Distal humerus fractures treated with the anconeus–triceps lateral flap approach: a case series of 10 consecutive patients

Giuseppe Bardellini; Andrea Celli; Luigi Celli

doi:10.1016/j.xrrt.2026.100819

. 2026 Jul 20;6(4):100819. doi: 10.1016/j.xrrt.2026.100819

Distal humerus fractures treated with the anconeus–triceps lateral flap approach: a case series of 10 consecutive patients

Giuseppe Bardellini ¹, Andrea Celli ^1,^∗, Luigi Celli ¹

PMCID: PMC13495366 PMID: 42630740

Abstract

Background

The surgical management of distal humeral fractures remains challenging. Posterior approaches involving the triceps mechanism are crucial for achieving stable fixation and functional recovery but are associated with potential approach-related complications. Traditional approaches often involve olecranon osteotomy to achieve adequate exposure, but this technique is associated with specific complications. The purpose of the present study is to describe the clinical outcomes and surgical rationale of the anconeus–triceps lateral flap (ATLF) approach applied to open reduction and internal fixation of distal humerus fractures and reports preliminary outcomes with a minimum follow-up of 24 months, highlighting its potential advantages in exposure, functional recovery, and intraoperative versatility.

Methods

Ten consecutive patients with distal humeral fractures underwent open reduction and internal fixation with dual plating through the triceps ATLF approach, which preserves the olecranon and the medial portion of the triceps tendon insertion. The surgical rationale of this technique is to enhance articular visualization while maintaining extensor mechanism integrity through partial, controlled triceps detachment. Clinical outcomes were assessed using the Mayo Elbow Performance Score, the Quick Disabilities of the Arm, Shoulder and Hand questionnaire, the visual analog scale score, and radiographic evaluation of fracture healing.

Results

At final follow-up, all patients achieved fracture healing and returned to work within 6 months. Nine patients reported overall satisfaction with the procedure. Mean outcome scores were: Mayo Elbow Performance Score 89.5 ± 10.39, Quick Disabilities of the Arm, Shoulder and Hand 7.03 ± 4.72, and visual analog scale 1.6 ± 1.89. All the patients in this group preserved the ability to keep the elbow against gravity with the forearm extended over the head. No major complications (requiring further surgery) attributable to the surgical approach or approach-related fixation failure were observed. Some minor complications occurred, such as ulnar nerve neurapraxia in 2 cases, heterotopic ossifications in 3 cases, and triceps decrease in strength in one patient.

Conclusion

This triceps approach provides a clinically effective balance between improved articular exposure and functional preservation of the extensor mechanism. The ATLF technique represents a valuable option for distal humerus fracture treatment within contemporary orthopedic practice, with the added advantage of enabling straightforward conversion to total or hemiarthroplasty if required.

Keywords: Distal humeral fractures, Triceps approach, Anconeus–triceps lateral flap, Open reduction and internal fixation, Surgical approach, Elbow joint

Adequate bone exposure is fundamental for the proper treatment of distal humeral fractures, and several surgical approaches have been described to achieve this goal. Achieving sufficient visualization of the articular surface while limiting damage to the extensor mechanism remains a central challenge in surgical treatment.

Among these, olecranon osteotomy remains one of the most widely used approaches, as it preserves the triceps and provides the broadest exposure of the articular surface compared to alternative techniques.⁴³ However, well-known complications associated with olecranon osteotomy include nonunion and hardware intolerance.¹³ To preserve olecranon integrity, paratricipital approach,²⁵ triceps-splitting approaches such as the Campbell¹⁰ and triceps-tongue approaches,¹⁴ or triceps-reflecting approaches such as the Bryan-Morrey⁸ and triceps-reflecting anconeus pedicle approach³² can be employed. Complete triceps detachment may delay rehabilitation, whereas traditional splitting techniques can compromise tendon integrity and postoperative strength but there is no strong consensus regarding postoperative triceps weakness or disruption when the triceps tendon insertion is violated.²⁶^,³¹ In 2015, a novel triceps-splitting approach for elbow arthroplasty was first described: the anconeus–triceps lateral flap (ATLF) approach,¹¹ which preserves the medial portion of the triceps tendon insertion. The first clinical results on total elbow arthroplasties performed with this technique were published in 2016.¹² From a conceptual standpoint, this represents a modification of traditional triceps techniques, aiming to enhance lateral and articular visualization while maintaining extensor mechanism continuity. However, olecranon osteotomy allows a bigger articular surface exposure and may be more suitable for the treatment of very comminuted distal humerus fractures like AO type C3.

