Symposium on The Elbow - surgical approaches

Moderator - Prof: SN Mothilal

Dr Prakash 26.05.2011

FIVE SURGICAL APPROACHES

1.Posterior approach 2.The medial approach 3.The anterior approach 4.The anterolateral approach 5.The posterolateral approach

POSTERIOR APPROACH
Provides The Best Possible Exposure
The uses of the posterior approach include the following:

ORIF of fractures of the distal humerus Removal of loose bodies within the elbow joint Treatment of nonunion of the distal humerus

ONE MAJOR DRAWBACK OSTEOTOMY OF THE OLECRANON

it usually requires an osteotomy of the olecranon on its articular surface, creating another fracture that must be internally fixed.

Position of the Patient

Patient prone Abduct the arm about 90 elbow to flex the forearm to hang over the side of the table Landmark bony olecranon process at the upper end of the ulna

Exsanguinate the limb by elevating it for 3 to 5 minutes and then apply a tourniquet as high up on the arm as possible

POSTERIOR APPROACH

INCISION
longitudinal incision 5 cm above the olecranon Extend till distal to ulna curving laterally at tip of olecranon.

SUPERFICIAL SURGICAL DISSECTION

Incise the deep fascia in the midline Palpate the ulnar nerve as it lies in the bony groove on the back of the medial epicondyle Secure the ulnar nerve with a tape around it

Olecranon osteotomy
If a screw is going to be used to fix the olecranon osteotomy, drill and tap the olecranon before the osteotomy is performed. A V-shaped osteotomy is inherently more stable than a transverse osteotomy, The apex of the V is directed distally

Olecranon osteotomy
Chevron osteotomy

DEEP SURGICAL DISSECTION

Strip the soft-tissue attachments elevate the triceps from the back of the humerus The posterior aspect of the distal end of the humerus is directly underneath

proximally, elevating the triceps from the back of the humerus

MEDIAL APPROACH The medial approach gives good exposure of the medial compartment of the joint. It also can be enlarged to expose the anterior surface of the distal fourth of the humerus

Uses of the medial approach include

 ORIF of coronoid process of the ulna medial humeral condyle Epicondyle  Removal of loose bodies

Position of the Patient

patient supine arm supported on an arm board Abduct the arm and rotate the shoulder fully externally so that the medial epicondyle of the humerus faces anteriorly. Flex the elbow 90

MEDIAL APPROACH

Landmarks medial epicondyle of the humerus,

Incision Make a curved incision 8 to 10 cm long on the medial aspect of the elbow, centering the incision on the medial epicondyle

brachialis muscle Proximally triceps muscle Internervous Plane brachialis muscle Distally pronator teres muscle

musculocutaneous nerve

radial nerve

musculocutaneous nerve

median nerve

Internervous Plane

Superficial Surgical Dissection

Palpate the ulnar nerve as it runs in its groove behind the medial condyle of the humerus. Incise the fascia over the nerve, starting proximal to the medial epicondyle; then, isolate the nerve along the length of the incision Retract the anterior skin flap>superficial flexor muscles of the forearm , pronator teres and the brachialis are visible

Superficial Surgical Dissection

Enter the interval between the pronator teres and the brachialis distally and brachialis and triceps proximaly.

care not to damage the MEDIAN NERVE, which enters the pronator teres near the midline or anterior interosseous nerve. perform osteotomy of the medial epicondyle, Reflect the epicondyle with its attached flexors distally

medial epicondyle osteotomy

Deep Surgical Dissection

The medial side of the joint now can be seen. Incise the capsule and the medial collateral ligament to expose the joint

Anterolateral Approach

Exposes the lateral half of the elbow joint, especially the capitellum and the proximal third of the anterior aspect of the radius.

