Posterior transolecranon exposure: - 6"-7" long longitudinal incision is made on posterior aspect of elbow curving laterally around olecranon. Sides of the olecranon is cleared of its muscle attachments. Narrow part of the olecranon is identified for osteotomy. Before osteotomizing the olecranon, a drill hole (3.5mm) is made through the olecranon starting at its tip upto the coronoid process anteriorly and tap it with a 4.5 mm tap for fixing it back in position at the end of surgery. The osteotomized olecranon with the attached triceps muscle is lifted proximally to expose the posterior surface of distal 4" of the humerus extraperiosteally and the condylar fragments with their articular surface. At this point it is necssary to give a good saline lavage to clear haematoma and visualize the fracture anatomy and displacement of the fragments. Muscles and soft tissues attached to posterior surface of condylar fagments and the distal 2" of the shaft are cleared extraperosteally. On medial side the ulnar nerve is mobilized carefully along with mucle mass from the medial epicondyle medial side of the ulna. No attempt is made to isolate it from other soft tissues.
The fractured lower end of humerus usually has three major fragments, the shaft proximally, and the lateral and medial condyle fragments with their articular surface distally. One of the condylar fragment is usually larger less fragmented than the other. There are usually a few smaller fragments with or without any soft tissue attachments.To start with it is easier to align larger fragment with the shaft and stabilize it with a 5-6 hole recon. plate and a screw (3.5mm) holding each fragment. Thereafter the other condylar fragment's articular surface is aligned to the articular surface of the former condylar fragment in such a way that ita other frature end gets aligned to the shaft.and the same is then stabilized with another recon. plate and/or a K-wire. In case there are more fragments, they are aligned like jig-saw puzzle while fixing the other condyle. A proper size lag screw is then used for intercondylar stabilty to align the articular surface of trochlea and capitulum fragments under compression. Other smaller fragment are used as fillers if possible or discarded. Once the anatomy of the distal end of the humerus is restored, fracture stabilty recon plates is augmented with additional screws. Wherever possible, these fixations are done extraperiosteally all along to preseve viability of the fragments. At the end of the procedure, the olecranon is fixed with a proper size lag screw and a k-wire to avoid any rotatory displacemnt. The muscles and soft tissues in the sides are suturedback without anteriorly transposing the ulnar nerve,
Postop AE POP slab applied for 6 weeks in 90 degree flexion of the elbow for 4 weeks; and then active mobilization of the extremity started. It takes around 3 to 6 months to get almost free elbow movemnts
