High-yield overview

Supine | Extends the Kocher (ECU-Anconeus) Interval | PIN Protected by Pronation | Preserve the LCL Complex

SupineArm draped free across the chest

PronationSwings the PIN away from the field

ECU / AnconeusKocher interval extended proximally

Bone fleckPreserves the LCL origin for repair

Critical Must-Knows

Supine with the arm draped free across the chest gives full lateral access and lets the forearm be pronated and supinated throughout
Internervous plane is between ECU (posterior interosseous nerve) and anconeus (radial nerve) - the Kocher interval extended proximally
Pronate the forearm to swing the posterior interosseous nerve (PIN) medially off the supinator and away from the surgical field
Preserve the lateral collateral ligament (LCL) complex, ideally on a fleck of bone from the lateral epicondyle, and repair it back to the epicondyle to prevent posterolateral rotatory instability
The radial nerve becomes at risk with proximal extension beyond roughly 10 cm above the lateral epicondyle

When & Why

What it exposes. The Wrightington extended lateral approach is an extensile lateral exposure of the distal humerus that elevates the common extensor origin from the lateral supracondylar ridge and extends the Kocher interval (ECU-anconeus) distally. This converts a limited lateral window into a broad exposure of the capitellum, the lateral trochlea, the anterior distal humeral cortex and the radiocapitellar joint, all without detaching the triceps mechanism or transposing the ulnar nerve. Why this approach is chosen. The capitellum and the anterolateral distal humerus are difficult to expose through a single standard approach. A simple Kocher gives only the radial head and radiocapitellar joint. By elevating the common extensor origin and extending Kocher proximally, the Wrightington approach gives direct articular visualisation that a plain Kocher cannot, while avoiding the morbidity of an olecranon osteotomy when lateral access is all that is required. ### Indications - Capitellar fractures, especially complex coronal shear fractures and those with trochlear extension (Dubberley type B)

Lateral column fractures of the distal humerus
Bicolumnar distal humeral fractures where the lateral column is addressed through this approach (often combined with a medial approach)
Distal humeral non-union or malunion requiring lateral access and bone stock visualisation
Selected total elbow arthroplasty where lateral column access or a combined extensile route is needed
Lateral soft-tissue and bony procedures on the radiocapitellar joint, including radial head ORIF through the distal Kocher component ### Contraindications - Pathology that is purely medial (use a medial approach with ulnar nerve management)
Severe soft-tissue compromise or active infection over the lateral elbow
Open physes in the skeletally immature (relative - take care around the lateral epicondylar apophysis)
A bicolumnar intra-articular fracture in which an olecranon osteotomy is judged to give superior global articular visualisation ### Alternative Approaches The extended lateral approach sits between a limited lateral (Kocher) window and a posterior extensile (olecranon osteotomy) exposure:

Lateral elbow approaches compared
Approach	Interval / route	Best for	Key structure at risk
Kocher	ECU-anconeus	Radial head and radiocapitellar joint	PIN (protected by pronation)
Wrightington extended lateral	Kocher extended proximally; common extensor origin elevated off the ridge	Capitellum, lateral trochlea, distal humerus, TEA access	PIN and LCL complex
Kaplan	ECRB-EDC, anterior to Kocher	Anterior radial head access	PIN at higher risk

Other options include the anterior (Henry) approach for anterior neurovascular structures, the medial approach for the medial column, coronoid and ulnar nerve transposition, and the olecranon osteotomy - the gold-standard extensile exposure for bicolumnar intra-articular distal humeral fractures, at the cost of osteotomy-site morbidity. ### Position & Landmarks Position: supine, with the arm draped free across the chest. A sandbag or bump under the ipsilateral scapula brings the elbow forward. The elbow is flexed and the forearm brought across the chest, supported by a folded sheet or a sterile arm support, so the assistant can pronate and supinate on command - pronation protects the PIN. A pneumatic tourniquet sits on the well-padded upper arm, and an image intensifier is available from the ipsilateral side if intra-operative imaging is anticipated. Surface landmarks to mark before incision: - Lateral epicondyle - the common extensor origin and the isometric origin of the LCL complex (the centre of elbow rotation)

Lateral supracondylar ridge - the ridge along which the approach extends proximally
Olecranon tip - posterior reference
Radial head - palpable, rotates with pronation and supination; defines the radiocapitellar joint
Kocher interval - the palpable soft spot just posterior to the radial head, between ECU and anconeus The incision is a curved line centred over the lateral epicondyle, beginning about 4 to 5 cm proximal to the epicondyle along the lateral supracondylar ridge and curving distally and posteriorly toward the Kocher interval between the radial head and the olecranon, 8 to 12 cm in total depending on the exposure required.

