Upper limb approaches Flashcards
superior Clavicle approach
Skin
- 10cm oblique incision over the superior aspect of the clavicle
Approach
- platysmus
- clavicopectoral fascia
- clavicle
risks
- supraclavicular nerve
Deltopectoral approach
position
- beach chair
- 45 degree
- head support
incision
- deltopectoral groove
- coracoid process to groove to lateral arm
internervous plane
axillary and pectoral nerves
Superficial
- skin, fat
- retract cephalic vein - ligate tributaries
- incise deltopectoral fascia
- deltoid - lateral
- pec major - medially
Deep
- divide clavipectoral fascia from coracoid process
- retract conjoided tendon medially - DANGER - MCN
- Supscap tendon
- capsule
subscap tendon - posterior shoulder dislocation - - modified Mc Laughlin
Dangers
- MCN - conjoined tendon
- Axillary - just distal to subscap - lat to medial
- cephalic bein
Extension - anterior approach to humerus
Anterolateral approach to humerus
Indications:
- ORIF middle and distal third diaphyseal
- prox extension to deltopectoral and distal to anterior elbow
position
* supine
* arm board
* arm abducted to 60 deg
NO INTERNERVOUS PLANE
skin
* curved longitudinal incision
* lateral border of biceps
* 10cm proximal to elbow crease to just prox to lat border of biceps
Superficial
- skin, fat and retract cephalic vein
- deep fascia
- LCNF retracted medially with biceps
Deep
- fascia
- intermuscular plane - brachioradialis and brachialis
- identify radial nerve distally - trace to lateral intermuscular septum and protect
brachialis elevated and retracted medially
Dangers
- lateral cutaneous nerve of the forearm
- radial nerve
anterior shoulder approach
Indications
- proximal and middle third humerus fractures
Internervous plane
- musculocutaneous nerve - medial 2/3rds brachialis
- radial nerve - lateral 1/3rd brachialis
skin and superifical dissection - same as anterolateral - incision 5cm proximal
dangers
- radial nerve -drilling anterior to posterior or during stripped humerus
- musculocutaneous nerve - identify before brachialis splitting
Posterolateral Elbow approaches
- kocher’s
- kaplan’s
Position
supine and armboard
pronate forearm to move PIN out of field
Incision
1cm prox to lateral epicondyle to 6 distal to tip of olecranon
Superficial
skin, fat, fascia inline with incision
Deep - KOCHER
- aponeurosis between ECU and anconeus
- ECU - posterior
- Anconeus - anteriorly
- capsulotomy
Dangers
- PIN - Pronate!!! keep prox to annular ligament
- radial nerve - if capsultomy too anterior
- lateral collateral ligaments
Deep KAPLAN
- ECRB (radial nerve) and EDC (PIN)
- greater risk to PIN
medial elbow approach
indications
* MCL repair
* medial facet coronoid process #
incision
curved 10cm centred on medial epicondyle
Intermuscular interval
- 2 heads of FCU
Dangers
-medial cutaneous antebrachial nerve - skin
- ulnar nerve - fascia/ FCU split
subcutaneous ulnar approach
Skin incision
- line between olecranon process and ulnar styloid process
Deep
- internervous plane between the posterior interosseous nerve (ECU) and ulnar nerve (FCU) - onto the ulnar
- risk - dorsal branch of the ulnar nerve - distal extension of wound
Henry’s approach to the forearm - middle and proximal?
Skin incision
- lateral to biceps tendon to radial styloid process
Superficial
- Proximal - brachioradialis (radial nerve) and pronator teres (median nerve)
- Middle - brachioradialis (radial nerve) and FCR (median nerve)
Dangers:
- radial artery lies deep to brachioradialis
- find the two venae comitantes to the radial artery, ligate and take radial artery medial
- superifical radial nerve - lies under brachoradialis and taken laterally
Deep
Proximal
- supinate to move PIN away
- incise medial border of supinator and elevate - protects PIN
- plate under supinator
Middle
- pronate to expose the lateral border of pronator teres
- elevate pronator teres
FCR approach to the distal radius
skin incision
- radial border of FCR
Superficial dissection:
- FCR and radial artery
- FCR tendon sheath opened
- FCR taken ulnar
Deep dissection:
- FPL and radial artery
- FPL taken ulnar
- pronator quadratus elevated (L-shaped) to expose radius - avoid attachment of volar radiocarpal ligaments
Dangers
- radial artery
- palmar cutaneous branch of median nerve
Dorsal approach to wrist
skin
- midline incision centred over wrist
superficial
- skin, fat and extensor retinaculum
deep
- incise extensor retinaculum over 3rd extensor compartment
- EPL taken radially
- 4th compartment elevated perosteally radially
Dangers
- superfical radial nerve
- radial artery
posterior approach to elbow
Options:
- triceps splitting
- triceps sparing - medial and lateral windows
- Extension - olecranon osteotomy - pre-drill plate
Triceps splitting
- fascia
- superficial triceps - long head taken medially and lateral head laterally
- deep triceps - split medial triceps
Dangers
- radial nerve
- profunda brachii
- no proximal extension
