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MINI-SYMPOSIUM: THE ELBOW

(i) Surgical approaches to the
elbow

All of these approaches allow good visualization of the distal
humeral articular surface, although it has been demonstrated
that the olecranon osteotomy provides the greatest exposure. The
work undertaken by Wilkinson and Stanley1 compared the area
of the distal humeral articular surface that was visible following
an olecranon osteotomy (57%), triceps split (35%) and triceps
reflecting approach (46%). The disadvantage of dividing the
olecranon however is the small risk of non-union, although it
should be noted that the other posterior approaches carry a risk
of postoperative triceps weakness2 not seen after osteotomy.
A posterior incision carries a lower risk of cutaneous nerve
injury compared with medial or lateral incisions3 and the incision
should be positioned in the midline, although care must be taken
not to cross the tip of the olecranon. Skirting around the tip on
the medial side has been associated with a better healing rate
than lateral incisions, with less tendency to contract. Therefore,
to avoid repetition, we have defined a universal posterior skin
incision as one that starts 10 cm proximal to the medial epicondyle in the midline, curving around the medial border of the
tip of the olecranon and continues along the subcutaneous
border of the ulna for 5 cm (see Figure 1). We use a postoperative
surgical drain for 24 h after surgery with an extension splint for
48 h that reduces the risk of wound complications associated
with all posterior approaches.
The patient can be positioned in either a supine or lateral position. In the supine position, the arm is draped across the chest. This
allows ease of access for an image intensifier, combined approaches
and access to the iliac crest, albeit with the need for an assistant. The
lateral position provides a comfortable operating approach without
the need for additional surgical assistance.

Chris Peach
David Stanley

Abstract
Surgical approaches to the elbow can be challenging in both trauma and
elective settings. Knowledge of the neurovascular and musculotendinous
anatomy is crucial to provide safe and optimal access to the desired part
of the elbow joint. This review describes common approaches to the posterior, lateral and medial aspects of the elbow. It should be noted that more
than one approach can be combined, often utilizing the same skin incision.

Keywords anatomy; elbow; surgical approaches

Introduction
The complexity of elbow injuries and pathology requires the
surgeon to be comfortable with a range of approaches to the
elbow joint. In trauma, selection of the most helpful approach is
determined by a combination of experience and familiarity with
the anatomy interpreted with respect to the fracture pattern. This
enables optimal exposure of the relevant parts of the elbow joint.
Familiarity with the complex neurovascular anatomy in close
proximity to the elbow joint is imperative to avoid iatrogenic
injury. The choice of skin incision may be dictated by previous
elbow surgery but should be chosen carefully, mindful of the
potential need for future related surgery or sequential combined
approaches (medial and lateral approaches using the same
posterior skin incision, for example). Finally, choice of patient
positioning will ensure comfort whilst operating for what can be
lengthy procedures, as well as ensuring mobility of the limb, for
example to facilitate intraoperative imaging. Adherence to these
principles will ensure the completion of safe and efficient surgical
procedures about the elbow.

Posterior approaches
This is the universal approach to the elbow, as the majority of the
joint can be reached irrespective of whether surgery is being
undertaken for fracture or an elective procedure. Several posterior surgical approaches have been described and the surgeon
should select the one that will optimize exposure for the particular procedure that is to be performed.

Chris Peach MD FRCS (Tr & Orth) Consultant Shoulder and Elbow Surgeon,
Upper Limb Unit, University Hospital of South Manchester, UK. Conflicts
of interest: none.

Figure 1 Universal posterior skin incision. Full thickness flaps are raised
on the lateral (1) and medial (2) sides, exposing the triceps (3) and ulna
nerve (4). Reused with permission of the author and the publishers.
Original source: Sales J.M, Videla M, Forcada P, Llusa M, Nardi J, Atlas de 
rgico,
osteosı´ntesis. Fracturas de los huesos largos Vı´as de acceso quiru
~a, S.L. All rights reserved. 
n. Ó2009, Elsevier Espan
2.a Edicio

David Stanley MBBS BSc FRCS Consultant Shoulder and Elbow Surgeon,
Dept of Shoulder and Elbow Surgery, Northern General Hospital,
Sheffield, UK. Conflicts of interest: none.

