Anatomy of a post operated case of left sided proximal humerus internal fixation with proximal femoral nail for left front of the same time

1. ANATOMY OF FOREARM
ESSEX LOPRESSETI INJURY
PLASTIC DEFORMATION OF
FOREARM
APPROACHES TO FOREARM
PRESENTER : DR. SANDEEP TRIPATHI
MODERATOR : PROF.SURENDHER KUMAR

2.  Bon
 Articulations and ligament
 Muscles
 Nerve and blood vessels
Anatomy

3. Sigmoid/semilunar/ trochlear notch
Anteriorly composed of coronoid process
Posteriorly composed of olecranon
process
Articulates with trochlea of humerus
Ulna

4.  Radial head articulates with
capitulum
 Radial neck tapers to radial
tuberosity which is insertion for
biceps brachii tendon
Radial Anatomy

5. - Elbow consists of 3 articulations:
Ulnohumeral (elbow flexion/extension)
Radiohumeral (forearm pronation/supination)
Radioulnar (forearm pronation/supination)
Elbow Joint Articulation

7. Muscles acting on elbow
Anterior arm
Posterior arm
Muscles originating at elbow, acting on forearm, wrist
and hand
 Flexor/pronator group (hand reference)
 Extensor/supinator group (3 medial, 3 lateral, 3
“outcropping”, 3 “accessory”)
Muscular Anatomy

8. Flexor/pronator group
Pronator teres
Flexor carpi radialis
Flexor digitorum superficialis
Flexor digitorum profundus
Palmaris longus
Flexor carpi ulnaris
Pronator quadratus
Flexor pollicus longus
Muscular Anatomy – Elbow Origin

11.  Origin: common flexor tendon at
medial epicondyle and medial
coronoid process
 Insertion: lateral surface of radial
shaft
 Innervation: median nerve
 Action: forearm pronation
Pronator Teres

12.  Origin: common flexor tendon
at medial epicondyle
 Insertion: base of 2nd and 3rd
metacarpals
 Innervation: median nerve
 Action: flexes and abduction
/radial deviate the wrist
Flexor Carpi Radialis

13.  Present in approximately 70% of
population
 Origin: common flexor tendon at
medial epicondyle
 Insertion: palmar aponeurosis
 Action: flexes wrist and tenses
palmar aponeurosis
Palmaris Longus

14.  Origin: common flexor tendon at
medial epicondyle and proximal
2/3 of posterior ulnar border
 Insertion: pisiform, hamate and
5th metacarpal
 Innervation: ulnar
 Action: flexes and
adduction/ulnar deviate the wrist
Flexor Carpi Ulnaris

15.  Origin: common flexor tendon at
medial epicondyle, medial aspect of
coronoid process and oblique line of
radius
 Insertion: sides of middle phalanges of
2nd – 5th digits
 Innervation: median nerve
 Action: flexes PIP joints, assists flexion
of MCP and wrist joints
Flexor Digitorum Superficialis

16.  Origin: anteriomedial proximal ulna
 Insertion: bases of distal phalanges
(anteriorly) of 2nd-5th digits
 Innervation: 1st and 2nd tendons by
anterior interosseous nerve (median
nerve), 3rd and 4th tendons by ulnar
nerve
 Action: flexes DIP joints, assists in
flexion of PIP and MCP joints
Flexor Digitorum Profundus

17. Flexor Pollicus Longus
 Origin: anterior radius
 Insertion: palmar surface
of base of distal phalanx
of thumb
 Innervation: palmar
interosseous nerve
 Action: flexion of 1st
interphalangeal and
metacarpophalangeal
joints

18. Pronator Quadratus
 Origin: anterior, distal
ulna
 Insertion: lateral, distal
radius
 Innervation: anterior
interosseous nerve
(median nerve)
 Action: forearm
pronation

