Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

SHOULDER

Anterior approach: Delto-Pectoral (Evidence by Chin Hsien Wu et al Injury 2011 vs. deltoid split)

Interneural plane (axillary and medial and lateral pectoral nerves)

Surface markings:

Coracoid process and oblique incision inferiorly between deltopectoral region

Dangers:

1. Musculocutaneous nervea. 2-5cm under coracoid and coracobrachialis medially (do not over retract)

2. Axillary Nervea. Length of PIPJ to tip of index finger under Coracoidb. Adduction brings axillary nerve towards joint

3. Brachial Plexus4. No medial instruments to humeral neck to avoid AVN

Waymarkers:

Cephalic vein o marks plane between deltoid and pectoralis muscleso Ligate tributaries and mobilise vessel

Tip of Coracoido Lateral side of conjoint tendon is “safe side”o Conjoint tendon made up from SH of biceps and coracobrachialiso Proximal extension improves

Leash of vessels at inferior margin of subscapulariso Lowest safe margin – brachial plexus below

To open joint split subscapularis tendono Externally rotate humerus to improve visualisation

Important Notes:

Quadrangular spaceo Laterally – humeruso Medially – Triceps tendono Superiorly – Teres minoro Inferiorly – Teres major

To open joint split subscapularis tendon aided with external rotation

Page 1 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Mackenzie Approach to the Shoulder: for access to proximal humerus, rotator cuff and subacromial space

Muscle splitting

Surface markings:

5cm vertical incision from acromion down line of arm

Dangers:

Axillary nerve – runs 3-7 cm (average 5cm) horizontally distal to acromion

Waymarkers:

Split deltoid in line of fibres – place a suture in apex distally to prevent split propagation

Important Notes:

Identify axillary nerve before making a 2nd vertical incision distally

Posterior Approach to the Shoulder: glenoid fractures

Interneural plane

Surface markings:

Longitudinal incision along scapular spine Extending to lateral acromion boarder

Dangers:

1. Axillary nerve - laterally2. Circumflex Scapular artery – medially3. Suprascapular nerve supplying infraspinatus – goes around spine of scapular

Waymarkers:

Junction between infraspinatus – multipennate muscle covered in fascia (Suprascapular nerve) and Teres Minor – a unipennate muscle (Posterior division of axillary nerve)

Peel off infraspinatus proximately watch for suprascapular nerve Can gain access to capsule proximately

Important Notes:

Rotator interval – between subscapularis and supraspinatus Ligaments found in the interval Subscapular bursa

Page 2 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

o Communicates with glenohumeral joint via foramen of Rouviereo Constantly found between superior and middle glenohumeral ligament

Scapula nerve supplies infraspinatus and goes around the scapula spine

Posterior arthroscopic to the shoulder:

Surface markings:

Lateral inferior corner of the acromium 2cm inferior and medial Soft area aiming for coracoid

Dangers:

1. Axillary nerve - laterally2. Circumflex Scapular artery - medially

Important Notes:

Rotator interval – between subscapularis and supraspinatus Ligaments found in the interval Subscapular bursa

o Communicates with glenohumeral joint via foramen of Rouviereo Constantly found between superior and middle glenohumeral ligament

HUMERUS

Anterior approach to the humerus: Upper 2/3 of humerus approach can extend proximately via deltopectoral approach and further access by elevating deltoid anteriorly

Indications:

Open # Vessel injury Pathological Floating elbow

Interneural plane (as Brachialis has dual innervation)

Surface markings:

Lateral side of biceps tendon with arm flexed Proximal extension into deltopectoral and elevate

deltoid from boneDangers: MUST STICK SUBPERIOSTEALLY TO AVOID NERVES

Radial nerve laterally – identify before brachialis is split

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Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Ulnar nerve medially Musculocutaneous nerve sub biceps

Waymarkers:

Split Brachialis (lateral 1/3 supplied by radius and medial 2/3 by musculocutaneous)

Important Notes:

Distally radial nerve is found between brachioradialis and Brachialis Cannot extend distally

Anterolateral approach to the humerus: use for radial nerve exploration distal humerus or shantz pin

Interneural plane

Surface markings:

Lateral to biceps muscle

Dangers:

Radial nerve (and the superficial branch)

Lateral cutaneous nerve of forearm (5cm from elbow crease)

Waymarkers:

