Anteromedial Approach to Hip

Author:
Topic updated on 05/03/11 8:35am
Anteromedial Approach to the Hip Introduction
 Attributed to Ludloff
 Indications include
o open reduction of congenital hip dislocation
o psoas release (approach gives excellent exposure to psoas
tendon)
o Biopsy and treament of tumors of the inferior portion of the
femoral neck and medial aspect of proximal femoral shaft.
o Obturator neurectomy

Intermuscular plane
 Superficial
o no intermuscular plane
 plane exists between adductor longus and gracilis, which are
both innervation by the anterior division obturator nerve
 Deep
o neuromuscular plane between
 adductor brevis (anterior division obturator nerve)
 adductor magnus (adductor portion supplied by posterior division
on obturator nerve and ischial portion supplied by the tibial portion
of the sciatic nerve)

Approach
 Position
o place patient supine with affected hip in flexed, abducted, and externally
rotated position.
 Incision
o longitudinal incision on the medial side of the thigh
o begin incision 3cm below pubic tubercle
o run incision over adductor longus
o length on incision determined by amount of femur that needs to be
exposed
 Superficial dissection
o develop plane between gracilis and adductor longus
 Deep dissection
o develop plane between adductor brevis and adductor magnus until u feel
lesser trochanter on the floor of the wound
 attempt to protect posterior division of the obturator nerve
o isolate psoas tendon by placing narrow retractor above and below lesser
 trochanter

Dangers
 Medial femoral circumflex artery
o passed around medial side of the distal part of the psoas tendon
o at risk in children when releasing psoas tendon. Be sure to isolate psoas
tendon and cut under direct vision.
 Anterior division of obturator nerve
o supplies adductor longus, adductor brevis,and gracilis in the thigh
 Posterior division of obturator nerve
o lies within substance of oburator externus
o supplies adductor portion of adductor magnus

Anterior Approach to Hip

(Smith-Petersen)
Author:
Topic updated on 10/02/11 8:14pm
Introduction
 Provides exposure to
o hip joint
o ileum
 Indications
o open reduction of congenital hip
dislocations
o synovial biopsies
o intra-articular fusions
o THA
o excision of pelvis tumors
o pelvic osteotomies

Internervous plane
 Superficial
o sartorius (femoral n.)
o tensor fasciae latae (superior gluteal n.)
 Deep
o rectus femoris (femoral n.)
o gluteus medius (superior gluteal n.)

Approach
  Incision
o make long incision following anterior half of iliac crest to ASIS
o from ASIS curve inferiorly in the direction of the lateral patella
for 8-10 cm
 Superficial dissection
o identify gap between sartorius and tensor fasciae latae
o dissect through subcutaneous fat (avoid lateral femoral
cutaneous n.)
o incise fascia on medial side of tensor fascia latae
o detach origin of tensor fasciae latae of iliac to develop
internervous plane
o ligate the ascending branch of the lateral femoral circumflex
artery (crosses gap between sartorius and tensor fascia
latae)
 Deep dissection
o identify plane between rectus femoris and gluteus medius
o detach rectus femoris from both its origins
o retract rectus femoris and iliopsoas medially and gluteus
medius lateral to expose the hip capsule
o adduct and externally rotate the hip to place the capsule on
stretch
o incise capsule with a longitudinal or T-shaped capsular
incision
o dislocate hip with external rotation after capsulotomy is
complete

Dangers
 Lateral femoral cutaneous nerve
o reaches thigh by passing approximately 10-15mm lateral to
ASIS, under inguinal ligament
o injury may lead to painful neuroma or decreased sensation
on lateral aspect of thigh
 Femoral nerve
o should remain protected as long as you stay lateral to
sartorius muscle
 Ascending branch of lateral femoral circumflex artery
o be sure to ligate to prevent excessive bleeding

Anterolateral approach to hip (Watson-Jones)

Author:
Topic updated on 10/04/11 6:20pm
Introduction
 Provides exposure to
 o acetabulum
o proximal femur
 Indications include
o THR
o hemiarthroplasty
o ORIF of femoral neck fxs
o synovial biopsy of hip
o biopsy of femoral neck

Intermuscular plane
 Between
o tensor fasciae latae (superior gluteal nerve)
o gluteus medius (superior gluteal nerve)

Approach
 Incision
o make 15 cm straight longitudinal incision centered over the
tip of the greater trochanter (crosses posterior 1/3 of
trochanter before running down the shaft of the femur)
 Superficial dissection
o incise fat in line with incision and clear fascia lata
o incise fascia
o develop interval between tensor fasciae latae and gluteus
medius
o externally rotate the hip to put the capsule on stretch
o identify origin of vastus lateralis
 Deep dissection
o detach abductor mechanism by one of two mechanisms
 trochanteric osteotomy
 partial detachment of abductor mechanism
o expose anterior joint capsule
o detach rectus femoris from the joint capsule to expose
the anterior rim of the acetabulum
o elevate part of the psoas tendon from the capsule
o Perform anterior capsulotomy
o dislocate hip with external rotation

Dangers
 Femoral nerve
o most common problem is compression neuropraxia caused
by medial retraction
 Femoral artery and vein
o can be damaged by retractors that penetrate the psoas
  Abductor limp
o cause by GT osteotomy and disruption of abductor
mechanism
 Femoral shaft fractures
o usually occurs during dislocation (be sure to perform and
adequate capsulotomy)

