Acute atraumatic carpal tunnel syndrome due to flexor tendon rupture following palmar plate osteosynthesis in a patient taking rivaroxaban

  • Wolfram WeschenfelderEmail author
  • Reinhard Friedel
  • Gunther O. Hofmann
  • Mark Lenz



Few case reports describe the development of a hematoma under oral anticoagulation as the cause of an atraumatic carpal tunnel syndrome.

Case report

A 76 years old woman presented an acute atraumatic carpal tunnel syndrome of her left hand under oral anticoagulation with rivaroxaban due to atrial fibrillation. 12 years ago, palmar plate osteosynthesis of a distal radius fracture had been performed on the affected wrist. Open decompression of the carpal canal was performed due to persistent severe pain under intense pain therapy and progressive neurological symptoms. The cause of the pain was a hematoma due to a rupture of the flexor pollicis longus and the second flexor digitorum profundus tendon with concomitant synovitis at the plate’s distal rim. After decompression, pain relieved and neurological deficits improved rapidly.


Ruptures of the flexor tendons occur in palmar plate osteosynthesis in up to 1.5% in the long term postoperative course. Very distal plate positions, like in this case, increase that risk. Under anticoagulation, the rupture induced a hematoma increasing local pressure resulting in an acute carpal tunnel syndrome. Acute nerve compression syndromes should be treated surgically without delay.


Therapy with anticoagulants may increase hematoma after tendon rupture, thus supporting the development of an atraumatic acute carpal tunnel syndrome and complicating the surgical therapy. Hardware removal after fracture healing should be advised in patients with Soong grade 2 plate positions especially those taking anticoagulants.


Oral anticoagulants Carpal tunnel syndrome Tendon rupture Palmar plate osteosynthesis 



There is no funding source.

Compliance with ethical standards

Conflict of interest

Wolfram Weschenfelder, Reinhard Friedel, Gunther O. Hofmann and Mark Lenz declare that they have no conflict of interest.

Research involving human and/or animal participants

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Komura S, Hirakawa A, Masuda T, Ito Y, Akiyama H (2017) Recurrent atraumatic acute carpal tunnel syndrome due to hematoma caused by distal radioulnar joint arthritis during anticoagulant treatment with apixaban. Arch Orthop Trauma Surg 137:1161–1164. CrossRefGoogle Scholar
  2. 2.
    Sibley PA, Mandel RJ (2012) Atraumatic acute carpal tunnel syndrome in a patient taking dabigatran. Orthopedics 35:e1286–e1289. CrossRefGoogle Scholar
  3. 3.
    Hohendorff B, Biber F, Sauer H, Franke J (2016) Acute carpal tunnel syndrome due to spontaneous bleeding after taking rivaroxaban (Xarelto®). Handchir Mikrochir Plast Chir 48:168–170. Google Scholar
  4. 4.
    Michelsen H, Posner MA (2002) Medical history of carpal tunnel syndrome. Hand Clin 18:257–268CrossRefGoogle Scholar
  5. 5.
    Azzi AJ, Aldekhayel S, Boehm KS, Zadeh T (2017) Tendon rupture and tenosynovitis following internal fixation of distal radius fractures: a systematic review. Plast Reconstr Surg 139:717e–724e. CrossRefGoogle Scholar
  6. 6.
    Orbay JL, Touhami A (2006) Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Clin Orthop Relat Res 445:58–67. Google Scholar
  7. 7.
    Soong M, Earp BE, Bishop G, Leung A, Blazar P (2011) Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am 93:328–335. CrossRefGoogle Scholar
  8. 8.
    Tarallo L, Mugnai R, Zambianchi F, Adani R, Catani F (2013) Volar plate fixation for the treatment of distal radius fractures: analysis of adverse events. J Orthop Trauma 27:740–745. CrossRefGoogle Scholar
  9. 9.
    Kitay A, Swanstrom M, Schreiber JJ, Carlson MG, Nguyen JT, Weiland AJ, Daluiski A (2013) Volar plate position and flexor tendon rupture following distal radius fracture fixation. J Hand Surg Am 38:1091–1096. CrossRefGoogle Scholar
  10. 10.
    Szabo RM (1998) Acute carpal tunnel syndrome. Hand Clin 14:419–429, ixGoogle Scholar
  11. 11.
    Eikelboom JW, Quinlan DJ, Hirsh J, Connolly SJ, Weitz JI (2017) Laboratory monitoring of non-vitamin K antagonist oral anticoagulant use in patients with atrial fibrillation: a review. JAMA Cardiol 2:566–574. CrossRefGoogle Scholar
  12. 12.
    Balla S, Koerber S, Flaker G (2017) Management of bleeding in patients receiving non-vitamin K antagonists. Postgrad Med J 93:221–225. CrossRefGoogle Scholar
  13. 13.
    Sjogren V, Bystrom B, Renlund H, Svensson PJ, Oldgren J, Norrving B, Sjalander A (2017) Non-vitamin K oral anticoagulants are non-inferior for stroke prevention but cause fewer major bleedings than well-managed warfarin: a retrospective register study. PLoS One 12:e0181000. CrossRefGoogle Scholar
  14. 14.
    Ahrens C, Unglaub F, Hohendorff B, Müller LP, Spies CK (2016) Perioperative anticoagulation in elective hand surgery: a literature review. Handchir Mikrochir Plast Chir 48:127–135. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Trauma, Hand and Reconstructive SurgeryUniversity Hospital JenaJenaGermany

Personalised recommendations