The patient was returned to the operating room for inspection of the wounds, followed by a repeat debridement and irrigation of the wound. The two lateral traumatic lacerations were intact with minimal serosanginous drainage. The wounds consisted of a 5 cm oblique distal laceration which did not communicate with the distal humerus or ulna fracture, and a stellate laceration more proximal, extending to near the midline posteriorly. (Figure 3).
The external fixator was removed and sterilized for later use. The Schanz pins were prepped and draped into the field. Debridement was again performed through the posterolateral laceration. A large amount of the distal lateral column of the humerus was missing. Additional findings included: a lateral diaphyseal butterfly, a split trochlea, and an avascular anterior capitellar (osteochondal fragment) (Figure 2). Cultures were obtained. The bridging external fixator was replaced (Figure 4). The cultures from the debridement were negative.
Due to the patient’s age and activity an attempt at reconstruction was warranted. The patient was placed into a lateral position with the humerus supported on towel bumps. The iliac crest was prepped out separately. A curvilinear posterior incision to incorporate a longitudinal arm of the stellate traumatic laceration was utilized. The olecranon fracture was then displaced to mobilize the triceps proximally. The operative tactic was to first reconstruct the sigmoid notch, elevating the impaction centrally. This was stabilized temporarily with threaded wires. A sagittal split in the proximal ulna was also reduced and held with a screw. With limited bone contact at the proximal extent of the humerus due to the fracture configuration, the bone was shortened minimally to improve apposition and improve construct stability.
Reconstruction of the humerus began with reduction of the trochlear fracture fragments. The medial column was reduced and stabilized provisionally. Length and alignment was confirmed radiographically. The appropriate length of a bicortical graft was harvested along with cancellous graft from the iliac crest. The cortical graft was fashioned to fit the length of the lateral column. Access to the anterior capitellum was through the fracture of the lateral epicondyle. The capitellum was reduced to the trochlea and attached to the cortical graft with the use of a Herbert screw. The medial column was then stabilized with a medial 3.5 reconstruction plate which was modified to accommodate a Schuli nut at the distal hole. The lateral column was bridged with a 3.5 reconstruction plate that was fixed to the graft and capitellum. The lateral epicondyle was repaired with sutures to the graft and lateral plate. Cancellous graft was then placed posteriorly at the proximal fracture, along the cortical graft, and to support the impaction of the fragments in the sigmoid notch. The proximal ulna was the stabilized with a 2.7mm reconstruction plate. Final radiographs were obtained (Figure 5 & Figure 6). The wound was closed over drains.