Musculoskeletal Approaches

Question 1

Approach to scapular body

Answer 1

Lateral approach over the spine of the scapula. After an incision of the deep fascia along the spine of the scapula, the omotransversarius and trapezius muscles are elevated from the scapular spine and cranial/caudal fossae

Question 2

Approach to the scapular neck

Answer 2

Craniolaterally or laterally. The acromion must be osteotomized or a tenotomy of the acromial head of the deltoid. *sometimes an osteotomy of the greater tubercle and/or tenotomy of the infraspinatus/teres minor is done to increase exposure.

Question 3

Approach to the scapular neck with muscle separation

Answer 3

Dissect through brachial fascia and retract the omotransversarius. Dissect between the supraspinatus muscle, acromial head of the deltoid. Retract the supraspinatus cranially and the infraspinatus with acromial deltoid caudally.

Question 4

Longitudinal myotomy to glenoid and supraglenoid

Answer 4

Myotomy at the midbelly of the supraspinatus muscle and continued distally to the level of its humeral insertion.

Question 5

Craniolateral approach to the shoulder

Answer 5

ex. for a shoulder arthrodesis
Elevate the insertion of the trapezius muscle and the omotransversarius from the spine. Continue the incision distally along the cranial border of the acromial deltoid to the insertion of the brachiocephalicus muscle. Incise the insertion of the superficial pectoral muscle. Elevate the supraspinatous proximally so that it can be retracted franially. ID the suprascapular nerve. TRANSECT the insertion of the infraspinatous muscle

Question 6

Caudal approach to the shoulder

Answer 6

Requires an assistant to adequately view an OCD lesion but less morbidity

Question 7

Caudolateral approach

Answer 7

Between the deltoid bellies: Retract the infraspinatous and teres minor craniodorsally to help protect the caudal circumflex humeral a. and the axillary nerve.

Question 8

Modified Cheli approach

Answer 8

Great for shoulder OCD and resurfacing. Flex shoulder and extend the elbow. Palpate joint under the acromion and incise skin and SQ. Visualize the junction between the acromial head of the deltoid and supraspinatus and incise between them. Take care not to damage the lateral collateral GH ligament

Question 9

Craniolateral approach to the humerus

Answer 9

Reflect the triceps caudally and the biceps/pectoral/brachiocephalicus cranially. The radial nerve with the brachialis muscle can be reflected cranially or caudally

Question 10

Medial approach to the humerus

Answer 10

Cut the origins of the pectoral muscles proximally. Reflect the biceps caudally and the brachiocephalicus cranially. Take care of the median and ulnar nerves when a medial approach is done

Question 11

Modified Wendelburg (caudal medial approach to elbow)

Answer 11

Skin incision over caudomedial proximal ulna and continued over the tubercle of the flexi carpi ulnaris. Incise over the spine of the ulna and continue towards the olecranon. Isolate the lateral aspect of the flexor carpi ulnaris and elevate it off of proximal ulna up towards origin. In original Wendelburg technique, osteotomized the epicondyle but in the modified, only elevate the soft tissues of the flexor carpi ulnaris from the tubercle. Continue the incision up line of tricep tendon and open joint capsule. Access to the humeral trochlea for OCD and medial coronoid

Question 12

Approach to lateral epicondyle of humerus

Answer 12

Skin incision along the lower portion of humerus and crossing the joint to the ulna. Retract the skin to find the deep brachial fascia and lateral head of the triceps. An incision is made through the deep fascia near the cranial border of the triceps. Bluntly undermining the trcieps allows it to be retracted caudolaterally to expose the condyle. To get to caudo lateral compartment, incise along cranial border of the triceps to its insertion on olecranon. Then incise into the anconeus and joint capsule - can get to anconeal process

Question 13

Approach to caudal compartment of elbow joint

Answer 13

Skin incision on caudolateral aspect and then incision in the fascia of the triceps along the cranial border of the lateral and medial heads. ID the ulnar nerve and avoid it. In cats, on the medial side that median nerve will be in the supracondylar foramen. Pass Gigli saw wire and cut olecranon at 45 degree angle to shaft of ulna.

Question 14

Approach to head of the radius and lateral compartments of elbow

Answer 14

Skin incision over lateral humeral epicondyle. Incise the deep brachial and antebrachial fascia. Incise the triceps and retract the lateral head of the triceps to see the anconeus m. Incise the origin of the anconeus m. along the lateral epicondylar ridge. Tenotomize the ulnaris lateralis if needed and retract the lateral digital extensor cranially. If more exposure is needed, osteotomize the lateral epicondyle (attachment of the collateral ligament and the extensors m.

