Introduction

Internervou
s plan

Posterior Approach to the Elbow

Indications

ORIF of fractures of the distal humerus

o
provides best possible intra-articular view of elbow joint

removal of loose bodies

treatment of non-unions of the distal humerus

triceps lengthening for extension contractures of the elbow

None

the extensor mechanism is either split or detached

the radial nerve innervates the triceps muscle more proximally

Anesthesia
o
general
o
supraclavicular or infraclaviclar nerve block
Position
o
prone or lateral decubitus

with elbow flexed and arm hanging from side of table

Tourniquet
o
can be applied if needed as sterile tourniquet to upper arm

Preparation

Approach

Incision
o
begin 5cm proximal to the olecranon in the midline of the posterior distal humerus
o
curve laterally proximal to the tip of the of the olecranon along the lateral aspect of the olecranon process
o
then curve medially over the middle of the posterior aspect of the subcutaneous ulna
Superficial dissection
o
first, palpate the ulnar nerve and fully dissect it out

is helpful to pass tape or penrose for identification at all times

o
incise deep posterior fascia in the midline
o
can either split triceps fascia, or continue with olecranon osteotomy
o
if performing olecranon osteotomy, drill and tap olecranon prior to osteotomy
o
score the olecranon with an osteotome to allow perfect reduction when the osteotomy is repaired
o
V-shaped osteotomy of the olecranon 2 cm from the tip using an oscillating saw
Deep dissection
o
strip soft tissue from the edges of the osteotomy site and retract the olecranon fragment proximally
o
subperiosteal dissection of the medial and lateral borders of the humerus allows exposure of entire distal fourth of the
humerus

Dangers

Ulnar nerve
o
should initially be indentified and protected during the approach
o
can usually be palpated 2cm proximal to medial epicondyle
o
transposition of the ulnar nerve has shown no benefit to reducing the incidence of ulnar neuritis
Median nerve
o
strict subperiosteal dissection off the anterior surface of the humerus protects the nerve
o
flexion of the elbow relaxes the anterior structures.
Radial nerve
o
in danger proximally as it travels from the posterior to anterior brachial compartments through lateral intermuscular septum
o
can usually be found at the lateral border of the humerus near distal 1/3 junction
Brachial artery
o
runs with the median nerve (see above)

Introduction

Internervou
s plan

Medial Approach to the Elbow

Indications

decompression and/or transposition of the ulnar nerve.

Ulnar removal of loose bodies

ORIF of the ulnar coronoid process

ORIF of the medial humeral condyle and epicondyle

debridement and reattachment of common flexor wad for medial epicondylitis

Proximally between
o
brachialis
(musculocutaneous nerve)
o
triceps
(radial nerve)
Distally between
o
brachialis (musculocutaneous nerve)
o
pronator teres
(median nerve)

Preparation

Anesthesia
o
general
o
supraclavicular or infraclaviclar nerve block
Position
o
supine

with arm flexed and supported by arm board over the patient
Tourniquet
o
applied to upper arm

Approach

Incision
o

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

centered over the medial epicondyle

Superficial dissection
o
incise the fascia over the ulnar nerve starting proximally

isolate nerve along the entire length of the incision

o
expose the common flexor origin on the medial epicondyle
o
develop brachialis and PT interval
o
avoid the median nerve which enters PT near the midline
o
if necessary can perform osteotomy of the medial epicondyle

osteotomy is reflected distally

ensure retained MCL ligament into osteotomy fragment

o
develop brachialis and triceps interval
Deep dissection
o
incise capsule and medial collateral ligament
Extension
o
local

abduction of forearm opens medial aspect of joint

can dislocate laterally by dissecting off joint capsule and periosteum

o
proximal

anterior surface of distal fourth of humerus can be exposed by developing plane between brachialis and triceps
o
distal

limited by the branches of the median nerve

Dangers

Ulnar nerve
o
is at risk during approach
o
must be dissected out to ensure protection
Median nerve
o
aggressive traction on the osteotomy fragment can cause a traction injury to the median and anterior interosseous nerves

Anterolateral Approach to The Elbow

Introduction

Internervou
s plan

Indications
o
distal biceps avulsion
o
neural compressions involving

PIN syndrome

Radial tunnel syndrome

Superficial radial nerves

o
total elbow replacements
o
elbow joint I&D
o
surgery of capitellum (ORIF, aseptic necrosis)
o
excision of tumors

Proximal
o
between brachialis (musculocutaneous nerve) and brachioradialis (radial nerve)
Distal
o
between brachioradialis (radial nerve) and pronator teres (median nerve)

