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presentation on surgical approach to elbow.pptx
- 1. SURGICAL APPROACHES TOELBOW Dr. Bishwobandhu Khadka DEPARTMENT OF ORTHOPAEDICS JR1 Moderator Dr. Amit Bikram Shah
- 2. Surgical Anatomy ofElbow • Joint • Articular surfaces • Ligaments • Muscles and movements • Important relations of joint with surrounding structures
- 6. Approaches • Posterior approachto the elbow with olecranon osteotomy(Macausland and Muller) • Posterior approach to the elbow without olecranon osteotomy(Bryan and Morrey) • Posterolateral approach to elbow(Campbell) • Extensile Posterolateral approach to elbow(Wardsworth) • Medial approach with osteotomy of medial epicondyle(Molesworth and Campbell) • Posteromedial approach to the coronoid process of ulna • Lateral approach to the elbow • Lateral J shaped approach • Posterolateral approach to the radial head • Anterior approach to the cubital fossa
- 7. Posterior Approach withOlecranon Osteotomy(Macausland and Muller) • Provide best possible view of bones of elbow joint. • Safe and reliable • Indications: ─ ORIF of # of distal humerus ─ Removal of loose bodies within elbow joint ─ Treatment of non-union of distal humerus ─ Extension contractures of elbow can be treated by using some portions of this approach to lenghthen triceps muscle, without an osteotomy.
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- 9. Incision • beginning 5cm above the olecranon • curve the incision laterally then curve medially so that it overlies the middle subcutaneous surface of ulna
- 10. • Incision ofdeep fascia in midline • Palpate ulnar nerve and incise fascia overlying it to expose nerve. • Fully dissect out it and pass tape around it for its identification
- 11. • V shapedosteotomy of olecranon about 2 cm, apex of which is placed distally. • Before osteotomy holes should be drilled and tapping for screw fixation.
- 12. • retract proximally,with the triceps muscle attached • Strip a portion of the joint capsule with an osteotome.
- 14. Precautions • Not todissect proximally above D/4th of humerus to protect radial nerve damage. • Flex elbow to relax anterior structures if they need to be elevated off the front of humerus. • Ulnar nerve must be kept clear of the operative field, anterior transposition can be done. • Great care taken to realign olecranon correctly during closure.
- 15. Posterior Approach withoutOlecranon Osteotomy (Bryan and Morrey) • Excellent exposure of the elbow while preserving bony anatomy • The creation of a flap consisting of the triceps muscle, its insertion into the olecranon, and the fascia covering the flexor carpi ulnaris muscle based laterally on the anconeus muscle • Indication • Open reduction and internal fixation of fractures of the distal humerus • Total joint arthroplasty • Excision of tumors
- 17. Incision • longitudinal incision •12 cm above the olecranon in the midline • curve the incision laterally • Distally continue the for 8 to 10 cm over the surface of ulna
- 18. • Reflect thetriceps mechanism from medial to lateral • detatch with a sliver of bone using a sharp osteotome
- 19. • Incise theposterior capsule • Reflect the entire extensor mechanism laterally flexing the elbow to 100 degrees
- 20. Posterolateral approach -Campbell • Old posterior dislocations • # distal humerus • arthroplasies
- 22. • 10 cmproximal to elbow • Continue distally for 13 cm • Expose aponeurosis of triceps as far distally as its insertion on olecranon.
- 23. • Triceps contracted– free aponeurosis proximally and retract distally • Triceps not contracted - divide muscle and aponeurosis longitudinally in midline periosteum of humerus- joint capsule – lateral border of olecranon.
- 24. • Elevate periosteumwith triceps muscle from posterior surface of distal humerus for 5 cm • The head of radius now lies in distal end of the wound.
- 25. Extensile Posterolateral Approach-Wardsworth •Displaced distal humeral# • Synovectomy • Total elbow arthroplasty • Procedures requiring extensive exposure
- 26. • curved incision •proximal limit of tricpes tendon • extend distally to posterior aspect of lateral epicondyle • farther distally and medially to posterior border of ulna, 4 cm distal to tip of olecranon.
