This document discusses various surgical approaches for the distal humerus. It begins by outlining key considerations for choosing an approach, such as the patient's age and fracture pattern. It then describes the posterior, olecranon osteotomy, para-tricipital, triceps-splitting, triceps V-Y splitting, triceps reflecting postero-medial, and triceps-reflecting anconeus pedicle approaches. For each approach, the document outlines the technique, pearls, perils, and indications. The posterior and olecranon osteotomy approaches provide the best exposure of the articular surface but carry risks of hardware complications, while the other approaches aim to avoid these

1. APPROACHES TO THE
DISTAL HUMERUS
DR.S.SENTHIL SAILESH
SEN O R A STA T PRO FESSO R
I
SSI
N
I STI
N TUTE O F O RTHO PA CS & TRA A LO G Y
EDI
UM TO
M DRA M CA CO LLEG E & RG G G H, CHEN A
A
S EDI L
N I

2. GREETINGS FROM MMC, CHENNAI

5. CHOICE OF EXPOSURE DETERMINANTS
• Age (paediatric / adult)
• Fracture pattern (articular comminution)
• Total Elbow Arthroplasty?
• Associated injuries ( Neurovascular injury)

6. APPLIED ANATOMY

7. OSSEOUS ANATOMY
POSTERIOR ASPECT
ANTERIOR ASPECT

8. • The medial and lateral columns support
the articular segment.
• The distal most part of the lateral column
is the capitellum and the distalmost part of
the medial column is the nonarticular
medial epicondyle.
• The trochlea is the medial part of the
articular segment and is intermediate in
position between the capitellum and
medial epicondyle.
• The articular segment functions
architecturally as a tie arch.

9. SURGICAL ANATOMY
Posterior Structures :
• Skin & Subcutaneous
Tissue
• Triceps Muscle With
Aponeurosis
• Ulnar Nerve – Behind
Medial Epicondyle
• Posterior Capsule

10. SURGICAL ANATOMY
Anterior Structures :
• Skin, Subcutaneous Tissue With Superficial
Veins
• Layer 1: Biceps With Bicipital Aponeurosis
• Layer 2: Median Nerve With Brachial
Vessels
• Layer 3: Brachialis, Brachio-radialis, Radial
Nerve
• Layer 4: Anterior Capsule

11. SURGICAL ANATOMY
LATERAL STRUCTURES:
• LCL
• Anconeus
• Extensors Of The Wrist

12. SURGICAL
ANATOMY
MEDIAL STRUCTURES:
•MCL
•Flexor Group Of Muscles
•Ulnar Nerve passes from behind
the medial epicondyle and
distally between the FCU and
FDP

13. WHY POSTERIOR APPROACH?
• Most orthopaedic procedures (m.c: fracture fixation) in and around the
distal procedures predominantly done through posterior approaches
owing to:
• SAFER - Less chance of damage to vital structures (comparing anterior)
• EASIER - Posterior structures are aponeurotic and dissection is easier with less
bleeding
• CLEARER – Better visualisation of articular surface
• Very few indications where other approaches may be necessary:
• Anterior: excision of myositic mass, fractures associated with vascular injuy
• Medial & Lateral approaches – partially articular/condylar fractures

14. POSTERIOR APPROACHES TO THE DISTAL
HUMERUS

15. POSTERIOR APPROACHES TO
DISTAL HUMERUS

16. PATIENT POSITIONING
LATERAL DECUBITUS
POSITION
(s wim m e r’s p o s itio n)
•Arm hanging over a post
•Sterile tourniquet if desired
•Very convenient for the surgeon
•Bit less convenient for the anaesthetist
especially if the patient has to be intubated
halfway during surgery following regional

17. COMMON STEPS FOR ALL POSTERIOR
APPROACHES
1) Longitudinal midline skin incision over the posterior
aspect of the elbow
2) Raising of subcutaneous flaps on either side to
expose the tricipital aponeurosis
3) Isolation of ulnar nerve

18. 1) SKIN INCISION
• Beginning atleast 5cm proximal to the
tip of the olecranon, curving slightly
laterally at the tip, then returning to the
midline and extending 5 cm distal to
the tip of the olecranon

19. 2) RAISING OF SUBCUTANEOUS FLAPS

20. 3) ISOLATION OF ULNAR NERVE
• Identification of the ulnar nerve first done proximally
where the nerve pierces the septum
• Release it from its tunnel by dividing the arcuate
ligament that passes between the two heads of the
flexor carpi ulnaris muscle
• Gently retract it with a rubber sling or a penrose
drain
• Extensive dissection of the nerve is inadvisable, as
this increases the risk of tethering and damage to its
vascularity.

