Current Concepts| Volume 45, ISSUE 12, P1157-1165, December 2020

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Proximal Median Nerve Compression: Pronator Syndrome

Published:September 03, 2020DOI:
      Pronator syndrome (PS) is a compressive neuropathy of the median nerve in the proximal forearm, with symptoms that often overlap with carpal tunnel syndrome (CTS). Because electrodiagnostic studies are often negative in PS, making the correct diagnosis can be challenging. All patients should be initially managed with nonsurgical treatment, but surgical intervention has been shown to result in satisfactory outcomes. Several surgical techniques have been described, with most outcomes data based on retrospective case series. It is essential for clinicians to have a thorough understanding of median nerve anatomy, possible sites of compression, and characteristic clinical findings of PS to provide a reliable diagnosis and treat their patients.

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        • Rodner C.M.
        • Tinsley B.A.
        • O’Malley M.P.
        Pronator syndrome and anterior interosseous nerve syndrome.
        J Am Acad Orthop Surg. 2013; 21: 268-275
        • Gross P.T.
        • Tolomeo E.A.
        Proximal median neuropathies.
        Neurol Clin. 1999; 17: 425-445
        • Tsai P.
        • Steinberg D.R.
        Median and radial nerve compression about the elbow.
        Nerve. 2008; 90: 420-428
        • Olewnik L.
        • Podgorski M.
        • Polguj M.
        • Wysiadecki G.
        • Topol M.
        Anatomical variations of the pronator teres muscle in a Central European population and its clinical significance.
        Anat Sci Int. 2018; 93: 299-306
        • Lee M.J.
        • LaStayo P.C.
        Pronator syndrome and other nerve compressions that mimic carpal tunnel syndrome.
        J Orthop Sports Phys Ther. 2004; 34: 601-609
        • Johnson R.K.
        • Spinner M.
        • Shrewsbury M.M.
        Median nerve entrapment syndrome in the proximal forearm.
        J Hand Surg Am. 1979; 4: 48-51
        • McCue F.C.
        • Alexander E.J.
        • Baumgarten T.E.
        Median nerve entrapment at the elbow in athletes.
        Oper Tech Sports Med. 1996; 4: 21-27
        • Eversmann W.W.J.
        Compression and entrapment neuropathies of the upper extremity.
        J Hand Surg Am. 1983; 8: 759-766
        • Dellon A.L.
        • Mackinnon S.E.
        Musculoaponeurotic variations along the course of the median nerve in the proximal forearm.
        J Hand Surg Br. 1987; 12: 359-363
        • Beaton L.
        • Anson B.
        The relation of the median nerve to the pronator teres muscle.
        Anat Rec. 2005; 75: 23-26
        • Werner C.O.
        • Rosen I.
        • Thorngren K.G.
        Clinical and neurophysiologic characteristics of the pronator syndrome.
        Clin Orthop Relat Res. 1985; 197: 231-236
        • Hartz C.R.
        • Linscheid R.L.
        • Gramse R.R.
        • Daube J.R.
        The pronator teres syndrome: compressive neuropathy of the median nerve.
        J Bone Joint Surg Am. 1981; 63: 885-890
        • Spinner M.
        • Linscheid R.
        Morrey’s The Elbow and Its Disorders.
        4th ed. Saunders, Philadelphia, PA2009
        • Mujadzic M.
        • Papanicolaou G.
        • Young H.
        • Tsai T.-M.
        Simultaneous surgical release of ipsilateral pronator teres and carpal tunnel syndromes.
        Plast Reconstr Surg. 2007; 119: 2141-2147
        • Seitz W.H.
        • Matsuoka H.
        • McAdoo J.
        • Sherman G.
        • Stickney D.P.
        Acute compression of the median nerve at the elbow by the lacertus fibrosus.
        J Shoulder Elbow Surg. 2007; 16: 91-94
        • Dang A.C.
        • Rodner C.M.
        Unusual compression neuropathies of the forearm, part II: median nerve.
        J Hand Surg Am. 2009; 34: 1915-1920
        • Hsiao C.
        • Shih J.
        • Hung S.
        Concurrent carpal tunnel syndrome and pronator syndrome: a retrospective study of 21 cases.
        Orthop Traumatol Surg Res. 2017; 103: 101-103
        • Olehnik W.K.
        • Manske P.R.
        • Szerzinski J.
        Median nerve compression in the proximal forearm.
        J Hand Surg Am. 1994; 19: 121-126
        • Xing S.G.
        • Tang J.B.
        Entrapment neuropathy of the wrist, forearm, and elbow.
        Clin Plast Surg. 2014; 41: 561-588
        • Bilecenoglu B.
        • Uz A.
        • Karalezli N.
        Possible anatomic structures causing entrapment neuropathies of the median nerve: an anatomic study.
        Acta Orthop Belg. 2005; 71: 169-176
        • Caetano E.B.
        • Sabongi J.J.
        • Vieira L.A.
        • Caetano M.F.
        • Moraes D.V.
        Gantzer muscle: an anatomical study.
        Acta Ortop Bras. 2015; 23: 72-75
        • Mangini U.
        Flexor pollicis longus muscle: its morphology and clinical significance.
        J Bone Joint Surg Am. 1960; 42-A: 467-470
        • Hagert E.
        • Hagert C.G.
        Manual muscle testing—A clinical examination technique for diagnosing focal neuropathies in the upper extremity.
        in: Upper Extremity Nerve Repair—Tips and Techniques: A Master Skills Publication. American Society for Surgery of the Hand, Chicago, IL2008: 451-466
        • Matsuzaki A.
        Operative treatment of pronator syndrome.
        Orthop Traumatol. 1999; 7: 34-43
        • Wertsch J.J.
        • Melvin J.
        Median nerve anatomy and entrapment syndromes: a review.
        Arch Phys Med Rehabil. 1982; 63: 623-627
      1. El-Haj M, Ding W, Sharma K, Novak C, Mackinnon SE, Patterson JMM. Median nerve compression in the forearm: a clinical diagnosis [published online ahead of print September 20, 2019]. Hand (N Y).

