APPROACHES TO THE
DISTAL HUMERUS
DR.S.SENTHIL SAILESH
SEN O R A STA T PRO FESSO R
I
SSI
N
I STI
N TUTE O F O RTHO PA CS & ...
GREETINGS FROM MMC, CHENNAI
CHOICE OF EXPOSURE DETERMINANTS
• Age (paediatric / adult)
• Fracture pattern (articular comminution)
• Total Elbow Arthro...
APPLIED ANATOMY
OSSEOUS ANATOMY

POSTERIOR ASPECT

ANTERIOR ASPECT
• The medial and lateral columns support
the articular segment.
• The distal most part of the lateral column
is the capite...
SURGICAL ANATOMY
Posterior Structures :
• Skin & Subcutaneous
Tissue
• Triceps Muscle With
Aponeurosis
• Ulnar Nerve – Beh...
SURGICAL ANATOMY
Anterior Structures :
• Skin, Subcutaneous Tissue With Superficial
Veins
• Layer 1: Biceps With Bicipital...
SURGICAL ANATOMY
LATERAL STRUCTURES:

• LCL
• Anconeus
• Extensors Of The Wrist
SURGICAL
ANATOMY
MEDIAL STRUCTURES:
•MCL
•Flexor Group Of Muscles
•Ulnar Nerve passes from behind
the medial epicondyle an...
WHY POSTERIOR APPROACH?
• Most orthopaedic procedures (m.c: fracture fixation) in and around the
distal procedures predomi...
POSTERIOR APPROACHES TO THE DISTAL
HUMERUS
POSTERIOR APPROACHES TO
DISTAL HUMERUS
PATIENT POSITIONING
LATERAL DECUBITUS
POSITION

(s wim m e r’s p o s itio n)
•Arm hanging over a post
•Sterile tourniquet ...
COMMON STEPS FOR ALL POSTERIOR
APPROACHES
1) Longitudinal midline skin incision over the posterior
aspect of the elbow
2) ...
1) SKIN INCISION
• Beginning atleast 5cm proximal to the
tip of the olecranon, curving slightly
laterally at the tip, then...
2) RAISING OF SUBCUTANEOUS FLAPS
3) ISOLATION OF ULNAR NERVE
• Identification of the ulnar nerve first done proximally
where the nerve pierces the septum
•...
ISOLATION OF ULNAR NERVE
OLECRANON
OSTEOTOMY
APPROACH
OLECRANON
OSTEOTOMY
APPROACH
TRANSVERSE

CHEVR
ON

• Technically easier to do

• Technically more difficult

• 30% inciden...
PLAN THE FIXATION OPTION BEFORE THE
OSTEOTOMY
OLECRANON
OSTEOTOMY
APPROACH
• If planning to use a screw for fixation (most common) of the
osteotomy, pre-drill and tap f...
OLECRANON
OSTEOTOMY
APPROACH
• A gauze swab is inserted from medial to lateral through the joint
across the notch to prote...
OLECRANON
OSTEOTOMY
APPROACH
• Small, thin oscillating saw
used to cut 95% of the
osteotomy along the line of
marking
• Al...
OLECRANON
OSTEOTOMY
APPROACH

• Osteotome used to crack
and complete it
OLECRANON
OSTEOTOMY
APPROACH

Exposure of the distal
humerus especially the
inter condylar area is
excellent after an
oste...
OSTEOTOMY FIXATION OPTIONS
OSTEOTOMY FIXATION

SINGLE SCREW WITH TBW TECHNIQUE:

1) Expose the tip by sharp dissection of soft tissues to
see the bon...
Length of screw may be important
to resist toggling and loss of
reduction
OSTEOTOMY FIXATION
TENSION BAND TECHNIQUE
WITH K-WIRES:

• Easy to place
• May be less stable than
independent lag screw o...
OSTEOTOMY FIXATION
DORSAL PLATING
• Low profile periarticular implants now available
• When using this method the plate is...
THE OSTEOTOMY APPROACH

PEARLS

PERILS

•Provides The Best Visualization Of
The Distal Humerus Articular Surface

•Nonunio...
THE OSTEOTOMY APPROACH
INDICATIONS

CONTRAINDICATIONS (RELATIVE)

•Although all articular fractures are best
visualised by...
PARA-TRICIPITAL (TRICEPS
PRESERVING) APPROACH
[ALONSO-LLAMES ]
PARA-TRICIPITAL (TRICEPS
PRESERVING) APPROACH
[ALONSO-LLAMES ]

