Virtual Operating Room

Severe Carpal Tunnel Syndrome 😬

This is what a median nerve looks like after many years of compression!

You can see the area of whitish-gray in the mid-portion of the nerve, right at the maximal point of compression. The more normal part of the nerve (on either end of the gray part) is where you can see the nerve has a larger caliber and appears more yellow-tinged. This represents where the epineurium and myelin tissue (the insulation of the nerve fibers) are normal.

A carpal tunnel release procedure, even in the setting of compression this severe, is usually still very successful and can substantially improve symptoms of pain and numbness. 🙂


#orthopedics #upperextremity #nervesurgery #nervesurgeon #orthopedicsurgeon #handtherapy #occupationaltherapy #physicianassistant #athletictrainer #handsurgery #carpaltunnelsyndrome #carpaltunnelrelease #HandNumbness #NightPain

Carpal Tunnel Release Surgery is usually straight forward, but it’s not without its pitfalls and challenges!!

This case highlights why it’s so important for hand surgeons to have an intricate knowledge of the median nerve anatomy and the common variations of its branches when doing this “routine” procedure.

**Transligamentous variants of the recurrent motor branch of the median nerve occur somewhere between 5-30% of people.


#anatomy #orthopedics #nervesurgery #carpaltunnelsyndrome #carpaltunnel #carpaltunnelsurgery

Mini-open Carpal Tunnel Release Surgery

If you’ve been told you need a #carpaltunnelrelease for #carpaltunnelsyndrome, you may be worried about the process and recovery!

This video shows you how easy it is to undergo a carpal tunnel release on BOTH SIDES under local anesthesia ONLY!


#orthopedicsurgery #WALANT #wideawakesurgery #handsurgery #carpaltunnelsyndrome #carpaltunnelrelease #minimallyinvasivesurgery #upperextremity #orthopedics #HandNumbness #nightpain


Here’s an example of a patient who had severe pain with daily activities like reaching behind her back or bringing her arm over her head. Her subscapularis tendon was pristine, and her biceps was completely normal, but her supraspinatus was a different story. She had a high-grade partial thickness tear on the articular side of the supraspinatus tendon. With a little bit of shaving, the tendon melted away and you can see the loss of attachment to the greater tuberosity footprint. At that point, it was time to drop anchors! This was a 4-anchor suturebridge repair, and it came back together perfectly!


#rotatorcuffrepair #shouldersurgeon
#orthopedics #shouldersurgery #shoulderscope #shoulderarthroscopy #upperextremity #arthroscopy #orthopedicsurgeon #handtherapy #occupationaltherapy #physicianassistant #athletictrainer


#CarpalTunnelRelease (CTR), either open or endoscopic, is a very reliable and successful procedure to treat #carpaltunnelsyndrome (CTS) when conservative measures like bracing and therapy have failed.

In a small percentage of cases following CTR, CTS symptoms may continue or recur after some initial improvement in the first few months post-op.

In these rare cases, I like to perform a re-release of the median nerve with an epineurolysis and a hypothenar fat flap (as seen in this video).

Placing fat (adipose tissue) directly around the nerve helps promote nerve gliding, provides nerve growth factors, and prevents recurrent scar formation.

This is a very reliable procedure that has a quick recovery and produces happy patients!


#orthopedics #upperextremity #nervesurgery #nervesurgeon #orthopedicsurgeon #handtherapy #occupationaltherapy #physicianassistant #athletictrainer #handsurgery #carpaltunnelsyndrome #carpaltunnelrelease #hypothenarfatflap #HandNumbness #NightPain

Music: Skate
Musician: Jeff Kaale


Sometimes patients present to me with a multitude of problems in the SAME hand/wrist!

In fact, I’m often blown away by how much bone/joint/nerve pain & dysfunction some patients tolerate in their daily lives for so many years!

Fortunately these problems can all be fixed at the same time. I call this type of surgery an “Around the World” procedure.

In this patient’s case the procedure included:

▶️ Capitolunate fusion for SLAC stage III #wristarthritis

▶️ Basal joint suture suspension arthroplasty for stage IV thumb #basaljointarthritis

▶️ Mini-open carpal tunnel release for #carpaltunnelsyndrome

Taking care of all of these problems at the same time means minimizing the downtime by overlapping the recoveries.

