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Orthopedic Surgery Ultimate > Thigh/Knee Approaches > Flashcards

Thigh/Knee Approaches Flashcards

1
Q

position for lateral approach to the femur

A

trochanteric #: supine

internal rotation 15°

in traction table

shaft #: lateral

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2
Q

incision for lateral approach to the femur

A

longitudinal incision over middle of GT extending down lateral side of thigh, length and position depending on where the fracture is

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3
Q

internervous plane for lateral approach to the femur

A

none. this is a vastus split

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4
Q

superficial dissection for lateral approach to the femur

A

incise fascia lata of thigh (usually the fibres of TFL end at the GT, but sometimes you need to split fibres there too)

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5
Q

deep dissection for lateral approach to the femur

A

incise fascia covering vastus lateralis

split the vastus lateralis with 2 homans

cauterize vessels as they arise from within the vastus

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6
Q

dangers for lateral approach to the femur

A

1) numerous perforating vessels from the profunda femoris artery

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7
Q

position for posterolateral approach to the femur

A

supine

sandbag under operative side buttock

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8
Q

incision for posterolateral approach to the femur

A

longitudinal starting at the lateral femoral condyle and extending proximally along the posterior edge of the femur

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9
Q

internervous plane for posterolateral approach to the femur

A

between vastus lateralis and the lateral intermuscular septum

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10
Q

superficial dissection for posterolateral approach to the femur

A

incise deep fascia of the thigh

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11
Q

deep dissection for posterolateral approach to the femur

A

dissect between the vastus lateralis and the lateral intermuscular septum and reflect the muscle anteriorly beginning at the distal end of the incision

ligate perforating femoral branches and superior lateral geniculate vessels

when you reach bone, begin to strip subperiosteally

use retractors to aid anterior displacement of vastus lateralis

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12
Q

dangers for posterolateral approach to the femur

A

1) perforating arteries
2) superior lateral geniculate artery and vein

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13
Q

position for anteromedial approach to the distal femur

A

supine

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14
Q

incision for anteromedial approach to the distal femur

A

make 10-15 cm longitudinal incision over interval between rectus femoris and vastus medialis, extending distally to medial edge of patella

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15
Q

internervous plane for anteromedial approach to the distal femur

A

none

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16
Q

superficial dissection for anteromedial approach to the distal femur

A

incise fascia

ID interval between rectus and vastus medialis

develop plane by retraction and blunt dissection

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17
Q

deep dissection for anteromedial approach to the distal femur

A

begin distally

open knee capsule

split quads tendon on its medial border

develop interval between vastus medialis and rectus

split vastus intermedius in line with fibres

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18
Q

dangers for anteromedial approach to the distal femur

A

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

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19
Q

position for posterior approach to the femur

A

prone

pelvis and chest longitudinal supports

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20
Q

incision for posterior approach to the femur

A

longitudinal 20 cm loong down the midline of the posterior aspect of the thigh ending proximally at the inferior margin of the gluteal fold

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21
Q

internervous plane for posterior approach to the femur

A

lateral intermuscular septum and biceps femoris

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22
Q

superficial dissection for posterior approach to the femur

A

incise deep fascia

watch for posterior femoral cutaneous nerve which runs in groove between biceps and semi T

ID lateral border of biceps

develop plane between biceps and vastus lateralis

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23
Q

deep dissection for posterior approach to the femur

A

begin proximally

retract biceps medially and vastus laterally

blunt dissection for plane

ID short head of biceps arising from posterolateral lip of linea aspera and detach it and reflect medially

*when distal, retract biceps laterally to expose sciatic nerve, then retract it laterally with biceps

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24
Q

dangers for posterior approach to the femur

A

1) sciatic nerve medial to biceps
2) nerve to biceps enters very proximal and medial, so usually not a worry

