J Anat. Soc. India 49(2) 182-190 (2000)
Surgical Incisions ? Their Anatomical Basis Part II - Upper Limb
1Patnaik V.V.G., 2Singla Rajan. K., 3 Gupta P.N. Department of Anatomy, Government Medical College, Patiala1, Amritsar2, 3Department of Orthopedics, Government Medical College, Chandigarh. INDIA
Abstract : The present paper is a continuation of the previous one by Patnaik et al (2000) where anatomical bases for surgical incisions in Head & Neck were discussed. Here we have made an attempt to compile various incisions for exposing different joints & bones of upper limbs. Also the important anatomical land marks to be taken care while designing & executing these incisions are discussed.
Keywords : Surgical incisions, shoulder, humerus, elbow, wrist, radius, ulna, hand.
During the last several decades, many �enew�f surgical approaches have been described, but few are truly original, many are either old approaches rediscovered or modifications of approaches already in use. (Crenshaw, 1992)
General guidelines for surgical incisions have been already discussed in Part-I of the paper by Patnaik et al (2000). Apart from those Crenshaw, 1992 has specified certain more guidelines for incisions in limbs whether upper or lower as follows?
1. The incision should be long enough not to hinder any part of operation.
2. A longitudinal incision on the flexor or extensor surface of a joint may cause a large unsightly scar or even a keloid that may permanently restrict motion. However, a long medio lateral incision, especially on a finger or thumb or on ulnar border of the hand, produces minimal scarring because it is located where movements of skin are significantly less.
3. The approach to deeper structures (bones), when possible should pass through intermuscular planes rather than through them. This helps reduce post operative scarring.
4. Important muscles & vessels must be spared, either by isolating & protecting them or by avoiding them completely.
5. Making a longitudinal incision parallel to the scar of a previous longitudinal incision is unjustified. An incision through an old scar will heal as well as the new incision. Further, 2nd incision made parallel to & near an old scar may impair the circulation in the strip of the skin between the two leading to its necrosis.
6. Patient should be positioned optimally to provide unhindered access to the desired area.
In the upper limbs, the incisions are made to approach different areas as below.
(A) Approaches to shoulder joint.
1. Antero medial approaches
(a) Thompson incision
(b) Henry incision
(c) Cubbins Collahan & Scuderi incision
2. Deltoid splitting approach
3. Trans acromial approach
4. Saber cut approach
5. Posterior approaches
(a) Kocher�fs approach
(b) Brodsky et al approach
(c) Posterior inverted U approach.
(B) Approaches to humerus.
1. Antero-lateral approach
2. Posterior approach
(C) Approaches to Elbow.
1. Postero lateral approach
2. Extensive Postero lateral approach
3. Extensive Posterior approach
4. Lateral approach
5. Lateral J. approach
6. Medial approach
7. Medial & lateral approach
(D) Approaches to Radius :
1. Approach to proximal & middle third of posterior surface.
2. Postero lateral approach to radial head & neck.
3. Anterior approach to entire shaft.
4. Anterior approach to distal half of radius.
(E) Approaches to Ulna :
1. Approach to proximal third of ulna & fourth of radius.
(a) Boyd technique.
(b) Gordan technique.
(F) Approaches to Wrist :
1. Dorsal approaches.
(a) Curvilinear incision.
(b) Transverse incision.
(c) Midline longitudinal incision.
2. Volar approach.
3. Lateral approach.
4. Medial approach.
(G) Approaches in Hand :
(A) Approaches to Shoulder Joint
1. Antero medial approaches
(a) Thompson (1918) :?Incision is begun over anterior aspect of acromio clavicular joint & carried medially along anterior margin of lateral third of clavicle and then distally along anterior margin of deltoid muscle to a point two thirds the distance between its origin & insertion. ( Fig. 1a). Anterior margin of deltoid & the deltopectoral groove is identified by presence of cephalic vein. Later though may be retracted medially yet preferably ligated because if damaged during surgery, it can cause troublesome bleeding. Origin of deltoid is exposed on clavicle & detached leaving some muscle fibres on the bone so that muscle can be stiched to it later on. Coracoid process is exposed & its tip osteotomised & retracted medially along with attached origins of pectoralis minor, coracobrachialis & short head of biceps. As an alternative, one can cut the attachments of coracobrachialis, short head of biceps & pectoralis minor suturing at the end of surgery. Subscapularis is cut 2.5 cm medial to its insertion on lesser tubercle & capsule & then glonoid labrum is exposed.
