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
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
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
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