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J Wrist Surg 2014; 03(04): 227-232
DOI: 10.1055/s-0034-1394136
Special Focus Section: Transverse Carpal Ligament
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Biomechanical Role of the Transverse Carpal Ligament in Carpal Tunnel Compliance

Zong-Ming Li
1   Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
2   Hand Research Laboratory, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
3   Hand Research Laboratory, Department of Physical Medicine and Rehabilitation, Cleveland Clinic, Cleveland, Ohio
,
Tamara L. Marquardt
1   Hand Research Laboratory, Department of Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio
,
Peter J. Evans
2   Hand Research Laboratory, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
,
William H. Seitz Jr.
2   Hand Research Laboratory, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
› Author Affiliations
Further Information

Publication History

Publication Date:
24 October 2014 (online)

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Abstract

The transverse carpal ligament (TCL) is a significant constituent of the wrist structure and forms the volar boundary of the carpal tunnel. It serves biomechanical and physiological functions, acting as a pulley for the flexor tendons, anchoring the thenar and hypothenar muscles, stabilizing the bony structure, and providing wrist proprioception. This article mainly describes and reviews our recent studies regarding the biomechanical role of the TCL in the compliant characteristics of the carpal tunnel. First, force applied to the TCL from within the carpal tunnel increased arch height and area due to arch width narrowing from the migration of the bony insertion sites of the TCL. The experimental findings were accounted for by a geometric model that elucidated the relationships among arch width, height, and area. Second, carpal arch deformation showed that the carpal tunnel was more flexible at the proximal level than at the distal level and was more compliant in the inward direction than in the outward direction. The hamate-capitate joint had larger angular rotations than the capitate-trapezoid and trapezoid-trapezium joints for their contributions to changes of the carpal arch width. Lastly, pressure application inside the intact and released carpal tunnels led to increased carpal tunnel cross-sectional areas, which were mainly attributable to the expansion of the carpal arch formed by the TCL. Transection of the TCL led to an increase of carpal arch compliance that was nine times greater than that of the intact carpal tunnel. The carpal tunnel, while regarded as a stabile structure, demonstrates compliant properties that help to accommodate biomechanical and physiological variants such as changes in carpal tunnel pressure.

