import { ComparisonTable, ContentSection, EvidenceCard, ExamCheatSheet, ExamPearl, ExamWarning, InfoCard, InfoCardGrid, MedicalImage, MnemonicCard, OnePagerSummary, SafetyAlert, Tab, Tabs, Timeline, TimelineItem, VivaScenario, VivaScenarioSection } from '@/components/mdx' The **ulnar nerve is at risk** throughout the approach. Identify early in cubital tunnel between medial epicondyle and olecranon. Decompress and transpose anteriorly in most cases, especially for TEA. Injury rate 8% overall - higher if nerve not mobilized. Document preoperative nerve function. **Anatomic triceps repair prevents extension lag** and weakness. Use heavy nonabsorbable suture through drill holes in olecranon for all reflecting techniques. Drill 3-4 transverse tunnels 5mm apart. Repair at 30 degrees flexion to avoid over-tightening. Poor repair causes 15% strength loss. **Choose approach based on pathology**. Triceps-splitting: simple fractures. Bryan-Morrey: TEA, complex fractures. Olecranon osteotomy: comminuted intra-articular fractures requiring perfect visualization. Osteotomy delays rehab 6 weeks but provides best exposure. **Prone or lateral decubitus** with arm over bolster. Prone allows bilateral access and gravity assists soft tissue retraction. Lateral easier for anesthesia. Arm over bolster with elbow flexed 90 degrees opens posterior compartment. Tourniquet applied proximal arm. The **posterior approach to the elbow** provides access for distal humerus fractures and total elbow arthroplasty (TEA) via three main techniques: **triceps-splitting (Van Gorder)** preserves insertion but limits exposure; **triceps-reflecting (Bryan-Morrey)** elevates triceps with anconeus as a continuous sleeve and is most popular for TEA; **olecranon osteotomy** (chevron with apex distal) provides maximum articular visualization but requires secure fixation and delays rehabilitation. The **ulnar nerve** must be identified in the cubital tunnel and protected throughout—injury rate is 8%, higher if not mobilized. Anterior transposition is performed in 60-80% of cases. **Anatomic triceps repair** through drill holes in the olecranon (at 30° flexion) is critical to prevent extension lag and 15% strength loss. The **posterior approach to the elbow** is the workhorse approach for complex distal humerus fractures, total elbow arthroplasty, and posterior elbow pathology. Multiple variations exist to balance exposure against morbidity to the triceps mechanism. **Historical development:** - **1933**: Van Gorder described triceps-splitting approach preserving insertion - **1982**: Bryan and Morrey described triceps-reflecting technique with anconeus sleeve - **Classic**: Olecranon osteotomy described by multiple surgeons for maximum articular exposure - **Modern**: Paratricipital approaches attempt to spare triceps entirely for simple fractures **Current indications for posterior approach:** This approach provides the best exposure for: - Distal humerus fractures (intra-articular and extra-articular) - Total elbow arthroplasty (primary and revision) - Elbow arthrodesis - Heterotopic ossification excision - Posterior elbow impingement lesions - Olecranon fractures requiring distal fixation - Triceps repair after rupture **Epidemiology:** Distal humerus fractures account for approximately 2% of all fractures in adults, with bimodal distribution (young males and elderly females). In Australia, approximately 300-400 total elbow arthroplasties are performed annually according to the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The posterior approach is used in over 90% of complex distal humerus fracture fixations. **Triceps-splitting** (Van Gorder): Simple extra-articular or minimally displaced fractures, preserves insertion. **Triceps-reflecting** (Bryan-Morrey): Total elbow arthroplasty, complex fractures, most versatile and popular. **Olecranon osteotomy**: Comminuted intra-articular fractures requiring perfect articular visualization, delays rehabilitation 6 weeks. **Paratricipital**: Simple fractures in young patients, very limited exposure. **Outcomes by approach:** Studies comparing approaches show: - **Triceps-splitting**: 5% extension lag, excellent for simple fractures - **Bryan-Morrey reflecting**: 10% extension lag if poor repair, gold standard for TEA - **Olecranon osteotomy**: 15% nonunion/malunion rate, best visualization - **Paratricipital**: minimal morbidity but inadequate