Carpal tunnel syndrome caused by a giant lipoma of the hand: A case report.

INTRODUCTION AND IMPORTANCE: Lipomas are common benign tumours which occur in up to 2% of the population. They are classified as giant when larger than 5 cm. Although they are usually asymptomatic, giant lipomas of the hand may cause compression of the underlying tissues. CASE PRESENTATION: A 62-year-old Caucasian male presented to the Plastic and Reconstructive Surgery outpatient clinic with numbness and pain in his left hand. The numbness in his fingers pointed to compression of the median nerve, as well as the ulnar nerve. He presented with a rapidly progressive swelling in his left palm. An MRI scan of the hand was made, which showed a lipoma of approximately 8,5 cm in diameter. The swelling was surgically removed and sent for histopathological analysis, which confirmed the diagnosis of benign giant lipoma of the hand. Two weeks postoperatively, pain and numbness significantly decreased. CLINICAL DISCUSSION: Neural injury in carpal tunnel syndrome is related to the duration and degree of compression. A giant lipoma is considered malignant until proven otherwise since variants with high potential for metastasizing exist. Distinguishing between a benign tumour and a malignant lipoma is essential, since a more radical treatment plan might be required. CONCLUSION: Giant lipomas of the hand are a rare cause of carpal tunnel syndrome and a malignant variant should always be suspected. A preoperative MRI scan should be performed. Rapid en bloc excision is necessary in case of compression of the underlying tissues.

Accuracy of magnetic resonance imaging to detect cartilage loss in severe osteoarthritis of the first carpometacarpal joint: comparison with histological evaluation.

BACKGROUND: Magnetic resonance imaging (MRI) is increasingly used for research in hand osteoarthritis, but imaging the thin cartilage layers in the hand joints remains challenging. We therefore assessed the accuracy of MRI in detecting cartilage loss in patients with symptomatic osteoarthritis of the first carpometacarpal (CMC1) joint. METHODS: Twelve patients scheduled for trapeziectomy to treat severe symptomatic osteoarthritis of the CMC1 joint underwent a preoperative high resolution 3D spoiled gradient (SPGR) MRI scan. Subsequently, the resected trapezium was evaluated histologically. The sections were scored for cartilage damage severity (Osteoarthritis Research Society International (OARSI) score), and extent of damage (percentage surface area). Each MRI scan was scored for the area of normal cartilage, partial cartilage loss and full cartilage loss. The percentages of the total surface area with any cartilage loss and full-thickness cartilage loss were calculated using MRI and histological evaluation. RESULTS: MRI and histological evaluation both identified large areas of overall cartilage loss. The median (IQR) surface area of any cartilage loss on MRI was 98% (82-100%), and on histological assessment 96% (87-98%). However, MRI underestimated the extent of full-thickness cartilage loss. The median (IQR) surface area of full-thickness cartilage loss on MRI was 43% (22-70%), and on histological evaluation 79% (67-85%). The difference was caused by a thin layer of high signal on the articulating surface, which was interpreted as damaged cartilage on MRI but which was not identified on histological evaluation. CONCLUSIONS: Three-dimensional SPGR MRI of the CMC1 joint demonstrates overall cartilage damage, but underestimates full-thickness cartilage loss in patients with advanced osteoarthritis.

[A man with a painful elbow]. / Een man met een pijnlijke elleboog.

A 54-year old man presented with unremitting pain in the left dorsolateral forearm, despite postural advice and glucocorticoid injections. Electromyography and MRI did not show any abnormality. Based on a clinical suspected radial tunnel syndrome, operative decompression was performed.

[Hypothenar hammer syndrome; rare arterial disorder of the hand due to blunt trauma]. / Hypothenar-hamersyndroom: zeldzame arteriële stoornis van de hand door stomp trauma.

