PRESSURES

A
CARPAL

S.

IN

COMPARISON
TUNNEL

ROJVIROJ,

W.

using

the wrist.
For each

pressure

position

pressure

normal
78.1%,

pressure
of 5.5 mmHg
an accuracy
of 78.5%,

There
are
syndrome

being

several
possible
but
most
cases

tunnel

pressure

Kaen

University,

in patients

in the patients

in the neutral
and a positive

and

causes
of carpal
tunnel
are
idiopathic.
Increased

pressure
due
to fluid
or the presence
of anomalous
structures
may
be associated
(Butler
and Bigley
1971;
Eriksen
1973) and a reduction
in the cross-sectional
area
ofthe
tunnel
may be found
in patients
with the syndrome
(Dekel

et al 1980; Liang
1987).
The pressure
in the carpal
tunnel
has been measured
by wick
catheter
in patients
and
normal
subjects
by
Gelberman
et al (1981),
but nearly
one-third
of their
patients
did not have the idiopathic
syndrome
and results
were
not
predictive
documented
idiopathic

given
in terms
of sensitivity,
specificity
or
value.
We have compared
pressures
in fullynormal
subjects
and
in patients
with
carpal
tunnel
syndrome,
then calculated
their

diagnostic

value.

carpal

position,

in the neutral

gave a diagnostic
value of 87.3%.

should

be sent

to Dr S. Rojviroj.

1990 British
Editorial
Society
ofBone
030l-620X/90/3087
$2.00
JBoneJoint
SurgfBr]
1990; 72-B:
516-8.

19 months).

516

All

in the distribution
of carpab
tunnel
signs,
nerve

Joint

Surgery

than in the controls,

the

Using

an upper

of 78.7%,

limit

of

a specificity

of

AND
METHODS
25 female
and 8 male,
in whom
by carpal
tunnel
syndrome.
Their

the wrist
percussion

patients

had

paraesthesia

or numbness

ofthe
median
nerve,
syndrome
was made
flexion
test

1987), then confirmed

showed
the affected
distal
sensory
latency

and the diagnosis

on the physical

test (Phalen
1972), and
(Tinel
1915;
Mossman

the median
and Bbau

by electrodiagnostic
studies.
These
median
nerve
to have
a prolonged
(more
than
3.5 msec),
or a distal

motor
latency
of more
than 4.5 msec,
or both (Kimura
1983).
Electromyograms
of the abductor
pollicis
brevis
were abnormal
in 1 1 hands,
and three had wasting
of the
muscles.
1 2 male

catheter
which

and

four

female

control

subjects

had

32

hands
with no history
of trauma
or abnormality
the wrist and normal
results
on ebectrodiagnostic

polyethylene
symmetrical

filled
and

control
of

higher
position.

sensitivity

testing
of their
Pressure
tests.
Srinagarind
Khon
Kaen

and in normal
and 90#{176}
palmarfiexion

ages ranged
from
19 to 67 years
(mean
46.5)
and the
duration
of symptoms
was one month
to 10 years,
(mean

normal
about

Medicine,
University,

syndrome

PATIENTS
We studied
33 patients,
61 hands
were affected

The

Correspondence

tunnel

90#{176}
dorsifiexion,

was very significantly

thenar

S. Rojviroj,
MD, Assistant
Professor
W. Sirichativapee,
MD, Instructor
W. Kowsuwon,
MD, Assistant
Professor
J . Wongwiwattananon,
M D, Instructor
N. Tamnanthong,
MD, Assistant
Professor
P. Jeeravipoolvarn,
MD, Associate
Professor
Department
ofOrthopaedics
and Rehabilitation
Hospital,
Faculty
of Medicine,
Khon
Kaen
40002,
Thailand.

WONGWIWATTANANON,

Thailand

with

the lowest

position
predictive

J.

SUBJECTS

JEERAVIPOOLVARN

in the neutral

in 90#{176}
dorsifiexion,

WITH

NORMAL

KOWSUWON,
P.

Khon

and recording

the mean

highest

AND

TAMNANTHONG,

in the carpal

a slit catheter

W.

TUNNEL

PATIENTS

SYNDROME

From

We studied

CARPAL

BETWEEN

SIRICHATIVAPEE,
N.

subjects,

THE

median
nerves.
The slit catheter

tubing
slits each

1 .2 mm
extending

is connected
is also attached
with

the system,
transducer

sterile

length

with
its end.

of
five
This

by tubing
to a transducer
dome,
to
a stopcock
with a 20 ml syringe

water.

Air

and
the tip
and the carpal

THE

is a 20 cm
in diameter,
3 mm from

JOURNAL

bubbles

of the
tunnel

are

connecting
are placed

OF BONE

AND

excluded

from

tube,
the
at the same

JOINT

SURGERY

PRESSURES

horizontal

bevel

while

the

system

monitor
records
zero pressure.
then elevated
to 54 cm and the
40 mmHg.
The system
is then
use(Fig.
1).
Under
local
plastic
distal

anaesthesia,

is adjusted

until

the

a 14 gauge

is withdrawn

tunnel.
plastic
sheath
checked

The
slit catheter
is then
inserted
through
the
sheath
until
resistance
is felt, when
the plastic
is withdrawn.
The
response
of the system
is
by pressing
a fingertip
over the carpal
tunnel

leaving

the plastic

response

on

carpal

to the
pabmaris

needle

the

in to the

with

tendon,

observing

pushed

needle
proximal
of the

longus

and

of the tips

within

the

Measurements
with

the wrist

palmar
standard

ofcarpab
placed

monitor.

accuracy

pressures

in neutral

In

et al (198 1), using a wick catheter,

found
pressure
in the carpal
tunnel
was elevated

in patients
with
catheter
system
a wick catheter

carpal
tunnel
syndrome.
We used a slit
this has been shown
to be as accurate
as
(Rorabeck
et ab 1981). Our results
differ

from those
of Gelberman
tunnel
pressures
were
group

(Table

II):

Table

were

I.

various

et al, in that
lower,
especially

only

one

ofour

Mean

our

patients

carpal
tunnel
pressure
of the wrist

positions

Mean

two
Position

pressure

mean
in our
had

of wrist

a pressure

9.32

3.21

12.68

90-

palmarfiexion

26.60

in 90#{176}

90

dorsiflexion

32.76

value
specificity,

Normal
(n = 32)

2.53

made

by Students
t-test.
The diagnostic
calculated
in terms of sensitivity,

in

0.43

pressures,
calculated,

s.e.m.