Retract Biceps medially and retract lateral antebrachial cutaneous nerve with it. Between Brachialis (Radial & musculocutaneous nerve) and Brachioradialis (radial

nerve) Develop intermuscular plane between these 2 muscles Brachialis also goes medially with the biceps muscle and tendon

Posterior Approach to the humerus: for inferior 2/3rds of humerus

Stanley 1999 JBJS approach with both splitting and reflection of the triceps

Surface markings:

8 cm proximal to olecranon skirting to the ulnar aspect and continuing 8cm distally along the ulnar subcutaneous boarder

Dangers:

Radial nerve

Page 4 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

o nerve crosses posterior aspect of humerus at 20-21 cm proximal to medial epicondyle and 14-15 cm proximal to lateral epicondyle

o from posterior cord of brachial plexuso Passing through triangular interval distal to teres majoro Pierces lateral intermuscular septum between brachialis and brachioradialis

Ulnar nerve – decompressed superficially

Waymarkers: split fascia between long and lateral head of triceps Split the triceps tendon 75% laterally and 25% medially continue distally past the

olecranon for further 6-7cm Elevate medial triceps and periosteum over olecranon as single unit continuing over

medial epicondyle Laterally subperiosteally elevate the flap, lifting off the triceps attachment from the

olecranon and anconeus from the lateral ulnar Reattachment of the soft tissues to the olecranon can occur with suture and drill holes

as required. radial nerve found in spiral groove proximately

Lateral Approach to the humerus: for Holsteine Lewis fracture of distal 1/3 of humus with radial nerve palsy ideal for exploringMuscle splitting plane

Surface markings:

Lateral supracondylar ridge between brachioradialis in upper 1/3 and ECRL in lower 1/3

Dangers:

Radial nerve pierces lateral septum between proximal 2/3rds and distal 1/3rd proximately

PIN distally

Waymarkers:

Muscle plane between triceps (radial nerve) and brachioradialis (radial nerve)

Reflect triceps posteriorly and brachioradialis anteriorly

Deeper common extensor origin and triceps can be elevated

Important Notes:

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Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

DISTAL EXTENSION Interneural plane between aconeus (radial) and ECU (PIN)

ELBOW:

Posterolateral or Kockers Approach to the Radial head:

Interneural interval – between aconeus and ECU

Surface markings:

Lateral epicondyle to end of proximal ulna

Dangers:

PIN – keep arm pronated to prevent injury

Waymarkers:

Aconeus (radial nerve) is fan shaped proximately and vertical distally

ECU (PIN)

Important Notes:

PIN is found between the muscle planes of EDC and ECRL interval

Boyd - Sub aconeus approach to radial head:

Page 6 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Surface markings:

From lateral side of olecranon towards radial styloid (whilst supinated)

Dangers:

PIN distance increased by pronation

Waymarkers

Aconeus (radial nerve) is fan shaped proximately and vertical distally

Page 7 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Elevate subperiosteally off ulna until radial head / neck exposed

Medial approach to elbow:

Surface markings:

Anteriorly directly in front of medial epicondyle

Dangers:

Ulnar nerve

Waymarkers:

Lift up corridor anterior to MCL fibres MCL attached distal to medial epicondyle – access to this must lift off flexors from

epicondyle

Anterior Approach to elbow

Surface markings:

Horizontal skin incision across skin crease Proximal incision lateral to biceps tendon Distal incision towards radial styloid

Dangers:

Musculocutaneous nerve – lateral to biceps tendon Superficial radial nerve – medial boarder of brachioradialis PIN – Supinator Brachial artery – medial to biceps tendon

Waymarkers:

Incise supinator ulnarly to find insertion of biceps tendon on proximal radius

Triceps Split

Surface markings:

Start 5cm proximal to olecranon and then curve medially around olecranon to middle of ulna distally

Dangers:

Ulnar nerve dissected out and protected if access is required to medial column Median nerve – stay subperiosteal anteriorly will protect nerve

Page 8 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Radial nerve – runs 14-15cm proximal to lateral epicondyle as is travels from posterior to anterior compartments in the arm

Waymarkers:

Incise fascia over midline and split muscle down to olecranon fossao Retrograde humeral nail insertion

Identify ulnar nerve and dissect out Chevron the olecranon making sure the olecranon is mountain shape Split with an osteotome to aid anatomical reduction after Subperiosteal elevation laterally and medially allows access to distal 4th of humerus.

