Anterior Approach to the Elbow (Antecubital)

What it exposes. The anterior (antecubital) approach gives direct access to the antecubital fossa, the distal biceps tendon insertion, the anterior capsule and coronoid process, and the major neurovascular structures crossing the elbow - the brachial artery, median nerve, lateral antebrachial cutaneous nerve, and radial nerve with its posterior interosseous branch. It is the only approach that allows simultaneous visualisation of all of these. Why this approach. It is the distal continuation of the Henry approach to the arm and is the workhorse exposure for distal biceps tendon repair, anterior capsular release for post-traumatic or post-operative stiffness, and exploration of the brachial artery or median nerve. The lazy-S incision minimises the skin contracture that a straight transverse incision would produce across the flexion crease. Primary indications. - Distal biceps tendon rupture repair (acute and chronic).

• Anterior capsular release for post-traumatic or post-operative elbow stiffness.
• Exploration and repair of the brachial artery after injury.
• Median nerve exploration or decompression at the elbow.
• Coronoid process fracture fixation through anterior access.
• Radial nerve or PIN exploration in the proximal forearm. Contraindications. Active infection in the antecubital fossa; severe soft-tissue scarring from previous surgery or trauma (consider an extensile or alternative approach); isolated posterior pathology (use a posterior approach); patient factors precluding positioning or tourniquet use. Alternative approaches. - Posterior (Kocher or Bryan-Morrey): triceps, olecranon, posterior capsule.
• Medial: ulnar nerve, medial collateral ligament, medial coronoid.
• Lateral (Kocher): radial head, capitellum, lateral collateral ligament.
• Two-incision technique for distal biceps: reduces PIN risk but sacrifices anterior visualisation. Position and landmarks. Supine with the arm abducted on a hand table, the shoulder at the edge of the table, and the elbow slightly flexed (30 to 45 degrees) for the initial exposure. Apply a tourniquet high on the arm and inflate after exsanguination; minimise tourniquet time (ideally less than 120 minutes) and release for at least 20 minutes before any re-inflation. Fluoroscopy should be available. Palpable bony landmarks are the medial and lateral epicondyles, the radial head (rotating in the lateral fossa with forearm rotation), and the olecranon for orientation. The key soft-tissue landmark is the biceps tendon (a palpable cord when the elbow is flexed against resistance), with the bicipital aponeurosis felt as a tense band medial to it and the brachial artery pulse in the midline of the fossa. Plan a lazy-S incision: it begins 5 to 6 cm proximal to the elbow flexion crease on the medial border of the biceps, crosses the fossa in a gentle curve, and extends 5 to 6 cm distal to the crease over the brachioradialis-pronator interval on the lateral forearm - a total length of about 12 to 15 cm.

Work down through the layers across the antecubital fossa, identifying and protecting the cutaneous nerve first, then the central neurovascular bundle, and finally developing the brachialis-brachioradialis internervous plane to reach the capsule and the radial tuberosity.

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Structures at risk, by layer

Anterior scarring - the major long-term risk. Anterior elbow scarring leading to flexion contracture is the most significant long-term complication, occurring in 10 to 20 percent of cases. It is more common after prolonged surgery, excessive retraction, or a straight rather than lazy-S incision. Prevention is meticulous soft-tissue handling, a layered closure without tension, and early range-of-motion exercises; an established contracture may require surgical release. Extensile options. Extend proximally along the medial border of the biceps (a direct continuation of the Henry approach) to reach the distal humerus and the brachial artery in the arm. Extend distally along the lateral forearm, developing the brachioradialis-pronator interval, to reach the proximal radius and radial head - identify and protect the PIN as it enters the supinator. The radial head is accessible through the lateral aspect of the fossa for replacement or ORIF, and for complex trauma the anterior approach can be combined with a lateral (Kocher) or medial approach. Closure. Copious irrigation and meticulous haemostasis (particularly around the venae comitantes) before tourniquet release. Close the deep fascia loosely if it was opened, approximate the subcutaneous tissue with absorbable suture, and close skin without tension. Apply a well-padded posterior splint or hinged brace and document neurovascular status immediately.

• Distal biceps tendon repair - prepare the tendon with locking sutures and reattach to the posterior aspect of the radial tuberosity using a cortical button, suture anchors, or transosseous tunnels; confirm full supination and flexion strength and protect the PIN throughout tuberosity preparation.
• Anterior capsular release for post-traumatic or post-operative stiffness - elevate the capsule from the anterior humerus and coronoid, release heterotopic ossification or scar, and perform a gentle manipulation; avoid over-release, which causes instability.
• Brachial artery exploration and repair - expose the artery proximal and distal to the zone of injury and repair with direct suture, vein patch, or interposition graft.
• Median nerve exploration or neurolysis, and radial nerve or PIN exploration in the proximal forearm.
• Coronoid process fracture fixation through anterior access.

The anterior elbow approach is used worldwide for distal biceps repair, anterior capsular release, and neurovascular exploration. The lazy-S incision, early identification of the brachial artery and median nerve, and protection of the lateral antebrachial cutaneous nerve and PIN are universal requirements across contemporary practice. Population evidence. Distal biceps rupture has an incidence of approximately 1.5 to 5.4 per 100,000 person-years, predominantly in men aged 40 to 60. Single-incision repair is the most common technique globally, with PIN injury rates of 1 to 3 percent and anterior scarring rates of 10 to 20 percent. Early motion protocols reduce post-operative stiffness. Consent (globally applicable). Discuss brachial artery injury (less than 1 percent), median nerve injury (2 to 5 percent, mostly transient), lateral antebrachial cutaneous nerve injury (5 to 15 percent, often permanent numbness), PIN injury (1 to 3 percent), anterior scarring and flexion contracture (10 to 20 percent), infection (1 to 2 percent), and the possibility of incomplete recovery of motion or strength.