Preoperative Patient Care 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 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 Neutralization plate and lag screws 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 Longitudinal Dorsal Incision 1 Mark and make the incision ensure that the exposure allows fixation of four cortices to the fracture both proximally and distally 2 Identify the neurovascular structures identify and protect the dorsal sensory nerve branches H Provisional Fixation 1 Place a reduction clamp place a reduction clamp for provisional fixation if the fracture geometry permits , place a 2.0 to 2.5 mm contoured plate over the fracture I Plate and Lag Screw Fixation 1 Place a neutralization plate if the fracture geometry permits , place a 2.0 to 2.5 mm contoured plate over the fracture 2 Place lag screws place a lag screw either alone or through the plate one advantage of placing the lag screw through the plate is that it minimizes the amount of soft tissue dissection along with improves stability 3 Place the remaining screws in the plate fill the screw holes in the remainder of the plate standard cortical screws are sufficient in the event that the metaphyseal portion of the bone needs fixation, locking screws can be placed J 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 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 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 Neutralization plate and lag screws 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 Longitudinal Dorsal Incision 1 Mark and make the incision ensure that the exposure allows fixation of four cortices to the fracture both proximally and distally 2 Identify the neurovascular structures identify and protect the dorsal sensory nerve branches H Provisional Fixation 1 Place a reduction clamp place a reduction clamp for provisional fixation if the fracture geometry permits , place a 2.0 to 2.5 mm contoured plate over the fracture I Plate and Lag Screw Fixation 1 Place a neutralization plate if the fracture geometry permits , place a 2.0 to 2.5 mm contoured plate over the fracture 2 Place lag screws place a lag screw either alone or through the plate one advantage of placing the lag screw through the plate is that it minimizes the amount of soft tissue dissection along with improves stability 3 Place the remaining screws in the plate fill the screw holes in the remainder of the plate standard cortical screws are sufficient in the event that the metaphyseal portion of the bone needs fixation, locking screws can be placed J 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