6. Upper and Lower Extremity Procedures

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BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 6. UPPER AND LOWER EXTREMITY PROCEDURES

Contents LAB OBJECTIVES ...... 2 Knowledge objectives...... 2 Preparation for lab ...... 2 6.1 ORGANIZATION OF THE LIMBS ...... 3 Upper limb superficial layers ...... 3 Upper limb investing deep fascia and muscle compartments ...... 3 Lower limb superficial layers ...... 5 Lower limb investing deep fascia and muscle compartments ...... 5 6.2 ORGANIZATION OF MAJOR ARTERIES AND VENAE COMITANTES ...... 7 Upper limb arteries and venae comitantes ...... 7 Lower limb arteries and venae comitantes ...... 9 LOWER EXTREMITY PROCEDURES ...... 11 1 Lower extremity fasciotomy: Double‐incision technique ...... 11 2 Thigh fasciotomy ...... 13 3 Foot fasciotomy: 5 compartments – medial, lateral, superficial, calcaneal, and interosseus ...... 13 4 Forearm fasciotomy: Volar, lateral and extensor compartments‐ ...... 14 5a Popliteal artery exposure: Posterior approach ...... 15 5b Popliteal artery exposure: Medial approach for proximal popliteal artery: ...... 15 6 Open femoral artery access ...... 16 6a Femoral endarterectomy/patch angioplasty ...... 17 7 Great saphenous vein harvest ...... 20

BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 6. UPPER AND LOWER EXTREMITY PROCEDURES

LAB OBJECTIVES Skills objectives 1. Lower extremity fasciotomy: Double‐incision technique 2. Thigh fasciotomy 3. Foot fasciotomy: 5 compartments – medial, lateral, superficial, calcaneal, and interosseus 4. Forearm fasciotomy: Volar, lateral and extensor compartments 5. Popliteal artery exposure: Posterior approach 6. Popliteal artery exposure: Medial approach for proximal popliteal artery: 7. Open femoral artery access 8. Femoral endarterectomy/patch angioplasty 9. Great saphenous vein harvest

Knowledge objectives. 1. Describe the fascial compartments and septa of the arm. Of the forearm. List four major neurovascular structures vulnerable at the wrist during a volar forearm compartment release or carpal tunnel release. 2. Describe the fascial compartments and septa of the thigh. Of the crus. Explain the position of the fibular (peroneal) nerve over the proximal fibula. 3. In the adult upper limb, the flexor surfaces of all upper limb joints face anteriorly. In the adult lower limb, the flexor surface of the hip and the dorsiflexor surface of the ankle joint face anteriorly whereas the flexor surfaces of the knee and digits face posteriorly. In general, blood vessels tend to run on the flexor surfaces of joints and to avoid the extensor surfaces. Applying this basic principle, a. Describe the pathways of the cephalic vein and basilic vein in the upper limb from the dorsal venous arch of the hand to their entries into deeper veins proximal to the shoulder joint and elbow joint respectively. b. Describe the pathways of the great saphenous vein and small saphenous vein in the lower limb from the dorsal venous arch of the foot to their entries into deeper veins proximal to the hip joint and knee joint respectively. c. Explain how the (superficial) femoral artery travels from the anterior compartment of the thigh to the posterior surface of the knee joint. Explain how the anterior tibial artery travels from the posterior surface of the knee joint to the anterior compartment of the crus.

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BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 6. UPPER AND LOWER EXTREMITY PROCEDURES 6.1 ORGANIZATION OF THE LIMBS

