Surgical Discussion

Patient positioning:  The patient was positioned supine with the arm placed on a radiolucent arm table to allow for optimal access to the humeral shaft and facilitate intraoperative imaging.

Anatomical surgical approach:  A posterior approach to the humerus was utilized, involving an incision along the posterior aspect of the arm. The triceps muscle was split longitudinally to expose the humeral shaft. Care was taken to identify and protect the brachial artery and intact neurovascular structures.

Intraoperatively, it was noted that the radial nerve was missing over 2 cm of its length, precluding immediate repair. Calcium phosphate beads impregnated with vancomycin and tobramycin were placed in the defect to manage infection risk and provide temporary structural support. These beads are expected to resorb in approximately six weeks, at which point autograft RIA will be performed for bone grafting. Elective nerve reconstruction is planned at the time of bone grafting due to the concussive effect on the nerve.

Postoperative protocol:   Postoperatively, the patient will be immobilized in a functional brace with elbow flexion to reduce tension on the radial nerve region. Passive range of motion exercises will commence at two weeks post-surgery, with active range of motion exercises introduced at six weeks post-surgery following bone grafting.

Follow up:   Not specified.

Orthopaedic implants used:   Narrow 4.5 mm Synthes posterolateral plate, 3.5 mm Synthes long medial plate, calcium phosphate beads impregnated with vancomycin and tobramycin.