J Orthop Sci (2010) 15:518523
DOI 10.1007/s00776-010-1496-7
Original article
Differential onset patterns and causes of carpal tunnel syndrome after
distal radius fracture: a retrospective study of 105 wrists
TOSHIRO ITSUBO1, MITO HAYASHI2, SHIGEHARU UCHIYAMA1, KAZUHIKO HIRACHI3, AKIO MINAMI3, and HIROYUKI KATO1
1
Department of Orthopaedic Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
2
Department of Orthopaedic Surgery, Shingu Municipal Medical Center, Wakayama, Japan
3
Department of Orthopaedic Surgery, Hokkaido University School of Medicine, Sapporo, Japan
Abstract
Background. It is well known that carpal tunnel syndrome
(CTS) can occur in a wide range of time periods after distal
radius fracture (DRF). Few studies have evaluated in detail
the relationship between fracture and electrophysiological
finding characteristics and time to onset of CTS after DRF. To
clarify the characteristics of CTS after DRF, we classified a
large number of clinical cases based on the period from the
injury to onset of CTS. These cases were analyzed
retrospectively.
Methods. We reviewed 105 wrists with CTS following DRF.
Patients ages ranged from 13 to 89 years. These 105 wrists
were divided into three groups according to the period of
post-fracture onset of CTS. Twenty-eight wrists were classified
into the acute onset group (when the symptoms of CTS
occurred within 1 week after fracture). Forty-seven wrists
were classified into the subacute onset group (when symptoms
of CTS occurred from 1 to 12 weeks after fracture). The
remaining 30 wrists were classified into the delayed onset
group (when symptoms of CTS occurred more than 12 weeks
after fracture). Deformity of the distal radius on X-ray films
was evaluated and distal motor latency (DML) of the median
nerve was recorded to compare values among these three
groups.
Results. In the acute onset group, 68% had an AO C-type
fracture and 46% were caused by a high-energy injury. The
percentage of this fracture pattern and mechanism was signifi-
cantly higher in the acute onset group than in the other groups
(P < 0.05; Kruskal-Wallis test). In the subacute onset and
delayed onset groups, 79% and 63% had an A-type fracture
and more than 90% were caused by a low-energy injury. In
the delayed onset group, the incidence of prolonged DML in
the contralateral wrists was 71%, which was significantly
higher than in the other two onset groups (P < 0.05; Kruskal-
Wallis test).
Conclusions. There were three onset patterns of CTS after
DRF, and each CTS onset pattern had different etiologic
mechanisms and different clinical features of CTS. In the acute
onset group, a high-energy fracture pattern was associated
Offprint requests to: T. Itsubo
Received: December 16, 2009 / Accepted: April 26, 2010
with CTS. In the subacute and the delayed onset groups, low-
energy injury in elderly women was associated with CTS. Both
deformity of the fracture and preexisting median nerve dys-
function were suggested as predisposing factor for CTS.
Introduction
Distal radius fracture (DRF) is the most common frac-
ture in the upper extremities. The occurrence of compli-
cations with this injury depends on the patients age,1
mechanism of injury,2,3 and fracture type.46 Carpal
tunnel syndrome (CTS) has been well described as one
of the major complications following DRF,3,4,7,8 and its
incidence has been reported to be between 3.3% and
17.2%.13,5,9,10 Several reports have analyzed the patho-
genesis of CTS following DRF and discussed predispos-
ing risk factors.25,7,1113 Suggested pathomechanisms of
developing CTS after DRFs include: (1) an increase in
intracarpal tunnel pressure caused by local anesthetic
injection at the time of manual reduction,12 (2) excessive
Cotton-Loder position in casting,14 (3) swelling of the
carpal tunnel region due to the DRF injury,13 (4)
increased pressure in the carpal tunnel from a hema-
toma,7,15 (5) excessive callus formation during healing of
the fracture, causing nerve compression,2,16 (6) tenosy-
novitis of the flexor tendons,3 and (7) abnormal course
of the median nerve at the wrist due to malunion of
the distal radius.3 Several of these factors may occur
simultaneously.
The onset time of CTS after DRF ranges widely, from
a few hours to 24 years,15 which suggests the existence
of different pathomechanisms for the development of
