Fibula – Approach

Fibula – approach

* position – supine with sandbag under buttock or lateral

* incision – long. incision just post. to fibula beginning behin lat. malleolus & extending to level of fibular head

* internervous plane – peroneal muscles (SPN) & flexor muscles (tibial n.)

* dissection
– find post. border of BF as it sweeps down past knee before inserting on head of fibula
– incise fascia & ID CPN
– trace course of CPN as it winds around fibular neck
– mobilize CPN from groove on back of neck
– develop plane btw PL & soleus
– incise periosteum of fibula
– strip muscle off fibula
– strip interosseous membrane subperiosteally from prox. to distal

* dangers
– CPN – winds around neck of fibula
– dorsal cut. branch of SPN – ID at jxn of distal & middle 1/3 of fibula
– peroneal art. – terminal branches lie close to deep surface of lat. malleolus
– lesser saphenous vein

Forearm – Volar Approach (Henry’s)

Forearm – volar approach (Henry’s)

* position – supine with tourniquet

*

Forearm – Dorsal Approach (Thompson)

Forearm – dorsal approach (Thompson)

* position – supine with tourniquet

* incision – straight incision from just anterior to lat. epicondyle –> ulnar side of Lister’s tubercle

* internervous plane:
– prox – ECRB (radial n.) & EDC (PIN)
– distal – ECRB (radial n.) & EPL (PIN)

* superficial dissection
– incise fascia
– interval btw ECRB & EDC
– start midshaft
– interval btw ECRB & EPL

* deep dissection
– proximal 1/3
> identify supinator
> locate PIN as it emerges 1 cm from distal end of muscle btw deep & superficial heads
> dissect nerve out of supinator
> fully supinate forearm
> detach supinator at insertion from ant. aspect of radius

– middle 1/3
> APL & EPB cross dorsal aspect of radius
> retract off bone & make incision along their sup. & inf. borders

– distal 1/3
> separating ECRB & EPL exposes lat. border of radius

* dangers – PIN – identify carefully b/c in 25% it touches the dorsal aspect of radius at level of biceps tuberosity

Hindfoot – Lateral Approach

Hindfoot – lateral approach

* position – supine with sandbag under buttock

* incision
– curved, transverse incsion starting just distal to distal end of lat. malleolus
– continue distally over lat. side of hindfoot & over sinus tarsi
– curve med. to end over talocalcaneonavicular joint

* internervous plane – peroneus tertius (DPN) & peroneal tendons (SPN)

* dissection
– don’t mobilize skin flaps widely — at risk of necrosis
– incise deep fascia in line with skin
– avoid tendons of peroneus tertius & EDL
– retract PT & EDL med.
– detach fat that lies in sinus tarsi
– detach origin of EDB from calcaneus
– expose dorsal capsule of talocalcaneonavicular joint in distal end of wound
– expose dorsal capsule of calcaneocuboid joint lat.
– incise peroneal retinacula & reflect peroneal tendons ant.
– incise capsule of post. talocalcaneal joint

Hip – Anterior Approach

Hip – anterior approach
Smith-Peterson approach

* position – supine +/- sandbag under affected hip

* incision
– long icision following ant. half of iliac crest to ASIS
– curve incision 8-10cm to run vertically down thigh towards lat. aspect of patella

* internervous plane
– sartorius (fem. n.) & TFL (sup. gluteal n.)
– rectus femoris (fem. n.) & gluteus medius (sup. gluteal n.)

* dissection
– ER leg to stretch sartorius
– ID gap btw TFL & sartorius usu 2-3 in below ASIS
– dissect down thru subcut. fat along intermuscular interval avoiding lat. fem. cut. n. –> pierces deep fascia of thigh close to interval
– incise deep fascia on med. side of TFL
– detach origin of TFL to develop plane
– ascending branch of lat. fem. circumflex art. crosses btw TFL & sartorius
– detach rectus from both origins (AIIS & sup. lip of acetabulum)
– adduct & ER leg to put capsule on stretch
– incise hip capsule either long. or t-shaped

* dangers
– lat. fem. cut. n.
> reches thigh by passing over, behind or thru sartorius 2.5 cm below ASIS
> beware of nerve when incising fascia btw TFL & sartorius

– femoral n. – lies directly ant. to hip joint in fem. triangle & well med. to rectus femoris

– ascending branch of lat. fem. circumflex art. – crossed field prox. btw TFL & sartorius

Hip – Anterolateral Approach

Hip – anterolateral approach
Watson-Jones

* position
– usu in lat. decubitus position
– may use supine position

* incision – 15 cm incision centered on GT, may curve slightly post. proximally

* internervous plane
– no true plane
– btw TFL & gluteus med. (sup. gluteal n.)

