Always a great speaker. From Tufts University, our next speaker is Dr. Chuck Cassidy. Chuck and I go way back working together when I was a hand fellow and he was a chief resident. I will tell you he has a brilliant mind and he is a very talented surgeon. Chuck. Thanks, Dave. I have nothing to disclose except for the fact that my brain is about to explode from all that I've learned this morning. These are some of the most challenging fractures that we treat and they're a lot of fun to treat. Decision making 2013 includes whether to do an electro-osteotomy. Usually I'll do it for articular fractures, ulnar nerve transposition goes along with the osteotomy, 90-90 versus parallel plating, I'm a 90-90 fan. This is our patient, bicondylar distal humerus fracture, medial comminution. A CT scan usually is not necessary but often obtained by our residents. Preoperative templating is very important, including preoperative planning. I'm going to stop here for one second. This is a test of friendship with the nursing staff. Give them a list before you start the operation rather than having them scramble during the case. And that includes mini C-arm, elbow holder, small mini fragment set, large fragment set, large pointed bone reduction clamps, large Steinman pins, periarticular plates, locking screws, headless screws, specialty retractors, especially malleables are helpful, mini osteotomes and a sterile tourniquet. I like the lateral decubitus position, it's important to make sure that the bony prominences are well padded, especially since this may be a long operation. Straight posterior midline incision, unless there's a soft tissue problem for me. Flaps are elevated at the level of the fascia. The next step for me is to identify and mobilize the ulnar nerve and this may be distorted by the fracture and the posterior approach. So it's helpful to place a CEN medially and retract the triceps and there you can expose the ulnar nerve. You want to mobilize it at least eight centimeters approximately and then into the cubital tunnel and then well within the flexor carpi ulnaris as you see here, the motor branches. Then I place a Penrose drain around the nerve and don't clamp that drain. Try to leave the inferior ulnar collateral artery branch intact if you can. Release the medial intermuscular septum. So this is all still just exposure. Next step is to prepare for the olecranon osteotomy. The flexor carpi ulnaris is elevated from the proximal ulna with care to protect the medial collateral ligament. And then after that, a second window is made laterally, elevating the anconeus from the proximal ulna as well. And then a trick that I learned from Jesse a long time ago is to place a 4x8, a moistened open 4x8 in the ulnar humeral joint. Across from medial to lateral, take the sponge, draw it across and then saw it back and forth and you'll find the deepest part of the sigmoid notch. You'll also protect the articular surfaces from the saw blade. Next step is to prepare for the chevron osteotomy, which is proximally based. If the bone quality is good, I like to use a 6.5 millimeter screw. So this is pre-drilling with a 3.2 millimeter drill bit aimed toward the radius slightly and then tap. And then you advance the tap until you get good endosteal purchase at which point you'd measure and that's going to be your screw length. The osteotomy is then done using a high speed saw with irrigation. I like to complete it along the medial and lateral margins, but not centrally so there's an irregular surface. This way you control the fracture. Take a thin, wide osteotome. Take your time with this step. It's very important not to have any misadventures. And then you pop it off and retract the olecranon with the triceps. There's the fracture, bicondylar, as we said, medial comminution. And then here's my tactic. Step one, restore the medial column. In this case with an interfragmentary screw and a neutralization plate. Step two, reduce the articular surface and stabilize it using a distally placed screw that won't interfere with the plates. Step three, reduce the articular block to the shaft and then stabilize that with two plates as you see here. Eight points of fixation in each plate on each side. So step one, medial column fixation. Reduce and stabilize the medial column. I use a countersink so that the head of the screw is not prominent and you can place the plate over this screw along the medial column. So now you have a stable foundation on which to build the articular surface. So here I've put a neutralization plate. It's just a one-third tubular plate poster aspect of the medial column as you see there. Next step is really the key to the operation. I use some joysticks and you have to think about where these are going to not interfere with your fixation. Two big K wires and then reduce the articular surface. Fragments tend to rotate internally toward the midline and use the ulna as a template. You need a friend to help with the bone reduction clamp so the clamp's in place. Then articular fixation as you see here. I'm going to stop for one second. I like to use a cannulated screw system to prepare and the reason is that you can, without any fluoro, see where that screw is going to end up. So I advance the guide wire all the way across, grab it on the other side, and then use a cannulated drill bit and then you don't need a cannulated screw. You can just put a standard screw in. Make sure that screw is distal as you see here. Third step is to reduce the articular block to the shaft and the humerus tends to sag and if you put a bump underneath the humerus you will reduce it there. So now we have the fracture reduced and now I'm looking at the articular surface at the distal capitellum to make sure that the plate is not impinging there. I like to fix the articular segment first with locking screws and then you can put a plate in compression approximately if you'd like. So now we have the posterolateral plate. And then finally, medial plate placement. A malleable retractor is really helpful. That way you don't have to torque on the arm to put the screws in. Slide the plate up along the medial column and then I use a variable angle drill here to place the screws so that I'm not interfering with that foundation screw distally. And if there's room for a medial column screw, that's great. So here we have three plates. So that's the plan executed. Next step to repair the osteotomy, transverse drill hole in the ulna with passage of a 20 gauge wire as you see here. Protect the ulnar nerve medially. And then it's really helpful to crisscross the wire right at the opening so that you eliminate any redundancy in the system. Then a unicortical hole for an olecranon clamp as you see here. If you don't have one of these, you can just use a towel clip and straighten out one of the tines of the towel clip. That will help to reduce and compress the osteotomy. Then a 6.5 millimeter screw and washer and I don't seat it fully until after I've tightened the wire. Second wire passed through the tricep around the screw and then these knots are tensioned simultaneously and then after that's done, I will seat the screw fully. And then of course, tamp down the knots. Haven't had many hardware problems using this technique. So here it is. Final construct, anatomic reduction of the articular surface, three points of fixation in each. The plates are not ending at the same level and the screw is engaging the endosteal cortex distally. So in terms of rehabilitation for me, as soon as you're happy with the soft tissues, early active motion, no resisted extension, no weight bearing on this and no HO prophylaxis. Thanks.

fracture treatment

decision-making

electro-osteotomy

preoperative planning

surgical technique