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Introduction
  • Indications
    • decompression and/or transposition of the ulnar nerve.
    • Ulnar removal of loose bodies
    • ORIF of the ulnar coronoid process
    • ORIF of the medial humeral condyle and epicondyle
    • debridement and reattachment of common flexor wad for medial epicondylitis
    
Internervous plane
  • Proximally between
    • brachialis  (musculocutaneous nerve)
    • triceps  (radial nerve)
  • Distally between
    • brachialis (musculocutaneous nerve)
    • pronator teres  (median nerve)
   
Preparation
  • Anesthesia
    • general
    • supraclavicular or infraclaviclar nerve block
  • Position
    • supine
      • with arm flexed and supported by arm board over the patient
  • Tourniquet
    • applied to upper arm
 
Approach
  • Incision
    • curved incision 8 to 10 cm long on the medial aspect of the elbow
      • centered over the medial epicondyle
  • Superficial dissection
    • incise the fascia over the ulnar nerve starting proximally
      • isolate nerve along the entire length of the incision
    • expose the common flexor origin on the medial epicondyle
    • develop brachialis and PT interval
    • avoid the median nerve which enters PT near the midline
    • if necessary can perform osteotomy of the medial epicondyle
      • osteotomy is reflected distally
      • ensure retained MCL ligament into osteotomy fragment
    • develop brachialis and triceps interval
  • Deep dissection
    • incise capsule and medial collateral ligament
  • Extension
    • local
      • abduction of forearm opens medial aspect of joint
      • can dislocate laterally by dissecting off joint capsule and periosteum
    • proximal
      • anterior surface of distal fourth of humerus can be exposed by developing plane between brachialis and triceps
    • distal
      • limited by the branches of the median nerve
 




Dangers
  • Ulnar nerve
    • is at risk during approach
    • must be dissected out to ensure protection
  • Median nerve
    • aggressive traction on the osteotomy fragment can cause a traction injury to the median and anterior interosseous nerves
 


 

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