Surgical Approaches Elbow

Symposium on The Elbow - surgical approaches

Moderator - Prof: SN MothilalDr Prakash26.05.2011

FIVE SURGICAL APPROACHES

1.Posterior approach2.The medial approach3.The anterior approach4.The anterolateral approach5.The posterolateral approach

POSTERIOR APPROACH Provides The Best Possible Exposure

The uses of the posterior approach include the following:

• ORIF of fractures of the distal humerus• Removal of loose bodies within the

elbow joint• Treatment of nonunion of the distal

humerus

ONE MAJOR DRAWBACK OSTEOTOMY OF THE OLECRANON

• it usually requires an osteotomy of the olecranon on its articular surface, creating another fracture �that must be internally fixed.

Position of the Patient

• Patient prone• Abduct the arm about 90°• elbow to flex• the forearm to hang over the side of the

tableLandmark

bony olecranon process at the upper end of the ulna

Exsanguinate the limb by elevating it for 3 to 5 minutes and then apply a tourniquet as high up on the arm as possible

POSTERIOR APPROACH

INCISION

• longitudinal incision

• 5 cm above the olecranon

• Extend till distal to ulna curving laterally at tip of olecranon.

SUPERFICIAL SURGICAL DISSECTION

• Incise the deep fascia in the midline• Palpate the ulnar nerve as it lies

in the bony groove on the back of the medial epicondyle• Secure the ulnar nerve with a

tape around it

Olecranon osteotomy

• If a screw is going to be used to fix the olecranon osteotomy, drill and tap the olecranon before the osteotomy is performed.• A V-shaped osteotomy is inherently

more stable than a transverse osteotomy, The apex of the V is directed distally

Olecranon osteotomyChevron osteotomy

DEEP SURGICAL DISSECTION

• Strip the soft-tissue attachments • elevate the triceps from the back of the

humerus• The posterior aspect of the distal end of

the humerus is directly underneath

proximally, elevating the triceps from the back of the humerus

MEDIAL APPROACH

The medial approach gives good exposure of the medial

compartment of the joint.

It also can be enlarged to expose the anterior surface of the distal

fourth of the humerus

Uses of the medial approach include

ORIF of • coronoid process of the ulna • medial humeral condyle • EpicondyleRemoval of loose bodies

Position of the Patient

• patient supine • arm supported on an arm board• Abduct the arm and rotate the shoulder fully

externally so that the medial epicondyle of the humerus faces anteriorly.

• Flex the elbow 90°

MEDIAL APPROACH

Landmarksmedial epicondyle of the humerus,

IncisionMake a curved incision 8 to 10 cm long on the medial aspect of the

elbow, centering the incision on the medial epicondyle

Internervous Plane

Proximally

brachialis muscle musculocutaneous

nerve

triceps muscle radial nerve

Distally

brachialis muscle musculocutaneous nerve

pronator teres muscle

median nerve

Internervous Plane

Superficial Surgical Dissection

• Palpate the ulnar nerve as it runs in its groove behind the medial condyle of the humerus. Incise the fascia over the nerve, starting proximal to the medial epicondyle; then, isolate the nerve along the length of the incision

• Retract the anterior skin flap>superficial flexor muscles of the forearm , pronator teres and the brachialis are visible

• Enter the interval between the pronator teres and the brachialis distally and brachialis and triceps proximaly.

• care not to damage the MEDIAN NERVE, which enters the pronator teres near the midline or anterior interosseous nerve.

• perform osteotomy of the medial epicondyle, Reflect the epicondyle with its attached flexors distally

medial epicondyle osteotomy

Deep Surgical Dissection

• The medial side of the joint now can be seen. Incise the capsule and the medial collateral ligament to expose the joint

Anterolateral Approach

• Exposes the lateral half of the elbow joint, especially the capitellum and the proximal third of the anterior aspect of the radius.

