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Palmaris Longus Tendon - Critical Anatomy and Safe Harvest Techniques
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Palmaris Longus Tendon - Critical Anatomy and Safe Harvest Techniques
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Transcript:
Language: EN.
Segment:0 .
SCOTT WOLFE: Hello. I'm Dr. Scott Wolfe, Orthopedic Hand Surgeon at Hospital for Special Surgery. On behalf of my co-author, Dr. Christine Johnson and the Hospital for Special Surgery, I'd like to present a video on the anatomy of the Palmaris Longus Tendon and nearby structures, as well as two safe and effective harvesting techniques. The Palmaris Longus Tendon is frequently used as a graft in a variety of procedures.
SCOTT WOLFE: Harvesting this tendon should be taken very seriously as inaccurate identification of the Palmaris Longus or improper technique may damage surrounding structures. Unfortunately, there have been reports in the literature of inadvertent harvest of the median nerve when harvesting the Palmaris Longus Tendon. This should be a "Never Event". The purpose of this video is to review the pertinent anatomy and to demonstrate how to safely harvest the Palmaris Longus Tendon.
SCOTT WOLFE: My purpose today is to show just how close the Palmaris Longus is to other important structures. So beginning over here, of course, we have pisiform, we have and maid hook, we have FCR, FCU tendon coming in here. We'll have the neurovascular structures, ulnar artery, ulnar nerve right in here. On this side we've got the thumb, trapezium, which is our other border of the transverse carpal ligament, thumb and trapezium.
SCOTT WOLFE: We've got radial artery. Next to radial artery are FCR, are Palmaris Longus, and then in the middle is our median nerve and of course, the median nerve gives off a branch which comes up to innervate this distribution in the palm. Our palmar cutaneous branch, and that's going to come up right through. So we're going to make our skin incision, we're going to dissect down through the immediate subcutaneous tissues
SCOTT WOLFE: and the purpose of this is to show how immediately subcutaneous the Palmaris Longus should be. If you're harvesting this and your tendon is not immediately below the skin, it is not the Palmaris Longus Tendon. The proximity of the palmar cutaneous branch of the Median Nerve, that's going to be right here in this fat. I'm going to dissect it out through a full incision to show you just how close Palmar Cutaneous and Median Nerve is to the Palmaris Longus Tendon.
SCOTT WOLFE: If you're ever in doubt about your Palmaris Longus Tendon and whether you have the right structure, the key to this is knowing that the Palmaris Longus will be in immediate proximity to the antebrachial fascia all the way up the forearm, piercing the fascia at a variable distance proximal to the wrist crease. Because it pierces the fascia, there is a barrier between it and the median nerve at the wrist crease.
SCOTT WOLFE: That barrier is the antebrachial fascia. The antebrachial fascia will be your protection against an injury to the median nerve. In this MRI, axial slice at the level of the distal radial ulnar joint, the pertinent anatomic structures are clearly seen. The black arrowheads outline the protective layer of the antebrachial investing fascia the forearm, interposed between the Palmaris Longus, which lies in the subcutaneous tissues and the median nerve, which lies dorsal to the tendon. To reach the medial nerve,
SCOTT WOLFE: the thick antebrachial fascia layer must be divided. In the mid forearm, the two structures widely diverge. Again, the Palmaris Longus lies in the superficial layer on top of the flexor digitorum superficialis muscle bellies, while the median nerve is over two centimeters deeper, tucked within and protected by the superficialis. Our next segment will demonstrate the clinical examination techniques that should be performed pre operatively to document the presence, caliber and length of the Palmaris Tendon.
SCOTT WOLFE: If the tendon cannot be definitively identified clinically, ultrasound should be utilized to accurately predict its presence and dimensions. The first test is the Schaeffer's standard test. The idea is to use clinical examination techniques to detect whether or not the patient has a Palmaris Longus. So I'm going to ask our volunteer to touch their thumb and their little finger, and there you can see right away
SCOTT WOLFE: and doing that, a structure becomes apparent. If I ask her to pull against me, to bend her wrist, it becomes even more apparent. So this is the most commonly used test for diagnosis of a Palmaris Longus Tendon. In the second test, we can just ask her to make a fist and flex the forearm a little bit, and this, as you can see, is a little bit more difficult. What happens here is we not only get that Palmaris Longus, but next to it, here we see the FCR tendon.
