Download Approaches to the elbow

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
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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.
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