High-yield overview

Supine, arm on a hand table | ulnar nerve protected | flexor-pronator origin and anterior MCL reflected with the epicondyle for coronoid and medial-column access

SupineArm abducted on a hand table, shoulder externally rotated

Ulnar nerveNumber-one structure at risk, protected and often transposed

Anterior MCLReflected with, and reattached with, the osteotomised epicondyle

4.0 mmCancellous lag screw for epicondyle reattachment

Critical Must-Knows

Medial (skin) incision centred on the medial epicondyle over the course of the ulnar nerve, with the patient supine on a hand table.
Ulnar nerve is identified, mobilised, protected throughout and frequently anteriorly transposed at closure.
Osteotomy of the medial epicondyle reflects the flexor-pronator origin and the anterior band of the MCL distally as a single sleeve.
Predrill and tap the epicondyle for screw reattachment BEFORE completing the osteotomy so it can be anatomically reduced.
Anatomical, rigid fixation of the epicondyle is essential because the origin of the anterior MCL must be restored to preserve valgus stability.

When & Why

What it exposes. The medial epicondylar osteotomy approach gives direct, line-of-sight access to the coronoid process, the anteromedial facet of the coronoid, the sublime tubercle and the medial column and trochlea of the distal humerus. It is the workhorse exposure for the anteromedial coronoid facet fracture (O'Driscoll type II) and for intra-articular distal humeral fractures needing medial visualisation. Why the osteotomy. The coronoid, and in particular its anteromedial facet, and the medial aspect of the trochlea lie deep to the flexor-pronator mass and the medial neurovascular structures and cannot be safely or adequately exposed through a lateral approach or a simple muscle split. By osteotomising the medial epicondyle, the surgeon reflects the entire flexor-pronator origin together with the anterior band of the MCL distally, converting a deep, hidden joint surface into one that is directly visible. Crucially, because the anterior MCL remains attached to the osteotomised epicondyle, its competence is preserved so long as the epicondyle is anatomically reduced and rigidly fixed at closure. Primary indications - Anteromedial coronoid facet fractures (O'Driscoll type II) — the varus posteromedial rotatory instability pattern — which are inaccessible from a lateral approach and demand direct medial visualisation and fixation.

Coronoid process fractures requiring fixation in elbow fracture-dislocation and the "terrible triad", where the coronoid fragment is large or medially based.
Intra-articular distal humeral fractures where the medial column, the trochlea or a medial shear component must be visualised and fixed directly.
Medial collateral ligament (MCL) reconstruction and medial capsular procedures requiring broad medial exposure.
Medial elbow contracture release and excision of heterotopic bone on the medial side. Contraindications (relative rather than absolute) - Active infection of the elbow or overlying skin.
Severe soft-tissue compromise on the medial side (abrasions, blistering, prior surgical or trauma scarring) — may dictate delay or an alternative route.
Previous ulnar nerve transposition with heavy, unidentifiable scarring — the nerve must be found and protected with particular care.
A simple, extra-articular pattern that does not need medial joint visualisation (use a less invasive alternative).

Comparison of medial and adjacent elbow approaches
Approach	Plane / Method	Best For	Key Drawback
Medial epicondyle osteotomy	Osteotomy of medial epicondyle; flexor-pronator and anterior MCL reflected distally	Anteromedial coronoid facet; trochlea and medial column	Needs epicondyle reattachment; ulnar nerve and MCL at risk
Hotchkiss (flexor-pronator split)	Split between FCU and the flexor-pronator mass, no osteotomy	Coronoid tip/base; simpler medial-column access	More limited exposure of the anteromedial facet
Taylor-Scham (medial utilitarian)	Extensile medial exposure with ulnar nerve transposition	Complex reconstructions; wide circumferential access	Large, extensile dissection with greater morbidity
Kocher (lateral)	True internervous plane: anconeus (radial) vs ECU (PIN)	Radial head; lateral collateral repair	No access to the coronoid or medial column
Bryan-Morrey (posterior)	Triceps reflection medial-to-lateral in continuity	Total elbow arthroplasty; distal humeral reconstruction	Limited anterior coronoid exposure

