Approach

Distal femur (anterolateral / lateral approach)

- Supine position no need table traction
- Landmark GT – Lateral condyle
- Incision mid lateral line femoral shaft curve anteriorly over lateral condyle toward to
tibia tubercle
- If Arthrotomy not necessary skin incision can stop 1-2 cm distal to the joint line
- Divide iliotibial band
- Elevation vastus lateralis, retract vastus anteromedially
- Several perforating vessel of the profunda femoralis artery and vein have to be
ligated
- Exposed the bone  fixated

Patella approach
- Supine position
- Landmark patella, tendon patella, tibia tubercle
- Make longitudinal midaxial incision from 5 cm above superior pole patella to the
tubercle
- After incision of superficial fascia, complete extent of injury must be identified

Shaft tibia approach

- Approach the anteromedial surface through longitudinal incision 1-2 cm lateral to
tibia crest
- The length of incision depends planned plate length
- Not to compromise saphenous vein nerve (risk when distal extend approach)
- Entrance into anterior tibia sheath tendon should be avoided can cause adhesion
- Full thickness skin and subcutaneous flap then mobilized in medial diretion
- Anteromedial aspect of tibia is directly exposed

Anteromedial approach
Advantages :
- Supine position  anesthesia easier
- No handling radial nerve
- Avoid radial nerve visualization and dissection, protecting neurovascular structure
- Less soft tissue dissection
- Ivan kirin study reported 5.4 % radial nerve palsy when applied anterolateral plating
Didn’t have radial nerve palsy on anteromedial plating
- Anterolateral plating frequently involved plate countering and erasing deltoid on
lateral surface
- Anteromedial no plate countering because relatively flat medial surface which
decerase operating time
 Anterior Humerus
- Patient in supine position abducted 60 degree
- Make curve incision from tip coracoid process distally in line with delpectoral groove
along lateral aspect of humerus
- Identify cephalic vein – take medially or laterally
- Incise deep fascia of the arm in line with skin incision
- Identify interval between brachialis and bicep
- Retracted bicep medially
- Identify musculocutaneus maintain

Intervenous plane
Proximal
- Deltoid muscle (axillary nerve)
- Pectoralis major ( medial and lateral pectoralis nerve)

Distal
Medial brachialis ( musculocutaneus nerve), lateral brachialis (radial nerve)

Henry approach
 Landmark process styloid radius – lateral bicep tendon
 Straight incision anterior part of forearm from flexor crease lateral bicep tendon to
process styloid radius
 Incise fascia develop plane between brachioradialis and flexor carpi radialis
 Retract superficial branch radial nerve with brachioradialis
 Deep of brachioradialis and flexor carpi radialis are supinator, pronater teres, FDS,
PQ
 Resect pronator teres to exposed the bone

Modified henry approach

 FCR palpated before making skin incise onto its radial side
 Sheath opened and retracted tendon medially
 Incision deepened between FPL and radial artery
 Avoid damaging radial artery on the lateral side and superficial palmar cutaneous
branch median nerve on medial side
 Used finger to developed interval between FPL and radial artery  Exposing PQ
 PQ elevated using L shaped incision
 Position radiocarpal joint can be determine by insertion hypodermic needle

Shaft radius
 Landmark styloid radius – lateral bicep tendon
Superficial dissection :
 Develop interval between brachioradialis and flexor carpi radialis
 Arterial branches arising from lateral side radial artery identified  ligated and
retracted to medial
 Superficial radial nerve under brachioradialis retracted laterally
Deep dissection :
 Proximal third : the forearm should be fully supinated to displaced PIN away from
surgical field
 Incised supinator muscle  gently elevated from bone surface to extent exposure
 Middle third :forearm fully pronated to exposed lateral border pronator teres and its
insertion