• The medial and lateral borders of the triceps are incise...
Full-thickness fasciocutaneous
flaps are elevated

The medial and lateral borders of the triceps are incised and
elevated ...
PARA-TRICIPITAL (TRICEPS
PRESERVING) APPROACH
[ALONSO-LLAMES ]

PEARLS
•Avoidance of an olecranon osteotomy,
therefore the...
TRICEPS SPLITTING
APPROACHES

• Developed to attempt to overcome the morbidity & the risk of hardware
complications associ...
TRICEPS- midline SPLITTING
APPR
OACH (CAMPBELL)

• Splitting the triceps longitudinally through the
midline of the triceps...
TRICEPS- midline SPLITTING
APPR
OACH (CAMPBELL)

• In order to improve triceps healing, GSCHWEND et al modified
the approa...
TRICEPS- midline SPLITTING
APPR
OACH (CAMPBELL)

PEARLS
•Relative technical ease
•The ability to convert from open
reducti...
Triceps V-Y splitting approach
(campbell – van gorder)
• This Approach Was Described By Campbell, And Later Modified By Va...
Triceps V-Y splitting approach
(campbell – van gorder)
Triceps V-Y splitting approach
(campbell – van gorder)
PEARLS

PERILS

•Avoidance of an olecranon osteotomy,
therefore the...
Triceps reflecting postero-medial
approach (Bryan-Morrey
Approach)
• Medial edge of triceps and distal
forearm fascia elev...
Triceps reflecting postero-medial
approach (Bryan-Morrey
Approach)
Triceps reflecting postero-medial
approach (Bryan-Morrey
Approach)
PEARLS
•Avoidance of an olecranon
osteotomy & its compl...
Triceps-Reflecting Anconeus
Pedicle (TRAP) Approach

• The approach begins laterally at the kocher
interval, between the e...
Triceps-Reflecting Anconeus
Pedicle (TRAP) Approach

• The anconeus-triceps flap was detached from its
distal attachment (...
Triceps-Reflecting Anconeus
Pedicle (TRAP) Approach
• The dissection started distally and working proximally.
• The poster...
THE TRAP APPROACH
PEARLS
•Avoidance of an olecranon osteotomy & its
complications
•Protects the neurovascular supply to th...
DON’T FORGET THE RADIAL NERVE…
• Dissect and protect the radial nerve when
the exposure is extended on the lateral
aspect ...
MEDIAL & LATERAL APPROACHES

• LATERAL - Extended Kocher Approach
• MEDIAL – Campbell’s medial approach
CAMPBELL’S MEDIAL APPROACH
PLA E O F DI
N
SSECTI N
O :
•PRO XI A
M LLY:
The internervous plane lies between
the brachialis...
TECHN QU
I
E incision centering joint on
• 10 cm “J” shaped
medial aspect

• Identify the ulnar nerve in the groove behind...
• Make sure that the ulnar nerve is retracted
inferiorly, osteotomize the medial epicondyle
(pre drilling & tapping can be...
CAMPBELL’S MEDIAL APPROACH
THE MEDIAL APPROACH
PEARLS

PERILS

•Avoidance of disruption of extensor
mechanism

•Inadequate visualisation of
inter con...
EXTENDED KOCHER APPROACH
• Utilizes the intermuscular interval between the anconeus and the
extensor carpi ulnaris.
TECHN ...
IDENTIFYING THE KOCHER’S INTERVAL

Ancone
us

EC
U
EXTENDED THE KOCHER’S INTERVAL
PROXIMALLY TO EXPOSE THE LATERAL
ASPECT OF DISTAL HMERUS
THE EXTENDED KOCHER’S
APPROACH
PEARLS

PERILS

•Avoidance of disruption of extensor
mechanism

•Inadequate visualisation o...
TAKE HOME MESSAGE
• Choose the appropriate approach
• Safeguard the ulnar & radial nerve
• Respect the soft tissues
• Get ...
PR
OGR
AMME SCHEDULE
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
 Surgical Approaches to distal  humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO
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Surgical Approaches to distal humerus fractures - DR.S.SENTHIL SAILESH, M.S.ORTHO

