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 4 week postoperative visit check for consolidation on radiographs remove K wires 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 K wires 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 Closed Reduction 1 Perform a closed reduction flex the MCP joint to obtain control of the distal fragment H K Wire Placement 1 Place the K wire place a 0.045 inch smooth K wire by hand on the radial or ulnar collateral recess 2 Check placement using fluoroscopy confirm that the placement is at the deepest concavity of the collateral recess take an oblique or near true lateral view to confirm placement of the pin in the sagittal plane I Wire Advancement 1 Advance the wire to the fracture site advance the wire using power into the shoulder of the metacarpal down the intramedullary canal up to the fracture site 2 Reduce the fracture 3 Advance the wire past the fracture site make sure that it stays in the intramedullary canal 4 Seat the wire in the bone of the metacarpal base another option for advancement is to use a mallet instead of power this allows bounce off of the far cortex J Passage of Second Wire 1 Pass a second wire this completes and strengthens the fracture stabilization reduction and fixation is optimum when both wires cross the fracture site
O Perioperartive 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 1 week R Complex Patient Care 1 Comprehensive pre-op planning/alternatives. 2 Modify and adjust post-op plan as needed