Abstract
Background
Given limited information about acute carpal tunnel syndrome (CTS) in children, the purpose of this study is to describe the presentation and treatment results of CTS after traumatic wrist or forearm injury in a pediatric population.
Methods
In this retrospective single-center cohort study, all children with post-traumatic CTS were identified. Demographic and clinical presentation, treatment, and outcomes data were collected from the electronic medical record. Descriptive statistics were calculated for variables of interest, and Χ2 and independent sample t-tests were used for subgroup comparisons.
Results
18 patients (16 male, average age 12.8 ± 3.6 years) with post-traumatic CTS were identified. 13 presented acutely (<3 days) versus 4 subacutely (1–6 weeks) and one delayed presentation (>6 weeks) after injury. Of associated traumas, 83% (15/18) involved distal radius fractures, of which 40% (6/15) had an associated ulna fracture. The most common symptoms were numbness (78%), paresthesias (33%), and increasing pain (28%). Three patients had clinical concerns for concomitant compartment syndrome. 6 patients were initially monitored (2 acute, 3 subacute, 1 delayed). Ultimately, 16/18 underwent operative release (13/13 acute, 2/4 subacute, 1/1 delayed). At follow-up, 81% of the surgically treated patients had complete symptomatic relief. There was no statistically significant difference in treatment outcomes between acute versus subacute or delayed presentation (OR: 6.67, p = .214). Of patients with acute CTS, delayed surgery resulted in prolonged recovery (28.0 vs. 2.4 weeks, p < .001).
Conclusions
Post-traumatic CTS more often presents acutely than as a delayed complication of distal radius fractures in children. The type of injury and clinical presentation can vary, but patients most often present with median neuropathy symptoms like numbness. Acute CTS should be treated urgently with carpal tunnel release. While patients with delayed presentation can trial observation, the patient will likely warrant surgery for complete symptom relief. Operative treatment for both acute and subacute cases generally results in positive outcomes.
Key Concepts
-
(1)
Post-traumatic CTS may present acutely as a complication of distal radius fractures in children with symptoms of numbness, paresthesias, and increasing pain.
-
(2)
Acute CTS should be treated with urgent carpal tunnel release to avoid prolonged recovery.
-
(3)
Children with delayed presentation of CTS can be safely monitored, but the patient often needs surgery to experience complete symptom relief.
-
(4)
Operative treatment for post-traumatic CTS in children generally results in positive outcomes.
Level of Evidence
IV Case Series
Keywords: Carpal tunnel syndrome, Pediatrics, Trauma
Introduction
Carpal tunnel syndrome (CTS) is rare in children but can occur after traumatic wrist or forearm injuries [1], [2], [3], [4], [5], [6], [7]. Distal radius fractures are the most common cause [8], [9], [10], [11], [12]. Patients present acutely in the emergency department after a recent injury and urgent carpal tunnel release is recommended [8]. Alternatively, those who present later after an injury are treated more like idiopathic CTS cases and may trial more conservative measures before surgery [10].
In adults with distal radius fractures, studies have shown good outcomes after acute carpal tunnel release done at the same time as open reduction and internal fixation [12], [13]. Given the limited information about CTS in children, the purpose of this study is to describe the presentation and treatment results of post-traumatic CTS in a pediatric population. It should be noted that children with mucopolysaccharide storage disorders such as Hurler syndrome can develop CTS without a history of trauma [14], [15].
Methods
Following approval from the institutional review board, a billing query was performed for patients aged 0–18.99 years based on diagnostic codes. International Classification of Disease 9 and 10 Codes for carpal tunnel syndrome, injury or lesion to the median nerve, and other/unspecified mononeuropathy of the upper limb were queried for patients from June 2007 to August 2022. This resulted in 155 patients. Each patient record was screened from the electronic medical record for a history of trauma prior to presentation for carpal tunnel syndrome. Patients without a history of trauma and those outside of the age range were excluded.