for complex fractures The choice of approach represents a balance between adequate exposure for the surgical goal and minimizing morbidity to the extensor mechanism. ### Surface Anatomy and Landmarks **Patient positioned - prone or lateral decubitus:** - Prone: patient face down, arm over bolster or arm table - Lateral: injured side up, arm draped free over bolster - Both allow gravity-assisted soft tissue retraction - Elbow flexed 90 degrees opens posterior compartment **Surface landmarks:** - Olecranon tip (palpable subcutaneously) - Medial epicondyle (prominent medial landmark) - Lateral epicondyle (less prominent laterally) - Ulnar nerve palpable in cubital tunnel (medial epicondyle to olecranon) - Triceps insertion to olecranon **Incision:** - Midline posterior over triceps and olecranon - Begins 10cm proximal to olecranon tip - Extends distally 8-10cm along subcutaneous border of ulna - Curves slightly medial or lateral around olecranon tip - Total length 15-20cm for adequate exposure ### Deep Anatomy and Structures at Risk **Triceps muscle anatomy:** The triceps has three heads converging to a common tendon: 1. **Long head** - origin from infraglenoid tubercle of scapula 2. **Lateral head** - origin from posterior humerus (lateral to radial groove) 3. **Medial head** - origin from posterior humerus (medial to radial groove) All three insert on the olecranon via a common tendon approximately 4cm wide. **Anconeus muscle:** Small triangular muscle lateral to triceps: - Origin: lateral epicondyle - Insertion: lateral olecranon and proximal ulna - Innervation: radial nerve - Function: assists elbow extension, stabilizes elbow In Bryan-Morrey approach, anconeus is elevated with triceps as continuous sleeve. **Ulnar nerve anatomy:** The ulnar nerve is THE critical structure at risk: - Descends medial intermuscular septum in arm - Passes through arcade of Struthers (medial head triceps) - Lies in cubital tunnel (between medial epicondyle and olecranon) - Covered by Osborne ligament (arcuate ligament) - Enters flexor carpi ulnaris between two heads - **Recurrent motor branch** to FCU given immediately distal to epicondyle The nerve is vulnerable throughout posterior approaches and must be identified early. **Radial nerve anatomy:** Less commonly injured but important: - Lies in spiral groove on posterior humerus - Passes anterior between brachialis and brachioradialis - Gives posterior interosseous nerve distal to elbow - At risk with proximal extension of approach or vigorous retraction **Blood supply:** Important vessels include: - **Brachial artery**: anterior, at risk if dissection carried too far medially - **Radial collateral artery**: anastomoses with radial recurrent, lateral side - **Medial collateral artery**: accompanies ulnar nerve, preserve during transposition - **Posterior ulnar recurrent artery**: runs with ulnar nerve, may need ligation **Safe zones:** - Ulnar nerve identified early prevents injury - Midline dissection avoids radial nerve laterally - Subperiosteal elevation protects neurovascular structures - Anterior dissection limited to avoid brachial vessels The posterior approach to the elbow does NOT use a true internervous plane. Instead, it splits or elevates the triceps muscle (innervated by radial nerve) to access the posterior distal humerus and elbow joint. **Triceps innervation:** The entire triceps muscle is innervated by the **radial nerve** (C7-C8): - Long head: branch from radial nerve in axilla - Lateral head: branches from radial nerve in spiral groove - Medial head: branches from radial nerve in spiral groove **Approach variations:** 1. **Triceps-splitting (Van Gorder)**: - Splits triceps in midline longitudinally - Preserves insertion on olecranon - Does NOT denervate muscle (splits between fascicles) - Minimal morbidity if split closed properly 2. **Triceps-reflecting (Bryan-Morrey)**: - Elevates triceps insertion from olecranon - Raises triceps and anconeus as continuous sleeve - Temporarily denervates insertion region - Requires anatomic repair for function 3. **Olecranon osteotomy**: - Osteotomizes olecranon with triceps attached - Preserves triceps insertion entirely - Maximizes articular exposure - Requires secure osteotomy fixation **Clinical implications:** Because this is NOT an internervous approach, **anatomic repair is essential** for all approaches that detach or split the triceps. The triceps