First Lumbrical Muscle Flap for Recurrence of Carpal Tunnel Syndrome: Anatomical Study and Surgical Technique

Abstract

Recurrence of carpal tunnel syndrome implies the reappearance of symptoms after release surgery. If the cause of recurrence is not an incomplete release, but a traction neuritis, the tendency is to add to the revision surgery of the carpal tunnel the use of flaps to cover the median nerve. These flaps establish a physical barrier between the nerve and the rest of the adjacent structures, preventing adhesions, and providing neovascularization and better nerve sliding.

In the present work, we detail a revision surgery in which the first lumbrical muscle is used as a covering flap. This flap has two benefits. Firstly, it acts as a vascularized coverage for the median nerve (avoiding the formation of fibrosis and favoring its sliding); secondly, a structure that takes up space is removed from the carpal tunnel, thus reducing the pressure within it.

Along with the explanation of the technique, the present article provides a detailed description of the anatomical variability of the first lumbrical muscle and its vascularization, as well as the results of a cadaveric study on the location of the vascular pedicle of the first lumbrical muscle.

Keywords

recurrence of carpal tunnel syndrome - first lumbrical muscle flap - muscle flap

Publication History

Received: 07 February 2021

Accepted: 08 March 2021

Article published online:
02 July 2021

• References

• 1 Steyers CM. Recurrent carpal tunnel syndrome. Hand Clin 2002; 18 (02) 339-345
• 2 Jones NF, Ahn HC, Eo S. Revision surgery for persistent and recurrent carpal tunnel syndrome and for failed carpal tunnel release. Plast Reconstr Surg 2012; 129 (03) 683-692
• 3 Amadio PC. Interventions for recurrent/persistent carpal tunnel syndrome after carpal tunnel release. J Hand Surg Am 2009; 34 (07) 1320-1322
• 4 Abzug JM, Jacoby SM, Osterman AL. Surgical options for recalcitrant carpal tunnel syndrome with perineural fibrosis. Hand (N Y) 2012; 7 (01) 23-29
• 5 Sameem M, Au M, Wood T, Farrokhyar F, Mahoney J. A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg 2012; 130 (01) 67e-77e
• 6 Soltani AM, Allan BJ, Best MJ, Mir HS, Panthaki ZJ. A systematic review of the literature on the outcomes of treatment for recurrent and persistent carpal tunnel syndrome. Plast Reconstr Surg 2013; 132 (01) 114-121
• 7 Koncilia H, Kuzbari R, Worseg A, Tschabitscher M, Holle J. The lumbrical muscle flap: anatomic study and clinical application. J Hand Surg Am 1998; 23 (01) 111-119
• 8 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 (02) 186-192
• 9 Siegel DB, Kuzma G, Eakins D. Anatomic investigation of the role of the lumbrical muscles in carpal tunnel syndrome. J Hand Surg Am 1995; 20 (05) 860-863
• 10 Palti R, Vigler M. Anatomy and function of lumbrical muscles. Hand Clin 2012; 28 (01) 13-17
• 11 Keen JA. A study of the arterial variations in the limbs, with special reference to symmetry of vascular patterns. Am J Anat 1961; 108: 245-261
• 12 Zarzecki MP, Popieluszko P, Zayachkowski A, Pękala PA, Henry BM, Tomaszewski KA. The surgical anatomy of the superficial and deep palmar arches: A Meta-analysis. J Plast Reconstr Aesthet Surg 2018; 71 (11) 1577-1592
• 13 Gnanasekaran D, Veeramani R. Newer insights in the anatomy of superficial palmar arch. Surg Radiol Anat 2019; 41 (07) 791-799
• 14 Gellman H, Botte MJ, Shankwiler J, Gelberman RH. Arterial patterns of the deep and superficial palmar arches. Clin Orthop Relat Res 2001; (383) 41-46
• 15 Zbrodowski A, Mariéthoz E, Bednarkiewicz M, Gajisin S. The blood supply of the lumbrical muscles. J Hand Surg [Br] 1998; 23 (03) 384-388