SURGICAL APPROACHES TO THE BONES

AND JOINTS
130 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Caudolateral Region of the Shoulder Joint

INDICATIONS
1. Osteochondroplasty of the humeral head for osteochondritis dissecans.
2. Open reduction of caudoventral luxations of the shoulder.
3. Open reduction of fractures of the ventral portion of the glenoid cavity.

ALTERNATIVE APPROACHES
The approach to the craniolateral region of the shoulder joint with osteotomy of the acromion
process (see Plate 26) provides improved access for reduction of shoulder luxations and
glenoid fractures but more surgical exposure than generally needed for osteochondritis dis-
secans lesions.
The approach to the craniolateral region of the shoulder joint by tenotomy of the infraspi-
natus muscle (see Plate 27) provides better exposure to osteochondritis dissecans lesions of
the humeral head. However, access to the caudal compartment of the shoulder joint for
removal of joint mice is better with this caudolateral approach (see Plate 28) or the caudal
approach (see Plate 29).

PATIENT POSITIONING
Place the animal in lateral recumbency with the affected limb uppermost.

DESCRIPTION OF THE PROCEDURE

A. Identify the spine of the scapula, acromion process, and greater tubercle of the
humerus by palpation. A curved incision begins at the middle of the scapula and
follows the spine distally, crossing the joint and continuing over the lateral surface
of the humerus to the midpoint of the shaft. Skin margins are undermined and
retracted after subcutaneous fascia and fat are incised in the same line as the
skin incision.
B. Deep fascia is incised over the ventral border of the distal scapular spine to free the
origin of the scapular part of the deltoideus muscle. This fascial incision is continued
distally over the acromial part of the deltoideus to the omobrachial vein. The incised
fascia is elevated and retracted cranially and caudally from the underlying deltoideus
muscle.
C. An incision is made on the ventral border of the spine of the scapula and continued
distally between the scapular and acromial parts of the deltoideus muscle.
 PLATE 28
Approach to the Caudolateral Region of the Shoulder Joint

Brachiocephalicus m. Deltoideus m.,

scapular part

Acromion process

Deltoideus m.,
acromial part
Fascial incision

Omobrachial v.

A B

Incision
Acromion process

Deltoideus m.,
Scapular part
Acromial part
(Line of elevation
of muscle from
bone for Part F)
Axillobrachial v.

C Omobrachial v.
132 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Caudolateral Region of the Shoulder Joint continued

D. The division between the two parts of deltoideus muscle is developed by blunt
dissection to allow freeing of the scapular part of the muscle and its caudal
retraction with the deep fascia. A muscular branch of the axillary nerve is found
between the two parts of the deltoideus. It is usually possible to preserve
this structure.
There are two possible ways to proceed from this point. Plate 28E illustrates
the simpler method, but it may not provide sufficient exposure in some animals.
Continuing as shown in Plate 28F and G will give additional exposure.
E. Working along the ventral border of the teres minor muscle, bluntly dissect between
this muscle and the underlying joint capsule. Strong dorsocranial retraction of the
teres minor muscle with a Senn retractor will expose the joint capsule. An incision is
made parallel and close to the rim of the glenoid cavity. Care is taken to protect the
subscapular vessels and axillary nerve lying between the joint capsule and the long
head of the triceps muscle. Internal rotation and adduction of the humerus provides
maximal exposure of the humeral head.
As an alternative, the junction between the infraspinatus and teres minor muscles
is separated. The teres minor muscle is elevated from the underlying joint capsule and
retracted caudoventrally, whereas the infraspinatus and acromial part of the deltoideus
muscles are retracted craniodorsally. Although there is less risk of damage to the
branches of the axillary nerve and caudal circumflex humeral vessels, less of the
articular cartilage on the humeral head can be seen as compared to the standard
caudolateral approach described previously.
 The Scapula and Shoulder Joint ■ 133

PLATE 28
Approach to the Caudolateral Region of the Shoulder Joint continued

Infraspinatus m.
Supraspinatus m.

Triceps m., Teres minor m.

accessory head
Triceps brachii m.,
long head

Muscular br. of
axillary n.,
caudal circumflex
Deltoideus m., humeral vessels
acromial part

Deltoideus m.,
scapular part

Teres minor m.