Position & landmarks. The patient is placed supine with the affected arm abducted onto a radiolucent hand table and the shoulder externally rotated so the medial elbow faces the surgeon; alternatively the arm may be brought across the chest over a bolster. A tourniquet is applied high on the arm, the limb is exsanguinated, and the whole elbow and forearm are prepped to allow circumferential handling. Palpate the medial epicondyle (the central landmark and the origin of the flexor-pronator mass and anterior MCL), the olecranon tip (posterior boundary of the cubital tunnel), the coronoid and sublime tubercle (the target), and the ulnar nerve in its groove behind the medial epicondyle, whose course must be mapped before incision. A medial incision 8 to 12 cm long, centred on the medial epicondyle and curving posterior to it along the medial border of the flexor-pronator mass, keeps the ulnar nerve in view from the outset.

The Exposure

Work down through the layers in the medial interval, protecting the ulnar nerve at every stage, predrill the epicondyle before you cut it, then reflect the flexor-pronator mass and anterior MCL distally with the osteotomised fragment to deliver the medial joint.

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Image Needed: Clinical PhotoHigh Priority

Intra-operative photograph of the medial epicondylar osteotomy approach to the elbow: a curved medial incision centred on the medial epicondyle, the ulnar nerve mobilised on a vessel loop, the medial epicondyle osteotomised and reflected distally with the flexor-pronator origin, exposing the coronoid, the anteromedial facet and the trochlea.

Context: A verified image is being sourced for this exposure.

Pending image generation or sourcing

Exposure sequence

Step 1Position and skin incision

Place the patient supine with the arm abducted on a radiolucent hand table and the shoulder externally rotated (or across the chest over a bolster). Apply a tourniquet, exsanguinate and drape to allow full flexion and extension of the elbow.
Make a medial incision centred on the medial epicondyle and along the course of the ulnar nerve, commonly curving posterior to the epicondyle and onto the medial border of the flexor-pronator mass — long enough (8 to 12 cm) to expose the epicondyle, the cubital tunnel and the proximal flexor-pronator origin.

Step 2Superficial dissection — protect the cutaneous nerves

Divide the subcutaneous tissue in line with the incision, identifying and protecting the branches of the medial antebrachial cutaneous nerve (MABCN), which cross the field superficially and are easily injured.
Raise flaps to expose the cubital tunnel and the flexor-pronator fascia.

Step 3Identify and mobilise the ulnar nerve first

Identify the ulnar nerve proximally where it lies behind the medial epicondyle, and trace it distally through the cubital tunnel.
Release any constricting bands — the cubital tunnel retinaculum or Osborne's band and the fascia between the two heads of flexor carpi ulnaris. Mobilise the nerve gently over a generous length, surround it with a vessel loop, and release the medial intermuscular septum so it can be transposed anteriorly if required.

Step 4Expose the epicondyle and develop the medial interval

Clear the soft tissue off the medial epicondyle and define the proximal border of the flexor-pronator mass.
Develop the medial interval — between brachialis (musculocutaneous nerve) anteriorly and the medial head of triceps (radial nerve) posteriorly — down to the medial column of the distal humerus, staying subperiosteal and keeping the mobilised ulnar nerve protected.

Step 5Predrill for reattachment — BEFORE the osteotomy

Before making the osteotomy, predrill and tap a screw trajectory across the proposed epicondyle fragment into the medial column, and place a preliminary K-wire for rotational control.
This guarantees the fragment can be anatomically reduced and securely fixed at closure without losing orientation — the single step that protects the MCL origin.

Step 6Osteotomise the medial epicondyle

Using a fine oscillating saw or osteotome, perform a medial epicondyle osteotomy — a chevron or transverse cut — taking a fragment large enough to carry the common flexor-pronator origin and the attachment of the anterior MCL.
Keep the ulnar nerve protected and in view throughout the cut, then reflect the fragment distally, delivering the flexor-pronator mass and the anterior MCL as a single, continuous musculo-ligamentous sleeve. This opens the medial joint.

