Humerus Shaft Fracture ORIF with Anterolateral Approach

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TECHNIQUE STEPS
 
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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

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

F

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
G

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
H

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
I

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

J

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
K

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
L

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
N

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
Postoperative Patient Care
 

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