Comprehensive guide to the posterior approach to the elbow including triceps-splitting, triceps-reflecting (Bryan-Morrey), and olecranon osteotomy techniques for distal humerus fractures and total elbow arthroplasty
Reviewed by OrthoVellum Editorial Team
Orthopaedic clinicians and medical editors • Published by OrthoVellum Medical Education Team
Triceps Management | Distal Humerus Exposure | Ulnar Nerve Protection
The ulnar nerve is at risk throughout the approach. Identify early in cubital tunnel between medial epicondyle and olecranon. Decompress and transpose anteriorly in most cases, especially for TEA. Injury rate 8% overall - higher if nerve not mobilized. Document preoperative nerve function.
Anatomic triceps repair prevents extension lag and weakness. Use heavy nonabsorbable suture through drill holes in olecranon for all reflecting techniques. Drill 3-4 transverse tunnels 5mm apart. Repair at 30 degrees flexion to avoid over-tightening. Poor repair causes 15% strength loss.
Choose approach based on pathology. Triceps-splitting: simple fractures. Bryan-Morrey: TEA, complex fractures. Olecranon osteotomy: comminuted intra-articular fractures requiring perfect visualization. Osteotomy delays rehab 6 weeks but provides best exposure.
Prone or lateral decubitus with arm over bolster. Prone allows bilateral access and gravity assists soft tissue retraction. Lateral easier for anesthesia. Arm over bolster with elbow flexed 90 degrees opens posterior compartment. Tourniquet applied proximal arm.
The posterior approach to the elbow provides access for distal humerus fractures and total elbow arthroplasty (TEA) via three main techniques: triceps-splitting (Van Gorder) preserves insertion but limits exposure; triceps-reflecting (Bryan-Morrey) elevates triceps with anconeus as a continuous sleeve and is most popular for TEA; olecranon osteotomy (chevron with apex distal) provides maximum articular visualization but requires secure fixation and delays rehabilitation. The ulnar nerve must be identified in the cubital tunnel and protected throughout—injury rate is 8%, higher if not mobilized. Anterior transposition is performed in 60-80% of cases. Anatomic triceps repair through drill holes in the olecranon (at 30° flexion) is critical to prevent extension lag and 15% strength loss.
Memory Hook:POSTERIOR approach selection depends on fracture complexity and desired exposure
Memory Hook:ULNAR NERVE protection prevents the most common complication of posterior elbow approaches
Memory Hook:TRICEPS repair technique determines functional outcome and extension strength
The posterior approach to the elbow is the workhorse approach for complex distal humerus fractures, total elbow arthroplasty, and posterior elbow pathology. Multiple variations exist to balance exposure against morbidity to the triceps mechanism.
Historical development:
Current indications for posterior approach:
This approach provides the best exposure for:
Epidemiology:
Distal humerus fractures account for approximately 2% of all fractures in adults, with bimodal distribution (young males and elderly females). In Australia, approximately 300-400 total elbow arthroplasties are performed annually according to the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The posterior approach is used in over 90% of complex distal humerus fracture fixations.
Approach Selection Logic
Triceps-splitting (Van Gorder): Simple extra-articular or minimally displaced fractures, preserves insertion. Triceps-reflecting (Bryan-Morrey): Total elbow arthroplasty, complex fractures, most versatile and popular. Olecranon osteotomy: Comminuted intra-articular fractures requiring perfect articular visualization, delays rehabilitation 6 weeks. Paratricipital: Simple fractures in young patients, very limited exposure.
Outcomes by approach:
Studies comparing approaches show:
The choice of approach represents a balance between adequate exposure for the surgical goal and minimizing morbidity to the extensor mechanism.
Patient positioned - prone or lateral decubitus:
Surface landmarks:
Incision:
Triceps muscle anatomy:
The triceps has three heads converging to a common tendon:
All three insert on the olecranon via a common tendon approximately 4cm wide.
Anconeus muscle:
Small triangular muscle lateral to triceps:
In Bryan-Morrey approach, anconeus is elevated with triceps as continuous sleeve.
