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Humerus Shaft Fracture ORIF with Anterolateral Approach

Planning

B

Preoperative Plan

1

Radiographic templating

  • template fracture with instrumentation

2

Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case

3

Description of potential complications and steps to avoid them

C

Room Preparation

1

Surgical Instrumentation

  • reduction clamps
  • LCP and DCP plates
  • K wires
  • Cobb or periosteal elevator

2

Room setup and Equipment

  • standard operating table
  • fluoroscopy

3

Patient Positioning

  • supine position with the extremity placed on a hand table

Technique

D

Anterolateral Approach

1

Identify and mark the incision

  • mark the skin incision beginning proximally at the deltoid tubercle and continue distally just proximal to the antecubital crease

2

Make the skin incision

3

Identify neurovascular structures

  • identify and protect the lateral antebrachial cutaneous nerve
  • this usually will be seen in the distal aspect of the wound
E

Deep Dissection

1

Identify the interval between the biceps and the brachialis

  • to enter this interval, sweep the finger from proximal to distal

2

Identify the musculocutaneous nerve

  • at the level of the midhumerus, identify the musculocutaneous nerve that will be found on the undersurface of the biceps
  • trace the nerve distally to protect the terminal branches
  • the terminal branches form the lateral antebrachial cutaneous nerve

3

Expose and protect the radial nerve

  • expose the radial nerve by dissecting the interval between the brachialis and the brachioradialis
  • protect the radial nerve with a vessel loop so that it can be identified at all times

4

Expose the fracture

  • split the brachialis in line with the fibers between the medial 2/3 and the lateral 1/3
  • this is an intervnervous plane between the radial nerve medially and the musculocutaneous nerve laterally
F

Fracture Preparation

1

Clear the fracture site

  • expose the fracture site by sharp perioseal dissection
  • clear the fracture site of hematoma and interfering soft tissue

2

Identify any degree of comminution

3

G

Fracture Reduction

1

Reduce the fracture

  • reduce the fracture by using gentle traction and rotation

2

Maintain the reduction

  • use reduction clamps to maintain the reduction

3

place K wires to provisionally fix the fracture

  • it is imperative to place the k wires so they do not interfere with plate fixation
H

Provisional Fixation

1

Place K wires to provisionally fix the fracture

  • it is imperative to place the k wires so they do not interfere with plate fixation

2

Determine the length of the plate

  • use a plate length that gives at least 6 cortices of fixation above and below the fracture
  • if the bone is large, a 4.5 mm DCP should be used
  • in smaller bones, a 4.5 mm LCP plate often provides a better fit

3

Template the plate on the shaft

  • place the plate on the shaft of the humerus and hold with a plate holding clamp
I

Definitive Fixation

1

Place cortical screws

  • place 4.5 mm cortical screws through the holes that are proximal and distal to the fracture site
  • make sure that there is no soft tissue or nerve in between the bone and the plate
  • make sure there is screw purchase in at least 6 cortices above and below the fracture

2

Test the stability of the fixation

  • rotate, flex and extend the arm to test the stability of the fixation
J

Wound Closure

1

Irrigation

  • copiously irrigate wound

2

Deep closure

  • use 0-vicryl for fascia

3

Superficial closure

  • use 2-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl for skin

4

Immobilization

  • place in sling

Patient Care

K

Preoperative H & P

1

Perform basic history and physical exam

  • check neurovascular status
  • identify medical co-morbidities that might impact surgical treatment

2

Ensure all studies are required to proceed with surgical intervention

  • radiographs
  • AP view and lateral views of the humerus

3

Perform operative consent

  • describe complications of surgery including
  • infection
  • nonunion
  • radial nerve palsy
  • shoulder impingement
  • elbow stiffness
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • order AP and lateral views to assess placement of implants
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2
  • inpatient physical therapy
  • remove in 1 to 2 days and start range of motion exercises
  • weightbearing is allowed based on the patients comfort
  • initial therapy should be elbow range of motion and shoulder pendulum exercises and passive self assist exercises
  • Appropriate medical management and medical consultation

2

Discharges patient appropriately

  • outpatient pt
  • pain meds
  • schedule follow up appointment in 2 weeks
M

Intermediate Evaluation and Management

1

Performs focused history and physical

  • history
  • mechanism of injury
  • premorbid level of function
  • history of malignancy
  • occupation and hand dominance
  • concomitant and associated orthopaedic injuries
  • perform neurovascular exam
  • physical exam
  • inspection
  • swelling
  • soft tissue injury
  • ecchymosis
  • deformity

2

Orders and interprets required diagnostic studies

3

Knowledge of surgical indications

4

Post operative management

  • postop: 2-3 week postoperative visit
  • wound check
  • check range of motion
  • diagnose and management of early complications
  • postop: ~ 6 week postoperative visit
  • diagnosis and management of late complications
  • check radiographs for healing of the tuberosities
  • check range of motion
  • the elbow motion should be near normal range
  • start shoulder strengthening
  • 3 month postoperative visit
  • check that callus is present on the xrays
  • if callus is not present, then repeat xrays every 6 weeks until radiographic evidence of healing
N

Advanced Evaluation and Management

1

Order appropriate imaging studies

2

Provides post-op management and rehabilitation

O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives.

2

Modify and adjust post-op plan as needed

3

Understand how to avoid and prevent complications

4

Treat simple complications intraoperatively and postoperatively

 

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