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Adult Humeral Inter-condylar Fractures: Preparation and Positioning

- Discussion:
    - anesthesia: insist on general anesthesia rather than regional anesthesia for the following reasons:
          - it is essential that the patient not move during delicate portions of the case;
          - it is often helpful to paralyze the patient during the fracture reduction;
          - it may be difficult to block T1 and T2, which innervates the skin of the upper arm;
          - it is difficult to intubate the patient in the lateral position (if the regional block fails);
          - it is essential that the patient be examined at the end of the case for possible neurologic injury;
    - foley catheter may be required since these cases often last several hours;
    - prep out for iliac-crest bone graft harvest;
    - position:
          - pt is placed in lateral decubitus position w/ involved limb supported on soft bolsters, with elbow positioned in approx 90 degrees of 
          - an axillary roll and padding underneath peroneal nerve are mandatory;
          - the opposite arm is placed on a well padded arm board (padding underneath the cubital tunnel) which is placed at right angles to the 
                 OR table (which allows one surgeon to stand above the armboard and one surgeon to stand below it);
                 - as an alteranative, many surgeons use a prone position;
          - the hand needs to be prepped so that the radial/ulnar pulses can be felt during the case;
          - plan to prep all the way to the shoulder using sterile split sheets;
   - equipment:
          - sterile tourniquet should be available;
          - it is also helpful to have one Mayo stand at the side for instruments and a sterile surgical basin on a stand which is positioned just 
                 below the the level of the patient's hand;
          - small fragment set (3.5 mm DCP or LCDCP), 3.5 mm pelvic reconstruction set, bone holding clamps, plate bending press, and a nerve stimulator

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