Supracondylar Humerus: Extra-articular Fracture

Abstract

Distal Humerus: Extra-articular Fracture Case Study

Clinical history: A 36-year-old right hand dominant male sustained a twisting injury to his right upper extremity upon falling. He presented to our clinic 1 week post injury with moderate soft tissue swelling, ecchymosis and intact skin.

Imaging: An AP and lateral view of the humerus revealed a long spiral fracture of the distal 1/4 of the humerus with an associated large spiral butterfly fragment. CT scan demonstrated that this fracture was extra-articular.

Indications: The patient’s employment required use of the arm on a regular basis, and with the prospect of an earlier return to function and more predictable long-term outcomes, he was indicated for open surgical repair.

Preoperative planning: Based on the fracture location starting in the supracondylar region and extending up proximally, it was felt that a direct midline, posterior, triceps splitting approach would allow best access with the least soft tissue disruption.

Surgical tact: The patient was placed on a beanbag in the left lateral position. After initial dissection through the subcutaneous tissues, the lateral and long heads of the triceps were identified in the proximal aspect of the wound, and this plane was further developed. The radial nerve, its lateral cutaneous branch, and associated profunda brachii artery were then identified and carefully dissected out. The incision was then extended distally by splitting the triceps down to the level of the olecranon fossa. The fractures were identified and provisionally reduced to one another using small K-wires and pointed bone reduction clamps. A 13-hole metaphyseal plate was applied on the posterior surface and secured with 4.5 mm screws proximally in the shaft and 3.5 mm screws distally. Based on the degree of comminution, a second, 12-hole 3.5 mm plate recon plate was then placed and secured posteriorly.

Postoperative care: Patient was placed into a sling for comfort and encouraged to elevate the extremity and actively begin range of motion exercises. Weight-bearing was limited to 1–2 pounds postoperatively and then advanced at approximately 3 months when fracture was fully healed and with only small limitations to the extremes of flexion and extension.