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 4 Provides postoperative management and rehabilitation postop: 2-3 week postoperative visit wound check remove sutures check radiograph postop: 4-6 week postoperative visit check radiograph start passive stretching initiate strengthening exercises on week 8 postop: 1 year postoperative visit 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 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 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 heterotopic ossification symptomatic hardware nonunion PIN injury prosthetic loosening instability
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
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids pain control elevate for 24 hours antibiotics continue antibiotics for 24 hours postoperatively advance diet as tolerated inpatient pt non weightbearing postoperative radiographs order biplanar radiographs of theelbow DVT prophylaxis wound management 2 Discharges patient appropriately pain meds wound care schedule follow up in 2 weeks outpatient physical therapy initiate active range of motion on post op day 1 when the LCLs were spared place in a collar and cuff with the elbow maintained at 90 degrees in between exercises use a static progressive extension splint for nighttime use for 12 weeks nonweightbearing active range of motion allowed when tolerated 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