Lateral approach to hip (Hardinge, transgluteal)

Author:
Topic updated on 10/17/11 10:30am
Introduction
 Indications
o total hip arthroplasty
 has lower rate of total hip prosthetic dislocations

Intermuscular plane
 No true internervous plane
o splits gluteus medius distal to innervation (superior gluteal
nerve)

Approach
 Incision
o longitudinal incision centered over tip of greater trochanter
 Superficial dissection
o split fascia lata to expose tendon of gluteus medius
 Deep dissection
o longitudinal incision in fibers of gluteus medius
 do not extend more than 5 cm above greater trochanter
to prevent injury to superior gluteal nerve
o extend incison inferior through the fibers of vastus lateralis
o detach origin of gluteus minimus from anterior greater
trochanter
o expose anterior joint capsule and perform capsulotomy

Dangers
 Superior gluteal nerve
o runs between gluteus medius and minimus 5 cm above
greater trochanter
o protect by limiting proximal incision of gluteus medius
  Femoral nerve

Posterior Approach to the Hip (Moore or Southern)

Author:
Topic updated on 02/27/11 5:41am
Introduction
 Provides exposure to
o acetabulum
o proximal femur
 Indications
o THA
o hemiarthroplasty
o ORIF of posterior acetabular fxs
o open reduction of posterior hip dislocations
o dependent drainage of hip sepsis
o removal of loose bodies
o pedicle bone grafting

Intermuscular plane
 fibers of gluteus maximus split (inferior gluteal nerve)

Approach
 Position
o place in true lateral position
o drape in order to allow full motion of hip
 Incision
o make 10 to 15 cm curved incision centered on posterior
aspect of greater trochanter
 begin 7 cm above and posterior to GT
 curve over the GT and continue down shaft of femur
 Superficial dissection
o incise fascia lata to uncover vastus lateralis distally
o lengthen fascial incision in line with skin incision
o split fibers of gluteus maximus in proximal incision (this is a
vascular plane, so split muscle gently and cauterize vessels
as they appear)
 Deep dissection
o internally rotate the hip to place the short external rotators
 on stretch
o place stay suture in piriformis and obturator internus tendon
(short external rotators)
o detach piriformis and obturator internus close to femoral
insertion and reflect backwards to protect sciatic nerve
o incise capsule with longitudinal or T-shaped incision
o dislocate hip with internal rotation after capsulotomy

Dangers
 Sciatic nerve
o can be damaged by retractors (keep them on the muscles)
o remember sciatic nerve can split into tibial and peroneal
branches in the pelvis. If you visualize the nerve and it
appears small, remember there may be another branch
 Inferior gluteal artery
o leaves pelvis beneath piriformis
o if it is cut and retracts into the pelvis, then treat by flipping
patient, open abdomen, and tie of internal iliac artery

 First perforating branch of profunda femoris

o at risk of injury with release of the gluteus maximus
insertion

 Femoral vessels
o at risk with failure to protect anterior aspect of the
acetabulum, or with placement of retractors anterior to the
iliopsoas muscle

Posterior Approach to the Acetabulum (Kocher-Langenbach)

Author:
Topic updated on 04/02/11 6:46pm
Introduction
 Provides exposure to
o posterior wall of acetabulum
o posterior column of acetabulum
  Indications
o posterior wall fx
o posterior column fx
o posterior wall and posterior column fx
o simple transverse fx (patient prone)

Intermuscular plane
 None

Approach
 Position
o lateral position for posterior wall and lip fxs (can use skeletal
traction when using lateral position)
o prone position for transverse fx (flex the knee to prevent
stretching of sciatic nerve)
 Incision
o longitudinal incision centered over greater trochanter
 start just below iliac crest
 end 10 cm below tip of greater trochanter
 Superficial dissection
o through subcutaneous fat
o incise facia lata in lower half of incision
o extend proximally along anterior border of gluteus maximus
o detach short external rotators after tagging
 the piriformis should be tagged approximately 1cm
from the tip of the greater trochanter to avoid
damaging the blood supply to the femoral head
 the piriformis will provide a landmark leading to
the greater sciatic notch
 the contents of the greater sciatic notch
include: include the piriformis, the superior
and inferior gluteal vessels and nerves, the
sciatic and posterior femoral cutaneous
nerves, the internal pudendal vessels, and
the nerves to the obturator internus and
quadratus femoris.
 the obuturator internus should be tagged 1 cm from
the greater trochanter and blunt disection should be
used to follow its origin to the lesser sciatic notch
 posterior retraction will protect the sciatic nerve
 Deep dissection
o posterior lip fractures can be visualized at this stage
o to expose the posterior column perform osteotomy of greater
 trochanter

Dangers
 Sciatic nerve
o Extend hip and flex knee to prevent injury
o minimize chance of injury by using proper gentle retraction
and releasing your short external rotators (obturator
internus) posteriorly to protect the sciatic nerve from traction
 Inferior gluteal artery
o leaves pelvis beneath piriformis
o if it is cut and retracts into the pelvis, then treat by flipping
patient, open abdomen, and tie of internal iliac artery
 Superior gluteal artery and nerve
o leaves the pelvis above the piriformis and enters the deep
surface of the gluteus medius. This tethering limits upward
retraction of gluteus medius and blocks you from reaching
the iliac crest
 Quadratus femoris
o excessive retraction and injury must be avoided to prevent
damage to medial circumflex artery

