DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right grade IIIA distal humerus fracture with intra-articular extension.
POSTOPERATIVE DIAGNOSIS: Right grade IIIA distal humerus fracture with intra-articular extension.
1. Irrigation and debridement of right distal humerus fracture.
2. Open reduction and internal fixation of right distal humerus fracture.
3. Application of VAC sponge.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
ESTIMATED BLOOD LOSS: 300 mL.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and laid supine on the operating room table. After general anesthesia was induced, the patient was turned to the lateral decubitus position with the right arm up on a bean bag. The right upper extremity was placed on a lateral arm post. The right arm was then prepped and draped in the usual sterile fashion after all bony prominences were well padded. Next, the open wound, which measured approximately 6 x 10 cm, was debrided of all necrotic skin and subcutaneous tissue as well as fascia and necrotic muscle. After thorough debridement, the wound was thoroughly irrigated with 9 liters of normal saline, the middle 3 liters of which contained 100,000 units of bacitracin. The fracture end surfaces were exposed and irrigated thoroughly. After thorough debridement and irrigation, the incision was extended distally as well as proximally. An olecranon osteotomy was performed using a TPS saw at the level of the joint. The ulnar nerve was isolated and identified and protected throughout the remainder of the procedure. The olecranon osteotomy was elevated and the triceps muscle was carefully lifted off of the distal humerus, taking care to protect the ulnar nerve. Next, the fracture was brought into full visualization. The fracture was highly comminuted in the metaphysis with two intra-articular pieces. Reduction of the articular surface was performed. The reduction was held with 1.25 mm K-wires. Two lag screws were placed, one from lateral to medial and one from medial to lateral, holding the articular surface reduced. Next, there was noted to be a large piece of bone that had been outside the wound prior to initiation of the procedure. This piece of bone was dirty and contaminated and therefore it was decided not to use this necrotic piece of bone because of risk of infection. The remainder of the metaphysis was highly comminuted and unsalvageable. Therefore, it was decided to restore the shaft to the articular surface. To do this, we had to accept a certain degree of shortening of the humerus. Therefore, the shaft was brought into contact with the distal humeral surface. Two Synthes small fragment locking plates were then contoured, one for the medial side and one for the lateral side. The lateral plate was advanced up into the humeral shaft after the radial nerve was identified and protected. Three screws were placed in the distal fragment followed by five screws in the proximal fragment holding the shaft reduced to the distal humeral segment. Next, the medial plate was contoured and also secured using three screws distal in the distal fragment and five screws in the proximal fragment. Excellent stability was obtained after placement of all screws on both the medial and lateral sides. The radial nerve was protected throughout the procedure. Next, the wound was thoroughly irrigated. The olecranon osteotomy was then repositioned and the 7.3 mm cannulated Synthes screw was reinserted. Prior to making the osteotomy cut at the beginning of the procedure, a 7.3 mm partially threaded screw, which was 100 mm in length, had been inserted into the olecranon tip into the ulnar shaft. This screw was reinserted. The repair was reinforced with 18 gauge stainless steel wire through a drill hole in the ulnar shaft and the wire was twisted in a figure-of-eight fashion around the olecranon screw at the tip of the olecranon. Once the screw was fully tightened, this wire was also tightened and crimped, obtaining excellent stability of the olecranon osteotomy repair. Once this was done, the elbow was taken through a full range of motion. No mechanical block was noted. The articular surface was restored as best as the injury allowed. Approximately 2 cm of shortening of the humerus had to be accepted due to significant comminution in the metaphysis, which was unreconstructable. The wound was then thoroughly irrigated again with normal saline. Closure was initiated using 0 Vicryl suture for the deep layer, which included the fascia of the triceps tendon. The subcutaneous layer was closed with 3-0 Vicryl suture in inverted fashion. An approximately 4.5 x 4.5 cm area was not able to be closed and therefore a VAC sponge was applied through this area. Staples were applied to the remainder of the incision. A tourniquet was used for this procedure, and prior to closure, the tourniquet was deflated and hemostasis was obtained. Sterile dressings were applied followed by a posterior plaster splint. The patient was then turned over to the supine position, extubated and transferred back onto a stretcher and taken to the PACU for recovery. There were no complications during the procedure. EBL was 300 mL.