Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam 2 Appropriately interprets basic imaging studies 3 Prescribes and manages non-operative treatment identifies indications for nonoperative treatment partial Lisfranc injuries non-displaced or minimally displaced extra-articular metatarsal base fractures with no intra-articular involvement treatment venous compression stocking and prefabricated fracture boot 4 Provides post-operative management and rehabilitation postop: 2-3 Week Postoperative Visit wound check diagnose and management of early complications check radiographs for alignment convert to venous compression stocking and prefabricated fracture boot start early progressive range of motion 5 Postop: ~ 3 month Postoperative Visit check weight-bearing radiographs if reduction stable, start weight-bearing advance to regular shoes and activity as tolerated B Advanced Evaluation and Management 1 Recognizes indications for and provides non-operative treatment of an unstable fracture 2 Capable of treating complications both intraoperatively and post-operatively 3 Appropriately orders and interprets advanced imaging studies 4 Provides a comprehensive assessment of most fractures on imaging studies C Preoperative H & P 1 Performs basic history and physical history identify mechanism of trauma position of the foot direction of the force extent of the energy involved physical exam assess for associated injuries check for diffuse swelling at the midfoot palpate the midfoot joints test midfoot stability perform passive range of motion of the metatarsal heads and passive abduction through the forefoot. 2 Order appropriate basic imaging studies order triplanar non-weightbearing views AP lateral oblique if the injury is subtle, obtain weight-bearing views 3 Perform operative consent describe complications of surgery including infection nonunion malunion Operative Techniques E Preoperative Plan 1 Radiographic templating template the fracture with instrumentation 2 Execute surgical walkthrough describe steps of the procedure verbally prior to the start of the case 3 List potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation K wire pointed reduction forceps 3.5 mm cortical screw 2 Room setup and equipment standard operative table fluoroscopy 3 Patient positioning patient is placed in the supine position with a bolster beneath the ipsilateral hip place protective padding around the contralateral limb to protect the peroneal nerve place a sterile bolster beneath the operative limb at the knee to facilitate access to the midfoot and intraoperative fluoroscopy place tourniquet G Dual Incision Approach 1 Identify anatomic landmarks and draw incision identify the EHL and center medial incision over the first tarsometatarsal joint identify the lateral border of the third tarsometatarsal joint for the lateral incision 2 Medial incision make the skin incision over the first tarsometatarsal joint expose the tarsometatarsal joint incise the EHL tendon sheath dorsally retract the EHL laterally incise the floor of the EHL tendon sheath create full thickness flaps perform subperiosteal dissection extending to the first tarsometatarsal joint and produce a full thickness flap use soft tissue flap to protect the neurovascular bundle identify the intercuneiform joint capsules and test the stability of each joint 3 Lateral incision elevate the third tarsometatarsal joint place a freer elevator under the full thickness skin flap to the level of the third tarsometatarsal joint make skin incision make skin incision over the lateral border of the third tarsometatarsal joint expose the third tarsometatarsal joint identify the extensor retinaculum expose the EDC tendon and the medial margin of the EDB muscle retract the EDC and the EDB laterally create full thickness flap perform a subperiosteal dissection directed medially towards the lateral portion of the of the second tarsometatarsal joint and laterally towards the fourth and fifth tarsometatarsal joint when needed H Articular Surface Assessment 1 Prepare fracture debride the fracture and articular surface of residual hematoma 2 Identify the extent of chondral damage if less than 50% of the articular surface of the medial and middle column joints is involved, then proceed with ORIF if more than 50% involved, proceed with arthrodesis I Provisional Reduction 1 Perform reduction place pointed reduction forceps place forceps from the medial cuneiform to the lateral border of the second metatarsal 2 Confirm reduction use fluoroscopy to confirm the reduction 3 Place a K wire place K wire in the intended path of the screw to provide rotational control 4 Identify the cortical shelf on the medial cuneiform this shelf provides an excellent buttress for screw purchase J Final Fixation 1 Place 3.5 mm cortical screw make stab incision directly over the cortical shelf medially place screw in the cortical shelf medially angle screw towards the proximal metaphysis of the second metatarsal remove the K wire 2 Confirm placement of screw with fluoroscopy K Wound Closure 1 Irrigate the wounds irrigate the wound 2 Deep closure close the subperiosteal flaps and the floor of the EHL sheath with 0-vicryl close the EHL tendon sheath with 0-vicryl 3 Superficial closure close the subcutaneous tissue with 2-0 vicryl close the skin with 3-0 monocryl 4 Dressings place in bulky jones dressings and weber splint Postoperative Patient Care O Perioperative inpatient management 1 Discharge patient appropriately take xrays of the foot in postop to verify reduction oral pain meds schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans 2 Order and interpret advanced imaging studies to complete preoperative plan with alternatives
