Surgical Approaches to the Elbow
Surgical Approaches to the Elbow
ELBOW APPROACHES
Luke S. Austin Joseph A. Abboud Matthew L. Ramsey Gerald R. Williams Jr.
The surgical exposures described for the elbow are divided into posterior, medial, and lateral approaches. These descriptions denote the deep surgical interval employed (Table 1).
Often, these deep approaches can be performed through a direct medial or lateral skin incision. Alternately, a midline posterior incision can be used and then subcutaneous flaps can be created to access the deeper medial or lateral intervals.
POSTERIOR APPROACH TO THE ELBOW
Releasing the triceps attachment to the olecranon is not advisable, owing to the difficulty of adequate repair and possible disruption during rehabilitation. Today, there are four choices of posterior exposure:
Triceps splitting Triceps reflecting Triceps preserving Olecranon osteotomy
Triceps-Splitting Approaches
Posterior Triceps-Splitting Approach (Campbell)
Care must be exercised to maintain the medial portion of the triceps expansion over the forearm fascia in continuity with the flexor carpi ulnaris.
Laterally, the anconeus and triceps are more stable, with less chance of disruption.
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Indications Total elbow arthroplasty ORIF of distal humerus fracture Removal of loose bodies |
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Table 1 Indications and Recommended and Alternative Surgical Approaches
Indication Recommended Approach Alternative Approach
Total elbow arthroplasty Bryan-Morrey, extended Kocher Gschwend et al, Campbell, and Wadsworth |
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Soft tissue reconstruction
Global
Kocher, Bryan-Morrey, and
Hotchkiss
T intercondylar fracture
MacAusland with chevron
olecranon osteotomy
Alonso-Llames
Radial head fracture
Kocher
Kaplan
Capitellum fracture
Kaplan extended lateral
approach
Kocher with or without Kaplan
Coronoid fracture
Taylor and Scham
Hotchkiss
Extra-articular distal
humerus fracture
Alonso-Llames
Bryan-Morrey, Campbell
Monteggia fracture-
dislocation
Gordon
Boyd
Radioulnar synostosis
excision
Kocher or Gordon
Boyd or Henry
Capsulectomies
Posterior exposure of the joint for ankylosis, sepsis, synovectomy, and ulnohumeral arthroplasty
Approach
Skin incision begins in the midline over the triceps, about 10 cm above the joint line, and is generally placed laterally or medially across the tip of the olecranon. It continues distally over the lateral aspect of the subcutaneous border of the proximal ulna for about 5 to 6 cm (FIG 1A).
Triceps is exposed, along with the proximal 4 cm of the ulna.
A midline incision is made through the triceps fascia and tendon as it is continued distally across the insertion of the triceps tendon at the tip of the olecranon and down the subcutaneous crest of the ulna (FIG 1B).
Triceps tendon and muscle are split longitudinally, exposing the distal humerus.
The anconeus is then reflected subperiosteally laterally, whereas the flexor carpi ulnaris is similarly retracted medially.
Insertion of the triceps is carefully released from the olecranon, leaving the extensor mechanism in continuity with the forearm fascia and muscles medially and laterally (FIG 1C).
Ulnar nerve is visualized and protected in the cubital tunnel.
Closure of the triceps fascia is required only proximal to the olecranon, but the insertion should be repaired to the olecranon with a suture passed through the ulna.
The incision is then closed in layers.
Triceps-Splitting, Tendon-Reflecting Approach (Van Gorder)
A variation of the technique described earlier Allows lengthening of the triceps if necessary
Has been largely abandoned in favor of the triceps-reflecting techniques
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FIG 1 • A. Skin incision for the posterior triceps-splitting approach. B. Medial and lateral flaps are elevated, allowing full access to the triceps tendon. The ulnar nerve is isolated along the medial border with a vessel loop.
C. The insertion of the triceps being elevated off the olecranon from medial to lateral. (A: Courtesy of Asif M. Ilyas, MD, and Jesse B. Jupiter, MD; B,C: Courtesy of Srinath Kamineni, MD.)
