14
ARTHROSCOPY OF THE ELBOW:
SETUP, PORTALS, AND DIAGNOSTIC
TECHNIQUE
G. DEXTER WALCOTT, JR.
FELIX H. SAVOIE, III
LARRY D. FIELD
Arthroscopy of the elbow was initially considered a danger-
ous procedure with few indications. With the development
of equipment and techniques, as well as increased clinical
experience, elbow arthroscopy has become a safe and effec-
tive tool for the treatment of various elbow disorders. It is,
however, still an uncommonly performed procedure for
most orthopedists and caution should be exercised when
proceeding with elbow arthroscopy. A precise knowledge
of the neurovascular anatomy of the elbow, extensive arthro-
scopic experience, and the availability of all necessary equip-
ment are essential to safely perform arthroscopy of the
elbow.
PREOPERATIVE EVALUATION
A thorough history and physical examination are per-
formed. Particular attention is paid to the location of the
ulnar nerve, whether in its groove or in a subluxated position
with elbow flexion. Likewise, a history of ulnar nerve trans-
position should be sought. A subluxating ulnar nerve, or
surgery that alters the normal neurovascular anatomy, may
be contraindications for certain arthroscopic portals or for
elbow arthroscopy altogether.
ANESTHESIA
General anesthesia is most commonly used for elbow ar-
throscopy. It allows total muscle relaxation and facilitates
G. D. Walcott: Alabama Orthopaedic Specialists, Montgomery, Alabama
36106.
F. H. Savoie, III: Mississippi Sports Medicine and Orthopaedic Center,
Jackson, Mississippi 39202.
L. D. Field: Mississippi Sports Medicine and Orthopaedic Center, and
the Department of Orthopaedic Surgery, University of Mississippi, Jackson,
Mississippi 39202.
positioning in the prone or lateral decubitus position. Re-
gional anesthesia with scalene, axillary, or Bier blocks may
be used in patients for whom general anesthesia is contrain-
dicated, or as an adjunct for postoperative pain control.
One disadvantage is that regional anesthesia does not allow
a complete neurovascular examination in the immediate
postoperative period.
POSITIONING
The choice of patient position is based upon the surgeon’s
training and preference. The position should allow access
to the entire elbow, manipulation of the elbow through a
full range of motion, and conversion to an open procedure
when needed. The supine, prone, and lateral decubitus posi-
tions have been described. Each position has advantages and
disadvantages.
Supine
In the supine position, described by Andrews and Carson
(1), the shoulder is abducted 90 degrees and placed at the
edge of the operating table. The elbow is flexed at 90 degrees
and either suspended by a traction device attached to the
hand or forearm or held and positioned by an assistant.
Advantages of the supine position include ease of posi-
tioning and access to the airway (1,2). Visualization of the
anterior compartment and conceptualization of intraarticu-
lar anatomy is simpler in the supine position. Conversion
to an open procedure is also facilitated in this position.
Disadvantages of the supine position include the need
for an overhead traction device, difficulty accessing the pos-
terior compartment, and difficulty manipulating the elbow
if a traction device is used. In addition, the suspended elbow
may be unstable and require the use of an assistant (3).
210 The Athlete’s Elbow
Prone
Described by Poehling and associates (4), the prone position
addresses some of the problems with supine positioning.
The patient is placed prone on the operating table with
chest rolls and padding for the head and face and for the
prominences of the lower extremities. The shoulder is ab-
ducted 90 degrees and the elbow flexed at 90 degrees, sup-
ported by an arm positioner or an arm board placed parallel
to the operating table.
Advantages of the prone position include improved ac-
cess to the posterior compartment and ease of manipulation
of the elbow from full extension to near full flexion. The
arm is in a stable position and does not require a traction
device or an assistant to hold the arm. In the prone position,
the anterior neurovascular structures are displaced away
from the joint giving an added margin of safety in the ante-
rior compartment. Conversion to an open procedure is not
difficult in this position (3,4); however, an anterior ap-
proach may require repositioning of the patient (2,5).
