Surgical Approaches

Lower Limb

Femoral Artery







On table angiogram


Longitudinal incision

- midpoint ASIS and pubic symphysis

- open femoral sheath


- insert catheter into artery

- inject contrast and follow with II





- patient supine

- leg externally rotated



- medial aspect distal thigh over sartorius

- extends over knee to 1 cm posterior border tibia


Superficial dissection

- divide deep fascia over sartorius

- retract sartorius anteriorly to expose femoral artery

- at the knee detach medial head of gastrocnemius to expose popliteal artery

- at tibia detach soleus to expose trifurcation



- first clear artery with embolectomy

- vein patch graft or anastomosis with reversed great saphenous vein

- repair 6.0 prolene non cutting needle











Lateral Approach




Split vastus lateralis




ORIF of femoral neck fractures 

Subtrochanteric or intertrochanteric osteotomy 

ORIF of femoral shaft or supracondylar femoral fractures 

Extra articular hip arthrodesis 

Treatment of chronic femoral osteomyelitis 

Biopsy and treatment of bone tumors 




Lateral position or fracture table 

- pad all prominences 


Longitudinal incision from middle of GT down lateral side of thigh 

- fasica lata split 

- may need to split TFL in line of fibres proximally to expose VL ( 30%)

- vastus lateralis split in line of fibres

- ligating perforators as located

- subperiosteal dissection of femoral shaft 


Posterolateral Approach




Elevate vastus lateralis anteriorly from lateral intermuscular septum




ORIF Supracondylar fracture 

Non unions of femoral fractures 

Femoral osteotomy 


Biopsy and treatment of bone tumors 





- use sandbag under buttock to expose posterolateral thigh 



- lateral epicondyle distally up posterolateral thigh proximally 


Internervous plane 

- between the vastus lateralis (covered by the ITB) and biceps femoris


Superficial dissection

- dissect the VL off the lateral intermuscular septum after posterior surface of ITB located

- difficult often as the VL has origin from the LIMS

- ligate the perforators 

- locate the linea aspera and take the periosteum off here 

- need retractor to elevate the vastus proximally due to bulk of muscle 


Extensile measures

- can extend into lateral parapatellar approach to knee

- allows visualisation of the knee joint for fracture reduction

- skin incision then curved anteriorly to Gerdy's tubercle 


Anteromedial Approach




Between Vastus Medialis and Rectus Femoris




ORIF of medial distal femoral fractures 

Treatment of osteomyelitis 

Biopsy of bone tumors 





- supine with leg draped free 



- 10-15 cm incision medial thigh between the rectus femoris and vastus medialis 

- extend distally as medial parapatellar incision if knee joint needs to be opened 


No internervous plane 


Superficial dissection 

- retract the RF laterally 

- begin distally and open the knee capsule in line with skin incision through the medial patellar retinaculum 

- split quads tendon with cuff of tendon on the VM allowing closure 

- expose the vastus intermedius proximally 

- split in line of fibres and subperiosteal dissection to expose femur 

- medial superior geniculate artery crosses field above the knee and should be controlled 

- must have good repair of the vastus medialis distally to avoid lateral patellar subluxation 


Extensile measures

- the incision can not be extended proximally as the vessels and nerve interfere 


Posterior Approach 




Between vastus lateralis and biceps femoris proximally

Access to middle 3/5 of femur and sciatic nerve




Infected non union of femur 

Chronic osteomyelitis 

Biopsy and treatment of bone tumors 

Exploration of sciatic nerve





- prone position with support and padding of pelvis and chest



- straight longitudinal incision down midline of posterior aspect of thigh

- ending proximally at inferior gluteal fold 


Internervous plane 

- between lateral intermuscular septum and biceps muscle 


Superficial dissection

- incise deep fascia in line of skin incision

- protect the posterior cutaneous nerve of thigh (in groove between semitendinosis and biceps)

- identify lateral margin of biceps proximally and develop plane between the biceps and VL

- retract long head biceps medially at proximal end and nerve retracted with it 


Deep Dissection

- detach short head of biceps from femur to expose shaft 

- distally long head of biceps retracted laterally and nerve exposed 

- sciatic nerve retracted laterally and posterior aspect of femur exposed 

- sciatic nerve not identified proximally but must be seen distally 

- cannot be extended proximally or distally 







Foot and Ankle




- anterior

- anterolateral

- posterolateral



- lateral

- Ollier's


Anterior approach to Ankle




Between EHL and EDL



- drainage of ankle joint

- ankle arthrodesis

- ORIF tibial plafond

- removal of loose bodies





- supine / tourniquet



- 15cm longitudinal incision over anterior aspect of ankle joint midway between malleolus 


Internervous plane

- no true internervous plane

- EHL / EDL define a clear intermuscular plane with anterior tibial vessels / deep peroneal nerve between them


Superficial dissection

- incise extensor retinaculum

- dissection in intermuscular plane between EHL / EDL a few cm above ankle joint

- identify anterior tibial vessels / deep peroneal nerve medial to EHL tendon

- retract EHL / NV bundle medially


Deep dissection

- incise anterior capsule ankle joint

- detach capsule from tibia or talus by sharp dissection



- superficial peroneal nerve

- anterior tibial vessels / deep peroneal nerve 


Extensile measures 

- extended proximally to expose anterior compartment & proximal tibia between Tibia and T anteror

- distal extension rarely required onto dorsum of foot


Anterolateral approach to ankle and hind foot


Anterolateral Approach Ankle




Between Peroneus Tertius and Brevis

Elevate EDB



- exposes AKJ / STJ / CCJ / STJ

- ankle fusions

- triple arthrodesis & pantalar arthrodesis

- talus excision

- open reduction of talar dislocations





- supine with sandbag under hip to IR leg



- 15cm curved incision on anterolateral aspect of ankle joint.

- begin 5cm proximal to ankle joint 

- 2cm anterior to fibular border

- crossing joint 2cm medial to lateral malleolus tip 

- end over base of 4th MT


Internervous plane 

- between peroneus tertius (DPN) and peroneus brevis (SPN)


Superficial dissection 

- identify dorsal cutaneous branches of SPN

- incise superior (tibia to fibula) / inferior extensor retinaculum (calcaneum to MM and fascia)

- incise down to bone lateral to peroneus tertius / EDL


Deep dissection 

- retract peroneus tertius / EDL medially to expose anterior ankle joint

- distally, expose origin of EDB on dorsum of calcaneus 

- detach EDB by sharp dissection reflecting origin distally and medial

- this will involve division branches of lateral tarsal artery

- identify dorsal capsules of TN / Calcaneo-cuboid joints.

