Medial Approach to the Elbow joint

Medial Approach to the Elbow joint indications:

The medial approach to the elbow joint gives good exposure of the medial compartment of the joint.

  • Medial approach to the elbow joint can be enlarged to expose the anterior surface of the distal fourth of the humerus.
  • The uses of the medial approach to the elbow joint include the following:
    1. Decompression and/or transposition of the ulnar nerve.
    2. Ulnar removal of loose bodies.
    3. Open reduction and internal fixation of the ulnar coronoid process.
    4. Open reduction and internal fixation of the medial humeral condyle and epicondyle.
    5. Debridement and reattachment of common flexor wad for medial epicondylitis.

The medial approach provides poor access to the lateral side of the joint and should not be used for routine exploration of the elbow. The joint may be dislocated during the procedure, however, to gain access to the lateral side of the elbow, if necessary.

Position of the Patient

  • Place the patient supine on the operating table with arm flexed and supported by arm board over the patient.
  • Abduct the arm and rotate the shoulder fully externally so that the medial epicondyle of the humerus faces anteriorly, and Flex the elbow 90 degrees .
  • Alternatively, flex the patient’s shoulder and elbow such that the forearm comes to lie over the front of the face. This allows easier exposure of the medial side of the elbow, but requires an assistant to hold the forearm to provide adequate exposure

Landmarks and Incision

  • Landmarks:
    • Medial epicondyle of the humerus.
  •  Incision:
    • Make a Curved incision 8 to 10 cm long on the medial aspect of the elbow, centering the incision over the medial epicondyle.
The medial approach to the elbow joint

Internervous plane

  • Proximally the Internervous plane lies between:
    • Brachialis muscle: which is innervate by the musculocutaneous nerve.
    • Triceps muscle: which is innervate by the radial nerve.
  • Distally the Internervous plane lies between:
    • Brachialis muscle: which is innervate by the musculocutaneous nerve.
    • Pronator teres muscle: which is innervate by the median nerve.
The medial approach to the elbow joint

Superficial dissection

  • Incise the fascia over the ulnar nerve starting proximally, and isolate nerve along the entire length of the incision.
  • Expose the common flexor origin on the medial epicondyle.
  • Develop the interval between the brachialis and pronator teres muscles.
  • Avoid the median nerve that enters pronator teres near the midline.
  • If necessary, an osteotomy of the medial epicondyle can be performed:
    • Osteotomy is reflected distally.
    • Ensure to retain the medial collateral ligament into osteotomy fragment.
  • Develop the interval between brachialis and triceps muscles.
The medial approach to the elbow joint

Deep dissection

  • Incise the capsule and the medial collateral ligament to expose the joint.

Approach Extension

The medial approach to the elbow joint can be extended Proximally and distally as following:

  • Local:
    • Abduction of the forearm opens the medial aspect of joint.
    • The joint can be dislocated laterally by dissecting off joint capsule and periosteum.
  • Proximal Extension:
    • Anterior surface of distal fourth of humerus can be exposed by developing plane between brachialis and triceps muscles.
    • Sub-periosteal dissection and elevation of the brachialis muscle expose the anterior surface of the distal fourth of the humerus.
  • Distal Extension:
    • The medial epicondyle of the humerus, with its attached flexor muscles, can be retracted only as far as the branches from the median nerve allow.
    • Thus, although the exposure provides an adequate view of the brachialis inserting into the coronoid, it cannot offer a more distal exposure of the ulna.

Dangers

  • The structures at risk during the medial approach to the elbow joint include:
    1. Ulnar nerve:
      • It is at risk during the medial approach to the elbow joint.
      • It must be dissected out to ensure protection.
    2. Median nerve:
      • Aggressive traction on the osteotomy fragment can cause a traction injury to the median and anterior interosseous nerves.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition
  • Campbel’s Operative Orthopaedics book 12th
  • Orthobullets Website

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