Pediatric median mononeuropathies: a clinical and electromyographic study

Etiology of Carpal Tunnel Syndrome in a Large Cohort of Children

(1) Background: Carpal tunnel syndrome (CTS), a compressive mononeuropathy of the median nerve at the wrist, is rare in childhood and occurs most frequently due to secondary causes. (2) Methods: Medical history, electrodiagnostic findings, and imaging data of patients with CTS from two pediatric neuromuscular centers were analyzed retrospectively. The etiology of CTS was investigated and compared with the literature. (3) Results: We report on a cohort of 38 CTS patients (n = 22 females, n = 29 bilateral, mean age at diagnosis 9.8 years). Electrodiagnostic studies of all patients revealed slowing of the antidromic sensory or orthodromic mixed nerve conduction velocities across the carpal tunnel or lack of the sensory nerve action potential and/or prolonged distal motor latencies. Median nerve ultrasound was diagnostic for CTS and confirmed tumorous and vascular malformations. Etiology was secondary in most patients (n = 29; 76%), and mucopolysaccharidosis was the most frequent underlying condition (n = 14; 37%). Idiopathic CTS was rare in this pediatric cohort (n = 9; 24%). (4) Conclusion: Since CTS in childhood is predominantly caused by an underlying disorder, a thorough evaluation and search for a causative condition is recommended in this age group.

[Median nerve compression in the carpal tunnel in children - a delayed diagnosis. About 20 clinical cases]

OBJECTIVES

The carpal tunnel syndrome is rare in children. We performed a retrospective study of 10 children. The aim is to show that the diagnosis of carpal tunnel syndrome is difficult in children.

PATIENTS AND METHODS

We identified all children with median nerve compression in the carpal tunnel between 2010 at 2020, managed in our service.

RESULTS

Ten children with 20 hands included. There was different etiologies of carpal tunnel syndrome: 5 lysosomal storage diseases, 4 idiopathic carpal tunnel syndrome, 1 genodermatose, 1 Byler syndrome and 1 VACTERL syndrome. Common presenting symptoms were pain (five patients) and under use of fingers (five patients). Two children had opposition deficit of the thumb. We operated 19 hands. Median age at diagnosis was 4 years and 7 months. One children or 2 hands had a reanimation of opposition by tendinous transfer of flexor digitorum superficialis tendon of the ring finger. All children had a complete regression of the painful symptoms, a use improvement of fingers and recovery of the opposition of the thumb.

CONCLUSION

The diagnosis of carpal tunnel syndrome is difficult in children. It is common to be confronted with an advanced clinical symptoms. The atypical symptoms may cause diagnostic delay. Due to the quality of the clinical results obtained, we recommend open carpal tunnel release even when the diagnosis seems delayed.

LEVEL OF EVIDENCE

IV.

Utility and practice of electrodiagnostic testing in the pediatric population: An AANEM consensus statement

Nerve conduction studies and needle electromyography, collectively known as electrodiagnostic (EDX) studies, have been available for pediatric patients for decades, but the accessibility of this diagnostic modality and the approach to testing vary significantly depending on the physician and institution. The maturation of molecular diagnostic approaches and other diagnostic technologies such as neuromuscular ultrasound indicate that an analysis of current needs and practices for EDX studies in the pediatric population is warranted. The American Association of Neuromuscular & Electrodiagnostic Medicine convened a consensus panel to perform literature searches, share collective experiences, and develop a consensus statement. The panel found that electrodiagnostic studies continue to have high utility for the diagnosis of numerous childhood neuromuscular disorders, and that standardized approaches along with the use of high-quality reference values are important to maximize the diagnostic yield of these tests in infants, children, and adolescents.

Peripheral nerve injuries in the pediatric population: a review of the literature. Part II: entrapment neuropathies

INTRODUCTION

Entrapment neuropathies are infrequent in children, and therefore remain unrecognized. The incidence of radial, median, and cubital mononeuropathies are all similar. Despite the rarity of such cases, extensive, albeit scattered, literature has accumulated concerning entrapment neuropathies in children.

OBJECTIVE

To the literature concerning entrapment neuropathies in children.

METHODS

A systematic review of the existing literature has been made.

