Scratch Collapse Test for Evaluation of Carpal and Cubital Tunnel Syndrome

doi:10.1016/j.jhsa.2008.05.022

The Journal of Hand Surgery

Volume 33, Issue 9, November 2008, Pages 1518-1524

https://doi.org/10.1016/j.jhsa.2008.05.022 Get rights and content

Purpose

The purpose of this study was to evaluate the clinical usefulness of a new test, the scratch collapse test, for the diagnosis of carpal tunnel syndrome and cubital tunnel syndrome.

Methods

The scratch collapse test was prospectively compared with Tinel's sign and flexion/nerve compression in 169 patients and 109 controls. One hundred nineteen patients were diagnosed with carpal tunnel syndrome and 70 patients were diagnosed with cubital tunnel syndrome based on history, examination, and positive electrodiagnostic test. For the new test, the patient resisted bilateral shoulder external rotation with elbows flexed. The area of suspected nerve compression was lightly “scratched,” and then resisted shoulder external rotation was immediately repeated. Momentary loss of shoulder external rotation resistance on the affected side was considered a positive test. The sensitivity, specificity, and predictive values were calculated.

Results

For carpal tunnel syndrome, sensitivities were 64%, 32%, and 44% for the scratch collapse test, Tinel's test, and wrist flexion/compression test, respectively. For cubital tunnel syndrome, sensitivities were 69%, 54%, and 46% for the scratch collapse test, Tinel test, and elbow flexion/compression test, respectively. The scratch collapse test had the highest negative predictive value (73%) for carpal tunnel syndrome. Tinel's test had the highest negative predictive value (98%) for cubital tunnel syndrome. Specificity and positive predictive values were high for all of the tests.

Conclusions

The scratch collapse test had significantly higher sensitivity than Tinel's test and the flexion/nerve compression test for carpal tunnel and cubital tunnel syndromes. Accuracy for this test was 82% for carpal tunnel syndrome and 89% for cubital tunnel syndrome. This novel test provides a useful addition to existing clinical maneuvers in the diagnosis of these common nerve compression syndromes.

Type of study/level of evidence

Diagnostic II.

Section snippets

Materials and Methods

From January 1, 2004, to December 1, 2005, 169 adult patients were referred to and evaluated for carpal tunnel syndrome or cubital tunnel syndrome by a single surgeon (S.E.M.). The clinical diagnosis of carpal tunnel syndrome was made if the patient had symptoms of numbness, tingling, and/or pain in the median nerve distribution, nocturnal or activity-related symptoms in the median nerve distribution, and the absence of clinical evidence of median nerve compression proximal to the carpal

Results

Details of the study and control groups are shown in TABLE 1, TABLE 2, TABLE 3. The study subjects had significantly higher body mass index than the control subjects (p < .01). All other demographic parameters were similar between the 2 groups. The patients diagnosed with carpal tunnel syndrome were more likely to be female (59%, p < .03), have bilateral involvement (62%, p < .002), and were less likely to report an injury associated with their diagnosis (26%, p < .02). The patients diagnosed

Discussion

There is no perfect gold standard for the diagnosis of compression neuropathy. For carpal tunnel syndrome, a combination of positive electrodiagnostic findings and clinical symptoms combined with positive clinical testing is believed to be the most accurate method.¹⁶ Accuracy of diagnosis can be improved by combining tests, especially when the tests have limited sensitivity and/or specificity. Systematic review of the literature on the diagnosis of carpal tunnel syndrome found reported

