Abstract
Dear Sir,
A right hand dominant, 63 year old housewife presented to us with intractable right wrist pain of two days duration. The pain was of sudden onset, throbbing in nature, exacerbated by wrist movement and associated with numbness along the right thumb and middle finger. There was no weakness of the hand or fingers. She had sustained a right distal radial shaft fracture, which had been treated with open plating using a volar approach, 12 weeks previously. The surgical exposure did not extend to the flexor retinaculum. She had been attending physiotherapy for wrist mobilisation. On presentation, there was tenderness over the volar aspect of her right wrist with a markedly positive Phalen’s test and Tinel’s sign. She also had sensory loss in the median nerve distribution but no motor deficit. Laboratory investigations, including coagulation profile, were within normal limits. A diagnosis of acute carpal tunnel syndrome was made and exploration carried out. Subperineural haemorrhage involving the median nerve throughout its course in the carpal tunnel was found (Fig. 1) and decompression of the carpal tunnel carried out. The investing layers of the nerve were not incised. There was immediate postoperative improvement of symptoms, which had almost completely disappeared 4 weeks later.
There are four previous reports of haemorrhage causing acute carpal tunnel syndrome in patients with a normal bleeding profile. Watson-Jones (1949) and Faithfull and Wallace (1987) each reported a case of haemorrhagic carpal tunnel syndrome following trauma. Both Hayden (1946) and Mandal et al. (2004) described spontaneous intraneural haemorrhage in the median nerve leading to acute carpal tunnel syndrome, with no immediate history of trauma. Whether the distal radius fracture had any bearing in our case is impossible to say, although a time difference of 12 weeks makes this less likely.