Shoulder surgical access.
1. Anterior superior medial incision.
Indications; shoulder dislocation, superior humeral fracture and superior tumor resection.
Incision and exposure: The incision starts at the anterior part of the acromioclavicular joint and extends inward along the anterior external 1/3 of the clavicle, then turns inferiorly and externally, completing the lower 2/3 of the incision along the anterior border of the deltoid muscle. The cephalic vein is protected at the groove between the deltoid and pectoralis major muscles, the deltoid muscle is drawn outward, and the subdeltoid space is carefully stripped to avoid injury to the posterior rotator humeral artery, the axillary nerve, and the deltoid branch of the thoracic acromionic artery. At a distance of 5 cm from the clavicle, the deltoid stop is cut and turned outward to expose the rostral process and the anterior portion of the shoulder capsule. For greater exposure, the short head of the biceps brachii and the rostro-humeral muscle can be severed approximately O.5 cm from the rostral process and flipped downward. The subscapularis muscle is cut at 1 cm from the lesser tuberosity of the humerus and turned inward to expose the anterior and anteromedial aspects of the shoulder capsule.
2.Anterior arcuate incision of the acromioclavicular joint.
Indications: Dislocation of the acromioclavicular joint and displaced distal clavicle fracture surgery.
Incision and exposure: The incision starts at the anterior superior border of the acromion, turns inward and downward along the outer 1/4 of the clavicle, goes down 4-5 cm along the anterior border of the deltoid muscle, protects the cephalic vein at the interosseous groove, cuts the deltoid muscle 0,5 cm from the clavicle stop, and turns downward to expose the rostral eminence, acromioclavicular joint, rostral lock ligament and rostral shoulder ligament.
Brachial surgical approach Brachial surgical approach: anterolateral incision of the arm.
Indications: Various surgeries of the humeral stem.
Incision and exposure: Beginning at the midpoint of the anterior deltoid muscle, the incision is made downward along the lateral border of the biceps muscle to the anteromedial bend of the elbow joint to 3 cm below the plane of the elbow joint. The upper part of the incision separates the deltoid from the pectoralis major muscle, while the lower part of the incision separates the brachialis fibers longitudinally to reach the humeral stem. Care is taken not to injure the medial cephalic vein and the lateral radial nerve.
Elbow surgical access.
1. Posterior median incision of the elbow joint.
Indications: humeral condylar fracture, elbow dislocation, elbow fusion, and plication.
Incision and exposure: Start from the posterior median line of the arm, 10 cm above the ulnar eminence, and extend downward to 3-4 cm below the eminence. The ulnar nerve is freed and protected; a tongue-shaped incision is made in the sexual part of the triceps tendon, with the surgical blade oblique to the midline, and the tip of the tongue is about 10 cm above the hawk’s beak, while the base of the tongue is extended on both sides at the level of the joint, reaching the internal and external condyles of the humerus, completing a tongue-shaped flap that is wide in the superficial part and narrow in the deep part, then it is turned to the distal side to reveal the posterior joint capsule of the elbow, and the periosteum and joint capsule are incised to reveal the hawk’s beak and the elbow joint.
2. Elbow lateral incision indications: humeral epicondyle reversal fracture, supracondylar humeral fracture, radial head resection.
Incision and exposure: The incision begins at the lateral elbow joint, 6 cm above the elbow joint line, and extends anteriorly downward through the lateral epicondylar ridge of the humerus, with the lower end of the incision slightly exceeding the radial head. Above the incision, a subperiosteal dissection is made along the lateral epicondylar ridge, below which the elbow muscle is incised and entered along the posterior border of the ulnar carpal extensor, and the posterior rotator muscle is cut close to the ulna and turned forward without damaging the deep branch of the radial nerve. The joint capsule is then incised longitudinally to reveal the humeral radial joint space.
3. Medial elbow incision.
Indications: Fracture of the medial humeral condyle, ulnar nerve exploration, elbow fusion.
