Scand J Plast Reconstr Surg Hand Surg, 2008; 42: 300
304

ORIGINAL ARTICLE

Comparison of carpal tunnel injection techniques: A cadaver study

KAHRAMAN OZTURK1, CEM ZEKİ ESENYEL1, MESUT SONMEZ1,

MELTEM ESENYEL2, SİNAN KAHRAMAN1 & BERNA SENEL3

Departments of 1Orthopedic Surgery and Traumatology, 2Physical Therapy and Rehabilitation Medicine,
Vakif Gureba Training and Research Hospital, Istanbul, 3The Republic of Turkey Ministry of Justice,
Council of Forensic Medicine, Istanbul Medical Faculty, Istanbul, Turkey

Abstract
The purpose of the study was to evaluate the accuracy of injections into the carpal tunnel using three different portals in
cadavers, and to define safe guidelines. In this study, 150 wrists of 75 cadavers (54 male, 21 female) were included. To
compare three injection sites, 50 wrists of 25 cadavers were used for each technique; we used 23 gauge needles, and acrylic
dye. The first injection technique: the needle was inserted 1 cm proximal to the wrist crease and directed distally by roughly
458 in an ulnar direction through the flexor carpi radialis tendon. The second injection technique: the needle was inserted
into the carpal tunnel from a point just ulnar to the palmaris longus tendon and 1 cm proximal to the wrist crease. The third
injection technique: the needle was inserted just distal to the distal skin crease of the wrist in line with the fourth ray. The
first injection technique gave the highest accuracy rate, and this was also the safest injection site. Median nerve injuries
caused by injection was seen mostly with the second technique. Although a steroid injection may provide symptomatic relief
in patients with carpal tunnel syndrome, the median nerve and other structures in the carpal tunnel are at risk of injury.
Because of that, the injection should be given using the correct technique by physicians skilled in carpal tunnel surgery.

Key Words: Carpal tunnel syndrome, injection, median nerve, cadaver, wrist injection

Introduction study has shown that in 2 of 26 cases, the carpal

Carpal tunnel syndrome is the most common
compression neuropathy of the upper extremity.
Unless there are signs of thenar atrophy or severe
sensory deficit, injection of the carpal tunnel with
steroid preparations is a popular and effective non-
operative treatment [1
4].
Flexor tendon synovitis commonly causes a cycle
of swelling within the carpal tunnel and compresses
the median nerve. Steroid injections are meant to
reduce the inflammation and swelling of the flexor
tenosynovitis, and reduce pressure on the median
nerve. They are also used as a diagnostic and
prognostic indicator of a favourable outcome from
operative release [5
7].
Cases of median nerve injury as a complication of
carpal tunnel injection have been reported [8
14]. If
the median nerve is injected, either temporary or
permanent damage may result. However, another
tunnel was completely missed, even by experienced
operators [4].
When we reviewed publications, the exact location
of insertion of the needle and the landmarks
recommended vary considerably [14
19]. There is
no overall consensus about the safest method of
injection. The purpose of the study therefore was to
evaluate the accuracy of injections into the carpal
tunnel using three different portals, in cadavers, and
to define safe guidelines.
Material and methods
The Science Institute of Forensic Medicine ap-
proved the study. A total of 150 wrists of 75 cadavers
(54 male, 21 female) were included. To compare
three injection sites, 50 wrists of 25 cadavers were
used for each injection technique. The mean age was

Correspondence: Cem Zeki Esenyel, MD, Vakif Gureba Training and Research Hospital, Department of Orthopedics and Traumatology, Adnan Menderes
Bulvarı (Vatan Caddesi), Capa 46, Aksaray, Fatih, TR-34093 Istanbul, Turkey. Tel: 90 212 5346900 (ext.1689). Fax: 90 212 6217580. E-mail:
esenyel@yahoo.com

(Accepted 24 June 2008)

ISSN 0284-4311 print/ISSN 1651-2073 online # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As)
DOI: 10.1080/02844310802401363

