Skin Incisions

Surgeons report a high incidence of cutaneous nerve injury with both medial4,6 and lateral2,3 incisions. Dowdy et al.1 reported that a posterior midline skin incision crosses significantly fewer nerves of smaller diameter than either a medial or lateral incision. The cutaneous nerves1 and the subcutaneous vascular plexus57,58 lie in the subcutaneous fat and are preserved if full-thickness fasciocutaneous flaps are elevated at the level of the deep fascia.

According to Shawn O'Driscoll, the front of the elbow is at the back. Therefore, we recommend a posterior mid-

TABLE 1.2. Summary of surgical approaches to the elbow

Approach

Author

Tissue plane

Posterior

Campbell38

Midline triceps split

Campbell38

Triceps aponeurosis tongue, deep head split

Van Gorder39

Triceps tongue (aponeurosis and part of deep head)

Wadsworth11

Triceps tongue (aponeurosis and full-thickness deep head), between ECU and anconeus

Bryan, Morrey43

Elevate triceps mechanism from olecranon and reflect laterally

Boyd12

Lateral border of triceps; anconeus and ECU released from ulna

Heim, Pfeiffer53

Chevron olecranon osteotomy

Alonso-Llames50

Retract triceps medially and laterally

Lateral

Kocher37

Between ECU and anconeus

Cadenat54

Between ECRB and ECRL

Kaplan55

Between ECRB and EDC

Key, Conwell56

Between brachioradialis and ECRL

Medial

Molesworth40 Campbell38

Medial epicondyle osteotomy and split FCU heads

Combined

Patterson et al.49

Between ECU and anconeus with or without lateral epicondyle osteotomy; FCU elevated from ulna

Anterior

Henry41

Between mobile wad and biceps tendon; elevate

supinator from radius

ECU, extensor carpi ulnaris; ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum commu-nis; FCU, flexor carpi ulnaris supinator from radius

ECU, extensor carpi ulnaris; ECRL, extensor carpi radialis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum commu-nis; FCU, flexor carpi ulnaris line incision for major elbow surgery.1,49,59 Placement of the incision just lateral to the olecranon takes it away from where the elbow rests on the medial aspect of the olecranon. The entire elbow, including the anterior aspect, can be exposed through this incision, and skin necrosis has not occurred in our patients when we have used this approach. When performing surgical procedures, such as an epicondyle release or an open reduction of simple radial head fractures, we find a more localized approach can be justified, but care for the cutaneous nerves is required.2-4,6

For major elbow procedures, we isolate the ulnar nerve and place a tape around it to act as a constant reminder of its location. To avoid inadvertently placing traction on the tape, we do not clamp the tape. Care is taken to preserve the ulnar collateral vessels. We excise the medial intermuscular septum and release the cubital retinaculum to allow the ulnar nerve to be mobilized. At the completion of the procedure, the nerve is placed into its native position. If it is stable throughout the range of motion, it is left in situ. If it dislocates, it is then transposed.

After major elbow surgery, we recommend that the surgeon elevate the patient's elbow in the extended position. We reported the use of the dynamic elbow suspension splint, which is a pediatric Thomas splint suspended from a Balkan frame; it allows the patient to mobilize the extremity while in bed.59 We now prefer to use a pediatric knee immobilizer because it is more easily applied. Extension facilitates wound closure and healing46,60 and reduces the risk of fixed flexion deformity.

In the following descriptions of named approaches to the elbow, the details of the skin incision have been omitted unless they have distinct advantages over the posterior midline incision.

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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