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Surgical approaches in a nutshell

Contents

Hand

Fingers

  • Volar zig zag at 90-degree Bruner
  • Deeper, stay close to the tendon sheath to avoid injury to the neurovascular bundle laterally

Midlateral

  • Make at dorsal extent of interphalangeal crease with flexed finger
  • Enter between dorsal and volar digital arteries
  • Will be above neurovascular bundle in the finger, and it will stay in the volar skin flap

Palm

  • Estimate of recurrent motor branch is line from radial aspect middle finger and Kaplans cardinal line (first web space parallel to proximal transverse palmar crease)

Pus Drainage

  • Distal palmar crease marks the A1 pulley and proximal edge of flexor sheath
  • Make transverse cut just proximal to it, and then dissect longitudinally through the palmar fascia. Locate and incise the A1 pulley. The digital nerves and vessels run directly under the incision longitudinally.
  • Superficial palmar arch (larger from ulnar) runs at level of distal transverse palmar crease
  • Deep is more proximal and is at level of Kaplans cardinal line

Midpalmar space

  • Between metacarpals and interossei and flexor tendons and lumbricals
  • Make transverse incision just proximal to distal palmar crease.
  • Dissect deeper with a snap longitudinally finding tendon to ring finger
  • Enter midpalmar space on the radial side of this tendon

Thenar space

  • Make longitudinal skin incision on ulnar side of the thenar crease
  • Spread deeper tissue with a snap
  • Find flexor tendon to index finger and dissect on its ulnar side, which will expose the thenar space
  • Dangers
    • Digital vessels and nerves longitudinally
    • Motor branch of median at Kaplans line and radial aspect of middle finger
    • Superficial arch at level of distal transverse palmar crease

Volar Scaphoid (Russe)

  • Skin incision
    • Radial border of flexor carpi radialis tendon over scaphoid tubercle to base of first metacarpal
  • Muscular interval
    • Flexor carpi radialis and radial artery
  • Dangers
    • Radial artery
    • Palmar branch of median nerve between palmaris longus and flexor carpi radialis

Dorsal Scaphoid

  • Skin incision
  • Muscular interval
    • Extensor pollicis longus and extensor pollicis brevis (1st and 3rd dorsal compartments)
  • Dangers
    • Sensory branch of radial nerve
    • Radial artery in floor of snuff box

Wrist

Dorsal

  • Skin incision
    • Over dorsum of wrist at Lister's tubercle
  • Muscular interval
    • 3rd and 4th extensor compartments (extensor pollicis longus and extensor digitorum communis)

Volar (Carpal Tunnel)

  • Skin incision
    • In line with flexed 4th digit, across flexor crease
    • Stay ulnar to thenar crease, radial border of 4th finger
    • From proximal transverse palmar crease to volar wrist crease
    • Dissect through skin and subcutaneous fascia; watch for palmar branch of median nerve; place small self-retainer
    • Identify transverse carpal ligament and find proximal edge; pass freer under edge and cut on freer
    • Continue to release fully
    • Beware of superficial arch distally, at the level of the distal transverse palmar crease
    • Stop when see fat at distal edge of transverse carpal ligament
  • Muscular interval
    • Ulnar to palmaris longus, through transverse carpal ligament
    • Flexor digitorum superficialis and flexor digitorum profundus ulnar, medial nerve, and palmaris longus radially
  • Dangers
    • Median nerve - Retract to radial side due to motor branch
    • Sensory branch between palmaris longus and flexor carpi radialis

Volar (Guyons Canal)

  • Volar incision over radial border of hypothenar eminence
  • Take flexor carpi ulnaris ulnarly, revealing nerve and artery from medial to lateral
  • Incise just radial to pisiform to unroof Guyons canal by incising volar carpal ligament
  • Protect the nerve and artery throughout

Forearm

Volar (Henry)