Incision and exposure: The incision is made on the medial side of the elbow with the medial epicondyle as the center and 5 cm above and below. The ulnar nerve is exposed and protected, and the medial epicondyle of the humerus is severed with a sharp bone chisel and turned downward along with the flexor stops. The joint capsule is incised longitudinally to expose the medial humeral condyle, ulnar eminence and their articular surfaces. If the force of the abducted forearm is increased, the elbow joint can be dislocated medially. At the end of the operation, the severed medial humeral epicondyle is repositioned and fixed with sutures or kerf pins.
Forearm surgical approach.
1. Dorsal ulnar incision of the forearm.
Indications: ulnar trunk fracture.
Incision exposure: 5 cm below the ulnar hawk’s beak, along the dorsal edge of the ulna, the appropriate length can be cut as needed, and the periosteum is cut between the ulnar carpal flexor and ulnar carpal extensor and elbow muscles, which can fully expose the ulnar trunk.
2.Dorsal radial incision of forearm.
Indications: Radial trunk fracture incision is revealed: it starts 4 cm below the radial tuberosity on the dorsal side of the forearm, and the appropriate length of longitudinal incision can be made as needed. The fascia is incised at the common finger extensor and radial short extensor carpi radialis, with the former pulled medially and the latter pulled laterally. The posterior rotator muscle and the deep and muscular branches of the radial nerve penetrating from the posterior rotator muscle are seen. The posterior rotator muscle was incised longitudinally along the lateral edge of the radial trunk and turned inward, and the periosteum was incised to reveal the radial trunk.
3. Posterior-lateral incision of the upper forearm.
Note that the posterior rotator muscle should be incised close to the ulna to prevent injury to the deep branch of the radial nerve.
Hip surgical approach.
1, anterolateral hip incision; indications: hip fusion, congenital hip dislocation capping, hip osteotomy, hip arthroplasty, hip tuberculosis lesion removal.
Incision and exposure: from the midpoint of the iliac spine, pass along the iliac spine forward and down through the anterior superior iliac spine, turn toward the outer edge of the patella for about 12 cm, incise the deep subcutaneous fascia, then incise the gluteus medius and broad fascial tensor at the outer edge of the iliac spine, peel and turn forward and downward under the periosteum, medially distract the suture muscle and the lateral femoral cutaneous nerve, which passes under the anterior superior iliac spine and above the suture muscle, pull the gluteus medius and the lateral femoral muscle laterally, at this time, visible The superior border of the acetabulum is visible.
For greater exposure, the anterior inferior iliac spine attachment of the rectus femoris and the upper acetabular attachment can be cut off and turned down. At this point, the anterosuperior aspect of the hip joint can be revealed. A “T”-shaped or “10”-shaped incision of the joint capsule is made to reveal the joint cavity.
2, lateral hip incision indications: femoral neck open repositioning three-wing nail fixation, intertrochanteric osteotomy, hip joint incision and drainage, hip arthroplasty, etc.
Incision and exposure. From 2 or 5 cm below the external anterior superior iliac spine, extending lateral to the greater trochanter and lateral to the femoral stem, ending 5 cm below the base of the trochanter. The joint capsule is revealed by dissecting between the gluteus medius and the broad fascialis tensor muscle, with the gluteus medius muscle retracted posteriorly and the broad fascialis tensor muscle retracted anteriorly.
Alternatively, a bone knife can be used to cut off the anterior half of the top of the ramus and pull apart the gluteus medius and minimus muscles posteriorly and superiorly to reveal a larger view.
3.Posterior lateral incision of the hip joint.
Indications: posterior hip dislocation combined with sciatic nerve injury or combined with fracture of the posterior superior border of the acetabulum, femoral neck fracture for internal fixation with tipped muscle flap graft, hip arthroplasty. Incision and exposure: The incision starts 5 cm below the posterior superior iliac spine and runs parallel to the gluteus maximus muscle fibers to the posterior superior aspect of the greater trochanter, then 5 cm down the posterior border of the greater trochanter of the femur.
The gluteus maximus fibers were incised in a parallel direction to the skin incision, and the gluteus maximus muscle was incised 5 cm along the vertical part of the incision at the attachment of the valve fascia, and the muscle was retracted to both sides to reveal the deep surface tissue of the gluteus maximus muscle. Care was taken to protect the important blood vessels and nerves pierced by the upper and lower edges of the pear-shaped muscle. The thigh is then made to rotate internally.