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MINI-SYMPOSIUM: THE ELBOW

Olecranon osteotomy
This approach gives the best exposure of the distal humerus for
fracture fixation.

taken not to complete the osteotomy with the saw but rather by
leverage with an osteotome proximally to crack the subchondral
bone. This creates a slightly irregular surface, which not only
eases repositioning of the olecranon at the end of the procedure,
but also may enhance stability. The triceps is incised on its
medial and lateral borders, leaving a small cuff of tendon on
either side to repair. The olecranon is reflected proximally with
the anconeus and triceps attached.

Indications: distal humerus fracture fixation (this approach is
not suitable for total elbow arthroplasty, as repair of the osteotomy site is impaired by the cemented ulnar component).
Approach (see Figure 2): the universal posterior skin incision is
used and medial and lateral full thickness skin flaps are raised.
The ulnar nerve is identified, decompressed and protected. The
capsule is incised on the medial side of the olecranon process at
the midpoint of the greater sigmoid notch of the ulna. A traditional olecranon osteotomy may denervate the anconeus muscle,
which has been shown to provide dynamic stability to the lateral
side of the elbow. The Mayo modification of the approach was
described to address this problem and to preserve the anconeus.4
The anconeus muscle is identified and elevated from its bed by
sharp dissection, leaving the attachment to the triceps aponeurosis and the lateral aspect of the olecranon at the site of the
osteotomy. The hardware to be used to repair the osteotomy at
the end of the procedure, for example a cancellous screw, should
be pre-drilled and positioned before the osteotomy is performed
and then removed. This facilitates anatomic alignment when
reconstruction is carried out at the end of the procedure. A
chevron osteotomy with its apex distally is performed with an
oscillating saw. This is preferred over transverse or oblique
osteotomies because of increased surface area for healing and
stability under compression. The osteotomy should be positioned
to enter the bare area on the ulna, which has little or no articular
cartilage and is overlaid by the intra-articular fat pads. Care is

AlonsoeLlames approach e triceps preserving5
This approach gives access to the elbow joint and can be useful
for simple extra articular fractures of the distal humerus. It
preserves the triceps mechanism but exposure is limited.
Indications: extra articular distal humeral fractures, paediatric
supracondylar fractures, total elbow arthroplasty, elbow
hemiarthroplasty.
Approach: the universal posterior skin incision is used and full
thickness medial and lateral skin flaps are raised. The ulnar
nerve is identified and protected. The medial and lateral borders
of the triceps tendon are incised and the muscle is elevated from
the posterior border of the distal humerus. The triceps is
retracted medially or laterally during the procedure, allowing
delivery of the distal humerus into the wound and facilitating the
surgical procedure.
Campbell approach e triceps split6
It is essential to identify and protect the ulna nerve and, if
exposing more proximally the radial nerve during the Campbell
approach. Careful attention to reconstruction at the end of the

Figure 2 Olecranon osteotomy. (a) The ulnar nerve (1) is identified and protected. The olecranon osteotomy (2) is positioned through the bare area (*).
The olecranon and triceps (3) is retracted proximally by dividing or mobilizing anconeus (4). Olecranon fat pad (5); olecranon fossa (6). (b) Wide exposure
of the distal humerus is achieved by proximal retraction of the triceps and division of the intermuscular septum (7). Reused with permission of the author
and the publishers. Original source: Sales J.M, Videla M, Forcada P, Llusa M, Nardi J, Atlas de osteosı´ntesis. Fracturas de los huesos largos Vı´as de acceso
~a, S.L. All rights reserved. 
n. Ó2009, Elsevier Espan 
rgico, 2.a Edicio
quiru

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MINI-SYMPOSIUM: THE ELBOW

Figure 3 (a) The triceps aponeurosis (1) is divided longitudinally. The medial head of triceps (2) and the tendon of triceps (3) are incised, exposing the
posterior aspect of the humerus and the olecranon (4). (b) After detaching the triceps entirely from the olecranon, the flexor carpi ulnaris (5) is retracted
medially and the anconeus muscle (6) laterally. Olecranon fat pad (7); ulnar nerve (8); posterior aspect of trochlea.