  1. 1. APPROACHES TO THE DISTAL HUMERUS DR.S.SENTHIL SAILESH SEN O R A STA T PRO FESSO R I SSI N I STI N TUTE O F O RTHO PA CS & TRA A LO G Y EDI UM TO M DRA M CA CO LLEG E & RG G G H, CHEN A A S EDI L N I
  2. 2. GREETINGS FROM MMC, CHENNAI
  3. 3. CHOICE OF EXPOSURE DETERMINANTS • Age (paediatric / adult) • Fracture pattern (articular comminution) • Total Elbow Arthroplasty? • Associated injuries ( Neurovascular injury)
  4. 4. APPLIED ANATOMY
  5. 5. OSSEOUS ANATOMY POSTERIOR ASPECT ANTERIOR ASPECT
  6. 6. • The medial and lateral columns support the articular segment. • The distal most part of the lateral column is the capitellum and the distalmost part of the medial column is the nonarticular medial epicondyle. • The trochlea is the medial part of the articular segment and is intermediate in position between the capitellum and medial epicondyle. • The articular segment functions architecturally as a tie arch.
  7. 7. SURGICAL ANATOMY Posterior Structures : • Skin & Subcutaneous Tissue • Triceps Muscle With Aponeurosis • Ulnar Nerve – Behind Medial Epicondyle • Posterior Capsule
  8. 8. SURGICAL ANATOMY Anterior Structures : • Skin, Subcutaneous Tissue With Superficial Veins • Layer 1: Biceps With Bicipital Aponeurosis • Layer 2: Median Nerve With Brachial Vessels • Layer 3: Brachialis, Brachio-radialis, Radial Nerve • Layer 4: Anterior Capsule
  9. 9. SURGICAL ANATOMY LATERAL STRUCTURES: • LCL • Anconeus • Extensors Of The Wrist
  10. 10. SURGICAL ANATOMY MEDIAL STRUCTURES: •MCL •Flexor Group Of Muscles •Ulnar Nerve passes from behind the medial epicondyle and distally between the FCU and FDP
  11. 11. WHY POSTERIOR APPROACH? • Most orthopaedic procedures (m.c: fracture fixation) in and around the distal procedures predominantly done through posterior approaches owing to: • SAFER - Less chance of damage to vital structures (comparing anterior) • EASIER - Posterior structures are aponeurotic and dissection is easier with less bleeding • CLEARER – Better visualisation of articular surface • Very few indications where other approaches may be necessary: • Anterior: excision of myositic mass, fractures associated with vascular injuy • Medial & Lateral approaches – partially articular/condylar fractures
  12. 12. POSTERIOR APPROACHES TO THE DISTAL HUMERUS
  13. 13. POSTERIOR APPROACHES TO DISTAL HUMERUS
  14. 14. PATIENT POSITIONING LATERAL DECUBITUS POSITION (s wim m e r’s p o s itio n) •Arm hanging over a post •Sterile tourniquet if desired •Very convenient for the surgeon •Bit less convenient for the anaesthetist especially if the patient has to be intubated halfway during surgery following regional
  15. 15. COMMON STEPS FOR ALL POSTERIOR APPROACHES 1) Longitudinal midline skin incision over the posterior aspect of the elbow 2) Raising of subcutaneous flaps on either side to expose the tricipital aponeurosis 3) Isolation of ulnar nerve
  16. 16. 1) SKIN INCISION • Beginning atleast 5cm proximal to the tip of the olecranon, curving slightly laterally at the tip, then returning to the midline and extending 5 cm distal to the tip of the olecranon
  17. 17. 2) RAISING OF SUBCUTANEOUS FLAPS
  18. 18. 3) ISOLATION OF ULNAR NERVE • Identification of the ulnar nerve first done proximally where the nerve pierces the septum • Release it from its tunnel by dividing the arcuate ligament that passes between the two heads of the flexor carpi ulnaris muscle • Gently retract it with a rubber sling or a penrose drain • Extensive dissection of the nerve is inadvisable, as this increases the risk of tethering and damage to its vascularity.
  19. 19. ISOLATION OF ULNAR NERVE
  20. 20. OLECRANON OSTEOTOMY APPROACH
  21. 21. OLECRANON OSTEOTOMY APPROACH TRANSVERSE CHEVR ON • Technically easier to do • Technically more difficult • 30% incidence of nonunion (Gainor et al, (1995) j s o uth o rtho p a s s o c 4:263) • More stable • Olecranon implant removal may be necessary due to irritation • Lesser incidence of nonunion • Olecranon implant removal may be necessary due to irritation
  22. 22. PLAN THE FIXATION OPTION BEFORE THE OSTEOTOMY
  23. 23. OLECRANON OSTEOTOMY APPROACH • If planning to use a screw for fixation (most common) of the osteotomy, pre-drill and tap for screw placement down the ulna canal • Expose the tip by sharp dissection of soft tissues to see the bone
