Acute Carpal Tunnel

Syndrome
A Review of Current Literature
Jonathan D. Gillig, MDa, Stephen D. White, MDa,
James Nicholas Rachel, MDa,b,*

KEYWORDS
 Acute carpal tunnel syndrome  Carpal tunnel syndrome  Review  Median nerve
 Wrist trauma

KEY POINTS
 Acute carpal tunnel syndrome is a known complication of wrist and hand trauma including
distal radius fractures and numerous atraumatic causes.
 Patient evaluation should differentiate ACTS, which is a progressive condition from normal
sensation to loss of two-point discrimination, from neuropraxic injury, which is stable loss
of sensation immediately after injury.
 Complete release of the transverse carpal ligament should be performed on emergent basis
after diagnosis. Concomitant fractures and underlying medical conditions should be treated
as indicated.

INTRODUCTION The onset of ACTS is often measured in

minutes to hours, in contrast to chronic CTS.
Carpal tunnel syndrome (CTS) is the most com- ACTS most commonly results following trauma;
mon peripheral nerve compression. The inci- however, numerous other etiologies have been
dence of CTS is 99 per 100,000 individuals and described at a significantly lower incidence. All
it is most common in patients older than 40.1,2 causes of ACTS do share the same underlying
Females also comprise between 65% and 75% pathology of an acute increase in pressure within
of all cases.3 It is often seen as a chronic progres- the carpal tunnel. This results in compromise of
sion of median nerve compression as the nerve the epineural blood flow and thus pain and dys-
passes beneath the transverse carpal ligament. esthesias in the distribution of the median nerve.
Although elective carpal tunnel release (CTR) is Urgent surgical decompression of the median
performed in severe or refractory cases, conser- nerve is necessary to prevent further progression
vative management and observation are used in of symptoms.
milder cases. Acute CTS (ACTS) is a less com-
mon presentation and requires more urgent ANATOMY
and aggressive management. Many conditions
can lead to ACTS, but central to this diagnosis The carpal tunnel is an enclosed space bordered
is a progressive worsening of median nerve func- on three sides by the carpal bones and on the
tion. This is an important distinction because fourth by the flexor retinaculum. As a result,
neurapraxia and nerve contusion can present the volume of the carpal tunnel is relatively
with a similar distribution of symptoms, but their constant at around 5 mL,4 with little room for
severity remains stable and does not progress expansion or swelling secondary to its inelastic
over time. borders. The tunnel itself is transversed by

a
Department of Orthopaedic Surgery, University of South Alabama School of Medicine, 3421 Medical Park Drive,
Mobile, AL 36693, USA; b The Orthopaedic Group, P.C, 6144 Airport Boulevard, Mobile, AL 36608, USA
* Corresponding author.
E-mail address: [email protected]

Orthop Clin N Am 47 (2016) 599–607

http://dx.doi.org/10.1016/j.ocl.2016.03.005
0030-5898/16/$ – see front matter ª 2016 Elsevier Inc. All rights reserved.
600 Gillig et al