CTS. Stewart et al.5 observed 100 patients with DRFs
and found that CTS developed in 17% at 3 months after
the injury and in another 12% 6 months afterwards. The
amount of distal motor latency (DML) of the median
nerve in both the affected and uninjured wrist can also
T. Itsubo et al.: Carpal tunnel syndrome after distal radius fracture
be a clue in assessing the pathogenesis of CTS, because
idiopathic CTS occurs mostly in bilateral hands. Aro et
al.4 reported that two of three patients and Taniguchi6
reported that four of nine patients with DRF had pro-
longed DML in the median nerve of the contralateral
uninjured hand as well.
The purpose of this study was to clarify the charac-
teristics of CTS patients following DRF and to analyze
the factors associated with different periods of CTS
onset after DRF.
Patients and methods
A total of 105 wrists in 104 patients who had CTS after
DRF were identified retrospectively from the medical
records (19792007) of ten institutions. There were 27
men (28 wrists) and 77 women (77 wrists), ranging in
age from 13 to 89 years (mean, 60 years). All patients
developed CTS in the injured wrist and 1 patient with
bilateral DRFs developed CTS in both wrists. Patients
presenting with median nerve palsy immediately after
DRF were excluded as these cases were usually caused
by direct injury to the median nerve. Furthermore,
patients in whom direct injury to the median nerve by
the displaced bone or joint was observed during open
carpal tunnel release were excluded from this study. The
protocol was approved by the institutional review board
of our institution.
CTS was diagnosed based on the following condi-
tions: (1) positive Tinel sign at the wrist, (2) positive
Phalen test, (3) numbness or pain in the area innervated
by the median nerve, and (4) positive sensory distur-
bance detected over the area innervated by the median
nerve. In acute onset cases, the Phalen test was excluded
because of still limited motion from the injury.
519
The clinical severity of CTS, as classified by Shinodas
grading system,17 was as follows: 47 wrists were grade 1
(numbness, no thenar muscle atrophy), 45 wrists were
grade 2 (some atrophy of the thenar muscle), and 13
wrists were grade 3 (substantial thenar muscle atrophy).
DRF treatments in this cohort included closed reduc-
tion and cast immobilization in 75 wrists, external fixa-
tion in 9, closed reduction and percutaneous pinning in
7, open reduction and internal fixation in 10, and cor-
rective radius osteotomy after closed reduction and cast
immobilization in 4.
Treatments for CTS were as follows: open carpal
tunnel release (OCTR) in 68 wrists, OCTR and correc-
tive radial osteotomy in 5, corrective radial osteotomy
alone in 2, and conservative treatment alone, such as
steroid injection into the carpal tunnel or splinting, in
30. Patients were followed from 6 to 72 months (mean,
12 months) after CTS treatment. The treatments
improved symptoms in all cases.
The interval between CTS symptom onset and DRF
varied from 1 day to 25 years. The distribution of onset
intervals is shown in Fig. 1. There were two distinct
peaks in the early period after fracture, followed by
scattered occurrences of CTS that fell over a wide range
of time. Therefore, we classified the period from DRF
to the onset of CTS into three groups: (1) the acute
onset group (when CTS occurred within 1 week after
the fracture), (2) the subacute onset group (when CTS
occurred from 1 to 12 weeks after the fracture), (3) and
the delayed onset group (when CTS occurred more than
12 weeks after the fracture). Twenty-eight, 47, and 30
wrists were classified into the acute, subacute, and
delayed onset groups, respectively.
In 99 of the 105 wrists, radiographs were taken just
after DRF and classified according to the AO classifica-
tion.11 In 6 wrists, post-injury X-rays could not be
Fig. 1. Distribution of carpal
tunnel syndrome (CTS) onset
intervals after distal radius
fractures (DRFs). The period
from DRF to onset of CTS
was classified into three
groups: the acute onset group
(when CTS occurred within 1
week of fracture), the sub-
acute onset group (when
CTS occurred with onset
ranging from 112 weeks),
and the delayed onset group
(when CTS occurred more
than 12 weeks after fracture).
W, Weeks; M, months; Y,
years
520 T. Itsubo et al.: Carpal tunnel syndrome after distal radius fracture

