ELBOW ARTHROSCOPY

10-Mark Structured Answer - Orthopaedics

DEFINITION

HISTORICAL NOTE

INDICATIONS

CONTRAINDICATIONS

• Bony ankylosis or severe fibrous ankylosis preventing safe arthroscope introduction
• Previous anterior transposition of ulnar nerve - eliminates certain portals (relative contraindication)
• Periarticular infection

PATIENT POSITIONING

1. Supine Position (most common)

• Hand/forearm in sterile waterproof stockinette suspension with 5-6 lb weight
• Shoulder: neutral rotation + 90° abduction
• Elbow: 90° flexion
• Allows access to both sides; neurovascular structures in antecubital fossa are relaxed
• Surgeon sits on rolling stool at chest level

2. Prone Position

• Patient prone on chest rolls with tourniquet proximally
• Shoulder in 90° abduction, elbow in 90° flexion, hand pointing toward floor
• Advantages: improved arthroscopic mobility, easier joint manipulation, better access to the posterior compartment

3. Lateral Decubitus Position

• Can be performed on standard operating table

PORTALS

FLOWCHART: Portal Establishment Sequence

START
  │
  ▼
Joint Distension
(Direct Lateral Portal / Soft Spot)
  │
  ├── 18-gauge needle → 20-30 mL saline
  ├── Triangular soft spot: lateral epicondyle + radial head + olecranon tip
  └── Capsule distension pushes NV structures away from joint
  │
  ▼
Anterolateral Portal (Diagnostic Portal - First)
  │
  ├── Proximal anterolateral: 2 cm proximal + 1 cm anterior to lateral epicondyle [PREFERRED]
  ├── Mid-anterolateral: just proximal + ~1 cm anterior to radiocapitellar joint
  └── Distal anterolateral (traditional): 2-3 cm distal + 1 cm anterior to lateral epicondyle
       At risk: Radial nerve, lateral antebrachial cutaneous nerve
  │
  ▼
Anteromedial / Proximal Medial Portal (Working Portal)
  │
  ├── Proximal medial (preferred): 2 cm proximal to medial epicondyle, anterior to septum
  ├── Anteromedial (traditional): 2 cm distal + 2 cm anterior to medial epicondyle
  └── At risk: Ulnar nerve, medial antebrachial cutaneous nerve, brachial artery, median nerve
  │
  ▼
Posterior Portals (for posterior compartment)
  │
  ├── Direct posterior (transtriceps): 3 cm proximal to olecranon tip, through olecranon fossa
  ├── Posterolateral: just lateral to triceps tendon, 1-4 cm proximal to olecranon
  ├── Proximal posterolateral: 2.5-3 cm proximal to olecranon, elbow in 30° flexion
  └── At risk: Posterior antebrachial cutaneous nerve, ulnar nerve
  │
  ▼
Direct Lateral Portal (if needed)
  │
  └── Center of triangle: lateral epicondyle + radial head + olecranon tip
      Traverses: skin → subcutaneous tissue → anconeus → capsule
  │
  ▼
PROCEDURE COMPLETE

Portal Anatomy - Images

TECHNIQUE: ELBOW ARTHROSCOPY (Technique 57.32, Campbell's 2026)

Step-by-Step Technique

• Inject 20-30 mL of normal saline using an 18-gauge needle
• Distension pushes neurovascular structures anteriorly and away

• Mark the proximal anterolateral portal: 2 cm proximal + 1 cm anterior to lateral epicondyle
• Nick skin with No. 11 blade; bluntly dissect down to fascia with mosquito hemostat
• Pass arthroscopy cannula + blunt trocar at ~70° to horizontal, capturing joint capsule laterally
• Examine: coronoid process, trochlear ridge, anterior capsule, medial collateral ligament, radiocapitellar joint, annular ligament, capitellum

• Established via Wissinger rod technique or under direct arthroscopic vision
• Used for instrumentation and assessment of medial structures

• Posterior to the radiocapitellar joint
• Traverses anconeus muscle
• Views: radiocapitellar articulation, radial head (pronation/supination), capitellum

• For posterior compartment: olecranon tip/fossa, posteromedial and posterolateral gutters, triceps, posterior medial collateral ligament

SYSTEMATIC ARTHROSCOPIC EXAMINATION

COMPLICATIONS

FLOWCHART: Complications

COMPLICATIONS OF ELBOW ARTHROSCOPY
            │
    ┌───────┴────────┐
  MAJOR            MINOR
    │                │
Nerve injury      Fluid extravasation
(most common &    Superficial infection
devastating)      Temporary neurapraxia
    │              Hematoma
  ┌─┴────────────┐  Stiffness
Anterior        Posterior
portals         portals
    │                │
Radial nerve    Posterior antebrachial
Median nerve    cutaneous nerve
Brachial artery Ulnar nerve
    │
Permanent motor/
sensory deficit

Nerve-Portal Risk Map

• Always use nick-and-spread technique (never stab blindly)
• Identify ulnar nerve and medial epicondyle before medial portals
• Distend joint fully before any portal creation
• Use blunt trocars, not sharp
• Monitor fluid extravasation; abort if antecubital fossa becomes tense

SPECIFIC PROCEDURES PERFORMED ARTHROSCOPICALLY

1. Loose body removal - most common indication; confirms diagnosis and removes fragments
2. OCD capitellum - debridement/fixation/microfracture for unstable lesions
3. Elbow contracture release - anterior and posterior capsulotomy; lysis of adhesions
4. Tennis elbow (lateral epicondylitis) release - ECRB debridement
5. Partial synovectomy - rheumatoid/inflammatory arthritis
6. Olecranon/coronoid osteophyte excision - valgus extension overload (throwing athletes)
7. Septic arthritis washout - effective as open drainage in acute cases
8. Radial head excision - select cases
9. Fracture-assisted reduction - radial head, coronoid fractures

POSTOPERATIVE CARE

• Portal wounds: steri-strips or single suture
• Bulky compressive dressing for 24-48 hours
• Early range-of-motion exercises started within 24-72 hours
• Neurovascular assessment on recovery

SUMMARY TABLE

• Campbell's Operative Orthopaedics, 15th Ed. (2026) - Chapter 57, p. 3223-3232
• Miller's Review of Orthopaedics, 9th Ed. - Elbow Arthroscopy portals, p. 731