For his rehab:

- 2 weeks in thumb spica splint,

- 2 more weeks in a short arm cast / beginning thumb ROM

- if fusion healed at 4wks, then place a removable brace and begin ROM of wrist.



#physicaltherapy #occupationaltherapy #orthopedicsurgery #wristsurgery #wristarthritis #carpaltunnelsyndrome #carpaltunnelrelease

Music: Whenever
Musician: LiQWYD

SHOULDER PAIN! - Patients who have calcific tendonitis know this all too well.😩

My patient in this video had 2 HUGE deposits (the size of 2 blueberries) in her supraspinatus tendon that HURT and wouldn’t come out through less invasive means.

Now for some calcific tendonitis of the shoulder Q&A!

Q: How bad is the pain from calcific tendonitis anyway?
A: The pain from calcific tendonitis can be really bad during a flare. These flares often result in so much pain that many patients are moved to tears, and sometimes they even seek pain relief in the local ER!

Q: Do I always need surgery to get this to go away?
A: No. Most of the time a cortisone injection, or a removal of the calcium with a needle under ultrasound guidance.

Q: What causes calcific tendonitis?
A: Nothing in particular, as these calcific deposits will arise spontaneously, and many times will affect both shoulders.


#shoulders #shoulderpain #orthopedics #shouldersurgery #shoulderscope #shoulderarthroscopy #upperextremity #arthroscopy #orthopedicsurgeon #occupationaltherapy #physicaltherapy #physicianassistant #athletictrainer #calcifictendonitis


If your distal biceps ever ruptures, you may feel like a pop or a rip in the front of the arm that can be audible!😳

With your biceps tendon detached, you will lose some elbow flexion strength, but you will actually lose substantially more supination strength (palm up) since that’s the primary role of the biceps.

Here is a single-incision endobutton technique that does a great job of firmly reattaching the tendon to its anatomic attachment on the radial tuberosity. This repair allows my patient to begin immediate elbow range of motion activities post-op.

I’ll typically have him return to most activities by around 3 months.💪

@peterdenoblemd @ModernOrthoNJ

#distalbicepsrupture #biceps #ElbowPain #orthopedicsurgery #orthopedics #elbowsurgery #upperextremity #distalbicepsrepair #physicaltherapy

Complex TFCC arthroscopic repair

This was a combo type 1B and 2B tear that I operated on - check out the intra-op pics!

@peterdenoblemd @modernorthonj

#orthopedics #handsurgery #tfccrepair #wristsurgery #upperextremity #arthroscopy #shouldersurgery #DRUJinjury #wristinjury #orthopedicsurgeon #handsurgeon #handtherapy #occupationaltherapy #physicaltherapy


When #rotatorcuff tendons are torn and retracted to the level of the glenohumeral joint, it’s often a gametime (intra-op) decision about whether a primary repair is possible versus requiring a reconstructive option (superior capsular reconstruction/pectoralis major transfer, etc.)

This was one of those cases. In addition, given patient’s age and chronic use of steroids for a medical condition, her bone quality was very poor, particularly along the lateral aspect of the greater tuberosity.

When these lateral anchors on the greater tuberosity started pulling out, it was a lifesaver to have a transosseous repair technique in my bag of tricks!


#rotatorcuffrepair #shouldersurgery #orthopedicsurgeon #physicaltherapy #orthopedicsurgeon #shouldersurgeon


This is most likely what your local hand surgeons are up to the day after a blizzard in your area! ❄️ 🩸

And on behalf of snowblower hand injury victims everywhere, I would humbly ask spouses, significant others, parents, etc, to cut them a TON of slack. Shame levels are off the charts, and I can guarantee they will never put their hands in a snowblower again!!

@peterdenoblemd @modernorthonj

#blizzzard #snowstorm
#snowblowerinjuries #snowblower #fingerfracture #nerveinjury #orthopedicsurgeon #handtherapy #occupationaltherapy #physicianassistant #upperextremity #orthopedics #intheor #handsurgery #handsurgeon #topdoctors

Small Finger PIP Joint Replacement

My patient has been struggling with right small finger joint pain for years due to arthritis. After several cortisone injections and waiting it out, she finally couldn’t take it anymore!