Disadvantages of the prone position include difficulties
in positioning the patient and in monitoring the airway by
the anesthesiologist. Positioning the patient prone requires
careful attention to placing chest rolls and padding of all
prominences, as well as careful handling of the head, neck,
and face. Patients undergoing regional anesthesia may not
tolerate this position, and conversion to general anesthesia
requires repositioning.
Lateral Decubitus
Described by O’Driscoll and Morrey (6), the lateral decubi-
tus position offers some of the advantages of the prone posi-
tion while avoiding some of the disadvantages. The patient
is positioned lateral with the shoulder flexed forward at 90
degrees over a padded bolster.
Advantages of the lateral decubitus position include those
stated for the prone position. In addition, there is better
access to the airway for the anesthesiologist and easier pa-
tient positioning.
The main disadvantage of this position is the need for
a special piece of equipment, the padded arm bolster. As
with the prone position, an easy conversion can be made
to an open procedure, although anterior access may require
repositioning (6,7).
PORTAL PLACEMENT
A thorough knowledge of the neurovascular anatomy of the
elbow is essential to safely perform arthroscopy of the elbow.
The described portals are based on avoiding these neurovas-
cular structures and must be accurately located. Marking
the surface landmarks on the skin is performed first. The
olecranon, medial epicondyle, ulnar nerve, lateral epicon-
dyle, and radial head are all palpated and marked.
In addition to ensuring their correct location, the tech-
nique with which the portals are created and used is impor-
tant. The elbow is first fully distended with fluid. An 18-
gauge spinal needle is used to inject 20 to 30 mL of sterile
saline, usually through the soft spot bounded by the olecra-
non, lateral epicondyle, and radial head. Distension creates
an added margin of safety by pushing the neurovascular
structures away from the joint (8). The spinal needle is then
used to confirm correct location of the portal site. Backflow
of fluid confirms intraarticular placement of the needle.
When the skin is incised, a no. 11 knife blade is used to
incise the skin only and thus protect the superficial cuta-
neous nerves. A hemostat is used to bluntly dissect to the
capsule, before a cannula with a blunt trocar is introduced
into the joint. Once a cannula is placed into the joint, it is
left there throughout the procedure. This will avoid the
risks of multiple passes through the soft tissues and decrease
fluid extravasation.
Anterior portals are created with the elbow at 90 degrees
of flexion, which allows the neurovascular structures to fall
away from the joint. Posterior portals are created with less
flexion. Several medial and lateral portals have been recom-
mended for use as the initial portal (1,4,9,10). The decision
which to use depends on the experience and preference of
the surgeon.
Proximal Medial
First described by Poehling and associates (4), the proximal
medial portal is located 2 cm proximal to the medial epicon-
dyle and just anterior to the medial intermuscular septum
(Fig. 14.1A). The elbow must be maintained at 90 degrees
of flexion during placement of the portal. The intermuscular
septum must be located and the cannula kept anterior to
it to avoid injury to the ulnar nerve. The blunt trocar and
cannula are directed along the anterior surface of the hu-
merus toward the radial head. Staying on the anterior sur-
face of the humerus will protect the median nerve and bra-
chial artery. The trocar should pierce the tendinous portion
of the flexor-pronator group and the medial capsule to enter
the joint. Subluxation of the ulnar nerve or a history of
transposition are contraindications to using this portal (3,
5,10,11).
The proximal medial portal provides visualization of the
entire anterior compartment of the joint. The capitellum,
radial head, coronoid process, trochlea, anterior capsule, and
medial and lateral gutters can all be evaluated (Fig. 14.1B
and C). With the patient prone or lateral decubitus, the
proximal medial portal is often used as the initial portal (3,
4,10). At highest risk of injury is the posterior branch of
the medial antebrachial cutaneous nerve, located on average
2.3 mm from the trocar (11). The median nerve is on aver-
age 12.4 to 22.3 mm from the trocar (10,11). The ulnar
nerve is on average 12 to 23.7 mm from the portal, and as

long as the trocar is anterior to the intermuscular septum,
is relatively safe (10,11).
