Chapter 39

Patient Positioning and Portal Placement

Frederick M. Azar and Richard Rainey

Chapter Synopsis

• A thorough understanding of the indications for elbow arthroscopy and the anatomic structures about the elbow allows safe and effective arthroscopic treatment of a number of elbow disorders. Appropriate patient positioning and correct portal placement are essential.

Important Points

• Thorough physical and imaging examinations are necessary for accurate diagnosis.

• A complete patient history is essential for identifying differential diagnoses.

• The most common contraindications to elbow arthroscopy are previous severe trauma and active infection.

Clinical and Surgical Pearls

• Before any portals are established, important anatomic structures should be marked on the extremity with indelible ink.

• Once the initial portal has been made, all subsequent portals should be made under direct visualization.

• Stab incisions should not be used to establish portals because they may damage neurovascular structures.

• Gravity or pump flow with pressures of 35 to 45 mm Hg will keep fluid from extravasating into soft tissues and causing compartment syndrome.

Clinical and Surgical Pitfalls

• The most common complication related to portal placement is nerve damage, which occurs in about 3% of procedures. Vulnerable nerves (ulnar, radial, posterior interosseous) should be identified and protected.

Elbow arthroscopy continues to evolve as a tool for diagnostic and therapeutic treatment of common and complex elbow problems. A thorough understanding of the anatomic structures and the surgical technique will allow safe and efficient treatment of these conditions.

Preoperative Considerations

Patient History

A thorough history of the patient’s symptoms will help to elucidate a cause and allow the generation of a differential diagnosis that will aid in treatment.

A typical history should include information about the following:

• Acuity versus chronicity

• Location

• Type of symptoms (pain vs. mechanical)

• When the symptoms occur (with activity vs. at rest)

• Instability

• Swelling

• Neurovascular symptoms

• History of previous injury

• Previous treatment(s) and their effectiveness

Physical Examination

The physical examination of the patient goes beyond just the symptomatic elbow. An effort should be made to assess both upper extremities for evaluation of side-to-side asymmetry at the elbow and shoulder; the cervical spine should be examined when a patient gives a history of neurovascular complaints. Following these steps will aid in making a comprehensive decision about the diagnosis instead of an isolated decision based on examination of only the affected elbow.

The examination should proceed in a sequential manner, beginning with inspection for and notation of any previous incisions or scars, swelling or fullness, and notable erythema. After the elbow has been inspected, palpation, again in a sequential fashion, will help to localize any areas of tenderness or pain. The elbow should be delineated into four regions for assessment: lateral, posterior, medial, and anterior. Because each region has anatomic structures that may account for the patient’s symptoms, positive findings at a specific region or regions should aid in generating a differential diagnosis.

• Stability of the elbow should be tested in standard fashion with the appropriate tests based on the patient’s history.

• Range of motion, including flexion-extension and pronation-supination, should be evaluated to identify any side-to-side differences and to ensure that functional motion has been preserved. The findings should be documented.

• Mechanical symptoms and their relative locations should be noted during active and passive motion of the elbow.

• The neurovascular status of the upper extremities should always be determined and documented.

Physical Examination Maneuvers

Medial Compartment:

• Check for valgus instability. With the elbow flexed to 30 degrees to relax the anterior capsule and to free the olecranon from its bony articulation in the olecranon fossa, apply valgus stress with the arm in full supination.

• Discomfort along the medial aspect of the elbow may indicate ulnar collateral ligament (UCL) injury.

• Palpate the proximal flexor-pronator mass and medial epicondyle.

• Test resisted wrist flexion and forearm pronation; pain with these maneuvers may indicate medial epicondylitis or flexor-pronator tendon disease.

• Palpate the ulnar nerve in the cubital tunnel; flex and extend the elbow as the nerve is palpated to detect nerve subluxation.

• Assess the Tinel sign over the ulnar nerve in all three zones.

