Updated: 8/30/2017

Elbow Kaplan Approach

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Introduction
  • Overview
    • allows exposure of the radial head, coronoid and anterolateral distal humerus
    • should only be done by experienced surgeons familiar with anatomy in this region given significant risk of injury to PIN  
  • Indications
    • radial head fractures
    • capitellum fractures
    • PIN decompression
    • lateral humeral condyle fractures
    • proximal radius tumors
    • irrigation and drainage of septic elbow
Surgical plane
  • Intermuscular
    • ECRB (radial n. or PIN) and EDC (PIN)  
      • ECRB has variable innervation
        • cadaveric study: 50% PIN, 35% superficial sensory, 15% radial nerve proper
Preparation
  • Anesthesia
    • general 
    • regional
      • supraclavicular block
        • risks: pneumothorax, phrenic nerve paresis
  • Position
    • supine
      • abducted arm on hand table
      • "sloppy lateral" - bump under ipsilateral scapula, arm draped over chest
  • Tourniquet
    • sterile vs. nonsterile
      • sterile best if proximal extension anticipated
Approach
  • Incision
    • proximal landmark: lateral epicondyle
    • distal landmark: Lister's tubercle
    • make 4cm longitudinal incision from tip of lateral epicondyle distally towards Lister's tubercle
  • Superficial dissection
    • identify ECRB / EDC interval and bluntly develop plane
    • retract ECRB radial and EDC ulnar to expose supinator deep
    • pronate the forearm to protect PIN
    • detach humeral and ulnar heads of the supinator to visualize annular ligament and capsule deep
  • Deep dissection
    • incise lateral annular ligament + capsule anterior to LUCL along the equator of the radiocapitellar joint to expose the radial head
  • Extension
    • proximal
      • same as proximal extension of Kocher approach
      • intermuscular: triceps (radial n.) and brachioradialis/ECRL (radial n.)
    • distal: posterolateral approach to the forearm (Thompson)
      • extend skin incision distally, still aiming towards Lister's tubercle
      • develop ECRB / EDC interval to visualize distal extent of supinator
      • identify PIN and protect
        • can palpate as bulge in muscle belly or make small nick in the muscle and dissect to find the nerve
      • supinate arm to bring supinator insertion into surgical field
      • incise supinator along radial insertion and elevate subperiosteally to expose the radial shaft
Dangers
  • Posterior interosseous nerve (PIN)
    • more anterior, greater risk than Kocher approach
    • pronation of forearm moves PIN ~1cm further from the radiocapitellar joint; supination moves PIN ~1cm closer to radiocapitellar joint
  • Radial nerve
  • Lateral antebrachial cutaneous nerve
    • travels within subcutaneous fat at the distal aspect of the incision
  • Radial recurrent artery (recurrent leash of Henry)
    • injury can result in post-op hematoma 
  • Lateral collateral ligament repair
    • more anterior approach avoids injury to LCL complex, but if LCL is traumatically disrupted it is difficult to access and repair via the Kaplan approach
      • necessitates release of EDC to visualize LCL complex
 

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