Molesworth's Medial Approach
Molesworth40 describes a medial approach. Its indications include fixation of fractures of the medial humeral epicondyle or condyle and fracture-dislocations of the elbow and include removal of loose bodies.
The incision is centered over the medial epicondyle, and the ulnar nerve is isolated and protected. In the muscular plane, the ulnar and humeral heads of the flexor carpi ulnaris are separated, exposing the ulnar nerve in the forearm. The muscular branches are preserved, and the articular branches are sacrificed.
In the subperiosteal planes, the surgeon can see the outline of the trochlea through the capsule. He or she incises the capsule parallel and behind the anterior band of the medial collateral ligament. Through this incision, an osteotome is pressed against the undersurface of the medial epicondyle, adjacent to the medial nonarticular surface of the trochlea after predrilling. The medial epicondyle is osteotomized in an upward direction, and the medial intermuscular septum is detached from this epi-condyle after dissecting the pronator teres from the septum. The medial epicondyle with the common flexor origin and the medial collateral ligament are retracted distally. The anterior and posterior portions of the capsule are elevated from the coronoid and olecranon fossae to expose the joint.
Molesworth40 does not discuss the extensibility of this approach. However, the humerus can be exposed proxi-
mally by subperiosteal dissection. Distally, the exposure is limited unless the distal attachment of the collateral ligament is released. Molesworth reported that the entire elbow joint can be visualized with this exposure.
After completing the procedure, the medial epicondyle is reattached with a screw, and the arthrotomy is closed. Molesworth recommends suturing the triceps to the bra-chialis.
Complications can occur with this approach. The branches of the median nerve to the pronator teres and the common flexor origin must be protected from traction. The ulnar nerve is at risk for injury and must be protected. Secure fixation is important to minimize the risk of nonunion of the osteotomy. Medial collateral instability can occur if the osteotomy is not positioned correctly or if the ligament is violated.
Modifications. Campbell38 modified the Molesworth approach by performing the osteotomy in an anteroposte-rior direction.
In his modification, Hotchkiss67 recommends elevating the pronator teres muscle from the medial supra-condylar ridge and retracting it anteriorly to expose the anterior joint capsule. Retraction of the biceps and bra-chialis provides greater exposure of the anterior capsule. The common flexor origin is left intact. Posteriorly, the triceps is elevated from the distal humerus at the raphe, which is identified distally between the flexor carpi ul-naris and the palmaris longus superficially and between the flexor carpi ulnaris and flexor digitorum superficialis muscles slightly deeper. The ligament complex is ex posed, and dissection up to 1 cm distal to the sublime tubercle is permissible. The dissection plane lies in an in-ternervous plane (i.e., median to ulnar), and it has been described extensively for reconstruction of the medial collateral ligament complex.68
Jobe describes a medial utility approach for medial collateral ligament reconstruction and for the treatment of medial epicondylitis (Fig. 1.26).69 A curvilinear incision is made over the anterior aspect of the medial epi-condyle, and care is taken to identify and preserve the multiple medial antebrachial cutaneous nerve branches that are encountered. The common flexor tendon can then be divided in line with its fibers or reflected distally to expose the medial capsule and ligaments.
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