Why pronation matters before you incise

Plan the draping so the forearm can be fully pronated the moment you work near the radial neck. The PIN lies closest to the radiocapitellar joint and radial neck in supination and swings medially off the supinator in pronation. Set up the limb so the assistant can pronate on command - this single habit prevents most iatrogenic PIN injuries during lateral elbow surgery.

Pre-operative Assessment Neurovascular (critical baseline): document pinch and finger extension (PIN function) and wrist and finger extension against resistance (radial nerve) pre-operatively; check distal pulses and capillary return, and sensation in the first web space (PIN) and the posterolateral forearm (radial sensory and posterior antebrachial cutaneous). Soft tissue: assess swelling, abrasions and blistering and apply the wrinkle test over the lateral elbow; exclude an open wound and check elbow stability and range of motion gently. High-energy injuries with blisters or a negative wrinkle test may need staging or a spanning external fixation while awaiting definitive fixation. ### Investigations Plain radiographs (initial): AP and lateral elbow for overall alignment and gross pattern, oblique views to define the capitellum and lateral column, and a radiocapitellar (Greenspan) view to profile the capitellum and radial head. CT is essential for any articular distal humeral fracture being considered for surgery - axial, coronal and sagittal reconstructions with 3D rendering define the size and displacement of the capitellar fragment, trochlear extension and any posterior column component (Dubberley B), which decide whether an extended lateral approach is sufficient or a second approach is needed.

CT is mandatory

Every articular distal humeral fracture being considered for surgery requires CT. Coronal shear fragments, trochlear extension and posterior column components - which decide whether an extended lateral approach is sufficient or a second approach is needed - are frequently underappreciated on plain radiographs.

The Exposure

Work down through the layers over the lateral epicondyle: protect the posterior antebrachial cutaneous nerve superficially, develop the ECU-anconeus (Kocher) interval distally, then elevate the common extensor origin off the ridge proximally to deliver the capitellum and lateral trochlea - all with the forearm pronated and the LCL complex preserved. ### Anatomy The distal humerus is formed by two columns (medial and lateral) joined to the trochlea and capitellum. The lateral column ends distally in the capitellum, a hemispherical articular surface articulating with the radial head that faces anteriorly and inferiorly and is almost entirely covered by cartilage - so its blood supply enters posteriorly through the non-articular surface, and excessive posterior stripping risks avascular necrosis. The lateral epicondyle is the common extensor origin and the origin of the lateral collateral ligament complex. | Layer | Muscle | Nerve supply | Role in the approach | |-------|--------|--------------|----------------------| | Superficial | Brachioradialis, ECRL | Radial nerve | Elevated anteriorly off the ridge | | Superficial | ECRB | Radial nerve (PIN) | Part of the common extensor mass elevated | | Deep (interval) | Extensor carpi ulnaris (ECU) | Posterior interosseous nerve | Anterior boundary of the Kocher interval | | Deep (interval) | Anconeus | Radial nerve | Posterior boundary of the Kocher interval | | Deep | Supinator | Posterior interosseous nerve | Houses the PIN - pronation moves the nerve off it | | Posterior | Triceps | Radial nerve | Preserved and retracted, not detached | ### Internervous Plane The deep internervous plane is between extensor carpi ulnaris (ECU), supplied by the posterior interosseous nerve, anteriorly; and the anconeus, supplied by the radial nerve, posteriorly. This is the Kocher interval, extended proximally by elevating the common extensor origin from the lateral supracondylar ridge. Above the joint the approach is not a true internervous plane - it is a muscle-elevating (subperiosteal) dissection in which the common extensor origin (ECRB, ECU) together with brachioradialis and ECRL is stripped off the ridge and reflected anteriorly, with the radial nerve setting the proximal limit.

Internervous plane nuance

Strictly, both ECU and anconeus are radial-nerve territory (ECU via the PIN, anconeus via a direct radial-nerve branch), so some texts call the Kocher plane inter-nervous-branch rather than truly inter-nervous. State the plane as ECU (PIN) and anconeus (radial nerve), then explain that proximally the approach becomes a subperiosteal elevation of the common extensor origin off the ridge, limited proximally by the radial nerve.

