Posterolateral approach to the elbow

Introduction

Indications

• All surgeries to the radial head, including excision of the radial head and prosthetic replacement.

Disadvantage

• The incision cannot be extended to the upper part of the radial shaft (below the annular ligament), risking damage to the posterior interosseous nerve.

Position of patient

• The patient is placed supine on the operating table; pronate the forearm and position it over the chest.
• Inflate a tourniquet after exsanguinating the limb.

Landmarks and incision

Landmarks

• Lateral humeral epicondyle.
• At the radial head, palpate the lateral humeral epicondyle, moving the fingers 2.5 cm distally until a depression is detected. As the forearm is pronated and supinated, movement of the radial head can be felt.

Incision

• A 5-cm longitudinal incision based proximally on the lateral humeral epicondyle. This incision follows the skin fold and lies directly over the radial head.

Internervous plane

• Between the anconeus (radial nerve) and the extensor carpi ulnaris (posterior interosseous nerve).

Superficial dissection

• The deep fascia incised in line with the skin incision.
• The interval between the extensor carpi ulnaris and the anconeus identified.
• Detach part of the superior origin of the anconeus as it arises from the lateral epicondyle of the humerus.

Deep dissection

• Full pronation of the forearm moves the posterior interosseous nerve away from the operative field.
• Incise the capsule of the elbow joint longitudinally to reveal the underlying capitulum, the radial head, and the annular ligament.

Dangers

Posterior interosseous nerve

• Full pronation of the forearm keeps the nerve far from the operative field.
• The dissection remains proximal to the annular ligament to ensure the safety of the nerve.
• Place the retractors directly on bone, as the posterior interosseous nerve actually may touch the radial neck.

Radial nerve

• The elbow joint is opened laterally and not anteriorly, as the radial nerve runs over the front of the anterolateral portion of the elbow capsule.

How to enlarge the approach

The approach cannot be extended in any direction.

Figures