Bryan-Morrey (Triceps-Reflecting) Approach to the Elbow

What it exposes. The Bryan-Morrey approach gives an extensile, wide and reproducible exposure of the entire distal humerus, the olecranon fossa and the elbow joint while preserving the continuity of the extensor mechanism. By reflecting the triceps insertion together with the anconeus and the forearm fascia as a single sleeve from medial to lateral, it allows the elbow to be flexed and dislocated so the distal humerus can be delivered and prepared. Primary indications: - Total elbow arthroplasty (TEA) — the workhorse exposure for linked (semiconstrained) elbow replacement in rheumatoid, post-traumatic and degenerative arthritis

• Complex distal humeral fractures in the elderly — particularly the unreconstructable, low, comminuted fracture where primary TEA is planned
• Distal humeral non-union and reconstruction — requiring wide exposure of the articular surface and columns
• Post-traumatic reconstruction including malunion correction and salvage of failed internal fixation
• Extra-articular conditions needing broad posterior exposure — ankylosis release, excision of heterotopic bone, and resection of selected tumours of the distal humerus Contraindications: - Active infection of the elbow or overlying skin — an absolute contraindication to elective arthroplasty
• Previous ulnar nerve transposition with heavy scarring — a relative caution; the nerve must be identified and protected with particular care
• Compromised posterior skin — previous incisions, soft-tissue coverage issues or chronic lymphoedema increase wound breakdown risk
• High functional demand of the affected limb — a relative contraindication to TEA itself (not to the approach), as linked implants tolerate load poorly Position & landmarks. The patient is placed in the lateral decubitus position with the affected arm uppermost, supported over a padded bolster or arm board with the forearm hanging free, so the elbow can be flexed beyond 90 degrees and the field lies horizontal. The supine position with the arm across the chest is an alternative, useful when a simultaneous anterior procedure is needed or in patients who cannot tolerate the lateral position. A sterile tourniquet is applied high on the arm; the limb is exsanguinated and the whole elbow and forearm prepped to allow circumferential handling and full flexion. Bony landmarks are the olecranon tip (the central posterior landmark), the medial epicondyle (common flexor origin and cubital tunnel), the lateral epicondyle (centre of rotation of the elbow) and the radial head; the ulnar nerve is palpable in the groove behind the medial epicondyle and its course mapped before incision. The incision is a straight posterior (posteromedial) skin incision about 15 cm long, passing just medial to the olecranon tip (so the scar avoids the pressure-bearing point and the ulnar nerve is accessible) and curving onto the radial side of the proximal ulna distally. How it compares with the other elbow approaches:

Work down through the layers from a posterior incision: identify and protect the ulnar nerve, then reflect the triceps, anconeus and forearm fascia as one continuous sleeve from medial to lateral so the elbow can be flexed and dislocated to deliver the distal humerus.

The anatomy that makes the approach work. The distal humerus is triangular distally, forming medial and lateral columns that support the trochlea and capitellum, with the olecranon fossa posteriorly and the coronoid fossa anteriorly. The triceps inserts broadly onto the olecranon and posterior proximal ulna, blending distally with the forearm fascia; the anconeus arises from the lateral epicondyle and lies in continuity with the triceps along the lateral aspect of the olecranon. This muscular continuity is exactly what the approach exploits — triceps, anconeus and forearm fascia are swept off the bone together as one sleeve. The centre of rotation of the elbow lies at the centre of the capitellum and trochlea, passing through the lateral epicondyle, and is the landmark for orienting the humeral component of an elbow replacement.

The four structures that define a safe case:

Extensile options. The incision can be extended proximally along the posterior humerus by developing the interval between the long and lateral heads of the triceps; this is limited by the radial nerve, which crosses the posterior humeral shaft in the spiral groove roughly 10 cm proximal to the distal articular surface — stay strictly subperiosteal, and never place a large self-retaining retractor high on the shaft. It can be extended distally along the subcutaneous border of the ulna, developing the interval between flexor carpi ulnaris (ulnar nerve) medially and extensor carpi ulnaris (posterior interosseous nerve) laterally — continuous with the classic ulnar (Boyd) approach. The exposure can also be extended laterally into a Kocher-type interval for access to the radial head or the lateral collateral complex, but it cannot reach the anterior structures of the elbow without a separate anterior incision. Closure. Reattach the triceps with a number-5 nonabsorbable cruciate suture through drill holes in the olecranon, plus a side-to-side repair to the forearm fascia and anconeus; transpose the ulnar nerve anteriorly into a subcutaneous pocket in almost all arthroplasty cases; close the fascial and subcutaneous layers over a drain; and immobilise the elbow in extension in a splint to protect the triceps repair. Depending on the security of the repair, controlled active extension and flexion are begun under a defined protocol; resisted extension is avoided until the triceps repair has healed. Approach-related complications:

Post-arthroplasty complications (approach-relevant):

• Total elbow arthroplasty — the linked semiconstrained prosthesis is implanted through this exposure; release of the lateral collateral complex to deliver the humerus is acceptable because a linked implant provides its own stability.
• Complex distal humeral fracture management — including primary total elbow arthroplasty for the unreconstructable, low, comminuted fracture in the elderly.
• Distal humeral non-union and malunion — wide bilateral-column access for revision fixation or reconstruction.
• Ankylosis release and excision of heterotopic bone — extensile access to the anterior and posterior elbow.
• Resection of selected distal humeral tumours — where a wide posterior exposure is sufficient.

Guidelines, Registries & Global Practice The Bryan-Morrey triceps-reflecting approach is a universally taught exposure used in elbow arthroplasty and distal humeral reconstruction across all examination systems. The technical principles converge globally: ulnar-nerve identification and protection, medial-to-lateral reflection of the extensor mechanism in continuity, and secure transosseous reattachment. Side-by-side principles (where guidance converges): | Body | Position on elbow arthroplasty exposure |

|------|-----------------------------------------| | AAOS (US) | Linked semiconstrained implants are the standard for inflammatory and complex post-traumatic arthritis; meticulous extensor-mechanism handling and secure reattachment are emphasised to limit triceps insufficiency | | BOA / BESS (UK) | TEA reserved for low-demand patients with inflammatory or post-traumatic arthritis; emphasise ulnar-nerve management, wound protection and lifelong activity restrictions | | EFORT / European consensus | A triceps-reflecting or triceps-sparing posterior exposure is standard for linked TEA; the linked implant provides stability after lateral soft-tissue release | Registry and outcome evidence: - National arthroplasty registries (for example the National Joint Registry, the Australian AOANJRR and the Swedish Elbow Arthroplasty Register) report that rheumatoid arthritis remains a leading indication for TEA and that revision is most commonly for aseptic loosening, infection, instability and component failure; triceps insufficiency is a recognised but less frequent cause of revision.

• Long-term cohort data show that the linked prosthesis implanted through a triceps-reflecting exposure gives durable pain relief and a functional arc in appropriately selected, low-demand patients. Global practice variation. In well-resourced settings a linked semiconstrained prosthesis implanted through a formal Bryan-Morrey exposure is standard. In resource-limited settings, distal humeral fractures and reconstructions are more often managed with internal fixation through a posterior approach, and TEA is reserved for a small selected group; the surgical anatomy and the principles of ulnar-nerve and extensor-mechanism handling remain identical. Consent (globally applicable). Discuss triceps insufficiency and the possibility of further surgery for extensor-mechanism failure, ulnar nerve symptoms (numbness or weakness), wound problems and infection, stiffness, implant loosening and the lifelong restriction on heavy or repetitive loading of the operated arm.