procedure avoids the olecranon buttonholing through the area of
relative weakness in the triceps tendon at the repair site.

distally over the tip of the olecranon and along the subcutaneous border of the ulna. The insertion of the triceps onto the
olecranon is sharply dissected off and the respective tissues are
reflected subperiosteally medially and laterally from the
humerus and proximal ulna. The anconeus is reflected laterally,
with medial retraction of the flexor carpi ulnaris. Therefore the
triceps mechanism remains in continuity with the forearm
muscles and fascia. The triceps fascia is closed proximally and
supplemented with transosseous sutures in the tip of the
olecranon.

Indications: total elbow arthroplasty, distal humeral fractures,
exposure of the posterior compartment, OK procedure.
Approach (see Figure 3): the universal posterior skin incision
is used. Full thickness medial and lateral skin flaps are raised
and the triceps is incised directly down to the posterior aspect
of the humerus in the midline. This incision is continued

Figure 4 Triceps turn down. (a) The superficial triceps aponeurosis is elevated (1) exposing the intramuscular tendon (2). The tendon is incised longitudinally exposing the posterior aspect of the joint. (b) A Z-plasty of the tendon is performed (2) in order to allow rebalancing of the triceps if necessary.
(c) The tendon (2) is repaired at the end of the procedure by suturing longitudinally and then repairing the superficial aponeurosis.

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MINI-SYMPOSIUM: THE ELBOW

Van Gorder approach e triceps turn down7
This modification of the Campbell triceps splitting technique can
allow rebalancing of the length of the triceps, in particular with
a stiff elbow being treated for soft tissue contracture.

Medial approaches
Indications: ulnar nerve decompression, transposition or stabilization of the ulnar nerve, repair or reconstruction of the medial
collateral ligament, isolated coronoid fracture fixation, release of
the stiff elbow.

Indications: contracture release, total elbow arthroplasty.

Hotchkiss extensile approach10
This extensile approach between the flexor digitorum supericialis
and the flexor carpi ulnaris allows access to the anterior and
posterior aspect of the elbow as well as to the ulnar nerve.

Approach (see Figure 4): the universal posterior skin incision is
used and full thickness medial and lateral skin flaps are raised.
The ulnar nerve is identified and protected. The fascia and triceps
aponeurosis are incised, creating a 10 cm length of aponeurosis in
the form of an inverted ‘V’ with the base attached to the olecranon.
This then allows longitudinal incision of the triceps, thus
preserving muscular vascularity much better than the original
approach based on a flap formed from the deep head. That
approach, originally described by Campbell,6 was associated with
high rates of infection due to vascular compromise, as well as
triceps weakness. The medial head is then divided in the midline
and reflected to expose the posterior aspect of the humerus.
Incising the lateral capsule and medially elevating the insertion of
the anconeus on the ulna can be used to extend the exposure
(modification described by Wadsworth8).

Indications: release of elbow contracture, particularly with
concomitant ulnar nerve pathology.
Approach (see Figure 5): A medial or a posterior skin incision is
used. The medial antebrachial cutaneous nerve is identified and
protected superficial to the superficial fascia, anterior to the medial
intermuscular septum. The ulnar nerve is identified proximally
and dissected distally. The brachial fascia is incised along the
anterior aspect of the medial supracondylar ridge, 5 cm proximal
to the medial epicondyle. This releases the flexor-pronator mass
from the supracondylar ridge. Retaining a cuff of the flexor carpi
ulnaris tendon posteriorly eases repair at the end of the procedure.
The muscles are elevated off of the anterior capsule to the lateral
side of the elbow. Subperiosteal dissection deep to the brachialis
ensures protection of the brachial artery and median nerve.

ShahaneeStanley approach e (combination triceps split
and reflection)9
This provides excellent exposure of the distal humerus whilst
protecting the ulnar nerve and its blood supply.

Medial approach to the coronoid
This approach, through the floor of the cubital tunnel, allows
adequate visualization of coronoid fractures for fixation when
approach through a radial head fracture is not possible.