obtained. In all wrists, X-rays of standard posteroante- height, 2 were from snowboard injuries, and 3 were from
rior and lateral views at the time of the CTS onset were other types of accidents, such as industrial accidents. In
taken. Ulnar variance (UV), palmar tilt (PT), and radial the acute onset group, 13 of 28 wrists were classified as
inclination (RI) were measured in each case to estimate having a high-energy injury. In the subacute onset group,
the severity of distal radius deformity. Mechanisms of 3 of 47 wrists were classified as having high-energy inju-
DRF injury were classified as low-energy injury, defined ries, and in the delayed onset group, 3 of 30 wrists were
as a fall from standing height, and high-energy injury, classified as having high-energy injuries. The incidence
defined as a fall from a height or injury due to a traffic of high-energy injury was significantly higher in the
accident. acute onset group than in the other two groups (P <
DML of the median nerve with CTS after DRF was 0.05, Kruskal-Wallis test; Table 2).
measured in 73 patients in both wrists. DML was
recorded by stimulating the median nerve at the distal
Radiographic evaluation
forearm 7 cm proximal to the recording electrode cen-
tered over the thenar muscle. A value of more than Nineteen of the 28 wrists in the acute onset group were
4.2 ms was defined as prolonged.18,19 In 12 cases, response classified as C-type fractures. Thirty-seven of the 47
of the abductor pollicis brevis could not be obtained. wrists in the subacute onset group were A-type frac-
Patient age, gender, injury mechanism, fracture type, tures, and 19 of the 30 wrists in the delayed onset group
incidence of deformity, and DML of the median nerve were A-type fractures as well (Table 3). The incidence
were compared among the three onset groups. Statistical
analysis was carried out with SPSS software (version
8.0.1; SPSS, Tokyo, Japan). Patient ages in the three onset
groups were compared using one-way analysis of vari- Table 1. Demographic data of 105 wrists with carpal tunnel
ance. Differences among the groups with respect to syndrome (CTS) after distal radius fracture (DRF)
gender and incidence of DRF from a low-energy injury Age (years) Range, 1389
were assessed with the Kruskal-Wallis test. The distribu- (mean, 60)
tions of fracture type and the severity of CTS in the three Gender
Male 27
groups were compared using the 2 test. The incidence of Female 77
prolonged DML in the contralateral side in the three Injury mechanism
groups was compared with Students t-test. A P value of Low energy 86
less than 0.05 was considered statistically significant High energy 19
Fracture type (AO classification)
A 13 61
B 13 6
Results C 13 32
Not classifieda 6
Demographic data of all 105 wrists are shown in Table Onset after distal radius fracture (weeks)
1. The factors described below were compared among Acute (<1) 28
the three onset groups. Subacute (1, <12) 47
Delayed (12) 30
Fracture reductionb
Age and gender Unacceptable 69
Acceptable 36
Table 2 presents the age and gender of patients with Severity of CTSc
CTS after DRF in each onset group, and reveals that Grade 1 (mild) 47
the patients in the acute onset group were significantly Grade 2 (moderate) 45
Grade 3 (severe) 13
younger (mean age, 49.0 years) than those in the other Distal motor latency (DML)d
two onset groups (P < 0.05, one-way analysis of vari- Within normal 13
ance). In the acute onset group, about half of the patients Prolonged 60
were male. However, in the subacute and chronic onset Not examined 32
groups, about 80% of the patients were female. The a
X-rays at the DRF were not obtained
b
proportion of males was significantly higher in the acute The criteria for acceptable reduction of DRF include palmar tilt 10
onset group than in the other two groups (P < 0.05, or less, radius inclination of at least 13, and ulnar variance less than
2 mm1
Kruskal-Wallis test). c
Shinodas grading system.16 Grade 1: mild symptoms; numbness, par-
esthesia, no atrophy of the thenar muscle, and possible complete
opposition. Grade 2: moderate symptoms; numbness, paresthesia,
Injury mechanism of DRF some atrophy of the thenar muscle, possible complete opposition.
Grade 3: severe symptoms; numbness, paresthesia, significant atrophy
Among the high-energy injuries, the injuries in 8 wrists of the thenar muscle, and incomplete opposition
were from a traffic accident, 6 were from falling from a d
Normal, 4.2 ms9,13
T. Itsubo et al.: Carpal tunnel syndrome after distal radius fracture 521