Humeral head
Glenoid

Joint capsule

Deltoideus m.,
Deltoideus m., scapular part
acromial part

E
134 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Caudolateral Region of the Shoulder Joint continued

F. The belly of the acromial part of the deltoideus is undermined along its cranial border
and elevated from the underlying humerus (see incision in Plate 28C). The deltoideus
is then retracted caudally to expose the tendons of insertion of the infraspinatus and
teres minor muscles on the greater tubercle of the humerus. Fascia overlying the
tendon of the teres minor is incised to allow tenotomy about 5 mm from its insertion.
Place a modified mattress or locking-loop suture in the tendon before its transection,
leaving the needle attached to the suture (see Figure 21).
G. The tendon suture is passed caudally under the acromial part of the deltoideus, and
the two bellies of the deltoideus are separated with Gelpi self-retaining retractors.
The tendon suture in the teres minor is used to apply gentle traction as the muscle
is dissected free from the underlying joint capsule. The infraspinatus is retracted
dorsally and the joint capsule is incised parallel to the rim of the glenoid. As this
incision is carried caudally to the flexor surface of the joint, care must be taken to
preserve the subscapular artery and axillary nerve that lie very close to the joint.
Internal rotation of the humerus will provide maximum exposure of the caudal
surface of the humeral head.

CLOSURE
The joint capsule is closed with interrupted sutures of 3-0 absorbable material. If the teres
minor tendon was cut, the preplaced tendon suture is placed through the tendon insertion
and tied. External rotation of the humerus will facilitate tying this suture. Additional small
mattress sutures are used in the tendon if necessary to gain adequate closure. The inter-
muscular septum between the two parts of the deltoideus is next sutured with the suture
material of choice, and the cranial border of the acromial part of the deltoideus is reat-
tached to the fascia on the proximal portion of the humeral shaft. The next step is to suture
the fascial origin of the scapular part of the deltoideus to the spine of the scapula. This
suture line is continued distally to close the fascia overlying the acromial part of the del-
toideus. Subcutaneous closure is made with care because of the tendency for subcutaneous
seroma to form.

PRECAUTIONS
The axillary nerve curves around the caudal border of the neck of the scapula, branching to
innervate teres minor and deltoideus muscles. These nerves, together with the subscapular
and cranial circumflex humeral arteries, cross the caudal aspect of the shoulder joint between
the joint capsule and long head of the triceps muscle.
 The Scapula and Shoulder Joint ■ 135

PLATE 28
Approach to the Caudolateral Region of the Shoulder Joint continued

Tendon of Deltoideus m.,

infraspinatus m. acromial part

Tenotomy of
teres minor m. Triceps m.,
and preplaced suture lateral head

Teres minor m.

Glenoid

Joint capsule

Triceps m.,
Accessory head
Lateral head Humeral head

Deltoideus m.,
Scapular part
Acromial part

G
212 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Lateral Humeroulnar Part of the Elbow Joint

Based on a Procedure of Snavely and Hohn46

INDICATIONS
1. Excision or fixation of an ununited anconeal process.
2. Open reduction of lateral elbow luxation.

ALTERNATIVE APPROACHES
Alternative approaches through a lateral incision provide exposure of the lateral aspect of
the condyle and epicondyle (see Plate 39) and the caudal humeroulnar joint compartment
(see Plate 42).

PATIENT POSITIONING
Lateral recumbency with the affected limb uppermost.

DESCRIPTION OF THE PROCEDURE

A. The skin incision is centered on the lateral humeral epicondyle, which is easily
palpated. The incision curves to follow the lateral epicondylar crest and the proximal
radius.
B. Subcutaneous fascia is incised on the same line as the skin. The fascia of the brachium
is incised along the cranial border of the lateral head of the triceps brachii to its
insertion on the olecranon.
 The Forelimb ■ 213

PLATE 41
Approach to the Lateral Humeroulnar Part
of the Elbow Joint

Triceps
brachii m.,
lateral head
A

Incision
in brachial
fascia

Region of
lateral humeral
epicondyle

B
214 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Lateral Humeroulnar Part of the Elbow Joint continued

C. Elevation of the triceps brachii exposes the anconeus muscle, which is incised at its
periosteal origin on the lateral epicondylar crest.
D. Subperiosteal elevation of the origin of the anconeus muscle exposes the caudolateral
compartment of the elbow and the anconeal process of the ulna.

ADDITIONAL EXPOSURE
Additional proximal exposure is obtained in combination with the approach to the distal
shaft of the humerus through a craniolateral incision (see Plate 37).
Additional distal exposure is obtained in combination with the approach to the head of
the radius (see Plate 46).
This lateral approach (see Plate 41) can be used in combination with the medial
approach to the distal shaft and supracondylar region of the humerus (see Plate 38) for open
reduction of T-Y fractures of the distal humerus to avoid the need for olecranon osteotomy
(see Plate 43) or triceps tenotomy (see Plate 44).

CLOSURE
The origin of the anconeus muscle is sutured to the origins of the extensor muscles of the
antebrachium. The fascia of the triceps brachii, subcutaneous fascia, and skin are closed in
separate layers.

