MEMORIZE Approaches Flashcards by Jasmine Lyng

Deltopectoral

Interval: Deltoid (axillary n.) & pec major (med & lat pectoral n.)

Incision: Coracoid to deltoid insertion, Coracoid to axillary fold

cephalic vein is landmark

Approach: Split deltoid and pec, incise clavipec fascia, come down on subscapularis then capsule

Dangers:
- cephalic vein,
- axillary n.,
- musculocutaneous n.
- Biceps tendon,
- anterior circumflex vessels

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Deltoid Split

Interval: none

Approach: Split fibres of deltoid

Dangers: Axillary n.. Crosses humerus approximately 5-7cm distal from tip of acromion

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Judet Approach Shoulder

Interval: Teres Minor (Axillary n.) and Infraspinatus (Suprascapular N.)

Incision: From posterolateral corner acromion medial along spine of scapula, then 90 degrees and distal to inferior pole

Approach: Split deltoid or elevate from scapular spine. Fat stripe between teres minor and infraspinatus. Brings you down on capsule.

Dangers:
- Axillary N with aggressive retraction of Deltoid or Teres Minor.
- Suprascapular nerve and artery, at superolateral border of interval: which goes from supra to infraspinous fossa and can be damaged by retracting too medially;
- Vessels: Posterior Humeral Circumflex Artery: in the quad space with the axillary nerve

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Anterolateral Approach Humerus

Interval:

Proximal: Deltoid (Axillary N.) & Biceps (Musculocutaneous)
Distal: Brachialis Split (Medial - Median n. lateral- radial N.)

Approach:
- Incision- coracoid to deltoid tuberosity then along lateral boarder of biceps.
- Establish deltopecotral interval, and separate between biceps and deltoid.
- As brachialis emerges, develelop split. - Can be extended into a henry approach of the volar forearm.

Dangers:
- Musculocutaneous N. Deep to biceps, superficial to brachialis.
- Radial N. Between brachialis and brachioradialis laterally and in spiral groove.
- LABCN between brachialis and brachioradialis

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Paratricipital Approach

Interval: Lateral head of triceps (radial n.) and lateral intramuscular septum (no true plane)

**Incision: **Midline posterior from tip of olecranon to 8cm distal to acromion

Approach:
- split superficial fascia in line with incision
- identify and protect radial n.
- btw lateral head triceps (Retract lateral) and long head triceps (retract medial)
- Either identify LABCN (and trace to radial nerve proper) or radial nerve as it plunges into the intramuscular septum (~10cm proximal to the lateral epicondyle. Once radial nerve proper identified protect, peel triceps off of posterior humerus.

Dangers:
- Radial nerve – Identify if needing to go proximally,
- Ulnar nerve – deep to the medial head, stay subperiosteal medially,
- Profunda brachii artery – lies with the radial nerve in the spiral groove – protect it with the radial nerve

* can do medial or lateral. Medially, radial nerve enters spiral groove ~14cm proximal to medial epicondyle. Ulnar nerve to be identified deep to brachioradialis.

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posterior transolecranon approach to elbow (Olecranon Osteotomy)

Interval: n/a

** Incision:** midline posterior over olecranon

**Intervals: **
- Proximal: Distal to radial nerve innervation of triceps, between Lateral head Triceps and BR lateral.
- Identify and isolate ulnar nerve medial.
- Distal: Anconeus and ECU lateral, FCU medial.
Olecranon Osteotomy: Predrill Olecranon, Chevron with point distal into bare area of sigmoid notch, take piece with triceps superior

**Dangers: **
- Radial n.– can’t extend past the dist 1/3 of humerus
- Ulnar n.– identify and protect it.
- Cartilage damage to olecranon.

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Boyd Approach

Interval: Between both anconeus (radial n.) and ECU (PIN), and subcutaneous boarder of ulna/ FCU (ulnar n.)

Approach: Develop interval between both anconeus and ECU, and lift both anteriorly. Release supinator subperiosteally.

Dangers: Increased risk of synostosis.

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Kocher Approach

Best for LUCL repair

Interval: Anconeus (radial n.) & ECU (PIN)

Approach: Look for fat stripe between the two. Anconeus fibres will run obliquely. Will need to elevate some of supinator to reveal distal insertion of LUCL on crestor supinatore.

Dangers:
PIN – limit dissection proximal to annular ligament with arm pronated, LUCL instability

* can extend proximally by detatching anconeus from its origin on the distal humerus, and triceps from lateral intramuscular septum.