SCOTT WOLFE: So bend it, I think you can see both tendons lying side by side. You've got your FCR and your Palmaris Longus. And the third test is to relax the patient's fingers, and we'll just have her bend her wrist as she's pulling her fingers against my resistance, and you can see again, Palmaris Longus. Pull. So these three tests, either in combination or singular, can help you to define whether Palmaris Longus Tendon is intact or not.
SCOTT WOLFE: In the next few minutes, I'll demonstrate the most widely used technique for harvesting the Palmaris Longus Tendon, but also the technique that's most highly implicated with the devastating complication of inadvertent harvest of the median nerve. Unfortunately, with the patient asleep, you're not able to do any of your various tests to identify where the Palmaris Longus is, but you can oftentimes feel it in the subcutaneous tissues.
SCOTT WOLFE: Know that if you make your incision right in the middle of the wrist, you'll be able to find it if it exists. So it becomes very important pre operatively to make sure that, you know, that the Palmaris Longus is there because through a small incision you're just not going to see very much. So to begin our single incision technique, we're going to make a small incision.
SCOTT WOLFE: Don't really need to be much bigger than that, and I'm going to dissect down through the subcutaneous tissues. Now right away you're going to see some fibers, now we can begin to see the Palmaris Longus Tendon right there. And note the relationship of the Palmaris Longus Tendon to the subcutaneous tissues. It is in the immediate, immediate layer below the skin. With the scissor tips, you can get under it. At this point in time,
SCOTT WOLFE: you don't want to pull very hard on it, you want to make absolutely sure that this is nothing but the Palmaris Longus. One way we can do that is to retract it to the side. All right, so we're showing the transverse fibers of the antebrachial fascia. Putting very gentle tension on it, we can see a telltale sign of the Palmaris proximally. Now, the next step is to dissect subcutaneously fairly far, proximally.
SCOTT WOLFE: We're going to lift this tendon up now, we're cutting. Next step is our tendon stripper, it has a small aperture. What we're going to do is insert our snap into the tendon stripper. OK then we're inserting this down. You can see the tip advancing in the forearm, keeping tension on it. Keep going.
SCOTT WOLFE: Beautiful. Now it's important to note the muscle. In the hand, as one would expect, the tendon has some muscle on it. Purpose of this demonstration is to show a two incision technique for harvesting the Palmaris Longus Tendon. The two incision technique is unquestionably the safest way to harvest a Palmaris Longus Tendon. It begins by identifying the structures in the hand, of course, the thumb on this side, a pisiform over here.
SCOTT WOLFE: Flexor Carpi Radialis, Flexor Carpi Ulnaris, Palmaris Longus tendon is going to be right in the middle. We're going to make a small incision in the wrist crease, nice cosmetic incision. Cosmetics means nothing if you harvest the medial nerve instead of the Palmaris Longus Tendon. So the overriding issue here is, if you cannot see well enough to harvest this safely, then you make a second incision. If you don't do this frequently, you should not be doing it through a one incision technique.
SCOTT WOLFE: So we dissect immediately below the skin and surrounded by fibers of the Palmar Fascia is the Palmaris Longus Tendon. In order to expose this, we did have to divide some fascial fibers immediately below the skin, but I want to stress that this tendon is at most only two, two millimeters deep to the skin edge. There's our tendon. So it can be confusing because as I pull up on this, I can't really feel it and I see nothing in the forearm.
SCOTT WOLFE: So this is a case where I would want to absolutely do a second incision to be sure that this is the tendon and not the nerve. So the first step would be to pass a nice soft loop under the structure that we have in question, and I think we can all agree that this looks like a tendon, but for safety's sake, we're going to go ahead with a second incision proximally. We're going to feel where that tendon is and draw a second incision about midway up the forearm.
SCOTT WOLFE: We'll go ahead and incize that, and this can be as generous as you need in order to confirm that this is the correct structure. Spread the subcutaneous tissues here, of course, is a small subcutaneous nerve that will preserve. With the subcutaneous structures retracted, the investing antebrachial fascia is visualized with a tendon immediately deep to it.
SCOTT WOLFE: The fascia is divided to expose and identify the Palmaris Longus. In the mid forearm, it lies deep too, but immediately adjacent to the antebrachial fascia. It's important to confirm that you have the same structure proximally and distally, has the same width, color as the structure distally, and of course you can do a push pull test. With that in mind, you can harvest this safely.
