Anatomical Exposures and Surgical Approaches to the Limbs Anatomische Darstellungen und Zugangswege in der Chirurgie der Extremitäten

285 Pages·1989·22.68 MB·English

by  Francesco Ruggieri M.D.

F. Ruggieri G. F. Zinghi S. Boriani L. Specchia
Anatomical Exposures
and Surgical Approaches
to the Limbs
Anatomische Darstellungen
und Zugangswege in der
Chirurgie der Extremitliten
DrawingslZeichnungen: G. Gamberini
Collaborators I Mitarbeiter:
P. Ruggieri, E. Sabetta, S. Sabalat
TranslatorslUbersetzer: S. Notini, M. Hendriks
I! il
M
Springer-Verlag
Aulo Gaggi Editore
~Wien New York E:::: "Bologna
Francesco Ruggieri, M.D.
Orthopaedic Surgeon, Ex-Chief-of-Staff of the 3rd Division, Rizzoli Orthopaedic Institute, Bologna, Italy
Gian Franco Zinghi, M.D.
Orthopaedic Surgeon, Chief of-Staff of the 3rd Division, Rizzoli Orthopaedic Institute, Bologna, Italy
Stefano Boriani, M.D.
Orthopaedic Surgeon, Attending-Staff of the 1 st Orthopaedic Clinic of the University, Rizzoli Ortho
paedic Institute, Bologna, Italy
Luigi Spec chi a, M.D.
Orthopaedic Surgeon, Resident at the 3rd Division, Rizzoli Orthopaedic Institute, Bologna, Italy
Gigliola Gamberini
Director of the Higher Institute of Anatomical Illustrations, Rizzoli Orthopaedic Institute, Bologna, Italy
Piero Ruggieri, M.D.
Orthopaedic Surgeon, Rizzoli Orthopaedic Institute, Bologna, Italy
Ettore Sabetta, M.D.
Orthopaedic Surgeon, Rizzoli Orthopaedic Institute, Bologna, Italy
Serge Sabalat, M.D.
Orthopaedic Surgeon, Rizzoli Orthopaedic Institute, Bologna, Italy
Sylvia Notini, Ph. D.
Professor at the University, Bologna, Italy
Matthias Hendriks, M.D.
Orthopaedic Surgeon, Rizzoli Orthopaedic Institute, Bologna, Italy
Translation from the Italian/Spanish edition
Ricerche anatomiche e vie d'accesso nella chirurgia degli arti
Investigaciones anat6micas y vias de acceso en la cirugia de los miembros
© 1989 by Aulo Gaggi Editore, Bologna
ISBN-13: 978-3-7091-7440-1
This work is published simultaneously by Springer-Verlag Wi en - New York and by Aulo Gaggi Editore, Bologna
and is subject to copyright.
All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprint
ing, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in
data banks.
© 1989 by Aulo Gaggi Editore, Bologna
Softcover reprint of the hardcover 1st edition 1989
Sole distribution rights: Springer-Verlag Wien - New York
With 410 mostly coloured Figures
Library of Congress Cataloging-in-Publication Data: Ricerche anatomiche e vie d'accesso nella chirurgia degli arti. Eng
lish. Anatomical exposures and surgical approaches to the limbs / F. Ruggieri ... let al.l; drawings, G. Gamberini; collab
orators, P. Ruggieri, E. Sabetta, S. Sabalat; translators, S. Notini, M. Hendriks - Anatomische Darstellungen und
Zugangswege in der Chirurgie der Extremitaten / F.R uggieri ... let al.l; Zeichnungen, G. Gamberini; Mitarbeiter, P. Ruggieri,
E. Sabetta, S. Sabalat; Ubersetzer, S. Notini, M. Hendriks. p. cm. Translation of: Ricerche anatomiche e vie d'accesso
nella chirurgia degli arti. ISBN 0-387-82055-8 (U.S.). I. Extremities (Anatomy) -Atlases. 2. Extremities (Anatomy) -Sur
gery -Atlases. I. Ruggieri, Francesco_ II. Notini, S. (Sylvia). III. Hendriks, M. (Matthias). IV. Title. V. Title: Anatomische
Darstellungen und Zugangswege in der Chirurgie der Extremitaten. [DNLM: I. Extremities -anatomy -atlases. 2. Ex
tremities -surgery -atlases. WE 17 R497a]. QM548.R5313 1989. 611'.98-dc19. 88-24783.
