The patient is a 74-year-old female with a slip and fall at home with resultant comminuted humerus fracture that extended from the mid diaphyseal region up to the proximal humerus. She underwent a CT scan demonstrating a comminuted fracture in multiple pieces with significant displacement. She also fell and sustained an inferior pole of the patella fracture with significant displacement. She was seen in the emergency room at Milford Hospital. She was then transferred to MidState Hospital for definitive operative intervention.
*
I saw the patient in preoperative holding area, had a long discussion with the patient regarding her diagnosis and treatment options. Following that discussion, she elected to proceed with surgery. I discussed risks, benefits, alternatives and complications including blood loss, nerve and vessel injury, as well as infection. Following that, she wished to proceed.
*
DESCRIPTION OF PROCEDURE:
The patient was seen in the preoperative holding area, surgical consent was obtained. Surgical site was marked. The patient was transported back to the operating room and placed supine on the operating table. General anesthesia was induced. At this point, the right upper extremity was then prepped and draped in normal sterile fashion. Following this, a standard anterior approach to the humerus was performed. It began at the coracoid process and extended down to the antecubital fossa. Dissection continued down. The deltopectoral interval was completed proximally. The cephalic vein was identified and retracted laterally. The clavipectoral fascia was released just lateral to the conjoined tendon. The CA ligament was released anteriorly. Dissection continued down. The long head of the biceps was identified as well as the deltoid insertion. There was a comminuted fracture extending from the humeral head distally. The fracture then became more comminuted around the proximal diaphysis and extended down as far as the mid diaphysis of the humerus. The biceps tendon was identified. The muscle was taken medially. The underlying brachialis muscle was identified and was split longitudinally down to the humeral shaft. At this point, copious irrigation was performed. Abundant hematoma was removed from around the fracture fragments. A large amount of comminution was present posterior to the pectoralis major insertion. Dissection continued around behind it, but due to the comminution in that area, it was required to perform a pectoralis major tenotomy for later repair. The ends of the tendon were identified and were then transected approximately 1 inch from the insertion. The tendon edges were tagged. A #5 FiberWire was then utilized to Krackow from the superior edge to the middle and then a second #5 was utilized to Krackow from the middle down to the inferior aspect of the tendon and muscle interface. This was then tagged for later repair. At this point, a meticulous dissection through the fracture bed was performed. Multiple reduction clamps were utilized to obtain a reduction. Once this was obtained, 2 lag screws were placed distally and 2 lag screws were placed proximally through the different fracture fragments. At this point, a bridge plate was then placed anteriorly, beginning distally with 3 screws distal to the fracture and extending proximally up to the humeral head. Due to the placement of the plate, it would be directly over the biceps tendon and the biceps tendon was then tenotomized for later tenodesis. Once screws were obtained proximally and distally, fluoroscopic images were taken demonstrating an anatomic reduction.
*
There was still difficulty with the fracture extending up into the greater tuberosity. Once the diaphyseal portion of the fracture was neutralized with the anterior bridge plate, attention was then paid to the proximal humerus. At this point, a lateral plate was then selected and this was checked on fluoroscopic imaging to obtain the correct height. A nonlocking screw was then placed through the sliding hole of the plate and the height was adjusted. Following this, sequential locking screws were placed through the proximal portion of the plate as well as distally interdigitating between these screws through the other plate.
*
This gave good overlap without any evidence of any stress risers in the humerus.
*
Intraoperative fluoroscopy was utilized to further check reduction and screw length, which demonstrated good position.
*
At this point, it was copiously irrigated. The biceps tendon was then tenodesed to the plate utilizing a #5 FiberWire.
*
At this point, the pectoralis tendon, which lay between the 2 plates, was then repaired utilizing a Krackow #5 FiberWire. These were then repaired to the tendon stump with reinforcement around the plate.
*
At this point, the wound was copiously irrigated again. At this point, skin was then closed with 2-0 Monocryl followed by staples. A sterile dressing was applied.
*
At this point, the drapes were then taken down and attention was then paid to the right patella. The right lower extremity was then prepped and draped in a normal sterile fashion. Superficial landmarks were delineated. An Esmarch bandage was then utilized to exsanguinate the limb and a 15 cm incision overlying the patella was performed. Dissection continued down to the tendon. Medial and lateral flaps were developed. The fracture bed was identified. There was only a thin fragment of bone inferiorly as well as superiorly and was an extraarticular part of the inferior pole. At this point, it was determined to perform the repair similar to the patellar tendon repair. Two #5 FiberWire were then utilized to Krackow through the patellar tendon. A drill hole was placed in the inferior pole of the patella and the 4 suture limbs were then brought through. At this point, 3 drill holes were placed in a parallel fashion through the patella. Once this was performed, a Hewson suture passer was utilized to pass the sutures through the patella. The sutures were then retrieved superiorly. The middle sutures were then passed both medially and laterally to be paired with the other suture. The leg was then taken into extension and the sutures were then sequentially tied, repairing the inferior pole of the patella to the patella. Following this, an internal brace was then utilized utilizing a SwiveLock. Two SwiveLock were placed, 1 medially and 1 laterally on the tibial tubercle. A drill guide was placed followed by a 4 mm reamer. At this point, 1 FiberTape as well as 2 of the anterior FiberWire were then placed. The FiberWire were placed under tension. The FiberTape was just placed into the SwiveLock. This was then anchored to the medial portion of the tibial tubercle. Following this, the FiberTape was then utilized along with a large free needle to pass a cerclage around from the medial up to the superior around the superior pole of the patella and then laterally. This was then tensioned in 20 degrees of knee flexion to maximize the sturdiness of the repair. Once this was tensioned to 20 degrees of flexion, the FiberTape as well as FiberWire were then placed down the SwiveLock reamed hole and the SwiveLock was then deployed. Following this, the knee was taken through a range of motion up to 90 degrees with no gapping. It was then copiously irrigated. The medial and lateral retinaculum were repaired with #1 Vicryl.
*
At this point, skin was then closed with 2-0 Monocryl followed by staples. A sterile dressing was applied. The patient was then extubated and transported to the postoperative care unit in stable condition.
*