Approaches Flashcards
Deltopectoral approach
Internervous plane between axillary and medial/lateral pectoral nerves
Intermuscular plane between deltoid and pec major superficially and biceps and conjoint tendon deep. Rotator cuff preserved.
Structures at risk - axillary nerve 1cm inferior to glenoid and 5cm distal to lateral tip of acromion, musculocutaneous nerve 5cm inferior to coracoid, posterior humeral circumflex artery around neck of humerus. Cords of brachial plexus under pec minor.
Anterolateral approach to humerus
Internervous plane between musculocutaneous, axillary and radial nerves. Incision made over lateral border of biceps brachii extending proximally over anterior border of deltoid and distally between biceps and mobile wad of brachioradialis.
Intermuscular plane between biceps brachii, deltoid and brachioradialis.
Structures at risk - radial nerve with variable course passing from medial to lateral posteriorly around humerus and piercing intermuscular septum 8cm superior to lateral epicondyle. Lateral cutaneous nerve of the forearm (extension of musculocutaneous nerve) between brachioradialis and biceps. Cephalic vein in deltopectoral groove. Musculocutaneous nerve sat under brachialis.
Challenges - radial nerve less visible
Benefits - supine positioning, easier for XR with radiolucent arm table.
Posterior approach to humerus
No true internervous plane but skin incision may cross into axillary nerve territory proximally.
Intramuscular plane between long and lateral heads of triceps (triceps split)
Structures at risk - radial nerve with variable course passing from medial to lateral posteriorly around humerus and piercing intermuscular septum 8cm superior to lateral epicondyle. Profunda brachii artery with radial nerve in spiral groove. Ulnar nerve passes from anterior to posterior compartment 8cm superior to medial epicondyle through intermuscular septum.
Challenges - arm across body (challenging for XR) or arm over bar (challenging for concomittant chest injury).
Benefits - can access distal humerus right down to olecranon so better for distal fractures or intra-articular extension.
Transolecranon approach to distal humerus
Incision curved laterally around olecranon and distally over ulnar diaphysis
Olecranon osteotomized through sigmoid notch (bare area of articular cartilage and narrowest point of olecranon on AP XR). Chevron osteotomy has inherent rotational stability and is preferred.
Ulnar nerve should be identified and protected (+/- transposed). Decompress nerve distally until first motor branch and division between two heads of FCU. Ulnar nerve should not be under tension or in contact with any metalwork.
Lateral approach to elbow
Incision centered over lateral epicondyle, extended proximally up the distal humerus ridge and distally along the line of the radius
Elevate muscles and capsule subperiosteally from lateral supracondylar ridge, distally split the common extensor muscles anterior to LCL. To access posterior column, elevate lateral triceps and anconeus from posterior aspect of distal humerus.
Kaplan interval - between ECRB and EDC
Kocher interval - between anconeus and ECU
(A comes before O in alphabet, therefore Kaplan more anterior and Kocher more posterior.)
Structures at risk - radial nerve divides at the level of the radial head. Radial nerve within supinator muscle and crosses from anterior to posterior about 3-5cm distal to radial head.
Henry’s approach to proximal forearm
Interval between brachioradialis and FCR (internervous plane - radial nerve and median nerve)
Identify recurrent radial artery branches and ligate (sits lateral to radial artery and medial to superficial radial nerve). Retract radial artery medially and SRN laterally.
PIN sits within supinator. Fully supinate forearm and lift supinator off proximal radius subperiosteally.
Structures at risk - radial artery lies underneath brachioradialis with SRN. PIN sits within supinator.
Henry’s approach to middle forearm
Interval between brachioradialis and FCR (internervous plane - radial nerve and median nerve)
Fully pronate forearm to expose lateral border of pronator teres and its insertion. Release from bone (if required)
Modified Henry’s approach to distal radius (FCR approach)
No true internervous plane
Incision centered over FCR and through fascia
Retract FCR & FPL medially
Radial artery taken laterally
Pronator quadratus lifted off distal radius subperiosteally
Release brachioradialis (for fractures)
Structures at risk - radial artery and palmar branch of median nerve which gives off branch ~5cm proximal to wrist crease.
Dorsal approach to distal forearm
Can approach in 4 intervals:
1. Between compartments I & II
2. Through compartment III
3. Between compartments IV & V
4. Through compartment VI
Extensor retinaculum is incised in line with EPL tendon to access 3rd compartment
Free tendon from its sheath and mobilise. Lift 4th compartment subperiosteally to access distal radius, leaving the compartment intact.
Radial styloid can be exposed by elevating 2nd compartment and retracting either medially or laterally.
During closure, close retinaculum beneath EPL where it contacts the plate so it doesn’t cause attritional rupture. Leave 1st/2nd compartments open.