- mobilize fat pad in sinus tarsi to identify subtalar joint (preserve fat pad )

- open joints by forcefully plantar flexing and inverting foot 




- Anterior tibial artery


Posterolateral approach Ankle Joint




Between Peroneals and T achilles



- treat conditions of posterior aspect of tibia and ankle joint

- ORIF posterior malleolus 

- removal benign tumors

- FHL tendonitis / Os trigonum





- patient prone



- 10cm longitudinal incision 

- halfway between posterior border of lateral malleolus and lateral border of T achilles


Internervous plane

- between PL and FHL tendon


Superficial dissection

- mobilize skin flaps

- identify peroneal tendons around back of lateral malleolus

- open peroneal retinaculum to release tendons

- retract them anteriorly to expose FHL muscle at level of ankle joint

- FHL is most lateral of deep calf flexors and is still muscular at this level


Deep dissection

- enhance exposure by making a longitudinal incision through lateral fibres of FHL origin on fibula

- retract FHL medially to expose posterior tibia & ankle joint



- sural nerve and short saphenous vein


Extensile measures 

- limited proximally by soleus


Lateral approach to STJ




Posterior / inferior to peroneal tendons



- STJ fusion

- ORIF calcaneal fracture





- supine with sandbag under buttock to IR leg and bring hind foot forward

- place a support on opposite iliac crest, tilt table 20 - 30o away from surgeon to improve access

- or put patient on side



- along line of peroneal tendons

- 10-13cm curved incision, beginning 4cm above tip of lateral malleolus on posterior border of fibula

- follow posterior border of fibula to tip lateral malleolus 

- curve incision forward, passing over peroneal tubercle


No Internervous plane


Superficial dissection

- avoid sural nerve and short saphenous vein behind lateral malleolus

- sural nerve posterior, superficial peroneal nerve anterior

- incise the separate sheaths of peroneus longus / brevis

- mobilize tendons anteriorly over distal end of fibula.

- ligaments of peroneal retinaculum must be repaired at the end to prevent anterior subluxation of tendons


Deep dissection

- identify and divide calcaneofibular ligament (part of STJ capsule)

- open STJ transversely to expose posterior facet of subtalar joint

- divide interosseous ligament for full exposure subtalar joint



- sural nerve, short saphenous vein


Lateral approach to hind foot (Olliers)




Incision from lateral malleolus to TNJ

Between P. tertius and Peroneals



- exposes AKJ / STJ / CCJ / TNJ

- triple arthrodesis

- individual joint arthrodesis 

- excision CN bar





- supine with sandbag under hip to IR leg and bring hind foot forward



- curved incision 

- commencing distal to lateral malleolus and slightly posterior to it

- continue distally along lateral side of hind foot & over the sinus tarsi 

- curve medially ending over the dorsum of TNJ


Internervous plane 

- between peroneal tendons (SPN) and peroneus tertius (DPN)


Superficial dissection 

- do not mobilize skin flaps widely as large skin flaps may necrose

- identify and protect SPN

- incise deep fascia along incision



- Peroneus tertius / EDL tendons cross distal end of wound and retract medially


Deep dissection

- EDL and tertius medially, peroneals inferior

- mobilize fat pad in sinus tarsi to identify subtalar joint (preserve fat pad)

- expose origin of EDB on dorsum of calcaneus

- detach by sharp dissection reflecting origin distally and medial

- this will involve division branches of lateral tarsal artery

- identify dorsal capsules of TN medially / Calcaneo-cuboid joints laterally

- open joints by forcefully plantar flexing and inverting foot 

- identify and open posterior talo-calcaneal joint / invert foot



- skin flaps notorious for producing necrosis

- avoid stripping / retraction and sharp incision curves

- branches of SPN


Extensile measures 



- continue incision along posterior border of fibula 

- dissect in plane between peroneal & flexor tendons 

- exposing length of fibula (rarely required)


Posterior & proximal 

- reach Achilles tendon












Anterior Approach / Smith Peterson



- neonatal hip sepsis

- open reduction hip DDH





- supine

- sandbag under buttock

- free drape leg



- iliac crest to ASIS / superior limb

- ASIS to lateral patella / inferior limb




Anterior half crest to ASIS  

- ASIS 10cm towards lateral patella


Bikini incision

- 2/3 lateral to ASIS and 1/3 medial

- 1-2cm below inguinal ligament


Superficial Dissection

-  between Tensor Fascia Lata (SGN) and Sartorious (FN)

-  ER leg to stretch sartorious

-  find plane 2 inches below crest

-  incise fascia over TFL to protect LFCN which runs over sartorius

-  take TFL off crest

-  divide ascending branch LCFA between the two muscles


Deep Dissection

- between RF and G. medius

- divide both heads of RF

- direct head to AIIS

- reflected head to acetabulum

- hip capsule is in base


Anterolateral Approach / Watson Jones



- between TFL and G. medius



- ORIF displaced subcapital






- floppy lateral, 45o up, radiolucent table



- longitudinal incision, anterior to GT



- plane between TFL and G medius

- TFL anterior

- G medius posterior,  sometimes detach some off GT

- find fatty tissue over capsule

- may have to elevate RF off anterior capsule

- open capsule

- flexing the hip 20-30o will detension tissues and make job much easier


Lateral Approach / Hardinge



- detach anterior 1/3 G. medius




- hemiarthroplasty





- 8cm incision parallel to anterior border of femur

- slightly anterior


Superficial dissection

- split ITB


Deep dissection


Find anterior border of G medius

- take off anterior third

- usually a fat plane underneath

- find G minimus and take off separately

- expose capsule



- T shaped for hemi / THR

- Z shaped for SUFE avoiding superior neck capsule


Posterior / Southern / Kocher Langenbeck Approach




- acetabular posterior wall ORIF





- lateral



- curve skin incision

- distal limb is over axis of femur

- curve over tip GT towards PSIS

- many variations

- can perform oblique incision over GT towards PSIS


Superficial dissection

- divide fascia

- split G. max

- there is a communicating vessel between superior & inferior gluteal arteries that crosses this plane & will bleed