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Image Needed: Clinical PhotoHigh Priority

Intra-operative photograph of the Wrightington extended lateral approach to the elbow: a curved incision over the lateral epicondyle, the common extensor origin elevated off the lateral supracondylar ridge and retracted anteriorly, the Kocher interval developed distally, and the capitellum and radiocapitellar joint exposed with the forearm held pronated to protect the PIN.

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

Pending image generation or sourcing

Exposure sequence

Step 1Incision

Make a curved incision centred over the lateral epicondyle, beginning about 4 to 5 cm proximal to it along the lateral supracondylar ridge and curving distally toward the Kocher interval between the radial head and the olecranon.
Length 8 to 12 cm, depending on the exposure required and the procedure planned.

Step 2Superficial dissection

Incise skin and subcutaneous tissue in line with the incision and identify and protect branches of the posterior antebrachial cutaneous nerve.
Raise flaps to expose the fascia over the common extensor origin, the lateral supracondylar ridge and the Kocher interval distally.

Step 3Define the Kocher interval

Distally, identify the interval between ECU anteriorly and the anconeus posteriorly - the extended Kocher interval.
Develop it bluntly down to the joint capsule and the radiocapitellar joint.

Step 4Pronate the forearm (critical)

Before any deep work near the radial neck, fully pronate the forearm.
This swings the posterior interosseous nerve (PIN) medially off the supinator and away from the surgical field; maintain pronation throughout the distal dissection.

Step 5Elevate the common extensor origin

Proximally, incise the periosteum on the lateral supracondylar ridge and elevate the common extensor origin (ECRB, ECU) together with brachioradialis and ECRL as a subperiosteal flap, reflecting the mass anteriorly to expose the lateral column and anterior distal humeral cortex.
Stay on bone and do not extend more than roughly 10 cm proximal to the lateral epicondyle without formally identifying the radial nerve.

Step 6Manage the lateral collateral ligament complex

Where possible, preserve the LCL complex origin on a small fleck of bone osteotomised from the lateral epicondyle and reflect it en bloc with the extensor flap.
If that is not feasible, sharply detach the LCL complex from the epicondyle and mark it for later repair - never leave it unrepaired, because the LUCL is the essential restraint to posterolateral rotatory instability.

Step 7Capsulotomy and articular exposure

With the extensor flap elevated and the PIN protected by pronation, perform a lateral and anterior capsulotomy and protect the annular ligament where possible.
This delivers wide exposure of the capitellum (anterior and inferior articular surface), the lateral trochlea, the radiocapitellar and proximal radioulnar joints and the anterior distal humeral cortex. Irrigate to clear haematoma and visualise the fragments.

Step 8Articular reduction and fixation

Reduce displaced capitellar and trochlear fragments anatomically, aiming for an articular step-off of less than 2 mm, held with small pointed reduction clamps and provisional K-wires.
Fix with headless compression screws placed subchondrally and countersunk (to avoid proud hardware breaching cartilage) and lateral column plating for columnar fractures; add cancellous autograft or bone substitute for any metaphyseal void after elevation of impacted fragments. Confirm screw length and joint congruity under fluoroscopy and direct vision.

Step 9Repair the LCL complex (mandatory)

If the LCL complex was taken on a bone fleck, reduce the fleck and fix it back to the lateral epicondyle; if it was detached, repair it to the isometric point on the lateral epicondyle (the centre of elbow rotation) using transosseous drill holes or suture anchors.
Restoring LUCL isometry prevents posterolateral rotatory instability.

Step 10Reattach the extensors and close

Reattach the elevated common extensor origin and brachioradialis to the lateral supracondylar ridge and lateral epicondyle through bone tunnels or to the preserved periosteal sleeve.
Irrigate copiously, achieve haemostasis and consider a drain; close the fascia, subcutaneous tissue and skin in layers. Apply a well-padded splint with the elbow in 90 degrees of flexion and the forearm neutral or pronated. Confirm reduction and fixation on fluoroscopy and obtain AP and lateral radiographs.

Protect the posterior interosseous nerve by pronation

The PIN is the single most important structure at risk in any lateral elbow approach. It enters the supinator through the arcade of Frohse about 3 cm distal to the radiocapitellar joint and lies closest to the radial neck in supination. Fully pronating the forearm swings it medially away from the field. Stay on bone, avoid blind retraction in the supinator, and document finger and thumb extension before and after surgery. PIN injury causes loss of finger and thumb extension with preserved sensation.

