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Anatomical considerations of US-guided carpal tunnel release in daily clinical practice

Hanne-Rose Honis
Hanne-Rose Honis
, 
Hannes Gruber
Hannes Gruber
, 
Sarah Honold
Sarah Honold
, 
Marko Konschake
Marko Konschake
, 
Bernhard Moriggl
Bernhard Moriggl
, 
Erich Brenner
Erich Brenner
, 
Elisabeth Skalla-Oberherber
Elisabeth Skalla-Oberherber
 y 
Alexander Loizides
Alexander Loizides
   | 11 sept 2023
Journal of Ultrasonography's Cover Image
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Article Category: Review paper
Publicado en línea: 11 sept 2023
Páginas: e131 - e143
Recibido: 23 feb 2023
Aceptado: 28 abr 2023
DOI: https://doi.org/10.15557/jou.2023.0022
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© 2023 Hanne-Rose Honis et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

Anatomical variations of the MN: Single MN (A), bifid MN (B), bifid MN with PMA (C), bifid MN in separate compartments (D), trifid MN (E)
Anatomical variations of the MN: Single MN (A), bifid MN (B), bifid MN with PMA (C), bifid MN in separate compartments (D), trifid MN (E)

Fig. 2.

Opened CT: Note the thickness and width of the FLR (tweezers)
Opened CT: Note the thickness and width of the FLR (tweezers)

Fig. 3.

Normal MN (dotted line) at the level of the FLR (arrows)
Normal MN (dotted line) at the level of the FLR (arrows)

Fig. 4.

Anatomical variations of the palmar arteries: UA (red), PMA (purple), RA (pink). Complete arch coming from the UA (A), complete arch coming from the UA + superficial palmar branch of RA (B), two complete arches (superficial and deep) from the UA and superficial palmar branch of RA connected with the deep palmar branch of RA (C), no arch with separate UA, PMA and RA (D), no arch with separate UA and superficial palmar branch of RA (E), no arch with separate UA and RA (F), no arch with separate UA and PMA (G), incomplete arch from the RA + PMA with separate UA (H), double arch from the UA + RA (I), complete arch from the UA + PMA (J), two complete arches from the UA+PMA and PMA+RA (K)
Anatomical variations of the palmar arteries: UA (red), PMA (purple), RA (pink). Complete arch coming from the UA (A), complete arch coming from the UA + superficial palmar branch of RA (B), two complete arches (superficial and deep) from the UA and superficial palmar branch of RA connected with the deep palmar branch of RA (C), no arch with separate UA, PMA and RA (D), no arch with separate UA and superficial palmar branch of RA (E), no arch with separate UA and RA (F), no arch with separate UA and PMA (G), incomplete arch from the RA + PMA with separate UA (H), double arch from the UA + RA (I), complete arch from the UA + PMA (J), two complete arches from the UA+PMA and PMA+RA (K)

Fig. 5.

Proximal superficial palmar arch from the UA and PMA, mobilized by tweezers
Proximal superficial palmar arch from the UA and PMA, mobilized by tweezers

Fig. 6.

Missing superficial palmar arch with separate PMA (arrow proximal and void arrow distal) supplying the index and radial middle fingers, next to the UA (full arrowhead) supplying the ulnar middle finger, ring finger, and small finger
Missing superficial palmar arch with separate PMA (arrow proximal and void arrow distal) supplying the index and radial middle fingers, next to the UA (full arrowhead) supplying the ulnar middle finger, ring finger, and small finger

Fig. 7.

Double superficial palmar arch with looping of the distal portion
Double superficial palmar arch with looping of the distal portion

Fig. 8.

US image depicting two portions of a bifid MN (dotted line) in a patient with CTS. Note the enlarged and hypoechogenic MN-portions
US image depicting two portions of a bifid MN (dotted line) in a patient with CTS. Note the enlarged and hypoechogenic MN-portions

Fig. 9.

US image depicting three portions of a trifid MN (dotted lines) and PMA in an asymptomatic patient
US image depicting three portions of a trifid MN (dotted lines) and PMA in an asymptomatic patient

Fig. 10.

Anatomical variations of the PBMN (straw yellow): Normal PBMN running superficial to the FLR (A), ulnar origin of PBMN (B), PBMN piercing the FLR (C), PBMN perforating the antebrachial fascia very proximal (D), PBMN piercing the antebrachial fascia prior to separating into its superficial and deep branches, deep branches pierce the FLR (E), double PBMN (F)
Anatomical variations of the PBMN (straw yellow): Normal PBMN running superficial to the FLR (A), ulnar origin of PBMN (B), PBMN piercing the FLR (C), PBMN perforating the antebrachial fascia very proximal (D), PBMN piercing the antebrachial fascia prior to separating into its superficial and deep branches, deep branches pierce the FLR (E), double PBMN (F)

Fig. 11.

Normal PBMN (arrows) radial to the MN (dotted line)
Normal PBMN (arrows) radial to the MN (dotted line)

Fig. 12.

