Surgical Approaches Based on Fracture Patterns

Fig. 24.1

Indications for surgical approaches based on fracture patterns

Fig. 24.2

Indications for posterior approaches based on fracture patterns

24.2 Lateral and Medial Approaches

In trauma reconstruction, a medial paratricipital approach, described by Hotchkiss [2], is indicated for the medial epicondyle fractures (A1.2) or the rare medial monocondylic fractures (B2) and the very rare isolated trochlear fractures (B3.2). Similarly, a Kocher approach with its variations (more or less extended proximally or distally) [2, 3] can be ideal to treat the lateral epicondylar fractures (A1.1), the lateral monocondylic fractures (B1), or the isolated capitellar fractures (B3.1, corresponding to the type I of the Dubberley classification [4]).

An extensile posterolateral exposure [2], feasible through a posterolateral skin incision, is indicated for capitellar and trochlear fractures (B3.3 type II of the Dubberley classification).

For the rare coronal plane fractures of the distal humerus involving not only the capitellum but also the posterior trochlea and the medial epicondyle (type of fracture not included in AO/OTA classification, corresponding to type 3B of the Dubberley classification [4] or to type 5 of the Ring classification [5]), the exposure of both columns is necessary, and therefore an olecranon osteotomy is the recommended approach. The indications for lateral and medial approaches are summarized in Fig. 24.1.

With both the lateral and medial approaches, there is a risk of injuring the antebrachial cutaneous nerve (lying between derma and fascia); therefore, a careful dissection with a full-thickness fasciocutaneous flap is recommended. As an alternative, a posterior skin incision is performed developing a lateral or medial exposure in the deep planes.

24.2.1 Hotchkiss Approach

It consists of exposing the anterior and posterior part of the medial column [2, 3] with distal extension toward the pronator and a portion of the common flexor tendon.

24.2.1.1 Technique

The ulnar nerve is identified and mobilized, and the medial supracondylar ridge is localized. Anteriorly, the brachialis is subperiosteally elevated from the anterior aspect of the humerus, and posteriorly the triceps is elevated from its posterior insertion. Distally, the approach is extended between pronator teres and flexor carpi radialis or between flexor carpi radialis and flexor carpi ulnaris (FCU). It is important to preserve the anterior band of the medial collateral ligament lying beneath the FCU.

24.2.2 Kocher Approach

In distal humerus fracture, the Kocher approach commonly used is the extensile variation [3] with exposure of the anterior and posterior part of lateral column (as described in lateral column procedure [6]), the lateral condyle, and the radial head as far as needed, preserving the LCL.

24.2.2.1 Technique

Anteriorly, the insertion of the brachioradialis, extensor carpi radialis longus, and brachialis is elevated from the lateral column; the triceps is elevated from its insertion on the posterior column. Proximally, the radial nerve is encountered approximately 8–10 cm above the lateral epicondyle as it crosses the lateral intermuscular septum.

Distally, the approach is extended in the Kocher interval between anconeus and extensor carpi ulnaris. It is important to preserve the lateral ulnar collateral ligament (LUCL) lying posterior to the equator of the capitellum and of the radial head.

24.2.3 Extensile Posterolateral Exposure

This exposure is an extension of the Kocher approach and allows to expose the anterior and posterior part of the capitellum and the anterior part of the trochlea through a dislocating maneuver of the elbow [2].

24.2.3.1 Technique

The exposure consists proximally of a lateral column procedure with release of the triceps from the posterior column, of the common extensor tendons, of the capsule, and of the lateral collateral ligament (if not yet detached by the fracture) from their humeral insertion. Distally, the approach consists of a Kocher approach. Applying a varus, flexion, and supination force, a subluxation maneuver is achieved, allowing a wide exposure of the anterior articular distal humerus surface.

24.3 Anterior Approach

The anterior approach is not usually required in the treatment of distal humerus fracture, even if it has been suggested to fix capitellar and trochlear fractures. This approach in our experience is not recommended in view of both the vicinity of neurovascular structures and the difficulties to obtain an accurate reduction of the fragments.

