Single posterior incision | Ulnar nerve at risk | Choose the deep window after the flaps
- Single posterior skin incision placed slightly lateral to the olecranon tip keeps the scar off the pressure point and protects the medial antebrachial cutaneous nerve branches
- Full-thickness fasciocutaneous flaps raised medially and laterally expose both the medial and lateral columns
- Ulnar nerve must be identified on the medial side and protected throughout - the single most important structure at risk
- The deep window is chosen AFTER the flaps: paratricipital, triceps-splitting, olecranon osteotomy, or triceps-reflecting
- Olecranon osteotomy gives the best intra-articular visualisation of the distal humerus for complex fractures
- Radial nerve is at risk with proximal extension along the posterior humeral shaft (spiral groove)
When & Why
What it exposes. The extensile posterior (global) approach is the most versatile exposure of the elbow. A single posterior skin incision with full-thickness fasciocutaneous flaps gives access to the entire extensor mechanism and both columns of the distal humerus, and it can be converted into any of four recognised deep windows depending on the procedure. It avoids crossing the anterior neurovascular bundle and respects the patient's soft-tissue envelope. Primary indications. - Complex intra-articular distal humeral fractures (AO/OTA type 13C) requiring direct visualisation and anatomic articular reconstruction
- Distal humeral non-union and malunion revision
- Total elbow arthroplasty (inflammatory arthritis, post-traumatic arthritis, and as primary treatment for unreconstructable comminuted fractures in low-demand elderly patients)
- Post-traumatic elbow stiffness or ankylosis requiring posterior capsular release and excision of heterotopic ossification
- Tumour resection around the distal humerus and elbow
- Complex revision elbow surgery and selected septic arthritis debridement Why this approach is chosen. The posterior (global) approach leaves the surgeon free to expose the articular surface (via olecranon osteotomy) or to spare the extensor mechanism entirely (via a paratricipital or triceps-reflecting window) - a decision that should be made pre-operatively. It gives direct access to both columns for orthogonal or parallel dual plating of 13C fractures, and the olecranon osteotomy window offers the best intra-articular visualisation of any elbow approach. Contraindications and relative cautions. - Compromised posterior soft-tissue envelope (blistering, abrasion, previous flaps, burns) - the thin skin over the olecranon tolerates poorly; consider delay or an alternative route
- Prior ulnar nerve transposition alters the medial anatomy and must be identified pre-operatively to avoid injury
- Active infection over the incision (consider staged or alternative management)
- An olecranon osteotomy is relatively avoided when future total elbow arthroplasty is anticipated (it violates the olecranon and complicates component seating) and in children with open olecranon physes Alternative approaches. Anterolateral (Kaplan) or lateral (Kocher) for the lateral column, radial head, capitellum and lateral collateral ligament complex; anterior (antecubital) for distal biceps repair, anterior capsule, brachial artery and median nerve; medial for the ulnar nerve, medial collateral ligament and coronoid; and paratricipital windows alone (without the full extensile incision) for isolated simple extra-articular pathology. ### Position and Landmarks Position. Lateral decubitus with the affected side up over a padded bolster is the workhorse position; it allows free elbow flexion and extension, good access for olecranon osteotomy and dual-column plating, and avoids the airway concerns of the prone position. Prone with the arm abducted on a radiolucent arm board is chosen by some trauma surgeons for combined complex posterior work (and bilateral access). Supine with the arm across the chest and a sandbag under the ipsilateral scapula is useful when an anterior procedure may also be required, though the limb is less stable. Before draping: confirm the planned deep window pre-operatively (it dictates exposure and position); pad all pressure points meticulously; apply an upper-arm tourniquet if the soft-tissue envelope permits (many surgeons prefer tourniquet-free to reduce swelling); confirm a radiolucent table with C-arm access; and prep the limb to the shoulder and drape freely so the elbow can be flexed and extended during the case.
There is no single correct position. Lateral decubitus is the most commonly cited position because it gives free access to the elbow, allows flexion and extension to judge reduction, and avoids the airway concerns of prone. State the position you would use and justify it: lateral for most distal humeral ORIF and TEA, prone for combined complex posterior work.
