A Intermediate Evaluation and Management 1 Provides post-operative management and rehabilitation Followup in 1 week; follow closely with serial radiographs 3 week postoperative visit: wound check remove cast if healing is adequate keep the cast off if healing is not adequate, place cast for another 2 weeks check radiographs remove the cast when evaluating xrays diagnose and management of early complications<br /> start range of motion exercises postop: 4-6 week postoperative visit continue range of motion exercises to wrist, hand, and elbow return to activity at ~8 wks C Preoperative H & P 1 Obtains history and performs basic physical exam injury mechanism neurovascular exam: Radial/ulnar and median nerve function; PIN assessment; radial and ulnar pulses 2 Order basic imaging studies AP,lateral and oblique elbow radiographs 3 Prescribe nonoperative treatments acceptable reduction is less than 30 degrees of angulation and less than 3 mm of translation 4 Perform operative consent describe complications of surgery including loss of forearm pronation and supination PIN nerve injury loss of joint congruity radial head overgrowth avascular necrosis of the radial head radial neck malunion/radiocapitellar stability post traumatic radioulnar synostosis heterotopic ossification
E Preoperative Plan 1 Evaluate for any associated injuries on AP, oblique and lateral views of the elbow check for medial epicondyle fracture, coronoid fracture or concomitant elbow dislocation 2 Examine the elbow under anesthesia pronate and supinate the forearm under fluoroscopy to determine the maximum plane of angulation and assess range of motion assess for joint instability and functional loss of forearm rotation 3 Execute surgical walkthrough describe key steps of the operation verbally to attending prior to beginning of case. describe potential complications and the steps to avoid them F Room Preparation 1 Surgical instrumentation K-wires Flexible nail set 2 Room setup and equipment setup OR with standard operating table and arm board/hand table turn table 90° c-arm in from foot of bed monitor in surgeon direct line of site on opposite side of OR table 3 Patient positioning supine with shoulder at edge of bed arm board centered at level of patient’s shoulder can add arm tourniquet placed high on upper arm with webril underneath check AP/Lat radiographs prior to draping G Attempt closed reduction 1 Patterson technique One person places hand medially against the distal humerus and one hand anteriorly on mid humerus to provide counter traction (proximally and medially) Second person (surgeon) supinates forearm, applies traction distally and pulls the forearm into varus Surgeon then directly applies pressure with thumb over the radial head to reduce the fracture 2 Israeli technique Flex elbow to 90 degrees Start with forearm supinated Thumb applies pressure to radial head to stabilize in position Forearm is rotated into full pronation to align the shaft and radial neck 3 An esmarch elastic bandage can also aid in reduction when wrapped from distal to proximal H Evaluate closed reduction 1 Confirm that radial head and capitellum are in alignment in all planes (multiple views on C-arm) 2 Evaluate forearm rotation and confirm that there is full pronation and supination 3 If adequate reduction is obtained the arm is placed in a long arm cast I Reduction with percutaneous pin 1 Forearm is positioned so that radial head is laterally displaced (usually in supination) 2 K-wire is inserted and slid along the posterior aspect of the ulna (to avoid PIN injury) aim from proximal to distal with entry point around 1/3 of the way down the forearm generally a 2.0 or larger K-wire is used and the blunt end may be used if it is falling into the fragment rather than disimpacting) 3 K-wire is inserted into the fracture site (approximately halfway across) it is then used to lever the proximal epiphyseal fragment into position a varus stress can be applied at this time to help aid reduction once the fragment is positioned medially (reduced) there is usually stability of the fracture and placing a patient in a long arm cast is adequate (k-wire or other fixation is rarely needed) J Metaizeau technique 1 1cm incision is made over the distal radial metaphysics (on the radial aspect) spread inline with incision and protect radial sensory nerve 2 Use an awl or drill to create an oblique cortical window just proximal to the physis 3 Insert a contoured flexible intramedullary nail and advance proximally continue advancing until it crosses the fracture and engages the proximal fragment 4 Rotate the flexible intramedullary nail to move the radial head into position then the nail can be advanced slightly to stabilize the reduction K Open reduction 1 Pronates forearm to protect PIN 2 Makes an oblique posterolateral incision (Kocher) 3 incise and develops the interval between anconeus and extensor carpi ulnaris 4 Identify joint capsule and incises this performing an arthrotomy avoid excessive periosteal stripping 5 reduce fracture correct translation and angulation evaluate if radiocapitellar joint is reduced 6 Internal fixation to stabilize fracture if an intramedullary nail was previously advanced up the radial shaft for Metaizeau technique then this can be advanced to stabilize the reduction alternatively 2 K-wires can be placed advancing from the radial head starting just distal to the articular surface and advancing distally into the radial neck/shaft (either parallel or divergent pin configuration) many surgeons prefer to cut and bury these wires and return to OR at a later time for removal rarely, in older adolescents with comminuted fractures plate and screw fixation may be indicated and care should be taken to place these in the "safe zone" (posterolateral portion- approx 90 degree zone that lies between a longitudinal line along the radial styloid and one along listers tubercle) 7 Superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 monocryl for skin 8 Places long arm cast long-arm cast with immobilization at 90° sling for comfort
O Perioperative Inpatient Management 1 Discharge patient appropriately pain meds cast care non weightbearing manage swelling monitor neurological and vascular status schedule follow up in 1 week, follow closely with serial radiographs