Anterior Approach

Henry's Approach

The extensile exposure that Henry41 describes is the most useful anterior exposure of the elbow joint (Fig. 1.30). Indications for this approach include repair and lengthening of the biceps tendon, anterior release of joint contractures, fixation of proximal radial shaft and coronoid process fractures, decompression of the radial and median nerves, and excision of tumors in the cubital fossa. It also can be used as part of a fasciotomy.

The patient is positioned supine with the upper limb

FIGURE 1.28. Global approach. Medial approach is made by reflecting the flexor carpi ulnaris (FCU) from the proximal ulna. (FDP, flexor digitorum profundus.

FIGURE 1.28. Global approach. Medial approach is made by reflecting the flexor carpi ulnaris (FCU) from the proximal ulna. (FDP, flexor digitorum profundus.

Radial nerve

Translation of the posterior interosseous nerve

Radial nerve

Translation of the posterior interosseous nerve

Retracted triceps tendon and anconeus muscle

\ Subperiosteal release of \ supinator muscle from ! V'v>- supinator crest

ECU and retracted lateral ep¡condylar osteotomy

Z capsulotomy anterior to LUCL

Triceps tendon retracted to expose

Anconeus muscle retracted

FIGURE 1.29. Global approach. Lateral approach is between the ECU and the anconeus muscle. (A) Olecranon fossa is exposed by retracting the triceps tendon. Z capsulotomy anterior to the LUCL allows simple repair of the annular ligament. (B) Lateral epicondylar osteotomy can be used to increase exposure. With the arm in pronation, the posterior interosseous nerve is moved away from the surgical field (inset). (LUCL, lateral ulnar collateral ligament; ECU, extensor carpi ulnaris.)

Retracted triceps tendon and anconeus muscle

Z capsulotomy anterior to LUCL

\ Subperiosteal release of \ supinator muscle from ! V'v>- supinator crest

ECU and retracted lateral ep¡condylar osteotomy

Triceps tendon retracted to expose

Anconeus muscle retracted

FIGURE 1.29. Global approach. Lateral approach is between the ECU and the anconeus muscle. (A) Olecranon fossa is exposed by retracting the triceps tendon. Z capsulotomy anterior to the LUCL allows simple repair of the annular ligament. (B) Lateral epicondylar osteotomy can be used to increase exposure. With the arm in pronation, the posterior interosseous nerve is moved away from the surgical field (inset). (LUCL, lateral ulnar collateral ligament; ECU, extensor carpi ulnaris.)

on an arm board. The surgeon makes an incision that is a handbreadth proximal to the antecubital flexion crease and a fingerbreadth lateral to the biceps. It curves across the elbow crease and distally along the ulnar border of the mobile wad of three muscles (brachioradialis and extensor carpi radialis longus and brevis). The cephalic vein and the lateral cutaneous nerve of the forearm need to be protected.

In the muscular plane, the biceps tendon is an important landmark and acts as a vertical partition that divides the proximal antecubital fossa into a "dangerous" medial side and a "safe" lateral side41 (see Fig. 1.8). The deep fascia on the lateral side of the biceps tendon is divided. Henry recommended that the surgeon pass a finger through "the swamp of fat" along the lateral edge of the guiding biceps tendon until the resistance of the "leash

FIGURE 1.30. Henry's anterior approach. (A) Skin incision lateral to biceps tendon curved across the elbow and medial to the mobile wad of three muscles. (B) The deep interval is lateral to the biceps tendon, and the leash of vessels is divided to increase the exposure.

FIGURE 1.30. Henry's anterior approach. (A) Skin incision lateral to biceps tendon curved across the elbow and medial to the mobile wad of three muscles. (B) The deep interval is lateral to the biceps tendon, and the leash of vessels is divided to increase the exposure.

of vessels" in which the recurrent branch of the radial artery is encountered. The recurrent branch is only the proximal rib of a fanlike spread of vessels that lie in several layers, each of which is divided and ligated. If further exposure is required, the muscular branches of the radial artery are divided and ligated. The mobile wad of three muscles is widely mobilized, and the elbow is flexed to 90° to allow exposure of the supinator muscle. The radial nerve branches only laterally; therefore, it can be safely retracted laterally with the brachioradialis.

In the periosteal plane, the dissection then follows the course of the biceps tendon to the radial tuberosity and the bicipital bursa. The bursa is divided, and the supina-tor muscle is elevated in the subperiosteal plane, sandwiching within its substance the posterior interosseous nerve. The forearm is fully supinated to protect the posterior interosseous nerve, and the supinator muscle is released in a subperiosteal fashion to expose the entire anterior aspect of the elbow joint.This exposure extends distally to the radial styloid. From this approach, the surgeon can visualize the proximal radius, radiocapitellar joint, and the anterolateral humerus.

The muscles are allowed to fall back, and the skin is sutured. Complications can occur with this approach. The posterior interosseous and superficial branch of the radial nerve must be protected.The recurrent branch of the artery should be preserved if possible. Compartment syndrome can occur from bleeding from the recurrent branch of the radial artery.

Cure Tennis Elbow Without Surgery

Cure Tennis Elbow Without Surgery

Everything you wanted to know about. How To Cure Tennis Elbow. Are you an athlete who suffers from tennis elbow? Contrary to popular opinion, most people who suffer from tennis elbow do not even play tennis. They get this condition, which is a torn tendon in the elbow, from the strain of using the same motions with the arm, repeatedly. If you have tennis elbow, you understand how the pain can disrupt your day.

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