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

0%
TECHNIQUE VIDEO
0%
TECHNIQUE STEPS
 
0
0
TECHNIQUE STEPS
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
 

Please rate topic.

Average 4.0 of 1 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Topic COMMENTS (0)
Private Note