10 structures, nine tendons and the median population experiences subligamentous branch-
nerve. The tendons include the four flexor ing, where the motor nerve originates within the
digitorum superficialis tendons, the four flexor carpal tunnel. Lastly, 20% of the population ex-
digitorum profundus tendons, and the tendon periences transligamentous branching, where
of the flexor pollicis longus. The dorsal floor of the nerve branches off within the carpal tunnel
the carpal tunnel is abutted by the triquetrum, and then pierces the transverse carpal ligament
hamate, capitate, and the scaphoid. Radially, on its course toward the thenar musculature.6
the scaphoid tubercle and the trapezium border Other terminal branches of the median nerve
the tunnel with the ulnar border being composed include the digital cutaneous branches, which
of the triquetrum, pisiform, and the hook of the supply sensation to the radial 3.5 digits on the
hamate. Finally, the volar surface of the tunnel is palmar side and the dorsal tips of the 3 most
composed of three structures that make up the radial digits. A small percentage of 1.2% to
flexor retinaculum. These include the deep fore- 23% of the population may also retain the gesta-
arm fascia, the transverse carpal ligament, and tional remnant of the median artery, which
the distal aponeurosis that divides the thenar courses with the median nerve into the hand.7,8
and hypothenar musculature. These include the
deep forearm fascia, the transverse carpal liga- PATHOPHYSIOLOGY
ment, and the distal aponeurosis that divides
the thenar and hypo thenar musculature (Fig. 1). Many presentations of ACTS have been reported
The most proximal portion of the carpal tunnel in the literature. Although ACTS itself is uncom-
begins at the volar wrist crease and then extends mon, its presentation is most often considered
distally to a line running from the abducted in the setting of trauma, such as distal radius frac-
border of the thumb to the hook of the hamate, tures or perilunate injuries. Awareness of these
Kaplan cardinal line. At Kaplan cardinal line, the possible causes should guide evaluation in emer-
average width of the tunnel is 25 mm.5 The carpal gency room settings; however, small case series
tunnel is at its narrowest, around 20 mm, at the and case reports describe innumerable other
level of the hook of the hamate. At the proximal causes ranging from gout to parvovirus. This
and distal portions of the tunnel, an opening ex- demonstrates the importance of a thorough
ists; however, synovium at either end results in nerve examination in all patients with any sign
the properties of a closed compartment. When of progressive nerve symptoms. The underlying
the pressure within the compartment rises above pathologic process that causes ACTS is the
a threshold, blood flow decreases resulting in creation of mass effect from a space-occupying
compromise to the median nerve and paresthe- lesion in the carpal tunnel resulting in increased
sias in the nerve distribution. compartmental pressures. This rise in compart-
The median nerve supplies sensation to the mental pressure creates a compartment syn-
most radial 3.5 fingers, the thenar musculature, drome that results in lack of epineurial perfusion
and the lumbricals of the index and middle fin- and ultimately ischemia. The lack of perfusion
gers. The palmar cutaneous branch of the me- causes local tissue edema, nerve conduction
dian nerve branches off just proximal to the delays propagated by demyelination along the
wrist flexion crease between the pollicis longus axon, and axonal transport dysfunction that
and the flexor carpi radialis and runs superficial inhibits recurrent nerve firing.9–11 Short intervals
to the flexor retinaculum. This nerve divides of decreased perfusion are rapidly reversible;
into a lateral branch, which supplies sensation however, a longer duration of compression in-
over the volar base of the thumb, and the medial creases the latency period before recovery and
branch, which supplies sensation to the radial also increases risk of permanent disability.
side of the palm. This sensory branch is not Previous animal and human studies show
affected by compression in the carpal tunnel, thinned nerves in the entrapped segment with
and thus its function can help to distinguish swelling of the nerve proximal to that region.
CTS from more proximal median neuropathy. This is thought to be caused by accumulation of
The recurrent branch of the median nerve inner- axoplasm, nerve edema, and chronic inflamma-
vates the opponens pollicis, abductor pollicis tory fibrosis of the nerve.12,13 Demyelination
brevis, and the superficial part of the flexor pol- and remyelination of the affected segments leads
licis brevis. The branching of this nerve has sub- to poorer nerve conduction and a loss of large
stantial anatomic variability with 50% of the myelinated axons leading to increased latency.
population having extraligamentous branching, The normal compartment pressure of the carpal
meaning that the motor branches occur distal tunnel is 2.5 mm Hg at rest, and this increases
to the carpal tunnel. Up to 30% of the with wrist flexion or extension. The average
 Acute Carpal Tunnel Syndrome 601

