Subacute nerve compressions after trauma and surgery of the hand.
BACKGROUND
It is accepted that major injuries of the upper limb may require not only fasciotomies but also nerve decompressions. That nerve compression(s) may occur after less dramatic injuries and "routine" surgery distal to the elbow is less well documented in the literature but well known to experienced clinicians. The aim of this study was to identify a possible link between injuries or elective surgery to the distal upper limb and "subacute nerve compressions."


METHODS
Over a 5-year period, data of patients who developed clinical symptoms of nerve compressions distal to the elbow within 6 months after trauma or elective surgery to the same upper limb that affected postoperative management were collected prospectively.


RESULTS
This study identified 91 patients (49 after trauma and 42 after elective surgery). Compression of the median nerve in the carpal tunnel was the most common syndrome (73 cases). Fasciectomy for Dupuytren's disease was the most frequent operation involved (23 cases). The average time from injury or surgery to diagnosis of nerve compression(s) was 8 weeks (range, 1 to 24 weeks). Surgical decompression of the involved nerves was performed in 43 patients (47.2 percent), with an average time from diagnosis to surgery of 30.4 weeks (range, 28 to 44 weeks). In the carpal tunnel syndrome group (47 men and 26 women), mean age was 49 years (men, 48 years; women, 50 years) and the male-to-female ratio was 1.8:1.


CONCLUSIONS
Subacute nerve compressions should be considered as a complication during the recovery period after injury and surgery of the upper limb.
Figus
Andrea
A
Chelmsford, Essex, United Kingdom From the Hand Surgery Department, St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital.
Iwuagwu
Fortune C
FC
Elliot
David
D
D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006225:Hand / Q000601:surgery*; D006230:Hand Injuries / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009408:Nerve Compression Syndromes / Q000209:etiology* / Q000601:surgery; D011183:Postoperative Complications / Q000209:etiology* / Q000601:surgery; D011446:Prospective Studies
Abouzahr, M. K. Compartment syndromes of the upper limb. In S. J. Aston, R. W. Beasley, and C. H. M. Thorne (Eds.), Grabb and Smith’s Plastic Surgery, 5th Ed. Philadelphia: Lippincott-Raven, 1997. Pp. 895–899.
Botte, M. J., and Gelberman, R. H. Acute compartment syndrome of the forearm. Hand Clin. 14: 391, 1998.
Szabo, R. M., Gelberman, R. H., Williamson, R. V., et al. Effects of increased systemic blood pressure on the tissue fluid pressure threshold of peripheral nerve. J. Orthop. Res. 1: 172, 1983.
Bauman, T. D., Gelberman, R. H., Mubarak, S. J., and Garfin, S. R. The acute carpal tunnel syndrome. Clin. Orthop. Relat. Res. 156: 151, 1981.
Bourrel, P., and Ferro, R. M. Nerve complications in closed fractures of the lower end of the radius. Ann. Chir. Main 1: 119, 1982.
Frykman, G. Fracture of the distal radius including sequelae: Shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop. Scand. 108 (Suppl.): 107, 1967.
Lynch, A. C., and Lipscomb, P. R. The carpal tunnel syndrome and Colles’ fractures. J.A.M.A. 185: 363, 1963.
Mack, G. R., McPherson, S. A., and Lutz, R. B. Acute median neuropathy after wrist trauma: The role of emergent carpal tunnel release. Clin. Orthop. Relat. Res. 300: 141, 1994.
Mason, M. L. Colles’s fracture: A survey of end-results. Br. J. Surg. 40: 340, 1953.
Meadoff, N. Median nerve injuries in fractures in the region of the wrist. Calif. Med. 70: 252, 1949.
Michelsen, H., and Poster, M. A. Medical history of carpal tunnel syndrome. Hand Clin. 18: 257, 2002.
Sponsel, K. H., and Palm, E. T. Carpal tunnel syndrome following Colles’ fracture. Surg. Gynecol. Obstet. 121: 1252, 1965.
Adamson, J. E., Srouji, S. J., Horton, C. E., et al. The acute carpal tunnel syndrome. Plast. Reconstr. Surg. 47: 332, 1971.
Maxwell, J. A., Kepes, J. J., and Ketchum, L. D. Acute carpal tunnel syndrome secondary to thrombosis of a persistent artery: Case report. J. Neurosurg. 38: 774, 1973.
