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KEY POINTS
When managing elbow fractures, selecting the most convenient approach is essential to perform an
adequate surgical technique and avoid unexpected complications.
When lateral approaches are done to treat radial head and capitellum fractures, the posterior interosseous nerve and the lateral collateral ligament must be protected.
Medial approaches for coronoid fracture fixation may result in ulnar nerverelated complications.
Extensive nerve dissection should be avoided.
Posterior approaches to treat distal humerus fractures may be through the olecranon or the triceps
tendon. Whenever possible, a paratricipital approach (Alonso-Llames) is preferred.
Disclosure: The authors have not received any financial benefit from the completion of this article.
Shoulder and Elbow Unit, Hospital Universitario La Paz, Paseo de la Castellana 261, Madrid 28046, Spain
* Corresponding author.
E-mail address: raulbarco@hotmail.com
Hand Clin 31 (2015) 509519
http://dx.doi.org/10.1016/j.hcl.2015.06.001
0749-0712/15/$ see front matter 2015 Elsevier Inc. All rights reserved.
hand.theclinics.com
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Fig. 4. Lateral and medial ligamentous complexes. pMCL, posterior band of the medial collateral ligament.
GENERAL PRINCIPLES
The correct diagnosis of the elbow injury leads to
an understanding of the natural history of the injury
pattern, and the associated injuries and potential
complications. A surgical plan is then developed,
which includes exposure, expected and potentially unexpected findings, repair, and rehabilitation. Previous scars must be taken into
consideration and although a previous mobile
scar may be obviated, it is probably better if it is
included in the new surgical plan. When a separate
incision must be made, an appropriate skin bridge
must be respected to avoid skin ischemia. Fullthickness subcutaneous flaps are favored
because they respect the skin circulation.
APPROACHES
There are many approaches described for elbow
surgery but only a few are really required to
perform the most common surgical procedures
related to elbow trauma. We present surgical approaches that are versatile for the whole spectrum
of elbow pathology.
Fig. 5. Knowing the three-dimensional location of nerves around the elbow is critical to avoid complications. The
radial nerve is at risk in the anterior part of the elbow as it enters the supinator. The ulnar nerve should be protected with any posterior or medial approach to the elbow. RN, radial nerve; UN, ulnar nerve.
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Table 1
Surgical approaches for fractures of the distal humerus according to fracture type
Indication
Extrarticular
Simple
intrarticular
Approach
Extension
Commentary
Alonso-Llames
Proximal with
Easy conversion to
(bilaterotricipital)
protection of
olecranon
radial and ulnar
osteotomy
nerve on the
lateral and medial
side, respectively.
Distal through
ECU-anconeous
interval
All distal humeral
Triceps splitting
Proximally limited
May be performed
fractures
by the radial
in the midline or
nerve
slightly medially
Slightly less
exposure for
internal fixation
compared with
olecranon
osteotomy
All distal humeral
Olecranon
Proximally until
The workhorse for
fractures, articular
osteotomy
radial nerve
internal fixation
distal humeral
of the distal
fractures
humerus
Fixation with
multiple options
Comminuted
Bryan-Morrey
Proximal medial
Must protect the
distal humerus
(to triceps) and
ulnar nerve,
fractures (elbow
distally between
especially during
arthroplasty)
ECU and FCU
dislocation of the
joint
Nerves in
Danger
Ulnar nerve,
radial nerve
Ulnar nerve,
radial nerve
Ulnar nerve
Ulnar nerve
Fig. 6. The Alonso-Llames approach allows access to the posterior part of the elbow joint without triceps
detachment.
supracondylar columns (Fig. 8). The chevron osteotomy is favored over transverse osteotomy
because of added intrinsic stability.
After the olecranon is identified, the ulnar nerve
should be located and protected. The ulnohumeral
joint is opened laterally to the olecranon and
protected with a sponge when performing the
osteotomy.
A distal chevron is made at the level of the bare
spot of the greater sigmoid notch of the ulna. The
cut is started with a saw and finished with an osteotome. The proximal olecranon and tendon are
retracted proximally and separated from capsular
attachments and collateral ligaments. The dissection can be carried out proximally as in a bilaterotricipital approach. At the end of the procedure the
olecranon is reduced and fixed with a cerclage and
K-wires, a lag screw, an intramedullary nail, or a
plate.