The hypothenar hammer syndrome is a condition characterised by ischaemia of a finger secondary to thrombosis or an aneurysm or pseudoaneurysm of the ulnar artery in the hand. It typically occurs in the dominant hand of middle-aged men whose occupational or recreational activities require the use of the hand as a hammer. Arteriography is considered to be the gold standard for diagnosing this condition. Severe symptomatic cases are treated by surgical resection and revascularisation. The pathophysiology of this syndrome, its diagnosis and its management are discussed in this article by means of two representative cases, each having a different clinical presentation, diagnostic method and treatment.

Application of infrared thermography for the analysis of rewarming in patients with cold intolerance.

Cold intolerance is a serious long-term problem after injury to the ulnar and median nerves, and its pathophysiology is unclear. We investigated the use of infrared thermography for the analysis of thermoregulation after injury to peripheral nerves. Four patients with injuries to the ulnar nerve and four with injuries to the median nerve (4-12 years after injury) immersed their hands in water at 15 degrees C for 5 minutes, after which infrared pictures were taken at intervals of 2-4 minutes. The areas supplied by the injured nerves could be identified easily in the patients with symptoms of cold intolerance. At baseline temperature distribution of the hand was symmetrical, but after testing the injured side warmed up much slower. We concluded that the infrared profile of the temperature of the hand after immersion in cold water is helpful to assess thermoregulation after injury to peripheral nerves.

Median and ulnar nerve injuries: a meta-analysis of predictors of motor and sensory recovery after modern microsurgical nerve repair.

BACKGROUND: The aim of this study was to quantify variables that influence outcome after median and ulnar nerve transection injuries. The authors present a meta-analysis based on individual patient data on motor and sensory recovery after microsurgical nerve repair. METHODS: From 130 studies found after literature review, 23 articles were ultimately included, giving individual data for 623 median or ulnar nerve injuries. The variables age, sex, nerve, site of injury, type of repair, use of grafts, delay between injury and repair, follow-up period, and outcome were extracted. Satisfactory motor recovery was defined as British Medical Research Council motor scale grade 4 and 5, and satisfactory sensory recovery was defined as British Medical Research Council grade 3+ and 4. For motor and sensory recovery, complete data were available for 281 and 380 nerve injuries, respectively. RESULTS: Motor and sensory recovery were significantly associated (Spearman r = 0.62, p < 0.001). Multivariate logistic regression analysis showed that age (< 16 years versus > 40 years: odds ratio, 4.3; 95 percent confidence interval, 1.6 to 11.2), site (proximal versus distal: odds ratio, 0.46; 95 percent confidence interval, 0.20 to 1.10), and delay (per month: odds ratio, 0.94; 95 percent confidence interval, 0.90 to 0.98) were significant predictors of successful motor recovery. In ulnar nerve injuries, the chance of motor recovery was 71 percent lower than in median nerve injuries (odds ratio, 0.29; 95 percent confidence interval, 0.15 to 0.55). For sensory recovery, age (odds ratio, 27.0; 95 percent confidence interval, 9.4 to 77.6) and delay (per month: odds ratio, 0.92; 95 percent confidence interval, 0.87 to 0.98) were found to be significant predictors. CONCLUSIONS: In this individual patient data meta-analysis, age, site, injured nerve, and delay significantly influenced prognosis after microsurgical repair of median and ulnar nerve injuries.

Spaghetti wrist trauma: functional recovery, return to work, and psychological effects.

