Exposure of a coronoid fracture is improved by elevating the fractured olecranon on the triceps as with an osteotomy.
If a second medial plate will be used to secure the coronoid, one can - after taking care to protect the ulnar nerve - either elevate the entire flexor pronator mass (Taylor and Sham) or use the interval where the ulnar nerve lies in the split of the FCU (“Over the top” or Hotchkiss).
During the exposure it should be verified whether the lateral collateral ligament origin is avulsed from the lateral epicondyle or not.
The radial head can be accessed either by recreating the apex posterior fracture of the proximal ulna - thereby subluxation or dislocating the radial head posterior to the capitellum as typically occurs in this injury - or one can use a separate lateral muscle interval (Kocher or Kaplan).
For most fractures of the radial head that are replaced with a prosthesis or have a repairable partial articular fracture, recreating the deformity and using and perhaps slightly enlarging the rent in the anconeus muscle usually provides sufficient exposure of the radius.
Sequence of repair
Address radial head fracture.
Address coronoid fracture.
Address lateral collateral ligament avulsion.
Realign and secure the olecranon fragment.
Partial radial head fractures
If there is partial articular fracture consisting of 1-2 fragments, screw fixation is used.
Check for dislocation or subluxation of the ulnohumeral joint in full gravity extension under a lateral image. Check for crepitation with forearm or elbow motion.
6. Postoperative treatment following ORIF
Postoperatively, the elbow may be placed for a few days in a posterior splint for pain relief and to allow early soft tissue healing, but this is not essential. To help avoid a flexion contracture, some surgeons prefer to splint the elbow in extension.
If drains are used, they are removed after 12 - 24 hours.
Active assisted motion is encouraged within the first few days including gravity-assisted elbow flexion and extension. Encourage the patient to move the elbow actively in flexion, extension, pronation and supination as soon as possible. Delay exercises against resistance until healing is secure.
Use of the elbow for low intensity activities is encouraged, but should not be painful.
Range of motion must be monitored to prevent soft tissue contracture.
Prevent loading of the elbow for 6-8 weeks.
Monitor the patient to assess and encourage range of motion, and return of strength, endurance, and function, once healing is secure.
The patient is seen at regular intervals (every 10-20 days at first) until the fracture has healed and rehabilitation is complete.
As the proximal ulna is subcutaneous, bulky plates and other hardware may cause discomfort and irritation. If so, they may be removed once the bone is well healed, 12-18 months after surgery, but this is not essential.