The superior and inferior subungual muscles and the internal foraminal muscle are cut off at the attachment of the greater trochanter and drawn posteriorly, and the pear-shaped muscle is pulled upward and the joint capsule is incised, so that the posterior view of the hip joint can be revealed.
Femoral surgical approach.
1, anterolateral femoral incision, indication: femoral stem fracture or tumor resection.
Incision and exposure: the direction of the incision is on the joint line between the anterior superior iliac spine and the outer edge of the dice bone, and an incision of appropriate length can be taken on this line according to the surgical needs. After incising the skin, subcutaneous and deep fascia, the rectus femoris and lateral femoral muscles are pulled apart along the muscle interval, and when the incision is superior, the descending branch of the lateral rotator femoris artery and the muscular branch of the femoral nerve can be encountered, and the vessels can be cut and tied to protect this nerve, and then incised in the direction of the intertrochanteric muscle fibers to the femoral stem.
2. Lateral femoral incision.
Indications: Same as above.
Incision and exposure: The direction of the incision is on the joint line of the greater trochanter and the femoral epicondyle. The skin is incised, subcutaneous, the iliotibial bundle is incised longitudinally, the lateral femoral muscle fibers are incised in the direction of the muscle and the femoral interrogator muscle, and the muscle is stripped to reach the lateral aspect of the femoral stem.
Knee surgical approach.
1. Medial anterior knee longitudinal incision.
Indications: Knee exploration, tuberculosis removal, anterior cruciate ligament repair, etc.
Incision and exposure: from 5 cm above the patella, along the inner edge of the quadriceps tendon, through the inner edge of the patella, and downward to the inner edge of the tibial tuberosity. The skin and subcutis are incised to protect the infrapatellar branch of the saphenous nerve. The deep fascia was incised, and a longitudinal incision was made at the tendinous junction of the rectus femoris and medial femoral muscles, and the medial patellar support band and joint capsule were incised. The cruciate ligament and the anterior 2/3 of the medial meniscus of the knee cavity are revealed by pushing the patella laterally and slightly flexing the knee joint. If the incision is extended slightly above and below and the patella is pulled laterally, a larger surgical view is revealed.
2. Anterolateral knee incision.
Indications: Tibial epicondyle fracture with concurrent lateral meniscus injury surgery.
Incision and exposure: begins 5 cm above the lateral edge of the patella, enters the quadriceps tendon at the lateral femoral muscle, follows the lateral edge of the quadriceps tendon, patella, and infrapatellar ligament, and ends 2 cm below the tibial tuberosity. The joint capsule and synovial membrane are incised in the same direction as the skin incision. The knee is flexed and the anterior tibial muscle is drawn outward, the patella and patellar ligament are drawn inward, and the lateral meniscus is revealed at the same time as the femoral epicondyle.
3. Posterior lateral knee incision.
Indications: repair and reconstruction of the lateral collateral ligament of the knee, exploration of the common peroneal nerve and lesions of the posterior lateral aspect of the knee.
Incision and exposure: A slight curved incision is made along the biceps femoris tendon to the anterior border of the fibular head. The biceps femoris tendon is retracted posteriorly, paying attention to the protection of the common peroneal nerve, and the posterior posterolateral aspect of the knee capsule is revealed by dissecting deeper, pulling the capsule forward and pulling the capsule and biceps tendon backward, and the posterior posterolateral part of the knee joint is revealed.
4. Posterior medial knee incision.
Indications. Knee valgus wedge osteotomy, medial meniscus rupture, and posterior medial knee lesions.
Incision and exposure. A longitudinal incision is made along the semitendinosus and semimembranosus tendons, approximately 6 to 8 cm in length. The skin and subcutaneous area are incised, taking care not to damage the saphenous nerve. A longitudinal incision is made from the medial epicondyle of the femur to reveal the medial aspect of the lower femoral stem, the posterior aspect of the medial meniscus and the upper part of the tibia.
Lower leg surgical approach.
1. Anterolateral calf incision.
Indications: Various surgeries on the tibial stem.