- can release G. max distally to increase exposure (leave 1.5cm stump on femur for reattachment)

- wipe fat off posterior short external rotators, identify sciatic nerve


Cruciate anastomosis

- branches are visible over the short external rotators

- inferior gluteal artery runs along lower edge of piriformis tendon

- MCFA runs along upper border of Quadratus (has run up between obturator externus and quadratus)

- ligate these vessels in THR


Deep dissection

- place homan lever under G medius and minimus to expose superior joint capsule

- piriformis can be seen and palpated 

- tag piriformis / conjoint tendon / quadratus femoris with sutures

- release from GT

- take capsule in same layer

- reflect to protect sciatic nerve


Non arthroplasty case 

- divide short external rotators 2cm from the insertion

- preserve the anastomosis of MCFA with the gluteal vessels

- don't divide quadratus femoris


Medial Approach / Ludloff



- between Longus and Gracilis

- between Brevis and Magnus



- DDH open reduction





- supine

- hip flexion, abduction & ER (ipsilateral foot placed onto opposite knee)

- makes adductor longus very palpable / visible



- adductor longus and pubic tubercle



- longitudinal / transverse incision

- begin 3cm below pubic tubercle

- continue down over adductor longus


Superficial dissection

- between adductor longus and gracilis (both supplied by anterior division obturator nerve)

- longus is anterior to gracilis


Deep dissection

- between adductor brevis (anterior division) and magnus (posterior division)

- brevis is anterior to magnus

- adductor brevis is between the two divisions of the nerve

- lesser trochanter with psoas tendon superior aspect of wound

- MFCA is medial to psoas tendon



- anterior branch Obturator nerve lies between longus & brevis

- posterior branch Obturator nerve lies between brevis & magnus

- medial femoral circumflex artery passes around medial side of the distal part of the psoas tendon between psoas & pectineus





ApproachesPosterior approach knee


Medial Parapatellar




Modified Posterior


Medial Parapatellar Approach











- longitudinal straight midline incision

- point 5 cm above patella to below level of tibial tuberosity 


No internervous plane


Superficial dissection

- between VM and RF through the quads tendon

- leaving thin tendinous cuff for repair to VM and along medial patella and patellar tendon 

- synovium incised in line with the capsular incision 

- dislocate patella laterally and flex knee to 90° 



- infrapatellar branch of the saphenous nerve cut often in this approach

- risk post operative neuroma formation

- patella tendon avulsion / reconstruction using semitendinosus tendon


Extensile measures

- can extend proximally as anteromedial approach to distal femur

- between rectus femoris & vastus medialis


Medial Approach


Medial Knee Anatomy




MCL repair

Inside out meniscal repair





- patient supine with knee flexed and abducted over the other leg 

- or knee flex 90°  



- locate infero-medial corner of patella and medial joint line



- curved incision centred on joint line

- middle of incision runs parallel to medial border of patella and 3 cm medial from it 

- preserve long saphenous vein and saphenous nerve


No internervous plane


Superficial dissection

- incise deep fascia along anterior part of sartorius 

- flex knee to allow sartorius to move posteriorly 

- semitendinosis and gracilis exposed 

- retract pes posteriorly to expose the tibial insertion of the superficial MCL 6-7 cm below the joint line 


Deep dissection


Anterior to Superficial MCL

- use to expose the superficial MCL , ACL and anterior medial meniscus 

- medial parapatellar incision to enter the joint above medial meniscus


Posterior to Superficial MCL

- access to posterior 1/3 of the medial meniscus and posteromedial corner of knee

- retract the pes posteriorly 

- back of the medial femoral condyle seen 

- expose the posteromedial capsule by retracting the medial head of gastrocnemius 

- postero-medial capsulotomy possible 


Femoral insertion MCL

- elevate vastus medialis superiorly



- infrapatellar branch of the saphenous nerve

- long saphenous vein

- medial inferior geniculate artery - lies beneath medial head of gastrocnemius & can be damaged when lifted off capsule 

- popliteal artery lies against posterior joint capsule adjacent to medial head of gastrocnemius 

- knee flex at 90° allows artery fall posteriorly

- can develop haematoma beneath skin flap with subsequent necrosis 


Lateral Approach


Lateral Approach 1Lateral Approach 2




Access to all structures on lateral aspect of the knee 

Posterolateral corner repair / reconstruction





- sandbag under buttock on affected side with knee flexed 90o on foot rest



- along lateral aspect of the thigh and 3cm lateral to patella curving down to the Gerdys Tubercle 


Superficial dissection

- internervous Plane between ITB and the Biceps femoris 

- identify and protect CPN at posterior border of the biceps tendon

- in acute injuries identify outside zone of injury and trace back to abnormal area 

- LCL origin on fibula identified between ITB and BF

- LCL insertion on femur identified in split of ITB

- posterolateral corner of the knee exposed 

- enter joint anterior or posterior to the LCL 


Anterior to LCL

- create lateral parapatellar approach 

- incise the lateral patellar retinacular fibres 

- begin arthrotomy 2cm above the joint line to avoid the lateral meniscus 


Posterior to the LCL

- dissect between the lateral head of gastrocneumius and posterolateral capsule 

- control LSGA in this plane

- peel lateral gastrocnemius off capuslte

- popliteus tendon can lie over the lateral capsule

- capsulotomy 2cm above joint to protect posterior horn of lateral meniscus 

- protect the intracapsular popliteus


Posterior Approach


Posterior approach to knee




Repair of the neurovascular structures of the knee 

Repair of avulsion fractures of PCL attachment 

Excision of popliteal cysts 

Access to posterior capsule of knee 





- patient prone on table with tourniquet except for vascular repairs 



- start incision over biceps tendon superiorly

- curve across the popliteal fossa

- extend distally medial to the medial head of gastrocnemius 


No internervous plane


Superficial dissection

- reflect skin flaps with the underlying fat 

- find short saphenous vein and then sural nerve

- sural nerve is deep to deep fascia

- follow back to the popliteal fossa to its origin from tibial nerve

- find origin of CPN from sciatic nerve at apex of fossa


Deep dissection

- popliteal artery and vein located deep & medial to tibial nerve 

- artery / vein / tibial nerve: medial to lateral

- MGA may need to be ligated to mobilise the popliteal artery 

- access joint via postermedial joint capsule 

- medial head of gastroc tendinous head reflected from the femur laterally and inferiorly to protect N-V bundle 


