What is the step-by-step procedure for treating a fracture of the distal humerus in an adult or elderly patient with a history of trauma or fall, and possible pre-existing conditions such as osteoporosis, using a posterior approach with triceps dissection and Open Reduction Internal Fixation (ORIF) with plating?

Posterior Approach with Triceps Dissection for Distal Humerus ORIF with Plating

For distal humerus fractures requiring ORIF, use a triceps-splitting or triceps-reflecting approach rather than olecranon osteotomy, as this provides adequate exposure with fewer complications, shorter operative times, and better functional outcomes, particularly for type C1 and C2 fractures. 1, 2

Preoperative Planning

Patient Positioning and Anesthesia

• Position the patient prone or lateral decubitus with the affected arm draped free across a padded bolster 3
• Use either general or regional anesthesia based on patient comorbidities 3
• Apply a sterile tourniquet to the proximal arm if hemostasis is needed 3

Fracture Assessment

• Confirm fracture classification using preoperative CT with 3D reconstruction for complete surgical planning 3
• Identify the fracture pattern (AO/OTA type A, B, or C) to determine plate configuration 3
• Assess bone quality, particularly in elderly patients with osteoporosis, as this influences fixation strategy 4

Surgical Approach: Step-by-Step

Incision and Superficial Dissection

• Make a posterior midline incision centered over the distal humerus, extending 8-10 cm proximal to the olecranon tip 2, 5
• Identify and protect the ulnar nerve by dissecting it free from the cubital tunnel and transposing it anteriorly 2, 3
• Mobilize the ulnar nerve throughout the procedure to prevent traction injury 3

Triceps Management (Triceps-Splitting Technique)

• Split the triceps tendon longitudinally in the midline, extending proximally through the muscle belly 5
• Develop full-thickness medial and lateral flaps by elevating the triceps off the posterior humerus subperiosteally 5
• Reflect the anconeus muscle laterally as a pedicle to preserve its blood supply (TRAP approach modification) 2
• This approach avoids olecranon osteotomy complications including nonunion, hardware prominence, and the need for osteotomy fixation removal 1, 2

Fracture Exposure and Reduction

• Expose the distal humerus by retracting the triceps flaps medially and laterally 5
• Clear the fracture site of hematoma and interposed soft tissue 3
• For intercondylar fractures (type C), first reduce and provisionally fix the articular surface with K-wires or lag screws 3, 4
• Reduce the reconstructed condylar block to the humeral shaft using pointed reduction forceps 3
• Verify anatomical reduction of the articular surface under direct visualization 3

Fixation Technique

Plate Configuration

• Use bicolumnar plating with either 90-90° (perpendicular) or 180° (parallel) plate configuration, as both provide superior biomechanical stability 3, 4
• For elderly patients with osteoporotic bone, the 90-90° bicolumnar construct enhances distal fragment fixation 4
• Position the medial plate along the medial column and the lateral plate along the lateral column 3, 4

Screw Placement Strategy

• Place intercondylar lag screws first to compress the articular fragments together 3
• Insert distal locking screws into both columns, aiming for at least 4-6 screws in the distal fragment 4
• Maximize distal fixation by using all available screw holes in the distal fragment, particularly in osteoporotic bone 4
• Place proximal screws in the humeral shaft in standard fashion 3
• Ensure screws do not penetrate the olecranon fossa anteriorly 3

Fixation Verification

• Confirm stable fixation by gently ranging the elbow through flexion and extension 3
• Obtain intraoperative fluoroscopy in AP and lateral views to verify reduction and hardware position 3
• Check that no screws violate the articular surface 3

Wound Closure

Triceps Repair

• Repair the triceps tendon split using heavy nonabsorbable sutures in a figure-of-eight or Krackow pattern 5
• Reattach the anconeus muscle to its anatomic position if it was elevated 2
• Proper triceps repair is critical to prevent extensor mechanism weakness 2, 5

Ulnar Nerve Management

• Transpose the ulnar nerve anteriorly and create a subcutaneous or submuscular pocket 3
• Avoid excessive tension on the transposed nerve 3

Final Closure

• Close the deep fascia over the triceps repair 5
• Close subcutaneous tissue and skin in layers 5
• Apply a well-padded posterior splint with the elbow at 90° flexion 3

Postoperative Protocol

Immediate Care

• Begin early active-assisted range of motion exercises within 3-5 days if fixation is stable 3
• Remove the splint for therapy sessions and reapply between sessions for the first 2 weeks 3
• Avoid resisted extension for 6 weeks to protect the triceps repair 5

Radiographic Monitoring

• Obtain AP and lateral radiographs immediately postoperatively and at 2,6, and 12 weeks 3
• Monitor for loss of reduction, hardware failure, and fracture healing progression 3

Critical Pitfalls and Complications

Approach-Related Complications

• Triceps-splitting approach reduces operative time, blood loss, and complication rates compared to olecranon osteotomy for type C1 and C2 fractures 1
• Transient ulnar nerve palsy occurs in approximately 5-10% of cases but typically resolves 2, 5
• Heterotopic ossification can limit motion but occurs in less than 5% of cases 2, 5

Fixation Failures

• Nonunion rates are higher in patients over 65 years with osteoporotic bone (approximately 20% in one series) 5
• In elderly patients with severely comminuted fractures and poor bone quality, consider total elbow arthroplasty as an alternative to ORIF 3
• Varus or valgus instability may occur if medial or lateral column fixation is inadequate 5

Functional Outcomes

• Type C1 and C2 fractures typically achieve 110-120° arc of motion 1, 2
• Type C3 fractures have more limited motion, averaging 85° arc of motion 2
• Final range of motion is typically achieved by 3-4 months postoperatively 1