Anterolateral Approach to the Elbow

The anterolateral approach to the elbow exposes the lateral half of the elbow joint, especially the capitulum and the proximal third of the anterior aspect of the radius.

  • Anterolateral approach to the elbow uses include the following:

    1.  Distal biceps avulsion
    2. Neural compressions involving
      1. PIN syndrome
      2. Radial tunnel syndrome
      3. Superficial radial nerves
    3. Total elbow replacements
    4. Drainage of infection from the elbow joint
    5. Surgery of capitulum (ORIF, aseptic necrosis)
    6. Excision of tumors

  • Patient is supine on the operating table with arm on radiolucent arm board.

  • Landmarks:
    1. The brachioradialis muscle.
    2. The biceps tendon.
  • Incision:
    • Make curved incision starting 5 cm proximal to flexion crease along the lateral border of the biceps muscle.
    • Continue distally by following medial border of the brachioradialis muscle.

Internervous plane for the anterolateral approach to the elbow:

  • Proximally between:
    • Brachialis muscle: innervated by musculocutaneous nerve,
    • Brachioradialis muscle: innervated by radial nerve.
  • Distally between:
    • Brachioradialis muscle: innervated by radial nerve,
    • Pronator teres muscle: innervate by median nerve.

  • Identify lateral antebrachial cutaneous nerve (sensory branch of the musculocutaneous nerve which becomes superficial 2 inches proximal to the elbow crease, lateral to the biceps tendon).
  • Incise the deep fascia along the medial border of the brachioradialis muscle.
  • Identify radial nerve proximally at level of the elbow joint (between brachialis and brachioradialis muscles).
  • Follow the radial nerve distally until it divides into its three main branches:
    • PIN (enters the supinator muscle).
    • Sensory branch (travels deep to brachioradialis muscle).
    • Motor branch to the Extensor Carpi Radialis Brevis muscle (ECRB).
  • Develop brachioradialis and Pronator Teres interval distal to the division of the radial nerve.
  • Ligate recurrent branches of the radial artery and muscular branches that enter the brachialis muscle just below the elbow to allow better retraction.

  • Joint capsule:
    • Incise the joint capsule between the radial nerve laterally and the brachialis muscle medially.
  • Proximal radius:
    • Expose proximal radius by supinating the forearm to bring the supinator muscle anteriorly.
    • Incise the muscle origin down to bone, lateral to the insertion of the biceps tendon.

Anterolateral approach to the elbow can be extended proximally and distally.

  • Proximal Extension:
    • Extends into the anterolateral approach to the arm developing the plane between the brachialis and the triceps muscles.
  • Distal Extension:
    • Extends to the anterior approach to the radius between the planes of the brachioradialis and pronator teres muscles proximally, and the brachioradialis and flexor carpi radialis (median nerve) muscles distally.

The structures at risk during anterolateral approach to the elbow joint include:

  1. Lateral antebrachial cutaneous nerve of the forearm.
    • Must incise skin and subcutaneous tissues carefully.
  2. Radial nerve.
  3. PIN:
    • Vulnerable as it winds around the neck of the radius within the substance of the supinator muscle.
    • Incise the supinator muscle at its origin with forearm supinated to protect the nerve.
  4. Recurrent branch of the radial artery:
    • Must be ligated to mobilize the brachioradialis muscle.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
Anterolateral Approach to the elbow Anterolateral Approach to the elbow Anterolateral Approach to the elbow Anterolateral Approach to the elbow Anterolateral Approach to the elbow Anterolateral Approach to the elbow
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