Approaches of elbow

1. ELBOW APPROACH
BY
DR.abdulaziz almohanna (R2)

2. Case 1
55y female,HTN fall on out streached hand
Tenderness over radial head, decrease ROM, swelling

3. postrolateral approach
Postion:
Landmark: lateral humeral epicondyle,2.5cm distaly is the radial
head

4. Incision:
5cm longtiudinal
Incision from lateral
epicondyle directly
over radial head
internervous plane:
Anconeus(Radial N.) ECU(PIN)

5. Superficial dissection:
Interval b/w anconeus and ECU>>>seprate using retractors
Plane-
Easy to identify distaly
Proximaly same aponeurosis
Deep dissection:
Pronate the arm>>> PIN away from
the field

6. Dangers:
PIN:
Safe if
- dissection proximal to anular lig
- pronation

7. Case 2
39 y/o male hx of fall , decrease ROM

8. Medial approach
Postion:
supine,abducte and EXT.rorate the shoulder
Flex elbow 90 degree,flex shoulder,lie over patient body

9. Landmark:
Palpate the medial epicondyle
Incision:
8-10cm long medial aspect of the elbow,centering the
incsion on the medial epicondyle

10. Internervous plane:
Proximal:-
Brachialis(musculocutaneous)and Triceps(radial)
Distal:-
Brachialis(musculocutaneous) and pronator teres(medial
nerve)

11. Superficial dissection:
Plapte ulnar nerve behind the medial condyle,incise the facia
over nerve
Retract the anterior skin flap with the facia to expose the
superficial flexors of the forearm

12. - between the pronator teres and brachialis
median nerve, which enters the pronator teres near the midline
- Retract pronator teres medially, lifting it off the brachialis
- Make sure that the ulnar nerve is retracted inferiorly
-perform osteotomy of the medial epicondyle
-Reflect the epicondyle with its attached flexors distally
avoiding traction that might damage the median or anterior
interosseous nerves
Superiorly, continue the dissection between the brachialis, retracting it
anteriorly, and the triceps, retracting it posteriorly

14. Deep dissection:
Capsule and medial collateral ligament
Dangers:
Ulnar,Median N

15. Case 3
80 y/o male HTN,DM with Hx of fall over the right elbow
Presented with deformaty ,swelling ,no ROM ,distal NV intact

16. Antrolateral approach
Postion:
Supine, arm on an arm board, tourniquet
Landmark:
Brachioradialis on the antrolaterl of
the forearm
Incision:
Curved 5cm above the flexor craese
Lateral boarder of the biceps, avoid crossing the crease at 90
degree,then medial boarder of brachioradialis

17. Internervous plane:
Proximally/ brachialis(MC nerve)and brachioradialis(R nerve)
Distally/ brachioradialis(R.nerve) and pronator
teres(M.nerve)

18. Superficial dissection:
Identify lateral cutaneous N.
2in superficial to deep facia,
b/w biceps tendon and brachialis
Retract it
Incise the deep facia in the medial boarder of
brachioradials and identify the superficial radial N.
(b/w brachialis-brachioradials) with blunt
dissection

19. Deep dissection:
Longitudinal incision in the anterior capsule
b/w the radial N laterally and bracialis medially
Supinate the forearm and
Dissecte supinator from its origin
Just lateral to biyceps tendon

20. Dangers:
Radial N.
PIN
Lateral cutaneous nerve
Recurrent branches of the radial artery must be ligated so
the brachioradialis cand mobilized fully