Upper Limb

Elbow

Approaches

 

Posterolateral

Anterior

Anterolateral

Posterior

Medial

 

Posterolateral / Kocher

 

Kochers Approach 1Kochers Approach 2

 

Concept

- between ECU and anconeus

 

Indications

- radial head ORIF / replacement

- washout elbow joint

 

Technique

 

Position 

- patient supine with arm on hand table

 

Landmarks 

- lateral epicondyle, head radius, olecranon

 

Incision 

- proximally over lateral supracondylar ridge 5cm proximal to elbow

- continue 5cm distal towards radial head

- curve posteriorly to ulna border

 

Inter-nervous plane 

- between ECU (PIN) & anconeus (RN)

 

Superficial dissection 

- identify the plane between the anconeus & ECU

- anconeus triangular muscle fanning from lateral epicondyle out to olecranon

- interval best identified distal to epicondyle

 

Deep dissection 

- fully pronate the forearm to move the PIN away

- elevate ECU and EDC off capsule anteriorly

- keep incision anterior to avoid dividing lateral ulna collateral of LCL

- LCL in line and deep to anterior fibres of anconeus

- divide capsule over radial head

- do not continue below the annular ligament or retract too vigorously to avoid damage to the PIN

 

Extension

- proximally between triceps and BR/ECRL anteriorly

 

Anterior Approach

 

Concept

- between Biceps and BR proximally

- between BR and PT Distally

 

Indications

- repair of median nerve / radial nerve / brachial artery

- reinsertion of biceps tendon

 

Technique

 

Incision

- S shaped incision over the anterior aspect of elbow

- 5cm above the flexion crease on medial side of biceps 

- curve across the front of elbow joint

- continue laterally along medial aspect of BR

- don't cross flexion crease at 90o

 

Internervous Plane

- between the BR (radial nerve) and Brachialis (MCN) proximally 

- between BR (radial nerve) and PT (median nerve) distally 

 

Superficial Dissection

- incise deep fascia in line with skin incision and ligate veins

- lateral cutaneous nerve of forearm located and preserved

- lacertus fibrosis identified and cut at the origin with the biceps tendon

- brachial artery beneath lacertus

- median nerve lies medial to artery 

- radial nerve found between the brachialis and BR

- passes lateral to biceps tendon

 

Deep dissection not required

 

Dangers

- lateral cutaneous nerve of forearm located between the Brachialis and Biceps 

- brachial artery immediately deep to lacertus

 

Extensions

- proximally along the medial side of the biceps to expose the brachial artery

- distally as anterior / Henry approach to forearm

 

Anterolateral Approach

 

Concept

- between BR / radial nerve and biceps / PT

 

Indications

- ORIF of capitellar fractures

- OCD of capitellum

- tumors of the proximal radius

- PIN compression

- distal biceps rupture

 

Technique

 

Incision 

- 5cm above the flexion crease of elbow over the lateral border of biceps muscle

- small curve at flexion crease of elbow

- extends distally following the medial border of brachioradialis

 

Internervous Plane 

- proximally between BR (radial nerve) and Brachialis (MCN)

- distally between the BR (radial nerve) and PT (median N)

 

Superficial dissection 

- preserve LCN of forearm (superficial to deep fascia in interval between biceps and brachialis)

- incise deep fascia along the medial aspect of BR

- identify and protect radial nerve proximally between the BR and brachialis

- brachialis / biceps reflected medially and BR reflected laterally 

 

Deep dissection

- follow the radial nerve until divides into the SRN / PIN and motor branch to ECRB

- develop plane between BR and PT

- will have to ligate the recurrent vessels (leash of Henry) here that enters BR

- retract radial artery and PT medially

- divide capsule longitudinally between the radial nerve laterally and the brachialis medially

- the proximal radius is further exposed by fully supinating the forearm

- detaching the supinator from the oblique line to avoid damage to the PIN

 

Dangers

- PIN

- radial nerve

- recurrent branches of radial artery

- lateral cutaneous nerve of forearm

 

Extension

- proximally by conversion into anterolateral approach to the humerus

- distally extended as the anterior approach to the forearm

 

