SHOULDER APPROACHES

Luke S. Austin Joseph A. Abboud Matthew L. Ramsey Gerald R. Williams, Jr.

ANTERIOR APPROACH TO THE SHOULDER

Indications

Surgical stabilization for recurrent dislocations Subscapularis repair and biceps tenodesis Shoulder arthroplasty

Fracture fixation

 

 

Incisions

 

 

Anterior shoulder can be approached through two different incisions. Anterior incision

 

A 10- to 15-cm incision along the deltopectoral interval (FIG 1A)

 

Incision begins just above the coracoid process and progresses toward the deltoid tuberosity.

 

Axillary incision

 

 

Vertical incision 8 to 10 cm long (FIG 1B)

 

Incision begins inferior to the tip of the coracoid and progresses toward the anterior axillary fold.

 

 

 

FIG 1 • A. Deltopectoral incision. B. Axillary incision beginning inferior to the tip of the coracoid and progressing toward the anterior axillary fold. C. In this dissection, the subscapularis tendon is being tagged at the superior border of the rotator interval.

 

Internervous Plane

 

Deltoid muscle is supplied by the axillary nerve.

 

Pectoralis major muscle is supplied by medial and lateral pectoral nerves.

 

Surgical Dissection

 

 

Skin flaps are developed around the deltopectoral interval. The deltopectoral interval, with its cephalic vein, is identified.

 

The deltopectoral interval is developed by retracting the pectoralis major medially and the deltoid laterally.

 

 

Vein may be retracted either medially or laterally.

 

We prefer to take it laterally, as fewer tributaries are disrupted.

 

The lateral border of the conjoint tendon is identified and the short head of the biceps (supplied by the musculocutaneous nerve) and coracobrachialis (supplied by the musculocutaneous nerve) are retracted medially to allow access to the anterior aspect of the shoulder joint.

 

 

Simple medial retraction of the conjoined tendon may be enough for a procedure such as subscapularis repair or capsular repair.

 

 

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If more exposure is necessary, the conjoint tendon can be detached with the tip of the coracoid process. The axillary artery is surrounded by cords of brachial plexus, which lie behind the pectoralis minor muscle.

 

To minimize risk for nerve injury, the arm should be kept adducted while work is being done around the coracoid process.

 

 

Remember, the musculocutaneous nerve enters the coracobrachialis on its medial side. Overly aggressive retraction can cause a neurapraxia of the musculocutaneous nerve.

 

Behind the conjoined tendon of the coracobrachialis and the short head of biceps lies the subscapularis muscle.

 

Externally rotating the arm brings the subscapularis further into the operative field.

 

 

This maneuver increases the distance between the subscapularis and axillary nerve as it disappears below the lower border of the muscle.

 

Identifiable landmarks on the inferior border of the subscapularis are three small vessels (from the anterior humeral circumflex artery) that run transversely and often require ligation or cauterization.

 

These vessels run as a triad (often called the three sisters): a small artery with its two surrounding venae comitantes.

 

The superior border of the subscapularis muscle blends in with the fibers of the supraspinatus muscle in the rotator interval (FIG 1C).

 

 

The tendon of the subscapularis is tagged with stay sutures.

 

There are various ways of taking down the subscapularis as per surgeon preference.

 

 

 

Some divide the subscapularis 1 to 2 cm from its insertion onto the lesser tuberosity. Some detach this insertion with a small flake of bone using an osteotome.

 

Some release the insertion subperiosteally directly from its insertion onto the lesser tuberosity.

 

 

The inferior border of the subscapularis is the easiest location to allow separation between the subscapularis and capsule.

 

The capsule is incised longitudinally to enter the joint wherever the selected repair must be performed.

 

Axillary nerve

• The axillary nerve branches off the posterior cord of the brachial plexus

and transverses under the subscapularis muscle posteriorly through the quadrilateral space. Traction or excessive inferomedial dissection can place the nerve at risk.

Musculocutaneous ▪ The musculocutaneous nerve branches off the lateral cord and enters the

nerve medial aspect of the conjoint tendon about 5 cm distal to the coracoid.

Excessive retraction on the conjoint tendon can lead to nerve palsy.

Axillary artery and

brachial plexus

• The axillary artery and brachial plexus course medially to the coracoid.

Dissection medial to the coracoid will place these structures at risk.