Its uses include

• ORIF of fractures of the capitulum• Excision of tumors of the proximal radius• Treatment of aseptic necrosis of the capitulum• Drainage of infection from the elbow joint• Treatment of biceps avulsion from the radial

tuberosity• Total elbow replacements

• Treatment of neural compression lesions of the proximal half of the posterior interosseous nerve and of the proximal part of the superficial radial nerve access to the arcade of Frohse, as well as treatment of radial head fractures with paralysis of this nerve

POSITION supine on the operating table, with the arm on an arm board

LANDMARKS• The brachioradialis is palpable as part of a

thick wad of muscle on the anterolateral aspect of the forearm. This mobile wad �consists of three muscles; the brachioradialis forms the medial border of the wad.

• The biceps tendon is a taut band that is palpable on the anterior aspect of the elbow.

Anterolateral Approach

Incision• Make a curved incision along the anterior aspect of

the elbow joint. • Begin 5 cm above the flexion crease of the elbow,

over the lateral border of the biceps muscle. Follow the lateral border of the biceps distally, but curve the incision laterally at the level of the elbow joint to avoid crossing a flexion crease at 90o.

• Then, continue the incision inferiorly, curving medially and following the medial border of the brachioradialis muscle.

• The lower limit of the extension depends on the amount of the radius that must be exposed

Internervous Plane

Proximally

brachialis musculocutaneous nerve

brachioradialis radial nerve

Distally

brachioradialis radial nerve

pronator teres median nerve


• Identify the lateral cutaneous nerve of the forearm (the sensory branch of the musculocutaneous nerve)

• It becomes superficial to the deep fascia in the distal 2 in. of the arm lateral to the biceps tendon in the interval between it and the brachialis muscle. Retract it with the medial skin flap

• Incise the deep fascia along the medial border of the brachioradialis.

• Identify the interval between the brachioradialis and brachialis muscles.

• Retract the brachioradialis laterally and the brachialis medially, and identify the radial nerve

Follow the RADIAL NERVE distally along the intermuscular interval until it divides

into its three terminal branches

• the posterior interosseous nerve enters the supinator muscle,

• the sensory branch passes down the forearm behind the brachioradialis, and

• the motor branch to the ECRB enters that muscle almost immediately.

radial nerve

• Below the division of the nerve, develop a plane between the brachioradialis on the lateral side and the pronator teres on the medial side. Ligate the recurrent branches of the radial artery


• longitudinal incision in the anterior capsule of the joint between the radial nerve laterally and the brachialis medially.

• To expose the proximal radius, fully supinate the forearm; note that the origin of the supinator muscle moves anteriorly.

• Incise the origin of the supinator down the bone, staying just lateral to the insertion of the biceps tendon.

• The POSTERIOR INTEROSSEOUS NERVE is vulnerable to injury as it winds around the neck of the radius within the substance of the supinator muscle.

• ensure that the SUPINATOR IS DETACHED FROM ITS INSERTION ON THE RADIUS WITH THE FOREARM IN SUPINATION.

• Do not cut through the muscle body to expose the bone

Anterior Approach

Anterior Approach to the Cubital Fossa

• least commonly used surgical approach to the elbow

• provides access to the neurovascular structures that are found in the cubital fossa

Its uses include the following

• Repair of lacerations to the median nerve• Repair of lacerations to the brachial artery• Repair of lacerations to the radial nerve• Reinsertion of the biceps tendon• Repair of lacerations to the biceps tendon• Release of posttraumatic anterior capsular

contractions• Excision of tumor

Position of the Patient supine on the operating table with the arm in the anatomic

position

LANDMARKS• The brachioradialis - fleshy muscle that forms

the lateral border of the supinated forearm.• tendon of the biceps - taut, easily palpable,

band-like structure that runs downward across the anterior aspect of the cubital fossa.

Incision

• Make a curved incision over the anterior aspect of the elbow.

• Begin 5 cm above the flexion crease on the medial side of the biceps.

• Curve the incision across the front of the elbow, then complete it by incising the skin along the medial border of the brachioradialis. Curving the incision avoids crossing the flexion crease at 90°

Incision for the anterior approach

Internervous Plane

• Distally, between the brachioradialis muscle (radial nerve) and the pronator teres muscle (median nerve)

• Proximally, between the brachioradialis muscle (radial nerve) and the brachialis muscle (musculocutaneous nerve).

