Pelvis/Hip Approaches Flashcards
(72 cards)
1
Q
position for anterior approach to iliac crest
A
supine, bump under operative side
2
Q
incision for anterior approach to iliac crest
A
8 cm, centred along crest, centred on iliac tubercle
3
Q
plane for anterior approach to iliac crest
A
no muscles cross the iliac crest
4
Q
superficial dissection for anterior approach to iliac crest
A
along crest subcutaneously
5
Q
deep dissection for anterior approach to iliac crest
A
strip glut med and glut min from bone
6
Q
danger (2) for anterior approach to iliac crest
A
- ASIS insertion of inguinal ligament 2. crest of ilium should be left for cosmesis
7
Q
position for posterior approach to iliac crest
A
prone, with gluteal cleft and PSIS exposed
8
Q
incision for posterior approach to iliac crest
A
8 cm, centred over PSIS along crest
9
Q
plane for posterior approach to iliac crest
A
no muscles cross the crest
10
Q
superficial dissection for posterior approach to iliac crest
A
subcutaneous along iliac crest
11
Q
deep dissection for posterior approach to iliac crest
A
-strip glut max to gluteal line -follow over the other side of gluteal line to strip glut med
12
Q
danger (3) for posterior approach to iliac crest
A
- 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
Q
position for anterior approach to pubic symphysis
A
supine with catheter in
14
Q
incision for anterior approach to pubic symphysis
A
15 cm incision centred over symphysis and 1 cm rostral to symphysis and superior rami
15
Q
plane for anterior approach to pubic symphysis
A
segmental innervation of rectus abdominus spares it
16
Q
superficial dissection for anterior approach to pubic symphysis
A
-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
Q
deep dissection for anterior approach to pubic symphysis
A
-use blunt dissection to open space of Retzius
18
Q
danger (1) for anterior approach to pubic symphysis
A
- bladder
19
Q
position for anterior approach to SI joint
A
supine, bump under operative side with 20° table tilt away
20
Q
incision for anterior approach to SI joint
A
curved 7 cm incision from iliac tubercle to ASIS, continued along inguinal ligament if necessary
21
Q
plane for anterior approach to SI joint
A
no muscles cross the crest
22
Q
superficial dissection for anterior approach to SI joint
A
-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
Q
deep dissection for anterior approach to SI joint
A
-mobilize iliacus and move medial with the bone you released from ASIS/crest
24
Q
danger (3) for anterior approach to SI joint
A
- LFCN arises 2 cm distal to ASIS and is often sacrificed in this approach
- 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
- 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
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
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
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
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
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
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
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
45
plane for anterior (Smith-Petersen) approach to the hip
superficial: between sartorius and TFL
deep: between rectus femoris and glut med
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
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
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
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
