A giant multi-compartment lipoma of the hand causing median nerve compression: A case report and review of literature.

INTRODUCTION & IMPORTANCE: Lipomas are slow growing benign soft tissue tumors that arise from mesenchymal preadipocytes. Histologically they are composed of mature adipocytes. They typically have a shawl like distribution in the body, anywhere from the subcutaneous space to bone, but are seen only rarely in the hand. When >5 cm, they are referred to as 'giant lipoma' and can be symptomatic due to neurovascular compression and impaired hand function. CASE PRESENTATION: A 51-year-old forensic analyst presented with a progressively enlarging lump over the thenar eminence and palm of his dominant right hand for 2 years duration. Although initially asymptomatic, he developed progressive numbness over the radial 21/2 fingers and impaired hand function due to its size resulting in occupational impairment. Examination revealed a 5x5cm painless lobulated lump over palm. NCS showed evidence of median nerve compression. MR imaging revealed a giant lipoma involving the thenar and midpalmar space. Enbloc surgical excision was performed and histology was confirmatory. CLINICAL DISCUSSION: Lipomas of the hand could be superficial or deep space. They are slow growing and asymptomatic initially and are brought to attention due to cosmetic concerns, nerve compression or mechanical hand impairment with enlargement. Giant lipomas must be treated with suspicion due to denovo liposarcoma and risk of sarcomatous change. CONCLUSION: Giant multi-compartment lipomas of the hand are rare. Surgical excision is advocated for suspicion of malignancy, nerve compression and functional limitation. Enbloc resection without fragmentation has minimal risk of recurrence and complications.

A very rare case of the accessory palmaris longus muscle and clinical significance.

The palmaris longus muscle is located in the forearm region. It morphological variability was noted during standard anatomical dissection of the upper limb. The muscle was characterized by a normal course, i.e. originating from the medial humeral epicondyle and inserting to the palmaris aponeurosis, but a small additional tendon attached to the flexor retinaculum was observed in its distal part. An accessory palmaris longus muscle was also observed nearby. Interestingly, this accessory muscle was reversed, and the first part was not muscular, but tendinous, represented by two tendons originating from the common muscular mass attached to the medial epicondyle of the humerus; these later connected together, creating one muscle belly distally attached to the flexor retinaculum. This additional structure was innervated by a neural branch from the median nerve and the ulnar artery was responsible for blood supply. The course of the median nerve is also clinically important, because before entering the carpal tunnel, it was located directly under the accessory palmaris longus muscle. In turn, the ulnar artery passed through a special hole created by the flexor digiti minimi brevis and flexor retinaculum, before passing under the palmaris brevis muscle.

Supracondylar Apophysis of the Humerus: Rare Cause of High Compression of the Median Nerve.

Supracondylar apophysis (SA) is a bony prominence that originates from the anteromedial aspect of the distal humerus with a lower projection and which, although usually asymptomatic, due to the relationship with adjacent structures can cause symptoms. We describe the case of a 42-year-old woman with pain complaints radiating from her elbow to her hand, with 6 months of evolution. On objective examination, the patient had a sensory deficit in the median nerve territory and decreased grip strength. Radiographs of the distal humerus were performed, in which a bone spike was visible, and magnetic resonance imaging showed thickening of the median nerve epineurium. Electromyography showed severe axonal demyelination of the median nerve proximal to the elbow. A median nerve compression caused by a SA was diagnosed. The patient underwent surgery and, 1 year after the operation, she had a complete clinical recovery. Supracondylar apophysis is a rare, but possible and treatable cause of high median nerve compression.

