Cutting edge Orthopedics

18 • CUTTING EDGE - ORTHOPEDICS through the olecranon fossa, and it is thought to potentially improve stability by adding two addi- tional cortices to the fixation [8, 9]. After the first pin is successfully placed, the same steps are repeated for the second pin. The two pins should diverge across the fracture in both the AP and lateral planes. The pins should be as far from each other as possible as they traverse the fracture site [9, 19] (Fig. 15). Generally, two pins are placed for Type II fractures and three pins for Type III fractures [8, 9, 14, 19, 61]. However, in all cases, the fracture should be stressed under live fluoroscopy intraop- eratively with varus, valgus, flexion, extension, and rotary forces (Video 3) [9]. If any instability or excessive motion at the fracture site is noted, an additional lateral pin may be added. If there is not enough space for another lateral pin or medial column comminution is present, a medial pin may be placed. If a medial pin is needed, a small incision should be made over the medial epicondyle. Blunt dissection down to the bone is performed. With the elbow extended, the pin is placed into the cortex of the medial epicondyle under direct visualization. The pin is directed laterally across the fracture site in a slight posterior to anterior direction. The pin entry point is visualized during flexion and extension of the elbow to ensure that there is no tethering of the ulnar nerve. Once the fracture is stable to stress testing under fluoroscopy (Video 3) and pulses are verified to be intact, the pins are bent and cut outside the skin [8, 9]. The pins may be wrapped in Xeroform, an antimicrobial gauze, or fitted with pin caps (Fig. 16) which have been suggested to help prevent pin migration [8]. The limb is then splinted or casted in approximately 45°–80° of elbow flexion [8, 9, 19]. ively with varus, valgus, flexion, and rotary forces (Video 4.3) [ 9 ]. If lity or excessive motion at the fracture ed, an additional lateral pin may be added. If there is not enough space for another lateral pin or medial column comminution is present, a medial pin may be placed. If a medial pin is needed, a small incision hould be made over the medial epicondyle. Blunt dissection down to the bone is performed. With the elbow extended, the pin is placed into the cortex of the medial epicondyle under direct visualization. The pin is directed late all across the fracture site in a slight posterior to anterior direction. The pin entry point is visualized during flexion and extension of the elbow to ensure that there is no tethering of the ulnar nerv . Once the fracture is stable to stress testing under fluoroscopy (Video 4.3) and pulses are verified to be intact, the pins are bent and cut outside the skin [ 8 , 9 ]. The pins may be wrapped in Xeroform, an antimicrobial gauze, or fitted with pin caps (Fig. 4.16 ) which have been sug- gested to help prevent pin migration [ 8 ]. The limb is then splinted or casted in approximately 45°–80° of elbow flexion [ 8 , 9 , 19 ]. roper pin placement for two and three lateral- structs (Courtesy of Dan A. Zlotolow, MD) he forearm m may be er ially to aid ance of en no ant is urtesy ospital for iladelphia, S.A. Russo and J.M. Abzug Fig. 14: The forearm and upper arm may be taped together circumferentially to aid with maintenance of reduction when no skilled assistant is available (Courtesy of Shriners Hospital for Children, Philadelphia, PA).