Now she decided to proceed with a silicone joint implant. This will allow her to maintain her motion and get rid of her joint pain.

@peterdenoblemd @modernorthonj

#modernapproach #orthopedics #handsurgery #jointreplacement #upperextremity #orthopedicsurgeon #handsurgeon #handtherapy #occupationaltherapy

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Video: How I Do An Endoscopic Carpal Tunnel Release, Wide Awake – Dr. Peter DeNoble


Hey guys, it’s Dr. DeNoble here. I’m going to show you how I do my endoscopic carpal tunnel releases in 60 seconds. Now I do these procedures under straight local, which means the hand is numb but my patients are wide awake. They’re usually listening to the music of their choice and, for about 15 minutes, hanging out with us, chit-chatting and very comfortable. I start by making an incision in the middle of the Palm about a centimeter and a half in length. I gently retract the skin edges with retractors and insert a clear cannula. Once the clear candle is inserted into the carpal tunnel, I take a look. I make sure that there’s nothing interposed between me and the transverse carpal ligament. Once I am comfortable that there’s a nice track, I mount a blade on the head of the scope and from a district approximate direction, I advance this very gently. As you’ll see, as I draw it back, the fibers have spread nicely and the release has almost finished. I then advanced one more time to complete the release and that’s it. A couple of stitches, small incisions, happy patients.

Video: Wrist Fracture-Dislocation – Transscaphoid Perilunate Dislocation

A young man was in an ATV accident that resulted in scaphoid bone fractures and wrist dislocation. The fracture was reduced and pinned and bones in the wrist were pinned to allow ligaments to heal. Watch the full video below.


This is Dr. Ratliff from Modern Orthopedics of New Jersey. This video is discussing a wrist fracture-dislocation that occurred in a young man in a quad ATV accident. Here, you see a displaced fracture in the scaphoid bone. The lateral x-ray shows that the wrist is actually dislocated, the capitate should be sitting in the cup of the lunate. This is a perilunate dislocation.

The incision is placed at the back of the wrist with the hand to the left, going through the skin and subcutaneous tissues. Next, we’ll identify the extensor pollicis longus tendon, pulling on it to show that the thumb moves with the tendon and then tracing and exposing the tendon through its sheath. Next, the posterior interosseous nerve is identified at the back of the wrist, crushed, cut and cauterized to try to limit pain and problems down the road. The tendons within their sheaths are elevated away from the bone, using the scalpel to peel those tissues away and expose the capsule on the back of the wrist as well as the radius.

Once the capsule is exposed, we can begin to work on the joint itself. Here, you can see two transverse tears in the capsule that occurred from the injury, not preexisting, and then identifying a loose piece of cartilage within the joint, which won’t be able to heal. Now using the instrument into that dislocation to shoehorn it back into place and the joint is now reduced and in proper position, but the fracture is still remaining. So here, showing the bones now no longer dislocated.

Next, we can expose the wrist with a V-shaped incision in the capsule to show the bones within the wrist and the dislocation, which has now been reduced. But that fracture at the scaphoid is still there, which you could see just moving. The wires are put in as joysticks to manipulate the fracture, and then this wire holds the bone in the proper position. These are adjusted, and now we can see that the joint is well lined up. This instrument shows that the joint surface is smooth and the fracture is in good position. So further wires are adjusted and put into position into that bone to hold it in place.

With the majority of the fracture now fixed, a piece on the back had pulled off with cartilage but still had good healthy bone. So this was sutured back to the bone to hold it in place and stabilize those ligaments that are attached to it. Now the wires are driven distally out past the base of the thumb where they will remain buried for approximately 10 weeks. The joint can now move freely with the wires buried beneath the cartilage. The ligament between those two bones just adjacent to the fracture is now examined, and they’re noted to be moving in unison without any direct injury to the ligament.

The wrist bones themselves all need to be stabilized, so wires are placed on both sides of the wrist. These wires will crisscross all of the little bones in the wrist and hold them in place for 10 weeks to allow ligament and bone healing. The capsule that was opened is now repaired. [inaudible] bone is now fixed and held with wires and the dislocation is back in place.