Supracondylar Apophysis of the Humerus: Rare Cause of High Compression of the Median Nerve / Apófise supracondilar do úmero: Causa rara de compressão alta do nervo mediano

Abstract Supracondylar apophysis (SA) is a bony prominence that originates from the anteromedial aspect of the distal humerus with a lower projection and which, although usually asymptomatic, due to the relationship with adjacent structures can cause symptoms. We describe the case of a 42-year-old woman with pain complaints radiating from her elbow to her hand, with 6 months of evolution. On objective examination, the patient had a sensory deficit in the median nerve territory and decreased grip strength. Radiographs of the distal humerus were performed, in which a bone spike was visible, and magnetic resonance imaging showed thickening of the median nerve epineurium. Electromyography showed severe axonal demyelination of the median nerve proximal to the elbow. A median nerve compression caused by a SA was diagnosed. The patient underwent surgery and, 1 year after the operation, she had a complete clinical recovery. Supracondylar apophysis is a rare, but possible and treatable cause of high median nerve compression.

Resumo A apófise supracondilar (ASC) é uma proeminência óssea que tem origem na face anteromedial do úmero distal com projeção inferior e que, apesar de habitualmente assintomática, pela relação com as estruturas adjacentes pode causar sintomatologia. Descrevemos o caso de uma mulher de 42 anos, com queixas álgicas irradiadas do cotovelo à mão, com 6 meses de evolução. Ao exame objetivo, a paciente apresentava um déficit sensorial no território do nervo mediano e diminuição da força de preensão. Foram realizadas radiografias do úmero distal nas quais era visível uma espícula óssea, e na ressonância magnética era evidente o espessamento do epineuro do nervo mediano. A eletromiografia apresentou uma desmielinização axonal grave do nervo mediano proximal ao cotovelo. Foi diagnosticada uma compressão do nervo mediano por uma ASC. A paciente foi submetida à cirurgia e 1 ano pós-operatório apresentou recuperação clínica total. A ASC é uma causa rara, mas possível e tratável da compressão alta do nervo mediano.

[Value of High-Frequency Ultrasound in the Diagnosis of Pronator Teres Syndrome].

Objective To investigate the clinical value of high-frequency ultrasound in the diagnosis of pronator teres syndrome (PTS). Methods The high-frequency ultrasound was employed to examine and measure the median nerve of the pronator teres muscle in 30 patients with PTS and 30 healthy volunteers (control group).The long-axis diameter (LA),short-axis diameter (SA) and cross-sectional area (CSA) of the median nerve were measured.The receiver operating characteristic curve of the median nerve ultrasonic measurement results was established,and the area under the curve (AUC) was calculated.The diagnostic efficiency of each index for PTS was compared with the surgical results as a reference. Results The PTS group showed larger LA[(5.02±0.50) mm vs.(3.89±0.41) mm;t=4.38,P=0.013],SA[(2.55±0.46) mm vs.(1.70±0.41) mm;t=5.19,P=0.009],and CSA[(11.13±3.72) mm2 vs.(6.88±2.68) mm2;t=8.42,P=0.008] of the median nerve than the control group.The AUC of CSA,SA,and LA was 94.3% (95%CI=0.912-0.972,Z=3.586,P=0.001),77.7% (95%CI=0.734-0.815,Z=2.855, P=0.006),and 78.8% (95%CI=0.752-0.821,Z=3.091,P=0.004),respectively.With 8.63 mm2 as the cutoff value,the sensitivity and specificity of CSA in diagnosing PTS were 93.3% and 90.0%,respectively. Conclusion High-frequency ultrasound is a practical method for diagnosing PTS,and the CSA of median nerve has a high diagnostic value.

Lacertus Syndrome: an Outcome Analysis After Lacertus Release.