  • Skin incision
    • Medial border of brachioradialis proximally to radial styloid between flexor carpi radialis and radial artery distally
    • Proximally is between brachioradialis and pronator teres
  • Muscular interval
    • Flexor carpi radialis and brachioradialis distally; pronator teres and brachioradialis proximally
    • Flexor digitorum superficialis - middle layer
    • Supinator, pronator teres, flexor pollicis longus, pronator quadratus - deepest layers
  • Dangers
    • Superficial radial nerve runs under brachioradialis
    • Radial artery runs in this interval; ligate its branches
    • Radial artery will cross field if taken with brachioradialis distally
    • Posterior interosseous nerve proximally in substance of supinator; from volar approach, supinate to release insertion of supinator safely

Posterior (Thompson)

  • Skin incision
    • 5 cm distal to radiocapitellar joint to point between lateral epicondyle and Listers tubercle
  • Muscular interval
    • Extensor carpi radialis brevis and extensor digitorum communis proximally
    • Abductor pollicis longus and extensor pollicis brevis cross the field in the middle
    • Extensor carpi radialis brevis and extensor pollicis longus distal interval
  • Dangers
    • Posterior interosseous nerve running in supinator muscle
    • Out croppers cross this interval

Dorsal

  • Skin incision
    • Over crest of ulna
  • Muscular interval
    • Extensor carpi ulnaris/flexor capri ulnaris
  • Dangers
    • Dorsal sensory branch of ulnar nerve in the distal one third of arm

Elbow

Triceps Sparing

  • Skin incision
    • Posterior midline
  • Muscular interval
    • Split triceps longitudinally along midline
    • Split ulnar periosteum over 3 cm along midline

Triceps Splitting

Anterior

  • Skin incision
    • S-shaped anteromedial to anterolateral
  • Muscular interval
    • Biceps and brachialis proximally
    • Pronator teres and brachioradialis distally
  • Dangers
    • Brachial artery and median nerve proximally directly under lacertus
    • Distally median nerve between heads of pronator teres and radial artery, angling radially to go under brachioradialis
    • Ulnar nerve posterior to medial epicondyle of elbow
    • Musculocutaneus nerve and lateral antebrachial cutaneous nerve between the biceps and brachialis

Posterolateral Kochers

  • Skin incision
    • Lateral epicondyle to radial neck with elbow flexed
  • Muscular interval
    • Extensor carpi ulnaris and anconeus
  • Dangers
    • Posterior interosseous nerve; pronate forearm to bring proximal radius away from nerve
      • Keep retractors off radial neck

Posterolateral Kaplans

  • Muscular interval
    • Extensor carpi radialis brevis and extensor digitorum communis
  • Dissection
    • At elbow, can dissect extensor carpi radialis longus and brachioradialis off lateral epicondyle
  • Dangers
    • Posterior interosseous nerve in supinator

Shoulder

Deltopectoral

  • Skin incision
    • Coracoid towards deltoid insertion on humerus
  • Muscular interval
    • Deltoid and pectoralis
    • Take cephalic vein either way
    • Stay lateral to conjoint tendon, and be aware of musculocutaneous nerve 3-8 cm below coracoid and axilla; below subscapularis and 5 cm inferior to tip of acromion
    • Dissect through clavipectoral fascia with arm adducted and externally rotated to expose the subscapularis
    • Protect inferior border of subscapularis with curved Kelley and release
    • Subscapularis
      • If lesser tuberosity off for fracture, modified Mcglachlin can leave subscapularis attached to lesser tuberosity
      • For Bankart repair or capsular shift leave the inferior one third intact with vertical cut 1cm off the lesser tuberosity for reattachment
    • Identify capsule and release with a T incision; vertical limb lateral
  • Dangers
    • Axillary nerve under subscapapular and through quad space 5 cm distal to acromion
    • Musculocutaneous nerve 3 to 8 cm distal to coracoid-age 6 cm

