A 33-Year-Old Woman With a Lump in Her Wrist

Angela Castillo, MD; Alfredo Cabello Buscema, MD; Francisco Valdiviezo, MD


May 10, 2018

Conservative treatment should always be the first option for CTS (eg, splint, steroid injection, physical therapy, yoga). In mild to moderate cases, wrist splinting at night for 3 weeks often results in remission. Local steroid injection can induce remission and often provides relief for 1-2 months. In severe cases, it can delay surgery for as long as 1 year. Nonsteroidal anti-inflammatory drugs, diuretics, and vitamin B6 are typically ineffective.

Surgical management is indicated in severe cases without improvement 4-6 months after conservative measures are initiated.[5,6] These patients usually have an inability to distinguish between two points < 6 mm apart, weakness of the thumb abduction, opposition and atrophy of the thenar compartment, and/or any other additional clinical features that complicate the natural course of the disease. The standard treatment approach is surgical decompression of the median nerve in the carpal tunnel by section of the flexor retinaculum. Endoscopic and open approaches are equally effective; however, patients return to work 1 week earlier with endoscopic techniques.

Some patients develop postoperative incisional pain that is related to injury of the fat pad situated between the palmar carpal ligament and the flexor retinaculum. The development of neuroma due to injury of the transverse branches of the palmar cutaneous nerves is another concern. Therefore, some surgeons have developed a modified technique that respects the integrity of the subretinacularis fat pad.

In this case, through a volar longitudinal approach of the wrist, the surgical team performed a broad resection of the cystic tumor attached to the flexor retinaculum (Figures 2-4).

Figure 2.

Figure 3.

Figure 4.

The mass also involved the palmaris longus and flexor carpi radialis tendon. After the resection, compression of the median nerve was released. A 3 cm × 2.5 cm histologic sample of a bland and brown cyst was sent for pathologic examination and was reported to be a synovial cyst with chronic inflammation and vascular congestion. The patient presented for follow-up 3 weeks after the surgical intervention and reported complete resolution of her symptoms.


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