provides the only active elbow extension, and injury or poor repair results in significant functional impairment. **Anconeus anatomy:** The anconeus (radial nerve innervation) is elevated with triceps in Bryan-Morrey approach, creating a continuous sleeve of extensor tissue. This provides broader lateral exposure and facilitates repair. Correct positioning optimizes exposure and facilitates surgical technique in posterior elbow approaches. **Position options:** ### Prone Position **Advantages:** - Both arms accessible (bilateral cases) - Gravity assists soft tissue retraction - Stable, secure position - Easy C-arm access from either side **Setup:** 1. Patient prone on chest rolls or Wilson frame 2. Arm abducted 90 degrees on arm table or bolster 3. Elbow flexed 90 degrees hanging off bolster 4. Forearm hanging dependent or supported 5. Head turned away from operative side **Padding critical:** - Chest and iliac crest on supports - Genitals (male) protected - Knees and toes padded - Elbows (opposite side) padded ### Lateral Decubitus Position **Advantages:** - Easier for anesthesia (airway access) - More familiar to shoulder surgeons - Easy conversion if approach extended **Setup:** 1. Lateral position with operative side up 2. Beanbag or supports for stability 3. Arm draped free over bolster or Mayo stand 4. Elbow flexed 90 degrees 5. Dependent axilla protected with roll **Padding critical:** - Axillary roll (two finger-breadths) - Lateral knee and fibular head - Dependent arm and shoulder ### Supine Position (Less Common) Can be used with arm across chest on folded towels: - Allows anterior access if needed - Less stable for fracture work - Difficult assistant positioning **Tourniquet:** - Applied to proximal arm after exsanguination - Pressure 250-300 mmHg for adults - Limit time to under 120 minutes - Release for TEA implantation (cement interdigitation) **Fluoroscopy:** - C-arm from contralateral side or over patient - Obtain AP and lateral views before draping - Ensure perfect lateral (anterior humeral line through capitellum) - Check position of arm allows full elbow extension for intraoperative views **Common positioning errors:** - Excessive abduction (brachial plexus stretch) - Inadequate padding (pressure injuries) - Arm position preventing full elbow motion - C-arm position inadequate for intraoperative imaging ### Skin Incision and Initial Dissection **Skin incision:** - Midline posterior from 10cm proximal to olecranon tip - Extend distally 8-10cm along subcutaneous border of ulna - Curve slightly medial or lateral around olecranon - Avoid placing directly over olecranon tip (pressure point) - Full-thickness through skin and subcutaneous tissue **Identify ulnar nerve:** This is the CRITICAL first step before proceeding: - Palpate nerve in cubital tunnel - Lies between medial epicondyle and olecranon - Gently dissect fascia overlying nerve - Mobilize nerve from proximal (arcade of Struthers) to distal (FCU) - Use vessel loop for identification and protection - Consider formal anterior transposition (see below) **Ulnar nerve management options:** 1. **In situ protection**: Gentle handling, protect with sponge (simple cases only) 2. **Anterior subcutaneous transposition**: Most common, move anterior to medial epicondyle, place in subcutaneous pocket 3. **Anterior submuscular transposition**: Under flexor-pronator mass, for chronic cubital tunnel or revision cases For most posterior approaches (fractures, TEA), **anterior transposition is recommended** to prevent postoperative cubital tunnel syndrome and protect nerve during approach. **Ulnar nerve transposition technique:** 1. Release cubital tunnel retinaculum 2. Release arcade of Struthers proximally 3. Release Osborne ligament (arcuate ligament) 4. Mobilize nerve from flexor carpi ulnaris distally 5. Preserve first motor branch to FCU 6. Preserve medial collateral artery with nerve 7. Create anterior subcutaneous pocket 8. Gently transpose nerve anterior to epicondyle 9. Ensure no kinking at proximal or distal end 10. Close fascia loosely (avoid compression) This completes the initial exposure and nerve protection. ### Van Gorder Triceps-Splitting Approach **Indications:** - Simple extra-articular distal humerus fractures - Olecranon fractures requiring distal fixation - Limited elbow pathology not requiring wide exposure - Young patients where triceps preservation important **Technique:** 