Anterolateral approach to the elbow

Introduction

Indications

• Surgery of the capitulum (ORIF, aseptic necrosis).
• Drainage of infection from the elbow joint.
• Neural compression involving:
  1. PIN syndrome.
  2. Radial tunnel syndrome.
  3. Superficial radial nerves.
• Treatment of biceps avulsion from the radial tuberosity.
• Total elbow replacements.
• Excision of tumors of the proximal radius.

Advantage

• Exposes the lateral half of the elbow joint, including the capitulum, and the proximal third of the anterior aspect of the radius.

Position of patient

• Patient is supine on the operating table, with the arm on an arm board.
• Inflate a tourniquet after exsanguinating the limb.

Landmarks and incision

Landmarks

• The brachioradialis forms the medial border of the wad of muscle on the anterolateral aspect of the forearm.
• The biceps tendon is palpable on the anterior aspect of the elbow.

Incision

• Make a curved incision, starting 5 cm proximal to flexion crease of the elbow, along the lateral border of the biceps.
• Continue distally by following medial border of the brachioradialis.

Internervous plane

Proximally

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

Distally

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

Superficial dissection

• The lateral cutaneous nerve of the forearm (sensory branch of the musculocutaneous nerve) is identified and retracted with the medial skin flap.
• The nerve lies superficial to the deep fascia in the proximal 2 inches of the flexion crease, lateral to the biceps tendon in the interval between it and the brachialis.
• The deep fascia is incised along the medial border of the brachioradialis.
• The radial nerve is identified proximally at the level of the elbow joint, deep between the brachialis and the brachioradialis.
• Develop the plane between the two muscles, retracting the brachioradialis laterally and the brachialis and the overlying biceps brachii medially.
• Follow the radial nerve distally along the intermuscular interval until it divides into its three terminal branches:
      1. PIN (enters the supinator).
      2. Sensory branch (travels deep to brachioradialis).
      3. Motor branch to ECRB.
• Below the division of the nerve, develop a plane between the brachioradialis on the lateral side and the pronator teres on the medial side.
• Ligate the recurrent branches of the radial artery and the muscular branches that enter the brachialis just below the elbow so that the muscle can be retracted adequately.

Deep dissection

Joint capsule

• Incise the joint capsule between the radial nerve laterally and the brachialis muscle medially.

Proximal radius

• Expose the proximal radius by supinating the forearm to bring the supinator muscle anteriorly.
• Incise the muscle origin down to bone, lateral to the insertion of the biceps tendon.

Dangers

Radial nerve

• Identified in the interval between the brachioradialis and brachialis muscles, before this interval is developed fully.
• The nerve lies anteromedial to the brachioradialis, within the fascial compartment of that muscle. If it is being sought at the level of the distal humerus or elbow, the intermuscular interval is the best place to find it.

Posterior interosseous nerve

• In danger as it winds around 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 insertion on the radius with the forearm in supination. Do not cut through the muscle body to expose the bone.

Lateral cutaneous nerve of the forearm

• Identified and its continuity preserved in the interval between the brachialis and biceps brachii muscles; retract it with the medial skin flap.

Recurrent branches of the radial artery

• Ligated so that the brachioradialis can be mobilized fully.

How to enlarge the approach

Proximal

• Extends into the anterolateral approach to the forearm, developing the plane between the brachialis and the triceps.

Distal

• Extends to the anterior approach to the radius between the planes of the brachioradialis and pronator teres muscles proximally and the brachioradialis and flexor carpi radialis (median nerve) muscles distally.

Figures