 

PEARLS AND PITFALLS

 

 

ANTEROSUPERIOR APPROACH TO THE SHOULDER

 

Indications

Rotator cuff repair

Subacromial decompression of the shoulder Acromioclavicular reconstructions

Open reduction and internal fixation (ORIF) of greater tuberosity fractures Removal of calcific deposits from the subacromial bursa

Reverse shoulder replacement Intramedullary nailing of humerus fractures

 

 

Incision

 

An incision is made paralleling the lateral acromion that begins at the anterolateral corner of the acromion and ends just lateral to the tip of the coracoid (FIG 2A).

 

Internervous Plane

 

The deltoid muscle is detached proximal to its nerve supply; therefore, there is no internervous plane with this approach.

 

Surgical Dissection

 

 

The incision is deepened to the deep deltoid fascia. Subcutaneous flaps are raised.

 

The location of the deltoid split depends on the pathology being managed. When the pathology requires more exposure, moving the deltoid split posteriorly will improve exposure (FIG 2B).

 

Subperiosteally, the anterior deltoid is elevated from the acromion and the acromioclavicular joint. Continue the detachment by sharp dissection laterally to expose the anterior aspect of the acromion.

 

 

Bleeding will be encountered during this dissection as a result of the division of the acromial branch of the coracoacromial artery.

 

The surgeon should not detach more of the deltoid than is necessary.

 

The deltoid split is extended 2 to 3 cm distal to the acromion.

 

 

Stay sutures are inserted in the apex of the split to prevent the muscle from inadvertently splitting distally during retraction and damaging the axillary nerve.

 

 

The split edges of the deltoid muscle are retracted to reveal the underlying coracoacromial ligament. The coracoacromial ligament is detached from the acromion by sharp dissection.

 

 

The supraspinatus tendon with its overlying subacromial bursa now can be visualized. The head of the humerus is rotated to expose different portions of the rotator cuff.

 

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FIG 2 • A. Anterosuperior approach to the shoulder. A transverse incision begins at the anterolateral corner of the acromion and ends just lateral to the coracoid. B. The posterior curve of the deltoid incision can be moved more posteriorly, as depicted here, to allow necessary exposure as dictated by the pathology.

 

Axillary

nerve

• The axillary nerve runs beneath the deltoid muscle 4.3-8.2 cm distal to the angle

of the acromion. A deltoid split distal to this point may injury the nerve.

Deltoid ▪ Deltoid dehiscence may occur following this approach and the deltoid should be

dehiscence reattached using heavy, nonabsorbable sutures through bone tunnels in the acromion.

 

PEARLS AND PITFALLS

 

 

POSTERIOR APPROACH TO THE SHOULDER

Indications

Repair in cases of recurrent posterior dislocation or subluxation of the shoulder Glenoid osteotomy

Treatment of fractures of the scapular neck

 

Treatment of posterior fracture and dislocations of the proximal humerus Spinoglenoid notch cyst drainage

 

 

Incision

 

A horizontal incision is made along the scapular spine extending to the posterolateral corner of the acromion (FIG 3A).

 

 

For extensile exposure to the scapula, the incision can be continued distally along the medial border of the scapula (Judet approach).

 

Internervous Plane

 

Between teres minor (axillary nerve) and infraspinatus (suprascapular nerve)

 

The suprascapular nerve passes around the base of the spine of the scapula as it runs from the supraspinatus fossa to the infraspinatus fossa.

 

Surgical Dissection

 

The origin of the deltoid is identified on the scapular spine. There are three ways to manage the deltoid during posterior exposures:

 

 

Detach the origin on the scapular spine.

 

 

Split the deltoid muscle along the length of its fibers. Elevate the deltoid from the inferior margin.

 

The plane between the deltoid muscle and the underlying infraspinatus muscle is identified.

 

 

The plane is easier to locate at the lateral end of the incision.

 

The internervous plane between the infraspinatus and teres minor muscles is identified (FIG 3B).

 

 

The axillary nerve runs longitudinally in the quadrangular space beneath the teres minor.

 

The posterior circumflex humeral artery runs with the axillary nerve in the quadrangular space between the inferior border of the teres minor muscle and the superior boarder of the teres major muscle.

 

The infraspinatus is retracted superiorly and the teres minor inferiorly to reach the posterior regions of the glenoid cavity and the neck of the scapula.

 

The posteroinferior corner of the shoulder joint capsule should be visible.