Posterior

  • Skin incisions
    • 6 cm vertical incision over posterior corner of acromion
    • Parallel to posterior axillary line
  • Muscular interval
    • Split deltoid from corner of acromion inferiorly
    • Axillary nerve is inferior and lateral to dissection
    • Find infraspinatus teres minor interval
    • Split or release infraspinatus off the greater tuberosity with a small cuff depending on need
    • Expose capsule
  • Dangers
    • Axillary nerve in quad space (minor/major/long/lateral)
    • Suprascapular nerve 2 cm medial to glenoid at spinoglenoid notch and 3 cm from glenoid at suprascapular notch

Humerus

Posterior

  • Skin incision
    • Posterior
  • Muscular interval
    • Proximal between long and lateral heads of triceps
    • Distal split tricep to locate rad nerve and deep brachial artery
    • Dissect medial head off the distal posterior humerus
  • Dangers
    • Radial nerve one handsbreadth above lateral epicondyle
    • Crosses post humerus in spiral groove
    • Ulnar nerve medially posterior to the medial epicondyle

Anterolateral

  • Skin incision
    • Anterior aspect of arm lateral to bicep
  • Muscle interval
    • Lateral to bicep
    • Always explore radial nerve at elbow with this approach; follow from lateral septum to elbow
    • Take bicep medially; go through lateral aspect of brachialis
  • Dangers
    • Musculocutaneous nerve between bicep and brachialis
    • Radial nerve between brachioradialis and brachialis

Hip

Anteromedial (Ludloff)

  • Skin incision
    • Immediately distal to groin crease, from longus insertion to neurovascular bundle
  • Muscular interval
    • Adductor longus tenotomy, pectineus, and adductor brevis below
    • Femoral neurovascular bundle above
  • Dangers
    • Obturator nerve
    • Femoral nerve, artery, and vein
    • Medial femoral circumflex artery
  • Approach
    • Incise just distal to groin crease with a transverse incision.
    • Identify and release the insertion of the adductor longus 1cm from its origin.
    • Retract the adductor longus to reveal the adductor brevis inferiorly and the pectineus superiorly, with the anterior branch of obturator nerve in between.
    • Release the posterior border of the pectineus proximally to its origin as well as distally.
    • Retract the pectineus superiorly.
    • Identify and divide the fascia over the psoas tendon.
    • Divide the fat over the hip capsule to expose the capsule, and then divide the capsule.
    • A small branch of the MCFL may be seen at this point and should be spared if possible.
    • Once longus is gone, the approach is basically dissection posterior to the pectineus, and then release of the psoas to expose the joint capsule.

Medial (Hoppenfeld)

  • Skin incision
    • Immediately distal to pubic tubercle over adductor longus
  • Muscular interval
    • Adductors longus and brevis above, gracilis and adductor magnus below
  • Dangers
    • Obturator nerve
    • Femoral nerve, artery, and vein
    • Medial femoral circumflex artery
  • Approach
    • Incise just distal to the pubic tubercle over the adductor longus.
    • Dissect between the adductor longus anteriorly and the gracilis posteriorly, taking the adductor longus anteriorly and the gracilis posteriorly. This will expose the anterior obturator nerve and the adductor brevis muscle.
    • Continue posterior to the adductor brevis and anterior to the adductor magnus. The deeper layer is between the adductor brevis and adductor magnus (posterior).
    • Continue between the adductor brevis and the adductor magnus. The anterior branch of the obturator is anterior to the brevis; the posterior branch is posterior to it.
    • The lesser trochanter and hip capsule are in the floor of the wound. Place a retractor anterior to the lesser trochanter to push the psoas posteriorly.
    • The anterior branch is between the adductor longus and adductor brevis; the posterior branch is between the adductor brevis and the adductor magnus.
    • The MCFL travels around the medial side of the distal part of the psoas tendon.

