Approches to the Elbow joint with basic anatomy

1. APPROACHES TO
THE ELBOW JOINT
DR. MOHAMMED JUNAIDH
DNB (Orthopaedic) Resident
Hospital for Orthopaedics, Sports Medicine, Arthritis and Trauma
(HOSMAT), Bangalore

2. DNB Questions
• Posterolateral approach to elbow – June 2013
• Post traumatic elbow stiffness – surgical management in
extension (REPEATED)

3. BASIC ANATOMY
• The “stabilizers of elbow joint” comprise of
Static:
• Bony articulation confer stability at less than 20° and more
than 120° of elbow position
• Capsule
• Medial collateral ligament
• Lateral collateral ligament
Dynamic:
• Muscles: Flexor carpi ulnaris is the predominant
• dynamic stabilizer of elbow others include biceps anteriorly,
triceps posteriorly, anconeus provides restraint against
posterolateral rotatory instability.

4. Valgus stress:
Primary:
• Medial collateral ligament:
• Anterior bundle: Principle-
stabilizer in 30–120° flexion
• Posterior bundle: Co-restraint
Secondary:
• Radial head
Tertiary:
• Flexor-pronator muscle groups
(flex carpi radialis, flex
digitorum superficialis)

5. Varus stress:
Primary:
• Lateral collateral ligament and
annular ligament complex
Secondary:
• Extensor muscles with fascial
bands
• Intermuscular septa.

6. NEUROVASULAR
STRUCTURES
• Cubital Fossa
• Ulna nerve

7. VARIOUS APPROACHES
• Anterior Approach
• Medial Approach
• Hotchkiss Medial over the top approach
• Lateral approach
- Kocher (Posterolateral approach)
- Kaplan
• Posterior Approach

8. ANTERIOR APPROACH
INDICATIONS:
• Open reduction and internal fixation 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
• Decompression of proximal half of PIN
• Total elbow arthroplasty
• Treatment of biceps avulsion from the radial tuberosity

9. • Position: Supine on
OT table with arm
on arm board
• Exsanguinate and
raise tourniquet

10. Landmarks and incision
• Landmarks: Brachioradialis on
AL aspect of forearm. Biceps
tendon on anterior aspect of
elbow.
• Incision: Start 5cm proximal to
flexor crease. At elbow crease
curve laterally. Then extend
inferiorly along medial border
of Brachioradialis.

11. SUPERFICIAL DISSECTION
Internervous plane:
• Proximally – between
Brachioradialis (Radial
N.) and Brachialis
(MCN)
• Distally – between
brachioradialis (Rdial
N.) and Pronator teres
(Median N.)

12. • Identify – Lateral antebrachial cutaneous nerve of FA (superficial to
fascia)

13. • Incise deep fascia over medial border of Brachioradialis (between BR
and brachialis)

14. • Develop plane between BR and brachialis using finger.
• Retract BR laterally and Brachialis medially.
• Exposes the Radial n.

15. • Follow the nerve distally, here develop plane between BR and
pronator teres.

16. • After complete supination, incise supinator from its origin – exposes
the Proximal radius.
• Proximally, incise capsule to expose the elbow joint.

17. DANGERS
RADIAL NERVE:
• Before developing complete interval between BR and brachialis, id the RN.
• The nerve lies anteromedial to the brachioradialis.
POSTERIOR INTEROSSEUS NERVE:
• Vulnerable to injury as it winds around Radius
• Ensure Supinator is detached from its insertion – DO NOT CUT THROUGH
MUSCLE BELLY!!!
LATERAL CUTANEOUS N OF FA
• must be identified and its continuity preserved in the interval between the
brachialis and biceps brachii
RECURRENT BRANCH OF RADIAL ARTERY
• Recurrent branches of the radial artery must be ligated so that the
brachioradialis can be mobilized fully. Ligation also reduces postoperative
bleeding and avoids the risk of an ischemic contracture developing
postoperatively as a result of the pressure caused by a postoperative bleed

18. MEDIAL APPROACH
INDICATIONS
• Removal of loose bodies (now more commonly removed
arthroscopically)
• ORIF of coronoid process
• ORIF of the medial humeral condyle and epicondyle