  24. 24. OLECRANON OSTEOTOMY APPROACH • A gauze swab is inserted from medial to lateral through the joint across the notch to protect the articular surfaces • The line of osteotomy (“V” shaped) is marked with a pen or a cautery
  25. 25. OLECRANON OSTEOTOMY APPROACH • Small, thin oscillating saw used to cut 95% of the osteotomy along the line of marking • Alternatively a 2mm drill bit can be used for multiple drilling and joining them
  26. 26. OLECRANON OSTEOTOMY APPROACH • Osteotome used to crack and complete it
  27. 27. OLECRANON OSTEOTOMY APPROACH Exposure of the distal humerus especially the inter condylar area is excellent after an osteotomy approach
  28. 28. OSTEOTOMY FIXATION OPTIONS
  29. 29. OSTEOTOMY FIXATION SINGLE SCREW WITH TBW TECHNIQUE: 1) Expose the tip by sharp dissection of soft tissues to see the bone 2) Pre-drilling & tapping should be done prior to osteotomy 3) Beware of the varus bow of the proximal ulna, which may cause a malreduction of the tip of the olecranon after screw placement 4) We prefer using a 6.5mm cannulated cancellous screw of length 60-70mm 5) Large-diameter screw threads may engage ulnar diaphysis (small medullary canal) prior to full seating of screw head, “Bite” of screw may be strong without full compression Hak and Golladay, 6) A Tension band wiring done before full tightening of the JAAOS, 8:266-75, 2000
  30. 30. Length of screw may be important to resist toggling and loss of reduction
  31. 31. OSTEOTOMY FIXATION TENSION BAND TECHNIQUE WITH K-WIRES: • Easy to place • May be less stable than independent lag screw or plate • Implant irritation is a problem Mullett et al (2000) I njury 31:427, Prayson et al (1997) J O rtho p Tra um a 11:565 Engage anterior ulnar cortex here with wires to improve fixation stability/strength
  32. 32. OSTEOTOMY FIXATION DORSAL PLATING • Low profile periarticular implants now available • When using this method the plate is prefixed to the olecranon and then removed before conducting the osteotomy. • Axial screw through plate can be used Hewin et al (2007) J O rtho p Tra um a 21:58 Tejwani et al (2002) Bull Ho s p Jt Dis 61:27
  33. 33. THE OSTEOTOMY APPROACH PEARLS PERILS •Provides The Best Visualization Of The Distal Humerus Articular Surface •Nonunion, malunion at the osteotomy site •Hardware irritation due to osteotomy fixation
  34. 34. THE OSTEOTOMY APPROACH INDICATIONS CONTRAINDICATIONS (RELATIVE) •Although all articular fractures are best visualised by this approach, the AO/OTA type C3 fracture is best managed by this approach •Very anterior articular fractures (AO/OTA type B3), which can be difficult to visualize through an osteotomy • Total elbow arthroplasty
  35. 35. PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH [ALONSO-LLAMES ]
  36. 36. PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH [ALONSO-LLAMES ] • The medial and lateral borders of the triceps are incised or alternatively erased from their respective intermuscular septae and elevated from the posterior aspect of the distal humerus. • The distal humerus can be button holed medially or laterally to gain access to the proximal forearm
  37. 37. Full-thickness fasciocutaneous flaps are elevated The medial and lateral borders of the triceps are incised and elevated from the posterior aspect of the distal humerus
  38. 38. PARA-TRICIPITAL (TRICEPS PRESERVING) APPROACH [ALONSO-LLAMES ] PEARLS •Avoidance of an olecranon osteotomy, therefore the risks of nonunion and symptomatic olecranon hardware are avoided •The triceps tendon insertion is not disrupted, allowing early active range of motion PERILS •Limited visualization of the articular surface of the distal humerus • The approach is usually inadequate for fixation of type c3 fractures. •Preserves the innervation and blood supply of the anconeus muscle, which provides dynamic posterolateral stability to the elbow. •If required,The several advantages of this approach certainly indicate its use for can be converted into an AO/OTA olecranon osteotomytypes A2, A3, B1, B2, and possibly C1 and C2 fractures
  39. 39. TRICEPS SPLITTING APPROACHES • Developed to attempt to overcome the morbidity & the risk of hardware complications associated with the use of olecranon osteotomy • Although some authors have reported a better functional outcome following the use of a triceps-splitting approach compared with olecranon osteotomy, others have reported the converse • The intact trochlear notch may be used as a template, against which the reduction of the trochlea can be assessed • Either internal fixation or total elbow arthroplasty (TER) can be performed but internal fixation is technically difficult.