24.4 Posterior Approaches

In distal humerus fractures, the exposure is posterior in the great majority of cases because of its great versatility. This approach permits to reach not only the posterior but also the medial, lateral, and (albeit to a lesser extent) anterior part of the joint, and every type of distal humerus fracture can be treated with a posterior skin incision. “The front door to the elbow is at the back” is the famous sentence by Shawn O’Driscoll [7]. Precisely for its maximal versatility, the extensile posterior cutaneous incision has also been named the “universal approach.”

Independently of the technique used to manage the triceps, the posterior approaches present some elements in common:

Patient’s position: Usually, a lateral decubitus with the arm supported over a bolster is preferred. Alternatively, a supine position with a bolster under the ipsilateral scapula and the arm crossing the chest with the humerus in a vertical position can be used. The choice between the two positions is essentially based on the surgeon’s preference; however, the lateral decubitus allowing full elbow flexion can maximize the exposure of the articular surface.
A pneumatic tourniquet during the ulnar nerve isolation and exposure/fixation of the fragments is helpful.
Skin incision: A posterior midline straight incision just medial or lateral to the tip of the olecranon is performed. For most distal humeral fractures, a skin incision about 15 cm long is performed, but it can vary based on the proximal and distal extension of the fracture.

The incision is carried down to the level of the deep fascia and triceps tendon, achieving two full-thickness fasciocutaneous flaps.
Ulnar nerve: In the treatment of distal humerus fractures involving the medial column, the ulnar nerve requires to be always identified and dissected free throughout the cubital tunnel to its first motor branch, and—in our practice—it is always anteriorly transposed to protect it during the procedure and to prevent contact with the plate.
Radial nerve: A proximal posterolateral extension over 10 cm requires to isolate the radial nerve.
Reconstruction surgery: Independently of the triceps management, a careful reconstruction of the extensor mechanism is mandatory to avoid complications and to allow a rapid rehabilitation.

On the contrary, the posterior approaches differ in the way used to face the extensor mechanism. Based on the technique used to move the triceps off, the selective posterior approaches for distal humerus fixation can be classified in olecranon osteotomy, triceps splitting, Bryan-Morrey exposure, triceps on (or triceps preserving), and TRAP.

Olecranon osteotomy approach offers the maximum exposure, and therefore it is the exposure to be preferred in case of complex but fixable distal humerus fractures.

The triceps-on approach, allowing to maintain the triceps integrity, is recommended for fixation of extra-articular fractures (A2–A3 types of the AO/OTA classification [1]) to manage a not fixable fracture with a linked total elbow arthroplasty. In case of surgical difficulties, the triceps on can be converted in TRAP approach obtaining a greater articular exposure.

In case of open distal humerus fractures, it is possible to take advantage from the triceps muscle rupture to perform the triceps-splitting approach; however, because of the limited exposure of the joint, this approach is not indicated to treat the more complex distal humeral fractures.

TRAP and Bryan-Morrey approaches are especially indicated when the decision to proceed with internal fixation or arthroplasty needs to be taken intraoperatively.

We prefer to use the TRAP rather than the Bryan-Morrey approach for its better exposure of the lateral column permitting an easier placement of the plates with parallel configuration. The indications for each posterior approach are summarized in Fig. 24.2.

24.4.1 Olecranon Osteotomy

It is certainly the most frequently used approach, as it provides the widest exposure of the articular surface of the distal humerus.

This approach is however associated with possible complications as delayed union, nonunion, malunion, prominent hardware, intra-articular adhesions, and arthritis.

Moreover, if a total elbow arthroplasty (TEA) is considered in face of a fracture not certainly reconstructible, the olecranon osteotomy is contraindicated.

24.4.1.1 Technique

The ulnar nerve is identified along the medial border of the triceps, dissected at least 6 cm proximally and distally, and anteriorly transposed at the end of the procedure. Once the greater sigmoid notch is exposed medially and laterally to clearly visualize the bare area (the nonarticular portion between the olecranon articular facet and the coronoid articular facet), an apex-distal chevron-shaped osteotomy is performed at that level, initially using an oscillating saw and completing the procedure with an osteotome. The osteotomized proximal fragment is reflected proximally, exposing the medial and lateral columns and all the posterior articular part. With elbow hyperflexion, also a part of the anterior distal humerus can be exposed.

Only gold members can continue reading. Log In or Register to continue