behind the medial epicondyle. It is usually necessary to identify the medial epicondyle and to transpose it anteriorly when doing complex fractures of the distal humerus. It is important to remember the location of this nerve and to protect it with this dissection. Because the triceps is split in line with its fibers, there is usually no functional problem with that muscle postoperatively.
TECHNIQUE
This procedure is done with the patient lying face down or at least with the opposite side down and the arm supported on a bolster, so that the posterior portion of the humerus is facing upward. At that point, the midline incision is made. It is carried through the subcutaneous tissue and through the triceps in line with its fibers down to the humerus. As you approach the elbow, either the triceps is reflected off of the olecranon or an olecranon osteotomy is done. This then allows the triceps to be retracted in its entirety exposing the back of the distal humerus. The radial nerve is usually not encountered in the approaches to the distal humerus. It will be seen underneath, that is, deep to the triceps, as you go more proximally. For the distal medial dissection, the ulnar nerve needs to be identified and separated from its underlying tissues and allowed to fall in an anterior direction.
TRICKS
There are no special tricks with this approach except to protect the nerves.
HOW TO TELL IF YOU ARE LOST
It is difficult to get lost in this approach because it is a midline approach. The major way you can get lost is by being too far proximal or distal for the pathology, and then you simply need to extend your incision.
FIGURE 9–1 The skin incision starting 10 cm from the olecranon and going distally.
FIGURE 9–2 The subcutaneous tissue spread with the fibers of the triceps running toward the olecranon.
FIGURE 9–3 The triceps split with the humerus seen in the depth of the incision.
FIGURE 9–4 The tissue retracted such that the olecranon and posterior elbow joint are visible. The olecranon fossa has also been cleaned out and is visible.
FIGURE 9–5 The ulnar nerve on the ulnar side. This is at risk if the triceps is going to be retracted completely off the distal humerus.
FIGURE 9–6 The proximal extension of the dissection with the radial nerve just barely visible.
FIGURE 9–7 The radial nerve now more thoroughly exposed as the overlying triceps is split.
SECTION
III
ELBOW
10
ANTEROLATERAL APPROACH
USES
This approach is useful for biceps tendon repairs. (Sometimes just the middle part of the approach is needed for biceps repair.) It can also be used for coranoid process open-reduction internal fixation. Additionally, it may be used for exploration of radial tunnel.
ADVANTAGES
This approach can be extended proximally and distally as necessary. By staying lateral to the biceps tendon, it stays in the internervous plane between the median and radial nerves.
DISADVANTAGES
There are important structures at risk with this approach and great care must be taken to identify and protect them.
STRUCTURES AT RISK
Laterally, the structure at risk is the radial nerve. This nerve enters the forearm underneath the brachioradialis muscle, which is the first muscle identified with this approach. The anterior edge of that muscle should be dissected and the nerve will be found on the inner border of the muscle. It should be retracted out of the way and protected.
The brachial artery and the median nerve are at risk if you are dissecting medial to the biceps tendon. As long as you stay lateral to those tendons, there is no significant risk.
The recurrent branch of the radial artery is at risk with this approach if you are dissecting distally. It will need to be clamped and sacrificed, which can be done without any major problem for the patient.
TECHNIQUE
A curved incision is made starting 5 or 6 cm proximal to the elbow flexor crease along the lateral side down to the lateral elbow joint, crossing the flexor crease at an angle almost parallel to the crease, going over to the medial side, and then going distally. This incision is carried through the subcutaneous tissue. The brachioradialis is identified and its anterior border developed so that the radial nerve can be identified and protected.
The muscle just medial to the brachioradialis is the brachialis muscle, and it is traced distally. The biceps tendon sheath is anterior to the brachialis and, once opened, the tendon of the biceps is identified and traced distally. If the surgery is being done for a biceps tendon rupture, then it is frequently necessary to work proximally along the brachialis until you encounter the retracted end of the biceps. This may require a fairly long proximal extension of the incision. If the surgery is to free up the radial nerve, dissection along the brachialis and biceps is not necessary.
If the purpose of the surgery is to reattach an avulsed biceps tendon, then follow the brachialis down to the ulna and go just lateral to that. Obviously, if the biceps is avulsed, you cannot trace it down to its insertion. By tracing the brachialis, you will stay lateral to the median nerve and brachial artery and you can then feel the bicipital tuberosity.
TRICKS