lSBN-13: 978-3-7091-7440-1 e-ISBN-13: 978-3-7091-6935-3
DOl: 10.1007/978-3-7091-6935-3
PREFACE
Our decision to dedicate several years to the writing of this Atlas was based on
the professional acknowledgement of negative surgical results due to incorrect or
incomplete approaches to the bones or joints requiring treatment. We are convinced
that in order to obtain the best possible anatomic and functional results in surgery
of the locomotor apparatus, it is necessary to obey several rules of behaviour con
stituting the basis for correct surgical execution:
a) to respect the anatomy of the muscular and neural formations;
b) to safeguard the vascularization of these anatomical elements and consequently
of the osteoarticular apparatus;
c) to use the most appropriate surgical approaches fully respecting the regional
anatomy and the least traumatic exposure of the skeleton;
d) to correctly perform surgery, thus creating the best conditions for the excel
lent recovery of the function of the limb.
The anatomic findings and surgical approaches to the extremities described here
are not complete: we have based our selection of the former on their frequency
in the normal surgical activity of any specialised ward, and the latter on the surgi
cal approaches most commonly used by the 3rd Division of the Rizzoli Orthopaedic
Institute.
Wide surgical approaches for the surgical treatment of bone tumors have been
excluded as they deal with specific «compartmental» methods which do not involve
the anatomic rules to be followed in the normal treatment of orthopaedic and trau
matologic affections of the extremities.
We have also excluded the anatomic findings and surgical approaches involv
ing the hand as they are considered to be specific to a surgical field which has be
come highly specialised in its anatomic-surgical and functional expression. Most
of the illustrations included in the text are the product of anatomic findings ob
tained over the past years and photographed on several occasions in relation to the
various surgical approaches used. Our recognition and special thanks go to Mrs.
G. Gamberini of the Superior Institute of Medical Illustration at the Rizzoli Or
thopaedic Institute who was able to skillfully and beautifully translate our anatom
ical observations as well as our, at times, mediocre photographic production.
We also wish to thank Drs. P. Ruggieri, E. Sabetta and S. Sabalat for their
collaboration in the writing of this text and for the anatomic research which they
carried out for the approximately seven years during which this study was gradual
ly completed. Finally, we wish to thank our publisher Aulo Gaggi for the editorial
format of our text and for his constancy in encouraging us to continue with our work.
We are happy to present the press with the product of our effort and experience;
and we hope that the readers of this study, in particular the younger ones, will be
able to enrich their knowledge of surgical anatomy to the advantage of their patients.
THE AUTHORS
VORWORT
Unbefriedigende Ergebnisse operativer Eingriffe am Skelett sind hiiufig auff eh
lerhafte oder unvollstiindige Zugangstechniken zurUckzufuhren. Diese Tatsache hat
uns zu dem EntschlujJ bewogen, das vorliegende Werk zu konzipieren und seiner
Ausarbeitung mehrere Jahre zu widmen.
Um mit der Chirurgie am Bewegungsapparat ein funktionell und anatomisch
optimales Ergebnis zu erzielen, sind unserer Meinung nach folgende Grundregeln
zu beach ten:
a) Berucksichtigung der anatomischen Verhiiltnisse der Muskel- und Nerven
strukturen.
b) Weitestgehende Erhaltung des GefiijJsystems der Muskeln und Nerven und
damit der Knochen- und Gelenkstrukturen.
c) Wahl geeigneter Zugangswege und wenig traumatisierende Freilegung des
Knochens.
d) Ein allgemein korrektes chirurgisches Vorgehen, um die besten Vorbedin
gungen fur eine vollstiindige Wiedererlangung der Bewegungsfunktionen der Ex
tremitiiten ZU schaffen.
Die Beschreibung der anatomischen Darstellungen und Zugangswege erhebt kei
nen Anspruch aUf Vollstiindigkeit.
