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Introduction
  • Indications
    • ORIF of fractures of the distal humerus
      • provides best possible intra-articular view of elbow joint
    • removal of loose bodies
    • treatment of non-unions of the distal humerus
    • triceps lengthening for extension contractures of the elbow
 
Internervous plane
  • None
    • the extensor mechanism is either split or detached
    • the radial nerve innervates the triceps muscle more proximally
 
Preparation
  • Anesthesia
    • general
    • supraclavicular or infraclaviclar nerve block
  • Position
    • prone or lateral decubitus
      • with elbow flexed and arm hanging from side of table
  • Tourniquet
    • can be applied if needed as sterile tourniquet to upper arm

Approach
  • Incision
    • begin 5cm proximal to the olecranon in the midline of the posterior distal humerus
    • curve laterally proximal to the tip of the of the olecranon along the lateral aspect of the olecranon process
    • then curve medially over the middle of the posterior aspect of the subcutaneous ulna
  • Superficial dissection
    • first, palpate the ulnar nerve and fully dissect it out
      • 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
  • Deep dissection
    • 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



Dangers
  • Ulnar nerve
    • should initially be indentified 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  
  • Median nerve
    • strict subperiosteal dissection off the anterior surface of the humerus protects the nerve
    • flexion of the elbow relaxes the anterior structures.
  • 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
  • Brachial artery
    • runs with the median nerve (see above)
 
 

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