The palmaris longus is frequently used as a graft source for elbow ligament reconstruction such as lateeral collateral ligament reconstruction or ulnar collateral ligament reconstruction.
Determine presence of palmaris longus tendon preoperative
Ask the patient to press the tip of his/her thumb against the tip of the 5th finger while flexing the wrist - this accentuates the presence of a palmaris longus at the wrist.
If there is not a palmaris longus on the involved side, check the other side as some patients have it only unilaterally.
If you cannot identify the palmaris longus with this test, it is probably not robust enough to be your graft and you should consider an alternative.
Arm on armboard
Provide OR photos to illustrate positioning
Single incision with use of tendon stripper
Multiple incision (2 or 3) without use of tendon stripper
Make a small horizontal incision at the proximal wrist flexion crease which is about 1 cm proximal to the distal flexion crease. The distal flexion crease is at the junction of the palm and forearm. The palmaris longus tendon is easily identified at the proximal wrist flexion crease and is always SUPERFICIAL to the fascia. All other tendons including FCR are deep to the fascia! At the more distal flexion crease the palmaris longus tendon blends with the palmar fascia and is much less distinct.
Use of a tendon stripper or small incisions proximally are both described.
Once certain that the palmaris longus has been identified distally pull on it and make small transverse incision in the forearm at length required proximally and then cut the tendon at musculotendionous junction and pull it out the distal incision with traction on the distal tendon. If required a 3rd incision can be used however often is not needed.
Pearls and Pitfalls
To avoid harvesting of the median nerve make certain you have unequivocally identified the palmaris longus and understand the local anatomy.
- Make certain that the patient has a palmaris longus tendon as described above
- Palpate the FCR tendon medially
- The median nerve is always DEEP to forearm fascia and usually has an artery running on the volar and radial surface of nerve.
- Confirm the palmaris longus tendon has attachments to palmar fascia distally
- The palmaris longus is wider than thick and has longitudinal fibers aligned in it
- When pulled up on distally, the palmaris longus stands out up past the mid forearm right under the skin
- When pulled up on from the distal incision the palm 'cups'
- If using a tendon stripper and it does not glide easily up the tendon make a second (and if necessary a third) incision more proximally.
As per procedure using graft is being used.
Iatrogenic median nerve harvest
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