46 (25
68) years, the mean height was 170 (160

180) cm, mean weight was 77 (50
100) kg, and
mean circumference of the wrist was 17.5 (15
20)
cm.
We compared the accuracy of injections through
three commonly used sites for carpal tunnel injec-
tions. The forearms of the cadavers were placed in
full supination and wrists were placed in 108
208 of
extension. The pollicis longus tendon (PL), flexor
carpi radialis (FCR), and flexor carpi ulnaris (FCU)
were marked with a surgical pen (Figure 1). Twenty-
three gauge needles and acrylic dye were used. After
the dye had been injected, the length of the needle
that had been inserted was measured. All injections
were made by the first author who has over 10 years’
experience in hand surgery.
Injection technique
The first injection on the radial side: the needle was
inserted 1 cm proximal to the wrist crease and
directed distally by about 458 in an ulnar direction
through the flexor carpi radialis tendon. When there
was no more resistance, 1 ml of acrylic dye was
injected. The length of the needle was measured.
This technique was described by Racasan and
Dubert [14].
The second injection in the midline was described
by Green [5]. The needle was inserted into the
carpal tunnel from a point just ulnar to the palmaris
longus tendon and 1 cm proximal to the wrist crease.
The needle was directed at a 308 angle beneath the
transverse carpal ligament until there was no more
resistance. Acrylic dye was injected with about 1

2 cm of the needle inserted.
Figure 1. Injection sites at the wrist. FCR flexor carpi radialis. PLpollicis longus.
Carpal tunnel injection techniques 301
The third injection on the ulnar side: the needle
was inserted just distal to the distal skin crease of the
wrist in line with the fourth ray. It was directed
distally by about 458 and in a radial direction by
roughly 458. When there was no more resistance the
acrylic dye was injected and the length of the needle
measured.
After the injections we made a longitudinal mid-
line surgical incision at the wrist; the site of the
acrylic dye was noted and recorded.
Statistical analysis
The significance of differences was assessed using
the Fisher exact test (two-sided, 95% confidence
interval (CI)). Comparisons were made between the
actual result and the expected result (100% rate of
placement in the carpal tunnel) and among the
injection techniques (first, second, and third). Prob-
abilities of B0.05 were accepted as significant.
Results
There was no palmaris longus tendon in both wrists
of two cadavers, and in a single wrist of five cadavers
(three right wrist, and two left wrist).
First injection: the mean (range) length of needle
inserted was measured as 17 (14
21) mm. Acrylic
dye was detected within the carpal tunnel in 48
wrists (96%), but this was not significantly different
from the expected results (100%) (p 0.115545). It
was detected outside the carpal tunnel in two wrists.
These two injections were in the transverse carpal
ligament (Table I). One injection in the carpal tunnel
was in the tendon of the flexor digitorum super-
ficialis, and one was in the tendon flexor pollicis
302 K. Ozturk et al.
Table I. Accuracy rates of intra-articular injections into the wrist.
Placement of needle (number of injections)
In the carpal tunnel
Total number of
Portals injections
Injection through the flexor carpi radialis 50
Midline injection 50
Ulnar site injection 50
longus (Table II). When all the injection sides were
considered, 46 injections (92%) were in the carpal
tunnel with no injury to any other structures within
the carpal tunnel, which differed from the expected
results (p 0.014035).
Second injection: the needle length was measured
as 13 (11
16) mm. Acrylic dye was present within
the carpal tunnel in 41 wrists (82%) (p 0.000088).
It was not placed in the carpal tunnel in nine wrists
(18%). In the injections that were outside the carpal
tunnel, the tip of the needle and dye were in the
transverse carpal ligament in two wrists, and in the
median nerve in three wrists (Table I). Forty-one
injections were in the carpal tunnel, but the tip of the
needle and dye were in the median nerve in eight of
41 wrists (Figure 2), in the flexor digitorum super-
ficialis tendon in five, in the sheet of the median
nerve in three, and in the flexor pollicis longus
tendon in one wrist (Table II). Only 24 injections
had entered the carpal tunnel without injuring any
other structures (pB0.000001).
Third injection: the needle length was measured
as 16 (9
20) mm. Acrylic dye was detected within
the carpal tunnel in 39 wrists (p0.000013). Eleven
injections were outside the carpal tunnel (10 were in
the transverse carpal ligament and one was over the
transverse carpal ligament) (Table I). The flexor
digitorum superficialis tendon of the third finger was
injured in two cases, and the fourth finger in one
case within the carpal tunnel (Table II) (Figure 3).
Table II. Injuries in the carpal tunnel with the injection techniques.
Structures injured in the carpal tunnel
No. of injections in Flexor digitorum
Site of injection the carpal tunnel superficialis Median nerve median nerve
Through the flexor 48 1 0
carpi radialis
Midline 41 5 8
Ulnar site 39 3 0
Outside the carpal tunnel
No. No. p value
48 2 0.115545
41 9 0.000088
39 11 0.000013
There were 36 injections in the carpal tunnel (72%),
the accuracy of which was not good.
Discussion
Steroid injections can provide symptomatic relief in
patients with carpal tunnel syndrome [9,19]. Injec-
tion should be given using a proper technique by
physicians skilled in carpal tunnel surgery [9].
The proper technique for injection of steroids into
the carpal canal has been investigated previously [9].
Their failure to provide symptomatic relief of the
symptoms of carpal tunnel syndrome may be the
result of poor injection technique. It is easy to miss
the carpal tunnel even for an experienced doctor. A
direct needle stick injury to the median nerve is the
main complication of carpal tunnel injections
[1,2,9,13,14,16,19]. Some commonly used steroid
preparations are neurotoxic and may cause serious,
prolonged, or even permanent disability, so injection
into the median nerve should be avoided [9,19].
Phalen [1] described patients who developed chemi-
cal neuritis after steroid injections. Wood showed by
inserting a needle and exploring to find out the
location of the needle tip immediately before surgical
decompression that in two of 26 cases (8%) the
carpal tunnel had been completely missed even by
experienced operators [4].
The distal skin crease is the surface landmark of
the proximal limit of the carpal ligament, but there is
No. of injections without
Sheet of the Flexor pollicis injuring any other structure
longus in the carpal tunnel
0 1
3 1
0 0

