CLINICAL TECHNIQUE

A Modified Surgical Approach to the Distal Humerus:

The Triceps Bundle Technique
Iain A Rankin1 , James Dixon2, Joaquim Goffin3, Alan J Johnstone4
Received on: 19 April 2024; Accepted on: 18 July 2024; Published on: 14 August 2024

A b s t r ac t
T his paper describes a modification of the traditional fascial tongue surgical approach to the distal humerus. In particular, we describe the
reflection and utilisation of radial and ulnar triceps bundles to allow complete visualisation of the distal humerus. This extensile technique allows
access to the entirety of the distal humerus and provides excellent visualisation to the operating surgeon. Indications for the surgical approach
include open reduction with internal fixation of fractures (both intra- and extra-articular) and total elbow replacement.
Whilst standard approaches to the distal humerus are well described, this modification describes a new surgical approach that improves access
and visualisation of the traditional fascial tongue technique. Alternative approaches to improve visualisation include an olecranon osteotomy;
the triceps bundle modification allows excellent exposure to the distal humerus whilst avoiding complications associated with an olecranon
osteotomy. The surgical technique is illustrated with intra-operative photographs, which aim to aid in guiding the surgeon in undertaking
critical steps of this approach.
Keywords: Distal humerus, Fracture, Surgical approach, Trauma.
Strategies in Trauma and Limb Reconstruction (2024): 10.5005/jp-journals-10080-1618

Introduction 1–4
Department of Orthopaedics, Aberdeen Royal Infirmary, Aberdeen,
Distal humerus fractures are common injuries for which appropriate Scotland, United Kingdom
reduction and restoration of the native elbow joint axis are Corresponding Author: Iain A Rankin, Department of Orthopaedics,
critical objectives to achieve a good outcome.1,2 Multiple surgical Aberdeen Royal Infirmary, Aberdeen, Scotland, United Kingdom,
approaches have been described to aid in achieving this, including Phone: +01224552537, e-mail: iain.rankin@nhs.scot
the triceps-reflecting anconaeus flap, para-tricipital, triceps- How to cite this article: Rankin IA, Dixon J, Goffin J, et al. A Modified
splitting, triceps-flexor carpi ulnar and olecranon osteotomy. No Surgical Approach to the Distal Humerus: The Triceps Bundle
clinical advantage has been shown for any one approach over Technique. Strategies Trauma Limb Reconstr 2024;19(2):99–103.
another.3,4 The olecranon osteotomy is often utilised in complex Source of support: Nil
distal humerus fractures as it provides clear visualisation of the Conflict of interest: None
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 (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic
elbow replacement if required.8 Trauma Association (AO/OTA) type 12.A1c) (Fig. 1).
The modified fascial tongue approach to the distal humerus The patient underwent open reduction and internal fixation
provides clear visualisation of the articular surface of the distal using the modified fascial tongue approach. The principal
humerus whilst avoiding the complications of an olecranon modification in this approach utilises bunching of the triceps
osteotomy. The triceps fascial tongue approach was first described muscle into two distinct bundles, allowing for complete reflection
in 1940.9 There are few subsequent publications describing of the muscle off the distal humerus whilst allowing for a later
this technique, and it is frequently not included in comparison robust repair.
studies.10–12 We describe the senior author’s (AJJ) modified fascial Surgery is performed under a general anaesthesia. The patient
tongue surgical approach to the distal humerus and elbow joint. is positioned in the lateral decubitus position with the operated arm
In particular, we describe the reflection and utilisation of radial and placed over a radiolucent bolster fixed to the side of the bed. The
ulnar triceps bundles to allow complete visualisation of the distal upper limb is prepped to the shoulder and standard surgical draping
humerus. The surgical approach is illustrated in the setting of an is applied. A sterile tourniquet is optional but only for distal fractures.
extra-articular humerus fracture with the application of modern A posterior midline incision (midline with lateral curve around
fracture fixation implants. the tip of the olecranon) is first marked out and then performed
(Fig. 2). Full-thickness flaps are elevated. The fascial tongue flap is
M at e r ia l s and Methods at this stage marked out. It measures approximately 9 cm in length
The modified fascial tongue approach was performed and the and 3 cm in width. The flap is rectangular, distally based, and it is
technique captured with multiple, sequential photographs. Patient essential when marking it to allow for sufficient adjacent fascia
consent for photographs was obtained prior to the procedure. The remaining for later repair at closure (Fig. 3).
patient is a 24-year old gentleman treated at our major trauma The ulnar nerve is identified, mobilised and subsequently
centre with a right comminuted distal third humerus fracture protected throughout the surgery (Fig. 4). Following ulnar nerve

© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
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 A Modified Surgical Approach to the Distal Humerus

Figs 1A and B: (A) Oblique and (B) lateral views of a comminated distal third humerus fracture (AO/OTA 12.A1c)

Fig. 2: Posterior midline incision marked out with lateral deviation over Fig. 4: Identification of the ulnar nerve
the olecranon

Fig. 5: Reflection of the distally based fascial flap

Fig. 3: Marking of the rectangular, distal based triceps fascial flap (leaving attached to the olecranon; it is wrapped in saline-soaked gauze to
a peripheral rim of fascia for reattachment of the flap) prevent desiccation (Fig. 5).
At this stage, the surgeon modifies the standard triceps splitting
identification, the fascial flap is sharply incised and elevated off approach. The exposed triceps is split longitudinally in the midline
the underlying muscle. As a distally based fascial flap, it remains with sharp dissection. The ulnar and radial bundles of the split

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 A Modified Surgical Approach to the Distal Humerus

Figs 6A and B: (A) Radial and (B) Ulnar limbs of the split triceps muscle

Fig. 7: Exposure of the medial and lateral columns of the distal Fig. 8: Proximal extension of the triceps split with exposure of the
(a) Humerus; (b) Olecranon; (c) Suture tagging of ulna triceps bundle; (d) radial nerve
Suture tagging of radial triceps bundle
then be used at the surgeon’s discretion. In this case, multiple lag
triceps muscle are then identified, reflected from the humerus and screws followed by a parallel plate construct was used (Fig. 9).
then the tendinous regions adjacent to their points of insertion Repair of the triceps is performed with placement of a number
onto the olecranon are circumferentially tied and transfixed with 1 braided absorbable suture through each of the triceps’ bundles.
a number 1 braided absorbable suture to create two distinct limbs This is then passed through the distal fascio-tendinous substance
(Fig. 6). This maintains the limbs for subsequent reattachment. of the triceps tendon flap, where it attaches to the olecranon and
The ends of these triceps bundles are divided at their insertions is repaired under tension; a modified Kessler repair is performed
onto the olecranon and reflected to expose the distal humerus, individually for each triceps bundle (Fig. 10). Approximating sutures
allowing full exposure to the distal medial and lateral columns are placed between the two triceps bundles. The fascial tongue
and posterior articular surface (Fig. 7). Traction on the ulna with flap is then returned to its original position and sutured into place
the elbow in the flexed position allows exposure of the inferior with number 1 braided absorbable sutures (Fig. 11). A number 1
surface of the humerus. If further exposure is required, the medial braided absorbable suture is subsequently used to repair the triceps
and lateral collateral ligaments can be divided longitudinally to aid longitudinal split. The ulnar nerve can be left in situ or transposed.
retraction of the ulna, and the olecranon tip (approximately 3 mm) Surgeon preference is then advised for closure of the subcutaneous
can be excised if further articular surface visualisation is needed. layer and skin. A bulky bandage is applied.
Extensile exposure was not performed in this case, and
the collateral ligaments were left intact. However, given the R e s u lts
proximal extension of the fracture, the proximal triceps is divided Anatomical reduction was achieved with a stable dual plating
longitudinally in the midline with sharp and subsequently blunt construct, allowing for immediate active mobilisation limited only
dissection until the radial nerve is identified, mobilised and by the bulky bandage. The patient commenced physiotherapy with
protected (Fig. 8). Standard reduction and fixation techniques can active range of motion exercises at two weeks follow-up. At six weeks

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 A Modified Surgical Approach to the Distal Humerus

