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Phani K. Dantuluri, MDDivision of Shoulder and Elbow & Upper Extremity Surgery

Resurgens OrthopaedicsEmory University Midtown Hospital

Emory St.Joseph’s Hospital

Postoperative Management of Elbow Surgery

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6 weeks Postoperative follow-up

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Orthogonal Plating

Orthogonal Plating

Orthogonal Plating

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Orthogonal Plating

Orthogonal Plating

Orthogonal Plating

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Orthogonal Plating

Orthogonal Plating

Orthogonal Plating

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Parallel Plating

Posterior Exposure

Paralell Plating

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Case

78 y.o. male

Independent

Active

CT Scan

CT Scan

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CT Scan

CT Scan

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Postop Xrays

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Follow up Xrays

Bone QualityQuality of Fracture FixationFracture ComplexityPatient ComplianceDegree of Soft Tissue Injury

Complex Intraarticular Fracture

Distal Humerus Fractures Mobilization

Begin when concerns for failure of fixation minimalTypically mobilize 2 weeks after distal Humerus ORIF, 4-6 weeks after complex fracture patternsPoor bone or poor fixation, immobilize for SIX WEEKS!!!Healed anatomic stiff fracture much easier to treat than failure of fixation…First shot is the best shot! CT Scan Evaluation

Distal Humerus Fractures Mobilization

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Olecranon Fractures

Olecranon Fractures

Capitellar Fractures

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Capitellar Fractures

Capitellar Fractures

Preoperative Incision

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Medial Window

Lateral Window

Subluxation Of Ulna Allows

Direct Humeral Exposure

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4 Weeks Postoperative

4 Weeks Postoperative

Case

52 y.o. active male s/p ORIF complex distal

humerus fracture

and removal of hardware with significant pain

and crepitus

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Case

76 y.owoman s/p ORIF complains of grinding noises from elbow

Case

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“I feel a bump on my elbow”

“I feel a bump on my elbow”

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Fix or Replace

Age of patient (Physiologic) Demands of the patient Fracture pattern Articular involvement Sagital fracture involvement Comorbidities

Conclusion

ORIF whenever possible Numerous complications with elbow replacement Lifetime functional limitations TEA good option low demand elderly patient if not fixable

Distal Biceps Ruptures

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Endobutton Technique

Endobutton Technique

Rehabilitation

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Distal biceps repairs protected x 6 weeksGentle active flexion and forearm rotation

with extension block at 90 degrees at 2 weeks. If poor quality tendon can wait 4-6 weeks. Strengthening at 3 monthsUnrestricted use at 4 – 6 months

Distal Biceps Rehabilitation

Chronic Distal Biceps Ruptures

Chronic Distal Biceps Repair

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Least common tendon injury

Males

Age 30 years

Avulsion fractures in Adolescents

Epidemiology

Flake Sign

Triceps Ruptures

Triceps Repair

Generally splinted for 4 weeks in full extension

Gentle AROM at 4 weeks, but if poor tendon repair wait 6 weeks

Gentle strengthening at 6 weeksUnrestricted activity at 6

months

Triceps Repairs

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ETIOLOGY Rare varus stressMost common cause

Elbow dislocation Lateral Epicondyle

nonunion Iatrogenic

Tennis elbow surgery Radial head excision

Posterolateral Rotary Instability(PLRI)

Tests for posterolateral rotatory instability

Supination-valgus moment is applied, causing subluxation at 40 degrees of flexion

Palpable, visible clunk Creates positive

apprehension

Lateral Pivot Shift Test

Lateral Pivot Shift Test

Dimpling

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Post Reduction

Potentially elderly, low demandRarely improves

nonoperativelyDaily function impairedHinged Elbow Brace

- With extension block, pronation

PRLI Conservative Treatment

LIGAMENT REPAIR

Origin AvulsedDirect RepairPlicate Capsule

PRLI Treatment

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PRLI Reconstruction

Surgical Exposure

Determination of Isocentric Point

Suture

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LUCL Reconstruction

Capsular Imbrication

Postoperative Closure

Splint in Pronation and Flexion- Splint at 70-80 Flexion- Wait 14 days before Flexion begun- Hinged Elbow Brace with Extension Block

Wean from brace 4-6 weeks3 Months protected activity6 Months activity as tolerated

PRLI Rehabilitation

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MCL Ruptures

NonoperativeNoncompetive athlete, particularly nonthrowing

Rehabilitation-Scapular stabilizers and rotator cuff muscles of ipsilateral shoulder-Flexor pronator mass strengthening, stretching-Grip exercises, slow progression

MCL Treatment Options

MCL Repair or Reconstruction

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“Docking” Procedure

Altchek, et al 2000

MCL Reconstruction

Splinted at 70 degrees flexion, protected for 6 weeks2 weeks – Active ROM4-6 Wks - Strengthening3-4 Months – Begin Throwing12-18 Months – Final Stages

MCL Repair or Reconstruction

Radial Head Fractures

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Radial Head Fractures

Radial Head Fractures

Splinted at 90 degrees flexion for 2 weeks2 weeks – Gentle AROM for ORIF

and Radial Head ReplacementIf complex ORIF begin AROM at 4

weeksResting Orthoplast splint at 90 for

comfort6 weeks splint discontinued

Isolated Radial Head Fractures

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TERRIBLE TRIADRadial head fracture, coronoid fracture, posterior elbow

dislocation

Terrible Triad Injuries

Case PresentationPugh, McKee

• Early operative repair

• Allowed earlier mobilization improving functional outcome

Radial Head Fragment

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Radial Head Fragment

Coronoid Fragment

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Posterior Approach

Radial Head Fracture

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Articular Delamination

LCL Avulsion

Articular Delamination

LCL Avulsion

Radial Head Fragments

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Coronoid Fracture

CoronoidFracture

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Splinted at 70 degrees flexion for 2 weeks2 weeks – Gentle PROM,

extension block at 70 in hinged elbow brace4 weeks – AAROM extension

block at 1356 weeks full extensionHinged Elbow brace for 3 months

Terrible Triad Injuries

Preoperative Radiographs

Heterotopic Ossification

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Preoperative Radiographs

Heterotopic Ossifcation

Posterior Approach

Medial Approach

Isolation of Ulnar Nerve

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Anterior Release

Posterior Release

Medial Access

Lateral Access

Lateral Access

Anterior Release

Posterior Release

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Heterotopic Ossification

Excision when mature on XraysIndomethacin 3 weeks postop Radiation in head injuries, or in

cases of severe HO formationDrain in for 24 hoursROM begins postop day oneCPM in certain complex casesCareful wound monitoring

necessary

Heterotopic Ossification Excision