This document discusses the surgical approach for intercondylar/supracondylar humerus fractures using a chevron osteotomy. It describes the posterior surgical approach as being safer and providing better visualization of the articular surface compared to anterior approaches. The key steps of the posterior approach are outlined, including a midline skin incision, raising subcutaneous flaps, isolating the ulnar nerve, preparing the osteotomy site with saw and chisel, performing the chevron-shaped osteotomy, reducing and fixing the joint fragments, and coupling the fragments to the metaphysis. Complications of the procedure are also listed.

1. Surgical approach
intercondylar/supracondylar
humerus fracture (chevron
osteotomy)
Dr.khadijah nordin

2. outline
• PRINCIPLE TREATMENT
• SURGICAL APPROACH
• WHY POSTERIOR APPROACH
• TYPE POSTERIOR APPROACH
• POSITION
• STEPS OF APPROACH
• PREPARATION OF OSTEOTOMY
• REDUCTION OF OSTEOTOMY

3. OSSEOUS ANATOMY
POSTERIOR ASPECT
ANTERIOR ASPECT

4. • 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.

5. Principle treatment
• Anatomical reduction
• Stable internal fixation of the articular surface
• Restoration of articular axial alignment
• Stable internal fixation of the articular surface
to the metaphysis and diaphysis
• Early range of motion of elbow

6. Surgical approach in supracondylar
humerus fracture
• Anterior approach
• Posterior approach
• Medial approach
• Lateral approach

7. Posterior approach
• MOST ORTHOPAEDIC PROCEDURES 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

8. Posterior approach
Triceps splintting
approach
Tricep tounge
splitting
Midine trcept
splintting
(campbell)
Osteotomy
approach
Olecranon
approach
Triceps reflecting
approach
Triceps reflecting
approach( bryan-
moore)
TRAP ( O-Driscoll)
Triceps
presreving
approach
Paratricipital
approach (alonso
Llamas

9. Position Posterior approach
Lateral decubitus position prone

10. COMMON STEPS FOR ALL POSTERIOR
APPROACHES
• Longitudinal midline skin incision over the
posterior aspect of the elbow
• Raising of subcutaneous flaps on either side
to expose the tricipital aponeurosis
• Isolation of ulnar nerve

11. SKIN INCISION
• Straight incision beginning level
with the junction of the middle
and distal thirds of, and
centered on, the humeral shaft.
• Some surgeons make a straight
incision, whereas others prefer
to curve the incision around the
olecranon to the radial side.
• The incision ends over the ulnar
diaphysis.

12. 2) RAISING OF SUBCUTANEOUS FLAPS

13. 3) ISOLATION OF ULNAR NERVE
• The ulnar nerve is identified proximally
along the medial border of the triceps.
• It is then released from the cubital tunnel
distally, through the flexor pronator
aponeurosis to the level of its first
anterior motor branch.
• Whenever possible, care should be taken
to preserve the perineural vessels.
• A vessel loop is placed around the ulnar
nerve, which is protected throughout the
entire procedure.

14. • This intraoperative view
shows the ulnar nerve freed
and tagged with a vessel
loop.
• Incise the fascia over the
flexor carpi ulnaris muscle
at the border of the ulnar
bone, as the first step in the
preparation of the extensor
apparatus flap.

15. Preparation for osteotomy
• Determine the site of the
osteotomy by incising either the
medial capsule, after retracting
the ulnar nerve, or the lateral
capsule, after elevating part of
the anconeus muscle and finding
the center of the trochlear notch.
• Clear the bone with a small
elevator at the site of the planned
osteotomy.
• Mark a chevron osteotomy with a
distal apex.

16. Osteotomy
• Saw
– Because of the shape
of the olecranon, use a
fine oscillating saw to
divide only up to three
quarters of the depth
of the bone.

17. • Chisel
– Use a chisel on the last
part of the bone, but
only just short of the
subchondral bone.
Remember that the
central ridge of the
olecranon, which is very
strong, will need to be
divided deeper, using a
very narrow bladed
chisel

18. • The subchondral
bone is then
fractured by levering
the osteotomy apart.

19. Chevron shape
• The chevron osteotomy is
preferred to give a better
and more stable bony
contact during the repair of
the olecranon reduction.
• The larger surface improves
bone healing, and the shape
improves rotational
stability.

20. reduction and fixation strategy
• reducing and fixation of joint components
• coupling to methaphisys

21. implants
• DCP 3,5mm plates are golden standard
• 1/3 small tubular plates for radial column
• LC DCP 3,5mm plates
• precontoured plates
• both plates posterior
• right angle config

25. Reduction and fixation of the
olecranon

26. Complication
• Early complications:
– Vascular injury
– Nerve injury
– Malunion
– Wound infection
• Delayed complications
– Heterotrophic ossification
– Elbow stiffness
– osteoarthritis

27. • Thank you