Modern Ortho of NJ - In the OR

Lacertus Syndrome can sneak up on you!

You’ve probably heard of carpal tunnel syndrome, but do you know about lacertus syndrome? Sometimes also referred to as pronator syndrome, this proximal median nerve compression at the elbow can be a reason why a carpal tunnel release alone doesn’t fully alleviate symptoms of numbness and tingling in the thumb, index, and middle fingers.

Additionally, this more proximal median nerve compression higher “upstream” can result in weakness in thumb and index finger flexion.

With a simple lacertus release procedure (picture 2 & 3), the weakness and numbness will typically resolve entirely!!

This is a young woman with a severe wrist injury at work. Fracture-dislocation of the wrist and very unstable after reduction.

I opened it up and the palmar ligaments sheared off the rim of bone with little fragments. I repaired the capsular shear and held the bone/capsule in place with suture anchors. Because of the damage, I wanted to protect the ligament repairs so I added a temporary wrist spanning plate to support the reduction and the repairs for healing. I took the plate out after a few months.

Last photo is 5.5 months from the injury and she has no pain!

Dr. David Ratliff

“Will my carpal tunnel come back?”

ANSWER: Not usually - but the most common cause of “recurrent carpal tunnel syndrome” is actually incomplete release! 😳

In this case, my patient had a general orthopedic surgeon release her carpal tunnel several years ago, but now she was suffering from a recurrence of her CTS symptoms. I noticed that her initial surgeon used an incision that more proximal than usual.

In this picture, take a look at what I found in her hand - AN INCOMPLETELY RELEASED CARPAL TUNNEL. You can actually see the advancing nerve that got caught up on the unreleased distal edge of the carpal tunnel!

As a patients, please understand that surgical expertise, whether it is hand/wrist surgery, nerve surgery, or hip and knee replacement is NOT a commodity skill. The “system” will tell you that, but use this type of case as a learning lesson! It is truly a speciality with tremendous risk with a spectrum of quality.

Carpal tunnel release surgery, while common, is highly risky, and can result in subpar results, possibly requiring re-operations.

If you have carpal tunnel syndrome, my recommendation is to find a dedicated hand surgeon who has added board-certification in surgery of the hand. This will likely maximize your chance of a having a great result, and will minimize the risks.

When will robotics and AI make their entry into hand surgery??

This case made me wonder.

This is a 16-year-old baseball player who took an errant hop to the throwing hand ring finger while fielding the ⚾️. He sustained this terrible intra-articular PIP fracture.

I percutaneously reduced the impacted intra-articular fracture and crafted an all-wire dynamic ex-fix ( technique).

But this made me wonder 🤔 - when will we see robotics make an entry into hand surgery?

During my career, will we see a robot that can reduce a fractured/displaced joint and meticulously apply this complex construct?

My knee-jerk reaction says no, but my better instincts tell me yes.

Thoughts??

**New orthopedic term**

The “Pseudo Grashey view”

Defined as: When the glenohumeral joint line can be visualized in an arthritic shoulder on a standard AP shoulder X-ray (taken perpendicular to the plane of the body), indicating a severely retroverted glenoid (~40-45 degrees).

Pre-operative planning with software using the patient’s own pre-op CT scan is super helpful in achieving a great result in cases like these!

Augmented reality folks, should I become a deciple?

Rotator Cuff Tears can come in all shapes and sizes! ⏹️🔼⏺️

This patient suffers from an anterosuperior rotator cuff tear-a combination of a supraspinatus tear with a subscapularis tear. This patient sustained this injury during a car accident.

Here is a great look at the subscapularis tear during the arthroscopic repair. Notice the frayed fibers and the red inflammation surrounding it.

Second pic is of the repaired subscapularis - done all through the scope via several 1cm incisions!

Lacertus Syndrome is REAL!

- If your carpal tunnel release didn’t fully relieve your symptoms, or your carpal tunnel symptoms have returned after a release, make sure a hand surgeon takes a look at your median nerve “upstream” at your elbow!

- This tight band courses directly over the median nerve at the elbow and puts a squeeze on it!

- Compression from this tight band can sometimes cause weakness in the thumb and index finger, and numbness in the palm and the fingers (thumb, index, middle, ring).

- Releasing this tight band often results in INSTANT relief of weakness and numbness! 😎

ANGRY SHOULDER

You are looking at an IMPRESSIVE amount of shoulder synovitis surrounding the subscapularis tendon attachment to the humeral head - seen best on a dry scope. 😳

When I first enter the shoulder joint during an arthroscopy, I like to look at the condition of the joint WITHOUT insufflating it with fluid. This shows me the inflammation in “full bloom”! 🌸

Once there is pressure inside the joint from fluid, the extent of the inflammation may not be so apparent.

This also helps me explain to my patients afterward why they had so much pain in their shoulder for so long!

In this case, the patient has a high-grade partial thickness supraspinatus tear that was causing this reactive inflammation throughout the front of the joint. The inflammation was removed, and the tendon repaired with a suture bridge construct.

