Medial (Hotchkiss Over-the-Top) Approach to the Elbow

What it exposes. The Hotchkiss medial over-the-top approach gives direct access to the coronoid process, the anteromedial coronoid facet, the sublime tubercle (insertion of the anterior bundle of the MCL) and the medial collateral ligament complex. It is the workhorse medial exposure for coronoid fixation in terrible triad injuries and for MCL reconstruction. Why this approach. The coronoid is the critical anterior buttress preventing posterior elbow subluxation. The over-the-top split provides direct visualisation of the entire coronoid and sublime tubercle while preserving the common flexor-pronator origin on the medial epicondyle - maintaining elbow stability and allowing a strong repair at closure. It exploits a true internervous plane, and in a terrible triad it is performed first (medial) and combined with a separate lateral (Kocher) approach, all with the patient supine and the arm across the chest. Primary indications: - Coronoid process fractures - especially the anteromedial facet - in terrible triad injuries

• Isolated coronoid fractures with elbow instability
• Anteromedial coronoid facet fractures with varus posteromedial rotatory instability (VPMRI)
• Medial collateral ligament reconstruction (acute or chronic)
• Selected medial-column distal humerus fractures requiring direct medial access
• Revision surgery after failed coronoid fixation or MCL reconstruction Contraindications: - Active infection over the medial elbow
• Severe soft-tissue compromise requiring alternative coverage
• Isolated radial head or lateral-column pathology (use the Kocher approach)
• A patient unable to tolerate the supine, arm-across-chest position

Position and landmarks. Supine on a radiolucent table with the arm across the chest, supported on a padded bolster or Mayo stand, the shoulder in slight external rotation and the elbow flexed about 90 degrees initially; tourniquet high on the arm after exsanguination. Palpate and mark the medial epicondyle, the medial supracondylar ridge, the course of the ulnar nerve behind the medial epicondyle, and the sublime tubercle on the medial ulnar border (roughly 5 to 7 mm distal to the joint line). Plan a curvilinear incision centred over the medial epicondyle - about 5 cm along the supracondylar ridge proximally and 6 to 8 cm along the ulnar border of the forearm distally. Position the C-arm from the opposite side or from distal, and confirm true AP and lateral views before incision.

Work from skin to capsule through the layers of the medial elbow, protecting the medial antebrachial cutaneous nerve and the ulnar nerve, then develop the over-the-top flexor-pronator split to bring the coronoid and sublime tubercle into view.

View larger

Structures at risk, by layer

Extensile options. Extend proximally along the medial supracondylar ridge, developing the plane between brachialis and triceps, to reach the medial column of the distal humerus (the median nerve and brachial artery become identifiable if vascular exploration is needed). Extend distally along the ulnar border of the forearm between pronator teres and flexor carpi ulnaris for combined ulnar nerve exploration; the ulnar artery lies deep to flexor carpi ulnaris. For terrible triad injuries, perform the medial Hotchkiss approach first to fix the coronoid and address the MCL, then use a separate Kocher lateral approach for the radial head and lateral collateral ligament - both done supine with the arm across the chest, without repositioning. A medial epicondylar osteotomy variant (osteotomising the epicondyle with its flexor origin, reflecting it anteriorly, and repairing with screws or tension band) is reserved for complex intra-articular distal humerus fractures needing extensive medial exposure. Complications

Ulnar nerve injury management. An intra-operative clean transection is repaired primarily; otherwise observe. For a post-operative deficit, document the extent, obtain an EMG at 3 to 4 weeks, and consider exploration if there is no recovery by 3 months. A permanent deficit may require tendon transfers (ECRB to EDC, FCR to intrinsics) or nerve grafting. Rehabilitation. Immobilise at 90 degrees for the first two weeks with gentle hand and wrist exercises, move to a hinged brace with a progressive flexion-extension arc avoiding valgus stress from weeks 2 to 6, regain full active range and begin strengthening from weeks 6 to 12, and return to sport or heavy labour at 3 to 6 months once strength is recovered. Monitor ulnar nerve motor and sensory function serially, and obtain an EMG at 6 to 8 weeks if recovery is in doubt.

• Coronoid ORIF - suture lasso, screw, or plate fixation of coronoid and anteromedial facet fractures.
• MCL reconstruction - anatomic graft tunnels on the sublime tubercle and medial epicondyle.
• Anteromedial facet fixation for varus posteromedial rotatory instability (VPMRI).
• Selected medial-column distal humerus fractures requiring direct medial access.
• Ulnar nerve decompression or transposition as a combined procedure.

Guidelines, Registries and Global Practice The Hotchkiss medial approach is used worldwide for coronoid fixation and MCL reconstruction, and its principles are consistent across contemporary practice and other examination systems. CT or MRI is mandatory for surgical planning of coronoid fractures and elbow instability, and ulnar nerve management is a universal examination topic. Side-by-side principles (where guidance converges): - AO Foundation - CT or advanced imaging for all coronoid fractures; combined medial-lateral approaches for the terrible triad; ulnar nerve identification mandatory.

• BOA / BESS - early mobilisation protocols; ulnar nerve monitoring and documentation; anatomic MCL reconstruction for chronic instability.
• AAOS / ASSH - anatomic coronoid reduction and MCL isometry as primary goals; transposition when the nerve is under tension. Registry and population evidence: - Coronoid fractures occur in approximately 2 to 10 percent of elbow dislocations, with anteromedial facet fractures carrying the highest risk of chronic instability if untreated.
• MCL reconstruction success rates exceed 85 percent when anatomic tunnel placement and early motion protocols are followed.
• Ulnar neuropathy after medial elbow surgery ranges from 5 to 15 percent and is predominantly transient. Global practice variation. In high-resource centres, dedicated coronoid plates, suture-button devices and hamstring autograft for MCL reconstruction are standard. In resource-limited settings, screw or suture-lasso fixation for the coronoid and local tendon autograft (palmaris or gracilis) remain effective. The choice of ulnar nerve transposition technique (subcutaneous versus submuscular) varies by surgeon preference and patient factors. Consent (globally applicable). Discuss ulnar nerve injury (5 to 15 percent, mostly transient), MABC neuroma (less than 5 percent), stiffness (20 to 40 percent), heterotopic ossification (5 to 10 percent), recurrent instability (5 to 10 percent), and the need for a combined lateral approach in terrible triad injuries.