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An anomalous muscle is a rare condition that can occur in the wrist, forearm, or hand. Anomalies in muscles can be caused by malformations in the layers of the intestinal tract, or masses such as ganglia, nerve sheath tumours, or muscle anomalies. These anomalies can cause compression of nerves, such as the posterior tibial nerve, resulting in pain and neurological symptoms. Treatment for symptomatic anomalous muscles often involves surgical excision, although the evidence supporting this procedure is limited. Anomalous muscles are usually clinically insignificant, but understanding their presence is important to avoid confusion during surgical procedures and to achieve optimal outcomes.
| Characteristics | Values |
|---|---|
| Definition | An anomalous muscle is a muscle variation that is encountered infrequently during surgery. |
| Types | Forearm, wrist, and hand muscles. |
| Treatment | Surgical excision is recommended for symptomatic anomalous muscles. |
| Prevalence | Relatively low prevalence in the general population, but often encountered by hand and wrist surgeons. |
| Symptoms | Neurological symptoms, pain, entrapment neuropathy, tendinopathy, and masses in the region of compression. |
| Diagnosis | Soft tissue imaging (ultrasound, MRI), electromyography, nerve conduction studies, and needle biopsy. |
| Clinical Significance | Usually clinically insignificant, but understanding their relevance is important to avoid confusion during surgery and achieve optimal outcomes. |
| Anatomy | Anomalous muscles can have variations in origin, muscle belly, tendon insertion, and number of heads or distinct muscles. |
| Complications | May cause carpal tunnel syndrome, intestinal pseudo-obstruction, and compression of nerves (posterior tibial nerve, ulnar nerve). |
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What You'll Learn
Anomalous forearm muscles
Anomalous muscles are those that differ from the typical muscle structure in terms of their shape, size, or location. They can develop in any part of the body, including the forearm, and may require surgical excision if they cause symptoms such as pain or neurological issues.
- Aberrant palmaris longus
- Anconeus epitrochlearis
- Palmaris profundus
- Flexor carpi radialis brevis
- Accessory head of the flexor pollicis longus
- Anomalous radial wrist extensors
The anconeus epitrochlearis, for example, is an anomalous muscle that originates from the medial border of the olecranon and inserts onto the medial epicondyle. The presence of anomalous muscles can be challenging to diagnose based on patient history and examination alone, as symptoms may overlap with more common issues. Soft tissue imaging, such as ultrasound or MRI, or surgical exploration, may be necessary for a definitive diagnosis.
In symptomatic cases, anomalous forearm muscles can cause neurological symptoms, pain, and physical evidence of entrapment neuropathy or tendinopathy. Treatment options depend on the specific type of anomalous muscle and the symptoms it presents. In many cases, surgical excision of the muscle is recommended when non-operative treatments are ineffective in managing pain or other issues.
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Anomalous wrist muscles
Anomalous muscles are those that deviate from the standard muscle structure in terms of their origin, insertion, or structure. They are relatively uncommon in the general population, but wrist surgeons frequently come across anomalous forearm muscles.
In a study of 42 normal wrists, 23 muscle variations were discovered. An accessory abductor digiti minimi was found in 10 wrists (24%), an absent palmaris longus in seven wrists (16%), a muscular palmaris longus tendon in three wrists (7%), a muscular flexor digitorum superficialis in two wrists (5%), and an aberrant lumbrical muscle in one wrist (2.4%).
In rare cases, anomalous muscles may cause carpal tunnel syndrome (CTS), with an incidence of less than 1.5% of cases. However, the true incidence of anomalous muscles causing compressive neuropathy at the wrist is unknown.
There are three variations of the radial wrist extensors of the forearm: extensor carpi radialis intermedius (ECRI), extensor carpi radialis accessorius, and extensor carpi radialis tertius. The ECRI is an extra wrist extensor located between the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB).
Symptomatic anomalous muscles are often treated with surgical excision. However, the evidence supporting this procedure is limited to small case series and individual reports, so surgeons should exercise caution.
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Muscle malformations
Forearm and Wrist Malformations
Anomalous muscles in the forearm and wrist are relatively uncommon but can be encountered by hand and wrist surgeons. There are three variants of radial wrist extensors of the forearm: extensor carpi radialis intermedius (ECRI), extensor carpi radialis accessorius, and extensor carpi radialis tertius. The presence of these anomalous muscles can result in neurological symptoms, pain, and entrapment neuropathy. Treatment options include surgical excision to resolve symptoms.
