Surgical approaches to the elbow

• 1.REM KUMAR RAI

2. ELBOW Posterior approach Anterolateral approach Medial approach Anterior approach of medial cubital fossa Posterolateral approach of radial head 3. POSTERIOR APPROACH INDICATION :- open reduction internal fixation of fracture of distal humerus Removal of loose bodies with in the elbow joint Treatment of non union of distal humerus 4. POSITION OF PATIENT :- Prone position with adequate padding.Exsanguinate with elevation for 3-5 min or exsanguinator. Arm abducted about 90degree LANDMARK :- Olecranon process 5. INCISION :- Longidutinal incision over posterior aspect of elbow begins 5cm above the olecranon over midline of posterior aspect of arm .At the tip of olecranon curved laterally. Distally curved again medially towards middle of ulna 6. INTERNERVOUS PLANE:-None Superficial surgical dissection :- The deep fascia is incised in the mid line and ulnar nerve is identified, dissected out, protected and marked the with a nerve tape . Pre-drilling and tapping of olecranon is done if osteotomy is planned( eg Chevron for more stability) 7. DEEP SURGICAL DISSECTION :- Dissect around the medial and lateral border of the bone to expose all the distal fourth of humerus .Radial Nerve. 8. STRUCTURES AT RISK :- Ulnar nerve : Identify and protect. Median nerve : Always remain in subperiosteal plane Radial nerve: Dont dissect too proximal at lateral intermuscular septum Brachial artery: Anteriorly located Extension:- Proximally Not possible than the distal third of humerus Distally - can be extended along the subcutaneous border of ulna 9. MEDIAL APPROACH INDICATIONS :- Removal of loose bodies Open reduction and internal fixation of fractures of the corocoid process of the ulna Open reduction and internal fixation of fractures of the medial humeral condyle and epicondyle. Contraindications: 1. Exploration of elbow as poor access to the lateral side 10. POSITION OF PATIENT:- Supine and arm supported on arm-board/table. the arm abduct & rotate the shoulder fully externally .Flex the elbow 90 degree. Exsanguinate. LANDMARKS :- Medial epicondyle of humerus 11. INSICION :- Curved incision 8-10cm on the medial surface of elbow is made centering on medial condyle. 12. INTERNERVOUS PLANE :- Proximally: Brachialis & Triceps Distally: Brachialis & Pronator Teres 13. SUPERFICIAL SURGICAL DISSECTION ulnar nerve is isolated. skin retracted anteriorly with the fascia to uncover the common origin of superficial flexor muscles of medial epicondyle. inteval b/w pronator teres and brachialis muscle is used. 14. Subperiosteal elevation beneath MCL or medial epicondyle is osteotomized with ligament attached to it. 15. DEEP SURGICAL DISSECTION Medial side of the joint exposed. The capsule and medial collateral ligament incised. 16. STRUCTURES AT RISK Ulnar nerve. Median nerve and its main branch AIN with vigorous traction of medial epicondyle or superficial flexor muscles EXTENSION Proximally : b/w triceps and brachialis muscle subperiosteally Distally: exposure provides adequate view of the brachialis inserting into coronoid. it cannot offer a more distal exposure but only upto the branching off of the median nerve. 17. ANTEROLATERAL APPROACH INDICATIONS :- Open reduction and internal fixation of the capitulum # Excision of proximal radius tumors Treatment of aseptic necrosis of the capitulum Drainage of septic elbow arthritis Neural decompression :lesions of the proximal half of the PIN and of the proximal part of the superficial radial nerve access to the arcade Frohse, as well as treatment of radial head fractures with paralysis of this nerve Biceps tendon avulsion re-attachment to radial tuberosity TEA 18. POSITION OF PATIENT :- Supine with arm on arm- board LANDMARKS :- Brachioradialis :palpable thick wad Biceps tendon: easily palpable taut structure 19. INCISION :- curved S incision given around the anterior aspect of the elbow. Begins at 5 cm above flexor crease along lateral border of the biceps muscle. The lower portion curves over the medial border of the brachioradialis muscle 20. INTERNERVOUS PLANE :- Proximally brachialis and brachioradialis Distally the brachioradialis and pro pronator teres 21. SUPERFICIAL SURGICAL DISSECTION :- Deep fascia is incised along the medial border of the brachioradialis. The lateral antebrachial cutaneous nerve (LCNFA) is identified and preserved. 