21. ISOLATION OF ULNAR NERVE

22. OLECRANON
OSTEOTOMY
APPROACH

23. OLECRANON
OSTEOTOMY
APPROACH
TRANSVERSE
CHEVR
ON
• Technically easier to do
• Technically more difficult
• 30% incidence of
nonunion (Gainor et al,
(1995) j s o uth o rtho p
a s s o c 4:263)
• More stable
• Olecranon implant removal may be necessary
due to irritation
• Lesser incidence of nonunion
• Olecranon implant removal may be necessary
due to irritation

24. PLAN THE FIXATION OPTION BEFORE THE
OSTEOTOMY

25. OLECRANON
OSTEOTOMY
APPROACH
• If planning to use a screw for fixation (most common) of the
osteotomy, pre-drill and tap for screw placement down the ulna
canal
• Expose the tip by sharp dissection of soft tissues to see the bone

26. OLECRANON
OSTEOTOMY
APPROACH
• A gauze swab is inserted from medial to lateral through the joint
across the notch to protect the articular surfaces
• The line of osteotomy (“V” shaped) is marked with a pen or a cautery

27. OLECRANON
OSTEOTOMY
APPROACH
• Small, thin oscillating saw
used to cut 95% of the
osteotomy along the line of
marking
• Alternatively a 2mm drill bit
can be used for multiple
drilling and joining them

28. OLECRANON
OSTEOTOMY
APPROACH
• Osteotome used to crack
and complete it

29. OLECRANON
OSTEOTOMY
APPROACH
Exposure of the distal
humerus especially the
inter condylar area is
excellent after an
osteotomy approach

30. OSTEOTOMY FIXATION OPTIONS

31. OSTEOTOMY FIXATION
SINGLE SCREW WITH TBW TECHNIQUE:
1) Expose the tip by sharp dissection of soft tissues to
see the bone
2) Pre-drilling & tapping should be done prior to
osteotomy
3) Beware of the varus bow of the proximal ulna, which
may cause a malreduction of the tip of the olecranon
after screw placement
4) We prefer using a 6.5mm cannulated cancellous screw
of length 60-70mm
5) Large-diameter screw threads may engage ulnar
diaphysis (small medullary canal) prior to full seating of
screw head, “Bite” of screw may be strong without full
compression
Hak and Golladay,
6) A Tension band wiring done before full tightening of the JAAOS, 8:266-75, 2000

32. Length of screw may be important
to resist toggling and loss of
reduction

33. OSTEOTOMY FIXATION
TENSION BAND TECHNIQUE
WITH K-WIRES:
• Easy to place
• May be less stable than
independent lag screw or
plate
• Implant irritation is a problem
Mullett et al (2000) I
njury 31:427,
Prayson et al (1997) J O rtho p Tra um a 11:565
Engage anterior ulnar cortex
here with wires to improve
fixation stability/strength

34. OSTEOTOMY FIXATION
DORSAL PLATING
• Low profile periarticular implants now available
• When using this method the plate is prefixed to the
olecranon and then removed before conducting
the osteotomy.
• Axial screw through plate can be used
Hewin et al (2007) J O rtho p Tra um a 21:58
Tejwani et al (2002) Bull Ho s p Jt Dis 61:27

35. THE OSTEOTOMY APPROACH
PEARLS
PERILS
•Provides The Best Visualization Of
The Distal Humerus Articular Surface
•Nonunion, malunion at the osteotomy site
•Hardware irritation due to osteotomy
fixation

36. THE OSTEOTOMY APPROACH
INDICATIONS
CONTRAINDICATIONS (RELATIVE)
•Although all articular fractures are best
visualised by this approach, the
AO/OTA type C3 fracture is best
managed by this approach
•Very anterior articular fractures (AO/OTA
type B3), which can be difficult to visualize
through an osteotomy
• Total elbow arthroplasty

37. PARA-TRICIPITAL (TRICEPS
PRESERVING) APPROACH
[ALONSO-LLAMES ]

38. PARA-TRICIPITAL (TRICEPS
PRESERVING) APPROACH
[ALONSO-LLAMES ]
• The medial and lateral borders of the triceps are incised or alternatively
erased from their respective intermuscular septae and elevated from
the posterior aspect of the distal humerus.
• The distal humerus can be button holed medially or laterally to gain
access to the proximal forearm

39. Full-thickness fasciocutaneous
flaps are elevated
The medial and lateral borders of the triceps are incised and
elevated from the posterior aspect of the distal humerus

40. PARA-TRICIPITAL (TRICEPS
PRESERVING) APPROACH
[ALONSO-LLAMES ]
PEARLS
•Avoidance of an olecranon osteotomy,
therefore the risks of nonunion and
symptomatic olecranon hardware are
avoided
•The triceps tendon insertion is not
disrupted, allowing early active range of
motion
PERILS
•Limited visualization of the
articular surface of the distal
humerus
• The approach is usually
inadequate for fixation of type c3
fractures.
•Preserves the innervation and blood
supply of the anconeus muscle, which
provides dynamic posterolateral stability to
the elbow.
•If required,The several advantages of this approach certainly indicate its use for
can be converted into an
AO/OTA
olecranon osteotomytypes A2, A3, B1, B2, and possibly C1 and C2 fractures