Question 15

Medial epicondyle approach to humerus

Answer 15

Skin incision over lower humerus parallel to the shaft and just slightly caudal to medial epicondyle. Incise the deep fascia near the cranial border of the medial head of the triceps. Elevate the triceps - you will see the ulnar nerve and collateral ulnar vessels - retract them. For reduction of the medial condyle

Question 16

Approach to the medial condyle with access to coronoid process

Answer 16

Incise on medial epicondylar crest and cross joint cranially. Incise deep fascia on a similar line ending at the pronator teres m. Mobilize and retract the deep fascia to find the brachial a. and median nerve at the origin of the pronator teres from the medial epicondyle. Cut the tendon of origin of pronator teres then cut into the joint capsule and collateral ligaments. For more access, instead of tenotomy of the pronator teres, can do a medial epicondyle osteotomy. The osteotomy should include all of the origin of the pronator teres and the flexor carpi radialis

Question 17

Approach to the wing of the ilium and sacroiliac joint

Answer 17

Lateral or sternal recumbency. Skin incision over the iliac crest and continue caudally parallel to the midline. Expose the iliac crest and cranial dorsal spine. Incise on the periosteal origin of the middle gluteal muscle on the lateral edge of the iliac crest and spine. To also expose the SI joint, you can make a periosteal incision on the medial edge of the iliac spine - this is the periosteal origin of the sacrospinalis muscle.

Question 18

Lateral approach to the ilium

Answer 18

Skin incision over the line of the iliac crest to the greater trochanter. Should see the middle gluteal –> incise into the intermuscular septum between the middle gluteal and the tensor fascia lata. You should now be able to see deep gluteal. Starting at the cranial and ventral border of the origin of the middle gluteal, incise along the ventral iliac spine and then subperiosteally elevate the middle gluteal up dorsally. To see to the cranial acetabulum, elevate the deep gluteal on the ventral aspect as well (this will sacrifice the cranial gluteal artery)

Question 19

Craniolateral approach to the hip

Answer 19

Skin incision over the greater trochanter to the cranial border of the femur. Incise through the fascia lata and gluteal fascia. Separate the tensor fascia lata from the cranial border of the biceps femoris. Continue proximally through the gluteal fascia along the cranial border of the superficial gluteal. Finger dissection at cranial border of the biceps will allow visualization of the vastus lateralis. Retract the vastus lateralis (and incise origin if needed) to see the joint capsule. Sometimes you will need to incise tendon of the deep gluteal for more access

Question 20

Approach to the hip through a dorsal intergluteal incision

Answer 20

To gain access to central acetabulum. Skin incision over the greater trochanter. Incise between the biceps femoris and superficial gluteal fascia. Then incise between the superficial gluteal and middle gluteal. The belly of the superficial gluteal is elevated and tenotomized at its insertion on the third trochanter –> the sciatic nerve can then be visualized. Cranial retraction of the middle gluteal muscle can result in a separation developing between the main and deep caudal bellies of the muscle or they can stay together. Incise the origin of the deep gluteal muscle at the dorsal border near the ischiatic spine. Retractors for the internal obturator and gemelli placed caudal to femoral head

Question 21

Approach to the hip by osteotomy of the greater trochanter

Answer 21

Skin incision over the greater trochanter. Incision is made in fascia of the biceps along the cranial border of the muscle. Retract biceps caudally and ID the sciatic nerve. Incise at the insertion of the superficial gluteal muscle just distal to the greater trochanter and continue the incision through the fascia lata to free all the tensor fascia lata. Greater trochanter is osteotomized by placing the osteotome on the lateral surface of the greater trochanter just proximal to the superficial gluteal muscle insertion on the 3rd trochanter. 45 degree angle with long axis of femur - cut should be flush with the femoral neck beneath the insertions of the middle and deep gluteal muscles

Question 22

Ventral approach to the hip

Answer 22

T like skin incision? Over the pectineus muscle in full abduction. Mobilize the belly of the pectineus with blunt dissection, care taken to protect the femoral artery, vein, and saphenous nerve (on the cranial border of the pectineus). Transect the pectineus near its origin on the prepubic tendon. Reflect the pectineus to reveal the iliopsoas and deep femoral artery and vein running caudally and medial to the acetabular portion of the pelvis. Divide between the iliopsoas and adductor. Retract the iliopsoas cranially and the adductor caudally.

Question 23

Approach to midshaft of the femur

Answer 23

Incision over the craniolateral border of the shaft of the bone. Incise the fascia lata along the cranial border of the biceps femoris muscle aponeurosis. Caudal retraction of the biceps and cranial retraction of the vastus lateralis muscle reveals the shaft of the femur. The adductor muscle will insert on the caudal aspect of the shaft of the femur on the linea aspera

Question 24

Parts of pes anserinus

Answer 24

gracilus, sartorius, semitendinosus