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Drs. Lionel Brown, MD, and John Lunt, MD Share Discoveries on Lacertus Tunnel Syndrome An Important Diagnostic Advantage

Doctors John Lunt and Lionel Brown news imageDrs. Brown and Lunt, upper extremity specialists and hand surgeons at The Hand Center at Danbury Orthopedics, have recently made an important contribution to their field. They have presented work on a condition of median nerve compression at the elbow which they call Lacertus Tunnel Syndrome, or LTS. This is a significant development in the treatment of upper extremity pain and weakness.

The latest findings on LTS were presented in December 2012 at the annual meeting of the prestigious New England Hand Society (NEHS) in Sturbridge, CT. This was followed by an invitation to The Hand Center in Hartford and the Combined Hand Service fellowship for a teaching/training session in February 2013.

NEHS was founded some 30 years ago by Dr. Kirk Watson of The Hand Center in Hartford. Dr. Watson is also founder and chief of the Connecticut Combined Hand Surgery Fellowship Training Program at Hartford Hospital, in association with the University of Connecticut. He has trained 134 orthopedic hand surgeons since starting the fellowship program.

Dr. Brown served as NEHS President from 1995-97. His presentation on LTS was well attended by leading hand surgeons and therapists from throughout New England. The meeting was chaired by Dr. David Ring, chief of the extremity service at Boston’s Massachusetts General Hospital. “NEHS is a great place to introduce new concepts for strong academic critique,” said Dr. Brown following his presentation.

Up until now, median nerve compression at the elbow, also known as pronator syndrome or proximal median nerve entrapment, has been a poorly understood yet very common entity. “By not knowing of LTS,” says Dr. Brown, “20% of all upper extremity compressions are being missed!”

A technique for diagnosing upper extremity compressions was first brought to the attention of the Drs. at the Hand Center by Prof. (retired) Carl-Goran Hagert from Lund Univ. in Sweden. Together, their research focuses attention on the lacertus tunnel where the median nerve passes between the lacertus fascia and the humeral troclea. Pressure rises in the tunnel when the lacertus is tightened in elbow extension accompanied by supination, and more commonly by contraction of the pronator teres in elbow flexion with forearm pronation. The condition of LTS is very much a result of repetitive pronosupination.

Symptoms and Treatment
Symptoms of LTS are typically weakness, fatigue and achiness – symptoms often confused with carpal tunnel syndrome. Pain is usually mild, in the elbow, and may refer up and down the extremity. Patient complaints include difficulty opening jars, needing to stop and rest, and of dropping things. Symptoms are closely related to variable compensations for the weakness. The pattern of strength loss as measured by a detailed physical examination of specific muscles confirms the nerve compression.

The goal of treatment is decompression of the nerve either by medication or surgery. It has been the doctors’ practice initially to inject cortisone under the lacertus. After two weeks, the majority of patients have full return of strength. If surgery is indicated, the approach mirrors that of carpal tunnel release: divide the offending fascia, and increase space for the nerve. Activities may be resumed as tolerated, and there is no need for therapy.

Study Results
In a 4-year review, from 2008 to 2012, 119 patients underwent 127 surgical releases, representing 15% of all upper extremity nerve decompressions. Post-operatively, patients are relieved of their pain and weakness, and standardized outcome measurements show a dramatic improvement to near normal function.

As the doctors conclude in their presentation, proximal compression of the median nerve occurs frequently under the lacertus fibrosus. The diagnosis is readily made by basic physical examination, and specific muscle strength testing. It is easily cured by a simple, minor surgical procedure. Preparations are being made for publication in The Journal of Hand Surgery.