Demographic variables of interest were age at the time of injury, age at the time of presentation of CTS, and sex. Clinical information collected from the patient record included the date of trauma/injury, type of injury, laterality, and date and presenting symptoms at the time of CTS diagnosis. Treatment variables collected included primary and/or surgical treatment for initial trauma or injury and primary and/or surgical treatment for CTS, date of surgery if indicated for CTS. Outcome variables of interest include the date of symptom resolution based on the patient report and physical exam and date of last follow-up. Based on dates of injury and dates of presentation, patients were categorized based on time of presentation (Acute < 3 days, Subacute 1–6 weeks, or Delayed > 6 weeks) and whether patients were monitored before surgical carpal tunnel release. Time to surgery was also calculated based on the date of presentation and date of surgery. Lastly, time to symptom resolution was calculated based on the date of symptom resolution and the date of last recorded intervention, either conservative or surgical.
Descriptive statistics were calculated for the demographic, clinical, and treatment variables to evaluate frequencies, averages, and spread. Patients were categorized based on both the time of presentation and based on whether patients trialed observation before surgical treatment or not. A Χ2 test of independence was performed to determine if there was an association between time to presentation and eventual symptom resolution. An Independent sample t-test was also used to compare time to symptom resolution between subgroups. p < .05 was considered statistically significant.
Results
Eighteen patients (16 male) with post-traumatic CTS were identified. The average age at the time of presentation was 12.8 ± 3.6 years. Of the associated traumas, 83% (15/18) had a history of a fracture involving the distal radius. Of these fractures, 93% (14/15) were displaced, 40% (6/15) had an associated ulna fracture, 40% (6/15) involved the physis, and 27% (4/15) were open fractures. Most of these patients (10/15) were treated with closed reduction of which 2 failed and went on to open reductions and internal fixation versus 5 who had primary open reductions and internal fixation.
In this group, 72% (13/18) of patients presented acutely including 6 with symptoms and clinical concern for CTS on the day of injury versus 22% (4/18) who presented subacutely, and one patient had a delayed presentation. For all presentations, the most common symptoms were numbness (78%), paresthesias (33%), swelling (33%), and increasing pain (28%). 17% (3/18) had clinical concern for concomitant compartment syndrome on presentation. While 6 patients were initially monitored (2 acute, 3 subacute, 1 delayed), ultimately, 16/18 of the patients underwent operative carpal tunnel release (13/13 acute, 2/4 subacute, 1/1 delayed). All patients with the clinical diagnosis of compartment syndrome underwent forearm fasciotomies in addition to carpal tunnel release.
At follow-up, 81% (13/16) of surgically treated patients had complete symptomatic relief. The remaining patients had mild pain (n = 2) and one had continued intermittent paresthesia at their latest follow-up. After carpal tunnel release, there was no detectable difference in the resolution of symptoms between patients who presented acutely versus subacutely or delayed (Odds Ratio: 6.67, p = .214). On average, there was not a significant difference in time to symptom resolution between patients who presented acutely versus those who presented subacutely or delayed (1.73 versus 1.58 months, p = .89). However, among children who developed symptoms acutely, patients who underwent a brief period of observation before carpal tunnel release had a significantly longer time to symptom resolution than those who underwent immediate carpal tunnel release (28.0 vs. 2.4 weeks, p < .001).
Discussion
Given its rare presentation, there are few studies reporting on CTS in a pediatric population. Rusch et al. review the etiology of CTS in a cohort of 38 children though only report on 2 traumatic cases [3]. This study adds to the literature a case series of further information on the presentation and outcomes of trauma-associated CTS in children and adolescents.
The clinical presentation of post-traumatic acute CTS can be similar to compartment syndrome including symptoms of pain out of proportion and paresthesia [16]. This overlap in symptoms was seen in 17% of our sample and may be a confounder for the nerve injury associated with CTS. Given the potential for permanent disability from long durations of decreased perfusion, acute compartment syndrome must be treated immediately. However, with the overlap in symptoms, surgeons may consider the concomitant carpal tunnel release as well. To address both, fasciotomies and CTR can be done together, as was done with some cases in our sample.
Timing of carpal tunnel release may also be important for symptom recovery time. Two patients with acute post-traumatic CTS who were observed to monitor symptom resolution had a longer recovery (28.0 vs. 2.4 weeks) than the six patients who had more urgent carpal tunnel release. Given the small sample size, these 2 patients may be outliers; however, this finding is consistent with results in adults, in whom delayed intervention for the traumatic carpal tunnel had permanent consequences including irreversible and intraneural fibrosis [8]. As such, to avoid these potential complications surgery should not be delayed in children with acute CTS.