Ilioinguinal Approach to the Acetabulum

Author:
Topic updated on 10/16/11 5:49am
Introduction
 Allows exposure to
o inner surface of the pelvis
from the SI joint to the
pubic symphysis
o anterior and medial
surface of acetabulum
(thus allows exposure
of anterior column)
o Requires mobilization of
the spermatic cord/round
ligament, femoral nerve, and external iliac vessels
 Indications
o ORIF of acetabular and pelvis fractures
 most commonly for Anterior Wall, Anterior Column,
 and Anterior Column plus posterior
hemitranverse fractures of the acetabulum
 in combination with the Kocher-Lagenback approach
for Both Column fractures
 less commonly for T-shaped (if minimal posterior
displacement) and Transverse (if major displacement is
anterior)

Positioning
 Supine with greater troch at edge of table
o place bump under ipsilateral buttock
 Insert catheter to empty bladder (will obscure vision)

Incision
 Make a curved incision from 5cm above ASIS to 1cm above pubic
tubercle at midline

Superficial Dissection
1. Dissect through subcutaneous fat
2. Divide aponeurosis of external oblique in line of fibers
o will often have to sacrifice lateral cutaneous nerve of the
thigh
3. Isolate spermatic cord/round ligament
4. Divide anterior rectus sheath to expose rectus abdominis muscle
5. Elevate iliacus from inside wing of ileum (start with sharp disection
but once inside pelvis use blunt dissection)

Deep Surgical Dissection

1. Divide rectus abdominal muscle 1cm proximal to its insertion into
symphysis pubis
2. Bluntly dissect a plane between the symphysis pubis and the
bladder (Cave of Retzius)
3. Cut though the posterior wall of the inguinal canal (internal oblique
and transversus abdominus)
4. must ligate the inferior epigastic artery to do so
5. Visualize peritoneum and push upwards to expose femoral vessels,
nerve, and ileopsoas tendon
6. Isolate femoral artery and vein with a rubber sling
7. Isolate ileopsoas tendon and femoral nerve with another rubber
sling
8. Palpate medial surface of acetabulum and superior pubic ramus
 9. Create 3 Windows after isolating the external iliac vessels and the
iliopsoas tendon:
o Medial window
 medial to external iliac artery & vein
 access to pubic rami; indirect access to internal iliac
fossa and anterior SI joint
o Middle window
 between external iliac vessels and the iliopsosas
(iliopectineal fascia)
 access to pelvic brim, quadrilateral plate, and a portion
of the superior pubic ramus
o Lateral window
 lateral to iliopsoas (iliopectineal fascia)
 access to quadrilateral plate, SI joint, and iliac wing

Dangers & Complications

 Femoral nerve
 Femoral & External Iliac Arteries
o damage can cause thrombosis
o protect by leaving in femoral sheath
 Lateral cutaneous nerve of thigh
o often have to sacrifice leaving numbness on the outer side of
the thigh
 Inferior epigastic artery
o must sacrifice
 Spermatic cord (contains vas deferens and testicular artery)
o must protect
o damage can cause testicular ischemia, infertility
 Heterotopic Ossification
o much more common in the extended iliofemoral and Kocher-
Lagenbeck approaches
 Obturator nerve
o causes medial thigh numbness when injured
Volar Approach to Radius (Henry)
Author:
Topic updated on 05/10/11 1:17pm
Introduction
 Indications
o ORIF of radius fxs
o radial osteotomy
o tumor / abscess biopsy and
excision
o anterior exposure of bicipital
tuberosity
o superficial radial nerve compression syndrome (Wartenberg
Syndrome)

 Interval
o Proximally between
 brachioradialis (radial n.) and PT (median n.)
o distally between
 brachioradialis (radial n.) and FCR (median n.)

Approach
 Position
o place supine on table and supinate arm and place on
armboard
o exsanguinate arm

 Incision
 o longitudinal incision
 begin just lateral to biceps tendon on flexor crease of
elbow
 end at radial styloid process

 Superficial dissection
o Incise the deep fascia in line with skin incision
o Develop a plane between BR and FCR distally
o Move proximal to develop plane between PT and BR
o Identify the superficial radial nerve beneath BR
o Ligate the branches of the radial artery to aid lateral
retraction of BR

 Deep dissection - proximal third

o Follow the biceps tendon to its insertion on the bicipital
tuberosity
o Radial to the insertion of biceps tendon incise the bursa to
gain access to the proximal part of radius (radial artery which
runs along the ulnar side of the biceps tendon)
o Fully supinate the forearm to displace the PIN radially and
bring the origin of the supinator muscle into the anterior
aspect of the radius
o Incise the supinator muscle along the line if its broad
insertion and continue subperiosteal dissection laterally

 Deep dissection - middle third

o pronate the forearm to bring the insertion of the pronator
teres, along the radial aspect of the radius, into view
o detach the pronator insertion from bone and retract medially

