Preoperative Patient Care A Outpatient Evaluation 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 2 week postoperative visit remove sutures check for consolidation on radiographs 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 Operative Techniques 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 DCP plating system 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 Dorsal Longitudinal Incision 1 Mark and make the incision make a skin incision over the center of the fractured metacarpal 2 Identify the neurovascular structures identify and protect the dorsal sensory nerve branches H Fracture Exposure 1 Expose the fracture extraperiosteally identify the radial and ulnar margins this helps in achieving appropriate reduction I Plate Placement 1 Measure the correct size DCP plate 2 Place the correct size plate J Provisional Fixation 1 Fix the plate provisionally fix the plate by clamping the plate to the bone proximally the most commonly used plates are 2.0 to 2.5 mm 2 Add a subtle concave bend to the plate before its application this helps compress the volar cortices 3 Check the alignment check the sagittal and coronal plane alignment by direct inspection of the fracture site assess the rotation clinically with the aid of tenodesis K Definitive Fixation 1 Place screws in compression mode achieve at least 4 cortices of fixation in both the proximal and distal fragments 2 Check the alignment and reduction check the anatomic fracture reduction with fluoroscopy L Wound Closure 1 Close the periosteum and soft tissues close the periosteum and the interosseous muscle fascia over the plate this provides a smooth gliding surface for the extensor mechanism 2 Superficial closure close the skin with 3-0 monocryl suture Postoperative Patient Care O Perioperative 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 2 weeks R Complex Patient Care 1 Comprehensive pre-op planning/alternatives. 2 Modify and adjust post-op plan as needed
A Outpatient Evaluation 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 2 week postoperative visit remove sutures check for consolidation on radiographs 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 DCP plating system 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 Dorsal Longitudinal Incision 1 Mark and make the incision make a skin incision over the center of the fractured metacarpal 2 Identify the neurovascular structures identify and protect the dorsal sensory nerve branches H Fracture Exposure 1 Expose the fracture extraperiosteally identify the radial and ulnar margins this helps in achieving appropriate reduction I Plate Placement 1 Measure the correct size DCP plate 2 Place the correct size plate J Provisional Fixation 1 Fix the plate provisionally fix the plate by clamping the plate to the bone proximally the most commonly used plates are 2.0 to 2.5 mm 2 Add a subtle concave bend to the plate before its application this helps compress the volar cortices 3 Check the alignment check the sagittal and coronal plane alignment by direct inspection of the fracture site assess the rotation clinically with the aid of tenodesis K Definitive Fixation 1 Place screws in compression mode achieve at least 4 cortices of fixation in both the proximal and distal fragments 2 Check the alignment and reduction check the anatomic fracture reduction with fluoroscopy L Wound Closure 1 Close the periosteum and soft tissues close the periosteum and the interosseous muscle fascia over the plate this provides a smooth gliding surface for the extensor mechanism 2 Superficial closure close the skin with 3-0 monocryl suture
O Perioperative 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 2 weeks R Complex Patient Care 1 Comprehensive pre-op planning/alternatives. 2 Modify and adjust post-op plan as needed