19. Muscular Anatomy – Elbow Origin
 Extensor/supinator group
 Brachioradialis
 Extensor carpi radialis longus
 Extensor carpi radialis brevis
 Extensor carpi ulnaris
 Extensor digitorum
 Extensor digiti minimi
 Supinator
 Anconeus
 Extensor indicis
 Extensor pollicus longus
 Extensor pollicus brevis
 Abductor pollicus longus

20.  Brachioradialis
 Extensor carpi radialis longus
 Extensor carpi radialis brevis
Lateral Muscles

21. Brachioradialis
 Brachioradialis
 Origin: lateral
supracondylar ridge of
humerus
 Insertion: lateral aspect
of radial styloid process
 Innervation: radial
nerve
 Action: elbow flexion,
especially w/ forearm in
neutral position

22. Extensor Carpi Radialis Longus
 Origin: lateral
supracondylar ridge of
humerus
 Insertion: dorsal base of
2nd metacarpal
 Innervation: radial nerve
 Action: extend and
abduct/radial deviate the
wrist

23. Extensor Carpi Radialis Brevis
 Origin: common extensor
tendon at lateral
epicondyle
 Insertion: dorsal base of
3rd metacarpal
 Innervation: radial nerve
 Action: extend and
abduct/radial deviate the
wrist

24.  Extensor digitorum
 Extensor carpi ulnaris
 Extensor digiti minimi
Medial Muscles

25. Extensor Digitorum
 Origin: common tendon
from lateral epicondyle
 Insertion: bases of middle
and distal phalanges via
bands of 4 tendons
 Innervation: radial nerve
 Action: MCP/IP joint
extension

26. Extensor Carpi Ulnaris
 Origin: common extensor
tendon at lateral
epicondyle
 Insertion: ulnar side of
base of 5th metacarpal
 Innervation: radial nerve
 Action: extend and
adduct/ulnar deviate the
wrist

27. Extensor Digiti Minimi
 Origin: common extensor
tendon at lateral
epicondyle
 Insertion: base of the 5th
proximal phalanx
 Innervation: posterior
interosseous (radial)
nerve
 Action: extension of 5th
MP joint

28.  Abductor pollicis longus
 Extensor pollicis longus
 Extensor pollicis brevis
“Outcropping” Muscles

29. Abductor Pollicis Longus
 Origin: posterior, distal
radius and ulna
 Insertion: base of 1st
metacarpal
 Innervation: median
nerve
 Action: extension,
abduction of 1st
carpometacarpal joint

30. Extensor Pollicis Longus/Brevis
 Origin: longus – posterior,
middle ulna, brevis – posterior,
distal radius
 Insertion: dorsal aspect of base
of distal phalanx of thumb
 Innervation: deep radial nerve
 Action: extension of 1st
carpometacarpal and
metacarpophalangeal joints

31.  Supinator
 Anconeus
 Extensor indicis
“Accessory” Muscles

32. Supinator
 Origin: lateral epicondyle,
annular ligament/RCL and
supinator crest of ulna
 Insertion: lateral proximal
1/3 of radius
 Innervation: posterior
interosseous nerve (deep
branch of radial nerve)
 Action: forearm
supination

33. Anconeus
 Anconeus
 Origin: lateral
epicondyle of humerus
 Insertion: lateral aspect
of olecranon and
posterior ulna
 Innervation: radial
nerve
 Action: assists elbow
extension

34. Extensor Indicis
 Origin: distal, lateral ulna
 Insertion: dorsal aspect of
2nd proximal phalanx
 Innervation: posterior
interosseous (radial)
nerve
 Action: index finger
extension and assists
with wrist extension

35.  Brachial artery
 Radial artery
 Ulnar artery
 Elbow vascular anastamosis
Vascular Structures

36. Vascular Structures
 Brachial artery
 Descends along arm
along medial aspect of
brachialis muscle
 Enters antecubital
fossa medial to biceps
brachii tendon and
lateral to median nerve
 Terminates at radial
head as radial/ulnar
arteries