Surface landmarks. The olecranon tip is the central subcutaneous prominence; the incision passes just lateral to it. The medial epicondyle marks the medial column and the roof of the cubital tunnel (ulnar nerve); the lateral epicondyle marks the lateral column and the origin of the common extensor origin and lateral collateral ligament complex; the radial head is palpable just distal to the lateral epicondyle, rotating with pronation and supination. The ulnar nerve is palpable in the groove behind the medial epicondyle and should be mapped before incision. Incision planning. A longitudinal posterior incision beginning 4 to 6 cm proximal to the olecranon tip, passing just lateral (radial side) to the olecranon tip, and continuing 4 to 6 cm distal onto the subcutaneous border of the ulna. Biasing the incision lateral to the tip keeps the suture line off the pressure point of the olecranon and protects the branches of the medial antebrachial cutaneous nerve, reducing painful neuroma. Straight midline incisions are also used, but they sit directly on the olecranon and are more prone to wound problems.
The Exposure
The extensile posterior approach works in two phases: first a common superficial phase - one posterior incision, full-thickness flaps, and identification of the ulnar nerve - and second a deep window chosen from four options according to the procedure and the articular exposure required. The whole exposure respects one principle: keep the flaps full-thickness and protect the ulnar nerve at every step.
Intra-operative photograph of the extensile posterior approach to the elbow: a single longitudinal posterior incision placed just lateral to the olecranon tip, full-thickness fasciocutaneous flaps retracted medially and laterally to expose the triceps and both distal humeral columns, with a vessel loop around the mobilised ulnar nerve behind the medial epicondyle.
Context: A verified image is being sourced for this exposure.
| Layer | Muscle / structure | Nerve supply | Role in the approach |
|---|---|---|---|
| Superficial | Triceps brachii | Radial nerve | The extensor mechanism - central to the deep window choice |
| Posterior floor | Brachialis (posterior part) | Musculocutaneous nerve | Forms the floor laterally; protects anterior structures |
| Medial column | Flexor-pronator mass from medial epicondyle | Median and ulnar nerves | Reflected for medial column access |
| Lateral column | Common extensor origin from lateral epicondyle | Radial nerve (posterior interosseous) | Reflected for lateral column access |
| Distal extension | Anconeus | Radial nerve | Key landmark on the lateral side; preserved in anconeus-sparing variants |
The internervous plane. There is no single internervous plane at the skin or flap level - the approach is developed in an extensile fashion down to the triceps, after which the chosen deep window determines the plane. The paratricipital window is the only one that exploits a true internervous dissection: laterally between triceps (radial nerve) and brachialis (musculocutaneous nerve), and medially between triceps (radial nerve) and the flexor-pronator mass (median and ulnar nerves). The olecranon osteotomy and triceps-splitting windows violate the radial-nerve-supplied triceps, but do so in its internervous substance or at an osteotomy; the triceps-reflecting window elevates the muscle extraperiosteally.
The extensile posterior approach itself has no classical internervous plane at the skin or flap level. The internervous plane is a property of the deep window: the paratricipital window exploits triceps (radial) versus brachialis (musculocutaneous) laterally. State clearly which window you are using before describing "the plane".
The Common Superficial Exposure
Common superficial exposure - the same first four steps for every deep window
- A longitudinal posterior incision, 4 to 6 cm proximal to the olecranon tip, passing just lateral to the tip, continuing 4 to 6 cm onto the subcutaneous border of the ulna.
- Biasing lateral to the tip keeps the scar off the olecranon pressure point and protects the medial antebrachial cutaneous nerve branches.
- Incise skin and subcutaneous tissue together in a single layer down to the fascia over the triceps.
- Raise full-thickness fasciocutaneous flaps medially and laterally off the triceps fascia, exposing the triceps from the humerus to its olecranon insertion and both intermuscular septa.
- The flaps must be full-thickness to preserve the dermal and subcutaneous blood supply - thin flaps necrose over the olecranon.
- Identify the ulnar nerve behind the medial epicondyle, in the cubital tunnel.
- Mobilise it gently and protect it with a vessel loop throughout; preserve the vasa nervorum and the first motor branches to flexor carpi ulnaris.