Williams et al (1999), use only vertical part of the incision for replacement of the joint, i.e. the part extending from junction of lateral & middle thirds of the clavicle to the lateral & just distal to anterior axillary fold. Rest of the steps of their dissection are same.
(b) Henry�fs Modification (1927) :?The incision arches like a shoulder strap over the shoulder from anterior to posterior. The anterior part of this incision is same as that of deltopectoral part of Thompson incision but at superior end, it proceeds directly over the superior aspect of shoulder & distal wards to spine of scapula. (Fig. 1b)
Fig. 1. Approaches to Shoulder Joint. (a) Thompson's antero medial approach (b) Henry's modification (c) Cubbin et al's Modification (d) Trans acromial approach (e) Sabar Cut approach (f) Posterior Approach (g) Posterior inverted U approach
(c) Cubbins, Collahan & Scuderi (1934) Modification :?This is helpful if wider exposure is required. Its anterior limb is like that in Thompson�fs approach. Its upper end is extended laterally around the acromian & medially along the lateral half of the spine of scapula (Fig. 1c). Deltoid is detached from the acromion & lateral half of spine of scapula & reflected inferiorly & laterally to expose, anterior, superior & posterior parts of joint capsule. Joint may be approached anteriorly or posteriorly by giving a corresponding incision in capsule. The rotator cuff which lies superiorly is not disturbed. Long head of biceps has to be saved. In this approach fibres of deltoid are not divided & thus the axillary nerve remains protected.
2. Deltoid Splitting Approach :?It is used to approach tendons inserted on greater tuberosity of humerus & to reach subdeltoid bursa because a limited field is exposed.
The incision is begun at antero lateral tip of the acromion & carried distally over deltoid muscle for 5 cm. The deltoid is split from acromion to about 4 cm dividing in the line of its fibers. It is not splitted distally for more than 3.8 cm from its origin to avoid damaging axillary nerve paralysing its anterior part. (Axillary nerve courses transversely from posterior to anterior).
A transverse skin incision 6.5 cm long placed 2.5 cm distal to inferior border of acromion may be used instead of longitudinal incision. However, the deeper dissection remains the same.
3. Trans acromial approach (Darrach 1945; Mclaughlin 1944) :?The incision is placed just lateral to acromio-clavicular joint from posterior aspect of acromion superiorly like a shoulder strap & anteriorly to a point 5 cm distal to anterior edge of acromion. (Fig. 1d). Deltoid is detached from acromial origin & coraco acromial ligament is divided. If complete exposure of joint is required, the acromion is osteotomised at position B as shown in fig. 1d & the rotator cuff is split in the line of fibres between subscapularis & supraspinatus. However, to approach only the rotator cuff, i.e. for repairing the tears, oblique osteotomy at position A (Fig. 1d) suffice.
4. Saber Cut Approach :?According to Armstrong (1949), it is useful when combined with complete excision of acromion & repair of origin of deltoid. The technique was given by Codman (1927).
In this, the incision is shaped like an inverted U, begining anteriorly 4 cm inferior to acromio clavicular joint & passing superiorly over the anterior third of deltoid muscle & acromioclavicular joint and then posteriorly and inferiorly over posterior third of deltoid ending 5 cm inferior to acromion. (Fig. 1e). Acromion is osteotomised at spine of scapula, retracted laterally along with deltoid splitting its fibres distally. Avoid damaging suprascapular nerve & transverse scapular artery as they pass through scapular notch.
Since this approach splits the deltoid muscles, it has disadvantage of endangering the nerve supply to the muscle i.e. axillary nerve passing deep to it.
5. Posterior approaches :?
(a) A similar approach is described by Kocher (1911), Mc Whoster (1932), Bannet (1941), Rowe & Yee (1944) & Harmon (1945). The incision is begun just lateral to the tip of acromion, passed medially & posteriorly along the border of acromion & curved along spine of scapula to end at its base. (Fig 1f). Deltoid is detached from its origin & reflected distally & laterally avoiding injury to axillary nerve & circumflex humeral vessels as they emerge from quadrangular space. For preventing this injury, don�ft retract deltoid distal to teres minor muscle which forms the superior border of quadrangular space. Joint capsule can be exposed detaching infraspinatus or passing between this muscle & teres minor.