PRECAUTIONS
Although not directly in the field, the radial nerve emerges from under the lateral head of
the triceps muscle and runs obliquely craniodistal on the brachialis muscle. It bifurcates into
superficial and deep branches that cross the flexor surface of the elbow medial to the origin
of the extensor carpi radialis muscle.
 The Forelimb ■ 215

PLATE 41
Approach to the Lateral Humeroulnar Part
of the Elbow Joint continued

Periosteal incision

Radial n. Lateral head,

triceps brachii m.

Extensor carpi Anconeus m.

radialis m.

Lateral epicondyle

Common digital
extensor m.

Lateral digital Ulnaris lateralis m.

extensor m.

Anconeus m.

Anconeal process
of olecranon

D
322 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Craniodorsal Aspect of the Hip Joint

Through a Craniolateral Incision in the Dog
Based on Procedures of Archibald, Brown, Nasti, and Medway 3
and Brown and Rosen6

INDICATIONS
1. Femoral head and neck resection.
2. Open reduction of fractures of the femoral head and neck.
3. Open reduction of coxofemoral luxations.
4. Installation of total hip prosthesis.

ALTERNATIVE APPROACHES
Greater exposure of the hip joint and dorsum of the acetabulum is provided by the dorsal
approach with osteotomy of the greater trochanter (see Plate 69 ) or with gluteal tenotomy
(see Plate 70 ).
The approach to the ventral aspect of the hip joint (see Plate 73) is an alternative for femoral
head and neck resection, but the amount of exposure gained is very limited.
The approach to the caudal aspect of the hip joint is an alternative for open reduction of
craniodorsal coxofemoral luxation (see Plate 71).
Total exposure of the hemipelvis is shown in Plate 72.

PATIENT POSITIONING
Lateral recumbency with the affected side uppermost.

DESCRIPTION OF THE PROCEDURE

A. The skin incision is centered at the level of the greater trochanter and lies over the
cranial border of the shaft of the femur. Distally, it extends one third to one half the
length of the femur; proximally, it curves slightly cranially to end just short of the
dorsal midline. When performing the total hip replacement procedure, the skin incision
is modified to facilitate femoral reaming; proximally it curves caudally over the
trochanter and toward the base of the tail.
B. The skin margins are undermined and retracted. An incision is made through the
superficial leaf of the fascia lata, along the cranial border of the biceps femoris muscle.
C. The biceps femoris muscle is retracted caudally to allow incision in the deep leaf of the
fascia lata to free the insertion of the tensor fasciae latae muscle. The incision continues
proximally through the intermuscular septum between the cranial border of the
superficial gluteal muscle and the tensor fasciae latae muscle.
 The Pelvis and Hip Joint ■ 323

PLATE 66
Approach to the Craniodorsal Aspect of the Hip Joint Through a
Craniolateral Incision in the Dog

Middle gluteal m.

Superficial gluteal m.

Greater
trochanter

Tensor fasciae Biceps

latae m. femoris m.

Incision in
superficial leaf
of fascia lata

Superficial gluteal m.

Sciatic n. and caudal

gluteal a. and v.

Intermuscular Biceps femoris m.

incision

Greater trochanter

Tensor fasciae
latae m.

Incision in deep leaf

of fascia lata

Lateral circumflex
femoral a. and v.
C
324 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Craniodorsal Aspect of the Hip Joint

Through a Craniolateral Incision in the Dog continued
D. The fascia lata and the attached tensor fasciae latae muscle are retracted cranially and
the biceps caudally. Blunt dissection and separation along the neck of the femur
with the fingertip allows visualization of a triangle bounded dorsally by the middle
and deep gluteal muscles, laterally by the vastus lateralis muscle, and medially by the
rectus femoris muscle.
E. The joint capsule is covered by areolar tissue, which must be cleared away by blunt
dissection. An incision is then made in the joint capsule and continued laterally along
the femoral neck through the origin of the vastus lateralis muscle on the neck and
lesser trochanter. Exposure can be improved by tenotomy of a portion of the deep
gluteal tendon close to the trochanter, leaving enough tendon on the bone to allow
suturing. The muscle is split proximally, parallel to its fibers, and the pedicle is
allowed to retract.
 The Pelvis and Hip Joint ■ 325

PLATE 66
Approach to the Craniodorsal Aspect of the Hip Joint Through a
Craniolateral Incision in the Dog continued

Superficial
gluteal m.
Middle
gluteal m.
Deep
gluteal m.

Tensor fasciae
latae m. Sciatic n. and caudal
gluteal a. and v.

Greater trochanter
Rectus
femoris m. Vastus lateralis m.