Keywords

ligament - carpal - pressure - wrist - surgery
 

  • References

  • 1 Fuss FK, Wagner TF. Biomechanical alterations in the carpal arch and hand muscles after carpal tunnel release: a further approach toward understanding the function of the flexor retinaculum and the cause of postoperative grip weakness. Clin Anat 1996; 9 (2) 100-108
    CrossrefPubMedGoogle Scholar
  • 2 Kung J, Budoff JE, Wei ML, Gharbaoui I, Luo ZP. The origins of the thenar and hypothenar muscles. J Hand Surg [Br] 2005; 30 (5) 475-476
    CrossrefPubMedGoogle Scholar
  • 3 Shen ZL, Li ZM. Biomechanical interaction between the transverse carpal ligament and the thenar muscles. J Appl Physiol (1985) 2013; 114 (2) 225-229
    CrossrefPubMedGoogle Scholar
  • 4 Silverstein BA, Fine LJ, Armstrong TJ. Occupational factors and carpal tunnel syndrome. Am J Ind Med 1987; 11 (3) 343-358
    CrossrefPubMedGoogle Scholar
  • 5 Rempel D, Keir PJ, Smutz WP, Hargens A. Effects of static fingertip loading on carpal tunnel pressure. J Orthop Res 1997; 15 (3) 422-426
    CrossrefPubMedGoogle Scholar
  • 6 Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH. The carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am 1981; 63 (3) 380-383
    CrossrefPubMedGoogle Scholar
  • 7 Luchetti R, Schoenhuber R, Nathan P. Correlation of segmental carpal tunnel pressures with changes in hand and wrist positions in patients with carpal tunnel syndrome and controls. J Hand Surg [Br] 1998; 23 (5) 598-602
    CrossrefPubMedGoogle Scholar
  • 8 Nakamichi K, Tachibana S. The use of ultrasonography in detection of synovitis in carpal tunnel syndrome. J Hand Surg [Br] 1993; 18 (2) 176-179
    CrossrefPubMedGoogle Scholar
  • 9 Lluch AL. Thickening of the synovium of the digital flexor tendons: cause or consequence of the carpal tunnel syndrome?. J Hand Surg [Br] 1992; 17 (2) 209-212
    CrossrefPubMedGoogle Scholar
  • 10 Campiglio GL, Di Giuseppe P, Migliorini L, Cazzaniga M, Lamperti E, Romorini A. Histopathology of the flexor tendon sheaths and its relevance in idiopathic carpal tunnel syndrome. Eur J Plast Surg 1999; 22: 230-233
    CrossrefPubMedGoogle Scholar
  • 11 Cobb TK, An KN, Cooney WP. Effect of lumbrical muscle incursion within the carpal tunnel on carpal tunnel pressure: a cadaveric study. J Hand Surg Am 1995; 20 (2) 186-192
    CrossrefPubMedGoogle Scholar
  • 12 Fuchs PC, Nathan PA, Myers LD. Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991; 16 (4) 753-758
    CrossrefPubMedGoogle Scholar
  • 13 Keir PJ, Bach JM. Flexor muscle incursion into the carpal tunnel: a mechanism for increased carpal tunnel pressure?. Clin Biomech (Bristol, Avon) 2000; 15 (5) 301-305
    CrossrefPubMedGoogle Scholar
  • 14 Weiss ND, Gordon L, Bloom T, So Y, Rempel DM. Position of the wrist associated with the lowest carpal-tunnel pressure: implications for splint design. J Bone Joint Surg Am 1995; 77 (11) 1695-1699
    PubMedGoogle Scholar
  • 15 Okutsu I, Ninomiya S, Hamanaka I, Kuroshima N, Inanami H. Measurement of pressure in the carpal canal before and after endoscopic management of carpal tunnel syndrome. J Bone Joint Surg Am 1989; 71 (5) 679-683
    PubMedGoogle Scholar
  • 16 Moore JS. Biomechanical models for the pathogenesis of specific distal upper extremity disorders. Am J Ind Med 2002; 41 (5) 353-369
    CrossrefPubMedGoogle Scholar