In our subacute post-traumatic CTS, symptoms may have developed later after the trauma from nerve contusion and/or stretch. Previous studies in adults who developed a transient CTS after trauma did not require surgical release of the carpal tunnel as nerve dysfunction resolved with observation, elevation, and adequate fracture reduction [10]. In our sample of patients who presented subacutely, half (2/4) ultimately went on to have carpal tunnel release and of the 2 who did not, 1 still had symptoms at last follow-up 18 months later. While the surgical decision is based on shared patient-family decision-making, we found that the patient may nonetheless need surgery for complete symptom relief. Similarly, previous studies have shown for patients with delayed presentations of CTS it is less likely that nonoperative treatment such as orthosis or steroid injections will relieve symptoms in pediatric patients [17]. In Van Meir’s review of 163 cases of pediatric carpal tunnel, 89% ultimately underwent carpal tunnel release [6]. Thus, while acute CTS should undergo urgent carpal tunnel release, there is a high likelihood that later presentations with symptoms directly from the trauma or as a complication from the trauma will undergo surgical treatment as well and should be anticipated. Encouragingly, operative treatment tends to result in positive outcomes. In our cohort, 80% of surgically treated patients had symptomatic relief at follow-up. These findings in children match adults, in which the clinical benefit of post-traumatic carpal tunnel release is as effective as those who underwent elective carpal tunnel release [2], [8], [9], [10], [12].
This study has its limitations. First, by being retrospective, there are inherent confines to data collection including standardization of documentation and follow-up. For example, we only had one patient considered in the delayed traumatic CTS group. In our initial query for patients with a diagnosis of carpal tunnel syndrome or who underwent carpal tunnel release, some may have a history of traumatic forearm injury treated at another institution and not documented in their chart and thus were screened out. Missed patients may also contribute to our small sample size which is another limitation of this study and may contribute to our results. For example, while a “brief period of observation” seemed to have a significant effect on nerve recovery, there was no significant effect on time-to-symptom resolution between patients with a delay in presentation. One possible explanation for this contradictory finding is the small sample size of our study creating a high likelihood for type 2 error.
Furthermore, our delayed post-traumatic CTS patient had full symptomatic relief at her first post-operative visit and no further follow-up. However, Velicki et al.’s study on outcomes of carpal tunnel release in pediatric and adolescents found that 4/5 of delayed traumatic CTS experienced recurrent or recalcitrant symptoms [8]. Moreover, given the rarity of CTS in children already, the sample size in our study is small. Still, to our knowledge, it is the largest reported cohort of post-traumatic CTS in a pediatric population.
Overall, CTS is a rare but known complication of traumatic forearm injuries, especially distal radius fractures. This diagnosis should not be missed in pediatric patients who present with numbness and tingling along the median nerve following injury to the forearm. Presentation and symptoms justify timely surgical intervention in the acute setting. Urgent surgery reduces the risk of prolonged neurologic recovery following acute CTS in children. Lastly, with subacute presentation, surgery should be considered for patients whose symptoms do not resolve after monitoring given the symptomatic alleviation after treatment.
Funding
No external funding or sources of support utilized for this study.
Author contributions
Apurva S. Shah: Conceptualization, Data curation, Supervision, Writing – review & editing. Julianna Lee: Conceptualization, Data curation, Formal analysis, Writing – original draft. Eliza Buttrick: Data curation, Project administration, Writing – review & editing.
