PREOPERATIVE DIAGNOSIS: Right supracondylar humerus fracture.
POSTOPERATIVE DIAGNOSIS: Right supracondylar humerus fracture.
OPERATION PERFORMED: ORIF of supracondylar humerus fracture, right, and subcutaneous ulnar nerve transposition.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
FLUIDS: 1700 mL crystalloid.
ESTIMATED BLOOD LOSS: 150 mL.
TOURNIQUET TIME: 120 minutes.
DESCRIPTION OF OPERATION: The patient was brought to the operating room where general endotracheal anesthesia was induced. The patient was then positioned in the left lateral decubitus position. An axillary roll was placed and the patient was secured into position using a padded bean bag. The peroneal nerves were padded. The knees were well padded. The patient was then prepped and draped in sterile fashion. A sterile tourniquet was applied to the right proximal arm and Esmarch bandage was used to gently exsanguinate the limb. Tourniquet was inflated to 250 mmHg.
A posterior midline incision was made centered about the olecranon process. Dissection was carried out sharply to the level of the fascia and the fascia was incised. Dissection was carried out medially and laterally, elevating full-thickness skin flaps. Dissection was carried medially and the ulnar nerve was identified in the cubital tunnel. Care was taken to visualize the ulnar nerve throughout the cubital tunnel, and I felt that to facilitate acceptable reduction and fixation of the fracture, that the ulnar nerve would need to be mobilized for the course of the surgery.
In light of this, the roof of the overlying fascia was released with Metzenbaum scissors. The ulnar nerve was gently dissected free from the distal aspect of the humerus and freed. Dissection was carried proximally along the ulnar nerve, taking care to release fascial attachments and muscular septae tethering the ulnar nerve. Once it had been adequately mobilized, a loosely applied vessel loop was used to mark the ulnar nerve. It was dissected free and away from the reduction site. Then, exposure of the distal humerus was continued. The triceps was elevated about the fracture line and the fracture line was noted to be transverse in nature just through the region of the olecranon fossa.
Visualization of the joint was limited, but the articular surface was felt to be completely intact without fracture lines extending into the joint. Thorough irrigation of the fracture site was performed and initial reduction maneuver realigned the distal humerus with the proximal fragment. Once it had been acceptably placed, temporary fixation with 0.0625 K-wires was accomplished.
Then, medial and lateral distal humerus locking plates were selected and the lateral plate was applied first. The plate with the flange was selected to provide additional fixation into the distal humerus. It was secured into preliminary position and secured with temporary K-wire. Then, a cortical screw was placed from posterior to anterior direction and used to loosely approximate the plate to the distal humerus. It had an excellent fit and did not require additional contouring.
Then, the locking sleeves were assembled onto the plate and a 2.0 drill bit was used to drill the track. Appropriate length screws were selected from the depth gauge and 2.7 mm distal humerus locking screws were applied and locked into the plate without difficulty. After this had been performed, a posterior-to-anterior screw was placed through the plate in a locking fashion as well with into the capitellum, taking care to stay short of articular surface. After this had been performed, screws were placed into the proximal fragment and the plate was tightened into position.
Compression was applied across the transverse fracture pattern prior to securing the plate. Then, a medial plate was selected at adequate position to the distal humerus. I did not feel that contouring the plate would be helpful, as I thought that it might preclude the use of screws in the distal humerus fragment. The plate was secured in a temporary fashion, and the distal humerus screws were placed in a locking fashion using the locking drill bit. Initially, two screws were placed and secured and locked in a locking fashion. Then, screws were placed proximally, using 3.5 mm cortical screws.
Intraoperative x-rays were obtained, and these demonstrated the distal humerus screws from the medial side to be somewhat long and I felt that they ought to be changed. The screws were removed and a single distal locking screw was placed from the medial side. A second distal lock had very little purchase, and I felt it better to leave this screw out. Thorough irrigation of the wound was performed. The elbow was taken through a full range of motion, and full extension and flexion were obtained and there was no motion at the fracture site noted. Thorough irrigation of the wounds performed. Hemostasis was ensured.
The vessel loop was released from the ulnar nerve. It was noted to be without additional contusion or injury. Upon placing the ulnar nerve back into the groove, it had some proximity to the medial plate, and in light of this, I felt that it would be better to allow the nerve to be positioned in the fashion away from the end of the medial locking plate. A fascial tether was fashioned using 0 Vicryl in a subcutaneous fashion. The ulnar nerve was inspected and noted to have full range without any limitation or impingement on the hardware.
A medium Hemovac drain was placed. The fascia was approximated with 0 Vicryl in a figure-of-eight fashion. Subcutaneous layer was closed with 2-0 Vicryl in an interrupted fashion and the skin was closed with staples. Wounds were dressed with Xeroform, 4x4s, ABD pads, and sterile Webril. Intraoperative x-rays were obtained. These demonstrated acceptable placement of the hardware and acceptable reduction. A long-arm posterior molded splint was applied. The patient was positioned back into the supine position, awakened from anesthesia, extubated, and transferred to the recovery room in stable condition.