Ulnar nerve anatomy:
The ulnar nerve is THE critical structure at risk:
The nerve is vulnerable throughout posterior approaches and must be identified early.
Radial nerve anatomy:
Less commonly injured but important:
Blood supply:
Important vessels include:
Safe zones:
The posterior approach to the elbow does NOT use a true internervous plane. Instead, it splits or elevates the triceps muscle (innervated by radial nerve) to access the posterior distal humerus and elbow joint.
Triceps innervation:
The entire triceps muscle is innervated by the radial nerve (C7-C8):
Approach variations:
Triceps-splitting (Van Gorder):
Triceps-reflecting (Bryan-Morrey):
Olecranon osteotomy:
Clinical implications:
Because this is NOT an internervous approach, anatomic repair is essential for all approaches that detach or split the triceps. The triceps provides the only active elbow extension, and injury or poor repair results in significant functional impairment.
Anconeus anatomy:
The anconeus (radial nerve innervation) is elevated with triceps in Bryan-Morrey approach, creating a continuous sleeve of extensor tissue. This provides broader lateral exposure and facilitates repair.
Correct positioning optimizes exposure and facilitates surgical technique in posterior elbow approaches.
Position options:
Advantages:
Setup:
Padding critical:
Advantages:
Setup:
Padding critical:
Can be used with arm across chest on folded towels:
Tourniquet:
Fluoroscopy:
Common positioning errors:
Skin incision:
Identify ulnar nerve:
This is the CRITICAL first step before proceeding:
Ulnar nerve management options:
For most posterior approaches (fractures, TEA), anterior transposition is recommended to prevent postoperative cubital tunnel syndrome and protect nerve during approach.
Ulnar nerve transposition technique:
This completes the initial exposure and nerve protection.
Ulnar nerve injury (8% incidence):
Mechanisms:
Prevention:
Recognition:
Management if injury occurs:
Radial nerve injury (less than 2%):
Rare but devastating:
Median nerve injury (rare):
Usually from excessive medial dissection or anterior retraction.
Extension lag (10-15% with poor repair):
Causes:
Prevention:
Management:
Triceps rupture (less than 5%):
Complete failure of repair:
Nonunion (5-10%):
Risk factors:
Prevention:
Management:
Prominent hardware (50% removal rate):
Very common with olecranon fixation:
Incidence: 30-50% have some limitation of motion
Risk factors:
Prevention:
Management:
Risk: 2-5% superficial, 1-3% deep
Prevention:
Management:
Incidence: 10-30% radiographic, 5-10% clinically significant
Risk factors:
Prevention:
Management:
Recovery room:
Splinting:
Pain management:
DVT prophylaxis:
Mobilization protocol depends on approach:
Soft tissue approach (triceps-split or reflecting):
Olecranon osteotomy:
Physiotherapy:
Radiographic follow-up:
Progression:
Strengthening program:
Return to activities:
Advanced strengthening:
Return to sport:
Expected outcomes:
ROM:
Strength:
Function:
Practice these scenarios to excel in your viva examination
"A 55-year-old female presents after a fall from standing height. Radiographs and CT show a comminuted intra-articular distal humerus fracture (AO/OTA 13-C2) with displaced fracture lines through the trochlea and capitellum. She is medically fit for surgery. How would you approach this fracture surgically?"
"You are performing a Bryan-Morrey approach for a distal humerus fracture in a 70-year-old osteoporotic female. After fracture fixation, you begin triceps repair through drill holes in the olecranon. As you tie the first suture, it pulls through the bone. What do you do now?"
"During a posterior approach for distal humerus ORIF, you identify the ulnar nerve and note it appears thickened and scarred, likely from previous minor trauma or chronic cubital tunnel syndrome. The nerve is mobile but appears unhealthy. How do you manage the nerve for this case?"
Approach Selection
Q: Which posterior elbow approach provides the BEST articular visualization for comminuted intra-articular distal humerus fractures?
