Preoperative Patient Care A Outpatient Evaluation and Management 1 Focused history and physical implications of soft tissue injury open fracture compartment syndrome ligamentous injury document neurovascular status concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies radiographs of the elbow AP lateral oblique traction films for preoperative planning CT scan with oblique or comminuted fracture pattern 3 Reduce fracture if necessary provisional fixation fluroscopic checks 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention indications fracture displacement 5 Provides postoperative management and rehabilitation postop: 10 day postoperative visit wound check remove sutures check radiograph postop: 4-6 week postoperative visit advance rehabilitation postop: 1 year postoperative visit 6 Diagnose and early management of complications Dx from periop xrays recognize infection recognize fracture displacement/dislocation B Advanced Evaluation and Management 1 Order appropriate imaging studies radiographs CT scan/3D reconstruction 2 Provides post-op management and rehabiliatation. 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 obtain biplanar radiographs and/or CT scan of the elbow 4 Perform operative consent describe complications of surgery including hardware irritation (40-80% for tension band, 20% for plate and screws) wound breakdown elbow stiffness (~50%) triceps avulsion post-traumatic arthritis 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 small fragment plates malleable recon plates or precontoured periarticular plates mini fragment plates Herbert screws Kwires sterile tourniquet reduction clamps 2 Room setup and equipment c-arm perpendicular to OR table 3 Patient positioning lateral decubitus position place affected extremity over arm bolster arm should be in 90 degrees of flexion pad all bony prominences place sterile tourniquet G Direct Posterior Approach to the Elbow 1 Mark and start the incision begin 5cm proximal to the olecranon in the midline of the posterior distal humerus curve laterally proximal to the tip of the of the olecranon along the lateral aspect of the olecranon process then curve medially over the middle of the posterior aspect of the subcutaneous ulna 2 Identify the ulnar nerve palpate the ulnar nerve and fully dissect it out is helpful to pass tape or penrose for identification at all times 3 Incise fascia incise deep posterior fascia in the midline can either split triceps fascia, or continue with olecranon osteotomy create full thickness flaps to minimize dead space/hematoma H Triceps Sparing Approach 1 Elevate the triceps lift the triceps directly from the humerus and the intermuscular septum retract the olecranon fragment proximally 2 Identify radial nerve identify the sensory branch of the radial nerve laterally follow the nerve proximally to identify the radial nerve proper 3 Divide or dissect the anconeus on its lateral side elevate this with the triceps expose the joint laterally 4 Alternative procedure olecranon osteotomy drill and tap olecranon prior to osteotomy score the olecranon with an osteotome to allow perfect reduction repair osteotomy V-shaped osteotomy of the olecranon 2 cm from the tip using an oscillating saw I Prepare Fracture and Obtain Articular Congruity 1 Expose fracture remove any clots from the fracture site 2 Evaluate the articular surface determine whether the entire articular surface is present J Obtain Provisional Articular Fixation with Kwire 1 Reduce the articular fragments use the proximal ulna and radial head as templates check the rotational alignment 2 Perform provisional reduction place two 2.0 mm smooth wires at the medial and lateral condyles for reduction these should be placed through the plates these will be replaced with screws later 3 Place medial and lateral plates these should be placed so that one of the distal holes of each plate slide over the smooth Kwires place one cortical screw in slotted hole through each plate keep loose so that adjustments to plate can be made K Obtain Definitive Plate Fixation 1 Place screws place 2 or more screws distally medially and laterally replace the 2 smooth Kwires with distal screws do not drill because of possible fracture 2 Perform compression perform compression back out the most proximal screw on one side place a large bone clamp distally to that side place bone clamp proximally to the opposite side maintain compression by application of a compression screw follow the same steps for the opposite side 3 Place remaining screws 4 Test range of motion of elbow L 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 close skin with 3-0 nylon 4 Dressing and immediate immobilization soft dressing (gauze, webril) long arm anterior splint splint in extension sling for comfort Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids antibiotics pain control wound care advance diet as tolerated compartment checks check radiographs in postop inpatient pt non weightbearing 2 Discharges patient appropriately outpatient physical therapy remove splint in 24-48 hours nonweightbearing active flexion with gravity assisted extension ice, elevation and compression pain meds wound care schedule follow up in 2 weeks 