DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left humerus fracture.
POSTOPERATIVE DIAGNOSIS: Left humerus fracture and left supracondylar humerus fracture.
OPERATION PERFORMED:
1. Open reduction and internal fixation of left supracondylar humerus fracture.
2. IM nail with cerclage wiring of left humerus fracture.
SURGEON: John Doe, MD
Treatment options were discussed with the patient including closed reduction and coaptation splint treatment. This was attempted on the floor. The patient was given 4 mg of morphine, and under conscious sedation, a coaptation splint was obtained with still approximately 45 degrees of varus deformity of humerus fracture. After full discussion with the patient and risks and benefits of intramedullary nail to the left humerus were discussed with her, the patient wished to proceed with the surgery. She understood particularly the risk of infection, nerve injury, malunion, nonunion, loss of motion and strength, and loss of normal function of the shoulder or elbow. We also explained that there was a significant anesthetic risk to her heart and lungs and risk of severe bleeding because of her low platelet count and cirrhosis leading to platelet dysfunction. The patient understood all these risks and wished to proceed with surgery.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed in the supine position. She was administered general anesthesia and prepped and draped in the usual sterile fashion. An incision was made over the lateral aspect of the arm, approximately 2 cm from the acromion, splitting through the skin down to the fascia overlying the deltoid. The fascia overlying the deltoid was split in longitudinal fashion and, through blunt dissection, it was taken down directly to the humeral head over the greater tuberosity. The rotator cuff was identified and was not violated throughout the entirety of the case.
An awl was placed in the greater tuberosity of the humeral head, and a guidewire was introduced into the humerus. The fracture was reduced with the use of fluoroscopy. Once fracture reduction was confirmed on both AP and lateral views, fluoroscopically assisted ruler was used to measure the diameter and length of the screw. A 7.5 mm in diameter, 225 mm long flexible Synthes intramedullary humeral nail was inserted. This was inserted, with fluoroscopy, through the fracture site and down to the distal humerus.
At this time, the humerus proximally and distally both viewed in multiple views in the AP and lateral planes, and there was no identifiable fracture. A proximal locking screw was then placed through a small stab incision through the lateral aspect of the arm. A hemostat was used to spread through the muscle tissues and protect any potential neurovascular structures underneath.
Once the locking screw was placed, the proximal locking screw was placed into the intramedullary nail. After completion of this, the elbow was gently straightened for insertion of the distal locking screw, and an audible and palpable clunk was heard. X-rays at this time revealed a supracondylar humerus fracture. The supracondylar humerus fracture was then reduced openly through a triceps-splitting approach posteriorly.
An incision was made from the tip of the olecranon proximally. This was taken through the skin and subcutaneous tissues down to the triceps. The triceps fascia was split longitudinally and triceps muscle was split in its mid belly to reveal the fracture. Because of the fracture plane and the previous nail, the previous nail was keeping the supracondylar humerus fracture from being properly reduced, a Midas saw was used to saw off the distal portion of the intramedullary nail through the locking holes, and a reduction was then obtained of the supracondylar humerus fracture and two interfragmentary lag screws were placed with 3.2 cortical screws through an oblique fracture line in the supracondylar humerus. This fracture line was then further stabilized by the use of an 8-hole Synthes, 3.5 mm LC-DCP locking plate. Two distal locking screws were placed in the distal fragment followed by three standard screws with Synthes cable fixation proximally.
We were unable to secure further fixation because of the previous intramedullary rod. This was discussed with the surgical team, and it was felt best to leave the intramedullary rod to further stabilize the proximal fragments. Fluoroscopy was then again used to confirm reduction of the elbow in both the AP and lateral planes. Final x-rays were taken proximally, which then showed that the lateral cortex, with holding in the intramedullary nail, had blown out due to severe osteoporosis of the left proximal humerus. An incision was then made extending the initial incision from the entrance of the intramedullary nail to the proximal locking screw.
This incision was then taken again through deltoid splitting in a longitudinal incision. Great care was made to ensure and identify that there was no axillary nerve in the surgical field. Two Zimmer cables were placed proximally to secure the intramedullary nail into the blown out lateral cortex and to reduce the blown out lateral cortex fragments. Blunt dissection was used for placement of these proximal cables around the bone to ensure that the radial nerve was protected within the spiral groove at all times and the cable was not placed on or near the radial nerve.
Once again, fluoroscopy was used to confirm reduction. Adequate reduction was confirmed throughout the shoulder, mid humerus, and elbow in both the AP and lateral planes. The wounds were then vigorously irrigated. Fascia overlying the triceps and deltoid were both repaired with 0 Vicryl suture followed by 2-0 Vicryl suture subcutaneously and staples for the skin. The wounds were covered with Xeroform gauze, 4 x 4’s, and Webril.
A post-mold plaster cast splint was placed over the left arm and wrapped with sterile Webril and Ace bandage. The patient awoke from anesthesia in stable condition and was transferred to the recovery room. Total intraoperative use of blood products included 1 unit of packed RBCs. The patient also received platelet transfusion during the case. The patient’s vitals are completely stable.