Incision in deep
gluteal m.
Middle gluteal m.
Superficial gluteal m.

Greater trochanter

Articularis Incision in origin

coxae m. of vastus lateralis m.

Rectus
femoris m.

Biceps femoris
m., retracted

Incision in
E joint capsule
326 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Craniodorsal Aspect of the Hip Joint

Through a Craniolateral Incision in the Dog continued
F. The origin of the vastus lateralis muscle is elevated from the femoral neck and reflected
distally. The muscle comes free most easily if the elevation proceeds from distal to
proximal. This elevation can be subperiosteal in the immature animal or extraperiosteal
in the mature animal. Hohmann retractors are placed intracapsularly ventral and
caudal to the femoral neck to allow visualization of the femoral head. Caution is
needed to be certain that the caudal retractor is intracapsular, or at least between the
deep gluteal muscle and the femoral neck, to avoid entrapping the sciatic nerve on the
caudodorsal surface of the deep gluteal muscle.

ADDITIONAL EXPOSURE
Extension of this approach cranially to gain exposure of the ilial shaft is possible by combin-
ing with the approach to the ilium through a lateral incision (see Plate 64).
Distally, exposure of the femur can be obtained in combination with the approach to the
greater trochanter and subtrochanteric region of the femur (see Plate 76) or the approach to
the shaft of the femur (see Plate 77).

CLOSURE
One or two mattress sutures (see Figure 21B) or a pulley suture (see Figure 21D) are placed
in the deep gluteal tendon incision, and the origin of the vastus lateralis muscle is sutured
to the cranial edge of the deep gluteal muscle. Continuous sutures are placed in the insertion
of the tensor fasciae latae muscle distally and are continued proximally along the cranial
border of the superficial gluteal muscle. The superficial leaf of the fascia lata distally and the
gluteal fascia proximally are closed to the cranial border of the biceps femoris with a continu-
ous pattern. The rest of the incision is closed routinely in layers.

PRECAUTIONS
Dorsal to the hip joint, the sciatic nerve emerges from the ischiatic foramen under the super-
ficial gluteal muscle. It passes caudal to the deep gluteal muscle, across the gemelli and
internal obturator muscles, then passes down the thigh deep to the biceps femoris muscle.
To reduce the risk of damage to the sciatic nerve, sharp retractors such as the Meyerding
should not be used to retract the biceps femoris muscle.
 The Pelvis and Hip Joint ■ 327

PLATE 66
Approach to the Craniodorsal Aspect of the Hip Joint Through a
Craniolateral Incision in the Dog continued

Middle gluteal m.

Sciatic n. and
Deep gluteal m.
caudal gluteal
a. and v.

Joint capsule

Rectus
femoris m.

Biceps
femoris m.,
retracted
Femoral head

Vastus lateralis m.
retracted

Femoral neck

F
392 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Stifle Joint Through a Lateral Incision

INDICATIONS

1. Cranial cruciate ligament reconstructions (see Comments).

2. Meniscectomy (see Comments).
3. Exploration of the stifle joint.

ALTERNATIVE APPROACHES
Depending on the compartment of most interest, approaches to the stifle can be made via a
medial incision (see Plate 82), bilateral exposure (see Plate 83), or osteotomy of the tibial
tuberosity (see Plate 84). For cranial cruciate ligament reconstruction the authors favor a
medial approach (see Plate 82), particularly in chronic injuries.

PATIENT POSITIONING
Either lateral or dorsal recumbency with the hindlimb suspended for draping.

DESCRIPTION OF THE PROCEDURE

A. The skin incision starts over the tibial tuberosity lateral to the patellar ligament. It
continues proximally to the level of the patella and then an equal distance proximally
following the cranial border of the femur (see Comments).
B. The arthrotomy incision follows the same line as the skin. The distal portion is made
in the lateral fascia first with the scalpel, starting opposite the distal pole of the patella
and a few millimeters lateral to the patellar ligament and continuing distally to the
tibia. A stab incision is made into the joint at the proximal end of this incision, which
will allow entry into the joint with little danger of damaging articular cartilage of the
femoral condyle. One blade of a scissor is inserted into the joint and the scissor is
advanced proximally, cutting joint capsule, lateral parapatellar fibrocartilage, and
fascia lata. As the proximal part of the incision is started, it is directed slightly laterally
so as to cut through the vastus lateralis parallel to the muscle fibers and to leave
enough tissue on the lateral side of the patella to permit suturing.
 The Hindlimb ■ 393

PLATE 81
Approach to the Stifle Joint Through a Lateral Incision

Fascia lata

Patella
Biceps
femoris m.
Incision in lateral
retinacular fascia
and joint capsule

Patellar ligament

B
394 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Stifle Joint Through a Lateral Incision continued

C. The patella can now be luxated medially. If the patella will not stay in position
medially, the proximal end of the incision is lengthened. Distal retraction of the fat pad
exposes the cruciate ligaments and menisci.