- With the flaps raised and the ulnar nerve protected, choose the deep window based on the procedure and the articular exposure required: paratricipital, triceps-splitting, olecranon osteotomy, or triceps-reflecting (see the selection guide and the window descriptions below).
Choosing the Deep Window The defining decision of this approach: after raising the flaps and identifying the ulnar nerve, choose the deep window based on the procedure and the articular exposure required.
| Deep window | What it does to the triceps | Best for | Key limitation |
|---|---|---|---|
| Paratricipital (Alonso-Llames) | Left intact; swept off both septa | TEA, simple or extra-articular fractures, children | Poor articular view - not for complex 13C fractures |
| Olecranon osteotomy | Apex-distal chevron; reflected proximally with the fragment | Complex intra-articular 13C fractures, non-unions | Adds an osteotomy that must heal; avoided if future TEA |
| Triceps-splitting | Divided in the midline, then peeled off both sides | TEA, low-energy fractures, ankylosis release | Moderate articular view; triceps repair is mandatory |
| Triceps-reflecting (Bryan-Morrey) | Elevated as a continuous sleeve medially to laterally | TEA where an osteotomy is to be avoided | Risk of triceps avulsion if reattachment fails |
The paratricipital approach is the standard for total elbow arthroplasty and for paediatric distal humeral fractures because it leaves the triceps intact. Its weakness is poor articular exposure - choose olecranon osteotomy for complex intra-articular fractures.
Triceps-splitting. The triceps tendon and the proximal forearm fascia are divided in the midline over the olecranon and along the subcutaneous ulna; the two halves are peeled medially and laterally off the posterior humerus and the olecranon subperiosteally to expose the distal humerus and olecranon fossa. At closure the triceps tendon is repaired side-to-side and reattached to the olecranon through drill holes. Indications: total elbow arthroplasty, low-energy distal humeral fractures, elbow ankylosis or contracture release. It needs no osteotomy and no major implant for closure, with good access to the olecranon fossa, but gives only moderate articular exposure and risks extensor mechanism weakness if the repair fails.
Triceps-splitting is frequently used for elbow ankylosis release (access to the posterior and anterior capsule through the same split) and for low-energy distal humeral fractures. Meticulous triceps repair is mandatory to avoid disabling extension weakness.
Olecranon osteotomy (apex-distal chevron). An extra-articular-to-intra-articular chevron osteotomy of the olecranon is made and the entire triceps insertion, still attached to the osteotomised fragment, is reflected proximally - delivering the best exposure of the articular surface of the distal humerus. Technique: expose the olecranon and the medial and lateral articular margins of the trochlear notch; identify and protect the ulnar nerve; make an apex-distal chevron osteotomy through the bare area of the olecranon articular surface (the non-articular central zone of the trochlear notch), using a pre-drilled hole and a thin oscillating saw completed with an osteotome to crack the subchondral bone and preserve the articular cartilage; reflect the fragment with the triceps proximally. Fixation at closure: tension-band wiring (classic), a contoured dorsal plate, or a 6.5 mm cancellous lag screw with tension band. Indications: complex intra-articular distal humeral fractures (AO/OTA 13C) and non-unions requiring articular visualisation - the workhorse for articular reconstruction.
Olecranon osteotomy provides the greatest exposure of the articular surface of the distal humerus and is the standard for 13C fractures requiring anatomic reconstruction. Make the cut through the bare area to spare articular cartilage, and pre-drill for later fixation. Tension-band wiring remains the classic fixation; plate fixation is increasingly favoured.
Triceps-reflecting (Bryan-Morrey). The triceps is elevated as a continuous sleeve from medial to lateral, in continuity with the forearm fascia and the anconeus, off the humerus and the olecranon, and reflected laterally - the extensor mechanism is left intact and attached distally as a sleeve, with no osteotomy. Technique: incise the medial border of the triceps and elevate the muscle extraperiosteally off the posterior humerus; continue the sleeve distally across the olecranon keeping the triceps expansion and anconeus in continuity with the forearm fascia; reflect the entire sleeve laterally. At closure, reattach the triceps firmly to the olecranon through drill holes (transosseous sutures). Indications: total elbow arthroplasty (especially where olecranon osteotomy is undesirable) and some distal humeral fractures in elderly patients.
