Surgical Approaches

Shoulder
Anterior (Deltopectoral) Anterolateral Lateral (Deltoid Splitting) Posterior
- Proximal humerus #s - Proximal humerus #-dislocations
- Rotator cuff repair
- Long head of í biceps injury - Proximal humerus #s - Glenoid #s/osteotomy
- Repair of í long head of í biceps
Indication - Reconstruction of recurrent dislocations - Rotator cuff repair - Scapular neck #s
- AC joint decompression
- Septic glenohumeral joint - Debridement of í subacromial space - Septic glenohumeral joint
- Anterior shoulder decompression
- Shoulder arthroplasty - Removal loose bodies
- Standard: Supine - Standard: Supine - Standard: Prone
Position - Beach-chair
- Alternative: Beach-chair - Alternative: Beach-chair - Alternative: Lateral, Beach-chair
- 10-15 cm incision following í line of í
deltopectoral groove - Incision is made from í coracoid process - 5 cm incision is made from í tip of í acromion - Incision is made along í scapular spine,
Incision
- In obese patients, í incision starts at í along í anterolateral edge of í shoulder. distally in line é í arm extending to í lateral acromial border
coracoid process
- No internervous plane - No internervous plane
Intervals - Between í Deltoid & Pectoralis major - Between í Teres minor & Infraspinatus
- Deltoid split proximally to í axillary n. - Deltoid is split in line é its fibers
- Musculocutaneous n.: renters medial side of
- Axillary n.: It runs transversely across í
biceps muscle 5-8 cm distal to coracoid (stay - Axillary n.: It runs transversely across í - Suprascapular n.: Passes around í base of í
surface of í deltoid muscle 5-7 cm distal to í
lateral) surface of í deltoid muscle 5-7 cm distal to í scapular spine (do not retract infraspinatus
acromion from posterior to anterior
- Cephalic vein acromion from posterior to anterior too vigorously)
Dangers - Cannot extend split further due to risk to
- Axillary n.: at risk é release of subscapularis - Acromial branch of í thoracoacromial artery: - Axillary n.: Runs through í quadrangular
denervation of anterior deltoid, if distal
tendon or é incision of teres major tendon or Runs directly under í deltoid muscle space beneath í teres minor (Stay superior to
extension is needed make a 2nd incision
latissimus dorsi tendon í teres minor)
distally
- Anterior circumflex humeral artery

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 Arm
Anterior (Brachialis Splitting) Anterolateral Approach to Distal Humerus Lateral Approach to Distal Humerus Posterior
- Humeral shaft #s - Humeral shaft #s (More cosmetic)
- Humeral shaft #s - Distal humeral #s (Lateral condyle)
Indication - Humeral tumor biopsy/resection - Provides good exposure to both middle &
- Radial n. exploration - Open treatment of Lateral epicondylitis
- Humeral osteotomy distal 1/3 humeral shaft #s
- Prone é arm on arm-board, abducted 45°-60°
Position - Supine é arm on arm-board, abducted 45°-60° - Supine é arm lying across chest
- Lateral é arm over í top of í body
- Curved incision from í tip of í coracoid process distally in line é deltopectoral groove along í
lateral border of í biceps - Curved or straight incision over í lateral - Incision from 8 cm distal to í acromion to í
Incision
- Incision should end approximately 5 cm short of elbow flexion crease (Lateral antebrachial Supracondylar ridge olecranon fossa
cutaneous n. at risk)
- Proximal: Deltoid & Pectoralis major - No internervous plane - No internervous plane - No internervous plane
Intervals
- Distal: Medial brachialis & lateral brachialis - Between í Brachialis & Brachioradialis - Between í Triceps & Brachioradialis - This is a muscle splitting approach
- Anterior circumflex humeral artery:
- Lateral Cutaneous n. of í forearm: At í distal
Proximally ( ) í Pectoralis major & Deltoid
end of í incision as it exits í biceps laterally - Radial n.: On í middle 1/3 of í humerus
- Axillary n.: é vigorous retraction of í deltoid
- Radial n.: On í middle 1/3 of í humerus where - Radial n.: é proximal extension, as í n. pierces where it lays in í spiral groove (Must be
Dangers - Radial n.: On í middle 1/3 of í humerus where
it lays in í spiral groove (Must be identified í lateral septum in í distal 1/3 of í arm identified before brachialis muscle incision or
it lays in í spiral groove (Must be identified
