Elbow/Forearm Approaches Flashcards
position for posterior approach to the elbow
prone
chest and abdomen free
tourniquet
abduct to 90°
sandbag under tourniquet
forearm hanging over table
incision for posterior approach to the elbow
begin 5 cm above olecranon laterally then as you cross the elbow curve medially and down the medial aspect of the ulna
internervous plane for posterior approach to the elbow
none
superficial dissection for posterior approach to the elbow
fascia midline
find ulnar nerve
V osteotomy of the olecranon about 2 cm from its tip with apex distal
deep dissection for posterior approach to the elbow
strip soft tissue from medial and lateral olecranon
retract proximally with triceps
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
position for medial approach to the elbow
supine
arm on board in front of patient
elbow flexed at 90°
tourniquet
incision for medial approach to the elbow
8-10cm on the nedial aspect of the elbow centred on the medial epicondyle
internervous plane for medial approach to the elbow
proximally between brachialis and triceps
distally between brachialis and pronator teres
superficial dissection for medial approach to the elbow
palpate ulnar nerve
incise fascia
retract pronator teres anteriorly
expose common flexor origin
develop interval between pronator teres and brachialis (watch for median nerve)
retract ulnar nerve inferiorly
osteotomize the medial epicondyle and reflect distally
deep dissection for medial approach to the elbow
incise the capsule and medial collateral ligament to expose the joint
danger for medial approach to the elbow
1) ulnar nerve
2) median nerve - careful when retracting PT and the flexors
position for anterolateral approach to the elbow
supine
arm board
tourniquet
incision for anterolateral approach to the elbow
curved incision starting on lateral aspect of biceps 5 cm above the flexor crease that crosses to midline then down mid forearm along medial border of brachioradialis
internervous plane for anterolateral approach to the elbow
proximally between brachialis and brachioradialis
distally between brachioradialis and PT
superficial dissection for anterolateral approach to the elbow
ID LCNF
retract medially with medial skin flap
fascia along medial brachioradialis
ID radial nerve beneath it
develop plane between brachialis and brachioradialis
below division of radial nerve develop the plane between brachioradialis and lateral side of pronator teres
ligate recurrent branches of radial artery
retract radial artery medially with PT
deep dissection for anterolateral approach to the elbow
incise joint between radial nerve (lateral) and brachialis (medial)
supinate
incise origin of supinator
deissect subperiosteally just lateral to biceps insertion
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
position for anterior approach to the cubital fossa
supine
arm board
tourniquet
incision for anterior approach to the cubital fossa
start along medial border of biceps 5 cm proximal to flexor crease and cruve across cubital fossa to run down the medial aspect of brachioradialis
internervous plane for anterior approach to the cubital fossa
distally between brachioradialis and PT
proximally brachioradialis and brachialis
superficial dissection for anterior approach to the cubital fossa
fascia
ligate vessels
LCNF lies lateral
ID biceps aponeurosis and cut then reflect latrally
ID radial artery, median nerve, brachial artery, brachial vein
deep dissection for anterior approach to the cubital fossa
if you need to get to the joint from here, retract biceps and brachialis medially and brachioradialis laterally
supinate
incise origin of supinator and dissect to bone and retract laterally
incise capsule
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
position for posterolateral approach to the radial head
supine
arm over chest
pronate arm
tourniquet
incision for posterolateral approach to the radial head
curved incision beginning over posterior surface of lateral epicondyle down medially across to posterior border of ulna about 6 cm long
internervous plane for posterolateral approach to the radial head
between anconeus and ECU
superficial dissection for posterolateral approach to the radial head
fascia
find interval between FCU and anconeus
detach part of anconeus origin
retract between these two muscles
deep dissection for posterolateral approach to the radial head
pronate to move PIN away from field
incise capsule
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
position for anterior approach to radius
supine
arm board
supinate forearm
incision for anterior approach to radius
lateral biceps tendon to radial styloid
internervous plane for anterior approach to radius
between brachioradialis and FCR/PT
superficial dissection for anterior approach to radius
fascia
find plane between BR and FCR/PT
ID superficial radial nerve under BR
ligate recurrent radial artery branches to BR
retract radial artery medially
proximal deep dissection for anterior approach to radius
find tendon of biceps on radial tuberosity and incise
supinate forearm
incise supinator along radial insertion subperiosteally and retract laterally to protect PIN
middle deep dissection for anterior approach to radius
pronate forearm to expose PT insertion and detach it subperiosteally and retract medial
distal deep dissection for anterior approach to radius
supinate again
incise periosteum lateral to PQ insertion
retract PQ and FPL medially
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
position for approach to ulna
supine
arm on chest
tourniquet
incision for approach to ulna
follow subcutaneous border of ulna where you need it
internervous plane for approach to ulna
between ECU and FCU
superficial dissection for approach to ulna
split some fibres of ECU usually necessary
deep dissection for approach to ulna
develop plane epiperiosteally in the direction needed
may have to detach some triceps tendon in the proximal 5th of the incision
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
position for posterior approach to the radius
supine
arm board
pronated
incision for posterior approach to the radius
lateral epicondyle at elbow to lister’s tubercle
internervous plane for posterior approach to the radius
ECRB and ED proximally
ECRB and EPL distally
superficial dissection for posterior approach to the radius
plane through fascia between ECRB and ED
uncover upper 1/3 radius covered by supinator
then plane betwen ECRB and EPL distal to origin of AbPL and EPB
ECRB
EPL
EPB
AbPL
ED
proximal deep dissection for posterior approach to the radius
detach origin of ECRB and ECRL at lateral epicondyle and retract laterally
palpate PIN proximal to supinator and dissect out prox to distal
supinate
detach supinator subperiosteally
middle deep dissection for posterior approach to the radius
incise superior and inferior borders of EPB and AbPL and retract depending on which direction is required
distal deep dissection for posterior approach to the radius
separate ECRB and EPL to view radius
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
