Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table with the arm placed across the chest on a padded support to allow for optimal access to the posterior aspect of the elbow.

Anatomical surgical approach:  A posterior approach was utilized, taking advantage of the existing olecranon fracture to access the distal humerus. The fracture allowed direct entry to the joint, facilitating visualization and manipulation of the articular fragments. Reconstruction focused on anatomically reducing the comminuted capitellum, split trochlea, and restoring column integrity, while assessing the feasibility of stable fixation throughout the procedure.

Intraoperatively, achieving stable fixation was challenging due to limited bone stock and multiple small fragments. The decision was made to proceed with limited open reduction and internal fixation (ORIF) of the medial and lateral columns and olecranon. The capitellum was deemed non-viable for fixation and excised. A cement spacer was considered for temporary stabilization, with plans for delayed conversion to TEA if necessary.

Postoperative protocol:   Postoperatively, the patient was immobilized in a posterior splint with the elbow in 90 degrees of flexion for two weeks. Early passive range of motion exercises were initiated at two weeks post-surgery, progressing to active-assisted exercises by six weeks, contingent on radiographic evidence of healing.

Follow up:   Not specified.

Orthopaedic implants used:   Dual plating system for medial and lateral column fixation, olecranon plate, potential use of a cement spacer.