SCOTT WOLFE: To do the harvest, we'll come back to our initial incision. We'll take a blade and we'll cut the tendon distally. This is our tendon. We're going to pass a loop around this one, we're going to come down distally. We'll do some subcutaneous dissection to free the tendon up from any adhesions. Take our tendon passer and we're going to pass the tendon passer up into the proximal wound and confirm that we're on the same structure there.
SCOTT WOLFE: Remove the loop and continue our tendon stripping up into the proximal forearm and then we can withdraw our Palmaris Longus Tendon. So that is a two incision approach to Palmaris Longus harvest. It's much safer than doing a single incision approach. At this point, I'm going to extend our incision. We'll go ahead and we'll extend it proximally, straight up the forearm and we'll lift this flap.
SCOTT WOLFE: So here's our Palmaris Longus. Note, you can't see your ulnar artery or your flexor tendons. Distally, this layer is contiguous with our carpal tunnel. The transverse carpal ligament is immediately contiguous with this layer. If you're ever in doubt, you can excise the antebrachial fascia and you can do this safely at this level by spreading underneath it
SCOTT WOLFE: and I'm going to cut this to show you the proximity of the other structures. We will always cut on the ulnar side so as not to endanger the palmar cutaneous branch. This is a very thick layer of fascia and this fascia covers your median nerve. I want to point out just how close that median nerve is to the overlying tendon nerve. Now, the nerve is larger than the tendon in most cases, and frequently has vessels that accompany it,
SCOTT WOLFE: and note, I'm excising fascia on the ulnar side of the nerve again so as to not disturb the palmar cutaneous branch. Here below the nerve obviously are all our flexor tendons are here. Superficialis tendons are laid out here. The deep tendons, of course, will be below. Dissecting on this side of the Palmaris Longus, you can immediately see the very important palmar cutaneous branch of the median nerve.
SCOTT WOLFE: This very important structure can be injured in an approach that strays to the radial side of the Palmaris Longus and the median nerve and can give you sensory loss here in the palm and also a sensory neuroma. What I'm going to show now is the relationship of the Palmaris Longus to the median nerve, not only here in the wrist, but also up here in the forearm, because this becomes important if you are having trouble dissecting this nerve, it's important to make a second incision.
SCOTT WOLFE: In this particular specimen, the Palmaris has already pierced the antebrachial fascia and lies in the immediate subcutaneous tissue. So I can put a little tension here and a little tension here, and we can see that we have the correct tendon. We've got Palmaris Longus, right next door is the Flexor Carpi Radialis tendon. Continuation of the deep fascia, the antebrachial fascia is continued over the superficialis tendons.
SCOTT WOLFE: The median nerve is going to lie deep inside this compartment. The superficialis is this structure here. Tendons all around, our median nerve lies within the superficialis, so far away from the subcutaneous tissues. If this is the structure that you had looped down here, you would have to dig very deep in the forearm to find it. The purpose of this is to show the difference between our tendon and our nerve.
SCOTT WOLFE: So we've elevated the nerve up from the depths to show you the differences. Now, in some sense they look similar, but in another sense they're quite different. So the size is pretty similar, tendon tends to be flatter, the nerve tends to be round, the tendon tends to be sort of a yellow, whereas the nerve is more of a clear, translucent, almost opalescent appearance.
SCOTT WOLFE: The nerve has more luster, the tendon is more flat, the tendon is obviously very fibular, a longitudinal arrangement of fibers. The nerve is also longitudinal, but is broken up into a fascicular structure rather than a fiber structure. You can see large and small fascicles running side by side, at least I can in my loops. Also within the nerve there will be epineurial and perineurial vessels that you can see within the nerve.
SCOTT WOLFE: You should not see vessels in the Palmaris Longus Tendon. If you do, recognize this as a warning that you may have isolated the wrong structure, re-examine your landmarks and your anatomic relationships, and, if necessary, increase your incision. In a patient with inflammatory disease, synovitis and hyperemia may disguise a tendon and create confusion. In summary, Dr. Johnson and I have demonstrated the dense relationships of critical anatomic structures at the wrist crease and the relationship of the Palmaris Longus Tendon to the median nerve at the wrist and in the mid forearm. We've described three useful clinical tests that should be employed pre operatively to identify the presence and dimensions of the Palmaris Longus Tendon.
SCOTT WOLFE: We've also detailed the surgical harvest of the Palmaris Longus through both a single incision at the wrist as well as the safer two incision technique. Finally, we've contrasted the physical attributes of the Palmaris Longus to the median nerve, as the two structures can be mistaken when visualized in isolation. We hope this has been educational and helpful and thank you for your attention.
