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Radial Head Fracture ORIF

Planning

B

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
C

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

Technique

D

Kocher Approach

1

Mark anatomic landmarks

  • palpate the radial head and the lateral epicondyle

2

Make 5cm posterolateral incision

  • make an oblique 5 cm incision starting from the posterolateral aspect of the lateral epicondyle to a point that is three fingerbreadths below the olecranon
  • this incision should be inline with the radial neck
  • divide the fascia in line with the skin incision

3

Identify the Kocher interval

  • interval between the anconeus and the ECU
  • this is distally identified by penetrating veins
  • use blunt dissection to develop the interval
  • visualize the ligamentous complex and joint capsule
  • pronate the arm to move the PIN nerve distally
E

Deep Dissection

1

Expose radiocapitellar joint

  • elevate the anconeus and ECU
  • reflect the anconeus posteriorly and the ECU anteriorly

2

Make arthrotomy

  • visualize the radial head fracture
F

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
G

Reduce Fracture

1

Elevate joint impaction

  • fill any voids with localized cancellous graft

2

Reduce fragments with tenaculum

H

Provisional Fixation

1

Place small Kwires

  • place 0.062 inch Kwires out of the zone where definitive fixation is planned
I

Final Fixation

1

Obtain definitive fixation

  • options
  • one or two countersunk 2.0 or 2.7 mm AO cortical screws perpendicular to the fracture
  • mini plates
  • placed when the fracture extends to the neck
  • small headless screws
  • placed parallel to each other for isolated head fractures
  • polyglycolide pins
  • small threaded wires
J

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

3

Superficial Closure

  • use 3-0 vicryl for subcutaneous closure
  • place subcutaneous drain
  • 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

Patient Care

K

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
L

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
M

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
N

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
O

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
 

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