before brachialis muscle incision or periosteal elevation)
before brachialis muscle incision or
periosteal elevation)
periosteal elevation)

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 Elbow
Posterior Anterolateral Medial Lateral (Radial Head)
- Distal biceps avulsion
- ORIF of #s of í distal humerus - Ulnar n. Decompression &/or transposition - Management of pathologies of í radial head
- Neural compressions involving:
- Best intra-articular view of í elbow - Ulnar removal of loose bodies - ORIF
- PIN syndrome
- Removal of loose bodies - ORIF of í Ulnar coronoid process - Radial head excision
Indications - Radial tunnel syndrome
- Non-unions of í distal humerus - ORIF of í Medial condyle & epicondyle - Radial head replacement
- Superficial radial nerves
- Triceps lengthening for extension - Debridement & reattachment of common - LCL reconstruction or repair
- Total elbow replacements
contractures of í elbow flexor wad for medial epicondylitis - Management of coronoid #s (limited access)
- Surgery of capitellum
- Supine é upper extremity supported on
- Prone or lateral decubitus é elbow flexed & - Supine é arm flexed & supported by arm patient's trunk & forearm pronated
Position - Supine é arm on radiolucent arm board
arm hanging from side of table board over í patient - Lateral decubitus é arm supported over a
bolster & forearm pronated
- Begin 5cm proximal to í olecranon in í
midline of í posterior distal humerus - Make curved incision starting 5 cm proximal
- Curve laterally proximal to í tip of í of í to flexion crease along í lateral border of í - Curved incision 8 to 10 cm long on í medial - 5cm longitudinal or gently curved incision
Incision olecranon along í lateral aspect of í biceps aspect of í elbow centered over í medial based off í lateral epicondyle & extending
olecranon process - Continue distally by following medial border epicondyle distally over í radial head approximately
- Then curve medially over í middle of í of í brachioradialis
posterior aspect of í subcutaneous ulna
- No internervous plane
- Proximal: ( ) Brachioradialis (radial n.) & - Proximal: ( ) Brachialis (musculocutaneous
- Extensor mechanism is either split or
Brachialis (Musculocutaneous n.) n.) & Triceps (radial n.) - Anconeus (radial n.) & Extensor carpi ulnaris
Intervals detached
- Distal: ( ) Brachioradialis (radial n.) & - Distal: ( ) Brachialis (musculocutaneous n.) (posterior interosseous n.)
- Radial n. innervates í triceps muscle more
Pronator teres (median n.) & Pronator teres (median n.)
proximally
- Lateral antebrachial cutaneous n. of í
- Ulnar n.: can usually be palpated 2cm
forearm: must incise skin & subcutaneous
proximal to medial epicondyle - Posterior Interosseous n.: not in danger as
tissues carefully - Ulnar n.: at risk during approach. must be
- Median n.: strict subperiosteal dissection off long as dissection remains proximal to
- Radial nerve dissected out to ensure protection
í anterior surface of í humerus protects it annular ligament. release supinator along
- PIN: vulnerable as it winds around í neck of í - Median n.: aggressive traction on í
Dangers - Radial n.: at risk proximally as it travels from posterior radius border beyond annular
radius éin í substance of í supinator muscle. osteotomy fragment can cause a traction
í posterior to anterior brachial ligament é forearm in full pronation
Incise í supinator muscle at its origin é injury to í median & anterior interosseous
compartments through lateral - Radial n.: not in danger as long as elbow
forearm supinated to protect í nerve. nerves
intermuscular septum. joint is entered laterally & not anteriorly
- Recurrent branch of í radial artery: must be
- Brachial artery: runs é í median n.
ligated to mobilize í brachioradialis

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 Forearm
Anterior Approach to Radius (Henry) Posterolateral Approach to Radius (Thompson) Subcutaneous Approach to Ulnar Shaft
- ORIF of proximal radius & radial shaft #s - ORIF of radial shaft #s using extensor side
- ORIF of ulnar #s
- Radial osteotomy - Radial osteotomy
- Ulnar osteotomy
- Tumor/abscess biopsy & excision - Osteomyelitis & Bone tumor resection/biopsy
Indications - Ulnar lengthening (Kienbock's disease)
- Anterior exposure of bicipital tuberosity - Access to í PIN as it passes through í arcade of Frohse for n.