Segment:0 .
SCOTT WOLFE: Hello. I'm Dr. Scott Wolfe, Orthopedic Hand Surgeon at Hospital for Special Surgery. On behalf of my co-author, Dr. Christine Johnson and the Hospital for Special Surgery, I'd like to present a video on the anatomy of the Palmaris Longus Tendon and nearby structures, as well as two safe and effective harvesting techniques. The Palmaris Longus Tendon is frequently used as a graft in a variety of procedures.
SCOTT WOLFE: Harvesting this tendon should be taken very seriously as inaccurate identification of the Palmaris Longus or improper technique may damage surrounding structures. Unfortunately, there have been reports in the literature of inadvertent harvest of the median nerve when harvesting the Palmaris Longus Tendon. This should be a "Never Event". The purpose of this video is to review the pertinent anatomy and to demonstrate how to safely harvest the Palmaris Longus Tendon.
SCOTT WOLFE: My purpose today is to show just how close the Palmaris Longus is to other important structures. So beginning over here, of course, we have pisiform, we have and maid hook, we have FCR, FCU tendon coming in here. We'll have the neurovascular structures, ulnar artery, ulnar nerve right in here. On this side we've got the thumb, trapezium, which is our other border of the transverse carpal ligament, thumb and trapezium.
SCOTT WOLFE: We've got radial artery. Next to radial artery are FCR, are Palmaris Longus, and then in the middle is our median nerve and of course, the median nerve gives off a branch which comes up to innervate this distribution in the palm. Our palmar cutaneous branch, and that's going to come up right through. So we're going to make our skin incision, we're going to dissect down through the immediate subcutaneous tissues
SCOTT WOLFE: and the purpose of this is to show how immediately subcutaneous the Palmaris Longus should be. If you're harvesting this and your tendon is not immediately below the skin, it is not the Palmaris Longus Tendon. The proximity of the palmar cutaneous branch of the Median Nerve, that's going to be right here in this fat. I'm going to dissect it out through a full incision to show you just how close Palmar Cutaneous and Median Nerve is to the Palmaris Longus Tendon.
SCOTT WOLFE: If you're ever in doubt about your Palmaris Longus Tendon and whether you have the right structure, the key to this is knowing that the Palmaris Longus will be in immediate proximity to the antebrachial fascia all the way up the forearm, piercing the fascia at a variable distance proximal to the wrist crease. Because it pierces the fascia, there is a barrier between it and the median nerve at the wrist crease.
SCOTT WOLFE: That barrier is the antebrachial fascia. The antebrachial fascia will be your protection against an injury to the median nerve. In this MRI, axial slice at the level of the distal radial ulnar joint, the pertinent anatomic structures are clearly seen. The black arrowheads outline the protective layer of the antebrachial investing fascia the forearm, interposed between the Palmaris Longus, which lies in the subcutaneous tissues and the median nerve, which lies dorsal to the tendon. To reach the medial nerve,
SCOTT WOLFE: the thick antebrachial fascia layer must be divided. In the mid forearm, the two structures widely diverge. Again, the Palmaris Longus lies in the superficial layer on top of the flexor digitorum superficialis muscle bellies, while the median nerve is over two centimeters deeper, tucked within and protected by the superficialis. Our next segment will demonstrate the clinical examination techniques that should be performed pre operatively to document the presence, caliber and length of the Palmaris Tendon.
SCOTT WOLFE: If the tendon cannot be definitively identified clinically, ultrasound should be utilized to accurately predict its presence and dimensions. The first test is the Schaeffer's standard test. The idea is to use clinical examination techniques to detect whether or not the patient has a Palmaris Longus. So I'm going to ask our volunteer to touch their thumb and their little finger, and there you can see right away
SCOTT WOLFE: and doing that, a structure becomes apparent. If I ask her to pull against me, to bend her wrist, it becomes even more apparent. So this is the most commonly used test for diagnosis of a Palmaris Longus Tendon. In the second test, we can just ask her to make a fist and flex the forearm a little bit, and this, as you can see, is a little bit more difficult. What happens here is we not only get that Palmaris Longus, but next to it, here we see the FCR tendon.