Its uses include

ORIF of fractures of the capitulum Excision of tumors of the proximal radius Treatment of aseptic necrosis of the capitulum Drainage of infection from the elbow joint Treatment of biceps avulsion from the radial tuberosity Total elbow replacements

 Treatment of neural compression lesions of the proximal half of the posterior interosseous nerve and of the proximal part of the superficial radial nerve access to the arcade of Frohse, as well as treatment of radial head fractures with paralysis of this nerve

POSITION
supine on the operating table, with the arm on an arm board

LANDMARKS The brachioradialis is palpable as part of a thick wad of muscle on the anterolateral aspect of the forearm. This mobile wad consists of three muscles; the brachioradialis forms the medial border of the wad. The biceps tendon is a taut band that is palpable on the anterior aspect of the elbow.

Anterolateral Approach

Incision
Make a curved incision along the anterior aspect of the elbow joint. Begin 5 cm above the flexion crease of the elbow, over the lateral border of the biceps muscle. Follow the lateral border of the biceps distally, but curve the incision laterally at the level of the elbow joint to avoid crossing a flexion crease at 90o. Then, continue the incision inferiorly, curving medially and following the medial border of the brachioradialis muscle. The lower limit of the extension depends on the amount of the radius that must be exposed

brachialis Proximally brachioradialis Internervous Plane brachioradialis Distally pronator teres

musculocutaneous nerve

radial nerve

radial nerve

median nerve

Superficial Surgical Dissection

Identify the lateral cutaneous nerve of the forearm (the sensory branch of the musculocutaneous nerve) It becomes superficial to the deep fascia in the distal 2 in. of the arm lateral to the biceps tendon in the interval between it and the brachialis muscle. Retract it with the medial skin flap

 Incise the deep fascia along the medial border of the brachioradialis. Identify the interval between the brachioradialis and brachialis muscles. Retract the brachioradialis laterally and the brachialis medially, and identify the radial nerve

Follow the RADIAL NERVE distally along the intermuscular interval until it divides into its three terminal branches
the posterior interosseous nerve enters the supinator muscle, the sensory branch passes down the forearm behind the brachioradialis, and the motor branch to the ECRB enters that muscle almost immediately.

radial nerve

 Below the division of the nerve, develop a plane between the brachioradialis on the lateral side and the pronator teres on the medial side. Ligate the recurrent branches of the radial artery

Deep Surgical Dissection

longitudinal incision in the anterior capsule of the joint between the radial nerve laterally and the brachialis medially. To expose the proximal radius, fully supinate the forearm; note that the origin of the supinator muscle moves anteriorly. Incise the origin of the supinator down the bone, staying just lateral to the insertion of the biceps tendon.

 The POSTERIOR INTEROSSEOUS NERVE is vulnerable to injury as it winds around the neck of the radius within the substance of the supinator muscle. ensure that the SUPINATOR IS DETACHED FROM ITS INSERTION ON THE RADIUS WITH THE FOREARM IN SUPINATION. Do not cut through the muscle body to expose the bone

Anterior Approach

Anterior Approach to the Cubital Fossa

least commonly used surgical approach to the elbow provides access to the neurovascular structures that are found in the cubital fossa

Its uses include the following

Repair of lacerations to the median nerve Repair of lacerations to the brachial artery Repair of lacerations to the radial nerve Reinsertion of the biceps tendon Repair of lacerations to the biceps tendon Release of posttraumatic anterior capsular contractions Excision of tumor

Position of the Patient supine on the operating table with the arm in the anatomic position
LANDMARKS The brachioradialis - fleshy muscle that forms the lateral border of the supinated forearm. tendon of the biceps - taut, easily palpable, band-like structure that runs downward across the anterior aspect of the cubital fossa.

Incision
Make a curved incision over the anterior aspect of the elbow. Begin 5 cm above the flexion crease on the medial side of the biceps. Curve the incision across the front of the elbow, then complete it by incising the skin along the medial border of the brachioradialis. Curving the incision avoids crossing the flexion crease at 90

Incision for the anterior approach

Internervous Plane
Distally, between the brachioradialis muscle (radial nerve and the pronator radial nerve) teres muscle (median nerve) median nerve Proximally, between the brachioradialis muscle (radial nerve and the brachialis radial nerve) muscle (musculocutaneous nerve musculocutaneous nerve).