        • Zancolli E.R.
        • Zancolli E.P.I.V.
        • Perrotto C.J.
        New mini-invasive decompression for pronator teres syndrome.
        J Hand Surg Am. 2012; 37: 1706-1710
        • Lee A.K.
        • Khorsandi M.
        • Nurbhai N.
        • Dang J.
        • Fitzmaurice M.
        • Herron K.A.
        Endoscopically assisted decompression for pronator syndrome.
        J Hand Surg Am. 2012; 37: 1173-1179
        • Morris H.H.
        • Peters B.H.
        Pronator syndrome: clinical and electrophysiological features in seven cases.
        J Neurol Neurosurg Psychiatry. 1976; 39: 461-464
        • Presciutti S.
        • Rodner C.M.
        Pronator syndrome.
        J Hand Surg Am. 2011; 36 ([quiz: 909]): 907-909
        • Cobb T.K.
        • An K.N.
        • Cooney W.P.
        • Berger R.A.
        Lumbrical muscle incursion into the carpal tunnel during finger flexion.
        J Hand Surg Br. 1994; 19: 434-438
        • Rehak D.C.
        Pronator syndrome.
        Clin Sports Med. 2001; 20: 531-540
        • Haussmann P.
        • Patel M.R.
        Intraepineurial constriction of nerve fascicles in pronator syndrome and anterior interosseous nerve syndrome.
        Orthop Clin North Am. 1996; 27: 339-344
        • Kodama A.
        • Sunagawa T.
        • Ochi M.
        Early treatment of anterior interosseous nerve palsy with hourglass-like fascicular constrictions by interfascicular neurolysis due to early diagnosis using ultrasonography: a case report.
        J Hand Surg Eur Vol. 2015; 40: 642-643
        • Gross P.T.
        • Jones H.R.
        Proximal median neuropathies: electromyographic and clinical correlation.
        Muscle Nerve. 1992; 15: 390-395
        • Mysiew W.J.
        • Colachis 3rd, S.C.
        The pronator syndrome: an evaluation of dynamic maneuvers for improving electrodiagnostic sensitivity.
        Am J Phys Med Rehabil. 1991; 70: 274-277
        • Seyfarth H.
        Primary myoses in the M. pronator teres as cause of lesion of the N. medianus (the pronator syndrome).
        Acta Psychiatr Neurol Scand Suppl. 1951; 74: 251-254

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