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 implications of soft tissue injury open fracture compartment syndrome ligamentous injury document neurovascular status concomitant and associated orthopaedic injuries 2 Knowledge of imaging studies/lab studies radiographs of the elbow AP lateral oblique traction films for preoperative planning CT scan with oblique or comminuted fracture pattern 3 Reduce fracture if necessary provisional fixation fluroscopic checks 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention indications fracture displacement 5 Provides postoperative management and rehabilitation postop: 10 day postoperative visit wound check remove sutures check radiograph postop: 4-6 week postoperative visit advance rehabilitation postop: 1 year postoperative visit 6 Diagnose and early management of complications Dx from periop xrays recognize infection recognize fracture displacement/dislocation B Advanced Evaluation and Management 1 Order appropriate imaging studies radiographs CT scan/3D reconstruction 2 Provides post-op management and rehabiliatation. 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 obtain biplanar radiographs and/or CT scan of the elbow 4 Perform operative consent describe complications of surgery including hardware irritation (40-80% for tension band, 20% for plate and screws) wound breakdown elbow stiffness (~50%) triceps avulsion post-traumatic arthritis
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 small fragment plates malleable recon plates or precontoured periarticular plates mini fragment plates Herbert screws Kwires sterile tourniquet reduction clamps 2 Room setup and equipment c-arm perpendicular to OR table 3 Patient positioning lateral decubitus position place affected extremity over arm bolster arm should be in 90 degrees of flexion pad all bony prominences place sterile tourniquet G Direct Posterior Approach to the Elbow 1 Mark and start the incision begin 5cm proximal to the olecranon in the midline of the posterior distal humerus curve laterally proximal to the tip of the of the olecranon along the lateral aspect of the olecranon process then curve medially over the middle of the posterior aspect of the subcutaneous ulna 2 Identify the ulnar nerve palpate the ulnar nerve and fully dissect it out is helpful to pass tape or penrose for identification at all times 3 Incise fascia incise deep posterior fascia in the midline can either split triceps fascia, or continue with olecranon osteotomy create full thickness flaps to minimize dead space/hematoma H Triceps Sparing Approach 1 Elevate the triceps lift the triceps directly from the humerus and the intermuscular septum retract the olecranon fragment proximally 2 Identify radial nerve identify the sensory branch of the radial nerve laterally follow the nerve proximally to identify the radial nerve proper 3 Divide or dissect the anconeus on its lateral side elevate this with the triceps expose the joint laterally 4 Alternative procedure olecranon osteotomy drill and tap olecranon prior to osteotomy score the olecranon with an osteotome to allow perfect reduction repair osteotomy V-shaped osteotomy of the olecranon 2 cm from the tip using an oscillating saw I Prepare Fracture and Obtain Articular Congruity 1 Expose fracture remove any clots from the fracture site 2 Evaluate the articular surface determine whether the entire articular surface is present J Obtain Provisional Articular Fixation with Kwire 1 Reduce the articular fragments use the proximal ulna and radial head as templates check the rotational alignment 2 Perform provisional reduction place two 2.0 mm smooth wires at the medial and lateral condyles for reduction these should be placed through the plates these will be replaced with screws later 3 Place medial and lateral plates these should be placed so that one of the distal holes of each plate slide over the smooth Kwires place one cortical screw in slotted hole through each plate keep loose so that adjustments to plate can be made K Obtain Definitive Plate Fixation 1 Place screws place 2 or more screws distally medially and laterally replace the 2 smooth Kwires with distal screws do not drill because of possible fracture 2 Perform compression perform compression back out the most proximal screw on one side place a large bone clamp distally to that side place bone clamp proximally to the opposite side maintain compression by application of a compression screw follow the same steps for the opposite side 3 Place remaining screws 4 Test range of motion of elbow L 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 close skin with 3-0 nylon 4 Dressing and immediate immobilization soft dressing (gauze, webril) long arm anterior splint splint in extension sling for comfort
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids antibiotics pain control wound care advance diet as tolerated compartment checks check radiographs in postop inpatient pt non weightbearing 2 Discharges patient appropriately outpatient physical therapy remove splint in 24-48 hours nonweightbearing active flexion with gravity assisted extension ice, elevation and compression pain meds wound care schedule follow up in 2 weeks 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