pressure is below the average capillary refill pres- Traumatic

sure of 32 mm Hg.14 However, with forceful wrist Following any significant wrist or hand trauma,
extension and flexion, the carpal tunnel pressure ACTS must be ruled out, because it is a common
can reach 30 mm Hg, and Lim and colleagues15 complication. High-energy injuries in young
showed that reduction in epineural blood flow is patients have the highest risk of developing
first noted with a carpal tunnel pressure of 20 to ACTS. In fact, ACTS was first described by Paget
30 mm Hg. Thus, a compartment pressure of in 1853 in a patient who had suffered a distal
30 mm Hg can lead to the development of radius fracture and suffered rapidly progressive
neuronal changes. It has also been shown that neuropathy. It is important to differentiate nerve
the microscopic changes occur in a dose- contusion from ACTS initially, because the man-
dependent manner with increased time periods agement differs significantly. Often a complete
of high pressure resulting in increased latency history and serial examinations can help to
and more permanent damage.16 distinguish the two. Mack and colleagues report
Extension and flexion of the wrist also causes key differences between these two conditions.
a decrease in the cross-sectional area of the car- Patients with ACTS have a normal median nerve
pal tunnel. With wrist extension, the narrowing examination initially with progression to loss of
occurs at the level of the pisiform. Wrist flexion two-point discrimination. In contrast, patients
results in narrowing at the level of the hook of with nerve contusions experience immediate,
the hamate.17 Wrist flexion also results in the but nonprogressive and static sensory loss. In
retraction of the transverse carpal ligament to ACTS, intercarpal pressure measurements were
a position that is closer to the distal radius, which also shown to be elevated in contrast to normal
results in a further decrease in area. levels in nerve contusion.
Distal radius fractures are one of the more
ETIOLOGY common associated injuries with ACTS (Figs. 2
and 3). A study by Dyer and colleagues18 looked
Acute carpal tunnel syndrome most often occurs at predictors of ACTS associated with distal
following traumatic injury to the patient’s wrist radius fractures. Out of 50 patients who had con-
or hand, however numerous atraumatic causes current ACTS and distal radius fractures, transla-
have been described in the literature and pro- tion of fracture greater than 35% and female age
viders must keep these alternatives in mind. A less than 48 years were the most highly corre-
schematic diagram of the variable etiologies lated risk factors for ACTS development. Dyer
will be discussed further in the following sections put the incidence of ACTS in the setting of distal
and can be easily visualized in Fig. 2. radius fractures at 5.4%, whereas several older

Fig. 1. Volar anatomic diagram of the carpal tunnel demonstrating compartment contents and surrounding
structures.
 602
Gillig et al
Fig. 2. Described causes of acute carpal tunnel syndrome in the literature.
 Acute Carpal Tunnel Syndrome 603

approximately 12 hours and resulted in residual

median neuropathy but improved hand
function.23

Atraumatic
The atraumatic causes of ACTS are almost innu-
merable. Many case reports have been written
regarding a variety of causes of atraumatic
ACTS and new causes will likely arise in the
future. Fortunately, atraumatic ACTS is a rare
entity. The goal in this article is not to mention
every cause of ACTS, but rather to build a frame-
work that helps to classify the varying causes into
categories to help diagnosticians when encoun-
tering a patient with symptoms consistent with
ACTS.
Infectious causes of ACTS are varied and
include viral, bacterial, and parasitic origins. In
all instances, the body’s inflammatory response
to these foreign organisms can create increased
pressure within the carpal tunnel leading to
sudden onset of symptoms. With nine tendons
traversing the carpal tunnel, infectious tenosyn-
ovitis of the flexor tendons is one atraumatic
cause that can affect any of the tendon
Fig. 3. ACTS distal radius fracture prereduction sheaths. Case reports identifying the causative
lateral. organism have included Staphylococcus aureus,
mycobacterium, Histoplasma capsulatum, cryp-
tococcus, Neisseria gonorrhea, and Brucella.24
studies cited the incidence as between 0.2% and Case reports involving septic arthritis,25 parvo-
21.5%.19 The cause of these traumatic ACTS is virus infection,26 filarial infection,27 and even a
most likely secondary to hemorrhage into the case of a cat bite28 have all demonstrated
tunnel at the fracture site. The former practice different infectious processes that can lead to
of splinting wrists in the Cotton-Loder position, ACTS.
which involved significant wrist flexion, has also Noninfectious inflammatory causes of ACTS is
been implicated in increasing the incidence of another category to be discussed. These condi-
ACTS following distal radius fractures.20 tions range from flexor synovitis,29 to gout30
Other trauma to the hand including carpal and pseudogout,31 to rheumatoid arthritis.32
fractures, dislocations, fracture-dislocations, Coagulopathies, whether congenital or medi-
and iatrogenic causes has been associated with cation induced, have been implicated in ACTS.
ACTS. Volar fracture and subluxation of the In these patients, even trivial injury can result in
bases of the second and third metacarpals into hematoma formation.33 With an aging popula-
the carpal tunnel have been reported as causes tion and increasing numbers of people requiring
of ACTS.21 Other case reports describe ACTS anticoagulation, this is a cause that needs to be
following nondisplaced fractures of the scaphoid considered more frequently. Even newer gener-
and fifth metacarpal.22 This demonstrates the ations of anticoagulants, such as dabigatran, in-
mass effect component secondary to swelling crease the risk of bleeding and can thus result
that can cause ACTS and not just fracture frag- in ACTS.34
ments infringing on the tunnel. Another case Individuals with anatomic anomalies and
report in 2010 describes how traumatic iatro- pathology have also been implicated in ACTS.
genic causes can result in ACTS. In this case, a Patients with a persistent median artery
patient on anticoagulation with an unsuccessful have been reported to develop ACTS following
arterial line placement developed ACTS and median artery thrombosis, aneurysm, and
forearm compartment syndrome. In this case, rupture.35–38 Venous malformations in patients
20 mL of blood and blood clots were removed have also been reported causes.39
from the carpal tunnel on urgent exploration. Iatrogenic causes of ACTS can be traumatic
This patient’s symptoms progressed over and atraumatic. Postsurgical hematoma is a
604 Gillig et al

