Preoperative Patient Care 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 remove splint start range of motion exercises active and active assisted flexion-extension between 30 and 130 degrees and forearm rotation with the elbow at 90 degrees postop: 4-6 week postoperative visit check radiograph unrestricted range of motion unrestricted strengthening at 8 weeks 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 Perform focused orthopedic 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 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 elbow stiffness acceptable range is 30 to 130 degrees wound breakdown post traumatic arthritis heterotopic ossification symptomatic hardware nonunion 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 guidewires no. 2-0 braided nonabsorbable suture cannulated screws mini plates small headless screws polyglycolide pins small threaded pins 2 Room setup and equipment standard OR table and hand table c-arm perpendicular to OR table 3 Patient positioning supine position place bump under ipsilateral scapula place sterile tourniquet G Lateral Approach of the Elbow 1 Make incision along the lateral supracondylar ridge of the humerus curve the incision at the lateral epicondyle toward the radial head and neck 2 Create full thickness skin flaps place self retaining retractors H Deep Dissection 1 Expose the coronoid split the common extensor tendon in line with its fibers 2 Check the LCL and common extensor tendon its very common for the LCL to be avulsed from the humerus check to see if the common extensor origin is avulsed avulsed 2/3 of the time I ORIF of the Coronoid 1 Prepare fracture debride fracture site of all soft tissue to allow proper reduction 2 Pass guidewires pass wires from the surface of the proximal ulna and be sure that it passes through the fracture site back the guidewire until it is just buried in the proximal piece 3 Reduce fracture use dental pick to hold the reduce fragment 4 Pass guidewire across the fracture site pass a second guidewire 5 Replace the guidewires with cannulated screws be sure to tap the fragment before placing screws to prevent splitting of the fragment J ORIF of the Radial Head 1 Prepare the fracture irrigate the wound and remove loose bodies 2 Inspect the fracture for degree of comminution rotate the forearm to get a full circumferential view of the fracture if more than three pieces of comminution present then proceed to radial head replacement 3 Elevate joint impaction fill any voids with localized cancellous graft 4 Place small Kwires place 0.062 inch Kwires out of the zone where definitive fixation is planned 5 Choose option for definitive fixation one or two countersunk 2.0 or 2.7 mm AO cortical screws perpendicular to the fracture mini plates placed when the fracture extends to the neck small headless screws placed parallel to each other for isolated head fractures polyglycolide pins small threaded wires K LCL Complex Repair 1 Identify origin of the LCL on the distal humerus slightly posterior to the lateral condyle at the center of the arc of the capitellum 2 Repair the LCL complex use no.2 braided nonabsorbable suture for the repair 3 Drill bone tunnels 4 Pass sutures through the distal humerus pass sutures into the tunnels through the LCL repeat with 2-3 sutures 5 Tie sutures place the elbow in 90 degrees of flexion and pronation when tying sutures L Elbow Stability Assessment 1 Check elbow flexion and extension acceptable range of motion is 30 to 130 degrees 2 Check stability in various rotations of the elbow 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 splint at 90 degrees of flexion and pronation sling for comfort Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control wound management nonweightbearing foley out when ambulating check appropriate labs DVT porphylaxis inpatient consults to manage medical comorbities check radiographs in postop check reduction and placement of hardware 2 Discharges patient appropriately outpatient PT immobilize in splint for 7-10 days nonweightbearing active range of motion allowed when tolerated ice, elevation and compression pain meds schedule follow up in 2 weeks discharge post op day 1 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
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 remove splint start range of motion exercises active and active assisted flexion-extension between 30 and 130 degrees and forearm rotation with the elbow at 90 degrees postop: 4-6 week postoperative visit check radiograph unrestricted range of motion unrestricted strengthening at 8 weeks 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 Perform focused orthopedic 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 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 elbow stiffness acceptable range is 30 to 130 degrees wound breakdown post traumatic arthritis heterotopic ossification symptomatic hardware nonunion
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 guidewires no. 2-0 braided nonabsorbable suture cannulated screws mini plates small headless screws polyglycolide pins small threaded pins 2 Room setup and equipment standard OR table and hand table c-arm perpendicular to OR table 3 Patient positioning supine position place bump under ipsilateral scapula place sterile tourniquet G Lateral Approach of the Elbow 1 Make incision along the lateral supracondylar ridge of the humerus curve the incision at the lateral epicondyle toward the radial head and neck 2 Create full thickness skin flaps place self retaining retractors H Deep Dissection 1 Expose the coronoid split the common extensor tendon in line with its fibers 2 Check the LCL and common extensor tendon its very common for the LCL to be avulsed from the humerus check to see if the common extensor origin is avulsed avulsed 2/3 of the time I ORIF of the Coronoid 1 Prepare fracture debride fracture site of all soft tissue to allow proper reduction 2 Pass guidewires pass wires from the surface of the proximal ulna and be sure that it passes through the fracture site back the guidewire until it is just buried in the proximal piece 3 Reduce fracture use dental pick to hold the reduce fragment 4 Pass guidewire across the fracture site pass a second guidewire 5 Replace the guidewires with cannulated screws be sure to tap the fragment before placing screws to prevent splitting of the fragment J ORIF of the Radial Head 1 Prepare the fracture irrigate the wound and remove loose bodies 2 Inspect the fracture for degree of comminution rotate the forearm to get a full circumferential view of the fracture if more than three pieces of comminution present then proceed to radial head replacement 3 Elevate joint impaction fill any voids with localized cancellous graft 4 Place small Kwires place 0.062 inch Kwires out of the zone where definitive fixation is planned 5 Choose option for definitive fixation one or two countersunk 2.0 or 2.7 mm AO cortical screws perpendicular to the fracture mini plates placed when the fracture extends to the neck small headless screws placed parallel to each other for isolated head fractures polyglycolide pins small threaded wires K LCL Complex Repair 1 Identify origin of the LCL on the distal humerus slightly posterior to the lateral condyle at the center of the arc of the capitellum 2 Repair the LCL complex use no.2 braided nonabsorbable suture for the repair 3 Drill bone tunnels 4 Pass sutures through the distal humerus pass sutures into the tunnels through the LCL repeat with 2-3 sutures 5 Tie sutures place the elbow in 90 degrees of flexion and pronation when tying sutures L Elbow Stability Assessment 1 Check elbow flexion and extension acceptable range of motion is 30 to 130 degrees 2 Check stability in various rotations of the elbow 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 splint at 90 degrees of flexion and pronation sling for comfort
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control wound management nonweightbearing foley out when ambulating check appropriate labs DVT porphylaxis inpatient consults to manage medical comorbities check radiographs in postop check reduction and placement of hardware 2 Discharges patient appropriately outpatient PT immobilize in splint for 7-10 days nonweightbearing active range of motion allowed when tolerated ice, elevation and compression pain meds schedule follow up in 2 weeks discharge post op day 1 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