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Medial approach to the elbow

Introduction

Indications

  • Open reduction and internal fixation of fractures of the coronoid process of the ulna, of the medial humeral condyle and epicondyle.
  • Removal of loose bodies.

Advantages

  • Good exposure of the medial compartment of the joint.
  • Can be enlarged to expose the anterior surface of the distal fourth of the humerus.

Disadvantages

  • Provides poor access to the lateral side of the joint and difficult used for routine exploration of the elbow.
  • Dislocating the elbow joint during the procedure to gain access to the lateral side of the elbow, if necessary.
  • The ulnar nerve (which runs across the operative field), median nerve, and brachial artery may be at risk in this exposure.

Position of patient

  • The patient is placed supine on the operating table, with the arm supported on an arm board over the patient.
  • Abduct the arm and rotate the shoulder fully externally so that the medial epicondyle of the humerus faces anteriorly.
  • Exsanguinate the limb and then inflate a tourniquet.

Landmarks and incision

Landmark

  • The medial epicondyle of the humerus.

Incision

  • Curved incision 8 to 10 cm long, centered on the medial epicondyle.

Internervous plane

Proximally

  • Between the brachialis (musculocutaneous nerve) and the triceps (radial nerve).

Distally

  • Between the brachialis(musculocutaneous nerve) and the pronator teres (median nerve).

Superficial dissection

  • Incise the fascia over the ulnar nerve, starting proximal to the medial epicondyle, and isolate the nerve.
  • Define the interval between the pronator teres and brachialis muscles, retracting the pronator teres medially and lifting it off the brachialis.
  • Osteotomy of the medial epicondyle, reflecting it with its attached common flexor origin distally.
  • Superiorly, develop interval between the brachialis, retracting it anteriorly, and the triceps, retracting it posteriorly.

Deep dissection

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

Dangers

Nerves

  • Ulnar nerve: Dissected out and isolated along the length of the incision before the medial epicondyle osteotomy.
  • Median nerve: Enters the pronator teres near the midline. Aggressive traction on the osteotomy fragment can cause a traction injury to the median and anterior interosseous nerves.

How to enlarge the approach

Local

  • Abduction of forearm opens medial aspect of joint.
  • Dislocate the joint laterally by dissecting off joint capsule and periosteum, allowing free mobility of the proximal ulna.

Proximal

  • Anterior surface of distal fourth of humerus can be exposed by developing plane between brachialis and triceps by subperiosteal dissection and elevation of the brachialis.

Distal

  • Limited by the branches of the median nerve.

Figures

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