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EDC Split

Interval: Split EDC Tendon

Approach: It is the “shiny” tendon on the lateral aspect of the elbow. Split 50/50. Gives more access to anterior structures of the elbow (ie coranoid).

Dangers: PIN, LUCL.

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Kaplan

Interval: EDC (PIN), ECRB (PIN)

Approach: Split interval above. Proximal interval of the Thompson approach to the forearm.

Dangers: PIN

*pictured: kocher vs kaplan

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Hotchkiss Medial Over-the-top

good for antermedial - access to top of coronoid process and anterior elbow joint

Interval:
* Distally: Through flexor pronator mass. FCU (ulnar n.) & FDS/Palmaris Longus (Median n.)

Approach:
- Unroof, identify and mobilize the ulnar n.
- Split flexor pronator mass, and elevate anteriorly. Care to be taken for MUCL

Dangers:
- Ulnar N.
- MUCL,
- Median N.
- Brachial A.,
- MABCN (found on fascia anterior to septum)

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FCU Split

Interval: None, between two heads of FCU (Ulnar N.)

Approach:
- Identify, unroof and protect median n. - Split two heads of FCU and elevate anteriorly. Care to be taken not to injure MUCL

Dangers: MUCL, Ulnar N. Median N. Brachial A.

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Modified Taylor and Scham

Interval: ECU (PIN), FCU (Ulnar N.)

Approach:
- identify and protect ulnar n.
- Dissect down to subcutaneous boarder of ulan and lift everything anteriorly. Akin to the boyd but on the medial side.
- Gives access to base of coranoid/sublime tubercle

Dangers: Ulnar N., MUCL

*1 = Hotchkiss, 2= FCU Split, 3=Taylor Scham

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Approach to Ulnar Shaft

Interval: ECU (PIN), FCU (Ulnar N.)

Approach: Dissect onto subcutaneous boarder of ulna. Lift ECU and FCU subperiosteally to expose.

Dangers: Ulnar N (under FCU, ontop of FDP), Dorsal cutaneous branch of ulna distally, Ulnar A (runs with Ulnar N, radial to ulnar N)

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Henry Approach Volar Forearm

Approach:
- Landmark incision from lateral aspect of biceps tendon to radial styloid.
* Superficial
* Proximally brachioradialis (radial n.) & FCR (median n.)
* ligate the arterial branch of lateral side of radial a. to mobize radial a. medially
* careful of superfical radial n under BR and retract laterally
* Distally brachioradialis (radial n.) & radial a.*
* Deep
* Proximal 1/3 - BR and PT, supinate forearm to protect PIN, incise supinator on medial edge and elevate
* middle 1/3 - pronate to expose lateral border of PT and can detach some of it
* distal 1/3 - elevate FPL, and PQ ulnarly

Dangers:
* Superficial radial N. (Deep to brachioradialis)
* PIN - radial neck under supinator
* Radial A. - under BR

*FCR approach, the interval is between FCR and radial artery (radial artery goes radially). In Henry, the radial artery comes medially.

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Thompson Approach Dorsal Forearm

Interval:

Superficial: EDC (PIN), ECRL/ECRB (Radial n., PIN)
Deep: Supinator (PIN) and Pronator Teres (median n.)

Approach:
- incision: anterior to lateral epicondyle to just ulnar to Lister’s tubercle

Intervals:
- Superficial:
- Proximal: ECRB (radial nerve) & EDC (PIN); (Kaplan)
- Distal: ECRB (radial nerve) & EPL (PIN);
- Deep:
- Proximal: Supinator – dissect PIN, then supinate forearm & subperiosteally dissect supinator;
- Middle: APL & EPB covers radius, elevate these;
- Distal: between ECRB (2nd compartment) and EPL (3rd compartment), on bone

Dangers:
Lateral antebrachial cutaneous, PIN, superficial radial nerve

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Modified Henry FCR Approach to the Distal Radius

Interval: FCR (Median N.) and Radial a. (brachioradialis- radial n.)

Approach:

Sharp incision over FCR tendon, sharply through skin, subcutaenous tissue and FCR sheath. Retract FCR tendon radially and incise through FCR subsheath.
Retract FPL tendon ulnarly
Incise PQ along distal and radial boarder and peel off subperiosteally to reveal distal radius

Dangers: Radial A., Median N., palmar cutaneous branch of median n.

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Volar Ulnar Approach at the Wrist

Interval: Flexor Tendons [(FDS) - Median N.)] & Ulnar A.

