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Triceps Reflecting Approach to the Elbow

- See: Posterior Approach to the Humerus;

- Positioning:
    - patient is in lateral position w/ arm brought across the chest;
    - plan on adusting flexion of elbow inorder to increase or decrease tension;
    - sterile tourniquet is required;

- Technique:
    - straight longitudinal incision beginning 7-10 cm above posterior aspect of humerus, avoiding the olecranon tip by shifting the incision 
          slightly medially, and then continue the incision over the border of the ulna;
    - ulnar nerve:
          - expose triceps fascia and ulnar nerve as it courses into the cubital tunnel;
          - proximall the ulnar nerve is found at medial margin of triceps lying in epineural fat;
          - dissect the ulnar nerve distally to its first motor branch;
          - proximally identify and remove the intermuscular septum;
          - it is then translocated anteriorly into a SubQ pocket;
    - instead of splitting the triceps, define the medial aspect of the triceps, and reflect it laterally;
    - elevate medial aspect of triceps from humerus to level of joint capsule;
    - distally incise the fascia along the medial aspect of the olecranon, and proximal ulna;
    - raise a full thickness "apron" of periosteum, fascia, and triceps insertion from a medial to a lateral direction, until the majority of the 
          olecranon is exposed;
          - as the apron of tissue is reflected laterally, attempt to include the posterior joint capsule;
          - distally the aconeus can be elevated off the ulna;
    - the medial 1/3 to medial 1/2 of the triceps insertion may be elevated from the tip of the olecranon;
    - the entire triceps is elevated off the posterior humerus;
    - wound closure include proximal reattachment of the triceps insertion into crossing drill holes into the olecranon, and more distally 
          anchoring the periosteum to the superficial forearm fascia;
          - deep forearm fascia is then securely closed to prevent ulnar subluxation