In modern orthopedic trauma surgery where early mobilization, soft-tissue respect, and adaptable surgical strategies are increasingly emphasized, this technique addresses a relevant clinical gap. The purpose of this study is to describe the surgical technique of the ATLF approach for open reduction and internal fixation (ORIF) of distal humeral fractures and to report preliminary clinical outcomes, highlighting its potential advantages in exposure, functional recovery, and intraoperative versatility.

Materials and methods

Clinical and radiographic assessment

This study included 10 consecutive patients with distal humeral fractures (AO type A, B, and C patterns) treated using the ATLF approach between 2018 and 2021 in our institution, with a minimum follow-up of 2 years (Table I). Fracture types were: 1 AO type A, 3 AO type B, and 6 AO type C (4 C1 and 2 C2).

Table I.

Pre-operative assessments

Case	Gender	Age	Dominant side	Side	Fracture type (AO classification)	Associated lesions
1	M	34	RHD	L	B	NO
2	F	42	LHD	R	C1	NO
3	F	35	RHD	L	C1	NO
4	M	33	RHD	R	A	NO
5	F	56	RHD	L	C2	HIP FRX
6	M	36	RHD	L	B	NO
7	M	60	LHD	R	C1	NO
8	F	26	RHD	R	B	NO
9	F	33	RHD	R	C2	NO
10	F	40	RHD	L	C1	NO

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M, male; L, left; F, female; R, right; AO, Arbeitsgemeinschaft für Osteosynthesefragen; RHD, right-hand dominance; LHD, left-hand dominance; HIP FRX, hip fracture; NO, no other fractures.

Fracture fixation was performed using precontoured plates in a 180° dual-plate construct supplemented by free articular screws when necessary. Standard follow-up consisted of clinical and radiographic evaluations at 1, 3, 6, and 12 months, and annually thereafter. Fracture reduction and healing were assessed by standard radiographs. Clinical outcomes were evaluated using the Visual Analog Scale²⁴, the Quick Disabilities of the Arm, Shoulder and Hand questionnaire,¹⁶ and the Mayo Elbow Performance Score.³⁰ Overall patient satisfaction was recorded. The extensor mechanism was assessed using the Medical Research Council (MRC) scale modified according to Paternostro-Sluga.^35,44 We also tested the ability to keep the elbow in extension against gravity maintaining the forearm up to the head. The original MRC scale neither considers the range of motion (ROM) for which a movement can be performed nor defines the strength of resistance against which a movement can be performed.⁴⁴ The score with the modification of Paternostro-Sluga³⁵ is graded in 5 groups and it takes into consideration the muscle function related to the possible passive and active ROM. Grade 0 is defined if there were no contractions of the muscle. If a contraction was perceived, it was graded 1. If a movement could be performed actively without gravity, it was graded 2, from grade 2 to 3 if the active movements against gravity without resistance less than 50% of the feasible ROM were achieved. If movement against gravity without resistance was possible more than 50% of the feasible passive ROM is graded 3. If the movement against light resistance could be performed less than 50% of the feasible passive ROM, muscle strength was graded as grade 3 to 4. If it was possible to move more than 50% of the ROM but weaker than the contralateral side, it was graded 4. Movement against resistance over the entire ROM with the same resistance as that on the contralateral side was rated grade 5.

The most recent antero-posterior and lateral radiographies of the elbows were analyzed to assess the healing process and the periarticular heterotopic ossifications. The heterotopic ossifications were classified according to Hastings and Graham classification.²⁰ Class I lesions are subclinical. Class IIA lesions limit flexion-extension. Class IIB lesions limit pronation-supination. Class IIC lesions limit motion in both planes. Class III describes complete ankylosis of the elbow joint.