37. Vascular Structures
 Radial artery
 Originates at radial
head, emerges from
antecubital fossa
between
brachioradialis and
pronator teres muscles
 Continues laterally
along forearm deep to
brachioradialis muscle

38. Vascular Structures
 Ulnar artery
 Originates at radial
head, continues
medially down forearm

39. Elbow Vascular Anastamosis
 Laterally – profunda
brachii artery meets radial
recurrent artery
 Medially – inferior ulnar
collateral artery meets
anterior ulnar recurrent
artery and superior ulnar
collateral artery meets
posterior ulnar recurrent
artery

40.  Terminal branches of brachial plexus
 Axillary
 Musculocutaneous
 Median
 Radial
 Ulnar
 Anterior interosseous nerve
 Dermatomes and myotomes
Neurological Structures

41. Musculocutaneous/Axillary Nerves
 Musculocutaneous
nerve
 Innervates biceps brachii,
coracobrachialis and brachialis
muscles
 Sensory distribution is anterior
arm and lateral forearm
 Axillary nerve
 Innervates deltoid and teres
minor muscles
 Sensory distribution is lateral
arm

42. Median Nerve
 Median nerve
 Enters antecubital
fossa medial to biceps
brachii tendon and
brachial artery
 Courses down medial
forearm to hand/wrist
distribution
 Sensory distribution is
pad of index finger

43. Radial Nerve
 Radial nerve
 Enteres antecubital fossa
posterior to brachialis
muscle
 Divides into superficial and
deep (posterior
interosseous) branches
 Courses down lateral
forearm to hand/wrist
distribution
 Sensory distribution is 1st
dorsal webspace

44. Ulnar Nerve
 Ulnar nerve
 Courses in cubital tunnel
posterior to medial
epicondyle
 Superficial and susceptible
to compression or
entrapment
 Courses down medial
forearm to hand/wrist
distribution
 Sensory distribution is pad
of little finger

45. Anterior Interosseous Nerve
 Anterior interosseous
nerve (branch of median
nerve)
 Passes between 2 heads
of pronator teres muscle,
may be impinged upon
 Anterior interosseous
nerve syndrome
characterized by
abnormal pinch deformity
(inability to extend DIP of
thumb and index finger)

46. Dermatomes
 C5 – lateral arm
 C6 – lateral forearm,
thumb and index finger
 C7 – posterior forearm
and middle finger
 C8 – medial forearm, ring
and little fingers
 T1 – medial arm

47. Myotomes
 C5 – shoulder abduction
 C6 – elbow flexion, wrist
extension
 C7 – elbow extension,
wrist flexion
 C8 – finger flexion/grip
strength
 T1 – finger
abduction/adduction

48. Olecranon Bursa
 Most frequently injured
bursa in the elbow
 Lays between skin and
olecranon process
 Allows
unrestricted/fluid
movement of skin over
olecranon process

49. Essex –Lopresti injury OR
longitudinal radioulnar
dissociation

50. is a complex injury that includes
 fracture of the radial head
 rupture of the interosseusmembrane of the forearm

 impaired integrity of the distal radioulnar joint

51.  Essex –Lopresti lesion leads to instability of the
forearm
 central migration of the radius.
 restriction of the radiocarpal motion
 reduction of the grip strength and wrist pain.