(b) Brodsky et al (1989) Modification :?In this approach abduction of the arm which raises inferior border of posterior deltoid to level of shoulder joint obviates the need to free deltoid form scapular spine or splitting it thus minimizing post operative immobilisation. For this, the patient is placed prone with shoulder abducted to 90�‹, A 10cm long vertical incision is given starting from posterior aspect of acromion downwards & deltoid is retracted superiorly. Capsule is reached through the interval between infra spinatus & teres minor. Avoid dissecting below infraspinatus (forming superior boundary of quadrangular space) inferiorly to prevent injury to axillary nerve & posterior circumflex humeral vessels.
(c) Posterior inverted U approach (Abbot & Lucas 1952) :?This approach is based on the fact that the deltoid muscle has 3 heads of origin & 3 parts? anterior, middle & posterior. Out of these, anterior & posterior parts have longitudinal fibres while the middle part has multipennate fibres. The chances of endangering the nerve supply is also minimal if interval is developed between the relatively avascular middle & posterior parts as the anterior & middle parts are supplied by anterior branch of axillary nerve while posterior part is supplied by its posterior branch. However, if the interval between the anterior & middle parts need to be developed, it shouldn't split the muscle fibres beyond approximately 4 cm. from origin, as anterior branch of axillary nerve supplying the anterior part of deltoid may supplying the anterior part of deltoid may be damaged as it courses from posterior to anterior.
The skin incision (fig. 1g) is begun 5cm distal to the spine of the scapula at the junction of its middle and medial thirds, and extended superiorly over the spine and then laterally to the angle of the acromion. Then it is curved distally for about 7.5 cm over the tendinous interval between the posterior & middle fibres is created. The resulting flap of skin and muscle are turned distally for 5 cm to expose the infraspinatus and teres minor muscles and the quadrangular space. The posterior humeral circumflex artery and the axillary nerve each divide into anterior and posterior branches, so that the splitting of the deltoid between its posterior and middle thirds does not injure them. The splitting of the deltoid may be carried to insertion to give full access to the quadrangular space if desired. To expose the joint, the rotator cuff tendons & capsule are divided.
(B) Approaches to Humerus :
1. Antero-lateral approach (Thomspon 1918, Henry 1924-25) : - The incision is placed in line with anterior border of deltoid from a point, midway between its origin & insertion distally to the level of its insertion, & then proceeded along lateral border of biceps to within 7.5 cm of elbow joint (fig 2a). Fasciae are divided & cephalic vein lying at lateral border of biceps is ligated. In proximal part of wound, deltoid is retracted laterally & biceps medially to expose humerus. More distally, brachialis is exposed by retracting biceps & triceps; split longitudinally to bone & retracted lateral half laterally & medial half medially. Its lateral half protects radial nerve as the later winds round the humeral shaft, & the medial half protects the musculocutaneous nerve.
(i) Brachialis is supplied by both radial (lateral half) & musculocutaneous nerves (medial half) so can be split longitudinally without paralysis.
(ii) Lateral half of brachialis protects radial nerve.
(iii) Should it be required to expose the shoulder the incision can be continued proximally.
2. Posterior approach (Berger & Backwalter, 1989) :- The bone is exposed through the
Fig. 2. Approach to Humerus (a) Antero lateral approach (b) Approach to humeral shaft
interval between lateral head of triceps & deltoid. It can expose proximal third of humerus & approach is limited proximally by axillary nerve & posterior circumflex humeral vessels & distally by radial nerve lying in the radial groove.
The incision is begun, 5 cm distal to posterior aspect of acromion & placed straight over the posterior border of deltoid i.e. interval between deltoid & triceps muscles extending distally to deltoid tuberosity. The interval between the two muscles is developed by blunt dissection. The subperiosteal retraction of triceps medially is continued proximally avoiding injury to radial nerve. Next periosteum is elevated laterally & retracted laterally along with deltoid. Axillary nerve & posterior circumflex humeral vessels which lie in the proximal part of the incision are protected.
