Radial Head Fx - Replacement

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Preoperative Patient Care
Operative Techniques
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

  • 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
G

Kocher Approach to the Elbow

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
H

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
I

Preparation of the Radial Head and Neck

1

Visualize the radial head

  • irrigate the wound and remove loose bodies

2

Excise the radial head and neck

  • remove the radial head and neck at a right angle to the medullary canal
  • this makes a smooth surface for seating of the radial head implant
  • ensure that complete excision has been performed with fluoroscopy

3

Evaluate the capitellum for chondral injuries or osteochondral injury

J

Size Radial Head Prosthesis

1

Template head size

  • reassemble the radial head
  • place radial head on sizing template
  • diameter of the prosthesis should be 2mm smaller than the outer diameter of the radial head that is excised
K

Trial and Place Implant

1

Place radial head implant

  • insert trial head onto the stem

2

Evaluate placement

  • check diameter, height, tracking and congruency of the prosthesis
  • the radial head prosthesis should articulate at the same height as the radial notch of the ulna
  • should also be 1 mm distal to the tip of the coronoid

3

Place Final Implant

4

Check Implant with Fluoroscopy

L

Evaluate Elbow Range of Motion and Stability

1

Check elbow flexion and extension

2

Check stability in various rotations of the elbolw

  • pronation
  • supination
  • neutral
N

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 anterior splint in extension
  • sling for comfort
Postoperative Patient Care
 

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