- Posterior triceps-on approach
For some extraarticular and simple articular fractures of the distal humerus, an approach that leaves the triceps insertion intact can provide adequate exposure for reduction and fixation.
This exposure is very similar to the transolecranon, but without the osteotomy. The triceps is elevated off the posterior humerus, but its insertion is not disturbed.
Make a straight incision beginning level with the junction of the middle and distal thirds of, and centered on, the humeral shaft. Some surgeons make a straight incision, whereas others prefer to curve the incision around the olecranon to the radial side. The incision ends over the ulnar diaphysis.
An ulnar-based subcutaneous flap is developed.
As a first step, the ulnar nerve is isolated and protected with a vessel loop.
Proximally, the ulnar nerve is followed along its course on the medial intermuscular septum, and the triceps muscle is mobilized radially.
If the ulnar nerve has been mobilized it is essential that the OR report should clearly describe how the ulnar nerve has been protected, and the location of the nerve at the end of the operation.
The triceps fascia is split, and the muscle is mobilized from the lateral intermuscular septum and humerus towards the ulnar side.
Distally, the anconeus muscle is detached from the radial column as much as is necessary.
In the case shown here, going up into the diaphysis, the radial nerve was identified and held with a vessel loop (1).
The entire triceps muscle is isolated with a gauze wrap (2). 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").
A contoured posteromedial plate has been placed and fixed to the distal humeral fragment.