Triceps Approach in Chronic Elbow Dislocation

Definition and Context

• Extensive heterotopic ossification around the joint
• Marked shortening and contracture of the triceps muscle
• Tightening of the ulnar nerve with any attempt at flexion
• Ossification or dense fibrous thickening of the joint capsule
• Dense fibrous tissue filling the olecranon and coronoid fossae
• "Radial humeral horn" - ossification of periosteal hematoma near the radial head
• Possible ankylosis

Treatment Options

In children, open reduction is worthwhile regardless of duration, as children regain useful arcs of motion.

The Triceps Approach: Core Principle

TECHNIQUE 66.11 - Speed's Open Reduction with V-Y Triceps Lengthening

Incision and Exposure

1. Make an incision over the posterolateral aspect of the elbow, beginning in the midline 10 cm proximal to the olecranon. Continue distally to just proximal to the olecranon tip, then curve slightly laterally over the lateral humeral condyle and the radial head, extending a further 5 cm distally on the forearm.
2. Undermine and retract wound edges to expose the tendinous insertion/aponeurosis of the triceps muscle on the posterior elbow.
3. Locate and protect the ulnar nerve - dissect it free from its groove in the medial humeral condyle and carefully retract it medially throughout the procedure.

Triceps Mobilization (the V-Y Step)

1. Beginning proximally with sharp dissection, reflect the triceps aponeurosis distally to form a flap of tissue still attached to the olecranon.
2. Beginning 7.5 cm proximal to the joint, make an incision in the midline of the arm through the triceps muscle fibers distally to the olecranon, then curve this deep incision around the lateral edge of the olecranon to the distal end of the skin incision.

Subperiosteal Mobilization

1. Subperiosteally strip all muscle attachments from the distal humerus, both anteriorly and posteriorly. Release all capsular and collateral ligament attachments around the condyles. The lower end of the humerus must be completely mobilized - the medial condyle and anterior humeral surface are the most difficult areas.
2. Remove all callus on the posterior humerus and in the olecranon fossa (from periosteal elevation at time of injury) along with any scar tissue.
3. Expose the radial head and clear the trochlear notch of the ulna.

Reduction

1. Rotate the forearm and gently press on the anterior surface of the capitellum to bring the radial head anteriorly into its normal position.
2. If the radial head cannot be reduced easily, widen the soft-tissue dissection rather than using force - the contracted tissues must be released before reduction is attempted.

Closure (the V-Y Lengthening)

• Fill the distal defect in the triceps tendon with the inverted V-shaped portion of the triceps fascia, and close the proximal defect by suturing the remaining two margins of the triceps together.
• Repair the triceps tendon, posterior capsule, and triceps aponeurosis with strong interrupted sutures.

Campbell's Posterolateral Approach (Technique 1.108) - Triceps Aponeurosis Tongue

1. Posterior longitudinal incision, reflect wound edges
2. Identify and protect the ulnar nerve
3. Free a tongue of triceps aponeurosis and reflect it distally (still attached at olecranon)
4. Deviate the incision distally and medially through the triceps aponeurosis to separate the anconeus from the extensor carpi ulnaris
5. Divide the posterior capsule in the same line
6. Reflect the triceps tendon distally, dividing muscle tissue obliquely with care; stay well clear of the radial nerve
7. Reflect anconeus and underlying capsule medially
8. Behind the lateral epicondyle, work in the interval between anconeus and common extensor origin; partially reflect the common extensor origin, lateral collateral ligament, and adjacent capsule to increase exposure
9. Apply varus strain on the elbow to further increase visualization
10. Closure: repair triceps tendon, posterior capsule, and aponeurosis with strong interrupted sutures

Triceps Management Considerations

• V-Y lengthening (Speed technique) is the most commonly used and described method when the muscle is significantly contracted
• Some surgeons use needle barbotage to incrementally lengthen the tendon (used in 25% of cases in Anderson et al.'s series)
• The triceps tendon can often be left intact (Anderson et al., 32 patients) - using complete soft-tissue release, intraarticular scar excision, and ulnar nerve transposition, without tendon lengthening or transfer - achieving 97% good-to-excellent results (Mayo Elbow Performance Index) at ~2 years
• Lengthening via V-Y is still considered standard by most authors when the elbow is fixed in extension with a contracted triceps

