Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam check the range of motion 2 Prescribes and manages nonoperative treatment attempts trial of physical therapy 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 1 week postoperative visit remove splint diagnose and management of early complications continue range of motion exercises remove all dressings by 4 weeks B Advanced Evaluation and Management 1 Provides post-op management and rehabilitation gradually increase range of motion C 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 wound complications neurovascular injury stiffness Operative Techniques E 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 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 Palmar Incision 1 Mark and make incision make a transverse incision in the middle of the palm extend the incision to the finger when needed extended incision is through a zig-zag brunner incision H Deep Dissection 1 Dissect through subcutaneous tissue undermine the skin flaps 2 Identify the diseased tissue carry the dissection proximally until a transition between normal and diseased fascia is identified I Excision of Diseased Tissue 1 Isolate the neurovascular structure isolate and protect the neurovascular structures from the diseased tissue and protect dissect the neuoravascular structures from the diseased cords, retract them and protect them during the entire procedure 2 Release the diseased tissue release the diseased tissue proximally and extend the dissection distally 3 Isolate the diseased tissue transect the pretendinous cord proximally and follow the cord distally, dividing all connections to the adjacent normal tissue if present, include the diseased Septa of Legueu and Juvara and a natatory cord from the diseased NL if the diseased tissue extends into the finger, follow the digital cord into the finger the digital cord must be dissected carefully because of the close proximity to the neurovascular bundle identify and release the distal insertion of the digital cord 4 Excise the dissected tissue J Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Closure of the palmar incision keep the transverse incision open to heal by secondary intention 3 Closure of the extensions of the incisions close any extensions of the original incision into the fingers 4 Dressings and immediate immobilization apply nonadherent gauze to the wound and immobilize the hand in a forearm based splint with the fingers in extension Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive postoperative orders pain management outpatient PT start active range of motion exercises 48 to 72 hours postop keep in nocturnal extension splint at night 2 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
A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam check the range of motion 2 Prescribes and manages nonoperative treatment attempts trial of physical therapy 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 1 week postoperative visit remove splint diagnose and management of early complications continue range of motion exercises remove all dressings by 4 weeks B Advanced Evaluation and Management 1 Provides post-op management and rehabilitation gradually increase range of motion C 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 wound complications neurovascular injury stiffness
E 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 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 Palmar Incision 1 Mark and make incision make a transverse incision in the middle of the palm extend the incision to the finger when needed extended incision is through a zig-zag brunner incision H Deep Dissection 1 Dissect through subcutaneous tissue undermine the skin flaps 2 Identify the diseased tissue carry the dissection proximally until a transition between normal and diseased fascia is identified I Excision of Diseased Tissue 1 Isolate the neurovascular structure isolate and protect the neurovascular structures from the diseased tissue and protect dissect the neuoravascular structures from the diseased cords, retract them and protect them during the entire procedure 2 Release the diseased tissue release the diseased tissue proximally and extend the dissection distally 3 Isolate the diseased tissue transect the pretendinous cord proximally and follow the cord distally, dividing all connections to the adjacent normal tissue if present, include the diseased Septa of Legueu and Juvara and a natatory cord from the diseased NL if the diseased tissue extends into the finger, follow the digital cord into the finger the digital cord must be dissected carefully because of the close proximity to the neurovascular bundle identify and release the distal insertion of the digital cord 4 Excise the dissected tissue J Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Closure of the palmar incision keep the transverse incision open to heal by secondary intention 3 Closure of the extensions of the incisions close any extensions of the original incision into the fingers 4 Dressings and immediate immobilization apply nonadherent gauze to the wound and immobilize the hand in a forearm based splint with the fingers in extension
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders pain management outpatient PT start active range of motion exercises 48 to 72 hours postop keep in nocturnal extension splint at night 2 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