Elbow/Forearm Approaches

Question 1

position for posterior approach to the elbow

Answer 1

prone

chest and abdomen free

tourniquet

abduct to 90°

sandbag under tourniquet

forearm hanging over table

Question 2

incision for posterior approach to the elbow

Answer 2

begin 5 cm above olecranon laterally then as you cross the elbow curve medially and down the medial aspect of the ulna

Question 3

internervous plane for posterior approach to the elbow

Answer 3

none

Question 4

superficial dissection for posterior approach to the elbow

Answer 4

fascia midline

find ulnar nerve

V osteotomy of the olecranon about 2 cm from its tip with apex distal

Question 5

deep dissection for posterior approach to the elbow

Answer 5

strip soft tissue from medial and lateral olecranon

retract proximally with triceps

Question 6

danger for posterior approach to the elbow

Answer 6

1) ulnar nerve must be ID’d
2) median nerve lies anterior to distal humerus
3) radial nerve if you do too far proximal
4) brachial artery lies with median nerve
5) realign olecranon with great care after osteotomy

Question 7

position for medial approach to the elbow

Answer 7

supine

arm on board in front of patient

elbow flexed at 90°

tourniquet

Question 8

incision for medial approach to the elbow

Answer 8

8-10cm on the nedial aspect of the elbow centred on the medial epicondyle

Question 9

internervous plane for medial approach to the elbow

Answer 9

proximally between brachialis and triceps

distally between brachialis and pronator teres

Question 10

superficial dissection for medial approach to the elbow

Answer 10

palpate ulnar nerve

incise fascia

retract pronator teres anteriorly

expose common flexor origin

develop interval between pronator teres and brachialis (watch for median nerve)

retract ulnar nerve inferiorly

osteotomize the medial epicondyle and reflect distally

Question 11

deep dissection for medial approach to the elbow

Answer 11

incise the capsule and medial collateral ligament to expose the joint

Question 12

danger for medial approach to the elbow

Answer 12

1) ulnar nerve
2) median nerve - careful when retracting PT and the flexors

Question 13

position for anterolateral approach to the elbow

Answer 13

supine

arm board

tourniquet

Question 14

incision for anterolateral approach to the elbow

Answer 14

curved incision starting on lateral aspect of biceps 5 cm above the flexor crease that crosses to midline then down mid forearm along medial border of brachioradialis

Question 15

internervous plane for anterolateral approach to the elbow

Answer 15

proximally between brachialis and brachioradialis

distally between brachioradialis and PT

Question 16

superficial dissection for anterolateral approach to the elbow

Answer 16

ID LCNF

retract medially with medial skin flap

fascia along medial brachioradialis

ID radial nerve beneath it

develop plane between brachialis and brachioradialis

below division of radial nerve develop the plane between brachioradialis and lateral side of pronator teres

ligate recurrent branches of radial artery

retract radial artery medially with PT

Question 17

deep dissection for anterolateral approach to the elbow

Answer 17

incise joint between radial nerve (lateral) and brachialis (medial)

supinate

incise origin of supinator

deissect subperiosteally just lateral to biceps insertion

Question 18

danger for antrolateral approach to the elbow

Answer 18

1) radial nerve and its 3 branches in proximal forearm
2) PIN in supinator near neck of radius
3) LCNF - retract with skin medially
4) recurrent branches of radial artery must be ligated to mobilize the brachioradialis

Question 19

position for anterior approach to the cubital fossa

Answer 19

supine

arm board

tourniquet

Question 20

incision for anterior approach to the cubital fossa

Answer 20

start along medial border of biceps 5 cm proximal to flexor crease and cruve across cubital fossa to run down the medial aspect of brachioradialis

Question 21

internervous plane for anterior approach to the cubital fossa

Answer 21

distally between brachioradialis and PT

proximally brachioradialis and brachialis

Question 22

superficial dissection for anterior approach to the cubital fossa

Answer 22

fascia

ligate vessels

LCNF lies lateral

ID biceps aponeurosis and cut then reflect latrally

ID radial artery, median nerve, brachial artery, brachial vein

Question 23

deep dissection for anterior approach to the cubital fossa

Answer 23

if you need to get to the joint from here, retract biceps and brachialis medially and brachioradialis laterally

supinate

incise origin of supinator and dissect to bone and retract laterally

incise capsule

Question 24

danger for anterior approach to the cubital fossa

Answer 24

1) LCNF - find between biceps and brachialis
2) radial artery lies immediately deep to bicipital aponeurosis
3) PIN vulnerable as it winds around the neck of radius within supinator