Approach: Develop interval between FDS and FCU. Work proximally to identify ulnar a. and ulnar n. Develop interval between ulnar a. and flexor tendons. Identify PQ, lift PQ radially to reveal ulnar aspect of distal radius. Can follow ulnar n. and relase guyons canal, can release carpal tunnel through this approach as well.

Dangers: Ulnar A. Ulnar N.

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Dorsal Approach to the Wrist

Interval: 3rd & 4th extensor compartments (both PIN).

Position: Supine, hand table
**Incision: **Just ulnar to Listers, in line with 3rd metacarpal.

**Interval: **
1st Layer:
- extensor retinaculum between 3rd compartment - EPL (PIN) radial and 4th compartment - EDC (PIN) ulnar
- use retinaculum to retract tendons.

2nd layer:
- Ligament Sparing: V-Shaped, with tip at triquetrum, Proximal limb in line with DRC fibers and Distal limb in line with DIC fibers, elevated radially with attachment left at radial styloid.
- Non-Ligament Sparing: In line dorsal capsulotomy, subperiosteally dissect under RSC radially and DRC ulnarly.
- Scaphoid: T-Shaped capsulotomy, along border of radius and distal to DIC fibers. Must flex wrist. Allows visualization of proximal scaphoid, SL ligament.

Dangers: PIN purely sensory at the wrist (can be ablated for pain control), Dorsal sensory branch of radial nerve, Dorsal carpal artery (supplies scaphoid)

Approach:

Incision centered over Lister’s tubercle
Elevate skin flap, excise extensor retinaculum.
Identify 3rd and 4th compartment and split the two.
Identify dorsal wrist capsule, dorsal intercarpal ligament, and dorsal radiocarpal ligament. (Ligament sparing capsulotomy)

Dangers: PIN purely sensory at the wrist under 4th compartment (can be ablated for pain control). SL, LT ligaments.

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Russe Approach (Volar Approach to Scaphoid)

Interval: Radial a. and FCR (Median N.)

Approach:

wagner iIncision centred over the scaphoid tubercle
Glabrous border of thumb between radial artery and FCR.
Identify FCR tendon, then cut through subsheath , retract FCR ulnarly
Split thenar muscles distally
: Incise RSC and long Radiolunate in line.
Incise capsule over scaphoid and expose scaphoid up to ST joint
Must extend wrist and often excise part of trapezium to obtain start point.

Dangers: Dorsal sensory branch of radial nerve, radial artery, volar scaphoid branch of radial artery.

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Subvastus/Lateral Approach to Femur

Interval: Lateral Intramuscular Septum & Vastus Lateralis (femoral n.). Technically none.

Approach:

Incise IT Band
Incise Vastus Lateralis fascia.
Lift Vastus lateralis from septum and femur, taking care to cauterize perforator branches.
- Can go either through vastus (direct lateral) or under vastus (posterolateral)

Dangers: Perforating branches of Profunda Femoral A.

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Anteromedial Approach to the Distal Femur

Interval: Vastus Medialis (femoral n.) & rectus femoris (femoral n.)

Approach:

Incision from anteromedial thigh to medial patella
Develop plane between vastus medialis and rectus femoris
Split vastus intermedius deep
Need to repair any detatched vastus medialis from quadriceps tendon insertion to patella

Dangers:

Medial geniculate artery (ligate)

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Medial Approach to Distal Femur

Interval:

Superficial: Adductor Longus (Obturator n.) & Sartorius (Femoral N.)
Deep: Adductor Longus (Obturator n.)& Vastus Medialis (Femoral N.)

Approach:

Incision over adductor tubercle and extend proximally
Develop plane between adductor longus and sartorisu, then deep vastus medialis.
Cannot go distal to vastoadductor membrane (9cm proximal to jont. This is the membrane that covers hunters canal deep to sartorius.

Dangers:

Saphenous n. (identify over adductor tendon)
Femoral A. (crosses ant to post 13cm bove joint)

Smith-Peterson (Anterior) Approach to the Hip

Interval: *only approach to the hip with TRUE internervous plane

Superificial: TFL (Superior Gluteal N.) & Sartorius (Femoral N.)
Deep: Rectus Femoris (Femoral N.) & Gluteus Medius (Superior Gluteal N.)