- Ulnar shortening (for radial malunion)
- Superficial radial n. compression syndrome (Wartenberg paralysis
- Osteomyelitis & tumors of ulna
Syndrome) - Resistant Tennis elbow
- Patient supine
- if arm is abducted to í side on an arm board, í forearm
- Patient supine é arm placed across chest or elbow flexed
Position - Patient supine é í arm supinated on armboard should be pronated
while surgical assistant holds forearm vertically
- if arm is adducted across í chest, í forearm should be
supinated
- Straight or gently curved incision along í dorsolateral aspect
of í forearm
- Longitudinal incision begin just lateral to biceps tendon on flexor - Linear longitudinal incision over subcutaneous border of ulna
Incision - Begin anterior & distal to í lateral epicondyle of í humerus &
crease of elbow & end at radial styloid process (length based on procedure)
end just distal & ulnar to Lister's tubercle
- Be aware of superficial radial n. & cephalic vein distally
- Proximal: Brachioradialis (radial n.) & Pronator teres (median n.) - Proximal: ECRB (radial n.) & EDC (PIN n.)
Intervals - ECU (PIN) & FCU (ulnar n.)
- Distal: Brachioradialis (radial n.) & FCR (median n.) - Distal: ECRB (radial n.) & EPL (PIN n.)
- PIN.: enters í supinator muscle beneath a fibrous arch known as í
arcade of Frohse (thickened edge of í superficial head of í
- PIN.: usually from retraction, plates placed high on í dorsal
supinator muscle) compression of í n. at this point causes PIN - Ulnar n. & artery: Proximally passes through 2 heads of FCU
surface may trap í nerve
Dangers entrapment syndrome travels down forearm under FCU & on top of FDP
- Posterior interosseous artery: accompanies í PIN along í
- Superficial radial n.: runs down forearm under body of - protect by dissecting FCU subperiosteally
interosseous membrane in í proximal 1/3 of radius
brachioradialis
- Radial artery: runs down middle of forearm under brachioradialis

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 Wrist
Volar Approach to í Wrist FCR Approach to Distal Radius Dorsal Approach to í Wrist
- ORIF of distal radius #s
- Decompression of median nerve
- ORIF of carpal #s & dislocations
- Flexor tendon synovectomy
- Synovectomy & repair of extensor tendons
- Carpal tunnel tumor excision
- ORIF of distal radius #s - Wrist fusion
Indications - Carpal tunnel nerve & tendon repair
- ORIF of carpus #s - PIN neurectomy
- Drainage of sepsis from í mid-palmar space
- Excision of lower end of radius
- ORIF of #s & dislocations of distal radius & carpus especially
- Proximal row carpectomy
volar lip intra-articular #s
- Proximal pole scaphoid #
- Patient supine é í arm supinated on armboard é palm facing
Position - Patient supine é í arm supinated on armboard - Patient supine é í arm pronated on armboard
up
- Incision just ulnar to í thenar crease in hand & medial to
palmaris longus in wrist - Incision along palpable flexor carpi radialis (FCR) tendon
Incision - Begin 4cm distal to flexion crease, make ulnar curve so you sheath make ulnar or radial curve so you don't cross - 8 cm incision halfway ( ) radial & ulnar styloid
don't cross perpendicular to flexion crease (protect palmar perpendicular to flexion crease
cutaneous branch), end 3 cm proximal to flexion crease
- No internervous plane
- No muscles are transected
- APB, Palmaris brevis fibers that cross í midline can
Intervals - Flexor carpi radialis (median n.) & Flexor pollicis longus (AIN) - Dissection carried out ( ) í 3rd & 4th extensor compartments
occassionally be dissected
- Major nerves dissected out & preserved
- Plane of dissection ( ) median n. & FCR
- Palmar cutaneous branch of median n.: arises 5 cm proximal
to wrist joint, runs ulnar to FCR before crossing flexor - Superficial radial n.: emerges from beneath brachioradialis
- Palmar cutaneous branch of median n.: arises 5 cm proximal
retinaculum (Greatest risk when you do not curve your tendon just above í wrist joint before traveling to dorsum of í
to wrist joint, runs ulnar to FCR
incision ulnar) hand
- Radial artery.
