A technique using an anterior midline incision with a medial parapatellar arthrotomy and a medial full-thickness skin flap for the open reduction and internal fixation of isolated medial tibial plateau fractures is presented. The approach is advocated as an alternative to a posteromedial approach when medial tibial plateau fractures are present alone. The anterior approach is simple and familiar for orthopaedic surgeons. It offers good visualization, simplifies reduction, and provides a functional scar if future procedures are necessary.

The defect of the femoral tunnel at the level of the physeal scar during transtibial and anteromedial portal (AMP) drilling for transphyseal anterior cruciate ligament reconstruction was compared. Five matched pairs of knees (n=10) were drilled, and computed tomography was used to evaluate tunnel position and size at the level of the physeal scar. Significant radiographic changes were observed, including tunnel defect area at the physeal scar: 0.44 cm (1.2%) in the transtibial group versus 0.99 cm (2.7%) in the AMP group (P=0.008). AMP drilling creates a larger and more lateral tunnel defect at the level of the physeal scar.

Elbow dislocations are frequently affiliated with a variety of fractures involving the ulna and radius. 2,4,5 To our knowledge, the literature contains no record of adult elbow dislocation occurring in association with a fracture of the distal humerus. We report a case of a right elbow dislocation in an adult associated with an open fracture in the distal portion of the ipsilateral humerus. Case reportA 43-year-old male arrived in the emergency department after falling from a height of 20 ft onto a concrete surface. Identified injuries included: a right elbow dislocation associated with an open supracondylar/intercondylar humerus fracture ( Fig. 1), an acetabular fracture, and fractures of both right and left distal radii. No other injuries were diagnosed. The patient was taken to the operating room for irrigation, debridement, and fracture stabilization.The patient was placed in the supine position and general endotracheal anesthesia was administered. A standard posterior incision was made through the skin, down to the level of the fascia, starting over the proximal one-half of the ulna and extending to the mid portion of the humerus. A standard olecranon chevron osteotomy was performed and the humerus exposed.The distal humerus fragment was displaced medially. The ulnar nerve was maintained in the cubital tunnel, in a normal position with respect to the medial epicondyle. All elbow ligaments were clearly disrupted. Inspection of the joint revealed an intercondylar split in the humeral trochlea. The fracture hematoma was evacuated and debris was removed from the laceration. Devitalized tissue including ragged edges was sharply excised. The wound was irrigated with copious normal saline using a pulse lavage system. The fracture was repaired using interfragmentary screws and a buttress plate fixation. The ulnar nerve was transposed to avoid later irritation of the nerve by the plates. Following reattachment of the olecranon osteotomy the elbow joint was reassessed. As expected, it was unstable to valgus stress, but remained stable through an arc of flexion and extension. The surgical and traumatic wounds were reapproximated, sterile dressing applied, and the patient placed in a posterior splint.

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