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Interview > Approaches > Flashcards

Approaches Flashcards

1
Q

General template prior to operation

A
  • Review the clinical information, confirm the approach method of fixation and equipment to be utilised and ensure has been discussed appropriately with the consultant
  • Informed consent, mark the patient pre-operatively
  • Ensure anaesthetic team and theatre team aware of the details of the case, and that the appropriate equipment is available
  • If the senior operator, ensure I am comfortable with the procedure and have appropriate help available if required
  • TTO in theatre, imaging intensifier available
  • Position the patient, shave skin if required, padded bony prominences
  • Scrub, appropriately prep and drape
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2
Q

Kocher

A
  • Posterolateral approach to the elbow
  • Used for management of radial head - replacement / ORIF. LCL reconstruction or repair
  • Positioning and tourniquet
    • Can be supine or lateral position
    • Consider sterile tourniquet
  • Incision
    • Feel for lateral epicondyle, olecranon and radial head
    • Gently curved incision based over the lateral epicondyle extending over the radial head
  • Internervous plane and superficial dissection
    • Incise deep fascia
    • Identify plane between ECU (PIN) and anconeus (radial n.)
    • Maintain pronation to protect PIN
    • Split the supinator fibres longitudinally, remaining on the posterior cortex of the radius
  • Structures at risk
    • PIN
      • Remain proximal to annular ligament where possible
      • Release supinator along posterior border
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3
Q

Kaplan

A
  • Anterolateral approach to elbow
  • Exposure of radial head, coronoid, anterolateral distal humerus
  • Positioning and tourniquet
    • Supine position
    • Sterile tourniquet
  • Incision
    • Incision from tip of lateral epicondyle, distally towards Lister’s tubercle
  • Internervous plane and superficial dissection
    • Plane between ECRB (radial n. or PIN), and EDC (PIN)
    • Identify ECRB / EDC interval
    • Expose the supinator deep to these
    • Incise the lateral annular ligament and capsule
  • Structures at risk
    • PIN at high risk, keep forearm in pronation
    • Lateral cutaneous nerve of forearm
    • Radial nerve and recurrent radial artery
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4
Q

Henry’s

A
  • Positioning and tourniquet
    • Supine, with tourniquet
  • Incision
    • Biceps tendon insertion, to radial styloid
  • Internervous plane
    • Identify plane between brachioradialis (radial n.) and FCR (median n.)
  • Dissection
    • Develop this plane, identify SRN on undersurface of brachioradialis
    • Radial artery and concurrent veins found under brachioradialis, retracted medially, many branches to brachioradialis that need to be coagulated
    • Deeper, need to detach supinator / pronator teres / FDS / FPL / PQ - depending on the exposure required
  • Structures at risk
    • SRN
    • PIN if extending proximally
    • Radial artery
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5
Q

Ulna shaft

A
  • Positioning and tourniquet
    • Supine, tourniquet
  • Incision
    • Along subcutaneous border of the ulna
  • Internervous plane
    • ECU (PIN) and FCU (ulna)
  • Dissection
    • Identify two muscles
    • Incise fascia and develop plane
    • Ulna nerve runs under FCU so care to remain subperiosteal
  • Structures at risk
    • Ulna nerve
    • Ulna artery
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5
Q

Ulna shaft

A
  • Positioning and tourniquet
    • Supine, tourniquet
  • Incision
    • Along subcutaneous border of the ulna
  • Internervous plane
    • ECU (PIN) and FCU (ulna)
  • Dissection
    • Identify two muscles
    • Incise fascia and develop plane
    • Ulna nerve runs under FCU so care to remain subperiosteal
  • Structures at risk
    • Ulna nerve
    • Ulna artery
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6
Q

Anterior humerus

A
  • Positioning and tourniquet
    • Supine or beach chair
    • Usually no tourniquet
  • Incision
    • Coracoid process, along deltopectoral groove and lateral border of biceps muscle
  • Internervous plane
    • Proximally - deltoid (axillary) and pec major (medial and lateral pectoral)
    • Distally - medial fibres of brachialis (musculocutaneous) and lateral fibres of brachialis (radial)
  • Dissection
    • Proximal dissection
      • Use cephalic vein to identify plane between pec major and deltoid, can be retracted either way
      • Develop plane down to deltoid tuberosity
      • Care retracting deltoid and putting too much pressure on axillary
      • Incise periosteum just lateral to insertion of pec major - some of insertion may need to be lifted
      • If need to exposure the head and neck of the humerus, then incise subscapularis muscle and capsule
    • Distal dissection
      • Incise deep fascia in line with skin incision
      • Identify plane between biceps and brachialis - retract biceps medially
      • Distally is the lateral cutaneous nerve of the forearm (terminal branch of musculocutaneous) - care to avoid this
      • Split the fibres of brachialis longitudinally down to bone
  • Structures at risk
    • Radial nerve - in spiral groove proximally and lateral anterior compartment distally
    • Axillary nerve - excessive retraction of deltoid
    • Anterior circumflex humeral vessels - cross the field around pec insertion
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7
Q

