DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right distal humerus fracture.
POSTOPERATIVE DIAGNOSIS: Right distal humerus fracture.
PROCEDURES PERFORMED:
1. Right olecranon osteotomy.
2. Open reduction and internal fixation, right distal humerus.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 300 mL.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male who fell approximately 8-10 feet while putting up a painting. The patient sustained the above-stated injury. Informed consent was obtained for operative fixation.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR and laid supine on the OR table. After general anesthesia was induced, the patient was turned over to the lateral decubitus position, and the right upper extremity was placed on a lateral arm post. Next, the right upper extremity was prepped and draped in the usual sterile fashion.
Next, a posterior approach to the distal humerus as well as the olecranon was performed. Dissection was carried down to the level of the olecranon, and the proximal aspect of the ulna was exposed. Prior to incision, a sterile tourniquet was placed, and the right upper extremity was exsanguinated, and the tourniquet inflated to 275 mmHg. Once the olecranon was exposed and the joint line was identified, a chevron-type osteotomy was performed with the TPS saw.
Prior to making the osteotomy cut, the ulnar nerve was identified medially and protected throughout the remainder of the case. The ulnar nerve was dissected carefully prior to making the osteotomy cut. After the osteotomy cut was made, the olecranon as well as the triceps were immobilized and retracted and clipped to the tourniquet to allow exposure of the distal humerus. There was noted to be an intercondylar extension of the fracture into the distal humerus. This intercondylar component was reduced and held provisionally using tenaculums. K-wires were placed for provisional reduction of the fracture.
Next, two lag screws were placed from medial to lateral, holding the intercondylar fragment reduced. The distal articular segment was reduced to the humeral shaft and held provisionally, again using K-wires. A medial distal humerus plate, which was a locking plate from the Synthes set, was selected. This was a 3.5 mm plate. The plate was situated over the medial column posteriorly. Three 3.5 mm cortical screws were placed in the proximal fragments followed by three 2.7 mm locking screws in the distal fragment.
Next, a locking distal humerus plate from the Synthes set was selected and again situated on the lateral column. Once again, three 3.5 mm cortical screws were placed in the proximal fragment followed by three 2.7 mm locking screws in the distal fragment. All screws were placed in standard AO fashion.
After placement of all, C-arm fluoroscopy was used to confirm excellent reduction of the fracture on both the AP and lateral fluoroscopic images. All screw lengths were noted to be of good length. None of the screws had penetrated the joint. The joint surface was felt to be adequately reduced and stable. Range of motion of the arm showed full flexion and extension.
Next, attention was directed toward repairing the olecranon osteotomy. The wound was thoroughly irrigated with normal saline prior to fixation of the olecranon osteotomy. Next, the guidewire that had previously been placed into the olecranon shaft, prior to making the osteotomy cut, was placed. The olecranon was reduced and held using tenaculums. Next, 100 mm, 7.3 cannulated screw from the Synthes set was inserted into the tip of the olecranon. Prior to final seating of the screw, which also had a washer on it, medial to lateral drill holes were made more distally in the olecranon.
An 18 gauge wire was passed and made into a figure-of-eight loop around the tip of the 7.3 mm cannulated screw. Next, the 7.3 mm cannulated screw was fully tightened, obtaining compression across the osteotomy site. The 18 gauge wire was also crimped and tightened on the medial aspect, and this helped produce more compression across the osteotomy site. The wire was then cut. Next, the wound was again thoroughly irrigated with normal saline. The deep layer was closed with 0 Vicryl suture in a figure-of-eight fashion, followed by 3-0 Vicryl suture for the subcutaneous layer, followed by staples for the skin. Sterile dressings were applied, and the patient was placed into a posterior elbow splint. There were no complications.