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25
position for minimal access approach to the distal femur
supine sandbag under thigh to put knee in 30° flexion
26
incision for minimal access approach to the distal femur
6-8 cm incision longitudinal over anterior half of the lateral femoral condyle extending rostral from the joint line second incision site will be along lateral femur at a position dependent on fixation to be used
27
internervous plane for minimal access approach to the distal femur
distally between vastus lateralis and biceps femoris proximally, none, as you split vastus lateralis
28
superficial dissection for minimal access approach to the distal femur
begin distally divide lateral retinaculum to see joint capsule develop plane between vastus lateralis and the lateral intermuscular septum ligate branchs of lateral genicular artery proximally, use vastus split as previously described
29
deep dissection for minimal access approach to the distal femur
divide knee joint capsule and synovium split and retract vastus lateralis proximally
30
danger for minimal access approach to the distal femur
1) superior genicular artery and veins need to be ligated
31
position for minimal access approach to proximal femur for intramedullary nailing
supine (better fracture control and distal locking screw): traction table adduct leg lateral flexion of trunk away from site flex and abduct the opposite hip and flex the knee reduce # use steinmann pin to manipulate the proximal fragment if necessary lateral (better entry point, needed for obese patients): traction adduct leg flex contralateral limb at hip and knee pad bony prominences reduce # use steinmann pin if necessary \*very obese = consider retrograde nailing
32
incision for minimal access approach to proximal femur for intramedullary nailing
entry point where a line drawn along the femoral shaft up and over the GT intersects a perpendicular line drawn from the ASIS posteriorly (this incision will be 3-7 cm depending on the nail you are using)
33
internervous plane for minimal access approach to proximal femur for intramedullary nailing
none split fibres of glut max and glut med
34
superficial dissection for minimal access approach to proximal femur for intramedullary nailing
fascia split glut max for 3 cm
35
deep dissection for minimal access approach to proximal femur for intramedullary nailing
continue distally to split glut med ID medial aspect of GT use fluoro to line the guidewire up AP and lateral with the medullary canal
36
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
37
position for minimal access approach to retrograde intramedullary nailing of femur
supine flex knee with triangle ridge to 90° sandbag under buttock
38
incision for minimal access approach to retrograde intramedullary nailing of femur
palpate medial border of patella 3 cm longitudinal incision 1 cm from medial border of patella about 2 cm distal to the distal pole of the patella
39
internervous plane for minimal access approach to retrograde intramedullary nailing of femur
none - you are just passing through medial retinaculum and synovium
40
superficial dissection for minimal access approach to retrograde intramedullary nailing of femur
incise capsule
41
deep dissection for minimal access approach to retrograde intramedullary nailing of femur
divide synovium ID intercondylar notch
42
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
43
position for arthorscopic approach to the knee
supine tourniquet knee free to manipulate
44
incision for arthorscopic approach to the knee
lateral: find where the lateral joint line meets the edge of the patella tendon make an 8 mm stab incision 1-1.5 cm proximal to the joint line medial: same procedure but medially \*note that the lateral incision should be slightly lower due to the lateral tibial condyle being slightly lower
45
internervous plane for arthorscopic approach to the knee
none
46
dissection for arthorscopic approach to the knee
flex knee to 90° incise retinaculum insert arthroscopic sheath and blunt trochar extend knee and remove trochar insert 30° camera switch on irrigation switch on light
47
what is the order of scoping in knee arthroscopy?
start in extension suprapatellar pouch patellofemoral joint lateral recess popliteal recess anterolateral meniscus medial femoral recess now flex to 90° valgus + external rotation medial compartment ACL + PCL varus stress with figure of 8 position lateral compartment
48
danger for arthorscopic approach to the knee
1) articular cartilage 2) meniscus
49
position for medial parapatellar approach to the knee
supine knee flexed hip support to stop abduction
50
incision for medial parapatellar approach to the knee
longitudinal midline from 5 cm above the patella to below the level of the tibial tubercle
51
internervous plane for medial parapatellar approach to the knee
none
52
superficial dissection for medial parapatellar approach to the knee
leave some capsular tissue on medial edge of patella to fascilitate repair enter midline through quads tendon retract or excise fat pad
53
deep dissection for medial parapatellar approach to the knee
dislocate patella laterally flex the knee to 90°
54
dangers for medial parapatellar approach to the knee
1) infrapatellar branch of the saphenous nerve 2) avulsion of the patella ligament during difficult dislocation
55
position for approach to medial meniscectomy
supine sandbag under thigh remove end of table to allow 90° knee flexion tourniquet
56
incision for approach to medial meniscectomy
begin at inferomedial corner of patella angle it inferiorly and posteriorly ending 1 cm below the joint line
57
internervous plane for approach to medial meniscectomy
none
58
