Cardiovasc Intervent Radiol
https://doi.org/10.1007/s00270-024-03734-9
LETTER TO THE EDITOR
Ultrasound-Guided Injection for Lacertus Syndrome
Thomas Apard1 • Jules Descamps2
Received: 4 February 2024 / Accepted: 10 April 2024
Ó Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe
(CIRSE) 2024
Level of Evidence III Local non-random sample.
The pronator syndrome was described in 1951 [1] as the
compression of the median nerve at the elbow between the
two heads of the pronator teres muscle or at the proximal
arch of the flexor digitorum superficialis. The anatomy of
the Lacertus fibrosus (LF) (or bicipital aponeurosis) has
been well-known ultrasonographically ever since the
development of the high frequency probe [2].
Recently, a number of articles reported the surgical
outcomes of Lacertus release [3, 4] in case of failure of a
conservative treatment regimen (rest, anti-inflammatory
drugs, rehabilitation, and/or local injection). However,
there is no consensus concerning the protocol for local
injection of LF. This study therefore evaluates the technical
feasibility of a safer ultrasound-guided injection in cadaver
specimens using a safe zone for a reliable procedure.
The protocol used ten intact forearms from five fresh
cadavers (from the Kerimedical cadaver lab in Archamps,
France). The study was performed according to the regu-
lations of the local ethics committee. A wireless ultrasound
scanner (Synergy MSK, Arthrex, France) with a 4–13 MHz
linear probe was used. For the injection, a 10-mL syringe
with an INTROCANÒ Safety Short Catheter/Without
& Thomas Apard
thomasapard@yahoo.fr
Jules Descamps
jules.descamps@aphp.fr
1 inflammatory process in the LF, but the effect of local
Ultrasound Guided Hand Surgery Center, 2 Rue Alexis de
Tocqueville, 78000 Versailles, France
2 swelling around the nerve, increased nerve gliding and a
Department of Orthopaedic Surgery, Ecole de Chirurgie,
Assistance-Publique Hôpitaux de Paris, 7 Rue du Fer a
Moulin, 75005 Paris, France
NON-VASCULAR INTERVENTIONS
Wings/22G/25 mm, with methylene blue used as an
injectable substance to observe diffusion into the tissues
(Figs. 1 and 2). The two operators were orthopedic sur-
geons with moderate experience in ultrasound-guided
injections. The protocol was divided into several sequential
steps. First, an ultrasound scan of the area of interest was
performed using the Konschake protocol (2) to define the
boundaries of the LF. The safe zone described here was
delimited between the LF at the top, the brachial artery at
the lateral side, the median nerve at the deep side and the
pronator teres muscle at the medial side. Then, a 22-G
needle was inserted into the ulnar side of the LF (ultra-
sound-guided in plane controlled). Finally, the area of
interest was dissected to ascertain the quality of the
injection, looking for infiltrated structures and eventually
vascular or nerve damage (Fig. 3).
The procedure was feasible in all forearms. Anatomical
dissection revealed no nerve lesions or punctures, nor was
there infiltration into the brachial vessels. Upon performing
dissection, an infiltration of methylene blue was identified
for 90% of the cases involving the pronator teres superficial
edge and 50% of the cases involving the deep edge, but
only 10% of the cases involving the tip of the muscle. The
median nerve was slightly colored in two cases.
In addition to suppressing inflammation, the effects of
local corticosteroid injections may target connective tissue
and adhesions by inhibiting the production of collagen,
other extracellular matrix molecules and granulation tissue.
There was no evidence to demonstrate that there is an
corticosteroids is most likely a combination of reduced
decreased neuroinflammatory response.
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 T. Apard, J. Descamps: Ultrasound-Guided Injection for Lacertus Syndrome

Fig. 1 Transversal view in a

cadaver specimen: notice the
safe zone described in this
article in red dotted line

Fig. 2 Illustrations of the in-

plane view superficial edge (S),
Deep edge (D), Tip (T) of the
Pronator teres (PT) muscle
Median nerve (MN), Brachial
vessels (BV), Brachialis muscle
(BR), Biceps tendon (BT),
Lacertus fibrosus (LF) The
extremity of the needle is placed
in the safe zone (red)

A recent study of perineural injection for pronator syn-

drome did report clinical improvement in 70% of the 14
patients who underwent this procedure [5]. Specifically, the
procedure involved a median nerve perineural injection in
the pronator tunnel through the pronator teres following the
performance of a hydrodissection. However, this study was
not based on any anatomical work. Our study encountered
several limitations. First, the subjects were all elderly
adults with possible muscle atrophy. Second, they most
likely did not have median nerve entrapment at the elbow.
Third, the two operators are surgeons, and their experience
with ultrasound-guided injection is respectable but not as
high as that of an experienced interventional radiologist,
which somewhat strengthens the validity of the present
results for an easy and safe procedure. Fourth, the number
of forearms on which the procedure was performed is
relatively small; as a result, without further clinical study,
it is impossible to ascertain if the injection is a hydrodis-
Fig. 3 Infiltration of the Nerve Pronator teres (PT), Median nerve
section of the median nerve to obtain a better gliding, or if
(MN), Brachialis muscle (BR), Lacertus fibrosus (LF)
the outcome of the injection is the result of the effects of
the steroids.

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T. Apard, J. Descamps: Ultrasound-Guided Injection for Lacertus Syndrome
Acknowledgements The authors would like to thank Djamel Taleb
and his team, Ecole de Chirurgie. This study was supported and
assisted by Mathilde Sennhauser (MD)
Funding This study was not supported by any funding.
Declarations
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethical
standards.
Informed Consent For this type of study, informed consent is not
required.
Consent for Publication For this type of study, consent for publi-
cation is not required.
References
1. Seyffarth H. Primary myoses in the M. pronator teres as cause of
lesion of the N. medianus (the pronator syndrome). Acta Psychiatr
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2. Konschake M, Stofferin H, Moriggl B. Ultrasound visualization of
an underestimated structure: the bicipital aponeurosis. Surg Radiol
Anat. 2017;39(12):1317–22. https://doi.org/10.1007/s00276-017-
1885-0.
3. 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(1):41–6. https://doi.org/10.1007/s115
52-012-9483-4.
4. Apard T, Mares O, Duparc F, Michelin P. Percutaneous ultra-
sound-guided release of the lacertus fibrosus for median nerve
entrapment at the elbow. CardioVasc Interv Radiol. 2022;45(8):
1198–202. https://doi.org/10.1007/s00270-022-03123-0.
5. Delzell PB, Patel M. Ultrasound-guided perineural injection for
pronator syndrome caused by median nerve entrapment. J Ultra-
sound Med. 2020;39:1023–9.
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