ADDITIONAL EXPOSURE
This exposure can be extended proximally for access to the supracondylar region by follow-
ing the approach shown in Plate 80 .
For exposure of the lateral fabella when performing extracapsular stabilization of a
cranial cruciate ligament rupture, the approach can be extended caudolaterally as shown in
Plate 85C.

CLOSURE
Distally, the joint capsule and lateral fascia of the stifle joint are closed in one layer with
interrupted sutures. Sutures are placed in the outer fibrous layer of the joint capsule to
prevent any suture material from penetrating the joint in a region where it could abrade
articular cartilage. Proximal to the patella the fascia lata can be closed with a continuous-
pattern suture. Subcutis and skin are closed routinely.

COMMENTS
For cosmetic reasons, this skin incision is often made medially, as in Plate 82. The skin can
easily be undermined and retracted laterally to make the lateral arthrotomy.
 The Hindlimb ■ 395

PLATE 81
Approach to the Stifle Joint Through a Lateral Incision continued

Incised fascia
lata

Incised vastus
lateralis m.

Joint capsule

Femoral
trochlear sulcus

Cranial cruciate Tendon of long

lig. digital extensor
m.

Fat pad and

intermeniscal
lig., retracted

C
164 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Midshaft of the Humerus Through

a Craniolateral Incision
INDICATION
Internal fixation of midshaft fractures of the humerus.

ALTERNATIVE APPROACH
The approach to the shaft of the humerus through a medial incision is an alternative (see
Plate 35). It provides exposure of the entire diaphysis of the humerus that may be valuable
for bone plate application.

PATIENT POSITIONING
Lateral recumbency with the affected limb uppermost.

DESCRIPTION OF THE PROCEDURE

A. Palpate the greater tubercle, deltoid tuberosity, and lateral epicondyle of the humerus.
The skin incision extends from the greater tubercle of the humerus proximally to the
lateral epicondyle distally, following the craniolateral border of the humerus.
B. Subcutaneous fat and fascia are incised on the same line and mobilized and retracted
with the skin. Fat and brachial fascia are incised and dissected away to allow
visualization of the cephalic vein. Brachial fascia is incised along the lateral
border of the brachiocephalicus muscle and distally over the cephalic vein.
The cephalic vein is ligated at the distal end of the field and again proximally, where it
disappears under the edge of the brachiocephalicus muscle. The axillobrachial and
omobrachial veins are similarly ligated and the isolated venous segment is removed.
An incision is made in the craniomedial fascia of the brachialis muscle and in the
insertion of the lateral head of the triceps brachii on the humerus.
 The Forelimb ■ 165

PLATE 34
Approach to the Midshaft of the Humerus Through
a Craniolateral Incision

Greater tubercle
of humerus

Deltoideus m.,
acromial part

Incision

Crest of
greater tubercle
of humerus Triceps brachii m.,
lateral head

Omobrachial v.
A
Axillobrachial v.

Brachiocephalicus m. Brachialis m.

Radial n.

Cephalic v.

Ext. carpi radialis m.

Anconeus m.

B
166 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Midshaft of the Humerus Through

a Craniolateral Incision continued
C. An incision is next made in the periosteal insertion of the superficial pectoral and
brachiocephalicus muscles on the humeral shaft. The radial nerve overlying the
brachialis muscle should be identified and protected when making these incisions.
D. Hohmann retractors are used to retract the brachialis and triceps muscles caudally and
expose the musculospiral groove of the humerus. Cranial retraction will elevate the
biceps brachii, superficial pectoral, and brachiocephalicus muscles from the shaft. Again,
the radial nerve must be protected during retraction. Avoid continuation of dissection
farther distally between the brachialis and brachiocephalicus muscles because the
superficial branch of the radial nerve may be inadvertently damaged. For additional
exposure of the humerus distally, retract the brachialis muscle and radial nerve cranially
(see Plate 37E).

ADDITIONAL EXPOSURE
Based on a procedure of Wallace and Berg,51 and a procedure of Newton.31 Greater visual-
ization of the distal shaft of the humerus can be obtained by transection of the brachialis
muscle, with the transected muscle being used as a physiologic retractor of the radial nerve,
its preservation being paramount.
Extension of this approach more proximally with subperiosteal elevation of the acromial
head of the deltoideus muscle (see Plate 33) provides good exposure of the proximal two
thirds of the humerus.
More distal exposure of the humeral shaft can be obtained by cranial retraction of the
brachialis muscle and radial nerve (see Plate 37E).
The entire length of the humerus is exposed by the combination of the craniolateral
approaches to the proximal (see Plate 33), middle (see Plate 34 ), and distal (see Plate 37)
portions of the humerus. The brachialis muscle and radial nerve cover the humeral shaft
distally and need to be protected and retracted.