RESULTS

The management of chronic pediatric pain is very important in such patients to prevent youths from experiencing prolonged absences from school, sports, or other productive activities, and limit the psychological burden of chronic disease. Nonsurgical treatment of both cubital and carpal tunnel syndromes has been disappointing in pediatric patients, with only limited success; and, to date, there is no clear explanation for the outcome differences generated by nonsurgical management between adults and youths. Simple decompression of the ulnar nerve at the elbow also has much higher rates of failure in children than in adults.

CONCLUSIONS

The presence of an entrapment neuropathy (specially carpal tunnel syndrome) in a pediatric-age patient should alert medical care providers to the potential of some underlying genetic condition or syndrome.

Bilateral Idiopathic Carpal Tunnel Syndrome in a 4-Year-Old Girl

Carpal tunnel syndrome (CTS), the most common entrapment neuropathy in adulthood, is rare in childhood. The symptoms may differ to those in adults, or may be misinterpreted owing to children's difficulties in expressing themselves. Cases of idiopathic, bilateral CTS under the age of 5 are rare. A 4-year-old girl presented with pain in both hands and difficulty opening them in the morning. Bilateral severe CTS was determined at electroneuromyography (ENMG). Bilateral wrist splints were advised for both hands. Improvement in ENMG was seen at 2 weeks following conservative treatment.

Idiopathic bilateral carpal tunnel syndrome in a 9-month-old infant presenting as a pseudo-dystonia

BACKGROUND

Carpal tunnel syndrome is the most common focal peripheral neuropathy seen in most electrophysiological laboratories. Although the incidence of carpal tunnel syndrome in adults is 50 to 150 cases per 100,000 people, it is rare in children. There are less than 200 case reports of carpal tunnel syndrome in children, with mucopolysaccharides and mucolipidosis being the most frequent cause. Idiopathic carpal tunnel syndrome with childhood onset occurs in less than 0.2% of cases.

PATIENT

We describe a 9-month-old infant who presented with intermittent abnormal posturing movement of both hands.

RESULTS

The clinical presentation and the electrophysiological studies confirmed the diagnosis of carpal tunnel syndrome. His dystonic posturing had disappeared completely 3 weeks after surgical release of both flexor retinaculi.

CONCLUSION

We are not only reporting the youngest child with carpal tunnel syndrome, but we also report a new cause of abnormal movement disorder in children.

[Carpal tunnel syndrome in children. About 10 clinical cases]

INTRODUCTION

The carpal tunnel syndrome is a common peripheral neuropathy in adults but is rare in children. We report a series of 10 carpal tunnel syndromes in children.

METHODS

We have supported five children, two males and three females, with a bilateral carpal tunnel syndrome. We studied the clinical history (history, symptoms, stage of disease), therapeutic management and remote development. Three children were diagnosed with a mucopolysaccharidosis, the fourth with VATER association. For the last child, it was a form considered idiopathic. Two children were referred for night pains, the others for under-utilization of their first three fingers, two of which had a thenar atrophy. Four children underwent an electromyogram for diagnostic confirmation. We realized open surgical treatment at one time, by section of the carpal ligament.

RESULTS

The average age of our patients was 4years. The average decline in the surgical study was 19 months. Postoperatively, we noted, in all patients, complete regression of the painful symptoms, a sensory improvement and recovery of the opposition of the thumb.

CONCLUSION

The scarcity of carpal tunnel syndrome in children and the atypical symptoms may cause diagnostic delay, with serious consequences. We keep vigilant and ready to access to additional tests (electromyogram). For our team, the therapeutic approach is a systematic open surgical treatment.

Carpal tunnel syndrome in children

BACKGROUND

Carpal tunnel syndrome or median neuropathy at the wrist is a rare condition in children. Of the reported patients with carpal tunnel syndrome, mucopolysaccharidoses and the mucolipidoses are the most common causes.

PATIENTS

We report 13 patients between the ages of 2 and 17 years of age with carpal tunnel syndrome.

RESULTS

Mucopolysaccharidoses was the cause in one child. In other children, trauma to the median nerve, malformations of the wrist, brachial plexopathy, obesity, inherited susceptibility to pressure palsies (PMP 22 gene deletion), and family history of median neuropathy at the wrist were identified. All patients had hand pain, numbness, and paresthesias in their hands. The nerve conduction studies showed prolongation of median sensory nerve latency and distal motor latency in median nerve.