Modified Posterior Approach



- between semitendinosus and medial head gastrocneumius

- medial head of gastrocnemius mobilised laterally to protect NV structures










Pfannenstiel Approach



- fracture medial to the iliopectineal eminence

- pubic diastasis

- fractures lateral to this prominence endangers the vascular sheath





- supine on radiolucent table

- IDC to empty bladder



- transverse incisions

- 15-20 cm in length and 2 cm above symphysis

- at the lateral edges of the incision take care to avoid the spermatic cords (or the round ligament in females)

- vertical incision is an alternative to the Pfannenstiel, in cases of concomitant abdominal trauma


Superficial Dissection    

- identification of the rectus

- normally, the rectus abdominus muscle tendons insert onto the anterior aspects of the pubis

- in acute case, rectus abdominis muscle has usually been avulsed and dissection is easy

- in chronic cases this dissection can be very difficult because of scar

- if the rectus has not be avulsed, then incise it, leaving a cuff of tissue attached to the pubis for later wound closure

- alternatively consider a vertical incision between the halves of the recti muscles, leaving the muscles attached to the pubis


Deep Dissection

- the dissection proceeds laterally until the external inguinal rings and the spermatic cords are identified

- exposure of symphysis

- identify the pubic eminences on either side of the symphysis

- the anterior portion of the symphysis is cleared of soft tissue



- spermatic cord

- bladder

- surgeon must stay on the skeletal plane to avoid injury to bladder                                    

- the bladder lies directly behind the symphysis pubis

- in males the bladder neck is attached to the posterior surface of the pubis by puboprostatic ligaments

- females in contrast, have a bladder that is in more contact with the pubococcygeal portions of the levator ani muscles

- with previous surgery or an old injury, the bladder may be scarred to the undersurface of the rectus and the symphysis pubis

- note proximity of symphysis both to spermatic cord & to NV structures


Ilioinguinal Approach



- anterior wall / anterior column acetabulum

- T type acetabular fractures

- periacetabular osteotomies



- inner pelvis / ilium to SIJ

- can expose outer surface by detaching abductors, but high risk of HO and disruption blood supply





- floppy lateral 0-30°

- drape to include contralateral iliac crest

- have to get right across pubis

- IDC to empty bladder

- radiolucent table


2 limb incision 

A.  Medial limb 

-  2-3 cm above symphysis pubis to ASIS

B.  Lateral limb 

- extends from ASIS along iliac crest

- start lateral & raise external oblique off iliac crest

- raise iliacus to expose SIJ


Superficial Dissection


Open inguinal canal

- divide external oblique along and proximal to inguinal ligament to the external inguinal ring

- need to leave flap to repair later

- spermatic cord (round ligament in females) is isolated & retracted medially

- laterally LFCN needs to be identified & protected


Open floor of inguinal canal

- internal oblique and transversalis off inguinal ligament

- again leave flap for attachment

- inferior epigastric artery crosses the floor of the inguinal canal at the medial border of the deep inguinal ring

- requires ligation

- symphysis can be exposed by releasing rectus


Deep Dissection


3 windows 

1.  Lateral window - lateral to iliopsoas

2.  Middle window - between psoas and vessels (key is iliopectineal fascia)

3.  Medial window - medial to vessels


Middle & Lateral window

- use peanuts to find external iliac vessels

- don't dissect out, simply identify, gently mobilise and place vessiloop around them

- mobilise psoas with femoral nerve, vessiloop

- find iliopectineal fascia

- finger up each side of fascia, is a vertical structure

- is the key to access from the false to the true pelvis

- divide it with scissors 

- retropubic space can be exposed by release of rectus


Exposure is then gained bw these 3 mobile tissue envelopes



- corona mortis

- anastomosis between external iliac and obturator artery

- behind superior pubic ramis

- present in about 10% of people

- can cause life threatening bleeding


Stoppa Approach



- anterior acetabular fracture





- radiolucent table in a supine position

- leg on the injured side draped freely

- both hips and knees slightly flexed to relax the iliopsoas muscle



- midline incision from umbilicus to symphysis


Superficial dissection

- open anterior rectus sheath vertically in midline

- open the preperitoneal space was opened and bluntly dissect to the symphysis pubis

- blunt dissect peritoneum from transversus

- mobilise peritoneal sac away from fracture site

- mobilise and protect CFA and CFV with vessiloop

- same with spermatic cord


Deep dissection

- subperiosteally dissect the superior pubic ramus

- identify and ligate corona mortis

- mobilise the psoas muscle and femoral nerve if needed

- expose the quadrilateral plate up to the medial SIJ












Posterolateral Approach



- ORIF distal 2/3 tibia 

- bone grafting tibial non-unions

- also permits exposure to posterior aspect of fibula





- lateral position or prone



- fibular shaft and ankle joint



- longitudinal incision 2cm behind the fibula


Internervous plane 

- between posterior & lateral compartments

- anterior - peroneus muscles

- posterior - gastrocnemius, soleus & FHL (distal)


Superficial dissection

- dissect T achilles (gastroc and soleus) posteriorly and peronei muscles anteriorly

- muscular branches of peroneal artery lie with peroneus brevis in proximal part of incision / ligated


Deep dissection

- detach lower part of soleus & FHL from fibula

- continue dissecting across the interosseous membrane, detaching tibialis posterior from it

- follow interosseous membrane to lateral border of tibia

- detaching tibialis posterior from posterior surface of tibia subperiosteal

- posterior tibial artery & tibial nerve are posterior to dissection on tibialis posterior



- peroneal artery - branches cross inter-muscular plane bt gastrocnemius & peroneus brevis 

- posterior tibial artery & tibial nerve - safe as long as dissection stays on interosseous membrane

- short saphenous vein - may be damage in mobilizing skin flaps


Extensile measures

- proximal - cannot be extended into proximal 1/4 of tibia as it is covered by popliteus

- distal - continuous with posterior approach to ankle


Anterolateral approach



- exposes middle 2/3 tibia

- technically simple, but only provides limited exposure to tibia for ORIF

- anterolateral bone grafting tibial non-unions





- lateral position or supine with sandbag under hip



- longitudinal incision over the shaft of fibula

- length of tibia exposed will be considerably shorter than length of fibula incision