To avoid denervation of the anconeus, some authors favor dissecting the anconeus distally, reflecting it from the ulna without detaching it from
the triceps to preserve its innervation.10
Bryan-Morrey approach
A posterior skin incision is performed just slightly
lateral to the tip of the olecranon. After elevating
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Fig. 7. Triceps-splitting approach. As seen in the picture, this approach gives good exposure and allows distal
extension by retracting the FCU and the anconeus.
Fig. 8. Olecranon osteotomy is the preferred approach for complex distal humerus fractures. The osteotomy
should be done through the bare area of the greater sigmoid notch (arrow).
Fig. 9. Bryan-Morrey approach was originally described for implantation of elbow arthroplasty and is rarely used
for trauma.
anterior half, without associated bony or ligamentous injury leading to instability. A skin incision extending from the lateral epicondyle toward the
Listers tubercle of the distal radius is performed
and the superficial interval between the extensor
carpi radialis and the extensor digitorum muscle
is developed (Fig. 10).12
The interval between the extensor carpi radialis
brevis and the supinator is located by noting that
the fibers of the supinator muscle are oblique to
the fibers of the extensor carpi radialis brevis.
The proximal aspect of the origin of the supinator
is detached and the capsule over the radial head
is incised longitudinally. The posterior interosseous nerve is in close vicinity to the distal part of
this incision and it is advisable to work with the
forearm in pronation.13
Kocher approach
The Kocher approach uses the interval between
the anconeus and the extensor carpi ulnaris
(ECU) (Fig. 11). It can be extended proximally
and is safe because the ECU protects the radial
nerve. However, in this approach care must be
taken to identify, preserve, or repair if necessary
the lateral ligamentous complex. This approach
is used for radial head fractures associated with
elbow instability and for capitellar fractures
without significant cominution or medial extension.
The interval between the anconeus and the ECU
can be identified by subtle palpation: by moving
your finger from posterior to anterior you can feel
the anterior margin of the anconeus. Additionally,
a thin strip of fat is usually present in this interval.
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Table 2
Surgical approaches for fractures involving the radial head
Indication
Approach
Extension
Commentary
Nerves in Danger
Kocher
Radial nerve
in proximal
extension.
Kaplan
ECU-anconeous
interval. Proximal
and distal
extension is
possible and can
be improved
further with
detachment of
one-third triceps
tendon (Mayo
modified Kocher
approach).
Proximally. Distally
limited by the PIN.
PIN. Beware of
retraction using
anterior Hohman
retractor around
the radial neck.
It is better defined distally, because more proximally the fascia of both muscles coalesces toward
the insertion.14
After the intermuscular plane is opened, the
lateral capsule and ligaments are identified and
incised to enter the joint. The LCL originates from
the lateral epicondyle and inserts on the crista supinatoris of the ulna. These fibers must be recognized and protected when opening the capsule.
It is usually safe to open the capsule just anterior
to the ligament if it is intact. If the ligament is
Fig. 10. Kaplan approach is more anterior than the Kocher approach and is used for fixation of simple radial head
fractures. The access to the radial head (RH) is easy, but care should be taken to avoid distal extension that may
jeopardize the posterior interosseous nerve (PIN).
Fig. 12. Medial approach to the elbow. Note the situation of the medial antebrachial cutaneous nerve (MACN),
crossing the surgical field. The approach goes in between both heads of the FCU. MCL, medial collateral
ligament.
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reduction and plate fixation. Extension of the fracture into the coronoid may include an anteromedial
fragment that may need additional plating or specific screw targeting for open reduction and internal fixation. Reduction can be accomplished by
extending the FCU-ECU approach medially reflecting the flexor-pronator mass.17 Again, the ulnar nerve must be identified and protected.
Decompression or transposition of the ulnar nerve
is left to the discretion of the surgeon.
SUMMARY
Elbow trauma presents with a diverse range of
injury patterns. Each injury pattern has a typical
mechanism and discrete elements that may
require surgical management. When managing
elbow trauma surgically, many operative approaches exist. As such, surgeons should have a
good working knowledge of elbow anatomy and
the advantages and disadvantages of the available
approaches.
ACKNOWLEDGMENTS
We would like to acknowledge the work of Drs
J. Ballesteros, M. LLusa and P. Forcada for the
surgical preparations that appear throughout the
chapter.
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