Approach:
* Incision vertically from ASIS towards lateral side of patella (8-10 cm)
* Incise TFL fascia, retract muscle laterally, and incise deep subfascia to protect LFCN.
* Bluntly develop plate between Rectus & Gluteus medius. Take care to identify and ligate/cauterize branches of lateral femoral circumflex a. in this interval.
* Can detatch reflected head of rectus from acetabulum to better expose capsule
* Come directly ontop of hip capsule and make capsulotomy

Dangers:

Lateral Femoral Cutaneous N. (branches over sartorius 2.5cm below ASIS)
Ascending branches of Lateral Femoral Circumflex A.

Hardinge (Lateral) Approach to the Hip

**Interval:** Splitting Gluteus Medius (lateral to innervation by Superior Gluteal N.) **Approach:** * Vertical incision centered over lateral aspect of greater trochanter. * incise TFL * Incisise IT Band * Split Gluteus Medius (2/3, 1/3 or 50/50) * Split Gluteus Minimus and Capsule * Peel Capsule, Gluteus Medius and Minimus anteriorly * Dislocate hip ANTERIOR **Dangers:** * Superior Gluteal N. * Branches 2-3 cm proximal to GT, dont split too high * Femoral A., V. & N. - be careful with retractor positioning anteriorly

Watson-Jones (Anteriomedial) Approach to the Hip

**Interval:** Gluteus Medius (Superior Gluteal N.) & TFL (Superior Gluteal N.) **Approach:** * Vertical incision on the lateral aspect of the GT curving the proximal aspect * Incise the lateral boarder of the TFL and retract anteriorly, revealling digastic tendon (glut med & vastus lateralis at the greater trochanter) * Develop plane between gluteus medius and TFL * Deep plane b/w rectus femoris and glut medius, May need to reflect vastus lateralis off femur * Can release vastus lateralis anteriorly **Dangers:** Femoral A., V. & N. (can be injured by excessive retraction/placement of anterior retractors)

Posterior (Moore-Southern) Approach to the Hip

**Interval:** No true IN plane, split ITB (Sup Gluteal N.) & Glut Maximus (Inf Gluteal N.) **Approach:** * Incision 10-15 centered on the posterior aspect of greater trochanter. Curved posterior proximally * Split ITB and Gluteus Maximus * Detatch piriformis and short external rotators, reflecting posteirorly to protect Sciatic N. * Internal rotation of leg will stretch short external rotators and bring them away from Sciatic N. * From this approach, Sciatic N. is deep to piriformis and superficial to short external rotators. * This exposes capsule for capsulotomy **Dangers:** 1. Sciatic N. (reflect SERs to protect) 2. Inferior Gluteal A. - ligate branches when splitting gluteus maximus 3. Ascending branches of medial femoral circumflex - runs along proximal boarder of quadratus femoris (may detatch proximal 1cm, but preserve otherwise)

Ludloff (Medial) Approach to the Hip

**Interval:** * Superficial: Adductor Longus (Obturator N.) & Gracilis (Obturator N.) * Deep: Adductor Brevis (Obturator N.) & Adductor Magnus (Obturator N. & Tibial Fibres of Sciatic N.) **Approach:** * Incision 3cm below pubic tubercle * No real Internervous Plane * Dissect superficially between adductor longus and gracilis. * Develop deep plane between adductor brevis and adductor magnus. * feel LT and capsule incision **Dangers:** 1. Anterior Division of Obturator N. (between longus and brevis) 2. Posterior Division of Obturator N. (on magnus under brevis) 3. Medial Femoral Circumflex A. on distal psoas

Ilioinguinal Approach (Windows, Boarders, Approach & Dangers)