Internervous plane

Superficial Surgical Dissection Incise the deep fascia in line with the skin incision and ligate the numerous veins that cross the elbow in this area

IDENTIFY The lateral cutaneous nerve of the forearm (the sensory branch of the musculocutaneous nerve) bicipital aponeurosis brachial artery radial artery brachial vein and the median nerve

lateral cutaneous nerve of the forearm

To find it, locate the interval between the biceps tendon and the brachialis muscle. The nerve emerges there to run down the lateral side of the forearm subcutaneously

BICIPITAL APONEUROSIS
Cut the aponeurosis close to its origin at the biceps tendon and reflect it laterally. Be careful not to injure the brachial artery, which runs immediately under the aponeurosis

 Identify the RADIAL ARTERY as it passes the biceps tendon and trace it proximally to its origin from the BRACHIAL ARTERY both the BRACHIAL VEIN and the MEDIAN NERVE lie medial to the artery

Deep Surgical Dissection

If the anterolateral approach is to be used only for exploration of the neurovascular structures, deep dissection is not required If you require access to the anterior capsule of the elbow joint, retract the biceps and brachialis muscle medially and the brachioradialis muscle laterally. Fully supinate the forearm and identify the origin of the supinator muscle from the anterior aspect of the radius. Incise the origin of this muscle and dissect it off the bone in a subperiosteal plane, carefully reflecting it laterally

Posterolateral Approach to the Radial Head

Posterolateral Approach to the Radial Head

useful for all surgeries to the radial head, excision of the radial head and insertion of a prosthetic replacement. POSITION supine on the operating table, with the affected arm positioned over the chest. Pronate the forearm

Incision
beginning over the posterior surface of the lateral humeral epicondyle and continuing downward and medially to a point over the posterior border of the ulna, about 6 cm distal to the tip of the olecranon. INTERNERVOUS PLANE between the anconeus, which is supplied by the radial nerve, and the ECU, which is supplied by the posterior interosseous nerve

Superficial Surgical Dissection

To find the interval between the extensor carpi ulnaris and the anconeus, look distally where the plane is easy to identify; proximally, the Detach part of the superior origin of the anconeus as it arises from the lateral epicondyle of the humerus. Then, separate the anconeus and extensor carpi ulnaris muscles, using retractors two muscles share a common aponeurosis

Deep Surgical Dissection

Fully pronate the forearm to move the posterior interosseous nerve away from the operative field Incise the capsule of the elbow joint longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament.

Deep Surgical Dissection

Do not incise the capsule too far anteriorly; the radial nerve runs over the front of the anterolateral portion of the elbow capsule. Do not continue the dissection below the annular ligament or retract vigorously, distally, or anteriorly, because the posterior interosseous nerve lies within the substance of the supinator muscle and is vulnerable to injury

Posterior Approaches Campbell WC Campbell WC Extended Kocher/Ewald Wadsworth TG Bryan RS, Morrey BF Midline triceps split Triceps aponeurosis tongue ECU and anconeus/triceps Triceps aponeurosis tongue and full-thickness deep head Elevate triceps mechanism from medial olecranon and reflect laterally Lateral border of triceps/ulna and anconeus/ECU Olecranon osteotomy transverse or chevron

Boyd HB Muller ME, MacAusland WR

Lateral Approaches Kocher TE Cadenat FM Kaplan EB Key CA, Conwell HE Medial Approach Hotchkiss R Between FCU and PL/FCR; brachialis resected laterally with PL/FCR/PT Medial epicondyle osteotomy Between FCU and anconeus Between ECRB and ECRL Between ECRB and ECU Between BR and ECRL

Molesworth WHL

Global Approach Patterson SD, Bain G, Mehta J Kocher interval; lateral epicondyle osteotomy; Kaplan interval; Hotchkiss interval; Taylor interval

Anterior Approach Henry AK Between mobile wad and biceps tendon; elevate supinator from radius