A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam check range of motion check radial and ulnar pulses 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 2 week postoperative visit remove sutures diagnose and management of early complications continue range of motion exercises 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 bowstringing
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 Superficial Dissection 1 Mark and make incision mark and make a 1 cm incision directly over the affected A1 pulley avoid crossing palmar skin creases at a right angle with any incision type incise only the skin and dermis with a no. 15 blade H Deep Dissection 1 Dissect through subcutaneous tissue use blunt dissection to spread the subcutaneous tissue I Neurovascular Structure Identification 1 Identify the neurovascular structures protect and retract the neurovascular structures the digital radial nerve is the nerve that is most at risk because it typically crosses the surgical field J A1 Pulley Release 1 Expose the A1 pulley use a sponge to expose the A1 pulley 2 Release the A1 pulley do not incise the A1 pulley until it is completely exposed use a knife to start the A1 pulley incision complete the release with scissors until the leaflets of the A1 pulley can be completely spread apart avoid cutting the A2 pulley K Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Superficial closure use 4-0 nylon to close the skin 3 Dressing and immediate immobilization place in soft dressing
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders pain management outpatient PT start active range of motion exercises 2 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