**Exposure**: Anterior Column and Quadrilateral Plate **Superficial Approach**: * Incision: midline 2 fingers above symphysis to iliac crest 1st layer: external oblique aponeurosis is open to unroof inguinal canal: isolate spermatic cord and vessels; 2nd layer: then open floor of inguinal canal; 3rd layer: divide iliopectineal fascia between vessels and ilopsoas: beware of corona mortis, iliacus mobilized off inner table to SI joint; Windows: - medial to lymphatics and external iliac artery/vein gives access to space of Retzius, - between external iliac and iliopsoas gives access to quadrilateral surface, - lateral to ilopsoas gives access to internal iliac fossa and SI joint **Windows & Deep Approach**: 1. Lateral Window: Illiac Wing to Psoas Tendon 1. Continue subperiosteal dissection and elevation of illiacus from false pelvis 2. Continue until SI joint/sufficient exposure reached 2. _Middle Window_: Psoas Tendon to Femoral Bundle 1. Develop illiopectineal fascia by careful retraction of femoral vessels. 2. Divide fascia under direct visualization 3. Subperiosteally expose the quadrilateral plate/true pelvis 3. _Medial Window_: Epigastric Vessels/Spermatic Cord to Rectus Abdominus Insertion 1. Release rectus insertion 2. Retraction of the spermatic cord/round ligament 3. Protect the bladder and develop space of Retzius with sponge 4. Subperiosteal dissection of superior pubic ramus to symphasis **Dangers**: 1. Lateral Femoral Cutaneous N. (2cm medial to ASIS) 2. Femoral N, A, V (in femoral sheath) 3. Inferior Epigastric A (medial to inguinal ring, identify and ligate) 4. Illioinguinal N. (runs with spermatic cord before entering peritoneum) 5. Corona Mortis (obt vessel and ext iliac vessels) 6. Spermatic Cord/Round Ligament 7. Bladder

Modified Stoppa Approach (Exposure, Approach, Dangers)

**Exposure:** * Quadrilateral Plate (direct instrumentation) * Pubic Symphasis * Entire Anterior Column when combined with lateral window of illioinguinal **Approach:** * foley catheter pre-op to decompress bladder * Pfannenstiel incision above pubic symphasis * Longitudinal incision of rectus fascia at linea alba * Protect bladder and retract with malleable * Expose carefully along medial surface of superior ramus * Look for and ligate corna mortise (~4cm medial to symphsis) * Disect the iliopectineal arch from the pelvic brim allowing elevation of femoral vessels * Can be limited by bifurcation of the illiac vessels * Continue dissection to reveal quadrilateral plate. Will need to elevate obturator internus * Obturator bundle crosses quadrilateral plate needs to mobilized and retracted **Dangers:** 1. Bladder 2. Corona Mortise 3. Obturator N. and Vessels 4. External illiac Vessels Illiac Vessels

Kocher Langenbeck Approach (Exposure, Approach & Dangers)

**Exposure:** Posterior Column, Wall **Approach:** **Position: **Lateral decubitus, prone **Incision:** Centered over tip of GT, extend distal along femur, proximal may gently curve posterior over glute max. **Plane: ** - 1st layer: Through TFL and gluteal fascia. - 2nd layer: internally rotate, flex and adduct hip, release piriformis, short external rotators off GT insertion. Dislocate hip posterior. Divide gluteus maximum proximal and retract gluteus medius superior. to expose posterior acetabulum. **Dangers:** * Sciatic Nerve * Superior Gluteal A & N - leaves pelvis above piriformis * First perforating branch of Profunda Femoris (at risk with release of glut max insertion) * Femoral Vessels (placement of retractors anterior to iliopsoas * Inferior Gluteal A. - Leaves pelvis beneath piriformis * Medial Circumflex A. (courses along superior edge of quadratus femoris) * Heterotopic Ossification

Extended Iliofemoral Approach (Exposure, Approach & Dangers)

**Exposure:** Posterior column and entire lateral aspect of illiac wing (anterior and posterior) * Can palpate quadrilateral plate **Approach:** * Incision: PSIS along illiac crest to ASIS then down towards lateral margin of knee * Expose illiac crest Incise along crest and elevate subperiostially * Elevate gluteals from posterior aspect of crest * Elevate obliques and illiacus from anterior aspect of wing * Take care to protect superior gluteal vessles and nerve emerging from greater sciatic notch * Detatch fascia lata muscle from ASIS and develop between sartorius and TFL (smith peterson interval * Retract posteriorly to expose direct and and reflected origins of rectus * Direct head will lead to hip capsule * Release gluteus minimus, retract posteriorly * Release gluteus medius and retract posteriorly * Release piriformis and SERs * Can open capsule if desired. **Dangers:** 1. Sciatic N 2. Lateral Femoral Cutaenous N. 3. Superior Gluteal Vessels & Nerve 4. Inferior Gluteal Vessels & Nerve 5. Medial Femoral Circumflex (coursing along superior edge of quadratus femoris) 6. Femoral Vessels with retractor placement anterior to iliopsoas 7. **Highest Risk of Heterotopic Ossification**

Medial Parapatellar Approach to the Knee

**Interval:** No internervious. Intramuscular - VMO and rectus **Approach** * Incision longitudinally over patella * Develop subcutanous fpals * Marke out arthrotocmy, leaving a 3-5mm cuff * Performe arthotomy **Dangers** 1. Articular Cartilage 2. Medial Meniscus **Variations** * Subvastus - medial boarder of patella along VMO * Midvastus - Divide VMO in line with fibres * Quadriceps Snip - proximal incision along quadrieps tendon. Patella slid not everted

