History of Carpal Tunnel Syndrome: P.C. Amadio

Chapter 1
History of Carpal Tunnel Syndrome 1

P.C. Amadio
Carpal tunnel syndrome is the most common condi- described a case of the median nerve entrapped in an
tion surgically treated by hand surgeons. It is interest- open fracture of the radius. In 1854 Paget [2] described
ing to note this condition was only definitively de- two cases of median neuropathy after fracture of the
scribed in the years after World War II. Retrospectively, distal radius. One case was treated by amputation and
however, this condition did not appear suddenly at that the other by splinting. Coming closer to our current un-
time but was known under a variety of different names derstanding and therapeutic regimen, Bouilly, in 1884,
in the past. Patients who appear to have suffered from described a 17-year-old with a Colles fracture and me-
carpal tunnel syndrome are clearly depicted in the sur- dian neuropathy treated by excision of prominent pal-
gical literature going back at least to the mid-1800s. The mar callus [3]. Additional cases were reviewed by Ble-
evolution of the clinical understanding that led to the cher in 1908 [4] and Kirchheim in 1909 [5]. By 1926
current knowledge of carpal tunnel syndrome is an in- Dickson was describing a case of causalgia after Colles
teresting one and represents a pattern that may be typi- fracture, relieved by median neurolysis [6]. Finally, in
cal for many medical conditions. Specifically, early on 1933 Abbott and Saunders, in their classic cadaver
there was confusion as to the pathophysiology, result- study, injected dye into the carpal tunnel and noticed
ing in a variety of etiological theories, which in turn re- increased resistance to dye flow with wrist flexion [7].
sulted in a variety of apparently different diagnoses be- As a result of this they condemned the Cotton-Loder
ing applied to the same clinical entity. Only later did the position (Fig. 1.1), which had been commonly used up
clinical threads merge and result in a single coherent until that time for the treatment of Colles fracture. Bun-
clinical picture. nell later stated that it was this paper by his San Francis-
For carpal tunnel syndrome there were three major co colleagues, Abbott and Saunders, which prompted
threads which needed to unite in order to establish our his own interest in what later came to be known as car-
current understandings. Specifically, these were the pal tunnel syndrome [8]. The problem of carpal tunnel
threads of acroparesthesia, thenar neuritis, and median syndrome after Colles fracture continues, of course, to
neuropathy after wrist fracture. The earliest of these remain an important clinical problem (Fig. 1.2).
threads was actually median neuropathy after wrist A related thread was that of median neuropathy as-
fracture, known at least since 1836 when Gensoul [1] sociated with lunate dislocation. Speed reported three
Fig. 1.1. The Cotton-Loder

position of wrist flexion to
maintain reduction after
Colles fracture has been jus-
tifiably condemned
4 I General
Fig. 1.2. Displaced Colles

fractures are still a common
cause of posttraumatic car-
pal tunnel syndrome
Fig. 1.3. a,b Chronic lunate

dislocation remains a classic
cause of carpal tunnel syn-
drome, and is still treated by
lunate excision. a Chronic
lunate dislocation associated
with symptoms of carpal
tunnel syndrome. b Com-
plete relief of symptoms af-
a ter excision of the dislocated
lunate
cases in 1922 [3], which improved with excision of the

lunate. Watson-Jones in 1927 [9] and Meyerding in
1927 [10] also reported excellent restoration of median
nerve function after removal of the dislocated lunate
bone. The problem of chronic lunate dislocation and its
treatment by lunate excision, of course, remains rele-
vant to the present day (Fig. 1.3).
The second major thread, historically speaking, was
that of acroparesthesias. Initially, there was no thought
that acroparesthesias and median neuropathy associat-
ed with wrist fractures might actually share a final
common anatomic bottleneck, namely the flexor reti-
naculum at the wrist. In 1862 Raynaud postulated that
there was a vasomotor origin for these acroparesthesias
[35]. Nonetheless he described what appears to be fair-
ly classical symptoms of carpal tunnel syndrome: “a de-
pressing sense of numbness and tingling…the tactile
sense may be so much impaired that it is difficult for the
fingers to retain small objects.” Certainly this is a com-
mon complaint among carpal tunnel syndrome pa-
tients even to this day. In 1880 Putnam, in Boston, re-
ported on 37 patients, mostly women, who had noctur-
nal paresthesias. He noted that “simply letting the arm
hang out of the bed or shaking it about…[or the use of]
prolonged rubbing would relieve the symptoms.” He al-
so noted “certain fingers were more severely affect-
ed…often it’s those supplied by the median nerve” [12].
b
Again, classic symptoms for present-day carpal tunnel

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Chapter 1

History of Carpal Tunnel Syndrome 1

Fig. 1.1. The Cotton-Loder

Fig. 1.2. Displaced Colles

Fig. 1.3. a,b Chronic lunate

cases in 1922 [3], which improved with excision of the

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