surgical approaches to shoulder arm elbow
DESCRIPTION
TRANSCRIPT
By Dr.BALAJI J
PG IN MS ORTHOGANDHI MEDICAL COLLEGE
Surgical Approaches to upperlimb
APPROACHES TO ACROMIOCLAVICULAR JOINT
Anterior approach to the clavicle
INDICATIONS ORIF OF FRACTURES
RECONSTRUCTION OF STERNOCLAVICLULAR AND ACROMIOCLAVICLULAR JOINTS
DRINAGE OF SEPSIS BIOPSY AND EXCISION OF TUMOURS
OSTEOTOMY FOR MALUNONS POSITION OF THE PATIENT SUPINE POSITION OF SANDBAG BETWEEN THE MEDIAL BORDER OF THE SCAPULLA AND SPINE
LANDMARKS STERNAL NOTCH
INCISION LONGITUDINAL INCISION
OVERLYING THE SBCUTANEOUS SURFACE OF
THE CLAVICLE
INTERNERVOUS PLANE NO INTERNERVOUS PLANE
SUPERFICIAL SURGICAL DISSECTIONDEEPEN THE INCISION THROUGH THE
PLATISMA MUSCLE TO EXPOSE THE SUBCUTANEOUS SURFACE OF THE CLAVICLE
DEEP SURGICAL RESECTION SOFT TISSUE STRIP OFF THE SUBCUTANEOUS
SURFACE OF THE CLAVICLE IN AN EPIPERIOSTEAL PLANE
STRUCTURES AT RISKBRACHIAL PLEXUSSUBACROMIAL VESSELSSUBCUTANEOUS ARTERIES
ANTEROLATERAL APPROACH
INDICATION :- Anterior decompression of shoulder
Repair of the rotatory cuff Repair or stabilization of the long head of biceps tendon Excision of osteophytes from acromioclavicular joint
POSITION OF PATIENT:- supine position with a sand bag
under the spine and medial border of the scapula Elevate the head at 45 degree.
LANDMARKS :- Corocoid process :- 1 inch in
from the anterior end of the clavicle just inferior to the clavicular concavity.
Acromion :- palpate the acromion at the shoulder
summit
INCISION :- Transerve incision :- begins at anterolateral part of acromion ends at just lateral to corocoid process
No
internervous plane is
availabe for this
approach
SUPERFICIAL EXPOSUREIncise the deep fascia in the line of skin incision to reveal the deltoid muscle
Detach the deltoid from the ac joint and 1cm of the anterior aspect of acromion
DEEP EXPOSURESDetach the corocoacromial ligament fromthe acromion either by sharp dissection or by removing it with block of bone from undersurface of theacromion
STRUCTURES AT RISKAxillary nerveAcromial branch of corocoacromial artery
HOW TO AVOID INJURIESapplying stay sutures at the apex of the deltoid spilt.
DISADVANTAGES :- No internervous plane for this approach No useful extensions either proximal or distal are possible .
SHOUDLER APPROACHES
Anterior Approach Lateral Approach Posterior Approach
ANTERIOR APPROACHINDICATION :-Reconstruction of recurrent
dislocations Drainage of sepsis Biopsy and excision of tumors Repair or stabilization of long head
of biceps Fixation of fractures of the proximal humerus
POSITION OF PATIENT :-
supine position , sand bag under spine and medial border of the scapula
LANDMARKS :- Coracoid Process, Clavicle & Deltopectoral groove
ANTERIOR INSICION :-10-15cm straight incision
along the D/p groove.
AXILLARY INSICION :- Supine and abduct the shoulder to 90 degree. Vertical insicion 8-10cm long starting at mid point of ant axillary fold extending posteriorly in to axilla.
True Internervous plane Deltoid (axillary) and Pec Major (pectoral nerve)
ANTERIOR SUPERFICIAL DISSECTION
Develop the groove b/w the fascia overlying pectoralis
Major and deltoid
ANTERIOR DEEP DISSECTION
Subscapularis muscle lies in the deep part part of the Wound and incised perpendicular to its fibres and Close to its tendon .External rotation to avoid damage to axillat nerve
DANGER ZONESMusculocutaneous Nerve Axillary Nerve
coracoid processCephalic Vien
ANTERIOR EXTENSILE MEASURESProximally – Excise middle third of clavicle to expose
brachial plexusDistally – Part of anterolateral approach to humerus.
