Radial Head Replacement – Anesthetic ConsiderationsPatient Background

• Age/Sex: 42-year-old female
• History: Sustained trauma from a road traffic accident
• Comorbidities: None reported
• Condition: Complex radial head fracture requiring excision or fixation

Preoperative Anesthesia EvaluationHistory

• Mechanism of injury:
• Time and type of accident
• Presence of associated injuries such as head trauma, loss of consciousness, cervical or back pain
• Upper limb symptoms:
• Numbness, paresthesia, or motor weakness
• Pain management:
• Current analgesic medications used
• Pregnancy status:
• Mandatory screening in women of reproductive age
• Past anesthetic history:
• Previous adverse reactions to anesthesia or difficulties with airway management
• Bleeding history:
• Any known bleeding disorders or use of anticoagulants
• Polytrauma assessment:
• Screening for other injuries commonly associated with road traffic accidents

Reference:

American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522-538. doi:10.1097/ALN.0b013e31823c1067

Investigations

• Laboratory: Complete blood count, renal and liver function tests, electrolytes, coagulation profile
• Urine: Urine pregnancy test
• Cardiac: Electrocardiogram (recommended for age >40)
• Imaging:
• X-ray/CT scan of elbow and forearm
• Chest X-ray or CT if blunt chest injury suspected
• Cervical spine screening where indicated

Reference:

American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology. 2012;116(3):522-538. doi:10.1097/ALN.0b013e31823c1067

Anesthetic Plan

• Primary technique: General anesthesia as per surgical request
• Regional anesthesia (brachial plexus block): Avoided because:
• Postoperative neurologic evaluation is required to detect surgical nerve injury
• Regional block may mask early signs of compartment syndrome
• Complex surgical dissection expected in close proximity to neural structures

Reference:

American Society of Anesthesiologists. Practice advisory for preanesthesia evaluation. Anesthesiology. 2012;116(3):522-538.

Intraoperative ManagementPositioning

• Supine with the operated arm supported across the chest using a padded bolster or arm board
• Key considerations:
• Neutral shoulder alignment; avoid excessive abduction or stretch
• Adequate padding under the elbow, wrist, and hand
• Secure all lines to ensure continuous airway access and monitor visibility
• Avoid chest compression that could impair ventilation

Reference:

American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory. Anesthesiology. 2018;128(4):657-668. doi:10.1097/ALN.0000000000002025

Radiation Exposure (if fluoroscopy used)

• Minimize exposure with pulse mode, beam collimation, and reduced fluoroscopy time
• Staff protection with lead aprons and thyroid shields
• Patient exposure monitored using:
• Cumulative Air Kerma (mGy)
• Dose Area Product (Gy·cm²)

Reference:

Miller DL, Vañó E, Bartal G, et al. Occupational radiation protection in interventional radiology: joint guideline of CIRSE and SIR. Cardiovasc Intervent Radiol. 2010;33(2):230-239. doi:10.1007/s00270-009-9756-7

Tourniquet Management

• Properly sized cuff applied to upper arm with soft padding
• Inflation pressure: Systolic blood pressure + 50–75 mmHg (if baseline unknown, ~200 mmHg)
• Record inflation and deflation times
• Surgical team notified every 60 minutes of inflation time

Reference:

Sharma JP, Salhotra R. Tourniquets in orthopedic surgery. Indian J Orthop. 2012;46(4):377-383. doi:10.4103/0019-5413.96368

Analgesia

• Regional anesthesia avoided
• Systemic multimodal analgesia employed:
• Intraoperative: Intravenous paracetamol, NSAIDs (if no contraindications), opioids (e.g., fentanyl)
• Consider adjuncts such as low-dose ketamine or dexmedetomidine for opioid-sparing
• Local wound infiltration by surgeon if feasible

Reference:

American Society of Anesthesiologists Task Force on Acute Pain Management. Guidelines for acute pain management. Anesthesiology. 2012;116(2):248-273. doi:10.1097/ALN.0b013e31823c1030

Postoperative ManagementPain Control

• Multimodal regimen continued with intravenous/oral paracetamol and NSAIDs
• Opioids reserved for breakthrough pain (e.g., tramadol, morphine, or PCA if indicated)
• Regional anesthesia techniques avoided to ensure reliable neurovascular assessment

Reference:

American Society of Anesthesiologists Task Force on Acute Pain Management. Guidelines for acute pain management. Anesthesiology. 2012;116(2):248-273.

Neurologic Monitoring

• Frequent assessment of radial, ulnar, and median nerves (motor and sensory)
• Essential due to:
• Extensive dissection near neurovascular structures
• Avoidance of regional anesthesia

Compartment Syndrome Surveillance

• Monitor for:
• Disproportionate pain
• Pain on passive muscle stretch
• Firm swelling of forearm compartments
• New-onset paresthesia or motor weakness
• Prompt surgical decompression if suspected

Reference:

Duckworth AD, McQueen MM. The diagnosis of acute compartment syndrome: a critical appraisal. Injury. 2011;42(12):1409-1414. doi:10.1016/j.injury.2011.08.023

Additional Measures

• DVT prophylaxis in immobilized patients
• Wound care and infection monitoring
• Early physiotherapy-guided mobilization to restore elbow function

Reference:

Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: ACCP guidelines. Chest. 2012;141(2 Suppl):e278S-e325S. doi:10.1378/chest.11-2404