 Deep dissection - distal third

o partially supinate the forearm
o dissect the periosteum off the lateral aspect of the distal third
of the radius, lateral to the pronator quadratus and flexor
pollicis longus
Dangers
 Posterior interosseous nerve
o the posterior interosseous nerve enters the supinator muscle
beneath a fibrous arch known as the arcade of Frohse. The
arch is formed by the thickened edge of the superficial head
of the supinator muscle.
 compression of the nerve at this point produces
paralysis or dysfunction of the extensors known
as posterior interosseous nerve entrapment syndrome.
o The PIN is vulnerable as it raps around neck of radius in
substance of supinator muscle. Protect by:
 dissecting supinator off radius subperiostally
 do not place retractors on posterior surface of radial
neck
 avoid excessive radiall retraction of supinator
 supinating the forearm to move PIN away from the
surgical field
o injury leads to a neuropraxia that takes 6-9 mos to resolve
 Superficial radial nerve
o runs down forearm under body of brachioradialis
o vulnerable with manipulation of mobile wad of three
o damage to it can cause a painful neuroma
 Radial artery
o runs down middle of forearm under brachioradialis
Dorsal Approach to Radius (Thompson)
Author:
Topic updated on 12/08/10 6:56pm
Indications
 Access
o provides exposure to proximal 1/3 of radius
 Indications
o ORIF of radial fractures
o treatment of nonunion
o access to the PIN as it passes through the arcade of Frohse
for
 nerve paralysis
 resistant tennis elbow
o radial osteotomy
o osteomyelitis and bone tumors

Internervous Plane
 Proximally between
o ECRB (radial nerve) and EDC (pin nerve)
 Distally between
o ECRB (radial nerve) and EPL (pin nerve) distally

Approach
 Position
o place patient supine
 if arm is on arm board, then pronate the forearm
 if arm is across chest, the supinate the forearm
 Incision
 o straight or gently curved incision from
 point anterior to the lateral epicondyle of the
humerus
 to point just distal to Lister's tubercle

 Superficial dissection
o proximally develop interval between ECRB and
the EDC
o proximally expose proximal third of the radius and
overlying supinator
o distally develop plane between
the ECRB and EPL and exposes lateral aspect
of distal third of the radius

 Deep dissection - proximal third

o Dissect PIN out of supinator to protect. Two methods
exist to protect
 proximal to distal: detach origin of ECRB and
ECRL from lateral epicondyle and identify and
dissect PIN as it enters supinator muscle
 distal to proximal: identify nerve as it exits
supinator and dissect it proximally out of
supinator substance
o pronate arm to expose anterior aspect of radius and
move PIN away from origin of supinator
 can supinate after successful identification of
nerve and after bony exposure is complete
o detach supinator muscle at insertion on anterior
aspect of radius
o subperiosteally strip supinator to expose proximal
third of radius

 Deep dissection - middle third

o make incision along superior and inferior borders
of APL and EPB and retract them off bone to expose
middle third of radius

Dangers
 Posterior interosseous nerve
o injury usually from retraction
o in 25% of patients the nerve actually touches the dorsal
aspect of the radius
 o plates placed high on the dorsal surface may trap the nerve
o PIN must be identified within the supinator muscle

Subcutaneous Approach to Ulnar Shaft

Author:
Topic updated on 04/12/10 3:02pm
Indications
 Inidications
o ORIF of ulnar shaft fxs
o Ulnar osteotomy
o Ulnar lengthening
(Kienbock's disease)
o Ulnar shortening (for radial
malunion)
o osteomyelitis and tumors of ulna

Internervous Plane
 Between
o ECU (PIN n.) and
o FCU (ulnar n.)

Approach
 Position
o place supine on table
o place arm across chest to expose subcutaneous
border of ulna
o exsanguinate arm

 Approach
o linear longitudinal incision over subcutaneous
border of ulna
 o length based on procedure

 Superficial dissection
o incise deep fascia in distal incision in line with skin
incision
o divide plane between ECU and FCU
o dissect down to subcutaneous border of ulna
( divide fibers of ECU to reach bone)

 Deep dissection
o incise periosteum over ulna
o perform sunperiosteal dissection
o In the proximal fifth of the ulna, part of the insertion
of the triceps will need to be detached to gain
access to the bone

Dangers
 Ulnar nerve
o proximally passes through two heads of FCU
o travels down forearm under FCU and on top of FDS
o protect by dissecting FCU subperiostally
 Ulnar artery
o travels down forearm with ulnar nerve (radial side)
o protect by dissecting FCU subperiostally

Dorsal Approach to the Wrist

Author:
Topic updated on 01/23/10 10:44am
Indications
 Exposure to
1. extensor tendons passing over wrist
2. dorsal wrist joint
3. dorsal carpus
4. dorsal surface of proximal ends of metacarpals
 Indications
1. synovectomy and repair of extensor tendons
2. wrist fusion
3. excision of lower end of radius
4. proximal row carpectomy
5. ORIF of
 distal radius fx (displaced intra-articular dorsal lip fxs)
  carpal fx and dislocations

Dangers
 Radial nerve (superficial radial nerve)
 Radial artery

Position
 Place supine on table
 Pronate arm and place on armboard
 Exsanguinate arm

