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

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