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Preoperative Patient Care
Operative Techniques

Preoperative Plan


Template fracture

  • identify fracture pattern, displacement, comminution, and presence of dislocation
  • true lateral radiograph needed to determine fracture pattern
  • simple transverse fractures can be treated with tension band construct
  • oblique and comminuted fractures require plate and screw systems for fixation


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

Room Preparation


Surgical instrumentation

  • tension band
  • K-wires (1.6 or 2.0 mm)
  • 1.0mm (18 gauge) sternal wire
  • 14 gauge angiocath


Room setup and equipment

  • turn table 90°
  • c-arm perpendicular to OR table


Patient positioning

  • supine
  • shoulder at edge of bed, no arm board, arm draped over chest at 90° on top of large bump (chest to chin)
  • lateral
  • beanbag to support patient
  • arm over radiolucent foam or blankets, on radiolucent hand table
  • place tourniquet

Posterior Approach to the Elbow


Identify anatomy

  • exsanguinate limb and inflate tourniquet if using tourniquet
  • identify ulnar nerve, tip of olecranon, ulna shaft, medial and lateral sides of elbow for orientation


Expose the elbow

  • use scalpel dissection along subcutaneous border of ulna, centered about fracture site
  • incision is along proximal ulna shaft, slightly wraps lateral to tip of olecranon, then extending proximally in line with the humeral shaft
  • avoid midline incision over olecranon tip due to skin irritation
  • extend the incision proximally, curving laterally around tip of olecranon
  • attention to hemostasis is paid with electrocautery
  • create full thickness flaps to minimize dead space/hematoma
  • place self retaining retractors proximally and distally

Fracture Reduction and Preparation


Clear fracture site

  • remove hematoma and soft tissue from the fracture site.
  • elevate 2-3 mm of periosteum from the fracture edges to ensure visualization


Reduce fracture

  • drill unicortical hole with1.6mm k-wire 2-3 cm distal to fracture
  • place one tine of point reduction clamp in drill hole so it doesn't slip, then place other tine on proximal fragment
  • reduce fracture as elbow is brought into extension
  • tighten and lock down clamps once reduced
  • add additional clamp(s) or K-wires as needed
  • do not block k-wire entry points or plate placement

Place Proximal K-Wires


Place first Kwire

  • aim 1st K-wire (1.6-2.0mm) perpendicular across fracture, inferior to superior just below articular surface


Check placement on biplanar radiographs

  • if placement of 1st kwire is appropriate, place 2nd K-wire parallel ~ 1-1.5cm apart


Drill unicortical hole with1.6mm k-wire 2-3 cm distal to fracture

  • again check placement on biplanar radiographs
  • want K-wires to just pierce anterior cortex but not endanger AIN, pull wires back ~1cm from anterior cortex


Identify the ulnar drill hole

  • move to distal ulna and measure out ~40mm distal to fracture and 5mm superior for ulna drill hole

Place Ulnar Drill Hole and Advance Wires


Drill unicortical holes

  • mark out separate drill holes on either side of ulna and use 2.0mm drill with sleeve to drill unicortical holes
  • use pointed reduction clamp on either side to join holes and toggle back and forth to enlarge opening for wire


Pass wire

  • take 18 gauge cardiac wire and pass through ulna drill hole
  • easier if cardiac/sternal wire needle still attached


Add 2nd 18 gauge wire

  • cross wire from ulna hole and add 2nd 18 gauge wire under triceps fascia through 14 gauge angiocath under K-wires
  • no catheter needed if you keep the cardiac/sternal wire needle still attached


Form figure of 8 with wires ending in twists on either side


Tension Band Reduction and Fixation


Manipulate proximal wires

  • move back to kwires and use pliers at base
  • use fraiser tip suction to bend kwires
  • cut with 1.5-2cm exposed out of olecranon
  • oblique fractures can be initially secured with 2.4, 2.7, or 3.5mm lag screw(s)
  • bend K-wire tips around 180° using pliers


Bury proximal wires

  • rotate tips of K-wires so that they hook proximally
  • use bone tamp with mallet to sink into bone
  • if K-wires overpenetrate, they can block rotation or injure AIN


Tension wires

  • place 2 wire manipulators or heavy needle drivers over one set of paired wires
  • place needle drivers locked on other site of wires
  • pull slack out of wires
  • tightly pull in opposite directions
  • pull up and out at 45°
  • start to form twist slowly and evenly for 5-6 tight twists in wire
  • repeat process for 2nd pair of wires


Bury wires

  • cut wire twists
  • use bone tamp and mallet to sink down on either side of ulna and distally away from fracture site to avoid irritation


Obtain final biplanar and oblique radiographs


Wound Closure


Irrigation and hemostasis

  • irrigate wounds thoroughly
  • deflate tourniquet (if elevated)
  • coagulate any bleeders carefully


Deep Closure

  • use 0-vicryl for deep closure
  • make sure hardware is well covered with soft tissue


Superficial Closure

  • use 3-0 vicryl for subcutaneous closure
  • close skin with 3-0 nylon


Dressing and immediate immobilization

  • soft dressing (gauze, webril)
  • long arm posterior splint optional
  • splint at 70-80° flexion for immobilization
  • sling for comfort
  • can consider post-op indomethacin to reduce heterotopic ossification
Postoperative Patient Care
Private Note

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