A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam 2 Appropriately interprets basic imaging studies 3 Prescribes and manages non-operative treatment identifies indications for nonoperative treatment partial Lisfranc injuries non-displaced or minimally displaced extra-articular metatarsal base fractures with no intra-articular involvement treatment venous compression stocking and prefabricated fracture boot 4 Provides post-operative management and rehabilitation postop: 2-3 Week Postoperative Visit wound check diagnose and management of early complications check radiographs for alignment convert to venous compression stocking and prefabricated fracture boot start early progressive range of motion 5 Postop: ~ 3 month Postoperative Visit check weight-bearing radiographs if reduction stable, start weight-bearing advance to regular shoes and activity as tolerated B Advanced Evaluation and Management 1 Recognizes indications for and provides non-operative treatment of an unstable fracture 2 Capable of treating complications both intraoperatively and post-operatively 3 Appropriately orders and interprets advanced imaging studies 4 Provides a comprehensive assessment of most fractures on imaging studies C Preoperative H & P 1 Performs basic history and physical history identify mechanism of trauma position of the foot direction of the force extent of the energy involved physical exam assess for associated injuries check for diffuse swelling at the midfoot palpate the midfoot joints test midfoot stability perform passive range of motion of the metatarsal heads and passive abduction through the forefoot. 2 Order appropriate basic imaging studies order triplanar non-weightbearing views AP lateral oblique if the injury is subtle, obtain weight-bearing views 3 Perform operative consent describe complications of surgery including infection nonunion malunion
E Preoperative Plan 1 Radiographic templating template the fracture with instrumentation 2 Execute surgical walkthrough describe steps of the procedure verbally prior to the start of the case 3 List potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation K wire pointed reduction forceps 3.5 mm cortical screw 2 Room setup and equipment standard operative table fluoroscopy 3 Patient positioning patient is placed in the supine position with a bolster beneath the ipsilateral hip place protective padding around the contralateral limb to protect the peroneal nerve place a sterile bolster beneath the operative limb at the knee to facilitate access to the midfoot and intraoperative fluoroscopy place tourniquet G Dual Incision Approach 1 Identify anatomic landmarks and draw incision identify the EHL and center medial incision over the first tarsometatarsal joint identify the lateral border of the third tarsometatarsal joint for the lateral incision 2 Medial incision make the skin incision over the first tarsometatarsal joint expose the tarsometatarsal joint incise the EHL tendon sheath dorsally retract the EHL laterally incise the floor of the EHL tendon sheath create full thickness flaps perform subperiosteal dissection extending to the first tarsometatarsal joint and produce a full thickness flap use soft tissue flap to protect the neurovascular bundle identify the intercuneiform joint capsules and test the stability of each joint 3 Lateral incision elevate the third tarsometatarsal joint place a freer elevator under the full thickness skin flap to the level of the third tarsometatarsal joint make skin incision make skin incision over the lateral border of the third tarsometatarsal joint expose the third tarsometatarsal joint identify the extensor retinaculum expose the EDC tendon and the medial margin of the EDB muscle retract the EDC and the EDB laterally create full thickness flap perform a subperiosteal dissection directed medially towards the lateral portion of the of the second tarsometatarsal joint and laterally towards the fourth and fifth tarsometatarsal joint when needed H Articular Surface Assessment 1 Prepare fracture debride the fracture and articular surface of residual hematoma 2 Identify the extent of chondral damage if less than 50% of the articular surface of the medial and middle column joints is involved, then proceed with ORIF if more than 50% involved, proceed with arthrodesis I Provisional Reduction 1 Perform reduction place pointed reduction forceps place forceps from the medial cuneiform to the lateral border of the second metatarsal 2 Confirm reduction use fluoroscopy to confirm the reduction 3 Place a K wire place K wire in the intended path of the screw to provide rotational control 4 Identify the cortical shelf on the medial cuneiform this shelf provides an excellent buttress for screw purchase J Final Fixation 1 Place 3.5 mm cortical screw make stab incision directly over the cortical shelf medially place screw in the cortical shelf medially angle screw towards the proximal metaphysis of the second metatarsal remove the K wire 2 Confirm placement of screw with fluoroscopy K Wound Closure 1 Irrigate the wounds irrigate the wound 2 Deep closure close the subperiosteal flaps and the floor of the EHL sheath with 0-vicryl close the EHL tendon sheath with 0-vicryl 3 Superficial closure close the subcutaneous tissue with 2-0 vicryl close the skin with 3-0 monocryl 4 Dressings place in bulky jones dressings and weber splint
O Perioperative inpatient management 1 Discharge patient appropriately take xrays of the foot in postop to verify reduction oral pain meds schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans 2 Order and interpret advanced imaging studies to complete preoperative plan with alternatives