ELBOW

Posterior Approach
 Position
o Prone with arm hanging over armboard
 Incision
o Over posterior aspect of elbow (lateral over tip)
 Plane
o Distal to radial nerve innervation of triceps
o Identify and isolate ulnar nerve
o Osteotomy of ulna olecranon
o Elevate triceps
 Dangers
o Radial nerve – can’t extend past the distal 1/3 of humerus
o Ulnar nerve – identify and protect it
o Median nerve – lying on anterior distal humerus
o Brachial Artery – lies with median nerve in the front of the elbow

Medial Approach
 Position
o Supine with armboard – arm abducted and externally rotated
 Incision
o Curved incision over medial epicondyle
 Plane
o Proximally between brachialis muscle (musculocutaneous nerve) and
triceps muscle (radial nerve)
o Distally between brachialis muscle (musculocutaneous nerve) and
pronator teres (median nerve)
o Identify and retract ulnar nerve inferiorly
o Epicondyle ostetomy reflected distally
o Incise capsule and medial collateral ligaments
 Dangers
o Ulnar nerve – isolate before medial epicondyle ostotomy
o Median nerve – Don’t retract common flexors too vigourously

Anterolateral Approach (can joint henry with deltopectoral)

 Position
o Supine with arm on armboard
 Incision
o S incision along anterior aspect of elbow NOT crossing the flexor
creases at 90°
 Plane
o Proximally between brachialis muscle (musculocutaneous nerve) and
brachioradialis (radial nerve)
 o Distally between brachioradialis (radial nerve) and pronator teres
(median nerve)
o Identify and protect the lateral cutaneous nerve of the forearm distally
and the radial nerve proximally between the brachioradialis and the
brachialis muscles
o Ligate the recurrent branch of the radial artery
o Incise capsule PRN and incise origin of supinator PRN
 Dangers
o Radial nerve – identify and protect it bw brachioradialis and brachialis
o PIN – Branch of radial, winds around neck of radius within the
substance of supinator
o Lateral Cutaneous nerve of the forearm – identify in the interval
between the brachialis and biceps brachii
o Recurrent braches of radial artery – ligate so brachioradialis can be
mobilized fully

Anterior Approach to the Cubital Fossa (least common, for NV repair)

 Position
o Supine with arm in anatomic position
 Incision
o Curved S incision from proximal lateral
 Plane
o Proximally between brachialis (musculocutaneous nerve) and
brachioradialis (radial nerve)
o Distally between brachioradialis (radial nerve) and pronator teres (median
nerve)
o Identify and protect the lateral cutaneous nerve of the forearm (between
biceps tendon and brachialis muscle)
o Incise bicipital aponeurosis (lacterus fibrosus) watchin out for brachial
artery underneith
o Watch for the radial nerve (between brachialis and brachioradialis)
 Dangers
o Lateral cutaneous nerve of the forearm – identify in the interval between
the brachialis and biceps brachii
o Radial artery - lies under bicipital aponeurosis

Posterolateral Approach to the Radial Head (Kocher)

 Position
o Supine with pronated arm over chest
 Incision
o Over posterior surface of lateral humeral epicondyle and radial head
 Plane
o Between anconeus (radial nerve) and extensor carpi ulnaris (PIN)
 Dangers
 o PIN – limit dissection proximal to annular ligament with arm pronated

The Boyd posterolateral approach to the elbow

 Posterior midline incision
 Subperiosteal elevation of the anconeus and ECU off the subcutaneous boder
 Under the ECU identify the ulnar insertion of the suppinator which is reflected
toward the volar aspect
 Protect both the PIN and the lateral collateral
 Divide the recurrent interosseous artery and reflect muscle further to get at the
IOM
 This approach is most useful for monteggia fractures.

