Posterior Approach to the Elbow

What it exposes. The posterior approach is the workhorse exposure for complex distal humerus fractures, total elbow arthroplasty (TEA) and posterior elbow pathology. It gives access to the whole posterior distal humerus, both columns, the olecranon fossa and, once the triceps is managed, the articular surface of the trochlea and capitellum. Indications.

• Distal humerus fractures, intra-articular and extra-articular - the commonest indication.
• Total elbow arthroplasty, primary and revision (Bryan-Morrey is the standard).
• Elbow arthrodesis and excision of heterotopic ossification.
• Posterior elbow impingement lesions and open contracture release.
• Olecranon fractures requiring distal fixation and triceps repair after rupture. There is no true internervous plane. Unlike most extensile approaches, the posterior elbow approach does not split between two nerves; it splits or elevates the triceps, which is entirely radial-nerve innervated (C7 to C8). The triceps has three heads - long (infraglenoid tubercle of the scapula), lateral and medial (posterior humerus either side of the radial groove) - converging on a common tendon about 4 cm wide at the olecranon. Because the muscle is not split along an internervous boundary, anatomic repair of any detached or split triceps is mandatory to preserve active elbow extension. Epidemiology and registry context. Distal humerus fractures account for approximately 2 percent of adult fractures (around 5 to 6 per 100,000 per year) with a bimodal distribution - high-energy trauma in young males and low-energy falls in elderly osteoporotic females, the latter rising with an ageing population. A posterior approach is used for essentially all bicolumnar and complex intra-articular fixations and is universal for TEA. Arthroplasty registries (NJR, AOANJRR, SHAR) consistently record TEA as a low-volume procedure, performed mostly for inflammatory arthritis, trauma and post-traumatic sequelae, and primary osteoarthritis. Position and landmarks. The patient is placed prone or in lateral decubitus (operative side up), the arm draped free over a bolster with the elbow flexed 90 degrees so gravity assists soft-tissue retraction. Prone gives bilateral access and a stable field; lateral is easier for the anaesthetist and familiar to shoulder surgeons. Surface landmarks are the olecranon tip, the medial and lateral epicondyles, and the ulnar nerve palpable in the cubital tunnel between the medial epicondyle and the olecranon. A proximal arm tourniquet is inflated to 250 to 300 mmHg and limited to under 120 minutes (released for TEA cementing), and fluoroscopy is set up from the contralateral side with AP and lateral views confirmed before draping. Historical development.
• 1940 - Van Gorder: triceps tongue and turn-down (splitting), preserving the olecranon insertion for supracondylar exposure.
• 1982 - Bryan and Morrey: triceps-reflecting technique, raising the extensor mechanism in continuity with the anconeus and forearm fascia.
• Classic: olecranon osteotomy popularised for maximum articular exposure of comminuted intra-articular fractures.
• Modern: paratricipital (triceps-on) windows developed to spare the triceps entirely for simple or extra-articular fractures and to triage to arthroplasty. The choice of approach balances exposure against morbidity to the extensor mechanism.

Work from the midline posterior incision down to the joint, making the ulnar nerve safe first, then managing the triceps to match the pathology. The sequence below follows the workhorse triceps-reflecting (Bryan-Morrey) exposure; where the splitting or osteotomy variations diverge, the difference is noted at that step.

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Structures at risk, by layer.

Complications.

• Ulnar neuropathy - around 25 to 30 percent postoperatively, mostly transient, with permanent iatrogenic injury under 5 percent; prevent with early identification, gentle handling and selective transposition.
• Extension lag - 10 to 15 percent when the triceps repair is poor; prevent with anatomic repair through drill holes at 30 degrees of flexion.
• Triceps rupture - under 5 percent, usually a technical failure of fixation and more common in revision surgery; it needs repair or reconstruction.
• Radial nerve injury - under 2 percent, from proximal triceps elevation or excessive lateral retraction.
• Osteotomy nonunion or malunion - around 5 to 10 percent; lower with a chevron cut and rigid plate fixation, higher with a transverse cut and early motion.
• Prominent hardware - up to a 50 percent removal rate after olecranon or osteotomy fixation.
• Elbow stiffness - 30 to 50 percent have some motion limitation; prevent with early motion and heterotopic ossification prophylaxis in high-risk cases.
• Infection - 2 to 5 percent superficial and 1 to 3 percent deep; prevent with a single dose of cefazolin 2 g IV within 60 minutes of incision per AAOS, NICE/SIGN and WHO guidance.
• Heterotopic ossification - 10 to 30 percent radiographic and 5 to 10 percent clinically significant; prophylaxis with indomethacin 75 mg daily for up to 6 weeks, or single-dose radiotherapy (700 to 800 cGy) when NSAIDs are contraindicated. Extensile options. Extend proximally along the posterior humerus to reach the humeral shaft, bearing in mind the radial nerve crossing the spiral groove; the paratricipital windows on either side of the triceps allow limited column access without disturbing the extensor mechanism and are the route of choice when converting to TEA. There is no useful distal extension beyond the proximal forearm. Closure.
• Triceps repair (Bryan-Morrey): roughen the olecranon and drill 3 to 4 transverse tunnels 5 mm apart through it, pass heavy non-absorbable suture (Ethibond #2 or FiberWire #5) through the tunnels and the triceps-anconeus sleeve, and tie with the elbow at 30 degrees of flexion; close the medial and lateral borders side-to-side to restore contour. For the splitting approach, close the raphe side-to-side - no drill holes are needed.
• Osteotomy fixation: reduce the osteotomy anatomically and fix with a tension band (two 1.6 mm K-wires and a figure-of-8 18-gauge wire) or, increasingly preferred, a dorsal plate with a lag screw across the osteotomy for more rigid fixation and earlier motion.
• Close the fascia, the thick subcutaneous layer and the skin in layers; consider a small drain for extensive dissection, and apply a posterior splint with the elbow at 90 degrees and the forearm in neutral rotation.

• Distal humerus ORIF with bicolumnar plating - the principal fracture operation through the posterior exposure.
• Total elbow arthroplasty - performed through the Bryan-Morrey reflecting approach.
• Olecranon ORIF and triceps tendon repair - posterior bony and soft-tissue work.
• Severely comminuted intra-articular fixation is often staged through an olecranon-osteotomy exposure.
• Elbow arthrodesis, heterotopic ossification excision, posterior impingement decompression and open contracture release.

Guidelines, registries and global practice. TEA is a low-volume procedure worldwide. Arthroplasty registries (NJR for England and Wales, AOANJRR for Australia, SHAR and the Swedish and Norwegian registries) consistently report linked semiconstrained cemented implants as the dominant construct, with inflammatory arthritis, acute trauma and post-traumatic sequelae and primary osteoarthritis as the leading indications. Registry and cohort data agree that revision rates are substantially higher when TEA is done for trauma or post-traumatic indications than for inflammatory arthritis, and outcomes are worse in younger, higher-demand patients - a recurrent examiner point. There is no single mandated approach: AO Foundation teaching favours a triceps-sparing or olecranon-osteotomy exposure depending on comminution, while the Bryan-Morrey sleeve remains the standard for TEA. For antibiotic prophylaxis, AAOS, NICE/SIGN and WHO converge on a single preoperative dose of a first-generation cephalosporin (cefazolin 2 g IV) within 60 minutes of incision with redosing after roughly two half-lives, and vancomycin or clindamycin for confirmed beta-lactam allergy. Distal humeral fractures account for around 2 percent of adult fractures with a bimodal distribution, and validated outcome tools (Mayo Elbow Performance Score, QuickDASH) are used internationally for follow-up.