SCOTT WOLFE: So bend it, I think you can see both tendons lying side by side. You've got your FCR and your Palmaris Longus. And the third test is to relax the patient's fingers, and we'll just have her bend her wrist as she's pulling her fingers against my resistance, and you can see again, Palmaris Longus. Pull. So these three tests, either in combination or singular, can help you to define whether Palmaris Longus Tendon is intact or not.
SCOTT WOLFE: In the next few minutes, I'll demonstrate the most widely used technique for harvesting the Palmaris Longus Tendon, but also the technique that's most highly implicated with the devastating complication of inadvertent harvest of the median nerve. Unfortunately, with the patient asleep, you're not able to do any of your various tests to identify where the Palmaris Longus is, but you can oftentimes feel it in the subcutaneous tissues.
SCOTT WOLFE: Know that if you make your incision right in the middle of the wrist, you'll be able to find it if it exists. So it becomes very important pre operatively to make sure that, you know, that the Palmaris Longus is there because through a small incision you're just not going to see very much. So to begin our single incision technique, we're going to make a small incision.
SCOTT WOLFE: Don't really need to be much bigger than that, and I'm going to dissect down through the subcutaneous tissues. Now right away you're going to see some fibers, now we can begin to see the Palmaris Longus Tendon right there. And note the relationship of the Palmaris Longus Tendon to the subcutaneous tissues. It is in the immediate, immediate layer below the skin. With the scissor tips, you can get under it. At this point in time,
SCOTT WOLFE: you don't want to pull very hard on it, you want to make absolutely sure that this is nothing but the Palmaris Longus. One way we can do that is to retract it to the side. All right, so we're showing the transverse fibers of the antebrachial fascia. Putting very gentle tension on it, we can see a telltale sign of the Palmaris proximally. Now, the next step is to dissect subcutaneously fairly far, proximally.
SCOTT WOLFE: We're going to lift this tendon up now, we're cutting. Next step is our tendon stripper, it has a small aperture. What we're going to do is insert our snap into the tendon stripper. OK then we're inserting this down. You can see the tip advancing in the forearm, keeping tension on it. Keep going.
SCOTT WOLFE: Beautiful. Now it's important to note the muscle. In the hand, as one would expect, the tendon has some muscle on it. Purpose of this demonstration is to show a two incision technique for harvesting the Palmaris Longus Tendon. The two incision technique is unquestionably the safest way to harvest a Palmaris Longus Tendon. It begins by identifying the structures in the hand, of course, the thumb on this side, a pisiform over here.
SCOTT WOLFE: Flexor Carpi Radialis, Flexor Carpi Ulnaris, Palmaris Longus tendon is going to be right in the middle. We're going to make a small incision in the wrist crease, nice cosmetic incision. Cosmetics means nothing if you harvest the medial nerve instead of the Palmaris Longus Tendon. So the overriding issue here is, if you cannot see well enough to harvest this safely, then you make a second incision. If you don't do this frequently, you should not be doing it through a one incision technique.
SCOTT WOLFE: So we dissect immediately below the skin and surrounded by fibers of the Palmar Fascia is the Palmaris Longus Tendon. In order to expose this, we did have to divide some fascial fibers immediately below the skin, but I want to stress that this tendon is at most only two, two millimeters deep to the skin edge. There's our tendon. So it can be confusing because as I pull up on this, I can't really feel it and I see nothing in the forearm.
SCOTT WOLFE: So this is a case where I would want to absolutely do a second incision to be sure that this is the tendon and not the nerve. So the first step would be to pass a nice soft loop under the structure that we have in question, and I think we can all agree that this looks like a tendon, but for safety's sake, we're going to go ahead with a second incision proximally. We're going to feel where that tendon is and draw a second incision about midway up the forearm.
SCOTT WOLFE: We'll go ahead and incize that, and this can be as generous as you need in order to confirm that this is the correct structure. Spread the subcutaneous tissues here, of course, is a small subcutaneous nerve that will preserve. With the subcutaneous structures retracted, the investing antebrachial fascia is visualized with a tendon immediately deep to it.
SCOTT WOLFE: The fascia is divided to expose and identify the Palmaris Longus. In the mid forearm, it lies deep too, but immediately adjacent to the antebrachial fascia. It's important to confirm that you have the same structure proximally and distally, has the same width, color as the structure distally, and of course you can do a push pull test. With that in mind, you can harvest this safely.
SCOTT WOLFE: To do the harvest, we'll come back to our initial incision. We'll take a blade and we'll cut the tendon distally. This is our tendon. We're going to pass a loop around this one, we're going to come down distally. We'll do some subcutaneous dissection to free the tendon up from any adhesions. Take our tendon passer and we're going to pass the tendon passer up into the proximal wound and confirm that we're on the same structure there.