Step 7Expose the coronoid, anteromedial facet and trochlea

With the epicondyle and flexor-pronator sleeve reflected distally, incise the capsule as needed to expose the coronoid process, the anteromedial facet and the sublime tubercle, and the trochlea and medial column of the distal humerus.
The medial articular surface is now directly visualised for reduction and fixation, confirmed on the image intensifier.

Step 8Reattach the epicondyle — the critical closure step

Return the osteotomised epicondyle to its anatomic bed and fix it with the predrilled screw — typically a 4.0 mm cancellous (lag) screw, with or without a washer; for a larger fragment use two small-fragment screws or a tension band.
Because the origin of the anterior MCL travels with the epicondyle, anatomical reduction and rigid fixation here restore valgus stability.

Step 9Repair the flexor-pronator mass, transpose the nerve, close

Repair the flexor-pronator fascia over the reattached epicondyle.
Transpose the ulnar nerve anteriorly into a subcutaneous (or, rarely, submuscular) pocket if indicated, or leave it decompressed in situ. Close the fascial and subcutaneous layers over a drain and close the skin.
Splint the elbow in a position that protects the repair — commonly flexed and pronated — according to the stability achieved.

The ulnar nerve is the number-one structure at risk

The ulnar nerve runs behind the medial epicondyle in the cubital tunnel and is threatened by traction, retractor compression, the osteotomy cut and postoperative scarring; ulnar neuritis is the commonest nerve complication of this exposure. Identify the nerve before any deep dissection, mobilise it generously, protect it with a vessel loop, keep it in view during the osteotomy, and frequently transpose it anteriorly at closure.

Predrill, then osteotomise

The defining technical point is to predrill the fixation before completing the osteotomy. The osteotomised epicondyle carries the origin of the anterior MCL; unless it is reduced anatomically and fixed rigidly, valgus stability is lost. Predrilling guarantees a reproducible, anatomic reattachment and is the single step that protects the MCL.

Internervous plane — the trap answer

If asked for the internervous plane, describe this as a subperiosteal/intermuscular exposure developed in the medial interval between brachialis (musculocutaneous nerve) and triceps (radial nerve) proximally, with the ulnar nerve protected; the osteotomy reflects a single median-nerve flexor-pronator sleeve distally off bone, so no muscle is denervated and there is no classical muscle-splitting plane for the osteotomy itself. Contrast this with the Kocher approach, which uses a true internervous plane between the anconeus (radial nerve) and the extensor carpi ulnaris (posterior interosseous nerve).

Dangers & Extensions

Structures at risk, by layer

Danger structures and how to protect them
Layer	Structure at risk	Protection
Superficial	Medial antebrachial cutaneous nerve	Identify and protect branches during superficial dissection
Superficial	Ulnar nerve	Identify first, mobilise, vessel loop, often transpose at closure
Deep	Ulnar nerve (at the osteotomy)	Keep in view during the epicondyle cut; avoid traction
Deep	Brachial artery and median nerve (anterior)	Stay posterior to brachialis; do not stray anteriorly off bone
Articular	Coronoid and trochlear cartilage	Careful retraction; protect during reduction and fixation
Repair	Anterior MCL	Restore by anatomical, rigid epicondyle reattachment

Extensile options. Extend proximally along the medial intermuscular septum and the medial column of the humerus to expose more of the medial distal humeral shaft for complex fractures — the ulnar nerve travels with this dissection and must be protected, and proximal extension is ultimately limited by the nerve's course and by the need to avoid straying toward the radial nerve in the spiral groove. Extend distally along the flexor-pronator mass and the ulna to reach the proximal ulna, flexor carpi ulnaris and the medial coronoid base. For complex patterns such as a terrible triad or a bicolumnar distal humeral fracture, the medial epicondyle osteotomy may be combined with a lateral (Kocher or Kaplan) approach to address the lateral collateral ligament complex and radial head: address the structures that determine stability, restore the coronoid and columns, and repair the lateral ligamentous complex. Closure. Anatomically reduce the osteotomised epicondyle to its bed and fix it with the predrilled 4.0 mm cancellous lag screw (with or without a washer; two small-fragment screws or a tension band for larger fragments), confirming reduction on imaging. Repair the flexor-pronator fascia over the reattached epicondyle, transpose the ulnar nerve anteriorly (subcutaneous most commonly) if indicated, and close over a drain. Splint the elbow in a position that protects the MCL repair and the epicondyle fixation, tailoring the arc and timing of mobilisation to the stability achieved. Complications