Important Notes:

Distally the ulnar nerve is found between the 2 heads of FCU

FOREARM

Volar Approach: Henry’s approach

Interneural plane

Surface markings:

Radial side of biceps tendon to radial styloid

Dangers:

Lateral antebrachial cutaneous nerve Radial artery and superficial radial nerve – under brachioradialis

(mobile wad) most easily injured as it leaves mobile wad PIN – enters supinator via arcade of Frohse – this is the most

superior and superficial layer of the supinator muscle Median nerve – under surface of FDS

Waymarkers:

Develop plane between brachioradialis – the mobile wad (radial nerve) and flexor carpi radialis (median nerve)

Start distal to proximal identify superficial radial nerve under brachioradialis and ligate branches of radial nerve to aid lateral retraction of brachioradialis

Proximately the bursa on the radial aspect of the biceps tendon can be incised to gain access (the radial artery lies ulnar side of biceps tendon TAN)

Proximal 1/3

Page 9 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

o Keep arm supinated to avoid PIN. o The supinator is mobilised from ulnar to radial side

Middle 1/3o Pronate to bring into view pronator teres and incise and mobilise from radially

to ulnar. Distal 1/3

o Semi supinate arm and elevate periosteum radially to FDS and PQ

Important Notes:

Proximately supinator needs to go ulnarly Middle Pronator teres can be peeled off radius in neutral position Distally plane is between FCR and Brachioradialis

Dorsal Approach: Thompson’s Approach

Internervous plane

Surface markings:

Lateral epicondyle to Lister’s tubercle – for access to proximal 1/3 of radius

Dangers:

PIN

Waymarkers:

Superficial dissection

Proximal 1/3 – ECRB (radial N) & EDC (Pin) plane Distal 1/3 – ECRB and EPL (Pin) plane

Deep dissection

Proximal 1/3 Must identify PIN as it leaves the Supinator muscle belly in SUPINATION

o Either dissect nerve out of muscle o Or Subperiosteally lift supinator off bone to protect nerve

Middle 1/3 Abductor pollicis longus and extensor pollicis brevis muscles are retracted off bone

Important Notes:

Page 10 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

PIN usually injured in retraction though 25% actually are in direct contact with the proximal radius

HIP:

Direct Lateral Approach: Hardinge

Splits gluteus medius distal to superior gluteal nerve

Surface markings:

Longitudinal incision centred over GT and curving posteriorly

Dangers:

Superior gluteal nerve 4-5cm above tip of GT

Waymarkers:

Skin, subcutaneous tissues down to fascia lata Take GM off GT and go proximately laterally <4cm for access Extend incision inferiorly through VL Gluteus minimus is excised off anterior GT Expose anterior joint capsule and perform T shaped capsulotomy down to fibrous rim

Important Notes:

Leave sufficient cuff on bone to help reattach GM tendon

Anterolateral Approach: Watson Jones

Inter muscular plane

Surface markings:

15cm incision centred over GT

Dangers:

Femoral vessels

Waymarkers:

Same approach as Modified Hardinge Find plane between GM and TFL (both superior gluteal nerve) Develop this interval and externally rotate hip to find origin of vastus lateralis Detach abductor mechanism

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Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

In front of the joint capsule will lie rectus femoris and psoas which may need elevating and retracting

Anterior Approach: Smith Peterson – Hoyter Modification

Interneural plane

Surface markings:

ASIS to lateral side of patella for 8-10 cm Incision can be extended proximately underneath line of ilium

Dangers:

Lateral cutaneous femoral nerve - Hospodar et al 1999o Passes 1-2cm medial to and inferior ASIS under inguinal ligamento Anterior to iliacus muscle and superficially onto of TFL fascia

Femoral nerveo Medial side of Sartorius muscle (forms lateral wall of femoral triangle)

Ascending branch of lateral femoral circumflex arteryo Ligate to avoid excessive bleeding

Waymarkers:

Identify gap between Sartorius (femoral N) and TFL (Superior gluteal N) Subcutaneous fat will have lateral cutaneous femoral nerve Incise fascia on medial side of TFL Detach origin of TFL to develop plane and identify and ligate lateral femoral

circumflex artery Deeper identify plane between rectus femoris (femoral N) & gluteus medius

