Distal Humerus Fracture ORIF

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Preoperative Patient Care
Operative Techniques
E

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
F

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
G

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
H

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
I

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
J

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
K

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

L

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
Postoperative Patient Care
 

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