1. **Identify triceps raphe**: - Midline longitudinal raphe between lateral and medial heads - Palpable as slight depression in tendon 2. **Split triceps longitudinally**: - Begin 8-10cm proximal to olecranon - Split in midline down to olecranon insertion - Use knife or scissors along natural raphe - Split preserves insertion on olecranon 3. **Elevate triceps laterally and medially**: - Elevate medial and lateral flaps off humerus - Subperiosteal elevation protects radial nerve - Expose distal humerus and posterior elbow joint 4. **Extend distally if needed**: - Can extend split into tendon to olecranon - Maintain 1-2cm cuff of tissue on olecranon for repair - Tag split edges with sutures for later closure **Exposure achieved:** - Distal humerus posterior surface - Limited articular visualization (flex elbow fully) - Adequate for simple extra-articular fractures - Insufficient for comminuted intra-articular fractures **Advantages:** - Preserves triceps insertion - Minimal extension weakness (5% only) - Faster rehabilitation - No osteotomy or formal detachment **Disadvantages:** - Limited articular exposure - Inadequate for complex fractures or TEA - Requires elbow flexion for joint visualization This concludes the triceps-splitting approach technique. ### Bryan-Morrey Triceps-Reflecting Approach **Indications:** - Total elbow arthroplasty (most common indication) - Complex distal humerus fractures (intra-articular) - Revision elbow surgery - Heterotopic ossification excision **Technique:** 1. **Mark triceps insertion**: - Triceps inserts on olecranon over 4cm width - Plan elevation of medial and lateral thirds with anconeus 2. **Elevate medial flap**: - Begin at medial border of triceps insertion - Elevate medial one-third of triceps from olecranon - Use sharp dissection with knife or electrocautery - Maintain 2-3mm cuff of tissue on olecranon for repair - Elevate proximally along medial column 3. **Elevate lateral flap with anconeus**: - Begin at lateral border of triceps insertion - Elevate lateral one-third of triceps from olecranon - Continue elevation to include entire anconeus muscle - Create continuous sleeve of triceps-anconeus laterally - Elevate proximally along lateral column 4. **Reflect triceps proximally**: - Elevate remaining central triceps from olecranon - Reflect entire triceps-anconeus sleeve proximally - Expose posterior distal humerus completely - Tag triceps edges with heavy sutures for later repair 5. **Expose elbow joint**: - Remove posterior capsule and fat pad - Expose olecranon fossa and posterior trochlea - Flex elbow to visualize articular surface - Extend elbow to expose distal humerus shaft **Exposure achieved:** - Complete posterior distal humerus exposure - Excellent articular visualization with elbow flexion - Access to medial and lateral columns - Adequate for complex fracture fixation and TEA **Key technical points:** - Continuous triceps-anconeus sleeve laterally facilitates repair - Maintain tissue cuff on olecranon for strong repair - Heavy tag sutures prevent retraction during case - Subperiosteal elevation proximally protects radial nerve This is the most versatile posterior elbow approach. ### Olecranon Osteotomy Approach **Indications:** - Severely comminuted intra-articular distal humerus fractures - Fractures requiring perfect articular reduction - Complex fracture-dislocations - Situations where articular surface must be directly visualized **Contraindications:** - Elbow arthroplasty (lose proximal ulna bone stock) - Severely osteoporotic bone (osteotomy may not heal) - Previous olecranon fracture or surgery **Osteotomy technique - Chevron (V-shaped):** 1. **Plan osteotomy**: - Apex distal at midpoint of trochlear notch - Arms extend proximally and laterally (inverted V) - Larger proximal fragment (better fixation surface) - Osteotomy parallel to joint line 2. **Mark osteotomy with K-wire**: - Drill pilot K-wire along planned osteotomy line - Verify position with fluoroscopy (lateral view) - Apex at deepest point of trochlear notch 3. **Perform osteotomy**: - Use oscillating saw or osteotome - Complete bone cut first - Then cut articular cartilage with knife - Preserve triceps insertion on proximal fragment 4. **Reflect olecranon proximally**: - Elevate proximal fragment with triceps attached - Retract proximally with bone hook or towel clip - Exposes entire distal humerus articular surface **Exposure