7. The patient is positioned in the lateral decubitus position,
well padded in the axillary region and all down areas.
8. This allows the elbow to lie over a bolster at 90o of flexion.
This is helpful as the bolster can support the articular surface,
metaphysis or shaft as necessary.
9. In addition, with the patient in the lateral decubitus position, full
flexion of the elbow is possible by retracting the arm such that it
is parallel with the body allowing for excellent anterior visualization
10. This is an advantage over the prone position, which requires
hyperextension of the shoulder in order to examine the anterior
articular surface.
11. MMEEDDIIAALL
The incision is made midline with a slight curve around the tip
of the olecranon as demonstrated. This will keep the scar from
being on the weight-bearing portion of the elbow.
12. The incision is brought down through skin and subcutaneous
tissue to expose the triceps mechanism. The first step is to
identify the ulnar nerve on the medial side of the elbow.
14. SPONGE PLACED
ANTERIOR TO
OLECRANON
The next step is to create the chevron osteotomy. In order to make
the osteotomy central in the articular surface of the olecranon, a
sponge is passed through the joint.
15. SPONGE PLACED
ANTERIOR TO
OLECRANON
This requires dissection of both the medial and lateral sides
of the joint with a clamp, enabling placement of the sponge.
16. TRICEPS
OLECRANON
By pulling on the sponge distally, the central point
of the olecranon can be identified easily.
17. While pulling on the sponge distally (arrow), a 3.2 drill bit is
introduced into the tip of the olecranon percutaneously through the
triceps mechanism and directed down the center of the ulna.
18. It is very important to template the length of the screw. As the
olecranon joins the ulna, there is a bow visualized on the A P
radiograph. If the screw is placed longer than the bow, it will abut
the the cortical surface of the ulna and not allow for compression.
19. After the 3.2 drill bit is used, a 6.5 tap is introduced and the
ulna is tapped 5mm past the template of the length of the
screw.
20. A bovi is used to come through the soft tissue on the
olecranon centered over the middle portion of the
semilunar articular surface.
21. A drill is used perpendicular to the olecranon while protecting
the nerve and the articular surface of the distal humerus with
the sponge. Drill holes are made along the templated
chevron osteotomy.
22. The dorsal osteotomy is complete with an osteotome. The osteotome
is then introduced anteriorly up to the level of the subchondral bone
and used to crack the articular surface.
23. This allows for an irregular fracture of the articular surface and
thus a better fitting reduction during the fixation of osteotomy.
25. OLECRANON ARTICULAR SURFACE
By tilting the osteotomy posteriorly, one can visualize
the articular surface of the osteotomized fragment.
26.
27. FREE ARTICULAR
FRAGMENT
TRICEPS
POSTERIOR ASPECT
OF DISTAL HUMERAL
SHAFT
MEDIAL
TROCHLEA
CENTER OF TROCHLEA
Dissection is then performed on the medial and lateral sides of the
triceps, with care taken not to damage the ulnar nerve or vascular
bundle. This allows for proximal retraction of the triceps mechanism
off the distal humerus, as visualized.
28. FREE ARTICULAR
FRAGMENT
TRICEPS
POSTERIOR ASPECT
OF DISTAL HUMERAL
SHAFT
MEDIAL
TROCHLEA
CENTER OF TROCHLEA
In some cases, free articular fragments, as visualized here
posterolaterally become evident at this point in the procedure.
29. K-wire
FREE POSTEROLATERAL
ARTICULAR SURFACE
The use of multiple clamps, joysticks and K-wires, as well as
manipulation of the elbow, is necessary to gain reduction of the
fragments. The figure demonstrates maintenance of reduction of
the trochlea with a K-wire.
30. K-wire
FREE POSTEROLATERAL
ARTICULAR SURFACE
The free area of posterior lateral articular surface is noted. After
the articular surface is reconstructed and held to the shaft, the
reconstructed articular surface is fixed to the shaft using plates.
31. K-wire
FREE POSTEROLATERAL
ARTICULAR SURFACE
The typical fixation construct includes a medial plate and a
posterolateral plate.
32. The fracture after medial and posterolateral plating. This particular
case had very severe comminution with only very little area from
screw fixation on the distal lateral surface.
33. For this reason, a smaller 2.7mm DCP plate was utilized, as this
allowed for more fixation points. As noted, the articular surface
is well reduced, but there is bone loss in several regions.
34. The construct of a medial and a posterolateral plate allows for 90-90
positioning and the most stable configuration. If the medial plate comes
down farther than the superior surface of the medial epicondyle (arrow),
then an ulnar nerve transposition is recommended.
35. CAPITELLUM TROCHLEA
After fixation, full hyperflexion of the elbow allows for visualization
of the anterior reduction. One can see the severe comminution of
the capitellum and the anatomic reduction of the trochlea. After
fixation is achieved, the olecranon osteotomy is repaired.
36. This is typically performed by placing a drill hole distally and allowing
a large Weber clamp to reduce the osteotomy with the elbow in
extension. The use of a chevron osteotomy allows for tight compression
of the osteotomy site without sliding.
37. The above image demonstrates the anatomic
reduction of the osteotomy.
38. This image demonstrates the figure-of-eight tension band that
has been placed through a drill hole distally in the olecranon,
and has been tightened down medially and laterally.
39. The 6.5 lag screw through the olecranon osteotomy is
not fully seated until after the tension band construct is
completely tightened.
40.
41. TRICEPS
OSTEOTOMY
OLECRANON
Final view of the olecranon osteotomy (dotted lines),
demonstrating the excellent reduction.
43. Closeup AP x-ray demonstrating anatomic reduction of the joint,
with lag screw at the level of the spool and bicolumn fixation.
44. Lateral radiograph demonstrating the two screws obtaining
purchase in the small portion of capitellum that remained.
Note the anatomic reduction of the chevron osteotomy.
