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Cline JA, Frantz LM, Adams JM, Hearon BF. Experience With Proximal Median Nerve Entrapment by the Lacertus Fibrosus. Hand (N Y) 2024; 19:904-911. [PMID: 36859808 PMCID: PMC11342709 DOI: 10.1177/15589447231153233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND Unconscious bias of the clinician favors the diagnosis of carpal tunnel syndrome (CTS) in patients with median paresthesia. We hypothesized that more patients in this cohort would be diagnosed with proximal median nerve entrapment (PMNE) by strengthening our cognitive awareness of this alternative diagnosis. We also hypothesized that patients with PMNE may be successfully treated with surgical release of the lacertus fibrosus (LF). METHODS In this retrospective study, cases of median nerve decompression at the carpal tunnel and in the proximal forearm for the 2-year periods before and after adopting strategies to mitigate cognitive bias for CTS were enumerated. Patients diagnosed with PMNE and treated by LF release under local anesthesia were evaluated to determine surgical outcome at minimum 2-year follow-up. Primary outcome measures were changes in preoperative median paresthesia and proximal median-innervated muscle strength. RESULTS There was a statistically significant increase in PMNE cases identified after our heightened surveillance was initiated (z = 3.433, P < .001). In 10 of 12 cases, the patient had previous ipsilateral open carpal tunnel release (CTR) but experienced recurrent median paresthesia. In 8 cases evaluated an average of 5 years after LF release, there was improvement in median paresthesia and resolution of median-innervated muscle weakness. CONCLUSIONS Owing to cognitive bias, some patients with PMNE may be misdiagnosed with CTS. All patients with median paresthesia, particularly those with persistent or recurrent symptoms after CTR, should be assessed for PMNE. Surgical release limited to the LF may be an effective treatment for PMNE.
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Affiliation(s)
- Justin A. Cline
- The University of Kansas School of Medicine, Wichita, KS, USA
| | - Lisa M. Frantz
- The University of Kansas School of Medicine, Wichita, KS, USA
| | | | - Bernard F. Hearon
- The University of Kansas School of Medicine, Wichita, KS, USA
- Advanced Orthopaedics Associates, Wichita, KS, USA
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Özdemir A, Güleç A, Yurteri A, Odabaşı E, Acar MA. Effect of pronator teres muscle botulinum neurotoxin type-A injection on proximal median nerve entrapment. HAND SURGERY & REHABILITATION 2024; 43:101604. [PMID: 37797787 DOI: 10.1016/j.hansur.2023.09.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE We aimed to evaluate the effect of botulinum neurotoxin type-A (Btx-A) injection into the pronator teres muscle in proximal median nerve entrapment (PMNE). METHODS Intramuscular injection of 30 IU Btx-A into the pronator teres muscle was performed in 12 patients (14 extremities) diagnosed with PMNE. The injection was made under nerve stimulator control. One patient with thoracic outlet syndrome was excluded from the study and not included in the clinical evaluation. Grip and pinch strength, 2-point discrimination, Q-DASH score, and pain on VAS were evaluated and compared before and 6-8 months after injection. The patients were contacted again by phone after the first and fifth years and asked about PMNE symptomatology. RESULTS None of the patients had complications. No significant difference in pinch strength was observed following Btx-A injection, but there was significant improvement in grip strength, 2-point discrimination, and Q-DASH and VAS pain scores. CONCLUSION The outcomes of our study were promising: Btx-A injection improved symptoms in patients with PMNE. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ali Özdemir
- Selcuk University Department of Orthopedics and Traumatology, Hand Surgery Department Akademi Mahallesi, Celal Bayar Cd. No:313, 42130 Selçuklu/Konya, Turkey.
| | - Ali Güleç
- Selcuk University Department of Orthopedics and Traumatology, Akademi Mahallesi, Celal Bayar Cd. No:313, 42130 Selçuklu/Konya, Turkey.
| | - Ahmet Yurteri
- Konya City Training And Researh Hospital, Akabe, Adana Çevre Yolu Cd. No:135/1, 42020 Karatay/Konya, Turkey.
| | - Egemen Odabaşı
- Beyhekim Training and Research Hospital, Beyhekim Mahallesi Devlethane Sokak No:2/C, Selçuklu/Konya, Turkey.
| | - Mehmet Ali Acar
- Selcuk University Department of Orthopedics and Traumatology, Hand Surgery Department Akademi Mahallesi, Celal Bayar Cd. No:313, 42130 Selçuklu/Konya, Turkey.
