1. REM KUMAR RAI

2. ELBOW
 Posterior approach
 Anterolateral approach
 Medial approach
 Anterior approach of medial cubital fossa
 Posterolateral approach of radial head

3. POSTERIOR APPROACH
INDICATION :-
1. ORIF of fracture of distal humerus
2. Removal of intra-articular loose bodies from elbow
joint
3. Treatment of non union of distal humerus
4. TEA
5. Triceps tendon repair

4. POSITION OF PATIENT :- Prone position with
adequate padding. Exsanguination done by elevating for 3-5
min or using exsanguinator. Tourniquet inflated and arm
abducted about 90 degrees
LANDMARK :- Olecranon process

5. INCISION :- Longidutinal incision over posterior
aspect of elbow begins 5cm above
the olecranon in midline of posterior
aspect of arm .At the tip of
olecranon its curved laterally. Distally its
curved again medially towards middle of ulna.

6. INTERNERVOUS PLANE:-None
Superficial surgical dissection :-
The deep fascia is incised in the mid line and ulnar nerve is identified,
dissected out, protected and marked the with a nerve tape . Pre-drilling and
tapping of olecranon is done if osteotomy is planned( eg Chevron for more
stability or simply tranverse
osteotomy)

7. DEEP SURGICAL DISSECTION :- Dissection done around
the medial and lateral
border of the bone
to expose all the
distal fourth of the
humerus .Radial Nerve.

8.  Bryan-Morrey triceps-reflecting approach is performed
by releasing the triceps tendon, forearm fascia, and
periosteum as one unit from medial to lateral off the
olecranon. At the end of the procedure, the triceps tendon
is repaired back to the olecranon by means of two
transosseous drill holes placed in
 a cruciate configuration. One additional drill hole is placed
between the two holes in a transverse orientation using
nonabsorbable suture. The triceps repair should be
protected for 6 weeks postoperatively, during which
time the patient must avoid active elbow extension against
resistance. Demerit:postoperative triceps insufficiency.

9. STRUCTURES AT RISK :-
Ulnar nerve : Identify and protect.
Median nerve : Always safe to remain in subperiosteal plane
Radial nerve: dissection not to be carried too proximal at lateral
intermuscular septum
Brachial artery: Anteriorly located
Extension:-
Proximally– Not possible proximally than the distal third of
humerus
Distally - can be extended along the subcutaneous border of ulna

10. MEDIAL APPROACH
INDICATIONS :-
1.Removal of loose bodies
2.ORIF of fractures of the corocoid process of the ulna
3.ORIF of fractures of the medial humeral condyle &
epicondyle
4.Medial capsular release of stiff elbows (Hotchkiss)
5.Reconstruction of medial collateral ligament injuries
Contraindications:
1. Exploration of elbow as poor access to
the lateral side

11. POSITION OF PATIENT:- Supine and arm supported
on arm-board/table. the
arm abducted & the
shoulder fully externally .
rotated. The
elbow flexed to90 degree.
Exsanguination.
LANDMARKS :- Medial epicondyle of humerus

12. INSICION :- Curved incision 8-10cm on the
medial surface of elbow is made centering
on medial epicondyle.

13. INTERNERVOUS PLANE :-
Proximally:
Brachialis &
Triceps
Distally:
Brachialis & Pronator
Teres

14. SUPERFICIAL SURGICAL DISSECTION
ulnar nerve is isolated. skin retracted anteriorly with the fascia
to uncover the common origin of superficial flexor muscles
of medial epicondyle. inteval between pronator teres and
brachialis muscle is used.

15. Subperiosteal elevation beneath MCL is done or medial
epicondyle is osteotomized with ligament attached to it.

16. DEEP SURGICAL DISSECTION
Medial side of the joint exposed after
incising medial collateral ligament and capsule

17. STRUCTURES AT RISK
Ulnar nerve.
Median nerve and its main branch AIN with vigorous traction
of medial epicondyle or superficial flexor muscles
EXTENSION
Proximally :
b/w triceps and brachialis muscle subperiosteally
Distally:
exposure provides adequate view of the
brachialis inserting into coronoid. it cannot offer a more
distal exposure but only upto the branching off of the
median nerve.

18. ANTEROLATERAL APPROACH
INDICATIONS :- Open reduction and internal fixation
of the capitulum #
Excision of proximal radius tumors
Treatment of aseptic necrosis of the capitulum
Drainage of septic elbow arthritis
Neural decompression :lesions of the proximal
half of the PIN 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
Biceps tendon avulsion re-attachment to radial
tuberosity
TEA

19.  Kaplan
 The Kaplan approach provides excellent exposure
of the radial head without interruption of the
lateral ulnar collateral ligament LUCL. One pitfall
of the Kaplan approach is locating it too anterior
and causing inadvertent injury to the posterior
interosseous nerve (PIN). Another limitation of this
approach is that distal extension can endanger the
PIN.