Indications
Same as those for midline-splitting approach described earlier
Approach
A posterior midline incision begins 10 cm proximal to the olecranon and extends distally onto the subcutaneous border of the ulna between the anconeus and the flexor carpi ulnaris.
Triceps fascia and aponeurosis are exposed along the tendinous insertion into the ulna.
Tendon is reflected from the muscle in a proximal to distal direction, freeing the underlying muscle fibers while preserving the tendinous attachment to the olecranon (FIG 2).
Triceps muscle is then split in midline, and the distal humerus is exposed subperiosteally.
Periosteum and triceps are elevated for a distance of about 5 cm proximal to the olecranon fossa, exposing the posterior aspect of the joint.
If more extensive exposure is desired, the subperiosteal dissection is extended to the level of the joint, exposing the condyles both medially and laterally.
Ulnar nerve should be identified and protected.
After the procedure, if an elbow contracture has been corrected, the joint should be maximally flexed.
The tendon slides distally from its initial position, and the proximal muscle and tendon are reapproximated in the lengthened relationship.
The distal part of the triceps is then securely sutured to the fascia of the triceps expansion, and the remainder of the wound is closed in layers.
Triceps-Reflecting Approaches
The triceps mechanism may be preserved in continuity with the anconeus and simply reflected to one side or the other.
Three surgical approaches have been described that preserve the triceps muscle and tendon in continuity with the distal musculature of the forearm fascia and expose the entire joint.
Bryan-Morrey Posteromedial Triceps-Reflecting Approach
Developed to preserve the continuity of the triceps with the anconeus
Indications
Total elbow arthroplasty Interposition arthroplasty
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FIG 2 • Triceps-splitting, tendon-reflecting approach. The tendon is reflected from the muscle in a proximal to distal direction.
P.13
Surgical treatment of elbow dislocations ORIF of distal humerus fracture Synovial disease
Infection
Approach
A straight posterior incision is made medial to the midline, about 9 cm proximal and 8 cm distal to the tip of the olecranon (FIG 3A).
The ulnar nerve is identified proximally at the margin of the medial head of the triceps and, depending on the procedure, is either protected or carefully dissected to its first motor branch and transposed anteriorly.
The medial aspect of the triceps is elevated from the posterior capsule.
The fascia of the forearm between the anconeus and the flexor carpi ulnaris is incised distally for about 6 cm.
The triceps and the anconeus are elevated as one flap from medial to lateral, skeletonizing the olecranon and subcutaneous border of the ulna (FIG 3B). This should be performed at 20 to 30 degrees of flexion to relieve tension on the insertion, thereby facilitating dissection.
The collateral ligaments may be released from the humerus for exposure as needed (FIG 3C).
If stability is important, these ligaments should be preserved or anatomically repaired at the conclusion of the surgery.
When performing a linked total elbow replacement, it is not necessary to preserve or repair the collateral ligaments.
The triceps attachment can be thin at the attachment to the ulna, and it is not uncommon for a buttonhole to be created when reflecting the triceps.
To prevent this, the flap can be raised as an osteoperiosteal flap (see osteoanconeus flap approach). A small osteotome is used to elevate the fascia with the petals of bone.
The flap is mobilized laterally, elevating the anconeus origin from the distal humerus until it can be folded over the lateral humeral condyle.
At this point, the radial head can be visualized.
The tip of the olecranon can be excised to help expose the trochlea.
Osteoanconeus Flap Approach
This provides excellent extension and reliable healing of the osseous attachment to the olecranon.
This approach exposes only the ulnar nerve, whereas the Mayo approach translocates the nerve.
Indications
This is a triceps-reflecting approach similar in concept to the Bryan-Morrey triceps-reflecting approach. Most often used for joint replacement or distal humeral fractures
Approach
A straight posterior incision is made medial to the midline, about 9 cm proximal and 8 cm distal to the tip of the olecranon.
The ulnar nerve is identified and protected but not translocated.
The triceps attachment is released from the ulna by osteotomizing the attachment with a thin wafer of bone.
This is the essential difference from the Bryan-Morrey approach.