Indications: total elbow arthroplasty.
Approach: the patient is positioned in lateral decubitus with the
arm hanging freely. The universal posterior skin incision is used.
Full thickness skin flaps can be raised to allow adequate exposure
of the posterior aspect of the elbow. The ulnar nerve is found
between the medial intermuscular septum and the medial head of
the triceps proximally and is superficially decompressed. The
nerve is not, however, mobilized from its soft tissue bed, nor is it
transposed anteriorly. The triceps is split on the medial aspect so
that 75% of the muscle lies laterally and 25% of the muscle
medially. The incision is continued distally to the tip of the
olecranon and distally for 7 cm incising the superficial fascia of
the forearm. The triceps and extensor mechanism is raised subperiosteally from the olecranon and then reflected medially and
laterally. The dissection continues to expose the tip of the medial
and lateral epicondyles. The medial segment of the triceps is
reflected from the posterior aspect of the humerus along with the
periosteum over the olecranon and the superficial fascia of the
forearm and this segment is retracted medially. The ulnar nerve
is not released from its deep soft tissues but the nerve and deep
soft tissues are displaced anteriorly during the surgical procedure
thereby reducing the risk of iatrogenic injury and minimizing
postoperative scarring. The lateral portion of the triceps tendon is
dissected from the tip of the olecranon and laterally to expose the
distal humerus. The anconeus is reflected subperiosteally from
the proximal ulna to expose the radial head.
At the end of the procedure the triceps is reattached using two
perpendicular drill holes through the olecranon process: the two
portions of the triceps can be balanced at this stage to adjust the
soft tissue tension if needed.

ORTHOPAEDICS AND TRAUMA 26:5

Indications: isolated coronoid fracture.

Figure 5 Hotchkiss extensile approach. After detaching the flexor-pronator
group and retracting the anterior joint capsule (1) and the brachialis
muscle (2), the coronoid process (3) and the medial collateral ligament (4)
can be visualized. The ulnar nerve (5) can be transposed over the flexor
carpi ulnaris muscle (6).

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MINI-SYMPOSIUM: THE ELBOW

Figure 6 Kocher approach. (a) Identify the interval between the anconeus and the extensor carpi ulnaris by the thin strip of fat distally. (b) After
developing this interval the recurrent interosseous artery can be found superficial to the capsule. Reused with permission of the author and the
publishers. Original source: Sales J.M, Videla M, Forcada P, Llusa M, Nardi J, Atlas de osteosı´ntesis. Fracturas de los huesos largos Vı´as de acceso
~a, S.L. All rights reserved. 
n. Ó2009, Elsevier Espan 
rgico, 2.a Edicio
quiru

Kocher approach11
This approach uses the intermuscular interval between extensor
carpi ulnaris and anconeus to access the elbow joint.

Approach: a midline posterior or medial skin incision is used.
The ulnar nerve is decompressed along it length and gently
retracted posteriorly. Transposition is not necessary unless
instability of the nerve is evident at the end of the procedure. The
interval between the humeral and ulnar heads of the flexor carpi
ulnaris (FCU) is developed and retracted, which exposes the
coronoid, the sublime tubercle and the more deeply placed
anterior band of the medial collateral ligament. The anterior
band is often attached to a large anteromedial fragment and
therefore should not be disturbed during dissection. The flexor
origin is not detached from its humeral origin. The FCU is
separated from the medial collateral ligament and the humeral
head of FCU can be retracted to expose the medial collateral
ligament and coronoid process. The distinction between the
tendinous insertion of the flexor/pronator group is clearer
distally and therefore it is best to begin the dissection at this point
in order to avoid damage to the ligament and postoperative
elbow instability.

Indication: removal of loose bodies, radial head excision, lateral
collateral ligament reconstruction.
Approach (see Figure 6): the patient is positioned supine with
the arm placed on an arm table. A pneumatic tourniquet is
applied. The curved skin incision starts 2 cm proximal to the
lateral epicondyle and extends distally over the radiocapitellar
joint to finish overlying the subcutaneous border of the ulna.
Alternatively a posterior incision, raising a full thickness lateral
skin flap, can be used. Proximally the interval between the
triceps posteriorly and the brachioradialis and extensor carpi
radialis longus anteriorly is developed by sharp dissection onto
the lateral condyle and supracondylar ridge. The interval
between the extensor carpi ulnaris and the anconeus is identified, and is often identifiable by a fatty streak. Further dissection
allows retraction of the ECU and the rest of the common extensor
origin anteriorly and the anconeus posteriorly. The capsule is
incised along the anterior border of the lateral ulnar collateral
ligament, which aligns with the midpoint of the capitellum. To
improve exposure, the common extensor origin can be further

Lateral approaches
Indications: intra-articular fractures, capsular release, removal
of loose bodies, debridement of the anterior aspect of the elbow,
excision of the radial head, reconstruction of the lateral collateral
ligament.

