Patient prepped in standard sterile fashion. 3 surgical staples
removed, underlying bone evaluated and found to be viable, flushed
and 2 skin defects from laceration of skin by middle fragment
closed with 4-0 PDS in simple continuous pattern. #15 blade used
to made new 2 cm linear incision over proximal fragment and middle
fragment. Blunt dissection used to reach proximal and middle
fragments. Bone appears viable but middle fragment has longitudinal
fissure lines. It appears viable with muscular/vascular attachments
caudo dorsally. A .062 mm IM pin was driven from proximal fragment
proximally through shoulder. This was then driven through middle
fragment and into distal fragment. Placement of IM pin confirmed
via C-arm. Rechecked via c-arm after driving pin a few more mm.
The medial fragment was displaced somewhat caudo-dorsally however
attempts to reduce this led to worsening of fissures visible
along length of middle fragment, so this effort was discontinued.
Two .045 mm pins were placed in the humerus--one in proximal
fragment and one in the distal. Middle fragment was not given
pin due to risk of catastrophic failure of this fragment. While
alignment not considered ideal, pins and cross pins all felt
stable. Flushed fracture with sterile saline. Closed skin incision
with 4-0 PDS in simple continuous pattern. Placed ESF fixator
bar via a penrose drain filled with epoxy. Bandaged fixator post-operatively.
Due to presence of a proximal clavicular fracture, also placed
body wrap. 
Patient considered high risk for osteomyelitis/delayed healing.
Recommend considering at least three weeks before beginning to
de stabilize implants due to poor alignment of middle fragment.

Patient induced 5% iso maintained 2%. VD, H view and right lateral views obtained. There is an open, segmented mid-diaphyseal fracture of the right humerus with minimal comminution. Right proximal clavicular fracture