n tips & techniquesSection Editor: Steven F. Harwin, MD

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Extended Paratricipital Approach for Intra-articular Fractures of the Distal HumerusShai Shemesh, MD; Mark Yan Loebenberg, MD; Yona Kosashvili, MD; Eliezer Sidon, MD; Steven Velkes, MD; Nir Cohen, MD

Fractures of the distal hu-merus are complex inju-

ries that often require surgical treatment.1 Open reduction with bicolumnar internal fixa-tion has been shown to provide more predictable outcomes and earlier joint mobilization. The

high density of neurologic, vascular, and ligamentous ele-ments around the distal part of the humerus makes these frac-tures particularly challenging to treat.

Posterior approaches to the distal humerus are indicated

for procedures such as triceps tendon repair and total elbow arthroplasty, as well as osteo-synthesis of distal humerus and olecranon fractures.2 Select-ing the most suitable approach depends on several factors, in-cluding patient factors, the de-gree of articular visualization required for anatomic reduc-tion and fixation, fracture char-acteristics, and any associated injuries.1

The transolecranon ap-proach to the elbow was de-scribed by MacAusland3 in 1915 and was later further developed by Müller et al4 to include a posterior oblique olecranon osteotomy. The transverse and oblique olecra-non osteotomies have largely been replaced by the chevron osteotomy.1

Compared with other pos-terior approaches, olecranon osteotomy allows the best visu-alization of the distal humerus articular surface.5,6 Olecranon osteotomy provides excellent

exposure of the distal humerus, is straightforward, and is asso-ciated with limited complica-tions when appropriate recon-struction techniques are used.

The main disadvantages of this approach are related to the osteotomy itself, including non-union, malunion, and hardware irritation.7-9 On the other hand, the paratricipital approach de-scribed by Alonso-Llames10 al-lows bicolumnar exposure and plating, while maintaining the triceps insertion undisturbed, minimizing the risk of post-operative extensor mechanism insufficiency.2,10 Knowledge of the location of the radial nerve with reference to the posterior aspect of the humerus and to the lateral epicondyle, as well as its influence on the potential proximal extent of the opera-tive approach, cannot be over-emphasized.11

Surgical TechniqueThe authors routinely ob-

tain conventional anteroposte-

The authors are from the Department of Orthopedic Surgery, Rabin Med-ical Center, Beilinson Campus, Petach Tikva, Israel.

Drs Shemesh and Cohen contributed equally to this work and should be considered as equal first authors.

The authors have no relevant financial relationships to disclose.Correspondence should be addressed to: Shai Shemesh, MD, Depart-

ment of Orthopedic Surgery, Rabin Medical Center, Beilinson Campus, 39 Jabotinski St, Petach Tikva 49100, Israel (shemesh.shai@gmail.com).

Received: February 21, 2014; Accepted: May 28, 2014.doi: 10.3928/01477447-20150701-04

Abstract: This article describes an extensile surgical exposure to the distal humerus that is suitable for complex fractures in-volving the articular surface and extending into the humeral di-aphysis proximal to the radial nerve. This method combines 2 approaches: olecranon osteotomy and the lateral paratricipital approach. This combination allows an appropriate exposure of both the articular surface and the humeral diaphysis up to the level of the deltoid tuberosity, while maintaining the extensor mechanism unharmed. [Orthopedics. 2015; 38(7):435-438.]

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rior and lateral radiographs, as well as preoperative computed tomography scans with 3- dimensional reconstruction, to

assist in preoperative planning (Figure 1).

The patient is placed on the operating table in the prone

position, with the injured arm placed on a support allowing at least 90° of elbow flexion. The limb is prepared circum-

ferentially and draped free in the operative field. The authors use a posterior longitudinal skin incision, begun proximal to the olecranon process, cen-tered on the triceps tendon, and taken distally over the olecranon process. The inci-sion is finished distally, 8 cm distal to the tip of the olecra-non. The fascia overlying the triceps is identified and split to allow the elevation of full-thickness fasciocutaneous me-dial and lateral flaps.

The medial and lateral as-pects of the triceps are identi-fied, and the ulnar nerve is iso-lated. The nerve is identified proximally, decompressed at the level of the 2 heads of the flexor carpi ulnaris, and left in its bed, marked with a vessel loop.

Next, a capsulotomy is per-formed on both sides of the olecranon. An osteotomy is created with an oscillating saw in a chevron configuration, typically with the apex pointed distally. An osteotome is used to complete the procedure so that a portion of the osteotomy site is serrated.

Afterward, a lateral inter-muscular plane is developed between the lateral border of the triceps tendon and the intermuscular septum. The dissection is extended proxi-mally to the point where the lateral branchial cutaneous nerve is identified. The dissec-tion along the lateral branchial cutaneous nerve is continued proximally along its course at the lateral aspect of the hu-merus up to the trifurcation of the radial nerve into the lateral branchial cutaneous nerve, the

Figure 1: Anteroposterior (A) and lateral (B) radiographs of a 41-year-old patient with a complete articular fracture (OTA 13-C) of the distal humerus extending into the diaphysis. Note the intra-articular comminution on axial computed tomography scan (C).

Figure 2: Lateral dissection along the lateral border of the triceps, continuing proximally to the level of the radial nerve (solid arrow), with elevation of the triceps muscle off the lateral humerus. An Acumed Elbow Plating System (Acumed USA, Hillsboro, Oregon) was used, with a 3.5 20-hole (206 mm) locking lateral plate and a 3.5 16-hole (175 mm) lock-ing medial plate. The radial nerve crosses the plate between the 14th and 16th holes. The open arrow points to the ulnar nerve (A). The ulnar nerve (open arrow) was anteriorly transposed after reduction and fixation of the fracture (B). At the end of the operation, the chevron osteotomy was fixated with a tension band wire, while the triceps muscle was spared and allowed to resume its position (C).