Approach-specific complications and prevention
Complication	Mechanism	Prevention
Ulnar neuritis	Traction, compression, scarring, the osteotomy	Identify first, mobilise, protect, transpose when indicated
MCL incompetence / valgus instability	Non-anatomical or failed epicondyle reattachment; nonunion	Predrill; anatomical, rigid cancellous-screw fixation
MABCN injury / neuroma	Transection of superficial branches	Identify and protect branches
Epicondyle nonunion or fixation failure	Inadequate fixation, small fragment, early motion	Rigid fixation; protected rehabilitation
Infection / wound breakdown	Contaminated or compromised medial soft tissues	Soft-tissue respect; delay if needed; antibiotics

Two complications examiners expect

The two complications examiners expect you to name for this approach are ulnar neuritis (the commonest nerve complication, from handling and scarring of the ulnar nerve) and MCL incompetence (from a malreduced, loose or un-united epicondyle, since the anterior MCL origin is restored only by anatomical reattachment). Both are prevented by meticulous technique — early nerve identification with transposition, and predrilled rigid epicondyle fixation.

Procedures Through This Approach

ORIF of the anteromedial coronoid facet (O'Driscoll type II / varus posteromedial rotatory instability) — the principal indication; the fragment is reduced and fixed with small-fragment or mini-fragment screws or a buttress plate.
Coronoid process fixation in elbow fracture-dislocation and the "terrible triad", where the coronoid fragment is large or medially based.
Intra-articular distal humeral fixation — the medial column, the trochlea and medial shear components.
Medial collateral ligament reconstruction and medial capsular repair.
Medial elbow contracture release and excision of medial heterotopic bone.

Why the anteromedial facet demands this approach

An anteromedial coronoid facet fracture represents varus posteromedial rotatory instability. Because the fragment is medial and the coronoid is central to anterior and rotatory stability, it cannot be visualised or fixed from a lateral approach. The medial epicondyle osteotomy gives the direct, line-of-sight access required for anatomic reduction, and the lateral collateral ligament must also be addressed (often repaired) to restore overall stability.

Viva & Exam Focus

Mnemonic

EPICONDYLEEPICONDYLE — the exposure steps

Expose epicondyle and ulnar nerve

Medial incision; identify the ulnar nerve first

Protect the ulnar nerve

Mobilise, vessel loop, transpose if required

Interval: brachialis vs triceps

Subperiosteal medial interval

Carry flexor-pronator and MCL

They travel with the epicondyle

Osteotomise after predrilling

Chevron or transverse cut; nerve in view

Never denervate muscle

Reflect a single sleeve off bone

Direct view of coronoid and trochlea

Anteromedial facet and medial column exposed

Yield an anatomical reduction

Reduce articular fragments under vision

Lag-screw the epicondyle back

Predrilled 4.0 mm cancellous screw

Examine and protect the nerve at closure

Transpose; repair flexor-pronator

Mnemonic

PROTECTPROTECT — ulnar nerve handling

Palpate and plan over the cubital tunnel

Map the nerve before incision

Release Osborne's band and FCU fascia

Open the cubital tunnel roof

Observe it during the osteotomy

Keep the nerve in view on the cut

Tape or vessel loop only

Never a metal retractor on the nerve

Expose a generous length

Mobilise to avoid traction

Cut the medial intermuscular septum

Allows conflict-free transposition

Transpose anteriorly when indicated

Subcutaneous pocket at closure

Clinical Decision Scenarios

Practise clinical reasoning and management decisions out loud

Viva scenarioStandard

Clinical prompt

“A 32-year-old sustains an elbow fracture-dislocation. CT shows a fracture of the anteromedial facet of the coronoid. Describe the approach you would use to fix it.”

