The triceps–flexor carpi ulnaris (TRIFCU) approach to the elbow

Abstract

Ann R Coll Surg Engl 2010; 92: 240-242 240Intra-articular fractures of the distal humerus frequently require internal fixation. Several approaches have been described, with the posterior approaches being most common. These include the olecranon osteotomy approach, tongue of triceps approach, posteriomedial approach, posteriolateral approach and tricep splitting approaches. [1][2][3][4] We present a new approach to the distal humerus via the lateral border of the triceps muscle. Patients and Methods Operative techniqueThe anaesthetized patient is positioned in a lateral position with the upper arm resting on a support and the elbow flexed. A tourniquet is placed as proximally as possible on the arm. With the arm hanging over the support, we prefer that the hand is rested on a Mayo table to keep the elbow flexed to approximately 20º. A standard midline posterior incision is made over the elbow from approximately 15 cm above the olecranon to 10 cm bellow the olecranon. The incision is curved laterally around the olecranon to avoid the scar lying directly over the olecranon. The skin and subcutaneous tissues are reflected laterally and medially exposing the triceps and olecranon (Fig. 1). Next, the ulna nerve is identified proximally and followed distally around the medial epicondyle. Care is taken not to mobilise or directly handle the nerve to minimise the risk of neuropraxia. We do not routinely use a tape around the ulna nerve to identify or retract it. The lateral border of the triceps muscle is identified and a plane is developed between this muscle and the lateral intermuscular septum. The lateral border of the insertion of triceps on the tip of the olecranon is identified. The anconeus muscle lies lateral to this plane. The triceps is reflected medially and, as this progresses distally, fascia covering the anconeus muscle is encountered. This fascia is incised half-way over the anconeus muscle. The distal insertion of anconeus muscle is detached and reflected medially away from its insertion, exposing the lateral border of the ulna (Fig. 2). As the triceps is being medially reflected, the origins of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) are encountered. These are subperiosteally reflected medially with the triceps tendon Intra-articular fractures of the distal humerus frequently require internal fixation. Several approaches have been described, with the posterior approaches being most common. We present a new approach to the distal humerus via the lateral border of the triceps muscle. PATIENTS AND METHODS The senior author has used this technique for fixation of intra-articular fractures of the distal humerus in 12 patients. RESULTS The approach is equally useful for intra-and extra-articular fractures. No cases of postoperative ulna nerve neuropraxia have been encountered. There have been no postoperative wound complications. The exposure has allowed sufficient access to allow anatomically contoured plates to be easily applied to both sides of the distal humerus with confi...

Distal humerus fractures: a review of current therapy concepts

“…Due to the small number of cases, no significant benefits concerning protection of the ulnar nerve or recovery of the extensor mechanism could be shown compared to olecranon osteotomy. The approach has been described to be used for extra-and intra-articular fractures [28].…”

Effects of surgical approach on functional outcomes of open reduction and internal fixation of intra-articular distal humeral fractures: a systematic review

“…12 All involve either detaching or mobilizing the extensor mechanism from the elbow to expose the joint. The triceps-splitting approach (Fig.…”

Exposure of the Distal Humerus Using a Triceps Hemi-peel Approach

“…5 The authors noted a decrease in elbow extensor peak torque of 10.3 Nm (80.1 Nm in the uninjured extremity vs 69.8 Nm in the injured extremity, recorded at 60° per second). 5 The TRIFCU approach, as described by Deakin and Deshmukh, 17 reflects the triceps insertion in a lateral to medial direction and releases the anconeus insertion to expose the distal humerus articular surface. Currently, to the authors' knowledge no published studies report outcome data on the use of the TRIFCU approach.…”

“…The initial steps of the hemipeel exposure are identical to those of the TRIFCU procedure, as described by Deakin and Deshmukh. 17 A posterior midline incision is made over the elbow, and the skin and subcutaneous tissue are reflected medially and laterally. A plane is developed between the lateral border of the triceps and the lateral intermuscular septum.…”

“…The TRIFCU involves complete reflection of the triceps periosteal sleeve from the proximal ulna in a lateral to medial direction and release of the anconeus insertion to expose the distal humerus articular surface. 17 The lateral-to-medial approach may decrease the risk of ulnar nerve complications, but the complete elevation of the triceps insertion may also predispose patients to the same extensor mechanism weakness or failure associated with classic medial to lateral reflection.…”