Proximal Lateral
The proximal lateral portal has been described by Stothers
and associates (11), Field and associates (9), and Savoie and
Field (12). It is located 2 cm proximal and 1 cm lateral
to the lateral epicondyle (Fig. 14.2A). The blunt trocar is
advanced toward the center of the joint in contact with
the anterior surface of the humerus. The trocar pierces the
brachioradialis and brachialis before entering the joint
through the lateral capsule.
14. Arthroscopy of the Elbow 211
FIGURE 14.1. A: Proximal medial portal. B:
Arthroscopic view from the proximal medial
portal. C: Illustration of an arthroscopic view
from the proximal medial portal.
The proximal lateral portal provides complete visualiza-
tion of the anterior compartment and may be used as the
initial portal (Fig. 14.2B and C) (9,11,12). In closest prox-
imity is the posterior branch of the lateral antebrachial cuta-
neous nerve, on average, 6.1 mm from the trocar (11). The
radial nerve is at a safe distance from this portal, on average
9.9 to 14.2 mm, than the standard anterolateral portal, 4.9
to 9.1 mm (9,11).
Anterolateral
Andrews and Carson (1) originally described the anterolat-
eral portal located 3 cm distal and 1 cm anterior to the lateral
212 The Athlete’s Elbow

B
FIGURE 14.2. A: Proximal lateral portal, preferred anterolateral portal, and standard anterolat-
eral portal. B: Arthroscopic view from the proximal lateral portal. C: Illustration of an arthroscopic
view from the proximal lateral portal.

epicondyle (Fig. 14.2A). Anatomic studies have shown that
3 cm is too distal in most patients and places the radial
nerve at increased risk (9,11). Other authors recommend a
more proximal entry point at the sulcus between the radial
head and capitellum (5) or just anterior to the lateral epicon-
dyle (9). The superficial nerves at risk are the anterior branch
of the posterior antebrachial cutaneous and the lateral ante-
brachial cutaneous.
The trocar is directed toward the center of the joint and
passes through the extensor carpi radialis brevis and lateral
capsule into the joint. Alternatively, the portal can be cre-
ated from inside out if a medial portal was created initially.
With the arthroscope medially, it is advanced to the capsule
just lateral to the radial head and replaced with a blunt rod.
The rod is pressed against the capsule to tent the overlying
skin, which is incised. A cannula can then be advanced over

the rod into the joint. This portal must be placed lateral to
the radial head, rather than anterior, to avoid radial nerve
injury (5,10,11).
The radial nerve was reported by Andrews and Carson
(1) to be 7 mm away from the trocar in the distended joint.
Lindenfeld (10) reported an average distance of 2.8 mm,
and Stothers et al. (11) reported 4.9 mm. Lynch et al. (13)
reported an average 4 mm in the nondistended joint, in-
creasing to 11 mm with distension.
The anterolateral portal allows visualization of the medial
side of the joint. The coronoid process, trochlea, and medial
part of the radial head can be seen (Fig. 14.2D and E).
Midlateral
The midlateral portal is also called the direct lateral or soft-
spot portal. It is located at the center of a triangle bounded
by the olecranon, the lateral epicondyle, and the radial head
(Fig. 14.3A). This site is often used for aspiration of the
FIGURE 14.3. A: Midlateral or direct lateral portal. B: Arthroscopic
view from the midlateral portal. C: Illustration of an arthroscopic
view from the midlateral portal.
14. Arthroscopy of the Elbow 213
elbow, and before arthroscopy, it is used to inject fluid to
distend the joint. For this portal, the trocar penetrates the
anconeus muscle and the lateral capsule. The portal is rela-
tively safe, with the nearest neurovascular structure being
the posterior antebrachial cutaneous nerve, an average of 7
mm away (14).
The midlateral portal provides visualization of the infe-
rior aspect of the radial head and capitellum, as well as the
proximal radioulnar articulation (Fig. 14.3B and C). One
disadvantage to using this portal is extravasation of fluid
into the relatively thin soft tissue here. Thus, it is often
better to delay use of this portal until the end of the opera-
tion (5,11,15).
