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)