Specific consideration for the distal humerus are given below.
Note on illustrations
Throughout this section generic fracture patterns are illustrated as:
Reduced and provisionally stabilized
2. Patient preparation
This procedure is normally performed with the patient in a supine position.
3. Pin insertion (humerus/forearm)
For safe pin placement make use of the safe zones and be familiar with the anatomy of the humerus and the proximal forearm.
Soft tissue dissection
Blunt dissection of the soft tissues and the use of small Langenbeck retractors will prevent damage to muscular, vascular and neurological structures.
Prepare a channel for insertion of the pin, using a blunt clamp down to the bone. If there is any doubt an incision should be made big enough to prove that the drill sleeve (for the humerus a must) will have direct contact with the bone.
Be especially careful of the radial nerve, which spirals around the humeral shaft and, in the distal third, it intersects the lateral intermuscular septum.
4. Frame construction / reduction and fixation (distal humerus)
Pearl: non-bridging fixator
If the fracture is far enough from the joint and there is good bone quality, sometimes it is possible to apply the external fixator only to the humerus, leaving the elbow joint free.
5. Aftertreatment following external fixation
The arm is supported in a “collar-and-cuff” sling for comfort.
Proper pin insertion To prevent postoperative complications, pin-insertion technique is more important than any pin-care protocol:
Correct placement of pins (see safe zones) avoiding ligaments and tendons, eg tibia anterior
Correct insertion of pins (eg trajectory, depth) avoiding heat necrosis
Extending skin incisions to release soft-tissue tension around the pin insertion (see inspection and treatment of skin incisions)
Pin-site care Various aftercare protocols to prevent pin tract infection have been established by experts worldwide. Therefore no standard protocol for pin-site care can be stated here. Nevertheless, the following points are recommended:
The aftercare should follow the same protocol until removal of the external fixator.
The pin-insertion sites should be kept clean. Any crusts or exudates should be removed. The pins may be cleaned with saline and/or disinfectant solution/alcohol. The frequency of cleaning depends on the circumstances and varies from daily to weekly but should be done in moderation.
No ointments or antibiotic solutions are recommended for routine pin-site care.
Dressings are not usually necessary once wound drainage has ceased.
Pin-insertion sites need not be protected for showering or bathing with clean water.
The patient or the carer should learn and apply the cleaning routine.
Pin loosening or pin tract infection In case of pin loosening or pin tract infection, the following steps need to be taken:
Remove all involved pins and place new pins in a healthy location.
Debride the pin sites in the operating theater, using curettage and irrigation.
Take specimens for a microbiological study to guide appropriate antibiotic treatment if necessary.
Before changing to a definitive internal fixation an infected pin tract needs to heal. Otherwise infection will result.
In the rare event that external fixation has been used as the definitive management of a distal humeral fracture, there is a significant risk of marked stiffness of the elbow joint. A prolonged program of rehabilitation under the supervision of the surgeon and an experienced physical therapist will be necessary.
See patient 7-10 days after surgery for a wound check. X-rays are taken to check the reduction.