Weiland, A. J., Lister, G. D., and Villarreal-Rios, A. Volar fracture dislocations of the second and third carpometacarpal joints associated with acute carpal tunnel syndrome. J. Trauma 16: 672, 1976.
Williams, L. F., and Geer, T. Acute carpal tunnel syndrome secondary to pyogenic infection of the forearm. J.A.M.A. 185: 409, 1963.
Szabo, R. M. Acute carpal tunnel syndrome. Hand Clin. 14: 419, 1998.
Bulstrode, N. W., Jemec, B., and Smith, P. J. The complications of Dupuytren’s contracture surgery. J. Hand Surg. (Am.) 30: 1021, 2005.
Grundernerg, A. B., and Reagan, D. S. Compression syndromes in reflex sympathetic dystrophy. J. Hand Surg. (Am.) 16: 731, 1991.
Koman, L. A., Poehling, G. G., and Smith, T. L. Complex regional pain syndrome: Reflex sympathetic dystrophy and causalgia. In D. P. Green, R. N. Hotchkiss, and W. C. Pederson (Eds.), Operative Hand Surgery, 4th Ed. London: Churchill Livingstone, 1999. Pp. 636–666.
Zyluk, A. A new clinical severity scoring system for reflex sympathetic dystrophy of the upper limb. J. Hand Surg. (Br.) 28: 238, 2003.
Florack, T. M., Miller, R. J., Pellegrini, V. D., et al. The prevalence of carpal tunnel syndrome in patients with basal joint arthritis of the thumb. J. Hand Surg. (Am.) 17: 624, 1992.
Hayes, C. W. Compression neuropathies in the upper limb. In S. J. Aston, R. W. Beasley, and C. H. M. Thorne (Eds.), Grabb and Smith’s Plastic Surgery, 5th Ed. Philadelphia: Lippincott-Raven, 1997. Pp. 917–927.
LaJoie, A. S., McCabe, S. J., Thomas, B., et al. Determining the sensitivity and specificity of common diagnostic tests for carpal tunnel syndrome using latent class analysis. Plast. Reconstr. Surg. 116: 502, 2005.
Lister, G. The Hand: Diagnosis and Indications, 2nd Ed. London: Churchill Livingstone, 1984.
Massy-Westropp, N., Grimmer, K., and Bain, G. A systematic review of the clinical diagnostic tests for carpal tunnel syndrome. J. Hand Surg. (Am.) 25: 120, 2000.
Tinel, J. Le signe du ‘fourmillement’ dans les lésions des nerfs périphériques. Presse Med. 47: 388, 1915.
Szabo, R. M. Entrapment and compression neuropathies. In D. P. Green, R. N. Hotchkiss, and W. C. Pederson (Eds.), Operative Hand Surgery, 4th Ed. London: Churchill Livingstone, 1999. Pp. 1404–1447.
Durkan, J. A. A new diagnostic test for carpal tunnel syndrome. J. Bone Joint Surg. (Am.) 73: 535, 1991.
Fertl, E. R., Wöber, C., and Zeitlhofer, J. The serial use of two provocative tests in the clinical diagnosis of carpal tunnel syndrome. Acta Neurol. Scand. 98: 328, 1998.
Paley, D., and McMurtry, R. Y. Median nerve compression test in carpal tunnel syndrome diagnosis. Orthop. Rev. 14: 411, 1985.
Phalen, G. S. The carpal tunnel syndrome: Seventeen years’ experience in diagnosis and treatment of six hundred fifty-four hands. J. Bone Joint Surg. (Am.) 48: 211, 1966.
Olehnik, W. K., Manske, P. R., and Szerzinski, J. Median nerve compression in the proximal forearm. J. Hand Surg. (Am.) 19: 121, 1994.
Greenwald, D., Moffitt, M., and Cooper, B. Effective surgical treatment of cubital tunnel syndrome based on provocative clinical testing without electrodiagnostics. Plast. Reconstr. Surg. 104: 215, 1999.
Dellon, A. L., and Mackinnon, S. E. Radial sensory entrapment in the forearm. J. Hand Surg. (Am.) 11: 199, 1986.
