by A. Lee Dellon, and J. Henk Coert Results of the Musculofascial Lengthening Technique for Submuscular Transposition of the Ulnar Nerve at the Elbow by A. Lee Dellon, and J. Henk Coert JBJS Essent Surg Tech Volume os-86(1 suppl 2):169-179 September 1, 2004 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The incision for the submuscular transposition of the ulnar nerve crosses the territories of the medial antebrachial and medial brachial cutaneous nerves, injury to either of which may be the source of postoperative incisional pain and the formation of a pa... The incision for the submuscular transposition of the ulnar nerve crosses the territories of the medial antebrachial and medial brachial cutaneous nerves, injury to either of which may be the source of postoperative incisional pain and the formation of a painful neuroma. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The fascia from the medial head of the triceps to the medial intermuscular septum is opened to reveal the ulnar nerve inferiorly and posteriorly. The fascia from the medial head of the triceps to the medial intermuscular septum is opened to reveal the ulnar nerve inferiorly and posteriorly. The median nerve is noted lying anterior to the medial intermuscular septum. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The medial antebrachial cutaneous nerve is protected with a vessel loop as the medial intermuscular septum is excised. The medial antebrachial cutaneous nerve is protected with a vessel loop as the medial intermuscular septum is excised. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The roof of the cubital tunnel is then opened. The roof of the cubital tunnel is then opened. The Osborne band (the band between the two heads of the flexor carpi ulnaris), if present, is divided, and the opening is continued distally to divide the fascia between the two heads of the flexor carpi ulnaris muscle. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The musculofascial lengthening is best understood in terms of a z-cut or step-cut in the flexor-pronator muscle mass. The musculofascial lengthening is best understood in terms of a z-cut or step-cut in the flexor-pronator muscle mass. The fascia is incised so that the proximal flap will be left attached to the medial humeral epicondyle, while the distal flap, containing the superficial head of the pronator teres and the common flexor tendon, will slide distally. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

Intraoperative photograph showing the neurolysis of the ulnar nerve completed and the markings for the musculofascial lengthening drawn on the flexor-pronator fascia. Intraoperative photograph showing the neurolysis of the ulnar nerve completed and the markings for the musculofascial lengthening drawn on the flexor-pronator fascia. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The common flexor tendon is divided down to the elbow joint capsule. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The common flexor tendon is dissected from the joint capsule, distally, so that the surgeon does not leave a fibrous ridge on which the ulnar nerve might lie. The common flexor tendon is dissected from the joint capsule, distally, so that the surgeon does not leave a fibrous ridge on which the ulnar nerve might lie. The medial collateral ligament of the elbow is protected. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

Intraoperative photograph demonstrating distal division of the lacertus fibrosus to permit distal rotation of the muscle flap. Intraoperative photograph demonstrating distal division of the lacertus fibrosus to permit distal rotation of the muscle flap. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The periosteal origin of the flexor carpi ulnaris muscle, the analog of the medial intermuscular septum proximally, is released distally from the ulna. The periosteal origin of the flexor carpi ulnaris muscle, the analog of the medial intermuscular septum proximally, is released distally from the ulna. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The submuscular transposition is completed by elevating the flap from the medial humeral epicondyle so that it can reach the fascial flap. The submuscular transposition is completed by elevating the flap from the medial humeral epicondyle so that it can reach the fascial flap. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

Intraoperative photograph showing the ulnar nerve transposed to lie on the brachialis muscle. Intraoperative photograph showing the ulnar nerve transposed to lie on the brachialis muscle. Note that the proximal and distal transposition sites have no points of impingement. The medial intermuscular septum is resected proximally, and the periosteal origin of the flexor carpi ulnaris has been released from the ulna. There is no tethering of the ulnar nerve toward the condyle by motor fascicles to the flexor carpi ulnaris. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

The ulnar nerve now lies anteriorly on the brachialis muscle. The ulnar nerve now lies anteriorly on the brachialis muscle. The now distal, fascial flap is sutured to the now proximal, medial humeral epicondylar flap with horizontal mattress sutures. Distally, the motor branch to the flexor carpi ulnaris muscle has been dissected sufficiently, intramuscularly, so that it does not tether the ulnar nerve. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

Intraoperative photograph showing the two flaps sutured in the advanced or lengthened position with use of three horizontal mattress sutures. Intraoperative photograph showing the two flaps sutured in the advanced or lengthened position with use of three horizontal mattress sutures. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.

Intraoperative photograph demonstrating that there is room for the surgeon's finger to pass beneath the flap. Intraoperative photograph demonstrating that there is room for the surgeon's finger to pass beneath the flap. A. Lee Dellon, and J. Henk Coert J Bone Joint Surg Am 2004;os-86:169-179 ©2004 by The Journal of Bone and Joint Surgery, Inc.