The Bryan-Morrey triceps-reflecting approach was described specifically for total elbow arthroplasty as a triceps-sparing alternative to osteotomy. The defining risk is triceps insufficiency or avulsion, so secure transosseous reattachment to the olecranon is critical.
Anconeus-sparing refinements. Two related refinements protect the anconeus (useful for elbow stability and a vascularised flap) while providing deep exposure. The anconeus flap transolecranon approach (Athwal) performs an olecranon osteotomy but leaves the anconeus attached to the osteotomised fragment and the triceps, preserving its blood supply and improving fragment healing - used for complex distal humeral fractures. The triceps-anconeus reflecting pedicle (TRAP, Sanchez-Sotelo and O'Driscoll) reflects the triceps and anconeus together as a single pedicle for total elbow arthroplasty, sparing the anconeus nerve supply and improving extensor mechanism recovery.
The anconeus, supplied by the radial nerve, is the key lateral landmark of the posterior elbow. Whether left in continuity with a reflected triceps sleeve (Bryan-Morrey, TRAP) or with an olecranon osteotomy fragment (anconeus flap transolecranon), preserving it improves soft-tissue healing and extensor mechanism function.
In every posterior elbow approach the ulnar nerve behind the medial epicondyle is the single most important structure at risk. Identify it first, mobilise it gently preserving the vasa nervorum and the flexor carpi ulnaris motor branches, protect it with a vessel loop throughout, and transpose it anteriorly when medial column hardware is placed or the nerve is unstable. Ulnar palsy is the commonest nerve deficit of this approach.
Dangers & Extensions
Structures at Risk
The single most important structure at risk. It runs behind the medial epicondyle through the cubital tunnel and between the two heads of flexor carpi ulnaris. Injury causes clawing of the hand, loss of finger abduction and adduction, and medial hand numbness. Prevention: identify it first, mobilise gently, protect with a vessel loop, and transpose anteriorly when medial column hardware is placed.
Lies in the spiral groove on the posterior humerus and pierces the lateral intermuscular septum approximately 10 cm proximal to the lateral epicondyle to become anterior. At risk with proximal extension along the humeral shaft. Prevention: stay subperiosteal on the posterior cortex and identify the nerve before any proximal release.
Run anteriorly and are protected by the brachialis. At risk only with aggressive anterior dissection or over-reduction clamps that perforate the anterior cortex. Prevention: keep dissection posterior to brachialis and protect the anterior cortex during reduction.
The medial, posterior and lateral antebrachial cutaneous nerves cross the operative field. Injury causes numbness and painful neuroma. Prevention: incision biased lateral to the olecranon tip, and careful full-thickness flap elevation so the nerves travel within the flap.
Extensile Options Proximal extension. The incision can be extended proximally along the posterior humeral shaft to expose the diaphysis for segmental or more proximal fractures. The radial nerve lies in the spiral groove and pierces the lateral intermuscular septum approximately 10 cm proximal to the lateral epicondyle to become anterior - it must be identified and protected before any proximal release. Stay strictly subperiosteal on the posterior humeral cortex. Distal extension. The incision continues distally along the subcutaneous border of the ulna, giving access to the proximal ulna and becoming continuous with a dorsal or Boyd-type forearm exposure when needed. This is useful when the fracture or pathology extends onto the proximal ulna, or when proximal radioulnar access is required. ### Closure Closure depends entirely on the deep window chosen and is as important as the exposure itself. - After olecranon osteotomy: reduce the fragment anatomically (restore the articular surface of the trochlear notch) and fix with a tension-band construct (two parallel K-wires and a figure-of-eight wire), a contoured dorsal plate, or a 6.5 mm cancellous lag screw with tension band; ensure the hardware is not prominent under the thin olecranon skin.
- After triceps-splitting: repair the tendon side-to-side with strong suture and reattach it to the olecranon through transosseous drill holes if elevated; test elbow extension against gravity before closure.