Internervous plane

- between peroneus brevis (posterior) & EDL (anterior)


Superficial dissection

- develop plane between anterior border of peroneus brevis & EDL 

- expose anterior aspect of tibia

- protect superficial peroneal nerve which lie on peroneus brevis muscle


Deep dissection

- subperiosteal dissection extensor muscles from anterior surface of interosseous membrane 

- extend onto lateral surface of tibia

- only endanger neurovascular bundle if sway off interosseous membrane



- SPN - motor branches given off proximal 1/3 then only sensory distally

- anterior tibial artery & DPN


Extensile measures 

- cannot be extended easily proximally or distally













Structures at risk

Superficial Dissection

Deep Dissection



Surgical approach


Check patient

- check correct procedure

- check side of patient

- pre-op NV assessment

- check skin

- confirm allergies


Place X-ray's on viewing box

- pre-op templating

- check implants

- check cement

- check bone graft / substitutes

- check equipment

- check nursing staff familiar with procedure



- GA / regional / LA

- type of table / radiolucent / hand table

- supine / prone / lateral decubitus

- protect nerves and pressure areas

- preop antibiotics

- IDC insertion

- table supports - bolsters / sandbags

- accessories - tourniquet / II / shavers / fluid pumps                 





- longitudinal / transverse

- position of incision

- length of incision


Structures at risk

- always important to mention early

- i.e. CPN, PIN


Superficial Dissection

- subcutaneous tissue

- deep fascia

- structures encountered / first plane


Deep Dissection

- second plane



- proximal and distal


Wound closure

- drains

- suture

- LA

- dressings

- splints       


Post op

- supervise moving patient off table

- check NV status in recovery

- mobilisation / weight bearing etc





Anterior Cervical

Via the carotid triangle


SCM / posterior belly digastric / superior belly omohyoid




Exposes inferior body C2 - T1




1.  Supine in tongs

2.  Sit on head board with head taped and slightly extended


Table 30° up

Turn head away from side of incision


Which Side


Most surgeons approach from the left

- the course of the Recurrent Laryngeal Nerve / RLN is more predictable on left


Right sided approach

- used sometimes for C7/T1 to avoid thoracic duct


Recurrent Laryngeal Nerve


Right side

- given off the vagus at the level of the subclavian artery

- slopes from lateral to medial across lower part of wound to reach the oesophagus / trachea interval

- crosses the surgical approach in 50% of cases

- usually at C6/7

- may be at C5/6


Left side

- arises at the level of the aortic arch

- doesn't slope across the wound


3 Fascial layers


1.  Deep Cervical Fascia

- under the subcutaneous fat

- invests neck like collar

- clavicle / sternum / spine scapula - mandible / base of skull

- invests SCM & trapezius

- Have to incise so can retract SCM


2.  Pretracheal

- covers trachea

- deep to the strap muscles

- extends from hyoid into chest

- splits to enclose thyroid

- fuses laterally with carotid sheath

- have to divide to retract carotid sheath laterally


3.  Prevertebral

- base of skull to T3

- invests longus colli and sympathetics

- divide to separate longus colli muscles to approach verebrae




Medial border SCM

Carotid Artery lateral to SCM



- Hyoid = C3

- Thyroid Cartilage = C4/5

- Cricoid = C6

- Carotid Tubercle = C6




Inject LA with adrenaline

Transverse incision at level required from midline to posterior border SCM


Superficial Dissection


Divide Platysma vertically at anterior border SCM


Superficial plane

- through investing layer of deep cervical fascia

- between strap muscles (Sternohyoid & Sternothyroid) & anterior border SCM


Deep Dissection


Palpate the Carotid Artery 

- divide the pretracheal fascia medial to the Carotid Sheath

- open plane between carotid sheath & medial structures

- medially oesphagus, trachea & thyroid

- note that anterior carotid sheath fuses to pretracheal fascia

- retract the carotid sheath & SCM laterally





- superior thyroid artery / superior laryngeal nerve behind

- common venous trunk of superior thyroid / lingual / facial vein



- ligate middle thyroid vein

- inferior thyroid artery


Blunt dissection medially

- behind the oesophagus

- expose the vertebrae covered by Longus Colli, prevertebral fascia & ALL

- sympathetic chain lies on the Longus Colli, just lateral to the vertebrae

- incise the Longus Colli in the midline

- subperiosteally expose the Vertebrae

- place retractors under Longus Colli


Check level with II




1. Recurrent Laryngeal Nerve

- lies between trachea & oesphagus

- on right crosses field from subclavian artery at C6/7 with inferior thryoid artery


2. Superior Thyroid Artery/ Superior Laryngeal Nerve

- C3/4

- superior thyroid artery pass from the Carotid Sheath medially to the midline structures

- superior laryngeal nerve runs with artery

- can divide artery but must preserve nerve

- otherwise get dysphagia


3.  Inferior Thyroid Artery

- lower approach may pass from lateral to medial


4. Sympathetic Chain on transverse processes

5. Vertebral Artery

6. Carotid Sheath with Vagus inside

7. Oesophagus

8. Trachea

9. Thoracic duct on left at C7 / T1 level





- thoracotomy

- thoracoabdominal

- abdominal




Anterior Approaches


C2 - T2

- anterior cervical approach

- may have to split manubrium / sternotomy for lowest levels


T3 - T7

- thoracotomy

- patient on side left side up to avoid veins

- always easier to mobilise aorta

- scapular in the way of the ribs

- release scapula and lift away from ribs

- go through bed of appropriate rib

- usually rib 2 above vertebra

- have to deflate lung with double lumen ETT

- divide segmental artery away from foramen

- identify discs (hills) and vertebral bodies (valleys)


T7 - T12

- thoracotomy

- patient on side

- bed of rib 2 above vertebra

- can usually push lung out of way without deflation


T12 - L1

- thoracoabdominal

- patient on side

- through bed of 10th rib

- diaphragm attaches at T12/L1 and 12th rib

- must take down diaphragm if need to instrument or cross T12/L1


L2 - L5

- anterolateral flank / retroperitoneal approach

- incision below 12th rib

- patient on side



- anterior / transabdominal approach

- pelvis blocks flank approach


Retroperitoneal Approach L2 - L4



- patient left side up 45o

- surgeon stands on right





- in line with 12th rib and towards pubic symphysis



- split musculature / external and internal oblique / transversalis

- identify and preserve peritoneum / stay retroperitoneal

- dissection done with peanuts

- ureter and genitofemoral nerve on psoas / reflect medially

- stay anterior to psoas to preserve nerve roots

- symphathetic chain medial to psoas

- aorta and IVC on vertebral bodies

- tie off segmental arteries

- gently reflect vessels


Transabdominal Approach L4 - S1



- patient supine




Paramedian incision

- stand on right / approach from left

- midway between umbilicus and symphysis

- through skin and subcutaneous fat

- divide anterior rectus sheath (external and internal oblique)