Table 2. Comparison of CTS onset groups according to age, gender, and injury mechanism
CTS classification Age, years (average) Female (%) High-energy injury (%)

Acute onset group (n = 28) 1380 (49.0)* 16 (57%)** 13 (46%)***

Subacute onset group (n = 47) 2089 (63.6) 37 (79%) 3 (6%)
Delayed onset group (n = 30) 5382 (64.3) 24 (80%) 3 (10%)
* The age of the acute onset group was significantly lower than that of the other two groups (P < 0.05, one-way analysis of variance)
** The proportion of males was significantly higher in the acute onset group than in the other two groups (P < 0.05, Kruskal-Wallis test)
*** The incidence of high-energy injury was significantly higher in the acute onset group than in the other two groups (P < 0.05, Kruskal-Wallis
test)

Table 3. AO classification of distal radius fractures

AO classification

CTS classification A B C Unknown

Acute onset group (n=28) 5 3 19 * 1
Subacute onset group (n=47) 37 2 7 1
Delayed onset group (n=30) 19 1 6 4 (Wrists)
*
The incidence of C-type fracture was significantly higher in the acute onset group than in the other two groups (P < 0.05, 2 test)

Table 4. Radiographic evaluation at the time of CTS onset in each CTS onset group
Radiographic measurement (mean + SD)

No. of cases with deformity or unacceptable

CTS classification UV (mm) PT () RI () reduction of the distal radius (%)

Acute onset group (n = 28) 2.8 2.4 15.2 19.8 14.6 6.2 21 (75%)
Subacute onset group (n = 47) 4.5 2.7 15.0 16.9 15.0 6.5 29 (62%)
Delayed onset group (n = 30) 3.8 2.5 10.0 13.4 14.9 7.7 19 (63%)
A high incidence of deformity or unacceptable reduction was observed in all groups, so there were no statistically significant differences
UV, ulnar variance; PT, palmar tilt; RI, radial inclination

