Pediatric Elbow Fractures by Joshua M. Abzug Martin J. Herman & Scott Kozin

Author:Joshua M. Abzug, Martin J. Herman & Scott Kozin
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Similarly, the Bryan-Morrey posterior triceps sparing approach can be used to visualize the articular surface [32]. In the authors’ experience, this requires more soft tissue dissection as the triceps is mobilized from a medial to lateral direction, unhinging the elbow joint for visualization. The triceps sparing approach requires manipulating the triceps to evaluate the joint space without compromising elbow extension function [9]. Typically the distal insertions at the olecranon will be elevated. Again a posterior midline incision is utilized. The long head of the triceps is identified down to the triceps tendon medially. The lateral column may be more difficult to visualize using the triceps sparing approach . The ulnar nerve should be correctly identified and protected. If preoperative ulnar dysfunction is present, transposition of the nerve is recommended [22].

Once the distal humerus is exposed, fixation is performed as described for the olecranon osteotomy approach. One obvious advantage of the triceps sparing approach is that there is no osteotomy to fix and instrument. It also spares any potential injury to the olecranon apophysis. The portion of the distal triceps insertion that was elevated from the olecranon will require repair. This can be down through a modified Krackow suture through bone tunnels or back to the periosteum. The Bryan-Morrey approach does not seem to produce any loss of strength from sliding the triceps and results in good clinical outcomes [9].

Kasser and colleagues argue that the triceps split is preferable to the olecranon osteotomy in the treatment of T-condylar humerus fractures to prevent violation of a developing apophysis. Although this holds true in a skeletally immature child, it is less of a concern in an adolescent that is near or at skeletal maturity [9]. The triceps splitting approach provides limited exposure of the articular surface and should be reserved for fractures where reduction of the articular service requires minimal effort or visualization. In addition, placing implants in a 90/90 orientation may be challenging.

The surgical approach is similar to a posterior skin incision. The margin of the lateral and long heads of the triceps is identified and split. The radial nerve should be safely out of the zone of injury in the posterior approach. In the authors’ experience, this approach should only be considered for more stable fracture patterns with minimal articular involvement.

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