Anterolateral Approach to the Knee/ Proximal Tibia

**Interval:** ITB and Tib Ant and Tibial Crest **Approach:** * Incision: Gerdy's tubercle, tibial crest and jointline. "hockeystick" * Incise ITB if working anteriorly, or work between ITB and biceps. * Perform submeniscal arthrotomy **Dangers:** 1. Peroneal Nerve - excessive posterolateral retraction 2. Lateral Meniscus

Posterior Approach to the Knee

**Interval:** none, popliteal fossa **Approach:** * S-shaped incision acorss flexor crese. * Dissect through fascia, idenfiity and prtect medial sural cutaneous nerve and short saphenous vein * identify semimembranosus and retract medially * Retract head of gastrocs laterally, to protecte NVB * Periosteially elevate soleus from proximal tibia **Dangers:** 1. Medial sural cuntaneous n. 2. Popliteal A, Tibial N. Popliteal V. 3. Short Saphenous V.

Medial Approach to the Knee

**Interval**: none **Approach:** * Curved incision from adductor tubercle * Eleavate Skin Flaps * Incise layeres anterior or posterior to MCL * Anterior: through sartorial fascia, along border of sartorius- retract pes tendons posteriorly * Posteriorly: retract sartorius, semi T & gracilis posterioly then incise posterior to MCL **Dangers:** 1. Infrapatellar branch of saphenous n. 2. Saphenous N & V (between gracilis and sartorius( 3. Medial inferior geniculate A. 4. Popliteal A - avoid going posteriorly

Anteriolateral Approach to Tibia

**Interval:** * Superificial: perneus brevis (SPN) & EDL (Deep Peroneal N. ) * Deep- IOM & Extensors (Deep Peroneal N.) **Approach:** * Incision - over fibular shaft * Develop between peroneus brevuis and EDL * Lift EDL anteromedially * Work over anterior fibula along IOM (beware of NVB) **Dangers:** 1. Small Saphenous V. 2. Superficial peronean N. (Btw EDL & Peroneus Brevis) 3. Anterior Compartment NVB (Deep peroneal n., ant tibial a & v.)

Posterolateral Approach to Tibia

**Interval:** Between posterior (Tibial N.) & Lateral compartments (SPN) - peroneal and FHL **Approach:** * Incision: posterior aspect of fibula * Develop between peroneals and lateral gastrocs * Detatch soleus from fibula * Find FHL, detatch from fibula and retract * Get onto IOM (tib post muscle protects NVB) * DIssect to expose tibia, lift subperosteally **Dangers:** 1. Short Saphenous Vein 2. Peroneal A Branches- pass from post compartment to peroneals. Ligate as you go. 3. Post Tib A, V 4. Tibial N.

Proximal Approach to Fibula

**Interval:** Posterior compartment (tibial) and Peroneals (SPN). **Approach:** * Incision: proximally, follow bicesp femoris tendon, distally follow posterior tibia * Find biceps femoris tendon, keep in mind the nerve is posterior to it. * Incise fascia posteior to tendon * Dissect out common peroneal n. * Cut overlying peroneus longus muscle at fibular neck * Subperiosteally elevate nerve off neck, and reflect anteriorly with penrose drain * Detend distally, develop plane between soleus and peroneals **Dangers:** 1. Common Peroneal N. 2. Peroneal A. - posterio to distal fibula - stay subperiosteal

Anterior Approach to Ankle

**Interval:** Internervous n/a. Choose deep interval. **Approach:** * Incision: longitudinal betwen medial and lateral malleolus * Dissect NVB and protect * Choose your interval (TA, EHL, EDB) * Incise capsule inline with wound **Dangers:** 1. Superficial Peroneal N. - crosses anterior 2. NVB - Ant Tib A., Deep Peroneal N.