Transverse (A) and longitudinal (B) US image depicting the MN (dotted line) and a neuroma (arrows) of the PBMN (arrowheads)
Transverse (A) and longitudinal (B) US image depicting the MN (dotted line) and a neuroma (arrows) of the PBMN (arrowheads)

Fig. 13.

TMB (arrowhead) arising typically from the radial aspect of the MN (arrows)
TMB (arrowhead) arising typically from the radial aspect of the MN (arrows)

Fig. 14.

US image in longitudinal direction, depicting the MN and the “recurrent” course of the TMB (arrows)
US image in longitudinal direction, depicting the MN and the “recurrent” course of the TMB (arrows)

Fig. 15.

PBMN (arrows) piercing the FLR (arrowhead)
PBMN (arrows) piercing the FLR (arrowhead)

Fig. 16.

Anatomical variations of the TMB: distal extraligamentous single TMB (A), subligamentous single TMB (B), transligamentous single TMB (C), supraligamentous single TMB (D), from ulnar side of MN originating single TMB (E), TMB with additional distal accessory branch (F), single (or double) TMB coming from a bifid MN (G), single (or double) TMB coming from a bifid MN accompanied by the PMA (H), single (or double) TMB coming from a bifid MN besides thick lumbrical muscles (I), TMB with an additional proximal accessory branch piercing the FLR (J), TMB with an additional proximal accessory TMB escorting the MN through CT (K), two TMBs originating both from the radial and ulnar sides of MN (L), TMB with communicating additional proximal accessory branch (M)
Anatomical variations of the TMB: distal extraligamentous single TMB (A), subligamentous single TMB (B), transligamentous single TMB (C), supraligamentous single TMB (D), from ulnar side of MN originating single TMB (E), TMB with additional distal accessory branch (F), single (or double) TMB coming from a bifid MN (G), single (or double) TMB coming from a bifid MN accompanied by the PMA (H), single (or double) TMB coming from a bifid MN besides thick lumbrical muscles (I), TMB with an additional proximal accessory branch piercing the FLR (J), TMB with an additional proximal accessory TMB escorting the MN through CT (K), two TMBs originating both from the radial and ulnar sides of MN (L), TMB with communicating additional proximal accessory branch (M)

Fig. 17.

TMB (arrows) arising from the ulnar side of the MN (arrowheads)
TMB (arrows) arising from the ulnar side of the MN (arrowheads)

Fig. 18.

Anatomical variations of the PCB1 (Berrettini branch) (green): PCB1 originating from the UN, more than 4 mm distal from the FLR (A), perpendicular PCB1 close to the FLR (B), PCB1 originating from the UN, proximal to the FLR or less than 4 mm distal (C), more than one communicating branches of the PCB1 (D), PCB1 originating from the MN (E), PCB1 originating proximal to the bistyloid line (F)
Anatomical variations of the PCB1 (Berrettini branch) (green): PCB1 originating from the UN, more than 4 mm distal from the FLR (A), perpendicular PCB1 close to the FLR (B), PCB1 originating from the UN, proximal to the FLR or less than 4 mm distal (C), more than one communicating branches of the PCB1 (D), PCB1 originating from the MN (E), PCB1 originating proximal to the bistyloid line (F)

Fig. 19.

Anatomical variations of the PCB2 (Riché-Cannieu anastomosis) (green): normal PCB2 linked to the TMB (A), PCB2 linked to the MN trunk (B), PCB2 linked to the MN at the level of its divisions into the CPDNs (C), PCB2 linked to one of the CPDNs (D), PCB2 linked to one of the PPDNs (E), more than one communicating branches with different connection points (F).
Anatomical variations of the PCB2 (Riché-Cannieu anastomosis) (green): normal PCB2 linked to the TMB (A), PCB2 linked to the MN trunk (B), PCB2 linked to the MN at the level of its divisions into the CPDNs (C), PCB2 linked to one of the CPDNs (D), PCB2 linked to one of the PPDNs (E), more than one communicating branches with different connection points (F).

Fig. 20.

Rare constellation showing the PPDN (pointed by the scissors) arising from the PCB1 (arrows)
Rare constellation showing the PPDN (pointed by the scissors) arising from the PCB1 (arrows)

Fig. 21.

PCB1 (arrow) with a sling (arrowhead) around the superficial palmar arch
PCB1 (arrow) with a sling (arrowhead) around the superficial palmar arch

Fig. 22.

Proximal PCB1 (arrows) running superficial to the FLR. If no caution is given, this branch can be hooked (arrowhead) and injured during a minimally invasive CTR procedure
Proximal PCB1 (arrows) running superficial to the FLR. If no caution is given, this branch can be hooked (arrowhead) and injured during a minimally invasive CTR procedure

Fig. 23.

PCB1 running close to the FLR, hooked (arrow) with knife
PCB1 running close to the FLR, hooked (arrow) with knife
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