54.  Radial head replacement
TREATMENT

55.  Distal radio ulnar joint
reduction(pinning)

56. APPROACHES TO FOREARM

57. VOLAR APPROACH TO RADIUS(HENRY)
INDICATIONS
 RADIAL OSTEOTOMY
 TUMOR / ABSCESS BIOPSY AND EXCISION
 ORIF OF RADIUS FIXATION
 ANTERIOR EXPOSURE OF BICIPITAL TUBEROSITY

58.  POSITION
 PLACE SUPINE ON TABLE AND SUPINATE
 ARM AND PLACE ON ARMBOARD
 EXSANGUINATE ARM
 INCISION
 LONGITUDINAL INCISION
 BEGIN JUST LATERAL TO BICEPS
TENDON ON FLEXOR CREASE OF
ELBOW
 END AT RADIAL STYLOID PROCESS

59. Internervous Plane
• Proximally between:
• brachioradialis (radial nerve)
• pronator teres (median nerve)
•Distally between:
• brachioradialis (radial nerve)
• FCR (median nerve)

60. SUPERFICIAL DISSECTION
 INCISE THE DEEP FASCIA IN LINE WITH SKIN
INCISION
 DEVELOP A PLANE BETWEEN BR AND
FCR DISTALLY
 MOVE PROXIMAL TO DEVELOP PLANE
BETWEEN PT AND BR
 IDENTIFY THE SUPERFICIAL RADIAL
NERVE BENEATH BR
 LIGATE THE BRANCHES OF THE RADIAL
ARTERY TO AID LATERAL RETRACTION OF BR

61.  DEEP DISSECTION -
PROXIMAL THIRD
 FOLLOW THE BICEPS TENDON TO ITS
INSERTION ON THE BICIPITAL
TUBEROSITY
 RADIAL TO THE INSERTION OF BICEPS
TENDON INCISE THE BURSA TO GAIN
ACCESS TO THE PROXIMAL PART OF
RADIUS
 FULLY SUPINATE THE FOREARM TO
DISPLACE THE PIN RADIALLY AND BRING
THE ORIGIN OF THE SUPINATOR MUSCLE
INTO THE ANTERIOR ASPECT OF THE
RADIUS
 INCISE THE SUPINATOR MUSCLE ALONG
THE LINE IF ITS BROAD INSERTION AND
CONTINUE SUBPERIOSTEAL DISSECTION
LATERALLY

62.  DEEP DISSECTION -
MIDDLE THIRD
 PRONATE THE FOREARM TO BRING THE
INSERTION OF THE PRONATOR TERES, ALONG
THE RADIAL ASPECT OF THE RADIUS, INTO
VIEW
 DETACH THE PRONATOR INSERTION FROM
BONE AND RETRACT MEDIALLY
 DEEP DISSECTION -
DISTAL THIRD
 PARTIALLY SUPINATE THE FOREARM
 DISSECT THE PERIOSTEUM OFF THE LATERAL
ASPECT OF THE DISTAL THIRD OF THE
RADIUS, LATERAL TO THE PRONATOR
QUADRATUS AND FLEXOR POLLICIS LONGUS

63. DANGERS
 POSTERIOR INTEROSSEOUS NERVE
 THE POSTERIOR INTEROSSEOUS NERVE ENTERS THE SUPINATOR MUSCLE
 SUPERFICIAL RADIAL NERVE
 VULNERABLE WITH MANIPULATION OF MOBILE WAD OF THREE
 DAMAGE TO IT CAN CAUSE A PAINFUL NEUROMA
 RUNS DOWN FOREARM UNDER BODY OF BRACHIORADIALIS
 RADIAL ARTERY
 RUNS DOWN MIDDLE OF FOREARM UNDER BRACHIORADIALIS

64. DORSAL APPROACH TO
RADIUS(THOMPSON)
 ACCESS
 PROVIDES EXPOSURE TO PROXIMAL
1/3 OF RADIUS
 INDICATIONS
 ORIF OF RADIAL FRACTURES
 TREATMENT OF NONUNION
 ACCESS TO THE PIN AS IT PASSES
THROUGH THE ARCADE OF FROHSE
FOR
 NERVE PARALYSIS
 RESISTANT TENNIS ELBOW
 RADIAL OSTEOTOMY
 OSTEOMYELITIS AND BONE TUMORS

