Abstract
Background
Carpal tunnel syndrome (CTS) is by far the most common entrapment neuropathy (Adams et al. Am J Ind Med 25:527–536, 1994; Cheadle et al. Am J Public Health 84:190–196, 1994; Stevens et al. Neurology 38:134–138, 1988). A combination of described symptoms, clinical findings and electrophysiological testing is used to confirm the diagnosis. Several studies have suggested that in patients with a clinical diagnosis of CTS, the accuracy of nerve sonography is similar to that for electromyography (Chen et al. BMC Med Imaging 11:22, 2011; Guan et al. Neurol Res 33:970–953, 2011; Kele et al. Neurology 61:389–391, 2003; Tai et al. Ultrasound Med Biol 38:1121–1128, 2012). In special cases though, the nerve sonography can reveal the cause of the median entrapment neuropathy (Fumière et al. JBR-BTR 85:1–3, 2002; Kele et al. J Neurosurg 97:471–473, 2002; Kele et al. Neurology 61:389–391, 2003; Zamora et al. J Clin Ultrasound 39:44–47, 2011).
Methods
A 43-year-old farmer was admitted to our department with 1 year of intermittent pain in the left hand and numbness of the thumb, index and middle finger. The pain and the numbness could be reproduced by extension of the wrist and fingers. The electrophysiological testing revealed signs of an entrapment median neuropathy in carpal tunnel.
Results
The high-resolution sonography (18 MHz) revealed signs of entrapment neuropathy with increased cross-sectional area, disturbed echostructure of the nerve and pathological wrist-to-forearm ratio, confirming the results from a similar study (Kele et al. Neurology 61:389–391, 2003). In addition, an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel could be identified. During the extension of the wrist and fingers, a greater protrusion of the muscle belly could be demonstrated causing compression of the median nerve.
Conclusions
We present a video case report of the sonographic findings of a patient diagnosed with carpal tunnel syndrome due to an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel. Our case highlights the importance of nerve sonography in the differential diagnosis of the cause of a carpal tunnel syndrome. With the aid of ultrasonography, it is possible to obtain very important information concerning different aspects of this case. First, in showing the presence of the elongated muscle belly of the flexor digitorum superficialis, the cause of the symptoms could be explained. Second, it was possible through the ultrasound study to explain the atypical clinical appearance in this case, demonstrating the compression neuropathy only after extension of the wrist and fingers. There have been no previous reports in which authors described an elongated muscle belly as cause of a CTS. Third, and perhaps most important, ultrasonography had a direct influence on our selection of therapeutical strategy and approach. As a result, we recommended in this patient a surgical therapy to completely solve the problem, but the patient declined this option and preferred a conservative therapy with a hand orthosis to prevent wrist extension. In conclusion we recommend ultrasonography as a very useful method in the diagnostic evaluation of carpal tunnel syndrome. We have clearly demonstrated that ultrasonography can be used to discover the cause of median nerve compression, especially in cases with an atypical clinical presentation.
Electronic supplementary material
The online version of this article (doi:10.1007/s11552-012-9435-z) contains supplementary material, which is available to authorized users.
Keywords: Carpal tunnel syndrome, Median nerve neuropathy, Ultrasound
Video 1
Cross-sectional scan with a 12-MHz probe of the median nerve in carpal tunnel
A hypoechoic structure could be immediately be identified as an elongated muscle belly of the flexor digitorum superficialis in the carpal tunnel (Fig. 1).
During the wrist and finger extension, a greater protrusion of the muscle belly of the flexor digitorum superficialis in the carpal tunnel could be demonstrated causing the entrapment neuropathy of the median nerve.
Fig. 1.
Still frame of the carpal tunnel, showing the different anatomic structures and the elongated muscle belly of flexor digitorum superficialis as the cause of the compression neuropathy of the median nerve
Electronic supplementary material
(MP4 228 kb)
Acknowledgments
Disclosures of all authors
A. Kerasnoudis reports no disclosures. This study was not industry sponsored.
References
- 1.Adams ML, Franklin GM, Barnhart S. Outcome of carpal tunnel surgery in Washington State workers' compensation. Am J Ind Med. 1994;25:527–536. doi: 10.1002/ajim.4700250407. [DOI] [PubMed] [Google Scholar]
- 2.Cheadle A, Franklin G, Wolfhagen C, et al. Factors influencing the duration of work-related disability: a population-based study of Washington State workers' compensation. Am J Public Health. 1994;84:190–196. doi: 10.2105/AJPH.84.2.190. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Chen SF, Lu CH, Huang CR, Chuang YC, Tsai NW, Chang CC, et al. Ultrasonographic median nerve cross-section areas measured by 8-point “inching test” for idiopathic carpal tunnel syndrome: a correlation of nerve conduction study severity and duration of clinical symptoms. BMC Med Imaging. 2011;11:22. doi: 10.1186/1471-2342-11-22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Fumière E, Dugardeyn C, Roquet ME, Delcour C. US demonstration of a thrombosed persistent median artery in carpal tunnel syndrome. JBR-BTR. 2002;85(1):1–3. [PubMed] [Google Scholar]
- 5.Guan J, Ji F, Chen W, Chu H, Lu Z. Sonographic and electrophysiological detection in patients with carpal tunnel syndrome. Neurol Res. 2011;33(9):970–975. doi: 10.1179/1743132811Y.0000000028. [DOI] [PubMed] [Google Scholar]
- 6.Kele H, Verheggen R, Reimers CD. Carpal tunnel syndrome caused by thrombosis of the median artery: the importance of high-resolution ultrasonography for diagnosis. Case report. J Neurosurg. 2002;97(2):471–473. doi: 10.3171/jns.2002.97.2.0471. [DOI] [PubMed] [Google Scholar]
- 7.Kele H, Verheggen R, Bittermann HJ, Reimers CD. The potential value of ultrasonography in the evaluation of carpal tunnel syndrome. Neurology. 2003;61(3):389–391. doi: 10.1212/01.WNL.0000073101.04845.22. [DOI] [PubMed] [Google Scholar]
- 8.Stevens JC, Sun S, Beard CM, O'Fallon WM, Kurland LT. Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Neurology. 1988;38:134–138. doi: 10.1212/WNL.38.1.134. [DOI] [PubMed] [Google Scholar]
- 9.Tai TW, Wu CY, Su FC, Chern TC, Jou IM. Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy. Ultrasound Med Biol. 2012;38(7):1121–1128. doi: 10.1016/j.ultrasmedbio.2012.02.026. [DOI] [PubMed] [Google Scholar]
- 10.Zamora CA, Zamora MA, Soto JD, Garcés MÁ. Myoepithelioma of the hand and carpal tunnel: an unusual cause of median nerve compression. J Clin Ultrasound. 2011;39(1):44–47. doi: 10.1002/jcu.20740. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
(MP4 228 kb)