PREOPERATIVE DIAGNOSIS: RIGHT MEDIAL COLUMN INTRAARTICULAR DISTAL HUMERUS FRACTURE.
PROCEDURES: RIGHT ELBOW ORIF, MEDIAL COLUMN IN INTRAARTICULAR PORTION WITH ANTERIOR ULNAR
NERVE TRANSPOSITION.
POSTOPERATIVE DIAGNOSIS: NONDISPLACED RIGHT MEDIAL COLUMN INTRAARTICULAR DISTAL HUMERUS FRACTURE.
ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE. ESTIMATE BLOOD LOSS: 20 CC. TOURNIQUET TIME: 90 MINUTES. ANTIBIOTICS: ANCEF 1 GM PREOP, 1 GM ANCEF POSTOP. COMPLICATIONS: NONE.
INDICATIONS: ... a closed right medial column nondisplaced intraarticular fracture of the distal humerus. Options, risks and benefits were discussed with the patient and he agreed with open reduction internal fixation and ulnar nerve transposition and possible olecranon osteotomy.
PROCEDURE: The patient was brought to the operating room and anesthesia was induced via endotracheal tube. The patient was placed in the left lateral decubitus position on a bean bag and the right upper extremity was prepped and draped in sterile fashion. His limb was exsanguinated and the tourniquet was inflated to 250.
A longitudinal incision was made over the olecranon and extended proximally and distally. The ulnar nerve was identified along the medial triceps and traced up to the medial intermuscular septum. It was traced distally down to the first branch to the flexor carpi ulnaris. A Penrose drain was placed around the ulnar nerve and that was used to protect the nerve throughout the case. The fracture surfaces were subperiosteally dissected irrigated out and curetted.
The trochlear fragment was reduced to the medial column and held with 1.3 K-wires. It was reduced to the capitellum and viewed by performing a partial triceps slide from medial to lateral. This allowed anatomic reduction. He had a 4.0 partially threaded cancellous screw placed through the trochlear into capitellum which obtained good purchase and maintained anatomic reduction.
A 6-hole Smith and Nephew 3.5 Recon plate was bent to fit along the medial column and a distal screw was placed through the plate which went up the medial column, it was a 4.0 fully threaded cancellous screw which obtained good purchase, maintained anatomic reduction of medical column. The proximal 3 holes were filled at cortical screws, one screw hole was left opened, and one was filled with cancellous. C-arm imaging was used intermittently throughout and he was found to have full range of motion, anatomic reduction upon visualization on C-arm with good position of the hardware. The ulnar nerve was transposed into a subcutaneous anterior position with no tension and a soft tissue sling was created with 0-Vicryl to prevent it from subluxating posterior to the medial epicondyle. The deep fascia was closed with a combination of running and interrupted 0-Vicryl, the subcutaneous tissue with running interrupted 2-0 Vicryl and the skin was closed with skin clips. The tourniquet had been let down just prior to subcutaneous closure and hemostasis obtained using pressure and electrocautery. Sterile dressings were applied and a posterior splint.
The patient remained intubated at the time of dictation of this procedure.