Elbow

Question 1

Posterior approach to the Elbow

Answer 1

• Incision: Posterior over elbow, curving laterally over tip of olecranon, then back over subcutaneous border of ulna
• Interval: No true interval - triceps split, olecranon osteotomy or paratricipital
• Superficial dissection: ID and protect ulnar nerve (from where it pierces intermuscular septum to where it enters FCU)
• Olecranon osteotomy: chevron shaped (apex distal) ~2cm from tip of olecranon (pre-drill for later fixation, then start with oscillating saw, finish with osteotome)
• Deep dissection: split triceps and subperiosteally elevate or work on either side (osteotomy or paratricipital option) and elevate triceps off posterior aspect of humerus
• Dangers: ulnar nerve, radial nerve (do not extend proximal to distal 1/4th of humerus), median nerve and brachial artery (subperiosteal dissection only anteriorly)

Question 2

Kocher Approach to Elbow

Answer 2

Posterolateral Approach to Radial Head and Neck

• Incision: Curve from posterior surface of lateral epicondyle to posterior border of ulna ~6cm from tip of olecranon
• Interval: ECU/anconeus
• Superficial dissection: Incise fascia, ID interval (distally is easier), bluntly dissect between ECU and anconeus, release a portion of the anconeus origin off lateral epicondyle
• Deep dissection: Pronate forearm (protects PIN), incise capsule; may extend distally to plate radial neck by releasing annular ligament with Z-cut (for later repair) but do not pass radial tuberosity (PIN in danger distally)
• Dangers: PIN (found 3-4 cm distal to radiocapitellar joint with arm in supination); avoid LCL by keeping dissection above equator of capitellum

Question 3

Medial Approach to Elbow

Answer 3

Hotchkiss “over-the-top” Approach to Coronoid

• Incision: Can use midline posterior incision with medial flap or make separate medial incision
• Interval: Splits flexor/pronator mass
• Superficial dissection: ID and protect ulnar nerve and MABC nerve (on fascia anterior to intermuscular septum); release flexor pronator mass from supracondylar ridge proximally and split it distally
• Deep dissection: Elevate brachialis, FCR and PT subperiosteally off anterior capsule (anterior band of MCL protected under FCU)
• Dangers: ulnar nerve, MABC, median nerve and vessels, MCL

Question 4

Anterior Approach to Cubital Fossa

Answer 4

• Incision: S-shaped incision (along medial border of BR distally, curved across flexor crease, medial proximally over medial border biceps)
• Interval: BR/brachialis proximally, BR/PT distally
• Superficial dissection: Incise fascia, ligate abundant veins; ID bicipital aponeurosis, cut close to origin at biceps and reflect laterally (watch for brachial artery below, brachial vein and median nerve are medial to it); ID radial artery passing biceps tendon and trace to brachial artery; ID radial nerve between BR and brachialis

Question 5

Boyd Approach

Answer 5

Proximal radius and ulna

• Incision: begins proximal to the elbow, lateral to the triceps tendon and distally over the lateral side of the tip of the olecranon, along the subcutaneous border of the ulna.
• Interval: subcutaneous border of ulna and anconeus/supinator
• Superficial/deep dissection: Incise ulnar border of anconeus and supinator and elevate subperiosteally, reflecting radially
• Exposes lateral border of ulna and proximal ¼ of radius
• Dangers: PIN (within substance of supinator)

Question 6

Answer 6

1. Hotchkiss
2. Henry
3. Key and Conwell
4. Cadenat

5 Kaplan

6 Kocher

7. Boyd
8. Campbell and Van Gorder
9. Bryan MOrrey
10. Molesworth