Posteriomedial Approach to the Ankle

**Interval:** non- choose your interval (know your medial structures, Tom, Dick & V. Nervous Harry) **Approach:** * Incision: longitudinal between medial malleolus and achilles * Incise deep fascia * Find FHL (only fleshy muscle at this level) * 4 Windows * Lateral to FHL (FHL and peroneals) * Medial to FHL (FHL & NVB) * Cut all tedons (used for soft tissue releases) * Medial to FHL (FDL and NVB) **Dangers:** 1. NVB - post tib A, V, tibial N. 2. Saphenous N - runs infront of medial mallolus

Medial Approach to the Ankle

**Interval:** None (essentially between TA/TP) **Approach:** * Incision: longitudinal, curved over medial malleolus * Incise down to bone and subperosteally elevate **Dangers:** 1. Saphenous N- runs over medial malleolus- stay subperiosteal 2. Tib Post Tendon, just behind malleolus

Sinus Tarsi Approach to Ankle

**Interval:** Anterir to peroneal tendons (SPN), and EDB (Deep Peroneal N.) **Approach:** * Incision: overlying peroneal tendons, from just distal to lat mal toward base of 4th MT * Mobilize flaps * Reflect peroneals posteriorly * partiallly detach or elevate EDB * Incise subtalar joint capsule **Dangers:** 1. Sural N. 2. Short Saphenous V.

Extensile Lateral Approach to Calcaneus

**Approach:** * Incision: L-shaped, just lateral to ahcilles to glaborous boarder and to the base of the 5th metatarsal * At corners, cut straight to bone * Use 15 balde to elevate full thickness flaps * Put kwires in the talar head, cuboid and distal fibula and bend to hold up skin flap * Be very careful with skin flap **Dangers:** 1. Sural nerve at proximal and distal end of incision 2. Peroneal tendons as you're elevating flap

Approach to Talar Neck (2 incisions)

**Approach:** * Anteromedial * Incision along talar neck * Interval: TA (Deep Peroneal N.) & TP (Tibial N.) * Incise, subcuatenous dissection onto capsule and neck * Anterolateral * Interval: peroneals (SPN) and EDB (deep peroneal n.) * Incision: in line with 4th MT * Incise, develop interval, retract EDB medially * Incise capsule **Dangers:** 1. Saphenosu V & N. (medially) 2. SPN (laterally)

Posterolateral Approach to Distal Fibula/Tibia

**Intervals**: Peroneals (SPN) & FHL (Deep Peroneal N.) **Approach** * Incision between fibula and achilles * Develop interval between peroneals and FHL (Fleshy) * Dissect FHL off of tibia subperiosteally **Dangers**: 1. Sural N. - in anterior flap

Anteriolateral Approach to the Lumbar Spine (Retroperitoneal)

**Exposure**: L1-Sacurm **Approach**: * Incision: Posteiror half of 12th rib to lateral boarder of rectus * Subcutaneous fat, external oblique aponeurosis * Divide Ext Oblique, Int Oblique And Trasverse Abdominus * Divide plane between retroperitoneum and psoas * Retract peritoneal cavity, follow psoas to lumbar bodies * Tie segmental lumbar arteries of aorta in field of dissection * L4L5 - mobilize aorta to contralateral side * L5S1 - work between bifurcation **Dangers**: 1. Sympathetic Chaoin - lateral aspect of vertebral bodies 2. Segmental Arteries of Aorta. 3. Ureter 4. Superior Hypogastric Plexus (retrograde ejaculation(

Wiltse Paraspinal Approach to the Spine

**Indication**: Far lateral disc herniation **Approach:** * For far lateral disc herniation *** Intramuscular plane between multifidus and longissimus** * Incision 3mm from midline **Dangers**: 1. Dorsal root ganglion

Anterior Transperitoneal Approach to Lumbar Spine

**Indications:** L5S1 Fusion **Approach:** * Incision: Longitudinal Midline - xyphoid to symphasis * Fat, then through linea alba * Incise peritoneum, lif to avoid injury to deep viscera and bladder * Retract viscera laterally, trendelenberg, pack abdomen * Ligate sacral artery, identify disc space * L5S1 lies below Aortic Bifurcation **Dangers**: 1. Superior hypogastric plexus 2. Vessesl : Aorta, IVC, Middle Sacral A. 3. Ureter 4. Bladder 5. Viscera

Anterior (Smith Robinson) Approach to the Cervical Spine

**Exposure**: C3-T1 **Approach**: - position: supine - transverse incision at level determined by xray along medial border of SCM - incise through skin, SQ fat and then sup fascia; protect ext jugular vein and split platysma - split deep cervical fascia and retract strap muscle medially and SCM laterally - retract pretracheal fascia, protecting sup and inf thyroid vessels within fascia medially and carotid sheath laterally - incise prevertebral fascia, protect sympathetic chain and recurrent laryngeal n and split left and right longus colli - confirm level with spinal needle in disc **Dangers**: 1. Recurrent Laryngeal Nerves (right more vulnerable than left) 2. Sympathetic Nerves - can have Horner's Syndrome 3. Carotid Sheath Contents (Carotid A, V, Vagus N.) 4. Retropharyngeal Hematoma 5. Trachea 6. Esophagus