We evaluated radiological signs of fracture healing process on 2 x-ray views. The radiographic signs of fracture healing include the presence of callus formation, the presence of bridging trabeculae across the fracture site, and a decrease in the size of the fracture line over time.¹⁵^,³³^,³⁸

Surgical technique and post-operative protocol

The following technique was used for all patients included in this study. Patient is placed in lateral decubitus. A universal posterior skin incision of 15-20 cm, centered on the elbow joint and slightly curved medially at the level of the olecranon apex, was performed. The ulnar nerve was isolated and completely mobilized for anterior sub-cutaneous transposition in every patient. If the fracture line extended more proximally, the radial nerve was identified and isolated at the lateral border of the humerus, approximately 10-11 cm proximal to the lateral epicondyle.¹⁷ A midline split of the triceps was carried down to the olecranon tip, preserving the medial portion of the triceps tendon insertion (Fig. 1). The triceps incision was limited to the myotendinous junction (up to about 10 cm from the olecranon insertion) to preserve the proximal vascularization and innervation of the anconeus muscle.²³^,²⁷^,³⁷ The incision was then extended along the medial border of the anconeus to its distal tip. The triceps muscle was mobilized from both the lateral and medial side. The Kocher interval was developed, and the anconeus was fully detached and raised as a single unit with the lateral part of the triceps (Figs. 2 and 3) (Video 1).

The medial tendon insertion (deep and superficial tendinous parts) can be palpable proximally and medially to the tip of the olecranon along the crest line of the ulna as a narrow thickened tendon.

The midline split was made through the triceps muscle tendon unit and down to the tip of the olecranon preserving the medial tendon insertion area in the olecranon footprint (about 1 cm).

The dissection was carried out distally sub-periosteal along the radial border of the ulnar crest and laterally in the Kocher’s interval.

After fracture exposure, double plating at 180° was performed following anatomical reduction. Following fixation, closure of the ATLF was achieved using either single interrupted or continuous non-absorbable side-to-side sutures (Fig. 4).

The lateral triceps maintaining the continuity with the anconeus muscle, as a flap single unit, was released and reflected proximally. The triceps medial part (superficial and deep) was not detached from the olecranon insertion but elevated from the humerus proximally up to where the triceps was split. The distal humeral fracture is exposed.

Two drains were routinely applied and removed after 24-48 hours. A postoperative splint in slight extension was maintained for the following 2 days. After drains removal, 1 or 2 days after surgery, passive motion was begun and patients were instructed to perform daily active ROM exercises.² Active motion in extension was allowed after 1 month. Assisted triceps strengthening exercises were started 2 months post-operatively. Return to normal activities and weight-bearing without restriction was generally achieved between 3 and 6 months, depending on clinical and radiographic evaluation. Patients did not receive any kind of formal therapy. Patients received prophylactic therapy for heterotopic ossifications with non-steroidal anti-inflammatory drugs (celecoxib 200 mg) for 21 days.

Results

Radiographic signs of fracture healing process¹⁵^,³³^,³⁸ and return to work within 6 months were achieved in all 10 patients. Overall, 9 of 10 patients reported satisfaction with the procedure. Mean Mayo Elbow Performance Score was 89.5 ± 10.39, mean Quick Disabilities of the Arm, Shoulder and Hand score was 7.03 ± 4.72, and mean visual analog scale was 1.6 ± 1.89 (Table II). No major complications directly attributable to the surgical approach were observed (Table II). All the patients in this group preserved the ability to keep the elbow against gravity with the forearm extended over the head as the contralateral side. Using the MRC scale modified according to Paternostro-Sluga,³⁵ 9 patients recovered the same triceps strength as that on the contralateral side and they are rated on grade 5. The other patient recovered triceps function against resistance over the entire ROM but weaker than the contralateral side and was rated as grade 4 (case 8). Pre-operative ulnar neuropathy was observed in 2 patients (case 4 and 5). In the post-operative evaluations, they reported a sensory neurapraxia that in one patient (case 4) did not improve during the follow-up time. The other patient (case 5) recovered completely by 6 weeks post-operatively. Heterotopic ossifications were observed in 3 patients (cases 2, 4, and 9), of whom one was classified as Hastings and Graham²⁰ class IIA and 2 as class IIB. We offered to remove heterotopic ossifications in one case (case 9), but the patient opted to avoid further surgery. Hence, there was no incidence of revision surgery at the current follow-up.

Table II.

