Master Tech Ortho Surgery Elbow CH1

40

PART I Exposures

Medial Column (“Over-the-Top” “Hotchkiss”) (6) Indications

●● Access to the coronoid with an intact radial head, anterior capsule release if ulnar nerve pathology is also to be addressed, anterior and posterior medial ectopic bone excision, anterior, posterior capsule excision. Note : It is not a good approach if there is a need for excision of heterotopic bone from the lateral elbow joint or if access to the radial head is needed. ●● Conversion or extension between the Bryan/Morrey, Mayo, and the Hotchkiss approach is readily accomplished but rarely indicated. Landmarks  The medial supracondylar ridge of the humerus, the medial intermuscular septum, the origin of the flexor pronator muscle mass, and the ulnar nerve.

Position  Supine, extremity supported by a hand or elbow table (Fig. 1B-60).

FIGURE 1B-60 The arm is placed on an arm board with the

shoulder externally rotated to expose the medial aspect of the elbow.

Skin Incision  Five centimeter distal and 5 cm proximal to medial epicondyle.

Technique ●● The medial intermuscular septum is identified. Anterior to the septum and superficial to the fascia (and not in the subdermal tissue), the medial antebrachial cutaneous nerve is identified and pro- tected. The line of reflection is identified distally at the raphe between the flexor carpi ulnaris and the pronator teres. Proximally, the intermuscular septum is identified (Fig. 1B-61). Note : If the patient has had previous surgery, the ulnar nerve is usually most easily identified proximally before proceeding distally.

FIGURE 1B-61