Carpal tunnel syndrome is a common condition and clinical diagnosis is often easily made. A system of direct referral for day-case carpal tunnel surgery was introduced. General practitioners, physicians and surgeons were advised of the service and the criteria for referral, which included female patients with bilateral symptoms and physical signs, and some response to conservative treatment. All patients were reviewed preoperatively by the senior author (GEBG). The service was an alternative to standard outpatient referral.

A total of 51 patients was seen. Two were refused surgery. In all those who underwent surgery, the symptoms either resolved or were improved. The service was well received, although some patients felt that they were poorly informed preoperatively. The mean waiting time for surgery was reduced by four months and the patients avoided an outpatient appointment.

Direct access day-case carpal tunnel surgery works well by reducing delays and the costs of treatment. Adequate patient information is important to make the best of the service.

In children with obstetric brachial plexus palsy (OBPP) who develop an internal rotation deformity of the shoulder, release of subscapularis improves the range of external rotation of the shoulder and the strength of supination of the forearm. We studied the strength of supination in 35 healthy adult volunteers at 45° of both internal and external rotation.

The mean and maximum torques were greater in external than internal rotation by 8.7% and 7.5%, respectively. This was highly significant (p < 0.0001).

The increased strength of supination in external rotation is probably because the maximum power of biceps, particularly the long head, may be exerted in this position. In children the difference may be even greater due to anatomical differences causing the dramatic increases in the strength of supination after surgery for OBPP.

In adults our findings suggest that the supination exercises which are undertaken after injury or surgery to the forearm or wrist should be performed in external rotation.

We aimed to prospectively assess the familial incidence of Carpal tunnel syndrome (CTS)

151 patients undergoing elective carpal tunnel surgery at a district general hospital were given a written questionnaire on the day of surgery. Patients were asked to give details of all adult family members and to identify relatives that had been diagnosed with CTS by a doctor or had undergone CTS surgery. CTS is commonly associated with pregnancy, trauma, hypothyroidism, diabetes, gout and rheumatoid arthritis. We asked if the patients had any of these conditions. All patients were contacted by telephone within one month of surgery to validate the data collected.

The average age was 58. 4 (Range 28 – 84). The female / male ratio of patients undergoing surgery was 4A. Overall 26% of patients had a relative with CTS. 7. 8% of children (aged > 20), 2. 4% of parents and 4. 2% of siblings were affected.

A study of 44, 233 US workers reported a prevalence of 1. 55%. The child of a person with CTS is therefore 5 times more at risk of developing CTS than the normal population. Many parents were deceased resulting in a lower recorded prevalence for this group. Familial CTS was more common than any of the conditions traditionally associated with CTS (Except pregnancy).

Familial Carpal Tunnel Syndrome is common. Family history should be enquired about in occupations at risk of developing carpal tunnel syndrome.

A prospective assessment of the cause and results of surgery for recurrent carpal tunnel syndrome.

All patients undergoing revision carpal tunnel surgery over a five year period in a specialist hand surgery unit were reviewed. The physical signs, symptoms, ENIG, operative findings and operative outcome were recorded prospectively.

The selection criteria for surgery included an appropriate history, positive neurophysiology and one or more positive physical signs (Tinel’s, Phalen’s or pressure signs). Patients with normal neurophysiology results only underwent open release if the signs and symptoms were clear-cut, typically with at least 2 out of 3 positive signs.

Twenty-two patients (twenty-four wrists, mean age 55, range 33 to 91) underwent revision surgery. The mean time to re-operation was 7 years. 20 wrists had a positive Tinel’s test, 18 had a positive Phalen’s test, 19 had a positive pressure test and 18 had positive neurophysiology.

At operation, 20 wrists were noted to have compression proximally, 3 mid-retinacular and 3 distally. The proximal end of the primary wound scar was 1 cm or more from the distal wrist crease in 9 patients.

All patients reported some benefit. Significant or complete relief of symptoms were reported in 19 wrists. Better results were achieved in patients who had noted some improvement after primary surgery that had lasted for at least 4 months before relapse.

Most papers report inadequate distal release as the most common cause of re-operation but this study found inadequate proximal release to be more common. Less experienced surgeons may be apprehensive about performing an adequate closed proximal release but should be encouraged to take the scar to the distal wrist crease and if in doubt, incise across it in a standard manner.