Practical approach

**Diagnosis and indication:** A fracture of the **anteromedial facet of the coronoid** (an O'Driscoll type II pattern) represents **varus posteromedial rotatory instability**. It is a medial lesion that cannot be visualised or fixed from a lateral approach, so the **medial epicondylar osteotomy approach** is indicated. **Position and incision:** The patient is placed **supine** with the arm on a hand table and the shoulder externally rotated. A medial incision centred on the medial epicondyle exposes the cubital tunnel and the flexor-pronator mass. **Ulnar nerve:** The **ulnar nerve is identified first**, mobilised from proximal through the cubital tunnel to distal, protected with a vessel loop, and the medial intermuscular septum is released so it can be transposed later. **Deep dissection and osteotomy:** The medial interval between **brachialis (musculocutaneous nerve)** and the **triceps (radial nerve)** is developed to the medial column. The fixation is **predrilled**, then the **medial epicondyle is osteotomised** and reflected distally with the **flexor-pronator origin and the anterior band of the MCL**, exposing the coronoid, the anteromedial facet and the sublime tubercle. **Fixation and closure:** The coronoid fragment is reduced and fixed with small-fragment or mini-fragment screws or a buttress plate under direct vision. The epicondyle is returned to its bed and fixed with the **predrilled 4.0 mm cancellous screw**, restoring the MCL origin. The flexor-pronator fascia is repaired, the ulnar nerve is transposed anteriorly if indicated, and the elbow is splinted to protect the repair.

Key clinical points

Diagnosis: anteromedial coronoid facet fracture (varus posteromedial rotatory instability)

It is a medial lesion that cannot be fixed from a lateral approach

Supine with the arm on a hand table, shoulder externally rotated

Identify and protect the ulnar nerve first

Predrill before osteotomising the medial epicondyle

Reflect the flexor-pronator origin and anterior MCL with the epicondyle

Fix the coronoid, then reattach the epicondyle with a 4.0 mm cancellous screw

Address the lateral collateral ligament to restore overall stability

Common pitfalls

Attempting to fix the anteromedial facet from a lateral approach

Osteotomising the epicondyle without first predrilling the fixation

Forgetting to identify and protect the ulnar nerve

Not restoring the MCL origin with anatomical, rigid epicondyle reattachment

Further questions

“What is the role of the lateral collateral ligament in this injury, and how is it addressed?”

“How does the anterior band of the MCL remain competent after this approach?”

“What is your postoperative mobilisation protocol?”

Viva scenarioChallenging

Clinical prompt

“Six weeks after a medial epicondyle osteotomy approach for a coronoid fracture, a patient reports new numbness in the little and ring fingers and weakness of intrinsic hand muscles. What is your assessment and management?”

Practical approach

**Diagnosis:** The picture is **ulnar neuropathy** — the commonest nerve complication of the medial elbow approach, arising from traction, compression by a retractor, irritation at the osteotomy or scarring around the nerve in the cubital tunnel. **Assessment:** Document a focused ulnar-nerve examination — sensation in the little finger and ulnar half of the ring finger, intrinsic muscle power (first dorsal interosseous, abductor digiti minimi), finger-crossing and Froment's sign, and compare with the preoperative baseline. Review the operative note for nerve handling and whether transposition was performed, and obtain plain radiographs or CT to exclude a medially placed screw, prominent hardware or epicondyle nonunion irritating the nerve. **Initial management:** Most early ulnar nerve deficits are neurapraxic and recover with conservative measures — activity modification, splinting of the elbow in extension at night, and observation. Ensure no correctable cause such as a prominent screw or a tight band remains. **Surgical consideration:** If a structural cause is identified (prominent hardware, epicondyle nonunion with irritation, or compression in an untransposed, scarred cubital tunnel), or if a dense lesion fails to recover, **ulnar nerve exploration with anterior transposition** (and removal of offending hardware or fixation of a nonunion) is indicated. **Prevention:** The episode underscores that the nerve must be **identified before any deep dissection, mobilised generously, protected from retractor compression, kept in view during the osteotomy, and transposed anteriorly** when at risk.