Stay on bone

All deep dissection stays on bone - subperiosteally along the ridge and within the Kocher interval. This keeps the PIN safe inside the supinator, protects the capitellar blood supply entering posteriorly, and delivers clean tagged soft-tissue flaps to repair at closure.

Dangers & Extensions

Structures at risk, by layer

Danger structures and how to protect them
Layer	Structure at risk	Protection
Skin / subcutaneous	Posterior antebrachial cutaneous nerve	Identify and protect during the skin incision
Muscle / interval	Posterior interosseous nerve (PIN) - enters supinator via the arcade of Frohse, about 3 cm distal to the radiocapitellar joint	Fully pronate the forearm; stay on bone; no blind retraction in the supinator
Ligamentous	Lateral collateral ligament (LUCL) complex - the essential restraint to posterolateral rotatory instability	Preserve on a bone fleck or detach and repair to the isometric point on the epicondyle
Proximal extension	Radial nerve - pierces the lateral intermuscular septum roughly 10 cm above the lateral epicondyle	Do not extend more than about 10 cm proximally without formally identifying it
Vascular	Radial recurrent artery (leash of Henry), anterior to the radial neck	Ligate as needed for distal access; does not require repair
Articular	Capitellar blood supply, entering posteriorly through the non-articular surface	Avoid excessive posterior stripping to prevent avascular necrosis

### Extensile Options Proximal extension: the incision and deep dissection extend along the lateral supracondylar ridge toward the distal arm to expose more of the distal humeral shaft and lateral column; the limit is the radial nerve, which pierces the lateral intermuscular septum roughly 10 cm proximal to the lateral epicondyle - identify and protect it before extending further. Distal extension: the approach continues as the Kocher approach to expose the radial head, radial neck and proximal radius - useful when a capitellar fracture coexists with a radial head fracture requiring fixation. The PIN remains at risk throughout the supinator, so maintain pronation. Combination with a medial approach: for bicolumnar patterns needing medial access, a separate medial approach (with ulnar nerve management) can be added, avoiding skin bridges that compromise vascularity. When an olecranon osteotomy is preferred instead: global bicolumnar intra-articular comminution, or where posterior articular visualisation is the priority. The extended lateral approach is then reserved for the lateral column or selected arthroplasty cases. ### Closure and LCL Repair The non-negotiable step of closure is repair of the LCL complex to the isometric point on the lateral epicondyle (via the bone fleck, transosseous tunnels or suture anchors), followed by reattachment of the common extensor origin and brachioradialis to the ridge, copious irrigation, haemostasis, a drain as needed, and layered closure with a splint in 90 degrees of flexion. ### Complications Intra-operative complications | Complication | Prevention | Management | |--------------|------------|------------| | PIN injury | Pronation, stay on bone, no blind retraction | Document, splint the wrist in extension, EMG at 3 weeks, explore if no recovery | | LCL deficiency / PLRI | Preserve on a bone fleck; mandatory repair to isometric point | Acute repair; reconstruction for chronic PLRI | | Radial nerve injury (proximal) | Identify the nerve before extending proximally | Primary repair if transected | | Intra-articular hardware | Confirm screw length under fluoroscopy and direct vision | Remove and replace with a shorter screw | | Capitellar AVN | Preserve posterior soft-tissue attachments | Observe; reconstruct if collapse occurs | Post-operative complications | Complication | Typical incidence | Prevention | Treatment | |--------------|-------------------|------------|-----------| | Posterolateral rotatory instability | Variable | Meticulous LCL/LUCL repair | Reconstruction (tendon reconstruction of the LUCL) | | Heterotopic ossification | Variable in high-energy injury | Gentle handling; prophylaxis in high-risk patients | Excision if functionally limiting and mature | | Infection | Low with healthy soft tissues | Antibiotics, meticulous closure | Debridement and antibiotics | | Stiffness / loss of motion | Common | Early controlled mobilisation | Physiotherapy; arthrolysis if refractory | | Post-traumatic arthritis | Depends on reduction quality | Anatomic articular reduction (step-off less than 2 mm) | Analgesia; arthroplasty if severe | PIN injury management: if the nerve is identified as transected intra-operatively, plan primary repair or grafting; if a neurapraxia is suspected post-operatively, document the deficit, splint the wrist in extension and arrange electromyography at 3 weeks; if there is no clinical or electrical recovery by about 3 months, consider nerve exploration. ### Outcomes Good prognostic factors: anatomic articular reduction (step-off less than 2 mm), a simple capitellar pattern without posterior column extension (Dubberley A), stable fixation allowing early mobilisation, and an intact LCL complex. Poor prognostic factors: an associated posterior column fragment (Dubberley B), comminution or a thin Kocher-Lorenz shell, a high-energy mechanism with soft-tissue injury, and delayed mobilisation from instability.