* dissection
– incise fat to reach deep fascia
– incise fascia latae at post. margin of GT distally
– ID interval btw TFL & GMax & incise fascia
– retract GMed & GMin prox. & lat. away from sup. margin of capsule
– ER leg to expose joint capsule
– dissect up fem. neck to expose capsule
– may require troch. osteotomy or detachment of ant. 1/3 of GMed
– detach reflected head of rectus
– incise hip capsule (H-shaped)
– dislocate hip

* dangers
– fem. n. – most lat. placed structure in fem. triangle & can be stretched with overzealous retraction of ant. tissues

– profunda femoris art. – lies on psoas muscle deep to fem. art. & can be damaged by poorly placed retractors

– fem. art & vein – may be damaged by incorrectly place acetabular retractors that penetrate iliopsoas

– femoral shaft #s – with dislocation of hip or with forced adduction & ER for reaming of shaft

Hip – Lateral Approach

Hip – lateral approach
Hardinge

* position – supine or lat. decubitus

* no internervous plane

* incision – 15 cm longitudinal incision centered over GT

* dissection
– incise fat & deep fascia in line with incision
– retract TFL ant. & GMax post.
– split fibers of GMed in direction of fibers in middle of GT
– split fibers of vastus lat.
– develop ant. flap of ant. GMed & vastus lat.
– detach muscles subperiosteally from GT or with flake of bone
– detach GMin with flap
– incise capsule (t-shaped)
– osteotomy of fem. neck
– extend capsulotomy
– remove fem. head
– complete exposure of acetabulum

* dangers
– SGN – runs btw GMed & GMin 3-5cm above upper border of GT
– more prox. dissection can cut nerve or produce traction injury

– fem. n. – vulnerable to inapporpriately placed retractors

– transverse branch of lat. fem. circumflex art. – cut as vastus lat. mobilized

Hip – Medial Approach

Hip – medial approach
Ludloff

* position – supine with affected hip flexed, abducted & ER

* incision – long. incision on med. side of thigh starting 3 cm below pubic tubercle over add. longus

* internervous plane
– add. longus & gracilis (both innervated by ant. branch of obturator n. but receive nerve supply prox. to dissection)
– add. brevis & magnus
– add. magnus – 2 nerve supplies (post. division of obturator n. & tibial portion of sciatic n.)

* dissection
– incise subcut. tissue
– develop plane btw add. longus & gracilis
– develop plane btw add. brevis & magnus
– ID LT
– place retractor above & below LT to isolate psoas tendon

* dangers
– ant. div. of obturator n.
> lies on top of obturator ext. & runs down med. side of thigh btw add. longus & add. brevis
> supplies add. longus, gracilis, add. brevis

– post. div. of obturator n.
> lies in substance of obturator ext. & runs down thigh on add. magnus & under add. brevis
> supplies obturator ext. & add. portion of add. magnus

– med. fem. circumflex art. – passes around med. side of distal part of psoas

MCQs – Anatomy 1

MCQs-Anatomy 1
MCQs-Anatomy
– static stabilizers of the shoulder: capsuloligamentous, articular surfaces, and the negative intra-articular pressure components. Dynamic stabilizers include the rotator cuff, biceps tendon, deltoid

– quadrangular space: teres minor, teres major, long head triceps, humeral shaft – axillary nerve and posterior circumflex humeral artery (at the front, you don’t see teres minor – the superior border is subscap)

– triangular interval: not really a space per se – radial nerve and profundi brachii

– triangular space: teres minor, teres major, long head of triceps – circumflex scapular goes through it

– rotator cuff is basically C5/6

– the omohyoid muscles lies anterior to anterior scalene muscle (which lies anterior to the brachial plexus)

– the suprascapular nerve and nerve to subclavius come off of the upper trunk
– the long thoracic nerve and dorsal scapular nerve come off the roots (look for them to tell you if the brachial plexus lesion is pre or post-ganglionic)

– acute brachial neuritis is characterized by acute onset of severe pain, which decreases dramatically over several weeks. Etiology unknown. Present with patchy neurologic findings in C5-T1 distribution. Motor weakness predominates over sensory change. Consider this diagnosis if the clinical picture is abit confusing, with various parts of the plexus affected.