Incision
 Make 8cm incision midline (halfway between radial and ulnar
styloid)
o extend 3 cm proximal to wrist joint and 5 cm distal

Intermuscular Plane
 Plane between ECRL and ECRB
o both supplied by radial nerve

Approach
1. Incise subcutaneous fat inline with skin incision
2. Expose extensor retinaculum

Volar Approach to the Wrist

Author:
Topic updated on 05/23/11 7:50pm
Indications
 Decompression of median nerve
 Flexor tendon synovectomy
 Carpal tunnel tumor excision
 Carpal tunnel nerve and tendon repair
 Drainage of sepsis tracking up from the mid-palmer space
 ORIF of fxs and dislocations of distal radius and carpus
o especially volar lip intra-articular fxs

Position
 Place supine on table
 Supinate arm and place on armboard
  Exsanguinate arm

Incision
 Make incision just ulnar to the thenar crease in hand and ulnar to
palmaris longus in wrist
o begin 4cm distal to flexion crease
o make ulnar curve so you don't cross perpendicular to flexion
crease
 also helps protect palmar cutaneous branch
o end 3 cm proximal to flexion crease

Approach
 Superficial dissection
1. incise skin flaps
2. incise fat
3. section fibers of superficial palmar fascia in line with incision
4. retract curved flaps medially to expose insertion of PL into
flexor retinaculum
5. retract PL tendon toward ulna to expose median nerve under
PL and FCR
6. pass a blunt object between median nerve and retinaculum.
7. incise entire length of retinaculum on ulnar side of nerve
 Deep dissection and access to volar wrist joint
1. identify motor branch of median nerve (where median nerve
emerges from carpal tunnel
2. mobilize median nerve and retract radially (so you dont
stretch motor branch)
3. mobilize and retract flexor tendons
4. incise base of carpal tunnel

Extension
 Proximal
o Indications
 to further expose median nerve
o Dissection
1. extend incision up middle of arm
2. incise deep fascia between PL and FCR
3. retract PL and FCR to expose FDS
4. median nerve adheres to deep surface of FDS

Dangers
 Palmar cutaneous branch of median nerve
o arises 5 cm proximal to wrist joint
 o runs ulnar to FCR
o greatest threat when you dont curve your incision ulnar
 Motor branch of median nerve
o significant anatomic variation
o risk to nerve minimize if incision through retinaculum made
ulnar to median nerve
o Superficial palmar arch

Anterior Approach to Shoulder

Author:
Topic updated on 01/21/11 6:19pm
Introduction
 Overview
o This approach can be a fairly extensile exposure, allowing
access to the anterior, medial, and lateral aspects of the
shoulder.
o This approach is done in a supine position with a roll or
wedge under the medial scapula.
 Indications
o Proximal humerus fractures
o Long head of the biceps injury
o Reconstruction of recurrent dislocations
o Septic glenohumeral joint
o Shoulder arthroplasty

Internervous plane
 Internervous plane
o Deltoid muscle (axillary nerve.)
o Pectoralis major (medial and lateral pectoral nerve)

Approach
 Incision
o An incision is made following the line of the deltopectoral
groove
 In obese patients, this may be difficult to palpate; the
incision starts at the coracoid process, which is
usually more easily palpable
 o A 10-15 cm incision is usually utilized, but is sized
according to surgical need and size of patient
 Superficial dissection
o Attention must be paid to superficial skin vessels, as these
can bleed significantly
o The deltopectoral fascia is encountered first ; the cephalic
vein is surrounded in a layer of fat and is used to identify
the interval
o The cephalic vein can be mobilized either medially or
laterally, depending on patient factors and surgeon
preference.
o Fibers of the deltoid are retracted laterally and the
pectoralis major is retracted medially
 Deep dissection
o The short head of the biceps and coracobrachialis arise
from the coracoid process and are retracted medially.
 The musculocutaneous nerve enters the biceps 5-
8cm distal to the coracoid process; retraction of the
conjoint tendon must be done with care.
o The fascia on the lateral side of the conjoint tendon is
incised to reveal the subscapularis
 External rotation puts the subscapularis fibers on
stretch
o The subscapularis may be released from its insertion on the
lesser tuberosity through the tendon or via an osteotomy
o The capsule is then incised (as needed) to enter the joint

Dangers
 Musculocutaneous nerve
o Enters medial side of biceps muscle 5-8 cm distal to
coracoid (stay lateral)
o Can have neuropraxia if retraction is too vigorous
 Cephalic vein
o Should be preserved if possible; if injured, can ligate
 Axillary nerve
o At risk with release of subscapularis tendon (runs distal to)
or with incision of teres major tendon or latissimus dorsi
tendon (runs proximal to)
Lateral Approach to Shoulder
Author:
Topic updated on 01/22/11 3:01pm
Introduction
 Overview
o provides access to the lateral proximal humerus, rotator
cuff, and acromion
o to extend the approach distally, a second separate incision
must be made distally to protect the axillary nerve
 Indications
o reduction and fixation of proximal humerus fractures
o rotator cuff repair
o debridement of subacromial space

Internervous plane
 Internervous plane
o none (deltoid is split in line with its fibers)