Additional Intraoperative Considerations

• Ulnar nerve transposition is commonly performed given the nerve is almost always tethered and at risk with flexion
• Heterotopic bone/callus removal from the olecranon fossa and posterior humerus is essential for restoration of motion
• External fixation or Internal Joint Stabilizer (IJS): After wide soft-tissue release, the elbow may be too unstable for early mobilization. The IJS device (Skeletal Dynamics) is now preferred over hinged external fixators - it maintains concentric reduction while allowing immediate range-of-motion exercises. It also protects early ligament reconstruction from failure. Elective removal at 4-6 months.
• "Cruciate" intraarticular ligament reconstruction has also been described for joint stabilization after reduction

Postoperative Care

• Early range-of-motion exercises are paramount - capsular release without prompt mobilization leads to re-stiffening
• IJS or hinged external fixation facilitates this even with ligamentous instability
• Active mobilization gradually introduced; unrestricted motion encouraged as early as tolerated
• Triceps-splitting approaches typically require a brief period of protected motion before unrestricted exercises (unlike paratricipital or lateral approaches)

Complications

• Radial nerve injury (especially with extensile lateral dissection)
• Ulnar nerve injury/neuropathy
• Heterotopic ossification
• Re-dislocation / instability
• Stiffness and loss of terminal extension (most common residual deficit)
• Avascular necrosis of the distal humerus

Triceps-Sparing Approaches to the Elbow

1. Paratricipital Approach (True Triceps-Sparing / Triceps-On)

Core Principle

Step-by-Step Technique

1. Skin incision: Extensive posterior longitudinal midline incision
2. Ulnar nerve: Identify and mobilize from the arcade of Struthers through the flexor carpi ulnaris (FCU) fascia; place a Penrose drain around it for protection throughout the case
3. Medial window:
   • Develop the interval between the triceps muscle and the medial intermuscular septum
   • Elevate the triceps muscle subperiosteally off the posterior humerus
   • Excise the medial intermuscular septum for improved access
4. Lateral window:
   • Elevate the triceps muscle off the lateral intermuscular septum and posterior humerus, in continuity with the anconeus
   • The anconeus and triceps are retracted together laterally
5. Exposure achieved: Medial and lateral columns, olecranon fossa, and posterior aspect of the trochlea are visible

Optional Third Window (Boyd Interval Modification)

• A third window can be added between the anconeus and the lateral olecranon (Boyd interval)
• This improves visualization of the distal humerus articular surface when needed

Advantages

• No olecranon osteotomy - avoids nonunion and symptomatic hardware
• Triceps insertion is undisturbed - allows immediate active range of motion postoperatively
• Preserves innervation and blood supply of the anconeus (which provides dynamic posterolateral stability)
• Can be converted to olecranon osteotomy if more exposure is needed intraoperatively
• Can be extended proximally using the Gerwin approach (triceps elevated lateral to medial), exposing 95% of the posterior humeral shaft and radial nerve

Disadvantages

• Limited articular visualization - inadequate for highly comminuted articular fractures (OTA/AO type C3)
• More technically demanding than triceps-splitting

Indications

Postoperative Care

2. Bryan-Morrey Approach (Commonly Mislabeled "Triceps-Sparing")

Important clarification from Rockwood & Green (2025): "The approach has been termed triceps-sparing, which has led to confusion. The approach does NOT 'spare' the triceps, but rather detaches the triceps tendon in continuity with the ulnar periosteum and anconeus creating a large reflection or sleeve."

Step-by-Step Technique

1. Posterior longitudinal skin incision
2. Identify and protect the ulnar nerve (always transpose in primary and revision TEA)
3. Starting medially, sharply reflect the triceps insertion and ulnar periosteum off the proximal ulna in a medial-to-lateral direction as a continuous sleeve
4. This sleeve incorporates the anconeus muscle - the entire extensor mechanism is reflected laterally as one unit
5. Release the medial and lateral collateral ligaments to allow joint dislocation for implant insertion (in TEA)

Closure

• Repair triceps tendon back to olecranon with transosseous sutures - this is mandatory and critical
• Postoperative triceps protection required for 6 weeks (no active extension against resistance)

