2. POSTEROLATERAL EXTENSILE (COLD)
APPROACH TO THE DISTAL HUMERUS
The combined olecranon osteotomy, lateral para tricipital sparing, deltoid insertion splitting approach for
concomitant distal intra-articular and humeral shaft fractures.
Surgical technique:
• Carry the distal limb of the incision distally over the subcutaneous border of the ulna far enough to allow an olecranon osteotomy and
anterior transposition of the ulnar nerves.
• Extend the proximal limb of the incision to allow further
mobilization of the lateral head of the triceps muscle and
exposure of the deltoid muscle insertion on the proximal
humerus.
• Pay careful attention to isolate and protect the radial
nerve and profunda brachii artery
Deltoid
insertion split
Radial nerve
Olecranon
osteotomy
component
Lateral
intermuscular
septum
3. Posterolateral approach
to the elbow in contracture to triceps
When the triceps muscle has been contracted by fixed
extension of the elbow, free the aponeurosis
proximally to distally in a tongue-shaped flap and
retract it distally to its insertion
If the triceps muscle has not been contracted, divide
the muscle and aponeurosis longitudinally in the
midline and continue the dissection through the
periosteum of the humerus, through the joint capsule,
and along the lateral border of the olecranon
4. Begin the skin incision 10 cm proximal to the elbow on the posterolateral aspect of the arm and continue it
distally for 13 cm
Deepen the dissection through the fascia and expose the aponeurosis of the triceps as far distally as its insertion
on the olecranon.
When the triceps muscle has been contracted by fixed extension of the elbow, free the aponeurosis proximally to
distally in a tongue-shaped flap and retract it distally to its insertion; incise the remaining muscle fibers to the bone
in the midline.
If the triceps muscle has not been contracted, divide the muscle and aponeurosis longitudinally in the midline and
continue the dissection through the periosteum of the humerus, through the joint capsule, and along the lateral
border of the olecranon.
Elevate the periosteum together with the triceps muscle from the posterior surface of the distal humerus for 5 cm.
For wider exposure, continue the subperiosteal stripping on each side, releasing the muscular and capsular
attachments to the condyles and exposing the anterior surface,taking care not to injure the ulnar nerve.
5. Strip the periosteum from the bone as conservatively as possible because serious damage to the blood supply of
the bone causes osteonecrosis. The head of the radius lies in the distal end of the wound.
When the elbow has been fixed in complete extension with a contracted triceps muscle, it should be flexed to a
right angle for closure of the wound. Fill the distal part of the defect in the triceps tendon with the inverted-V–
shaped part of the triceps fascia and close the proximal part by suturing the remaining two margins of the triceps.
7. With the patient prone and the elbow flexed 90 degrees over a support and the forearm dependent, begin a
curved skin incision over the center of the posterior surface of the arm at the proximal limit of the triceps
tendon and extend it distally to the posterior aspect of the lateral epicondyle and farther distally and medially
to the posterior border of the ulna, 4 cm distal to the tip of the olecranon.
Dissect the medial skin flap far enough medially to expose the medial epicondyle, and gently elevate the lateral
skin flap a short distance; keep both skin flaps retracted with a single suture in each.
Identify the ulnar nerve proximally and 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.
To fashion a tongue of triceps tendon with its base attached to the olecranon, leaving a peripheral tendinous rim
attached to the triceps for later repair, begin sharp dissection at the medial surface of the proximal part of the
olecranon, extend it proximally along the triceps tendon, across laterally, and distally through the tendon to the
posterior aspect of the lateral epicondyle. From this point, deviate the incision distally and medially through
the triceps aponeurosis to separate the anconeus from the extensor carpi ulnaris.
8. Divide the posterior capsule in the same line.
Reflect the triceps tendon distally, dividing the muscle tissue with care in an oblique manner for minimal damage
to the deep part of the muscle; stay well clear of the radial nerve.
Reflect the anconeus and underlying capsule medially.
Behind the lateral epicondyle, the incision lies between the anconeus muscle and the common tendinous origin
of the forearm extensor muscles. To increase exposure, partially reflect from the humerus the common extensor
origin, the lateral collateral ligament, and the adjacent capsule.
Excellent exposure is easily achieved; increase the exposure by putting a varus strain on the elbow joint.
During closure, repair the triceps tendon, posterior capsule, and triceps aponeurosis with strong interrupted
sutures.
10. Expose the elbow posteriorly through an incision beginning 5 cm distal to the tip of the olecranon and extending
proximally medial to the midline of the arm to 10 to 12 cm above the olecranon tip.
Reflect the skin and subcutaneous tissue to either side carefully to expose the olecranon and triceps tendon.
Expose the distal humerus through a transolecranon approach.
Isolate the ulnar nerve and gently retract it from its bed with a Penrose drain or a moist tape.
Drill a hole from the tip of the olecranon down the medullary canal; then tap the hole with the tap to match a
large (6.5-mm) AO cancellous screw 8 to 10 cm in length.
Divide three fourths of the olecranon transversely with an osteotome or thin oscillating saw approximately 2 cm
from its tip. Fracture the last fourth of the osteotomy.
Reflect the olecranon and the attached triceps proximally to give excellent exposure of the posterior aspect of the
lower end of the humerus.
11. Alternatively, the osteotomy may be done in a chevron fashion to increase bone surface area for healing and to
control rotation.
At wound closure, reduce the proximal fragment and insert a cancellous screw using the previously drilled and
tapped hole in the medullary canal.
Drill a transverse hole in the ulna distal to the osteotomy site, pass a No. 20 wire through this hole around the
screw neck, and tighten it in a figure-of-eight manner. In our experience, posterior plate and screw fixation of
the osteotomy yields a higher union rate but the hardware often has to be removed after union because of its
subcutaneous location.
13. Place the patient in the lateral decubitus position or tilted 45 to 60 degrees with sandbags placed under the
back and hip. Place the limb across the chest.
Make a straight posterior incision in the midline of the limb, extending from 7 cm distal to the tip of the olecranon
to 9 cm proximal to it.
Identify the ulnar nerve proximally at the medial border of the medial head of the triceps and dissect it free
from its tunnel distally to its first motor branch.
In total joint arthroplasty, transplant the nerve anteriorly into the subcutaneous tissue.
Elevate the medial aspect of the triceps from the humerus, along the intermuscular septum, to the level
of the posterior capsule.
Incise the superficial fascia of the forearm distally for about 6 cm to the periosteum of the medial aspect of
the olecranon.
14. Carefully reflect as a single unit the periosteum and fascia medially to laterally. The medial part of the junction
between the triceps insertion and the superficial fascia and the periosteum of the ulna is the weakest portion of
the reflected tissue. Take care to maintain continuity of the triceps mechanism at this point; carefully dissect the
triceps tendon from the olecranon when the elbow is extended to 20 to 30 degrees to relieve tension on the tissues,
and then reflect the remaining portion of the triceps mechanism.
To expose the radial head, reflect the anconeus subperiosteally from the proximal ulna; the entire joint is now
widely exposed.
The posterior capsule usually is reflected with the triceps mechanism, and the tip of the olecranon may be
resected to expose the trochlea clearly.
Close the wound in layers and leave a drain in the wound. In total joint arthroplasty, dress the elbow with the
joint flexed about 60 degrees to avoid direct pressure on the wound by the olecranon tip.
