OPERATION PERFORMED: Open Reduction internal fixation of right distal humerus and right olecranon osteotomy.
OPERATION IN DETAIL: The patient was brought to the OR and laid supine on the OR table for open reduction internal fixation of right distal humerus and right olecranon osteotomy. After general anesthesia was induced, the patient was turned over to the lateral decubitus position with the right arm over a lateral arm post. The right upper extremity was then prepped and draped in the usual sterile fashion after all bony prominences were well padded and then axillary pad was placed.
Next, the right lower extremity was prepped and draped in the usual sterile fashion. Next, a standard approach to the distal humerus and the proximal olecranon was performed. This was done after a sterile tourniquet was placed and the arm was exsanguinated and the tourniquet inflated to 275 mmHg. Full thickness skin flaps were raised on either side of the triceps tendon.
Next, dissection was carried out medially and, carefully, we dissected out the ulnar nerve for later mobilization of the triceps tendon.
Next, a guidewire was placed, 7.3 mm cannulated screw into the distal tip of the olecranon and down into the olecranon shaft. C-arm fluoroscopy was used to confirm good position of the wire on both the AP and lateral fluoroscopic images.
Next, the 7.3 cannulated screw was partially inserted and then removed. Next, the level of the olecranon osteotomy was determined. A saw was used to make the chevron osteotomy and osteotomes were used to complete the osteotomy.
Next, a Bovie was use to elevate the triceps tendon along with the proximal tip of the olecranon around the medial and lateral sides. Care was taken to protect the ulnar nerve during the mobilizing of the tendon. As the tendon was mobilized, the distal humerus fracture was visualized including the intraarticular extent of it.
Next, the fracture was cleaned of periosteum and fibrin clot. A tenaculum was used to obtain anatomic reduction of the articular surface. There was a split down the trochlea, which was reduced anatomically.
Next, the distal humeral piece was reduced to the shaft after K-wires were used to provisionally hold the distal piece reduced. K-wires were also used to hold the distal humeral piece to the proximal shaft anatomically.
Next, a distal humeral locking plate from the Synthes set was used for the lateral condyle. Four locking screws were placed into the distal fragment.
Next, a medial distal humeral locking plate was also selected from the Synthes set and fashioned through the medial column. Again, two distal locking screws were placed as well as the one long 2.7 mm cortical screw across the trochlear fracture through the medial plate. Three cortical screws were also placed approximately in the medial plate. Excellent fixation was obtained. All K-wires were removed. The wound was thoroughly irrigated with normal saline.
Next, attention was directed towards reattaching the olecranon osteotomy. The olecranon osteotomy was reduced and a guidewire was passed down into the ulnar shaft. A 7.3 mm cannulated screw from the Synthes set measuring 100 mm in length was inserted into the tip of the olecranon and into the ulnar shaft. Prior to tightening it, a drill hole was made in the ulna from medial to lateral sides and 18 gauge wire was passed and this 18 gauge wire was fashioned in a figure-of-eight fashion around the washer of the cannulated screw. The screw was then fully tightened obtaining compression across the osteotomy site. The 18 gauge wire was then tightened around the medial side and crimped and cut short, curved down into the tendon to prevent irritation on the skin. Excellent fixation of the olecranon was obtained.
Next, a C-arm fluoroscopy was used to confirm excellent reduction of fracture and placement of all hardware as well as excellent position of the cannulated screw and the olecranon osteotomy. Plain films were then obtained in the OR.
The wound was thoroughly irrigated with normal saline. The triceps tendon was closed with figure-of-eight suture of 0 Vicryl in the lateral side. Subcutaneous layer was closed with 3-0 Vicryl suture in inverted fashion followed by staples for the skin. Sterile dressings were applied and the patient was placed into a posterior elbow splint.
The patient was then turned over to the supine position, awakened from anesthesia, transferred back onto a stretcher and taken to the PACU for recovery. There were no complications post the open reduction internal fixation of right distal humerus and right olecranon osteotomy.