ADVANTAGES :- The approach is through an internervous plane b/w deltoid
and pectoralis major Incision can be
expanded proximally or distally
DISADVANTAGES :- The approach is clearly the best
and it has no significant disadvantages
POSTERIOR APPROACH OF SHOULDER JOINT
INDICATIONS :- Repairs in cases of recurrent posterior dislocation or subluxation of the shoulder
Glenoid osteotomy
Biopsy and excision of tumors
Removal of loose bodies in the posterior recess of the shoulder
Drainage of sepsis
fractures of the scapula neck,
particularly those in association
with fractured clavicles
posterior fracture dislocations of
the proximal humerus
POSITION OF THE PATIENT :-
LANDMARKS :- Acromion and spine of scapula
INCISION :-Linear over the entire length of scpular
line extending to post corner of acromion
INTERNERVOUS PLANE :-
SUPERFICIAL DISSECTION Identify the origin of the deltoid muscle, the spine ofthe scapula, and the attachment from its origindetaching the muscle from the lateral to themedial point
DEEP SURGICAL DISSECTIONS
STRUCTURES AT RISK
Axillar nerve Suprascapular nerve Post circumflex humeral artery
HUMERUS
LATERAL APPROACH OF PROXIMAL HUMERUS
INDICATIONS :- Open reduction and internal fixation of the displaced fractures of the greater tuberosity of the humerus.
Open and internal fixation of humeral neck fractures.
Removal of calcific deposits from the subacromial bursa
Repair of supraspinatus tendon .
Repair of rotator cuff.
POSITION OF PATIENT :- supine position with effected arm on edge of table
LANDMARKS :- Acromion
INCISION :- 5cm longitudinal incision from tip of acromion to lateral aspect of
arm
INTERNERVOUS PLANE :- No internervous plane
SUPERFICIAL SURGICAL EXPOSURESplit the deltoid muscle in the line of fibres from the
acromion downwards for 5cm and apply a stay sutures at inferior apex.
DEEP SURGICAL EXPOSURES
STRUCTURES AT RISK AXILLARY NERVE
EXTENSILE MEASURES :- Proximal Extension -incision
superiorly and medially across the acromion
ANTEROLATERAL APPROACH OF DISTAL HUMERUS
INDICATIONS :- Internal fixation and fracture of humerus Osteotomy of humerus Biopsy and resection of bone
tumors Treatment of osteromelitis
POSITION OF PATIENT :- Supine position on the operating table with the
arm on arm board abducted about 60 degree
LANDMARK :- Palpate the corocoid process immediately below the junction of middle 3rd and outer 3rd of clavicle .
INSICION :- Longidutinal incisin over the tip of the corocoid process of scapula
INTERNERVOUS PLANE :-
SUPERFICIAL SURGICAL EXPOSURESProximal Humeral Shaft
Identify the deltopectoral groove, using the
cephalic vein as a guide and separate the
two muscles, retracting the cephalic vein
either medially with the pectoralis major or
laterally with the deltoid
Distal Humeral Shaft
Incise the deep fascia of the arm in line with
the skin incision. Identify the muscular interval
between the biceps brachii and the brachialis
DEEP SURGICAL EXPOSURESProximal Humeral Shaft To expose the upper part of the shaft of the humerus, incise the periosteum longitudinally just lateral to the insertion of the tendon of the pectoralis major. Continue the incision proximally, staying lateral to the tendon of the long head of biceps To expose the bone fully, you may need to detach
part or all of the insertion of the pectoralis major muscle from the lateral lip of the bicipital groove of the humerus
STRUCTURES AT RISKRADIAL NERVE
AXILLARY NERVE
ANTERIOR HUMERAL CIRCUMFLEX MUSCLES
Extensile MeasuresProximal Extension :- Because the anterior
approach uses the deltopectoral interval, its upper end can be modified easily into an anterior approach to the shoulder
Distal Extension The anterior approach cannot be extended
distally.
SUPERFICIAL SURGICAL EXPOSERS
Proximal window :- Identify the deltopectoral groove using cephalic vein as a guide separate the two muscles.Distal window :-Incise the deep fascia of arm in the line of the skin incision and identify of the muscular interval b/w the biceps branchii and brachialis. Develop this interval by retracting the biceps medially and identify the brachialis muscle covering the anterior humeral shaft.
