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 attempts trial of physical therapy 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 2 week postoperative visit diagnose and management of early complications remove skin sutures 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 wound complications painful neuroma altered sensation CRPS
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 Nerve Exposure 1 Make the incision over the injured nerve 2 Bluntly dissect to the injured nerve 3 Expose both ends of the injured nerve H Nerve Mobilization 1 Mobilize the nerve mobilize nerve ends for about 1 to 2 cm at either end avoid any unnecessary stripping of the mesoneurium over long distances 2 Identify and preserve vital structures preserve the common sheath of the neurovascular bundles this maintains nerve vascularity and minimizes the tension on the nerve repair I Epineural Repair 1 Expose the fascicles expose the nerve fascicles until they are clean and pouting 2 Identify the epineurium identify the epineurium circumferentially by resection or pushing back at the mesoneurium correct alignment of the nerve ends is critical 3 Correctly align the epineurium line up the blood vessels and other external markings in the epineurium match the fascicular bundles into two bundles 4 Select the appropriate suture suture needs to be monofilament on an atraumatic needle to minimize the trauma to the nerve ends suture size in the arm is usually 8-0 is used in the arm, 9-0 in the fingers repair with larger suture does not add strength to the repair 5 Place the initial sutures place 2 simple sutures 180 degrees from one another avoid penetrating fascicle with the needle leave one tail of each suture long to stabilize the nerve during the repair J Anterior Repair 1 Place additional sutures place three or four additional sutures on the anterior face of the repair as needed this is done to approximate the epineurium and prevent fascicular extrusion 2 Remove excess tension on the nerve flex the limb to further to relax the nerve K Posterior Repair 1 Expose the posterior face of the nerve turn the nerve over expose the posterior wall by using the suture tails 2 Stabilize the nerve weigh each suture down using a vascular clip 3 Perform the posterior wall repair complete the posterior wall repair with three or four simple epineurial sutures cut the long tails short 4 re-evaluate the nerve examine the nerve to ensure that the epineural seal is complete L Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Superficial closure use running subcuticular nonabsorbable monofilament suture 3 Dressing and immediate immobilization immobilize the extremity place the elbow in 90 degrees of flexion avoid wrist flexion greater than 20 degrees
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders remove splint in one week pain management 2 Orders appropriate inpatient occupational and physical therapy (weight-bearing, ROM, limitations of 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