  • 17 John V, Nau HE, Nahser HC, Reinhardt V, Venjakob K. CT of carpal tunnel syndrome. AJNR Am J Neuroradiol 1983; 4 (3) 770-772
    PubMedGoogle Scholar
  • 18 Li ZM, Tang J, Chakan M, Kaz R. Carpal tunnel expansion by palmarly directed forces to the transverse carpal ligament. J Biomech Eng 2009; 131 (8) 081011
    CrossrefPubMedGoogle Scholar
  • 19 Xiu KH, Kim JH, Li ZM. Biomechanics of the transverse carpal arch under carpal bone loading. Clin Biomech (Bristol, Avon) 2010; 25 (8) 776-780
    CrossrefPubMedGoogle Scholar
  • 20 Gabra JN, Domalain M, Li ZM. Movement of the distal carpal row during narrowing and widening of the carpal arch width. J Biomech Eng 2012; 134 (10) 101004
    CrossrefPubMedGoogle Scholar
  • 21 Taleisnik J. The ligaments of the wrist. J Hand Surg Am 1976; 1 (2) 110-118
    CrossrefPubMedGoogle Scholar
  • 22 Tengrootenhuysen M, van Riet R, Pimontel P, Bortier H, Van Glabbeek F. The role of the transverse carpal ligament in carpal stability: an in vitro study. Acta Orthop Belg 2009; 75 (4) 467-471
    PubMedGoogle Scholar
  • 23 Garcia-Elias M, An KN, Cooney III WP, Linscheid RL, Chao EY. Stability of the transverse carpal arch: an experimental study. J Hand Surg Am 1989; 14 (2 Pt 1) 277-282
    CrossrefPubMedGoogle Scholar
  • 24 Uchiyama S, Itsubo T, Yasutomi T, Nakagawa H, Kamimura M, Kato H. Quantitative MRI of the wrist and nerve conduction studies in patients with idiopathic carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 2005; 76 (8) 1103-1108
    CrossrefPubMedGoogle Scholar
  • 25 Monagle K, Dai G, Chu A, Burnham RS, Snyder RE. Quantitative MR imaging of carpal tunnel syndrome. AJR Am J Roentgenol 1999; 172 (6) 1581-1586
    CrossrefPubMedGoogle Scholar
  • 26 Horch RE, Allmann KH, Laubenberger J, Langer M, Stark GB. Median nerve compression can be detected by magnetic resonance imaging of the carpal tunnel. Neurosurgery 1997; 41 (1) 76-82 , discussion 82–83
    CrossrefPubMedGoogle Scholar
  • 27 Mesgarzadeh M, Schneck CD, Bonakdarpour A, Mitra A, Conaway D. Carpal tunnel: MR imaging. Part II. Carpal tunnel syndrome. Radiology 1989; 171 (3) 749-754
    CrossrefPubMedGoogle Scholar
  • 28 Li ZM, Masters TL, Mondello TA. Area and shape changes of the carpal tunnel in response to tunnel pressure. J Orthop Res 2011; 29 (12) 1951-1956
    CrossrefPubMedGoogle Scholar
  • 29 Richman JA, Gelberman RH, Rydevik BL , et al. Carpal tunnel syndrome: morphologic changes after release of the transverse carpal ligament. J Hand Surg Am 1989; 14 (5) 852-857
    CrossrefPubMedGoogle Scholar
  • 30 Ablove RH, Peimer CA, Diao E, Oliverio R, Kuhn JP. Morphologic changes following endoscopic and two-portal subcutaneous carpal tunnel release. J Hand Surg Am 1994; 19 (5) 821-826
    CrossrefPubMedGoogle Scholar
  • 31 Lee CH, Kim TK, Yoon ES, Dhong ES. Postoperative morphologic analysis of carpal tunnel syndrome using high-resolution ultrasonography. Ann Plast Surg 2005; 54 (2) 143-146
    CrossrefPubMedGoogle Scholar
  • 32 Kato T, Kuroshima N, Okutsu I, Ninomiya S. Effects of endoscopic release of the transverse carpal ligament on carpal canal volume. J Hand Surg Am 1994; 19 (3) 416-419
    CrossrefPubMedGoogle Scholar
  • 33 Brooks JJ, Schiller JR, Allen SD, Akelman E. Biomechanical and anatomical consequences of carpal tunnel release. Clin Biomech (Bristol, Avon) 2003; 18 (8) 685-693
    CrossrefPubMedGoogle Scholar