superficial dissection for approach to medial meniscectomy
incise medial retinaculum incise joint capsule
59
deep dissection for approach to medial meniscectomy
incise synovium and enter above the joint line to avoid damaging structures within
60
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
61
position for medial approach to knee
supine knee flexed hip externally rotated to rest affected lateral ankle on shin of unaffected leg tourniquet
62
incision for medial approach to knee
longitudinal, curved starting 2 cm proximal to adductor tubercle down to 6 cm below the joint line on the anteromedial tibia running 3 cm medial to patella
63
internervous plane for medial approach to knee
none
64
superficial dissection for medial approach to knee
fascia spare the saphenous nerve (not the infrapatellar branch) and saphenous vein
65
deep dissection for medial approach to knee
incise either anterior or posterior to the MCL anterior: fascia along border of sartorius starting at the pes and moving to 5 cm proximal to joint retract the 3 pes muscles posteriorly expose superficial MCL now go to medial parapatellar to expose the ligament from inside posterior: same except after retraction of pes, then separate medial head of gastrocs from semi M to see posteriomedial corner
66
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
67
position for approach to lateral meniscectomy
supine sandbag under thigh knee free to flex \>90° tourniquet
68
incision for approach to lateral meniscectomy
start at the inferolateral corner of the patella continuing downward and backward for about 5 cm remaining anterior and superficial to LCL
69
internervous plane for approach to lateral meniscectomy
none
70
superficial dissection for approach to lateral meniscectomy
incise anterolateral aspect of the knee capsule
71
deep dissection for approach to lateral meniscectomy
incise synovium and fat opening anterolateral portion of joint beginning well above to avoid meniscal damage
72
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
73
position for lateral approach to the knee
supine sandbag under buttock flex knee to 90° tourniquet
74
incision for lateral approach to the knee
long, curved 3 cm lateral to patella extending distal over Gerdy's tubercle to 4-5 cm past the joint line, while the upper end should be extended along the line of the femur
75
internervous plane for lateral approach to the knee
between IT band and biceps femoris
76
superficial dissection for lateral approach to the knee
fascia avoid common peroneal on posterior border of biceps tendon retract IT band anterior retract biceps posterior with peroneal nerve
77
deep dissection for lateral approach to the knee
enter joint either in front of or behind LCL: anterior: make sure to stay superior to joint line to avoid meniscal damage as you enter the joint posterior: dissect between lateral head of gastrocs and the posterolateral corner ligate superior geniculate arteries arthrotomy well above joint line to avoid damage to meniscus or tendon of popliteus
78
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
79
position for posterior approach to the knee
prone lateral pillows tourniquet
80
incision for posterior approach to the knee
curved incision starting laterally over biceps muscle, obliquely across the popliteal fossa turning downward over medial head of gastrocs and inferiorly into the calf
81
internervous plane for posterior approach to the knee
none
82
superficial dissection for posterior approach to the knee
incise skin and ID vein with medial sural cutaneous nerve incise fascia using medial sural cutaneous nerve as a guide tracing it back to the tibial nerve - dissect to the apex dissect out the common peroneal nerve from the apex now find aartery and vein which run deep and medial to tibial nerve find the 5 branches of the popliteal artery near the knee (2 superior, 2 inferior, 1 middle)
83
biceps femoris
84
plantaris
85
common peroneal nerve
86
lateral head of gastrocs
87
medial sural cutaneous nerve
88
small saphenous vein
89
medial head of gastrocs
90
tibial nerve
91
semi M
92
deep dissection for posterior approach to the knee
posteromedial: detach medial gastrocs and retract with vessels/nerves inferolaterally posteriolateral: detach lateral gastrocs and pull medial developing the plane between biceps and gastrocs
93
why would you use the posterior approach to the knee if you can see both corners with either lateral or medial approaches?
avulsed PCL tibial component is the only real reason
94
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
95
position for lateral approach to distal femur for ACL surgery
supine sandbag under thigh knee in 30° flexion tourniquet
96
incision for lateral approach to distal femur for ACL surgery
10 cm incision parallel to and over the indentation between the biceps femoris and IT band ending distally at the flare of the lateral femoral condyle
97
internervous plane for lateral approach to distal femur for ACL repair
vastus lateralis and biceps femoris
98
superficial dissection for lateral approach to distal femur for ACL repair
incise IT band slightly anterior to lateral intermuscular septum
99
deep dissection for lateral approach to distal femur for ACL repair
ID vastus lateralis and retract anteriorly ID lateral superior geniculate artery - ligate incise periosteum at junction of shaft and flare dissect with an elevator distally and medially until you get to the intercondylar notch via the posterior distal femur pass instrument posterior to femur until it is visible in the medial parapatellar incision
100
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

Orthopedic Surgery Ultimate (88 decks)

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