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FIG 3 • The Bryan-Morrey posterior approach. A. Straight posterior skin incision. B. The ulnar nerve has been translocated anteriorly. The medial border of the triceps is identified and released, and the superficial forearm fascia is sharply incised to allow reflection of the fascia and periosteum from the proximal ulna. C. The extensor mechanism has been reflected laterally, and the collateral ligaments have been released.
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The medial aspect of the triceps, in continuity with the anconeus, is elevated from the ulna (FIG 4A,B).
The collateral ligaments are either maintained or released, depending on the pathology being addressed and the need for stability.
After the surgical procedure, the wafer of bone is secured to its bed by nonabsorbable sutures placed through bone holes (FIG 4C).
Interrupted sutures are used to repair the remaining distal portion of the extensor mechanism.
Extensile Kocher Posterolateral Triceps-Reflecting Approach
Indications
Joint arthroplasty Ankylosis
ORIF of distal humerus fractures Synovectomy
Radial head excision Infection
Approach
Extensile exposure from the Kocher approach
Skin incision begins 8 cm proximal to the joint just posterior to the supracondylar ridge and continues distally over the Kocher interval between the anconeus and extensor carpi ulnaris about 6 cm distal to the tip of the olecranon.
Proximally, the triceps is identified and freed from the brachioradialis and extensor carpi radialis longus along the intramuscular septum to the level of the joint capsule.
The interval between the extensor carpi ulnaris and the anconeus is identified distally.
The triceps in continuity with the anconeus is subperiosteally reflected. Sharp dissection frees the bony attachment of the triceps expansion to the anconeus from the lateral epicondyle.
The triceps remains attached to the tip of the olecranon.
The lateral collateral ligament complex is released from the humerus.
The joint may be dislocated with varus stress. If additional exposure is necessary, the anterior and posterior capsule can be released.
Routine closure of layers is performed, but the radial collateral ligament should be reattached to the bone through holes placed in the lateral epicondyle.
Mayo Modified Extensile Kocher Approach
The extensile Kocher approach and the Mayo modification of the extensile Kocher approach provide sequentially greater exposure from the initial Kocher approach.
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FIG 4 • Posterior view of the right elbow demonstrates a straight fascial incision to the lateral aspect of the tip of the olecranon. A. The line of release after the ulnar nerve has been identified and protected. B. The olecranon has been osteotomized and the triceps swept from medial to lateral in continuity with the anconeus and forearm fascia. (continued)
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FIG 4 • (continued) C. Closure with sutures placed through bone and the distal extensor mechanism is done with interrupted sutures.
Indications
Release of ankylosed joint Interposition arthroplasty Replacement arthroplasty
Approach
A modification of the extensile Kocher approach consists of reflecting the anconeus and triceps expansion from the tip of the olecranon by sharp dissection.
The extensor mechanism (triceps in continuity with the anconeus) may be reflected from lateral to medial.
The ulnar nerve should be decompressed or transposed if an extensile lateral approach is used. The triceps is reattached in a fashion identical to that described for the Mayo approach.
Triceps-Preserving Approaches
Posterior Triceps-Sparing Approach
Because the triceps is not elevated from the tip of the olecranon, rapid rehabilitation is possible.
Indications
Tumor resection
Joint reconstruction for resection of humeral nonunion Joint replacement
Approach
A posterior incision is made medial to the tip of the olecranon. Medial and lateral subcutaneous skin flaps are elevated.
The ulnar nerve is identified and transposed anteriorly.
The medial and lateral aspects of the triceps are identified and developed distally to the triceps attachment on the ulna (FIG 5).
For distal humerus fractures fixation
The common flexors and common extensors are partially released from the distal humerus to expose the supracondylar column for plate fixation.
For total elbow arthroplasty or tumor resection
The common flexors and extensors are fully released from the medial and lateral epicondyle. The collateral ligaments and capsule are released and the distal humerus is excised.
The distal humerus is exposed by bringing it through the defect along the lateral margin of the triceps (FIG 6).
The ulna is exposed by supinating the forearm.
