# Need help tackling complicated distal humerus fracture!!



## Ccgerson (Mar 18, 2016)

Preoperative Diagnosis: Left arm grade 2 open comminuted distal humerus fracture
Postoperative Diagnosis: Left arm, grade 2 open comminuted and intra-articular distal humerus fracture

PROCEDURE: 
Operation performed: Exploration of wound with irrigation and debridement; open reduction and internal fixation of fracture utilizing multiple plates and screws.

Utilizing fluoroscopic guidance I evaluated the fracture and felt we had an intra-articular comminuted fracture of the supracondylar region of the left distal humerus. At this point the patient was carefully placed into a lateral decubitus position with right side down. The left upper extremity was then prepped and draped in usual sterile fashion. A posterior approach was utilized and dissection begun distal to the tip of the olecranon extending proximally. Dissection was taken down to the extensor mechanism of the elbow. I initially made by deep dissection laterally on the lateral edge of the triceps. I entered the fracture site. There was a severely comminuted fracture with multiple fragments. There appeared to be an intra-articular component with 3 fairly large and what appeared to be fixable fragments on the distal side of the fracture and then the shaft component. At this point I carefully identified the ulnar nerve medially and freed it and transposed it anteriorly. Next we irrigated the wound with 3000 mL of bacitracin irrigation fluid. Upon further inspection I felt that this was fixable. At this point I proceeded to perform a olecranon osteotomy in the usual fashion. The tip of the olecranon and the distal triceps was then carefully right retracted and blunt subperiosteal dissection was done to expose the fractures proximally. At this point I went ahead and turned my attention to the intra-articular component. We reduced the capitellum and trochlea and then placed a cannulated screw guidepin across. Was felt to be in good position. Measurements were taken and we reamed the near cortex. The 4.0 cannulated screw was then placed to re-create the articular surface. He had stable fixation. Next I went ahead and turned my attention to the medial and lateral columns. As noted above the fracture was extremely comminuted and it took some time to reestablish the medial and lateral columns. The medial column unfortunately had the main fracture line separating the shaft from the medial, but also had a distal fracture separating the medial column from the medial epicondyle. At this point I carefully reduced the medial column and placed a direct medial plate on and secured it with a guidepin. I then placed 2 screws on the distal side utilizing 2.7 screws. Both had excellent purchase. On the proximal side and on the shaft side of the fracture went ahead and placed a whirlybird. Once I placed a whirlybird and cinched down the bone to the plate we had excellent reduction of the medial column. Next I went ahead and secured both the distal and proximal sides of the plate. Distally we utilized 2.7 locking screws and proximally a utilized 3.5 cortical screws. After this was done I turned my attention to the lateral column. We had previously placed a posterior lateral plate on the condylar distal fragment. It had excellent purchase. We then reduced the shaft to the lateral column and the plate and held it with a whirlybird. Fluoroscopic views demonstrated excellent alignment of fracture could place and the hardware. At this point I placed multiple 3.5 fully threaded cortical screws on the shaft side of the fracture and multiple 2.7 locking screws on the distal side of the fracture. Once this was done I felt we had excellent purchase of all the fracture fragments and I brought the elbow through range of motion and it appeared stable. At this point we irrigated with copious amounts of irrigation fluid with bacitracin. I then went ahead and placed some bone graft which I retrieved while fixing the fractures and placed it in the void and filled it nicely. Again further irrigation and debridement was done with bacitracin. At this point I went ahead and repaired my olecranon osteotomy with a 4.5 partially threaded cannulated screw and an 18-gauge cerclage wire. We had excellent purchase and stability on the osteotomy. At this point I went ahead and irrigated again and then closed the rent on both sides of the triceps with 0 Vicryl. I completed my anterior transposition of the ulnar nerve. Next I irrigated again with about irrigation fluid. We reinforced our soft tissue repair at the level of the osteotomy with 0 Vicryl. Subcutaneous tissues approximate deep layer of 0 Vicryl superficial layer 2-0 Vicryl in simple trip. Sutures. Skin was approximated with Xeroform. The small wound posterior laterally was irrigated and the edges were freshened. I then loosely approximated the edges


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## jjhamer1 (Mar 21, 2016)

Definitely complicated...this is my take on the procedure:

24545-LT - Dx: S42422B

In 24545, the physician performs open treatment of a supracondylar or transcondylar humeral fracture that does not have an extending fracture line present between the condyles. In 24546, the humeral condylar fracture has an extending fracture line between the condyles that may create a third fracture piece. The physician makes a posterior incision from midline of the arm to just distal to the olecranon, exposing the olecranon, triceps tendon, and distal humerus. The ulnar nerve is isolated and retracted. Preserving as much soft tissue attachment as possible, the physician exposes and assembles the fragments, reducing the condyles and fixing the fragments with screws, pins, or plates as may be needed to hold the condyles firmly reduced to the metaphysis. The joint is irrigated and the wounds are closed with drain placement if needed.

24515 LT - Dx: S42352B

The physician repairs a humeral shaft fracture openly with a plate or screws, with or without cerclage. A lateral or anterolateral incision is made overlying the fracture site. The fracture is reduced by manipulation and bone reduction forceps. A compression plate with screws secures and compresses the fragments. Cerclage wiring might be used to facilitate fixation of the fracture. One or more wires may be placed around the humerus, over the fracture site. The incision is closed with sutures, staples, and/or Steri-strips.


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## AlanPechacek (Mar 24, 2016)

Based on the operative report description of the fracture, this was a comminuted supracondylar fracture with inter/intracondylar extension into the joint.  Fractures of this severity usually involve the joint and are very difficult to repair, and may require several different types of fixation (plates and screws, screws, pins, whatever it takes to hold things in place).  The fact that he used a plate and screws does not mean it extended up to the "shaft" level, but he had to get a hold of enough bone above the fracture to get good fixation.  Therefore, this fracture stays within the S42.4 code set.  Unfortunately, S42.42 _ _ for Comminuted Supracondyle Fracture of the Distal Humerus is *without intercondylar* extension into the joint.  There is not a code in this set that does have *with intercondylar *extension.  In other words, there is no code in this code set for this patient's fracture.  Since it is not one of the listed diagnosis codes for S42.4, then it has to be *other*, S42.492B.  *B* for open fracture of Gustilo Type 2 based on his Pre and Postop Diagnoses.  I don't know why there is no code for Comminuted Supracondylar Humerus Fracture *with* inter/intracondylar extension, but there isn't. 

I hope this helps.

Respectfully submitted, Alan Pechacek, M.D.


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