3. Other approaches :
(a) Anterior aspect of humeral shaft at junction of a middle & distal third can be approached between biceps & brachialis medially & brachioradialis laterally. (Fig 2b). This can be used as an extension of antero-lateral approach.
(b) Henry (1925) exposed the posterior humeral shaft in middle thirds by splitting triceps by a posterior approach. It is of value in reaching the lesions that can not be reached by antero lateral approach. This approach is also useful for stabilising the distal humeral fractures with a plate as posterior surface of the distal humerus is suitable for plating.
(C) Approaches to Elbow :
1. Postero lateral approach :- This was described by Campbell (1932) for treatment of old posterior dislocation, fracture of distal humerus & arthroplasties of elbow joint. The incision is begun 10 cm of elbow joint. The incision is begun 10 cm proximal to elbow on postero lateral aspect of the arm & carried distally for 13 cm. (Fig 3a). Triceps aponeurosis is exposed as far distally as its insertion on olecranon. It is freed from proximal to distal raising a tongue shaped flap distally Incise the remaining muscles fibres in midline to reach posterior aspect of bone & joint reach posterior aspect of bone & joint capsule. As an alternative, the triceps muscle & its aponeurosis in its distal third may be split longitudinally in the middle instead of raising a tongue shaped flap. Thetongue shaped flap is useful where there is a contracture of triceps from a long standing pathology.
As a 2nd alternative, instead of splitting the triceps, osteotomy of olecranon can be done, lifting olecranon & triceps muscle proximally. This is useful to expose distal articular surface of humerus in inter condylar fractures.
2. Extensive postero lateral approach :- To achieve the maximum & safe exposure of the elbow & proximal radio ulnar joints, Wardsworth (1979) described a modified postero lateral approach. It is useful for displaced distal humeral articular fractures, synovectomy, total elbow arthroplasty etc.
A curved incision is begun over the centre of posterior surface of arm at the proximal limit of triceps tendon, extending it distally to the posterior aspect of lateral epicondyle & further distally & medially to the posterior border of ulna, 4 cm distal to the tip of olecranon. (Fig 3b). Medial skin flap is dissected to expose medial epicondyle. Ulnar nerve is isolated by dividing the arcuate ligament passing between 2 heads of flexor carpi ulnaris muscle & then gently retracted. Triceps is reflected as in postero lateral approach & anconeus is separated from extensor carpi ulnaris reaching the capsule of elbow joint. Exposure can be increased by putting a varus strain on elbow joint.
3. Extensive posterior approach : - Bryan & Morrey (1982) developed a modified posterior approach to elbow joint that provides excellent exposure & preserves
Fig. 3. Approaches to Elbow Joint. (a) Postero lateral approach (b) Wardsworth's extensive postero lateral approach (c) Lateral approach (d) Lateral J approach (e) Medial approach
the continuity of triceps mechanism which allows easy repair & rapid rehabilitation. A straight posterior incision is made in the midline of limb extending from a point. 7 cm distal to tip of olecranon to a point 9 cm proximal to it. Ulnar nerve is identified & may be transposed anterior to medial epicondyle into subcutaneous tissue. Triceps is elevated from medial aspect of humerus upto posterior aspect of capsule. Next its insertion on ulna is lifted along with periosteum. This is the weakest point of reflected triceps mechanism & here the care has to be exercised to maintain this continuity of triceps mechanism. Tip of olecranon may be resected for a wider exposure. Erasing the anconeus from ulna & reflecting it proximally will give access to radial head.
4. Lateral approach :?This is an excellent approach for fractures of lateral condyle.
Incision is begun 5 cm proximal to lateral epicondyle of humerus & carried distally to epicondyle & along antero lateral surface of forearm for approximately 5 cm. (Fig 3c). Lateral border of humerus can be exposed by developing from distal to proximal, the interval between triceps posteriorly & extensor carpi radialis longus & brachioradialis anteriorly. In the proximal end of wound, care has to be taken to avoid radial nerve as it enters the interval between brachialis & brachioradialis muscles. Next, the common extenser origin is separated from lateral condyle if required & lateral aspect of joint is exposed. Deep branch of radial nerve has to be protected as it enters supinator muscle.
5. Lateral J approach (Kocher, 1911) :?It is a modified lateral approach. The incision is begun 5 cm proximal to elbow over lateral supracondylar ridge of humerus & extended distally along this ridge to 5 cm distal to radial head. Then it is curved medially & posteriorly to end at posterior border of ulna. (Fig 3d).