Figure 7 Kaplan approach. (a) Incise the interval between the extensor carpi radialis brevis (ECRB) muscle and the extensor digitorum communis muscle
(EDC). Extensor digiti minimi (EDM); extensor carpi ulnaris (ECU). (b) The supinator muscle (1) and the underlying capsule (2) is incised longitudinally
allowing access to the anterior part of the radial head. The posterior interosseous nerve (3) is in close proximity but it can be moved further from the
operative field by placing the forearm in full pronation.

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MINI-SYMPOSIUM: THE ELBOW

released from the supracondylar ridge, taking care to avoid injury
to the radial nerve that traverses the lateral intermuscular
septum. The radial nerve is reliably found one third of the way
along a line connecting the lateral epicondyle to the lateral aspect
of the acromion process. The lateral collateral ligament, if
necessary, can be elevated posteriorly from the lateral epicondyle
but must be carefully repaired afterwards and can improve
exposure to the radiocapitellar joint. Distally the posterior
interosseous nerve is found approximately 3 cm distal to the
radiocapitellar joint, which increases to approximately 4 cm with
the forearm in full pronation.12
The column procedure, described by Mansat and Morrey13 for
capsular release of the stiff elbow, utilizes the proximal part of
this approach by dissection anterior to the lateral border of the
humerus. Elevation of the distal brachioradialis and extensor
carpi radialis longus allows access to the anterior capsule and
elevation of the triceps allows access to the posterior aspect of
the elbow.

Appreciation of the complex neurovascular anatomy, as well
as the ligamentous anatomy, prevents iatrogenic injury leading
to considerable morbidity for the patient.
A

REFERENCES
1 Wilkinson JM, Stanley D. Posterior surgical approaches to the elbow:
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2 Hildebrand KA, Patterson SD, Regan WD, MacDermid JC, King GJ.
Functional outcome of semiconstrained total elbow arthroplasty.
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3 Dowdy PA, Bain GI, King GJ, Patterson SD. The midline posterior
elbow incision. An anatomical appraisal. J Bone Joint Surg Br 1995;
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4 Athwal GS, Rispoli DM, Steinmann SP. The anconeus flap transolecranon
approach to the distal humerus. J Orthop Trauma 2006; 20: 282e5.
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humerus in children. Acta Orthop Scand 1972; 43: 479e90.
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8 Wadsworth TG. A modified posterolateral approach to the elbow and
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10 Kasparyan NG, Hotchkiss RN. Dynamic skeletal fixation in the upper
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the posterior interosseous nerve during posterolateral approaches to
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13 Mansat P, Morrey BF. The column procedure: a limited lateral
approach for extrinsic contracture of the elbow. J Bone Joint Surg Am
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Joint Surg Am 1941; 23: 86e92.

Kaplan approach14
An approach between the extensor digitorum communis and
extensor carpi radialis brevis and longus, which provides excellent exposure to the radial head.
Indications: radial head fracture fixation.
Approach (see Figure 7): the patient is placed in the supine
position with the arm on an arm table. The incision starts over
the lateral epicondyle and extends approximately 5 cm distally in
line with the shaft of the ulna, with the radiocapitellar joint in the
midpoint of the incision. The interval between the extensor
digitorum communis and extensor carpi radialis brevis and longus is developed and the capsule beneath is incised longitudinally, opening the radiocapitellar joint.

Summary
Selecting the optimal surgical approach to the elbow joint
requires careful consideration, taking into account multiple
factors including site of injury, previous scars and whether
approaches are required to both sides of the joint simultaneously.

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