DEEP SURGICAL EXPOSURESProximal window - Develop the plane b/w the deltoid and pectorlis major
down to the bone Distal window - split the fibres of the brachialis longitudianlly develop a epiperiosteal plane b/w the
deep surface of the brachialis and periostieum covering the ant surface of the humerus
STRUCTURES AT RISKRadial nerve
Musculocutaneous nerve
ANTEROLATERAL APPROACH OF DISTAL HUMERUS
INDICATIONS :- Open reduction and internal fixation of fractures
Exploration of the radial nerve in the distal part of arm POSITION OF PATIENT Place the patient supine on the operating table, with the arm lying on an arm board and abducted about 60°
LANDMARKS :- Biceps brachii muscle and flexor
crease of elbow.
INCISION :- Long curved longitudinal incision
over the lateral border of biceps
about 10 cms above the flexion crease of elbow.
INTERNERVOUS PLANE:- No true internervousplane
SUPERFICIAL SURGICAL DISSECTION
Incise deep fascia of arm in line with the skin incision
then identify lateral border of biceps.Retract the biceps medially to reveal bracialis andbrachioradialis.
DEEP SURGICAL DISSECTIONIncise lateral border of brachialis muscle
longitudinally cutting down till bone and incise periosteum of
antero-lateral aspect of humerus and retract the brachillismedially
STRUCTURES AT RISK
Radial nerve
EXTENSILE MEASURES :- Proximal incision can be
extended by developing a plane between the
brachialis medially and lateral
head of the triceps posterio laterally
POSTERIOR APPRAOCH TO THE DISTAL HUMERUS
INDICATIONS Open reduction internal fixation of the fracture of humerus
Treatment of osteomyelitis
Biopsy and excision of the tumours
Treatment of nonunion of the fractures
Exploration of the radial nerve in the spiral groove
Insertion of retrograde humeral veins
POSITION OF PATIENT
LANDMARKS :- acromion and olecranon fossa
INSICION :- longitudinal incision in the midline of the
posterior aspect of the arm, from 8 cm
below the acromion to the olecranon
fossa
INTERNERVOUS PLANE :- No true internervous plane
SUPERFICIAL SURGICAL EXPOSERS:-To identify the gap between the lateral and long heads, begin proximally, above the point at which the two head fuse to form a common tendon Proximally, develop this interval between the heads by blunt dissection, retracting the lateral head laterally and the long head medially
DEEP SURGICAL EXPOSURES:- Incise the medial head in the midline, continuing the dissection down to the periosteum of the humerus. Then, strip the muscle off the bone by subperiosteal dissection. The plane of operation must remain in a subperiosteal location to avoid damaging the ulnar nerve
STRUCTURES AT RISK :- Radial nerve Ulnar nerve Profunda brachii artery
EXTENSILE MEASURES :- Proximal bone not exposed
Distally skin incision can be
exteded over the olecranon
Access the elbow joint by
olecrenon osteotomy
ELBOW Posterior approach Anterolateral approach Medial approach Anterior approach of medial cubital fossa Posterolateral approach of radial head
POSTERIOR APPROACH
INDICATION :- open reduction internal fixation
of fracture of distal humerus
Removal of loose bodies with
in the elbow joint
Treatment of non union of distal humerus
POSITION OF PATIENT :- prone position with arm
abducted about 90degree
LANDMARKS :- Olecranon process at upper end of ulna
INCISION :- Longidutinal incision over posterior aspect of elbow begins 5cm above the olecranon over midline of
posteior aspect of arm just above th tip of olecranon curved incision
INTERNERVOUS PLANE:- No true internervous plane
Superficial surgical dissection :-Incisie
the deep fascia in the mid
line and dissect the ulnar\
nerve from its bed and
hold it free with the tape
DEEP SURGICAL DISSECTION :- Dissect around the
medial and lateral
border of the bone
to expose all the
distal fourth of
humerus
STRUCTURES AT RISK :- Ulnar nerve Medial nerve Radial nerve Brachial artery
EXTENSILE MEASURES :- Proximal externsion – cannot
possible than the distal third
of humerus Distal externsion - can
be exteded from the subcutaneous border of
ulna
MEDIAL APPROACHINDICATION :- Removal of loose bones Open reduction and
internal fixation of fractures of the corocoid process of the
ulna Open reduction and internal fixation of fractures of the medial humeral condyle
and epicondyle.
POSITION OF PATIENT:- Supine and arm supported
on arm board abduct the
arm rotate the shoulder
fully externally .Flex the
elbow 90 degree.
LANDMARKS :- Medial epicondyle of humerus
INSICION :- Curved incision 8-10cm on the medial surface of elbow
centering the incision on medial condyle.