Posterior humerus

A
  • Positioning and tourniquet
    • Usually lateral incision, no tourniquet
  • Incision
    • Midline humeral shaft
  • Internervous plane
    • No true internervous plane
  • Dissection
    • Work radially to find the posterior cutaneous branch of the radial nerve, this can be followed proximally to identify the radial nerve
    • Identify plane between long and lateral head of triceps and develop this
    • Medial head of triceps may need to be split longitudinally
  • Structures at risk
    • Radial nerve
    • Posterior cutaneous branch of radial nerve
    • Deep brachial artery - runs with radial nerve
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8
Q

Deltopectoral

A
  • Positioning and tourniquet
    • Supine / beach chair
    • Sandbag under scapula
  • Incision
    • Coracoid process to deltoid tuberosity
  • Internervous plane
    • Deltoid (axillary), pec major (lat med pectoral nerves)
  • Dissection
    • Cephalic vein, can be retracted either way
    • Plane between deltoid and pec major
    • Identify conjoint tendon and retract it medially, if further exposure is required a coracoid osteotomy can be done
    • Incise subscapularis, with stay sutures to repair later
    • Incise through capsule
  • Structures at risk
    • Cephalic vein
    • Musculocutaneous nerve - enters coracobrachialis muscle medially, so just remain lateral
    • Axillary nerve - In danger when retracting deltoid, and when incising subscapuslaris as it sits just inferior to it going through the quadrangular space
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9
Q

Lower limb fasciotomies

A
  • Positioning and tourniquet
    • Supine, no tourniquet
  • Incision
    • Lateral - halfway between fibula and tibial crest
    • Medial - 2cm posterior to the border the tibia
  • Dissection
    • Lateral
      • Identify SPN at distal aspect of wound
      • Localise the inter muscular septum at the proximal end of the wound
      • Incision anterior and posterior to this
      • Using mayo scissors, release the fascia the entire length
      • Assess muscle colour
    • Medial
      • Identify saphenous vein and nerve
      • Incise the fascia in line with incision and assess musculature of superficial compartment
      • Soleus muscle retracted posteriorly and then deep fascia incised
      • NV bundle is just beneath this
  • Structures at risk
    • Saphenous nerve and vein
    • Superficial peroneal nerve
    • Posterior NV bundle
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9
Q

Lower limb fasciotomies

A
  • Positioning and tourniquet
    • Supine, no tourniquet
  • Incision
    • Lateral - halfway between fibula and tibial crest
    • Medial - 2cm posterior to the border the tibia
  • Dissection
    • Lateral
      • Identify SPN at distal aspect of wound
      • Localise the inter muscular septum at the proximal end of the wound
      • Incision anterior and posterior to this
      • Using mayo scissors, release the fascia the entire length
      • Assess muscle colour
    • Medial
      • Identify saphenous vein and nerve
      • Incise the fascia in line with incision and assess musculature of superficial compartment
      • Soleus muscle retracted posteriorly and then deep fascia incised
      • NV bundle is just beneath this
  • Structures at risk
    • Saphenous nerve and vein
    • Superficial peroneal nerve
    • Posterior NV bundle
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10
Q

Ex-fix

A
  • Humerus
    • Proximal 1/3 - Lateral
    • Middle 1/3 - Anterior
    • Distal 1/3 - Medial epicondyle
  • Ulna
    • Anywhere
  • Radius
    • Proximal - NO
    • Middle - Dorsal - dorsal/lateral
    • Distal - Lateral - dorsal/lateral (care to avoid SRN too distal and too lateral)
  • 2nd metacarpal bone
    • One in head, one in base - angled 45 deg dorsal/lateral
  • Pelvis
    • Iliac crest - 2x pins immediately pastier to ASIS
      • Drill only cortex
      • Insert pins by hand
      • Angle down towards ischial spine
    • Pins can also be placed through AIIS, more stable but more technically challenging
  • Femur
    • Lateral always safe
    • Anterior safe in middle / distal
    • Distally can go lateral → medial to skeletal traction
  • Tibia
    • Subcutaneous border along entire length
  • Calcaneus
    • Medial to lateral
    • 2cm inferior to medial mal, 2cm anterior to posterior border of calc
  • Base of 1st metatarsal
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11
Q