Incision and exposure: A longitudinal or curved incision (convex side facing outward) is made at the anterior edge of the tibia in front of the calf. Cut the skin, subcutaneous, cut the deep fascia on the lateral side of the tibial ridge, pull the anterior tibial muscle, and the long toe extensor muscle to the lateral side, which can reveal the external dehiscence surface of the tibia.
2.Lateral calf incision.
Indications: Various surgeries on the fibular stem.
Incision and exposure: Longitudinal incision is made along the lateral side of the fibula.
Cut the skin, subcutaneous, along the posterior edge of the peroneus longus muscle, and cut the deep fascia. To expose the upper end of the fibula, the common peroneal nerve should be found at the posterior border of the biceps femoris tendon. The peroneus longus muscle is stripped from the fibula. The common peroneal nerve can be retracted over the head of the fibula. To expose the middle fibula, the long and short peroneal tendons can be peeled backward from the fibula and pulled apart without damaging the superficial peroneal nerve. Generally, the lower end of the fibula is not excised because it affects the stability of the ankle joint.
Ankle surgical approach: 1.
1. Anterolateral ankle incision.
Indications: ankle exploration, ankle fusion, ankle lesion removal.
Incision 1 and exposure: 5-7 cm in the anterior median of the pedal joint, on the ankle joint line, extending slightly medially down the tibial ridge to the talocrural joint. The skin and subcutis are incised to protect the superficial peroneal nerve. The deep fascia and transverse calf ligament are incised along the tibial ridge. Between the anterior tibial tendon and the extensor digitorum longus tendon, the deep peroneal nerve and anterior tibial vessels were located. The anterior tibial muscle is pulled medially, and the extensor digitorum longus tendon and the deep peroneal nerve and anterior tibial vessels are pulled laterally, and the anterior aspect of the ankle capsule is revealed. If the joint capsule is incised, the front of the ankle joint is revealed by the metatarsal session.
2. Posterior lateral ankle incision.
Indications: internal fixation of ankle fracture by incision (posterior-lateral fracture block), ankle fusion, etc.
Incision and exposure: From about 12-14 cm proximal to the tip of the outer ankle, extend downward along the posterior edge of the fibula to the tip of the outer pedicle, and bend forward slightly to 2-3 cm. If the fibula is not fractured, the periosteum of the fibula is peeled off at 10 cm proximal to the tip of the outer ankle and the fibula is severed with a wire saw.
Separate the interosseous membrane and cut the anterior and posterior ankle ligaments to protect the heel fibular and tibial brown ligaments. The distal end of the severed fibula was turned downward and outward to reveal the lateral aspect of the ankle joint and the anterior and posterior margins of the lower tibia. At the time of incision closure, the down-turned fibula was repositioned and secured by tightening a screw on the proximal side of the lateral ankle transversely to the tibia. The tendon is repositioned and the supporting band is sutured, and the incision is closed.
3.Posterior medial ankle incision.
Indications. Posterior pedicle fracture, talar body fracture, and surgery of the Achilles tendon.
Incision and exposure; make a longitudinal incision along the medial edge of the Achilles tendon, incise the superficial and deep fascia and pay attention to the posterior tibial vessels and nerves behind the medial ankle. The Achilles tendon was carefully retracted outward and the posterior tibial tendon, posterior tibial vessels and nerves were retracted inward to reveal the posterior side of the posterior ankle and lower tibia.
4. Posterior lateral ankle incision.
Indications: Same as above.
Incision and exposure: The longitudinal incision along the lateral border of the Achilles tendon is approximately 13 cm. The incision starts at the Achilles stop of the Achilles tendon, the superficial and deep fascia is cut, and the Achilles tendon and posterior ankle fat and cellular tissue are cut with a “z” incision. In the gap between the flexor digitorum longus and the peroneus longus and shortus tendons, the posterior side of the tibia is reached and the flexor digitorum longus tendon is drawn inward to reveal the lower end of the tibia, the posterior ankle, the posterior side of the talus body and the dorsal side of the subtalar joint and the top of the heel bone. It should be noted that the medial side of the flexor hallucis longus tendon has posterior tibial vessels and nerves, which should be protected.