Post-operative assessments

Case #	Healed fracture	Follow-up (mo)	Flexion-extension arc (degree)	Flexion (degree)	Extension (degree)	Pronation-supination arc (degree)	Pronation (degree)	Supination (degree)	MEPS	QuickDASH score	VAS	Patient satisfaction
1	Yes	24	130	130	0	160	80	80	100	4.5	0	Yes
2	Yes	32	130	130	0	120	60	60	90	9.1	0	Yes
3	Yes	38	130	140	10	160	80	80	100	2.3	0	Yes
4	Yes	28	100	120	20	150	70	80	85	13.6	4	Yes
5	Yes	35	130	140	10	160	80	80	85	4.5	3	Yes
6	Yes	24	130	140	10	160	80	80	100	2.3	0	Yes
7	Yes	33	140	140	0	160	80	80	100	4.5	0	Yes
8	Yes	28	80	100	20	160	80	80	70	15.9	5	No
9	Yes	36	140	140	0	120	60	60	80	4.5	2	Yes
10	Yes	40	110	130	20	160	80	80	85	9.1	2	Yes

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MEPS, Mayo Elbow Performance Score; QuickDASH, Quick Disabilities of the Arm, Shoulder and Hand; VAS, visual analog scale.

Discussion

Management of distal humeral fractures requires balancing sufficient visualization of the articular surface with preservation of the extensor mechanism and identifying the optimal posterior approach remains challenging. The ATLF approach offers a simple, reproducible technique for both dissection and fracture reconstruction. The anconeus muscle is preserved, although its functional significance continues to be debated.²⁹^,³⁶^,³⁹ The ATLF approach, similar to the Studer–King technique,⁴⁰ involves a midline triceps split while preserving the medial tendon insertion. Unlike the para-olecranon incision, it allows lateral joint access through the Pankovich interval³⁴ rather than the Boyd interval.⁷ While articular exposure is more limited compared with olecranon osteotomy or triceps-reflecting approaches,¹ the ATLF avoids the need for additional hardware and relies on straightforward side-to-side suturing. The approach can be further extended by releasing the lateral ulnar collateral ligament with the extensor tendons, enabling controlled elbow dislocation for improved fracture reduction or arthroplasty.²¹^,²⁸ The lateral ulnar collateral ligament was not detached in any case of this series given the types of fractures treated. Our experience has confirmed the feasibility of using the ATLF approach for ORIF of distal humeral fractures, particularly for fractures involving the columns and proximal extensions. The role of the anconeus muscle in the extensor mechanism is critical during distal humeral fracture exposure. Basmajian⁴ described its main function as stabilizing the elbow in extension and against resistance, with a potential role in ulnar stabilization during hypersupination. Electromyographic studies have confirmed synchronous contraction of the lateral triceps and anconeus, highlighting the dynamic, synergistic function of these muscles within the extensor apparatus.¹⁸^,¹⁹^,²² Choice of triceps approach should consider fracture pattern, enabling exposure for precise anatomic reduction and surgeon preference. Anatomical studies of the extensor mechanism underpin the ATLF technique. The triceps tendon exhibits medial–lateral asymmetry: the lateral portion is relatively thin and continuous with the anconeus and fascia, while the medial portion is thicker, forming the proper tendon insertion into the posterior medial olecranon.³^,⁵^,⁹^,²⁵ The medial insertion, approximately 20 mm wide and 8 mm thick, represents the primary functional component of the triceps.³ The anconeus originates from the lateral epicondyle and lateral triceps fascia, inserting on the radial aspect of the olecranon and proximal ulna, with innervation from the terminal radial nerve branch and vascularization via the interosseous recurrent artery.⁵^,²⁵ The ATLF preserves both the anconeus and its neurovascular supply, maintaining integrity of the lateral triceps–anconeus complex. In any posterior approach to the elbow, it is mandatory to avoid injury of the radial nerve branches that supply the medial head of the triceps and anconeus muscle. Anatomical studies confirm that the anconeus muscle can be reflected alongside the triceps without compromising its vitality or function. This is due to the course of the radial nerve,⁴² which emits a branch within the spiral groove that supplies the lateral part of the triceps medial head before directly innervating the anconeus.⁶ Prior to this, just below the teres major, the nerve also gives rise to the ulnar collateral nerve of Krause for the medial section of the medial head of the triceps.⁴¹ Consequently, performing a distal-to-proximal midline split of the triceps for approximately 10 cm or up to the myotendinous junction fully preserves the neurovascular integrity of the anconeus, allowing it to be mobilized safely without risk of denervation²³^,²⁷^,³⁷ (Fig. 5). Compared to olecranon osteotomy, historically the gold standard due to extensive exposure,¹³^,⁴³ the ATLF minimizes complications such as nonunion, hardware irritation, altered olecranon mechanics, and high hardware removal rates.¹⁰^,¹⁴ While its surgical window is smaller than osteotomy or triceps-reflecting approaches,¹⁰^,¹⁴ it suffices for most distal humeral fractures with minimum extension to the articular portion,²¹^,²⁸ like the AO type C1 and C2 treated in this case series. AO type C3 should probably be treated using olecranon osteotomy. Traditional triceps-splitting methods, including the Campbell approach⁹ and triceps-tongue technique,¹¹ often compromise tendon integrity, resulting in delayed recovery, weakness, and scarring.²^,¹²^,¹⁷ In contrast, the ATLF preserves approximately 1 cm of the medial tendon insertion, the thickest and most functionally significant region, while splitting only the lateral portion.²⁹^,³⁶^,³⁹ Triceps-reflecting approaches⁸^,³² provide wide exposure but require complete tendon detachment, raising concerns regarding tendon healing, delayed strengthening, and occasional residual insufficiency. By preserving tendon continuity, the ATLF supports early active motion and maintains MRC grade 4-5 extensor strength,³⁵ as observed in this series. Biomechanical studies reinforce the rationale for preserving the medial triceps insertion, responsible for most of the terminal extension torque.²⁹^,³⁶^,³⁹ Preservation of the anconeus is another theoretical advantage. Previously considered vestigial, it is now recognized as contributing to elbow extension and posterolateral stability, particularly during hypersupination or resisted extension.¹^,⁷^,²¹^,²⁸ Anatomical and functional preservation of the anconeus in the ATLF aligns with our clinical outcomes. Compared to para-olecranon or purely lateral approaches, including Studer–King⁴⁰ and Boyd interval,⁷ the ATLF provides a central line of pull via a midline triceps split and lateral elevation through the Pankovich interval,³⁴ allowing direct lateral column access with minimal soft-tissue retraction. An additional benefit is compatibility with elbow arthroplasty if it is necessary. Preservation of the triceps insertion permits intraoperative conversion from ORIF to hemiarthroplasty or total elbow arthroplasty without additional soft-tissue detachment, advantageous in elderly or osteoporotic patients.³^,²²^,²⁸ Limitations include reduced exposure in highly comminuted C3 fractures with medial column involvement and the need for familiarity with lateral elbow anatomy. Nonetheless, the low rates of approach-related complications, satisfactory functional outcomes, and preserved extension strength suggest the ATLF represents a safe, effective balance between exposure and soft-tissue preservation. Further comparative studies and biomechanical analyses are warranted to clarify indications and efficacy relative to osteotomy-based and triceps-reflecting approaches. Our preliminary results indicate that the ATLF approach reduces the risk of triceps insufficiency while combining the exposure advantages of triceps-splitting and reflecting techniques with the functional preservation of the medial proper tendon. At final follow-up, all patients achieved active forearm extension against gravity, graded 4-5 on the modified MRC scale,³⁵ supporting the functional benefits of tendon and anconeus preservation.

