Anterolateral approach to the elbow

The anterolateral approach to the elbow joint provides exposure to the lateral half of the elbow, specifically the capitellum and the proximal third of the anterior radius.

Indications for the Anterolateral Elbow Approach

This surgical approach is commonly used for the following procedures:

1. Distal biceps tendon rupture repair
2. Treatment of nerve compression lesions affecting the proximal posterior interosseous nerve (PIN) and the proximal superficial radial nerve, including access to the Frohse arcade and management of radial head fractures with associated nerve palsy.
3. Total elbow arthroplasty
4. Drainage of elbow joint infections
5. Open reduction and internal fixation (ORIF) of the capitellum
6. Treatment of avascular necrosis of the capitellum
7. Resection of proximal radius tumors

This approach represents a distal extension of the anterolateral approach to the humerus and a proximal continuation of the anterior approach to the radius. Theoretically, the anterolateral elbow approach can connect these two exposures to reveal the entire upper extremity from the shoulder to the wrist.

Patient Positioning

Position the patient supine on the operating table with the arm resting on a radiolucent arm board.

Landmarks and Incision

Landmarks

• The brachioradialis muscle
• The biceps tendon

Incision

Make a curved incision starting 5 cm proximal to the flexion crease, following the lateral border of the biceps muscle. Continue distally along the medial edge of the brachioradialis muscle.

Internervous Plane

The internervous plane for the anterolateral elbow approach is located:

Proximally between:

• Brachialis muscle (innervated by the musculocutaneous nerve)
• Brachioradialis muscle (innervated by the radial nerve)

Distally between:

• Brachioradialis muscle (innervated by the radial nerve)
• Pronator teres muscle (innervated by the median nerve)

Superficial Dissection

Identify the lateral antebrachial cutaneous nerve (the sensory branch of the musculocutaneous nerve), which becomes superficial about 2 inches proximal to the elbow crease, lateral to the biceps tendon. Incise the deep fascia along the medial border of the brachioradialis muscle. Locate the radial nerve proximally at the level of the elbow joint, between the brachialis and brachioradialis muscles.

Follow the radial nerve distally until it divides into its three main branches:

• The posterior interosseous nerve (PIN), which enters the supinator muscle
• The sensory branch, which travels deep to the brachioradialis muscle
• The motor branch to the extensor carpi radialis brevis (ECRB) muscle

Develop the interval between the brachioradialis and pronator teres muscles distal to the radial nerve bifurcation. To facilitate better retraction, ligate recurrent branches of the radial artery and muscular branches that enter the brachialis muscle just below the elbow.

Deep Dissection

Incise the joint capsule between the radial nerve laterally and the brachialis muscle medially. Expose the proximal radius by supinating the forearm to bring the supinator muscle forward. Incise the muscle origin down to the bone, lateral to the biceps tendon insertion.

Approach Extension

The anterolateral elbow approach can be extended both proximally and distally.

• Proximal extension: Continues into the anterolateral approach to the arm by developing the plane between the brachialis and triceps muscles.
• Distal extension: Extends into the anterior approach to the radius, developing the plane between the brachioradialis and pronator teres muscles proximally, and the brachioradialis and flexor carpi radialis (median nerve) muscles distally.

Dangers

Structures at risk during the anterolateral approach to the elbow joint include:

1. Lateral antebrachial cutaneous nerve of the forearm: Skin and subcutaneous tissue must be incised carefully.
2. Radial nerve
3. Posterior interosseous nerve (PIN): This nerve is vulnerable as it winds around the radial neck within the substance of the supinator muscle. To protect it, incise the supinator muscle at its origin with the forearm supinated.
4. Recurrent branch of the radial artery: This must be ligated to mobilize the brachioradialis muscle.

References and Further Reading

• Book: "Surgical Exposures in Orthopaedics" – 4th Edition
• Campbell's "Operative Orthopaedics," 12th Edition
• Orthobullets Website