achieved:** - Complete visualization of trochlea and capitellum - Direct view of articular comminution - Access to both columns simultaneously - Best exposure available for distal humerus **Osteotomy fixation after fracture work:** **Tension band wiring technique:** 1. Reduce osteotomy anatomically 2. Drill two parallel 1.6mm K-wires across osteotomy 3. Advance wires to engage anterior cortex 4. Drill transverse hole in ulna 2-3cm distal to osteotomy 5. Pass figure-of-8 wire (18-gauge) around K-wires and through drill hole 6. Tension wire while assistant holds reduction 7. Bend K-wire ends and bury subcutaneously **Plate fixation (preferred by many surgeons):** - One-third tubular plate or precontoured olecranon plate - 6-8 hole plate for adequate fixation - Lag screw across osteotomy first - Plate applied dorsally in compression mode - More rigid than tension band, allows earlier motion **Advantages of osteotomy:** - Best articular visualization - Facilitates anatomic reduction of complex fractures - Allows bicolumnar plating without soft tissue stripping **Disadvantages of osteotomy:** - Adds another fracture to heal (10-15% nonunion/malunion) - Delays rehabilitation 6 weeks for osteotomy healing - Hardware prominence common (50% removal rate) - More invasive than soft tissue approaches This approach provides maximum exposure at cost of osteotomy morbidity. ### Distal Humerus Fracture Fixation Principles After adequate exposure via chosen approach, fracture fixation follows systematic sequence. **Fracture assessment:** - Remove hematoma and debris - Identify all fracture fragments - Assess articular comminution - Note soft tissue attachments (preserve blood supply) **Reduction sequence for intra-articular fractures:** **Step 1: Reconstruct articular surface** - Reduce trochlea and capitellum fragments - Achieve perfect articular alignment - Provisional fixation with K-wires - Definitive fixation with lag screws (3.5mm or 4.0mm) **Step 2: Restore articular block to shaft** - Reduce articular block to distal humeral shaft - Align in both coronal and sagittal planes - Provisional fixation with K-wires - Check alignment with fluoroscopy **Step 3: Bicolumnar plating** **Parallel plating (most common):** - Medial plate along medial column - Lateral plate along lateral column - Plates parallel in coronal plane - 90-90 configuration (perpendicular in axial plane) - Provides maximum stability **Perpendicular plating:** - Medial plate along medial column - Lateral plate posterolaterally - Plates perpendicular in sagittal plane - Easier placement but less stable **Plate fixation technique:** - Precontoured anatomic plates preferred - Locking screws in distal fragments - Nonlocking screws proximally (compression) - 6-8 screws in each column if possible - Verify no intra-articular hardware (fluoroscopy) **Total elbow arthroplasty (via Bryan-Morrey):** For unreconstructable fractures in elderly or severe comminution: 1. Excise comminuted distal humerus 2. Prepare humeral canal (reaming) 3. Prepare ulnar canal (reaming) 4. Trial components for sizing 5. Cement humeral and ulnar components (in Australia, cemented stems preferred per AOANJRR) 6. Link components with hinge mechanism 7. Verify alignment and stability This completes the fracture fixation portion of the procedure. ### Wound Closure and Triceps Repair **Critical triceps repair (Bryan-Morrey approach):** This is NOT optional - functional outcome depends on repair quality: 1. **Prepare olecranon**: - Roughen bone surface where triceps detached - Drill 3-4 transverse tunnels through olecranon 5mm apart - Tunnels 2-3mm diameter, parallel to each other - Tunnels exit on anterior cortex of ulna 2. **Pass heavy sutures**: - Use heavy nonabsorbable suture (Ethibond #2, #5 FiberWire) - Pass sutures through lateral triceps-anconeus sleeve - Pass through drill holes (medial to lateral or vice versa) - Pass through medial triceps flap - Creates secure bone-tendon-bone repair 3. **Tension repair at 30 degrees flexion**: - Assistant holds elbow flexed 30 degrees - Tie sutures securely (minimum 4 throws) - Do NOT over-tighten (causes extension contracture) - Repair with triceps under slight tension 4. **Side-to-side closure**: - Close medial and lateral borders of elevated triceps - Use absorbable suture (1 Vicryl) - Recreates normal triceps contour **Repair for triceps-splitting approach:** - Close split with