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15 Jul 2025
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Open Posteromedial Distal Humerus Fracture with Transverse Acetabular Fracture

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Clinical Details

Clinical and radiological findings:  A 26-year-old male sustained injuries from a motor vehicle rollover while evading law enforcement. The patient presented with a 1 cm open fracture on the posteromedial aspect of the distal humerus, classified as AO/OTA 13-A2. The patient also sustained a transverse acetabular fracture. No major injuries were noted aside from significant road rash. The patient was hemodynamically stable with no vascular or neurological deficits. Initial radiographs and traction views revealed no central comminution, coronal plane fractures, trochlear impaction, or skid zone involvement.

Preoperative Plan

Planning remarks:  The preoperative plan involved utilizing a triceps-on approach to manage the distal humerus fracture, avoiding an olecranon osteotomy if possible. The absence of central comminution and impaction, along with the radial exit of the articular fracture, suggested that a triceps-on strategy might be feasible. However, an olecranon osteotomy was considered as a contingency if adequate reduction could not be achieved.

Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table with the affected arm supported on a radiolucent arm table to allow for optimal access and imaging.

Anatomical surgical approach:  A posterior approach to the distal humerus was initially attempted using a triceps-on technique. Due to difficulties in achieving satisfactory reduction of the metaphyseal and articular components, an olecranon osteotomy was performed. This allowed for improved visualization and manipulation of the fracture fragments. The ulnar nerve was identified and protected throughout the procedure.

Operative remarks: 

Despite initial optimism for a triceps-on approach, challenges in maintaining reduction due to an unstable metaphyseal pattern necessitated conversion to an olecranon osteotomy. The bulky triceps muscle and repeated loss of reduction influenced this decision. Parallel plating was employed to stabilize the fracture, which was effective given the fracture pattern. Concerns regarding potential medial ulnar collateral ligament (MUCL) injury were unfounded upon intraoperative assessment.

Postoperative protocol:   The postoperative rehabilitation protocol included early active and passive range of motion exercises to promote joint mobility and prevent stiffness.

Follow up:   Not specified.

Orthopaedic implants used:   Parallel plates for fracture stabilization.

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