SHOULDER - Peggers Super · Web viewSubperiosteal elevation laterally and medially allows...

Notes on anatomy surgical exposure

SHOULDER

Anterior approach: Delto-Pectoral

Interneural plane (axillary and medial and lateral pectoral nerves)

Surface markings:

Coracoid process and oblique incision inferiorly between delotpectoral region

Dangers:

1. Musculocutaneous nervea. 2-5cm under coracoid and coracobrachialis medially (do not over retract)

2. Axillary Nervea. Length of PIPJ to tip of index finger under Coracoid

3. Brachial Plexus

Waymarkers:

Cephalic vein o marks plane between deltoid and pectoralis muscleso Ligate tributaries and mobilise vessel

Tip of Coracoido Lateral side of conjoint tendon is “safe side”o Conjoint tendon made up from SH of biceps and coracobrachialis

Leash of vessels at inferior margin of subscapulariso Lowest safe margin – brachial plexus below

Important Notes:

Quadrangular space Bursa

Mackenzie Approach to the Shoulder: for access to proximal humerus, rotator cuff and subacromial space

Muscle splitting

Surface markings:

5cm vertical incision from acromion down line of arm

Dangers:

Axillary nerve – runs 5-7 cm horizontally distal to acromion

Waymarkers:

Split deltoid in line of fibres – place a suture in apex to prevent split propagation

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Important Notes:

Identify axillary nerve before making a 2nd vertical incision distally

Posterior Approach to the Shoulder: glenoid fractures

Interneural plane

Surface markings:

Longitudinal incision along scapular spine Extending to lateral acromion boarder

Dangers:

1. Axillary nerve - laterally2. Circumflex Scapular artery - medially

Waymarkers:

Junction between infraspinatus – multipennate muscle covered in fascia (Suprascapular nerve) and Teres Minor – a unipennate muscle (Posterior division of axillary nerve)

Important Notes:

Rotator interval – between subscapularis and supraspinatus Ligaments found in the interval Subscapular bursa

o Communicates with glenohumeral joint via foramen of Rouviereo Constantly found between superior and middle glenohumeral ligament

Posterior arthroscopic to the shoulder:

Surface markings:

Lateral inferior corner of the acromium 2cm inferior and medial Soft area aiming for coracoid

Dangers:

1. Axillary nerve - laterally2. Circumflex Scapular artery - medially

Important Notes:

Rotator interval – between subscapularis and supraspinatus Ligaments found in the interval Subscapular bursa

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o Communicates with glenohumeral joint via foramen of Rouviereo Constantly found between superior and middle glenohumeral ligament

HUMERUS

Anterior approach to the humerus: Upper 2/3 of humerus approach can extend to shoulder approach between deltoid and pectoralis major

Interneural plane (as Brachialis has dual innervation)

Surface markings:

Lateral side of biceps tendon with arm flexed

Dangers: MUST STICK SUBPERIOSTEALLY TO AVOID NERVES

Radial nerve laterally – identify before brachialis is split

Ulnar nerve medially

Waymarkers:

Split Brachialis (lateral 1/3 supplied by radius and medial 2/3 by musculocutaneous)

Important Notes:

Distally radial nerve is found between brachioradialis and Brachialis

Cannot extend distally

Anterolateral approach to the humerus: use for radial nerve exploration distal humerus

Interneural plane

Surface markings:

Lateral to biceps muscle

Dangers:

Radial nerve (and the superficial branch)

Lateral cutaneous nerve of forearm (5cm from elbow crease)

Waymarkers:

Retract Biceps medially and retract lateral antebrachial cutaneous nerve with it. Between Brachialis (Radial & musculcutaneous nerve) and Brachioradialis (radial

nerve)

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Develop intermuscular plane between these 2 muscles Brachialis also goes medially with the biceps muscle and tendon

Important Notes:

Posterior Approach to the humerus: for inferior 2/3rds of humerus

Muscle splitting approach

Surface markings:

8 cm distal to the acromion to the olecranon fossa

Dangers:

Radial nerve

o nerve crosses posterior aspect of humerus at 20-21 cm proximal to medial epicondyle and 14-15 cm proximal to lateral epicondyle

Waymarkers:

split fascia between long and lateral head of triceps

retract lateral head laterally and long head medially

radial nerve found in spiral groove

Important Notes:

Lateral Approach to the humerus: for Holsteine Lewis fracture of distal 1/3 of humus with radial nerve palsy ideal for exploring

Muscle splitting plane

Surface markings:

Lateral supracondylar ridge between brachioradialis in upper 1/3 and ECRL in lower 1/3

Dangers:

Radial nerve pierces lateral septum between proximal 2/3rds and distal 1/3rd proximately

PIN distally

Waymarkers:

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Muscle plane between triceps (radial nerve) and brachioradialis (radial nerve)

Reflect triceps posteriorly and brachioradialis anteriorly

Deeper common extensor origin and triceps can be elevated

Important Notes:

DISTAL EXTENSION Interneural plane between aconeus (radial) and ECU (PIN)

ELBOW:

Posterolateral or Kockers Approach to the Radial head:

Interneural interval – between aconeus and ECU

Surface markings:

Lateral epicondyle to end of proximal ulna

Dangers:

PIN – keep arm pronated to prevent injury

Waymarkers:

Aconeus (radial nerve) is fan shaped proximately and vertical distally

ECU (PIN)

Important Notes:

PIN is found between the muscle planes of EDC and ECRL interval

Triceps Split

Surface markings:

Start 5cm proximal to olecranon and then curve medially around olecranon to middle of ulna distally

Dangers:

Ulnar nerve dissected out and protected

Median nerve – stay subperiosteal anteriorly will protect nerve

Radial nerve – runs 14-15cm proximal to lateral epicondyle as is travels from posterior to anterior compartments in the arm

Waymarkers:

Incise fascia over midline identify ulnar nerve and dissect out

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Chevron the olecranon making sure the olecranon is mountain shape

Split with an osteotome to aid anatomical reduction after

Subperiosteal elevation laterally and medially allows access to distal 4th of humerus.

Important Notes:

Distally the ulnar nerve is found between the 2 heads of FCU

FOREARM

Volar Approach: Henry’s approach

Interneural plane

Surface markings:

Radial side of biceps tendon to radial styloid

Dangers:

Lateral antebrachial cutaneous nerve

Radial artery and superficial radial nerve – under brachioradialis (mobile wad)

PIN – enters supinator via arcade of Frohse – this is the moster superior and superficial layer of the supinator muscle

Waymarkers:

Develop plane between brachioradialis (radial nerve) and flexor carpi radialis (median nerve)

Start distal to proximal identify superficial radial nerve under brachioradialis and ligate branches of radial nerve to aid lateral retraction of BR

Proximately the bursa on the radial aspect of the biceps tendon can be incised to gain access (the radial artery lies ulnar side of biceps tendon TAN)

Proximal 1/3

o Keep arm supinated to avoid PIN.

o The supinator is seen in the proximal 1/3 and this is incised along its broad insertion

Middle 1/3

o Pronate to bring into view pronator teres and incise and retract medially

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Distal 1/3

o Semi supinate arm and elevate periosteum lateral to FDS and PQ

Important Notes:

Proximately supinator needs to go ulnarly

Middle Pronator teres can be peeled off radius in neutral position

Distally plane is between FRC and Brachioradialis

Dorsal Approach: Thompson’s Approach

Internervous plane

Surface markings:

Lateral epicondyle to listers tubercle – for access to proximal 1/3 of radius

Dangers:

PIN

Waymarkers:

Superficial dissection

Proximal 1/3 – ECRB (radial N) & EDC (Pin) plane

Distal 1/3 – ECRB and EPL (Pin) plane

Deep dissection

Proximal 1/3 Must identify PIN as it leaves the Supinator muscle belly

o Either dissect nerve out of muscle

o Or Subperiosteally lift supinator off bone to protect nerve

Middle 1/3 Abductor pollicis longus and extensor pollicis brevis muscles are retracted off bone

Important Notes:

PIN usually injured in retraction though 25% actually are in direct contact with the proximal radius

HIP:

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Lateral Approach: Hardinge or Modified Hardinge

Splits gluteus medius distal to superior gluteal nerve

Surface markings:

Longitudinal incision centred over GT and curving posteriorly

Dangers:

Superior gluteal nerve 4-5cm above tip of GT

Waymarkers:

Skin, subcutaneous tissues down to fascia lata

Take GM off GT and go proximately laterally <4cm for access

Extend incision inferiorly through VL

Gluteus minimus is excised off anterior GT

Expose anterior joint capsule and perform T shaped capsulotomy down to fibrous rim

Important Notes:

Leave sufficient cuff on bone to help reattach GM tendon

Anterolateral Approach: Watson Jones

Inter muscular plane

Surface markings:

15cm incision centred over GT

Dangers:

Femoral vessels

Waymarkers:

Same approach as Modified Hardinge

Find plane between GM and TFL (both superior gluteal nerve)

Develop this interval and externally rotate hip to find origin of vastus lateralis

Detach abductor mechanism

In front of the joint capsule will lie rectus femoris and psoas which may need elevating and retracting

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Anterior Approach: Smith Peterson – Hoyter Modification

Interneural plane

Surface markings:

ASIS to lateral side of patella for 8-10 cm

Incision can be extended proximately underneath line of ilium

Dangers:

Lateral cutaneous femoral nerve

o Passes 10-15 cm laterally to ASIS under inguinal ligament

Femoral nerve

o Medial side of Sartorius muscle (forms lateral wall of femoral triangle)

Ascending branch of lateral femoral circumflex artery

o Ligate to avoid excessive bleeding

Waymarkers:

Identify gap between Sartorius (femoral N) and TFL (Superior gluteal N)

Subcutaneous fat will have lateral cutaneous femoral nerve

Incise fascia on medial side of TFL

Detach origin of TFL to develop plane and identify and ligate lateral femoral circumflex artery

Deeper identify plane between rectus femoris (femoral N) & gluteus medius (superior gluteal N)

Detach rectus femoris from attachment and retract medially with psoas, GM can go laterally to expose capsule

Externally rotate hip also to aid this

Posterior Approach (Moore or Southern)

Inter muscular pane splitting of gluteus maximus (inferior gluteal nerve)

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Surface markings:

Posterior curvilinear approach centred over GT

Can mark this out by flexing hip to 900 and draw a straight line in line with the femur, when the leg straightens it is now curvilinear

Dangers:

Sciatic nerve – can split look around piriformis to see if there is another branch

Inferior gluteal artery – leaves pelvis under piriformis

Perforating branch of profunda femoris – can be cut whilst releasing gluteus maximus insertion

Anterior to acetabulum are the femoral vessels

Waymarkers:

Superficial

Split fascia in line with incision to visualise vastus lateralis and gluteus fan shaped incision proximately

Split maximus in line with its fibres

Deep

Internally rotate hip to place tension on short rotators

Detach piriformis and obturator internus 1cm from femoral insertion.

FEMUR

Lateral

None splits vastus lateralis

Surface markings:

Lateral thigh with leg internally rotated 15 degrees

Dangers:

Perforating vessels of profunda femoris artery – bleeding ++

Waymarkers

Fascia lata

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Fascial covering to VL

Split VL

Subperiosteal dissection to expose femur

Posterolateral

Interneural plane

Surface markings:

Posterior aspect of femoral condyle up the shaft

Dangers:

Perforating branches of the pronfunda femoris artery Superior lateral geniculate artery and vein

Waymarkers

Deep fascia of thigh

Feel intermuscular septum go anteriorly between VL (femoral N) & hamstrings (sciatic N)

Reach the linea aspera

KNEE

Medial para-patella – relative CI is previous lateral para-patella

None

Surface markings:

5cm above superior pole of patella down to tibial tubercle (either straight or curvilinear)

Dangers:

Superior lateral geniculate artery

Infra-patella branch of saphenous nerve

o Subcutaneous after leaving fascia lata

Waymarkers

Superficial

Deepen dissection between vastus medialis and quads tendon

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Medial arthrotomy medial to patella tendon

Excise fat pad

Deep

Reflect patella laterally

If difficult extend incision proximately

ANKLE

Lateral ankle

None

Surface markings:

Centre incision over fracture make long enough to avoid skin tension

Dangers:

Superficial peroneal nerve – 6-10 cm proximal to tip of fibula from posterior to anterior

Short saphenous vein

Sural nerve runs along posterior aspect of fibula

Waymarkers

Blunt dissection in subcutaneous tissues

Stick to bone and stay subperiosteally when clearing fracture site

Anteromedial ankle

None

Surface markings:

8-10cm incision curving anteriorly centred over anterior 1/3 of malleolus

Dangers:

Saphenous nerve – numbness over medial foot and vein

Waymarkers

Skin flap blunt dissection in subcutaneous tissues

Stick to bone and lift out fracture to expose joint

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Longitudinal split to bring screw to bony tip

Posterolateral ankle: - for posterior malleolus fracture size is not necessarily an issue by note mechanism – if axial or shearing it should be fixed

None

Surface markings:

Begin 12cm proximal to lateral malleoli tip

Half way between tendon and fibula

Curve to posterior fibula and then follow peroneal tendons to 2cm below and anterior to malleolar tip

Dangers:

Sural nerve half way between Achilles and fibula

Deep are the posterior n/v bundles going posterior to the medial malleolus

Waymarkers

Aim to go between muscle bellies of peroneals either side depending on access

Meat to the heal is FHL

Anterior to ankle:

None inter-tendinous all supplied by deep peroneal nerve

Surface markings:

Lateral to EHL is where the anterior tibial artery and deep peroneal nerve

Dangers:

Anterior tibial artery

Deep peroneal nerve

Waymarkers

Incise fascia and locate EHL – n/v bundle lateral to this

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SHOULDER - Peggers Super · Web viewSubperiosteal elevation laterally and medially allows...

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