CONCLUSIONS

Carpal tunnel syndrome occurs in children and a variety of risk factors predispose to its occurrence.

Increased prevalence of carpal tunnel syndrome in albright hereditary osteodystrophy

CONTEXT

Albright hereditary osteodystrophy (AHO) is a rare genetic disorder characterized by phenotypic abnormalities including brachydactyly/brachymetacarpia, short stature, and sc ossifications. Carpal tunnel syndrome (CTS) is a chief complaint in many patients with AHO.

OBJECTIVE

The objective of the study was to investigate the prevalence of CTS in patients with AHO.

DESIGN

This was a cross-sectional study.

SETTING

The study was conducted at the Clinical Research Center (Institute of Clinical and Translational Medicine), Johns Hopkins University School of Medicine and Albright Clinic, Kennedy Krieger Institute.

PARTICIPANTS

Thirty-three subjects with a diagnosis of AHO participated in the study.

MAIN OUTCOME MEASURES

We assessed for the presence and location of hand tingling, numbness, pain, weakness, flick sign, difficulty with fine motor skills, severe hand or nail biting, and nocturnal symptoms in the setting of normocalcemia and a euthyroid state. Patients were considered to have CTS if they were positive for three of these symptoms. All subjects were analyzed for mutations in the GNAS gene.

RESULTS

Twenty-two subjects (67%) had a clinical diagnosis of CTS (95% confidence interval 0.48, 0.82). Twenty-eight of 33 subjects were confirmed to have mutations in GNAS, of whom 68% had CTS (95% confidence interval 0.48, 0.84). There were 14 children in this study; 36% had a clinical diagnosis of CTS. Body mass index, brachydactyly/brachymetacarpia, prior GH treatment, and specific GNAS mutations were not associated with CTS.

CONCLUSIONS

We report a high prevalence of CTS in both adults and children with AHO. The diagnosis of CTS should be considered when evaluating a patient with AHO because the intervention for CTS could improve overall function and quality of life in these patients.

Pediatric median neuropathy due to pruritus in Alagille syndrome

Median entrapment neuropathy or carpal tunnel syndrome is uncommon in children. The majority of cases are related to genetic conditions which result in skeletal dysplasia or altered connective tissue characteristics, direct injury to the median nerve caused by intensive sports or trauma, or hereditary neuropathy with liability to pressure palsies. This report describes a 10-year-old patient with Alagille syndrome who presented with poor fine motor skills because of an entrapment neuropathy of the median nerve at the wrist. This condition was probably caused by intermittent external compression at the wrists due to years of rubbing both wrists and hands to relieve pruritus. To our knowledge, median neuropathy has never been associated with Alagille syndrome, although severe pruritus is considered a major symptom and many patients exhibit widespread scratching and rubbing.

Carpal tunnel syndrome in children

Carpal tunnel syndrome is a condition rarely encountered in infants. We describe five patients with nine involved hands. One was reported earlier. In three cases the cause of carpal tunnel syndrome is a storage disease: one girl with mucolipidosis type III and a boy and a girl with mucopolysaccharidosis type I. The fourth case is a girl presenting with unilateral macrodactyly of the right third and fourth digits. The last case involves a boy with familial carpal tunnel syndrome. We briefly discuss these patients and review the literature since 1989.

Severe bilateral carpal tunnel syndrome in juvenile chronic arthritis

Carpal tunnel syndrome, although rare, is known to occur in children mainly because of genetic or metabolic disorders. The clinical findings are variable and include symptoms of burning pain, tingling, numbness, and weakness or atrophy in the hands of the patients. It is usually diagnosed by demonstration of prolonged distal latency times during the electrodiagnostic studies. Reported here is a patient with juvenile chronic arthritis and a diagnosis of severe bilateral carpal tunnel syndrome, the first patient reported in the literature, to the best of the authors' knowledge.

An evaluation of gender, obesity, age and diabetes mellitus as risk factors for carpal tunnel syndrome

OBJECTIVES

The aim of this study is to identify gender, high body mass index (BMI), age and diabetes mellitus (DM) as independent risk factors (RF) for carpal tunnel syndrome (CTS) and to analyse the strength of association of these factors, both globally and in individual subgroups.

METHODS

We performed a case-control study with 791 CTS cases and 981 controls. Patients were selected from those referred to nerve conduction studies and electromyography in 3 university hospitals and two private services. We calculated the odds ratio between the two groups to analyse the RF. Possible sources of bias were studied using stratified and multivariate analyses.

