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

Preoperative Patient Care

A

Basic Preoperative 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
  • light activities of daily living allowed
  • postop: 4-6 week postoperative visit
  • check radiograph
  • increase weightbearing
  • 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
  • stiffness
  • wound breakdown
  • arthritis
  • heterotopic ossification
  • symptomatic hardware
  • nonunion
  • AVN

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

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

3

Make arthrotomy anterior to the 50% line of the capitellum to avoid damage to the lateral collateral ligament

4

5

  • Make a longitudinal arthrotomy in line with the radial shaft
  • Visualize the radial head fracture
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

2

Reduce fragments with tenaculum

Pearls
  • Maintain as many soft tissue attachments as possible
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

O

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain control
  • antibiotics
  • wound management
  • outpatient physical therapy
  • immobilize in splint for 7-10 days
  • 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
 

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