Posterior Approach

 

Indication

- ORIF distal 1/3 humerus

 

Technique

 

Position

- patient on side, arm over bolster

 

Incision 

- midline and extending distally 

- curve laterally about the tip of olecranon

- avoids sensitive scar

 

Superficial dissection

- identify ulnar nerve medially

- dissect from its bed (divide Osbourne's fascia) and vessiloop

 

Deep dissection

1.  Mobilise medial and lateral sides of triceps

- beware radial nerve proximally on lateral side

 

2.  Intra-articular fracture

- chevron osteotomy

- predrill and tap the olecranon for 6.5 mm screw 

- Chevron osteotomy 2 cm from tip with osteoclasis of articular surface

- elevate the triceps superiorly off the humerus with olecranon

- can extend to lower 1/4 - any higher can endanger the radial nerve in groove

- cannot extend proximally but able to extend distally to expose the entire surface of the ulna

 

Medial Approach

 

Indications

- ORIF coronoid process fracture

- ORIF medial epicondyle

 

Technique

 

Incision 

- curved incision on the medial aspect of the elbow 8-10 cm length

- centered on the medial epicondyle

 

Internervous Plane

- proximal - Brachialis (anterior) and Triceps (posterior)

- distal - PT and Brachialis 

 

Superficial dissection 

- locate the ulnar nerve and divide the fascia over the nerve

- mobilise and retract the ulna nerve posteriorly

- identify CFO

 

Options

1.  Osteotomy medial epicondyle and reflect CFO

2.  Open plane between PT and FCR

 

Dangers

- median nerve or AIN palsy with traction of the medial epicondyle

- ulnar nerve injury

 

Distal extension 

- is limited by the median nerve

 

 

 

 

 

 

Forearm

Approaches

 

Anterior Approach to Radius

Posterior Approach to Radius

Approach to the Ulna

 

Anterior Approach to Radius / Henry

 

Indications 

- ORIF of radius fractures

- bone grafting of non unions 

- radial osteotomy 

 

Technique

 

Position

- arm table

- tourniquet

 

Incision

- avoid full exsanguination to see vascular structures more easily

- supinate forearm

- straight incision from flexion crease just lateral to biceps tendon down to radial styloid

 

Internervous plane

- proximally between brachioradialis / BR and pronator teres / PT (median nerve)

- distally between the BR (radial nerve) and FCR (median nerve) 

 

Superficial Dissection

- proximally between PT and BR

- distally between FCR and BR

- begin distal and work proximally

- superficial radial nerve deep to BR  / retract radially with BR

- recurrent leash of Henry from the radial artery to BR just below elbow joint need to be ligated 

- radial artery beneath the BR in middle of wound and runs with two vena commitante

- may need to be mobilised and retracted medially particularly proximally and distally

 

Deep Dissection

 

Proximal Third

- follow biceps tendon to insertion on bicipital tuberosity

- just lateral to tendon is bicep bursa

- incise bursa to access proximal radius 

- radial artery superficial and medial to tendon

- fully supinate the forearm to expose the supinator and protect the PIN

- incise supinator along insertion on radius and lift subperiosteally (anterior oblique line)

- reflect from medial to lateral

- 25% of patients: PIN in contact with radial neck / thus take care with retractors 

 

Middle third

- anterior aspect covered by PT and FDS

- insertion of PT into radius exposed by pronating forearm

- detach PT from insertion along with FDS subperiosteally

 

Distal third

- FPL and Pronator Quadratus arise from the anterior aspect of distal third of radius

- incise periosteum of radius just lateral to PQ and FPL 

- subperiosteally dissect medially off radius

- this protects Median Nerve

 

Dangers

- PIN

- superficial radial nerve

- radial artery

- recurrent radial artery (anterior and posterior groups lie either side of radial nerve)

 

Posterior Approach to Radius / Thompson approach

 

Concept

- between ECRB and EDC proximally

- between ECRB and EPL distally

 

Indications 

- ORIF of radial fractures

- non union of radial fractures 

- decompression of PIN

 

