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Metacarpal Fracture Closed Reduction and Pinning

Planning

B

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case

2

Description of potential complications and steps to avoid them

C

Room Preparation

1

Surgical Instrumentation

  • K wires

2

Room setup and Equipment

  • standard operating table
  • hand table

3

Patient Positioning

  • patient placed in the supine position with hand on hand table
  • place tourniquet high on the affected extremity

Technique

D

Closed Reduction

1

Perform a closed reduction

  • flex the MCP joint to obtain control of the distal fragment
E

K Wire Placement

1

Place the K wire

  • place a 0.045 inch smooth K wire by hand on the radial or ulnar collateral recess

2

Check placement using fluoroscopy

  • confirm that the placement is at the deepest concavity of the collateral recess
  • take an oblique or near true lateral view to confirm placement of the pin in the sagittal plane
F

Wire Advancement

1

Advance the wire to the fracture site

  • advance the wire using power into the shoulder of the metacarpal down the intramedullary canal up to the fracture site

2

Reduce the fracture

3

Advance the wire past the fracture site

  • make sure that it stays in the intramedullary canal

4

Seat the wire in the bone of the metacarpal base

  • another option for advancement is to use a mallet instead of power
  • this allows bounce off of the far cortex
G

Passage of Second Wire

1

Pass a second wire

  • this completes and strengthens the fracture stabilization
  • reduction and fixation is optimum when both wires cross the fracture site

Patient Care

K

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • check neurovascular status
  • check range of motion

2

Perform operative consent

  • describe complications of surgery including
  • malunion
  • delayed union or nonunion
  • pin site or surgical wound infection
  • extensor tendon adhesions or ruptures
  • MCP or interphalangeal capsular contractures
L

Perioperartive Inpatient Management

1

Write comprehensive postoperative orders

2

Orders appropriate inpatient occupational and physical therapy

3

Discharges patient appropriately

  • write for pain meds
  • schedule follow up appointment in 1 week
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • differential diagnosis and physical exam tests

2

Prescribes and manages nonoperative treatment

  • orders appropriate orthosis

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Provides postoperative management and rehabilitation

  • 4 week postoperative visit
  • check for consolidation on radiographs
  • remove K wires
  • diagnose and management of early complications
N

Advanced Evaluation and Management

1

Provides post-op management and rehabilitation

O

Complex Patient Care

1

Comprehensive pre-op planning/alternatives.

2

Modify and adjust post-op plan as needed

 

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