Posterior (Kocher-Langenbeck)

  • Skin incision
    • Lateral thigh over posterior aspect of greater trochanter
    • From tip of greater trochanter, aim towards posterior superior iliac spine; allows triradiate exposure if needed
  • Muscular interval
    • Split iliotibial band over lateral aspect of greater trochanter following skin incision towards posterior superior iliac spine
    • Split bluntly through gluteus maximus halfway to origin
    • Stay above quadratus femoris
    • Leave > 1 cm of short external rotators
    • Release piriformis, superior and inferior gemellus, and obturator internus; leave obturator externus and quadratus femoris alone
  • Dangers
    • Sciatic nerve medially
    • MCFL upper border of quadratus femoris and along short external rotators to base of neck
    • For extra exposure, can release some of gluteus maximus insertion no higher than 5 cm above tip of greater trochanter; only split half of gluteus maximus

Lateral (Hardinge)

  • Skin incision
    • Lateral thigh
    • Split iliotibial band in line with incision
  • Muscular interval
    • Anterior one third of gluteus medius; dissect through gluteus medius and minimus, through capsule to neck
  • Dangers
    • Maximum dissection 5 cm distal to tip of greater trochanter for superior gluteal neurovascular bundle

Anterolateral (Watson-Jones)

  • Skin incision
    • Lateral thigh
  • Muscular interval
    • Tensor fasciae latae and gluteus medius
    • Incise ilitibial band over greater trochanter and aim towards anterior superior iliac spine
    • Take tensor fasciae latae medially and gluteus medisu posteriorly to expose the neck

Anterior (Smith-Petersen)

  • Skin incision
    • Anterior superior iliac spine down anterolateral thigh
  • Muscular interval
    • Sartorius and tensor fasciae latae
    • Deep rectus and gluteus medius
  • Dangers
  • Lateral femoral cutaneous nerve and ascending branch of lateral femoral circumflex artery

Knee

Posterior

  • Skin incision
    • S-shaped over the popliteal fossa
  • Muscular interval
    • Biceps and lateral gastrocnemius vs. semimembranosus and semitendinosus and medial gastrocnemius
  • Dangers
    • Sural, tibial, and peroneal nerves
  • Approach
    • Make an S-shaped incision and identify the popliteal fascia.
    • Just under the popliteal fascia are the small saphenous vein medially and medial sural nerve laterally. Use the vein as a guide to the nerve and the nerve as a guide to the popliteal fossa.
    • Incise medial to the vein and follow the nerve back to the tibial nerve. Dissect to the apex (semimembranosus and biceps femoris).
    • Watch for the common peroneal at the apex; it is on the underside of the biceps femoris tendon.
    • The  popliteal artery is medial to the nerve in the fossa
    • The medial and lateral borders of the inferior aspect of the approach are the medial and lateral gastrocnemius.

Medial

  • Skin incision
    • Medial
  • Muscular interval
    • Anterior to hamstrings
  • Dangers
    • Saphenous nerve between gracilis and sartorius
  • Approach
    • Make a medial incision and watch for the saphenous vein and nerve.
    • Stay anterior to the hamstrings(sartorius) and anterior to the saphenous nerve and vein. Note the superficial medial cruciate ligament attaching 6 cm distal to the joint line.
    • Stay between the medial cruciate ligament and hamstring tendons to the posterior knee capsule. Retraction of the medial gastrocnemius laterally will protect the popliteal artery.
    • This is the incision to use for open meniscus repair or exposure to the posteromedial structures for ORIF of a medial plateau fracture.
    • Outer layer: sartorius; middle layer: superficial medial cruciate ligament and medial patellofemoral ligament; deep layer: capsule and deep medial cruciate ligament
    • Burks and Schaffer approach is between the semimembranosus and gastrocnemius.
      • This gives good access to the back of the knee.
      • Stay posterior to the hamstrings and anterior to the medial gastrocnemius; favoured approach for the avulsed posterior cruciate ligament.
      • Protect the saphenous nerve and vein by holding the hamstring tendons anteriorly and staying posterior to them.