INTERNERVOUS PLANE :-
SUPERFICIAL SURGICAL DISSECTION
Retract the skin anteriorly with the fascia to uncover the common origion of superficial flexor muscles of medial epicondyle.Define inteval b/w pronator teres and brachialis
muscle
DEEP SURGICAL DISSECTION Medial side of the joint exposed incise the capsule and medial collateral ligament .
STRUCTURES AT RISK Ulnar nerve Median nerve and its main branch ant.interosseous nerve
EXTENSILE MEASURES Proximally externsion – extended proximally by developing plane b/w tricpes and brachialis muscle Distal extension -- exposure provides adequate view of the brachialis inserting into coronoid it cannot offer a more distal exposure.
ANTEROLATERAL APPROACHINDICATIONS :- Open reduction and internal fixation of fractures of the capitulum
Excision of tumors of the proximal radius
Treatment of aseptic necrosis of the capitulum
Drainage of infection from the elbow joint
Treatment of neural compression lesions of the proximal half of the posterior interosseous nerve and of the proximal part of the superficial radial nerve—access to the arcade Frohse, as well as treatment of radial head fractures with
paralysis of this nerve
POSITION OF PATIENT :- Supine with arm on arm
board
LANDMARKS :- Brachioradialis Biceps tendon
INCISION :- curved incision around the anterior aspect of the elbow. upper portion of the incision follows the lateral border of
the biceps muscle. The lower
portion follows the medial border of the brachioradialis muscle
INTERNERVOUS PLANE :- Proximally b/w the brachialis and brachoradialis distally
b/w the brachioradialis
and pronator teres
SUPERFICIAL SURGICAL DISSECTION :- Incise
the deep fascia along the medial
border of the brachioradialis. Be careful to identify the lateral antebrachial cutaneous nerve
and retract
DEEP SURGICAL DISSECTION :- Make a longitudinal incision in the
anterior capsule of the joint between
the radial nerve and the
brachialis muscle to expose the radial
head and capitulum. To expose the radius further, remove the supinator muscle distally in a subperiosteal manner
STRUCTURES AT RISK :- Radial nerve Posterior interosseous
nerve Lateral cutaneous nerve
of fore arm Reccurent branch of
radial arteryEXTENSILE MEASURES :- This approach can
be extended proximally and distally
ANTERIOR APPROACH OF CUBITAL FOSSAINDICATIONS :- Repair of lacerations to the median nerve
Repair of lacerations to the brachial artery Repair of lacerations to the radial nerve
Reinsertion of the biceps tendon
Repair of lacerations to the biceps tendon
Release of posttraumatic anterior capsular contractions
POSITION OF PATIENT :- Supine position with arm
in anatomical position
LANDMARKS :- Brachoradialis and tendon of biceps
INSICIONS :- The brachioradialis is a fleshy muscle
that forms the lateral border of the
supinated forearm. The tendon of the biceps is a
taut, easily palpable,band-like
structure that runs downward across the anterior aspect of the cubital
fossa
INTERNERVOUS PLANE :- proximally b/w the brachioradialis muscle
and brachialis muscle distally
b/w the brachoradlialis and pronator teres .
SUPERFICIAL SURGICAL DISSECTIONS :- Incise
the deep fascia in line with the skin incision and ligate the numerous veins that cross the elbow in this area. Locate the lateral cutaneous nerve of the forearm in the interval between the biceps tendon and the brachialis, and preserve
DEEP SURGICAL DISSECTIONS:- not required .
STRUCTURES AT RISK Lateral cutaneous nerve
radial artey posterior
interosseous
nerve
POSTERIOR APPROACH OF RADIAL HEAD
POSITION OF PATIENT - Supine on operating table with
affected arm positioned over
chest ,pronate the arm
LANDMARK :- Lateral humeral epicondyle
INCISION :- beginning over the posterior surface
of the lateral humeral epicondyle and continuing downward and medially to a point over the
posterior border of the ulna, about 6 cm
distal to the tip of the olecranon.
INTERNERVOUS PLANE :-
SUPERFICIAL SURGICAL APPROACHES Incise the deep
fascia in line with the skin incision. To find the interval between
the extensor carpi
ulnaris and the anconeus. Detach part of the superior origin of
the anconeus as it
arises from the lateral epicondyle of the
humerus
DEEP SURGICAL EXPOSURES Fully pronate the forearm to move the posterior interosseous nerve away from the operative field . Incise the capsule of the elbow joint longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament.
STRUCTURES AT RISK :- Posterior interosseous nerve
Radial nerve
EXTENSILE MEASURES :- Proximally extended for
exposure of distal humerus .
Distally not possible
THANK YOU