– the elbow MCL – both the anterior and posterior bands are tight in flexion; the capsule is also tight in flexion.

– the nerves most apt to get bagged when doing posterior iliac crest grafting – cluneal (more than 8 cm from PSIS);

– anterior vertebral artery insufficiency – anterior cord syndrome: motor and temp/pain sensation; dorsal columns intact

– the superior thyroid artery may get in your way doing a C4-5 approach; the inferior thyroid artery is more around the C6-7 region.

– C6 quad: no function in FDS

– Tendon transfers for tetraplegic hand – the order of innervation goes:

first: deltoid (C4,5), then biceps
1. brachioradialis
2. ECRL
3. ECRB
4. Pronator teres
5. FCR
6. finger extensors
7. thumb extensors
8. partial digital flexors
9. intrinsics

– C5 – ?
– C5/6 – deltoid
– C6 – deltoid, biceps, brachioradialis, ECRL, ECRB, pronator
– C7 – deltoid, biceps, brachioradialis, ECRL, ECRB, pronator, FCR, triceps
– C8 – deltoid, biceps, brachioradialis, ECRL, ECRB, pronator, FCR, triceps, finger extension, thumb extension, finger flexion
– T1 – all of the above plus intrinsics.

– the spinal cord begins embrylogically down at around L3/4, but by full term neonate it is at L1

– landmark for the posterior approach of the knee – medial sural cutaneous nerve and small saphenous vein.

– the Bruser lateral approach to the knee – flex the knee maximally and make a transverse incision over the lateral meniscus; endangers the lateral inferior geniculate artery

– the tibial and femoral insertions of the ACL – the femoral is stronger (??)

– outer wall of a myelomeningocele: epidermis

– the supraclavicular block for the brachial plexus would be performed between the anterior and middle scalene muscles (the plexus comes out from between the two.)

– if you get stabbed in the neck and lose pec major completely – you’ve lost all 5 nerves (C5-T1). The lateral pectoral nerve comes off the lateral cord, the medial from the medial cord. The clavicular head of pec major is mainly innervated by C5 and C6 in particular. The sternocostal head is mainly C7 and C7, and some T1.

– the subclavian vein is anterior to the artery

– Horner’s syndrome – myosis, ptosis, anhidrosis – from first rib fracture, T1 root avulsion, stellate ganglion disruption. An injury to the white rami communicantis of T1 does not cause a Horners.

– Artery of Adamkowitz – Left T9-L2 in most cases.

– medial cord, brachial plexus – gives off axillary and radial nerves, and the upper and lower subscapular nerves, and the thoracodorsal nerve.

– posterior approach to shoulder – muscle splitting

Knee – Lateral Approach

Knee – lateral approach

* position – supine with sandbag under buttock & knee flexed to 90 deg.

* incision
– long, curved incision
– at level of mid patella & 3 cm lat. to it
– with knee flexed, cut inf. over Gerdy’s tubercle & 4-5cm distal to joint line
– curve upper end to follow line of femur

* internervous plane – btw biceps femoris (sciatic n.) & IT band

* dissection
– mobilize skin flaps
– incise fascia in interval btw IT band & BF
– avoid CPN on post. border of BF tendon
– retract ITB ant. & BF post.
– uncover superficial LCL running from lat. epicondyle to head of fibula
– enter joint either ant. or post. to superfical LCL

> ant. arthrotomy
– to inspect entire lat. meniscus
– begin arthrotomy 2 cm above joint line

> post. arthrotomy
– find lat. head of gastroc. at its origin at back of lat. condyle
– dissect btw it & posterolat. corner of joint capsule
– watch for lat. sup. genicular art.
– watch for popliteus
– long. incision in capsule starting well above joint line to avoid meniscus

* dangers
– CPN – lies on post. border of BF tendon
– lat. sup. genicular art. – runs btw lat. head of gastroc. & posterolat. capsule
– popliteus tendon – travels within joint before it attaches to post. aspect of meniscus & femur
– lat. meniscus
– coronary lig.