Lateral

  • Skin incision
    • Midline lateral incision 3 cm from lateral edge of patella
    • Distally over iliotibial band to Gerdys tubercle
  • Muscular interval
    • Stay between biceps tendon and iliotibial band.
    • Keep biceps posterior to protect the common peroneal nerve; will expose lateral collateral ligament (lateral epicondyle to fibular head)
    • Dissect anterior to gastrocnemius and posterior to lateral collateral to access posterior aspect of the knee and proximal tibia
  • Dangers
    • Common peroneal nerve posterior to bicep tendon
    • Structures of the posterolateral aspect of knee
  • Superficial layer - iliotibial band and bicep tendon; middle layer - lateral collateral ligment; deep - capsule, popliteus, and deep lateral collateral ligament, which also goes to fibular head

Posterolateral Corner

  • Lateral collateral ligament
  • Arcuate ligament complex
  • Popliteus
  • Fabellofibular
  • Biceps femoris

Tibia

Posterolateral

  • Muscular interval
    • Flexor hallucis longus and peroneal
  • Dangers
    • Peroneal and posterior tibial artery, lesser saphenous vein
    • Safe zone at proximal fibula is 3-8 cm from tip
    • Posterior neurovascular bundle
  • Approach
    • Incise 2 cm posterior to the fibula and identify the superficial posterior muscles and flexor hallucis longus.
    • Dissect between the peroneals and flexor hallucis longus. Take the soleus and flexor hallucis longus off the fibula.
    • Dissect medially on the posterior aspect of the interosseus membrane. Dissect the posterior tibial off the posterior interosseous membrane to protect the posterior neurovascular bundle.

Compartment Syndrome

  • Two-incision technique
    • Incise 2 cm posterior to border of tibia with a 20 cm incision; watch the saphenous nerve and vein and take them anteriorly.
    • Make a small transverse incision to find the medial intermuscular septum between the superficial and deep compartments. Release the superficial posterior compartments proximally and distally.
    • Release the fascia of the deep posterior compartment by releasing  the flexor digitorum longus
    • Release tissue off the posterior aspect of the tibia anterior to the intermuscular septum to release the posterior tibial muscle.
    • With cobb, strip the soleus bridge off the posterior tibia to finish the release of the deep posterior compartment if it has attachments.
    • Release v proximally and down to the medial malleolus.
    • Anteriorly incise 20 cm between the tibial crest and the fibula longitudinally.
    • Make a small transverse incision to identify the lateral intermuscular septum that separates the lateral and anterior compartments. This also localizes the superficial peroneal nerve in the lateral compartment. Release both with longitudinal incisions under direct vision.
    • Watch for the anterior neurovascular bundle and superficial peroneal nerve.
    • Assess all four compartments manually and with a pressure monitor if at all concerned.
  • Irrigate and cover with saline soaked gauze, wet to dry.
  • Give perioperative abts and return in 24 hours.
  • Have the plastic surgery determine if a graft if needed or place staples and rubber vessel loop to close.

Foot

Olliers

  • Skin incision
    • Across, dorsolateral foot and sinus tarsi
  • Muscular interval
    • Peroneus tertius and brevis, reflect extensor digitorum brevis
  • Dangers
    • Deep branch of peroneal nerve and superficial peroneal nerve anterior
    • Sural nerve volar

Spine

Anterior Cervical

  • Muscular interval
  • Dangers
    • Recurrent laryngeal nerve ascends between the trachea and esophagus
    • Esophagus lacerations are possible and are very dangerous
  • C3 hyoid bone
  • C4-5 thryroid cartilage
  • C6 cricoid cartilage and carotid tubercle
  • Approach
  • Patient in beach chair position, 30 degrees, with a sandbag between the shoulders
    • Careful head position; turn head away from side of incision.
    • Left side approach; recurrent laryngeal nerve more consistent on that side
    • Transverse incision at the appropriate level (vertical if need three or more levels)
    • Platysma incision vertically; incise anteriorly to sternocleidomastoid muscle
    • Take the sternocleidomastoid laterally and strap muscles and trachea esophagus medially
    • Through deep cervical fascia. Identify the carotid sheath.
    • Medial to the carotid sheath through pretrachial fascia, between it and the midline structures trachea, esophagus, and thyroid gland.
    • Retract the sternocleidomastoid muscle, carotid sheath laterally
    • Superior and inferior thryroid arteries between the carotid sheath and midline structure at C3-4 and C6-7 levels, respectively
    • Watch for recurrent laryngeal nerve between trachea and esophagus after circling aorta on left
    • Continue dissection in midline; identify longus colli over vertebrae and the anterior long ligament over anterior aspect of vertebral bodies
    • Split longus colli over vertebrae
    • Dissect through the prevertebral fascia, staying subperiosteally
    • Be cautious of sympathetic chains lateral to the vertebral bodies; vertebral arteries also lateral to midline in foramen transversarium, anterior to nerve roots

