Surgical approaches to the elbow
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The document describes various surgical approaches to the elbow joint. The posterior approach is described in detail, including indications such as ORIF of distal humerus fractures. Key steps involve identifying the ulnar nerve, protecting it, and exposing the distal fourth of the humerus through a longitudinal incision over the posterior olecranon. The medial, lateral, anterior cubital fossa, and posterolateral radial head approaches are also outlined, identifying structures at risk and ways to optimize exposure for various procedures.
Surgical approaches to the elbow
- 2. ELBOW Posterior approach Anterolateral approach Medial approach Anterior approach of medial cubital fossa Posterolateral approach of radial head
- 3. POSTERIOR APPROACH INDICATION :- 1. ORIF of fracture of distal humerus 2. Removal of intra-articular loose bodies from elbow joint 3. Treatment of non union of distal humerus 4. TEA 5. Triceps tendon repair
- 4. POSITION OF PATIENT :- Prone position with adequate padding. Exsanguination done by elevating for 3-5 min or using exsanguinator. Tourniquet inflated and arm abducted about 90 degrees LANDMARK :- Olecranon process
- 5. INCISION :- Longidutinal incision over posterior aspect of elbow begins 5cm above the olecranon in midline of posterior aspect of arm .At the tip of olecranon its curved laterally. Distally its 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 or simply tranverse osteotomy)
- 7. DEEP SURGICAL DISSECTION :- Dissection done around the medial and lateral border of the bone to expose all the distal fourth of the humerus .Radial Nerve.
- 8. Bryan-Morrey triceps-reflecting approach is performed by releasing the triceps tendon, forearm fascia, and periosteum as one unit from medial to lateral off the olecranon. At the end of the procedure, the triceps tendon is repaired back to the olecranon by means of two transosseous drill holes placed in a cruciate configuration. One additional drill hole is placed between the two holes in a transverse orientation using nonabsorbable suture. The triceps repair should be protected for 6 weeks postoperatively, during which time the patient must avoid active elbow extension against resistance. Demerit:postoperative triceps insufficiency.
- 9. STRUCTURES AT RISK :- Ulnar nerve : Identify and protect. Median nerve : Always safe to remain in subperiosteal plane Radial nerve: dissection not to be carried too proximal at lateral intermuscular septum Brachial artery: Anteriorly located Extension:- Proximally– Not possible proximally than the distal third of humerus Distally - can be extended along the subcutaneous border of ulna
- 10. MEDIAL APPROACH INDICATIONS :- 1.Removal of loose bodies 2.ORIF of fractures of the corocoid process of the ulna 3.ORIF of fractures of the medial humeral condyle & epicondyle 4.Medial capsular release of stiff elbows (Hotchkiss) 5.Reconstruction of medial collateral ligament injuries Contraindications: 1. Exploration of elbow as poor access to the lateral side
- 11. POSITION OF PATIENT:- Supine and arm supported on arm-board/table. the arm abducted & the shoulder fully externally . rotated. The elbow flexed to90 degree. Exsanguination. LANDMARKS :- Medial epicondyle of humerus
- 12. INSICION :- Curved incision 8-10cm on the medial surface of elbow is made centering on medial epicondyle.
- 13. INTERNERVOUS PLANE :- Proximally: Brachialis & Triceps Distally: Brachialis & Pronator Teres
- 14. 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 between pronator teres and brachialis muscle is used.
- 15. Subperiosteal elevation beneath MCL is done or medial epicondyle is osteotomized with ligament attached to it.
- 16. DEEP SURGICAL DISSECTION Medial side of the joint exposed after incising medial collateral ligament and capsule
- 17. 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.
- 18. 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
- 19. Kaplan The Kaplan approach provides excellent exposure of the radial head without interruption of the lateral ulnar collateral ligament LUCL. One pitfall of the Kaplan approach is locating it too anterior and causing inadvertent injury to the posterior interosseous nerve (PIN). Another limitation of this approach is that distal extension can endanger the PIN.
- 20. POSITION OF PATIENT :- Supine with arm on arm- board LANDMARKS :- Brachioradialis :palpable thick wad Biceps tendon: easily palpable taut structure
- 21. 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
- 22. INTERNERVOUS PLANE :- Proximally brachialis and brachioradialis Distally the brachioradialis and pro pronator teres
- 23. SUPERFICIAL SURGICAL DISSECTION :- Deep fascia is incised along the medial border of the brachioradialis. The lateral antebrachial cutaneous nerve (LCNFA) is identified and preserved.
- 24. Blunt dissection with finger. Radial nerve between BR and Brachialis. PIN enters supinator. SupercialRadialN is beneath the Brachioradialis Motor branch to ECRB.
- 25. 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
- 27. 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.
- 28. 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
- 29. POSITION OF PATIENT :- Supine position with arm in anatomical position LANDMARKS :- Brachoradialis: fleshy wad tendon of biceps: taut
- 30. 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.