common cause that must be looked for in the changes. The widespread adoption of these
postoperative period. One case report of ACTS monitoring devices has been limited by the
occurred in a total wrist arthroplasty patient sensitivity of a good physical examination in
6 years postoperatively from metallosis of the diagnosing ACTS.
components.40 A far less common cause in-
cludes tumescence fluid being injected into the Imaging
carpal tunnel during burn surgery.41 Lastly, a ACTS does not in itself require specific imaging
case of ACTS was reported in a patient who because it is based on a clinical evaluation. Ra-
was undergoing radiation therapy for a high- diographs should be standard in the manage-
grade sarcoma on his right hand.42 ment of cases secondary to trauma. Dyer
Large shifts in body fluids have also resulted demonstrated that distal radius fracture transla-
in ACTS, such as during pregnancy43 and in tion was the most important factor leading to
postresuscitative burn patients.44 Other rare ACTS (Figs. 3 and 4). The increased risk in
case reports, such as in pancreatic-renal women younger than 48 and those with greater
transplants45 and in patients exposed to snake than 35% fracture translation can be helpful
venom,46 result from third spacing of fluids. when evaluating patients. Prophylactic CTR
Lastly, oncologic causes of ACTS are another may be appropriate in this group; however,
category to be aware of. These are more likely to ACTS remains a clinical diagnosis that must be
be of gradual onset and thus more likely fall into monitored over time. Advanced imaging, such
the category of CTS but they are included here as MRI or computed tomography, can be used
for completeness. A study by Martı́nez-Villén if needed in a case of trauma for preoperative
and colleagues47 demonstrated these symptoms planning. They may also be required for more
in patients with diagnoses including a giant cell atypical causes, such as masses or infections.
tumor of a tendon sheath, synovial chondroma- These advanced imaging techniques have
tosis, tuberculosis granuloma, and tophaceous been helpful from a research standpoint in
gout. determining carpal tunnel physiology and me-
chanics during wrist motion. Nonetheless, it is
DIAGNOSIS important to remember that emergent CTR
Physical Examination should not be significantly delayed for these
A thorough physical examination with moni- tests because it could lead to irreversible me-
toring over time remains the best avenue for dian nerve damage.
diagnosing ACTS. The evaluating physician
Treatment
must be diligent in the evaluation of the pa-
Complete release of the transverse carpal
tient’s neurovascular status and maintain a
ligament is usually the required treatment of
high level of clinical suspicion for ACTS similar
to compartment syndrome in injuries that pre-
dispose patients to this condition. Nerve contu-
sion must be distinguished from progressive
neuropraxia in the median nerve distribution.
Nerve contusion is represented by static symp-
toms that gradually improve over time. ACTS
instead presents as initially paresthesias and
dysesthesias that progress with increasingly
worsening two-point discrimination. As un-
treated ACTS progresses, the patient loses all
sensation distal to the carpal tunnel in the me-
dian nerve distribution and often experiences
loss of grip strength. Physical examination ma-
neuvers, such as Phalen, Tinel, and Durkan,
can further exacerbate ACTS progression, and
thus their use should be limited. Lastly,
compartment pressure monitoring provides
the most objective measure to determine
increased carpal tunnel pressures. Pressures
greater than 20 mm Hg have demonstrated
decreased epineuronal blood flow with pres-
sures closer to 30 mm Hg resulting in neuronal Fig. 4. ACTS distal radius fracture postreduction.
 Acute Carpal Tunnel Syndrome 605

