Authors of section

Authors

Arnold Besselaar, Daniel Green, Andrew Howard

Executive Editor

James Hunter

General Editor

Fergal Monsell

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Lateral approach

1. Introduction

Open procedures use an incision on the lateral aspect of the thigh.

Skin incision line for lateral approach

2. Principles

The major vessels and nerves are located medially/posteromedially to the femoral shaft and are not exposed using this approach.

Cross-section of the thigh

3. Skin incision

Perform an incision along a line between the lateral femoral epicondyle and the greater trochanter, along the length of the femur determined by the specific fracture pattern.

Skin incision line

4. Opening the fascia lata

Incise the fascia lata with a scalpel and split it with scissors parallel to the skin incision, along its fibers.

Expose the fascia over the vastus lateralis.

Opening the fascia lata

5. Principles of a safe approach

As the fibers of origin of the vastus lateralis are elevated from the intermuscular septum, identify the perforating vessels and protect or ligate them.

If divided close to the septum, the proximal ends can retract into the posterior compartment of the thigh, causing troublesome occult bleeding.

Cross-section of the thigh dissection path

6. Separation of vastus lateralis from fascia lata

Separate the vastus lateralis from the fascia lata using blunt dissection.

Separation of vastus lateralis from fascia lata

7. Incision of the fascia vastus lateralis

Retract the vastus lateralis anteromedially.

Incise the fascia investing the vastus lateralis 1 cm anterior to the intermuscular septum.

Incision of the fascia vastus lateralis

8. Mobilization of vastus lateralis from intermuscular septum

Detach the muscle from the lateral intermuscular septum and the linea aspera with a periosteal elevator.

Mobilization of vastus lateralis from intermuscular septum

9. Control of perforating vessels

Identify the perforating vessel bundles.

These vessels perforate the lateral intermuscular septum from the posterior side and run anteriorly, remaining closely applied to the femoral shaft.

In children these vessels can be cauterized with the diathermy.

Cauterization of perforating vessels

10. Exposure of the bone

Using the elevator, continue extraperiosteal detachment of the vastus lateralis to expose the femoral shaft.

Exposure of the bone

11. Exposure of the proximal femoral shaft

If exposure of the proximal femoral shaft is necessary, identify the origin of the vastus lateralis.

Retract the muscle anteriorly and perform an L-shaped incision down to the bone. The transverse part of the incision lies in the interval between gluteus medius and vastus lateralis.

Exposure of the proximal femoral shaft

Dissect the muscle from its origin using a periosteal elevator.

Detachment of vastus lateralis

12. Closure

Return the vastus lateralis to its original position over the lateral femur. Repair the origin and close the tensor fascia lata.

The subcutaneous tissue and skin are closed according to surgeon’s preference.