Subcutaneous Approach to Ulnar Shaft

Subcutaneous Approach to Ulnar Shaft is the simplest of all forearm approaches, uncovering the entire length of bone.

  • The uses of the Subcutaneous Approach to Ulnar Shaft include the following:
    1. Open reduction and internal fixation of ulnar fractures.
    2. Treatment of delayed union or nonunion of ulnar fractures.
    3. Osteotomy of the ulna.
    4. Treatment of chronic osteomyelitis.
    5. Treatment of the fibrous anlage of the ulna in cases of ulnar clubhand.

    6. Ulnar lengthening (in Kienböck’s disease).
    7. Ulnar shortening (in cases of distal radial malunion) .

  • Patient supine with arm placed across chest.
  • Or elbow flexed while surgical assistant holds forearm vertically.

  • Landmarks:
    • The subcutaneous border of the ulna.
  • Incision:
    • Palpate subcutaneous ulnar border of ulna
    • Make linear longitudinal incision over subcutaneous border of ulna
      • Length based on procedure.
      • In cases of fracture, center the incision over the fracture site.

  • The internervous plane for subcutaneous approach to ulnar shaft lies between:
    1. The extensor carpi ulnaris muscle which is supplied by the posterior interosseous nerve, 
    2. The flexor carpi ulnaris muscle which is supplied by the ulnar nerve.

  • Incise deep fascia in distal incision in line with skin incision.
  • Divide plane between extensor carpi ulnaris muscle and flexor carpi ulnaris muscle.
  • Dissect down to subcutaneous border of ulna.
    • at middle 1/3 of ulna must divide fibers of  extensor carpi ulnaris muscle to reach bone.

  • Incise periosteum over ulna:
    • perform sub-periosteal dissection.
  • In the proximal fifth of the ulna, part of triceps insertion must be detached to gain access to the bone.

  • The approach cannot be extended usefully distally.
  • It can be extended over the olecranon and up the back of the arm.

  • The structures at risk during subcutaneous approach to ulnar shaft includes:
    1. Ulnar nerve:
      • Proximally passes through two heads of flexor carpi ulnaris muscle.
      • Travels down forearm under flexor carpi ulnaris muscle and on top of flexor digitorum profundus muscle.
      • Protected by dissecting flexor carpi ulnaris muscle sub-periosteally.
    2. Ulnar artery:
      • Travels down forearm with ulnar nerve,
        • Ulnar artery is radial to ulnar nerve.
      • Protected by dissecting flexor carpi ulnaris muscle sub-periosteally.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
Subcutaneous Approach to Ulnar Shaft Subcutaneous Approach to Ulnar Shaft Subcutaneous Approach to Ulnar Shaft Subcutaneous Approach to Ulnar Shaft
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