6. Medial approach with osteotomy of medial epicondyle :?It was developed by Molesworth (1930) & Campbell (1932) independently of each other. Radius & Ulna both can be dislocated on humerus so all parts of joint including articular surfaces can be inspected. Incision is placed on tip of medial epicondyle from 5 cm distal to joint to a point 5 cm proximal to it (Fig. 3e). Ulnar nerve is isolated & retracted posteriorly. Medial epicondyle is freed from all soft tissue except common flexor origin, osteotomised & reflected distally along with flexor origin. While doing so, branches of median nerve to flexor muscles are to be saved. Thus capsule is reached & incised vertically to reach the joint.
7. Medial & lateral approach :?When extensive exposure is not needed, an incision of 5 cm length can be made on either or both sides of the joint just anterior to the condyles & parallel to epicondylar ridges of humerus. This is occasionally used for supra-condylar fractures of humerus.
(D). Approaches to Radius :
1. Approach to proximal & middle third of posterior surface (Thompson 1918) :?Exposure of proximal third of radius should be done carefully because deep branch of radial nerve as it traverses within supinator muscle is liable for injury.
Incision is placed over proximal & middle third of radius along a line drawn from centre of the dorsum of the wrist to a point 1.5 cm (one finger breadth) anterior to lateral humeral epicondyle, with the forearm pronated. (Fig. 4a) Radius is exposed between extensor digitorum superficialis & extensor carpi radialis brevis. The radial nerve is protected by erasing the supinator from distal to proximal. Should the supinator required to be cut, the radial nerve should be isolated first.
2. Postero lateral approach to radial head & neck :?A postero lateral oblique
Fig. 4. Approaches to Radius (a) Thompson's approach to proximal 2/3rd of posterior surface (b) Thompson's approach to proximal 2/3rd of posterior surface (b) Postero lateral approach to radial head & neck (c) Anterior approach to entire shaft (d) Anterior approach to distal 1/2 of radius.
approach safely exposes the radial head & neck. It corresponds to the distal limb of lateral J approach of Kocher (1911) to the elbow. It is best approach to excise radial head as can be extended proximally & distally without endangering major vessels & nerves. Also it preserves nerve supply to anconeus.
An oblique incision is begun over posterior surface of the lateral humeral condyle & continued obliquely distal wards & medially to a point over posterior border of ulna 3-5 cm distal to tip of olecranon. (Fig. 4b) Radial head is approached between extensor carpi ulnaris & anconeus. The deep branch of radial nerve which lies between 2 planes of supinator remains undisturbed.
3. Anterior approach to entire shaft (Henry's technique) :- A long serpentine incision is begun just lateral & proximal to biceps tendon & extended distally in the forearm along the medial border of brachioradialis & if necessary, as far as to radial styloid. (Fig. 4c) Deep fascia is divided in line with skin incision protecting radial vessels. Radial recurrent artery & vein are isolated & ligated. Brachioradialis & superficial branch of radial nerve are retracted laterally while radial vessels & flexor carpi radialis are retracted medially to expose radial shaft. The muscles found in the depth of the wound i.e. pronator quadratus & flexor pollicis longus may be erased if required.
4. Anterior approach to distal half of radius (Henry 1927) : - With forearm in supination, a 15-20 cm longitudinal incision is made over the interval between brachioradialis & flexor carpii radialis. (Fig 4d). Radial artery & veins are carefully mobilised & retracted medially while brachioradialis is retracted laterally. The flexor pollicis longus & pronator quadratus which lie in the depth of the wound require to be erased to gain exposure of the bone.
(E) Approaches to Ulna
Since part of posterior surface of ulna throughout its length lies just under skin, any part of the bone can be approached by incising skin, fascia & periosteum along this surface. So it will not be discussed in this article.
1. Approaches to proximal third of ulna & fourth of radius :
(a) Boyd technique (1940) :- This approach is useful for Monteggia fracture. The incision is begun 2.5cm proximal to the elbow joint. Just lateral to triceps tendon, continuing it distally over the lateral side of the tip of olecranon & along the subcutaneous border of ulna & ending it at the junction of proximal & middle thirds of the bone. The bones are approached through the interval between ulna on medial side and anconeus & extensor carpii ulnaris on lateral side. The incision on the ulna can be continued distally if required.
