- See:
Posterior Approach to the Humerus;
- Discussion:
- considered to be the most versatile approach to the elbow;
- most surgeons use straight longitudinal incision, which avoids olecranon tip, by shifting the incision slightly laterally or medially;
- Variations of Posterior Approach:
-
Transolecranon Osteotomy
- indicated for
condylar fractures;
- can be intra-articular or extra-articular;
- affords best visualization, of the distal articular fragments;
-
Triceps Splitting: (Urbaniak)
-
Tricpers Reflecting:
- Caputo Technique:
- indicated for extra-articular adult supracondylar fractures;
- uses a standard posterior skin incision;
- medial and lateral windows are created on either side of the
triceps muscle;
- medially, the
ulnar nerve is carefully identified from its entrance between the two heads of the
FCU up to a point cephalad to the
arcade of Struthers;
- see:
anatomy of the cubital tunnel;
- note that dissection proximal to the arcade of Struthers may injure the
brachial artery;
- laterally, the
radial nerve is identified as it passes between the
triceps and
brachialis;
- the nerve can be found crossing this interval at a point just distal to the deltoid insertion;
- once both nerves have been identified and protected, the medial and lateral borders of triceps is identified are dissected down to bone;
- triceps can then be mobilized to either side to allow exposure to the medial and lateral sides of the distal humerus;
- Modified Pediatric Approach:
- posterior approach may be indicated for irreducible
supracondylar frx (see
open reduction) or for displaced
lateral condyle frx;
- posterior incision is made which curves along the medial side of olecranon;
-
ulnar nerve is identified and protected;
-
triceps tendon is transected 1 cm from its insertion (so that an adequate cuff of tendon is left for closure);
- remaining triceps insertion is elevated medially or laterally;
- the proximal portion of the tendon is mobilized proximally;
- posterior capsule is opened transversely from medial to lateral;
- the frx site is exposed and fixed appropriately;
- triceps tendon is closed securely w/ non absorbable sutures;
- arm is then immobilized in a cast (3 weeks for supracondyalr frx and 4-5 weeks for lateral condyle frx);
Extensive posterior exposure of the elbow. A triceps-sparing approach.
The posterior approach to the elbow revisited. MA Gruber MD and WA Healey MD. J. Pediatric Orthopedics. Vol 16. 1996. p 215-219.
Alternative Operative Exposures of the Posterior Aspect of the Humeral Diaphysis. With Reference to the Radial Nerve.
M. Gerwin MD, R.N. Hotchkiss MD, and A.J. Weiland MD. JBJS Vol 78-A, No 11, Nov. 1996. p 1690-1706.
The triceps-dividing approach to open reduction of complex distal humeral fractures in adolescents: a Cybex evaluation of triceps function and motion.
JR Kasser et al. J. Pediatric Orthopedics. Vol 10. 1990. p 93-96.
The midline posterior elbow incision. An antomical appraisal. PA Dowdy et al. JBJS. Vol 77-B (5) 1995. p 696-699.