Anteromedial
The anteromedial portal was initially described by Andrews
and Carson (1) as being 2 cm distal and 2 cm anterior to
the medial epicondyle (Fig. 14.4A). The trocar passes
214 The Athlete’s Elbow
through the flexor-pronator origin deep to the median nerve
and brachial artery before entering the joint. This portal
provides visualization of the entire anterior compartment,
particularly the lateral structures (Fig. 14.4B and C).
At risk with the anteromedial portal are the medial ante-
brachial cutaneous nerve and the median nerve (11,13). The
medial antebrachial cutaneous nerve is on average 1 mm
away from the trocar (11). The median nerve is on average
7 mm to 14 mm away in the distended joint (11,13). Lin-
denfeld (10) found a greater margin of safety 22 mm from
the median nerve, with placement of the medial portal 1
cm proximal and 1 cm anterior to the medial epicondyle.
FIGURE 14.4. A: Anteromedial portal. B:
Arthroscopic view from the anteromedial
portal. C: Illustration of an arthroscopic
view from the anteromedial portal.
This allows the trocar to be directed more parallel to the
median nerve.
Posterolateral
The posterolateral portal is located 3 cm proximal to the
tip of the olecranon and just lateral to the edge of the triceps
tendon (Fig. 14.5A). The elbow is held at about 45 degrees
of flexion to relax the triceps and posterior capsule and to
increase the posterior joint space. A blunt trocar is then
directed toward the center of the olecranon fossa, passing
lateral to the triceps tendon.

FIGURE 14.5. A: Posterolateral and straight posterior portals. B: Arthroscopic view from the
posterolateral portal.
The posterolateral portal provides visualization of the
entire posterior compartment, including the olecranon, ole-
cranon fossa, and medial and lateral gutters (Fig. 14.5B and
C). When evaluating the medial gutter, the surgeon must
be careful because the ulnar nerve is just superficial to the
medial capsule in this location (5,16).
This portal has one of the largest areas of safety of any
portal (5). The nearest structures to this portal are the poste-
rior antebrachial cutaneous and the lateral brachial cuta-
neous nerves.
Straight Posterior
The straight posterior or transtriceps portal is located 3 cm
proximal to the tip of the olecranon (Fig. 14.5A). The portal
site is located with a spinal needle straight into the olecranon
fossa to confirm position, followed by a no. 11 knife blade
straight into the fossa. A blunt trocar with cannula is then
placed into the center of the olecranon fossa, and the can-
nula is slid down the trocar until it makes contact with the
bone. Egress of fluid confirms intraarticular placement. This
portal is on average 2 cm from both the posterior antebra-
chial cutaneous nerve and the medial brachial cutaneous
nerve (5).
The straight posterior portal allows visualization of the
entire posterior compartment. In combination with the pos-
terolateral portal, this portal can be used to remove loose
14. Arthroscopy of the Elbow 215
B
bodies, debride osteophytes, and fenestrate the distal hu-
merus for an ulnohumeral arthroplasty.
OPERATIVE TECHNIQUE
A thorough preoperative evaluation is performed. Neuro-
vascular function, range of motion, and stability are
checked. As mentioned previously, the position of the ulnar
nerve is noted.
Although general anesthesia is used, many of our patients
also receive a scalene or axillary block for postoperative pain
control. After the administration of anesthesia, the patient
is positioned prone on chest bolsters with careful padding
of all bony prominences. The shoulder is abducted at 90
degrees and the arm is either placed in a commercially avail-
able arm holder or placed over a padded block on an arm
board attached parallel to the table (Fig. 14.6). An examina-
tion under anesthesia is performed.
A tourniquet with padding is placed as proximally as
possible on the extremity, the arm is exsanguinated, and
the tourniquet inflated with the arm flexed. The arm is then
prepared and draped with a Coban wrapped around the
hand and forearm to limit fluid extravasation.
The video monitor and other equipment are positioned
on a mobile cart on the opposite side of the patient. A Mayo
stand with the required instruments is placed next to the
surgeon. We use a standard 4-mm 30-degree arthroscope
216 The Athlete’s Elbow
FIGURE 14.6. Prone position.
with a 2.7-mm arthroscope available for some very small
patients or those with extremely limited joint volume.