  • 34 Gartsman GM, Kovach JC, Crouch CC, Noble PC, Bennett JB. Carpal arch alteration after carpal tunnel release. J Hand Surg Am 1986; 11 (3) 372-374
    CrossrefPubMedGoogle Scholar
  • 35 Flores LP, Cavalcante TF, Neto OR, Alcântara FS. Quantitative analysis of the variation in angles of the carpal arch after open and endoscopic carpal tunnel release. Clinical article. J Neurosurg 2009; 111 (2) 311-316
    CrossrefPubMedGoogle Scholar
  • 36 Goss BC, Agee JM. Dynamics of intracarpal tunnel pressure in patients with carpal tunnel syndrome. J Hand Surg Am 2010; 35 (2) 197-206
    CrossrefPubMedGoogle Scholar
  • 37 Kim DH, Marquardt TL, Gabra JN , et al. Pressure-morphology relationship of a released carpal tunnel. J Orthop Res 2013; 31 (4) 616-620
    CrossrefPubMedGoogle Scholar
  • 38 Guo X, Fan Y, Li ZM. Effects of dividing the transverse carpal ligament on the mechanical behavior of the carpal bones under axial compressive load: a finite element study. Med Eng Phys 2009; 31 (2) 188-194
    CrossrefPubMedGoogle Scholar
  • 39 Kline SC, Moore JR. The transverse carpal ligament. An important component of the digital flexor pulley system. J Bone Joint Surg Am 1992; 74 (10) 1478-1485
    CrossrefPubMedGoogle Scholar
  • 40 Wehbé MA. Transverse carpal ligament. An important component of the digital flexor pulley system. J Bone Joint Surg Am 1993; 75 (10) 1575-1576
    PubMedGoogle Scholar
  • 41 Mashoof AA, Levy HJ, Soifer TB, Miller-Soifer F, Bryk E, Vigorita V. Neural anatomy of the transverse carpal ligament. Clin Orthop Relat Res 2001; (386) 218-221
    PubMedGoogle Scholar
  • 42 Allampallam K, Chakraborty J, Robinson J. Effect of ascorbic acid and growth factors on collagen metabolism of flexor retinaculum cells from individuals with and without carpal tunnel syndrome. J Occup Environ Med 2000; 42 (3) 251-259
    CrossrefPubMedGoogle Scholar
  • 43 Nakamichi K, Tachibana S. Histology of the transverse carpal ligament and flexor tenosynovium in idiopathic carpal tunnel syndrome. J Hand Surg Am 1998; 23 (6) 1015-1024
    CrossrefPubMedGoogle Scholar
  • 44 Stecco C, Macchi V, Lancerotto L, Tiengo C, Porzionato A, De Caro R. Comparison of transverse carpal ligament and flexor retinaculum terminology for the wrist. J Hand Surg Am 2010; 35 (5) 746-753
    PubMedGoogle Scholar
  • 45 Prantil RK, Xiu K, Kim KE , et al. Fiber orientation of the transverse carpal ligament. Clin Anat 2012; 25 (4) 478-482
    CrossrefPubMedGoogle Scholar
  • 46 Isogai S, Murakami G, Wada T, Akita K, Yamashita T, Ishii S. Laminar configuration of the transverse carpal ligament. J Orthop Sci 2002; 7 (1) 79-83
    CrossrefPubMedGoogle Scholar
  • 47 Pacek CA, Chakan M, Goitz RJ, Kaufmann RA, Li ZM. Morphological analysis of the transverse carpal ligament. Hand (NY) 2010; 5 (2) 135-140
    CrossrefPubMedGoogle Scholar
  • 48 Manley M, Boardman M, Goitz RJ. The carpal insertions of the transverse carpal ligament. J Hand Surg Am 2013; 38 (4) 729-732
    CrossrefPubMedGoogle Scholar
  • 49 Shen ZL, Li ZM. Ultrasound assessment of transverse carpal ligament thickness: a validity and reliability study. Ultrasound Med Biol 2012; 38 (6) 982-988
    CrossrefPubMedGoogle Scholar
  • 50 Shen ZL, Vince DG, Li ZM. In vivo study of transverse carpal ligament stiffness using acoustic radiation force impulse (ARFI) imaging. PLoS ONE 2013; 8 (7) e68569
    CrossrefPubMedGoogle Scholar