(b) Gordan technique (1967) :- It is a combination of postero lateral approach to head of radius & distal part of Boyd approach later exposing ulnar shaft.
(F) Approaches to wrist :
1. Dorsal approach (Crenshaw, 1992) :- described 2 dorsal approaches to wrist :
(a) Through a 10 cm dorsal curvilinear incision [Fig. 5a-(i)] centred over Lister's tubercle, the dorsal carpal ligament & extensor tendon sheaths on dorsum of wrist are exposed. Interval is made between extensor pollicis longus & extensor digitorum & capsule of wrist exposed & incised transversly.
(b) A transverse curved incision is begun on medial side of head of ulna & extended across the dorsum of wrist to a point 1.5 cm proximal & posterior to radial styloid [Fig 5a-(ii)]. Tendons of extensor digitorum can be retracted ulnarwards or radialwards
Fig. 5. Approaches to Wrist joint (a) -(i) Dorsal curvilinear incision (ii) Transverse curved incision (b) Lateral approach
& dorsal aspect of capsule of wrist joint is exposed.
(c) Williams et al (1999) :?Use a midline longitudinal incision on the dorsum of the wrist avoiding superficial veins, rest of the dissection being same.
2. Volar approach :?This is used to approach the lunate bone.
A transverse incision is made across the volar aspect of wrist in distal flexor crease. Palmaris longus tendon & median nerve deep to it is identified & retracted laterally along with flexor pollicis longus tendon (If palmaris longus tendon is absent congenitally, median nerve is most superficial.) while flexor digitorum superficialis et profundus are retracted medially to expose joint capsule which is incised transversally.
3. Lateral approach :?A 7.5 cm long incision is shaped like a bayonet on radial side of wrist (Fig. 5b). In this approach, radial artery passing between abductor pollicis longus & extensor pollicis brevis laterally & radial collatal ligament medially is protected along with superficial branches of radial nerve to reach lateral aspect of capsule after incising the radial collateral ligament longitudinally.
4. Medial approach :?This technique is used for arthrodesis of wrist & tendon transplant surgeries. It is not a commonly used approach.
(G) Approaches in Hand
As long as the following principles are observed, skin incisions can be made anywhere on the hand including major skin creases-
1. Incisions within deep creases should be avoided. Here subcutaneous fat is thin, and moisture tends to accumulate, macerating the skin edges.
2. An incision should be long enough to expose the deep structures without excessive stretching of the skin edges; greater exposure is possible if the skin and subcutaneous fat are dissected from the underlying fascia.
3. Generally, shorter incisions may suffice on the dorsum of the hand because here the skin is more lax & can be retracted more easily.
4. If the incision is gently curved, the scar is less noticeable and usually conforms better to natural lines. Exposure is usually better on the concave side of a semicircular incision; an S-shaped incision provides even more exposure.
5. Parallel or nearly parallel incisions that are too close together or too long should be avoided, because healing may be slow or skin necrosis may develop due to impairment of the blood supply. Scars that adhere to the underlying structures, especially bone & tendons should be avoided if possible. This can be done by placing the incisions away from these structures.
6. The plane of motion of a part is approximately perpendicular to the long axis of skin creases. Therefore an incision should not cross a crease at a right angle, since the resulting scar, being in the line of motion, will hypertrophy; or lead to contracture limiting the motion which can create significant impairment of function.
Various Incisions that can be executed in hand are shown in Fig 6.
Fig. 6. Various skin incisions in hand. A, Midlateral incision in finger. B, Incision for draining felon. C, Midlateral incision in thumb. D, Incision to expose central slip of extensor tendon. E, Inverted V incision for arthrodesis of distal interphalangeal joint. F, incision to expose metacarpal shaft. G, Incision to expose palmar fascia distally. H, Incision to expose structures in middle of palm. I, L incision of base of finger. J, Short transverse incision to expose flexor tendon sheath. K, S incision in base of finger. L, Incision to expose proximal and of flexor tenson sheath of thumb. M, Incision to expose structures in thenar eminence. N, Extensive palmar and wrist incision. O, Incisions in dorsum of wrist. Q, Incision in base of thumb. R, Alternate incision to drain a felon.
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