fingers. This, in combination with a positive Tinel’s sign, established the diagnosis and she was immediately taken to the operating room. The swelling over the area was still very slight. The skih was anaesthetized with a subcutaneous local anaesthetic. A Z-shaped palmar skin incision was made. Blood with small droplets of fat under high pressure was released when the transverse carpal ligament was divided. On examining I
Fig. 1. Radiographs showing undisplaced fractures of the distal radial tubercle of the scaphoid and the base of the 5th metacarpal bones of the right hand.
Olerud and Lbnnquist:
199
Acute carpal tunnel syndrome
the median nerve an indentation could be clearly seen as it passed under the ligament. The ligament was left unsutured and only the skin was closed. The girl was relieved of the intense pain as soon as the ligament was opened. On examination the next day she had perfectly normal sensation on the thumb and index finger but she had an area of numbness approximately 1 x 2cm on the radial side of the palmar aspect of the middle finger. After 3 weeks the sensation was normal in all fingers. The fractures healed uneventfully.
DISCUSSION
Compression of the median nerve in the carpal tunnel is a well-known syndrome. It was first described by Marie and Foix (1913). Acute compression is extremely rare. There are only a few case reports in the literature. In most instances the compression is associated with Colles’ fractures and is considered to be due to bleeding, soft tissue swelling or the position of the hand during immobilization (McClain and Wissinger, 1976; Weiland et al., 1976; Bauman et al., 1981). There are also some reports of other traumatic causes such as fracturedislocation of the metacarpal bone (Weiland et al., 1976) and some non-traumatic causes like thrombosis of a median artery (Maxwell et al., 1973), spontaneous intraneural haemorrhage (Hayden, 1964) or infection (Williams and Geer, 1963). As far as we know, the syndrome has not been described after such a mild injury as undisplaced fractures of the scaphoid and the 5th metacarpal bones. The girl described in this paper had a high energy injury of her hand. There was probably quite a large effusion into the carpal area and the soft tissue injury was likely to be extensive. The condition developed quickly. It was less than half an hour from the onset of the symptoms to such severe pain that administration of morphine was necessary. The haematoma rather than the oedema, which probably had not then developed, was the cause of the compression of the median nerve. The small droplets of fat indicated communication with the fractures.
The early evacuation of the haematoma led to a fast recovery of the nerve function. Weiland et al. (1976) and McClain and Wissinger (1976) also report good results after early surgical intervention. CONCLUSION
Even small undisplaced fractures in the carpal area can be associated with extensive haemorrhage that can spread through the loose connective tissue and cause acute compression of the median nerve in the carpal tunnel. This shows the importance of a thorough investigation of the nerve function even in cases with apparently minor injuries. Early decompression relieves the patient of the intense pain and is vital for a fast and complete recovery of the nerve’s function.
REFERENCES
Bauman T. D., Gelberman R. H., Mubarak ‘8. J. et al. (1981) The acute carpal tunnel syndrome. Clin. Orthop. 156, 151. Hayden J. W. (1964) Median neuropathy in the carpal tunnel caused by spontaneous intraneural hemorrhage. J. Bone Joint Surg. 46A, 1242. Marie P. and Foix C. (1913) Atropie isolee de l’eminance thtmiere d’origine ntvritique. Rote du ligament annulaire anterieur du carpe dans la pathogenic de la lesion. Rev. Neurol. 26, 641. McClain E. J. and Wissinger H. A. (1976) The acute carpal tunnel syndrome: nine case reports. J. Truuma 16(l), 75. Maxwell J. A., Kepes J. J. and Ketchum L. D. (1973) Acute carpal tunnel syndrome secondary to thrombosis of a persistent median artery. J. Neurosurg. 38, 114. Weiland A. J., Lister G. D. and Villarreal-Rios A. (1976) Volar fracture dislocations of the second and third carpometacarpal joints associated with acute carpal tunnel syndrome. J. Trauma 16(8), 672. Williams L. F. and Geer T. (1963) Acute carpal tunnel syndrome secondary to pyogenic infection of the forearm. JAMA 185,409. Paper accepted 10 February
1984.
Requests for reprints should be addressed to: Dr Claes Olerud, Department of Orthopaedic Surgery, University Hospital, Uppsala, Sweden.
Injury(1984) 16, 198-199
Printedin
Great Britain
Acute carpal tunnel syndrome caused by fracture the scaphoid and the 5th metacarpal bones
of
Claes Olerud and Lennart Lbnquist University Hospital, Uppsala, Sweden Summary A case of acute carpal tunnel syndrome in a 19-year-old girl is described. She sustained undisplaced fractures of the right scaphoid and 5th metacarpal bones during a motorcycle collision with a deer. The carpal tunnel syndrome developed within 3 hours of the accident and the diagnosis was easily established since she developed intense pain in her wrist, together with paraesthesiae in the distribution of the median nerve. The carpal tunnel was decompressed within 1 hour of the onset of the symptoms, revealing a fracture haematoma under pressure. The pain disappeared immediately and the sensation was next to normal within 12 hours and completely normal within 3 weeks.