65. INTERNERVOUS
PLANE
 PROXIMALLY BETWEEN
 ECRB (RADIAL NERVE)
AND EDC (PIN NERVE)
 DISTALLY BETWEEN
 ECRB (RADIAL NERVE)
AND EPL (PIN NERVE) DISTALLY
 APPROACH

66. POSITION
PLACE PATIENT SUPINE
IF ARM IS ON ARM BOARD, THEN PRONATE THE FOREARM
IF ARM IS ACROSS CHEST, THE SUPINATE THE FOREARM
INCISION
STRAIGHT OR GENTLY CURVED INCISION FROM
POINT( 1.5) ANTERIOR TO THE LATERAL EPICONDYLE OF THE
HUMERUS
TO POINT JUST DISTAL TO LISTER'S TUBERCLE( mid point of the wrist)

67. SUPERFICIAL
DISSECTION
 PROXIMALLY DEVELOP INTERVAL
BETWEEN ECRB AND THE EDC
 PROXIMALLY EXPOSE PROXIMAL
THIRD OF THE RADIUS AND
OVERLYING SUPINATOR
 DISTALLY DEVELOP PLANE BETWEEN
THE ECRB AND EPL AND EXPOSES
LATERAL ASPECT OF DISTAL THIRD OF
THE RADIUS

68.  DEEP DISSECTION -
PROXIMAL THIRD
 PRONATE ARM TO EXPOSE
ANTERIOR ASPECT OF RADIUS
AND MOVE PIN AWAY FROM
ORIGIN OF SUPINATOR
 DETACH SUPINATOR MUSCLE AT
INSERTION ON ANTERIOR ASPECT
OF RADIUS
 SUBPERIOSTEALLY STRIP
SUPINATOR TO EXPOSE
PROXIMAL THIRD OF RADIUS

69.  DEEP DISSECTION - MIDDLE THIRD
 MAKE INCISION ALONG SUPERIOR AND INFERIOR BORDERS OF APL AND
EPB AND RETRACT THEM OFF BONE TO EXPOSEMIDDLE THIRD OF RADIUS
 DANGERS
 POSTERIOR INTEROSSEOUS NERVE
 INJURY USUALLY FROM RETRACTION
 IN 25% OF PATIENTS THE NERVE ACTUALLY TOUCHES THE DORSAL
ASPECT OF THE RADIUS
 PLATES PLACED HIGH ON THE DORSAL SURFACE MAY TRAP THE NERVE
 PIN MUST BE IDENTIFIED WITHIN THE SUPINATOR MUSCLE

70. APPROACH TO ULNA
 INIDICATIONS
 ORIF OF ULNAR SHAFT FXS
 ULNAR OSTEOTOMY
 ULNAR LENGTHENING (KIENBOCK'S
DISEASE)
 ULNAR SHORTENING (FOR RADIAL
MALUNION)
 OSTEOMYELITIS AND TUMORS OF ULNA
 INTERNERVOUS PLANE
 BETWEEN ECU AND FCU
 POSITION
 PLACE SUPINE ON TABLE
 PLACE ARM ACROSS CHEST TO EXPOSE
SUBCUTANEOUS BORDER OF ULNA

71.  APPROACH
 LINEAR LONGITUDINAL INCISION OVER
SUBCUTANEOUS BORDER OF ULNA
 SUPERFICIAL DISSECTION
 INCISE DEEP FASCIA IN DISTAL INCISION IN LINE
WITH SKIN INCISION
 DIVIDE PLANE BETWEEN ECU AND FCU
 DISSECT DOWN TO SUBCUTANEOUS BORDER
OF ULNA
 DEEP DISSECTION
 INCISE PERIOSTEUM OVER ULNA
 PERFORM SUBPERIOSTEAL DISSECTION

