Anterior Approach to the Cubital Fossa

The anterior approach may be the least commonly used surgical approach to the elbow and provides access to the neurovascular structures that are found in the cubital fossa. Its uses include the following:

1. Repair of lacerations to the median nerve

2. Repair of lacerations to the brachial artery

3. Repair of lacerations to the radial nerve

4. Reinsertion of the biceps tendon into the bicipital tuberosity of the radius

5. Repair of lacerations to the biceps tendon

6. Release of posttraumatic anterior capsular contractions

7. Excision of tumor

Position of the Patient

Place the patient supine on the operating table with the arm in the anatomic position. 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 (see Fig. 3-23).

Landmarks and Incision

Landmarks

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.

Incision

Make a curved, “boat-race” incision∗ over the anterior aspect of the elbow. Begin 5 cm above the flexion crease on the medial side of the biceps. Curve the incision across the front of the elbow, then complete it by incising the skin along the medial border of the brachioradialis muscle. Curving the incision avoids crossing the flexion crease at 90 degrees (Figs. 3-31 and 3-32).

Internervous Plane

Distally, the internervous 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. 3-33).

Proximally, the plane lies between the brachialis muscle (which is supplied by the radial and musculocutaneous nerves) and the pronator teres (which is supplied by the median nerve).

Figure 3-31 Superficial view of the elbow and forearm, showing superficial veins and nerves.

Figure 3-32 Incision for the anterior approach to the cubital fossa.

Superficial Surgical Dissection

Mobilize the skin flaps widely. Incise the deep fascia in line with the skin incision and ligate the numerous veins that cross the elbow in this area.

The lateral cutaneous nerve of the forearm (the sensory branch of the musculocutaneous nerve) must be preserved. To find it, locate the interval between the biceps tendon and the brachialis muscle. The nerve emerges there to run down the lateral side of the forearm subcutaneously (Fig. 3-34).

Figure 3-33 Internervous plane. Distally, the plane is between the brachioradialis (radial nerve) and the pronator teres (median nerve); proximally, it is between the brachialis (musculocutaneous nerve) and pronator teres.

Figure 3-34 Superficial surgical dissection. Locate the lateral cutaneous nerve of the forearm, in the interval between the biceps tendon and the brachialis and preserve it.

Next, identify the bicipital aponeurosis (lacertus fibrosus), which is a band of fibrous tissue coming from the biceps tendon and swinging medially across the forearm, running superficial to the proximal part of the superficial flexor muscles (see Fig. 3-34). Cut the aponeurosis close to its origin at the biceps tendon and reflect it laterally. Be careful not to injure the brachial artery, which runs immediately under the aponeurosis (Fig. 3-35).

Identify the radial artery as it passes the biceps tendon and trace it proximally to its origin from the brachial artery. Note that both the brachial vein and the median nerve lie medial to the artery. To identify the radial nerve, look between the brachialis and the brachioradialis; the nerve crosses in front of the elbow joint.

Figure 3-35 After cutting the bicipital aponeurosis (lacertus fibrosus), identify the brachial artery. Note that the median nerve lies medial to the artery. The brachial vein, which accompanies the artery, consists of a series of small, fine vessels, the venae comitantes.

Identifying these structures and understanding their relationship are the keys to operating successfully in the cubital fossa (see Fig. 3-35).

Deep Surgical Dissection

If the anterior approach is to be used only for exploration of the neurovascular structures, deep dissection is not required. If you require access to the anterior capsule of the elbow joint, retract the biceps and brachialis muscle medially and the brachioradialis muscle laterally. Fully supinate the forearm and identify the origin of the supinator muscle from the anterior aspect of the radius. Incise the origin of this muscle and dissect it off the bone in a subperiosteal plane, carefully reflecting it laterally. Take care not to insert a retractor on the lateral aspect of the proximal radius as this may compress the posterior interosseous nerve. The anterior capsule of the elbow joint is now exposed and may be incised to expose the anterior aspect of the elbow joint (see Fig. 3-37).

Dang

Because this approach exposes the neurovascular structures of the fossa so quickly, they may be damaged if care is not taken.

points are crucial, as follows:

1. The lateral cutaneous nerve of the forearm (the sensory branch of the musculocutaneous nerve; see Fig. 3-34) is vulnerable to injury in the distal fourth of the arm during incision of the deep fascia. Pick it up in the interval between the biceps and brachialis muscles in the arm, trace it downward, and preserve it (see Fig. 3-34).

2. The radial artery lies immediately deep to the bicipital aponeurosis; the aponeurosis must be incised carefully to avoid damage to the artery (see Fig. 3-35).

3. The posterior interosseous nerve is vulnerable to injury as it winds round 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 (see Fig. 3-29).

How to Enlarge the Approach

Extensile Measures

The approach may be extended for more extensive exposure of the neurovascular structures.

Median Nerve

Proximal Extension. Extend the incision superiorly along the medial border of the biceps, and incise the deep fascia in line with the incision. The brachial artery lies immediately under the fascia, between the biceps muscle and the underlying brachialis muscle. The median nerve runs with the artery.

Figure 3-36 Trace the median nerve distally into the pronator teres. Incise a portion of the muscle superficial to the nerve, if necessary, to expose the nerve. The incision lies between the humeral and ulnar heads of the pronator teres.

Figure 3-37 Retract the biceps tendon and carefully detach and retract the proximal supinator muscle to gain access to the anterior joint capsule, which may be incised to expose the elbow joint.

Distal Extension. Trace the median nerve as it disappears into the pronator teres muscle. Simple retraction of the muscle may provide adequate exposure. Take care not to cut any branches of the median nerve going to the flexor-pronator group of muscles that pass from the medial side of the median nerve at the level of the elbow joint. This incision lies between the humeral and ulnar heads of the pronator teres and allows the plane between the two heads to be developed for the distal exposure of the nerve (Fig. 3-36).

Brachial Artery. The brachial artery runs with the median nerve and is exposed in the same way.

Radial Artery. To expose the radial artery, trace it distally as it crosses the surface of the pronator teres, running toward the lateral side of the forearm. Developing the plane proximally between the pronator teres and brachioradialis muscles, and distally between the flexor carpi radialis and brachioradialis muscles allows the artery to be followed to the wrist.