41. TRICEPS SPLITTING
APPROACHES
• Developed to attempt to overcome the morbidity & the risk of hardware
complications associated with the use of olecranon osteotomy
• Although some authors have reported a better functional outcome following the
use of a triceps-splitting approach compared with olecranon osteotomy, others
have reported the converse
• The intact trochlear notch may be used as a template, against which the
reduction of the trochlea can be assessed
• Either internal fixation or total elbow arthroplasty (TER) can be performed but
internal fixation is technically difficult.

43. TRICEPS- midline SPLITTING
APPR
OACH (CAMPBELL)
• Splitting the triceps longitudinally through the
midline of the triceps aponeurosis down to
bone followed by sub-periosteal elevation of
the triceps medially and laterally.
• Triceps split extends distally onto the
olecranon and proximally, the radial nerve
limits the extent of dissection.

44. TRICEPS- midline SPLITTING
APPR
OACH (CAMPBELL)
• In order to improve triceps healing, GSCHWEND et al modified
the approach to incorporate a flake of olecranon bone, to be
later fixed
• Mckee et al compared the extensor mechanism strength of
patients treated with an olecranon osteotomy versus a triceps
splitting approach and found no statistical significant difference,
concluding that both approaches are effective

46. TRICEPS- midline SPLITTING
APPR
OACH (CAMPBELL)
PEARLS
•Relative technical ease
•The ability to convert from open
reduction and internal fixation to
total elbow arthroplasty with few
consequences
PERILS
•Limited visibility of the articular
surface
•Disruption of the extensor
mechanism requiring
postoperative protection and the
risk of triceps dehiscence

47. Triceps V-Y splitting approach
(campbell – van gorder)
• This Approach Was Described By Campbell, And Later Modified By Van Gorder
And Wadsworth
• The deep head of the triceps is divided in its midline for a length of about
8 cm.
• The flap is distally based and should extend to the outer part of the
humeral condyles in order to allow an adequate approach . Sufficient
tendon tissue at both sides of the flap must be preserved to obtain a good
repair.
• Thickness of flap: 1/3rd of the muscle thickness proximally, 2/3rd in the
middle, full thickness distally
• To perform a V-Y advancement the triceps is sutured in the midline for the

48. Triceps V-Y splitting approach
(campbell – van gorder)

49. Triceps V-Y splitting approach
(campbell – van gorder)
PEARLS
PERILS
•Avoidance of an olecranon osteotomy,
therefore the risks of nonunion and
symptomatic olecranon hardware are
avoided
•Limited visibility of the articular
surface
•Lengthening of the extensor
mechanism can be done if required
•Higher rate of infection
•Risk of triceps necrosis
This approach is indicated for
•Total Elbow arthroplasty
•ORIF of distal humerus fractures when there is an associated complete or
high grade partial triceps tendon laceration.
•Chronic Elbow dislocations

51. Triceps reflecting postero-medial
approach (Bryan-Morrey
Approach)
• Medial edge of triceps and distal
forearm fascia elevated as single unit
off olecranon and reflected laterally
along with a thin wafer of bone to
facilitate bone-to-bone healing
• Resection of extra-articular tip of
olecranon
• Now the entire triceps muscle with the
posterior capsule is reflected upwards
and laterally, and the elbow is flexed to
expose the joint.

52. Triceps reflecting postero-medial
approach (Bryan-Morrey
Approach)

53. Triceps reflecting postero-medial
approach (Bryan-Morrey
Approach)
PEARLS
•Avoidance of an olecranon
osteotomy & its complications
PERILS
•Risk of triceps pull out if careful
transosseous resuturing is not done
properly or if the tendon repair fails or the
tissue quality is poor, as in rheumatoid
patients.
•Delayed active mobilisation
This approach is best suited for unrepairable distal humerus fractures
in which primary elbow arthroplasty is planned.

