A 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 indications 4 Provides postoperative management and rehabilitation postop: 2-3 week postoperative visit <br> wound check remove sutures check radiograph postop: 4-6 week postoperative visit check radiograph start active extension postop: 1 year postoperative visit permanent weight restrictions of 10 lbs of lifting at once permanent weight restrictions of 5lbs on repetitive lifting 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 Obtain history and 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 Order basic imaging studies order biplanar radiographs of the elbow 3 Perform operative consent describe complications of surgery including deep infection wound breakdown loosening instability periprosthetic fractures triceps insufficiency ulnar neuropathy
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 unlinked total elbow arthroplasty set 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 Superficial Posterior Approach to the Elbow 1 Exsanguinate the extremity 2 Mark and start the incision make a straight posterior incision just off the tip of the olecranon incision should extend 9 cm proximal and 8 cm distal to the tip of the olecranon create subcutaneous flaps 3 Identify the ulnar nerve palpate the ulnar nerve and fully dissect it out is helpful to pass tape or penrose for identification at all times create a subcutaneous pocket for the ulnar nerve excise 1 cm of the distal intermuscular septum this is to prevent constriction of the nerve H Deep Dissection and Elbow Dislocation 1 Elevate the triceps lift the triceps directly from the humerus and the intermuscular septum elevate the medial aspect of the triceps off of the posterior humerus all the way down to the tip of the olecranon 2 Incise fascia between FCU and anconeus incise the superficial fascia between the anconeus and the FCU from the posteromedial border of the ulna distally 3 Perform medial and lateral release perform lateral release elevate this with the triceps Divide or dissect the anconeus on its lateral side expose the radiocapitellar joint laterally release the lateral and medial collateral ligaments from the origins of the humeral condyles Release medial collateral ligaments release medial collateral ligaments 4 Dislocate Elbow externally rotate the shoulder and flex the elbow separate the ulna from the humerus I Resect Bone and Broach Humerus and Ulna 1 Resect and broach humeral side remove the central portion of the trochlea identify the roof of the olecranon enter intrmadullary canal create a window in the olecranon fossa expose the intramedullary canal of the humerus use the cutting jig of the specific implant system to guide the resection of the distal humerus ensure the anatomic fit of the component between the humeral condyles 2 Resect and broach Ulnar side enter the intramedullary canal of the ulnar side use a high speed burr at the base of the coronoid enlarge the canal to allow passage of the ulnar broach broaches must be passed parallel to the subcutaneous border of the ulna this ensures proper placement J Trial Implants 1 Place the implants 2 Perform a trial reduction check the range of motion of the joint full flexion and extension should be achieved 3 Test for bony impingement check olecranon impingement on the humerus posteriorly check the coronoid tip anteriorly remove any impingements with a rongeur 4 Assess implant placement assess alignment, stability and component tracking K Cement Implants 1 Place the cement introduce antibiotic impregnated cement into the intramedullary canal with a long flexible cement nozzle cement should have a relatively liquid consistency place methylene blue into the cement to identify the bone cement interface 2 Add cement restrictors in the humerus and ulna this improves canal pressurization 3 Place the final implants the humeral components axis of rotation is at the level of the medial and lateral epicondyles the ulnar components axis of rotation through the center of the greater sigmoid notch L Reattach Collateral Ligaments and Triceps 1 Repair collateral ligaments reattach the medial and lateral collateral ligaments to there origin on the humerus 2 Reattach the triceps pass No. 5 nonabsorbable suture in cruciate tunnels through the triceps suture should be passed in a Bunnell fashion pass suture through an additional horizontal tunnel this allows the suture to cinch down to the olecranon 3 Tie knots place elbow in 90 degrees of flexion tie knots to the side this is to prevent subcutaneous prominence N Wound Closure 1 Irrigation and hemostasis irrigate wounds thoroughly deflate tourniquet (if elevated) coagulate any bleeders carefully 2 Deep Closure repair the fascia of the FCU and anconeus to surrounding tissue with nonabsorbale suture transpose the ulnar nerve into the prepared pocket 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 volar splint in extension sling for comfort
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders pain control antibiotics DVT prophylaxis wound management inpatient pt non weightbearing advance diet as tolerated check appropriate labs 2 Discharges patient appropriately outpatient physical therapy remove splint in 24-48 hours nonweightbearing avoid active extension for six weeks gravity assisted and passive extension are permitted 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