Question 25

position for posterolateral approach to the radial head

Answer 25

supine arm over chest pronate arm tourniquet

Question 26

incision for posterolateral approach to the radial head

Answer 26

curved incision beginning over posterior surface of lateral epicondyle down medially across to posterior border of ulna about 6 cm long

Question 27

internervous plane for posterolateral approach to the radial head

Answer 27

between anconeus and ECU

Question 28

superficial dissection for posterolateral approach to the radial head

Answer 28

fascia find interval between FCU and anconeus detach part of anconeus origin retract between these two muscles

Question 29

deep dissection for posterolateral approach to the radial head

Answer 29

pronate to move PIN away from field incise capsule

Question 30

danger for posterolateral approach to the radial head

Answer 30

1) PIN is in the supinator and also on radial neck opposite the bicipital tuberosity 2) radial nerve - open joint laterally, not anteriorly

Question 31

position for anterior approach to radius

Answer 31

supine arm board supinate forearm

Question 32

incision for anterior approach to radius

Answer 32

lateral biceps tendon to radial styloid

Question 33

internervous plane for anterior approach to radius

Answer 33

between brachioradialis and FCR/PT

Question 34

superficial dissection for anterior approach to radius

Answer 34

fascia find plane between BR and FCR/PT ID superficial radial nerve under BR ligate recurrent radial artery branches to BR retract radial artery medially

Question 35

proximal deep dissection for anterior approach to radius

Answer 35

find tendon of biceps on radial tuberosity and incise supinate forearm incise supinator along radial insertion subperiosteally and retract laterally to protect PIN

Question 36

middle deep dissection for anterior approach to radius

Answer 36

pronate forearm to expose PT insertion and detach it subperiosteally and retract medial

Question 37

distal deep dissection for anterior approach to radius

Answer 37

supinate again incise periosteum lateral to PQ insertion retract PQ and FPL medially

Question 38

danger for anterior approach to the radius

Answer 38

1) PIN around neck of radius and within supinator 2) superficial radial nerve under brachioradialis 3) radial artery vulnerable during mobilization of brachioradialis and near the biceps tendon 4) recurrent radial arteries must be ligated to properly mobilize the brachioradialis

Question 39

position for approach to ulna

Answer 39

supine arm on chest tourniquet

Question 40

incision for approach to ulna

Answer 40

follow subcutaneous border of ulna where you need it

Question 41

internervous plane for approach to ulna

Answer 41

between ECU and FCU

Question 42

superficial dissection for approach to ulna

Answer 42

split some fibres of ECU usually necessary

Question 43

deep dissection for approach to ulna

Answer 43

develop plane epiperiosteally in the direction needed may have to detach some triceps tendon in the proximal 5th of the incision

Question 44

dangers for approach to ulna

Answer 44

1) ulnar nerve travels throught the two head and then under FCU on FDP 2) ulnar artery travels just radial to the nerve

Question 45

position for posterior approach to the radius

Answer 45

supine arm board pronated

Question 46

incision for posterior approach to the radius

Answer 46

lateral epicondyle at elbow to lister's tubercle

Question 47

internervous plane for posterior approach to the radius

Answer 47

ECRB and ED proximally ECRB and EPL distally

Question 48

superficial dissection for posterior approach to the radius

Answer 48

plane through fascia between ECRB and ED uncover upper 1/3 radius covered by supinator then plane betwen ECRB and EPL distal to origin of AbPL and EPB

Question 49

Answer 49

ECRB

Question 50

Answer 50

EPL

Question 51

Answer 51

EPB

Question 52

Answer 52

AbPL

Question 53

Answer 53

ED

Question 54

proximal deep dissection for posterior approach to the radius

Answer 54

detach origin of ECRB and ECRL at lateral epicondyle and retract laterally palpate PIN proximal to supinator and dissect out prox to distal supinate detach supinator subperiosteally

Question 55

middle deep dissection for posterior approach to the radius

Answer 55

incise superior and inferior borders of EPB and AbPL and retract depending on which direction is required

Question 56

distal deep dissection for posterior approach to the radius

Answer 56

separate ECRB and EPL to view radius

Question 57

danger for posterior approach to the radius

Answer 57

1) PIN - 25% of people have a PIN that touches the radius opposite the bicipital tuberosity - so protect it by stripping supinator subperiosteally