A Outpatient Management 1 Obtains focused history and performs physical examination provocative tests differential diagnosis and physical exam tests 2 Orders basic imaging studies radiographs AP true AP with active shoulder abduction Axillary lateral Scapular Y view 3 Prescribes non-operative treatment physical therapy anti-inflammatory medication 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provide basic post op management postop: 2-3 week postoperative visit wound check remove sutures diagnose and management of early complications<br /> B Advanced Evaluation and Management 1 Interpret basic imaging studies radiographs MRI labral tears arthritis C Preoperative H & P 1 Obtain history and perform physical exam history age gender smoker trauma physical exam check range of motion weakness of the extremity inspect for atrophy identify medical co-morbidities that might impact surgical treatment 2 Perform operative consent describe complications of surgery including infection damage to the suprascapular nerve and vessels incomplete decompression
E Preoperative Plan 1 Radiographic templating 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Make sure tower working 30° arthroscope fluid pump system standard arthroscopic instruments arthroscopic shavers and burrs radiofrequency ablation wand arthroscopic scissors 2 Room setup and Equipment standard OR table for lateral decubitus position 3 Patient Positioning lateral decubitus position pad any prominences of the extremities position the head and neck in neutral alignment G Scope Insertion 1 Outline landmarks Outline the acromion, distal clavicle, coracoid process and portal placement 2 Place posterior portal mark portal 1 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion make small skin incision place blunt trocar with the arm in 15° of abduction and 30° of forward flexion use lateral traction to avoid damage to the articular surface place the 30° arthroscope. 3 Place anterior portal halfway between acromioclavicular joint and the lateral aspect of the coracoid pierce the anterior fibers of the deltoid and enter the joint in the interval between the supraspinatus and subscapularis 4 Place lateral portal place laterally in line with the mid clavicle and 2 to 3 cm lateral to its lateral edge 5 Place medial portal place 3-3.5 cm medial to the bisecting line at the midclavicle H Diagnostic Arthroscopy 1 Visualize the anatomy articular cartridge of the humeral head and glenoid labrum biceps tendon inferior recess articular surface insertion of the subscapularis, supraspinatus, infraspinatus and teres minor 2 Establish anterior portal localize portal with an 18 gauge spinal needle placement place a seven millimeter cannula using the outside-in technique I Notch Identification 1 Incise the labrum with an intact labrum, the joint capsule above the superior-posterior labrum is incised start posterior to the biceps root and extend posteriorly for 2 to 3 cm 2 After incision of the capsule, identify the spinoglenoid notch the fibrous raphe between the supraspinatus and infraspinatus that is seen lateral to the spinoglenoid notch is a good landmark palpate the notch with an arthroscopic instrument this provides a bony landmark that can be correlated with the cyst position that is seen on the preoperative MRI J Ganglion Cyst Excision 1 Place a posterolateral accessory portal through this portal bluntly dissect through the fibrovascular tissue that covers the neurovascular bundle this can be done with a switching stick or with a similar tool the suprascapular nerve is positioned medially in direct contact with the bone of the spinoglenoid notch the vascular structures are positioned more laterally and closer to the glenoid 2 Excise the ganglion cyst ganglion cysts are typically found posterior to the nerve remove the cyst in its entirety including the lining 3 Inspect the nerve inspect the nerve for any additional sites of decompression K Wound Closure 1 Irrigation and hemostasis irrigate the portals 2 Deep closure use 3-0 biosyn for closure 3 Superficial closure use 4-0 biosyn for skin 4 Dressing and immediate immobilization place sling
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care schedule follow up orders and interprets basic imaging studies order postoperative radiographs of the shoulder to ensure appropriate implant placement 2 outpatient PT sling for 2-3 days for comfort pendulum exercises POD 1 increase active motion as tolerated R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed post-operative stiffness 2 Order and interpret advanced imaging studies MRI 3 Treats intra-operative and post operative complications irrigation and debridement for infection proper infection treatment infectious disease consultation