of C-type fractures was significantly higher in the acute
onset group than in the other two groups (P < 0.05, 2
test). The criteria for acceptable reduction of DRF
included palmar tilt of 10 or less, radius inclination of
13 or more, and ulnar variance of less than 2 mm.4
Based on these findings, unacceptable reduction or
deformity of the DRF was recognized in 21 of the 28
wrists in the acute onset group, 29 of the 47 wrists in the
subacute onset group, and 19 of the 30 wrists in the
delayed onset group. A high incidence of deformity or
unacceptable reduction was observed in all groups, so
no statistically significant differences were detected
(Table 4).
DML of the median nerve
Electrophysiological assessment of the median nerve
with CTS after DRF was performed in 73 patients in
both wrists and on the affected side only in 2 patients.
Sixty of 75 (80%) wrists showed prolonged DML in the
affected side, including 11 of 17 (65%) wrists in the
acute onset group, 30 of 35 (86%) wrists in the subacute
group, and 19 of 23 (83%) wrists in the delayed onset
group. Twenty-nine of the 73 (40%) wrists had pro-
longed DML in the median nerve of the contralateral
side. The incidence of prolonged DML in the contralat-
eral wrists was 35%, 23%, and 71% in the acute, sub-
522
Table 5. Comparison of CTS onset groups according to DML
No. of cases with
CTS classification DML measured
Acute onset group (n = 28) 17
Subacute onset group (n = 47) 35
Delayed onset group (n = 30) 23 (21)a
DML, distal motor latency
* The incidence of prolonged DML in the contralateral side was significantly higher in the delayed onset group than in the other two groups (P
< 0.05, Students t-test)
a
DML of the median nerve was measured in 21 cases in both wrists and 2 cases in the affected side only
acute, and delayed onset group, respectively. The
incidence of prolonged DML in the contralateral
side was significantly higher in the delayed onset group
than in the other two groups (P < 0.05; Students t-test;
Table 5).
Severity of CTS
Grade 1 CTS according to Shinodas grading system was
seen in 19 of the 28 (68%) patients in the acute onset
group, 18 of the 47(38%) patients in the subacute onset
group, and 10 of the 30 (33%) patients in the delayed
onset group. Grade 3 CTS was seen in 1 of the 28 (4%)
patients in the acute onset group, 6 of the 47 (13%)
patients in the subacute onset group, and 6 of the 30
(20%) patients in the delayed onset group. There were
no statistically significant significances between the
groups.
Discussion
There have several reports regarding the occurrence
and onset of CTS following DRF.3,5,13 Lynch and Lip-
scomb3 reported that CTS occurred in a time period
after Colles fracture varying from a few hours in some
cases to up to 24 years in one case. Sponsel and Palm13
observed that symptoms appeared immediately after
reduction in the majority of cases and usually within 3
months after fracture. Stewart et al.5 described that CTS
was observed both acutely and late after the injury and
the incidence of CTS was 17% at 3 months. In our
patients, the onset of symptomatic median neuropathy
varied from 1 day to 25 years after the injury and the
onset timing could be divided into three groups.
In the acute onset group, half of the patients had
intraarticular fractures of the distal radius at a rate sig-
nificantly higher than the rates in the other two onset
groups. Frykman9 reported that intraarticular fracture
involvement increased the risk of late compression neu-
ropathies. The degree of trauma itself is also important
because it correlates with the magnitude of hemorrhage
T. Itsubo et al.: Carpal tunnel syndrome after distal radius fracture
No. of cases with prolonged No. of cases with prolonged
DML in affected side (%) DML in unaffected side (%)
11 (65%) 6 (35%)
30 (86%) 8 (23%)
19 (83%) 15 (71%)*
and edema; we agree with Kongsholm and Oleruds
opinion that acute CTS results in an increase in carpal
tunnel pressure because of hemorrhage and edema
around the nerve.12 The present study demonstrated
that half of the cases of CTS in the acute onset group
were caused by a high-energy injury, and no cases were
caused by reduction of the fracture under local anesthe-
sia9 or palmar-flexed wrist immobilization.14 Frykman9
described that 4% of patients had acute median neu-
ropathy and no patients in his series had severe symp-
toms. Our findings agree, in that 25 of 28 wrists in
the acute onset group showed CTS grade 1 or 2 of
severity.
As presented in Fig. 1, the incidence of CTS had a
second peak from 1 to 12 weeks after DRF. These cases
formed the subacute onset group, where most patients
were relatively older women and had AO A-type frac-
tures. In the subacute onset group, most DRFs were
caused by low-energy injuries. These clinical character-
istic features were very similar to those of the delayed
onset group, in which CTS occurred more than 12 weeks
after fracture.
Aro et al.4 described that one of the causes of late
median neuropathy after a Colles fracture was a nar-
rowing of the cross-sectional area of the carpal tunnel.
This deformity, described by Taleisnik and Watson,20
showed dorsal angulation of the lunate and dorsal trans-
lation and flexion of the midcarpal joint as a result of
dorsal angulation of the distal fragment of the radius.
Stewart et al.5 reported that the degree of residual
dorsal angle of the distal radius had a statistically sig-
nificant correlation with the occurrence of CTS. We
could not precisely measure the deformity or narrowing
of the carpal tunnel using computed tomography (CT).
However, the present study demonstrated that more
than 62% of wrists in the three onset groups had unac-
ceptable deformity of the DRF, indicating that changes
in the anatomical configuration of the carpal tunnel due
to DRFs could be one of the main causes of CTS,
regardless of the onset time following the initial injury.
It should be noted that because its incidence was so low,
a correlation between CTS and fracture malreduction
T. Itsubo et al.: Carpal tunnel syndrome after distal radius fracture
could not be made without a co-analysis of patients with
similar fracture malreductions who did not have CTS
after DRF.
Aro et al.4 reported that two of three patients who
underwent electrophysiological studies had prolonged
motor nerve conduction velocities in the contralateral
side, and these authors described that DRF aggravated
the symptoms in the injured hand. In our two later onset
groups, most patients had unacceptable reduction of
DRF, prolonged DML of the median nerve in the unin-
jured side, or both. In the subacute onset group, the
incidence of cases of an unacceptable reduction of the
DRF was higher than that in the patients with pro-
longed DML in the median nerve of the contralateral
side. However, the opposite was true in the delayed
onset group, which suggests that subclinical median
nerve dysfunction may have been present in the bilat-
eral hands and the injured side became symptomatic
after DRF.
There are several limitations to this study. Firstly, this
was a retrospective study and the methods for data
acquisition, such as measuring DML, sensory distur-
bance, and frequency of patient follow up were different
among the institutions. Quantitative methods to evalu-
ate sensory disturbance, such as the Semmes-Weinstein
test or two-point discrimination test, were conducted in
some institutions only; thus, clinical findings before and
after treatment of CTS were not standardized. Secondly,
nerve conduction studies were not done uniformly
because most institutions did not measure sensory nerve
conduction velocity. Thirdly, prolonged DML in this
study was defined by reference to the literature, not
according to the value determined by each institution,
so the incidence of prolonged DML may have been dif-
ferent if it had been defined differently. During the time
hiatus between DRF and the development of CTS,
there could have also been other contributing variables
not controlled in the study which may have contributed
to the development of CTS. These include age, diabetes
mellitus, and hypothyroidism. Fourthly, we could not
completely exclude cases of median nerve palsy at the
time of injury in the acute onset group, and cases of
idiopathic CTS may have been present in the delayed
onset group. Lastly, some could argue that the classifica-
tion into three groups based on the time interval from
fracture was somewhat arbitrary. However, as clearly
defined groups were obtained and significant findings
achieved, we believe that our classifications were appro-
priate. This study has demonstrated that each onset
group has characteristic age, gender, mechanism of
injury, severity of CTS, and contralateral DML values
that should be considered in the treatment of DRF and
CTS.
523
Acknowledgments. The authors wish to thank Dr. S. Matsuda,
Dr. A. Tsuchikane, and Professor Kevin C. Chung for their
help in relation to this project. No benefits of any form have
been or will be received from a commercial party related
directly or indirectly to the subject of this article.
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