ANATOMY
Neurovascular structures
 Nerves
o Median Nerve
 Crossed front of the elbow joint on its medial side
 Covered by bicipital aponeurosis (lacterus fibrosus)
 Disappears between the two heads of pronator teres (humeral head
on medial epicondyle / common flexor origin AND unlar head on
medial side of coronoid process)
 Runs down the forearm adhering to deep surface of flexor
digitorum superficialis

 Sites of entrapment of the median nerve around the elbow (from

Wheeless)
 Supracondylar process of humerus and struther’s
ligament
o http://www.abdn.ac.uk/zoohons/struthers/ligament1.hti
 Lacertus fibrosus
o Behind lacertus and in front of brachialis
 Pronator teres
 Sublimis bridge
o Fibrotendinous arcade at origin of FDS muscle
 Median nerve braches (Median nerve, AIN, motor branch of
median nerve, sensory innervation)
 Median nerve
o Pronator Teres
o FCR
o Palmaris Longus
o FDS
 AIN (from median n. 5cm proximal to medial epicondyle,
runs on volar surface of FDP and along interosseous
membrane between ulna and radius)
 o FDP (radial)
o FPL
o Pronator Quadratus
 Motor Branch of Median nerve (innervates the muscles in
the hand)
o Lumbricals (middle and index)
o Abductor pollicus Brevis
o Flexor Pollicus Brevis (part, shares with ulnar n.)
o Opponens Pollicis
 Sensory Branches
o Palmar cutaneous branch
o Digital branches
 Radial digital nerve of the thumb
 Ulnar digital nerve ot the thumb
 Radial digital nerve of the index finger
 Common Digital nerve of the second web
space
 Common Digital nerve of the third web
space

o Radial Nerve
 Crosses front of elbow joint in the interval between the brachialis
and brachioradialis
 Divides in the cubital fossa at the radiohumeral joint into the PIN
(enters the supstance of the supinator muscle) and superficial radial
nerve (descends down the lateral side of the forearm under cover
of the brachioradialis muscle)
 Sites of entrapment of the radial nerve around the elbow (from
Wheeless)
 Tendinous origin of ECRB
 Leash of Henry - Radial recurrent vessels
 Fibrous bands anterior to the radial head at the entrance of
the radial tunnel
 Arcade of Frohse (MOST COMMON) – tendinous
proximal border of supinator
 Distal edge of supinator at exit (least common)

o Ulnar nerve
 Crosses the joint in the groove on the back of the medial
epicondyle
 Enters the anterior compartment of the forearm passing between
the two heads of FCU
 Runs down the forearm on the anterior surface of the flexor
digitorum profundus
  Sites of compression of ulnar nerve (wheeless – Cubital Tunnel
Syndrome)
 Arcade of Struthers (8cm above elbow – band extending
from the medial head of triceps to the medial intermuscular
septum)
 Medial head of Triceps
 Medial Intermuscular septum (distal thickening as it
inserts onto the medial epicondyle)
 Medial Epicondyle
 Cubital tunnel (FCU aponeurosis)
 Anconeus epitrochlearis (anomalous muscle)
 Arcuate Ligament (aponeurosis of FCU – connects the
ulnar and humeral heads of FCU)
 Deep Flexor-Pronator Aponeurosis

 Vessels
o Brachial Artery
 Enters the cubital fossa on the lateral side of the median nerve on
brachialis
 Divides halfway down the cubital fossa into the radial and ulnar
arteries
 Under the biciptal aponeurosis
o Radial Artery
 Passes medial to biceps tendon
 Turns anterior and lying on supinator and pronator teres insertion
o Ulnar Artery
 Passes deep to deep head of pronator teres

PIN idiopathic compression syndrome:

            - sites of compression:
 fibrous bands anterior to the radial head at the entrance of radial tunnel (uncommon cause of
compression);
                  radial recurrent vessels (leash of Henry);
                  - tendinous origin of ECRB: the ECRL is more superficial and is not a source of
compression;
                  - arcade of Froshe:
                        - this is the most common location of nerve compression in radial tunnel syndrome;
                        - lies deep to the extensor carpi radialis brevis
                        - tendinous proximal border of supinator (arcade of Frohse):