Advantages over Paratricipital

• Better visualization of the proximal ulna - important for ulnar component preparation in TEA
• Familiar, widely taught approach

Comparison Summary

Application in Chronic Elbow Dislocation

• It preserves the extensor mechanism in a joint that has already undergone significant soft-tissue scarring
• It allows immediate postoperative mobilization, which is paramount after capsular release (re-stiffening is the main enemy)
• The medial window provides direct access for ulnar nerve transposition (almost always needed)
• The lateral window allows access to the radiocapitellar joint and lateral column for release

Paratricipital (Triceps-On) Approach - Complete Technique

What Makes It "Triceps-On"

Patient Positioning

• Supine with the affected arm across the chest, sandbag under ipsilateral shoulder
• OR lateral decubitus position with arm over a padded support
• Sterile tourniquet applied; limb exsanguinated before inflation
• Mark the medial and lateral epicondyles before draping to remind the team of ulnar nerve location

Step-by-Step Surgical Technique

Step 1 - Skin Incision

• Straight posterior longitudinal incision, curved slightly medially around the olecranon tip
• Extend proximally as needed (typically 10-12 cm above olecranon, distally 5 cm below)
• Raise full-thickness medial and lateral subcutaneous flaps until the margins of the triceps are clearly visible on both sides

Step 2 - Ulnar Nerve (Critical First Step)

• Identify the ulnar nerve in its groove behind the medial epicondyle
• Mobilize it from the arcade of Struthers proximally down through the flexor carpi ulnaris (FCU) fascia distally
• Place a Penrose drain around the nerve and keep it visible throughout the entire procedure
• Plan for anterior transposition at closure

Step 3 - Medial Window

• Develop the interval between the triceps muscle belly and the medial intermuscular septum
• Excise the medial intermuscular septum - this is important as it improves mobility of the triceps and protects the ulnar nerve from tethering
• Elevate the triceps muscle subperiosteally off the posterior aspect of the distal humerus
• This exposes the medial column and the posterior aspect of the trochlea

Medial window - arrow shows medial intermuscular septum being excised; T = triceps tendon undisturbed

Step 4 - Lateral Window

• On the lateral side, elevate the triceps off the lateral intermuscular septum and posterior humerus, working in continuity with the anconeus
• The triceps and anconeus are retracted together as one unit laterally
• This exposes the lateral column, olecranon fossa, and posterior trochlea

Lateral window - triceps (T) elevated to expose lateral column (L) and olecranon fossa; insertion on olecranon completely intact

Step 5 - Para-Olecranon Variant (Campbell's preferred for TEA)

• Additionally, reflect the lateral cubital retinaculum and anconeus off the lateral ulna as a single unit, keeping the direct triceps attachment on the olecranon tip undisturbed
• Excise the posterior capsule and fat pad for joint entry
• Collateral ligaments are released on each side to allow elbow dislocation for implant insertion (when doing TEA)

Step 6 - Third Window (Boyd Interval - Optional)

• When more articular visualization is needed, a third window can be added between the anconeus and the lateral border of the olecranon (Boyd interval)
• Increases visualization of the articular surface without touching the triceps

What Is Exposed

Closure

• No triceps repair needed - the insertion was never touched
• Reattach/repair the anconeus to the ulna if elevated (fascial sutures)
• Anterior transposition of ulnar nerve
• Layered wound closure

Postoperative Care

• Immediate unrestricted active range of motion - flexion, extension, pronation, supination - all allowed from day 1
• No triceps protection or restriction required whatsoever
• Sling for comfort only
• Strengthening avoided for first 3 months; lifting limited to 5 lbs for 3 months, then 10 lbs thereafter

Advantages vs. All Other Posterior Approaches

• No risk of triceps rupture or weakness postoperatively
• Avoids olecranon osteotomy complications (nonunion, symptomatic hardware)
• Preserves anconeus innervation and blood supply (dynamic posterolateral stabilizer)
• Convertible intraoperatively to olecranon osteotomy if more exposure unexpectedly needed
• Convertible to Gerwin approach proximally (exposes 95% of posterior humeral shaft) if shaft fracture present

Key Danger - Do NOT Do This

Never divide the triceps transversely in this approach - this converts it into a triceps-cutting approach and nullifies the entire benefit. The rule: work beside the triceps, never through it.