Anterior Thoracic, for T1 to T4

  • Dangers
    • Need thoracics to help with

Anterior Thoracoabdominal, for T4 to T10

  • Skin incision
    • Go through 5th or 6th rib on right side
  • Muscular interval
    • Go through latissimus dorsi; tag ends and serratus
    • Resect rib; watch for intercostals at inferior edge
    • Speak to anesthesia before entering pleura; need two barrel endotracheal tubes
    • Deflate lung, and then retract anterior with wet gauze
    • Watch for trachea/esophagus and aorta on left side
    • Have to cross pleura again over midline
    • Intercostal vessels need to be taken
    • Have nasogastric tube placed
  • Dangers
    • Enter two ribs above level; highest rib is T5

Thoracolumbar Junction, for T10 to L1

  • Incise over 10th rib
  • Go through 10th rib
  • Take diaphram down above L1
  • Take diaphram from the top and leave cuff for repair
  • Watch the peritoneum under diaphram; take feeder vessels in field
  • Watch for artery of Adamkiewietz, usually on left side of T10; leave if possible, or take as needed
  • Watch for aorta on left side and caval opening on right side
  • Go on left side -- caval side, plus no liver

Retroperitoneal, for L1 to L5

  • Skin incision
    • Left side to avoid liver and inferior vena cava
    • Incise along 12th rib, from 1 hand breadth off posterior midline to median rectus edge
  • Muscular interval
    • Three layers of abdomen
    • Stop at lateral edge of rectues
    • Identify peritoneum; take peritoneum forward with wet sponge
    • Look for ureter and genitofemoral nerve on psoas, sympathetics just medial to psoas on the vertebrae
    • Identify and release segmental vessels, using blunt retractors and bipolar cautery
  • Dangers
    • Ureter
    • Comes forward with peritoneum
    • Vascular branches, aorta

Costotransversectomy

  • Indications
    • For drainage of thoracic abscess
    • Also good for disc biopsy in T spine
    • Difficult to do from post bc cant pull dura aside to get by crd for biopsy.
    • Can do transpedicular for vert body biopsy or CT guided posterolateral but may need open bx
  • Skin incision
    • 10 cm incision 6-8 cm lateral to spinous process centered over rib of affected level
  • Muscular interval
    • Split traps and paraspinal muscles
    • Cut down to post aspect of rib
    • Dissect above/below and lat 6-8 cm and remove rib after cutting It 6-8 cm from midline
    • Take the transverse process at that level
    • Enter the retropleural space by digital dissection removing parietal pleura from vertebral body
  • Dangers
    • Dura medially, intercostal arteries, pneumothorax