Declarations of competing interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
- 1.Padua L., Coraci D., Erra C., Costanza P., Paolasso I., Loreti C., et al. Carpal tunnel syndrome: clinical features, diagnosis, and management. Lancet Neurol. 2016;15(12):1273–1284. doi: 10.1016/s1474-4422(16)30231-9. [DOI] [PubMed] [Google Scholar]
- 2.Kim P.T., Lee H.J., Kim T.G., Jeon I.H. Current approaches for carpal tunnel syndrome. Clin Orthop Surg. 2014;6(3):253–257. doi: 10.4055/cios.2014.6.3.253. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Rüsch C.T., Knirsch U., Weber D.M., Rohrbach M., Eichenberger A., Lutschg J., et al. Etiology of carpal tunnel syndrome in a large cohort of children. Children. 2021;8(8):624. doi: 10.3390/children8080624. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Davis L., Vedanarayanan V.V. Carpal tunnel syndrome in children. Pedia Neurol. 2014;50(1):57–59. doi: 10.1016/j.pediatrneurol.2013.08.019. [DOI] [PubMed] [Google Scholar]
- 5.Codd C.M., Abzug J.M. Upper extremity compressive neuropathies in the pediatric and adolescent populations. Curr Rev Musculoskelet Med. 2020;13(6):696–707. doi: 10.1007/s12178-020-09666-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Van Meir N., De Smet L. Carpal tunnel syndrome in children. Acta Orthop Belg. 2003;69(5):387–395. [PubMed] [Google Scholar]
- 7.Shah A.S., Guzek R.H., Miller M.L., Willey M.C., Mahan S.T., Bae D.S. Descriptive epidemiology of isolated distal radius fractures in children: results from a prospective multicenter registry. J Pedia Orthop. 2023;43(1):1–8. doi: 10.1097/bpo.0000000000002288. [DOI] [PubMed] [Google Scholar]
- 8.Gillig J.D., White S.D., Rachel J.N. Acute carpal tunnel syndrome: a review of current literature. Orthop Clin N Am. 2016;47(3):599–607. doi: 10.1016/j.ocl.2016.03.005. [DOI] [PubMed] [Google Scholar]
- 9.Velicki K., Goldfarb C.A., Roberts S., Wall L.B. Outcomes of pediatric and adolescent carpal tunnel release. J Hand Surg. 2021;46(3):178–186. doi: 10.1016/j.jhsa.2020.09.009. [DOI] [PubMed] [Google Scholar]
- 10.Pope D., Tang P. Carpal tunnel syndrome and distal radius fractures. Hand Clin. 2018;34(1):27–32. doi: 10.1016/j.hcl.2017.09.003. [DOI] [PubMed] [Google Scholar]
- 11.Gohel S., Baldwin K.D., Hill J.F. Closed reduction of pediatric distal radial fractures and epiphyseal separations. JBJS Ess Surg Tech. 2020;10(4) doi: 10.2106/jbjs.st.19.00059. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Chauhan A., Bowlin T.C., Mih A.D., Merrell G.A. Patient-reported outcomes after acute carpal tunnel release in patients with distal radius open reduction internal fixation. Hand. 2012;7(2):147–150. doi: 10.1007/s11552-012-9400-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Medici A., Meccariello L., Rollo G., De Nigris G., Mccabe S.J., Grubor P., et al. Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes? Injury. 2017;48(Suppl 3):S30–S33. doi: 10.1016/s0020-1383(17)30654-x. [DOI] [PubMed] [Google Scholar]
- 14.Holt J.B., Van Heest A.E., Shah A.S. Hand disorders in children with mucopolysaccharide storage diseases. J Hand Surg Am. 2013;38(11):2263–2266. doi: 10.1016/j.jhsa.2013.08.100. [DOI] [PubMed] [Google Scholar]
- 15.Van Heest A.E., House J., Krivit W., Walker K. Surgical treatment of carpal tunnel syndrome and trigger digits in children with mucopolysaccharide storage disorders. J Hand Surg Am. 1998;23(2):236–243. doi: 10.1016/s0363-5023(98)80120-2. [DOI] [PubMed] [Google Scholar]
- 16.Kanj W.W., Gunderson M.A., Carrigan R.B., Sankar W.N. Acute compartment syndrome of the upper extremity in children: diagnosis, management, and outcomes. J Child Orthop. 2013;7(3):225–233. doi: 10.1007/s11832-013-0492-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Batdorf N.J., Cantwell S.R., Moran S.L. Idiopathic carpal tunnel syndrome in children and adolescents. J Hand Surg Am. 2015;40(4):773–777. doi: 10.1016/j.jhsa.2015.01.026. [DOI] [PubMed] [Google Scholar]