Intestinal Muscle Malformations
There are two primary forms of intestinal muscular malformations: segmental additional muscle coat and diffuse abnormal muscle layering. These malformations involve abnormalities in the muscularis propria, which is normally composed of two layers, the externa (longitudinal) and interna (circular). Smooth muscle hyperplasia, often seen in conditions like Crohn's colitis, can lead to the diffusion of smooth muscle fibers, impacting the normal structure of the intestinal tract.
Venous Malformations of Skeletal Muscle
Venous malformations of skeletal muscle are often mistaken for tumors due to their similar presentation. These malformations can occur in any muscle group but are most common in the head, neck, and extremities. They are typically identified at birth or during childhood and adolescence. Pain and swelling are common symptoms, while skeletal problems are rare. Treatment options include sclerotherapy, excision, or a combination of both, depending on the extent and location of the malformation.
Anconeus Epitrochlearis
The anconeus epitrochlearis is an anomalous muscle originating from the medial border of the olecranon and inserting onto the medial epicondyle. This muscle malformation can be a cause of intestinal pseudo-obstruction, similar to Hirschsprung's disease, which may present in infancy but remain unrecognized for several years.
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Muscular dystrophy
Duchenne muscular dystrophy (DMD) is the most common form of muscular dystrophy. It mainly affects boys, but girls can also have a milder version of it. As DMD progresses, it affects the heart and lungs. Becker muscular dystrophy (BMD) is the second most common type and mainly affects boys, but once again, girls can exhibit milder symptoms. Emery-Dreifuss muscular dystrophy (EDMD) mainly affects male children and young adults. It tends to cause muscle weakness in the shoulders, upper arms and shins. EDMD also affects the heart. Facioscapulohumeral muscular dystrophy (FSHD) most commonly affects muscles in the face, shoulders and upper arms. Limb-girdle muscular dystrophy (LGMD) affects the muscles in the upper arms, upper legs, shoulders and hips. It affects people of all ages. Oculopharyngeal muscular dystrophy (OPMD) weakens muscles in the eyelids and throat. Congenital muscular dystrophies (CMD) refers to a group of muscular dystrophies that become apparent at or near birth. Distal muscular dystrophy affects the muscles of the hands, feet, lower arms and lower legs.
Myotonic dystrophy is the most common type of muscular dystrophy diagnosed in adulthood and affects men and women equally. People with myotonic dystrophy have difficulty relaxing their muscles after using them. The condition can also affect the heart and lungs and may cause endocrine issues, such as thyroid disease and diabetes.
Medicines and other treatments can help manage the symptoms and slow the course of muscular dystrophy.
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Muscle disorders
Anomalous muscles are a type of muscle malformation that can occur in the forearm and are often encountered by hand and wrist surgeons. They can cause neurological symptoms and pain, and may require surgical excision for symptom resolution. Anomalous forearm muscles can be symptomatic or asymptomatic. When symptomatic, they can cause entrapment neuropathy, tendinopathy, and pain that does not respond to non-operative treatment. In these cases, the recommended treatment is excision of the muscle. However, surgeons must be cautious to avoid attributing symptoms to incidental findings, as the evidence supporting muscle excision is limited.
There are three variants of radial wrist extensors of the forearm that are considered anomalous: extensor carpi radialis intermedius (ECRI), extensor carpi radialis accessorius, and extensor carpi radialis tertius. The ECRI is an accessory wrist extensor that originates between the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB). However, it may also derive from the radial side of the ECRL or the ulnar side of the ECRB. In some cases, a mass may be found in the region of compression that enlarges with contraction, requiring soft tissue imaging or ultrasound to diagnose.
Some other examples of muscle disorders include malignant hyperthermia, Miyoshi myopathy, multiminicore disease, myopathy with a deficiency of iron-sulfur cluster assembly enzyme, myostatin-related muscle hypertrophy, myotonia congenita, and nemaline myopathy. Treatment for muscle disorders varies depending on the specific disorder and can include medications, physical therapy, occupational therapy, and surgery.
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Frequently asked questions
An anomalous muscle is a rare muscular variation that can cause carpal tunnel syndrome (CTS). Anomalous muscles are usually clinically insignificant, but symptomatic anomalies can cause pain and neurological symptoms.
There are three types of anomalous radial wrist extensors of the forearm: extensor carpi radialis intermedius (ECRI), extensor carpi radialis accessorius, and extensor carpi radialis tertius. Anomalies of the wrist muscles include anatomic variants of the palmaris longus (PL), flexor digitorum superficialis (FDS), lumbricalis, and abductor digiti minimi (ADM).
The treatment for symptomatic anomalous muscles is typically surgical excision. However, the evidence supporting muscle excision is limited to small case series and individual case reports, so surgeons must be careful to avoid attributing symptoms to incidental findings.