BACKGROUND: Few studies on spaghetti wrist trauma have been published. The study populations have all consisted of small numbers of patients, and most studies have focused on functional recovery. In addition, different definitions of this injury have been used. The objective of this study was to assess outcome for a larger group of patients in terms of functional recovery, return to work potential, and psychological distress, and to compare outcomes between the two most commonly used definitions for spaghetti wrist injury. METHODS: The initial study-population consisted of 67 patients. Fifty patients completed a questionnaire package consisting of the Disabilities of Arm, Shoulder, and Hand questionnaire, including the Functional Symptom Score (range, 0 to 100), a questionnaire to evaluate return to work and time off work (range, 0 to 52), and the Impact of Event Scale (range, 0 to 75). Motor recovery and sensory recovery were assessed in an outpatient setting, on average, 10 years (range, 2 to 18) after the operation (n = 43). RESULTS: The mean Functional Symptom Score was 15.1 (SD, 16.1; range, 0 to 74) after a mean follow-up of 10.0 years (SD, 4.4; range, 2 to 18). Mean time off work was 34.7 weeks (SD, 17.9; range, 4 to 52), and 45.2 percent of the patients could not return to work within 1 year after the injury. Mean score on the Impact of Event Scale was 26.2 (SD, 19.7; range, 2 to 69). Compared with the unaffected hand, grip and tip pinch strength were decreased with means of 23.5 percent (SD, 22.4; range, 0 to 93) and 33.9 percent (SD, 23.7; range 0 to 83), respectively. Regarding sensory recovery, 12 patients (27.9 percent) had no protective sensation. No statistical differences were found between the two different definitions. CONCLUSIONS: This study demonstrated that spaghetti wrist injury can be placed among the severe disabling injuries. Comparison of the two definitions did not reveal any differences in outcome. To complete the evaluation of long-term outcome, a patient-derived assessment of function can be added to the clinical examination, and attention should be paid to psychological distress following the injury.

Measuring the strength of the intrinsic muscles of the hand in patients with ulnar and median nerve injuries: reliability of the Rotterdam Intrinsic Hand Myometer (RIHM).

PURPOSE: To determine the reliability and measurement error of measurements of intrinsic muscle strength of a new hand-held dynamometer (the Rotterdam Intrinsic Hand Myometer [RIHM]). METHODS: With the RIHM we obtained repeated measurements of the intrinsic muscle strength of the hand in 27 patients with peripheral nerve injury of the ulnar and/or median nerve in different stages of rehabilitation. The average time period after injury was 4.4 years (range, 99 days-11 years). RESULTS: Differences between 2 measurements greater than 6.3 N were interpreted as a real change in assessing the strength of the abduction of the little and index finger; for the median innervated muscles of the thumb this value was 16 N. CONCLUSIONS: In patients with nerve injuries the muscle strength is usually assessed with manual muscle strength testing and grip- and pinch-strength dynamometers. Preferably the intrinsic muscle strength should be measured in isolation and quantitatively. The RIHM is a new dynamometer that allows for measurements of the intrinsic muscle strength in isolation with reliability comparable to grip and pinch measurements.

Long-term outcome of muscle strength in ulnar and median nerve injury: comparing manual muscle strength testing, grip and pinch strength dynamometers and a new intrinsic muscle strength dynamometer.

OBJECTIVE: To compare the outcome of muscle strength with manual muscle strength testing grip and pinch strength measurements and a dynamometer which allows for measurements of the intrinsic muscles of the hand in isolation (the Rotterdam Intrinsic Hand Myometer, RIHM). METHODS: Thirty-four patients more than 2 years after ulnar and/or median nerve injury. Muscle strength was evaluated using manual muscle strength testing (MMST), grip, pinch and intrinsic muscle strength measurements. RESULTS: Manual muscle strength testing showed that most muscles recover to grade 3 or 4. Average grip strength recovery, as percentage of the uninjured hand, was 83%. Pinch strength recovery was 75%, 58% and 39% in patients with ulnar, median and combined nerve injuries, respectively. The RIHM measurements revealed a poor recovery of the ulnar nerve innervated muscles in particular (26-37%). No significant correlation (Pearson) was found between the measurements of the RIHM and grip strength. Pinch strength was significantly correlated with strength of the abduction of thumb and opposition of the thumb strength (r 0.55 and 0.72, p = 0.026, 0.002) as measured with the RIHM. CONCLUSION: While manual muscle strength testing and grip strength measurements show a reasonable to good recovery, measurements of the intrinsic muscles by means of the RIHM showed poor recovery of intrinsic muscle strength after peripheral nerve injury. No correlation was found between the recovery of intrinsic muscle strength and grip strength measurements.

