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Olecranon Fracture ORIF with Tension Band

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

 

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