Preoperative Patient Care A Outpatient Management 1 Obtains focused history and performs focused exam document distal neurovascular status concomitant and associated orthopaedic injuries 2 Interpret basic imaging studies triplanar films of the knee AP lateral oblique 3 Prescribes nonoperative management fracture brace long leg cast 4 Make informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit continue physical therapy and range of motion exercises discontinue DVT prophylaxis wound check staples/sutures removed diagnose and management of early complications continue toe partial weight-bearing at for additional for additional 6-9 weeks postop: ~ 3 month postoperative visit repeat radiographs advance to full weightbearing diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Prioritizes the needs of the polytrauma patient works with consulting 2 Complex wound management and debridement understanding need for consultation for flap coverage 3 Capable of treating complications both intraoperatively and post-operatively manages post operative infection C Preoperative H & P 1 Performs focused orthopaedic exam check neurovascular status check for compartment syndrome check soft tissues 2 Appropriately orders basic imaging studies order triplanar radiographs of the knee AP lateral oblique 3 Perform operative consent describe complications of surgery including compartment syndrome infection superficial and deep wound problems DVT Operative Techniques E Preoperative Plan 1 Template fracture reductions draw key fragments of fracture and plan for reduction 2 Execute surgical walkthrough resident can describe key steps of the operation verbally to attending prior to beginning of case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation External Fixation System 2 Room setup and equipment radiolucent flat top table c-arm fluoroscopy 3 Patient positioning place patient supine place a sterile bump or triangle under the knee G Proximal Pin Placement 1 Mark out the placement of the Schanz pins 2 Make a stab incision at the site of the pin placement 3 Bluntly dissect down to the bone 4 Place the proximal pins place 2 Schanz pins alont the anterolateral thigh place these pins in the midshaft of the femur H Distal Pin Placement 1 Mark the site of the tibial pin insertion 2 Make a stab incision at the site of pin placment 3 Bluntly dissect down to bone 4 Place the distal pins place 2 Schanz pins into the midshaft and distal tibia place the pins far enough away from the distal extension of the proximal tibia that there will be no interference in the event future incisions are needed for definitive fixation I Bar Placement 1 Loosley place a bar to connect the proximal and distal pins place a solitary bar to span all of the pins J Reduction 1 Reduce the fracture perform longitudinal traction to reduce the fracture 2 Confirm placement confirm under fluoroscopy 3 Position the knee maintain slight flexion of the knee check reduction with fluoroscopy K Final Tightening 1 Tighten the external fixator tighten all of the connectors this is done to maintain ligamentotaxis reduction L Multibar Fixation (optional) 1 Irrigation, hemostasis, and drain connect the two proximal pins using a single bar connect the two distal pins using another bar these bars are then used to manipulate the fracture to achieve reduction of the plateau 2 place a third bar to connect the proximal and distal bars tighten the bars to maintain reduction Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control prescribe appropriate DVT prophylaxis wound management pin care check appropriate labs antibiotics 2 Check radiographs in postop check placement of pins 3 Initiate physical therapy on POD 1 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately pain meds outpatient physical therapy schedule 2 week follow up R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Outpatient Management 1 Obtains focused history and performs focused exam document distal neurovascular status concomitant and associated orthopaedic injuries 2 Interpret basic imaging studies triplanar films of the knee AP lateral oblique 3 Prescribes nonoperative management fracture brace long leg cast 4 Make informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit continue physical therapy and range of motion exercises discontinue DVT prophylaxis wound check staples/sutures removed diagnose and management of early complications continue toe partial weight-bearing at for additional for additional 6-9 weeks postop: ~ 3 month postoperative visit repeat radiographs advance to full weightbearing diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Prioritizes the needs of the polytrauma patient works with consulting 2 Complex wound management and debridement understanding need for consultation for flap coverage 3 Capable of treating complications both intraoperatively and post-operatively manages post operative infection C Preoperative H & P 1 Performs focused orthopaedic exam check neurovascular status check for compartment syndrome check soft tissues 2 Appropriately orders basic imaging studies order triplanar radiographs of the knee AP lateral oblique 3 Perform operative consent describe complications of surgery including compartment syndrome infection superficial and deep wound problems DVT
E Preoperative Plan 1 Template fracture reductions draw key fragments of fracture and plan for reduction 2 Execute surgical walkthrough resident can describe key steps of the operation verbally to attending prior to beginning of case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation External Fixation System 2 Room setup and equipment radiolucent flat top table c-arm fluoroscopy 3 Patient positioning place patient supine place a sterile bump or triangle under the knee G Proximal Pin Placement 1 Mark out the placement of the Schanz pins 2 Make a stab incision at the site of the pin placement 3 Bluntly dissect down to the bone 4 Place the proximal pins place 2 Schanz pins alont the anterolateral thigh place these pins in the midshaft of the femur H Distal Pin Placement 1 Mark the site of the tibial pin insertion 2 Make a stab incision at the site of pin placment 3 Bluntly dissect down to bone 4 Place the distal pins place 2 Schanz pins into the midshaft and distal tibia place the pins far enough away from the distal extension of the proximal tibia that there will be no interference in the event future incisions are needed for definitive fixation I Bar Placement 1 Loosley place a bar to connect the proximal and distal pins place a solitary bar to span all of the pins J Reduction 1 Reduce the fracture perform longitudinal traction to reduce the fracture 2 Confirm placement confirm under fluoroscopy 3 Position the knee maintain slight flexion of the knee check reduction with fluoroscopy K Final Tightening 1 Tighten the external fixator tighten all of the connectors this is done to maintain ligamentotaxis reduction L Multibar Fixation (optional) 1 Irrigation, hemostasis, and drain connect the two proximal pins using a single bar connect the two distal pins using another bar these bars are then used to manipulate the fracture to achieve reduction of the plateau 2 place a third bar to connect the proximal and distal bars tighten the bars to maintain reduction
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control prescribe appropriate DVT prophylaxis wound management pin care check appropriate labs antibiotics 2 Check radiographs in postop check placement of pins 3 Initiate physical therapy on POD 1 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately pain meds outpatient physical therapy schedule 2 week follow up R Complex Patient Care 1 Develops unique, complex post-operative management plans