- Distal posterior approach
For some extraarticular and simple articular fractures of the midshaft and distal humerus, the posterior approach may be extended distally, leaving the triceps insertion intact. This provides adequate exposure for reduction and fixation.
This exposure is very similar to the transolecranon approach, but without the osteotomy. The triceps is elevated off the posterior humerus, but its insertion is not disturbed.
This retains the tendinomuscular integrity of the triceps and allows more rapid postoperative rehabilitation.
The complete incision is illustrated. Depending on the fracture and its location a smaller section might be used.
Incise the skin, beginning at the tip of the olecranon.
The incision runs proximally in a straight line from the olecranon along the posterior midline of the arm. It crosses the radial nerve in the mid-humeral region and the axillary nerve proximally.
Incise the deep fascia in line with the skin incision.
As a first step, the ulnar nerve is identified, mobilized and protected with a vessel loop.
Proximally, the ulnar nerve is followed along its course on the medial intermuscular septum.
Take care that the protecting vessel loop does not violate the ulnar nerve by uncontrolled traction. Don’t use heavy clamps to secure the loop.
Next, the triceps muscle is mobilized and retracted laterally. This may be achieved by bluntly dissecting the medial head of the triceps from the posterior aspect of the humerus.
Depending on the fracture location the exposure may need to be extended distally. Therefore, the ulnar nerve needs to be freed off the ulnar sulcus.
In the case shown here, going up into the diaphysis, the ulnar nerve was identified and held with a vessel loop (1).
The entire triceps muscle is isolated with a gauze wrap (2).
The triceps fascia is split, and the lateral head of the triceps is mobilized from the lateral intermuscular septum and humerus towards the ulnar side.
Remaining muscle fibers still attached to the posterior aspect of the humerus can also be dissected from the lateral side. This ends up in a liberated muscle complex containing the long head, lateral head and the medial head of the triceps. This permits the whole triceps muscle to be moved towards either the lateral or medial side, in order to get access to the humerus (“triceps flip”). Alternatively, a gauze can be placed between the posterior aspect of the humerus and the triceps. By wrapping the gauze upwards, the entire triceps can be isolated bluntly.
The radial nerve can be detected at its penetration through the intermuscular septum and followed upwards in the radial groove.