P04 Trophic ulceration secondary to carpal tunnel syndrome

Published Date: 19th July 2016

Publication Authors: Ngan K

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A 56-year-old man presented with a 3-month history of nontraumatic painful ulceration affecting his left hand. He described numbness and pins and needles affecting his left hand with minimal altered sensation affecting his dominant right hand. He has a past medical history of myocardial infarction and is a nonsmoker with a history of alcohol excess. On examination, five linear ulcerations with no inflammatory edge were noted on the first four fingers of his left hand, with significant tissue loss down to the bone on the index finger. Wasting of the left thenar eminence was noted with reduced sensation to light touch. Examination of the right hand was unremarkable. There were strong peripheral pulses with good capillary refill time bilaterally. Histology was nonspecific, and blood tests, including autoantibody screen, were unremarkable. Thoracic outlet syndrome was ruled out by the vascular team and a normal computed tomography angiogram. Neurological review and nerve conduction studies confirmed severe carpal tunnel syndrome (CTS) in the left hand, with mild CTS in the right hand [left wrist-palm median sensory latency was absent; right wrist-palm median sensory latency was 2.6 ms (normal 1.5-2.2 ms)]. While awaiting carpal tunnel decompression surgery, the patient developed osteomyelitis necessitating amputation of his second and third distal phalanges. He has subsequently undergone surgery with symptomatic improvement. CTS is the most common form of entrapment neuropathy, caused by compression of the median nerve. Common symptoms include numbness, paraesthesia, pain and weakness. Skin changes have been described in up to 20% of cases of CTS (Sola-Ortigosa E, Dilm.e-Carreras E, Glesias-Sanco M et al. Ulcerous skin lesions in carpal tunnel syndrome. Eur J Dermatol 2011; 21: 96-7). These include finger erythema, oedema and blisters. Cutaneous ulcerations are rare but can develop in severe CTS. These ulcers are often unilateral, predominantly affecting the index and middle fingers, and may be associated with nail discoloration, onycholysis and dystrophy. Gangrene and acroosteolysis of the terminal phalanges have also been described. Causes of skin lesions include a combination of autonomic and vasomotor dysfunction, impaired thermalgesic sensitivity and exposure to mechanical and thermal microtrauma. Clinical suspicion can be supported by Phalen's and Tinel's tests. Diagnosis is confirmed by neurophysiological examination. Surgical decompression of the median nerve may improve symptoms in about 60% of cases of CTS with cutaneous involvement, but can take months before an improvement is seen. Postoperative management should focus on treating the ulcerations and preventing secondary infection.

Wong, JLC; Karumanchery, R; Ngan, K; Stewart, L. (2014).  P04 Trophic ulceration secondary to carpal tunnel syndrome . British Journal of Dermatology. 171 (Supplement S1), 20

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