Proximal median nerve release at the pronator tunnel surgical technique
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The commonest site of compression of the median nerve is the carpal tunnel. Rarely, a primary more proximal compression may be responsible for symptoms and a careful review of patients with failed symptom resolution after carpal tunnel decompression (CTD) may identify a source of proximal compression that requires release.
There are various common sites pression at this site may be due to the lacertus fibrosis, the proximal edge of the pronator muscle or the flexor digitorum superficialis (FDS) arch. The typical symptoms include proximal forearm pain, sensory disturbance in the radial volar digits and palm, Tinel’s sign at the point of compression and pain on resisted pronation or resisted FDS contraction to the middle finger.
Imaging of the nerve should be performed prior to surgery to exclude an intrinsic nerve tumour or extra-neural mass causing pressure in this tight space. Surgery aims to identify the median nerve at the proximal edge of the lacertus fibrosus and trace distally decompressing the nerve throughout its course while protecting proximal motor branches.
Dominic Power MA MB BChir(Cantab)FRCSEd FRCSLon FRCS(Tr & Orth)
Consultant Hand and Peripheral Nerve Surgeon
Honorary Senior Clinical Lecturer, University of Birmingham, UK
West Midlands Peripheral Nerve Injury Service
Birmingham Hand Centre, UK
Author: Dominic Power FRCS (Tr & Orth)
Institution: West Midlands Peripheral Nerve Injury Service, Birmingham Hand Centre, UK
- Each operation and the questions associated become a named course in the CPD section
- The operative technique itself is read as a lesson as is any company implant information if this is being assessed.
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- The vast majority of operations have a 10-15 MCQ quiz covering all aspects of the decision making and the technique
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- There are additional quiz modules on the surgical steps, the implants and problem cases being added continually
- The course is completed once all the lessons are read and quizzes submitted and passed.
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The pass mark is 75%.
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- Operation Quiz – 1 CPD point
- Surgical steps Quiz – 1/4 CPD point
- Implants Quiz – 1/4 CPD point
- Problem case Quiz – 1/2 CPD point
One CPD point equates to one hour of academic activity
Welcome to the Professional Development question section. The objective of taking these tests is to demonstrate that you have understood all aspects of the assessment and management of patients requiring surgical intevention. On successful completion you will receive a certificate accredited by both the Royal College of Surgeons of both England and Edinburgh as well as the British Orthopaedic Association.
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