Key clinical points

Diagnosis: ulnar neuropathy, the commonest nerve complication of the approach

Mechanisms: traction, retractor compression, osteotomy irritation, scarring

Examine sensation, intrinsic power and Froment's sign versus baseline

Exclude a correctable cause: prominent hardware, epicondyle nonunion

Most early deficits are neurapraxic and managed conservatively

Explore and transpose if a structural cause is found or recovery fails

Prevented by early identification, gentle handling and protective transposition

Common pitfalls

Reassuring the patient without examining for a structural cause

Failing to exclude prominent hardware or epicondyle nonunion

Promising full recovery — some axonal injuries do not fully recover

Forgetting that prevention rests on the quality of intraoperative nerve handling

Further questions

“When would you explore an ulnar nerve after this approach?”

“How would you manage a symptomatic epicondyle nonunion?”

“What is the value of anterior transposition at the index operation?”

Viva scenarioStandard

Clinical prompt

“What are the key differences between the medial epicondyle osteotomy approach and the Kocher (lateral) approach to the elbow?”

Practical approach

**Medial epicondyle osteotomy (medial):** Targets the **coronoid, the anteromedial facet and the medial column of the distal humerus**. Position: supine with the arm on a hand table, shoulder externally rotated. Dissection: a **subperiosteal/intermuscular** exposure developed in the medial interval between **brachialis (musculocutaneous nerve)** and **triceps (radial nerve)**; the medial epicondyle is osteotomised and reflected distally with the flexor-pronator origin and the anterior MCL. Key structure at risk: the **ulnar nerve** (motor and sensory — intrinsic weakness and numbness). Key complications: **ulnar neuritis** and **MCL incompetence**. **Kocher (lateral):** Targets the **radial head and neck and the lateral collateral ligament complex**. Position: supine with the arm across the chest or pronated on a hand table. Dissection: a **true internervous plane** between the **anconeus (radial nerve)** and the **extensor carpi ulnaris (posterior interosseous nerve)**. Key structure at risk: the **posterior interosseous nerve** (motor — wrist and finger extension). **Stability comparison:** The Kocher approach risks the lateral collateral complex and **posterolateral rotatory instability** if the LUCL is not respected; the medial epicondyle osteotomy risks the **medial collateral ligament** and **valgus instability** if the epicondyle is not anatomically reattached. In complex instability such as the terrible triad, **both sides** must often be addressed: the coronoid and medial column through the medial approach, and the lateral complex through Kocher.

Key clinical points

Medial: targets the coronoid, anteromedial facet and medial column

Kocher: targets the radial head and lateral collateral complex

Medial: ulnar nerve at risk; Kocher: posterior interosseous nerve at risk

Medial: subperiosteal/intermuscular; Kocher: true internervous plane (anconeus vs ECU)

Medial risks valgus instability (MCL); Kocher risks posterolateral rotatory instability (LUCL)

Medial: predrill and reattach the epicondyle; Kocher: preserve and repair the LUCL

Both may be needed in the terrible triad to restore stability

Common pitfalls

Confusing which nerve is at risk in each approach

Claiming the medial osteotomy uses a true internervous plane

Forgetting that the terrible triad needs both medial and lateral address

Not knowing how the anterior MCL is preserved in the medial approach

Further questions

“How is the anterior MCL preserved during the medial epicondyle osteotomy?”

“What is the internervous plane of the Kocher approach?”

“When would you use both approaches in a single elbow injury?”