- separate left rectus muscle from posterior rectus sheath

- posterior rectus sheath is deficient by L4/5, ending in semilunar membrane

- divide posterior rectus sheath (transversalis / internal oblique), staying outside peritoneum

- divide peritoneum

- mobilise bowel


Aorta bifurcates at L4/5

- common iliac artery and vein on medial psoas

- identify sacral promontory between

- divide posterior peritoneum in midline distal to bifurcation

- superior hypogastric plexus on common iliac vein / sympathetic

- injury causes retrograde ejaculation



- reflect artery and vein medially

- have to divide and ligate iliolumbar vein




Access between common iliac vessels

- must divide median sacral vein




Upper Limb










Posterolateral / Kocher


Kochers Approach 1Kochers Approach 2



- between ECU and anconeus



- radial head ORIF / replacement

- washout elbow joint





- patient supine with arm on hand table



- lateral epicondyle, head radius, olecranon



- proximally over lateral supracondylar ridge 5cm proximal to elbow

- continue 5cm distal towards radial head

- curve posteriorly to ulna border


Inter-nervous plane 

- between ECU (PIN) & anconeus (RN)


Superficial dissection 

- identify the plane between the anconeus & ECU

- anconeus triangular muscle fanning from lateral epicondyle out to olecranon

- interval best identified distal to epicondyle


Deep dissection 

- fully pronate the forearm to move the PIN away

- elevate ECU and EDC off capsule anteriorly

- keep incision anterior to avoid dividing lateral ulna collateral of LCL

- LCL in line and deep to anterior fibres of anconeus

- divide capsule over radial head

- do not continue below the annular ligament or retract too vigorously to avoid damage to the PIN



- proximally between triceps and BR/ECRL anteriorly


Anterior Approach



- between Biceps and BR proximally

- between BR and PT Distally



- repair of median nerve / radial nerve / brachial artery

- reinsertion of biceps tendon





- S shaped incision over the anterior aspect of elbow

- 5cm above the flexion crease on medial side of biceps 

- curve across the front of elbow joint

- continue laterally along medial aspect of BR

- don't cross flexion crease at 90o


Internervous Plane

- between the BR (radial nerve) and Brachialis (MCN) proximally 

- between BR (radial nerve) and PT (median nerve) distally 


Superficial Dissection

- incise deep fascia in line with skin incision and ligate veins

- lateral cutaneous nerve of forearm located and preserved

- lacertus fibrosis identified and cut at the origin with the biceps tendon

- brachial artery beneath lacertus

- median nerve lies medial to artery 

- radial nerve found between the brachialis and BR

- passes lateral to biceps tendon


Deep dissection not required



- lateral cutaneous nerve of forearm located between the Brachialis and Biceps 

- brachial artery immediately deep to lacertus



- proximally along the medial side of the biceps to expose the brachial artery

- distally as anterior / Henry approach to forearm


Anterolateral Approach



- between BR / radial nerve and biceps / PT



- ORIF of capitellar fractures

- OCD of capitellum

- tumors of the proximal radius

- PIN compression

- distal biceps rupture





- 5cm above the flexion crease of elbow over the lateral border of biceps muscle

- small curve at flexion crease of elbow

- extends distally following the medial border of brachioradialis


Internervous Plane 

- proximally between BR (radial nerve) and Brachialis (MCN)

- distally between the BR (radial nerve) and PT (median N)


Superficial dissection 

- preserve LCN of forearm (superficial to deep fascia in interval between biceps and brachialis)

- incise deep fascia along the medial aspect of BR

- identify and protect radial nerve proximally between the BR and brachialis

- brachialis / biceps reflected medially and BR reflected laterally 


Deep dissection

- follow the radial nerve until divides into the SRN / PIN and motor branch to ECRB

- develop plane between BR and PT

- will have to ligate the recurrent vessels (leash of Henry) here that enters BR

- retract radial artery and PT medially

- divide capsule longitudinally between the radial nerve laterally and the brachialis medially

- the proximal radius is further exposed by fully supinating the forearm

- detaching the supinator from the oblique line to avoid damage to the PIN




- radial nerve

- recurrent branches of radial artery

- lateral cutaneous nerve of forearm



- proximally by conversion into anterolateral approach to the humerus

- distally extended as the anterior approach to the forearm


Posterior Approach



- ORIF distal 1/3 humerus





- patient on side, arm over bolster



- midline and extending distally 

- curve laterally about the tip of olecranon

- avoids sensitive scar


Superficial dissection

- identify ulnar nerve medially

- dissect from its bed (divide Osbourne's fascia) and vessiloop


Deep dissection

1.  Mobilise medial and lateral sides of triceps

- beware radial nerve proximally on lateral side


2.  Intra-articular fracture

- chevron osteotomy

- predrill and tap the olecranon for 6.5 mm screw 

- Chevron osteotomy 2 cm from tip with osteoclasis of articular surface

- elevate the triceps superiorly off the humerus with olecranon

- can extend to lower 1/4 - any higher can endanger the radial nerve in groove

- cannot extend proximally but able to extend distally to expose the entire surface of the ulna


Medial Approach



- ORIF coronoid process fracture

- ORIF medial epicondyle





- curved incision on the medial aspect of the elbow 8-10 cm length

- centered on the medial epicondyle


Internervous Plane

- proximal - Brachialis (anterior) and Triceps (posterior)

- distal - PT and Brachialis 


Superficial dissection 

- locate the ulnar nerve and divide the fascia over the nerve

- mobilise and retract the ulna nerve posteriorly

- identify CFO



1.  Osteotomy medial epicondyle and reflect CFO

2.  Open plane between PT and FCR



- median nerve or AIN palsy with traction of the medial epicondyle

- ulnar nerve injury


Distal extension 

- is limited by the median nerve










Anterior Approach to Radius

Posterior Approach to Radius

Approach to the Ulna


Anterior Approach to Radius / Henry



- ORIF of radius fractures

- bone grafting of non unions 

- radial osteotomy 





- arm table

- tourniquet



- avoid full exsanguination to see vascular structures more easily

- supinate forearm

- straight incision from flexion crease just lateral to biceps tendon down to radial styloid


