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