Forearm fascial hernia after harvesting the palmaris longus tendon

摘要

Dear Sir, A 32-year-old male carpenter presented with a painful swelling in the left forearm. The pain was exacerbated by active wrist flexion and prevented him from working. Thirty-three months before visiting our clinic he had undergone ligament reconstruction surgery for lateral collateral ligament insufficiency in the left elbow, using the palmaris longus tendon, which was harvested with a tendon stripper. Approximately 9 months after the operation, he noticed a painful swelling in the left forearm. Physical examination revealed a palpable fascial defect over the flexor-pronator compartment of the mid-forearm. On active wrist flexion, a 3 x 3 cm firm mass became apparent, corresponding to the fascial defect. A dynamic ultrasound examination demonstrated flexor muscles protruding through the fascial defect. Magnetic resonance images revealed a herniation of the flexor carpi ulnaris (FCU) muscle that became more prominent with muscle contraction. Because the symptoms had persisted for 4 months, surgical exploration was undertaken. Under general anaesthesia, a palmar zig-zag skin incision was made over the fascial defect in the forearm. A 3 x 4 cm fascial defect overlying the belly of FCU was found. Passive wrist flexion caused the muscle belly to protrude through the fascial defect (Fig 1). The defect could not be closed directly and extending the fasciotomy from the proximal edge of the defect proximally was also ineffective in reducing the volume of the herniated muscle belly. The ultimate size of the defect was 6 x 4 cm. Therefore, we repaired the fascial defect with an onlay graft of fascia lata harvested from the right thigh. The fascia was attached to the adjacent fascia with appropriate tension using 3-0 nylon sutures (Fig 2). There was no protrusion of the muscle belly on passive wrist flexion after the graft. Five months postoperatively, the patient was asymptomatic without evidence of recurrent herniation in the forearm. Postoperative MRI showed no muscle protrusion at the repaired site.