3.48

1 1 .87

I .53

1.06

1.16

of
Table II. Mean
wrist
positions
syndrome

value.

carpal
tunnel
pressure
s.e.m.
(range)
in various
in two
series
of patients
with
carpal
tunnel

Mean

RESULTS

pressure

Gelberman
(n = 15)

in mmHg

et al 1981

Rojviroj et al 1990
(n = 61)

The carpal
tunnel
pressures
are shown
in Table
I. In both
patients
and controls
the mean pressure
was lowest
in the
neutral
position
and highest
in 90#{176}
dorsiflexion.
In all

Position
Neutral

32

0.98(2to50)

11.87

three
positions
there
ences
between
the
compared
with
the
position
p < 0.0002,

90

94 5.18(20to250)

26.60

2.56(5to8I.8)

32.78

3.21

ences were
We found
the

left

and

right

but again
dorsiflexion
than

were very highly

significant
differmean
pressures
in the
patients
control
subjects.
For
the neutral
and the significances
of the differ-

even greater
no statistically

in dorsiflexion
significant

hands

of the control

in the neutral
position.
We chose
5.5 mmHg

carpal
tunnel
a sensitivity

subjects

(p

>

palmarfiexion

90dorsiflexion

110

5.68(15to250)

of 78.5%.
87.3%.

upper

limit

for normal

position.
This gave
of 78.1%,
and
a

The

positive

predictive

DISCUSSION
Pressure
several

in the carpab
tunnel
has been
measured
ways.
Tanzer
(1959)
introduced
a mercury

and showed
that
pressure
extension
of the wrist.
Our
pressure
Wilkinson
wrist

is greatest
(1947),

dorsiflexion

flexion.
VOL.

72-B,

was increased
study
showed

at 90#{176}
dorsiflexion.
studying
cadavers,
caused

a greater

by
that

Brain,
also

increase

in
bag

flexion
or
the mean
Wright
found

than

and
that
Fig.

pabmarDiagram

No.

3, MAY

1990

(4to

in

54
as the

l.53(I.5to62.2)

0.4)

significantly
higher
and in pabmarflexion

pressure
in the neutral
of 78.7%,
a specificity

diagnostic
accuracy
value of the test was

ofwrist

and palmarfiexion.
difference
between

the pressure
was very
than in pabmarflexion,

carpal
patient

in mmHg

Carpal tunnel
syndrome
(n = 61)

Neutral

proved.

position,

in 90#{176}
dorsiflexion.
and standard
errors

predictive

Gebberman
the mean

used, the catheters

and the correct
was

517

the

Mean
were

and

that

TUNNEL

The

within

tunnel

tunnel

passively

flexion,
and
deviations

and analysed
the test was

the carpal

tunnel.

sheath

clinical
cases regional
anaesthesia
was
were left in place
during
the operation,
location

CARPAL

The connecting
tube
is
range
control
adjusted
to
calibrated
and ready
for

sheath
is inserted
at 45#{176}
1 cm
wrist
crease,
on the ubnar
side
and

IN THE

of apparatus.

cm.

111.2)

S. ROJVIROJ,

518

Table
wrist

III. Mean carpal tunnel

pressure
positions
in two series of normal
Mean

pressure

W. SIRICHATIVAPEE,

s.e.m.
subjects

(range)

W. KOWSUWON,

in various

et al 1981

Rojvlroj et al 1990
(n = 32)

Gelberman
(n = 12)

Neutral

2.5 0. 17 (0 to 7)

3.48

0.43

90palmarflexion

31.0

0.86(15to75)

9.54

l.06(2to28.5)

90dorsiflexion

30.0

l.24(4to50)

12.46

of more
than
100 mm/Hg.
This
cases were idiopathic
in origin.

sensitive

diagnostic

that

mean

finding

the

sensitive
as wrist
Conclusions.
The
with
an idiopathic

(0 to 8.6)

1.16(3.2

be the most
Our

(Gebman
was

provocative
extension

et ab 1986).

highest

in 90#{176}
of

testing
for carpab
may be at least as

flexion.
pressure
in the carpal
tunnel
carpal
tunnel
syndrome,

of patients
was very

significantly
higher
than
normal.
In both
patients
and
control
subjects,
the mean
pressure
was highest
in 90#{176}
of
wrist
dorsiflexion,
and lowest
in the neutral
position.

to 27.4)

Using
our
5.5 mmHg

may be because
all our
In our control
subjects,

all confirmed
by normal
ebectrodiagnostic
studies,
also found
bower mean pressures
(Table
III).
The wrist flexion
or Phaben
test has been claimed

test

pressure

dorsifiexion,
implies
that
tunnel
syndrome
by wrist

in mmHg

Positionofwrist

ET AL

tive

value

slit catheter
method,
a pressure
of more than
in the neutral
position
had a positive
predicof 87.3%

for carpab

tunnel

syndrome.

we
No benefits
commercial
article.

to

in any
party

form have been

related
directly

received
or will be received
or indirectly
to the subject

from a
of this

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JOINT

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