Shoulder anterior approach: Delto-Pectoral

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  • PIN


Superficial dissection

  • Proximal 1/3 – ECRB (radial N) & EDC (Pin) plane

  • Distal 1/3 – ECRB and EPL (Pin) plane

Deep dissection

  • Proximal 1/3 Must identify PIN as it leaves the Supinator muscle belly in SUPINATION

    • Either dissect nerve out of muscle

    • Or Subperiosteally lift supinator off bone to protect nerve

  • Middle 1/3 Abductor pollicis longus and extensor pollicis brevis muscles are retracted off bone

Important Notes:

  • PIN usually injured in retraction though 25% actually are in direct contact with the proximal radius


Direct Lateral Approach: Hardinge

Splits gluteus medius distal to superior gluteal nerve

Surface markings:

  • Longitudinal incision centred over GT and curving posteriorly


  • Superior gluteal nerve 4-5cm above tip of GT


  • Skin, subcutaneous tissues down to fascia lata

  • Take GM off GT and go proximately laterally <4cm for access

  • Extend incision inferiorly through VL

  • Gluteus minimus is excised off anterior GT

  • Expose anterior joint capsule and perform T shaped capsulotomy down to fibrous rim

Important Notes:

Anterolateral Approach: Watson Jones

Inter muscular plane

Surface markings:

  • 15cm incision centred over GT


  • Femoral vessels


  • Same approach as Modified Hardinge

  • Find plane between GM and TFL (both superior gluteal nerve)

  • Develop this interval and externally rotate hip to find origin of vastus lateralis

  • Detach abductor mechanism

  • In front of the joint capsule will lie rectus femoris and psoas which may need elevating and retracting

Anterior Approach: Smith Peterson – Hoyter Modification

Interneural plane

Surface markings:

  • ASIS to lateral side of patella for 8-10 cm

  • Incision can be extended proximately underneath line of ilium


  • Lateral cutaneous femoral nerve - Hospodar et al 1999

    • Passes 1-2cm medial to and inferior ASIS under inguinal ligament

    • Anterior to iliacus muscle and superficially onto of TFL fascia

  • Femoral nerve

    • Medial side of Sartorius muscle (forms lateral wall of femoral triangle)

  • Ascending branch of lateral femoral circumflex artery

    • Ligate to avoid excessive bleeding


  • Identify gap between Sartorius (femoral N) and TFL (Superior gluteal N)

  • Subcutaneous fat will have lateral cutaneous femoral nerve

  • Incise fascia on medial side of TFL

  • Detach origin of TFL to develop plane and identify and ligate lateral femoral circumflex artery

  • Deeper identify plane between rectus femoris (femoral N) & gluteus medius (superior gluteal N)

  • Detach rectus femoris from attachment and retract medially with psoas, GM can go laterally to expose capsule

  • Externally rotate hip also to aid this

Posterior Approach (Moore or Southern)

Inter muscular pane splitting of gluteus maximus (inferior gluteal nerve)

Surface markings:

  • Posterior curvilinear approach centred over GT

  • Can mark this out by flexing hip to 900 and draw a straight line in line with the femur, when the leg straightens it is now curvilinear


  • Sciatic nerve – can split look around piriformis to see if there is another branch

  • Inferior gluteal artery – leaves pelvis under piriformis

  • Perforating branch of profunda femoris – can be cut whilst releasing gluteus maximus insertion

  • Anterior to acetabulum are the femoral vessels



  • Split fascia in line with incision to visualise vastus lateralis and gluteus fan shaped incision proximately

  • Split maximus in line with its fibres


  • Internally rotate hip to place tension on short rotators

  • Detach piriformis and obturator internus 1cm from femoral insertion.



None splits vastus lateralis

Surface markings:

  • Lateral thigh with leg internally rotated 15 degrees


  • Perforating vessels of profunda femoris artery – bleeding ++


  • Fascia lata

  • Fascial covering to VL

  • Split VL

  • Subperiosteal dissection to expose femur


Interneural plane

Surface markings:

  • Posterior aspect of femoral condyle up the femoral shaft



  • Deep fascia of thigh

  • Feel intermuscular septum go anteriorly between VL (femoral N) & hamstrings (sciatic N)

  • Reach the linea aspera


Medial para-patella – relative CI is previous lateral para-patella


Surface markings:

  • 5cm above superior pole of patella down to tibial tubercle (either straight or curvilinear)


  • Superior lateral geniculate artery

  • Infra-patella branch of saphenous nerve

    • Subcutaneous after leaving fascia lata




  • Reflect patella laterally

  • If difficult extend incision proximately

Antero-lateral Tibial plateau: Lobenhoffer and Frosch 2010 for knee approaches


Surface markings:

  • Curvilinear incision - Half way between patella tendon and biceps femoris


  • LCL

  • Common peroneal nerve behind fibula – head osteotomy increases exposure


Antero-medial Tibial plateau:

Surface markings:

  • Curvilinear incision - Half way between patella tendon and MCL


  • MCL

  • Saphenous nerve and vein


  • Fascia

  • Stick subperiosteally and peel off extensor muscle bellies to expose plateau

  • Horizontal capsulotomy to expose joint

Dorsolateral Tibial Plateau:

Surface markings:

  • Straight incision lateral side of gastrocnemius


  • CPN – posterior to biceps tendon

  • Distal extension is 4cm due to anterior tibial artery piercing interosseous membrane


  • Fascia

  • Lateral side of gastrocnemius

  • Peel soleus and popliteus off posterolateral aspect of tibia - subperiosteally

Dorsomedially Tibial Plateau:

Surface markings:

  • Straight incision medial side of gastrocnemius


  • Popliteal artery if Subperiosteal dissection not carried out


  • Fascia

  • Medial side of gastrocnemius

  • Mobalise popliteus muscle subperiosteally.