 

 

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FIG 3 • A. Horizontal incision along the scapular spine allowing for the posterior approach to the shoulder. B. Cadaveric specimen depicting the internervous plane between the infraspinatus and teres minor as well as the axillary nerve in the quadrangular space. (A: From Goss TP. Glenoid fractures: open reduction and internal fixation. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures, ed 2. Philadelphia: Lippincott Williams & Wilkins, 1998:3-17; B: Courtesy of Jesse A. McCarron, MD, Michael Codsi, MD, and Joseph P. Iannotti, MD.)

 

PEARLS AND PITFALLS

Suprascapular

nerve

• Identifying the internervous plane between the infraspinatus and teres minor

is critical and not always easy to visualize. Retraction of the infraspinatus muscle belly superiorly should protect the suprascapular nerve.

Axillary nerve

and posterior circumflex humeral vessel

• Maintaining the surgical dissection superior to the teres minor and medial to

the long head of the triceps should protect these structures.

 

 

HUMERUS APPROACHES

ANTERIOR APPROACH TO THE HUMERUS

Indications

Internal fixation of fractures of the humerus Management of humeral nonunions Osteotomy of the humerus

 

 

Incision

 

A longitudinal incision is made over the tip of the coracoid process of the scapula; it runs distally and laterally in the line of the deltopectoral interval to the insertion of the deltoid muscle on the lateral aspect of the humerus, about halfway down its shaft.

 

The incision should be continued distally as far as necessary, following the lateral border of the biceps muscle (FIG 4A).

 

Internervous Plane

 

The anterior approach uses two different internervous planes.

 

Proximally, the plane lies between the deltoid muscle (supplied by axillary nerve) and the pectoralis major muscle (supplied by medial and lateral pectoral nerves) (FIG 4B).

 

Distally, the plane lies between the medial fibers of the brachialis muscle (musculocutaneous nerve) and the lateral fibers of the brachialis muscle (radial nerve) (FIG 4C).

 

Surgical Dissection

 

Proximal Humeral Shaft

 

The deltopectoral interval is identified using the cephalic vein as a guide and the two muscles are separated, retracting the cephalic vein either medially with the pectoralis major or laterally with the deltoid.

 

The muscular interval is developed distally down to the insertion of the deltoid into the deltoid tuberosity and the insertion of the pectoralis major into the lateral lip of the bicipital groove (FIG 4D,E).

 

To expose the bone fully, the surgeon may need to detach part or all of the insertion of pectoralis major muscle.

 

The minimum amount of soft tissue should be detached to allow adequate visualization and reduction of the fracture.

 

If further exposure is needed, the surgeon dissects medially in a subperiosteal manner to avoid damage to the radial nerve, which lies in the spiral groove of the humerus and crosses the back of the middle third of the bone in a medial to lateral direction.

 

Distal Humeral Shaft

 

 

The surgeon identifies the muscular interval between the biceps brachii and brachialis. The interval is developed by retracting the biceps medially (FIG 4F).

 

Beneath it lies the brachialis muscle, which covers the humeral shaft.

 

The fibers of the brachialis are split longitudinally in the interval between the medial two-thirds and the lateral one-third to expose the periosteum on the anterior surface of the humeral shaft.

 

The periosteum is incised longitudinally in line with the muscle dissection, and the brachialis is stripped off the anterior surface of the bone (FIG 4G).

 

In the anterior compartment of the distal third of the arm, the radial nerve pierces the lateral intermuscular septum and lies between the brachioradialis and brachialis muscles.

 

 

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FIG 4 • A. Patient prepared for an anterior approach to the humerus. B. The internervous plane between the deltoid muscle and the pectoralis major muscle. C. Further distally, one can appreciate the internervous plane between the medial fibers of the brachialis (musculocutaneous nerve) medially and the lateral fibers of the brachialis (radial nerve) laterally. D. Deltopectoral incision: developing the interval between the deltoid and pectoralis major. The cephalic vein can be seen separating these two structures. E. With deeper dissection, the biceps tendon is seen running in the rotator interval. F. Further distal dissection reveals the musculocutaneous nerve passing along the medial border of the biceps muscle. G. To expose the distal third of the humerus, the fibers of the brachialis are split. Flexion of the elbow will relieve the tension off the brachialis, making the exposure easier. (A: Courtesy of Matthew J. Garberina, MD, and Charles L. Getz, MD.)