- 27. • Dissect medialand lateral skin flap • Identify ulnar nerve and release it, retarct it with rubber sling. • Distally based tongue of trieps tendon attached to olecranon • peripheral tendinous rim attached to the tricpes for later repair.
- 28. • Reflect tricpestendon distally • Reflect anconeus and underlying capsule medially. • Partially reflect the common extensor origin, lateral collateral ligament and adjacent capsule for better expsure. • One can increase the exposure by putting varus starin on the elbow joint.
- 29. Medial Approach(Molesworth andCampbell) • Removal of loose bodies • ORIF of the coronoid process of the ulna • ORIF of the medial humeral condyle and epicondyle.
- 30. Position Abduct the armand rotate the shoulder fully externally medial epicondyle of the humerus faces anteriorly. Flex the elbow to 90 degrees flex the patient’s shoulder and elbow forearm comes to lie over the front of the face easier exposure of the medial side of the elbow requires an assistant to hold the forearm
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- 32. Internervous plane • Proximally,the plane is between the brachialis and the triceps • Distally, it is between the brachialis and the pronator teres
- 33. • Retract theanterior skin flap, together with the fascia overlying the pronator teres. • The superficial flexor muscles of the forearm now are visible
- 34. • medial epicondyleis osteotomized the ligament remains attached to the medial epicondyle. • Reflect the epicondyle with its attached flexors distally
- 35. • The medialside of the joint now can be seen. • Incise the capsule and the medial collateral ligament to expose the joint
- 36. Posteromedial Approach tothe Coronoid Process of the Ulna • ORIF of fractures of the coronoid process • Repair of the medial collateral ligament • Exposure of the sublime tubercle of the ulna for stabilization of fractures.
- 37. Incision • 8 cmlong curved incision • proximally just posterior to the medial epicondyle • extend distally along the medial aspect of the forearm
- 38. • Isolate thenerve lifting it out of its groove on the back of the medial epicondyle • Identify the sublime tubercle of the ulna • Develop a plane between the two heads of flexor carpi ulnaris.
- 39. Detach the ulnaheads of flexor carpi ulnaris and pronator teres from the ulna to reveal the proximal ulna and coronoid process
- 40. Lateral approach • #lateral condyle
- 41. Incision • Begin appx5 cm proximal to the lateral epicondyle • Carry it distally along the epicondyle and anterolateral surface of the forearm for approximately 5 cm
- 42. • Dissect distallyto proximally the interval between the triceps and the extensor carpi radialis longus and brachioradialis • In the proximal angle of the wound, avoid the radial nerve
- 43. • Separate thecommon origin of the extensor muscles • Elevate subperiosteally the origins of the brachioradialis and extensor carpi radialis longus muscles • Incise the capsule to expose the lateral aspect of the elbow joint.
- 44. Lateral J shapedapproach ( Kocher) • Begin the incision 5 cm proximal to the elbow over the lateral supracondylar ridge • Continue it 5 cm distal to the radial head, medially and posteriorly • End at the posterior border of the ulna • Dissect between the triceps muscle posteriorly and the brachioradialis and extensor carpi radialis longus muscles anteriorly
- 45. • Distal tothe head, separate the extensor carpi ulnaris from the anconeus • Reflect anteriorly the common origin of the extensor muscles from the lateral epicondyle • Reflect the anconeus subperiosteally from the proximal ulna to dislocate and examine the joint • With the lateral capsule acting as a hinge, dislocate the joint
- 46. Anterolateral approach • Exposesthe lateral half of elbow joint, especially the capitulum and proximal 3rd of anterior aspect of radius. • Indications: o ORIF of # of capitulum o Excision of tumours of the proximal radius o Treatment of aseptic necrosis of capitulum o Drainage of infection from elbow joint o Treatment of biceps avulsion from radial tuberosity o Total elbow replacements o Treatment of neural compression of proximal half of PIN and proximal part of superficial radial nerve as well as treatment of radial head # with paralysis of this nerve.
