Anatomic Landmarks to Locate the Median Nerve for Safe Wrist Block or Carpal Tunnel Steroid Injection

Introduction: Carpal tunnel syndrome is the most common entrapment neuropathy involving the upper extremity. As such, various nonoperative techniques have been developed to aid in management of mild to moderate disease, including local steroid injection. However, definitive guidelines for needle/injection location have not been defined, especially in relation to diminishment of iatrogenic injury to the median nerve. Methods: A cadaveric study was designed to determine the average width of the median nerve, as well as its location specifically in relation to the palmaris longus (if present), the flexor carpi radialis, and the midpoint of the wrist. All measurements were obtained at the radial tip of the interstyloid line. Results: Data demonstrated that the average width of the median nerve was 7.85 mm and that it lies ulnar in location to the palmaris longus (3 mm), as well as the midpoint of the wrist at the radial tip of the interstyloid line (0.43 mm). Furthermore, the distance between the median nerve and the flexor carpi radialis was measured to be 9.57 mm. Outcomes: Therefore, injection location should be radial with respect to the palmaris longus and the midline of the wrist. It can be just ulnar to the flexor carpi radialis tendon or between 8 and 10 mm radial to the midpoint of the wrist in order to prevent median nerve injection and direct trauma to the nerve.