INTRODUCTION ACUTE compression of the median nerve in the carpal tunnel is a rare condition. It is usually associated with distal fractures of the radius and is considered to be due either to the position of the hand during immobilization or to bleeding or oedema produced by the injury. There are also occasional reports in the literature of other conditions in the wrist area that are associated with the syndrome, such as carpal fractures, infections and thrombosis of the median artery. The present report consists of one case of acute carpal tunnel syndrome after undisplaced fractures of the scaphoid and the base of the 5th metacarpal bones. CASE REPORT A 19-year-old girl who collided with a deer on her motorcycle injured her right arm. On admission 20 minutes after the accident she complained of pain in her right wrist. Examination revealed a slight swelling over the wrist and tenderness at the base of the 5th metacarpal bone and over the scaphoid bone. She had normal function of the hand. Radiography showed undisplaced fractures of the base of the 5th metacarpal bone and of the tuberosity of the scaphoid (Fig. 1). The forearm and hand were splinted in neutral position in a split, padded plaster cast. Three hours after the injury the girl started to develop severe pain in her wrist. The intensity of the pain increased in spite of the removal of the cast. Parallel to the onset of pain paraesthesia started to develop in the palmar aspects of the three radial fingers. This, in combination with a positive Tinel’s sign, established the diagnosis and she was immediately taken to the operating room. The swelling over the area was still very slight. The skih was anaesthetized with a subcutaneous local anaesthetic. A Z-shaped palmar skin incision was made. Blood with small droplets of fat under high pressure was released when the transverse carpal ligament was divided. On examining I
Fig. 1. Radiographs showing undisplaced fractures of the distal radial tubercle of the scaphoid and the base of the 5th metacarpal bones of the right hand.
Olerud and Lbnnquist:
199
Acute carpal tunnel syndrome
the median nerve an indentation could be clearly seen as it passed under the ligament. The ligament was left unsutured and only the skin was closed. The girl was relieved of the intense pain as soon as the ligament was opened. On examination the next day she had perfectly normal sensation on the thumb and index finger but she had an area of numbness approximately 1 x 2cm on the radial side of the palmar aspect of the middle finger. After 3 weeks the sensation was normal in all fingers. The fractures healed uneventfully.
DISCUSSION
Compression of the median nerve in the carpal tunnel is a well-known syndrome. It was first described by Marie and Foix (1913). Acute compression is extremely rare. There are only a few case reports in the literature. In most instances the compression is associated with Colles’ fractures and is considered to be due to bleeding, soft tissue swelling or the position of the hand during immobilization (McClain and Wissinger, 1976; Weiland et al., 1976; Bauman et al., 1981). There are also some reports of other traumatic causes such as fracturedislocation of the metacarpal bone (Weiland et al., 1976) and some non-traumatic causes like thrombosis of a median artery (Maxwell et al., 1973), spontaneous intraneural haemorrhage (Hayden, 1964) or infection (Williams and Geer, 1963). As far as we know, the syndrome has not been described after such a mild injury as undisplaced fractures of the scaphoid and the 5th metacarpal bones. The girl described in this paper had a high energy injury of her hand. There was probably quite a large effusion into the carpal area and the soft tissue injury was likely to be extensive. The condition developed quickly. It was less than half an hour from the onset of the symptoms to such severe pain that administration of morphine was necessary. The haematoma rather than the oedema, which probably had not then developed, was the cause of the compression of the median nerve. The small droplets of fat indicated communication with the fractures.
The early evacuation of the haematoma led to a fast recovery of the nerve function. Weiland et al. (1976) and McClain and Wissinger (1976) also report good results after early surgical intervention. CONCLUSION
Even small undisplaced fractures in the carpal area can be associated with extensive haemorrhage that can spread through the loose connective tissue and cause acute compression of the median nerve in the carpal tunnel. This shows the importance of a thorough investigation of the nerve function even in cases with apparently minor injuries. Early decompression relieves the patient of the intense pain and is vital for a fast and complete recovery of the nerve’s function.
REFERENCES
Bauman T. D., Gelberman R. H., Mubarak ‘8. J. et al. (1981) The acute carpal tunnel syndrome. Clin. Orthop. 156, 151. Hayden J. W. (1964) Median neuropathy in the carpal tunnel caused by spontaneous intraneural hemorrhage. J. Bone Joint Surg. 46A, 1242. Marie P. and Foix C. (1913) Atropie isolee de l’eminance thtmiere d’origine ntvritique. Rote du ligament annulaire anterieur du carpe dans la pathogenic de la lesion. Rev. Neurol. 26, 641. McClain E. J. and Wissinger H. A. (1976) The acute carpal tunnel syndrome: nine case reports. J. Truuma 16(l), 75. Maxwell J. A., Kepes J. J. and Ketchum L. D. (1973) Acute carpal tunnel syndrome secondary to thrombosis of a persistent median artery. J. Neurosurg. 38, 114. Weiland A. J., Lister G. D. and Villarreal-Rios A. (1976) Volar fracture dislocations of the second and third carpometacarpal joints associated with acute carpal tunnel syndrome. J. Trauma 16(8), 672. Williams L. F. and Geer T. (1963) Acute carpal tunnel syndrome secondary to pyogenic infection of the forearm. JAMA 185,409. Paper accepted 10 February
1984.
Requests for reprints should be addressed to: Dr Claes Olerud, Department of Orthopaedic Surgery, University Hospital, Uppsala, Sweden.