Surface landmarks are drawn on the skin with a marking
pen. The medial and lateral epicondyles, olecranon, radial
head, ulnar nerve, and intermuscular septum are marked.
In addition, the sites for the planned arthroscopic portals
are marked.
Distension of the elbow joint is achieved by using an
18-gauge needle and syringe to inject 20 to 30 mL of saline.
The injection site is usually the soft spot between the olecra-
non, radial head, and lateral epicondyle. Intraarticular posi-
tion is confirmed by backflow of fluid through the needle.
The senior author (F.H.S.) uses the proximal medial por-
tal as the initial portal. After joint distension, the spinal
needle is directed along the anterior humerus to enter the
anteromedial capsule. The return of fluid confirms intraar-
ticular placement and the needle is removed. The skin is
carefully incised and a blunt trocar and cannula are then
directed along the same trajectory as the needle into the
joint. Again, return of fluid confirms intraarticular place-
ment.
The arthroscope is then inserted and the anterior com-
partment is systematically examined. The capitellum and
radial head are viewed, with pronation and supination of
the forearm allowing most of the radial head to be seen. The
anterior and lateral capsule are examined and the coronoid
process, trochlea, coronoid fossa, and medial gutter are
viewed as the arthroscope is withdrawn. Care is taken not
to remove the cannula from the joint.
The medial aspect of the joint is best seen laterally. The
anterolateral portal is established either from inside out or
directly. For the inside-out technique, the arthroscope is
advanced to the lateral capsule at the radiocapitellar joint.
The arthroscope is then removed and a switching stick is
advanced through the lateral capsule. A skin incision is made
at the tip of the switching stick. A second cannula is then
placed over the rod into the joint. The camera can then be
moved to the lateral side. From this portal, the medial cap-
sule, trochlea, coronoid process, and coronoid fossa are eval-
uated.
The posterior compartment is examined from the pos-
terolateral portal. The medial and lateral gutters, olecranon
tip, olecranon fossa, and posterior aspect of the radiocapi-
tellar joint can be examined. If a working portal is needed,
a straight posterior portal can be established.
At the conclusion of the procedure, drains may be placed
into the joint through the cannulas if needed. The cannulas
are then removed and the portals are closed with adhesive
strips. If a soft-spot portal was used, it is closed with a suture
to prevent fistula formation through the thin soft tissue in
this area. Depending on the procedure, a splint or soft dress-
ing is applied to the extremity.
COMPLICATIONS
Injury to the nerves about the elbow are the most commonly
reported complications of elbow arthroscopy (1,13,17–20).
Nerve injuries can occur as a result of direct injury from
trocars and cannulas, compression by cannulas, excessive
joint distension or fluid extravasation, or the use of local
anesthetics (1,13,18).
Use of the anterolateral portal places the radial nerve at
risk. There have been reports of injuries to the radial nerve,
the posterior interosseous nerve, and the superficial branch
of the radial nerve (13,18,20). The median nerve is at risk
with use of the anteromedial portal. Injuries to the median
nerve and the anterior interosseous nerve have been reported
(1,13,19). Ulnar nerve injuries have also been reported with
use of medial portals (17).
Other complications reported are similar to complica-
tions reported for arthroscopy of other joints. Infection,
articular cartilage injury, synovial fistula formation, instru-
ment breakage, and tourniquet-related complications have
been reported (6,5).
SUMMARY
Increasing clinical experience with elbow arthroscopy and
the development of new techniques have led to an expansion
of the indications for arthroscopy in treating elbow disor-
ders. Meticulous attention to detail and technique in the
performance of elbow arthroscopy will help avoid complica-
tions and allow effective treatment of elbow pathology.
REFERENCES
1. Andrews JR, Carson WG. Arthroscopy of the elbow. Arthroscopy
1985;1:97–107.
2. Carson WG Jr, Meyers JF. Diagnostic arthroscopy of the elbow:
supine position, surgical technique, arthroscopic and portal anat-