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Elbow Terrible Triad ORIF

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
 

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