Approach
 Position
o approach is done in a supine position, with a bump or roll
placed under the spine or ipsilateral scapula
 Incision
o 5 cm incision is made from the tip of the acromion distally in
line with the arm
 this is generally made at the posterior edge of the
clavicle, but can be adjusted according to pathology
 Superficial dissection
o deltoid is split in line with its fibers no more than 5 cm distal
to the acromion (to protect the axillary nerve)
o a stay suture is placed at the apex of the split to prevent
propogation of the split
 Deep dissection
o subacromial bursa is seen and can be excised to reveal the
underlying rotator cuff and proximal humerus

Dangers
 Axillary nerve
o runs transversely 5-7 cm distally to the edge of the
acromion from posterior to anterior
o cannot extend split further due to risk to denervation of
anterior deltoid
o need to make a second incision distally in order to provide a
 safe "second window" if distal extension is needed
(generally for fractures)

Posterior to Shoulder
Author:
Topic updated on 01/22/11 5:43pm
Introduction
 Overview
o this approach is infrequently used
o this approach offers access to the posterior and inferior
aspects of the shoulder
 Indications
o proximal humerus fracture-dislocations
o glenoid fractures/osteotomy
o removal loose bodies
o irrigation and debridement of septic joint
o scapular neck fractures

Internervous plane
 Internervous plane
o teres minor (axillary nerve)

o infraspinatus muscle (suprascapular nerve)

Approach
 Incision
o the patient is positioned in the lateral decubitus position with
the ipsilateral arm draped free
o the incision is made along the scapular spine, extending to
the lateral acromial border
 Superficial dissection
o attention must be paid to superficial skin vessels, as these
can bleed significantly
o the origin of the deltoid is released from the scapular spine
o the plane between the deltoid and infraspinatus is
encountered and bluntly developed
 this is typically easiest to find at the lateral aspect of
the incision
o the deltoid is retracted distally/laterally
  Deep dissection
o the interval between the infraspinatus (suprascapular nerve)
and teres minor (axillary nerve) is bluntly developed
 this is often difficult to find, but should be done
carefully
o retract the infraspinatus superiorly and the teres minor
inferiorly to expose the posterior glenoid and scapular neck

Dangers
 Suprascapular nerve
o passes around the base of the scapular spine (do not
retract infraspinatus too vigorously)
 Axillary nerve
o runs through the quadrangular space beneath the teres
minor (stay superior to the teres minor)
o this is accompanied by the posterior circumflex humeral
artery

Judet to Scapula
Author:
Topic updated on 03/04/11 10:27am
Introduction
 Overview
o This approach is a fairly limited exposure, allowing little
anterior exposure.
 Indications
o Proximal humerus fracture-dislocations (posterior)
o Complex scapular and glenoid fractures

Internervous plane
 Internervous plane
o none

Approach
 Incision
o the patient is prone for this approach.
o an incision is made following at the posterolateral lip of the
acromion, extends along the spine of the scapula, and turns
at a right angle inferiorly along the medial border of the
scapula.
 Superficial dissection
 o the posterior deltoid is elevated off the spine of the scapula.
 Deep dissection
o the underlying infraspinatus is elevated off the medial
border of the scapula and retracted laterally on its
suprascapular neurovascular pedicle, while care is taken to
protect the pedicle.

Dangers
 Suprascapular nerve and artery
o At risk when retracting the infraspinatus

Anterior Approach to Humerus

Author:
Topic updated on 02/14/11 6:46am
Introduction
 Indications
o Open reduction and internal fixation of humeral shaft
fractures
o Humeral tumor biopsy/resection
o Humeral osteotomy

Surgical Plane
 Internervous plane
o proximal
 Deltoid muscle (axillary nerve) and pectoralis major
(medial and lateral pectoral nerves)
o distal
 Medial brachialis (musculocutaneous nerve) and
lateral brachialis (radial nerve)

Approach
 Position
 o Supine with arm on arm board, abducted 60 degrees

 Incision
o Make a curved incision from the tip of the coracoid process
distally in line with deltopectoral groove along the lateral
aspect of the humerus
o Incision should end approximately 5 cm short of elbow
flexion crease (lateral antebrachial cutaneous nerve at risk)

 Superficial dissection
o Identify the cephalic vein - can take medially or laterally
o Proximally, develop the interval between the deltoid and
pectoralis major muscle
o Distally, incise the deep fascia of the arm in line with the
skin incision
o Identify the interval between the biceps and brachialis
 Biceps can be retracted medially or laterally (typically
is taken medially)

 Deep dissection
o Proximally, incise the periosteum lateral to the pectoralis
major tendon insertion, staying lateral to the long head of
the biceps tendon
 The anterior humeral circumflex artery is seen here
and must be ligated
o Distally, the fibers of the brachialis are split longitudinally
along the midline to expose the periosteum and humeral
shaft

 Extension
o Proximal extension can be obtained by developing the
anterior approach to the shoulder with full deltopectoral
dissection
o Distal extension cannot be obtained with this approach

Dangers
 Anterior circumflex humeral artery
o At risk proximally between the pectoralis major and deltoid
muscle
 Axillary nerve
o Can be injured with vigorous retraction of the deltoid
 Radial nerve
o Must be identified before any incision is made into the
 brachialis muscle or before periosteal elevation of the
brachialis off the humerus occurs
o Also at risk on the middle 1/3 of the humerus where it lays
in the spiral groove on the posterior humerus

Anterolateral Approach to Distal Humerus

Author:
Topic updated on 12/05/10 2:20pm
Introduction
 Indications
o Open reduction and internal fixation of humeral shaft
fractures
o Radial nerve exploration

 Internervous plane (none)

o Between the brachialis (radial n.) and brachioradialis (radial
n.)