Die Auswahl der anatomischen Darstellungen ist nach Gesichtspunkten der
Hiiufigkeit und Wichtigkeit in der tiiglichen Arbeit einer orthopiidischen Abteilung
getroffen worden. Die beschriebenen Zugangswege sind die in der chirurgischen Rou
tine der 3. Abteilung des Instituts Rizzoli ublichen. Die grojJen Zugangswege der
operativen Behandlung von Knochentumoren wurden aujJer Acht gelassen, da es
sich hierbei um Spezialtechniken handelt, die nicht den anatomischen Grundsiitzen
der Orthopiidie und Traumatologie unterworfen sind. Ebenfalls nicht beschrieben
sind die anatomischen Darstellungen und Zugangswege der Hand, die heute einem
selbstiindigen Bereich der Chirurgie angeh6ren. Die Illustrationen sind zu einem
grojJen Teil das Ergebnis anatomischer und photographischer Studien, die wir in
den letzten Jahren durchgefuhrt haben.
Unser Dank gilt in besonderem MajJe Frau G. Gamberini vom «Istituto Superi
ore di Disegno Anatomico dell'Istituto Ortopedico Rizzoli» fur die hervorragende
graphische Ausarbeitung unserer anatomischen Darstellungen und mitunter mit
telmiijJigen Photographien. Unseren Mitarbeitern Dr. P. Ruggieri, Dr. E. Sabetta
und Dr. S. Sabalat danken wir fur ihre verdienstvolle Hilfe wiihrend der etwa sie
benjiihrigen Arbeit am Text und an den anatomischen Darstellungen. SchliejJlich
sind wir dem Verleger Aulo Gaggifur die repriisentative Ausstattung dieses Werkes,
vor allem aber fur die Beharrlichkeit, mit der er uns immer wieder zur Fortfuhrung
unserer Arbeit ermutigt hat, sehr zu Dank verpflichtet. Wir freuen uns, mit diesem
Atlas unsere Erfahrungen vorlegen zu k6nnen, und hoffen, dajJ insbesondere die
jungeren und angehenden Fachiirzte hier nutzliche Elemente zur Erweiterung ihrer
anatomisch-chirurgischen Kenntnisse finden werden.
DIE AUTOREN
CONTENTS
CHAPTER ONE
UPPER LIMB-ANATOMICAL EXPOSURES Page 13
The brachial plexus in the supraclavicular region ............................... . » 16
The neurovascular plexus in the subclavicular region ............................ . » 20
Large approach to the brachial plexus ....................................... . 24
))
The neurovascular bundle at the axilla ...... . . . . . ............................ . 26
))
The circumflex nerve in the posterior site ..................................... . 28
))
The musculocutaneous nerve at the arm ... . .. ... . ............................ . 32
))
The ulnar nerve at the arm ............. .. ............................... .. . 34
))
The ulnar nerve at the elbow .............................................. . 36
))
The ulnar nerve and artery at the forearm .................................... . 38
))
The ulnar nerve at Guyon's canal ........................................... . 42
))
The median nerve at the arm ....................... . ...................... . 44
))
The humeral artery and median nerve at the elbow ............................. . 46
))
The median nerve at the forearm ................. . ......................... . 48
))
The median nerve at the carpus ............................................ . 50
))
The radial nerve at the posterior cavity of the arm ............................. . 52
))
The radial nerve at the anterior cavity of the arm .............................. . 58
))
The radial nerve at the bifurcation .......................................... . 60
))
The interosseous dorsal nerve ...................... ........................ . 62
))
The radial artery at the mid-distal third of the forearm ......................... . 64
))
The radial artery at the anatomical snuff-box ................................. . 66
))
CHAPTER TWO
UPPER LIMB-SURGICAL APPROACHES 69
))
Approach to the clavicle .................................................. . 70
))
Approach to the sternoclavicular joint ........... . ............ . .............. . )) 72
Approach to the acromioclavicular joint ..................................... . 74
))
Approach to the spine of scapula, supra- and subspinous region .................. . 76
))
Approach to the external margin of the scapula ............................... . 78
))