54. Triceps-Reflecting Anconeus
Pedicle (TRAP) Approach
• The approach begins laterally at the kocher
interval, between the extensor carpi ulnaris
and the anconeus.
• TRAP approach incorporates modified
kocker's approach on lateral side and a
triceps reflecting approach on the medial
side. both approaches converge distally at
the tip of the anconeus
Triceps
insertio
n
Ancone
us

55. Triceps-Reflecting Anconeus
Pedicle (TRAP) Approach
• The anconeus-triceps flap was detached from its
distal attachment (5-7 cm from the tip of
olecranon) and dissected off the lateral side of
the elbow and proximal ulna, preserving the
integrity of the lateral collateral ligament
complex, including annular ligament
• The flap is reflected to expose the lower end of
the humerus

56. Triceps-Reflecting Anconeus
Pedicle (TRAP) Approach
• The dissection started distally and working proximally.
• The posterior capsule incised and the dissection was
carried out proximally between the triceps and posterior
humerus. the fibers of the deep head of the triceps
were dissected off the posterior humerus by sharp and
blunt dissection
• Fixation of the fracture proceeded
• The triceps was reattached with interrupted number-2
braided polyester sutures, with use of drill-holes
through bone in the region of the olecranon

57. THE TRAP APPROACH
PEARLS
•Avoidance of an olecranon osteotomy & its
complications
•Protects the neurovascular supply to the
anconeus muscle
PERILS
•Risk of triceps dehiscence
•Possible extensor
weakness

58. DON’T FORGET THE RADIAL NERVE…
• Dissect and protect the radial nerve when
the exposure is extended on the lateral
aspect for fixing the lateral column
• Gerwin et al : if further proximal exposure is
required for associated fractures of the
humeral shaft, the lateral side of the
approach can be converted into the Gerwin
approach, which involves reflection of the
triceps muscle unit from lateral to medial to
expose 95% of the posterior humeral shaft
and the radial nerve

60. MEDIAL & LATERAL APPROACHES
• LATERAL - Extended Kocher Approach
• MEDIAL – Campbell’s medial approach

61. CAMPBELL’S MEDIAL APPROACH
PLA E O F DI
N
SSECTI N
O :
•PRO XI A
M LLY:
The internervous plane lies between
the brachialis muscle
(musculocutaneous nerve) and the
triceps muscle (radial nerve)
•DI
STA
LLY
The plane lies between the brachialis
muscle (musculocutaneous nerve) and
the pronator teres muscle

62. TECHN QU
I
E incision centering joint on
• 10 cm “J” shaped
medial aspect
• Identify the ulnar nerve in the groove behind
the medial condyle of the humerus, and
isolate the nerve along the length of the
incision
• Retract the skin anteriorly with the fascia to
uncover the common origin of the superficial
flexor muscles from the medial epicondyle
• Enter the interval between the pronator teres
and the brachialis. retract the pronator teres

63. • Make sure that the ulnar nerve is retracted
inferiorly, osteotomize the medial epicondyle
(pre drilling & tapping can be done) and
retract it with its attached flexors.
• Superiorly, continue the dissection between
the brachialis, retracting it anteriorly, and the
triceps, retracting it posteriorly
• The medial side of the joint now can be
seen. incise the capsule and the medial
collateral ligament to expose the joint

64. CAMPBELL’S MEDIAL APPROACH

65. THE MEDIAL APPROACH
PEARLS
PERILS
•Avoidance of disruption of extensor
mechanism
•Inadequate visualisation of
inter condylar region
•No risk of postoperative triceps pull out,
dehiscence, need for immobilisation
•Cannot approach the lateral
aspect
I DI TI N :
N CA O S
•Removal of loose bodies
•Fixation of fractures of the coronoid process of the ulna
•Fixation of fractures of the medial humeral condyle and epicondyle

66. EXTENDED KOCHER APPROACH
• Utilizes the intermuscular interval between the anconeus and the
extensor carpi ulnaris.
TECHN QUE :
I
• The anconeus and extensor carpi ulnaris muscles are identified by palpation. A thin
strip of fat can almost always be observed in the interval between these muscles
• The muscle fibres of the anconeus and the extensor carpi ulnaris muscles tend to
blend together towards the insertion, so it is easier to develop the interval distally and
then progress proximally.
• The deep fascia is then opened , the anconeus is dissected posteriorly
• The lateral elbow capsule with the annular ligament is identified and incised
longitudinally anterior to the lateral ulnar collateral ligament

67. IDENTIFYING THE KOCHER’S INTERVAL
Ancone
us
EC
U

68. EXTENDED THE KOCHER’S INTERVAL
PROXIMALLY TO EXPOSE THE LATERAL
ASPECT OF DISTAL HMERUS

69. THE EXTENDED KOCHER’S
APPROACH
PEARLS
PERILS
•Avoidance of disruption of extensor
mechanism
•Inadequate visualisation of
inter condylar region
•No risk of postoperative triceps pull out,
dehiscence, need for immobilisation
•Cannot approach the medial
aspect of distal humerus
I DI TI N :
N CA O S
•Fixation of lateral condylar fractures
•Partially articular fractures
•Repair or reconstruction of the lateral
ligaments.

70. TAKE HOME MESSAGE
• Choose the appropriate approach
• Safeguard the ulnar & radial nerve
• Respect the soft tissues
• Get familiarized with a particular approach

73. PR
OGR
AMME SCHEDULE