Combined Medial and Lateral Approaches

If required, a combination of the medial and lateral approaches could be used. Indications for this approach include fixation of complex fracture of the radial head, coronoid process, or capitellum and include soft tissue contracture release. Instead of using two separate skin incisions, we recommend that the surgeon use a posterior midline skin incision (Fig. 1.27).

Global Approach

In the muscular and periosteal planes, the muscles of the medial side of the proximal ulna (flexor carpi ulnaris and flexor digitorum profundus) are released subperiosteally, leaving a strip of deep fascia for later repair (Fig. 1.28). The ulnar nerve is released by dividing the cubital reti-naculum and releasing the flexor carpi ulnaris fascia. Retraction of the muscles exposes the medial collateral lig ament and the anterior joint capsule. Capsulotomy is made anterior to the anterior bundle of the medial collateral ligament. The common flexor origin and medial collateral ligament are left intact. This approach extends proximally along the medial supracondylar ridge and distally by reflecting the flexor carpi ulnaris from the ulna. The medial collateral ligament and the common flexor origin can be released from the medial epicondyle, if required.

Laterally, the interval between the anconeus and the extensor carpi ulnaris is palpated and visualized as a thin strip of fat beneath the deep fascia (Fig. 1.29). It is easily identified distally, and the overlying deep fascia is divided, allowing the anconeus and extensor carpi ulnaris to be retracted to expose the anterolateral joint capsule. The triceps is retracted from the distal humerus to expose the olecranon fossa. The annular ligament is divided with a step-cut incision that allows it to be repaired anatomically. If greater exposure is required for osteosynthesis of the radial head, a lateral capsulotomy is performed as shown in Figure 1.21. Alternatively, a lateral epicondy-lar osteotomy can be performed. The surgeon predrills the lateral epicondyle and accomplishes a chevron osteotomy that includes the entire extensor origin. The muscles of the supracondylar ridge are elevated subperios-teally. The lateral ulnar collateral ligament is not violated; it remains in continuity with the epicondyle.

On the lateral aspect, the exposure is extensile proxi-mally to where the radial nerve perforates the lateral intermuscular septum. Distally, the exposure extends along the proximal third of the radius. By pronating the forearm, the surgeon translates the posterior interosseous nerve away from the surgical field to increase the zone of safety.15 The supinator muscle is released from the supinator crest and retracted along with the posterior in-

FIGURE 1.26. Jobe's medial utility approach. (A) Skin incision's proximity to branches of medial antebrachial cutaneous nerve. (B) Exposure of capsule and ligaments.

FIGURE 1.26. Jobe's medial utility approach. (A) Skin incision's proximity to branches of medial antebrachial cutaneous nerve. (B) Exposure of capsule and ligaments.

FIGURE 1.27. Global approach. (A) Posterior midline skin incision with full-thickness fasciocutaneous flaps. (B) Medial and lateral muscular and periosteal plane incisions.

FIGURE 1.27. Global approach. (A) Posterior midline skin incision with full-thickness fasciocutaneous flaps. (B) Medial and lateral muscular and periosteal plane incisions.

terosseous nerve, thereby exposing the radius. The posterior interosseous artery may require ligation.

From this exposure, the surgeon can visualize the elbow joint, distal humerus, proximal radius, and ulna. The medial collateral ligament and the common flexor origin should be repaired with transosseous sutures if they have been elevated. The lateral epicondylar osteotomy is reat-tached with a screw.

When using this approach, the surgeon must protect the posterior interosseous nerve. We have not witnessed lateral epicondylar osteotomy nonunion and posterolat-eral rotatory instability or ectopic bone formation with this approach.

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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