  40. 40. TRICEPS- midline SPLITTING APPR OACH (CAMPBELL) • Splitting the triceps longitudinally through the midline of the triceps aponeurosis down to bone followed by sub-periosteal elevation of the triceps medially and laterally. • Triceps split extends distally onto the olecranon and proximally, the radial nerve limits the extent of dissection.
  41. 41. TRICEPS- midline SPLITTING APPR OACH (CAMPBELL) • In order to improve triceps healing, GSCHWEND et al modified the approach to incorporate a flake of olecranon bone, to be later fixed • Mckee et al compared the extensor mechanism strength of patients treated with an olecranon osteotomy versus a triceps splitting approach and found no statistical significant difference, concluding that both approaches are effective
  42. 42. TRICEPS- midline SPLITTING APPR OACH (CAMPBELL) PEARLS •Relative technical ease •The ability to convert from open reduction and internal fixation to total elbow arthroplasty with few consequences PERILS •Limited visibility of the articular surface •Disruption of the extensor mechanism requiring postoperative protection and the risk of triceps dehiscence
  43. 43. Triceps V-Y splitting approach (campbell – van gorder) • This Approach Was Described By Campbell, And Later Modified By Van Gorder And Wadsworth • The deep head of the triceps is divided in its midline for a length of about 8 cm. • The flap is distally based and should extend to the outer part of the humeral condyles in order to allow an adequate approach . Sufficient tendon tissue at both sides of the flap must be preserved to obtain a good repair. • Thickness of flap: 1/3rd of the muscle thickness proximally, 2/3rd in the middle, full thickness distally • To perform a V-Y advancement the triceps is sutured in the midline for the
  44. 44. Triceps V-Y splitting approach (campbell – van gorder)
  45. 45. Triceps V-Y splitting approach (campbell – van gorder) PEARLS PERILS •Avoidance of an olecranon osteotomy, therefore the risks of nonunion and symptomatic olecranon hardware are avoided •Limited visibility of the articular surface •Lengthening of the extensor mechanism can be done if required •Higher rate of infection •Risk of triceps necrosis This approach is indicated for •Total Elbow arthroplasty •ORIF of distal humerus fractures when there is an associated complete or high grade partial triceps tendon laceration. •Chronic Elbow dislocations
  46. 46. Triceps reflecting postero-medial approach (Bryan-Morrey Approach) • Medial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflected laterally along with a thin wafer of bone to facilitate bone-to-bone healing • Resection of extra-articular tip of olecranon • Now the entire triceps muscle with the posterior capsule is reflected upwards and laterally, and the elbow is flexed to expose the joint.
  47. 47. Triceps reflecting postero-medial approach (Bryan-Morrey Approach)
  48. 48. Triceps reflecting postero-medial approach (Bryan-Morrey Approach) PEARLS •Avoidance of an olecranon osteotomy & its complications PERILS •Risk of triceps pull out if careful transosseous resuturing is not done properly or if the tendon repair fails or the tissue quality is poor, as in rheumatoid patients. •Delayed active mobilisation This approach is best suited for unrepairable distal humerus fractures in which primary elbow arthroplasty is planned.
  49. 49. Triceps-Reflecting Anconeus Pedicle (TRAP) Approach • The approach begins laterally at the kocher interval, between the extensor carpi ulnaris and the anconeus. • TRAP approach incorporates modified kocker's approach on lateral side and a triceps reflecting approach on the medial side. both approaches converge distally at the tip of the anconeus Triceps insertio n Ancone us
  50. 50. Triceps-Reflecting Anconeus Pedicle (TRAP) Approach • The anconeus-triceps flap was detached from its distal attachment (5-7 cm from the tip of olecranon) and dissected off the lateral side of the elbow and proximal ulna, preserving the integrity of the lateral collateral ligament complex, including annular ligament • The flap is reflected to expose the lower end of the humerus
