Preoperative Patient Care A Outpatient Evaluation and Management 1 Focused history and physical recognizes implications of soft tissue injury open fracture compartment syndrome ligamentous injury document neurovascular status concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies true lateral radiograph needed to determine fracture pattern CT scan with oblique or comminuted fracture pattern 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention indications fracture displacement elbow instability transolecranon injury 4 Provides postoperative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures remove splint and begin range of motion exercises place in removable brace postop: 4-6 week postoperative visit advance weight-bearing status in removable elbow brace advance rehabilitation postop: 1 year postoperative visit 5 Capable of diagnosis and early management of complications Dx from periop xrays recognize infection recognize fracture displacement/dislocation B Advanced Evaluation and Management 1 Able to 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 basic physical 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 Splints 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 hardware irritation (40-80% for tension band, 20% for plate and screws) wound breakdown elbow stiffness (~50%) AIN injury due to overpenetration of K-wires through anterior cortex post-traumatic arthritis Operative Techniques E Preoperative Plan 1 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 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 tension band K-wires (1.6 or 2.0 mm) 1.0mm (18 gauge) sternal wire 14 gauge angiocath 2 Room setup and equipment turn table 90° c-arm perpendicular to OR table 3 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 G Posterior Approach to the Elbow 1 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 2 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 H Fracture Reduction and Preparation 1 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 2 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 I Place Proximal K-Wires 1 Place first Kwire aim 1st K-wire (1.6-2.0mm) perpendicular across fracture, inferior to superior just below articular surface 2 Check placement on biplanar radiographs if placement of 1st kwire is appropriate, place 2nd K-wire parallel ~ 1-1.5cm apart 3 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 4 Identify the ulnar drill hole move to distal ulna and measure out ~40mm distal to fracture and 5mm superior for ulna drill hole J Place Ulnar Drill Hole and Advance Wires 1 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 2 Pass wire take 18 gauge cardiac wire and pass through ulna drill hole easier if cardiac/sternal wire needle still attached 3 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 4 Form figure of 8 with wires ending in twists on either side K Tension Band Reduction and Fixation 1 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 2 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 3 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 4 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 5 Obtain final biplanar and oblique radiographs L 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 make sure hardware is well covered with soft tissue 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) 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 O Perioperative Inpatient Management 1 Discharges patient appropriately wound care pain meds schedule follow up in 2 weeks outpatient physical therapy nonweightbearing ice, elevation and compression start range of motion no later than 7-10 days postop 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 5 Understands how to avoid/prevent potential complications
A Outpatient Evaluation and Management 1 Focused history and physical recognizes implications of soft tissue injury open fracture compartment syndrome ligamentous injury document neurovascular status concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies true lateral radiograph needed to determine fracture pattern CT scan with oblique or comminuted fracture pattern 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention indications fracture displacement elbow instability transolecranon injury 4 Provides postoperative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures remove splint and begin range of motion exercises place in removable brace postop: 4-6 week postoperative visit advance weight-bearing status in removable elbow brace advance rehabilitation postop: 1 year postoperative visit 5 Capable of diagnosis and early management of complications Dx from periop xrays recognize infection recognize fracture displacement/dislocation B Advanced Evaluation and Management 1 Able to 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 basic physical 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 Splints 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 hardware irritation (40-80% for tension band, 20% for plate and screws) wound breakdown elbow stiffness (~50%) AIN injury due to overpenetration of K-wires through anterior cortex post-traumatic arthritis
E Preoperative Plan 1 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 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 tension band K-wires (1.6 or 2.0 mm) 1.0mm (18 gauge) sternal wire 14 gauge angiocath 2 Room setup and equipment turn table 90° c-arm perpendicular to OR table 3 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 G Posterior Approach to the Elbow 1 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 2 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 H Fracture Reduction and Preparation 1 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 2 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 I Place Proximal K-Wires 1 Place first Kwire aim 1st K-wire (1.6-2.0mm) perpendicular across fracture, inferior to superior just below articular surface 2 Check placement on biplanar radiographs if placement of 1st kwire is appropriate, place 2nd K-wire parallel ~ 1-1.5cm apart 3 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 4 Identify the ulnar drill hole move to distal ulna and measure out ~40mm distal to fracture and 5mm superior for ulna drill hole J Place Ulnar Drill Hole and Advance Wires 1 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 2 Pass wire take 18 gauge cardiac wire and pass through ulna drill hole easier if cardiac/sternal wire needle still attached 3 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 4 Form figure of 8 with wires ending in twists on either side K Tension Band Reduction and Fixation 1 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 2 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 3 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 4 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 5 Obtain final biplanar and oblique radiographs L 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 make sure hardware is well covered with soft tissue 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) long arm posterior splint optional splint at 70-80° flexion for immobilization sling for comfort can consider post-op indomethacin to reduce heterotopic ossification
O Perioperative Inpatient Management 1 Discharges patient appropriately wound care pain meds schedule follow up in 2 weeks outpatient physical therapy nonweightbearing ice, elevation and compression start range of motion no later than 7-10 days postop 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 5 Understands how to avoid/prevent potential complications