A 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 2 week postoperative visit remove sutures check for consolidation on radiographs diagnose and management of early complications B Advanced Evaluation and Management 1 Provides post-op management and rehabilitation 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 malunion delayed union or nonunion pin site or surgical wound infection extensor tendon adhesions or ruptures MCP or interphalangeal capsular contractures
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 Neutralization plate and lag screws 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 Dorsolateral Longitudinal Exposure 1 Mark and make the incision ensure that the exposure allows fixation of four cortices to the fracture both proximally and distally 2 Identify the neurovascular structures identify and protect the dorsal sensory nerve branches H Fracture Reduction 1 Reduce the fracture 2 Use pointed clamps to maintain the reduction 3 Confirm the reduction with fluoroscopy I Lag Screw Placement 1 Place a lag screw perpendicular to the fracture this maximizes compression 2 Place another screw perpendicular to the axis of the intramedullary canal this resists the axial loads 3 Place additional lag screws place lag screw in different planes to achieve fracture compression and resist loads that are applied to the metacarpal 4 Confirm reduction and fixation use live fluoroscopy to confirm the reduction and screw placement of the multiple screws J Wound Closure 1 Close the periosteum and soft tissues close the periosteum and the interosseous muscle fascia over the plate this provides a smooth gliding surface for the extensor mechanism 2 Superficial closure close the skin with 3-0 monocryl suture
O Perioperative 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 2 weeks R Complex Patient Care 1 Comprehensive pre-op planning/alternatives. 2 Modify and adjust post-op plan as needed