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Surgical Decision Making for Mild-to-Moderate Cubital Tunnel Syndrome
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The management of ulnar neuropathy remains unclear as there are neither consensus guidelines nor compelling data available to inform optimal treatment. Identifying patients in the mild-to-moderate group that would benefit most from surgery is challenging as their symptoms can be subtle and less debilitating. This study investigated predictors of surgical intervention among patients presenting with McGowan mild or moderate cubital tunnel syndrome (CuTS).
This is an institutional review board–approved study. Patients evaluated from March 2016 to July 2022 were included if they were diagnosed with McGowan mild or moderate CuTS and underwent concurrent electrodiagnostic and ultrasound evaluations. Patient demographics, symptom presentation, and clinical and diagnostic test findings were analyzed. Variables were analyzed using Student t test, Mann-Whitney U test, or Pearson’s chi-square test. Multivariable logistic regression was used to assess the association of covariates and surgery.
Seventy-three patients and 103 elbows were identified. The mean age and body mass index were 51 years and 26.9, respectively. Most patients were men, right-handed, and unilaterally symptomatic in the dominant hand. Twenty-six elbows were surgically treated. Bivariable analyses by surgical treatment showed that patients who underwent surgery more often had positive electrodiagnostic findings including motor nerve conduction velocity <50 m/s and a >10 m/s conduction velocity difference across the forearm compared with elbow. Fifty-nine cases were categorized as electrodiagnostically normal. Of the electrodiagnostically normal cases, 29 had positive findings of CuTS on ultrasound. Logistic regression model showed that electrodiagnostically severe cases had 3.7 times higher odds of being surgically treated than normal counterparts (adjusted odds ratio, 3.7; 95% CI, 1.11–12.6; P = .03).
Not many differences in objective findings identify patients who should receive operative treatment. In addition to test results, more subjective findings from patients such as patient-reported level of impairment may be able to bridge this gap in surgical decision making.
This study contributes to treatment decision making for mild and moderate CuTS.
On the Physiology of the Sensory-Collapse Test
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The sensory-collapse test (formerly the scratch-collapse test) is a physical examination finding describing a momentary inhibition of external shoulder rotation following light stimulation of an injured nerve in the ipsilateral limb. Similar to other physical examination tests designed to interrogate nerve compression, such as the Phalen or Tinel tests, its test characteristics demonstrate variation. There remains speculation about the test’s existence and anatomic basis. The literature of mammalian reflex physiology was reviewed with an emphasis on the sensory pathways from the upper extremity, the extrapyramidal system, and newly discovered pathways and concepts of nociception. A clear reflex pathway is described connecting the stimulus within an injured nerve through the afferent pathways in the fasciculus cuneatus in the spinal cord directly to the lateral reticulospinal tract, resulting in the inhibition of extensor muscles in the proximal limb (eg, shoulder) and activation of the limb flexors by acting upon alpha and gamma motor neurons. The sensory-collapse test represents a reflex pathway that teleologically provides a mechanism to protect an injured nerve by withdrawal toward the trunk and away from the noxious environment.
Pinch strength analyses in lacertus syndrome
2023, Hand Surgery and Rehabilitation
Lacertus syndrome is defined as proximal median nerve entrapment at the lacertus fibrosus. We aimed to analyze change in pinch strengths in patients who underwent median nerve release at the lacertus fibrosus under WALANT (wide-awake local anesthesia, no tourniquet).
Pinch strength was measured with a pinch gauge. Subjective DASH score and pain, numbness in the operated extremity and satisfaction on visual analog scales were analyzed before and 6 weeks after surgery.
There were 32 patients. Median nerve release under the lacertus fibrosus elicited statistically significant increases in tip-to-tip, lateral and tripod pinch strength at postoperative week 6. Improvements in DASH score, pain and paresthesia were also statistically significant.
For lacertus syndrome treatment, mini-incision release of the lacertus fibrosus under WALANT was satisfactory and increased pinch strength significatively.
Therapeutic, Level IV – Case series.
Le syndrome du Lacertus est défini comme une compression du nerf médian lors de son passage sous le Lacertus Fibrosus. Notre objectif était d'analyser l'évolution de la force des différentes pinces pollici-digitales des patients ayant bénéficié d’une libération du nerf Médian au Lacertus Fibrosus, sous anesthésie de type Wide-Awake Local Anesthesia No Tourniquet (WALANT).
Les forces de serrage des patients ont été mesurées à l'aide d'un dynamomètre et du questionnaire subjectif DASH. La douleur, l'engourdissement des extrémités digitales concernées et la satisfaction des patients ont été évaluées à l'aide d'une échelle visuelle analogique avant et six semaines après l’intervention.