Anterior Approach to the Iliac Crest For Bone Graft

**Position:** Supine with sandbag under ass **Incision: **From 3-5cm posterior to ASIS over the iliac tubercle parallel to the crest **Plane: ** - 1st layer: between the origin of gluteus medius and Tensor fascia and the external oblique (segmental innervation). - 2nd layer: elevate iliacus, external and internal obliques, transversalis abdominis fascia. Cut bone with saw/osteotomes, may leave medial hinge if just cancellous, may take cortical if need tricortical graft. **Dangers:** Inguinal Ligament and lateral femoral cutaneous nerve – (stay posterior to ASIS)

Posterior Approach to the Iliac Crest for Bone Graft

**Position:** Prone **Incision: **longitudinal Centered over the PSIS in line with the iliac crest **Plane: **Between gluteus maximus (inferior gluteal nerve) AND paraspinal muscles (segmental innervation) and lat dorsi (long thoracic) **Dangers: **Cluneal nerves cross the crest 8 cm in front of PSIS, so stay posterior: Their loss causes no problem, just numb ass; Sciatic nerve deep and superior gluteal vessel – stay proximal to sciatic notch

Carpal Tunnel Release

**Position:** Supine, hand table **Incision:** In line with border between 3rd/4th digit when flexed, proximal to Kaplan's cardinal line extending proximal to wrist crease. **Interval: ** - 1st Layer; Skin, palmar subcutaneous tissue, sweep palmaris brevis ulnar, expose transverse carpal ligament (TCL). - 2nd layer: Release TCL along ulnar aspect (cheat ulnar; median nerve less likely immediately deep to it, recurrent motor branch usually more radial, palmar cutaneous branch of median nerve radial). Ensure complete release distal to palmar fat (but no further, due to superficial palmar arch, recurrent motor branch. Ensure complete release proximal to antebrachial fascia of the forearm. **Dangers:** Palmar cutaneous branch of median nerve (between FCR and PL), recurrent motor branch of median nerve (50% extraligamentous - arise distal, 30% subligamentous - arise in carpal tunnel, 20% transligamentous - go through TCL), median nerve proper, Superficial palmar arch artery.

Guyon’s Canal Release

**Position: **Supine, hand table **Incision: **Ulnar over the hypothenar with Brunner extension over wrist crease to forearm. **Interval: ** - 1st Layer; Skin, palmar subcutaneous tissue, sweep palmaris brevis radial, expose palmar carpal ligament. - 2nd layer: Release palmar carpal carpal ligament and antebrachial fascia of forearm proximal (to decompress Zone 1). Identify hook of hamate medial, incise along ulnar edge to decompress deep motor branch (Zone 2). Release distal fascia (Zone 3). **Dangers: **Ulnar nerve proper and artery, deep motor branch ulnar nerve, superficial volar sensory branches ulnar.

Anterior Approach to the Cubital Fossa (NV Exploration, Biceps Repair)

**Position: **Supine with arm in anatomic position **Incision: **Curved S incision: Start proximal at medial side of biceps, Turn transverse across crease, Then turn distal lateral at medial side of brachioradialis **Intervals: ** - Proximally: between biceps brachii (musculocutaneous nerve) and brachialis (musculocutaneous nerve), identify the brachial vessels and median nerve. - Transverse: Incise bicipital aponeurosis (lacertus fibrosus) at insertion on biceps tendon, ligate recurrent branches of brachial artery and protect lateral antebrachial cutaneous nerve of the forearm (between biceps tendon and brachialis muscle) heading lateral over BR. - Distally: between brachioradialis (radial nerve) and pronator teres (median nerve). Watch for the radial nerve (between brachialis and brachioradialis) and superficial radial nerve. PIN travels through supinator deep. **Dangers: **Lateral antebrachial cutaneous nerve of the forearm – identify in the interval between the brachialis and biceps brachii, Radial artery - lies under bicipital aponeurosis, recurrent branches (ligate). Median nerve and brachial artery - lie medial to biceps brachii and brachialis. Radial nerve proper, superficial radial nerve and PIN run laterally in the distal exposure.