Posterior Knee: Popliteal fossa


Surface markings

  • Lazy S incision starting proximately over biceps femoris and extending medially over medial head of gastrocnemius




  • Find Sural and short saphenous vein distally

  • Follow vessels into fascia between gastrocnemius heads

  • Common peroneal nerve proximately

  • Release medial head of gastrocnemius if more exposure required


  • Ligate geniculate vessles to mobilise tibial neurovascaurl structures

  • PCL attachment superior to popliteus (enters capsule via arcuate ligament)


Lateral ankle


Surface markings:

  • Centre incision over fracture make long enough to avoid skin tension


  • Superficial peroneal nerve – 6-12 cm proximal to tip of fibula from posterior to anterior (junction between middle and distal 1/3)

  • Short saphenous vein

  • Sural nerve runs along posterior aspect of fibula


  • Blunt dissection in subcutaneous tissues

  • Stick to bone and stay subperiosteally when clearing fracture site

Anteromedial ankle


Surface markings:

  • 8-10cm incision curving anteriorly centred over anterior 1/3 of malleolus


  • Saphenous nerve – numbness over medial foot and vein


  • Skin flap blunt dissection in subcutaneous tissues

  • Stick to bone and lift out fracture to expose joint

  • Longitudinal split to bring screw to bony tip

Posterolateral ankle: - for posterior malleolus fracture size is not necessarily an issue by note mechanism – if axial or shearing it should be fixed


Surface markings:

  • Begin 12cm proximal to lateral malleoli tip

  • Half way between tendon and fibula

  • Curve to posterior fibula and then follow peroneal tendons to 2cm below and anterior to malleolar tip


  • Sural nerve half way between Achilles and fibula

  • Deep are the posterior n/v bundles going posterior to the medial malleolus


  • Aim to go between muscle bellies of peroneals either side depending on access

  • Meat to the heal is FHL

Anterior to ankle:

None inter-tendinous all supplied by deep peroneal nerve

Surface markings:

  • Lateral to EHL is where the anterior tibial artery and deep peroneal nerve


  • Anterior tibial artery

  • Deep peroneal nerve


  • Incise fascia and locate EHL – n/v bundle lateral to this


Anteromedial approach:


Surface markings:

  • Medial malleolus to navicular N spot


  • Saphenous nerve and vein

  • Tibialis posterior tendon attaches onto Navicular

  • EHL

  • Medial malleolus can undergo osteotomy to improve access


  • Straight down to capsule onto bone

Anterolateral approach:


Surface markings:

  • Fibula to 5th metatarsal base


  • Peroneal nerves


  • Down to peroneus brevis

  • Anteriorly through capsule

Posterior para Achilles approach:


Surface markings:

  • Medial of lateral side to Achilles tendon


  • Medially

    • Posterior tibial artery and nerve

  • Laterally

    • Sural nerve




Medial approach:


Surface markings:

  • Junction of sole to lateral skin of the foot extending proximately half way between fibular and achilles

  • Keep angle of flap >1000

  • Full thickness flap elevate off bone


  • Peroneal tendons

  • Sural nerve proximately


  • Straight down onto bone

Surgical approach for assessing limb alignment: Buckley et al 2011 showed a 50% malrotation in the MIPO technique despite every effort being made intra-operatively

Leg length

Varus/valgus (coronal)

  • Centre of the femoral head to centre of the knee to centre of the ankle (>100 correct)

Recurvatum (sagittal)

  • Excessive notch on AP confirms recurvatum

  • Place drapes under distal femur to allow flexion of distal femoral condyles


  • Flex knee and check IR and ER for symmetry

  • Symmetry of foot position with leg straight

  • Lesser trochanter sign

    • IR increases size (LT is a Anteromedial structure)

Surgical exposure for IM nailing

Humeral nailing:

  • Antegrade via deltoid and supraspinatus splitting

  • Retrograde via triceps muscle splitting approach down to olecranon fossa – excise fat

    • Radial nerve damaged in distal locking screws best avoided via open dissection down to bone

Tibial nailing:

  • Must be midline entry no evidence parapatella is better than transpatella

  • Anatomical studies show

    • 30% of time lateral meniscus damaged

    • 20% of time nail is intra-articular

Femoral nailing:

  • Antegrade via GT or piriformis fossa

    • Incise 5-7cm proximal to GT

  • Retrograde with knee flexed 30-600

    • Through patella tendon nail inserted through femoral trochlear 7-15% of articular surface destroyed

    • Can use in intra-articular fractures by fixing intra-articular fragment first

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