(superior gluteal N) Detach rectus femoris from attachment and retract medially with psoas, GM can go

laterally to expose capsule Externally rotate hip also to aid this

Posterior Approach (Moore or Southern)

Inter muscular pane splitting of gluteus maximus (inferior gluteal nerve)

Surface markings:

Posterior curvilinear approach centred over GT Can mark this out by flexing hip to 900 and draw a straight line in line with the

femur, when the leg straightens it is now curvilinear

Page 12 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Dangers:

Sciatic nerve – can split look around piriformis to see if there is another branch Inferior gluteal artery – leaves pelvis under piriformis Perforating branch of profunda femoris – can be cut whilst releasing gluteus maximus

insertion Anterior to acetabulum are the femoral vessels

Waymarkers:

Superficial

Split fascia in line with incision to visualise vastus lateralis and gluteus fan shaped incision proximately

Split maximus in line with its fibres

Deep

Internally rotate hip to place tension on short rotators Detach piriformis and obturator internus 1cm from femoral insertion.

FEMUR

Lateral

None splits vastus lateralis

Surface markings:

Lateral thigh with leg internally rotated 15 degrees

Dangers:

Perforating vessels of profunda femoris artery – bleeding ++

Waymarkers

Fascia lata Fascial covering to VL Split VL Subperiosteal dissection to expose femur

Posterolateral

Interneural plane

Page 13 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Surface markings:

Posterior aspect of femoral condyle up the femoral shaft

Dangers:

Perforating branches of the profunda femoris artery Superior lateral geniculate artery and vein

Waymarkers

Deep fascia of thigh Feel intermuscular septum go anteriorly between VL (femoral N) & hamstrings

(sciatic N) Reach the linea aspera

KNEE

Medial para-patella – relative CI is previous lateral para-patella

None

Surface markings:

5cm above superior pole of patella down to tibial tubercle (either straight or curvilinear)

Dangers:

Superior lateral geniculate artery Infra-patella branch of saphenous nerve

o Subcutaneous after leaving fascia lata

Waymarkers

Superficial

Deepen dissection between vastus medialis and quads tendon Medial arthrotomy medial to patella tendon Excise fat pad

Deep

Reflect patella laterally If difficult extend incision proximately

Antero-lateral Tibial plateau: Lobenhoffer and Frosch 2010 for knee approaches

None

Page 14 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Surface markings:

Curvilinear incision - Half way between patella tendon and biceps femoris

Dangers:

LCL Common peroneal nerve behind fibula – head osteotomy increases exposure

Waymarkers

Fascia Stick subperiosteally and peel off extensor muscle bellies to expose plateau Horizontal capsulotomy to expose joint

Antero-medial Tibial plateau:

Surface markings:

Curvilinear incision - Half way between patella tendon and MCL

Dangers:

MCL Saphenous nerve and vein

Waymarkers

Fascia Stick subperiosteally and peel off extensor muscle bellies to expose plateau Horizontal capsulotomy to expose joint

Dorsolateral Tibial Plateau:

Surface markings:

Straight incision lateral side of gastrocnemius

Dangers:

CPN – posterior to biceps tendon Distal extension is 4cm due to anterior tibial artery piercing interosseous membrane

Waymarkers

Fascia Lateral side of gastrocnemius Peel soleus and popliteus off posterolateral aspect of tibia - subperiosteally

Dorsomedially Tibial Plateau:

Page 15 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Surface markings:

Straight incision medial side of gastrocnemius

Dangers:

Popliteal artery if Subperiosteal dissection not carried out

Waymarkers

Fascia Medial side of gastrocnemius Mobalise popliteus muscle subperiosteally.

Posterior Knee: Popliteal fossa

None

Surface markings

Lazy S incision starting proximately over biceps femoris and extending medially over medial head of gastrocnemius

Dangers

Short saphenous and sural nerve Common peroneal Tibial vessels from superficial to deep (nerve, artery, vein)

Waymarkers

Superficial

Find Sural and short saphenous vein distally Follow vessels into fascia between gastrocnemius heads Common peroneal nerve proximately Release medial head of gastrocnemius if more exposure required

Deep

Ligate geniculate vessles to mobilise tibial neurovascaurl structures PCL attachment superior to popliteus (enters capsule via arcuate ligament)

ANKLE

Lateral ankle

None

Page 16 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Surface markings:

Centre incision over fracture make long enough to avoid skin tension

Dangers:

Superficial peroneal nerve – 6-12 cm proximal to tip of fibula from posterior to anterior (junction between middle and distal 1/3)

Short saphenous vein Sural nerve runs along posterior aspect of fibula

Waymarkers

Blunt dissection in subcutaneous tissues Stick to bone and stay subperiosteally when clearing fracture site

Anteromedial ankle

None

Surface markings:

8-10cm incision curving anteriorly centred over anterior 1/3 of malleolus

Dangers:

Saphenous nerve – numbness over medial foot and vein

Waymarkers

Skin flap blunt dissection in subcutaneous tissues Stick to bone and lift out fracture to expose joint Longitudinal split to bring screw to bony tip

Posterolateral ankle: - for posterior malleolus fracture size is not necessarily an issue by note mechanism – if axial or shearing it should be fixed

None

Surface markings:

Begin 12cm proximal to lateral malleoli tip Half way between tendon and fibula Curve to posterior fibula and then follow peroneal tendons to 2cm below and anterior

to malleolar tip

Dangers:

Sural nerve half way between Achilles and fibula Deep are the posterior n/v bundles going posterior to the medial malleolus

Page 17 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Waymarkers

Aim to go between muscle bellies of peroneals either side depending on access Meat to the heal is FHL

Anterior to ankle:

None inter-tendinous all supplied by deep peroneal nerve

Surface markings:

Lateral to EHL is where the anterior tibial artery and deep peroneal nerve

Dangers:

Anterior tibial artery Deep peroneal nerve

Waymarkers

Incise fascia and locate EHL – n/v bundle lateral to this

TALUS

Anteromedial approach:

None

Surface markings:

Medial malleolus to navicular N spot

Dangers:

Saphenous nerve and vein Tibialis posterior tendon attaches onto Navicular EHL Medial malleolus can undergo osteotomy to improve access

Waymarkers

Straight down to capsule onto bone

Anterolateral approach:

None

Surface markings:

Fibula to 5th metatarsal base

Page 18 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Dangers:

Peroneal nerves

Waymarkers

Down to peroneus brevis Anteriorly through capsule

Posterior para Achilles approach:

None

Surface markings:

Medial of lateral side to Achilles tendon

Dangers:

Mediallyo Posterior tibial artery and nerve

Laterallyo Sural nerve

Waymarkers

Straight down to achilles fat pad then capsule onto bone

CALCANEUM

Posterolateral:

Medial approach:

None

Surface markings:

Junction of sole to lateral skin of the foot extending proximately half way between fibular and achilles

Keep angle of flap >1000

Full thickness flap elevate off bone

Dangers:

Peroneal tendons Sural nerve proximately

Waymarkers

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Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

Straight down onto bone

Surgical approach for assessing limb alignment: Buckley et al 2011 showed a 50% malrotation in the MIPO technique despite every effort being made intra-operatively

Leg length

Prep both legs and check leg length

Varus/valgus (coronal)

Centre of the femoral head to centre of the knee to centre of the ankle (>100 correct)

Recurvatum (sagittal)

Excessive notch on AP confirms recurvatum Place drapes under distal femur to allow flexion of distal femoral condyles

Rotation

Flex knee and check IR and ER for symmetry Symmetry of foot position with leg straight Lesser trochanter sign

o IR increases size (LT is a Anteromedial structure)

Surgical exposure for IM nailing

Humeral nailing:

Antegrade via deltoid and supraspinatus splittingo Modern nails go through articular cartilageo Axillary nerve damaged with locking screws best done via open approach

Retrograde via triceps muscle splitting approach down to olecranon fossa – excise fato Radial nerve damaged in distal locking screws best avoided via open

dissection down to bone

Tibial nailing:

Must be midline entry no evidence parapatella is better than transpatella Anatomical studies show

o 30% of time lateral meniscus damagedo 20% of time nail is intra-articular

Femoral nailing:

Antegrade via GT or piriformis fossa o Incise 5-7cm proximal to GT

Retrograde with knee flexed 30-600

Page 20 of 21

Notes on anatomy surgical exposure“Anatomy without clinical is dead. Clinical without anatomy is deadly”

o Through patella tendon nail inserted through femoral trochlear 7-15% of articular surface destroyed

o Can use in intra-articular fractures by fixing intra-articular fragment first

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