- 47. Position • Supine witharm on arm board
- 48. Incison • Curved incisionalong the anterior aspect of elbow joint • Begin 5cm above the flexion crease over the lateral boarder of biceps muscle . • Follow the lateral boarder of biceps muscle distally • curve the incision laterally at the level of the elbow joint • Continue inferiorly curving medially following the medial boarder of the brachioradialis .
- 49. Internervous plane • Proximally,the plane is between the brachialis and the brachioradialis • Distally, it is between the brachioradialis and the pronator teres
- 50. • Identify lateralcutaneous nerve of forearm along the medial boarder of brachioradialis • lies superficial to deep fascia between biceps tendon and bracialis muscle lateral to biceps tendon in distal 5cm of the arm.
- 51. • Incise thedeep fascia along the medial border of the brachioradialis • Identify the radial nerve proximally at the level of the elbow joint • Retract the brachioradialis laterally and the brachialis and the overlying biceps brachii medially
- 52. • The radialnerve divides into its three terminal branches: the posterior interosseous nerve, the sensory branch (which appears under the brachioradialis), and a motor branch to the extensor carpi radialis brevis. • Develop a plane between the brachioradialis and the pronator teres.
- 53. • make alongitudinal incision in the anterior capsule of the joint between the radial nerve laterally and the brachialis medially
- 54. • To exposethe proximal radius, fully supinate the forearm • Incise the origin of the supinator down the bone • Complete the exposure of the proximal radius by circumferential subperiosteal dissection
- 55. forearm supination movesthe posterior interosseous nerve lateral to the incision into the radiohumeral joint and away from the incision
- 56. Posterolateral approach Indications: o Allsurgeries of radial head o Excision o Insertion of prosthetic implant
- 57. Position • Supine witharm positioned over the chest • Pronation of forearm
- 58. Incision • Gently curvedincision beginning over the posterior surface of lateral humeral epicondyle and continuing downward and medially to a point over the posterior boarder of ulna about 6 cm distal to tip of the olecranon. • Alternatively, make a 5-cm longitudinal incision based proximally on the lateral humeral epicondyle
- 59. Internervous plane • liesbetween the anconeus (radial nerve) and the extensor carpi ulnaris (posterior interosseous nerve). • proximally, the two muscles share a common aponeurosis
- 60. • Detach thesuperior origin of the anconeus from the lateral epicondyle, and separate the anconeus and the extensor carpi ulnaris. • Pronation of the forearm moves the posterior interosseous nerve medially away from the operative field
- 61. • Incise thecapsule of the elbow joint longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament.
- 62. Anterior approach • Leastcommonly used • Provide access to neurovascular structures found in cubital fossa • Indications: o Repair of laceration to ─ Median nerve ─ Brachial artery ─ Radial nerve ─ Biceps tendon o Reinsertion of biceps tendon o Post traumatic release of anterior capsular contractions o Excision of tumors
- 63. Position and Incision •Supine with arm in anatomical position. • Curved boat raced incision over the anterior aspect of elbow • Begin 5 cm above the flexion crease on the medial side of biceps • Curve the incision across the front of elbow, then complete it by incising the skin along the medial boarder of the brachioradialis.
- 64. • Locate thelateral cutaneous nerve of the forearm, in the interval between the biceps tendon and the brachialis and preserve it
- 65. • Identify theradial artery as it passes the biceps tendon and trace it proximally to its origin from the brachial artery • Both the brachial vein and the median nerve lie medial to the artery. • To identify the radial nerve, look between the brachialis and the brachioradialis in front of the elbow joint.
- 66. • Retract proximalsupinator muscle to gain access to expose anterior capsule of elbow joint.
- 67. • Trace themedian nerve distally into the pronator teres. • The incision lies between the humeral and ulnar heads of the pronator teres • The brachial artery runs with the median nerve and is exposed in the same way
- 68. References • Campbell’s OperativeOrthopedics, 13th edition. • Surgical Exposures in Orthopedics, Anatomic approch, 4th edition by Stanley Hoppenfeld.
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