Key outcome message

Outcome after surgery through the extended lateral approach is driven by anatomic articular reduction (step-off less than 2 mm), addressing any posterior column component, and a secure LCL repair that permits early controlled mobilisation without instability.

Procedures Through This Approach

Capitellar and coronal shear fractures - the principal indication; fixed with countersunk headless compression screws
Radial head ORIF - through the distal Kocher component, when a capitellar fracture coexists with a radial head fracture
Lateral column distal humeral fractures - lateral column plating
Bicolumnar distal humeral fractures - the lateral column addressed here, combined with a medial approach
Distal humeral non-union and malunion - lateral access and bone stock visualisation
Selected total elbow arthroplasty - lateral column exposure in combined extensile strategies
Lateral soft-tissue and radiocapitellar procedures ### Capitellar Fracture Patterns (Bryan and Morrey) - Type I (Hahn-Steinthal): complete fracture of the capitellum
Type II (Kocher-Lorenz): anterior shell with minimal osseous attachment
Type III: comminuted capitellar fracture
Complex coronal shear variants extend into the trochlea and demand an extended lateral exposure ### Dubberley Classification (Capitellar and Trochlear) The Dubberley system drives approach selection - a posterior column fragment (B) worsens prognosis and may demand an added approach.

Dubberley types and surgical implication
Type	Description	Implication
1A	Capitellum, no posterior column fragment	Extended lateral, good prognosis
1B	Capitellum with posterior column fragment	Extended lateral, worse prognosis
2A	Capitellum and trochlea as one piece, no posterior fragment	Extended lateral
2B	Capitellum and trochlea with posterior column fragment	Worst prognosis, extended lateral plus added approach

Strategy by fracture pattern
Pattern	Strategy	Notes
Isolated capitellum (Dubberley 1A)	Extended lateral, headless screws	Good prognosis
Capitellum with posterior column (1B/2B)	Extended lateral plus medial	Worse prognosis; address the posterior column
Bicolumnar comminuted	Olecranon osteotomy	Best global articular view
Unreconstructable, elderly low-demand	Total elbow arthroplasty	Early mobilisation, weight limits

### Fixation Principles and Fix Versus Arthroplasty ORIF is preferred in physiologically young, active patients with reconstructable articular fragments; total elbow arthroplasty is considered in elderly, low-demand patients with unreconstructable comminution or pre-existing inflammatory arthritis, where the extended lateral approach can contribute the lateral column exposure in selected strategies. The fixation principles are anatomic articular reduction (step-off less than 2 mm), subchondral countersunk headless compression screws for capitellar fragments, lateral column plating for columnar fractures, restoration of the LCL complex to avoid posterolateral rotatory instability, and bone graft for any metaphyseal void.

Viva & Exam Focus

Mnemonic

WRIGHTWRIGHT - the extended lateral approach

Wrightington extended lateral

Extensile lateral exposure of the distal humerus

Reflect the common extensor origin

Elevate off the supracondylar ridge and reflect anteriorly

Interval ECU-anconeus

The extended Kocher internervous plane

Guard the PIN

Pronate the forearm to swing it medially off the supinator

Handle the LCL on a bone fleck

Preserve it and repair to the isometric point

Tight closure

Repair the LCL, reattach the extensors, close in layers

Exam Viva Scenarios

Practise clinical reasoning and management decisions out loud

Viva scenarioStandard

Clinical prompt

“A 32-year-old woman falls on an outstretched hand and CT shows a displaced capitellar coronal shear fracture with extension into the lateral trochlea but no posterior column fragment. Describe your surgical approach.”

