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Distal Humerus Fracture ORIF

Planning

B

Preoperative Plan

1

Template fracture

  • identify fracture pattern, displacement, comminution, and presence of dislocation

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • description of potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • small fragment plates
  • malleable recon plates or precontoured periarticular plates
  • mini fragment plates
  • Herbert screws
  • Kwires
  • sterile tourniquet
  • reduction clamps

2

Room setup and equipment

  • c-arm perpendicular to OR table

3

Patient positioning

  • lateral decubitus position
  • place affected extremity over arm bolster
  • arm should be in 90 degrees of flexion
  • pad all bony prominences
  • place sterile tourniquet

Technique

D

Direct Posterior Approach to the Elbow

1

Mark and start the incision

  • begin 5cm proximal to the olecranon in the midline of the posterior distal humerus
  • curve laterally proximal to the tip of the of the olecranon along the lateral aspect of the olecranon process
  • then curve medially over the middle of the posterior aspect of the subcutaneous ulna

2

Identify the ulnar nerve

  • palpate the ulnar nerve and fully dissect it out
  • is helpful to pass tape or penrose for identification at all times

3

Incise fascia

  • incise deep posterior fascia in the midline
  • can either split triceps fascia, or continue with olecranon osteotomy
  • create full thickness flaps to minimize dead space/hematoma
E

Triceps Sparing Approach

1

Elevate the triceps

  • lift the triceps directly from the humerus and the intermuscular septum
  • retract the olecranon fragment proximally

2

Identify radial nerve

  • identify the sensory branch of the radial nerve laterally
  • follow the nerve proximally to identify the radial nerve proper

3

Divide or dissect the anconeus on its lateral side

  • elevate this with the triceps
  • expose the joint laterally

4

Alternative procedure olecranon osteotomy

  • drill and tap olecranon prior to osteotomy
  • score the olecranon with an osteotome to allow perfect reduction
  • repair osteotomy
  • V-shaped osteotomy of the olecranon 2 cm from the tip using an oscillating saw
F

Prepare Fracture and Obtain Articular Congruity

1

Expose fracture

  • remove any clots from the fracture site

2

Evaluate the articular surface

  • determine whether the entire articular surface is present
G

Obtain Provisional Articular Fixation with Kwire

1

Reduce the articular fragments

  • use the proximal ulna and radial head as templates
  • check the rotational alignment

2

Perform provisional reduction

  • place two 2.0 mm smooth wires at the medial and lateral condyles for reduction
  • these should be placed through the plates
  • these will be replaced with screws later

3

Place medial and lateral plates

  • these should be placed so that one of the distal holes of each plate slide over the smooth Kwires
  • place one cortical screw in slotted hole through each plate
  • keep loose so that adjustments to plate can be made
H

Obtain Definitive Plate Fixation

1

Place screws

  • place 2 or more screws distally medially and laterally
  • replace the 2 smooth Kwires with distal screws
  • do not drill because of possible fracture

2

Perform compression

  • perform compression back out the most proximal screw on one side
  • place a large bone clamp distally to that side
  • place bone clamp proximally to the opposite side
  • maintain compression by application of a compression screw
  • follow the same steps for the opposite side

3

Place remaining screws

4

Test range of motion of elbow

I

Wound Closure

1

Irrigation and hemostasis

  • irrigate wounds thoroughly
  • deflate tourniquet (if elevated)
  • coagulate any bleeders carefully

2

Deep closure

  • use 0-vicryl for deep closure

3

Superficial closure

  • use 3-0 vicryl for subcutaneous closure
  • close skin with 3-0 nylon

4

Dressing and immediate immobilization

  • soft dressing (gauze, webril)
  • long arm anterior splint splint in extension
  • sling for comfort

Patient Care

K

Preoperative H & P

1

Perform focused orthopedic physical exam

  • age
  • gender
  • mechanism of injury
  • deformity
  • skin integrity
  • open/closed injury
  • check neurovascular status
  • need to assess for associated injuries such as radial head and capitellum fractures

2

Splint fracture appropriately

  • place in posterior splint

3

Order basic imaging studies

  • obtain biplanar radiographs and/or CT scan of the elbow

4

Perform operative consent

  • describe complications of surgery including
  • hardware irritation (40-80% for tension band, 20% for plate and screws)
  • wound breakdown
  • elbow stiffness (~50%)
  • triceps avulsion
  • post-traumatic arthritis
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • antibiotics
  • pain control
  • wound care
  • advance diet as tolerated
  • compartment checks
  • check radiographs in postop
  • inpatient pt
  • non weightbearing

2

Discharges patient appropriately

  • outpatient physical therapy
  • remove splint in 24-48 hours
  • nonweightbearing
  • active flexion with gravity assisted extension
  • ice, elevation and compression
  • pain meds
  • wound care
  • schedule follow up in 2 weeks
M

Outpatient Evaluation and Management

1

Focused history and physical

  • implications of soft tissue injury
  • open fracture
  • compartment syndrome
  • ligamentous injury
  • document neurovascular status
  • concomitant and associated orthopaedic injuries

2

Knowledge of imaging studies/lab studies

  • radiographs of the elbow
  • AP
  • lateral
  • oblique
  • traction films for preoperative planning
  • CT scan with oblique or comminuted fracture pattern

3

Reduce fracture if necessary

  • provisional fixation
  • fluroscopic checks

4

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention
  • indications
  • fracture displacement

5

Provides postoperative management and rehabilitation

  • postop: 10 day postoperative visit
  • wound check
  • remove sutures
  • check radiograph
  • postop: 4-6 week postoperative visit
  • advance rehabilitation
  • postop: 1 year postoperative visit

6

Diagnose and early management of complications

  • Dx from periop xrays
  • recognize infection
  • recognize fracture displacement/dislocation
N

Advanced Evaluation and Management

1

Order appropriate imaging studies

  • radiographs
  • CT scan/3D reconstruction

2

Provides post-op management and rehabiliatation.

  • increase ROM as healing progresses
  • adequate/proper postop xrays
O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives

  • use of external fixation
  • radial head replacement
  • elbow arthroplasty

2

Modify and adjust post-op plan as needed

  • dynamic/static stretch splinting
  • revise therapy

3

Understands how to avoid/prevent potential complications

4

Treat simple complications both intraoperatively and postoperatively.

  • revise hardware placement
  • recognize improper hardware position
 

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