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Triceps Splitting Approach to the Elbow

- See: Posterior Approach to the Humerus;

- Discussion:
    - the distal triceps can be split down the middle with the dissection carried straight down to bone over the olecranon;
    - care is taken to mobilize full thickness fascial and periosteal flaps both medially and laterally;
    - the dissection may procede all the way to the epicondyles if necessary;
    - as Urbaniak notes, if care is taken to elevate full thickness flaps (and care is taken to obtain a secure closure), then triceps avulsion is not a 
          major problem;

- Positioning:
    - patient is in lateral position w/ arm brought across the chest;
    - plan on adusting flexion of elbow inorder to increase or decrease tension;
    - sterile tourniquet is required;

- Technique:
    - indicated for condylar fractures;
    - disadvantages: detachment of the medial triceps insertion is a potential complication, which has led some to routinely use the medial triceps 
           reflecting approach;
    - straight longitudinal incision beginning 7-10 cm above posterior aspect of humerus, avoiding olecranon tip by shifting incision either 
          slightly laterally or medially;
    - proximally incise thru the medial triceps fascia, continue across the olecranon, and finally across the lateral aspect of ulna;
    - longitudinally incise thru triceps tendon, and subperiosteally reflect aconeus laterally, more distally the FCU is reflected and retracted 
    - proximally the radial nerve will be encountered in the spiral groove, approximately 13-15 cm above the joint line;
    - distally the incision continues over the lateral border of the ulna;
    - preserve as much of the triceps insertion as possible (up to 3/4 of the insertion can be sharply elevated off the ulna;;
    - further exposure can be achieved by removing the most proximal portion of the olecranon process (removing only the non articular 
          portion of the olecranon);
    - wound closure include proximal reattachment of the triceps insertion into crossing drill holes into the olecranon, and more distally 
          anchoring the periosteum to the superficial forearm fascia

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