Biopsy Anatomical Approach

Region specific approaches



- want to traverse one muscle / one compartment

- keep away from NV bundle

- as a rule perform open biopsy through compartment the tumour is in

- this is the compartment that will require surgical removal in wide excision

- direct approach without going through muscle if possible i.e. tibia, distal ulna


Lower Limb




1.  Lateral compartment ST tumour

- lateral approach

- through ITB

- through vastus lateralis / anterior to lateral intermuscular septum


2.  Medial compartment ST tumour

- medial approach

- through gracilis

- keep away from NV bundle


3.  Posterior compartment ST tumour

- posterior approach / transmuscular




1.  Femoral head / neck

- depends if lesion benign or malignant

- tdranstrochanteric: for completely contained osseous tumour

- Watson-Jones: however if is malignant will consign patient to extra-articular resection


Proximal Femur Tumour


Proximal Femur Bony Tumour0001Proximal Femur Bony Tumour0002


2.  Subtrochanteric

- remember lesions here in elderly may be chondrosarcoma from enchondroma

- lateral approach


Tumour Subtrochanteric Femur


3.  Femoral Shaft

- lateral through vastus lateralis

- anterior cortical window


Femoral Shaft Bony Lesion


4.  Condyles

- medial or lateral approach

- incision through medial or lateral vastus


Bony Lesion Lateral Distal Femur


Popliteal fossa


Popliteal fossa / parosteal OS

- posterior approach

- go through hamstrings or gastrocnemius

- depending on whether lesion medial or lateral


Parosteal Osteosarcoma




Direct anterior


Patella Lytic Lesion




1.  Medial plateau proximal tibial bony tumour

- direct medial approach directly onto bone


Proximal Tibial Lytic Epiphyseal Lesion XrayTibial Shaft Lesion


2.  Lateral plateau proximal tibial bony tumour

- through biceps femoris

- avoid CPN


3.  Tibial shaft

- through tibialis anterior


4.  Medial malleolus

- direct medial approach


5.  Posterior distal tibia

- posterolateral approach




1.  Fibular head

- incision posterior fibular head

- expose and protect CPN


2.  Fibular shaft

A.  Direct lateral

- straight down to bone

- fibula / peroneals and nerve get taken in salvage

B.  Posterolateral approach


3.  Lateral malleolus

- direct lateral approach


Distal Fibular Lucent Lesion




1.  Proximal posterior compartment ST tumour

- medial to tibia

- preserve anterolateral compartment


2.  Proximal anterolateral compartment ST tumour

- direct approach through tibialis anterior

- will likely not be able to preserve CPN




1.  Head and neck

- medial approach between T anterior and T posterior

- may need medial malleolar osteotomy


2.  Body

- Ollier's approach




Bony tumour

- direct lateral

- avoid medial NV bundles


Calcaneal Bony Lesion CTCalcaneal Bony Lesion MRI




1.  Navicular / Medial cuneiform

- direct medial


2.  Cuboid

- direct lateral


3.  Intermediate cuneiform

- between EHL and EDC but away from dorsalis pedis


4.  Lateral cuneiform

- lateral to EDC


5.  Metatarsals / phalangeals

- dorsal approach


Metatarsal tumour


6.  Soft tissue tumour

- medial or lateral as required


Soft tissue sarcoma medial foot




Iliac crest

- definitive surgery via ilioinguinal approach

- best to use iliac crest aspect of this approach

- can go medial or lateral to crest


Pelvis Soft Tissue Sarcoma


Anterior column

- Watson - Jones through G medius

- avoid femoral NV bundle


Posterior column

- Kocher - Lagenbeck through G maximus



- Pfannenstiel approach



- lithotomy position

- detach adductor and hamstrings




Direct posterior approach


Upper Limb




1.  Proximal humeral bony tumour

- direct lateral

- through deltoid muscle

- never deltopectoral (condemns patient to forequarter amputation)


2.  Shaft

- modified Henry


3.  Distal humerus bony tumour

- lateral longitudinal to capitellum

- medial approach to trochlea




1.  Proximal bony tumour

- protect radial nerve at all times


A.   Radial head: Kocher approach / through anconeus

B.   Proximal third:  Henry approach / take off supinator

C.   Middle third: Henry approach / take off pronator teres

D.   Distal third: Henry approach / take off pronator quadratus


2.  Distal radius

- dorsal approach as salvage is always wrist fusion

- through second compartment / sacrificeable


Lesion distal radius


Wrist / Hand


1.  Carpus

- dorsal approach


2.  Metacarpal / phalanges

- dorsal approach

- avoid volar to preserve NV bundle


Sarcoma Finger




1.  Proximal ulna bony tumour

- direct subcutaneous approach

- away from ulna nerve


2.  Coronoid

- posterior approach with window for biopsy


3.  Distal ulna bony tumour

- direct lateral approach between FCU and ECU

- down onto subcutaneous surface of ulna





- direct subcutaneous




Acromion - deltoid split

Spine - transverse approach

Body - Judet posterior approach

Glenoid - posterior approach, through T major

Coracoid - deltopectoral approach




C1-2 bony tumour

- anterior retropharyngeal approach

- anterior to SCM

- resect submandibular gland and ligate duct

- CN XII superiorly

- between carotid sheath and larynx

- biopsy through longus colli



- Smith-Robinson approach

- vertical incision

- split longus colli


T2 - T12

- posterior approach and transpedicular

- open or CT guided



- anterior retroperitoneal approach