Larghi approach ........................................................ . 80
))
Larghi approach enlarged externally ......................................... . 82
))
Upper transdeltoid approach (Nelaton's «shoulder pad») ........................ . 84
))
Posterior transacromiodeltoid approach ...................................... . 86
))
Posterior transdeltoid approach ............................................ . 88
))
Approach to the proximal metaphysis and diaphysis of the humerus ............... . 92
))
External bicipital approach ................................................ . 94
))
Large approach to the humerus ............................................ . 96
))
Lateral approach to the lower third of the diaphysis ............................ . 98
))
Transtricipital approach .................................................. . 100
))
Transolecranic approach .................................................. . 104
))
Boyd approach ......................................................... . 106
))
7
Approach to the olecranon and proximal third of the ulna .. .... ... ... .. .... .. ... . Page 110
Approach to the ulnar diaphysis . ....... . .. . .... . .......... ..... . . ........ . . . » 112
Approach to the radius (proximal half) .......... ..... .. ................ .. .. . . » 114
Approach to the radius (distal half) ... ..... ....... ... ..................... .. . » 116
Approach to the wrist .. .. ........ . .. ....... .. .... . . ......... . ..... . ... .. . . » 118
CHAPTER THREE
LOWER LIMB-ANATOMICAL EXPOSURES » 121
The gluteal artery .. ......... . . .. .. ....... .. . ... .. .... .... ............... . » 124
The sciatic nerve in the gluteal site ......... . ........... . .............. .. .. . . . » 126
The femoral artery at Scarpa's triangle ........................ . ....... ... ... . » 128
The crural nerve at the root of the thigh (approach enlarged upwards) .......... . . . . » 130
The femorocutaneous nerve . . . ............. .. ....... . . . .. .. ... . . .. . . .. .. .. . » 132
The anterior branch of the obturator nerve and artery .... .. . .. . . .. .... . . .. .... . . » 134
The sciatic nerve (upper third of the thigh) ........ ..... .. . . ... . .. . .......... . . » 140
The sciatic nerve at the middle third of the thigh ....... . ..... ....... ..... .. .. . . » 142
The sciatic nerve (approach enlarged to the thigh) . .. ....... ....... . . .... . .. . ... . » 144
The femoral artery at Hunter's canal ... .. .. . ........ . ...... ... . ... . . .. . . .... . » 148
The femoropopliteal arterial trunk ...... .... ..... .. . . . . ..... . ... . . . ....... . . . » 150
The neurovascular plexus at the popliteal lozenge .... . ... . ............. ........ . » 154
The external popliteal sciatic nerve (peroneus communis) in the popliteal region ... . . . . » 158
The posterior tibial artery at the middle third of the leg .. ........ .. ... .. ... . . .. . . » 160
The posterior tibial artery at the distal third of the leg .. .......... . ... .. .... ... . . » 162
The posterior tibial artery in the malleolar site ................ ..... ........... . » 164
The peroneal artery at the upper middle third of the leg .... . .... ... . ...... . . . .. . . » 166
The external plantar artery ..... .. . ... . .... . .. . .. ......... . . .... ...... .. ... . » 168
The internal plantar artery ....... . . . . ...... .. ........ .. .. .. .. . .. . . .. . .. .. . . » 170
The tibialis anterior at the proximal two-thirds of the leg ..... . ... . .. . ... . .... . .. . » 172
The tibialis anterior at the ankle ....... ..... ...... ..... ........ . . . ...... .. .. . » 174
The dorsal artery of the foot at the dorsum of the foot ... .... . . . .............. . . » 176
CHAPTER FOUR
LOWER LIMB-SURGICAL APPROACHES » 179
Iliocrural approach ... ... . . . . .. .. ... ...... .. ... ..... ..... .. . ... .. . ... . . .. . » 180
Judet-Letournel ilioinguinal approach ....... . . .. .. . .......... ..... .. .. . ... ... . » 184
Letournel lateral approach . . . . ............ .. . . .. .......... .... ..... . . .. ... . » 190
Iselin approach . . ....... . .. ... ............. .. .............. . ............ . » 196