Practical approach

I would confirm the fracture pattern on CT, including the trochlear extension and the absence of a posterior column component, which makes an extended lateral approach appropriate. I position the patient supine with the arm draped free across the chest so the forearm can be pronated and supinated throughout, and I apply a tourniquet. I mark the lateral epicondyle, the lateral supracondylar ridge and the radial head. I make a curved incision centred on the lateral epicondyle, extending proximally along the ridge and distally toward the Kocher interval between the radial head and the olecranon. In the superficial dissection I protect the posterior antebrachial cutaneous nerve branches. Distally I develop the Kocher interval between extensor carpi ulnaris, supplied by the posterior interosseous nerve, and anconeus, supplied by the radial nerve. Before any work near the radial neck I fully pronate the forearm to swing the PIN medially off the supinator. Proximally I incise the periosteum on the lateral supracondylar ridge and elevate the common extensor origin with brachioradialis as a flap, staying on bone and not extending more than roughly ten centimetres proximally without identifying the radial nerve. I preserve the lateral collateral ligament complex on a bone fleck where possible. I then perform a lateral capsulotomy to visualise the capitellum, lateral trochlea and radiocapitellar joint, reduce the fragment anatomically aiming for a step-off of less than two millimetres, and fix it with countersunk headless compression screws. Before closing I repair the lateral collateral ligament complex back to the isometric point on the lateral epicondyle, reattach the common extensor origin, and close in layers.

Key clinical points

Confirm the pattern on CT: capitellar coronal shear, trochlear extension, no posterior column

Supine with the arm free across the chest to allow pronation and supination

Curved lateral incision over the epicondyle extending into the Kocher interval

Plane is ECU (PIN) and anconeus (radial nerve), extended proximally

Pronate the forearm to protect the PIN

Elevate the common extensor origin off the supracondylar ridge

Preserve and then repair the LCL complex to the isometric point

Anatomic reduction with headless compression screws

Common pitfalls

Operating without CT and missing trochlear or posterior column extension

Failing to pronate and injuring the PIN near the radial neck

Leaving the lateral collateral ligament complex unrepaired, causing posterolateral rotatory instability

Proud hardware breaching the articular cartilage of the capitellum

Further questions

“How would your plan change if there were a posterior column fragment?”

Viva scenarioChallenging

Clinical prompt

“Six weeks after a capitellar fracture fixed through a lateral approach, a patient describes the elbow catching and a sense of it giving way, particularly when rising from a chair pushing through the arm. Examination shows a positive lateral pivot-shift apprehension. What has happened and how do you manage it?”

Practical approach

The presentation is classic for posterolateral rotatory instability from deficiency of the lateral ulnar collateral ligament, almost certainly because the LCL complex was either not preserved or not repaired during the index lateral approach. The LUCL is the essential restraint described by O'Driscoll, and its loss allows the humeroulnar joint to rotate posterolaterally under axial, valgus and supination load, giving the catching and giving-way symptoms and a positive lateral pivot-shift apprehension. I would confirm the diagnosis clinically and with stress radiographs or MRI to assess the ligament and any associated bony deficiency, and review the fixation to confirm the fracture has united and is not contributing to a mechanical block. For symptomatic instability that has failed a period of activity modification and physiotherapy, the definitive management is surgical reconstruction of the lateral collateral ligament complex - typically using a tendon graft such as palmaris longus routed through the lateral epicondyle, the ulna at the supinator crest and the radial head to recreate the LUCL, tensioned at thirty degrees of flexion with the forearm pronated. If there is a substantial bony avulsion of the lateral epicondyle, I would fix that primarily. The key lesson is prevention: during any lateral elbow approach the LCL complex should be preserved on a bone fleck where possible, or carefully detached and repaired to the isometric point on the lateral epicondyle through transosseous tunnels or suture anchors.

Key clinical points

Diagnosis is posterolateral rotatory instability from LUCL deficiency

Mechanism: LCL complex not preserved or repaired at the index procedure

LUCL is the essential restraint (O'Driscoll)

Confirm with stress radiographs or MRI, and confirm the fracture has united

Definitive treatment is LUCL reconstruction with a tendon graft

Prevention: preserve on a bone fleck or repair to the isometric point

Common pitfalls

Attributing the symptoms to the fracture hardware without assessing instability

Promising spontaneous resolution of an established ligamentous deficiency

Reconstructing the ligament without addressing any bony deficiency

Not counselling the patient that the original injury was potentially preventable

Further questions

“How do you perform and interpret the lateral pivot-shift test?”

Viva scenarioChallenging

Clinical prompt

“A 50-year-old man has a bicolumnar intra-articular distal humeral fracture. You are considering the Wrightington extended lateral approach versus an olecranon osteotomy. How do you choose?”

