Lymph Node In Hands

Reverse Carpal Tunnel Syndrome

Carpal Tunnel Syndrome Causes and Treatment

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• Be aware of possibility of intraarticular injection of Marcaine into radial artery

• Rupture of the FCR tendon is possible with an injection. It can be avoided by using an orthoplast splint for 10 days postinjection.

Lymph Node Hand Radial Artery
Figure 31—1. Clinical hand that demonstrates location of tenderness over the flexor carpi radialis (FCR).
Lymph Nodes Hands
Figure 31—2. Robert's view of the carpometacarpal (CMC) joint demonstrating grade IVEaton CMC arthritis.

Diagnostic Studies

Anteroposterior (AP) and lateral oblique and Robert's view (hyperpronated AP of the thumb) show abnormalities of the CMC joint (Fig. 31-2).

Differential Diagnosis

Scaphotrapezial arthritis

Scaphoid nonunions

Basal joint arthritis of the thumb

Linberg's syndrome

Volar ganglion

FCR tendonitis

Diagnosis

Flexor Carpi Radialis (FCR) Tendinitis

Repetitive wrist motions experienced by some athletes can lead to a stenosis and synovitis within the fibro-osseous tunnel containing the FCR.

The FCR passes through a synovial tunnel bordered by the scaphoid tuberosity, trapezial ridge, and the transverse carpal ligament (Fig. 31-3). Within the tunnel, the tendon occupies 90% of the available space. As the tendon enters this tunnel, it

Scaphoid Tubercle Pain
Figure 31—3. (A) The FCR passes through the scaphoid tubercle to insert on the second metacarpophalangeal joint. Note how CMC arthritis can lead to FCR tendinitis. (B) Synovitis of the FCR with pain on wrist motion. (Illustrations courtesy of The Indiana Hand Center and Gary Schnitz.)

deviates 30 degrees dorsally over the volar pole of the scaphoid to insert at the base of the second and third metacarpals and provides a slip to the trapezial ridge. Weeks has suggested that this angulation may create mechanical irritation and predispose the athlete to tenosynovitis.

Athletes with FCR tendonitis have pain over the volar aspect of the wrist, proximal to the wrist crease and overlying the FCR tendon. Lister described a provocative test performed by abruptly extending a relaxed wrist to reproduce the pain. Pain also may be elicited on resisted flexion and radial deviation. Chronic synovitis and tendon ruptures may not allow active testing in some patients.

Nonsurgical Management

Immobilization, antiinflammatory medication, and a corticosteroid injection may provide relief in the setting of a primary tendinitis (Fig. 31-4). Chronic processes may be resistant and often require decompression of the fibro-osseous tunnel. In the setting of an FCR rupture, simple debridement of the stump can provide effective pain relief. A wrist splint placed in neutral rotation often will alleviate all the pain.

Lymph Nodes HandProximal Ulna Lymph
Figure 31—5. (A) Note exposed anatomy of the FCR and radial artery and proximal cutaneous branch of the median nerve (PCBMN). (B) Probe placed in FCR tunnel prior to release.

Surgical Management

Surgical treatment is rarely, if ever, needed and performed only in conjunction with CMC arthroplasty. If nonoperative treatment fails, the FCR tunnel can be decompressed. An incision is made radial to the FCR to prevent injury to the palmar cutaneous branch. The thenar muscles are reflected off the transverse carpal ligament and the tendon sheath is opened proximal to distal. The fibro-osseous tunnel along the ulnar border of the trapezium is released. The FCR should then be free to its insertion. Following surgery, range-of-motion exercises should be started early under the guidance of and occupational hand therapist (Fig. 31—5).

Complications

Rupture of FCR tendon Intraarteriolar Marcaine injection

Suggested Readings

Bishop AT, Gabel G, Carmichael SW. Flexor carpi radialis tendinitis I. Operative anatomy. J Bone Joint Surg [Am] 1994;76A:1009-1014.

Fitton J, Shea FW, Goldie W. Lesion of the flexor carpi radialis tendon and sheath causing pain in the wrist. J Bone Joint Surg [Br] 1968;50B:359-363.

Froimson A. Tenosynovitis and tennis elbow. In: Green DP, ed. Operative Hand Surgery. 3rd ed. New York: Churchill Livingstone; 1992:1989-2006.

Gabel G, Bishop AT, Wood MB. Flexor carpi radialis tendinitis: II. Results of operative treatment. J Bone Joint Surg [Am] 1994;76A:1015-1018.

Kiefhaber TR, Stern PJ. Upper extremity tendinitis and overuse syndromes in the athlete. Clin Sports Med 1992;11:39-55.

Linburg RM, Comstock BE. Anomalous tendon slips from the flexor pollicis longus to the flexor digitorum profundus. J Hand Surg [Am] 1989;4A:79-83.

FLEXOR CARPI RADIALIS TUNNEL SYNDROME| Lister G. The Hand. 2nd ed. Edinburgh: Churchill Livingstone; 1984:244.

Pyne JIB, Adams BD. Hand tendon injuries in athletics. Clin Sports Med 1992; 11 : 833-850.

Stern PJ. Tendinitis, overuse syndromes, and tendon injuries. Hand Clin 1990;6: 467-476.

Weeks PM. A cause of wrist pain: Non-specific tenosynovitis involving the flexor carpi radialis. Plast Reconstr Surg 1978;62:263-266.

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