Pelvis/Hip Approaches Flashcards Preview

Orthopaedic Anatomy > Pelvis/Hip Approaches > Flashcards

Flashcards in Pelvis/Hip Approaches Deck (72):
1

position for anterior approach to iliac crest

supine, bump under operative side

2

incision for anterior approach to iliac crest

8 cm, centred along crest, centred on iliac tubercle

3

plane for anterior approach to iliac crest

no muscles cross the iliac crest

4

superficial dissection for anterior approach to iliac crest

along crest subcutaneously

5

deep dissection for anterior approach to iliac crest

strip glut med and glut min from bone

6

danger (2) for anterior approach to iliac crest

1. ASIS insertion of inguinal ligament 2. crest of ilium should be left for cosmesis

7

position for posterior approach to iliac crest

prone, with gluteal cleft and PSIS exposed

8

incision for posterior approach to iliac crest

8 cm, centred over PSIS along crest

9

plane for posterior approach to iliac crest

no muscles cross the crest

10

superficial dissection for posterior approach to iliac crest

subcutaneous along iliac crest

11

deep dissection for posterior approach to iliac crest

-strip glut max to gluteal line -follow over the other side of gluteal line to strip glut med

12

danger (3) for posterior approach to iliac crest

1. cluneal nerves start 8 cm lateral to PSIS 2. sciatic nerve if you go too far inferior to sciatic notch 3. superior gluteal artery travels by the sciatic notch, proximal to piriformis

13

position for anterior approach to pubic symphysis

supine with catheter in

14

incision for anterior approach to pubic symphysis

15 cm incision centred over symphysis and 1 cm rostral to symphysis and superior rami

15

plane for anterior approach to pubic symphysis

segmental innervation of rectus abdominus spares it

16

superficial dissection for anterior approach to pubic symphysis

-open subcutaneous to rectus sheath -ligate superficial epigastric artery/vein -divide rectus sheath 1 cm rostral to bone -divide rectus abdominus 1 cm rostral to insertion and retract

17

deep dissection for anterior approach to pubic symphysis

-use blunt dissection to open space of Retzius

18

danger (1) for anterior approach to pubic symphysis

1. bladder

19

position for anterior approach to SI joint

supine, bump under operative side with 20° table tilt away

20

incision for anterior approach to SI joint

curved 7 cm incision from iliac tubercle to ASIS, continued along inguinal ligament if necessary

21

plane for anterior approach to SI joint

no muscles cross the crest

22

superficial dissection for anterior approach to SI joint

-strip 1 cm of gluts and TFL -incise periosteum or anterior third of iliac crest -saw the iliac crest -crack inner cortex -detach ASIS

23

deep dissection for anterior approach to SI joint

-mobilize iliacus and move medial with the bone you released from ASIS/crest

24

danger (3) for anterior approach to SI joint

1. LFCN arises 2 cm distal to ASIS and is often sacrificed in this approach

2. sacral nerve roots if: i) go too medial with dissection; ii) put a homan in a foramina; iii) put more than 1 screw in the anterior sacrum

3. large nutrient vessels enter the anterior ileum - use bone wax

25

position for posterior approach to the SI joint

prone

26

incision for posterior approach to the SI joint

3 cm distal and lateral to PSIS following the curve of the iliac crest to its highest point

A image thumb
27

plane for posterior approach to the SI joint

none

28

superficial dissection for posterior approach to the SI joint

-detach and reflect glut max

29

deep dissection for posterior approach to the SI joint

-detach and reflect glut med -may have to detach piriformis to reduce SI dislocation -check reduction with finger through greater sciatic notch

A image thumb
30

danger (4) for posterior approach to the SI joint

1. IGN is in the deep surface of glut max

2. SNG in is the deep surface of glut med

3. sacral nerve roots may be injured by inaccurate screws

4. IGA/SGA run with their respective nerves

31

position for inguinal approach to the acetabulum

supine, catheter in, GT at edge of table

32

incision for inguinal approach to the acetabulum

curved starting 5 cm above ASIS, ending midline 1 cm above the pubic symphysis

A image thumb
33

plane for inguinal approach to the acetabulum

none

34

superficial dissection for inguinal approach to the acetabulum

-subcutaneous sacrifice of LFCN near ASIS -divide external oblique from ASIS to superficial inguinal ring -isolate spermatic cord/round ligament -divide anterior rectus sheath -strip iliacus from inner iliac wing

35

deep dissection for inguinal approach to the acetabulum

-divide rectus abdominus 1 cm rostral to insertion -develop plane in space of Retzius -cut through the tendon of internal oblique and transverse abdominus on the posterior wall of the inguinal ligament -ligate inferior epigastric artery and vein -finish dividing I.O. and T.A. along the course of the incision -retract peritoneum to visualize 3 windows: i) iliac wing to psoas tendon/FN ii) psoas tendon/FN to external iliac vessels iii) external iliac vessels to symphysis

A image thumb
36

danger (7) for inguinal approach to the acetabulum

1. FN on iliopsoas

2. LFCN 2 cm distal to ASIS (usually divided)

3. femoral/external iliac vessels

4. inferior epigastric A/V need to be ligated

5. spermatic cord

6. bladder

. corona mortis on lateral superior rami

37

position for posterior approach to the acetabulum

lateral (unless a transverse #, then prone)

38

incision for posterior approach to the acetabulum

centred on GT from just below the iliac crest to 10 cm past the GT

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39

plane for posterior approach to the acetabulum

none - glut max is split

40

superficial dissection for posterior approach to the acetabulum

-incise fascia lata to anterior border of glut max -retract to reveal piriformis and SERs -partially detach glut max from femur

