Anterior approach to the cubital fossa

Introduction

Indications

• Repair of lacerations to the median nerve, brachial artery, radial nerve and biceps tendon.
• Reinsertion of the biceps tendon.
• Release of post-traumatic anterior capsular contractions.
• Excision of tumor.

Advantage

• Least commonly used surgical approach to the elbow; provides access to the neurovascular structures.

Position of patient

• The patient is placed supine on the operating table.
• Apply a tourniquet after exsanguinating the limb.

Landmarks and incision

Landmarks

• The brachioradialis: A fleshy muscle that forms the lateral border of the supinated forearm.
• Tendon of the biceps: Band-like structure that runs downward across the anterior aspect of the cubital fossa.

Incision

• Begin 5 cm above the flexion crease on the medial side of the biceps from the anterior cubital fossa.
• Curve the incision across the front of the elbow, then complete it by incising the skin along the medial border of the brachioradialis muscle.

Internervous Plane

Proximally

• Between the brachioradialis muscle (radial nerve) and the brachialis muscle (musculocutaneous nerve).

Distally

• Between the brachioradialis muscle (radial nerve) and the pronator teres muscle (median nerve).

Superficial dissection

• The deep fascia is incised in line with the skin incision; ligate the numerous veins that cross the elbow in this area.
• Locate the interval between the biceps tendon and the brachialis muscle to identify the lateral cutaneous nerve of the forearm as it emerges there to run down the lateral side of the forearm subcutaneously.
• The bicipital aponeurosis (lacertus fibrosus)is cut close to its origin at the biceps tendon and reflected laterally.
• Trace the radial artery as it passes the biceps tendon proximally to its origin from the brachial artery. Both the brachial vein and the median nerve lie medial to the artery.
• At the interval between the brachialis and the brachioradialis, identify the radial nerve as it crosses in front of the elbow joint.

Deep dissection

• The biceps and brachialis muscle are retracted medially and the brachioradialis muscle laterally.
• Fully supinate the forearm and incise the origin of supinator muscle from the anterior aspect of the radius reflecting it laterally.
• The anterior capsule of the elbow joint is now exposed.

Dangers

Lateral cutaneous nerve of the forearm

• Can be injured in the distal fourth of the arm during incision of the deep fascia.

Radial artery

• Can be injured when the bicipital aponeurosis is cut, as the nerve runs immediately under it.

Posterior interosseous nerve

• Do not insert a retractor on the lateral aspect of the proximal radius; this may compress the nerve as it winds round the neck of the radius within the substance of the supinator muscle, which is detached from its insertion in supination.

How to enlarge the approach

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

Median Nerve

• Proximally, the incision can be extended superiorly along the medial border of the biceps; 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 medial nerve runs with the artery.
• Distally, the median nerve disappears into the pronator teres muscle; simple retraction of the muscle may provide adequate exposure.

Brachial Artery

• Exposed in the same way as the median nerve, as they run together.

Radial Artery

• Developing the plane proximally between the pronator teres and the brachioradialis muscles, and distally between the flexor carpi radialis and brachioradialis muscles, allows the artery to be followed to the wrist.

Figures