Exam day cheat sheet

Medial epicondylar osteotomy approach — exam-day essentials

Position & Incision

Supine with the arm abducted on a hand table, shoulder externally rotated
Arm across the chest over a bolster is an alternative
Medial incision centred on the medial epicondyle over the ulnar nerve
Exposes the cubital tunnel, the epicondyle and the flexor-pronator mass
Full flexion and extension confirmed before draping

Ulnar Nerve

The number-one structure at risk — identify it first
Mobilise from proximal through the cubital tunnel to distal
Protect with a vessel loop; never compress it with a retractor
Release the medial intermuscular septum
Frequently transposed anteriorly (subcutaneous) at closure

Internervous Plane

A subperiosteal/intermuscular exposure, NOT a true internervous plane
Proximally: brachialis (musculocutaneous) vs triceps (radial)
Distally: brachialis vs pronator teres (median)
The osteotomy reflects a single flexor-pronator sleeve off bone
Contrast with Kocher: a true plane between anconeus and ECU

The Osteotomy

Predrill the screw trajectory and place a K-wire BEFORE the osteotomy
Chevron or transverse osteotomy of the medial epicondyle
Reflect the epicondyle distally with the flexor-pronator origin and anterior MCL
Keep the ulnar nerve protected and in view during the cut
Exposes the coronoid, anteromedial facet, sublime tubercle and trochlea

Epicondyle Reattachment (Closure)

Anatomical, rigid fixation restores the origin of the anterior MCL
Typically a 4.0 mm cancellous lag screw, with or without a washer
Two small-fragment screws or a tension band for larger fragments
Repair the flexor-pronator fascia over the reattached epicondyle
Transpose the ulnar nerve anteriorly when indicated; splint to protect the repair

Indications & Complications

Principal indication: anteromedial coronoid facet fracture (O'Driscoll type II)
Also: coronoid fixation in terrible triad; medial column of distal humerus; MCL reconstruction
Ulnar neuritis is the commonest nerve complication
MCL incompetence arises from malreduced or un-united epicondyle
Address the lateral collateral ligament as well in instability patterns

References

Guidelines, Registries & Global Practice The medial epicondylar osteotomy approach to the elbow is a universally taught exposure for coronoid and medial-column pathology across all examination systems. The technical principles converge globally: early ulnar-nerve identification and protection, a subperiosteal/intermuscular dissection in the brachialis–triceps interval, predrilling before osteotomy, and anatomical, rigid reattachment of the epicondyle to restore the anterior MCL.

Where guidance converges on coronoid and medial-column exposure
Body	Position on coronoid and medial-column exposure
AAOS (US)	Anteromedial coronoid facet fractures require direct medial exposure and fixation; the MCL origin must be preserved and restored; address the lateral collateral complex to restore overall stability
BOA / BESS (UK)	Coronoid reduction is central to stability in complex elbow fracture-dislocation; meticulous ulnar-nerve handling and protected rehabilitation are emphasised to limit neuritis and stiffness
EFORT / European consensus	A medial approach with epicondyle osteotomy or flexor-pronator split is standard for anteromedial coronoid and medial-column pathology; column-specific fixation is preferred over single-incision compromises

Outcome evidence. The anteromedial coronoid facet fracture is now recognised as a distinct, unstable pattern (varus posteromedial rotatory instability) that is missed on plain films and demands CT and a direct medial approach. Anatomical reduction and stable fixation of the coronoid, combined with restoration of the medial and lateral ligamentous constraints, are the determinants of a stable, functional elbow; residual instability and stiffness drive poor outcomes. Global practice variation. In well-resourced settings, CT-defined fragment-specific fixation through a medial epicondyle osteotomy with small-fragment or mini-fragment implants is standard. In resource-limited settings, the same medial exposure is used with whatever small-fragment fixation is available, and external fixation may have a larger role for gross instability. The surgical anatomy and the principles of ulnar-nerve and MCL handling are identical. Consent (globally applicable): discuss ulnar nerve symptoms (numbness or weakness in the hand) and the possibility of further surgery for ulnar neuritis, medial collateral ligament incompetence and valgus instability (related to epicondyle fixation), hardware prominence, stiffness, infection and wound problems, and the possibility of heterotopic bone.