A image thumb
41

deep dissection for posterior approach to the acetabulum

-internal rotation to stretch SERs -detach SERs -insert retractor into greater sciatic notch -insert 2nd retractor into lesser sciatic notch to expose posterior column -T-shaped capsulotomy -distract femoral head to view inner acetabulum -view posterior wall directly -to see more posterior column, osteotomize GT and retract anterior with glut min release -flex and external rotation with glut min release will view anterior wall

A image thumb
42

danger (3) for posterior approach to the acetabulum

1. avoid vigorous retraction of SERs to protect sciatic nerve 2. IGA/IGN leave pelvis inferior to piriformis 3. SGA/SGN leave pelvis superior to piriformis

43

position for anterior (Smith-Petersen) approach to the hip

supine

44

incision for anterior (Smith-Petersen) approach to the hip

long incision on anterior half of iliac crest to ASIS, then veers vertical toward the lateral aspect of the patella for 10 cm

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45

plane for anterior (Smith-Petersen) approach to the hip

superficial: between sartorius and TFL

deep: between rectus femoris and glut med

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46

superficial dissection for anterior (Smith-Petersen) approach to the hip

external rotation to stretch sartorius-ID gap between TFL and sartorius-incise fascia medial to TFL-retract medial and lateral-detach TFL from ileum-ligate ascending branch of the lateral femoral circumflex artery

47

deep dissection for anterior (Smith-Petersen) approach to the hip

ID rectus femoris - glut med interval, which should be well lateral to femoral artery-detach rectus femoris and move medially-retract glut med laterally-retract iliopsoas and detach fibres that may attache to inferior hip joint-externally rotate-T-shaped capsulotomy-dislocate with external rotation

48

danger (3) for anterior (Smith-Petersen) approach to the hip

1. LFCN lies on sartorius

2. FN lies over hip joint medial to rectus femoris

3. must ligate ascending branch of lateral femoral circumflex artery

49

position for anterolateral (Watson-Jones) approach to the hi

supine, buttock off edge of table, tilt away from you

50

incision for anterolateral (Watson-Jones) approach to the hi

with the leg flexed 30° and adducted, make a 8-15 cm longitudinal incision centred over the GT and down the femoral shaft

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51

plane for anterolateral (Watson-Jones) approach to the hip

none really, but just don't dissect to the origin of TFL - where it is innervated

52

superficial dissection for anterolateral (Watson-Jones) appr

-incise fascia lata and cut antero-superiorly to the ASIS and distal to expose vastus lateralis-blunt dissection to find glut med-retract TFL medial and glut med lateral-externally rotate to stretch capsule-incise and reflect the uppermost 1 cm of vastus lateralis to expose the joint

53

deep dissection for anterolateral (Watson-Jones) approach to

-chose either i) trochanteric osteotomy or detach abductors at tendon with stay suture-retract rectus and iliopsoas medially-H-shaped capsulotomy-dislocate hip with external rotation

54

danger (4) for anterolateral (Watson-Jones) approach to the hip

1. FN injury with aggressive medial retraction

2. FA/FV damage if retraction through iliopsoas

3. profunda femoris lies on iliopsoas

4. femoral shaft prone to # with dislocation maneuvers when there is an incomplete capsulotomy

55

position for lateral approach to the hip

supine, buttock over the edge of the table

56

incision for lateral approach to the hip

5 cm rostral to GT, centred over it. to 8 cm down the femoral shaft

A image thumb
57

plane for lateral approach to the hip

none - split glut med and vastus lateralis

58

superficial dissection for lateral approach to the hip

incise fascia to pull TFL anterior and glut max posterior

59

deep dissection for lateral approach to the hip

-split glut med starting at GT and going no more than 3 cm rostral-split vastus lateralis-develop glut med, glut min, vastus lateralis as an anterior flap-detach insertion of glut min-blunt exposure of capsule-T-shaped capsulotomy-osteotomize femoral neck-extract head

60

danger (4) for lateral approach to the hip

1. SGN runs between glut med and min 3-5 cm rostral to GT

2. FN runs on psoas, so anterior retractors should only be placed on bone

3. FA/FV run medial to nerve but could be injured if retraction too medial

4. transverse branch of the lateral femoral circumflex artery must be ligated as vastus lateralis is cut.

61

position for posterior approach to the hip

true lateral

62

incision for posterior approach to the hip

10-15 cm curved incision centred on the posterior aspect of GT in line with the glut max fibres

A image thumb
63

plane for posterior approach to the hip

none - split the fibres of glut max

64

superficial dissection for posterior approach to the hip

incise fascia to expose vastus lateralis-split glut max proximally, bluntly

65

deep dissection for posterior approach to the hip

protect sciatic nerve-internally rotate hip to stretch SERs-stay suture in piriformis and OI then detach and retract-try to leave QF (much lateral circumflex bleeding)-T-shaped capsulotomy-dislocated with internal rotation

66

danger (2) for posterior approach to the hip

1. sciatic nerve emerging from beneath piriformis

2. IGA emerging under piriformis

67

position for the medial approach to the hip

supine, affected side in frog leg position

68

incision for the medial approach to the hip

longitudinal along the medial thigh starting 3 cm below the pubic tubercle running over adductor longus

69

plane for the medial approach to the hip

superficial: between longus and gracillus

deep: between brevis and magnus

70

superficial dissection for the medial approach to the hip

-gracillus and longus plane --> retract

-ID anterior division of obturator nerve

-magnus and brevis --> retract

-ID posterior division of obturator nerve

71

deep dissection for the medial approach to the hip

feel for LT-place bone spike above and below LT to isolate iliopsoas tendon

72

danger (3) for the medial approach to the hip

1. anterior ON lies on OE and brevis

2. posterior ON goes through OE and lies on magnus

3. MFCA passes around medial and distal to psoas tendon