Approach
 Position
o Supine with arm on arm board, abducted 45-60 degrees

 Incision
o Make a curved incision over the lateral border of the biceps
centered over the fracture site

 Superficial dissection
o Identify the lateral border of the biceps muscle and retract
medially
o Ensure that the lateral antebrachial cutaneous nerve is
retracted with the biceps
o This reveals the brachialis and brachioradialis muscles lying
underneath

 Deep dissection
o Incise the fascia overlying these muscles and develop the
intermuscular plane
o The radial nerve lies between the brachialis and

brachioradialis muscles
  The nerve is generally easiest to find in the distal arm,
just proximal to the elbow
 This must be traced proximally until it pierces the
lateral intermuscular septum and be carefully
protected
o The brachialis and biceps are retracted medially and the
brachioradialis laterally
o Subperiosteal elevation of the brachialis reveals the
humeral shaft underneath

 Extension
o Proximal extension can be obtained by developing the
interval between the brachialis medially and the lateral head
of the triceps posterolaterally.
o Distal extension can be obtained by extending into an
anterior approach to the elbow
 This distal interval lies between the brachioradialis
(radial n.) and pronator teres (median n.)
 Care must be taken to avoid iatrogenic injury to the
lateral antebrachial cutaneous nerve in this extensile
approach

Dangers
 Lateral cutaneous nerve of the forearm
o This terminal branch of the musculocutaneous nerve is
injured at the distal end of the incision as it exits the biceps
laterally
 Radial nerve
o Must be identified before any incision is made into the
brachialis muscle or before periosteal elevation of the
brachialis off the humerus occurs

Posterior Approach to Humerus

Author:
Topic updated on 02/19/11 3:42pm
Introduction
 Indications
 o Open reduction and internal fixation of humeral shaft
fractures
 often thought to be more cosmetic when compared to
the anterolateral approach
 provides good exposure to both middle and distal 1/3
humeral shaft fractures

Internervous plane
 There is no internervous plane and this is a muscle splitting
approach

Approach
 Position
o prone with arm on arm board, abducted 45-60 degrees
o lateral with arm over the top of the body

 Incision
o incision from 8 cm distal to the acromion to the olecranon
fossa

 Superficial dissection
o fascia should be splint in line with incision

 Deep dissection
o Split the fascia between the long and lateral head of the
triceps
 lateral head is retracted laterally and the long head
medially
o Radial nerve will be identified along with the profunda
brachii vessels in the spiral groove
 often times a tourniquet is beneficial until the nerve is
identified

 Extension
o proximal extension can be obtained by elevating the lateral
head of the triceps
 Allows for radial nerve to be elevated in superior
direction
 Limited by branch of radial nerve to medial head of
triceps
o Gerwin's modification of this approach allows for great
proximal extension than the classic approach
Lateral Approach to Distal Humerus
Author:
Topic updated on 12/12/10 7:09pm
Introduction
 Indications
o Open reduction and internal fixation of distal humerus
fractures (lateral condyle)
o Open treatment of lateral epicondylitis

 Internervous plane (none)

o Between the triceps (radial n.) and brachioradialis (radial n.)

Approach
 Position
o Supine with arm lying across chest

 Incision
o Make a curved or straight incision over the lateral
supracondylar ridge

 Superficial dissection
o Incise the deep fascia in line with the skin incision
o Identify the plane between the brachioradialis and triceps
 Cut in between these two muscles down to bone
 Reflect the triceps posteriorly and the brachioradialis
anteriorly

 Deep dissection
o The common extensor origin can be released off the lateral
humerus and the triceps can be similarly elevated
posteriorly

 Extension
o Proximal extension cannot be obtained due to the radial
nerve crossing proximally in line with the incision
o Distal extension can be obtained by extending into the
interval between the anconeus (radial n.) and extensor carpi
ulnaris (posterior interosseous n)
  This extension can only be carried to the radial head
to avoid potential injury to the posterior interosseous
nerve

Dangers
 Radial nerve
o This nerve is at risk with proximal extension, as the nerve
pierces the lateral septum in the distal third of the arm

Posterior Approach to Elbow

Author:
Topic updated on 04/12/10 12:47pm
Introduction
 Indications
o ORIF of fractures of the distal humerus
o removal of loose bodies
o treatment of non-unions of the distal humerus
o triceps lengthening for extension contractures of the elbow

Intermuscular plane
 None. The extensor mechanism is detached. The radial nerve
innervates the triceps proximally

Approach
  Position
o prone position with shoulder abducted 90 degrees, elbow
flexed and forearm handing from side of table

 Incision
o begin 5cm proximal to the olecranon in the midline of the
posterior distal humerus
o curve laterally proximal to the tip of the of the olecranon
along the lateral aspect of the olecranon process
o then curve medially over the middle of the posterior aspect
of the ulnar