Dangers - Motor branch of median n.: risk to n. minimized if incision - Dorsal cutaneous branches: lie in subcutaneous fat
- Volar wrist capsule ligaments: do not remove from volar
through retinaculum made ulnar to median nerve - Radial artery
distal radius unless access to wrist joint is needed (lead to
- Superficial palmar arch: crosses palm at level of distal end of - Interosseous ligaments: can cause carpal instability
radiocarpal instability)
outstretched thumb, avoid injury if retinaculum cut under - Scaphoid devascularization
direct observation for its entire length

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 Acetabulum
Posterior Approach (Kocher-Langenbeck) Ilioinguinal Approach Extensile (Extended iliofemoral) Approach
- Posterior wall #s - Transtectal transverse # é roof impaction
- Anterior wall #
- Posterior column #s - Transverse é posterior wall #s
- Anterior column #
- Posterior column/posterior wall #s - T--shaped #s é posterior wall involvement
- Anterior column/posterior hemitranverse #
- Transverse (Juxtatectal, infratectal or é posterior wall) #s - T-shaped #s é pubic symphysis dislocation
- Transverse # if displacement is anterior
Indications - Some T-type #s - Both-column #s é posterior wall or posterior column
- Majority of associated Both-column #s even in presence of
- THA & Hip hemiarthroplasty comminution, SI joint involvement,
posterior wall # (not recommended for #s associated é
- Removal of loose bodies - Delayed fixation of both column, T-shaped, or transverse +
comminuted post wall #s or SI joint #s)
- Dependant drainage of septic hip posterior wall #s (> 3 wks)
- Minimally posteriorly displaced T-type #s
- Pedicle bone grafting - Malunion/nonunion/deformity correction
- Entire posterior column - Sacroiliac joint - External aspect of í ilium
- Greater & lesser sciatic notches - Internal iliac fossa - Anterior column as far as í
- Ischial spine - Pelvic brim iliopectineal eminence
Access:
- Retroacetabular surface - Quadrilateral surface - Posterior column as far as í
- Ischial tuberosity - Superior pubic ramus upper ischial tuberosity
- Ischiopubic ramus - Limited to external iliac wing
- Lateral position: for joint arthroplasty (allows for femoral
- Supine é greater trochanter on side of # at edge of table
head dislocation)
Position - Hip & knee are flexed to relax í ilipsoas & neurovascular - Lateral position
- Prone position: for transverse # (flex í knee to prevent
structures
stretching of sciatic n.)
- Longitudinal incision centered over greater trochanter start - Incision begins at midline 3-4cm proximal to symphysis - Incision is carried along í iliac crest starting from í PSIS &
Incision just below iliac crest, lateral to PSIS, extend to 10 cm pubis, proceeds laterally to ASIS, then along anterior 2/3 of running anteriorly to í ASIS, it is then continued down from í
below tip of greater trochanter iliac crest ASIS in line é í posterior femur
- Sciatic n.: initially located along posterior surface of - Femoral n., Femoral & External Iliac Arteries: protect by - Superior gluteal artery & vein
quadratus femoris muscle (extend hip & flex knee to prevent leaving in femoral sheath - Sciatic nerve
injury), minimize chance of injury by using proper gentle - Lymphatics: present in fatty areolar tissue around vessels, - Lateral femoral cutaneous n.
