Patients accepted in transfer following initial treatment should have wounds inspected on arrival. Since this injury represented a Gustillo / Anderson grade III injury, a repeat debridement was indicated. An inventory of the remaining bone fragments for future reconstruction at the debridement helped develop a surgical tactic.
Antibiotics were continued following each surgery. Wound cultures were obtained at the second surgical inspection to assess the existence of persistent contamination because of the amount of bone loss and the need for acute bone grafting in an early reconstruction. Repeat debridements were planned if cultures were positive for bacterial contamination.
Autograft reconstruction was elected over the use of allograft due to the size of the defect and because of concerns over the longevity of an osteochondral articular allograft in the elbow. Urbaniak feels despite his experience osteochondral articular allografting should remain a salvage procedure (CORR 1997). In addition, an initial attempt at autograft reconstruction would not preclude future allograft reconstruction if a nonunion developed (Jupiter JBJS 1988).
The goals of union and stability of the elbow were met with this reconstruction. No evidence of osteonecrosis of the capitellum was present at 6 month follow up. Despite early motion significant stiffness resulted. This has minimally improved with the use of splinting following union. Despite reestablishment of anatomic structure, adequate stability of the reconstruction, and aggressive rehabilitation complex intra-articular fractures of the distal humerus (C3) are associated with significant disability.