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. Treatment of neural compression lesions of the proximal half of the posterior interosseous nerve and of the proximal part of the superficial radial nerve access to the arcade of Frohse, as well as treatment of radial head fractures with paralysis of this nerve.
3. Total elbow replacements.
4. Drainage of infection from the elbow joint.
5. Open reduction and internal fixation of the capitulum.
6. Treatment of aseptic necrosis of the capitulum
7. Excision of tumors of the proximal radius.

This approach is a distal extension of the anterolateral approach to the humerus and a proximal extension of the anterior approach to the radius.

Theoretically, the anterolateral approach to the elbow can link the two together to expose the entire upper extremity from shoulder to wrist.

Position of the Patient

Place the patient supine on the operating table with arm on radiolucent arm board.

Landmarks and Incision

Landmarks:

• The brachioradialis muscle.
• 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

Internervous plane for the anterolateral approach to the elbow:

Proximally lies between:

• Brachialis muscle: it’s innervated by the musculocutaneous nerve,
• Brachioradialis muscle: it’s innervated by the radial nerve.

Distally lies between:

• Brachioradialis muscle: it’s innervated by the radial nerve,
• Pronator teres muscle: it’s innervate by the median nerve.

Superficial dissection

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:

• Posterior interosseous nerve (PIN) enters the supinator muscle.
• Sensory branch travels deep to brachioradialis muscle.
• Motor branch to the Extensor Carpi Radialis Brevis muscle (ECRB)

Develop the interval between the brachioradialis and Pronator Teres muscles 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.

Deep dissection

Incise the joint capsule between the radial nerve laterally and the brachialis muscle medially.

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.

Approach Extension

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.

Dangers

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: It’s 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: It must be ligated to mobilize the brachioradialis muscle.

References & More

• Surgical Exposures in Orthopaedics book – 4th Edition
• Campbel’s Operative Orthopaedics book 12th
• Orthobullets Website