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Introduction
  • Overview
    • also known as Kocher or posterolateral approach
  • Indications
    • management of pathologies of the radial head
      • ORIF
      • radial head replacement
      • radial head excision
    • lateral collateral ligament (LCL) reconstruction or repair
    • management of coronoid fractures (limited access)
       
Plane
  • Intermuscular plane between
    • anconeus (radial n.) 
    • extensor carpi ulnaris (posterior interosseous n.) 
        
Preparation
  • Anesthesia
    • general
      • advantageous for immediate post-operative neurologic examination or intra-operative airway control in patients with difficult airway
    • brachial plexus nerve blocks
      • advantageous for post-operative pain control
  • Position
    • supine
      • with upper extremity supported on a hand table or on patient's trunk
    • lateral decubitus 
      • with arm supported over a bolster 
    • forearm pronated in both positions
  • Tourniquet applied to arm
    • sterile tourniquet
      • greater elbow access with sterile tourniquet
      • exsanguinate limb with Esmarch or elevation
 
Approach
  • Incision
    • landmarks
      • lateral humeral epicondyle
      • radial head
        •  2.5 cm distal to lateral epicondyle, head (or crepitus in fractured) palpable with pronation/supination
      • olecranon
    • incision
      • make a ~5cm longitudinal or gently curved incision based off the lateral epicondyle and extending distally over the radial head approximately
      • incision angle can be varied based on need to address associated pathology
  • Superficial dissection
    • incise deep fascia in line with incision
    • identify plane between ECU and anconeus distally
  • Deep dissection
    • maintain arm in pronation to move PIN away from field 
    • split proximal fibers of supinator, staying on the posterior cortex of the radius away from PIN
    • if LCL intact, stay 1 cm anterior to crista supinatoris to avoid damage
      • in cases of elbow dislocation, LCL frequently not intact
    • incise capsule longitudinally
      • avoid dissecting distally or anteriorly (PIN)
      • maintain dissection in mid radiocapitallar plane to avoid damaging LCL
  • Extension
    • proximal
      • extend superficial dissection by dissecting down onto lateral supracondylar ridge
      • avoid origin of LCL unless operation directed at its repair/reconstruction
    • distal
      • this approach should not be extended distally as this places the PIN at risk 
   





Dangers
  • Posterior Interosseous nerve
    • not in danger as long as dissection remains proximal to annular ligament
    • release supinator along posterior radius border beyond annular ligament with forearm in full pronation
    • retractors placed blindly anteromedially or with excessive retraction may lead to nerve injury 
  • Radial nerve
    • not in danger as long as elbow joint is entered laterally and not anteriorly
 

 

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