Pelvis

Ilioinguinal

  • Windows
    • Lateral to psoas (femoral nerve)
      • Iliac fossa and sacroiliac joint
    • Between psoas and femoral vessels
      • Excision of the iliopectineal fascia to expose the quadrilateral plate
      • Split them to expose the pelvic brim, quadrilateral plate and posterior column
    • Medial to femoral vessels
      • Pull the femoral vessels and spermatic cord (round ligament) and lymphatics laterally to expose the medial window consisting of the pubic ramus and pubic symphysis
    • Corona mortis between external iliacs (femoral at that level) and the obturator vessels
    • Use to access anterior column/wall and many transverse or t type and anterior with hemi transverse that do not have significant posterior fracture displacement
  • Approach
    • Make an incision along the iliac crest. Release the abdominal muscles and iliacus off the crest and inner table to expose the iliac fossa and sacroiliac joint.
    • Medially unroof inguinal canal by releasing the external oblique. Isolate the spermatic cord or inguinal ligament. Look for the ilioinguinal nerve.
    • The conjoint tendon (internal oblique and transversalis abdominus) are the floor of the inguinal canal.
    • Incise the floor of the canal and watch for the lateral femoral cutaneous nerve. Good closure of the internal oblique and tranversalis abdominus is crucial to avoid hernias. Release rectus from lateral to medial for 1 cm. Helfet leaves the conjoint tendon intact over the neurovascular bundle for protection and mobilizes around it.
    • Watch for the inferior epigastric just medial to the deep ring.
    • The iliopectineal fascia separates the psoas and femoral nerve from the vascular bundle. It is between the middle and lateral windows. It needs to be released off the pelvic brim to expose the quadrilateral plate.
    • Separates true from false pelvis and travels from the sacroiliac joint to the pelvic brim.
    • Watch for corona mortis - anomalous branch from the external iliac to the obturator vessels.
    • Lateral to the iliopectineal fascia, release the conjoint tendon (internal oblique and tranversalis abdominus) off the inguinal ligament, leaving a 2 mm cuff for repair. Medial to the vessels, incise the conjoint tendon and continue laterally from the pubic tubercle to the pubic symphysis. Watch for the inferior epigastric artery around the deep inguinal ring.
    • Helfet says to leave the conjoint tendon intact over the femoral artery and vein.
    • Reflect the psoas and nerve off the iliopectineal fascia laterally and the vascular bundle off medially.
    • Place Penrose drains around these two structures
    • Release the iliopectineal fascia off the pelvic brim.
  • Summary
    • Skin incision
    • Expose inguinal canal
    • Release floor of canal
      • Mobilize sperm cord/round ligament
        • Watch inferior epigastric medial to deep ring
    • Release iliopectineal fascia
      • Sits between vascular structures medially and femoral nerve and psoas laterally
      • Watch for corona mortise with femoral vessel mobilization
        • Mobilize femoral nerve laterally and vascular bundle medially
    • Take lateral edge of rectus for 1 cm
      • Watch bladder posterior to symphysis pubis

Kocher-Langenbeck
See above

Iliofemoral

  • Skin incision
    • Over the iliac crest from posterior superior iliac spine to anterior superior iliac spine
  • Muscular interval
    • Sartorius and tensor fascia lata
    • Rectus and gluteus medius deep muscular interval.
  • Dangers
    • H.O.
    • Lateral femoral cutaneous nerve and ascending lateral cutaneous femoral artery
    • Superior gluteal artery and nerve
  • Approach
    • Start by releasing the tensor fascia lata and gluteus medius off the iliac crest, which exposes the proximal fibers of the rectus femoris. Stay lateral to lateral femoral cutaneous nerve, but watch for it.
    • Release both the direct and reflected heads of the rectus femoris.
    • Helfets book has the anterior superior iliac spine and the anterior inferior iliac spine off as a bony piece to release the sartorius as well.
    • Ligate the ascending branch of the lateral femoral artery.
    • The gluteus medius and minimus are released off the iliac crest and off the greater trochanter. Leave a cuff for reattachment.
    • This leaves the gluteus medius and minimus and tensor fascia lata as a free pedicle on the superior gluteal artery and nerve.
    • The short external rotators are tagged and released.
    • This exposes the anterior and posterior columns

