Radial Head Fracture (Mason Type 2) ORIF T-Plate and Kocher Approach

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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

P

1

Mark anatomic landmarks

  • Palpate and mark the radial head and the lateral epicondyle

2

Make 5cm posterolateral incision

  • Make a 5 cm incision starting from the lateral epicondyle extending approximately 30 -45 degrees posterior to the long axis of the forearm

3

Identify the Kocher interval

  • Interval between the anconeus and the ECU
  • The anconeus can be identified posteriorly, the muscle and tendon can be appreciated
  • Blunt dissection with a Weitlaner is used to develop the interval
  • Visualize the ligamentous complex and joint capsule
  • The lateral collateral ligament is a capsular thickening running in line with the interval
  • Pronate the arm to move the PIN nerve distally
Pearls
  • Interval can be identified by fat stripe.
  • If fat stripe not visualized, them make facial incision in line with the skin incision
H

Deep Dissection

P
P

1

Expose radiocapitellar joint

  • Elevate the anconeus and ECU to expose the capsule
  • reflect the anconeus posteriorly and the ECU anteriorly

2

Make arthrotomy

  • Make a longitudinal arthrotomy in line with the radial shaft
Pearls
  • Blunt disection can be taken through the proximal portion of the supinator
  • The annular ligament can be divided and repaired later
Pitfalls
  • Make arthrotomy anterior to the 50% line of the capitellum to avoid damage to the lateral collateral ligament
I

Prepare and Inspect Fracture

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
J

Reduce Fracture

P

1

Elevate joint impaction

  • Fill any voids with localized cancellous graft
Pearls
  • Maintain as many soft tissue attachments as possible

2

Reduce fragments with tenaculum

K

Provisional Fixation

1

Place small Kwires

  • Place 0.045 inch Kwires out of the zone where definitive fixation is planned
L

Final Fixation

P

1

Obtain definitive fixation

  • Place T Miniplate
  • Obtain provisional plate placement secure with either kwires or a screw
  • Confirm placement
  • Place remaining screws
  • Non-locking screws can be used to reduce the plate to the bone and then replaced with locking screws
  • Range elbow to ensure no mechanical block or instability
  • Confirm appropriate screw length by rotation the forearm under live flouroscopy
Pearls
  • Confirm plate is in the "safe zone" which is a 90 deg arc directly lateral with the forearm in neutral rotation
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
  • Repair the annular ligament if violated

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)
  • Place in splint at 90 degrees of flexion and pronation
  • Sling for comfort
Postoperative Patient Care
 

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