Internervous plane

- proximally between brachioradialis / BR and pronator teres / PT (median nerve)

- distally between the BR (radial nerve) and FCR (median nerve) 


Superficial Dissection

- proximally between PT and BR

- distally between FCR and BR

- begin distal and work proximally

- superficial radial nerve deep to BR  / retract radially with BR

- recurrent leash of Henry from the radial artery to BR just below elbow joint need to be ligated 

- radial artery beneath the BR in middle of wound and runs with two vena commitante

- may need to be mobilised and retracted medially particularly proximally and distally


Deep Dissection


Proximal Third

- follow biceps tendon to insertion on bicipital tuberosity

- just lateral to tendon is bicep bursa

- incise bursa to access proximal radius 

- radial artery superficial and medial to tendon

- fully supinate the forearm to expose the supinator and protect the PIN

- incise supinator along insertion on radius and lift subperiosteally (anterior oblique line)

- reflect from medial to lateral

- 25% of patients: PIN in contact with radial neck / thus take care with retractors 


Middle third

- anterior aspect covered by PT and FDS

- insertion of PT into radius exposed by pronating forearm

- detach PT from insertion along with FDS subperiosteally


Distal third

- FPL and Pronator Quadratus arise from the anterior aspect of distal third of radius

- incise periosteum of radius just lateral to PQ and FPL 

- subperiosteally dissect medially off radius

- this protects Median Nerve




- superficial radial nerve

- radial artery

- recurrent radial artery (anterior and posterior groups lie either side of radial nerve)


Posterior Approach to Radius / Thompson approach



- between ECRB and EDC proximally

- between ECRB and EPL distally



- ORIF of radial fractures

- non union of radial fractures 

- decompression of PIN





- supine with pronated forearm to expose the dorsal surface 



- from point just anterior to the lateral epicondyle to Lister's tubercle on dorsal radius 


Intermuscular plane 

- proximally is between the ECRB and EDC (PIN)

- distally the plane is between the ECRB and EPL (PIN)


Superficial Dissection

- deep fascia split in line of the skin incision

- identify plane between ECRB and EDC

- more obvious distally where the APL and EPB separate the two muscles 

- upper 1/3 contains the supinator at the base 

- proximal 1/3 then centres on exposure of the PIN between the two heads of supinator 

- PIN emerges 1cm proximal to distal edge of supinator 

- divides into branches to the extensor compartment 


Proximal to Distal PIN exposure

- detach origin of the ECRB and part of ECRL

- locate the PIN proximally and dissect out distally 


Distal to Proximal PIN exposure

- identify nerve as emerges from supinator and follow proximal 

- protecting all branches 


Deep Dissection

- once protected fully supinate the forearm to expose the supinator fully 

- strip the supinator subperiosteally to expose the proximal radius 

- in the middle 1/3 the APL and EPB blanket the approach as they cross the radius radially 

- they are mobilised by incising the superior and inferior borders 

- the distal 1/3 is exposed with subperiosteal dissection 



- 25% of cases have the PIN in touch with the radial shaft and so must be exposed 

- the nerve is protected with the supinator and reflected 



- proximally to expose the lateral epicondyle

- distally as the posterior approach to the wrist 


Approach to the Ulna



- ORIF of Ulna fractures 

- treatment of delayed or non union of ulnar fractures 

- osteotomy of Ulna

- ulnar lengthening / shortening





- place arm across chest of the supine patient 



- linear longitudinal incision along the subcutaneous border of the ulna 


Internervous plane 

- between the ECU and FCU 

- attach via shared aponeurosis onto subcutaneous border of the ulna

- cannot be separated at origin 

- fibers of ECU usually detached from the aponeurosis



- deep fascia incised along line of skin incision 

- continue to subcutaneous border of the ulna 

- proximally dissect between the Anconeus and FCU

- periosteum incised longitudinally 

- in proximal 1/5 part of triceps insertion released 



- the ulnar nerve lies on FDP deep to FCU

- safe as long as FCU stripped subperiosteally 

- in proximal dissections (1/5) should be identified between the two heads of FCU prior to stripping 

- ulnar artery also at risk 

- this incision also able to be extended proximally as posterior approach to humerus













Lateral (to distal humerus)


Anterior Approach



- elevate biceps and split brachialis



- ORIF of humerus shaft

- humeral osteotomy

- biopsy and resection of tumors

- treatment of osteomyelitis





- arm on table and abducted 60o

- no tourniquet



- tip of coracoid process of scapula along the deltopectoral groove

- towards the deltoid insertion and then heads distally along the lateral border of biceps

- stop 5 cm proximal to elbow flexion crease


Internervous planes

- two

- proximally between the deltoid and pectoralis major

- distally between the two halves of Brachialis (musculocutaneous and radial nerve)


Superficial dissection

- mobilise cephalic vein in deltopectoral groove

- open fascia on lateral edge of biceps

- the biceps is reflected medially to expose the brachialis muscle

- musculocutaneous nerve identified between biceps and brachialis and protected


Deep dissection



- incise periosteum lateral to pect major insertion and lateral side of LHB tendon

- ligate ACHA



- brachialis is split in midline

- lifted off the humerus subperiosteally



- radial nerve at risk in two areas

- spiral groove on back of humerus (care with drilling AP)

- distal 1/3 (protected by lateral 1/2  of the brachialis muscle)


Extensile measures

- can extend proximally as anterior approach to shoulder 

- cannot extend distally - need to extend as anterolateral approach of distal humerus into forearm 