(a) Ulnar collateral nerve of Krause. (b) The radial nerve emits a branch that descends distal to the lateral portion of the triceps medial head, innervating several muscle branches before reaching the anconeus muscle. (c) The dashed lines depict the anconeus triceps lateral flap approach.

Conclusion

The ATLF represents a triceps-based posterior approach for distal humerus fractures, combining enhanced articular visualization with partial extensor mechanism detachment. The ATLF approach is a viable alternative for the treatment of distal humeral fractures, combining technical simplicity with the option to easily convert from ORIF to arthroplasty when required. Limitations include reduced exposure in highly comminuted C3 fractures with medial column involvement. Preliminary clinical outcomes are encouraging, and further studies with larger cohorts are warranted to support broader adoption of this technique.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Patient consent: Obtained.

Footnotes

Institutional Review Board approval was granted by Garofalo Health Care (0033GHCIRB- 2025).

Supplementary data to this article can be found online at https://doi.org/10.1016/j.xrrt.2026.100819.

Supplementary Data

Video 1

The Kocher interval was developed, and the anconeus was fully detached and raised as a single unit with the lateral part of the triceps.

Download video file^{(4.9MB, mp4)}

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Video 1

The Kocher interval was developed, and the anconeus was fully detached and raised as a single unit with the lateral part of the triceps.

Download video file^{(4.9MB, mp4)}

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PERMALINK

Distal humerus fractures treated with the anconeus–triceps lateral flap approach: a case series of 10 consecutive patients

Giuseppe Bardellini, MD

Andrea Celli, MD

Luigi Celli, MD