Posterior Approach to the Elbow indications:

The Posterior Approach to the Elbow provides the best possible view of the bones that comprise the elbow joint.

The posterior approach to the elbow usually requires an osteotomy of the olecranon on its articular surface, creating another “fracture” that must be internally fixed.

The uses of the posterior approach to the elbow include the following:

  1. Open reduction and internal fixation of fractures of the distal humerus:
    • It provides best possible intra-articular view of the elbow joint.
  2. Removal of loose bodies in the joint.
  3. Treatment of non unions of the distal humerus.
  4. Triceps muscle lengthening for extension contractures of the elbow.
Posterior Approach to the Elbow

Position of the Patient

  • Place the patient in prone or lateral decubitus with the elbow flexed and the arm hanging from side of table.
Posterior Approach to the Elbow

Landmarks and Incision

  • Landmark:
    • Olecranon process.
  • Incision:
    • Make a longitudinal incision on the posterior aspect of the elbow. Begin 5 cm above the olecranon in the midline of the posterior aspect of the arm.
    • Just above the tip of the olecranon, curve the incision laterally so that it runs down the lateral side of the process.
    • To complete the incision, curve it medially again so that it overlies the middle of the subcutaneous surface of the ulna.
    • Running the incision around the tip of the olecranon moves the suture line away from devices that are used to fix the olecranon osteotomy and away from the weight-bearing tip of the elbow.
Posterior Approach to the Elbow

Internervous plane

There is No true internervous plane for the Posterior Approach to the Elbow:

  • The extensor mechanism (the triceps muscle) is either split or detached.
  • The radial nerve innervates the triceps muscle more proximally.

Superficial dissection

  • First, palpate the ulnar nerve and fully dissect it out:
    • It is helpful to pass tape or penrose for identification at all times.
  • Incise deep posterior fascia in the midline.
  • Can either split triceps fascia, or continue with olecranon osteotomy.
  • If performing olecranon osteotomy, drill and tap olecranon prior to osteotomy.
  • Score the olecranon with an osteotome to allow perfect reduction when the osteotomy is repaired.
  • V-shaped osteotomy of the olecranon 2 cm from the tip using an oscillating saw.

Deep dissection

  • Strip soft tissue from the edges of the osteotomy site and retract the olecranon fragment proximally.
  • Subperiosteal dissection of the medial and lateral borders of the humerus allows exposure of entire distal fourth of the humerus.

Approach Extension

Posterior Approach to the Elbow can be extended as following:

  • Proximal Extension:
    • The posterior approach to the elbow 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.

Dangers

The structures at risk during Posterior Approach to the Elbow include:

  1. Ulnar nerve:
    • The ulnar nerve should initially be identified and protected during this approach.
    • It can usually be palpated 2cm proximal to medial epicondyle.
    • Transposition of the ulnar nerve has shown no benefit to reducing the incidence of ulnar neuritis.
  2. Median nerve:
    • Strict subperiosteal dissection off the anterior surface of the humerus protects the nerve.
    • Flexion of the elbow relaxes the anterior structures.
  3. Radial nerve:
    • Radial nerve is in danger proximally as it travels from the posterior to anterior brachial compartments through lateral intermuscular septum.
    • It can usually be found at the lateral border of the humerus near distal 1/3 junction.
  4. Brachial artery:
    • Brachial artery runs with the median nerve.

References

  • Surgical Exposures in Orthopaedics book – 4th Edition
  • Campbel’s Operative Orthopaedics book 12th