Anterior approach to elbow (Henry)

  • Indication

  • Anatomy

  • Considerations

  • Positioning

  • Skin incision

  • Superficial dissection

  • Deep dissection

  • Exposure extension

  • Closure

  • Post operatively

  • References

    •

    Indication

    Spastic elbow contracture (This can also be performed through a posterior global approach).

    Isolated anterior capsular contractures.

     

    Anatomy

    See general anatomical considerations around the elbow (link)

     

    Considerations

     

    Positioning

     

    Skin Incision

    Begin a hands breadth proximal to the elbow flexion crease, a finger breadth lateral to the biceps, curve across the elbow crease and distally along the ulnar border of the extensor mobile wad.

    Protect the cephalic vein and the medial and lateral cutaneous nerves of the forearm.
     

    Superficial dissection

    The biceps tendon is important, it divides the proximal antecubital fossa into a dangerous medial side, and a safe lateral side.

    The lateral antebrachial cutaneous nerve is at risk on the lateral side of the biceps tendon and should be identified and protected.

     

    Deep dissection

    Divide the deep fascia on the lateral side of the biceps tendon.

    Pass a finger through "the swamp of fat" along the lateral edge of the guiding biceps tendon until the resistance of the recurrent vascular loop is encountered.

    This loop is only the proximal rib of a fanlike spread of vessels that lie in several layers, each of which is divided and ligated.

    If additional exposure is required, divide and ligate the muscular branches of the radial artery.

    Mobilise the mobile wad of three muscles and flex the elbow to 90° to allow exposure of the supinator muscle.

    The radial nerve only gives branches laterally; therefore, it can be safely retracted laterally with brachioradialis.

    Follow the course of the biceps tendon to the radial tuberosity and the bicipital bursa.

    Divide the bursa and elevate supinator subperiostealy, sandwiching within its substance the posterior interosseous nerve.

    To perform an anterior capsular release:

    Identify:

    • The radial nerve laterally

    • The median nerve and brachial artery medially

    Develop the interval between the biceps tendon and pronator teres.

    Dissect the brachialis muscle off the anterior joint capsule.

    The lateral dissection is between the radial nerve and the brachialis.

    Elevate the entire anterior soft tissue wad, (median nerve, brachial artery, brachialis, and biceps) off the anterior capsule.

    The entire anterior capsule can be visualized and released.

     

    Exposure extension

     

    Closure

     

    Post operatively

     

    References

    Clinical orthopaedics and related research; (370), January 2000, pp 19-33; Surgical Approaches to the Elbow; Patterson, Stuart D; Bain, Gregory I; Mehta, Janak A.

     

    Page created by: Lee Van Rensburg
    Last updated 11/09/2015