19. POSITION
• Supine
• Abduct the arm. Flex and
ER the shoulder
• Flex the elbow 90o
• Support the forearm on
arm board

20. LANDMARKS AND INCISION
• Landmark – Medial
epicondyle
• Incision – 8-10 cm long
curved incision centering
over the medial epicondyle

21. INTERNERVOUS PLANE
• Proximally – Radial nerve and Musculocutaneous nerve (Triceps and
Brachialis)
• Distally – Median nerve and Musculocutaneous nerve (P. teres and
Brachialis)

22. SUPERFICIAL DISSECTION
1. Ulna nerve – Palpate behind the M. epicondyle – dissect proximal
to distal and isolate

23. 1. Anterior skin flap – Along with fascia over Pronator teres raise an
anterior skin flap
2. Common flexor origin over the medial epicondyle is seen

25. • Define the interval between Brachialis and PT
• MEDIAN NERVE!!! Enters the PT here in the midline.
• Ulna nerve – Retract inferiorly.
• Perform M. Epi O’tomy after predrilling.

26. • Careful of the UCL during osteotomy.
• Place a periosteal elevator beneath UCL to be certain of making osteotomy
without detaching it from M epicondyle
• VALGUS INSTABILITY!

27. • Raise the Osteotomized M epicondyle with flexor tendons attached to it
distally
• DO NO OVERSTRETCH – Median nerve and AIN
• Superiorly, continue the dissection between the brachialis, retracting it
anteriorly, and the triceps, retracting it posteriorly

28. DEEP DISSECTION
• The medial side of the joint now can be seen. Incise the capsule to
expose the joint

29. DANGERS
• Ulna nerve must be dissected out before ostetomy
• Median nerve may suffer a traction lesion between the two
heads of P. Teres

30. EXTENSILE MEASURES
• To dislocate the elbow, the joint capsule and periosteum
should be stripped off the distal humerus, working from
within the joint. By this means, the mobility of the proximal
ulna will be increased significantly.
• This increased mobility then will allow dislocation of the joint
laterally, thereby opening all the surfaces of the joint to
inspection.

31. MEDIAL “OVER THE TOP”
APPROACH
• Hotchkiss medial approach
• Advantages
1. Extensile – Medial, Anterior and posterior
2. Localize, protect and transposition of Ulna nerve
3. No Medial epicondyle osteotomy
4. Preserves elbow stability – Anterior band of UCL and Posterolateral
ulnohumeral ligament complex
5. Access to Coronoid process
6. Coversion to Bryan Moorey’s Triceps sparing approach
• Disadvantage
1. Cannot access lateral aspect
2. Poor access to Biceps tendon insertion
3. Close proximity to Median nerve, Brachial artery and vein

32. POSITION
• Supine with arm table
• Sterile Tourniquet if
any anticipation for
proximal extension

33. LANDMARK AND INCISION
• Landmark – Medial epicondyle
• Incision – Pure medial or
posteromedial skin incision. In
case of posteromedial incision,
large anterior flap may have to
be raised.

34. SUPERFICIAL DISSECTION
1. After skin incision and
subcut dissection, it is
Medial intermuscular
septum.
2. Anterior to it is Medial
Antebrachial cut nerve.
3. Ulna nerve – Palpate
behind the M. epicondyle
– dissect proximal to
distal and isolate
4. Origin of flexor-pronator
mass over ME.

35. DEEP DISSECTION
• The flexor-pronator mass is cut
leaving a cuff of tissue attached to
ME
• The anterior musculature of distal
humerus is dissected and
subperiosteally elevated
• Median nerve and Brachial artery
lie anterior to brachialis here.
• Brachialis retracted anteriorly
• Beneath is anterior joint capsule

36. • The dissection of capsule and brachialis can proceed distally and laterally
• To some extent radial head and capitellum can be visualized.
• Proceeding further laterally, Radial nerve lies between BR and brachialis.
So remain deep to these 2 muscles.

37. POSTERIOR DISSECTION
• Release the ulna nerve free proximally and distally. Retract it
anteriorly

38. • Dissect triceps from the distal humerus and elevate posteriorly using Cobb
or Langenbeck.
• The posterior capsule can be separated from triceps now to view the ejoint

39. • During closure, attach the Flexor-pronator mass to its origin.
• Anterior transposition of ulna nerve.