Il y avait 32 malades. La libération du nerf Médian sous le Lacertus Fibrosus a amélioré de façon statistiquement significative la force des pinces pollici-digitales termino-terminales et termino-latérales au contrôle de la sixième semaine post-opératoire. Les améliorations en ce qui concerne le score DASH, la douleur et les paresthésies étaient également statistiquement significatives.
Pour le traitement du syndrome du lacertus, la libération du nerf médian par mini-incision sous WALANT anesthésie est satisfaisante et augmente les forces de serrage des pinces pollici-digitales de façon significative.
Diagnostic Considerations in Compressive Neuropathies
2023, Journal of Hand Surgery Global Online
Peripheral nerve compression of the upper extremity is a common pathology often necessitating surgical intervention, much is known, but much more is left to understand. For the more common pathologies, carpal tunnel syndrome, cubital tunnel syndrome, and ulnar tunnel syndrome, research and clinical efforts directed toward standardization and reduction of resource use have been attempted with varied success. Diagnosis of many of these syndromes is largely based on a proper history and physical examination. Electrodiagnostic studies continue to have value, but proportionally less than previous decades. In addition, emerging technologies, including magnetic resonance neurography, novel ultrasound evaluation techniques, and ultrasound-guided diagnostic injections, are beginning to demonstrate their ability to add value to the diagnostic algorithm, particularly when less common compressive neuropathies are present and/or the diagnosis is in question.
Modern Treatment of Cubital Tunnel Syndrome: Evidence and Controversy
2023, Journal of Hand Surgery Global Online
Cubital tunnel syndrome is the second most common peripheral mononeuropathy in the upper extremity. However, the diagnosis and treatment of cubital tunnel syndrome remains controversial without a standard algorithm. Although diagnosis can often be made from the patient’s history and physical examination alone, electrodiagnostic studies, ultrasound, computed tomography (CT), and magnetic resonance image (MRI) can also be useful in diagnosing the disease and selecting the most appropriate treatment option. Treatment options include conservative nonoperative techniques as well as various surgical options, including in situ decompression with or without transposition, medial epicondylectomy, and nerve transfer in advanced disease. The purpose of this review is to summarize the most up-to-date literature regarding cubital tunnel syndrome and propose a treatment algorithm to provide clarity about the challenges of treating this complex patient population.
The Scratch Collapse Test in patients diagnosed with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES): A report of three cases
2023, International Journal of Surgery Case Reports
The Scratch Collapse Test (SCT) is currently used as a supportive tool diagnosing peripheral nerve neuropathies including carpal tunnel syndrome or peroneal nerve entrapment. Some patients with chronic abdominal pain suffer from entrapment of terminal branches of intercostal nerves (anterior cutaneous nerve entrapment syndrome, ACNES). ACNES is characterized by a severe disabling pain at a predictable area of the anterior abdomen. Clinical examination shows altered skin sensation and painful pinching at the area of pain. However, these findings may be subjective.
In three female patients aged 71, 33, and 43 years with suspected ACNES, the SCT was positive when scratching over the skin of the affected nerve-ending at the abdominal wall. The diagnosis ACNES was confirmed with a local abdominal wall infiltration at the tenderpoint in all three patients. In case three, the SCT turned negative after lidocaine infiltration.
ACNES was hitherto a clinical diagnosis just based on clues in medical history and physical examination. Performing a SCT in patients possibly having ACNES may additionally contribute to the diagnosis.
The SCT may serve as an additional tool for diagnosing patients with possible ACNES. A positive SCT in patients with ACNES supports the hypothesis that ACNES is indeed a peripheral neuropathy of terminal branches of the lower thoracic intercostal nerves. Controlled research is necessary to confirm the role of a SCT in ACNES.

View all citing articles on Scopus

: The authors would like to thank Linda Schultz, RN, PhD, for her assistance in collecting data and obtaining informed consent from the study and control subjects.

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Scientific articleScratch Collapse Test for Evaluation of Carpal and Cubital Tunnel Syndrome

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Materials and Methods

Results

Discussion

J Hand Surg

J Hand Ther

Brain Res

Pain

Electroencephalogr Clin Neurophysiol

Clin Neurophysiol

J Hand Surg

J Hand Surg

J Clin Epidemiol

Clin Neurophys

Determining the sensitivity and specificity of common diagnostic tests for carpal tunnel syndrome using latent class analysis

Plast Reconstr Surg

Scientific article
Scratch Collapse Test for Evaluation of Carpal and Cubital Tunnel Syndrome