Approaches Flashcards
(23 cards)
What is always in danger in the proximal third of the radius?
The PIN which is either in close contact with the bone or near to its periosteum as it spirals around the radius
What is the patient position for a Henry’s approach to the forearm?
Supine, arm on arm board, tourniquet but do not fully exsanguinate, arm in supination
What are the landmarks for a Henry’s approach to the forearm?
Biceps tendon, brachioradialis as part of the mobile wad (w ECRL+B) and radial styloid
What is the start and finish points for the incision?
Anterior flexor crease of the elbow just lateral to the biceps tendon to the radial styloid in a straight line
What is the internervous plane for a Henry’s approach?
Plane between brachioradialis (radial nerve) and FCR (distally) or pronator teres proximally which are both median nerve
What is the superficial dissection in a Henry’s approach?
Deep fascia with the skin, medial border of BR and FCR. Start dissection distally and work proximally. Identify SRN on undersurface of BR. Ligate the leash of vessels from radial artery going to BR called recurrent radial artery. This enables lateral mobilisation of the BR.
When doing a Henry’s approach, where do you look for the radial artery?
Beneath BR in the middle part of the forearm. May need to be mobilised medially for exposure.
Where does the SRN run?
Under BR. Careful protection needed to avoid injury and painful neuroma
What are the structures at risk in the superficial dissection of the Henry’s approach?
Lateral antebrachial cutaneous nerve, SRN, radial artery
Henry’s approach proximal third deep dissection?
Follow biceps tendon to insertion and incise bursa to get to proximal shaft of radius. Incise the supinator along the line of insertion DO NOT SPLIT muscle. Continue subperiosteal dissection laterally.
How do you protect the PIN in the deep dissection of the proximal third of the radius?
Full supination of the forearm to displace it posterior and laterally, avoid excessive traction during dissection, do not split supinator, no retractors on the posterior radial neck.
What is the deep dissection middle third of radius in Henry’s approach?
Pronate arm to expose the insertion of PT. Detach PT and strip off bone medially, preserve as much attachment as possible. Also detaches some of FDS origin
What is the deep dissection of distal third radius in Henry’s approach
Partially supinate forearm and incise the periosteum of the lateral aspect of the radius lateral to PQ and FPL then continue distally and lifting the muscles off medially
What is the difference between a Henry’s approach and a modified Henry’s approach?
The modified Henry approach utilizes the interval between flexor carpi radialis tendon and the radial artery, whereas the classical Henry approach goes between brachioradialis and the radial artery. The modified approach is medial to the radial artery.
What structures are at risk in the modified Henry’s approach?
Radial artery and palmar branch of the median nerve
What are the structures at risk in the Henry’s approach to the forearm?
SRN, radial artery, recurrent radial artery, PIN
What are the three practical internevous approaches to the anterior forearm?
- Between radial and median nerves btw BR and FCR or PT
- Between median and ulnar nerves btw FCU and FDS
- Between ulnar nerve and PIN btw FCU and ECU
What is the purpose of a posterolateral (Thompson) approach to the forearm?
Access radial shaft- particularly good for middle and distal thirds
What are the landmarks for a posterolateral (Thompson) approach to the forearm?
Proximally the lateral epicondyle (won’t extend up to here), distally Lister’s tubercle
What are the structures at risk in the superficial dissection of a posterolateral (Thompson) approach to the forearm?
Cephalic vein and SRN in the distal part of the incision
What is the deep dissection for the middle third of the radius in the posterolateral (Thompson) approach to the forearm?
Distal starting point is the proximal crossing point of APL as it crosses obliquely from ulnar to radial. Develop plane beneath the muscle to retract and access radial shaft beneath
Proximally develop plane between the ECRB and EDC- this exposes supinator proximally and APL distally.
Then fully supinate the arm to protect PIN and allow for some lifting of supinator if required to access shaft
How do you extend the posterolateral (Thompson) approach to proximal third?
NB CONSIDERABLE RISK TO PIN
Elevate supinator off it’s insertion on the radius- helped by supinating the forearm, need to protect the PIN- this can be identified by palpating for a bulge in supinator or making a small hole to visualise it.
What is the approach for a DHS?
Appropriately consented and anaesthetised patient, supine on traction table, reduce fracture under image intensifier.
Straight lateral incision commencing just proximal to GT of about 10cm in length.
Blunt dissection down to iliotibial tract. Split fascia in line with incision, peel vastus off the intermuscular spetum and retract ventrally to expose shaft of femur
