This study attempts to analyze the amount of the articular surface which is exposed in the three most common surgical approaches for distal humerus fractures. The authors use 12 preserved adult cadaveric elbow specimens. One of the following surgical procedures was performed: 1) triceps splitting, 2) triceps reflecting, and 3) olecranon osteotomy. After exposure of the articular surface, the visible surface was painted with Methylene blue and the exposed area was mapped and compared to the entire articular surface. The authors found that the amount of articular surface exposed for the triceps splitting was 35%, the triceps reflecting was 46%, and the olecranon osteotomy was 57% of the articular surface, respectively. Of note, even the olecranon osteotomy approach failed to provide visualization of more than 40% of the articular surface of the distal humerus. When examining the two most difficult areas of the distal humerus to stabilize, the olecranon osteotomy approach was best for the capitellar surface, but none of the approaches provided access to the anterior articular surface of the trochlea. All three approaches provided sufficient exposure to the medial and lateral columns.
The significance of this study is that numerous surgical exposures have been advocated to stabilize the articular surface of the distal humerus. Mckee et al. studied the results of triceps reflecting versus olecranon osteotomy in the management of distal humerus fractures and reported that triceps reflecting provided a better functional outcome than olecranon osteotomy. The results of this study would indicate that in the presence of comminution of the capitellum or in low distal humerus fractures, olecranon osteotomy may provide superior exposure of the articular surface. It would appear that when these two studies are taken together, a triceps reflecting approach is superior unless exposure of the anterior capitellum is necessary. When a triceps reflecting approach is utilized, the elbow must be hyperflexed and the tip of the olecranon removed to optimize exposure.