CLOSURE
The insertions of the superficial pectoral and brachiocephalicus muscles are sutured to the
superficial fascia of the brachialis muscle distally and to the deltoideus muscle proximally.
The insertion of the lateral head of the triceps is attached to the brachiocephalicus. Brachial
fascia, subcutaneous fat and fascia, and skin are closed in separate layers.

PRECAUTIONS
The brachialis muscle and overlying radial nerve cover the distal one third of the humeral
shaft and need to be protected and gently retracted.
 The Forelimb ■ 167

PLATE 34
Approach to the Midshaft of the Humerus Through
a Craniolateral Incision continued

Deltoideus m.,
acromial part

Crest of Triceps brachii m.,

greater tubercle lateral head
of humerus

Incision

Superficial
pectoral m.

Brachialis m.
Brachiocephalicus m.
Brachiocephalicus m.

Radial n. Superficial
pectoral m.

C Brachialis m.

Radial n.

Biceps brachii m.

D
276 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Shaft of the Radius Through

a Medial Incision
INDICATIONS
1. Open reduction of fractures.
2. Osteotomy of the radius for treatment of growth deformities and malunion.

ALTERNATIVE APPROACH
The lateral approach to the shaft of the radius (see Plate 56) has the advantage that both the
radius and ulna (see Plate 53) can be exposed through the same skin incision.

PATIENT POSITIONING
Dorsal recumbency with the affected limb abducted and suspended for draping.

DESCRIPTION OF THE PROCEDURE

A. The skin incision extends from the medial epicondyle of the humerus to the styloid
process of the radius. The cephalic vein crosses beneath the distal portion of the
incision and is protected during the incision.
B. Subcutaneous fascia is incised on the same line as the skin, and the skin edges are
retracted to expose the underlying muscles. The deep antebrachial fascia is incised
between the extensor carpi radialis and pronator muscles proximally, with the distal
portion of the incision paralleling the extensor muscle. Note the proximity of the
brachial artery and vein and median nerve at the proximal end of this incision (shown
in more detail in Plate 50A).
 The Forelimb ■ 277

PLATE 55
Approach to the Shaft of the Radius Through
a Medial Incision

Tendon of biceps
brachii m.
A

Flexor carpi Extensor carpi

radialis m. radialis m.

Superficial Pronator teres m.

digital flexor m.

Incision in
antebrachial fascia
Deep digital
flexor m.,
humeral head
Shaft of radius

Radial a.

Median a. and n.

Abductor pollicis longus

tendon and fascia

Cephalic v.

B
278 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Shaft of the Radius Through

a Medial Incision continued
C. Retraction of the extensor muscles laterally reveals the supinator muscle. If needed for
exposure of the proximal radius, the insertions of the pronator and supinator muscles
are incised on the radius.
D. Elevation of the pronator and supinator muscles completes the exposure of the
proximal portion of the radius. The radial nerve lies deep to the proximal supinator
and should be protected (see Plate 54C).

ADDITIONAL EXPOSURE
The flexor carpi radialis and deep digital flexor muscles can be elevated caudally for addi-
tional exposure of the radial shaft, but caution is needed to avoid severing the radial and
caudal interosseous arteries that pass between the radius and these muscles.
Distally the skin incision can be curved toward the dorsal surface of the paw for additional
exposure of the distal radius and carpus (see Plate 57 ).

CLOSURE
The pronator and supinator muscles are sutured to their insertions. If insufficient tissue
remains at the insertion, these muscles are sutured to adjacent muscles: the pronator quadra-
tus for the supinator and the medial edge of the extensor carpi radialis for the pronator. The
deep antebrachial fascia and subcutaneous fascia are closed in separate layers.

PRECAUTIONS
During elevation of the pronator and supinator muscles, great care must be taken to protect
the median and radial nerves. At the flexor surface of the elbow, the median nerve and bra-
chial artery and vein dip laterally and pass deep to the pronator teres muscle. After emerging
from under the pronator teres, the deep branch of the radial nerve gives off muscular
branches innervating the flexor carpi radialis, superficial digital flexor, and the radial head
of the deep digital flexor muscles. The deep branch of the radial nerve crosses the lateral
surface of the elbow, then continues under the extensor carpi radialis and supinator muscles.
On emerging from under the supinator, it immediately divides into branches that innervate
the common and lateral digital extensor muscles.
 The Forelimb ■ 279

PLATE 55
Approach to the Shaft of the Radius Through
a Medial Incision continued

Tendon of biceps
brachii m.
Supinator m.