After the implant has been inserted, the joint is articulated.
There is no need to close or repair the extensor mechanism with this approach.
Olecranon Osteotomy
Worldwide, the transosseous approach is probably the exposure most often used, especially for distal humeral fractures.
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The oblique osteotomy has almost been abandoned, and the transverse osteotomy has largely been replaced by the chevron.
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FIG 5 • Posterior triceps-sparing approach. (A) Medial window begins distally between the olecranon and flexor carpi ulnaris and proceeds proximally between the triceps and the intramuscular septum. The ulnar nerve should be transposed anteriorly. (B) Lateral window begins distally between the olecranon and the anconeus and proceeds proximally, splitting the lateral head of the triceps.
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FIG 6 • Exposure of the distal humerus through the lateral window. A, distal humerus; B, radial head; C, triceps tendon; D, olecranon; E, penrose drain placed around the ulnar nerve.
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FIG 7 • Olecranon osteotomy. A. The triceps is released medially and laterally, whereas the ulnar nerve is protected. B. A chevron osteotomy with a distal apex is initiated with an oscillating saw. C. The proximal portion containing the olecranon osteotomy and triceps tendon is retracted proximally, exposing the elbow joint.
Chevron Transolecranon Osteotomy
Intra-articular osteotomy, first described by MacAusland, was originally recommended for ankylosed joints.
It has been adapted by some for radial head excision and synovectomy and used or modified by others for T and Y condylar fractures.
The chevron osteotomy enhances rotational stability compared to a transverse osteotomy.
Indications
Ankylosed joints
Intra-articular distal humerus fractures
Approach
A posterior incision is made medial to the tip of the olecranon. Medial and lateral subcutaneous skin flaps are elevated.
The ulnar nerve is identified and transposed anteriorly.
The medial and lateral aspects of the triceps are identified and developed distally to the triceps attachment on the ulna.
An apex-distal chevron or V osteotomy is performed with a thin oscillating saw but not completed through the subchondral bone. An osteotome completes the osteotomy, creating irregular surfaces that interdigitate increasing stability (FIG 7A,B).
The triceps tendon, along with the osteotomized portion of the olecranon, may then be retracted proximally, and by flexing the elbow joint, the joint can be exposed (FIG 7C).
Occasionally, the medial or lateral collateral ligaments are released for better exposure.
These ligaments are then repaired at the end of the procedure.
At the completion of the procedure, the tip of the olecranon is secured via tension band, screw, or plate fixation.
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Ulnar nerve
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The ulnar nerve must be identified and protected whenever performing a
posterior approach to the elbow.
Radial
nerve
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The radial nerve is in danger when proximal exposure exceeds 10 cm from the
lateral epicondyle.
Triceps ▪ Triceps insufficiency typically occurs due to fixation failure (tendon or osteotomy).
insufficiency Performing a triceps-sparing approach is the best method of preventing this complication.
PEARLS AND PITFALLS
LATERAL APPROACH TO THE ELBOW
Lateral exposures to the elbow are widely used to treat a variety of elbow pathologies. The exposures differ according to the deep interval used.
With any of the lateral exposures to the joint or to the proximal radius, the surgeon must be constantly aware of the possibility of injury to the posterior interosseous or recurrent branch of the radial nerve.
Anterolateral Approach to the Elbow (Kaplan)
Indications
Anterior capsular release
Posterior interosseous nerve exposure Capitellar/lateral column fractures
Approach
Deep interval for the anterolateral approach lies between the extensor digitorum communis and the extensor carpi radialis longus muscles. (Intermuscular interval is best found by observing where vessels penetrate the fascia along the anterior margin of the extensor digitorum communis aponeurosis.)
Fascia is split longitudinally between the extensor digitorum communis and the extensor carpi radialis longus. (As the dissection is carried deep through the extensor carpi radialis longus, the extensor carpi radialis brevis is encountered.)
Deep to the extensor carpi radialis brevis, the transversely oriented fibers of the supinator are encountered,
along with the posterior interosseous nerve. The posterior interosseous nerve defines the distal extent of the exposure. Pronation moves the radial nerve away from the surgical field.