Anterior approach hip

A
  • Also Smith-Petersen approach
  • Anterior approach THA / washout of joint / open reduction of NOF fracture
  • Positioning and tourniquet
    • Supine position, potentially specialised traction table
  • Incision
    • Longitudinal incision, inferior and lateral to ASIS
  • Internervous plane
    • TFL (superior gluteal) and sartorious (femoral)
  • Dissection
    • Identify plane between TFL and sartorious - usually 4-5cm below ASIS
    • Care to avoid LFCN
    • Incise the deep fascia on the medial side of TFL
    • Detatch TFL at its origin
    • Identify ascending branch of lateral femoral circumflex artery
    • Identify plane between gluteus medius and rectus femoris and retract RF medially - needs to be detached from its origins at AIIS, superior acetabulum and hip capsule
    • Incise capsule with T-shaped incision
  • Structures at risk
    • Lateral femoral cutaneous nerve
    • Femoral nerve and artery
    • Ascending branch of lateral femoral circumflex artery
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12
Q

Posterior approach hip

A
  • Lateral position, padding, drape whole leg
  • Approach
    • Incision centred just posterior to centre of femur and GT, curves posteriorly
    • Superficial dissection, haemostasisi
    • Knife to fascia distally, extend proximally where it becomes more musculature
    • Charnley retractor
    • Internal rotation of the leg
    • Need to identify the SERs and specifically piriformis posteriorly
    • Homen put over gluteus minimise and beneath gluteus medius
    • Incise through plane between minimus and piriformis
    • Homen then between piriformis and minimus
    • Diathermy to release piriformis and the proximal SERs, with stay sutures
    • Dislocate head
  • Structures at risk
    • Sciatic nerve
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13
Q

Anterolateral approach tibial plateau

A
  • Positioning and tourniquet
    • Supine, tourniquet, sterile triangle bolster to help with positioning
  • Incision
    • L-shaped incision, commencing just distal to the joint line, anteriorly over Gerdy’s tubercle, then down anterolateral shaft, lateral to patella tendon
  • Internervous plane
    • No internervous plane
  • Dissection
    • Incise through subcutaneous tissue, haemostasis
    • Incise joint capsule transversely just below the lateral meniscus
    • Incise through fascia overlying tibialis anterior, strip off tibialis anterior medially
    • Detatch lateral meniscus from its inferior attachments, using stay sutures
  • Structures at risk
    • Common peroneal nerve, however should be posterior to the operating zone
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14
Q

Posteromedial approach tibial plateau

A
  • Positioning and tourniquet
    • Supine, tourniquet, sandbag under other hip to externally rotate
  • Incision
    • Over posteromedial border of the tibia, just below joint line
  • Internervous plane
    • No internervous plane
  • Dissection
    • Subcutaneous tissue
    • Care to avoid saphenous nerve and vein, usually seen anterior to the incision
    • Identify pes insertion, often needs to be partially released
    • Identify MCL underneath and care not to damage
  • Structures at risk
    • Saphenous nerve and vein
    • MCL
15
Q

Posterolateral ankle

A
  • Positioning and tourniquet
    • Can be done prone or lazy lateral position, tourniquet
  • Incision
    • Halfway between posterior border of the lateral malleolus and the lateral border of the Achilles tendon
  • Internervous plane
    • Between peroneus brevis (SPN) and FHL (tibial n.)
  • Dissection
    • Subcutaneous tissue
    • Care to avoid short saphenous vein and sural nerve, usually anterior to incision
    • Incise deep fascia and identify plane between FHL and peroneal tendons
  • Structures at risk
    • Short saphenous vein and sural nerve
16
Q

Lisfranc

A
  • Positioning and tourniquet
    • Supine, bolster under knee so foot flat on table
    • Tourniquet
  • Incision
    • Inline with lateral border of 1st MT
  • Internervous plane
    • No internervous plane
  • Dissection
    • Identify EHL tendon and NV bundle which is lateral to it
    • Retract these
    • Sharp dissection onto capsule and through periosteum over 1st TMTJ
  • Structures at risk
    • EHL
    • NV bundle of DPN and dorsalis pedis artery
17
Q

Arthroscopy ports

A
  • Shoulder
    • Posterior - 2cm inferior and 1cm medial to posterolateral tip of acromion
    • Anterior - Halway between coracoid process and anterior acromion
  • Knee
    • Anterolateral - Just lateral to patella tendon, above joint line
    • Anteromedial - Just medial to patella tendon, above joint line
  • Ankle
    • Anterolateral - Between peroneus tertius and lateral malleolus
    • Anteromoedial - Between tibial anterior and medial malleolus

Interview (4 decks)

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