A Modified Surgical Approach to the Distal Humerus: The Triceps Bundle Technique

INTRODUCTION

Distal humerus fractures are common injuries for which appropriate reduction and restoration of the native elbow joint axis are critical objectives to achieve a good outcome.^1,2 Multiple surgical approaches have been described to aid in achieving this, including the triceps-reflecting anconaeus flap, para-tricipital, triceps-splitting, triceps-flexor carpi ulnar and olecranon osteotomy. No clinical advantage has been shown for any one approach over another.^3,4 The olecranon osteotomy is often utilised in complex distal humerus fractures as it provides clear visualisation of the articular surface.⁵ Complications of the osteotomy, however, include non-union, symptomatic malunion and implant loosening.^5–7 In addition, this approach makes it challenging to convert to a total elbow replacement if required.⁸

The modified fascial tongue approach to the distal humerus provides clear visualisation of the articular surface of the distal humerus whilst avoiding the complications of an olecranon osteotomy. The triceps fascial tongue approach was first described in 1940.⁹ There are few subsequent publications describing this technique, and it is frequently not included in comparison studies.^10–12 We describe the senior author’s (AJJ) modified fascial tongue surgical approach to the distal humerus and elbow joint. In particular, we describe the reflection and utilisation of radial and ulnar triceps bundles to allow complete visualisation of the distal humerus. The surgical approach is illustrated in the setting of an extra-articular humerus fracture with the application of modern fracture fixation implants.

MATERIALS AND METHODS

The modified fascial tongue approach was performed and the technique captured with multiple, sequential photographs. Patient consent for photographs was obtained prior to the procedure. The patient is a 24-year old gentleman treated at our major trauma centre with a right comminuted distal third humerus fracture (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 12.A1c) (Fig. 1).

The patient underwent open reduction and internal fixation using the modified fascial tongue approach. The principal modification in this approach utilises bunching of the triceps muscle into two distinct bundles, allowing for complete reflection of the muscle off the distal humerus whilst allowing for a later robust repair.

Surgery is performed under a general anaesthesia. The patient is positioned in the lateral decubitus position with the operated arm placed over a radiolucent bolster fixed to the side of the bed. The upper limb is prepped to the shoulder and standard surgical draping is applied. A sterile tourniquet is optional but only for distal fractures.

A posterior midline incision (midline with lateral curve around the tip of the olecranon) is first marked out and then performed (Fig. 2). Full-thickness flaps are elevated. The fascial tongue flap is at this stage marked out. It measures approximately 9 cm in length and 3 cm in width. The flap is rectangular, distally based, and it is essential when marking it to allow for sufficient adjacent fascia remaining for later repair at closure (Fig. 3).

The ulnar nerve is identified, mobilised and subsequently protected throughout the surgery (Fig. 4). Following ulnar nerve identification, the fascial flap is sharply incised and elevated off the underlying muscle. As a distally based fascial flap, it remains attached to the olecranon; it is wrapped in saline-soaked gauze to prevent desiccation (Fig. 5).

At this stage, the surgeon modifies the standard triceps splitting approach. The exposed triceps is split longitudinally in the midline with sharp dissection. The ulnar and radial bundles of the split triceps muscle are then identified, reflected from the humerus and then the tendinous regions adjacent to their points of insertion onto the olecranon are circumferentially tied and transfixed with a number 1 braided absorbable suture to create two distinct limbs (Fig. 6). This maintains the limbs for subsequent reattachment. The ends of these triceps bundles are divided at their insertions onto the olecranon and reflected to expose the distal humerus, allowing full exposure to the distal medial and lateral columns and posterior articular surface (Fig. 7). Traction on the ulna with the elbow in the flexed position allows exposure of the inferior surface of the humerus. If further exposure is required, the medial and lateral collateral ligaments can be divided longitudinally to aid retraction of the ulna, and the olecranon tip (approximately 3 mm) can be excised if further articular surface visualisation is needed.

Extensile exposure was not performed in this case, and the collateral ligaments were left intact. However, given the proximal extension of the fracture, the proximal triceps is divided longitudinally in the midline with sharp and subsequently blunt dissection until the radial nerve is identified, mobilised and protected (Fig. 8). Standard reduction and fixation techniques can then be used at the surgeon’s discretion. In this case, multiple lag screws followed by a parallel plate construct was used (Fig. 9).

