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