Jesse Jupiter演绎肘关节后侧入路 / 四六文摘

本月19号，河北三院召开手术入路学习班，其中肘关节手术入路解剖操作由我来演示，Deadline法则又起了作用，在公众号先温习跟随导师Jupiter学些过的相关知识。

尺骨近段为直切口，理由在于：The cutaneous nerves come from either side and the least chance you have of injuring those is straight dorsally, so a straight dorsal approach to the proximal ulna is recommended。

向尺骨鹰嘴延伸，the tip is where the triceps attaches, and one can just split the triceps attachment and have access to the olecranon

还记得第一次在麻省总医院手术室看JUPITER劈开三头肌附着处的潇洒动作，左手的镊子放到鹰嘴尖下方，心里有数，下刀有神

Now to know where the joint is, by just lifting up a little bit of the muscle, one can appreciate where the joint is of the olecranon，注意这里用词a little bit of, not most of.

肘肌即在刀下，Now we're in the joint of the olecranon sulcus.注意左上角手臂的位置，他在术中非常重视上肢的相对位置。

放置尺骨钢板时候要注意骨干本身不是直的，有7度弯曲： The ulna itself has generally a 7 degree angle. And so it's not exactly straight, and so when one puts the implant on, it's important to realize that.

有些人喜欢采用这个入路向前显露桡骨近段，即Boyd-Thompson入路，这种显露有造成尺桡骨融合的风险，需要切开旋后肌，注意保护桡神经深支PIN

作者不推荐这样显露，理由是：it’s not a very favorable approach, because it’s cutting through muscle, and many people would rather go through two approaches, one anterior and one in the front for the radius.其实更深刻的一个理由在于近段尺骨靠背侧，远端桡骨靠背侧。骨科手术的关键是显露显露再显露，轻松快捷显露。

历尽艰辛，通过掀开伸肌和旋后肌cut too much muscles，终于显露了桡骨近端。因此大师并不推荐常规采用这种入路。

只有经尺骨鹰嘴的复杂骨折脱位，此时不需要剥离肌肉，经过骨折线入路处理桡骨近端骨折，才考虑这个入路，大师原话如下：Generally, if you have a complex olecranon fracture with a radial head, a radial neck fracture, before fixing the olecranon or proximal ulna, one can go right through the fracture to get here, and avoid elevating the muscle. So this is the Boyd-Thompson approach, and it’s a muscle elevation, but it risks creating a synostosis, a bone healing between the bones.

如果是肱骨远端骨折，则切口需要向近段延伸，以下图片来自梅奥诊所Scott教授，可见左侧的尺神经。