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