- After triceps-reflecting (Bryan-Morrey): reattach the entire triceps-anconeus-forearm fascia sleeve to the olecranon with multiple transosseous sutures through drill holes - this is the step most prone to failure, so a secure, tension-free repair is essential to prevent triceps avulsion. Ulnar nerve management. If medial column hardware has been placed, or the nerve is unstable (subluxes) after release, perform an anterior subcutaneous (or submuscular) transposition. If the nerve lies comfortably and no medial hardware threatens it, it may be left in situ. Document the decision and the nerve's condition. Skin closure. Close the fasciocutaneous flaps over a suction drain if there is any dead space or concern for haematoma; close in layers over the olecranon avoiding tension (the thin posterior skin is unforgiving); and apply a well-padded splint with the elbow in extension or 30 to 60 degrees of flexion per surgeon preference. ### Complications
| Complication | Prevention | Management |
|---|---|---|
| Ulnar nerve injury | Identify first, gentle mobilisation, protect throughout | Document, neurovascular review, explore if complete palsy suspected |
| Radial nerve injury (proximal extension) | Identify before proximal release, subperiosteal dissection | Document, observe, EMG at 3 weeks, explore if no recovery |
| Articular cartilage damage | Osteotomy through the bare area, complete with an osteotome | Resect any step-off; revise fixation if malreduced |
| Inadequate articular exposure | Choose olecranon osteotomy for 13C fractures | Convert window intra-operatively if needed |
| Complication | Incidence / note | Prevention | Treatment |
|---|---|---|---|
| Ulnar nerve palsy | Commonest nerve deficit | Identify and protect; transpose when indicated | Most are neurapraxia; observe, splint, EMG at 3 weeks |
| Wound breakdown / infection | Thin olecranon skin; 2 to 5 percent range | Full-thickness flaps, drain, avoid tension | Dressings, antibiotics, debridement if deep |
| Olecranon non-union / prominent hardware | Specific to osteotomy | Anatomical reduction, secure fixation | Refixation; hardware removal once healed |
| Triceps insufficiency / avulsion | Splitting and reflecting windows | Secure transosseous repair | Re-repair; rarely reconstruction |
| Heterotopic ossification | Higher with head injury or burns | Prophylaxis in high-risk patients | Excision once mature if it blocks motion |
| Stiffness | Common after complex trauma | Early controlled motion | Arthrolysis if a functional arc is not achieved |
- Painful cutaneous neuroma of the medial (or posterior) antebrachial cutaneous nerve is a recognised, disabling complication; the incision is deliberately biased lateral to the olecranon tip to spare the medial branches, and flaps are kept full-thickness so the cutaneous nerves travel within the flap rather than being transected at skin level.
- Haematoma and seroma beneath the flap threaten the skin; a suction drain is used when dead space exists.
- Patients should be counselled about possible numbness around the scar. ### Post-operative Care Immediate: neurovascular check documenting ulnar (and radial and median) nerve function against the pre-operative baseline; splint and elevation to control swelling; wound inspection at 48 hours. Range of motion: early controlled motion once the skin is stable and the extensor mechanism repair is secure, aiming for a functional arc of approximately 30 to 130 degrees of flexion; after olecranon osteotomy fixation, motion protocols respect the fixation construct; protect the triceps repair (avoid resisted extension for 6 to 8 weeks after splitting or reflecting windows). Follow-up: 2 weeks for wound check, suture removal and radiographs; 6 and 12 weeks for radiographs to confirm olecranon osteotomy or fracture union and hardware position; functional assessment at 3 to 6 months.
Procedures Through This Approach
- ORIF of complex distal humeral fractures - dual-column orthogonal or parallel plating, most often via an olecranon osteotomy for articular reconstruction.
- Total elbow arthroplasty through a triceps-sparing paratricipital or triceps-reflecting window.
- Elbow arthrolysis and capsular release for post-traumatic stiffness, through a triceps-splitting window.
- Excision of heterotopic ossification.
- Tumour resection around the distal humerus.
- Revision elbow surgery and selected debridement for septic arthritis.
Viva & Exam Focus
POSTERIORPOSTERIOR elbow - the surgical steps
ULNARULNAR nerve - protection principles
Olecranon osteotomy (apex-distal chevron through the bare area). Reflecting the triceps with the osteotomised olecranon fragment proximally exposes the entire articular block and is the standard for complex AO/OTA 13C fractures.