- 31. INTERNERVOUS PLANE :- proximally b/w the brachioradialis muscle and brachialis muscle distally b/w the brachoradlialis and pronator teres .
- 32. 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.
- 33. Brachial vein and median nerve lie medial to the artery.
- 34. DEEP SURGICAL DISSECTIONS:- Used to explore the NV structures. If anterior capsule needs exposure then Biceps and brachialis retracted medially and BR laterally.
- 35. STRUCTURES AT RISK 1. LCNFA a sensory branch of musculocutaneous nerve at distal ¼ of the arm. Emerges between biceps & brachialis. 2. Radial artery 3.PIN
- 36. EXTENSION 1. For Median Nerve Proximally: Along medial border of biceps Distally: Pronator Teres simple retraction between humeral and ulnar heads 2. For Brachilal Artery As above
- 37. EXTENSION 3. For Radial Artery Proximally: Plane between PT & BR Distally : Between FCR & BR to the wrist
- 38. 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
- 39. 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.
- 40. INTERNERVOUS PLANE :-Anconeus & ECU
- 41. 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.
- 42. 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.
- 43. STRUCTURES AT RISK :- Posterior interosseous nerve (PIN) : 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 : Don’t extend anteriorly
- 47. Kocher approach Traditional posterolateral approach Bit cosmetic Spares lateral ulnar collateral ligamnet LUCL
Editor's Notes
- #7: The osteotomy is created with an oscillating saw in a chevron configuration,typically with the apex pointed distally.An osteotome is used to complete the procedure so that a portion of the osteotomy site is serrated. This serrated area will provide improved interdigitation of the fragments for fixation at the end of the procedure. Demerits of olecranon osteotomy: 1. non-union of osteotomy site 2. intra-articular adhesions resulting in stiffness as a result of intra-articular insult 3. symptomatic olecranon hardware.
- #8: Bryan-Morrey triceps-reflecting approach is performed by releasing the triceps tendon, forearm fascia, and periosteum as one unit from medial to lateral off the olecranon. At the end of the procedure, the triceps tendon is repaired back to the olecranon by means of two transosseous drill holes placed in a cruciate configuration. One additional drill hole is placed between the two holes in a transverse orientation using nonabsorbable suture. The triceps repair should be protected for 6 weeks postoperatively, during which time the patient must avoid active elbow extension against resistance. Demerit:postoperative triceps insufficiency.
- #11: Hotchkiss The medial Hotchkiss approach, described for capsular release of stiff elbows, originally incorporated a longitudinal posteromedial skin incision. 2
- #19: The lateral approach to the elbow has become a standard means to gain access for contracture release and to manage fractures on the lateral side of the elbow, such as of the radial head and the capitellum. Variations of the lateral exposure include the Kaplan, the Kocher, and the lateral column Kaplan The Kaplan approach provides excellent exposure of the radial head without interruption of the lateral ulnar collateral ligament LUCL. One pitfall of the Kaplan approach is locating it too anterior and causing inadvertent injury to the posterior interosseous nerve (PIN). Another limitation of this approach is that distal extension can endanger the PIN.
- #45: Bryan-Morrey triceps-reflecting approach is performed by releasing the triceps tendon, forearm fascia, and periosteum as one unit from medial to lateral off the olecranon. At the end of the procedure, the triceps tendon is repaired back to the olecranon by means of two transosseous drill holes placed in a cruciate configuration. One additional drill hole is placed between the two holes in a transverse orientation using nonabsorbable suture. The triceps repair should be protected for 6 weeks postoperatively, during which time the patient must avoid active elbow extension against resistance. Demerit:postoperative triceps insufficiency. Wadsworth is an EXTENSILE POSTEROLATERAL APPROACH TO THE ELBOW. Boyd approach especially useful when treating fractures of the proximal third of the ulna associated with dislocation of the radial head. It also can be used to expose the proximal fourth of the radius alone, with less danger to the deep branch of the radial nerve than with other approaches.
- #51: The lateral approach to the elbow has become a standard means to gain access for contracture release and to manage fractures on the lateral side of the elbow, such as of the radial head and the capitellum. Variations of the lateral exposure include the Kaplan, the Kocher, and the lateral column Kaplan The Kaplan approach provides excellent exposure of the radial head without interruption of the lateral ulnar collateral ligament LUCL. One pitfall of the Kaplan approach is locating it too anterior and causing inadvertent injury to the posterior interosseous nerve (PIN). Another limitation of this approach is that distal extension can endanger the PIN. Molesworth is MEDIAL APPROACH WITH OSTEOTOMY OF THE MEDIAL EPICONDYLE
- #52: When the coronoid process fragment is large, the FCU may be reflected anteriorly using subperiosteal dissection from the proximal ulna, including the flexor-pronator mass proximally, as described by Taylor and Scham. Taylor interval: FCU and Prox ulna with flexor and pronator mass