DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right distal humerus fracture with intraarticular extension.
POSTOPERATIVE DIAGNOSIS: Right distal humerus fracture with intraarticular extension.
OPERATION PERFORMED:
1. Open reduction and internal fixation of right distal humerus fracture with olecranon osteotomy.
2. Open reduction and internal fixation of the olecranon.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. She was administered general anesthesia and then placed in the prone position. All bony prominences were well padded. A tourniquet was placed over her right upper arm. The patient was then prepped and draped in the usual sterile fashion. The extremity was then exsanguinated, and the tourniquet was inflated to 250 mmHg pressure.
A longitudinal skin incision was made from the olecranon tip extending proximally over the posterior aspect of the arm. This was taken down through the skin and subcutaneous tissue down overlying the triceps muscle and overlying the olecranon tip. The periosteum was stripped from the olecranon at an osteotomy site approximately 2 cm distal to the tip. An osteotomy was then performed of the olecranon in a chevron fashion with an oscillating saw. Prior to displacement of the fracture, two smooth K-wires were placed from the tip of the olecranon into the anterior cortex of the ulna distally. The K-wires were then removed, and these spots were marked for future hardware placement. The olecranon tip was then completed with an osteotome, and the distal humerus joint was exposed by elevating these structures.
With the use of blunt dissecting scissors, the triceps muscle was removed from the distal humerus. The ulnar nerve was identified and freed up from the surrounding soft tissues. A vessel loop was placed around the ulnar nerve, and the ulnar nerve was taken out of the operative field and protected throughout the entirety of the case. The distal humerus fracture site was then identified. The fracture fragments were freed up, and the hematoma was removed with curette and bulb irrigation. A pointed reduction clamp was placed over the distal humerus to first identify and reduce the articular surface. A smooth K-wire was placed at intraarticular surface to maintain this reduction.
A 4.5 mm cannulated screw was then placed over this to hold the articular surface in the appropriately reduced position. This was confirmed with the use of arthroscopy to ensure that the articular surface remains reduced to decrease the risk of postoperative arthritis. The remaining distal humerus fracture fragments were then stabilized. A lateral plate was first placed. This was the Synthes distal humerus locking plate. The locking screws were placed throughout on the posterolateral aspect of the humerus to stabilize the plate. The fracture reduction was confirmed on AP and lateral fluoroscopic views. There was one area of comminution over the lateral cortex of the humerus, which was not fully reduced with the plate. A separate lag screw was placed through this comminuted fragment, which was a 3.5 fully-threaded cortical screw. This was placed in the medial cortex of the humerus to maintain reduction. To provide further buttress effect across the distal humerus, a medial plate was also placed. This was the Synthes distal humerus medial locking plate. Locking screws were then placed into the distal humerus. Again, reduction was confirmed on AP and lateral radiographic views.
The wound was then vigorously irrigated. The ulnar nerve was then placed within its normal groove within the elbow. Soft tissue was placed over the ulnar nerve to avoid ulnar nerve complications postoperatively. The olecranon osteotomy was then fixed with the previously placed smooth K-wires into the anterior cortex of the ulna. One drill hole was placed distal to the osteotomy site in the olecranon for placement of a wire. A figure-of-eight tension band construct was then placed through this drill hole and around the K-wires to stabilize the olecranon osteotomy. The wire ends were then cut and then bent and placed underneath the muscles to avoid postoperative irritation. The ends of the K-wires were also cut and bent back to be placed within the triceps muscle. Subcutaneous tissues were then closed with 2-0 Vicryl sutures followed by staples in the skin. Sterile Xeroform, 4 x 4s, and Webril were then placed, and the arm was placed in a plaster splint. The patient awoke from anesthesia without complication and was transferred to the recovery room in stable condition.