22. Deeper blunt dissection with finger. Radial nerve between BR and Brachialis. PIN enters supinator. SupercialRadialN is beneath the Brachioradialis Motor branch to ECRB. 23. DEEP SURGICAL DISSECTION :- longitudinal incision is made in the anterior capsule of the joint between the radial nerve laterally and the brachialis muscle medially to expose the radial head and capitulum. To expose the radius further, forearm is fully supinated & supinator muscle removed distally in a subperiosteal manner 24. STRUCTURES AT RISK :- Radial nerve : in brachioradialis and brachialis interval Posterior interosseous nerve : Winding around the radial neck. Lateral cutaneous nerve of forearm: LCNFA emerging from brachioradialis and biceps brachii interval Reccurent branch of radial artery: Ligation decreases post-op bleed and chance of VIC EXTENSION:- Proximally: BR/Triceps Distally: Along entire anterior surface of the radius between BR/PT and further distally BR/FCR. 25. ANTERIOR APPROACH OF CUBITAL FOSSA INDICATIONS :- Repair of lacerations to the Median nerve Brachial artery Biceps tendon Radial nerve Biceps tendon re-insertion Posttraumatic anterior capsular contractures release Excision of tumors 26. POSITION OF PATIENT :- Supine position with arm in anatomical position LANDMARKS :- Brachoradialis: fleshy wad tendon of biceps: taut 27. INSICIONS :- Curved boat-shaped .Begins 5 cm above the flexor crease on the medial side of the biceps. Crosssing the crease at 90 degrees must avoided. 28. INTERNERVOUS PLANE :- proximally b/w the brachioradialis muscle and brachialis muscle distally b/w the brachoradlialis and pronator teres . 29. SUPERFICIAL SURGICAL DISSECTIONS :- The deep fascia is incised in line with the skin incision and the numerous veins that cross the elbow in this area are ligated.Lateral cutaneous nerve of the forearm (LCNFA) in the interval between the biceps tendon and the brachialis, is identified and preserved Lacertus fibrosus is identified as the brachial artery is immediately under it. 30. Brachial vein and median nerve lie medial to the artery. 31. DEEP SURGICAL DISSECTIONS:- Explore the NV structures. If anterior capsule needs exposure then Biceps and brachialis retracted medially and BR laterally. 32. STRUCTURES AT RISK 1. LCNFA a sensory branch of musculocutaneous nerve at distal of the arm. Emerges between biceps & brachialis. 2. Radial artery 3.PIN 33. EXTENSION 1. For Median Nerve Proximally: Medial border of biceps Distally: Pronator Teres simple retraction between humeral and ulnar heads 2. For Brachilal Artery As above 34. EXTENSION 3. For Radial Artery Proximally: Plane between PT & BR Distally : Between FCR & BR to the wrist 35. POSTEROLATERAL APPROACH OF RADIAL HEAD Indications: Radial head excision or prosthetic replacement POSITION OF PATIENT - Supine on operating table with affected arm over chest ,pronate the forearm 36. LANDMARK :- Lateral humeral epicondyle. Olecranon tip INCISION :- gentle curve beginning over the posterior surface of the lateral humeral epicondyle and continuing downward and medially over the posterior border of the ulna, at about 6 cm distal to the tip of the olecranon. 37. INTERNERVOUS PLANE :-Anconeus & ECU 38. SUPERFICIAL SURGICAL APPROACHES The deep fascia incised in line with the skin incision. To find the interval between the extensor carpi ulnaris and the anconeus. a part of the superior origin of the anconeus as it arises from the lateral epicondyle of the humerus is detached. 39. DEEP SURGICAL EXPOSURES The forearm is fully pronated so as to move the posterior interosseous nerve (PIN) away from the operative field . The capsule of the elbow joint is incised longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament. No dissection below annular ligament as PIN within the supinator. 40. STRUCTURES AT RISK :- Posterior interosseous nerve : Remain proximal to the annular ligament. Pronate the Forearm to keep the PIN far from the operative field. Place the retractors directly on the bone. Avoid retractors directly opposite to the bicipital tuberosity Radial nerve : Dont extend anteriorly