Purpose: The lacertus fibrosus or bicipital aponeurosis is a sheet of ligamentous tissue just distal to the elbow joint and can be a compression point for the median nerve. Essentially, lacertus syndrome is a subset of pronator syndrome and an uncommon diagnosis by itself. Surgical release of the lacertus consists of a small 2-cm incision that can be performed under local anesthesia. This study aimed to evaluate the outcome of lacertus release in resolving median nerve symptoms. Methods: This retrospective study was performed at Prince Court Medical Centre, Kuala Lumpur, Malaysia, from January 2020 until June 2021. Ninety-three patients who presented with numbness of fingers, hand, or upper limb; forearm pain; and muscle weakness. They were diagnosed with lacertus syndrome on the basis of local tenderness at the lacertus fibrosus with either weakness of flexor pollicis longus and flexor digitorum profundus of the index finger or paresthesia over the thenar eminence. The patients underwent 3 months of hand therapy, and those with no symptom improvement were offered lacertus release performed by a single surgeon. The surgical technique consists of a surgical incision starting from a point 2 cm distally and 2 cm radially to the medial epicondyle. The incision projects 2 cm distally in an oblique fashion toward the radial styloid. A wide-awake local anesthesia no tourniquet (WALANT) technqiue was utilized and 20 mL of local anesthesic was injected subcutaneously around this region at least 20 minutes before the surgery. Careful dissection was made subcutaneously, and the lacertus fibrosus was identified as a thickened, shiny white structure and released. The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, grip strength, and pinch strength were tested before and after surgery. At 6 months after surgery, the QuickDASH score was again assessed with a WALANT satisfactory questionnaire. Results: A total of 93 patients were included in the study. The mean age of the patients was 38.7 years, and most were women (77.4%). The mean operating time was 70 minutes. The mean preoperative QuickDASH score was 53, which significantly reduced immediately after surgery to 7.8 (P < .001) and remained low at 6 months after surgery (10.6). The mean grip strength showed a significant increase from a preoperative mean of 16 kg to a postoperative mean of 24 kg (P < .001). Pinch strength also significantly increased from a preoperative mean of 9 kg to 13 kg after surgery (P < .001). Conclusions: Lacertus syndrome remains an underdiagnosed disease that can be treated efficiently with a directed minimal surgical incision under wide-awake local anesthesia. Lacertus release appears to significantly reduce pain and numbness with markedly improved hand grip and pinch strength. The corresponding QuickDASH scores also improved significantly after surgery. This study is vital to our understanding of proximal median nerve entrapment and to accurately diagnose it. Type of study/level of evidence: Therapeutic III.

The Inlet and Outlet Ratio: Retrospective and Prospective Study on an Improved Diagnostic Ultrasound Tool for Carpal Tunnel Syndrome.

Purpose: This study hypothesized that ratios of sonographic cross-sectional areas (CSAs) throughout the median nerve provide a more reliable tool for diagnosing carpal tunnel syndrome (CTS) than a single CSA value. We first tested this hypothesis in a retrospective cohort and subsequently confirmed it in a prospective blinded case-control series. Methods: Seventy patients were included in the retrospective study, and 50 patients and matched controls were included for the prospective study. We evaluated 4 CSAs, at the forearm, inlet, tunnel, outlet, and their ratios (Rforearm, Rinlet, Routlet, Routlet forearm) to evaluate compression of the median nerve. All patients underwent nerve conduction studies. For the prospective cohort, Disabilities of the Arm, Shoulder, and Hand scores and Boston Carpal Tunnel Questionnaire scores were evaluated, and ultrasound was performed by 2 examiners for each participant. Results: The Boston and Disabilities of the Arm, Shoulder, and Hand scores showed worse subjective function in patients with CTS than in controls. Three ultrasonography parameters (CSAs at the inlet, Rinlet, and Routlet) correlated significantly with subjective function. Age and Rinlet were significantly correlated with severity of CTS in the nerve conduction studies. In both the retrospective and prospective patient groups, the numbers of CSAs at the inlet and outlet were significantly higher than that of CSAs at the tunnel, whereas in the control group, no such compression was found. Of the single measurements, CSAs at the inlet had the best diagnostic performance with an optimized cutoff of 11.75 mm2. The Rinlet and Routlet ratios performed even better and showed the highest adjusted odds ratios for predicting CTS of all parameters (cutoff Rinlet, 1.25; Routlet, 1.45). Inter-observer correlation was generally high, with better values for single CSAs than for ratios. Conclusions: The 3 CSA measurements of the median nerve and the associated ratios improved diagnostic power for ultrasonography in CTS in our study. Type of study/level of evidence: Diagnostic I.