Exposure of the ischiatic tuberosity ................... . ...... . . ... .... . . . ... . » 200
Smith-Petersen approach .... . ...... .. ..... .. . ... ... ... .... . .. .... .. ....... . » 204
Watson-Jones anteroexternal approach .. .... ... . .. .......... .. .. . ... ..... . . .. . » 208
Gibson posteroexternal approach ...... .. ........ ....... ... ... ............ . . . » 210
Moore posteroexternal approach ........ .... ........... . ...... . . . ... . . . . .. .. . » 214
Large lateral approach to the coxofemoral joint .... ....... .. . . .. . . .. . . . ....... . » 218
8
Approach to the proximal metaphysis ....................................... . Page 222
Approach to the proximal third of the diaphysis ............................... . » 226
Approach to the diaphysis (enlarged) ........................................ . » 230
Approach to the middle third of the diaphysis (posterior approach) ................ . » 234
Approach to the distal metaphysis (external approach) ...................... . ... . » 238
Approach to the distal metaepiphysis (enlarged) ............................... . » 240
External approach to the knee ........................................... .. . » 242
Internal approach to the knee .............................................. . » 244
Posteroexternal approach to the knee ..... . .................................. . » 246
External approach to the tibial plate ........................................ . » 248
Posterior approach to the proximal tibial metaphysis .............. . ............ . » 250
Anteroexternal approach to the tibia ............... . . ......... . . . .. . ....... . . » 254
Approach to the interosseous membrane .... . ................. . . . .. . . ........ . » 256
Approach to the tibial malleolus ............................................ . » 260
Approach to the medial malleolus and the third malleolus ....................... . » 262
Lateral approach to the ankle joint ........................ . . .......... . .... . » 264
Anterior approach to the ankle joint ........................................ . » 266
Medial approach to the ankle joint .......................................... . » 268
Anteroexternal approach to the ankle joint and midtarsal joint . . ................. . » 270
Lateral approach to the talocalcanean joint and the calcaneum . . ................. . » 274
Approach to the tarsal scaphoid bone » 276
Anterior approach to the midtarsal joint ................................. . ... . » 278
Lateral approach to the talocalcanean and midtarsal joints ....................... . » 280
Dorsal approach to the metatarsus ......................................... . . » 284
Approach to the proximal interphalangeal joint of the second toe ................. . » 286
Approach to the metatarsophalangeal joint of the second toe ........ . ............ . » 286
Medial approach to the metatarsophalangeal joint of the great toe .... . ............ . » 288
Dorsal approach to the metatarsophalangeal joint of the great toe ..... . .... ....... . » 288
Plantar approach to the metatarsophalangeal joint of the second toe ............... . » 290
9
INHALTSVERZEICHNIS
KAPITEL I
OBERE EXTREMITAT-ANATOMISCHE DARSTELLUNGEN Seite 13
Plexus brachialis im supraklavikuliiren Bereich .............................. . » 18
GejiijJ-Nervenstrang im subklavikuliiren Bereich ... ...................... . ... . » 20
GrojJer Zugang zum Plexus brachialis ..................................... . » 24
GejiijJ-Nervenstrang in der Regio axil/aris .................................. . » 26
N. axil/aris von dorsal ................................................. . » 28
N. musculocutaneus am Oberarm ........................................ . » 32
N. ulnaris am Oberarm ....................................... ......... . » 34
N. ulnaris am Ellenbogengelenk ......................................... . » 36
N. ulnaris und A. ulnaris am Unterarm ................................... . » 38
N. ulnaris im «Guyon-Kanal» ........................................... . » 42
