Anatomic Approaches

Contents

PEARL

The most common questions clerks will encounter in the operating room concern relevant neurovascular structures involved in the surgical approach. Review the internervous plane of the operation before each case

Shoulder

Approach/Eponym	Interval – Muscle (nerve)
*Deltopectoral – Henry	Deltoid (axillary) & Pectoralis major (medial/lateral pectoral)
Lateral	Deltoid splitting no internervous plane (~5cm limit)
Posterior	Infraspinatus (suprascapular) & Teres minor (axillary)

Proximal Humerus

Approach/Eponym	Interval – Muscle (nerve)
Anterior	Deltoid (axillary) & Pectoralis major (medial/lateral pectoral) Medial brachialis (musculocutaneous) & lateral brachialis (radial)
Anterolateral	No true internervous interval; Brachialis (radial) & Brachioradialis (radial)
Posterior	No true internervous interval; long and lateral head of Triceps superficial, medial head splitting deep (radial)
Lateral	No true internervous interval; Triceps (radial) & Brachioradialis (radial)

Elbow

Approach/Eponym	Interval – Muscle (nerve)
*Posterior	No internervous plane
Medial	Proximal – Brachialis (musculocutaneous) & Triceps (radial) Distal – Brachialis (musculocutaneous) & Pronator Teres (median)
Anterolateral	Proximal – Brachialis (musculocutaneous) & Brachioradialis (radial) Distal – Pronator Teres (median) & Brachioradialis (radial)
Anterior	Proximal – Brachialis (musculocutaneous) & Brachioradialis (radial) Distal – Pronator Teres (median) & Brachioradialis (radial)
Posterolateral – Kocher	Anconeus (radial) & Extensor carpi ulnaris (posterior interosseous)

Forearm

Approach/Eponym	Interval – Muscle (nerve)
Anterior – Henry	Proximal – Pronator Teres (median) & Brachioradialis (radial) Distal – Brachioradialis (radial) & Flexor carpi radialis (median)
Dorsal – Thompson	Proximal – Extensor carpi radialis brevis (radial) & Extensor digitorum communis (posterior interosseous) Distal – Extensor carpi radialis brevis (radial) & Extensor pollicus longus (posterior interosseous)
Ulnar	Extensor carpi ulnaris (posterior interosseous) & Flexor carpi ulnaris (ulnar)

Wrist

Approach/Eponym	Interval – Muscle (nerve)
Dorsal	No internervous plane; between 3rd & 4th compartments
*Scaphoid – volar	No internervous plane; Flexor carpi radialis (median) & radial artery
Scaphoid – dorsolateral	No internervous plane; between Extensor pollicis longus & Extensor pollicis brevis (posterior interosseous)

Pelvis

Approach/Eponym	Interval – Muscle (nerve)
Ilioinguinal	No true internervous plane (along pelvic crest)
Extended iliofemoral	Superficial – Sartorius (femoral) & Tensor fascia latae (superior gluteal) Deep – Rectus femoris (femoral) & Gluteus medius (superior gluteal)

Hip

Approach/Eponym	Interval – Muscle (nerve)
Anterior – Smith-Peterson	Superficial – Sartorius (femoral) & Tensor fascia latae (superior gluteal) Deep – Rectus femoris (femoral) & Gluteus medius (superior gluteal)
Anterolateral – Watson-Jones	No true anterolateral; Tensor fascia latae (superior gluteal) & Gluteus medius (superior gluteal)
*Lateral – Hardinge	No true internervous plane Deep -splits Gluteus medius proximally (superior gluteal) -splits Vastus lateralis distally (femoral)
*Posterior – Southern/Moore	No true internervous plane Splits Gluteus maximus (inferior gluteal)
Medial – Ludloff	Superficial – No true internervous plane; Adductor longus & Gracilis (anterior division obturator) Deep – Adductor brevis (anterior division obturator) & Adductor magnus (sciatic (tibial) & posterior division of obturator)

Femur

Approach/Eponym	Interval – Muscle (nerve)
Lateral	No internervous plane; splits Vastus lateralis (femoral)
Anterolateral	No internervous plane Vastus lateralis (femoral) & Vastus medialis (femoral)
Posterolateral	Vastus lateralis (femoral) & Hamstrings (sciatic)
Posterior distal femur	Biceps femoris (sciatic) & Vastus lateralis (femoral)

Knee

Approach/Eponym	Interval – Muscle (nerve)
*Medial parapatellar	No internervous plane Vastus medialis (femoral) & Rectus femoris (femoral)
Medial	No internervous plane Vastus medialis (femoral) & Sartorius (femoral)
Lateral	Iliotibial band (superior gluteal) & Biceps femoris (sciatic)
Posterior	Semimembranosus/Medial Gastrocnemius (tibial) & Biceps femoris/Lateral Gastrocnemius (tibial)

Leg

Approach/Eponym	Interval – Muscle (nerve)
Anterior	No internervous plane; Tibialis anterior (peroneal) & tibial periosteum
Anterolateral	Superficial Peroneus brevis (superficial peroneal) & Extensor digitorum longus (deep peroneal)
Posterolateral	Gastrocnemius, Soleus, Flexor hallucis longus (tibial) & Peroneus brevis and longus (superficial peroneal)
Fibula	Peroneal muscles (superficial peroneal) & Flexor muscles (tibial)

Ankle

Approach/Eponym	Interval – Muscle (nerve)
Anterior or Dorsal	No internervous plane; Extensor hallucis longus (deep peroneal) & Extensor digitorum longus (deep peroneal)
*To Medial Malleolus	No internervous plane; direct approach
*To Lateral Malleolus	Peroneus tertius (deep peroneal) & Peroneus brevis (superficial peroneal)
Posteromedial	No internervous plane; Tibialis posterior or Flexor digitorum longus (tibial) & Flexor digitorum longus or Flexor hallucis longus (tibial)
Posterolateral	Peroneus brevis (superficial peroneal) & Flexor hallucis longus (tibial)

Commonly Encountered Anatomical Approach

Attachments:

approach ankle.jpg (image/jpeg)

approach elbow.jpg (image/jpeg)

approach femur.jpg (image/jpeg)

approach forearm.jpg (image/jpeg)

approach hip.jpg (image/jpeg)

approach knee.jpg (image/jpeg)

approach leg.jpg (image/jpeg)

approach leg.jpg (image/jpeg)

approach pelvis.jpg (image/jpeg)

approach proximal humerus.jpg (image/jpeg)

approach shoulder.jpg (image/jpeg)

approach wrist.jpg (image/jpeg)