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Kong G, Brutus JP, Vo TT, Hagert E. The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb. HAND SURGERY & REHABILITATION 2023; 42:475-481. [PMID: 37714514 DOI: 10.1016/j.hansur.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/04/2023] [Accepted: 09/09/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.
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Affiliation(s)
- Geraldine Kong
- Hamad Medical Corporation, Dept. of Orthopedic Surgery, Doha, Qatar
| | | | | | - Elisabet Hagert
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar; Karolinska Institutet, Dept. of Clinical Science and Education, Sodersjukhuset, Stockholm, Sweden
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Gupta P, Gupta D, Shrivastav S. Lacertus Fibrosus Syndrome: A Case Report. Cureus 2023; 15:e47158. [PMID: 38021701 PMCID: PMC10651808 DOI: 10.7759/cureus.47158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Lacertus fibrosus syndrome is described as compression of the median nerve, which takes place beneath a layer of ligamentous tissue (lacertus fibrosus, also known as bicipital aponeurosis) slightly beyond the elbow joint. Both sexes can develop lacertus fibrosus syndrome, most often after the age of 35. The possible risk factors are repetition of movements, overwork, and manual work while the forearm is pronated. Lacertus fibrosus syndrome presents a distinct diagnostic challenge because it is a somewhat unknown and non-documented disease. Its symptoms are often mistaken for those of carpal tunnel syndrome, which complicates the differential diagnosis and management of the patient. All patients who report tingling, numbness, loss of strength, muscle loss, manual endurance, or dexterity should be investigated and tested for both carpal tunnel syndrome and lacertus syndrome. Here, a case of a 43-year-old woman is discussed, who presented with chief complaints of pain and tingling sensation in the left upper limb, which was associated with loss of thumb pinch grip. The pain was aggravated with elbow extension and relieved with rest. The patient underwent left elbow median nerve decompression and was discharged in steady condition. This case report highlights the accurate clinical presentation and surgical intervention for the syndrome, for which the outcome turned out to be satisfying.
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Affiliation(s)
- Pranav Gupta
- Orthopaedics, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Dhananjay Gupta
- Orthopaedics, Fortis Flt. Lt. Rajan Dhall Hospital, New Delhi, IND
| | - Sandeep Shrivastav
- Orthopaedics, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Hagert E, Jedeskog U, Hagert CG, Marín Fermín T. Lacertus syndrome: a ten year analysis of two hundred and seventy five minimally invasive surgical decompressions of median nerve entrapment at the elbow. INTERNATIONAL ORTHOPAEDICS 2023; 47:1005-1011. [PMID: 36757413 PMCID: PMC10014674 DOI: 10.1007/s00264-023-05709-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 02/10/2023]
Abstract
PURPOSE This study aims to assess the clinical presentation and surgical outcomes of lacertus syndrome (LS) and concomitant median nerve entrapments. METHODS A retrospective study of prospectively collected data was conducted on patients undergoing lacertus release (LR) from June 2012 to June 2021. Available DASH (Disability of the Arm Shoulder Hand questionnaire) scores and post-operative Visual Analogue Scale (VAS) of pain, numbness, subjective satisfaction with surgical outcome, and intra-operative return of strength were analyzed. RESULTS Two-hundred-seventy-five surgical cases were identified of which 205 cases (74.5%) underwent isolated LR, and 69 cases (25.1%) concomitant lacertus and carpal tunnel release. The three most common presenting symptoms in LS patients were loss of hand strength (95.6%), loss of hand endurance/fatigue (73.3%), and forearm pain (35.4%). Numbness in the median nerve territory of the hand was found in all patients with combined LS and carpal tunnel syndrome. Quick-DASH significantly improved (pre-operative 34.4 (range 2.3-84.1) to post-operative 12.4 (range 0-62.5), p < 0.0001) as did work and activity DASH (p < 0.0001). The postoperative VAS scores were pain VAS 1.9 and numbness VAS 1.8. Eighty-eight percent of patients reported good/excellent satisfaction with the surgical outcome. Intra-operative return of strength was verified in 99.2% of cases. CONCLUSION LS is a common median nerve compression syndrome typically presenting with loss of hand strength and hand endurance/fatigue. Minimally invasive LR immediately restores hand strength, significantly improves DASH scores, and yields positive outcomes regarding VAS pain, numbness, and subjective satisfaction with surgery in patients with proximal median nerve entrapment at a minimum six month follow-up.