Repair of the triceps is performed with placement of a number 1 braided absorbable suture through each of the triceps’ bundles. This is then passed through the distal fascio-tendinous substance of the triceps tendon flap, where it attaches to the olecranon and is repaired under tension; a modified Kessler repair is performed individually for each triceps bundle (Fig. 10). Approximating sutures are placed between the two triceps bundles. The fascial tongue flap is then returned to its original position and sutured into place with number 1 braided absorbable sutures (Fig. 11). A number 1 braided absorbable suture is subsequently used to repair the triceps longitudinal split. The ulnar nerve can be left in situ or transposed. Surgeon preference is then advised for closure of the subcutaneous layer and skin. A bulky bandage is applied.

RESULTS

Anatomical reduction was achieved with a stable dual plating construct, allowing for immediate active mobilisation limited only by the bulky bandage. The patient commenced physiotherapy with active range of motion exercises at two weeks follow-up. At six weeks follow-up, the patient displayed full elbow flexion of 150 degrees, equal to the contralateral side. The final 20 degrees of extension were limited at this stage (range of motion 20–150 degrees). Pronation and supination were normal, as were shoulder movements. At 12-week follow-up, the patient had returned to a normal range of motion at the elbow for both flexion and extension, reported no concerns and was functioning well with a return to normal activities. Radiographs showed evidence of bony union (Fig. 12).

DISCUSSION

The modified fascial tongue surgical approach to the distal humerus offers excellent visualisation of the distal humerus articular surface, metaphyseal and diaphyseal regions, whilst avoiding the complications of an olecranon osteotomy. Further advantages include a reduced operation time, a non-technically challenging approach, and the option to convert from fixation to total elbow arthroplasty if required.

The modified fascial tongue approach is suitable for total elbow arthroplasty, extra-articular fractures and intra-articular fractures. In our practice, this approach is utilised for all distal humerus fractures in combination with excision of the olecranon tip if further articular surface visualisation is needed. The principal benefit of this technique is the ease with which it can be performed and the improvement in visualisation when compared to other non-osteotomy techniques. Gorder is credited with popularising the original fascial tongue technique for treatment of fractures, while more recent authors have described its use for total elbow arthroplasty.^9,13 Using the modified dual triceps bundle approach, the operating surgeon will be able to confidently delineate the anatomy of the distal humerus with elegant reflection of the muscle combined with a later robust repair.

The olecranon osteotomy has been compared to the triceps fascial tongue approach previously and suggested to provide superior outcomes; Elmadag et al. showed an osteotomy group had improved range of motion and a higher Mayo elbow score when compared to the fascial tongue group. However, the study design was flawed, with more complex fractures in the fascial tongue group and a prolonged period of immobilisation when compared to the osteotomy group.¹⁴ As such, the findings cannot be compared directly. A more recent cohort-based study has shown that the triceps tongue technique had reduced blood loss, greater maximal flexion, and achieved a larger flexion-extension arc when compared to those with an olecranon osteotomy.¹⁵ There is otherwise limited data comparing these two approaches directly, and evidence to date has shown no superior functional outcomes of any one distal humerus approach versus another.^11,16

A reported limitation of the triceps fascial tongue approach is triceps weakness when used for total elbow arthroplasty.⁴ Recent data have disputed this, with one series showing all postoperative total elbow replacement patients that underwent a fascial tongue approach as having grade IV or V strength at last follow-up; this was a significant improvement on all patients preoperative strength.¹⁷ In our experience, return of range of motion and upper limb strength is reliable when using this approach.

The modified triceps fascial tongue approach provides excellent visualisation, is extensile, and is versatile. It allows for anatomic reduction of fracture fragments while still allowing easy conversion to joint replacement if required. It is straightforward to teach and master and allows for timely exposure of the distal humerus. It is our exposure of choice for distal humerus fractures. We believe the modified triceps fascial tongue is a useful approach for any surgeon treating distal humerus fractures.

ORCID

Iain A Rankin https://orcid.org/0000-0003-3458-1408

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