Posterior approach to the elbow

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Introduction

Indications

  • Open reduction and internal fixation of fractures of the distal humerus.
  • Removal of loose bodies within the elbow joint.
  • Treatment of nonunions of the distal humerus.

Advantages

  • Wide exposure of the bones that comprise the elbow joint.
  • Safe and reliable operative technique.

Disadvantage

  • Osteotomy of the olecranon on its articular surface, creating a fracture that need to be internally fixed.

Position of patient

Two positions can be used.

Prone

  • The intubated patient is placed prone on the operating table.
  • Padding for the chest and pelvis allow free movement of the abdomen during respiration.
  • Tourniquet applied as high up on the arm as possible after exsanguinate the limb by elevating it for 3 to 5 minutes.
  • Abduct the arm about 90° and place a small sandbag underneath the tourniquet, elevating the upper arm from the table and allowing the elbow to flex and the forearm to hang over the side of the table.

Supine

  • The patient is placed supine with arm across the chest. A gown is placed between the chest and the elbow to allow 90° flexion of the elbow joint.

Landmarks and incision

Landmarks

  • Tip of olecranon (conical and has a relatively sharp apex), medial epicondyle, ulnar nerve in cubital tunnel, nonarticular portion of olecranon.

Incision

  • Beginning 5 cm above the olecranon in the midline of the posterior aspect of the arm, make a longitudinal incision on the posterior aspect of the elbow.
  • Above the tip of the olecranon, curve the incision laterally so that it runs down the lateral side of the process.
  • Curve the incision medially again so that it overlies the middle of the subcutaneous surface of the ulna.

Internervous plane

There is no true internervous plane as the radial nerve of the triceps muscle enters the muscle well proximal to the dissection.

Superficial dissection

  • The deep fascia is incised in the midline.
  • Palpate the ulnar nerve as it lies in the bony groove on the back of the medial epicondyle and incise the fascia overlying the nerve to expose it and pass tapes around it so that it can be identified at all times.
  • Make a V-shaped osteotomy of the olecranon about 2 cm from its tip using an oscillating saw; the apex of the V is directed distally.
  • Divide the bone until it is cut through almost entirely and snap the remaining cortex by wedging the two cut surfaces apart with an osteotome.
  • If a screw is going to be used to fix the olecranon osteotomy, drill and tap the olecranon before the osteotomy is performed.

Deep dissection

  • Strip the soft-tissue attachments off the medial and lateral sides of the portion of the olecranon that has been subjected to osteotomy and retract it proximally, elevating the triceps from the back of the humerus.
  • The posterior aspect of the distal end of the humerus is directly underneath. Subperiosteal dissection around the medial and lateral borders of the bone allows exposure of all surfaces of the distal fourth of the humerus.
  • Note that excessive stripping of the soft-tissue attachments off the bone leaves the bone fragments without a vascular supply and jeopardizes healing.

Dangers

Nerves

  • The ulnar nerve is in no danger as long as it is identified early and protected, and excessive traction is not placed on it.
  • As the median nerve lies anterior to the distal humerus, it may be endangered if the anterior structures are not stripped off the distal humerus. A strictly subperiosteal plane dissection must be used to avoid damage to the nerve
  • Be careful not to extend the dissection proximally above the distal fourth of the humerus, because the radial nerve, which passes from the posterior to the anterior compartment of the arm through the lateral intermuscular septum, may be damaged.

Vessels

  • As the brachial artery lies with the median nerve in front of the elbow, it should be afforded the same protection as is the nerve.

How to enlarge the approach

Proximal Extension

  • The posterior approach cannot be extended more proximally than the distal third of the humerus because of the danger to the radial nerve.

Distal Extension

  • The incision can be continued along the subcutaneous border of the ulna, exposing the entire length of that bone.
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