  51. 51. Triceps-Reflecting Anconeus Pedicle (TRAP) Approach • The dissection started distally and working proximally. • The posterior capsule incised and the dissection was carried out proximally between the triceps and posterior humerus. the fibers of the deep head of the triceps were dissected off the posterior humerus by sharp and blunt dissection • Fixation of the fracture proceeded • The triceps was reattached with interrupted number-2 braided polyester sutures, with use of drill-holes through bone in the region of the olecranon
  52. 52. THE TRAP APPROACH PEARLS •Avoidance of an olecranon osteotomy & its complications •Protects the neurovascular supply to the anconeus muscle PERILS •Risk of triceps dehiscence •Possible extensor weakness
  53. 53. DON’T FORGET THE RADIAL NERVE… • Dissect and protect the radial nerve when the exposure is extended on the lateral aspect for fixing the lateral column • Gerwin et al : if further proximal exposure is required for associated fractures of the humeral shaft, the lateral side of the approach can be converted into the Gerwin approach, which involves reflection of the triceps muscle unit from lateral to medial to expose 95% of the posterior humeral shaft and the radial nerve
  54. 54. MEDIAL & LATERAL APPROACHES • LATERAL - Extended Kocher Approach • MEDIAL – Campbell’s medial approach
  55. 55. CAMPBELL’S MEDIAL APPROACH PLA E O F DI N SSECTI N O : •PRO XI A M LLY: The internervous plane lies between the brachialis muscle (musculocutaneous nerve) and the triceps muscle (radial nerve)   •DI STA LLY The plane lies between the brachialis muscle (musculocutaneous nerve) and the pronator teres muscle
  56. 56. TECHN QU I E incision centering joint on • 10 cm “J” shaped medial aspect • Identify the ulnar nerve in the groove behind the medial condyle of the humerus, and isolate the nerve along the length of the incision   • Retract the skin anteriorly with the fascia to uncover the common origin of the superficial flexor muscles from the medial epicondyle • Enter the interval between the pronator teres and the brachialis. retract the pronator teres
  57. 57. • Make sure that the ulnar nerve is retracted inferiorly, osteotomize the medial epicondyle (pre drilling & tapping can be done) and retract it with its attached flexors. • Superiorly, continue the dissection between the brachialis, retracting it anteriorly, and the triceps, retracting it posteriorly • The medial side of the joint now can be seen. incise the capsule and the medial collateral ligament to expose the joint
  58. 58. CAMPBELL’S MEDIAL APPROACH
  59. 59. THE MEDIAL APPROACH PEARLS PERILS •Avoidance of disruption of extensor mechanism •Inadequate visualisation of inter condylar region •No risk of postoperative triceps pull out, dehiscence, need for immobilisation •Cannot approach the lateral aspect I DI TI N : N CA O S •Removal of loose bodies •Fixation of fractures of the coronoid process of the ulna •Fixation of fractures of the medial humeral condyle and epicondyle
  60. 60. EXTENDED KOCHER APPROACH • Utilizes the intermuscular interval between the anconeus and the extensor carpi ulnaris. TECHN QUE : I • The anconeus and extensor carpi ulnaris muscles are identified by palpation. A thin strip of fat can almost always be observed in the interval between these muscles • The muscle fibres of the anconeus and the extensor carpi ulnaris muscles tend to blend together towards the insertion, so it is easier to develop the interval distally and then progress proximally. • The deep fascia is then opened , the anconeus is dissected posteriorly • The lateral elbow capsule with the annular ligament is identified and incised longitudinally anterior to the lateral ulnar collateral ligament
  61. 61. IDENTIFYING THE KOCHER’S INTERVAL Ancone us EC U
  62. 62. EXTENDED THE KOCHER’S INTERVAL PROXIMALLY TO EXPOSE THE LATERAL ASPECT OF DISTAL HMERUS
  63. 63. THE EXTENDED KOCHER’S APPROACH PEARLS PERILS •Avoidance of disruption of extensor mechanism •Inadequate visualisation of inter condylar region •No risk of postoperative triceps pull out, dehiscence, need for immobilisation •Cannot approach the medial aspect of distal humerus I DI TI N : N CA O S •Fixation of lateral condylar fractures •Partially articular fractures •Repair or reconstruction of the lateral ligaments.
  64. 64. TAKE HOME MESSAGE • Choose the appropriate approach • Safeguard the ulnar & radial nerve • Respect the soft tissues • Get familiarized with a particular approach
  65. 65. PR OGR AMME SCHEDULE

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