Practical approach

For a true bicolumnar intra-articular distal humeral fracture the priority is global visualisation of the articular surface to achieve an anatomic reduction, and for that an olecranon osteotomy is generally preferred over the extended lateral approach. The osteotomy gives an unmatched view of the trochlea and both columns from posterior, which is why it remains the gold-standard extensile exposure for these fractures, accepting the morbidity of the osteotomy itself and the need for secure fixation of the olecranon at the end. I would reserve the extended lateral approach for situations where lateral access is the principal requirement: an isolated capitellar or lateral column fracture, selected non-unions, or particular arthroplasty strategies. Even then, if the CT shows trochlear comminution or a posterior column component, I would either add a medial approach or convert to an olecranon osteotomy to ensure I can reduce the whole articular surface under direct vision. My decision therefore turns on the CT: simple capitellar or lateral column pathology gets an extended lateral approach, while bicolumnar intra-articular comminution gets an olecranon osteotomy. The key principle is that the approach must serve the reduction - a beautiful exposure of the wrong column is useless if the articular surface is not anatomically reduced and stably fixed.

Key clinical points

For bicolumnar intra-articular fractures, olecranon osteotomy gives the best articular view

The extended lateral approach suits isolated capitellar or lateral column pathology

Decision is CT-driven: define all columns and fragments first

Posterior column or trochlear comminution pushes toward osteotomy or a combined approach

The approach must serve an anatomic, stable articular reduction

Accept olecranon osteotomy morbidity when global articular visualisation is needed

Common pitfalls

Using an extended lateral approach for a fracture that needs global articular visualisation

Not ordering CT and underestimating trochlear or posterior column involvement

Forgetting that the olecranon osteotomy itself needs secure fixation

Prioritising a tidy single approach over an anatomic reduction

Further questions

“How do you perform and fix an olecranon osteotomy?”

Exam day cheat sheet

WRIGHTINGTON EXTENDED LATERAL APPROACH TO THE ELBOW

Patient position

Supine with the arm draped free across the chest
Bump under the ipsilateral scapula to bring the elbow forward
Forearm must be free to pronate (protects PIN) and supinate throughout
Pneumatic tourniquet on the well-padded upper arm
Image intensifier available from the ipsilateral side

Internervous plane

Between ECU (posterior interosseous nerve) and anconeus (radial nerve)
This is the Kocher interval extended proximally
Proximally becomes subperiosteal elevation of the common extensor origin off the lateral supracondylar ridge
Limited proximally by the radial nerve at roughly 10 cm above the lateral epicondyle
Stay on bone throughout to protect nerves

PIN protection

PIN enters the supinator via the arcade of Frohse, about 3 cm distal to the radiocapitellar joint
Closest to the radial neck in supination
Fully pronate the forearm to swing it medially away from the field
Avoid blind retraction in the supinator
Document finger and thumb extension before and after surgery

LCL preservation and repair

LUCL component is the essential restraint to posterolateral rotatory instability (O'Driscoll)
Preserve on a bone fleck from the lateral epicondyle where possible
Otherwise detach sharply and repair to the isometric point
Repair through transosseous drill holes or suture anchors
Unrepaired LCL deficiency causes recurrent instability

Procedures through the approach

Capitellar fractures, especially complex coronal shear
Lateral column distal humeral fractures
Bicolumnar fractures where lateral access is combined with a medial approach
Distal humeral non-union and selected total elbow arthroplasty
Radial head ORIF through the distal Kocher component

Closure and complications

Repair the LCL complex to the isometric point - mandatory
Reattach the common extensor origin to the ridge
Layered closure, drain as needed, splint in 90 degrees of flexion
Avoid varus and extension stress on the LCL repair early on
Watch for PIN injury, PLRI, stiffness and post-traumatic arthritis