 

 

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PEARLS AND PITFALLS
	Musculocutaneous ▪ Proximally, the risks are the same as the deltopectoral approach.

 

	nerve ▪ Distally, the nerve can be found running between the biceps brachii and the brachialis. Locally, the nerve innervates the biceps brachii and the medial aspect of the brachialis. During this exposure, the biceps brachii should be retracted medially and the brachialis split in the midline of the muscle belly. The brachialis is dually innervated by the musculocutaneous nerve medially and the radial nerve laterally.     Radial nerve ▪ Proximally, the risks are the same as the deltopectoral approach. Distally, the nerve runs posterior to the humerus in the spiral groove and innervates the lateral aspect of the brachialis. Splitting the brachialis in the midline protects the nerve. In cases of open reduction, the nerve must be visualized prior to reduction, as it can become incarcerated between fracture fragments.

 

 

POSTERIOR APPROACH TO THE HUMERUS

Indications

ORIF of a fracture of the humerus Treatment of nonunion

Exploration of the radial nerve in the spiral groove

 

 

Incision

 

A longitudinal incision is made in the midline of the posterior aspect of the arm, from 8 cm below the acromion to the olecranon fossa (FIG 5A).

 

Internervous Plane

 

There is no true internervous plane; dissection involves separating the heads of the triceps brachii muscles, all of which are supplied by the radial nerve.

 

The medial head, which is the deepest, has a dual nerve supply (radial and ulnar nerves).

 

 

 

FIG 5 • A. Posterior approach to the humerus, showing the longitudinal incision along the midline of the posterior aspect of the arm. B. Once the outer layer of the triceps is isolated, one can see the two heads, the lateral head and long head. (continued)

 

Surgical Dissection

 

 

The surgeon incises the deep fascia of the arm in line with the skin incision. The triceps muscle has two layers.

 

The outer layer consists of two heads: The lateral head arises from the lateral lip of the spiral groove and the long head arises from the infraglenoid tubercle of the scapula (FIG 5B).

 

The inner layer consists of the medial head, which arises from the whole width of the posterior aspect of the humerus below the spiral groove all the way down to the distal fourth of the bone.

 

The spiral groove contains the radial nerve; the radial nerve separates the origins of the lateral and medial heads (FIG 5C).

 

To avoid iatrogenic nerve injury, the surgeon should never continue dissection down to bone in the proximal two-thirds of the arm until the radial nerve has been identified.

 

 

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FIG 5 • (continued) C. In this humeral shaft nonunion, the triceps is reflected medially and the radial nerve can be seen passing through the spiral groove. (A: Courtesy of Matthew J. Garberina, MD, and Charles L. Getz, MD.)

 

MODIFIED POSTERIOR APPROACH TO THE HUMERUS

Indications

ORIF of humeral shaft fractures ORIF of lateral condyle fractures

 

 

FIG 6 • A. The lower lateral brachial cutaneous nerve, which branches off the radial nerve, is identified along the posterior aspect of the intermuscular septum. The entire triceps here is retracted slightly medially. B. The intermuscular septum is divided deep to the lower lateral brachial cutaneous nerve for 3 cm to expose the radial nerve distally. (continued)

Treatment of humeral nonunion

Exploration of the radial nerve in the spiral groove

 

 

 

 

Incision

 

The surgeon makes a straight incision along a line between the posterolateral aspect of the acromion and the lateral edge of the olecranon.

 

 

The length of the incision is dictated by the requirement for exposure. Extensile exposure is limited proximally by the axillary nerve.

Internervous Plane

 

There is no true internervous plane because both the medial and lateral heads of the triceps are supplied by the radial nerve.

 

Surgical Dissection

 

The deep fascia is incised in line with the skin incision along the lateral aspect of the triceps.

 

The triceps is retracted medially and the lower lateral brachial cutaneous nerve branch from the radial nerve is identified. This nerve is traced proximally to the main trunk of the radial nerve (FIG 6A).

 

The intermuscular septum is divided distally to allow the radial nerve to be mobilized (FIG 6B).

 

Subperiosteally, the medial and lateral heads of the triceps are reflected medially to expose the humeral shaft (FIG 6C).

 

 

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FIG 6 • (continued) C. The medial and lateral heads of the triceps are retracted subperiosteally in a medial direction to expose the posterior aspect of the humeral diaphysis.