A: Olecranon osteotomy (chevron or transverse). It provides the widest visualization of the trochlea and capitellum by elevating the entire proximal ulna with attached triceps. Disadvantages include need for secure fixation, delayed rehabilitation (6 weeks), and risk of nonunion.
Bryan-Morrey Approach
Q: What is the Bryan-Morrey approach to the elbow and what is its primary indication?
A: Triceps-reflecting approach that elevates the triceps with a continuous sleeve including the anconeus and forearm fascia from medial to lateral. Primary indication is total elbow arthroplasty (TEA). The triceps is reflected as a single unit, preserving the extensor mechanism while providing adequate exposure for component placement.
Structure Most at Risk
Q: What is the structure MOST at risk during posterior approach to the elbow and how is it protected?
A: Ulnar nerve (8% injury rate overall). It lies in the cubital tunnel between the medial epicondyle and olecranon. Protection requires early identification, decompression, and often anterior transposition (subcutaneous or submuscular). Transposition is performed in 60-80% of cases, especially for TEA.
Chevron Osteotomy
Q: In which direction should the apex of a chevron olecranon osteotomy be oriented and why?
A: Apex distal. This creates a larger proximal fragment attached to the triceps for more stable fixation. The osteotomy is typically performed at the bare area (deepest point of trochlear notch) and fixed with tension band wiring, plate, or cannulated screw. Apex distal orientation resists proximal displacement by the triceps.
AOANJRR data for total elbow arthroplasty: According to the Australian Orthopaedic Association National Joint Replacement Registry 2023 report, 300-400 total elbow arthroplasties are performed annually in Australia. The Bryan-Morrey triceps-reflecting approach is used in over 80% of cases, with the posterior approach being universal for TEA. Indications include rheumatoid arthritis (40%), trauma (30%), and osteoarthritis (20%). Linked cemented TEA demonstrates 88% survival at 10 years, compared to 85% for uncemented implants. Revision rates are higher for trauma indication (35% at 10 years) compared to rheumatoid arthritis (15% at 10 years).
PBS and pharmaceutical guidelines: Indomethacin is PBS-listed for heterotopic ossification prophylaxis after major joint surgery. The Australian eTG guideline recommends indomethacin 75mg daily (modified release) or 25mg three times daily for 6 weeks as first-line prophylaxis in high-risk cases. Single-dose radiation therapy (700-800 cGy within 72 hours postoperatively) is available at major centers as an alternative, particularly when there is concern about NSAID effects on bone healing.
eTG antibiotic guidelines: Australian eTG guidelines for surgical prophylaxis in elbow surgery recommend cefazolin 2g IV at induction (within 60 minutes of incision), with redosing every 4 hours if the procedure exceeds 4 hours. Duration is typically a single dose, or maximum 24 hours for complex cases. For penicillin allergy, vancomycin 25-30 mg/kg IV is recommended, infused over 60-120 minutes starting within 120 minutes of incision. High-risk patients (diabetes, immunosuppression, revision surgery) may require extended prophylaxis to 24 hours postoperatively based on individual risk assessment.
Australian injury epidemiology: Distal humerus fractures demonstrate a bimodal distribution in Australia, affecting young males through high-energy trauma and elderly females through falls. The incidence is approximately 5-6 per 100,000 population per year. Falls account for 60% of cases in the elderly population, while motor vehicle accidents account for 30% in young adults. Work-related injuries account for 10% and are covered by WorkCover schemes. Return to work timing varies from 6-8 weeks for office work to 4-6 months for manual labor. Functional outcome scores such as QuickDASH are used for impairment assessment in compensation claims.
Medicare and healthcare delivery: Posterior elbow approaches for fracture fixation and arthroplasty are covered under Medicare for both public and private hospital settings. These procedures are typically performed in public hospitals for acute trauma cases or private hospitals for elective arthroplasty, with funding arrangements varying based on insurance status and indication. Multidisciplinary team involvement including hand therapy and occupational therapy is essential for optimal outcomes, particularly given the high rate of stiffness complications requiring intensive rehabilitation.
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