A CB

A C

B

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branch to the medial head of the triceps, and the continu-ation of the radial nerve into the forearm. The lateral head of the triceps is then reflected medially en masse, maintain-ing the continuity of its fibers. The radial nerve is protected and marked with a vessel loop (Figure 2). Further proximal dissection, above the course of the nerve on the lateral as-pect of the humerus, provides exposure of the humeral shaft to the point of insertion of the deltoid muscle. The dissection between the medial and lateral tissue planes meets at the pos-terior humeral cortex as the tri-ceps muscle is separated from the humerus. Adequate expo-sure of the fracture is obtained, allowing open reduction and plate osteosynthesis.

The authors routinely use the Acumed Elbow Plating System (Acumed USA, Hills-boro, Oregon) in an orthogo-nal (Figure 3) or parallel orientation, depending on the fracture pattern. Long plates are allowed to be placed un-der the radial nerve and fixa-tion with proximal and distal screws through the plate is achieved. The olecranon is reattached with two 1.8-mm parallel Kirschner wires and a tension band wire in a figure-of-8 configuration beneath the triceps tendon. Thereafter, the medial and lateral heads of the triceps resume their anatomi-cal position. The elbow is then put through a full range of mo-tion to test the stability of the entire fixation.

The elbow usually is im-mobilized in the perioperative period for less than 10 days to

allow for soft tissue healing, at which time a gentle, active rehabilitation program is insti-tuted.

DiScuSSionThe extensile posterior ap-

proach described here has sev-eral distinct advantages. First, it provides excellent visualiza-tion of the articular surface, al-lowing accurate reduction and stable fixation. Second, the radial nerve is explored and protected at the fracture site. Third, it provides adequate ex-posure of both columns, allow-ing bicolumnar plating while monitoring both the ulnar and radial nerves. Fourth, it has the potential to be extended as needed should fracture exten-sion or comminution mandate more proximal fixation. Final-ly, it avoids dissection through the triceps or forceful retrac-tion on adherent tissues, as the dissection is made through natural tissue planes.

The authors believe that distal intra-articular humeral

fractures with long column fragments are optimal frac-ture patterns for this exposure. Although distal humerus frac-tures can be properly treated using other posterior ap-proaches (eg, simple chevron osteotomy, Alonso-Llames’ or Campbell’s triceps split-ting approach),1,2,9,12 the cur-rent authors believe that none of these approaches alone can sufficiently visualize both the articular surface and the mid-shaft extension of the complex fractures described here.

The drawbacks of the ex-tensile posterior approach are the long surgical wound, the extensive soft tissue stripping, and the aforementioned disad-vantages of the olecranon oste-otomy. Nevertheless, adequate surgical exposure for this type of injury is obligatory.

concluSionThe authors’ modified ap-

proach to the elbow securely and adequately exposes the elbow joint and the diaphyseal

distal humerus for fracture fixation purposes, allowing for safe exploration of the radial nerve. Through this exposure, the entire articular surface is readily accessible. The authors have used this approach in sev-eral cases of complex fractures and have found it safe and re-producible.

referenceS 1. Morrey BF, Sanchez-Sotelo J,

eds. The Elbow and Its Disor-ders. 4th ed. Philadelphia, PA: WB Saunders; 2009.

2. Cheung EV, Steinmann SP. Sur-gical approaches to the elbow. J Am Acad Orthop Surg. 2009; 17(5):325-333.

3. MacAusland WR. Ankylosis of the elbow: with report of four cases treated by arthroplasty. JAMA. 1915; 64(4):312-318.

4. Müller ME, Allgöwer M, Sch-meider R, Willenegger H. Manual of Internal Fixation: Techniques Recommended by the AO-ASIF Group. New York, NY: Springer-Verlag; 1991.

5. Dakouré P, Ndiaye A, Ndoye J-M, et al. Posterior surgical ap-proaches to the elbow: a simple method of comparison of the articular exposure. Surg Radiol Anat. 2007; 29(8):671-674.

Figure 3: Intraoperative anteroposterior (A) and lateral (B) fluoroscopic images and anteroposterior (C) and lateral (D) radiographs obtained after 6 months of follow-up showing union of the fractures as well as the olecranon osteotomy.

DCBA

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6. Wilkinson JM, Stanley D. Pos-terior surgical approaches to the elbow: a comparative anatomic study. J Shoulder Elbow Surg. 2001; 10(4):380-382.

7. Gainor BJ, Moussa F, Schott T. Healing rate of transverse oste-otomies of the olecranon used in reconstruction of distal hu-merus fractures. J South Orthop

Assoc. 1995; 4(4):263-268.

8. Henley MB, Bone LB, Parker B. Operative management of intra-articular fractures of the distal humerus. J Orthop Trau-ma. 1987; 1(1):24-35.

9. Ring D, Gulotta L, Chin K, Ju-piter JB. Olecranon osteotomy for exposure of fractures and nonunions of the distal hu-

merus. J Orthop Trauma. 2004; 18(7):446-449.

10. Alonso-Llames M. Bilatero- tricipital approach to the elbow: its application in the osteosyn-thesis of supracondylar frac-tures of the humerus in chil-dren. Acta Orthop Scand. 1972; 43(6):479-490.

11. Gerwin M, Hotchkiss RN,

Weiland AJ. Alternative opera-tive exposures of the posterior aspect of the humeral diaphy-sis with reference to the radial nerve. J Bone Joint Surg Am. 1996; 78(11):1690-1695.

12. Patterson SD, Bain GI, Mehta JA. Surgical approaches to the elbow. Clin Orthop Relat Res. 2000; 370:19-33.