20. POSITION OF PATIENT :- Supine with arm on arm-
board
LANDMARKS :- Brachioradialis :palpable thick wad
Biceps tendon: easily palpable taut
structure

21. INCISION :- curved S incision given around the
anterior aspect of the elbow. Begins at 5
cm above flexor crease along lateral border of the
biceps muscle. The lower portion
curves over the medial border of
the brachioradialis muscle

22. INTERNERVOUS PLANE :-
Proximally
brachialis and
brachioradialis
Distally
the brachioradialis and
pro pronator teres

23. SUPERFICIAL SURGICAL DISSECTION :- Deep
fascia is incised along the medial border of the
brachioradialis. The lateral antebrachial cutaneous nerve
(LCNFA) is identified and preserved.

24. Blunt dissection with finger. Radial nerve between BR and
Brachialis. PIN enters supinator. SupercialRadialN is beneath the
Brachioradialis Motor branch to ECRB.

25. DEEP SURGICAL DISSECTION :-
longitudinal incision is made in the anterior
capsule of the joint between the
radial nerve laterally and the brachialis
muscle medially to expose the radial head
and capitulum. To expose the
radius further, forearm is fully supinated
& supinator muscle removed distally in a
subperiosteal manner

27. STRUCTURES AT RISK :-
Radial nerve : in brachioradialis and brachialis interval
Posterior interosseous nerve : Winding around the radial
neck.
Lateral cutaneous nerve of forearm: LCNFA emerging
from brachioradialis and biceps brachii interval
Reccurent branch of radial artery: Ligation decreases
post-op bleed and chance of VIC
EXTENSION:-
Proximally: BR/Triceps
Distally: Along entire anterior surface of the radius between
BR/PT and further distally BR/FCR.

28. ANTERIOR APPROACH OF CUBITAL FOSSA
INDICATIONS :-
Repair of lacerations to the
Median nerve
Brachial artery
Biceps tendon
Radial nerve
Biceps tendon re-insertion
Posttraumatic anterior capsular contractures release
Excision of tumors

29. POSITION OF PATIENT :- Supine position with arm
in anatomical position
LANDMARKS :- Brachoradialis: fleshy wad
tendon of biceps: taut

30. INSICIONS :-
Curved boat-shaped .Begins 5 cm above the flexor
crease on the medial side of the biceps. Crosssing
the crease at 90 degrees must avoided.

31. INTERNERVOUS PLANE :- proximally b/w the
brachioradialis muscle and
brachialis muscle distally b/w
the brachoradlialis and
pronator teres .

32. SUPERFICIAL SURGICAL DISSECTIONS :-
The deep fascia is incised in line with the skin incision and the
numerous veins that cross the elbow in this area are ligated.
Lateral cutaneous nerve of the forearm (LCNFA) in the
interval between the biceps tendon and the brachialis, is
identified and preserved.
Lacertus fibrosus is identified as the brachial artery is immediately
under it.

33. Brachial vein and median nerve lie medial to the
artery.

34. DEEP SURGICAL DISSECTIONS:-
Used to explore the NV structures. If anterior
capsule needs exposure then Biceps and
brachialis retracted medially and BR laterally.

35. STRUCTURES AT RISK
 1. LCNFA a sensory branch of musculocutaneous nerve
at distal ¼ of the arm. Emerges between biceps &
brachialis.
 2. Radial artery
 3.PIN

36. EXTENSION
 1. For Median Nerve
 Proximally: Along medial border of biceps
 Distally: Pronator Teres simple retraction between humeral
and ulnar heads
 2. For Brachilal Artery
 As above

37. EXTENSION
 3. For Radial Artery
 Proximally: Plane between PT & BR
 Distally : Between FCR & BR to the wrist

38. POSTEROLATERAL APPROACH OF
RADIAL HEAD
Indications: Radial head excision or prosthetic
replacement
POSITION OF PATIENT
- Supine on operating table with
affected arm over
chest ,pronate the forearm

39. LANDMARK :- Lateral humeral epicondyle.
Olecranon tip
INCISION :- gentle curve beginning over the posterior
surface of the lateral humeral epicondyle
and continuing downward and
medially over the posterior
border of the ulna, at about 6 cm distal
to the tip of the olecranon.

40. INTERNERVOUS PLANE :-Anconeus & ECU

41. SUPERFICIAL SURGICAL APPROACHES
The deep fascia incised
in line with the skin
incision. To find the
interval between the
extensor carpi ulnaris
and the anconeus.
a part of the
superior origin of the
anconeus as it arises
from the lateral
epicondyle of the humerus is
detached.

42. DEEP SURGICAL EXPOSURES
The forearm is fully pronated so as
to move the posterior
interosseous nerve (PIN)
away from the operative
field . The capsule
of the elbow joint is incised
longitudinally to reveal
the underlying capitulum,
the radial head, and
the annular ligament. No
dissection below annular ligament as PIN within the
supinator.

43. STRUCTURES AT RISK :-
Posterior interosseous nerve (PIN) :
Remain proximal to the annular ligament.
Pronate the Forearm to keep the PIN far from the operative field.
Place the retractors directly on the bone.
Avoid retractors directly opposite to the bicipital tuberosity
Radial nerve :
Don’t extend anteriorly

44. Eponymous Approaches

47.  Kocher approach
 Traditional posterolateral approach
 Bit cosmetic
 Spares lateral ulnar collateral ligamnet LUCL

50. Eponymous Approaches

51. Eponymous Approaches