How To Tell If You Are Lost

If you just see muscle and do not see the radial nerve underneath the brachioradialis, you are probably lost in a lateral direction and are developing the interval between the brachioradialis and the wrist extensors. The brachioradialis is loose at the level of the elbow joint and you should clearly see its medial border. If you are lost too far medially, you will see the biceps tendon. The lacertus fibrosis from the biceps frequently needs to be transected, but you should clearly see the lateral border of the biceps and not be dissecting along its medial border. If you are lost too far proximally or distally, rotation of the forearm will identify the area of the radial head and bicipital tuberosity.

Case 15 Anterolateral (iNTERNERVous) Approach • 53

FIGURE 15—2 The brachioradialis underneath the subcutaneous tissue. This is the first muscle encountered. You should be able to see the fibers running longitudinally, paralleling the forearm.

FIGURE 15—1 The skin incision starting at the lateral aspect of the elbow flexor crease and going distally.

FIGURE 15—2 The brachioradialis underneath the subcutaneous tissue. This is the first muscle encountered. You should be able to see the fibers running longitudinally, paralleling the forearm.

FIGURE 15—3 The fat underneath the brachioradialis at the level of the elbow joint. This is your clue that you are in the area of the radial nerve.

O Brachioradialis

B Nerve in Fat Under Muscle

D Sensory Branch of Radial Nerve

ET Recurrent Branches of Radial Artery

FIGURE 15—4 The muscle being retracted. The sensory branch of the radial nerve is seen in the fat underneath the muscle. The nerve is paralleling the muscle at this point.

Q Radial Nerve Area

Q Supinator

EI Pronator Teres

FIGURE 15—5 The blood vessels crossing from medial to lateral. This is the only structure that needs to be transected with this approach.

FIGURE 15—5 The blood vessels crossing from medial to lateral. This is the only structure that needs to be transected with this approach.

FIGURE 15—6 The brachioradialis and superficial sensory branch retracted laterally, exposing the supinator underneath. The deep branch of the radial nerve is not yet apparent, but it is found just proximal to the supinator and going into that muscle.

FIGURE 15—7 The supinator retracted in a radial direction, having been freed from the radius. The pronator teres is seen dis-tally and the shaft of the radius is apparent. This incision could be carried more proximally to expose the radial head at the elbow or distally as far as necessary.

El Brachioradialis

E Nerve in Fat Under Muscle B Sensory Branch of Radial Nerve

E] Recurrent Branches of Radial Artery

B Radial Nerve Area B Supinator B Radius B Pronator Teres

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