Orthopaedic relevance

For the Operative Surgery station you must describe the medial epicondylar osteotomy approach systematically: supine positioning, early ulnar-nerve identification and protection, the subperiosteal/intermuscular dissection in the brachialis–triceps interval, predrilling before osteotomy, reflection of the flexor-pronator origin and anterior MCL with the epicondyle, and anatomical rigid reattachment with a cancellous screw. Know that the two complications examiners expect are ulnar neuritis and MCL incompetence.

Evidence

Fracture of the Anteromedial Facet of the Coronoid Process: Surgical Techniques

LoE 4

Doornberg JN, Ring D • Journal of Bone and Joint Surgery (Am) (2006)

Key Findings:

Described the medial approach with a medial epicondyle osteotomy to expose and fix the anteromedial facet of the coronoid
The osteotomy reflects the flexor-pronator origin and the anterior band of the medial collateral ligament with the epicondyle
Predrilling the epicondyle before osteotomy allows anatomical reattachment and preserves the MCL origin
Defined the operative strategy for the anteromedial coronoid facet fracture as a distinct unstable pattern

Clinical implication: The primary source establishing the medial epicondyle osteotomy as the standard exposure for the anteromedial coronoid facet fracture

Evidence

Fractures of the Coronoid Process of the Ulna

LoE 4

Regan W, Morrey B • Journal of Bone and Joint Surgery (Am) (1990)

Key Findings:

Introduced the widely used Regan-Morrey classification of coronoid fractures (types I to III by fragment size)
Established the coronoid as a critical stabiliser of the elbow whose fractures are associated with instability
Larger coronoid fragments were associated with worse outcome, informing the drive toward operative fixation
Provided the foundation on which later fragment-specific (including anteromedial facet) classifications built

Clinical implication: The classic report that established coronoid fracture classification and the importance of the coronoid to elbow stability

Evidence

Coronoid Process Fracture

LoE 4

Steinmann SP • Journal of the American Academy of Orthopaedic Surgeons (2008)

Key Findings:

Reviewed the surgical approaches to coronoid fractures, including the medial approach and medial epicondyle osteotomy
Emphasised that the anteromedial facet is critical to varus and posteromedial rotatory stability and requires a medial exposure
Stressed protection of the ulnar nerve and preservation of the medial collateral ligament origin during the approach
Outlined fragment-specific fixation principles for coronoid and medial-column pathology

Clinical implication: A widely cited review codifying the indications, technique and pitfalls of the medial approach for coronoid fractures

Evidence

The Effect of Anteromedial Facet Fractures of the Coronoid and Lateral Collateral Ligament Status on Elbow Stability

LoE 3

Pollock JW, Brownhill J, Ferreira L, McDermid JC, Johnson J, King G • Journal of Shoulder and Elbow Surgery (2009)

Key Findings:

Biomechanically demonstrated that anteromedial coronoid facet fractures compromise elbow stability
Showed that the degree of instability increases with larger anteromedial facet fragments
Confirmed that integrity of the lateral collateral ligament complex modulates the resulting instability
Provided the experimental rationale for fixing the anteromedial facet and addressing the lateral complex

Clinical implication: Biomechanical evidence justifying operative fixation of the anteromedial coronoid facet and concurrent lateral ligament management

Evidence

Varus Posteromedial Rotatory Instability of the Elbow: The Anteromedial Coronoid Facet

LoE 4

O'Driscoll SW, Spinner RJ, McKee MD, Kibler WB, Hastings H 2nd, Morrey BF, Kato H, Takayama S, Imatani J, Toh S, Graham HK • Instructional Course Lectures / Journal of Shoulder and Elbow Surgery (2001)

Key Findings:

Recognised anteromedial coronoid facet fracture as the basis of varus posteromedial rotatory instability of the elbow
Defined a pattern that is frequently missed on plain radiographs and requires CT for diagnosis
Argued that the medial lesion must be exposed and fixed directly through a medial approach
Established the clinical importance of the coronoid's anteromedial facet as a distinct elbow stabiliser

Clinical implication: The conceptual work that established the anteromedial coronoid facet fracture as a distinct, unstable injury demanding a medial approach