Elbow Resources

Approaches to elbow (R) Approaches to elbow (R)


Medial approach to the elbow

Indications

Access to medial side of joint and coronoid process

Position
Supine
Arm supported over body on arm table.

Landmark
Medial epicondyle of the humerus

Incision
Curved incision 8-10cm long on medial aspect of elbow, centred on the medial epicondyle.

Internervous plane
Proximally, between brachialis (MCN) and triceps (radial nerve).
Distally, brachialis (MCN) and pronator teres (median nerve).

Superficial dissection
Dissect the ulnar nerve free and isolate with a vessel loop.
Retract the anterior skin flap and the fascia over pronator teres to expose the superficial flexor muscles of the forearm.
Define the interval between pronator teres and brachialis, taking care not to damage the median nerve.
Perform an osteotomy of the medial epicondyle and reflect the epicondyle distally, avoiding traction on the median nerve which enters near the midline.
Superiorly, continue the dissection between the brachialis and triceps.

Deep dissection
The medial side of the joint and collateral ligaments can now be seen. Incise the capsule and the medial collateral ligament to expose the joint.

Dangers
Ulnar nerve. Needs to be isolated before performing the medial epicondylectomy
Median nerve. Can be damaged by excessive traction on the pronator teres.

Extensile measures
Proximal. Elevate the brachialis anteriorly to expose the anterior surface of the distal fourth of the radius.
Distally. Not possible, as too much retraction on the pronator teres will cause a median nerve lesion.
Posterolateral approach to the radial head (Kocher's approach)

Essence
Utilizes plane between anconeus and extensor carpi ulnaris.

Indications
Access to radial head and capitellum.

Position
Supine
Elbow pronated to move posterior interosseous nerve anteriorly. With the forearm pronated fully at least the proximal 38mm of the radius can be safely exposed; with the forearm supinated this decreases to 22mm.

Landmarks
Lateral humeral epicondyle.
Radial head
Olecranon

Incision
Longitudinal incision running distally and posteriorly, beginning at the lateral humeral epicondyle.
Internervous plane.
Between anconeus (radial nerve) and extensor carpi ulnaris (posterior interosseous nerve).

Superficial surgical dissection
Find interval between anconeus and extensor carpi ulnaris, which is easier to do distally, because the muscles share a common aponeurotic origin proximally. If you can't find the interval then you can dissect straight down onto the lateral humeral epicondyle.

Deep dissection
Fully pronate the forearm to move the posterior interosseous nerve anteriorly.
The capsule of the elbow is divided to display the radial head and capitellum.
It is important to not retract too vigorously distally or anteriorly to limit the risk of damaging the PIN.

Dangers
PIN. Try to stay proximal to the annular ligament, and pronate the forearm.
To enlarge the approach

Local measures
The extensor apparatus can be dissected off the lateral supracondylar ridge both anteriorly and posteriorly to gain access to the distal humerus and the capitellum.

Extensile measures
Not possible.
Anterolateral approach
This is an extension of the anterolateral approach to the humerus and can be extended into the anterior approach to the radius. Using these approaches the full length of the arm and forearm can be exposed.

Position
Supine

Landmarks
Brachioradialis is the medial border of the mobile wad of three
The biceps tendon is palpable as a taut band on the anterior aspect of the elbow.

Incision
Begins 5cm above the elbow flexion crease, curves over the flexion crease and then follows the medial border of brachioradialis.

Internervous plane
Proximally: between BR (radial nerve) and brachialis (MCN)
Distally: between BR (RN) and PT (MN)

Superficial dissection
Identify the interval between the brachialis and BR by blunt dissection. Beware of the lateral cutaneous nerve of the arm which becomes superficial to the deep fascia in the distal 5cm of the arm.
Distally, the recurrent branches of the radial artery cross the field. These need to be ligated. The interval between PT and BR is developed.

Deep dissection
The radial head is exposed by fully supinating supinator to carry the PIN away, then the supinator is subperiosteally dissected from the radial head.

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