A Intermediate Evaluation and Management P 1 Performs focused physical exam document neurovascular status Pearls If digital nerve injury suspected and child not able to complete sensory exam = use wrinkle test by submerging in water 2 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 3 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check remove dressings after 7-14 days diagnose and management of early complications<br /> 4 Capable of diagnosis and early management of complications wound infection, incompletely released and persistent trigger finger, digital nerve injury B Advanced Evaluation and Management 1 Modifies and adjusts post-operative treatment plan as needed recognize deviations from typical postoperative course C Preoperative H & P 1 Obtains history and performs basic physical exam radial and ulnar pulse assessment radial and ulnar nerve sensation assessment if possible identify medical co-morbidities that might impact surgical treatment 2 Perform operative consent describe complications of surgery including superficial wound infection incompletely released and persistent trigger thumb digital nerve injury
E Preoperative Plan 1 Template incision 2 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 basic hand set loupe magnification 2 Room setup and equipment setup OR with standard operating table hand table 3 Patient positioning supine with shoulder at edge of bed place hand supine on hand table add arm tourniquet placed high on upper arm with webril underneath G Transverse Incision 1 Identify the location of the incision care should be taken to center the incision directly over the thumb flexor sheath which is pronated relative to the plane of the palm 2 Mark and make a 7 to 10 mm transverse incision at the palmar crease of the thumb metacarpophalangeal joint the exact location of the incision depends on the location of the A1 pulley relative to the crease in the thumb with fixed flexion posture, the proximal edge of the A1 pulley is immediately distal to the location of the palpable nodule when the IP joint is maximally extended care should be taken to plan the incision directly over the thumb flexor sheath which is pronated relative to the plane of the palm preserve the skin that is immediately adjacent to the digital nerves H Deep Dissection 1 Expose the A1 pulley use blunt dissection to dissect through the subcutaneous tissue the digital nerves do not need to be visualized as long as the transverse fibers of the pulley are very clearly visualized under loupe magnification be aware of the crossing digital radial nerve I Open Release P 1 Identify the distal and proximal edges of the A1 pulley 2 Release the pulley use sharp dissection to incise the pulley longitudinally along its entire length 3 Identify and protect the oblique pulley 4 Complete the release gently spread with blunt scissors in the proximal aspect of the sheath entering the thenar eminence this release minimizes the incidence of recurrence 5 Test release to ensure that release is adequate, the FPL should be visualized from the palm to the oblique pulley. the thumb IP joint should have full ROM Pearls Be aware of the crossing digital radial nerve and stay within the tedon sheath for this proximal release J Wound Closure P 1 Irrigation and hemostasis copiously irrigate the wound infiltrate the wound with long acting anesthetic without epinephrine 2 Superficial closure close with simple interrupted sutures Pearls Absorbable suture such as 5-0 chromic or plain gut is ideal in the pediatric population 3 Dressings cover the wound with sterile gauze and several layers of bandage and tape to prevent the child from removing the bandage
O Perioperative Inpatient Management 1 Discharge patient appropriately pain meds schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans