Dangers & Planes Flashcards
internervous plane for lateral approach to the femur
none. this is a vastus split
dangers for lateral approach to the femur
1) numerous perforating vessels from the profunda femoris artery
internervous plane for posterolateral approach to the femur
between vastus lateralis and the lateral intermuscular septum
dangers for posterolateral approach to the femur
1) perforating arteries
2) superior lateral geniculate artery and vein
internervous plane for anteromedial approach to the distal femur
none
dangers for anteromedial approach to the distal femur
1) medial superior genicular artery - ligate to avoid hematoma formation
2) low fibres of vastus medialis attach to patella - make sure you take a small cuff of tendon so you can repair this later to prevent lateral subluxation of the patella
internervous plane for posterior approach to the femur
lateral intermuscular septum and biceps femoris
dangers for posterior approach to the femur
1) sciatic nerve medial to biceps
2) nerve to biceps enters very proximal and medial, so usually not a worry
internervous plane for minimal access approach to the distal femur
distally between vastus lateralis and biceps femoris
proximally, none, as you split vastus lateralis
danger for minimal access approach to the distal femur
1) superior genicular artery and veins need to be ligated
internervous plane for minimal access approach to proximal femur for intramedullary nailing
none
split fibres of glut max and glut med
danger for minimal access approach to proximal femur for intramedullary nailing
1) too lateral with your nail and you will get a varus deformity
2) too far medial and you will get an iatrogenic # of the femoral neck
3) superior gluteal nerve runnign through glut med 3-5 cm above the tip of GT
internervous plane for minimal access approach to retrograde intramedullary nailing of femur
none - you are just passing through medial retinaculum and synovium
danger for minimal access approach to retrograde intramedullary nailing of femur
1) infrapatellar branch of saphenous nerve should be distal to the incision
2) PCL on lateral aspect of medial femoral condyle may be damaged by reamers
internervous plane for arthorscopic approach to the knee
none
danger for arthorscopic approach to the knee
1) articular cartilage
2) meniscus
internervous plane for medial parapatellar approach to the knee
none
dangers for medial parapatellar approach to the knee
1) infrapatellar branch of the saphenous nerve
2) avulsion of the patella ligament during difficult dislocation
internervous plane for approach to medial meniscectomy
none
danger for approach to medial meniscectomy
1) infrapatellar branch of the saphenous nerve
2) popliteal artery posterior to joint capsule should be safe
3) coronary ligament if incision too distal
4) superficial medial ligament if incision too posterior
5) fat pad in anterior knee joint should be spared to prevent adhesions and maintain blood supply to patella
6) medial meniscus can be damaged during approach if incision too distal
internervous plane for medial approach to knee
none
danger for medial approach to knee
1) neuroma formation if infrapatellar branch of saphenous not buried in fat
2) saphenous vein in posterior corner of superficial dissection
3) medial inferior geniculate artery curves around the upper end of tibia
4) popliteal artery lies against posterior joint capsule in midline
internervous plane for approach to lateral meniscectomy
none
danger for approach to lateral meniscectomy
1) lateral inferior geniculate artery
2) LCL if too posterior with incision
3) lateral meniscus if too distal with incision
internervous plane for lateral approach to the knee
between IT band and biceps femoris
dangers for lateral approach to the knee
1) common peroneal nerve on posterior border of biceps
2) lateral superior geniculate artery between lateral gastrocs and corner
3) popliteus tendon within the joint posterolaterally
4) lateral meniscus if too distal with incision
5) coronary ligament if too distal with incision
internervous plane for posterior approach to the knee
none
danger for posterior approach to the knee
1) medial sural cutaneous nerve travelling lateral to the small saphenous vein
2) tibial nerve
3) common peroneal nerve
4) small saphenous vein
5) popliteal vessels
internervous plane for lateral approach to distal femur for ACL repair
vastus lateralis and biceps femoris
danger for lateral approach to distal femur for ACL repair
1) peroneal nerve posterior to biceps
2) lateral superior geniculate artery must be ligated
3) popliteal artery if plane does not stay subperiosteal
danger (2) for anterior approach to iliac crest
- ASIS insertion of inguinal ligament
- crest of ilium should be left for cosmesis
danger (3) for posterior approach to iliac crest
- cluneal nerves start 8 cm lateral to PSIS
- sciatic nerve if you go too far inferior to sciatic notch
- superior gluteal artery travels by the sciatic notch, proximal to piriformis
danger (1) for anterior approach to pubic symphysis
- bladder
danger (3) for anterior approach to SI joint
- LFCN arises 2 cm distal to ASIS and is often sacrificed in this approach
- sacral nerve roots if: i) go too medial with dissection; ii) put a homan in a foramina; iii) put more than 1 screw in the anterior sacrum
- large nutrient vessels enter the anterior ileum - use bone wax
danger (4) for posterior approach to the SI joint
- IGN is in the deep surface of glut max
- SGN in is the deep surface of glut med
- sacral nerve roots may be injured by inaccurate screws
- IGA/SGA run with their respective nerves
danger (7) for inguinal approach to the acetabulum
- FN on iliopsoas
- LFCN 2 cm distal to ASIS (usually divided)
- femoral/external iliac vessels
- inferior epigastric A/V need to be ligated
- spermatic cord
- bladder
- corona mortis on lateral superior rami
plane for posterior approach to the acetabulum
none - glut max is split
danger (3) for posterior approach to the acetabulum
- avoid vigorous retraction of SERs to protect sciatic nerve
- IGA/IGN leave pelvis inferior to piriformis
- SGA/SGN leave pelvis superior to piriformis
plane for anterior (Smith-Petersen) approach to the hip
superficial: between sartorius and TFL
deep: between rectus femoris and glut med
danger (3) for anterior (Smith-Petersen) approach to the hip
- LFCN lies on sartorius
- FN lies over hip joint medial to rectus femoris
- must ligate ascending branch of lateral femoral circumflex artery
plane for anterolateral (Watson-Jones) approach to the hip
none really, but just don’t dissect to the origin of TFL - where it is innervated
danger (4) for anterolateral (Watson-Jones) approach to the hip
- FN injury with aggressive medial retraction
- FA/FV damage if retraction through iliopsoas
- profunda femoris lies on iliopsoas
- femoral shaft prone to # with dislocation maneuvers when there is an incomplete capsulotomy
plane for lateral approach to the hip
none - split glut med and vastus lateralis
danger (4) for lateral approach to the hip
- SGN runs between glut med and min 3-5 cm rostral to GT
- FN runs on psoas, so anterior retractors should only be placed on bone
- FA/FV run medial to nerve but could be injured if retraction too medial
- transverse branch of the lateral femoral circumflex artery must be ligated as vastus lateralis is cut.
plane for posterior approach to the hip
none - split the fibres of glut max
danger (2) for posterior approach to the hip
- sciatic nerve emerging from beneath piriformis
- IGA emerging under piriformis
plane for the medial approach to the hip
superficial: between longus and gracillus
deep: between brevis and magnus
danger (3) for the medial approach to the hip
- anterior ON lies on OE and brevis
- posterior ON goes through OE and lies on magnus
- MFCA passes around medial and distal to psoas tendon
internervous plane for anterior approach to ankle
use the intermuscular plane between EHL and EDL
dangers for anterior approach to ankle
cutaneous branches of superficial peroneal nerve
deep peroneal nerve
anterior tibial artery
dangers for approaches to medial malleolus
anterior - saphenous nerve, long saphenous vein
posterior - tom, dick and very nervous harry
both - vascularity of bone fragments
dangers for posteromedial approach to ankle
posterior tibial artery
tibial nerve
internervous plane for posterolateral approach to the ankle
peroneus brevis and FHL
dangers for posterolateral approach to ankle
short saphenous vein
sural nerve
dangers for the lateral approach to the lateral malleolus
sural nerve
terminal branches of peroneal artery lying on the medial surface of the distal fibula
internervous plane for anterolateral approach the ankle hindfoot
between peroneals and extensors
dangers for anterolateral approach to the ankle and hindfoot
deep peroneal nerve
anterior tibial artery
internervous plane for lateral approach to hindfoot
peroneus tertius and peroneal tendons
dangers for lateral approach to hindfoot
exposures here are notorious for skin necrosis
dangers for lateral approach to the posterior talocalcaneal joint
sural nerve
dangers for lateral approach to calcaneus
sural nerve
soft tissue necrosis a risk
danger for dorsomedial approach to MTP joint
tendon of EHL
tendon of FHL
danger for dorsal approach to the metatarsophalangeal joints (other than 1st)
long extensor tendon
plantar nerves and vessels lie deep to transverse metatarsal ligament between the metatarsal heads
danger for approach to the dorsal web spaces
dorsal cutaneous nerve
take care to protect plantar neurovascular bundle
danger for anterior approach to the clavicle
1) brachial plexus
2) subacromial artery and vein immediately inferior to clavicle - avoid inferior dissection
internervous plane for anterior approach to shoulder joint
between deltoid and pecs
danger for anterior approach to shoulder joint
1) MSK nerve as it enters the coracobrachialis 5-8 cm distal to corocoid
2) cephalic vein
internervous plane for anterolateral approach to the AC joint and subacromial space
none - delt is detached
danger for anterolateral approach to the AC joint and subacromial space
1) axillary nerve runs deep to delt 7 cm below the acromion
2) acromial branch of the coracoacromial artery must be ligated just under the delt as you approach
internervous plane for lateral approach to proximal humerus
none - split delt
danger for lateral approach to proximal humerus
1) axillary nerve 7 cm below acromion travelling transversely under delt
*note that the minimally invasive lateral approach is also available with 2 incisions, but the key is ID the axillary nerve and go deep to it*
internervous plane for posterior approach to the shoulder joint
between teres minor and infraspinatus
danger for posterior approach to the shoulder joint
1) axillary nerve as it runs through quadrangular space beneath teres minor
2) suprascapular nerve passes around the base of the spine of scapula
3) posterior circumflex humeral artery runs with axillary nerve
internervous plane for anterior approach to the humeral shaft
proximally between pec and delt
distally between medial and lateral fibres of brachialis
danger for anterior approach to the humeral shaft
1) radial nerve - vulnerable at 2 spots - spiral groove and anterior compartment of distal third of arm between brachialis and brachioradialis
2) axillary nerve running under deltoid 7 cm distal to acromion
3) anterior humeral circumflex artery
4) lateral ante-brachial cutaneous nerve medial to brachialis
*note that this can also be done via two small minimally invasive incisions
danger for anterolateral approach to the distal humerus
1) ID the radial nerve and protect it
internervous plane for posterior approach to the distal humerus
none - separate heads of triceps
danger for posterior approach to the distal humerus
1) radial nerve between medial and lateral head of triceps
2) ulnar nerve as in passes posteromedially
3) profunda brachii artery with radial nerve
internervous plane for lateral approach to distal humerus
none - between triceps and brachioradialis
dangers for lateral approach to distal humerus
1) radial nerve pierces lateral intermuscular septum in distal third of arm
danger for minimal access approach for humeral nailing
1) axillary nerve 7 cm below the acromion under deltoid
2) brachial artery medial to proximal humerus
3) median nerve with brachial artery
4) supraspinatus tendon is partially incised - take care when drilling not to cause more damage
danger for posterior approach to the elbow
1) ulnar nerve must be ID’d
2) median nerve lies anterior to distal humerus
3) radial nerve if you do too far proximal
4) brachial artery lies with median nerve
5) realign olecranon with great care after osteotomy
internervous plane for medial approach to the elbow
proximally between brachialis and triceps
distally between brachialis and pronator teres
danger for medial approach to the elbow
1) ulnar nerve
2) median nerve - careful when retracting PT and the flexors
internervous plane for anterolateral approach to the elbow
proximally between brachialis and brachioradialis
distally between brachioradialis and PT
danger for antrolateral approach to the elbow
1) radial nerve and its 3 branches in proximal forearm
2) PIN in supinator near neck of radius
3) LCNF - retract with skin medially
4) recurrent branches of radial artery must be ligated to mobilize the brachioradialis
internervous plane for anterior approach to the cubital fossa
distally between brachioradialis and PT
proximally brachioradialis and brachialis
danger for anterior approach to the cubital fossa
1) LCNF - find between biceps and brachialis
2) radial artery lies immediately deep to bicipital aponeurosis
3) PIN vulnerable as it winds around the neck of radius within supinator
internervous plane for posterolateral approach to the radial head
between anconeus and ECU
danger for posterolateral approach to the radial head
1) PIN is in the supinator and also on radial neck opposite the bicipital tuberosity
2) radial nerve - open joint laterally, not anteriorly
internervous plane for anterior approach to radius
between brachioradialis and FCR/PT
danger for anterior approach to the radius
1) PIN around neck of radius and within supinator
2) superficial radial nerve under brachioradialis
3) radial artery vulnerable during mobilization of brachioradialis and near the biceps tendon
4) recurrent radial arteries must be ligated to properly mobilize the brachioradialis
internervous plane for approach to ulna
between ECU and FCU
dangers for approach to ulna
1) ulnar nerve travels throught the two head and then under FCU on FDP
2) ulnar artery travels just radial to the nerve
internervous plane for posterior approach to the radius
ECRB and ED proximally
ECRB and EPL distally
danger for posterior approach to the radius
1) PIN - 25% of people have a PIN that touches the radius opposite the bicipital tuberosity - so protect it by stripping supinator subperiosteally
internervous plane for dorsal approach to the wrist
none
use intermuscular plane between ECRB and ECRL
danger for dorsal approach to wrist
1) superficial radial nerve emerges from under brachioradialis just proximal to wrist joint
2) radial artery crosses wrist laterally - stay below periosteum and it will be hard to damage
internervous plane for volar approach to the wrist
none
danger for volar approach to the wrist
1) palmar cutaneous branches of median arise 5 cm proximal to wrist joint run on ulnar side of FCR befor crossing flexor retinaculum
2) motor branch of median nerve
3) superficial palmar arch crosses plam at level of outstretched thumb - cut flexor retinaculum only under direct vision
danger for volar approach to ulnar nerve
1) ulnar nerve at 2 locations - during approach through FCU and during detachment of volar carpal ligament
danger for posterior approach to the lumbar spine
1) segmental arteries between TPs near facet joints
2) dorsal rami between TPs near facet joints
3) ID nerve roots individually
4) venous plexi around nerves and on floor of canal
5) iliac vessels anterior to vertebral body if you puncture annulus fibrosis
which muscles might you encounter during posterior approach to the lumbar spine?
superficial = lat. dorsi.
deep = sacrospinalis, multifidus and rotatores
danger for transperitoneal approach to the lumbar spine
1) presacral nerve plexi - can use retroperitoneal saline injection to assist
2) midline sacral artery
3) lumbar vessels carefully dissectedand ligated to access great vessels
4) ureters must be mobilized laterally
dangers for retroperitoneal approach to lumbar spine
1) presacral nerve plexus should mobilize medial with peritoneum
2) ureters should mobilize medial with peritoneum
3) sympathetic chain on lateral vertebral body
4) segmental arteries and veins if you go above L5
dangers for anterolateral approach to lumbar spine
1) sympathetic chain on lateral vertebral body wall
2) genitofemoral nerve on anteromedial surface of psoas
3) segmental arteries and veins (must tie off)
4) vena cava if approaching from R side
5) ureter - retract with peritoneum
danger for posterior approach to the cervical spine
1) don’t traction cord
2) venous plexus bleeding around cord
3) do not enter transverse foramen
4) 3rd occipital nerve lateral to skin incision
danger for posterior approach to C1/C2 specifically
1) do not retract cord near C1/2!
2) C2 and C3 occipital nerves are lateral to this field
3) vertebral artery crosses the field superior to C1
which vertebrae can you access with anterior approach to C-spine?
C3-T1
anatomical landmark for C2-3
jaw line
anatomical landmark for C4-5
thyroid cartilage
anatomical landmark for C6
cricoid cartilage
internervous plane for anterior approach to the cervical spine
none superficial, however, between SCM and neck strap muscles intermediate and between R and L longus colli muscles deep
danger for anterior approach to the cervical spine
1) protect recurrent laryngeal nerve by placing retractors medial to longus colli
2) avoid sympathetic chain by subperiosteal midline dissection
3) avoid dissecting out to TP
4) avoid self-retainers near carotid sheath
5) take care not to lose the inferior thyroid artery behind the carotid sheath
6) do not extend this approach
internervous plane for Wiltse approach to the spine
none. however, intermuscular plane between multifidus and longissimus
danger for posterolateral approach to the thoracic spine
1) intercostal arteries often damaged - this is okay, but bleeding must be controlled with ties
2) if dissection is too intensive you can enter the central canal
3) pleural tears require chest tubes
danger for anterior approach to thoracic spine
1) intercostal arteries are vulnerable at 2 points: during rib resetion and vertebral body approach
2) expand the lungs every 30 min
dangers for posterior approach in scoliosis
) posterior rami emerge between TPs
2) segmental arteries emerge between TPs