If required, proximal dissection with elevation of the extensor carpi radialis longus, extensor carpi radialis brevis, and brachioradialis anteriorly from the lateral supracondylar ridge of the humerus provides exposure of the anterior joint capsule.
Modified Distal Kocher Approach
Indications
Reconstruction of the lateral ulnar collateral ligament
Approach
The skin incision begins just proximal to the lateral epicondyle of the humerus and extends obliquely for about 6 cm in line with the fascia of the anconeus and extensor carpi ulnaris muscles (FIG 8A).
The Kocher interval between the anconeus and extensor carpi ulnaris is incised (FIG 8B). Development of the Kocher interval reveals the lateral joint capsule.
The anconeus is then reflected posteriorly off the joint capsule distally to expose the crista supinatoris.
The extensor carpi ulnaris and the common extensor tendon are released from the lateral epicondyle and reflected anteriorly, exposing the lateral capsule. The radial nerve is at a safe distance from the dissection, and it is protected by the extensor carpi ulnaris and extensor digitorum communis muscle mass (FIG 8C).
A longitudinal incision is made through the capsules to expose the radiocapitellar joint.
Boyd (Posterolateral) Approach
Radioulnar synostosis may occur as the proximal radius and ulna are exposed subperiosteally.
Indications
Monteggia fracture-dislocations Radial head fractures
Resection of radioulnar synostosis
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FIG 8 • Distal Kocher approach. A. The incision begins about 2 to 3 cm above the lateral epicondyle over the supracondylar ridge and extends distally and posteriorly for about 4 cm. (continued)
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FIG 8 • (continued) B. The interval between the anconeus and the extensor carpi ulnaris is identified. C.
Development of this interval reveals the capsule.
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Approach
The incision begins just posterior to the lateral epicondyle lateral to the triceps tendon and continues distally to the lateral tip of the olecranon and then down to the subcutaneous border of the ulna.
The anconeus and supinator are subperiosteally elevated from the subcutaneous border of the ulna (anconeus and supinator) (FIG 9A,B).
Retraction of the anconeus and supinator exposes the joint capsule overlying the radial head and neck.
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FIG 9 • The Boyd approach. A. The incision begins along the lateral border of the triceps about 2 to 3 cm above the epicondyle and extends distally over the lateral subcutaneous border of the ulna about 6 to 8 cm past the tip of the olecranon. The ulnar insertion of the anconeus and the origin of the supinator muscle are elevated subperiosteally. More distally, the subperiosteal reflection includes the abductor pollicis longus, the extensor carpi ulnaris, and the extensor pollicis longus muscles. The origin of the supinator at the crista supinatoris of the ulna is released, and the entire muscle flap is retracted radially, exposing the radiohumeral
joint. B. The posterior interosseous nerve is protected in the substance of the supinator.
The supinator muscle protects the posterior interosseous nerve.
This lateral capsule contains the lateral ulnar collateral ligament, and its division can lead to posterolateral rotatory instability.
To expose the radial shaft, the incision may be continued along the subcutaneous ulnar border, elevating the muscles off the lateral aspect of the ulna (extensor carpi ulnaris, abductor pollicis longus, and extensor pollicis longus).
The posterior interosseous and recurrent interosseous arteries may need ligation.
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PEARLS AND PITFALLS
Posterior ▪ The posterior interosseous nerve prevents distal extension of the lateral
interosseous exposure. Pronation of the forearm can help protect the nerve. It is at most risk nerve with the Kaplan approach.
Lateral ulnar
collateral ligament
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Incision through the lateral capsule can disrupt the lateral ulnar collateral
ligament and lead to posterior lateral rotatory instability.
MEDIAL APPROACH TO THE ELBOW
There are relatively few indications for medial exposure of the elbow joint. This has been superseded by arthroscopic approaches.
The most valuable contribution to medial joint exposure is that described by Hotchkiss. This extensile exposure provides greater flexibility, particularly for exposure of the coronoid and for contracture release.