A finite element analysis of the carpal arch with various locations of carpal tunnel release.

Objective: The purpose of this study was to investigate the effects of the location of transverse carpal ligament (TCL) transection on the biomechanical property of the carpal arch structure. It was hypothesized that carpal tunnel release would lead to an increase of the carpal arch compliance (CAC) in a location-dependent manner. Methods: A pseudo-3D finite element model of the volar carpal arch at the distal carpal tunnel was used to simulate arch area change under different intratunnel pressures (0-72 mmHg) after TCL transection at different locations along the transverse direction of the TCL. Results: The CAC of the intact carpal arch was 0.092 mm2/mmHg, and the simulated transections ranging from 8 mm ulnarly to 8 mm radially from the center point of the TCL led to increased CACs that were 2.6-3.7 times of that of the intact carpal arch. The CACs after radial transections were greater than those ulnarly transected carpal arches. Conclusion: The TCL transection in the radial region was biomechanically favorable in reducing carpal tunnel constraint for median nerve decompression.

Value of High-Frequency Ultrasound in the Diagnosis of Pronator Teres Syndrome / 中国医学科学院学报

Objective To investigate the clinical value of high-frequency ultrasound in the diagnosis of pronator teres syndrome (PTS). Methods The high-frequency ultrasound was employed to examine and measure the median nerve of the pronator teres muscle in 30 patients with PTS and 30 healthy volunteers (control group).The long-axis diameter (LA),short-axis diameter (SA) and cross-sectional area (CSA) of the median nerve were measured.The receiver operating characteristic curve of the median nerve ultrasonic measurement results was established,and the area under the curve (AUC) was calculated.The diagnostic efficiency of each index for PTS was compared with the surgical results as a reference. Results The PTS group showed larger LA[(5.02±0.50) mm vs.(3.89±0.41) mm;t=4.38,P=0.013],SA[(2.55±0.46) mm vs.(1.70±0.41) mm;t=5.19,P=0.009],and CSA[(11.13±3.72) mm2 vs.(6.88±2.68) mm2;t=8.42,P=0.008] of the median nerve than the control group.The AUC of CSA,SA,and LA was 94.3% (95%CI=0.912-0.972,Z=3.586,P=0.001),77.7% (95%CI=0.734-0.815,Z=2.855, P=0.006),and 78.8% (95%CI=0.752-0.821,Z=3.091,P=0.004),respectively.With 8.63 mm2 as the cutoff value,the sensitivity and specificity of CSA in diagnosing PTS were 93.3% and 90.0%,respectively. Conclusion High-frequency ultrasound is a practical method for diagnosing PTS,and the CSA of median nerve has a high diagnostic value.

High-resolution ultrasound in the diagnosis of failed carpal tunnel decompression: a study of 35 cases.

We used high-resolution ultrasound to examine 35 median nerves (35 patients) with failed carpal tunnel decompression to identify the cause of failure. The carpal tunnel was examined before revision surgery, and the results were correlated with surgical findings. The cross-sectional area was measured, and nerve morphology was analysed at the sites of compression. We found persistent median nerve compression in 30 out of 35 patients. In 20 patients, the compression was caused by a residual transverse carpal ligament, in four by perineural fibrosis, in five by both of these causes and in one by tenosynovitis. In four patients, evidence of median nerve injury with an epineural/fascicular lesion was detected; and in one, no abnormalities were found. Surgical findings were consistent with the ultrasound findings except in one patient where tenosynovitis was associated with a giant cell tumour, which was missed by ultrasound. High-resolution ultrasound can provide helpful information in preoperative diagnosis of failed carpal tunnel decompression with good correlation between the ultrasound and surgical findings.Level of evidence: IV.

Effectiveness of mini-transverse incision versus traditional reduced technique in the treatment of carpal tunnel syndrome. A prospective cohort study.

