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 26. 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. 27. 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 28. POSITION OF PATIENT :- Supine position with arm in
anatomical position LANDMARKS :- Brachoradialis: fleshy wad tendon
of biceps: taut 29. 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. 30. INTERNERVOUS PLANE :-
proximally b/w the brachioradialis muscle and brachialis muscle
distally b/w the brachoradlialis and pronator teres . 31.
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. 32.
Brachial vein and median nerve lie medial to the artery. 33. DEEP
SURGICAL DISSECTIONS:- Used to explore the NV structures. If
anterior capsule needs exposure then Biceps and brachialis
retracted medially and BR laterally. 34. STRUCTURES AT RISK 1.
LCNFA a sensory branch of musculocutaneous nerve at distal of the
arm. Emerges between biceps & brachialis. 2. Radial artery
3.PIN 35. 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 36.
EXTENSION 3. For Radial Artery Proximally: Plane between PT &
BR Distally : Between FCR & BR to the wrist 37. 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 38.
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. 39. INTERNERVOUS PLANE :-Anconeus & ECU 40.
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. 41. 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. 42. 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 : Dont extend anteriorly 43. Eponymous Approaches 44. Kocher
approach Traditional posterolateral approach Bit cosmetic Spares
lateral ulnar collateral ligamnet LUCL 45. Eponymous Approaches 46.
Eponymous Approaches