Extensile Medial Over-the-Top Approach
Excellent visualization of the anteromedial and posteromedial elbow
Not a sufficient approach for excision of heterotopic bone on the lateral side of the joint
Does not provide adequate access to the radial head
Indications
Coronoid fractures
Contracture release (when ulnar nerve exploration required) Anterior and posterior access to the joint
May be converted to a triceps-reflecting exposure of Bryan-Morrey
Approach
Superficial dissection
Skin incision can vary between the boundaries of a pure posterior skin incision and midline medial incision (FIG 10A).
Subcutaneous skin is elevated.
The medial supracondylar ridge of the humerus, the medial intramuscular septum, the origin of the flexor pronator mass, and the ulnar nerve are identified.
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FIG 10 • A. Medial skin incision along the midline. B. The medial intermuscular septum (light blue) is excised from the medial epicondyle to 5 cm proximal to it. The ulnar nerve is shown tagged with a suture loop. C,D. If the extensile exposure is needed, the entire flexor pronator muscle mass is elevated from the medial epicondyle. (continued)
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FIG 10 • (continued) E. The capsule can be sharply excised in cases of capsular contracture.
Anterior to the septum, running just on top of the fascia (not in the subdermal tissue), the medial antebrachial cutaneous nerve is identified and protected.
The ulnar nerve is identified. If the patient previously had surgery, the ulnar nerve should be identified proximally before the surgeon proceeds distally.
If anterior transposition was performed previously, the nerve should be mobilized carefully before the operation proceeds.
The surface of the flexor-pronator muscle mass origin is found by sweeping the subcutaneous tissue laterally with the medial antebrachial cutaneous nerve in this flap of subcutaneous tissue.
The medial intramuscular septum divides the anterior and posterior compartments of the elbow. The medial intramuscular septum is ultimately excised from the medial epicondyle to 5 cm proximal to it (FIG 10B).
The ulnar nerve is protected, and the veins at the base of the septum are cauterized.
Deep anterior exposure
The flexor pronator mass origin is identified and totally or partially released from the medial epicondyle.
If extensile exposure is needed, the entire flexor-pronator mass is elevated from the medial epicondyle (FIG 10C,D).
If less extensile exposure is needed, the flexor-pronator mass is divided parallel to the fibers, leaving about 1.5 cm of flexor carpi ulnaris tendon attached to the epicondyle.
A small cuff of fibrous tissue of the origin can be left on the supracondylar ridge as the muscle is elevated; this facilitates reattachment when closing.
The flexor-pronator origin should be dissected down to the level of bone but superficial to the joint capsule. As this plane is developed, the brachialis muscle is encountered from the underside.
The brachialis muscle is identified along the supracondylar ridge and released in continuity with the flexor-pronator mass.
These muscles should be kept anterior and elevated from the capsule and anterior surface of the distal humerus.
The median nerve and the brachial vein and artery are superficial to the brachialis muscle and protected with the subperiosteal release of the brachialis.
Dissection of the capsule proceeds laterally and distally to separate it from the brachialis.
In the case of contracture, the capsule, once separated from the overlying brachialis and brachioradialis, can be sharply excised (FIG 10E).
Deep posterior capsule exposure
The ulnar nerve is mobilized to permit anterior transposition with a dissection carried distally to the first motor branch to allow the nerve to rest in the anterior position without being sharply angled as it enters the flexor carpi ulnaris.
With the Cobb elevator, the triceps is elevated from the posterior distal surface of the humerus.
The posterior capsule can be separated from the triceps as the elevator sweeps from the proximal to distal.
Closure
The flexor-pronator mass should be reattached to the supracondylar ridge.
The ulnar nerve should be transposed and secured with a fascial sling to prevent posterior subluxation.
Ulnar nerve
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The ulnar nerve must be exposed and isolated throughout the case.
Median nerve and
brachial artery
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These structures are at risk when exposing anterior to the brachialis or
medial to the pronator teres.
Medial antebrachial
cutaneous nerve
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This nerve should be identified just superficial to the fascia and
protected to prevent injury and possible neuroma formation.