Difficulties in conducting a prospective outcome study.

The success of an outcome study depends largely on the number of recruited patients, the loss of followup, and the response rate to postal questionnaires. In this article, different strategies were proposed to increase the aforementioned items. Most presented strategies were developed because of failure of measures used earlier. In the authors' study concerning hand surgery, this resulted in missed inclusions and loss of followup. It is hoped that by reading and using the strategies discussed, future researchers will start at the end of the learning curve and will shed a bright light on the obscurity of recovery after hand injury.

Predictors for return to work in patients with median and ulnar nerve injuries.

PURPOSE: One of the consequences of median and ulnar nerve trauma is delayed return to work. The aim of this study was to determine return to work (RTW) and risk factors for delayed RTW in addition to time off work (TOW). Differences among median, ulnar, and combined median-ulnar nerve injuries were examined. METHOD: In this study 96 patients who were employed at the time of injury and who had undergone surgery for median, ulnar, or combined nerve injuries between 1990 and 1998 were evaluated. The response rate was 84% (n = 81). RESULTS: Within 1 year after injury, 59% (n = 48) returned to work. Mean TOW was 31.3 weeks. Return to work after combined nerve injuries was 24% versus after isolated median (80%) and ulnar (59%) nerve injuries. Level of education, type of job, and compliance to hand therapy were predictors for RTW. Furthermore, grip strength loss, tip pinch strength loss, and sensory recovery differed strongly between the RTW and no-RTW population. CONCLUSIONS: The predictors found in this study increase our understanding of delayed RTW after median and ulnar nerve injury and may be used to optimize postinjury rehabilitation.

Early psychological stress after forearm nerve injuries: a predictor for long-term functional outcome and return to productivity.

Forearm and wrist injuries can result in a nonfunctional hand caused by loss of motor and sensory functions. Psychological stress is known to accompany traumatic hand injuries and may therefore affect functional outcome. The authors conducted a retrospective study of 107 patients diagnosed with a median, ulnar, or combined median-ulnar nerve injury (79% response rate) who completed a questionnaire package consisting of the Impact of Event Scale (IES); Disabilities of Arm, Shoulder, and Hand; and a questionnaire concerning return to work and time off work. In an outpatient setting, motor and sensory recovery were examined. Ninety-four percent of those studied experienced early psychological stress. Thirty-six percent of patients reported sufficient symptoms 1 month postoperatively to be classified as in need for psychological treatment (IES score > 30 points). Combined median-ulnar nerve injuries (mean, 35.0 +/- 20.3 points [standard deviation]) were accompanied by a higher psychological stress compared with single nerve injuries (median injuries: mean, 24.2 +/- 20.6 points; ulnar injuries: mean, 22.6 +/- 19.5 points; p = 0.049 and p = 0.021 respectively). Multiple linear regression adjusting for age, gender, and severity of the trauma revealed an association between the IES score and the functional symptom score (beta = 0.51; 95% confidence interval [CI], 0.35-0.65), mean time off work (beta = 0.44; 95% CI, 0.25-0.75), and motor recovery (grip: beta = 0.37; 95% CI, 0.09-0.65; tip-pinch: beta = 0.46; 95% CI, 0.13-0.80). Patients with higher scores on the IES were found to be at increased risk for incapacity for work (odds ratio, 3.32; 95% CI, 1.60-6.91). Higher education was found to be a protecting variable for posttraumatic psychopathology (beta = -0.23; 95% CI, -6.05--0.246). This study demonstrated a high level of early posttraumatic psychological stress after forearm and wrist nerve injuries. These data provide evidence that functional outcome and work resumption are influenced negatively by early psychological stress, independent from severity of the somatic trauma. This indicates that outcome after upper extremity nerve injuries may be influenced positively by psychological intervention.