Identify it first behind the medial epicondyle, mobilise it gently protecting its blood supply, and protect it throughout. Perform an anterior transposition (subcutaneous or submuscular) when medial column hardware is placed or when the nerve is unstable after release.
Laterally, between triceps (radial nerve) and brachialis (musculocutaneous nerve); medially, between triceps (radial nerve) and the flexor-pronator mass (median and ulnar nerves). The triceps itself is left intact.
In the spiral groove on the posterior humerus; it pierces the lateral intermuscular septum approximately 10 cm proximal to the lateral epicondyle to become anterior. Identify it before any proximal release and stay subperiosteal.
A triceps-sparing window - the paratricipital (Alonso-Llames) or the triceps-reflecting (Bryan-Morrey). Olecranon osteotomy is relatively avoided when arthroplasty is planned because it compromises the olecranon.
To keep the suture line off the pressure point of the olecranon (reducing wound breakdown) and to protect the branches of the medial antebrachial cutaneous nerve, reducing painful neuroma.
Exam viva scenarios
Practise clinical reasoning and management decisions out loud
“A 32-year-old man sustains a high-energy AO/OTA 13C distal humerus fracture. Describe your surgical approach.”
“An 82-year-old woman with rheumatoid arthritis sustains a comminuted, unreconstructable distal humerus fracture. How would you approach this?”
“During a posterior approach for a distal humerus fracture, when would you transpose the ulnar nerve, and how?”
Incision and flaps
- Single posterior incision lateral to the olecranon tip (4 to 6 cm proximal and distal)
- Full-thickness fasciocutaneous flaps raised medially and laterally off the triceps
- Lateral bias protects the medial antebrachial cutaneous nerve and the pressure point
- Exposes both columns and the entire extensor mechanism
Ulnar nerve
- The single most important structure at risk
- Identify behind the medial epicondyle first, mobilise gently, protect with a vessel loop
- Preserve vasa nervorum and the FCU motor branches
- Transpose anteriorly when medial hardware is placed or the nerve is unstable
Deep window choice
- Paratricipital (Alonso-Llames): triceps intact - TEA, simple fractures, children
- Triceps-splitting: ankylosis release, low-energy fractures
- Olecranon osteotomy: best articular exposure - 13C fractures
- Triceps-reflecting (Bryan-Morrey): triceps-sparing TEA
Olecranon osteotomy
- Apex-distal chevron through the bare area of the olecranon articular surface
- Pre-drill for later fixation; complete the cut with an osteotome
- Fix with a tension band, contoured dorsal plate, or lag screw with tension band
- Relatively avoided when future total elbow arthroplasty is planned
Structures at risk
- Ulnar nerve - commonest deficit; identify and protect
- Radial nerve - spiral groove, with proximal extension (approximately 10 cm above the lateral epicondyle)
- Median nerve and brachial artery - protected by brachialis
- Cutaneous nerves - neuroma risk; full-thickness flaps and lateral incision
Closure and morbidity
- Securely repair or reattach the triceps (side-to-side and through drill holes)
- Fix the olecranon osteotomy anatomically
- Full-thickness, tension-free skin closure over the olecranon; drain if dead space
- Wound breakdown and cutaneous neuroma are the dominant morbidity
References
Guidelines, Registries and Global Practice The extensile posterior approach and its deep windows are taught and applied consistently across examination systems (advanced orthopaedic practice and advanced orthopaedic practice, DNB and MS, MRCS, SICOT) and across AO Foundation trauma principles. The choice of deep window is governed by the procedure and the required articular exposure, not by regional preference. Side-by-side principles (where guidance converges): - AO Foundation: anatomic articular reconstruction and stable dual-column fixation (orthogonal or parallel plating) for 13C distal humeral fractures; olecranon osteotomy for articular exposure; early controlled motion.
- AAOS and orthopaedic trauma societies: CT-based planning for articular distal humeral fractures; ulnar nerve identification and protection is standard of care; tension-band or plate fixation of olecranon osteotomy.
