“The Three Windows” Anterior Approach to the Elbow

By: Luis Fernando Calixto B., MD; Alejandro Ramírez G., MD; and Jairo Fernando Gomez R., MD

During elbow surgery, the elbow is traditionally exposed using medial and/or lateral approaches, while the posterior approach is used when a more universal access to the elbow is required. These routinely used approaches allow visualization and ease surgical procedures primarily for the posterior aspect of the elbow. When facing anterior structures, such approaches need to be extended, thus requiring muscle and ligament detachment. 

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Various surgical descriptions have been published regarding the anterior elbow approach. For example, Oberlin described in the 1990s how the longitudinal approach is performed mostly in coronoid fractures. Previously, Urbaniak had proposed this approach to liberate the anterior capsule in rigidity of the elbow in flexion. Descriptions of other attempts to approach the anterior surface of the elbow arthroscopically have also been reported. To our knowledge, however, no literature exists on the use of an anterior transverse approach. We conducted a study to introduce a new single anterior transverse incision to the elbow at the flexion crease, granting safe access—through three separate windows—to the anterior articular elbow surface and its structures.

Study methods, surgical technique
The study involved 20 dissections of all anatomic elbow structures taken from fresh cadaveric elbows with no history of trauma. All dissections were performed using the three windows anterior approach, from skin to superficial joint, using three neurovascular intervals: the central, medial, and lateral windows. The anatomic structures involved were duly documented and explained. Photographic and written evidence of measurements were taken to describe the three safe and reproducible windows.

We began by making a 4 cm transverse incision at the anterior elbow crease. This incision allowed the approach to all three windows, enabling the lateral antebrachial cutaneous nerve, cephalic vein, and the median cubital vein to be identified and retracted to the lateral side of the incision.

The biceps tendon was the reference point for each window. We sectioned the lacertus fibrosus perpendicular to its fibers (Fig. 1) to identify the brachial artery and median nerve beneath (Fig. 2, A). From there we developed three intervals (windows); the central window between the biceps and the brachialis neurovascular bundle (Fig. 2, A-D); the lateral window (Fig. 3, A,B), just lateral to the biceps tendon; and the medial window just medial to the brachialis neurovascular bundle. Through these windows we were able to see all structures of the anterior surface of the elbow, the trochlea, the capitellum, the radial head, the coronoid, and the sublime tubercle by only making a blunt longitudinal split of the brachialis muscle.


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Fig. 1
Courtesy of Luis Fernando Calixto B., MD

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Fig. 2
Courtesy of Luis Fernando Calixto B., MD

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Fig. 3
Courtesy of Luis Fernando Calixto B., MD

Discussion
Medial and lateral approaches have limitations with respect to fractures of the anterior articular portion of the trochlea, capitellum, and coronoid. For example, it is very difficult to reduce and set coronoid fractures from anterior to posterior when using a lateral approach, particularly when the radial head has not been removed. When using a medial approach, ulnar nerve dissection and detachment of flexor-pronator muscles are needed. With a posterior approach, an olecranon osteotomy is frequently necessary. In some cases, dislocation is necessary to gain complete access to the anterior surface of the elbow when treating coronal fractures, resulting in the potential for rigidity or instability. 

Anterior approaches to the elbow have been underused when dealing with fractures that involve the anterior articular surface of the elbow. The three windows approach allows for a safe and reproducible access to the whole anterior articular surface of the elbow through a small single anterior transverse incision to the elbow at the flexion crease, disturbing only the brachialis muscle and allowing a complete visualization of the anterior capsule and the front faces of the trochlea and capitellum. Benefits include less scarring, no detachment of muscle or ligaments, and an uncompromised condyles blood supply. The windows can be used on their own or together to perform anatomic reduction and direct fixation from anterior to posterior or to reinsert the articular capsule.

We have used the three windows anterior approach for the past 5 years at the Orthopedic and Traumatology Service of the National University of Colombia in Bogota’s Tunal Hospital on 20 patients with coronoid fractures, coronal fractures of the distal humerus, and radial head fractures. Good results were reported in all cases, with no vascular or nerve complications. We have found the three windows approach to be safe and reproducible to fix and stabilize elbow fractures. In addition, the approach results in faster and better recovery of elbow function in lesions that usually do not obtain good results.

Luis F. Calixto, MD, is chairman of the Department of Orthopedic Surgery at National University of Colombia. Jairo F. Gomez, MD, is adjunct professor of the Department of Orthopedic Surgery at National University of Colombia. Alejandro Ramirez, MD, is a PGY orthopedic resident at National University of Colombia.

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