Lacertus Fibrosus Syndrome: “The eyes only see what the mind knows”

Abstract

Lacertus fibrosus (LF) syndrome is the most common cause of proximal compression of the median nerve around the elbow. It is characterized by pain in the forearm and weakness in certain movements of the hand and wrist.

It is a commonly underdiagnosed pathology, which requires a high clinical suspicion and a thorough examination in the physical examination since complementary imaging and electrodiagnostic examinations are usually not useful.

Initially, it is conservative treatment, but if this fails, surgical release may be indicated.

The LF release technique can be performed under a local anesthesia technique without sedation or an ischemia tourniquet (WALANT), which allows the surgeon to evaluate intraoperatively the immediate recovery of strength of the muscle groups compromised in this condition. Postoperative functional results have been shown to be excellent in terms of resolution of pain and recovery of strength.

LF syndrome is common; it must be diagnosed and treated correctly to achieve a satisfactory resolution of the symptoms.

Keywords

Lacerto Fibrosus Syndrome - median nerve entrapment - hand surgery - WALANT

Publication History

Received: 05 October 2024

Accepted: 16 October 2024

Article published online:
23 December 2024

• Referencias

• 1 Al-Hashimi Y, Ferembach B, Martinel V, Hagert E. Painful nerve compression beyond the carpal tunnel: recognizing the lacertus syndrome. Plast Aesthet Res 2024; 11: 9
• 2 Olney RK. Carpal tunnel syndrome: complex issues with a “simple” condition. Neurology 2001; 56 (11) 1431-1432
• 3 Padua L, Cuccagna C, Giovannini S. et al. Carpal tunnel syndrome: updated evidence and new questions. Lancet Neurol 2023; 22 (03) 255-267
• 4 Osiak K, Elnazir P, Walocha JA, Pasternak A. Carpal tunnel syndrome: state-of-the-art review. Folia Morphol (Warsz) 2022; 81 (04) 851-862
• 5 Cline JA, Frantz LM, Adams JM, Hearon BF. Experience With Proximal Median Nerve Entrapment by the Lacertus Fibrosus. Hand (N Y) 2024; 19 (06) 904-911
• 6 Tang JB. Median nerve compression: lacertus syndrome versus superficialis-pronator syndrome. J Hand Surg Eur Vol 2021; 46 (09) 1017-1022
• 7 Ahmad AA, Abdullah S, Thavamany AS, Tong CY, Ganapathy SS. Lacertus Syndrome: an Outcome Analysis After Lacertus Release. J Hand Surg Glob Online 2023; 5 (04) 498-502
• 8 Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet 1973; 2 (7825) 359-362
• 9 O'Brien AL, Zimmer J, West JM, Moore AM. Multiple Concurrent Decompressions for the Treatment of Upper Extremity Pain. J Hand Surg Glob Online 2022; 5 (01) 87-91
• 10 Azócar C, Corvalán G, Orellana P, Cobb P, Liendo R, Román J. Intraoperative immediate strength recovery following lacertus fibrosus release in patients with proximal median nerve compression at the elbow. Int Orthop 2023; 47 (11) 2781-2786
• 11 Molinari III WJ, Elfar JC. The double crush syndrome. J Hand Surg Am 2013; 38 (04) 799-801, quiz 801
• 12 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. Int Orthop 2023; 47 (04) 1005-1011
• 13 Adler JA, Wolf JM. Proximal Median Nerve Compression: Pronator Syndrome. J Hand Surg Am 2020; 45 (12) 1157-1165
• 14 Apard T, Martinel V, Batby G, Draznieks G, Descamps J. Lacertus syndrome: recent advances. Hand Surg Rehabil 2024; 43 (04) 101738
• 15 Martinel V, Apard T. The Lacertus Antagonist Test: A Predictive Test for Strength Recovery after Surgery for Lacertus Syndrome. Plast Reconstr Surg Glob Open 2023; 11 (10) e5309
• 16 Hagert E. Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study. Hand (N Y) 2013; 8 (01) 41-46
• 17 Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am 2005; 30 (05) 1061-1067
• 18 Lalonde D, Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg 2013; 21 (08) 443-447
• 19 Lalonde DH. Conceptual origins, current practice, and views of wide awake hand surgery. J Hand Surg Eur Vol 2017; 42 (09) 886-895
• 20 Kurtzman JS, Etcheson JI, Koehler SM. Wide-awake Local Anesthesia with No Tourniquet: An Updated Review. Plast Reconstr Surg Glob Open 2021; 9 (03) e3507
• 21 Caetano EB, Vieira LA, Almeida TA, Gonzales LAM, Bona JE, Simonatto TM. Bicipital aponeurosis. Anatomical study and clinical implications. Rev Bras Ortop 2017; 53 (01) 75-81
• 22 Dubois de Mont-Marin G, Laulan J, Le Nen D, Bacle G. Topographic anatomy of structures liable to compress the median nerve at the elbow and proximal forearm. Orthop Traumatol Surg Res 2021; 107 (02) 102813
• 23 Peters BR, Pripotnev S, Chi D, Mackinnon SE. Complete Foot Drop With Normal Electrodiagnostic Studies: Sunderland “Zero” Ischemic Conduction Block of the Common Peroneal Nerve. Ann Plast Surg 2022; 88 (04) 425-428
• 24 Mackinnon S. Nerve Surgery. Thieme Medical Publishers, Inc; 2015
• 25 Archambault G, Boudier-Revéret M, Hagert E, Effatparvar MR, Sobczak S. Effect of lacertus fibrosus release on perineural pressure of the median nerve at the elbow: a cadaveric study. Int Orthop 2023; 47 (05) 1277-1284
• 26 Hagert E, Gnanapragasam R, Martinel V. The OK and W Signs in Pre-/Intraoperative Testing of Lacertus and Cubital Tunnel Syndrome. Plast Reconstr Surg Glob Open 2024; 12 (09) e6179
• 27 Ayhan E, Cimilli E, Cevik K. Pinch strength analyses in lacertus syndrome. Hand Surg Rehabil 2023; 42 (04) 305-309 https://www.sciencedirect.com/science/article/pii/S2468122923000774 [Internet]
• 28 Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg Am 2008; 33 (09) 1518-1524
• 29 García-Medrano B, Simón Pérez CL, Corella Montoya MA, Delgado PJ, Corella Montoya F. Objective evaluation of the “scratch collapse test” for the diagnosis of carpal tunnel syndrome. Injury 2021; 52 (Suppl. 04) S145-S150
• 30 Apard T, Descamps J. Ultrasound-guided injection for lacertus syndrome. Cardiovasc Intervent Radiol 2024; 47 (07) 1015-1017 ; Online ahead of print