Postoperative Diagnosis: Comminuted right distal humerus fracture involving the supracondylar ridge and humeral
shaft; no articular extension.
Intraoperative Findings: Patient did have a comminuted distal humerus fractures that involved the humeral shaft and
a seperate supracondylar ridge fractue medially.
Wound Classification: Clean.
Indication for Surgery: Patient is a 24-year-old right-hand dominant female who was involved in an electric scooter
collision on 04/20/2026. She had immediate pain and dysfunction and was taken to Queen of the Valley Hospital for
evaluation and treatment. Patient was diagnosed with a comminuted distal humerus fracture. Patient was seen in
my clinic on 04/23/2026. Based on fracture displacement and comminution, I did recommend surgical intervention of
open reduction, internal fixation, and a possible radial nerve neurolysis. I did discuss all risks and benefits regarding
the surgical procedure along with expectations for both operative and nonoperative treatments. Patient stated that
she understood both operative and nonoperative options and wished to proceed with surgical intervention. The
patient did complete all preoperative labs and studies as requested.
Procedure In Detail: Patient was met in preop holding on the morning of 05/01/2026. Again, all risks and benefits
regarding the above-indicated procedure were discussed with the patient. The patient stated that she understood and
wished to proceed with surgery as recommended and discussed. After appropriate patient identification was
completed, the right upper extremity was marked as the correct operative site. The patient was then taken back to
operative suite #6 at Intercommunity Hospital. Once in the operating room, patient was transferred over to the OR
table. At this time, care was then turned over to the anesthesiologist who provided endotracheal intubation, then
followed by a regional nerve block to the right upper extremity. Please refer to anesthesia notes for details. At this
time, the patient was positioned on the operating room table and all bony prominences were well padded. SCDs were
placed to bilateral lower extremities along with a Bair Hugger to the lower body and legs. The preoperative images
were obtained confirming comminuted right distal humerus fracture with extension to the supracondylar ridge. The
right upper extremity was then prepped and draped in normal sterile fashion. An operative time-out was completed
and all parties agreed that the right upper extremity was the correct operative site. A sterile tourniquet was then
placed high in the patient's axilla. The patient did receive 2 g Ancef for antimicrobial prophylaxis per standard
surgical protocol along with 1 g of tranexamic acid. The right arm was elevated and exsanguinated with an Esmarch.
Tourniquet was then inflated to 250 mmHg. At this time, an incision was made midline over the humerus and taken
slightly lateral to the olecranon process. Full-thickness skin flaps were then elevated. Hemostasis was obtained with
cautery. The deep fascia overlying the triceps was then incised sharply. A lateral paratricipital window was
completed distally going distal down through the anconeus in line with Boyd's interval. The posterior cutaneous nerve
branch was identified laterally and traced up to the radial nerve. At this time, the lateral aspect of the distal triceps
was mobilized and I was able to appreciate the comminuted fracture fragments. At this time, I elected to deflate the
tourniquet and tourniquet was removed. A longer incision proximally was then made to expose 75% of the patient's
humerus. At this time, full-thickness skin flaps were then elevated and deep fascia of the triceps was open. The
posterior cutaneous nerve was then traced back to the radial nerve and the radial nerve was identified and
neurolysed. Once the radial nerve was neurolysed, a vessel loop was placed around the radial nerve and protected
throughout the duration of the case. Attention was then turned back distally and the large butterfly comminuted
fracture was released off local soft tissues. This separate fracture fragment involved the supracondylar ridge of the
distal humerus. All fracture fragments were then curetted and the fracture hematoma was removed. After the
surgical incision site was then thoroughly irrigated and fracture ends were freshened up, the comminuted butterfly
fracture fragment was then reduced and held preliminarily with multiple lobster claws to the proximal fracture
fragment. With direct visualization and axial traction, I was then able to reduce the distal humerus fracture fragment
back to the proximal shaft fracture fragment and again multiple lobster claws were used to hold temporary fixation.
At this time, two 3.5 mm lag screws were placed in standard fashion to hold the reduced fracture in place. Based on
fracture length involving the supracondylar ridge of the distal humerus and long oblique humeral shaft fracture, I
elected to proceed with placement of an 8-hole extra-articular distal humerus plate. This plate was held with
temporary fixation using a K-wire and multiple fracture reduction clamps. Fluoroscopic images were pushed in and
obtained. Fluoroscopic images showed that the hardware was in appropriate position. There was a small loss of
reduction of the comminuted fracture, however, this was very minimal. Therefore, I elected to leave the fracture
fragments in their stable position since the small lost reduction will be inconsequential in her long term healing range
of motion. At this time, 2 nonlocking cortical screws were placed proximally followed by 2 distal nonlocking cortical
screws. After these screws were placed, multiple additional nonlocking screws were placed both proximally and
distally followed by 2 locking screws distally. With final fixation of the plate, I was able to obtain at least 8 cortices of
fixation both proximal and distal to the fracture site, thus neutralizing the fracture forces and successfully bridging the
fracture. The radial nerve was examined and confirmed to be completely intact without any compression. The radial
nerve is crossing the plate in a medial- to-lateral direction at the 4th and 5th holes of the plate counting from the most
proximal aspect of the plate. Vessel loop was removed. Previously placed K-wire through the plate was removed.
Final fluoroscopic images of the reduced humeral shaft were obtained confirming appropriate fracture reduction and
appropriate placement of all hardware. The patient did have full range of motion with flexion and extension to the
elbow and pronation and supination. The surgical incision site was then thoroughly irrigated. Surgical incision site
was then closed in standard layered fashion using 0 Vicryl, followed by 2-0 Vicryl, followed by 3-0 Vicryl, followed by
staples for the skin. Dry sterile dressings were placed. All drapes were removed. Patient was then placed into a
long posterior splint with the elbow flexed at 90 degrees and the forearm in neutral position. There were no
complications.
Care was then turned back over to the anesthesiologist who extubated the patient without any complications. Please
refer to her notes for details.