Brachial a., v.,

and median n.
Pronator
teres m. Extensor carpi
radialis m.

Periosteal incisions

Superficial
digital flexor m.

Flexor carpi
radialis m.

C Supinator m.

Pronator teres m. Pronator

quadratus m.

Median a. and n.

Radial a.

Abductor pollicis
longus tendon
and fascia Cephalic v.

D
280 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Shaft of the Radius Through

a Lateral Incision
INDICATIONS
1. Open reduction and internal fixation of fractures of the shafts of the radius and ulna.
2. Osteotomy of the radius and ulna.

ALTERNATIVE APPROACH
The approach to the shaft of the radius through a medial incision (see Plate 55) is the
alternative, but it does not permit simultaneous exposure of the ulna through the same
skin incision.

PATIENT POSITIONING
Lateral recumbency with the affected limb uppermost and suspended for draping.

DESCRIPTION OF THE PROCEDURE

A. The incision is centered over the lateral edge of the radius, starting near the radial head
and extending to the distal end of the bone. The subcutaneous fat and superficial
antebrachial fascia are incised on the same line.
B. After retracting the skin margins, the shaft of the radius will come into view through
the deep antebrachial fascia. This fascia is incised along the cranial border of the
common digital extensor muscle to free this muscle for retraction.
 The Forelimb ■ 281

PLATE 56
Approach to the Shaft of the Radius Through
a Lateral Incision

Extensor carpi
radialis m.
Common digital
extensor m.

Lateral digital
extensor m.

Cephalic v.

Shaft of radius Ulnaris lateralis m.

Abductor pollicis
longus m.
Incision in deep
antebrachial fascia

A B
282 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Shaft of the Radius Through

a Lateral Incision continued
C. Caudal retraction of the common and lateral digital extensor muscles exposes most
of the shaft of the radius laterally. Better views of the cranial aspect are obtained
by medial retraction of the extensor carpi radialis muscle. If more exposure of the
caudolateral aspect of the radius and the ulna is needed, an incision is made through
the abductor pollicis longus muscle near its origin on the ulna and parallel to the
muscle extensor pollicis longus et indicis proprius.
D. Retraction of the extensor muscles provides complete exposure of the shafts of the
radius and ulna.

ADDITIONAL EXPOSURE
For fractures and osteotomies, exposure of the ulna (see Plate 53) can be gained through the
same skin incision.
Proximally, complete exposure of the radial head and proximal radius can be gained in
combination with the approach shown in Plate 54.
Distally the skin incision can be curved toward the dorsal surface of the paw for additional
exposure of the distal radius and carpus (see Plate 57).

CLOSURE
The abductor pollicis longus muscle is either reattached to its origin on the ulna or sutured
to the cranial border of the extensor pollicis muscle. The deep antebrachial fascia is closed
separately from the superficial fascia/subcutaneous fat layer. The skin is closed routinely.

COMMENTS
In the case of fractures, the choice between this lateral approach and the medial approach
(see Plate 55) is often personal preference. However, if there is a need to reduce and apply
fixation to the ulna in support of the radial fixation, this approach is superior to the medial
approach. Soft-tissue injuries may also dictate which approach to choose.
 The Forelimb ■ 283

PLATE 56
Approach to the Shaft of the Radius Through
a Lateral Incision continued

Extensor pollicis
longus et indicis
proprius m.

Common and lateral

Extensor carpi digital extensor
radialis m. mm. retracted

Incision near
ulnar origin of
abductor pollicis
longus m.

Shaft of radius

Shaft of ulna

Extensor pollicis
longus et indicis
proprius m.

Abductor pollicis
longus m.

D
372 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Shaft of the Femur in the Dog

Based on a Procedure of Brinker 4

INDICATION
Open reduction of fractures of the femoral shaft proximal to the supracondylar region.

PATIENT POSITIONING
Lateral recumbency with the hindlimb suspended for draping.

DESCRIPTION OF THE PROCEDURE

A. The skin incision is made along the craniolateral border of the shaft of the bone from
the level of the greater trochanter to the level of the patella. The subcutaneous fat and
superficial fascia are incised directly under the skin incision.
B. The skin margins are undermined and retracted and the superficial leaf of the fascia
lata is incised along the cranial border of the biceps femoris muscle. This incision
extends the entire length of the skin incision. If muscle fibers are encountered, the
incision should be directed more cranially.
C. Caudal retraction of the biceps femoris reveals the shaft of the femur. It is necessary to
incise the fascial aponeurotic septum on the lateral shaft of the bone to adequately
retract the vastus lateralis.
D. The vastus lateralis and intermedius muscles on the cranial surface of the shaft are
retracted by freeing the loose fascia between the muscle and the bone.

