A 45-year-old female with a history of Hodgkin’s disease and long-standing carpal tunnel symptoms presented to the emergency department with acutely worsening, severe right wrist pain several days following an EMG. Physical exam and EMG findings were consistent with carpal tunnel syndrome. X-rays were unremarkable (Figure 10.2a). An ultrasound was also performed which showed no fluid collection. There was concern for evolving CRPS; therefore, thorough evaluation was performed including CT and MRI. Both studies showed abnormal calcification along the volar wrist (Fig. 10.2b–d, e–g).

The decision was made to proceed with debridement and carpal tunnel release. Intraoperatively, a significant amount of fluid was found surrounding the FPL tendon sheath and underneath the nerve. Calcification was also present along the FPL tendon sheath (Fig. 10.2h–k). The area was carefully debrided and specimens were sent for pathology and cultures. The pathology report showed calcifying synovitis. Cultures were negative. The patient’s symptoms resolved by 3 months postoperatively.

A 48-year-old right-hand dominant female from Iowa with a history of Sjogren’s syndrome and interstitial lung disease presented with a 5–6-month history of right wrist swelling and paresthesias. She described constant numbness and tingling along the radial aspect of the hand, exacerbated by activities such as driving, typing, or holding a phone. She also reported weakness of the right hand. The patient had been previously treated with splinting and a carpal tunnel corticosteroid injection 2 months prior to presentation. The injection provided relief for approximately 1 month; however, her symptoms returned.

On physical examination, the patient had significant swelling along the volar wrist, extending through the palm and into the thumb. Carpal tunnel compression test was positive on the right and negative on Tinel’s sign bilaterally. She was found to have weakness of thumb opposition (2.3 kg on the right, 4.6 kg on the left), as well as grip (4 kg on the right, 20 kg on the left). Two-point discrimination was 4–5 mm throughout all digits. Range of motion of the wrists was symmetric. EMG findings were consistent with carpal tunnel syndrome. X-rays were unremarkable (Fig. 10.3a, b). MRI showed extensive tenosynovitis (Fig. 10.3c–f).

The decision was made to proceed with carpal tunnel release and tenosynovectomy (Fig. 10.3g–i). Pathology and culture specimens were obtained at the time of surgery (Fig. 10.3j–k). The pathology report showed “non-necrotizing granulomatous inflammation of the right wrist flexor tenosynovium and FPL tenosynovium.” Initial culture results were negative. However, 2 weeks later cultures revealed Histoplasma capsulatum. Therefore, the patient was subsequently admitted to the hospital for intravenous antifungals. After consultation with our infectious disease colleagues, the patient was treated with intravenous AmBisome for 2 weeks, followed by oral itraconazole for 3 months.

Fortunately, the patient’s symptoms improved over time. The pain, swelling, and numbness had nearly completely resolved at the most recent follow-up visit. This case illustrates the importance of careful evaluation and consideration of these unusual conditions. A detailed occupational, travel, and social history is also essential.

A 13-year-old female was involved in an ATV accident and sustained distal radius/ulna fractures. She presented with numbness in the median nerve distribution. Initial X-rays showed 100% displacement and 80° of dorsal angulation (Fig. 10.4a, b). Closed reduction was performed in the emergency department (Fig. 10.4c, d). The decision was made to proceed with operative fixation. Intraoperatively, the median nerve was visualized and found to be tented and under a significant amount of stretch (Fig. 10.4e, f). The nerve was carefully dissected from its interposition between the radius and ulna fracture fragments. ORIF of the fractures was then performed (Fig. 10.4g, h).

The fractures went on to heal uneventfully (Fig. 10.4i, j). The patient’s nerve function gradually improved over time. At the time of the last follow-up (2 years from injury), two-point discrimination was 7 mm in the thumb and 5 mm in the other digits bilaterally. Tinel’s sign over the median nerve was negative. She was able to make a full fist and had symmetric wrist flexion/extension as well as pronation/supination.