- Regional arthroplasty guidance: primary total elbow arthroplasty for unreconstructable comminuted distal humeral fractures in low-demand elderly patients; triceps-sparing (paratricipital or reflecting) windows preferred to olecranon osteotomy. Registry and population evidence. National arthroplasty registries (the Australian AOANJRR, the Nordic registries, and the UK National Joint Registry) increasingly capture elbow arthroplasty; total elbow arthroplasty carries one of the higher revision burdens among joint replacements, with aseptic loosening, instability and infection as the leading causes. Complex distal humeral fractures occur in a bimodal distribution - high-energy injuries in young adults and low-energy fragility fractures in the elderly, the latter increasingly managed with total elbow arthroplasty when comminution precludes fixation. Global practice variation. In high-resource settings, anatomic pre-contoured periarticular plates, headless and locking screws, and linked semi-constrained elbow prostheses are standard, and CT is routine for articular fractures. In resource-limited settings, the same biomechanical principles (dual-column buttress or plating, secure osteotomy fixation) are achieved with small-fragment reconstruction plates and tension-band wiring, and olecranon osteotomy exposure remains universally applicable. Consent (globally applicable). Discuss ulnar nerve injury (the commonest nerve deficit, mostly transient), wound breakdown and infection over the thin olecranon skin (a few percent), olecranon osteotomy non-union and prominent hardware, triceps weakness or avulsion after splitting or reflecting windows, stiffness, heterotopic ossification, and the possibility of future total elbow arthroplasty if post-traumatic arthritis develops.
For the operative surgery station, describe this approach systematically: the single posterior incision lateral to the olecranon tip, full-thickness flaps, ulnar nerve identification and protection, the four deep windows and when each is chosen, the structures at risk (especially the ulnar and radial nerves), and closure. Know that olecranon osteotomy gives the best articular exposure and that triceps-sparing windows are preferred for arthroplasty.
Extensive Posterior Exposure of the Elbow: A Triceps-Sparing Approach
- The landmark description of the triceps-reflecting extensive posterior exposure of the elbow
- The triceps is elevated as a continuous sleeve from medial to lateral in continuity with the forearm fascia and anconeus, leaving the extensor mechanism intact and avoiding an olecranon osteotomy
- Designed primarily for total elbow arthroplasty, providing wide exposure while preserving the extensor mechanism
- Established the triceps-reflecting (Bryan-Morrey) window as a standard for elbow arthroplasty
Bilaterotricipital Approach to the Elbow: Its Application
- Described the paratricipital (bilaterotricipital) approach in which the triceps is left completely intact
- Medial and lateral windows are developed by elevating the triceps off both intermuscular septa
- Originally applied in children, where preserving the extensor mechanism is especially valuable
- Established the paratricipital window as a triceps-sparing option suitable for total elbow arthroplasty and simple or extra-articular fractures
Posterior Surgical Approaches to the Elbow: A Comparative Anatomic Study
- Compared the principal posterior exposures (olecranon osteotomy, triceps-splitting and triceps-reflecting) in cadaveric specimens
- Quantified the articular surface exposure achieved by each posterior approach
- Olecranon osteotomy provided the greatest exposure of the articular surface of the distal humerus
- Provided the comparative anatomic rationale for selecting the deep window based on the exposure required
The Anconeus Flap Transolecranon Approach to the Distal Humerus
- Described an olecranon osteotomy modification that preserves the anconeus attached to the osteotomised fragment
- Maintaining the anconeus in continuity is intended to preserve its blood supply and support healing of the osteotomy
- Provided an anconeus-sparing option for exposure of complex distal humeral fractures
- Added a refinement to the classic olecranon osteotomy aimed at reducing osteotomy-related morbidity
Total Elbow Arthroplasty as Primary Treatment for Distal Humeral Fractures in Elderly Patients
- Established primary total elbow arthroplasty as a treatment for acute, comminuted distal humeral fractures in elderly patients
- Selected for fractures not amenable to stable internal fixation in low-demand patients
- Reported durable functional outcomes in this population at midterm follow-up
- Defined the clinical paradigm of arthroplasty rather than ORIF for unreconstructable comminuted distal humeral fractures in the elderly