N. medianus am Oberarm .............................................. . » 44
A. brachialis und N. median us am Ellenbogen .............................. . » 46
N. medianus am Unterarm ............................................. . » 48
N. medianus am Handgelenk ......................... ................... . » 50
N. radialis in der Regio brachii posterior .................................. . » 52
N. radialis in der Regio brachii anterior ................................... . » 58
N. radialis an der A ujzweigung ............. . . . . . . . . . . . . . . . . . . . . . . . . ..... . » 60
N. interosseus dorsalis ................................................. . » 62
A. radialis im mittleren und distalen Unterarmdrittel ......................... . » 64
- A. radialis in der Foveola radialis ........................................ . » 66
KAPITEL II
OBERE EXTREMITAT-ZUGANGSWEGE » 69
Zugang zur Clavicula .................................................. . » 70
Zugang zur Articulatio sternoclavicularis » 72
Zugang zur Articulatio acromioclavicularis ................................. . » 74
Zugang zur Spina scapulae ............................................. . » 76
Zugang zum Margo lateralis scapulae ....................... . ............. . » 78
Zugang nach Larghi (Schultergelenk von ventral) ............................ . » 80
Zugang nach Larghi, lateral erweitert ..................................... . » 82
Proximaler Zugang durch den M. deltoideus (<<Nelatonsche Schulter») ........... . » 84
- Dorsaler Zugang durch das Acromion und den M. deltoideus .................. . » 86
Dorsaler Zugang durch den M. deltoideus ................................. . » 88
Zugang zur proximalen Metaphyse und zur Diaphyse des Humerus ............. . » 92
Antero-lateraler Zugang zum Humerus .................................... . » 94
GrojJer Zugang zum Humerusschajt ...................................... . » 96
Lateraler Zugang zum distalen Humerusdrittel .............................. . » 98
Zugang durch den M. triceps brachii » 100
- Dorsaler Zugang mit temporiirer Olecranon-Osteotomie ....................... . » 104
- Zugang nach Boyd .................................................... . » 106
10
Zugang zum Olecranon und proximalen Ulnadrittel ........... . .. .. ........ .. . Seite 110
Zugang zum Ulnaschaft ........................ ... . ..... . ........... . . . . » 112
Zugang zur proximalen Hiilfte des Radius ..................... .. .......... . » 114
Zugang zur distalen Hiilfte des Radius . .. ........... . ....... .. .. . . ........ . » 116
Zugang zum Handgelenk . . ... ................... ....... . . . .. ...... . .. .. . » 118
KAPITEL III
UNTERE EXTREMITAT-ANA TOMISCHE DARSTELLUNGEN » 121
- A. glutaea superior .. . ................................................ . » 124
N. ischiadicus in der Regio glutaea .................................... ... . » 126
A. femoralis im Trigonum femorale (<<Scarpa-Dreieck») ................. .. . .. . » 128
N. femoralis im Leistenbereich (nach proximal erweiterter Zugang) .... ........ . . » 130
N. cutaneus femoris lateralis .. ..... .... ..... ... ... ...... .. . ..... ... .. .. . . » 132
A. obturatoria und der ventrale Ast des N. obturatorius ....... . ............ .. . » 136
N. ischiadicus im proximalen Oberschenkeldrittel ............................ . » 140
N. ischiadicus im mittleren Oberschenkeldrittel ..... ... ..................... . » 142
N. ischiadicus (erweiterter Zugang am Oberschenkel) ............ ... .......... . » 144
A. femoralis im Canalis adductorius (<<Hunter-Kanab») ... .. .. ... ....... ...... . » 148
Truncus femoropopliteus .. ... ....... .. ................. .. .............. . » 150
GefiijJ-Nervenstrang in der Fossa poplitea .................................. . » 154
N. peronaeus communis im Kniebereich ................................... . » 158
A. tibialis posterior im mittleren Unterschenkeldrittel ...................... .. . » 160
A. tibialis posterior im distalen Unterschenkeldrittel ......................... . » 162
A. tibialis posterior am Malleolus medialis ................................. . » 164