Figure 2. Median nerve injury during the midline injection.
no overall agreement as to where on this crease the
needle should be inserted.
It is recommended by Phalen [1], Green [5], and
Wood [4] that the needle should be inserted to the
ulnar aspect of the palmaris tendon in line with the
fourth ray. However, Frederick et al. [20] reported
that this is hazardous; the median nerve is just dorsal
and radial to the palmaris longus tendon at the level
of the carpal tunnel. Gelberman et al. [15] recom-
mended that the needle should be inserted on the
Figure 3. Tendon injury during the injection. TCLtransverse carpal ligament.
Carpal tunnel injection techniques 303
radial aspect of the palmaris longus tendon, between
that tendon and that of the flexor carpi radialis.
The relation of the median nerve to the tendons
along the radial portion of the wrist is remarkably
constant, although there are anatomical variations of
the median nerve within the carpal tunnel, so it is
also recommended by Kay and Marshall [16], and
Frederick et al. [20], that remaining ulnar to the
palmaris longus provides a greater margin of safety.
If there is no palmaris longus, the needle should be
304 K. Ozturk et al.
in line with the superficial flexor tendon of the ring
finger. Kay and Marshall [16] used the technique,
which was described as the third injection technique
that we used. This technique includes that the
needle enters the carpal canal with the tip lying
deep to the median nerve. However, they stated that
the tip of the needle was embedded in one of the
flexor tendons or its synovium. They reviewed
the 250 patients, and there were no cases of injury
to the median nerve. However, they stated that 8%
of the injections completely missed the carpal
tunnel. In our study with the same technique there
was also no injury to the median nerve. In the carpal
tunnel three tendons were injured. However, the
accuracy rate was 72%, which was lower than radial
side injection and higher than midline injections.
McConnell and Bush [9] reported three cases in
which median nerves were injured during injection
of the carpal tunnel. They recommended the
method described by Green [5]. We found with the
midline technique 11 injections injured the median
nerve (22%), which was the largest number of
median nerve injuries. The median nerve was
injured outside the carpal tunnel in three patients
and within the carpal tunnel in eight patients. In
addition to the median nerve injuries, tendons in the
carpal tunnel were injured in six patients, which
showed the highest injury rates among the three
injection techniques. Nine injections were outside
the carpal tunnel. Two of the nine injections were in
the transverse carpal ligament and three of these
were within the median nerve.
Dubert and Racasan [19] also found that the
median nerve extended beyond the medial edge of
the pollicis longus in 88% of cases, so the midline
injection might cause nerve injury [19]. They also
stated that the median nerve extended laterally
beyond the edge of the pollicis longus by more