retraction & releasing your short external rotators (obturator disruption can impair postoperative lymphatic drainage & - Perforating branches of í femoral artery
internus) posteriorly to protect í sciatic n. from traction, treat cause edema - Heterotopic Ossification : highest rate of heterotopic bone
injury é observation & use of ankle-foot orthosis - Lateral cutaneous n. of thigh: often have to sacrifice leaving formation of all pelvic approaches
- Inferior gluteal artery: leaves pelvis beneath piriformis, if it is numbness on í outer side of í thigh
cut & retracts into í pelvis, then treat by flipping patient, - Inferior epigastic artery: must sacrifice if has anomoulous
open abdomen & tie off internal iliac artery origin off obturator artery to allow retraction of iliac vessels
- First perforating branch of profunda femoris: at risk of injury - Spermatic cord: must protect, damage can cause testicular
é release of gluteus maximus insertion ischemia, infertility
Dangers
- Femoral vessels: at risk é failure to protect anterior aspect of - Heterotopic Ossification: much more common in í extended
í acetabulum or é placement of retractors anterior to í iliofemoral & Kocher-Lagenbeck approaches
iliopsoas muscle - Obturator n.: causes medial thigh numbness when injured
- Superior gluteal artery & n.: leaves í pelvis above í piriformis
& enters í deep surface of í gluteus medius, this tethering
limits upward retraction of gluteus medius & blocks you from
reaching í iliac crest
- Quadratus femoris: excessive retraction & injury must be
avoided to prevent damage to medial circumflex artery
- Heterotopic Ossification: debride necrotic gluteus minimus
muscle to decrease incidence of HO

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 Hip
Anterior (Iliofemoral, Smith-Petersen) Anterolateral (Watson-Jones) Direct Lateral (Hardinge, Transgluteal) Posterior (Moore or Southern)
- THA
- THA: minimally invasive approach (no
- DDH - THA
posterior soft tissue disruption)
- Intra-articular fusions - THA: has lower rate of total hip prosthetic - Hemiarthroplasty
- Hemiarthroplasty
Indications - Excision of pelvic tumors dislocations - Removal of loose bodies
- ORIF of femoral neck #
- Pelvic osteotomies - ORIF of proximal femur # - Dependant drainage of septic hip
- Synovial biopsy of hip
- Irrigation & debridement of septic hip - Pedicle bone grafting
- Biopsy of femoral neck
- Synovial biopsy of hip
- Lateral decubitus: for hip arthroplasty
- Lateral decubitus
Position - Supine - Lateral decubitus (Allows for femoral head dislocation)
- Supine
- Prone: for transverse acetabular #s
- Incision starts 2.5 cm posterior & distal to - 10 -15 cm curved incision one inch posterior
- Longitudinal incision begins 5cm proximal to
- Incision from anterior 1/2 of iliac crest to ASIS then runs distal to become centered to posterior edge of greater trochanter
tip of greater trochanter centered over tip of
Incision ASIS & from ASIS curve inferiorly in í over í tip of í greater trochanter, then it - Begin 7 cm above & posterior to GT then
greater trochanter & extends down í line of í
direction of í lateral patella for 8-10 cm crosses posterior 1/3 of trochanter before curve posterior to GT & continue down shaft
femur about 8cm
running down í shaft of femur of femur
- No internervous or Intermuscular plane
- Internervous plane: - No Internervous or Intermuscular plane - Split Gluteus maximus (inferior gluteal
- Superficial: Sartorius (femoral n.) & Tensor - Split Gluteus medius distal to nerve) till í first nerve branch to upper part
- Tensor fasciae latae (superior gluteal nerve)
Intervals fasciae latae (superior gluteal n.) innervation (superior gluteal nerve) & Vastus of muscle is encountered
& Gluteus medius (superior gluteal nerve)
- Deep: Rectus femoris (femoral n.) & lateralis lateral to innervation (femoral - Vascular plane: Superior gluteal artery
Gluteus medius (superior gluteal n.) nerve) supplies proximal 1/3 of muscle & inferior
gluteal artery supplies distal 2/3 of muscle
- Femoral nerve: most common problem is
- Lateral femoral cutaneous nerve: reaches
compression neuropraxia caused by medial - Superior gluteal nerve: runs ( ) gluteus
thigh by passing under inguinal ligament,
retraction, direct injury can occur from medius & minimus 3-5 cm above greater
injury may lead to painful neuroma or
placing retractor into the psoas muscle trochanter, protect by limiting proximal
decrease sensation on lateral aspect of thigh
- Femoral artery & vein: can be damaged by incision of gluteus medius
Dangers - Femoral nerve: remain protected as long as - As Kocher-Langenbeck approach
retractors that penetrate í psoas - Femoral nerve: most lateral structure in
you stay lateral to sartorius muscle
- Abductor limp: caused by trochanteric neurovascular bundle of anterior thigh
- Ascending branch of lateral femoral
osteotomy and/or disruption of abductor - keep retractors on bone é no soft tissue
circumflex artery: found proximally ( ) í
mechanism or denervation of í tensor under to prevent iatrogenic injury
tensor fascia latae & sartorius
fasciae by aggressive muscle split

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