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Affiliation(s)
- Elisabet Hagert
- Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, 29222, Doha, Qatar.
- Dept of Clinical Science and Education, Karolinska Institutet, Sodersjukhuset, Stockholm, Sweden.
| | | | | | - Theodorakys Marín Fermín
- Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, 29222, Doha, Qatar
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How to Differentiate Pronator Syndrome from Carpal Tunnel Syndrome: A Comprehensive Clinical Comparison. Diagnostics (Basel) 2022; 12:diagnostics12102433. [PMID: 36292122 PMCID: PMC9600501 DOI: 10.3390/diagnostics12102433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/17/2022] Open
Abstract
The diagnostic process that allows pronator syndrome to be differentiated reliably from carpal tunnel syndrome remains a challenge for clinicians, as evidenced by the most common cause of pronator syndrome misdiagnosis: carpal tunnel syndrome. Pronator syndrome can be caused by compression of the median nerve as it passes through the anatomical structures of the forearm, while carpal tunnel syndrome refers to one particular topographic area within which compression occurs, the carpal tunnel. The present narrative review is a complex clinical comparison of the two syndromes with their anatomical backgrounds involving topographical relationships, morphology, clinical picture, differential diagnosis, and therapeutic options. It discusses the most frequently used diagnostic techniques and their correct interpretations. Its main goal is to provide an up-to-date picture of the current understanding of the disease processes and their etiologies, to establish an appropriate diagnosis, and introduce relevant treatment benefiting the patient.
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Löppönen P, Hulkkonen S, Ryhänen J. Proximal Median Nerve Compression in the Differential Diagnosis of Carpal Tunnel Syndrome. J Clin Med 2022; 11:3988. [PMID: 35887752 PMCID: PMC9317082 DOI: 10.3390/jcm11143988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is the most common median nerve compression neuropathy. Its symptoms and clinical presentation are well known. However, symptoms at median nerve distribution can also be caused by a proximal problem. Pronator syndrome (PS) and anterior interosseous nerve syndrome (AINS) with their typical characteristics have been thought to explain proximal median nerve problems. Still, the literature on proximal median nerve compressions (PMNCs) is conflicting, making this classic split too simple. This review clarifies that PMNCs should be understood as a spectrum of mild to severe nerve lesions along a branching median nerve, thus causing variable symptoms. Clear objective findings are not always present, and therefore, diagnosis should be based on a more thorough understanding of anatomy and clinical testing. Treatment should be planned according to each patient's individual situation. To emphasize the complexity of causes and symptoms, PMNC should be named proximal median nerve syndrome.
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Affiliation(s)
- Pekka Löppönen
- Department of Orthopedics and Traumatology, Seinäjoki Central Hospital, FI-60220 Seinäjoki, Finland
| | - Sina Hulkkonen
- Department of Hand Surgery, Helsinki University Hospital, University of Helsinki, FI-00029 Helsinki, Finland; (S.H.); (J.R.)
| | - Jorma Ryhänen
- Department of Hand Surgery, Helsinki University Hospital, University of Helsinki, FI-00029 Helsinki, Finland; (S.H.); (J.R.)
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