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Metacarpal Head Fractures ORIF

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

  • headless screws
  • guidewires

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

Incision

1

Mark and make the incision

  • make a longitudinal or curvilinear incision over the metacarpal head

2

Bluntly dissect to the extensor mechanism

H

Soft Tissue Dissection

1

Expose the fracture site

  • split the extensor mechanism
  • longitudinally incise the capsule
I

Fracture Reduction

1

Manipulate the MCP joint

  • flex the MCP joint
  • this will facilitate the exposure of the fracture

2

Reduce the fracture

  • use a dental pick or small pointed reduction forceps to reduce the fracture
J

Provisional Fixation

1

Place guidewires

  • insert guidewires from a cannulated headless screw set
K

Definitive Fixation

1

Place headless screws

  • insert headless screws over the guidewires

2

Confirm placement and reduction

  • check the screw placement and fracture reduction radiographically
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

Repair the extensor mechanism

  • close the extensor mechanism with 4-0 nonabsorbable suture

3

Superficial closure

  • close the skin with 3-0 monocryl suture
N

Wound Closure

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

 

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