Anterolateral Approach



- between biceps / brachialis medially and BR / triceps laterally

- identify and protect radial nerve



- ORIF humerus

- exploration radial nerve in distal arm 





- supine with arm abducted on hand table



- from coracoid down deltopectoral groove

- lateral aspect of biceps


Internervous Plane

- no true internervous plane 

- between brachialis and brachioradialis


Superficial dissection

- retract biceps medially 

- find plane between the brachialis and brachioradialis 

- identify and protect radial nerve distally

- retract brachioradialis laterally and brachialis and biceps medially 

- stay on medial side of the radial nerve

- expose humerus subperiosteally 



- proximal - deltopectoral groove

- distal - Henry's approach to forearm


Posterior Approach



- between long and lateral heads triceps

- medial head split



- ORIF of distal 2/3 humerus

- exploration of radial nerve in spiral groove





- patient lateral decubitus

- arm over arm rest

- no tourniquet



- posterior midline incision from 8 cm below the acromion to olecranon fossa


No true internervous plane


Superficial dissection

- divide fascia in midline

- develop the plane between the long and lateral heads of triceps

- small blood vessels cross the muscle and need to be coagulated


Deep dissection

- the medial head of triceps lies deep to the other two heads

- radial nerve lies in spiral groove proximal medial head

- identify and protect the radial nerve

- incise the medial head in midline to bone and then dissect subperiosteal off the bone to avoid the ulnar nerve

- never dissect to bone until the radial nerve is safe


Extensile measures

- cannot extend proximal to spiral groove due to deltoid crossing the field

- can extend distally over the olecranon


Lateral Approach to Distal Humerus



- between BR and Triceps



- ORIF of lateral condyle fractures 

- surgical treatment of tennis elbow 





- supine with arm abducted on hand table



- 4-6cm curved incision on lateral aspect of elbow over the supracondylar ridge 


Internervous plane 

- between brachioradialis and triceps 


Superficial dissection

- BR anteriorly

- triceps posteriorly

- down onto supracondylar ridge


Extensile measures

- cannot extend proximally as radial nerve crosses the line of dissection 

- distal - can extend to radial head via plane between the ECU and Anconeus  (Kocher approach)











Anterior Approach / Deltopectoral



- shoulder stabilization

- arthroplasty

- fracture fixation





- beach chair

- upper body elevated 30- 40o / reduces venous pressure and bleeding

- knees flexed / pressure point care

- headrest

- sandbag under ipsilateral shoulder / lifts shoulder forward so arm can fall back / opens GHJ

- arm draped free



- coracoid process and deltoid groove




1. Anterior

- deltopectoral groove

- from coracoid to axilla


2. Axillary

- incision in anterior axillary skin fold

- requires more extensive undermining of skin edges


Superficial Dissection

- find cephalic vein in deltopectoral groove

- take laterally or medially (more branches to ligate)

- finger dissection in groove and up to coracoid

- insert retractor

- identify conjoint tendon

- dissection remains lateral to conjoined tendon to avoid NV bundle

- musculocutaneous nerve enters medially

- divide clavipectoral fascia

- elevate subdeltoid space

- place retractor under conjoint tendon / gentle retraction


Deep dissection

- subscapularis muscle underlies clavipectoral fascia

- arm put in ER to reveal SSC 

- sutures in medial aspect SSC

- subscapularis incised 1cm from insertion and separated from capsule

- leave inferior 1/4 of SSC to protect AXN


Anterior shoulder approach





- superomedially over middle 1/3 clavicle 

- perform clavicular osteotomy to gain access to underlying axillary artery and brachial plexus



- release upper 1/2 pectoralis raphe +/- part deltoid insertion

- biceps retracted medially & brachialis split


Anterolateral Approach



- acromioplasty

- ACJ resection

- open rotator cuff repair

- ORIF GT fracture

- IM humeral nail





- beach chair



- antero-lateral corner of the acromion

- transversely from ACJ along anterior edge acromion

- antero-laterally from AL corner acromion



- find raphae between anterior and lateral deltoid

- deltoid split, must protect underlying rotator cuff

- detach anterior deltoid from anterior acromion

- control bleeding acromial branch of thoracoacromial artery

- axillary nerve 7 cm below acromion

- cannot split futher than 5 cm below acromion

- coracoacromial ligament detached from acromion

- bursectomy

- humeral head rotated to examine RC


Posterior approach



- open posterior stabilisation

- glenoid osteotomy / bone graft

- ORIF glenoid neck fracture




Shoulder Posterior ApproachPosterior shoulder anatomy



- lateral position with arm draped free

- beach chair with access to posterior shoulder



- acromion and scapula spine



1.  Transverse along entire scapular spine to PL corner acromion

2.  Longitudinal from postero-lateral acromion to axilla


Internervous plane

- between IS (suprascapular nerve) and T minor (axillary nerve)


Superficial dissection


1. Deltoid split in line of fibres

- infraspinatous and teres minor exposed

- IS tagged laterally then detached 1 cm from insertion

- joint capsule exposed


Posterior shoulder approachPosterior shoulder approachPosterior shoulder approachPosterior shoulder approach


2. Detach deltoid from spine of scapula

- reflect deltoid laterally

- expose infraspinatus

- tenotomy


Posterior approach shoulder Posterior approach shoulder 2Posterior approach shoulder 3


Posterior approach shoulder 4Posterior approach shoulder 5Posterior approach shoulder 6






Axillary nerve / posterior circumflex humeral artery

- emerges through quadrangular space beneath T minor


Suprascapular nerve

- passes around base of scapular spine

- IS must not be forcefully retracted medially to stretch the nerve around base of scapular spine







Volar Approach



- decompression of median nerve

- synovectomy of the flexor tendons of wrist

- ORIF distal radial fractures





- curve incision around thenar eminence from the midpalm (ulnar to thenar crease)

- to flexion crease of wrist (don't cross at 900)

- then along FCR


Superficial dissection

- dissect through fat

- avoid the palmar cutaneous branch of the median Nnerve

- incise fascia over FCR

- mobilse FCR ulna side

- reflect pronator quadratus from radial side

- expose distal radius


Dorsal Approach



- synovectomy 

- repair of extensor tendons in rheumatoid 

- wrist fusion 

- SL repair

- dorsal wrist ORIF

- proximal row carpectomy 

- tumour biopsy





- 8 cm long and longitudinal crossing the wrist joint midway between the radial and ulnar styloids 

- 3 cm proximal to wrist joint and 5 cm distal to it 


Superficial dissection

- protect branches SRN

- expose the extensor retinaculum 

- incise retinaculum over the EDC and EIP tendons in 4th wrist compartment 

- reflect EPL to radial side

- reflect EDC to ulna side

- expose the underlying distal radius 



- longitudinal capsulotomy 

- ligament sparing / radially based between DRC and DIC ligaments