Very generally, the organization of the limbs consists of a superficial layer (skin and subcutaneous fat) and musculoskeletal compartments (bones, joints, and muscles surrounded by investing deep fascia and separated into functional compartments by fascial septa (Figures 6‐1 and 6‐2). The subcutaneous fat (superficial fascia) of the limbs consists of fatty loose connective tissue deep to, and functionally supporting, the skin. The subcutaneous fat of the limbs often contains a distinct membranous layer similar to the Scarpa fascia over the inferior abdomen. Structures found within the subcutaneous fat of the limbs include superficial veins, lymphatic vessels and nodes accompanying superficial veins, and cutaneous nerves and vessels supplying the skin but arising from structures within the deep fascial compartments. The thick investing deep fascia of the limbs is a continuous layer surrounding the muscles, bones, and joints and muscles of the limbs. The deep fascia of the limbs forms distinct fascial compartments by sending fascial septa inward to fuse with the periosteum of the underlying bones and with the fibrous capsules of the joints. Structures within each deep fascial compartment include muscles sharing common functions and the major blood supply and motor innervation of those muscles. Cutaneous nerves and perforating blood vessels supplying the overlying skin leave the deeper neurovascular structures within the fascial compartments and pierce the deep investing fascia surrounding the compartments to enter the subcutaneous fat. Upper limb superficial layers The superficial veins of the upper limb begin at the dorsal venous arch of the hand. The cephalic vein leaves the radial side of the dorsal arch, crosses to the anterior side of the forearm, contributes to the medial cubital vein, and enters the axillary vein proximal to the shoulder joint (Figure 6‐1). The basilic vein leaves the ulnar side of the dorsal venous arch, contributes to the medial cubital vein, and enters the brachial vein proximal to the elbow joint. Upper limb investing deep fascia and muscle compartments The brachial fascia is the deep investing fascia of the arm (brachium). The antebrachial fascia is the deep investing fascia of the forearm (antebrachium). The brachial and antebrachial fascia are continuous at the elbow joint where they fuse with the fibrous joint capsule. At the wrist, the antebrachial fascia thickens to form the extensor and flexor retinacula. Brachial compartments. Lateral and medial intermuscular fascial septa divide the arm muscles into anterior and posterior compartments (Figure 6‐1). Muscles in the anterior brachial compartment flex the shoulder and/or elbow joint and receive their neurovascular supply from the brachial artery and musculocutaneous nerve. The triceps muscle in the posterior brachial compartment extends the elbow joint and receives its neurovascular supply from the radial nerve and deep brachial artery. Antebrachial compartments. The interosseous membrane and the lateral and medial intermuscular fascial septa divide the forearm muscles into anterior and posterior compartments (Figure 6‐1). Thinner transverse fascial septa divide the anterior and posterior compartment muscles into superficial and deep groups. Muscles in the anterior antebrachial compartment flex the wrist and digits and receive their neurovascular supply from the median and ulnar nerves and the radial and ulnar arteries. Muscles in the posterior antebrachial compartment extend the wrist and digits and receive their neurovascular supply from the radial nerve and posterior interosseous branch of the ulnar artery. The mobile wad (of Henry) is a subdivision of the posterior compartment consisting of the brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis muscles.

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Figure 6‐1. Axial sections through the arm and forearm. (Modified from Netter Atlas of Human Anatomy, 5th Edition. Philadelphia: Elsevier, 2010.)

Lower limb superficial layers The superficial veins of the lower limb begin at the dorsal venous arch of the foot. The great saphenous vein leaves the tibial side of the dorsal arch, jogs posteriorly at the knee, and enters the femoral vein at the groin (Figure 6‐2). The small saphenous vein leaves the fibular side of the dorsal venous arch, crosses to the posterior surface of the crus, and enters the popliteal vein proximal to the knee joint. Lower limb investing deep fascia and muscle compartments The fascia lata is the deep investing fascia of the thigh. The crural fascia is the deep investing fascia of the crus (leg). The fascia lata and crural fascia are continuous at the knee joint where they fuse with the fibrous joint capsule. At the ankle, the crural fascia thickens to form the extensor and flexor retinacula. Thigh compartments. Lateral, medial, and posterior intermuscular fascial septa divide the thigh muscles into anterior, posterior, and medial compartments (Figure 6‐2).

Muscles in the anterior anterior compartment of the thigh flex the hip and/or extend the knee joint (except sartorius, which flexes the knee joint) and receive their neurovascular supply from the femoral nerve and (superficial) femoral artery. Muscles in the posterior compartment of the thigh extend the hip joint and flex the knee joint and receive their neurovascular supply primarily from the tibial nerve and perforating branches of the deep femoral artery. Muscles in the medial compartment of the thigh adduct the lower limb at the hip joint and receive their neurovascular supply from the obturator nerve and obturator artery. Crural compartments. The interosseous membrane and the anterior and posterior intermuscular fascial septa divide the crural muscles into anterior, posterior, and lateral compartments. A thinner transverse fascial septum divides the posterior compartment muscles into superficial and deep groups. Muscles in the anterior crural compartment dorsiflex the ankle joint and/or extend the digits and receive their neurovascular supply from the deep branch of the fibular nerve and the anterior tibial artery. Muscle in the posterior crural compartment flex the knee joint and/or plantarflex the ankle joint and/or extend the digits. Posterior crural compartment muscles receive their neurovascular supply from the tibial nerve and posterior tibial artery. Muscles in the lateral crural compartment evert the foot at the intertarsal joints and receive their neurovascular supply from the superficial branch of the fibular nerve and perforating branches of the fibular artery.

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Figure 6‐2. Axial sections through the thigh and crus. (Modified from Netter Atlas of Human Anatomy, 5th Edition. Philadelphia: Elsevier, 2010.)

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6.2 ORGANIZATION OF MAJOR ARTERIES AND VENAE COMITANTES Upper limb arteries and venae comitantes

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Figure 6‐1. $. (Modified from Netter Atlas of Human Anatomy, 5th Edition. Philadelphia: Elsevier, 2010.)

