Where to Start?
By Erik R. Dorf, MD
We have all been there. Comminuted distal humerus fractures are some of the most challenging fractures we tackle. This day was no different, and I had my hands full. A 27-year-old, healthy athletic female, crashed snowboarding on Vail Mountain. Comminuted intraarticular distal humerus fracture in her dominant right elbow. Her x-ray was terrible, and the CT scan made it look worse. Meeting her in the pre-op area did not make me feel any better. Part time yoga instructor, graduate student and sharp as a tack. I tried to present an optimistic but realistic picture of our expectations. Sometimes I think that I am doing this for myself, as much as for my patient.
I do these cases in the lateral position because they can be long and allowing my assistant to be hands free helps tremendously. I utilize a triceps sparing approach, and only do an osteotomy when I absolutely must, so that was the plan. Plans change. The osteotomy confirmed my concerns. I hate that feeling when pieces of articular cartilage with tiny bony attachments come pouring out of the wound. Where to start?
In these situations, I search for guidance from my mentors. In this moment my inspiration came from the late Dr. David Kahler from the University of Virginia. “Dorf” he would say, “when you are looking at a fracture, and you don’t know where to start, just start by fixing something.”
I picked the two largest fragments from the capitellum and assembled them on the back table. These went together with a fragment from the medial column. The next couple of fragments were more difficult, but I knew that I had them in the right place. Back to the elbow. One piece at a time. Be patient. Listen to my scrub tech. Listen to my PA. This is just a complicated 3D puzzle and everyone’s input is appreciated. Eventually, it looked like a joint. She would do great. The inspiration to take that first step came from Dr. Kahler. “Just start by fixing something.” Thank you Dr. Kahler.