72.  DANGERS
 ULNAR NERVE
 PROXIMALLY PASSES
THROUGH HEADS OF FCU
 TRAVELS DOWN FOREARM UNDER
FCU AND ON TOP OF FDP
 ULNAR ARTERY
 TRAVELS DOWN FOREARM WITH
ULNAR NERVE (RADIAL SIDE)
 PROTECT BY DISSECTING FCU
SUBPERIOSTALLY

73. POSTERIOR APPROACH TO PROXIMAL 3RD
ULNA AND RADIAL HEAD(BOYDS)
 INDICATION
 PROXIMAL THIRD ULNA FRACTURE WITH RADIAL HEAD
DISLOCATION(MONTEGGIA)
 ISOLATED RADIAL HEAD AND NECK FRACTURE
 INCISION
INCISION GIVEN ABOUT 2.5 CM ABOVE ELBOW JOINT JUST LATERAL TO
TRICEPS TENDON
EXTEND OVER OLECRONON TO PROXIMAL AND MIDDLE 3RD OF ULNA
POSTERIORALY

74. DISSECTION
 DEVELOP THE INTERVAL
BETWEEN THE ULNA ON
MEDIAL SIDE , ANCONEUS AND
ECU LATERALLY
 STRIP THE ANCONEUS
SUBPERIOSTEALLY TO EXPOSE
THE RADIAL HEAD
 DISTAL TO RADIAL HEAD,
REFLECT THE SUPINATOR
SUBPERIOSTEALLY FROM ULNA

75. FCR APPROACH TO DISTAL RADIUS
 INDICATIONS
 ORIF OF FRACTURE AND DISLOCATIONS OF
DISTAL RADIUS AND CARPUS
 POSITION
 PLACE SUPINE ON TABLE
 SUPINATE ARM AND PLACE ON ARMBOARD
 APPLIED TOURNIQUET
 INCISION
 MAKE INCISION ALONG PALPABLE FLEXOR
CARPI RADIALIS (FCR) TENDON SHEATH

76. SUPERFICIAL DISSECTION
 INCISE SKIN FLAPS AND SUBCUTANEOUS
FAT
 SECTION FIBERS OF VOLAR FCR TENDON
SHEATH IN LINE WITH TENDON
 RETRACT FCR TENDON ULNARLY AND
INCISE THROUGH THE DORSAL ASPECT
OF THE FCR SHEATH
 CAN RETRACT FCR RADIALLY IF CARPAL
TUNNEL ACCESS IS NECESSARY

77.  DEEP DISSECTION AND ACCESS TO VOLAR WRIST
JOINT
 UNDERNEATH THE FCR SHEATH IS THE FLEXOR POLLICIS LONGUS (FPL) - THIS
MUST BE RETRACTED ULNARLY
 AFTER THE FPL RETRACTED, THE PRONATOR QUADRATUS (PQ) IS SEEN
 INCISE THE RADIAL AND DISTAL BORDERS OF THE PQ, ELEVATING THE
MUSCLE OFF THE VOLAR RADIUS

78.  PROXIMAL EXTENSION
 DISSECTION
 EXTEND INCISION UP MIDDLE OF ARM
 INCISE DEEP FASCIA BETWEEN PL AND
FCR
 RETRACT PL AND FCR TO EXPOSE FDS
 INDICATIONS
 TO FURTHER EXPOSE MEDIAN NERVE
OR RADIUS
 MEDIAN NERVE IS IMMEDIATELY UNDER
THE DEEP SURFACE OF FDS

79.  DISTAL EXTENSION
INDICATIONS
 TO FURTHER EXPOSE THE SCAPHOID
 DISSECTION
 EXTEND INCISION OBLIQUELY IN A RADIAL DIRECTION ACROSS
THE FLEXOR CREASE
 CONTINUE THIS IN LINE WITH THE THUMB RAY
 ELEVATE THE THENAR MUSCULATURE OFF THE VOLAR WRIST
CAPSULE
 OPEN CAPSULE IF NECESSARY

80. THANK YOU