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Lower limb arteries and venae comitantes

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Figure 6‐1. $. (Modified from Netter Atlas of Human Anatomy, 5th Edition. Philadelphia: Elsevier, 2010.)

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LOWER EXTREMITY PROCEDURES

1 Lower extremity fasciotomy: Double‐incision technique a. A generous longitudinal incision on the lateral aspect of the lower leg between the fibular shaft and the crest of the tibia, oriented directly over the intermuscular septum between the anterior and lateral compartments. b. Skin flaps are raised medially and laterally to expose the fascia of the anterior and lateral compartments.

c. The anterior and lateral compartments are opened via separate, parallel 12‐ to 20‐cm fascial incisions using Metzenbaum or Cooley scissors, taking care to avoid injury to the common superficial and deep peroneal nerves (most at risk for injury near the fibular head) d. Terminate the proximal extent of these fascial incisions 4 to 5 cm distal to the fibular head. e. Second incision is placed on the medial aspect of the leg 1 to 2cm posterior to the tibia for decompression of the two posterior compartments. Taking care to preserve saphenous nerve and vein in the subcutaneous tissue. f. Superficial posterior compartment decompressed via longitudinal incision along the gastrocnemius fascia g. Deep posterior compartment decompressed by dividing the attachments of the soleus muscle to the tibia, and exposing the fascia overlying tibialis posterior and flexor muscles of foot (avoid posterior tibial artery).

Video: http://www.surgicalcore.org/videoplayer/510000057/58

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Indications for Fasciotomy Absolute Indications Potential Indications

Tense compartment plus either: Acute ischemia >6 hr with few Tense compartment in a patient who cannot be examined serially due to collaterals obtundation or need for other operations. Combined arterial and venous ICP minus mean blood pressure <40 mm Hg traumatic injuries ICP minus diastolic blood pressure <10 mm Hg Phlegmasia cerulea dolens Tense compartment after crush injury Tense compartment after fracture

ICP, Intracompartmental pressures. Chung J, Modrall Gregory J. Chapter 163. Compartment Syndrome. In:Rutherford’s Vascular Surgery, 8e. Philadelphia, PA: Elsevier Saunders; 2014. https://www‐clinicalkey‐com.ezp‐ prod1.hul.harvard.edu/#!/content/book/3‐s2.0‐B9781455753048001631. Accessed February 04, 2015

Cross‐section of mid‐calf showing the four fascial compartments and their contents. Open arrows show sites of double‐incision fasciotomy; closed arrow shows site of single‐incision fasciotomy. Frykberg ER. Compartment syndrome. In: Cameron JL, ed. Current Surgical Therapy. 5th ed. St. Louis, MO: Mosby‐Yearbook; 1995:850,© Elsevier.

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2 Thigh fasciotomy a. In most cases a single lateral incision can be used to decompress the posterior and anterior compartments (medial compartment rarely required) b. Incision is placed along the lateral thigh, beginning just distal to the intertrochanteric line and extending distally to the lateral epicondyle. c. Iliotibial band is exposed and incised longitudinally along the length of the skin incision to decompress the anterior compt. d. The vastus lateralis is reflected medially to expose the lateral intermuscular septum. The intermuscular septum is incised over the length of the skin incision to release the posterior compartment.

3 Foot fasciotomy: 5 compartments – medial, lateral, superficial, calcaneal, and interosseus a. Two longitudinal dorsal incisions are used. Fine scissors are used to incise compts. i. One incision placed slightly medial to second metatarsal, reaching between first and second metatarsals into medial compartment and between second and third metatarsals into central compartment ii. Second dorsal incision made just lateral to fourth metatarsal, reaching between fourth and fifth metatarsals into lateral compartment b. Care is taken to avoid the medial and lateral plantar neurovascular bundles that traverse longitudinal axis of the foot

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4 Forearm fasciotomy: Volar, lateral and extensor compartments‐ a. Consists of longitudinal centrally placed incision over extensor compartment and curvilinear incision on flexor aspect beginning at antecubital fossa i. One volar curvilinear incision and one dorsal longitudinal incision b. Incision is extended transversely across wrist flexion crease to ulnar side of wrist, then arched across volar forearm, back to ulnar side at elbow c. At elbow, just radial to medial epicondyle, incision is curved across elbow flexion crease; deep fascia is then released d. The fascia overlying the superficial flexor compartment is incised along the entire length of skin incision. e. The radial nerve and brachioradialis muscle are retracted to the radial side of the forearm, and the flexor carpi radialis and radial artery are retracted to the ulnar side. f. The fascia overlying each of the muscles of the deep flexor compartment is incised to complete the volar fasciotomy. g. Second straight dorsal incision can be made to release dorsal compartment i. From lateral epicondyle to the wrist ‐ between the extensor carpi radialis brevis and the extensor digitorum communis.