References

Guidelines, Registries & Global Practice Lateral approaches to the elbow are used worldwide, and the operative principles are convergent across examination systems. Two principles recur in every modern description: protect the posterior interosseous nerve by pronating the forearm, and preserve or repair the lateral collateral ligament complex to prevent posterolateral rotatory instability. Side-by-side principles (where guidance converges): | Body | Position on lateral elbow approaches |

|------|--------------------------------------| | AO Foundation | CT mandatory for articular distal humeral fractures; lateral column addressed through a lateral approach with the PIN protected by pronation; anatomic articular restoration is the goal | | AAOS / OTA | Anatomic articular reduction and stable fixation as primary goals; recognise that many capitellar fractures are complex articular injuries with trochlear extension | | BOA / BOAST | Soft-tissue assessment and timing matter; photographic documentation for open injuries; definitive fixation once soft tissues permit | Global practice variation: in high-resource settings, pre-contoured lateral column plates, headless compression screws and suture anchors for LCL repair are standard, and CT guides every articular case; in resource-limited settings the same principles are applied with small-fragment reconstruction plates and transosseous sutures for the LCL. The extended lateral approach is universally valued where lateral column access suffices, while olecranon osteotomy remains the global standard for bicolumnar intra-articular comminution. Consent (globally applicable): discuss posterior interosseous nerve injury (prevented by pronation), posterolateral rotatory instability (prevented by LCL repair), infection, stiffness, heterotopic ossification, and the possibility of post-traumatic arthritis or later arthroplasty if the articular surface is severely damaged.

Evidence

Posterolateral Rotatory Instability of the Elbow

LoE 4

O'Driscoll SW, Bell DF, Morrey BF • Journal of Bone and Joint Surgery (Am) (1991)

Key Findings:

Identified the lateral ulnar collateral ligament (LUCL) as the essential lesion in posterolateral rotatory instability of the elbow
Described the lateral pivot-shift test and the spectrum from subluxation to dislocation
Established that integrity of the lateral collateral ligament complex is critical to lateral elbow stability
Forms the anatomical rationale for preserving and repairing the LCL complex during any lateral elbow approach

Clinical implication: Every lateral elbow approach must preserve or repair the LUCL component of the LCL complex, or iatrogenic posterolateral rotatory instability will follow

Evidence

Anatomical Considerations Regarding the Posterior Interosseous Nerve During Posterolateral Approaches to the Proximal Forearm

LoE 4

Diliberti T, Botte MJ, Abrams RA • Journal of Bone and Joint Surgery (Am) (2000)

Key Findings:

Mapped the course of the posterior interosseous nerve through the supinator in relation to the proximal radius
Demonstrated that pronation of the forearm moves the PIN away from the surgical field
Quantified the safer distance between the nerve and the radius in pronation compared with supination
Provides the anatomical basis for pronating the forearm to protect the PIN during lateral elbow surgery

Clinical implication: Full forearm pronation is a reproducible, evidence-based manoeuvre to protect the PIN when working near the radial neck and supinator

Evidence

Articular Fractures of the Distal Part of the Humerus

LoE 4

Ring D, Jupiter JB, Gulotta L • Journal of Bone and Joint Surgery (Am) (2003)

Key Findings:

Showed that many capitellar fractures are in fact complex articular distal humeral injuries with trochlear and posterior column extension
Emphasised the need for an extended lateral approach to visualise and fix these fragments
Demonstrated that inadequate visualisation leads to missed fragments and malreduction
Supported the use of an extensile lateral exposure for coronal-plane articular distal humeral fractures

Clinical implication: Plan the exposure from the CT: complex coronal shear fractures require an extended lateral approach rather than a limited lateral window

Evidence

Outcome After Open Reduction and Internal Fixation of Capitellar and Trochlear Fractures

LoE 4

Dubberley JH, Faber KJ, MacDermid JC, Patterson SD, King GJW • Journal of Bone and Joint Surgery (Am) (2006)

Key Findings:

Reported good functional outcomes after ORIF of capitellar and trochlear fractures through an extended lateral approach
Introduced a classification separating fractures with and without a posterior column component
Identified an associated posterior column fragment as a negative prognostic factor
Supported early mobilisation after stable fixation

Clinical implication: The presence of a posterior column component worsens prognosis and must be identified on CT and addressed surgically

Evidence

Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis with Reference to the Radial Nerve

LoE 4

Gerwin M, Hotchkiss RN, Weiland AJ • Journal of Bone and Joint Surgery (Am) (1996)

Key Findings:

Mapped the course of the radial nerve around the humerus relative to the lateral epicondyle
Defined the safe zones for posterior and lateral humeral approaches
Showed that the radial nerve crosses and pierces the lateral intermuscular septum in the distal third of the arm
Established the proximal limit for safe extension of lateral elbow approaches along the supracondylar ridge

Clinical implication: Proximal extension of the extended lateral approach beyond roughly 10 cm above the lateral epicondyle risks the radial nerve unless it is formally identified