A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests 2 Prescribes and manages nonoperative treatment attempts trial of physical therapy 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 Zone I and II 2 week postoperative visit remove sutures diagnose and management of early complications Zone I and II 6 week postoperative visit remove the pin continue splinting for rigorous activity and at night for six weeks Zone III 2 week postoperative visit remove sutures postoperative rehabilitation for children and less compliant adults continue immobilization for 2 weeks Zone III 4 week postoperative visit postoperative rehabilitation for children and less compliant adults remove pin or splint protected motion program B Advanced Evaluation and Management 1 Provides post-op management and rehabilitation C Preoperative H & P 1 Performs basic medical and orthopaedic history and physical evaluates neurovascular status evaluates range of motion 2 Obtains operative consent describes potential complications of surgery painful neuroma altered sensation CRPS
E Preoperative Plan 1 Executes surgical walkthrough describes the steps of the procedure verbally prior to the start of the case 2 Describes potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation loupe magnification 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 G Zone I Repair 1 Expose the lacerated tendon 2 Perform primary repair of the tendon place a running cross stitch or figure of eight stitch with 5-0 absorbable suture in the tendon avoid shortening the tendon 3 Place a K wire place the DIP joint in neutral support the repair by placing a 0.045 inch Kwire across the DIP joint 4 Close the skin H Zone II Repair 1 Expose the lacerated tendon use Bruner or midaxial incision 2 Bluntly dissect down to the lacerated tendon 3 Perform primary repair perform primary tendon repair with a running 4-0 or 5-0 cross stitch suture 4 Close the skin 5 Stabilize the repair splint the DIP joint or pin the joint in extension for 6 weeks I Zone III Primary Repair 1 Make a skin incision at the site of the repair 2 Expose the site of repair bluntly dissect to the site of repair 3 Perform a primary repair of the central slip use a running stitch with 4-0 or 5-0 suture to repair the central slip 4 Repair the lateral bands repair the lateral band or bands with single 4-0 or 5-0 monofilament 5 Close the skin J Zone III Reconstruction in Cases with Tendon Loss 1 Choose type of procedure to perform Consider v-y advancement of the central tendon or a turndown of the central slip proximal to the laceration to cover the defect 2 Make and extend the incision extend the skin incision proximally almost to the MCP joint incise a V in the central slip with the apex just distal to the MCP joint make the distal end the width of the tendon take care to not damage the overlying epitenon 3 Advance the tendon distally minimize disruption to the loose alveolar tissue between the tendon and the periosteum as much as possible 4 Close the incised V close the V into a Y with a 4-0 or 5-0 suture 5 Repair the distal end of the advanced central slip use a running stitch with 4-0 or 5-0 suture for the repair 6 Close the skin 7 Immobilize the repair use static splinting or pinning of the PIP joint in full extension N Wound Closure
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders pain management 2 Orders appropriate inpatient occupational and physical therapy for compliant patients 0 to 30 degrees of active PIP flexion and extension is allowed starting a few days after surgery do this with a palmar flexion block splint with a free wrist and MCO joint 3 Discharges patient appropriately write for pain meds schedule follow up appointment in 1 week R Complex Patient Care 1 Comprehensive pre-op planning/alternatives. 2 Modify and adjust post-op plan as needed