Other

Upper Extremity Compartment Syndrome

Carpal Tunnel and Fascial Release of the forearm

  • Patient supine with arm extended on arm board
  • Incision to include carpal tunnel, forearm to just above elbow to expose lacertus fibrosus
  • Begin just ulnar to the thenar crease, one third of the way into the palm
  • Extend proximally obliquely over the wrist crease, staying ulnar until distal one third of forearm
  • Angle laterally to medial edge of brachioradialis and extend proximally, angling medially to cross cubital fossa and crease obliquely on medial aspect of upper arm
  • Complete the carpal tunnel release with cautious protection of median nerve and its motor branch
  • Follow skin incision, avoiding palmar branch of median nerve
  • Slightly pronate arm to release flexor digitorum superficialis and protanator teres off the radius, exposing the deep layer of forearm and course of median nerve on the flexor digitorum profundus
    • Can also retract flexor digitorum superficialis and protanator teres laterally to see deep compartments
  • Release fascial envelope off deep structures flexor pollicis longus and prontator quadratus
  • Proximally watch for radial artery
  • Release lacertus fibrosus with brachial artery directly beneath and median nerve medial to artery
  • Release all muscular fascias in forearm
  • Palpate mobile wad and dorsal compartement to determine if release is needed; release if any concern
    • Mobile wad through volar approach and dorsal compartment through dorsal incision from lateral epicondyle to listers tubercle; leave 7-cm skin bridge

Maneuver for Closed Reduction of the Femoral neck

  • Gentle maneuver performed only once
  • Flexion to 90 degrees
  • Adduct
  • Externally rotate
  • Internal withtraction and counter traction to unlock the fragement
  • Extend with circumduction into extension and internal rotation
  • Acceptable
    • No varus
    • 10 degrees valgus
    • 10 degrees on laterals

Compartment Syndrome of the Foot

Anatomy

  • First layer
    • Abductor digiti minimi brevis
    • Flexor digitorum brevis
    • Abductor hallucis
    • Neurovascular bundle
      • Between layers
      • Medial and lateral plantar nerve and artery
  • Second layer
    • Flexor hallucis longus
    • Flexor digitorum longus
    • Quadratus plantae
    • Lumbricals (from flexor digitorum longus)
  • Third Layer
    • Adductor hallucis
    • Flexor hallucis brevis
    • Flexor digiti minimi
  • Fourth Layer
    • Interossei
    • Deep arteries of the foot
      • From anterior tibial artery

Foot Compartments

  • 9 in total
    • Medial
    • Lateral
    • Superficial
    • Adductor
    • Calcaneus
    • 4 interiossei compartments
  • Medial, lateral, and superficial compartments run full length of foot
  • Calcaneal compartment contains quadratus plantae muscle and lateral planter nerve
  • Distal edge of quadratus plantae inserts into the posterior edge of flexor digitorum longus tendon

Release

  • Three-incision release, two dorsal, one medial
    • Medial incision releases the medial, lateral and superficial compartments and the deeply seated calcaneal compartment.
  • 6-cm incision 3 cm off the sole of foot, starting 4 cm from back of heel
  • Abductor hallucis fascia is localized and used as guide (without incision) to more plantar superficial compartment containing flexor digitorum brevis; this is released, and then abductor hallucis is released
    • May want to localize the flexor digitorum brevis fascia and open it after the calcaneal compartment
  • Muscles of abductor hallucis are used as guide to calcaneal compartment
  • Pull abductuctor hallucis muscle upwards with muscle retractor to expose intermuscular septum covering calcaneal compartment (bright, thick, white covering); open with caution to avoid hitting lateral plantar nerve (located in this compartment with quadratus plantae)
  • Next, release superficial compartment; retract muscle fibers inferiorly to follow plantar surface of calcaneal compartment across to the lateral side of foot to lateral compartment, which is release from medial side as it is encountered
  • Release adductor and interossei compartments through two dorsal incisions, with the medial just medial to the second metacarpal and the second just lateral to the fourth
  • Through medial dorsal incision, release interossei from first and second space; in deep aspect of first space, bluntly expose fascia of adductor compartment and release with blunt instruments
  • Third and fourth interossei are released through lateral dorsal incision
  • Postoperatively, cover with wet dressings and return in 24-36 hours to wash out wound and either have plastics assess for skin graft or place as figure of 8 dynamic rubber band skin closure technique.
  • Dangers
    • Obturator nerve
    • Femoral nerve, artery, and vein
    • Medial femoral circumflex artery

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