SCOTT WOLFE: Remove the loop and continue our tendon stripping up into the proximal forearm and then we can withdraw our Palmaris Longus Tendon. So that is a two incision approach to Palmaris Longus harvest. It's much safer than doing a single incision approach. At this point, I'm going to extend our incision. We'll go ahead and we'll extend it proximally, straight up the forearm and we'll lift this flap.
SCOTT WOLFE: So here's our Palmaris Longus. Note, you can't see your ulnar artery or your flexor tendons. Distally, this layer is contiguous with our carpal tunnel. The transverse carpal ligament is immediately contiguous with this layer. If you're ever in doubt, you can excise the antebrachial fascia and you can do this safely at this level by spreading underneath it
SCOTT WOLFE: and I'm going to cut this to show you the proximity of the other structures. We will always cut on the ulnar side so as not to endanger the palmar cutaneous branch. This is a very thick layer of fascia and this fascia covers your median nerve. I want to point out just how close that median nerve is to the overlying tendon nerve. Now, the nerve is larger than the tendon in most cases, and frequently has vessels that accompany it,
SCOTT WOLFE: and note, I'm excising fascia on the ulnar side of the nerve again so as to not disturb the palmar cutaneous branch. Here below the nerve obviously are all our flexor tendons are here. Superficialis tendons are laid out here. The deep tendons, of course, will be below. Dissecting on this side of the Palmaris Longus, you can immediately see the very important palmar cutaneous branch of the median nerve.
SCOTT WOLFE: This very important structure can be injured in an approach that strays to the radial side of the Palmaris Longus and the median nerve and can give you sensory loss here in the palm and also a sensory neuroma. What I'm going to show now is the relationship of the Palmaris Longus to the median nerve, not only here in the wrist, but also up here in the forearm, because this becomes important if you are having trouble dissecting this nerve, it's important to make a second incision.
SCOTT WOLFE: In this particular specimen, the Palmaris has already pierced the antebrachial fascia and lies in the immediate subcutaneous tissue. So I can put a little tension here and a little tension here, and we can see that we have the correct tendon. We've got Palmaris Longus, right next door is the Flexor Carpi Radialis tendon. Continuation of the deep fascia, the antebrachial fascia is continued over the superficialis tendons.
SCOTT WOLFE: The median nerve is going to lie deep inside this compartment. The superficialis is this structure here. Tendons all around, our median nerve lies within the superficialis, so far away from the subcutaneous tissues. If this is the structure that you had looped down here, you would have to dig very deep in the forearm to find it. The purpose of this is to show the difference between our tendon and our nerve.
SCOTT WOLFE: So we've elevated the nerve up from the depths to show you the differences. Now, in some sense they look similar, but in another sense they're quite different. So the size is pretty similar, tendon tends to be flatter, the nerve tends to be round, the tendon tends to be sort of a yellow, whereas the nerve is more of a clear, translucent, almost opalescent appearance.
SCOTT WOLFE: The nerve has more luster, the tendon is more flat, the tendon is obviously very fibular, a longitudinal arrangement of fibers. The nerve is also longitudinal, but is broken up into a fascicular structure rather than a fiber structure. You can see large and small fascicles running side by side, at least I can in my loops. Also within the nerve there will be epineurial and perineurial vessels that you can see within the nerve.
SCOTT WOLFE: You should not see vessels in the Palmaris Longus Tendon. If you do, recognize this as a warning that you may have isolated the wrong structure, re-examine your landmarks and your anatomic relationships, and, if necessary, increase your incision. In a patient with inflammatory disease, synovitis and hyperemia may disguise a tendon and create confusion. In summary, Dr. Johnson and I have demonstrated the dense relationships of critical anatomic structures at the wrist crease and the relationship of the Palmaris Longus Tendon to the median nerve at the wrist and in the mid forearm. We've described three useful clinical tests that should be employed pre operatively to identify the presence and dimensions of the Palmaris Longus Tendon.
SCOTT WOLFE: We've also detailed the surgical harvest of the Palmaris Longus through both a single incision at the wrist as well as the safer two incision technique. Finally, we've contrasted the physical attributes of the Palmaris Longus to the median nerve, as the two structures can be mistaken when visualized in isolation. We hope this has been educational and helpful and thank you for your attention.
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