side-to-side sutures - Use absorbable suture (0 or 1 Vicryl) - Running or interrupted technique - No drill holes needed (insertion preserved) **Secure osteotomy fixation** (if performed): - Verify reduction of osteotomy - Tension band or plate fixation as described - Check stability with elbow flexion-extension **Subcutaneous closure:** - Thick subcutaneous tissue in elbow - Close in layers with 2-0 Vicryl - Avoid dead space (seroma risk) **Skin closure:** - Subcuticular with 3-0 Monocryl, or - Interrupted nylon or staples - Skin glue reinforcement **Drain placement:** - Consider drain for extensive dissection - Small 10Fr hemovac or JP drain - Exit laterally away from incision - Remove when output under 30mL per 24 hours **Dressing:** - Bulky soft dressing with posterior splint - Elbow at 90 degrees flexion - Forearm neutral rotation - Avoid circumferential dressing (swelling risk) The wound is now closed with secure triceps repair complete. ### Neurovascular Injuries **Ulnar nerve injury (8% incidence):** **Mechanisms:** - Direct injury during dissection or retraction - Stretch injury during elbow manipulation - Compression from postoperative hematoma or swelling - Inadequate decompression with scarring **Prevention:** - Early identification and mobilization - Gentle handling with soft loops - Anterior transposition for most cases - Avoid excessive traction during manipulation - Document baseline function preoperatively **Recognition:** - Preoperative examination critical (fracture may cause injury) - Postoperative examination in recovery room - Motor: weakness of FCU, FDP (ring/small), intrinsics - Sensory: numbness small finger and ulnar half ring finger **Management if injury occurs:** - Document examination findings - Observe for 3-6 months (most recover) - Nerve conduction studies at 6-12 weeks - Consider exploration if no recovery at 6 months - Occupational therapy for hand function **Radial nerve injury (less than 2%):** Rare but devastating: - Injury during proximal triceps elevation - Excessive lateral retraction - Results in wrist drop and hand weakness **Median nerve injury (rare):** Usually from excessive medial dissection or anterior retraction. ### Triceps Complications **Extension lag (10-15% with poor repair):** **Causes:** - Inadequate triceps repair - Repair under insufficient tension - Sutures pulling through bone (osteoporotic bone) - Repair failure during rehabilitation **Prevention:** - Anatomic repair through drill holes - Heavy nonabsorbable suture - Adequate number of drill holes (3-4 minimum) - Repair at appropriate tension (30 degrees flexion) - Protected rehabilitation first 6 weeks **Management:** - Observation for 6-12 months (may improve with therapy) - Triceps advancement if persistent lag over 30 degrees - Consider allograft reconstruction for severe cases **Triceps rupture (less than 5%):** Complete failure of repair: - Usually technical failure (inadequate fixation) - More common in revision surgery - Requires surgical repair or reconstruction ### Osteotomy Complications **Nonunion (5-10%):** **Risk factors:** - Transverse osteotomy (less stable than chevron) - Inadequate fixation - Early aggressive motion - Smoking, diabetes, NSAIDs **Prevention:** - Chevron osteotomy preferred (more stable) - Rigid fixation (plate better than tension band) - Protected rehabilitation first 6 weeks - Avoid NSAIDs for HO prophylaxis if possible **Management:** - Revision fixation with bone graft if symptomatic - Hardware removal if asymptomatic but painful **Prominent hardware (50% removal rate):** Very common with olecranon fixation: - K-wires and tension band prominent subcutaneously - Plate less prominent but still noticeable - Removal common after fracture/osteotomy union ### Elbow Stiffness **Incidence:** 30-50% have some limitation of motion **Risk factors:** - Severe initial trauma - Prolonged immobilization (osteotomy) - Heterotopic ossification - Inadequate physiotherapy **Prevention:** - Early motion (soft tissue approaches) - Indomethacin for HO prophylaxis (75mg daily for 6 weeks per Australian eTG) - Aggressive physiotherapy - Avoid prolonged immobilization **Management:** - Physiotherapy and stretching program - Consider manipulation under anesthesia at 3-6 months - Arthroscopic or open contracture release if persistent ### Infection **Risk:** 2-5% superficial, 1-3% deep **Prevention:** - Cefazolin 2g IV pre-incision (Australian eTG guidelines) - Redose every 4 hours if case over 4 hours - Meticulous soft tissue handling - Consider drain for dead space - Layered closure **Management:** - Superficial: oral antibiotics, local wound care - Deep early (under 3 weeks): irrigation and debridement, retain hardware - Deep late: hardware removal after union, long-term antibiotics ### Heterotopic Ossification **Incidence:** 10-30% radiographic, 5-10% clinically significant **Risk factors:** - High-energy trauma - Head injury - Delayed surgery - Extensive soft tissue dissection **Prevention:** - Indomethacin 75mg daily for 6 weeks (eTG guideline) - Single-dose radiation (700-800 cGy within 72 hours postop) alternative - Gentle soft tissue handling - Early motion **Management:** - Observation for 12-18 months (maturation) - Excision if mature and limiting function - Restart prophylaxis after excision ### Immediate Postoperative (0-48 hours) **Recovery room:** - Document neurovascular examination (ulnar nerve especially) - Check motor function: wrist/finger extension (radial), intrinsics (ulnar) - Check sensory function: all nerve distributions - AP and lateral elbow radiographs to confirm reduction/fixation **Splinting:** - Posterior splint at 90 degrees flexion - Forearm neutral rotation - Well-padded to allow for swelling - Avoid circumferential cast initially (compartment syndrome risk) **Pain management:** - Multimodal analgesia (reduce opioid use) - Regional nerve block if available (interscalene or peripheral) - NSAIDs cautious if osteotomy performed (nonunion risk) - Ice and elevation **DVT prophylaxis:** - Low molecular weight heparin (Australian eTG guidelines) or - Rivaroxaban 10mg daily for upper extremity high risk patients - Consider prophylaxis for inpatient stay ### Early Postoperative (Week 1-6) **Mobilization protocol depends on approach:** **Soft tissue approach (triceps-split or reflecting):** - Begin gentle active-assisted ROM at 2-7 days - Gravity-assisted extension - Active flexion allowed - Avoid active resisted extension for 6 weeks (triceps repair protection) - Target: 30-130 degrees by 6 weeks **Olecranon osteotomy:** - Protected motion for 6 weeks until osteotomy heals - Passive ROM only for first 3 weeks - Active-assisted ROM weeks 3-6 - Active ROM after radiographic union at 6 weeks - More conservative to protect osteotomy **Physiotherapy:** - Critical for preventing stiffness - Supervised therapy 2-3 times weekly - Home exercise program daily - Focus on terminal flexion and extension - Gentle passive stretching **Radiographic follow-up:** - 2 weeks: check reduction maintained - 6 weeks: assess fracture/osteotomy healing - 12 weeks: confirm union ### Intermediate (6 weeks to 3 months) **Progression:** - Remove splint at 6 weeks (if fracture/osteotomy stable) - Begin active resisted extension (triceps strengthening) - Progressive resistance exercises - Continue ROM exercises - Goal: functional arc 30-130 degrees **Strengthening program:** - Isometric exercises initially - Progressive resistance with bands/weights - Eccentric triceps exercises - Functional activities (lifting, carrying) **Return to activities:** - Light activities at 6-8 weeks - Lifting restrictions under 5kg until 12 weeks - Progressive increase in demands ### Long-term (3-6 months and beyond) **Advanced strengthening:** - Heavy resistance exercises - Sport-specific training if applicable - Return to manual labor 4-6 months **Return to sport:** - Non-contact sports: 3-4 months - Contact sports: 6 months minimum - Individualized based on fracture healing and strength **Expected outcomes:** **ROM:** - 90% achieve functional arc (30-130 degrees) - 10-20% have some limitation - Terminal extension loss common (10-20 degrees) **Strength:** - 80-90% of contralateral strength at 1 year - Triceps-splitting: 95% strength - Bryan-Morrey: 85-90% strength if good repair - Osteotomy: 85% strength **Function:** - Most achieve good to excellent function - Simple fractures better than comminuted - TEA outcomes depend on indication and bone quality **Q: Which posterior elbow approach provides the BEST articular visualization for comminuted intra-articular distal humerus fractures?** A: **Olecranon osteotomy** (chevron or transverse). It provides the widest visualization of the trochlea and capitellum by elevating the entire proximal ulna with attached triceps. Disadvantages include need for secure fixation, delayed rehabilitation (6 weeks), and risk of nonunion. **Q: What is the Bryan-Morrey approach to the elbow and what is its primary indication?