than 6 mm in 12% of the cases, so that the median
nerve can be injured even when the needle is placed
at the medial edge of the flexor carpi radialis. We
made the radial side injection through the flexor
carpi radialis, as recommended by Gelberman et al.
[15]. With this technique there were no median
nerve injuries in our series.
References
[1] Phalen GS. The carpal tunnel syndrome: seventeen years of
experience in diagnosis and treatment of six hundred and
fifty four hands. J Bone Joint Surg 1966;48A:211
28. / /
[2] Posh JL, Marcotte DR. Carpal tunnel syndrome: an analysis
of 1,201 cases. Orthop Rev 1976;5:25
35. / /
[3] Irwin LR, Beckett R, Suman RK. Steroid injection for carpal
tunnel syndrome. J Hand Surg 1996;21B:355
7. / /
[4] Wood MR. Hydrocortisone injections for carpal tunnel
syndrome. Hand 1980;12:62
4.
/ /
[5] Green DP. Diagnostic and therapeutic value of carpal tunnel
injection. J Hand Surg 1984;9A:850
4. / /
[6] Goodman HV, Foster JB. Effect of local corticosteroid
injection on median nerve conduction in carpal tunnel
syndrome. Ann Phys Med 1962;6:287
94. / /
[7] Edgell SE, McCabe SJ, Breidenbach WC, LaJoie AS, Abell
TD. Predicting the outcome of carpal tunnel release. J Hand
Surg 2003;28A:255
61.
/ /
[8] Linskey ME, Segal R. Median nerve injury from local steroid
injection in carpal tunnel syndrome. Neurosurgery 1990;26: / /
512
5.
[9] McConnell JR, Bush DC. Intraneural steroid injection as a
complication in the management of carpal tunnel syndrome.
Clin Orthop 1990;250:181
4. / /
[10] Tavares SP, Giddins GE. Nerve injury following steroid
injection for carpal tunnel syndrome. J Hand Surg 1996;
/
21B:208
9. /
[11] Wilbourn AJ. Iatrogenic nerve injuries. Neurol Clin 1998; /
16:55
83.
/
[12] Kasten SJ, Louis DS. Carpal tunnel syndrome: a case of
median nerve injection injury and a safe and effective
method for injecting the carpal tunnel. J Fam Pract 1996; /
43:79
82.
/
[13] Linskey ME, Segal R. Median nerve injury from local steroid
injection in carpal tunnel syndrome. Neurosurgery 1990; /
250:181
4.
/
[14] Racasan O, Dubert T. The safest location for steroid
injection in the treatment of carpal tunnel syndrome.
J Hand Surg 2005;30B:412
4. / /
[15] Gelberman RH, Aronson D, Weisman MH. Carpal tunnel
syndrome: results of a prospective trial of steroid injection
and splinting. J Bone Joint Surg 1980;62A:1181
4.
/ /
[16] Kay NR, Marshall PD. A safe reliable method of carpal
tunnel injection. J Hand Surg 1992;17A:1160
1. / /
[17] Dippe PA, Bacon PA, Bamji AN, Watt I. Atlas of clinical
rheumatology. Philadelphia: Lea & Febiger; 1986. p 4
5.
[18] Robbins H. Anatomical study of the median nerve in the
carpal tunnel and etiologies of the carpal tunnel syndrome.
J Bone Joint Surg 1963;45A:953
66. / /
[19] Dubert T, Racasan O. A reliable technique for avoiding the
median nerve during carpal tunnel injections. Joint Bone
Spine 2006;73:77
9.
/ /
[20] Frederick HA, Carter PR, Littler JW. Injection injuries to the
median and ulnar nerves at the wrist. J Hand Surg 1992; /
17A:645
7. /