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Radial Neck Fracture ORIF

Planning

B

Preoperative Plan

1

Evaluate for any associated injuries on AP, oblique and lateral views of the elbow

  • check for medial epicondyle fracture, coronoid fracture or concomitant elbow dislocation

2

Examine the elbow under anesthesia

  • pronate and supinate the forearm under fluoroscopy to determine the maximum plane of angulation and assess range of motion
  • assess for joint instability and functional loss of forearm rotation

3

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • K-wires
  • Flexible nail set

2

Room setup and equipment

  • setup OR with standard operating table and arm board/hand table
  • turn table 90°
  • c-arm in from foot of bed
  • monitor in surgeon direct line of site on opposite side of OR table

3

Patient positioning

  • supine with shoulder at edge of bed
  • arm board centered at level of patient’s shoulder
  • can add arm tourniquet placed high on upper arm with webril underneath
  • check AP/Lat radiographs prior to draping

Technique

D

Attempt closed reduction

1

Patterson technique

  • One person places hand medially against the distal humerus and one hand anteriorly on mid humerus to provide counter traction (proximally and medially)
  • Second person (surgeon) supinates forearm, applies traction distally and pulls the forearm into varus
  • Surgeon then directly applies pressure with thumb over the radial head to reduce the fracture

2

Israeli technique

  • Flex elbow to 90 degrees
  • Start with forearm supinated
  • Thumb applies pressure to radial head to stabilize in position
  • Forearm is rotated into full pronation to align the shaft and radial neck

3

An esmarch elastic bandage can also aid in reduction when wrapped from distal to proximal

E

Evaluate closed reduction

1

Confirm that radial head and capitellum are in alignment in all planes (multiple views on C-arm)

2

Evaluate forearm rotation and confirm that there is full pronation and supination

3

If adequate reduction is obtained the arm is placed in a long arm cast

F

Reduction with percutaneous pin

1

Forearm is positioned so that radial head is laterally displaced (usually in supination)

2

K-wire is inserted and slid along the posterior aspect of the ulna (to avoid PIN injury)

  • aim from proximal to distal with entry point around 1/3 of the way down the forearm
  • generally a 2.0 or larger K-wire is used and the blunt end may be used if it is falling into the fragment rather than disimpacting)

3

K-wire is inserted into the fracture site (approximately halfway across)

  • it is then used to lever the proximal epiphyseal fragment into position
  • a varus stress can be applied at this time to help aid reduction
  • once the fragment is positioned medially (reduced) there is usually stability of the fracture and placing a patient in a long arm cast is adequate (k-wire or other fixation is rarely needed)
G

Metaizeau technique

1

1cm incision is made over the distal radial metaphysics (on the radial aspect)

  • spread inline with incision and protect radial sensory nerve

2

Use an awl or drill to create an oblique cortical window just proximal to the physis

3

Insert a contoured flexible intramedullary nail and advance proximally

  • continue advancing until it crosses the fracture and engages the proximal fragment

4

Rotate the flexible intramedullary nail to move the radial head into position

  • then the nail can be advanced slightly to stabilize the reduction
H

Open reduction

1

Pronates forearm to protect PIN

2

Makes an oblique posterolateral incision (Kocher)

3

incise and develops the interval between anconeus and extensor carpi ulnaris

4

Identify joint capsule and incises this performing an arthrotomy

  • avoid excessive periosteal stripping

5

reduce fracture

  • correct translation and angulation
  • evaluate if radiocapitellar joint is reduced

6

Internal fixation to stabilize fracture

  • if an intramedullary nail was previously advanced up the radial shaft for Metaizeau technique then this can be advanced to stabilize the reduction
  • alternatively 2 K-wires can be placed advancing from the radial head starting just distal to the articular surface and advancing distally into the radial neck/shaft (either parallel or divergent pin configuration)
  • many surgeons prefer to cut and bury these wires and return to OR at a later time for removal
  • rarely, in older adolescents with comminuted fractures plate and screw fixation may be indicated and care should be taken to place these in the "safe zone" (posterolateral portion- approx 90 degree zone that lies between a longitudinal line along the radial styloid and one along listers tubercle)

7

Superficial closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl for skin

8

Places long arm cast

  • long-arm cast with immobilization at 90°
  • sling for comfort

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • injury mechanism
  • neurovascular exam: Radial/ulnar and median nerve function; PIN assessment; radial and ulnar pulses

2

Order basic imaging studies

  • AP,lateral and oblique elbow radiographs

3

Prescribe nonoperative treatments

  • acceptable reduction is less than 30 degrees of angulation and less than 3 mm of translation

4

Perform operative consent

  • describe complications of surgery including
  • loss of forearm pronation and supination
  • PIN nerve injury
  • loss of joint congruity
  • radial head overgrowth
  • avascular necrosis of the radial head
  • radial neck malunion/radiocapitellar stability
  • post traumatic radioulnar synostosis
  • heterotopic ossification
L

Perioperative Inpatient Management

1

Discharge patient appropriately

  • pain meds
  • cast care
  • non weightbearing
  • manage swelling
  • monitor neurological and vascular status
  • schedule follow up in 1 week, follow closely with serial radiographs
M

Intermediate Evaluation and Management

1

Provides post-operative management and rehabilitation

  • Followup in 1 week; follow closely with serial radiographs
  • 3 week postoperative visit:
  • wound check
  • remove cast
  • if healing is adequate keep the cast off
  • if healing is not adequate, place cast for another 2 weeks
  • check radiographs
  • remove the cast when evaluating xrays
  • diagnose and management of early complications
  • start range of motion exercises
  • postop: 4-6 week postoperative visit
  • continue range of motion exercises to wrist, hand, and elbow
  • return to activity at ~8 wks
 

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