Updated: 10/9/2017
CPT Codes: 24685 Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), includes internal fixation, when performed

Olecranon Fracture ORIF with Plate Fixation

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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

Order basic imaging studies/lab studies

  • true lateral radiograph needed to determine fracture pattern
  • CT scan with oblique or comminuted fracture pattern

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention
  • indications
  • fracture displacement
  • elbow instability
  • transolecranon injury

4

Provides postoperative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures
  • remove splint and begin range of motion exercises
  • place in removable brace
  • postop: 4-6 week postoperative visit
  • advance weight-bearing status in removable elbow brace
  • advance rehabilitation
  • postop: 1 year postoperative visit

5

Diagnose and early management of complications

  • Dx from periop xrays
  • recognize infection
  • recognize fracture displacement/dislocation
B

Advanced Evaluation and Management

1

Able to 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
  • hardware irritation (40-80% for tension band, 20% for plate and screws)
  • wound breakdown
  • elbow stiffness (~50%)
  • AIN injury due to overpenetration of K-wires through anterior cortex
  • post-traumatic arthritis

Operative Techniques

E

Preoperative Plan

1

Template fracture

  • identify fracture pattern, displacement, comminution, and presence of dislocation
  • true lateral radiograph needed to determine fracture pattern
  • simple transverse fractures can be treated with tension band construct
  • oblique and comminuted fractures require plate and screw systems for fixation, may require CT scan pre-op

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

  • precontoured plate system
  • small fragment set

2

Room setup and equipment

  • turn table 90°
  • c-arm perpendicular to OR table

3

Patient positioning

  • supine
  • shoulder at edge of bed, no arm board, arm draped over chest at 90° on top of large bump (chest to chin)
  • lateral
  • beanbag to support patient
  • arm over radiolucent foam or blankets, on radiolucent hand table
  • place tourniquet
G

Posterior Approach to the Elbow

1

Identify anatomy

  • exsanguinate limb and inflate tourniquet if using tourniquet
  • identify ulnar nerve, tip of olecranon, ulna shaft, medial and lateral sides of elbow for orientation

2

Expose the elbow

  • use scalpel dissection along subcutaneous border of ulna, centered about fracture site
  • incision is along proximal ulna shaft, slightly wraps lateral to tip of olecranon, then extending proximally in line with the humeral shaft
  • avoid midline incision over olecranon tip due to skin irritation
  • extend proximally, curving laterally around tip of olecranon
  • pay attention to hemostasis with electrocautery
  • create full thickness flaps to minimize dead space/hematoma
  • place self retaining retractors proximally and distally
H

Fracture Reduction and Preparation

1

Clear the fracture site

  • remove hematoma and interposed soft tissue from the fracture site(s)
  • elevate 2-3mm of periosteum from fracture edges to ensure visualization

2

Reduce the transverse fracture

  • drill unicortical hole with1.6mm k-wire 2-3 cm distal to fracture
  • place one tine of point reduction clamp in drill hole so it doesn't slip, then place other tine on proximal fragment
  • reduce fracture as elbow is brought into extension
  • tighten and lock down clamps once reduced
  • add additional clamp(s) or K-wires as needed
  • do not block k-wire entry points or plate placement
I

Plate and Screw Fixation

1

Check plate placement

  • check size, length, and rotation of plate on dorsal (tension) side of proximal ulna
  • oblique fractures can be initially secured with 2.4, 2.7, or 3.5mm lag screw(s)

2

Split the triceps at the tip of the olecranon

  • this allows full seating of the plate on the ulna

3

Temporarily fix plate

  • use K-wires or whirly-bird into plate to temporarily fix plate to bone

4

Permanent fixation

  • place non-locking screw first in ulna shaft to bring plate down to bone
  • insert locking and/or non-locking screws into proximal fragment through plate
  • need to place at least 2-3 screws into each fracture fragment, depending on amount of comminution
  • can place screw from proximal plate across fracture, into distal fragment ("home run screw")
  • may advance distal triceps tendon over plate to reduce hardware prominence

5

Obtain final biplanar and oblique radiographs

J

Wound Closure

1

Irrigation, hemostasis, and drain

  • irrigate wounds thoroughly and 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 posterior splint optional
  • splint at 70-80° flexion for immobilization
  • sling for comfort
  • can consider post-op indomethacin to reduce heterotopic ossification

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • schedule follow up in 2 weeks
  • outpatient physical therapy
  • nonweightbearing
  • start range of motion no later than 7-10 days postop
  • 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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