ADDITIONAL EXPOSURE
Proximally this approach can be extended to combine with the approach to the greater tro-
chanter and subtrochanteric region of the femur (see Plate 76 ).
Distally this approach can be extended to combine with the approach to the distal femur
and stifle joint through a lateral incision (see Plate 80 ).

CLOSURE
Closure consists of suturing the fascia lata to the cranial border of the biceps muscle in one
tier and the subcutaneous fat and fascia in a second tier.

COMMENTS
Limit elevation of the adductor muscle on the caudal one third of the shaft to the extent
necessary for visualization of fracture lines. This muscle is a valuable source of periosteal
blood supply to the healing fracture.

PRECAUTIONS
Caudal to the hip joint the sciatic nerve passes across the gemelli and internal obturator
muscles. Passing down the caudal thigh under the biceps femoris muscle, it crosses over the
quadratus femoris, adductor, and semimembranosus muscles. At about midthigh it branches
into tibial and peroneal nerves. To reduce the risk of damage to the sciatic nerve, care should
be taken during retraction of the biceps femoris muscle.
 The Hindlimb ■ 373

PLATE 77
Approach to the Shaft of the Femur in the Dog

Tensor fasciae
latae m.

Biceps femoris m.
Incision in
superficial leaf
of fascia lata

A B

Vastus
lateralis m.
Vastus lateralis m.
retracted

Shaft of femur

Incision in Vastus
Biceps
aponeurotic leaf intermedius m.
femoris m.
of fascia lata

Adductor
magnus m.

C D
428 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Shaft of the Tibia

Based on Procedures of Brinker 4 and Wilson52

INDICATION

Open reduction of fractures of the shaft of the tibia.

PATIENT POSITIONING
Dorsal recumbency with the affected hindlimb suspended for draping.

DESCRIPTION OF THE PROCEDURE

A. The skin incision can be varied to suit the situation. For maximal exposure of both the
medial and lateral cortices and for bone plate application, the curved incision shown
provides the best approach. A straight medial incision can be used for intramedullary
pinning but would result in the plate being directly under the skin incision with only
scanty subcuticular tissue to cover it if used in plating procedures. A curved, laterally
based incision can be used if a plate is to be applied laterally.
The medially based incision shown here starts proximally over the medial tibial
condyle and curves cranially to the midline of the tibia at midshaft. It then curves
caudally to end near the medial malleolus. The subcutis is incised on the same line.
Although not essential, an effort is made to preserve the saphenous vessels and nerve
crossing the tibia.
B. The bone is exposed by incision of the crural fascia over the medial shaft of the bone.
Elevating the fascia exposes the muscles.
C. The cranial tibial and medial digital flexor muscles can be retracted by incising fascia
along their borders to free them from the bone.
 The Hindlimb ■ 429

PLATE 90
Approach to the Shaft of the Tibia

Incision in
crural fascia

Cranial branch, med.

saphenous a. and v.

Saphenous n.

Tibialis cranialis m.

A B

Shaft of
tibia

Deep digital
flexor m.,
med. part
Tibialis
cranialis m.

C
430 ■ Piermattei’s Atlas of Surgical Approaches to the Bones and Joints of the Dog and Cat

Approach to the Shaft of the Tibia continued

D. To expose the lateral cortex, the crural fascia is incised along the cranial border of the
cranial tibial muscle, starting at the tibial tuberosity and extending distally to the
tendinous portion of the muscle.
E. The cranial tibial and long digital extensor muscles are retracted caudolaterally to
expose the tibial shaft. The cranial tibial artery courses between the tibia and fibula and
can be damaged by the tips of the Hohmann retractor if they are placed over the artery.
Exposure of the distal lateral region of the tibia can be gained by incising fascia lateral
to the tendons of the cranial tibial and long digital extensor muscles. Cranial retraction
of these tendons provides visualization of the tibia.

ADDITIONAL EXPOSURE
Proximally this approach can be extended to expose the medial side of the proximal tibia as
shown in Plate 89.

CLOSURE
The deep crural fascia must be closed securely. Continuous sutures are used here and in the
subcutaneous tissues. Skin and subcutis are closed routinely.
 The Hindlimb ■ 431

PLATE 90
Approach to the Shaft of the Tibia continued

Tibialis
cranialis m.
Cranial border
(crest) of tibia

Incision in
crural fascia

Cranial branch,
lat. saphenous
a. and v.

Cranial branch,
med. saphenous
a. and v.

Cranial tibial m.

Long digital ext. m.

Shaft of tibia