** A: **Triceps-reflecting approach** that elevates the triceps with a continuous sleeve including the anconeus and forearm fascia from medial to lateral. Primary indication is **total elbow arthroplasty (TEA)**. The triceps is reflected as a single unit, preserving the extensor mechanism while providing adequate exposure for component placement. **Q: What is the structure MOST at risk during posterior approach to the elbow and how is it protected?** A: **Ulnar nerve** (8% injury rate overall). It lies in the cubital tunnel between the medial epicondyle and olecranon. Protection requires early identification, decompression, and often **anterior transposition** (subcutaneous or submuscular). Transposition is performed in 60-80% of cases, especially for TEA. **Q: In which direction should the apex of a chevron olecranon osteotomy be oriented and why?** A: **Apex distal**. This creates a larger proximal fragment attached to the triceps for more stable fixation. The osteotomy is typically performed at the bare area (deepest point of trochlear notch) and fixed with tension band wiring, plate, or cannulated screw. Apex distal orientation resists proximal displacement by the triceps. **AOANJRR data for total elbow arthroplasty:** According to the Australian Orthopaedic Association National Joint Replacement Registry 2023 report, 300-400 total elbow arthroplasties are performed annually in Australia. The Bryan-Morrey triceps-reflecting approach is used in over 80% of cases, with the posterior approach being universal for TEA. Indications include rheumatoid arthritis (40%), trauma (30%), and osteoarthritis (20%). Linked cemented TEA demonstrates 88% survival at 10 years, compared to 85% for uncemented implants. Revision rates are higher for trauma indication (35% at 10 years) compared to rheumatoid arthritis (15% at 10 years). **PBS and pharmaceutical guidelines:** Indomethacin is PBS-listed for heterotopic ossification prophylaxis after major joint surgery. The Australian eTG guideline recommends indomethacin 75mg daily (modified release) or 25mg three times daily for 6 weeks as first-line prophylaxis in high-risk cases. Single-dose radiation therapy (700-800 cGy within 72 hours postoperatively) is available at major centers as an alternative, particularly when there is concern about NSAID effects on bone healing. **eTG antibiotic guidelines:** Australian eTG guidelines for surgical prophylaxis in elbow surgery recommend cefazolin 2g IV at induction (within 60 minutes of incision), with redosing every 4 hours if the procedure exceeds 4 hours. Duration is typically a single dose, or maximum 24 hours for complex cases. For penicillin allergy, vancomycin 25-30 mg/kg IV is recommended, infused over 60-120 minutes starting within 120 minutes of incision. High-risk patients (diabetes, immunosuppression, revision surgery) may require extended prophylaxis to 24 hours postoperatively based on individual risk assessment. **Australian injury epidemiology:** Distal humerus fractures demonstrate a bimodal distribution in Australia, affecting young males through high-energy trauma and elderly females through falls. The incidence is approximately 5-6 per 100,000 population per year. Falls account for 60% of cases in the elderly population, while motor vehicle accidents account for 30% in young adults. Work-related injuries account for 10% and are covered by WorkCover schemes. Return to work timing varies from 6-8 weeks for office work to 4-6 months for manual labor. Functional outcome scores such as QuickDASH are used for impairment assessment in compensation claims. **Medicare and healthcare delivery:** Posterior elbow approaches for fracture fixation and arthroplasty are covered under Medicare for both public and private hospital settings. These procedures are typically performed in public hospitals for acute trauma cases or private hospitals for elective arthroplasty, with funding arrangements varying based on insurance status and indication. Multidisciplinary team involvement including hand therapy and occupational therapy is essential for optimal outcomes, particularly given the high rate of stiffness complications requiring intensive rehabilitation.

Posterior Approach to the Elbow

Posterior Approach to the Elbow