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    Elbow: Posterior Approach

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    haitham alkhamaiseh
    The document describes several approaches for surgery on the elbow. The posterior approach involves an incision over the posterior elbow with risks to the radial nerve. The medial approach uses a curved medial incision with dangers to the ulnar nerve. The anterolateral approach uses an S-shaped anterior incision between nerves. All approaches aim to identify and protect important neurovascular structures in the elbow.

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    Elbow: Posterior Approach

    Uploaded by

    haitham alkhamaiseh
    40 views5 pages
    The document describes several approaches for surgery on the elbow. The posterior approach involves an incision over the posterior elbow with risks to the radial nerve. The medial approach uses a curved medial incision with dangers to the ulnar nerve. The anterolateral approach uses an S-shaped anterior incision between nerves. All approaches aim to identify and protect important neurovascular structures in the elbow.

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    Elbow

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    The document describes several approaches for surgery on the elbow. The posterior approach involves an incision over the posterior elbow with risks to the radial nerve. The medial approach uses a curved medial incision with dangers to the ulnar nerve. The anterolateral approach uses an S-shaped anterior incision between nerves. All approaches aim to identify and protect important neurovascular structures in the elbow.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    40 views5 pages

    Elbow: Posterior Approach

    Uploaded by

    haitham alkhamaiseh
    The document describes several approaches for surgery on the elbow. The posterior approach involves an incision over the posterior elbow with risks to the radial nerve. The medial approach uses a curved medial incision with dangers to the ulnar nerve. The anterolateral approach uses an S-shaped anterior incision between nerves. All approaches aim to identify and protect important neurovascular structures in the elbow.

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    ELBOW

    Posterior Approach
     Position
    o Prone with arm hanging over armboard
     Incision
    o Over posterior aspect of elbow (lateral over tip)
     Plane
    o Distal to radial nerve innervation of triceps
    o Identify and isolate ulnar nerve
    o Osteotomy of ulna olecranon
    o Elevate triceps
     Dangers
    o Radial nerve – can’t extend past the distal 1/3 of humerus
    o Ulnar nerve – identify and protect it
    o Median nerve – lying on anterior distal humerus
    o Brachial Artery – lies with median nerve in the front of the elbow

    Medial Approach
     Position
    o Supine with armboard – arm abducted and externally rotated
     Incision
    o Curved incision over medial epicondyle
     Plane
    o Proximally between brachialis muscle (musculocutaneous nerve) and
    triceps muscle (radial nerve)
    o Distally between brachialis muscle (musculocutaneous nerve) and
    pronator teres (median nerve)
    o Identify and retract ulnar nerve inferiorly
    o Epicondyle ostetomy reflected distally
    o Incise capsule and medial collateral ligaments
     Dangers
    o Ulnar nerve – isolate before medial epicondyle ostotomy
    o Median nerve – Don’t retract common flexors too vigourously

    Anterolateral Approach (can joint henry with deltopectoral)


     Position
    o Supine with arm on armboard
     Incision
    o S incision along anterior aspect of elbow NOT crossing the flexor
    creases at 90°
     Plane
    o Proximally between brachialis muscle (musculocutaneous nerve) and
    brachioradialis (radial nerve)
    o Distally between brachioradialis (radial nerve) and pronator teres
    (median nerve)
    o Identify and protect the lateral cutaneous nerve of the forearm distally
    and the radial nerve proximally between the brachioradialis and the
    brachialis muscles
    o Ligate the recurrent branch of the radial artery
    o Incise capsule PRN and incise origin of supinator PRN
     Dangers
    o Radial nerve – identify and protect it bw brachioradialis and brachialis
    o PIN – Branch of radial, winds around neck of radius within the
    substance of supinator
    o Lateral Cutaneous nerve of the forearm – identify in the interval
    between the brachialis and biceps brachii
    o Recurrent braches of radial artery – ligate so brachioradialis can be
    mobilized fully

    Anterior Approach to the Cubital Fossa (least common, for NV repair)


     Position
    o Supine with arm in anatomic position
     Incision
    o Curved S incision from proximal lateral
     Plane
    o Proximally between brachialis (musculocutaneous nerve) and
    brachioradialis (radial nerve)
    o Distally between brachioradialis (radial nerve) and pronator teres (median
    nerve)
    o Identify and protect the lateral cutaneous nerve of the forearm (between
    biceps tendon and brachialis muscle)
    o Incise bicipital aponeurosis (lacterus fibrosus) watchin out for brachial
    artery underneith
    o Watch for the radial nerve (between brachialis and brachioradialis)
     Dangers
    o Lateral cutaneous nerve of the forearm – identify in the interval between
    the brachialis and biceps brachii
    o Radial artery - lies under bicipital aponeurosis

    Posterolateral Approach to the Radial Head (Kocher)


     Position
    o Supine with pronated arm over chest
     Incision
    o Over posterior surface of lateral humeral epicondyle and radial head
     Plane
    o Between anconeus (radial nerve) and extensor carpi ulnaris (PIN)
     Dangers
    o PIN – limit dissection proximal to annular ligament with arm pronated

    The Boyd posterolateral approach to the elbow


     Posterior midline incision
     Subperiosteal elevation of the anconeus and ECU off the subcutaneous boder
     Under the ECU identify the ulnar insertion of the suppinator which is reflected
    toward the volar aspect
     Protect both the PIN and the lateral collateral
     Divide the recurrent interosseous artery and reflect muscle further to get at the
    IOM
     This approach is most useful for monteggia fractures.