ACTS. This procedure is performed through an approaches.34,52–56 For instance, Black and
open technique via a palmar incision. Similar to colleagues52 suggest maintaining international
an elective CTR, the incision should be made in normalized ratio and not stopping therapy,
line with the radial border of the ring finger or whereas Bonatz and colleagues54 suggest
ulnar border of the palmaris longus to prevent reversing the anticoagulant if possible and
injury to the palmar cutaneous branch and recur- attempting conservative treatment. One must
rent motor branch of the median nerve. Often be cautious when attempting conservative man-
this is performed through a more extensile inci- agement, however, because of the possible per-
sion than for an elective CTR. This allows for bet- ilous consequences of delayed treatment, such
ter visualization because of significant swelling as prolonged or incomplete recovery and
that is often present after acute injury. It also possible increased risk of early reflex sympathetic
allows the surgeon to address other underlying dystrophy.34,54,55 Early surgical intervention has
pathology, such as a mass or fracture/disloca- been shown to have rapid and full recovery of me-
tion. The incision may be carried 2 cm proximal dian nerve function.34,52,55 Sibley and Mandel34 in
to wrist flexion crease for perilunate disloca- a case report showed a patient who developed
tion48 or further proximal as necessary for treat- ACTS after dabigatran therapy and underwent
ment of a distal radius fracture.49 It is important emergent CTR with complete recovery of median
that a complete release of the transverse carpal nerve. They recommended prompt surgical
ligament be performed, which is another reason decompression in cases of ACTS caused by
visualization needs to be optimal. Care should bleeding. In these less common situations where
be taken at the distal aspect of the incision as there is a medical cause, it is important to take a
not to cause injury to the transverse arch. Special multidisciplinary approach to fully treat the pa-
attention should also be directly ulnarly so as not tient’s condition. After the appropriate urgent
to risk injury to the ulnar neurovascular bundle. surgical management has been undertaken, this
One must also be cognizant of retractor place- may require consulting physicians with the proper
ment, particularly with retracting along the radial expertise to make sure the patient’s medical
aspect of the median nerve because this can management is optimized.
result in injury to the recurrent motor branch.48
Surgical timing is as important as complete Outcomes
release of the carpal ligament. Outcomes of On review of published literature, outcomes are
many case series show delayed release leads to related to timely CTR. If CTR is performed early,
irreversible damage and intraneural fibrosis.50,51 the nerve often recovers fully. If delayed, irre-
These reports have not recommended a specific versible nerve damage can lead to permanent
time frame for release. However, ACTS should nerve impairment. However, there is no
be viewed as a surgical urgency if not an emer- consensus presented in the literature on a rec-
gency, with release when an operating room is ommended time window from onset to release.
available and the patient is stable for surgery. Bauman and colleagues50 and Ford and Ali51
In the setting of wrist or hand trauma, a closed demonstrated in case series that delayed inter-
reduction should first be attempted of any dis- vention of only 36 to 96 hours can have perma-
placed fractures or dislocations. The wrist should nent consequences. Mack and colleagues
then be placed in a neutral position followed by recommended release within 8 hours of onset
strict elevation. Mack and colleagues suggested to improve outcomes. Outcomes vary in atrau-
if pain and progressive median nerve dysfunc- matic and medical cases based to some degree
tion persist for 2 hours after presentation and on the time from onset to treatment and the un-
reduction, then intracarpal pressure should be derlying pathology that precipitated the ACTS.
checked. In pressure readings 40 mm Hg and Larger series are reported in cases secondary
greater, a CTR is performed emergently within to trauma. Chauhan and colleagues57 retrospec-
8 hours of onset. If pressures are normal, tively compared outcomes of acute CTR in com-
continued observation is recommended. bination with open reduction internal fixation of
Although ACTS typically results from trauma, it distal radius fractures and elective CTR. They
can possibly result from an underlying medical found no long-term differences in Boston Carpal
cause. In these instances, the treatment typically Tunnel Questionnaire scores, symptom severity,
requires more than a simple CTR but also appro- and functional status. Obviously other than
priate medical treatments for such conditions as timely treatment, there is certainly an element
gout or bleeding disorders. There have been of the severity of the underlying cause that af-
several case reports of ACTS caused by anticoag- fects outcomes, although this has not been spe-
ulants; many of these show varying treatment cifically addressed in the literature. This
606 Gillig et al

particularly applies to traumatic causes, with graded compression of the rabbit vagus nerve. J
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likely being related to worse outcomes. 14. Gelberman RH, Hergenroeder PT, Hargens AR,
et al. The carpal tunnel syndrome: a study of carpal
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