5a Popliteal artery exposure: Posterior approach a. A lazy S‐shaped incision is made with the superior end starting on the medial side of the thigh to expose the proximal popliteal artery and saphenous vein. b. Incision extends laterally across the flexion crease of the knee and ends on the lateral aspects of the proximal part of the calf, directly over the proximal small saphenous vein. c. Proximal artery is identified by palpation distal to the adductor canal and exposed by separation of the semimembranosus and semitendinosus muscles located medially from the long head of the biceps femoris located laterally.

5b Popliteal artery exposure: Medial approach for proximal popliteal artery: a. The knee is flexed and a roll is placed under the thigh. b. The skin incision is made in the lower thigh at the superior edge of the sartorius muscle and below the muscle belly of the vastus medialis. c. If the ipsilateral GSV is used for conduit, then one incision may be used for both harvesting the vein and dissecting out the popliteal artery. d. Cutting the superficial fascia allows entry into the sheath of the sartorius muscle; this muscle is isolated and reflected posteriorly along with the semitendinosus and gracilis muscles. e. The popliteal fat space is exposed. f. The dissection is performed close to the femur, retracting the great adductor muscle anteriorly and exposing the adductor hiatus. g. The popliteal artery is found by palpation (doppler may be used)

Video for MEDIAL APPROACH: http://www.surgicalcore.org/videoplayer/510000062/58

6 Open femoral artery access a. With the patient supine, the pulse is palpated just below the inguinal ligament as the femoral artery crosses the inguinal ligament at approximately its mid point. b. Either a horizontal, longitudinal or oblique incision about 2‐3 cm in length is made c. Electrocautery is used to dissect the subcutaneous tissue down to the level of the fascia and placement of self‐ retaining retractor aids in exposure d. Fascia is cleared and sharp dissection used to expose artery (lateral to femoral vein).

6a Femoral endarterectomy/patch angioplasty

a. A vertical incision 3‐5cm in length is made proximal to the inguinal ligament and continued for about 3‐4cm distally over the femoral pulse. b. More proximal exposure can be obtained by division of the recurrent portion of the inguinal ligament or the entire ligament (Peter Martin incision). c. If the pulse is absent, the incision should be made 1‐2cm lateral to the pubic tubercle where the femoral artery is usually located. d. The femoral artery is exposed longitudinally to avoid lymphatic disruption and the lymphatics dissected laterally e. A self‐retractor is used to help expose the vessel f. The CFA, SFA, and PF artery are dissected and isolated with vessel loops g. The lateral circumflex femoral vein is identified between the origins of the SFA, and PF and ligated. h. Before occluding the inflow, the patient is given an initial heparin bolus of 100 units/kg; the activated clotting time (ACT) is kept above 250 seconds. i. The CFA, SFA, PF arteries and any additional tributaries are now cross‐clamped. j. The femoral arteriotomy is made using a No.11 blade and then extended with Potts scissors.

k. With a Freer elevator, develop a cleavage plane between the media and the adventitia. l. Continue proximally and distally to excise the inner layer containing the atheroma. m. Pull the plaque transversely away from the artery with lateral traction (avoid traumatizing the artery)

Adapted from Clinical Anatomy: The Logical Approach. © T. Van Houten, 1997. All rights reserved. LAB &. UPPER AND LOWER EXTREMITY PROCEDURES Page &‐19 n. Ensure a smooth transition or tack down the distal endpoint. An ideal end point is gradually tapering and feathered. o. A patch is chosen (artery, vein or prosthetic) and cut to size. The ends are rounded to avoid narrowing at the apices. p. A double‐ended, non‐absorbable monofilament suture is used. q. Starting at one end, pass the needle through the patch and through the artery and secure with a knot on the outside of the artery. r. Suturing is continued around the artery, starting at the far wall, the needle passing outside‐in on the patch and inside‐out on the artery. s. Direct the assistant to follow and keep appropriate tension on the suture line. t. Once around the apex, the second needle should be used to finish the first apex. u. Before closing, the inflow and outflow are released to remove any clot, and the artery flushed with heparinised saline v. The suture is then tied on one side of the repair, away from the apices.

Video: http://www.surgicalcore.org/videoplayer/510000058/58

7 Great saphenous vein harvest Typically pre‐operative duplex vein mapping has been completed and drawing of a line with indelible ink directly over the vein conduit is done, avoiding creation of unnecessary skin flaps. a. Groin incision two fingerbreadths lateral to the pubic tubercle b. Saphenofemoral junction at the fossa ovalis identified to expose GSV c. Once main trunk is identified, the incision is extended distally, directly over the vein with a No.10 blade or Cooley scissors – can be done with skip incisions d. Side‐branches ligated and divided with 3‐0 or 4‐0 silk (leaving short stump)

Video: http://www.surgicalcore.org/videoplayer/510000026/50