Technique

 

Position 

- supine with pronated forearm to expose the dorsal surface 

 

Incision

- from point just anterior to the lateral epicondyle to Lister's tubercle on dorsal radius 

 

Intermuscular plane 

- proximally is between the ECRB and EDC (PIN)

- distally the plane is between the ECRB and EPL (PIN)

 

Superficial Dissection

- deep fascia split in line of the skin incision

- identify plane between ECRB and EDC

- more obvious distally where the APL and EPB separate the two muscles 

- upper 1/3 contains the supinator at the base 

- proximal 1/3 then centres on exposure of the PIN between the two heads of supinator 

- PIN emerges 1cm proximal to distal edge of supinator 

- divides into branches to the extensor compartment 

 

Proximal to Distal PIN exposure

- detach origin of the ECRB and part of ECRL

- locate the PIN proximally and dissect out distally 

 

Distal to Proximal PIN exposure

- identify nerve as emerges from supinator and follow proximal 

- protecting all branches 

 

Deep Dissection

- once protected fully supinate the forearm to expose the supinator fully 

- strip the supinator subperiosteally to expose the proximal radius 

- in the middle 1/3 the APL and EPB blanket the approach as they cross the radius radially 

- they are mobilised by incising the superior and inferior borders 

- the distal 1/3 is exposed with subperiosteal dissection 

 

Dangers 

- 25% of cases have the PIN in touch with the radial shaft and so must be exposed 

- the nerve is protected with the supinator and reflected 

 

Extension

- proximally to expose the lateral epicondyle

- distally as the posterior approach to the wrist 

 

Approach to the Ulna

 

Indications 

- ORIF of Ulna fractures 

- treatment of delayed or non union of ulnar fractures 

- osteotomy of Ulna

- ulnar lengthening / shortening

 

Approach

 

Position 

- place arm across chest of the supine patient 

 

Incision 

- linear longitudinal incision along the subcutaneous border of the ulna 

 

Internervous plane 

- between the ECU and FCU 

- attach via shared aponeurosis onto subcutaneous border of the ulna

- cannot be separated at origin 

- fibers of ECU usually detached from the aponeurosis

 

Dissection 

- deep fascia incised along line of skin incision 

- continue to subcutaneous border of the ulna 

- proximally dissect between the Anconeus and FCU

- periosteum incised longitudinally 

- in proximal 1/5 part of triceps insertion released 

 

Dangers 

- the ulnar nerve lies on FDP deep to FCU

- safe as long as FCU stripped subperiosteally 

- in proximal dissections (1/5) should be identified between the two heads of FCU prior to stripping 

- ulnar artery also at risk 

- this incision also able to be extended proximally as posterior approach to humerus

 

 

 

 

 

 

Humerus

Approaches

 

Anterior

Anterolateral

Posterior

Lateral (to distal humerus)

 

Anterior Approach

 

Concept

- elevate biceps and split brachialis

 

Indication

- ORIF of humerus shaft

- humeral osteotomy

- biopsy and resection of tumors

- treatment of osteomyelitis

 

Technique

 

Position 

- arm on table and abducted 60o

- no tourniquet

 

Incision

- tip of coracoid process of scapula along the deltopectoral groove

- towards the deltoid insertion and then heads distally along the lateral border of biceps

- stop 5 cm proximal to elbow flexion crease

 

Internervous planes

- two

- proximally between the deltoid and pectoralis major

- distally between the two halves of Brachialis (musculocutaneous and radial nerve)

 

Superficial dissection

- mobilise cephalic vein in deltopectoral groove

- open fascia on lateral edge of biceps

- the biceps is reflected medially to expose the brachialis muscle

- musculocutaneous nerve identified between biceps and brachialis and protected

 

Deep dissection

 

Proximally 

- incise periosteum lateral to pect major insertion and lateral side of LHB tendon

- ligate ACHA

 

Distally 

- brachialis is split in midline

- lifted off the humerus subperiosteally

 

Dangers

- radial nerve at risk in two areas

- spiral groove on back of humerus (care with drilling AP)

