Posterior Approach to the Elbow without Olecranon Osteotomy

The posterior approach to the elbow without osteotomy provides excellent exposure of the elbow while preserving bony anatomy.6 A variety of techniques have been described for this approach but all of them have the same end point—the creation of a flap consisting of the triceps muscle, its insertion into the olecranon, and the fascia covering the flexor carpi ulnaris muscle based laterally on the anconeus muscle.7

The uses for the posterior approach include the following:

1. Open reduction and internal fixation of fractures of the distal humerus.3,4

2. Total joint arthroplasty

3. Excision of tumors

Position of the Patient

Place the patient lateral on the operating table ensuring adequate protection for the chest, pelvis, and arm using a padded table. Exsanguinate the limb by elevating it and apply a tourniquet as high up on the arm as possible. Allow the elbow to flex and the forearm and hand to lie over the side of the table (Fig. 3-6)

Landmarks and Incision

Landmark

Palpate the large, bony olecranon process at the upper end of the ulna. It is conical and has a relatively sharp apex. Palpate the medial and lateral epicondyles and mark them to be sure during surgery which side is medial and which side is lateral.

Incision

Make a longitudinal incision on the posterior aspect of the elbow. Begin 12 cm above the olecranon in the midline of the posterior aspect of the arm. Just above the elbow curve the incision laterally so that it runs down the lateral side of the olecranon process. Distally continue the incision along the subcutaneous surface of the ulna for 8 to 10 cm. Running the incision around the tip of the olecranon moves the suture line and resultant surgical scar away from the prominent olecranon (Fig. 3-7).

Internervous Plane

There is no true internervous plane because the approach involves little

more than detaching the extensor mechanism of the elbow from its insertion into the ulna. The nerve supply of the triceps muscle (radial nerve) enters the muscle well proximal to the dissection.

Superficial Surgical Dissection

Incise the deep fascia in the midline. Palpate the ulnar nerve as it lies in the bony groove at the back of the medial epicondyle and incise the fascia overlying the nerve to expose it. Fully dissect out the ulnar nerve and pass tapes around it so that it can be identified at all times (see Fig. 3-3). Do not use these tapes for retraction as this can create a traction lesion to the nerve. Incise the fascia overlying the flexor carpi ulnaris muscle at the border of the ulna.

Figure 3-6 Place the patient in the lateral position on the operating table.

Figure 3-7 Make a 12-cm longitudinal incision on the posterior aspect of the elbow. Gently curve the incision to run on the lateral side of the olecranon process.

Figure 3-8 With the elbow flexed about 30 degrees reflect the triceps mechanism

from medial to lateral in continuity with the forearm fascia and the olecranon and ulnar periosteum.

Figure 3-9 Incise the fascia on the medial border of the triceps. Reflect the entire extensor mechanism laterally flexing the elbow to 100 degrees to improve visualization of the joint surface.

Deep Surgical Dissection

The key to this approach is keeping a large thick fascial insertion of triceps for reinsertion onto the olecranon when the approach is complete. With the elbow flexed about 30 degrees reflect the triceps mechanism from medial to lateral in continuity with the forearm fascia and the olecranon and ulnar periosteum. Strip the forearm fascia and triceps insertion off the ulna by sharp dissection. At the level of the olecranon detach these structures together with a sliver of bone using a sharp osteotome (Fig. 3-8). Proximal to the olecranon of the elbow incise the fascia on the medial border of the triceps (Fig. 3-9). Incise the posterior capsule of the joint and reflect the entire extensor mechanism laterally flexing the elbow to 100 degrees to improve visualization of the joint surface (Fig. 3-10). Always be aware of the ulnar nerve on the medial side of the elbow.

Dang

Nerves

The ulnar nerve is always at risk, and must be protected throughout from a traction injury.

Special Points

Great care must be taken when the triceps tendon is detached from the olecranon to ensure that the full thickness of the triceps tendon is detached. To ensure this removing a small sliver of bone is advised.

Figure 3-10 Proximal to the olecranon incise the posterior capsule of the elbow.

How to Enlarge the Approach

Extensile Measures

Proximal Extension. The posterior approach can be easily extended proximally by freeing the medial aspect of the triceps muscle from the medial intermuscular septum preserving the ulna nerve.

Distal Extension. The incision can be continued along the subcutaneous border of the ulna exposing the entire length of that bone between the extensors of the elbow and wrist and the flexors of the wrist.