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Approaches to the elbow Medial approach to the elbow Indications Access to medial side of joint and coronoid process Position Supine Arm supported over body on arm table. Landmark Medial epicondyle of the humerus Incision Curved incision 8-10cm long on medial aspect of elbow, centred on the medial epicondyle. Internervous plane Proximally, between brachialis (MCN) and triceps (radial nerve). Distally, brachialis (MCN) and pronator teres (median nerve). Superficial dissection Dissect the ulnar nerve free and isolate with a vessel loop. Retract the anterior skin flap and the fascia over pronator teres to expose the superficial flexor muscles of the forearm. Define the interval between pronator teres and brachialis, taking care not to damage the median nerve. Perform an osteotomy of the medial epicondyle and reflect the epicondyle distally, avoiding traction on the median nerve which enters near the midline. Superiorly, continue the dissection between the brachialis and triceps. Deep dissection The medial side of the joint and collateral ligaments can now be seen. Incise the capsule and the medial collateral ligament to expose the joint. Dangers Ulnar nerve. Needs to be isolated before performing the medial epicondylectomy Median nerve. Can be damaged by excessive traction on the pronator teres. Extensile measures Proximal. Elevate the brachialis anteriorly to expose the anterior surface of the distal fourth of the radius. Distally. Not possible, as too much retraction on the pronator teres will cause a median nerve lesion. Posterolateral approach to the radial head (Kocher’s approach) Essence Utilizes plane between extensor carpi ulnaris. anconeus and Indications Access to radial head and capitellum. Position Supine Elbow pronated to move posterior interosseous nerve anteriorly. With the forearm pronated fully at least the proximal 38mm of the radius can be safely exposed; with the forearm supinated this decreases to 22mm. Landmarks Lateral humeral epicondyle. Radial head Olecranon 1 Incision Longitudinal incision running distally and posteriorly, beginning at the lateral humeral epicondyle. Internervous plane Between anconeus extensor carpi interosseous nerve). (radial nerve) and ulnaris (posterior Superficial surgical dissection Find interval between anconeus and extensor carpi ulnaris, which is easier to do distally, because the muscles share a common aponeurotic origin proximally. If you can’t find the interval then you can dissect straight down onto the lateral humeral epicondyle. Deep dissection Fully pronate the forearm to move the posterior interosseous nerve anteriorly. The capsule of the elbow is divided to display the radial head and capitellum. It is important to not retract too vigorously distally or anteriorly to limit the risk of damaging the PIN. Dangers 1. PIN. Try to stay proximal to the annular ligament, and pronate the forearm. To enlarge the approach Local measures The extensor apparatus can be dissected off the lateral supracondylar ridge both anteriorly and posteriorly to gain access to the distal humerus and the capitellum. Extensile measures Not possible. Anterolateral approach This is an extension of the anterolateral approach to the humerus and can be extended into the anterior approach to the radius. Using these approaches the full length of the arm and forearm can be exposed. Position Supine Landmarks Brachioradialis is the medial border of the mobile wad of three The biceps tendon is palpable as a taut band on the anterior aspect of the elbow. Incision Begins 5cm above the elbow flexion crease, curves over the flexion crease and then follows the medial border of brachioradialis. Internervous plane Proximally: between BR (radial nerve) and brachialis (MCN) Distally: between BR (RN) and PT (MN) Superficial dissection Identify the interval between the brachialis and BR by blunt dissection. Beware of the lateral cutaneous nerve of the arm which becomes superficial to the deep fascia in the distal 5cm of the arm. Distally, the recurrent branches of the radial artery cross the field. These need to be ligated. The interval between PT and BR is developed. Deep dissection The radial head is exposed by fully supinating supinator to carry the PIN away, then the supinator is subperiosteally dissected from the radial head. 2