Fig. 9: Reduction and fixation of the humerus fracture Fig. 11: Closure of the fascial tongue flap and repair of proximal triceps
split

Fig. 10: Closure of the triceps bundles through distal fascio-tendinous

tissue at olecranon Figs 12A and B: Twelve-week postoperative radiographs. (A)
Anteroposterior and (B) Lateral
follow-up, the patient displayed full elbow flexion of 150 degrees,
equal to the contralateral side. The final 20 degrees of extension were tip if further articular surface visualisation is needed. The principal
limited at this stage (range of motion 20–150 degrees). Pronation and benefit of this technique is the ease with which it can be performed
supination were normal, as were shoulder movements. At 12-week and the improvement in visualisation when compared to other
follow-up, the patient had returned to a normal range of motion at non-osteotomy techniques. Gorder is credited with popularising
the elbow for both flexion and extension, reported no concerns and the original fascial tongue technique for treatment of fractures,
was functioning well with a return to normal activities. Radiographs while more recent authors have described its use for total elbow
showed evidence of bony union (Fig. 12). arthroplasty.9,13 Using the modified dual triceps bundle approach,
the operating surgeon will be able to confidently delineate the
Discussion anatomy of the distal humerus with elegant reflection of the muscle
The modified fascial tongue surgical approach to the distal humerus combined with a later robust repair.
offers excellent visualisation of the distal humerus articular The olecranon osteotomy has been compared to the triceps
surface, metaphyseal and diaphyseal regions, whilst avoiding the fascial tongue approach previously and suggested to provide
complications of an olecranon osteotomy. Further advantages superior outcomes; Elmadag et al. showed an osteotomy group had
include a reduced operation time, a non-technically challenging improved range of motion and a higher Mayo elbow score when
approach, and the option to convert from fixation to total elbow compared to the fascial tongue group. However, the study design
arthroplasty if required. was flawed, with more complex fractures in the fascial tongue group
The modified fascial tongue approach is suitable for total and a prolonged period of immobilisation when compared to the
elbow arthroplasty, extra-articular fractures and intra-articular osteotomy group.14 As such, the findings cannot be compared
fractures. In our practice, this approach is utilised for all distal directly. A more recent cohort-based study has shown that the
humerus fractures in combination with excision of the olecranon triceps tongue technique had reduced blood loss, greater maximal

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 A Modified Surgical Approach to the Distal Humerus

flexion, and achieved a larger flexion-extension arc when compared 6. Haglin JM, Lott A, Kugelman DN, et al. Olecranon osteotomy fixation
to those with an olecranon osteotomy.15 There is otherwise limited following distal humerus open reduction and internal fixation:
data comparing these two approaches directly, and evidence to Clinical results of plate and screws versus tension band wiring.
Orthopedics 2021;44(1):E107–E113. DOI: 10.3928/01477447-2020
date has shown no superior functional outcomes of any one distal
1007-03.
humerus approach versus another.11,16 7. Feinstein SD, Paterno A V, Allen AD, et al. Techniques and fixation of
A reported limitation of the triceps fascial tongue approach is olecranon osteotomy: A systematic review. J Hand Surg Glob Online
triceps weakness when used for total elbow arthroplasty.4 Recent 2023;5(5):643–649. DOI: 10.1016/j.jhsg.2023.04.001.
data have disputed this, with one series showing all postoperative 8. McKee MD, Veillette CJH, Hall JA, et al. A multicenter, prospective,
total elbow replacement patients that underwent a fascial tongue randomized, controlled trial of open reduction-internal fixation
approach as having grade IV or V strength at last follow-up; this was versus total elbow arthroplasty for displaced intra-articular distal
a significant improvement on all patients preoperative strength.17 In humeral fractures in elderly patients. J Shoulder Elb Surg 2009;18(1):
our experience, return of range of motion and upper limb strength 3–12. DOI: 10.1016/j.jse.2008.06.005.
9. GV Gorder, George W. Surgical approach in supracondylar “T”
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fractures of the humerus requiring open reduction. J Bone Jt
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Iain A Rankin https://orcid.org/0000-0003-3458-1408 adults. J Bone Joint Surg Am 2011;93(7):686–700. DOI: 10.2106/
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