Internervous plane

Superficial Surgical DissectionIncise the deep fascia in line with the skin incision and ligate the numerous veins that cross the elbow

in this area

IDENTIFY• The lateral cutaneous nerve of the forearm (the

sensory branch of the musculocutaneous nerve) • bicipital aponeurosis • brachial artery• radial artery • brachial vein and • the median nerve

lateral cutaneous nerve of the forearm

• To find it, locate the interval between the biceps tendon and the brachialis muscle. The nerve emerges there to run down the lateral side of the forearm subcutaneously

BICIPITAL APONEUROSIS

• Cut the aponeurosis close to its origin at the biceps tendon and reflect it laterally. Be careful not to injure the brachial artery, which runs immediately under the aponeurosis

• Identify the RADIAL ARTERY as it passes the biceps tendon and trace it proximally to its origin from the BRACHIAL ARTERY

• both the BRACHIAL VEIN and the MEDIAN NERVE lie medial to the artery


• If the anterolateral approach is to be used only for exploration of the neurovascular structures, deep dissection is not required

• If you require access to the anterior capsule of the elbow joint, retract the biceps and brachialis muscle medially and the brachioradialis muscle laterally.

• Fully supinate the forearm and identify the origin of the supinator muscle from the anterior aspect of the radius.

• Incise the origin of this muscle and dissect it off the bone in a subperiosteal plane, carefully reflecting it laterally

Posterolateral Approach to the Radial Head

Posterolateral Approach to the Radial Head

useful for all surgeries to the radial head, • excision of the radial head and • insertion of a prosthetic replacement.

POSITIONsupine on the operating table,

with the affected arm positioned over the chest. Pronate the forearm

Incision

• beginning over the posterior surface of the lateral humeral epicondyle and continuing downward and medially to a point over the posterior border of the ulna, about 6 cm distal to the tip of the olecranon.

INTERNERVOUS PLANE• between the anconeus, which is supplied by

the radial nerve, and the ECU, which is supplied by the posterior interosseous nerve


• To find the interval between the extensor carpi ulnaris and the anconeus, look distally where the plane is easy to identify; proximally, the

• Detach part of the superior origin of the anconeus as it arises from the lateral epicondyle of the humerus.

• Then, separate the anconeus and extensor carpi ulnaris muscles, using retractors two muscles share a common aponeurosis


• Fully pronate the forearm to move the posterior interosseous nerve away from the operative field

• Incise the capsule of the elbow joint longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament.


• Do not incise the capsule too far anteriorly; the radial nerve runs over the front of the anterolateral portion of the elbow capsule.

• Do not continue the dissection below the annular ligament or retract vigorously, distally, or anteriorly, because the posterior interosseous nerve lies within the substance of the supinator muscle and is vulnerable to injury

Posterior ApproachesCampbell WC Midline triceps split

Campbell WC Triceps aponeurosis tongue

Extended Kocher/Ewald ECU and anconeus/triceps

Wadsworth TG Triceps aponeurosis tongue and full-thickness deep head

Bryan RS, Morrey BF Elevate triceps mechanism from medial olecranon and reflect laterally

Boyd HB Lateral border of triceps/ulna and anconeus/ECU

Muller ME, MacAusland WR Olecranon osteotomy—transverse or chevron

Lateral Approaches

Kocher TE Between FCU and anconeus

Cadenat FM Between ECRB and ECRL

Kaplan EB Between ECRB and ECU

Key CA, Conwell HE Between BR and ECRL

Medial Approach

Hotchkiss R Between FCU and PL/FCR; brachialis resected laterally with PL/FCR/PT

Molesworth WHL Medial epicondyle osteotomy

Global Approach

Patterson SD, Bain G, Mehta J Kocher interval; ± lateral epicondyle osteotomy; ± Kaplan interval; ± Hotchkiss interval; ± Taylor interval

Anterior Approach

Henry AK Between mobile wad and biceps tendon; elevate supinator from radius

THANK YOU

Surgical Approaches Elbow

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