Preparation

Patient is supine on table with arm on radiolucent arm board

Consider use of sterile tourniquet if dissection may proceed proximally
Ensure fluoroscopic imaging can be obtained

Approach

Incision
o
Make curved incision starting 5 cm proximal to flexion crease along the lateral border of the biceps
o
Continue distally by following medial border of the brachioradialis
Superficial dissection
o
Identify lateral antebrachial cutaneous nerve (sensory branch of the musculocutaneous nerve
which becomes superficial 2 inches proximal to the elbow crease, lateral to the biceps tendon)
o
Incise the deep fascia along the medial border of the brachioradialis
o
Identify radial nerve proximally at level of the elbow joint (between brachialis and brachioradialis)
o
Follow the radial nerve distally until it divides into its three main branches:

PIN (enters the supinator)

sensory branch (travels deep to brachioradialis)

motor branch to ECRB

o
Develop brachiaradialis and PT interval distal to the division of the radial nerve.
o
Ligate recurrent branches of the radial artery and muscular branches that enter the brachialis just
below the elbow to allow better retraction
Deep dissection
o
Joint capsule

incise the joint capsule between the radial nerve laterally and the brachialis muscle
medially
o
Proximal radius

expose proximal radius by supinating the forearm to bring the supinator muscle anteriorly.

Incise the muscle origin down to bone, lateral to the insertion of the biceps tendon
Extension
o
Proximal

extends into the anterolateral approach to the arm developing the plane between
the brachialis and the triceps muscles
o
Distal

extends to the anterior approach to the radius between the planes of the brachioradialis
and pronator teres muscles proximally, and the brachioradialis and flexor carpi radialis
(median nerve) muscles distally.

Dangers

Lateral antebrachial cutaneous nerve of the forearm

o
must incise skin and subcutaneous tissues carefully
Radial nerve
PIN
o
vulnerable as it winds around the neck of the radius within the substance of the supinator muscle.
Incise the supinator muscle at its origin with forearm supinated to protect the nerve.
Recurrent branch of the radial artery
o
must be ligated to mobilize the brachioradialis

Posterolateral Approach to The Elbow

Introduction

Internervou
s plan

Overview
o
also known as Kocher or posterolateral approach
Indications
o
management of pathologies of the radial head

ORIF

radial head replacement

radial head excision

o
lateral collateral ligament (LCL) reconstruction or repair
o
management of coronoid fractures (limited access)

Intermuscular plane between

anconeus (radial n.)

extensor carpi ulnaris (posterior interosseous n.)

Preparation

Anesthesia
o
general

advantageous for immediate post-operative neurologic examination or intra-operative airway control in patients
with difficult airway
brachial plexus nerve blocks

advantageous for post-operative pain control

Position
o

supine

with upper extremity supported on a hand table or on patient's trunk

o
lateral decubitus

with arm supported over a bolster

o
forearm pronated in both positions
Tourniquet applied to arm
o
sterile tourniquet

greater elbow access with sterile tourniquet

exsanguinate limb with Esmarch or elevation

Approach

Incision
o

landmarks

lateral humeral epicondyle

radial head

2.5 cm distal to lateral epicondyle, head (or crepitus in fractured) palpable with pronation/supination

olecranon
o
incision

make a ~5cm longitudinal or gently curved incision based off the lateral epicondyle and extending distally over
the radial head approximately

incision angle can be varied based on need to address associated pathology

Superficial dissection
o
incise deep fascia in line with incision
o
identify plane between ECU and anconeus distally
Deep dissection
o
maintain arm in pronation to move PIN away from field
o
split proximal fibers of supinator, staying on the posterior cortex of the radius away from PIN
o
if LCL intact, stay 1 cm anterior to crista supinatoris to avoid damage

in cases of elbow dislocation, LCL frequently not intact

o
incise capsule longitudinally

avoid dissecting distally or anteriorly (PIN)

maintain dissection in mid radiocapitallar plane to avoid damaging LCL

Extension
o
proximal

extend superficial dissection by dissecting down onto lateral supracondylar ridge

avoid origin of LCL unless operation directed at its repair/reconstruction

this approach should not be extended distally as this places the PIN at risk

distal

Dangers

Posterior Interosseous nerve

o
not in danger as long as dissection remains proximal to annular ligament
o
release supinator along posterior radius border beyond annular ligament with forearm in full pronation
Radial nerve
o
not in danger as long as elbow joint is entered laterally and not anteriorly