Posterior Compartment:

• Palpate the triceps muscle insertion and the posterolateral and posteromedial joint to check for bone spurs or impingement.

• Perform the “clunk” test for posterior olecranon impingement: Grasp the patient’s upper arm to stabilize the arm as the elbow is brought into full extension. Pain with this maneuver may indicate compression of the olecranon into the fossa (valgus extension overload).

Lateral Compartment:

• Palpate the lateral epicondyle and extensor origin to identify lateral epicondylitis or tendon disease.

• Pain with resisted wrist dorsiflexion and forearm supination is indicative of lateral epicondylitis.

• Palpate the radiocapitellar joint while the forearm is pronated and supinated to check for crepitus or catching, which may indicate chondromalacia.

• Inspect the “soft spot” to check for synovitis or effusion.

Stability:

• The O’Driscoll posterolateral instability test can be performed to evaluate posterolateral rotatory instability. However, because of the patient’s apprehension, the test result is usually negative. This test is best done with the patient under general anesthesia.

Range of Motion:

• Flexion, extension, pronation, and supination are determined and compared with those of the opposite extremity.

Differential Diagnosis

The differential diagnosis can be based on the patient’s subjective complaints or objective findings or both.

Lateral

• Radial head or neck fracture

• Lateral epicondylitis

• Extensor mechanism strain or avulsion

• Capitellar osteochondritis dissecans (OCD)

• Chondromalacia of the radial head or the capitellum

• Loose bodies

• Synovitis

Posterior

• Triceps tendinitis

• Triceps tendon avulsion

• Olecranon bursitis

• Olecranon stress fracture

• Posterior or posteromedial impingement

• Loose body

• Triceps enthesopathy

Medial

• Medial epicondyle fracture or avulsion

• Medial epicondylitis

• Flexor-pronator strain or avulsion

• Ulnar collateral ligament (UCL) sprain or rupture

• Ulnar neuritis

• Ulnar nerve subluxation

Anterior

• Distal biceps tendinitis

• Distal biceps tendon rupture

• Brachialis muscle strain

• Anterior capsular sprain

• Coronoid process fracture

Imaging

Radiography

Radiography may or may not help in confirming the diagnosis. All elbows should be imaged for assessment of bony pathology including fractures, subluxation, dislocation, or presence of loose bodies.

Views should include the following:

• Anteroposterior view: performed with the elbow in full extension

• Lateral view: performed with the elbow in 90 degrees of flexion

• Oblique view: rarely performed but may be useful in assessing for avulsions, fractures, or shear injuries

• Axial view: used to assess for signs of posteromedial impingement (posteromedial osteophytes)

• Gravity stress test view: special test used to assess for valgus laxity

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is useful for assessing and confirming musculotendinous injuries of the extension and flexor origins, chondral lesions including radiocapitellar OCD, and ligamentous injuries including lateral ulnar collateral ligament (LUCL) and UCL injuries (best assessed by arthrography with injection of saline or gadolinium) and for detecting loose bodies.

Elbow Arthroscopy

Indications

• Synovectomy (partial or complete)

• Evaluation and treatment of OCD lesions of the capitellum

• Removal of posterior or posteromedial osteophytes

• Evaluation and removal of loose bodies

• Debridement of the joint of chondral lesions

• Capsular release

• Lysis of adhesions

• Pain with inconclusive examination and imaging

Contraindications

• Bony ankylosis

• Soft tissue contracture

• Local soft tissue infection

• Any alteration of the normal bony or soft tissue anatomy that would not allow safe entry of the arthroscope into the joint

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Open Repair of Posterior Shoulder Instability Autologous Chondrocyte Implantation in the Knee Arthroscopic Rotator Cuff Repair: Double-Row Techniques Surgical Treatment of Posterolateral Instability of the Elbow Primary Repair of Osteochondritis Dissecans in the Knee Arthroscopic Meniscus Repair: All-Inside Technique

Stay updated, free articles. Join our Telegram channel

Join

Full access? Get Clinical Tree