BACKGROUND: Carpal tunnel syndrome has attracted attention as an occupational disease due to the dramatic increase on its magnitude, and its prevalence in the general population, who's has been reported from a 0.6 to 3.4%. Currently, there are various techniques for its approach. However, there is great controversy when it comes to establishing which of the methods is the most beneficial. The objective of this study was to compare the efficacy of the mini-transverse incision against the traditional longitudinal technique in treatment of carpal tunnel syndrome. MATERIALS AND METHODS: A series of cases is presented, prospectively included, of patients with a diagnosis of carpal tunnel syndrome, who are beneficiaries of a government hospital. We present a series of cases with a diagnosis of carpal tunnel syndrome, which were performed with two different techniques. Both techniques were evaluated by comparing the recovery and work reintegration times, as well as the decrease in pain and the absence of complications. RESULTS: A total of 8 patients operated with a minimal incision and 9 with a traditional reduced incision were studied. Significant differences were shown in the days taken to return to work, with a median of 17.5 (q25-q75 14-21) days for mini-transverse incision group and of 28 (q25-q75 21-28) days for the longitudinal traditional incision group (p = 0.002). Likewise, differences were obtained in the visual analogue pain scale during the first week of evaluation 4 vs 7 (p = 0.000), in contrast to complications where there were no differences at all. CONCLUSION: The results obtained corroborate a greater efficacy of the mini-transverse incision technique, in reducing disability times. This favors the health institution to reduce the costs of rehabilitation and for the patient to have a prompt work reintegration. It is suggested to strengthen the scientific evidence that supports the use of this technique by exploring other areas such as functional status or long-term benefits.

Uncommon causes of nerve compression in the distal forearm / Causas poco frecuentes de compresión nerviosa en el antebrazo distal

Introduction: Nerve compression by anomalous masses located at the wrist and distal forearm is an infrequent condition. They may compress underlying structures in the carpal tunnel region, causing pain and paresthesias, which leads to the wrong diagnosis of carpal tunnel syndrome. Clinical cases: We present three cases of patients with symptomatology and clinical tests compatible with compression of the median nerve in the carpal tunnel but whose physical examination showed a soft mass in the distal region of the forearm which was compressing the median nerve, as demonstrated by ultrasound evaluation. Discussion: The reported cases of accessory muscles or lipomas described in the literature as causes of median nerve compression clinic are mainly described only after the surgical decompression of the carpal tunnel, due to the maintenance of residual symptoms. Conclusion: Careful examination with an ultrasound evaluation prior to surgery may help to identify these cases and help planning surgical treatment.(AU)

Introducción: La compresión del nervio mediano por masas anómalas localizadas en la muñeca y en el antebrazo distal es una condición infrecuente. Las estructuras subyacentes en la región del túnel carpiano pueden ser comprimidas, causando dolor y parestesias, pudiendo llevar al diagnóstico erróneo de síndrome del túnel carpiano. Casos clínicos: Se presentan 3 casos de pacientes con sintomatología y pruebas clínicas compatibles con compresión del nervio mediano en el túnel carpiano. Sin embargo, a la inspección presentaban leve edema en la región proximal del canal, y en la evaluación por ultrasonido se detectó sendas tumoraciones que comprimían el nervio mediano previo a su ingreso en el canal carpiano. Discusión: En la literatura, los casos de músculos accesorios o lipomas como causas de compresión del nervio mediano son las causas más probables de persistencia de los síntomas tras la descompresión quirúrgica del canal carpiano. Conclusión: La exploración clínica detallada junto con la evaluación ultrasonográfica antes de la cirugía pueden ayudar a identificar estos casos y planificar un mejor abordaje quirúrgico.(AU)

Uncommon causes of nerve compression in the distal forearm.