PEARLS AND PITFALLS
ANTERIOR APPROACH TO THE ELBOW
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Because of the vulnerability of the brachial artery and median nerve, the anteromedial approach to the elbow is not recommended.
The extensile exposure described by Henry, and modified by Fiolle and Delmas, is best known and is the most useful for anterior exposure of the joint. Minor modifications of the Henry approach have been described, and a limited anterolateral exposure has been described by Darrach.
Modified Anterior Henry Approach
Indications
Anteriorly displaced fracture fragments Excision of tumors in this region
Reattachment of the biceps tendon to the radial tuberosity Exploration of nerve entrapment syndromes
Anterior capsular release for contracture
Approach
The skin incision begins about 5 cm proximal to the flexor crease of the elbow joint and extends distally along the anterior margin of the brachioradialis muscle to the flexion crease.
At the elbow flexion crease, the incision turns medially to avoid crossing the flexor crease at a right angle. The incision continues transversely to the biceps tendon and then turns distally over the medial volar aspect of the forearm (FIG 11A).
The fascia is released distally between the brachioradialis and pronator teres.
The interval between the brachioradialis laterally and the biceps and brachialis medially is identified. This interval is entered proximally, and gentle, blunt dissection demonstrates the radial nerve coursing on the inner surface of the brachioradialis muscle (FIG 11B).
Care is taken to avoid injury to the superficial sensory branch of the radial nerve.
Because the radial nerve gives off its branches laterally, it can safely be retracted with the brachioradialis muscle.
At the level of the elbow joint, as the brachioradialis is retracted laterally and the pronator teres is gently retracted medially, the radial artery can be observed where it emerges from the medial aspect of the biceps tendon, giving off its muscular and recurrent branches in a mediolateral direction.
The muscle branch is ligated, but the recurrent radial artery should be sacrificed only if the lesion warrants an extensive exposure.
The posterior interosseous nerve enters the supinator and continues along the dorsum of the forearm distally.
Dissection continues distally, exposing the supinator muscle, which covers the proximal aspect of the radius and the anterolateral aspect of the capsule (FIG 11C).
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FIG 11 • The anterior Henry approach. A. An incision is made about 5 cm proximal to the elbow crease on the lateral margin of the biceps tendon. It extends transversely across the joint line and curves distally over the medial aspect of the forearm. The interval between the brachioradialis and brachialis proximally and the biceps tendon and pronator teres in the distal portion of the wound is identified. The radial nerve is protected and retracted along with the brachialis. B. The supinator muscle is released from the anterior aspect of the radius, which is fully supinated. (continued)
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FIG 11 • (continued) C. The radial recurrent branches of the radial artery and its muscular branches are identified and sacrificed if more extensive exposure is required. The biceps tendon is retracted medially along with the brachialis muscle. D. This interval may now be developed to expose the anterior aspect of the elbow joint.
Muscle attachments to the anterior aspect of the radius and those distal to the supinator include the discrete tendinous insertion of the pronator teres and the origins of the flexor digitorum sublimis and the flexor pollicis longus.
The brachialis muscle is identified, elevated, and retracted medially to expose the proximal capsule.
If more distal exposure is needed, the forearm is fully supinated, demonstrating the insertion of the supinator muscle along the proximal radius.
This insertion is incised, and the supinator is subperiosteally retracted laterally (FIG 11D).
The supinator serves as a protection to the deep interosseous branch of the radial nerve, but excessive retraction of the muscle should be avoided.
The proximal aspect of the radius and the capitellum are thus exposed.
Additional visualization may be obtained both proximally and distally because the radial nerve has been identified and can be avoided proximally.
The posterior interosseous nerve is protected distally by the supinator muscle, and the radial artery is visualized and protected medially if a more extensile exposure is required.
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PEARLS AND PITFALLS |
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Radial nerve |
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and posterior interosseous nerve
interosseous nerve branches off just distal to the radial head and courses laterally around the radial neck. Excessive retraction or improper retractor placement may injure the nerve.
Radial recurrent artery
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Radial recurrent artery should be ligated if distal exposure is required.