40. LATERAL APPROACH
INDICATIONS
• ORIF of Radial head
• Radial head replacement
• Fixation of coronoid process

41. POSITION
• Supine
• Affected arm over the chest
and forearm pronated
• Tourniquet

42. LANDMARK AND INCISION
• Landmark – Lateral
epicondyle – 2.5 cm
distally is the radial head.
• Incision – A curved incision
starting over posterior
surface of LE
• Curve it medially towards
ulna

43. INTERNERVOUS PLANE
• Anconeus (Radial nerve) and ECU (PIN)– Kocher’s interval
• ECRB (Radial n. or PIN) and EDC (PIN) – Kaplan’s interval (more risk of
injury to PIN due to its proximity)
• Kaplan is more anterior – close proximity to PIN

44. DISSECTION
• Incise the deep fascia in line with skin incision
• Define the interval between Anconeus and ECU (diverging muscle fibers) or ECRB and EDC
• Fully pronate the forearm to move PIN away from operative field
• Do not incise the capsule too anteriorly!

45. 1.Between ECU and Anconeus.
Elevate ECU anteriorly
2.Anteriorly LCL and posteriorly
LUCL. Stay anterior to preserve
LUCL – gives varus and
pposterolateral rotatory
stability
3.Incise LCL and AL – to visualize
capsule. Arthrotomy.
4.Radial-capi joint exposed.
5.If distal exposure is required to
see, proximal 3rd of radius, in
pronation, elevate Supinator of
its origin (saving PIN)

46. DANGERS
• The PIN is safe as long as the FA is pronated
• Radial nerve lies anterior.

47. POSTERIOR APPROACH
INDICATIONS
• Open reduction and internal fixation of fractures of the distal
humerus
• Removal of loose bodies within the elbow joint
• Treatment of nonunions of the distal humerus

48. POSITION
1. Prone
• Tourniquet and abduct the
arm to 90o
• Sandbag under the tournquet
• Elbow – flexed and forearm
hanging free on table side

49. • Lateral decubitus position
(Swimmer’s position)
• Arm hanging over a post
• tourniquet if desired
• Very convenient for the surgeon

50. LANDMARK AND INCISION
• Landmark – Olecranon
• Incision
 A longitudinal midline
incision
 starting 5cm
proximally from the
olecranon tip
 Curve it laterally over
the olecranon
 And then again
medially to lie on
subcutaneous surface
of the Ulna

51. DISSECTION
• No true internervous plane
• SUPERFICIAL SURGICAL
DISSECTION
 Incise the fascia in the
midline
 Palpate the ulna nerve
medially on the bony groove
over medial epicondyle.
 Incise the fascia over it and
dissect the nerve. Pass a
tape around it. SAFE!!

52. ISOLATING THE NERVE
• Identification of the ulnar
nerve first done proximally
where the nerve pierces the
septum
• Release it from its tunnel by
dividing the arcuate
ligament that passes
between the two heads of
the flexor carpi ulnaris
muscle

53. TRANSVERSE
• Technically easier to
do
• 30% incidence of
nonunion (Gainor et
al, 1995)
CHEVRON
• Technically more
difficult
• More stable
• Lesser incidence of
nonunion

54. • If planning to use a screw for fixation of the osteotomy, pre-
drill and tap for screw placement down the ulna canal

55. DEEP DISSECTION
• Strip the soft-tissue
attachments off the
medial and lateral sides.
• Elevate the triceps
along with the
osteotomised part of
olecranon
• Do not extend the
dissection proximally
above the distal fourth
of humerus!!

56. DANGERS
• The ulnar nerve - no danger as long as it is identified early and
protected, and excessive traction is not placed on it.
• Radial Nerve - at risk if the dissection ventures farther
proximally
• Median Nerve and Brachial artery – lies anterior.

57. EXTENSILE MEASURES
• Distal Extension. The incision can be continued along the
subcutaneous border of the ulna, exposing the entire length
of that bone

58. References
• Hoppenfeld 4th Edition
• Green’s Operative hand surgery 7th Edition
• AO surgical reference (AOSR)
• Hotchkiss, Robert & Kasparyan, George. (2000). The Medial
“Over the Top” Approach to the Elbow. Techniques in
Orthopaedics. 15. 105-112. 10.1097/00013611-200015020-
00003.