- distal 1/3 (protected by lateral 1/2  of the brachialis muscle)

 

Extensile measures

- can extend proximally as anterior approach to shoulder 

- cannot extend distally - need to extend as anterolateral approach of distal humerus into forearm 

 

Anterolateral Approach

 

Concept

- between biceps / brachialis medially and BR / triceps laterally

- identify and protect radial nerve

 

Indication 

- ORIF humerus

- exploration radial nerve in distal arm 

 

Technique

 

Position  

- supine with arm abducted on hand table

 

Incision 

- from coracoid down deltopectoral groove

- lateral aspect of biceps

 

Internervous Plane

- no true internervous plane 

- between brachialis and brachioradialis

 

Superficial dissection

- retract biceps medially 

- find plane between the brachialis and brachioradialis 

- identify and protect radial nerve distally

- retract brachioradialis laterally and brachialis and biceps medially 

- stay on medial side of the radial nerve

- expose humerus subperiosteally 

 

Extension 

- proximal - deltopectoral groove

- distal - Henry's approach to forearm

 

Posterior Approach

 

Concept

- between long and lateral heads triceps

- medial head split

 

Indication 

- ORIF of distal 2/3 humerus

- exploration of radial nerve in spiral groove

 

Technique

 

Position 

- patient lateral decubitus

- arm over arm rest

- no tourniquet

 

Incision 

- posterior midline incision from 8 cm below the acromion to olecranon fossa

 

No true internervous plane

 

Superficial dissection

- divide fascia in midline

- develop the plane between the long and lateral heads of triceps

- small blood vessels cross the muscle and need to be coagulated

 

Deep dissection

- the medial head of triceps lies deep to the other two heads

- radial nerve lies in spiral groove proximal medial head

- identify and protect the radial nerve

- incise the medial head in midline to bone and then dissect subperiosteal off the bone to avoid the ulnar nerve

- never dissect to bone until the radial nerve is safe

 

Extensile measures

- cannot extend proximal to spiral groove due to deltoid crossing the field

- can extend distally over the olecranon

 

Lateral Approach to Distal Humerus

 

Concept

- between BR and Triceps

 

Indications

- ORIF of lateral condyle fractures 

- surgical treatment of tennis elbow 

 

Technique

 

Position 

- supine with arm abducted on hand table

 

Incision 

- 4-6cm curved incision on lateral aspect of elbow over the supracondylar ridge 

 

Internervous plane 

- between brachioradialis and triceps 

 

Superficial dissection

- BR anteriorly

- triceps posteriorly

- down onto supracondylar ridge

 

Extensile measures

- cannot extend proximally as radial nerve crosses the line of dissection 

- distal - can extend to radial head via plane between the ECU and Anconeus  (Kocher approach)

 

 

 

Shoulder

Approaches

 

Anterior

Anterolateral

Posterior

 

Anterior Approach / Deltopectoral

 

Indications

- shoulder stabilization

- arthroplasty

- fracture fixation

 

Approach

 

Position

- beach chair

- upper body elevated 30- 40o / reduces venous pressure and bleeding

- knees flexed / pressure point care

- headrest

- sandbag under ipsilateral shoulder / lifts shoulder forward so arm can fall back / opens GHJ

- arm draped free

 

Landmarks

- coracoid process and deltoid groove

 

Incisions

 

1. Anterior

- deltopectoral groove

- from coracoid to axilla

 

2. Axillary

- incision in anterior axillary skin fold

- requires more extensive undermining of skin edges

 

Superficial Dissection

- find cephalic vein in deltopectoral groove

- take laterally or medially (more branches to ligate)

- finger dissection in groove and up to coracoid

- insert retractor

- identify conjoint tendon

- dissection remains lateral to conjoined tendon to avoid NV bundle

- musculocutaneous nerve enters medially

- divide clavipectoral fascia

- elevate subdeltoid space

- place retractor under conjoint tendon / gentle retraction

 

Deep dissection

- subscapularis muscle underlies clavipectoral fascia

- arm put in ER to reveal SSC 

- sutures in medial aspect SSC

- subscapularis incised 1cm from insertion and separated from capsule

- leave inferior 1/4 of SSC to protect AXN

 