INTRODUCTION: Nerve compression by anomalous masses located at the wrist and distal forearm is an infrequent condition. They may compress underlying structures in the carpal tunnel region, causing pain and paresthesias, which leads to the wrong diagnosis of carpal tunnel syndrome. CLINICAL CASES: We present three cases of patients with symptomatology and clinical tests compatible with compression of the median nerve in the carpal tunnel but whose physical examination showed a soft mass in the distal region of the forearm which was compressing the median nerve, as demonstrated by ultrasound evaluation. DISCUSSION: The reported cases of accessory muscles or lipomas described in the literature as causes of median nerve compression clinic are mainly described only after the surgical decompression of the carpal tunnel, due to the maintenance of residual symptoms. CONCLUSION: Careful examination with an ultrasound evaluation prior to surgery may help to identify these cases and help planning surgical treatment.

Extended-Hours Hemodialysis without Dietary Restrictions Is Associated with Lower Risk for Developing of Dialysis-Related Amyloidosis.

Dialysis-related amyloidosis (DRA) is characterized by the deposition of amyloid consisting of beta2-microglobulin in the musculoskeletal system, causing carpal tunnel syndrome, destructive spondyloarthropathy, and/or bone cysts. Increased cystic radiolucency of the bones and tendon thickening due to inflammation are common findings in DRA. We have developed a new dialysis method, extended-hours hemodialysis without dietary restrictions for the aim of improving both hypertension and malnutrition. We retrospectively evaluated the clinical effects of dialysis time on the risk for developing of DRA. The study subjects were all of the 30 patients who had received this treatment for more than 11 years. They were divided into two groups according to the weekly dialysis hours: 15 patients ≥ 16.5 hours/week (L-group) and 15 patients ≤ 15.5 hours/week (S-group). Plain x-ray imaging and ultrasonography were used to assess cystic radiolucency of the bones and thickness/diameter of the soft tissues. The proportion of the carpal bone cystic radiolucency was lower in the L-group. The severity of median nerve compression at the wrist was significantly less in the L-group (right hand: p = 0.0082, left hand: p = 0.0137). Multivariate regression analysis showed that dialysis time was a predictor of median nerve compression (ß = -0.559, p = 0.005). In conclusion, extended-hours hemodialysis without dietary restrictions contributes to lower the risk for developing of DRA at the wrist. We therefore propose that extended-hours hemodialysis without dietary restrictions is a preferred method which maintains the patients' quality of life compared with the conventional hemodialysis method.

Median Nerve Compression in the Forearm: A Clinical Diagnosis.

Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.

Volar fracture dislocation of the 2nd metacarpal base associated with acute carpal tunnel syndrome: A case report.

Posttraumatic acute carpal tunnel syndrome is a not a usual complication in traumatic hand injuries but requires more urgent and aggressive management. Compression of the median nerve should be systematically sought when there is a major and painful swelling of the hand, associated with one or several hand and wrist fractures. In rare case, a single metacarpal fracture or dislocation can be the only cause of median nerve compression and requires urgent diagnosis. If missed or neglected irreversible damage could occur to the median nerve. If surgery is perform in a timely manner outcomes are excellent, with complete recovery in most of the cases. We present the case of a 24-year-old man with an acute compression of the median nerve due to an intra-articular fracture of the 2nd metacarpal base. A bony fragment shifting from the base of 2nd metacarpal was found in the carpal tunnel participating, at least in part, in the compression of the median nerve.

The Palmaris Longus and Its Association with Carpal Tunnel Syndrome.

Background The palmaris tendon inserts into the palmar fascia and is positioned in close association with the transverse carpal ligament. Loading of this tendon has been demonstrated to increase carpal tunnel pressures. Purpose The purpose of this study was to determine if a relationship exists between the palmaris tendon, carpal tunnel syndrome (CTS), and handedness. The sensitivity, specificity, positive predictive value, and negative predictive value for Schaeffer's test were calculated. Methods A retrospective review of patient charts undergoing endoscopic carpal tunnel release was performed. Rates of palmaris longus agenesis (PLA) were compared to a population matched data set. Statistical analysis was performed using a one-proportion z -test. Schaeffer's test for the palmaris longus tendon was performed on all patients and compared to intraoperative confirmation. Results A total of 520 carpal tunnel releases were performed in 389 consecutive patients. The frequency of PLA in this surgical cohort was significantly lower compared to the population matched dataset. No correlation between handedness and laterality of CTS or PLA was found. Schaeffer's test was evaluated to yield sensitivity (93.6%), specificity (100%), positive predictive value (100%), and negative predictive value (50.8%). Conclusion The palmaris tendon was more prevalent in a population of patients undergoing carpal tunnel release. These findings can be used to provide further insight into the pathophysiology of CTS. While Schaeffer's test was accurate in detecting the palmaris longus tendon, a negative test was frequently incorrect. Further imaging is recommended in patients with a negative Schaeffer's test when the palmaris longus is desired for surgical utilization. Level of Evidence This is a Level III, prognostic study.

