A Basic Preoperative Outpatient Evaluation and Management 1 Focused history and physical check range of motion of the elbow document neurovascular status concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies radiographs of the elbow AP lateral oblique 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides postoperative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures check radiograph light activities of daily living allowed postop: 4-6 week postoperative visit check radiograph increase weightbearing postop: 1 year postoperative visit 5 Diagnose and early management of complications Dx from periop xrays recognize infection B Advanced Evaluation and Management 1 Order appropriate imaging studies radiographs CT scan/3D reconstruction 2 Provides post-op management and rehabilitation. increase ROM as healing progresses adequate/proper postop xrays C Preoperative H & P 1 Perform focused orthopedic physical exam age gender mechanism of injury deformity skin integrity open/closed injury check neurovascular status need to assess for associated injuries such as radial head and capitellum fractures 2 Splint fracture appropriately place in posterior splint 3 Order basic imaging studies order biplanar radiographs and/or CT scan of the elbow 4 Perform operative consent describe complications of surgery including stiffness wound breakdown arthritis heterotopic ossification symptomatic hardware nonunion AVN
E Preoperative Plan 1 Template fracture Identify fracture pattern, displacement, comminution, and presence of dislocation 2 Execute surgical walkthrough Describe key steps of the operation verbally to attending prior to beginning of case. Description of potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Screws, headless screws and plating system 2 Room setup and equipment C-arm perpendicular to OR table 3 Patient positioning Supine position place affected extremity over arm bolster arm should be in 90 degrees of flexion place bump under ipsilateral scapula place sterile tourniquet G Kocher Approach P 1 Mark anatomic landmarks Palpate and mark the radial head and the lateral epicondyle 2 Make 5cm posterolateral incision Make a 5 cm incision starting from the lateral epicondyle extending approximately 30 -45 degrees posterior to the long axis of the forearm 3 Identify the Kocher interval Interval between the anconeus and the ECU The anconeus can be identified posteriorly, the muscle and tendon can be appreciated Blunt dissection with a Weitlaner is used to develop the interval Visualize the ligamentous complex and joint capsule The lateral collateral ligament is a capsular thickening running in line with the interval Pronate the arm to move the PIN nerve distally Pearls Interval can be identified by fat stripe. If fat stripe not visualized, them make facial incision in line with the skin incision H Deep Dissection P P 1 Expose radiocapitellar joint Elevate the anconeus and ECU to expose the capsule reflect the anconeus posteriorly and the ECU anteriorly 2 Make arthrotomy Make a longitudinal arthrotomy in line with the radial shaft Pearls Blunt disection can be taken through the proximal portion of the supinator The annular ligament can be divided and repaired later Pitfalls Make arthrotomy anterior to the 50% line of the capitellum to avoid damage to the lateral collateral ligament I Prepare and Inspect Fracture 1 Prepare the fracture Irrigate the wound and remove loose bodies 2 Inspect the fracture for degree of comminution Rotate the forearm to get a full circumferential view of the fracture if more than three pieces of comminution present then proceed to radial head replacement J Reduce Fracture P 1 Elevate joint impaction Fill any voids with localized cancellous graft Pearls Maintain as many soft tissue attachments as possible 2 Reduce fragments with tenaculum K Provisional Fixation 1 Place small Kwires Place 0.045 inch Kwires out of the zone where definitive fixation is planned L Final Fixation P 1 Obtain definitive fixation Place T Miniplate Obtain provisional plate placement secure with either kwires or a screw Confirm placement Place remaining screws Non-locking screws can be used to reduce the plate to the bone and then replaced with locking screws Range elbow to ensure no mechanical block or instability Confirm appropriate screw length by rotation the forearm under live flouroscopy Pearls Confirm plate is in the "safe zone" which is a 90 deg arc directly lateral with the forearm in neutral rotation N Wound Closure 1 Irrigation and hemostasis Irrigate wounds thoroughly Deflate tourniquet (if elevated) Coagulate any bleeders carefully 2 Deep Closure Use 0-vicryl for deep closure Repair the annular ligament if violated 3 Superficial Closure Use 3-0 vicryl for subcutaneous closure Close skin with 3-0 nylon 4 Dressing and immediate immobilization Soft dressing (gauze, webril) Place in splint at 90 degrees of flexion and pronation Sling for comfort
O Perioperative Inpatient Management 1 Discharges patient appropriately pain control antibiotics wound management outpatient physical therapy immobilize in splint for 7-10 days nonweightbearing active range of motion allowed when tolerated ice, elevation and compression R Complex Patient Care 1 Comprehensive pre-op planning/alternatives use of external fixation radial head replacement elbow arthroplasty 2 Modify and adjust post-op plan as needed dynamic/static stretch splinting revise therapy 3 Understands how to avoid/prevent potential complications 4 Treat simple complications both intraoperatively and postoperatively. revise hardware placement recognize improper hardware position