Triceps fascial tongue exposure for intra-articular distal humerus fracture: revisiting the Van Gorder approach

摘要

Distal humerus fractures account for up to 7% of all fractures and 30% of elbow fractures. Sixty-one percent of these fractures involve the articular surface. The injuries present in a bimodal distribution: an early peak in young males associated with high-energy trauma and a late peak in elderly women with osteoporotic bone.12,13,15 Articular fragment reduction, re-establishment of the joint axis, and early motion are key tenets to restore function. Many different surgical approaches have been well described, including olecranon osteotomy, triceps-reflecting anconeus flap, Bryan Morrey (Mayo), paratricipital, triceps splitting, and triceps-flexor carpi ulnaris.3,11,20 To date, there appears to be no clear clinical advantage of one approach over the other.6,16 The olecranon osteotomy has been considered the gold standard in complex distal humerus fractures as it is considered the most extensile and provides the most visualization of the articular surface.18 However, complications including malunion, nonunion, symptomatic implant, and implant loosening can arise from performing the osteotomy.1,7,16,19 Additionally, this approach increases expense and also increases the difficulty to convert to a total elbow arthroplasty (TEA), which can be as high as 25%.8 As TEA becomes an increasingly used treatment option for distal humerus fractures, a universal surgical approach that allows adequate visualization of the articular surface while allowing for easy conversion to TEA becomes increasingly advantageous.9,14 Van Gorder originally described the triceps fascial tongue approach in 1940 for T-type distal humerus fractures.17 However, other than the original description, there is a paucity of literature on the technique and it has been excluded in many review articles or comparison studies over the last 2 decades.3,6,12,20 The triceps fascial tongue approach was reintroduced recently in 2015 as an approach for primary TEA.9 In this technique article, we describe and illustrate this approach to the distal humerus in the setting of a complex intra-articular fracture with application of modern implants.