Barclay, V., Collier, R. J., and Jones, A. Treatment of various hand injuries by pulsed electromagnetic energy (diapulse). Physiotherapy 69: 186, 1983.
Rozmaryn, L. M., Dovelle, S., Rothman, E. R., et al. Nerve and tendon gliding exercises and the conservative management of carpal tunnel syndrome. J. Hand Ther. 11: 171, 1998.
Skov, O. The incidence of hospital-treated occupational hand injuries. J. Hand Surg. (Br.) 19: 118, 1994.
Rosberg, H. E., and Dahlin, L. B. Epidemiology of hand injuries in a middle-sized city in southern Sweden: A retrospective comparison of 1989 and 1997. Scand. J. Plast. Reconstr. Surg. Hand Surg. 38: 347, 2004.
Hill, C., Riaz, M., Mozzam, A., et al. A regional audit of hand and wrist injuries: A study of 4873 injuries. J. Hand Surg. (Br.) 23: 196, 1998.
Elliot, D., and Ragoowansi, R. Dupuytren’s disease secondary to acute injury, infection or operation distal to the elbow in the ipsilateral upper limb: A historical review. J. Hand Surg. (Br.) 30: 148, 2005.
Geoghegan, J. M., Forbes, J., Clark, D. I., Smith, C., and Hubbard, R. Dupuytren’s disease risk factors. J. Hand Surg. (Br.) 29: 423, 2004.
Tucci, M., Sud, V., and Freeland, A. Compression of the median nerve in CTS is mediated by periods of acute synovial swelling. Biomed. Sci. Instrum. 37: 299, 2001.
Phalen, G. S. Reflections on 21 years’ experience with the carpal-tunnel syndrome. J.A.M.A. 212: 1365, 1970.
Abbot, L. C., and Saunders, J. B. Injuries of the median nerve in fractures of the lower end of the radius. Surg. Gynecol. Obstet. 57: 507, 1933.
de Krom, M. C., Knipschild, P. G., Kester, A. D., et al. Carpal tunnel syndrome: Prevalence in the general population. J. Clin. Epidemiol. 45: 373, 1992.
Atroshi, I., Gummesson, C., Johnsson, R., et al. Prevalence of carpal tunnel syndrome in a general population. J.A.M.A. 282: 153, 1999.
Atroshi, I., Gummesson, C., Johnsson, R., et al. Severe carpal tunnel syndrome potentially needing surgical treatment in a general population. J. Hand Surg. (Am.) 28: 645, 2003.
Ferry, S., Pritchard, T., Keenan, J., et al. Estimating the prevalence of delayed median nerve conduction in the general population. Br. J. Rheumatol. 37: 630, 1998.
Mondelli, M., Giannini, F., and Giacchi, M. Carpal tunnel syndrome incidence in a general population. Neurology 58: 289, 2002.
Nordstrom, D. L., DeStefano, F., Vierkant, R. A., et al. Incidence of diagnosed carpal tunnel syndrome in a general population. Epidemiology 9: 342, 1998.
Papanicolaou, G. D., McCabe, S. J., and Firrel, J. The prevalence and characteristics of nerve compression symptoms in the general population. J. Hand Surg. (Am.) 26: 460, 2001.
Stevens, J. C., Sun, S., Beard, C. M., et al. Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Neurology 38: 134, 1988.
Gousheh, J., and Iranpour, A. Association between carpal tunnel syndrome and arteriovenous fistula in hemodialysis patients. Plast. Reconstr. Surg. 116: 508, 2005.
Atroshi, I., and Johnsson, R. Evaluation of portable nerve conduction testing in the diagnosis of carpal tunnel syndrome. J. Hand Surg. (Am.) 21: 651, 1996.
Finsen, V., and Russwurm, H. Neurophysiology not required before surgery for typical carpal tunnel syndrome. J. Hand Surg. (Br.) 26: 61, 2001.
Grundberg, A. B. Carpal tunnel decompression in spite of normal electromyography. J. Hand Surg. (Am.) 8: 348, 1983.
Louis, D. S., and Hankin, F. M. Symptomatic relief following carpal tunnel decompression with normal electromyographic studies. Orthopaedics 10: 434, 1987.
Jablecki, C. K., Andary, M. T., So, Y. T., et al. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. Muscle Nerve 16: 1392, 1993.