Anterolateral Approach to the Elbow
Anterolateral Approach to the Elbow
The anterolateral approach exposes the lateral half of the elbow joint, especially the capitulum and the proximal third of the anterior aspect of the
radius. Its uses include the following:
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Open reduction and internal fixation of fractures of the capitulum
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Excision of tumors of the proximal radius
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Treatment of aseptic necrosis of the capitulum
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Drainage of infection from the elbow joint
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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 of Frohse, as well as treatment of radial head fractures with paralysis of this nerve
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Treatment of biceps avulsion from the radial tuberosity
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Total elbow replacements
This approach is a distal extension of the anterolateral approach to the humerus and a proximal extension of the anterior approach to the radius. Theoretically, the approach can link the two together to expose the entire upper extremity from shoulder to wrist.
Position of the Patient
Place the patient supine on the operating table, with the arm on an arm board. Exsanguinate the limb either by elevating it for 3 to 5 minutes or by applying a soft rubber bandage or exsanguinator. Then, inflate a tourniquet (Fig. 3-23).
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Figure 3-23 Position of the patient on the operating table.
Landmarks and Incision
Landmarks
The brachioradialis is palpable as part of a thick wad of muscle on the anterolateral aspect of the forearm. This “mobile wad” consists of muscles; the brachioradialis forms the medial border of the wad.
The biceps tendon is a taut band that is palpable on the anterior aspect of the elbow.
Incision
Make a curved incision along the anterior aspect of the elbow joint. Begin 5 cm above the flexion crease of the elbow, over the lateral border of the biceps muscle. Follow the lateral border of the biceps distally, but curve the incision laterally at the level of the elbow joint to avoid crossing a flexion crease at 90 degrees. Then, continue the incision inferiorly, curving medially and following the medial border of the brachioradialis muscle. The lower limit of the extension depends on the amount of the radius that must be exposed (Fig. 3-24).
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Figure 3-24 Incision for the anterolateral approach to the elbow. The upper portion of the incision follows the lateral border of the biceps muscle. The lower portion follows the medial border of the brachioradialis muscle.
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Figure 3-25 Internervous plane. Proximally, the plane is between the brachialis (musculocutaneous nerve) and the brachioradialis (radial nerve); distally, it is between the brachioradialis and the pronator teres (median nerve).
Internervous Plane
Proximally, the plane lies between the brachialis muscle (which is supplied by the musculocutaneous nerve) and the brachioradialis muscle (which is supplied by the radial nerve).
Distally, the plane lies between the brachioradialis muscle (which is supplied by the radial nerve) and the pronator teres muscle (which is supplied by the median nerve) (Fig. 3-25).
Superficial Surgical Dissection
Identify the lateral cutaneous nerve of the forearm (the sensory branch of the musculocutaneous nerve) as it becomes superficial to the deep fascia in the distal 5 cm of the arm lateral to the biceps tendon in the interval between it and the brachialis muscle. Retract it with the lateral skin flap
(Fig. 3-26). It is more superficial than the superficial radial nerve, lying outside the fascial compartment of the brachioradialis; the superficial radial nerve still lies within the compartment at this level.
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Figure 3-26 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 it.
Incise the deep fascia along the medial border of the brachioradialis (see Fig. 3-26). Identify the radial nerve proximally at the level of the elbow joint between the brachialis and the brachioradialis. It lies deep between the two muscles and cannot be seen fully until they are separated. The intermuscular plane is oblique with the brachioradialis overlying the brachialis muscle. Develop the plane between the two muscles using your finger, retracting the brachioradialis laterally and the brachialis and the overlying biceps brachii medially (Fig. 3-27).
Follow the radial nerve distally along the intermuscular interval until it divides into its terminal branches: The posterior interosseous nerve enters the supinator muscle, the sensory branch passes down the forearm
behind the brachioradialis, and the motor branch to the extensor carpi radialis brevis enters that muscle almost immediately. Below the division of the nerve, develop a plane between the brachioradialis on the lateral side and the pronator teres on the medial side. Ligate the recurrent branches of the radial artery and the muscular branches that enter the brachialis just below the elbow so that the muscle can be retracted adequately. Ligation also allows the radial artery, which runs down the proximal third of the forearm on the pronator teres, to be retracted medially (Fig. 3-28).
Deep Surgical Dissection
To expose the capitulum and the lateral compartment of the elbow, make a longitudinal incision in the anterior capsule of the joint between the radial nerve laterally and the brachialis medially (Fig. 3-29).
To expose the proximal radius, fully supinate the forearm; note that the origin of the supinator muscle moves anteriorly. Incise the origin of the supinator down the bone, staying just lateral to the insertion of the biceps tendon. Complete the exposure of the proximal radius by circumferential subperiosteal dissection (see Fig. 3-29, inset, and Anterior Approach to the Radius in Chapter 4).
Dang
Nerves
The radial nerve must be identified in the interval between the brachioradialis and brachialis muscles before this interval is developed fully. Note that the nerve lies anteromedial to the brachioradialis, within the fascial compartment of that muscle. If it is being sought at the level of the distal humerus or elbow, the intermuscular interval is the best place to find it.
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Figure 3-27 Identify the interval between the brachioradialis and brachialis muscles. Retract the brachioradialis laterally and the brachialis medially, and identify the radial nerve.
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Figure 3-28 The radial nerve divides into its terminal branches: the posterior interosseous nerve, the sensory branch (which appears under the brachioradialis), and a motor branch to the extensor carpi radialis brevis. Develop a plane between the brachioradialis and the pronator teres.
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Figure 3-29 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 (inset).
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Figure 3-30 Place the forearm in supination to move the posterior interosseous nerve lateral to the incision into the radiohumeral joint and away from the incision into the origin of the supinator muscle, protecting it.
The posterior interosseous nerve is vulnerable to injury as it winds around the neck of the radius within the substance of the supinator muscle. To prevent damage to the nerve, ensure that the supinator is detached from its origin on the radius with the forearm in supination. Do not cut through the muscle body to expose the bone (see Anterior Approach to the Radius in Chapter 4; Fig. 3-30; see Fig. 3-42).
The lateral cutaneous nerve of the forearm must be identified and its continuity preserved in the interval between the brachialis and biceps brachii muscles; retract it with the medial skin flap (see Fig. 3-26).
Vessels
Recurrent branches of the radial artery must be ligated so that the brachioradialis can be mobilized fully. Because there are many branches this procedure may be time consuming but ligation also reduces postoperative bleeding and avoids the risk of an ischemic contracture developing postoperatively as a result of the pressure caused by a postoperative bleed (see Fig. 3-28).
How to Enlarge the Approach
Extensile Measures
Proximal Extension. The anterolateral approach can be extended easily into an anterolateral approach to the distal humerus by developing the plane between the brachialis and the triceps muscles. Remember that the radial nerve crosses the lateral border of the humerus about one handbreadth above the lateral epicondyle. (For details, see Anterolateral Approach to the Distal Humerus.)
Distal Extension. The anterolateral approach can be extended easily to expose the entire anterior surface of the radius by developing the plane proximally between the brachioradialis muscle (which is supplied by the radial nerve) and the pronator teres muscle (which is supplied by the median nerve), and distally between the brachioradialis muscle (which is supplied by the radial nerve) and the flexor carpi radialis muscle (which is supplied by the median nerve).