Anterior shoulder approach

 

Extension

 

Proximally

- superomedially over middle 1/3 clavicle 

- perform clavicular osteotomy to gain access to underlying axillary artery and brachial plexus

 

Distally

- release upper 1/2 pectoralis raphe +/- part deltoid insertion

- biceps retracted medially & brachialis split

 

Anterolateral Approach

 

Indications

- acromioplasty

- ACJ resection

- open rotator cuff repair

- ORIF GT fracture

- IM humeral nail

 

Approach

 

Position

- beach chair

 

Incision

- antero-lateral corner of the acromion

- transversely from ACJ along anterior edge acromion

- antero-laterally from AL corner acromion

 

Dissection

- find raphae between anterior and lateral deltoid

- deltoid split, must protect underlying rotator cuff

- detach anterior deltoid from anterior acromion

- control bleeding acromial branch of thoracoacromial artery

- axillary nerve 7 cm below acromion

- cannot split futher than 5 cm below acromion

- coracoacromial ligament detached from acromion

- bursectomy

- humeral head rotated to examine RC

 

Posterior approach

 

Indications

- open posterior stabilisation

- glenoid osteotomy / bone graft

- ORIF glenoid neck fracture

 

Approach

 

Shoulder Posterior ApproachPosterior shoulder anatomy

 

Position

- lateral position with arm draped free

- beach chair with access to posterior shoulder

 

Landmarks

- acromion and scapula spine

 

Incision

1.  Transverse along entire scapular spine to PL corner acromion

2.  Longitudinal from postero-lateral acromion to axilla

 

Internervous plane

- between IS (suprascapular nerve) and T minor (axillary nerve)

 

Superficial dissection

 

1. Deltoid split in line of fibres

- infraspinatous and teres minor exposed

- IS tagged laterally then detached 1 cm from insertion

- joint capsule exposed

 

Posterior shoulder approachPosterior shoulder approachPosterior shoulder approachPosterior shoulder approach

 

2. Detach deltoid from spine of scapula

- reflect deltoid laterally

- expose infraspinatus

- tenotomy

 

Posterior approach shoulder Posterior approach shoulder 2Posterior approach shoulder 3

 

Posterior approach shoulder 4Posterior approach shoulder 5Posterior approach shoulder 6

 

 

 

Dangers

 

Axillary nerve / posterior circumflex humeral artery

- emerges through quadrangular space beneath T minor

 

Suprascapular nerve

- passes around base of scapular spine

- IS must not be forcefully retracted medially to stretch the nerve around base of scapular spine

Wrist

Approaches

 

Volar

Dorsal

 

Volar Approach

 

Indications 

- decompression of median nerve

- synovectomy of the flexor tendons of wrist

- ORIF distal radial fractures

 

Technique

 

Incision 

- curve incision around thenar eminence from the midpalm (ulnar to thenar crease)

- to flexion crease of wrist (don't cross at 900)

- then along FCR

 

Superficial dissection

- dissect through fat

- avoid the palmar cutaneous branch of the median Nnerve

- incise fascia over FCR

- mobilse FCR ulna side

- reflect pronator quadratus from radial side

- expose distal radius

 

Dorsal Approach

 

Indications 

- synovectomy 

- repair of extensor tendons in rheumatoid 

- wrist fusion 

- SL repair

- dorsal wrist ORIF

- proximal row carpectomy 

- tumour biopsy

 

Technique

 

Incision

- 8 cm long and longitudinal crossing the wrist joint midway between the radial and ulnar styloids 

- 3 cm proximal to wrist joint and 5 cm distal to it 

 

Superficial dissection

- protect branches SRN

- expose the extensor retinaculum 

- incise retinaculum over the EDC and EIP tendons in 4th wrist compartment 

- reflect EPL to radial side

- reflect EDC to ulna side

- expose the underlying distal radius 

 

Capsulotomy

- longitudinal capsulotomy 

- ligament sparing / radially based between DRC and DIC ligaments