Posterior Approach to the Elbow

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. ORIF of fractures of the distal humerus:
      • provides best possible intra-articular view of elbow joint.
    2. Removal of loose bodies.
    3. Treatment of non-unions of the distal humerus.
    4. Triceps lengthening for extension contractures of the elbow.

  • Prone or lateral decubitus:
    • With elbow flexed and arm hanging from side of table.

  • Landmark:
    1. Olecranon process .
  • Incision:
    1. Begin 5cm proximal to the olecranon in the midline of the posterior distal humerus.
    2. Curve laterally proximal to the tip of the of the olecranon along the lateral aspect of the olecranon process.
    3. Then curve medially over the middle of the posterior aspect of the subcutaneous ulna.

  • There is No true internervous plane for the Posterior Approach to the Elbow:
    • The extensor mechanism is either split or detached
    • The radial nerve innervates the triceps muscle more proximally

  • 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.

  • 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.

  • 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 .

  • The structures at risk during Posterior Approach to the Elbow includes:

    1. Ulnar nerve:
      • Should initially be identified and protected during the approach.
      • 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:
      • In danger proximally as it travels from the posterior to anterior brachial compartments through lateral intermuscular septum.
      • Can usually be found at the lateral border of the humerus near distal 1/3 junction.
    4. Brachial artery:
      • Runs with the median nerve.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
Posterior Approach to the elbow Posterior Approach to the elbow Posterior Approach to the elbow Posterior Approach to the elbow Posterior Approach to the elbow Posterior Approach to the elbow
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