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Surgical Exposures of the Elbow
Introduction
Few joints require familiarity with as many surgical exposures as does the elbow. Depending on the lesion and the surgical goal, the joint and the surrounding region may be approached from the lateral, posterior, medial, or anterior direction. It is not the purpose of this chapter to discuss all of the approaches to the joint but rather to provide a comprehensive collection and critique of those relevant exposures that should prove helpful to the practicing orthopedic surgeon.
Exposures from the medial and lateral aspects that once allowed the removal of loose bodies and the treatment of certain localized fractures are less necessary with the advent of arthroscopy. Some form of an extensile posterior exposure is used for most complex fractures and joint reconstructive procedures, and this is considered the universal approach to the joint by the authors.
General Principles
Rigorous adherence to the principles of good surgical technique is absolutely essential at the elbow. The most appropriate surgical approach depends on the specific treatment goal and on the nature and extent of the pathology. Hence, the choice of surgical approach should be based on the considerations listed in Box 11.1 .
Box 11.1
Principles of Exposure of the Elbow Region
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Flexible—allows extension
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Adequate—visualization of pathology
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Safety—especially nerves
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Preservation—respect anatomy
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Natural plane—extend along fascial, subcutaneous planes
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Hemostasis—release tourniquet, drain as necessary
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Closure—modified by specific features of case
A thorough understanding of the anatomy of the elbow region and the relationship of the nerves and vessels is of particular importance to best satisfy these requirements ( Fig. 11.1 ).
Lateral Approaches
Recognition of the various intramuscular intervals is important to appreciate the different approaches and their utility, and this is especially true for the lateral exposure of the elbow joint ( Fig. 11.2 ). It is used for radial head excision, removal of loose bodies, and repair of lateral ligaments, to fix condylar and Monteggia fractures, to release the joint capsule, and to remove osteophytes. Access to the radiohumeral articulation has been described by several authors. The techniques differ according to the muscle interval entered and the means of reflecting the muscle mass from the proximal ulna. With any of the lateral exposures to the joint or to the proximal radius, the surgeon must be constantly aware of the possibility of injury to the posterior interosseous or recurrent branch of the radial nerve.
Focused Lateral Exposures
We recognize two such exposures: Kaplan and the “Column.” The latter is able to be expanded into the “family” of lateral exposures.
Kaplan Exposure
Indication
Radial head and neck pathology.
Contraindication
Potential need to expand into a more extensile exposure.
Landmark
Interval between the extensor digitorum communis and the extensor carpi radialis longus and brevis muscles.
Note
Because of the proximity of the posterior interosseous nerve, pronation of the forearm is recommended to carry the radial nerve out of the surgical field.
Position
Supine, arm brought across the chest.
Skin incision
Palpate Kocher's interval and make a 10-cm incision 1 cm anterior to this interval.
Deep exposure
The dissection is carried through the interval between the common extensor and the extensor carpi radialis longus (ECRL) ( Fig. 11.3A ). The supinator muscle is visualized.
Note
The posterior interosseous nerve is precariously close to the interval and has been used to decompress the posterior interosseous nerve (see Fig. 11.3B and see Chapter 72 ).
The joint capsule is entered anterior to the lateral ulnar collateral ligament (LUCL), and the radial head is exposed (see Fig. 11.3C ) and may be split for a distance of 4 cm from the articular margin of the radial head, exposing the neck and allowing plate fixation for selected fractures.
The Limited to Expansile Proximal Lateral Exposure (Column Approach)
Indication
Stiff elbow, anterior capsular excision.
Landmarks
Extensor carpi radialis longus, lateral epicondyle, radial head, anterior capsule.
Note
This may truly be termed a minimally invasive procedure.
Position
Supine, arm across the chest. The incision is over the lateral column, extending distally over the lateral epicondyle to the radial head ( Fig. 11.4A ).
Deep dissection
The extensor carpi radialis longus and distal fibers of the brachial radialis are elevated from the lateral column and epicondyle (see Fig. 11.4B ). The brachialis muscle is separated from the anterior capsule, which can be safely performed, especially if the joint has been entered at the radiocapitellar articulation (see Fig. 11.4C ). The arthrotomy provides accurate spatial orientation across the joint, so damage to neurovascular structures is avoided. The procedure then continues as described in Chapter 54 .
The Kocher Approach and Its Variations
Some variation of the Kocher exposure is the most frequently used approach to the lateral aspect of the joint. This has the advantage of being extensile, affording a full complement of surgical options as the exposure is extended. This approach enters the joint anterior to the lateral ulnar collateral ligament and through the interval of the anconeus and extensor carpi ulnaris, thus providing protection to the deep radial nerve and to the ligament. In addition to providing a limited exposure for radial head excision and loose body removal, the particular value of this technique is that it may be converted to an extensile posterolateral approach to the entire distal humerus.
Limited Distal Lateral Approach: The Kocher “J”
Indication
Radial head exposure and repair/reconstruction of the lateral ulnar collateral ligament.
Landmarks
Lateral epicondyle, radial head, palpate interval between anconeus and extensor carpi ulnaris.
Skin incision
Progresses from the subcutaneous border of the ulna obliquely and proximally across the posterolateral aspect of the elbow in line with Kocher's interval. The interval between the anconeus and extensor carpi ulnaris is identified and entered, and the muscles are reflected anteriorly and posteriorly ( Fig. 11.5A,B ). For excision of the radial head, the extensor carpi ulnaris and a small portion of the supinator muscle are dissected free of the capsule and retracted anteriorly. The annular ligament is then identified and entered. Care should be taken to enter the annular ligament approximately 1 cm anterior and proximal to the crista supinatoris to avoid injury to the lateral ulnar collateral ligament (see Fig. 11.5C ).
Extensile Posterolateral Exposure (Kocher)
This is an extension of the limited exposures described above involving the release of the collateral ligament and capsule. It can be modified to be more or less extensive according to the pathology being treated.
Indications
Reconstructive procedures including lateral ulnar collateral ligament (see Chapter 71 ), open reduction internal fixation, total elbow arthroplasty (resurfacing), and interposition arthroplasty.
Landmarks
Proximal: lateral column; distal: Kocher interval.
Skin incision
As described above, extended proximally and distally as needed.
Deep dissection
The exposure is extended by elevating the anterior and posterior tissues from the lateral column ( Fig. 11.6A ). The extensor mechanism is raised as a sleeve of tissue exposing the anterior joint (see Fig. 11.6B ). Similarly, the posterior aspect of the exposure is developed by elevating the triceps 6 to 7 cm proximal to the lateral epicondyle without fear of violence to the radial nerve. Importantly, the anconeus is completely elevated from the ulna (see Fig. 11.6C ). The lateral collateral ligament is released from the humeral origin as a separate structure or if prior surgery has caused scarring, with the common extensor tendon complex. The anterior capsule is then incised. A varus stress is applied to the elbow, which opens like a book hinging on the medial ulnar collateral ligament and common flexor muscles (see Fig. 11.6D ). The triceps remains attached to the ulna.
Mayo Modified Kocher Extensile Posterolateral Exposure
Essential feature
The lateral 25% to 40% of the triceps is further released from its attachment.
Indications
More extensive release and joint subluxation required for ankylosis release, resurfacing arthroplasty, open reduction with internal fixation (ORIF).
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