Wrist pain - This patient has inflammatory arthritis with significant destructive changes at the wrist. The hand was basically falling palmarly off the forearm. He was in significant pain and with that many wrist changes, the only surgical option is fusion.

Amazingly the patient had no pain after surgery and all of the wrist pain was immediately gone. One of the happiest and most satisfied patients that I’ve ever had.

Bifid Median Nerve

This was an interesting finding!

This patient came to me for recurrent carpal tunnel syndrome symptoms after having a carpal tunnel release by another surgeon several years ago.

So I performed a hypothenar fat flap - a great procedure for this problem.

Check out that severe constriction point in the middle of the median nerve in this first pic! 😳 Also, as you can see, there looks like there are 2 nerves running through the carpal tunnel- but this is actually a bifid median nerve!

A bifid median nerve was found in one study to occur in 13% of people, is associated with a median artery (also an uncommon anatomic variant), and is more common in the left hand.

’ve pinned a lot of fingers over the years. The exposed pins can often bind and limit motion contributing to finger stiffness. I’m always looking for ways to get better results and this swollen fractured hand is at high risk for stiffness. Due to that concern, I fixed these displaced fractures with percutaneous screws. No more trauma than pins and the early motion will likely be easier. Always reevaluate what you’re doing and strive to improve your results.

Metacarpal Factory Friday!

…with and !

This patient had a very painful metacarpal nonunion that he was living with for 9 months! 😳😩

Today we took down the non-union at the 5th metacarpal neck, grafted it with bone from the distal radius, and placed an intramedullary screw to stabilize the bone and promote healing.

We will get him moving in a couple days! 🤚

Elbow nerve pain!
We see a lot of ulnar neuropathy in our practice. Pressure on the ulnar nerve at the inside of the elbow can cause pain at the medial elbow and pain, numbness, and weakness of the hand. Banging this nerve is the “funny bone” sensation that everyone knows.

A less common cause of pressure on the nerve at the elbow is the anconeus epitrochlearis, an anomalous accessory muscle over the cubital tunnel at the inside of the elbow. Most people don’t have this muscle but sometimes it’s there. Nerve tests can be normal but the symptoms tend to respond well to surgery.

In this case, a large anconeus epitrochlearis muscle was pushing on the nerve causing persistent symptoms. After taking all of the pressure off of the nerve, it was unstable so the nerve was moved to the front of the elbow to keep it from being under tension.



Dr. David Ratliff
Modern Orthopaedics of New Jersey

Distal humerus fracture

Complex elbow fractures can be devastating. This patient fell from a height and had an open elbow fracture. Lots of small pieces with some bone loss but there was enough joint surface to put together and recreate the overall alignment and joint

Patients hate crooked wrists! 😩🦴

My patient was in a car crash, and her wrist served as her personal crumple zone - it’s always better the wrist than the head tho!

Unfortunately, due to the red tape of our insurance system and probably some language barrier issues, there was a delay in her course of treatment, and she presented to me at nearly 4 weeks with this painful wrist deformity that had basically healed. 😖

You can clearly see how the crooked-looking wrist correlates with the loss of radial inclination and some loss of radial height on X-ray.

This week I fixed her wrist by re-breaking it into several pieces, releasing scar tissue, and fixing it with a plate. 💪

I think she’ll be happier…now for the healing and recovery! 😎

Dupuytren’s contracture fasciectomy

Before & After

Teenage girl that jammed her finger playing softball. The fracture at the joint isn’t too hard to see but the subtle dorsal shift of the finger is easy to miss if you’re not looking for it. This joint was hinging on the fracture instead of gliding when she tried to bend it and that won’t work out well long term!

I don’t like to open fingers if I can avoid it but this finger needed help. By opening the joint and reducing the bone, the joint is now concentric and solid and she can begin moving it. Tiny screws hold the fracture in place.

Thumb vs. woodchipper 😳

It’s never good to lose part of your thumb, but fortunately there are creative ways we can move tissues around and recreate what was lost!

This patient lost most of the pulp of his thumb when he get his hands too close to the working end of a woodchipper and his glove got caught! He lost most of the thumb pulp along with a bit of the distal phalanx. I chose to perform a modified Moberg flap to gain volar coverage of the remaining distal phalanx.

Last pic is at 2 months post-op, completely healed. 👍 Patient is doing well now, and is adapting to his new thumb, both physically and psychologically. The emotional component to even a small partial loss of a digit can be the largest hurdle to recovery for many patients with these types of injuries.

Education comes full circle!

Just a few days after lecturing the residents about fractures at the base of the thumb, this patient came to clinic. All those knowledge pearls get put to use!

Here’s a nice exposure of the median nerve in the forearm, right after it was released from the surrounding structures that were entrapping it.

We’ve all heard of carpal tunnel syndrome, but sometimes the symptoms of numbness in the thumb, index, middle, and radial aspect of the ring fingers is instead caused by compression of the same median nerve but higher upstream near the elbow.

Various physical exam tests can be used to determine median nerve entrapment at this level, and if symptoms persist, a surgical release may be warranted.