A. peronaea im mittleren Unterschenkeldrittel (oberer Abschnitt) ............ . . . . » 166
- A. plantaris lateralis ................ ............................... .. .. . » 168
- A. plantaris medialis .................................................. . » 170
- M. tibialis anterior im proximalen und mittleren Unterschenkeldrittel ............ . » 172
- M. tibialis anterior im distalen Abschnitt des Unterschenkels » 174
- A. dorsalis pedis am FujJriicken .................. ..................... . . . » 176
KAPITEL IV
UNTERE EXTREMITAT-ZUGANGSWEGE » 179
I1iocruraler Zugang . .... . ... . ... . .. . . .. .... ............. .... .... . ... .. . » 180
Ilioinguinaler Zugang nach Judet-Letournel .. ... .... ... . . ..... . ............ . » 184
Lateraler Zugang nach Letournel ...... ... ................. .............. . » 190
Zugang nach Iselin .................................................... . » 196
Freilegung des Tuber ischiadicum ................. ....................... . » 200
Zugang nach Smith-Petersen . .. ..................... ............... .... . . » 204
Antero-lateraler Zugang nach Watson-Jones ...... .... .... . ..... . . . ..... . ... . » 208
Dorso-lateraler Zugang nach Gibson .......................... ............ . » 210
Dorso-lateraler Zugang nach Moore ... .... .............................. . . » 214
GrojJer lateraler Zugang zum Hiiftgelenk ..................... ... .......... . » 218
11
Zugang zur proximalen Metaphyse des Femur ... .............. .... . . ... .... . Seite 222
Zugang zum proximalen Femurschaftdrittel ....... ...... .. .... ... . .. . ... ... . » 226
Erweiterter Zugang zum Femurschaft .. .. ...................... . . . ... .. ... . » 230
Dorsaler Zugang zum mittleren Femurschaftdrittel .. .. . ............. . . ... . ... . » 234
Lateraler Zugang zum distalen Femurdrittel .................. . . . . . ..... .... . » 238
Erweiterter Zugang zum distalen Femurdrittel . . .. . ...... . .... ..... . . . . ... . . . » 240
Lateraler Zugang zum Kniegelenk .... .. . .. .... . .. .. .......... ..... . . ... .. . » 242
Dorso-medialer Zugang zum Kniegelenk ........... ... ...... .. ....... . . .. .. . » 244
Dorso-Iateraler Zugang zum Kniegelenk ........... ............ . ...... .... . . » 246
Zugang zum lateralen Tibiakopfplateau . .... .. . .. . ... . ... .... . ... ..... . ... . » 248
Dorsaler Zugang zur proximalen Metaphyse der Tibia ..... . . .... .. .... .. . .. .. . » 250
Antero-Iateraler Zugang zur Tibia .... . .. . ..... ....... ... .... ............. . » 254
Zugang zur Membrana interossea cruris .............. . ....... . ........ . .. . . » 256
Zugang zum Malleolus medialis ........ ................. . . .. .......... ... . » 260
Zugang zum Malleolus medialis und zum Volkmann-Dreieck ..... . . . . .. ... . .. . . » 262
Lateraler Zugang zum oberen Sprunggelenk . . .. ... .......... ... .... . . .... . . . » 264
Dorsaler Zugang zum oberen Sprunggelenk .... . ...... ............ ......... . » 266
Medialer Zugang zum oberen Sprunggelenk ................... .. .. . ... ..... . » 268
Antero-Iateraler Zugang zum oberen und unteren Sprunggelenk . .. .... ........ . . » 270
Lateraler Zugang zur Articulatio subtalaris und zum Calcaneus .. . . . . ... . . . .... . » 274
Zugang zum Os naviculare . . . ... .... .......... . .. ...... . ... ..... .. .... . . » 276
Dorsaler Zugang zum Chopart-Gelenk ... .................... ... ... . . . .... . » 278
Lateraler Zugang zur Articulatio subtalaris und zum Chopart-Gelenk ........ . ... . » 280
Dorsaler Zugang zum Metatarsus ................. ........... . . . .... . .... . » 284
Zugang zum Mittelgelenk der zweiten Zehe .... .. ... .... ........ . ........ . . . » 286
Zugang zum Grundgelenk der zweiten Zehe ........ ... ..... ... .. ...... . . . . . . » 286
Medialer Zugang zum Grundgelenk der GrojJzehe .. .......... ... . ........ . .. . » 288
Dorsaler Zugang zum Grundgelenk der GrojJzehe .... ................... . .. . . » 288
Plantarer Zugang zum Grundgelenk der zweiten Zehe .. ... . . . .. . . . .. . . ....... . » 290
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