 

PEARLS AND PITFALLS
	Ulnar ▪ When using a medial window to the humerus, the ulnar nerve must be identified and nerve protected.     Radial ▪ When using a lateral window to the humerus, the radial nerve must be identified and nerve protected. It exits the spiral groove roughly 10-15 cm proximal to the lateral epicondyle.

 

	Axillary ▪ Proximal exposure of the humerus is limited by the axillary nerve, and the approach nerve should not be taken any closer than 8 cm distal to the acromion.

 

 

 

ELBOW APPROACHES

 

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.

 

Indications Total elbow arthroplasty ORIF of distal humerus fracture Removal of loose bodies Capsulectomies Posterior exposure of the joint for ankylosis, sepsis, synovectomy, and ulnohumeral arthroplasty     P.3579
	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

 

	Soft tissue reconstruction Global Kocher, Bryan-Morrey, and Hotchkiss     T intercondylar fracture MacAusland with chevron Alonso-Llames olecranon osteotomy     Radial head fracture Kocher Kaplan     Capitellum fracture Kaplan extended lateral Kocher with or without Kaplan approach     Coronoid fracture Taylor and Scham Hotchkiss     Extra-articular distal Alonso-Llames Bryan-Morrey, Campbell humerus fracture     Monteggia fracture- Gordon Boyd dislocation     Radioulnar synostosis Kocher or Gordon Boyd or Henry excision

 

 

 

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 7A).

 

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 7B).

 

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 7C).

 

Ulnar nerve is visualized and protected in the cubital tunnel.

 

 

 

FIG 7 • 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.)

 

 

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

 

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.

 

 

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FIG 8 • Triceps-splitting, tendon-reflecting approach. The tendon is reflected from the muscle in a proximal to distal direction.

 

 

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 8).

 

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

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 9A).

 

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 9B). 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 9C).

 

 

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

 

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FIG 9 • 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.

 

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.

 

The medial aspect of the triceps, in continuity with the anconeus, is elevated from the ulna (FIG 10A,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 10C).

 

Interrupted sutures are used to repair the remaining distal portion of the extensor mechanism.

 

 

 

 

FIG 10 • 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. (continued)

 

 

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FIG 10 • (continued) B. The olecranon has been osteotomized and the triceps swept from medial to lateral in continuity with the anconeus and forearm fascia. C. Closure with sutures placed through bone and the distal extensor mechanism is done with interrupted sutures.

 

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.

 

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.

 

 

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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 11).

 

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.

 

 

 

FIG 11 • 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.

 

 

 

FIG 12 • 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.

 

 

The distal humerus is exposed by bringing it through the defect along the lateral margin of the triceps (FIG 12).

 

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. The oblique osteotomy has almost been abandoned, and the transverse osteotomy has largely been replaced by the chevron.

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

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FIG 13 • 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.

 

 

 

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 13A,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 13C).

 

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.

 

Ulnar nerve

• The ulnar nerve must be identified and protected whenever performing a

posterior approach to the elbow.

Radial

nerve

• 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 tricepssparing 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.

 

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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 14A).

 

The Kocher interval between the anconeus and extensor carpi ulnaris is incised (FIG 14B).

 

 

 

FIG 14 • 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. B. The interval between the anconeus and the extensor carpi ulnaris is identified. C. Development of this interval reveals the capsule.

 

 

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 14C).

 

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 15 • 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.

 

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 15A,B).

 

 

Retraction of the anconeus and supinator exposes the joint capsule overlying the radial head and neck. 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.

 

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

• 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 16A).

 

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 16 • 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. 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 16B).

 

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 16C,D).

 

If less extensile exposure is needed, the flexor-pronator mass is divided parallel to the fibers, leaving about

 

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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 16E).

 

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

• The ulnar nerve must be exposed and isolated throughout the case.

Median nerve and

brachial artery

• These structures are at risk when exposing anterior to the brachialis or

medial to the pronator teres.

Medial antebrachial

cutaneous nerve

• 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

 

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 17A).

 

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 17B).

 

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 17C).

 

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.

 

 

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FIG 17 • 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. 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.

 

 

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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 17D).

 

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.

 

PEARLS AND PITFALLS

 

Radial nerve and posterior interosseous nerve

• The radial nerve runs beneath the brachioradialis, and the posterior 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

  • Radial recurrent artery should be ligated if distal exposure is required.