 Superficial dissection
o incise deep fascia in the midline
o incise fascia over the ulnar nerve, dissect it out completely
and pass loops around it for identification
o drill and tap olecranon prior to performing osteotomy
o score the olecranon with an osteotome to allow perfect
reduction when the osteotomy is repaired
o V-shaped osteotomy of the olecranon 2 cm from the tip
using an oscillating saw

 Deep dissection
o strip soft tissue from the edges of the osteotomy site and
retract the fragment proximally
o subperiosteal dissection of the medial and lateral borders of
the humerus allows exposure of all surfaces of the distal
fourth of the humerus

Dangers
 Ulnar nerve
o Protected during the approach
 Median nerve
o Strict subperiosteal dissection of the anterior surface of the
humerus protects the nerve. Flexion of the elbow relaxes
the anterior structures.
 Radial nerve
o Proximal extension endangers the radial nerve as it travels
from the posterior to the anterior compartment at the lateral
border of the humerus approximately 14 to 15 cm proximal
to the lateral epicondyle
 Brachial artery
 o runs with the median nerve (see above)

Medial Approach to the Elbow

Author:
Topic updated on 04/12/10 12:49pm
Introduction
 Indications
o removal of loose bodies
o ORIF of the coronoid process of the ulna
o ORIF of the medial humeral condyle and epicondyle

Intermuscular plane
 Proximally between
o brachialis (musculocutaneous nerve)
o triceps (radial nerve)
 Distally between
o brachialis (musculocutaneous
o pronator teres (median nerve)

Approach
 Position
o supine, arm supported by an arm board over the patient
 Incision
o curved incision 8 to 10 cm long on the medial aspect of
the elbow,
 centered over the medial epicondyle

 Superficial dissection
o incise the fascia over the ulnar nerve starting proximally
o isolate nerve along the entire length of the incision
o expose the common flexor origin on the medial
epicondyle
o develop brachialis and PT interval
 avoid the medial nerve which enters PT near the
midline
o perform osteotomy of the medial epicondyle and reflect
distally
o develop brachialis and triceps interval
  Deep dissection
o incise capsule and medial collateral ligament

 Extension
o local:
 abduction of forearm opens medial aspect of joint
 can dislocate laterally by dissecting off joint
capsule and periosteum
o proximal:
 anterior surface of distal fourth of humerus can be
exposed by developing plane between brachialis
and triceps
o distal:
 limited by the branches of the median nerve

Dangers
 Ulnar nerve (as above)
 Median nerve: Aggressive traction on the osteotomy fragment
can cause a traction injury to the median and anterior
interosseous nerves

Anterolateral Approach to the Elbow

Author:
Topic updated on 04/12/10 12:50pm
Introduction
 Indications
o distal biceps avulsion
o neural compressions involving
 PIN syndrome
 Radial tunnel syndrome
 Superficial radial nerves
o total elbow replacements
 o elbow joint I&D
o surgery of capitellum (ORIF, aseptic necrosis)
o excision of tumors

 Intermuscular plane
o Proximally bwtween:
 brachialis (musculocutaneous n.)
 brachioradialis (radial nerve)
o Distally between
 brachioradialis (radial nerve)
 pronator teres (median nerve)

Approach
 Position
o Supine with arm on arm board

 Incision
o Make curved incision starting 5 cm proximal to flexion
crease along the lateral border of the biceps
o Continue distally by following medial border of the
brachioradialis

 Superficial dissection
o Identify lateral antebrachial cutaneous nerve (sensory
branch of the musculocutaneous nerve which becomes
superficial 2 inches proximal to the elbow crease, lateral to
the biceps tendon)
o Incise the deep fascia along the medial border of the
brachioradialis
o Identify radial nerve proximally at level of the elbow joint
(between brachialis and brachioradialis)
o Follow the radial nerve distally until it divides into its three
main branches:
 PIN (enters the supinator)
 sensory branch (travels deep to brachioradialis)
 motor branch to ECRB
o Develop brachiaradialis and PT interval distal to the division
of the radial nerve.
o Ligate recurrent branches of the radial artery and muscular
branches that enter the brachialis just below the elbow to
allow better retraction

 Deep dissection
 o Joint capsule
 incise the joint capsule between the radial nerve
laterally and the brachialis muscle medially
o Proximal radius
 expose proximal radius by supinating the forearm to
bring the supinator muscle anteriorly.
 Incise the muscle origin down to bone, lateral to the
insertion of the biceps tendon
 Extension
o Proximal
 extends into the anterolateral approach to the forearm
developing the plane between the brachialis and the
triceps muscles
o Distal
 extends to the anterior approach to the
radius between the planes of the brachioradialis and
pronator teres muscles proximally, and the
brachioradialis and flexor carpi radialis (median nerve)
muscles distally.

Dangers
 Lateral cutaneous nerve of the forearm
 Radial nerve
 PIN
o vulnerable as it winds around the neck of the radius within
the substance of the supinator muscle. Incise the supinator
muscle at its origin with forearm supinated to protect the
nerve.
 Recurrent branch of the radial artery
o must be ligated to mobilize the brachioradialis