RESULTS

The mean BMI and age were greater in the case group than in the control. Female gender, BMI>30, age of 41-60 years and DM were significantly more frequent in the case group. Males tend to have a more severe CTS and DM was a significant RF for bilateral lesions. Stratified analysis showed female gender, obesity and age of 41-60 years as independent RF. DM, when stratified by BMI category, was not significantly associated with CTS.

CONCLUSIONS

Our study confirms that female gender, obesity and age are independent RF for CTS. DM may be a weak RF, especially among women.

Carpal tunnel syndrome in children

CTS is uncommon in children. A number of conditions predispose children to developing CTS. These conditions include the lysosomal storage diseases, a multigenerational history of CTS, and macrodactyly. Because many case are idiopathic, isolated cases are possible even in the normal child or adolescent. Children with CTS often have modest complaints in spite of long-standing difficulties such as decreased manual dexterity in one hand or poorly localized pain. Physical findings tend to be dramatic abnormalities such as severe thenar weakness and atrophy. These findings suggest that many children are diagnosed late in the course of their nerve compression. Because some patients have profound atrophy at a young age, the condition can be confused with primary thenar hypoplasia. Provocative tests, the Tinel and Phalen tests, are often normal in children with long-standing nerve compression. Electrodiagnostic studies are essential to establishing the diagnosis in many children. Pediatric cases of CTS tend to demonstrate bilateral electrophysiologic abnormalities, even if only one hand is primarily involved clinically. Therefore, it is recommended that EMG and NCS be performed bilaterally in all suspected children. Sedation may be helpful in obtaining electrodiagnostic studies in a small child. Open operative release is the only treatment documented to be effective in the treatment of childhood CTS.

Proximal median neuropathies

Proximal median neuropathies are uncommon. They are usually caused by overuse of the forearm, anatomic variations, or both. Forearm pain, weakness of muscles supplied by the affected nerves, and sensory loss, including the thenar eminence, are common clinical findings. Nerve conduction studies and needle electromyography are helpful in the diagnosis of these syndromes. Treatment is avoidance of overuse and release of mechanical compression. Prognosis is generally good.

Mutilating hand syndrome in an infant with familial carpal tunnel syndrome

A 7-month-old infant, son of consanguinous Indian parents, presented with recurrent chewing of his digits in a median nerve distribution as the primary manifestation of carpal tunnel syndrome, in conjunction with features consistent with congenital insensitivity to pain. Electromyography (EMG) demonstrated severe median nerve entrapment at the wrist bilaterally, but other nerves were normal. In spite of clinical evidence of diffuse pain insensitivity, sural nerve and skin biopsies were normal, and he had no evidence of autonomic dysfunction. Hand findings evolved with scarring and infection of median innervated digits and loss of fine motor skills. Carpal tunnel release resulted in complete clinical resolution and significant EMG improvement. Milder symptoms and EMG evidence of median nerve entrapment were demonstrated in both parents, paternal grandparents, and several of his father's siblings. We hypothesize this child may be homozygous for a mutant allele that in its heterozygous state predisposes to familial autosomal dominant carpal tunnel syndrome. Homozygosity for this or another mutant allele may be responsible for his congenital insensitivity to pain.

Pediatric radial mononeuropathies: a clinical and electromyographic study of sixteen children with review of the literature

Sixteen pediatric radial mononeuropathies were seen among 2077 electromyograms performed in the electromyography laboratory at The Children's Hospital, Boston, during 16.5 years, 1979-1995. Eight (50%) of these radial neuropathies, including 2 in newborns with apparent prenatal onset, were atraumatic, primarily related to compression in 6 and entrapment in 2. The other 8 (50%) were traumatic related to fractures or lacerations. Electromyography documented the radial neuropathy to be localized to the proximal main radial nerve trunk in 2 (13%), distal main radial nerve trunk in 9 (56%), and posterior interosseous nerve in 5 (31%) children. Significant improvement was noted in 13 of the 16 radial neuropathies--within 6-12 weeks for demyelinating lesions and up to 17 months for axonal injuries. Rarely, a child with a chronic progressive radial neuropathy or a postfracture radial neuropathy that does not improve in 3 months may require exploration.