Hypertrophied reversed palmaris longus muscle (pseudotumor) of the forearm causing median nerve compression: a case report.

BACKGROUND: The palmaris longus muscle is considered one of the most anatomically variable muscles in the human body. Localized swelling of the forearm due to hypertrophy of the palmaris longus muscle is rare. CASE PRESENTATION: Here, we report a rare case of a 24-year-old Arab man who presented with a painful mass on his forearm with symptoms of median nerve compression. A full radiological assessment was performed, and he was treated conservatively. CONCLUSION: This case confirmed that a hypertrophied palmaris longus muscle can be the cause of swelling on the forearm and should always be considered in the differential diagnosis. With this report, we aimed to increase awareness regarding the unusual variations of palmaris longus muscle and the importance of using radiological investigations to establish a diagnosis.

The Use of Alfa-Lipoic Acid-R (ALA-R) in Patients with Mild-Moderate Carpal Tunnel Syndrome: A Randomised Controlled Open Label Prospective Study.

INTRODUCTION: Carpal tunnel syndrome is one of the most common peripheral neuropathies. Only a few studies evaluate the efficacy of "nutraceuticals" on peripheral nerves and neuropathic pain. The aim of the present investigation is to evaluate the role of Alfa-Lipoic Acid-R (ALA-R) on clinical and functional outcomes in patients affected by mild to moderate carpal tunnel syndrome. MATERIAL AND METHODS: The present investigation is a prospective randomised controlled open label study, performed at our Hand Surgery Department (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome) from October 2018 to March 2019. The enrolled patients were divided in two groups: Group A (ALA-R 600mg once day for 60 days) and Group B (control Group, no drug administration). RESULTS: 134 patients (74 F, 60 M) met the inclusion and exclusion criteria. In Group A, there was a statistically significant pain reduction compared to the control Group. Using the Boston Carpal Tunnel Questionnaire, there were no significant improvements in the other symptoms and function. CONCLUSION: ALA-R full dose administration for two months leads to positive short term results in terms of symptoms and function improvement, even if the surgical carpal tunnel release remains the treatment of choice.

The Use of Alfa-Lipoic Acid-R (ALA-R) in Patients with Mild-Moderate Carpal Tunnel Syndrome: A Randomised Controlled Open Label Prospective Study

@#Introduction:Carpal tunnel syndrome is one of the most common peripheral neuropathies. Only a few studies evaluate the efficacy of “nutraceuticals” on peripheral nerves and neuropathic pain. The aim of the present investigation is to evaluate the role of Alfa-Lipoic Acid-R (ALA-R) on clinical and functional outcomes in patients affected by mild to moderate carpal tunnel syndrome. Material and Methods: The present investigation is a prospective randomised controlled open label study, performed at our Hand Surgery Department (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome) from October 2018 to March 2019. The enrolled patients were divided in two groups: Group A (ALA-R 600mg once day for 60 days) and Group B (control Group, no drug administration). Results: 134 patients (74 F, 60 M) met the inclusion and exclusion criteria. In Group A, there was a statistically significant pain reduction compared to the control Group. Using the Boston Carpal Tunnel Questionnaire, there were no significant improvements in the other symptoms and function. Conclusion: ALA-R full dose administration for two months leads to positive short term results in terms of symptoms and function improvement, even if the surgical carpal tunnel release remains the treatment of choice.