    ANATOMY
    Neurovascular structures
     Nerves
    o Median Nerve
     Crossed front of the elbow joint on its medial side
     Covered by bicipital aponeurosis (lacterus fibrosus)
     Disappears between the two heads of pronator teres (humeral head
    on medial epicondyle / common flexor origin AND unlar head on
    medial side of coronoid process)
     Runs down the forearm adhering to deep surface of flexor
    digitorum superficialis

     Sites of entrapment of the median nerve around the elbow (from


    Wheeless)
     Supracondylar process of humerus and struther’s
    ligament
    o http://www.abdn.ac.uk/zoohons/struthers/ligament1.hti
     Lacertus fibrosus
    o Behind lacertus and in front of brachialis
     Pronator teres
     Sublimis bridge
    o Fibrotendinous arcade at origin of FDS muscle
     Median nerve braches (Median nerve, AIN, motor branch of
    median nerve, sensory innervation)
     Median nerve
    o Pronator Teres
    o FCR
    o Palmaris Longus
    o FDS
     AIN (from median n. 5cm proximal to medial epicondyle,
    runs on volar surface of FDP and along interosseous
    membrane between ulna and radius)
    o FDP (radial)
    o FPL
    o Pronator Quadratus
     Motor Branch of Median nerve (innervates the muscles in
    the hand)
    o Lumbricals (middle and index)
    o Abductor pollicus Brevis
    o Flexor Pollicus Brevis (part, shares with ulnar n.)
    o Opponens Pollicis
     Sensory Branches
    o Palmar cutaneous branch
    o Digital branches
     Radial digital nerve of the thumb
     Ulnar digital nerve ot the thumb
     Radial digital nerve of the index finger
     Common Digital nerve of the second web
    space
     Common Digital nerve of the third web
    space

    o Radial Nerve
     Crosses front of elbow joint in the interval between the brachialis
    and brachioradialis
     Divides in the cubital fossa at the radiohumeral joint into the PIN
    (enters the supstance of the supinator muscle) and superficial radial
    nerve (descends down the lateral side of the forearm under cover
    of the brachioradialis muscle)
     Sites of entrapment of the radial nerve around the elbow (from
    Wheeless)
     Tendinous origin of ECRB
     Leash of Henry - Radial recurrent vessels
     Fibrous bands anterior to the radial head at the entrance of
    the radial tunnel
     Arcade of Frohse (MOST COMMON) – tendinous
    proximal border of supinator
     Distal edge of supinator at exit (least common)

    o Ulnar nerve
     Crosses the joint in the groove on the back of the medial
    epicondyle
     Enters the anterior compartment of the forearm passing between
    the two heads of FCU
     Runs down the forearm on the anterior surface of the flexor
    digitorum profundus
     Sites of compression of ulnar nerve (wheeless – Cubital Tunnel
    Syndrome)
     Arcade of Struthers (8cm above elbow – band extending
    from the medial head of triceps to the medial intermuscular
    septum)
     Medial head of Triceps
     Medial Intermuscular septum (distal thickening as it
    inserts onto the medial epicondyle)
     Medial Epicondyle
     Cubital tunnel (FCU aponeurosis)
     Anconeus epitrochlearis (anomalous muscle)
     Arcuate Ligament (aponeurosis of FCU – connects the
    ulnar and humeral heads of FCU)
     Deep Flexor-Pronator Aponeurosis

     Vessels
    o Brachial Artery
     Enters the cubital fossa on the lateral side of the median nerve on
    brachialis
     Divides halfway down the cubital fossa into the radial and ulnar
    arteries
     Under the biciptal aponeurosis
    o Radial Artery
     Passes medial to biceps tendon
     Turns anterior and lying on supinator and pronator teres insertion
    o Ulnar Artery
     Passes deep to deep head of pronator teres

    PIN idiopathic compression syndrome:


                - sites of compression:
     fibrous bands anterior to the radial head at the entrance of radial tunnel (uncommon cause of
    compression);
                      radial recurrent vessels (leash of Henry);
                      - tendinous origin of ECRB: the ECRL is more superficial and is not a source of
    compression;
                      - arcade of Froshe:
                            - this is the most common location of nerve compression in radial tunnel syndrome;
                            - lies deep to the extensor carpi radialis brevis
                            - tendinous proximal border of supinator (arcade of Frohse):

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