Overview
Elbow arthroscopy has grown in popularity and sophistication, but the proximity of the radial, median and ulnar nerves and the brachial artery makes knowledge of portal anatomy essential (Campbell).
Indications and Contraindications (Campbell's Concepts)
Indications
Evaluation and removal of loose bodies (probably the most common indication)
Osteochondritis dissecans of the capitellum; chondral or osteochondral lesions of the radial head
Excision of humeral and olecranon osteophytes
Partial synovectomy, especially in rheumatoid disease
Debridement and lysis of adhesions in posttraumatic or degenerative stiffness
Tennis elbow release
Painful elbow when other tests are inconclusive
Debridement of olecranon bursitis; stabilization procedures; some intra-articular fractures
Contraindications
Bony or severe fibrous ankylosis preventing safe arthroscope entry
Previous surgery altering anatomy, such as anterior ulnar nerve transposition (eliminates some portals; relative contraindication)
Periarticular infection
Setup (Campbell)
General anesthesia for complete relaxation; tourniquet as high as possible on the arm.
4-mm 30-degree and 2.7-mm 70-degree arthroscopes.
Maintain portals with interchangeable cannulas or cannulas with diaphragms to avoid repeated passes near nerves and to limit extravasation.
Gravity or low-pressure pump inflow (40-50 mm Hg). Monitor antecubital soft-tissue tension throughout; abort the procedure if extravasation becomes excessive.
Positions
Position | Setup | Features |
|---|---|---|
Supine | Hand in a sterile stockinette suspension with 5-6 lb weight; shoulder neutral rotation and 90 degrees abduction; elbow 90 degrees | Access to both sides; relaxes antecubital neurovascular structures |
Prone | On chest rolls; arm board parallel to the table with a sandbag under the proximal arm; shoulder 90 degrees abduction, elbow 90 degrees with the hand toward the floor; no traction | Better mobility and joint manipulation, better posterior access and more complete viewing |
Lateral decubitus | Beanbag and kidney rest; arm over a small bolster with the elbow hanging at 90 degrees | Easy posterior access and easier airway management |
After exsanguination, mark the lateral epicondyle, radial head, medial epicondyle, olecranon tip and the course of the ulnar nerve before distention.
Portals (Campbell)
Portal | Location | Structures at risk / notes |
|---|---|---|
Direct lateral (soft spot) | Center of the triangle formed by the lateral epicondyle, radial head and olecranon tip; just posterior and proximal to the radiocapitellar joint | Passes through anconeus; used for initial distention; posterior radiocapitellar joint and OCD lesions |
Proximal anterolateral | 2 cm proximal and 1 cm anterior to the lateral epicondyle | Safest from the radial nerve (mean 13.7 mm); medial instrumentation harder |
Midanterolateral (authors' preference) | Just proximal and about 1 cm anterior to the radiocapitellar joint | Radial nerve about 10.9 mm |
Distal anterolateral (traditional) | 2-3 cm distal and 1 cm anterior to the lateral epicondyle | Radial nerve about 7.2 mm (within 4 mm without distention); no longer used by the authors |
Anteromedial | 2 cm distal and 2 cm anterior to the medial epicondyle (medial end of the flexor crease) | Through pronator teres and FDS; cannula about 14 mm from the median nerve and 17 mm from the brachial artery with flexion and distention; medial antebrachial cutaneous nerve and basilic vein |
Proximal medial (supracondylar) | 2 cm proximal (and anterior) to the medial epicondyle, anterior to the intermuscular septum | Palpate the ulnar nerve first; keep the cannula on the anterior humerus, aimed at the radial head; better view of the whole joint than the anteromedial portal |
Posterolateral | 2-3 cm proximal to the olecranon tip, lateral to the triceps tendon along the supracondylar ridge (elbow 45-60 degrees flexion if supine) | Posterior antebrachial and lateral brachial cutaneous nerves; ulnar nerve 2.5 cm medial to the joint center |
Straight posterior | 2-3 cm proximal to the olecranon tip, through the triceps tendon (about 2 cm medial to the posterolateral portal) | Ulnar nerve if too medial; second posterior working portal |
Flexion to 90 degrees and joint distention move the radial nerve anteriorly away from lateral portals.
Incise skin only (No. 11 blade, pulling skin against the blade) and spread to the capsule with a hemostat to protect cutaneous nerves.
Retractor portals can be made 2-3 cm proximal to the corresponding arthroscopy portals.
Technique 57.32: Arthroscopic Elbow Examination (Campbell)
Anterior compartment
Insert an 18-gauge needle through the direct lateral portal toward the center of the joint (between olecranon, radial head and humerus), avoiding the antecubital soft tissues. Distend with about 20 mL of fluid; free backflow confirms intra-articular position. Distention displaces the neurovascular structures anteriorly.
With distention maintained, place a second needle at the midanterolateral portal and confirm backflow.
Incise the skin, spread bluntly with a mosquito hemostat to the fascia.
Pass the cannula and blunt trocar along the needle path, just proximal and anterior to the radiocapitellar joint; capture the lateral capsule, then increase the angle to about 70 degrees toward the joint center without skiving medially.
Insert the arthroscope: view the coronoid and trochlear ridge.
Examine the medial capsule: the anterior 10-15% of the anterior bundle of the UCL may be visible. With valgus stress at 30-90 degrees of flexion and the forearm supinated, medial opening more than 1 mm indicates laxity (Andrews and Baumgarten).
Withdraw to view the radial head and radioulnar joint with pronation and supination; inspect the capsular insertion and coronoid fossa for loose bodies, osteophytes and adhesions.
Establish the anteromedial (or proximal medial) portal by the Wissinger rod technique or with a spinal needle under direct vision, pushing the cannula with a twisting motion so it does not slide anteriorly over the capsule.
Switch the arthroscope medially to view the radiocapitellar and radioulnar joints and annular ligament; varus stress and extension expose the capitellum; inspect the lateral gutter (a synovial plica may be normal but can become thickened and symptomatic).
Direct lateral portal
Enter just posterior to the anterolateral portal with a blunt trocar.
Inspect the radial head-capitellum articulation, chondral and OCD lesions (probe through an accessory portal), and the olecranon-trochlear articulation, where small loose bodies hide. A normal bare area exists at the olecranon physeal scar.
Chondromalacia and osteophytes at the posteromedial olecranon tip indicate posteromedial impingement related to valgus laxity in throwers.
Posterior compartment
With the arthroscope in the direct lateral portal looking posteriorly, place a needle toward the olecranon fossa and create the posterolateral portal (or, when the direct lateral portal is the working portal for OCD, place it at or just above the olecranon tip in line with the radial gutter and use a 70-degree scope).
View the olecranon fossa and tip, posterior trochlea and the posterior band of the UCL. Loose bodies often gravitate posteriorly.
The ulnar nerve lies immediately superficial to a posteromedial olecranon osteophyte, separated only by capsule; take care with shavers and osteotomes posteromedially.
Add a straight posterior portal under vision if a second working portal is needed. In stiff elbows the direct posterior portal may be easier, and a 2.7-mm arthroscope helps.
Loose Bodies (Campbell)
Only about 38% of loose bodies are obvious on radiographs and 72% on CT arthrography.
Identify the source (capitellar osteochondral lesion, lateral compression osteochondral fracture, synovial chondromatosis).
Probe the coronoid, radial and olecranon fossae; release embedded fragments with a shaver or scissors. Move large fragments to an accessible area before retrieval.
Rehabilitation begins immediately with motion as pain and swelling allow.
References
Brolin TJ, Lamplot JD. Arthroscopy of the upper extremity. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 57, Technique 57.32.