  • 51 Main EK, Goetz JE, Baer TE, Klocke NF, Brown TD. Volar/dorsal compressive mechanical behavior of the transverse carpal ligament. J Biomech 2012; 45 (7) 1180-1185
    CrossrefPubMedGoogle Scholar
  • 52 Holmes MW, Howarth SJ, Callaghan JP, Keir PJ. Carpal tunnel and transverse carpal ligament stiffness with changes in wrist posture and indenter size. J Orthop Res 2011; 29 (11) 1682-1687
    CrossrefPubMedGoogle Scholar
  • 53 Zheng YP, Li ZM, Choi AP, Lu MH, Chen X, Huang QH. Ultrasound palpation sensor for tissue thickness and elasticity measurement—assessment of transverse carpal ligament. Ultrasonics 2006; 44 (Suppl. 01) e313-e317
    CrossrefPubMedGoogle Scholar
  • 54 Li ZM. Gender difference in carpal tunnel compliance. J Musculoskeletal Res 2005; 9 (3) 153-159
    CrossrefPubMedGoogle Scholar
  • 55 Miyamoto H, Miura T, Morizaki Y, Uehara K, Ohe T, Tanaka S. Comparative study on the stiffness of transverse carpal ligament between normal subjects and carpal tunnel syndrome patients. Hand Surg 2013; 18 (2) 209-214
    CrossrefPubMedGoogle Scholar
  • 56 Carrigan SD, Whiteside RA, Pichora DR, Small CF. Development of a three-dimensional finite element model for carpal load transmission in a static neutral posture. Ann Biomed Eng 2003; 31 (6) 718-725
    CrossrefPubMedGoogle Scholar
  • 57 Ishiko T, Puttlitz CM, Lotz JC, Diao E. Scaphoid kinematic behavior after division of the transverse carpal ligament. J Hand Surg Am 2003; 28 (2) 267-271
    CrossrefPubMedGoogle Scholar
  • 58 Jakab E, Ganos D, Cook FW. Transverse carpal ligament reconstruction in surgery for carpal tunnel syndrome: a new technique. J Hand Surg Am 1991; 16 (2) 202-206
    PubMedGoogle Scholar
  • 59 Seitz WH, Lall A. Open carpal tunnel release with median neurolysis and Z-plasty reconstruction of the transverse carpal ligament. Curr Orthop Pract 2013; 24 (1) 53-57
    CrossrefPubMedGoogle Scholar
  • 60 Netscher D, Dinh T, Cohen V, Thornby J. Division of the transverse carpal ligament and flexor tendon excursion: open and endoscopic carpal tunnel release. Plast Reconstr Surg 1998; 102 (3) 773-778
    CrossrefPubMedGoogle Scholar
  • 61 Netscher D, Mosharrafa A, Lee M , et al. Transverse carpal ligament: its effect on flexor tendon excursion, morphologic changes of the carpal canal, and on pinch and grip strengths after open carpal tunnel release. Plast Reconstr Surg 1997; 100 (3) 636-642
    CrossrefPubMedGoogle Scholar
  • 62 Netscher DT. The benefit of transverse carpal ligament reconstruction following open carpal tunnel release. Plast Reconstr Surg 2003; 111 (6) 2020-2022
    CrossrefPubMedGoogle Scholar
  • 63 Sucher BM, Hinrichs RN, Welcher RL, Quiroz LD, St Laurent BF, Morrison BJ. Manipulative treatment of carpal tunnel syndrome: biomechanical and osteopathic intervention to increase the length of the transverse carpal ligament: part 2. Effect of sex differences and manipulative “priming.”. J Am Osteopath Assoc 2005; 105 (3) 135-143
    PubMedGoogle Scholar
  • 64 Li ZM, Gabra JN, Marquardt TL, Kim DH. Narrowing carpal arch width to increase cross-sectional area of carpal tunnel—a cadaveric study. Clin Biomech (Bristol, Avon) 2013; 28 (4) 402-407
    CrossrefPubMedGoogle Scholar
  • 65 Porrata H, Porrata A, Sosner J. New carpal ligament traction device for the treatment of carpal tunnel syndrome unresponsive to conservative therapy. J Hand Ther 2007; 20 (1) 20-27 , quiz 28
    CrossrefPubMedGoogle Scholar