Preoperative Patient Care A Outpatient Evaluationa 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 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 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 Incision 1 Make the incision over the injured nerve 2 Bluntly dissect to the injured nerve 3 Expose both ends of the injured nerve H Conduit Selection and Preparation 1 Mobilize the nerve 2 Measure the nerve diameter 3 Choose a conduit that is oversized by 1 mm this is done to avoid constriction of the regenerating nerves 4 Rehydrate the conduit in saline for 5 minutes I Suture Placement 1 Place sutures invaginate each end of the nerve into the tube for a distance of 5 to 8 mm using a mattress suture followed by anchoring suture for stability first pass the suture through the tube from the outside in and 5 mm from the tube edge pass the suture then transversely across the epineurium 3 mm from the edge of the nerve stump and then back through the tube in an inside to outside direction J Nerve Placement 1 Place additional sutures 2 Gently ease the nerve into the tube as the knot is tightened place a simple suture between the epineurium and the edge of the tube at a diametrically opposite point to anchor the tube and prevent rotation 3 Repeat the same steps for the distal stump fill the tube with saline using a fine cannula K Wound Closure and Immobilization 1 Expose the posterior face of the nerve 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 Postoperative Patient Care 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
A Outpatient Evaluationa 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 Incision 1 Make the incision over the injured nerve 2 Bluntly dissect to the injured nerve 3 Expose both ends of the injured nerve H Conduit Selection and Preparation 1 Mobilize the nerve 2 Measure the nerve diameter 3 Choose a conduit that is oversized by 1 mm this is done to avoid constriction of the regenerating nerves 4 Rehydrate the conduit in saline for 5 minutes I Suture Placement 1 Place sutures invaginate each end of the nerve into the tube for a distance of 5 to 8 mm using a mattress suture followed by anchoring suture for stability first pass the suture through the tube from the outside in and 5 mm from the tube edge pass the suture then transversely across the epineurium 3 mm from the edge of the nerve stump and then back through the tube in an inside to outside direction J Nerve Placement 1 Place additional sutures 2 Gently ease the nerve into the tube as the knot is tightened place a simple suture between the epineurium and the edge of the tube at a diametrically opposite point to anchor the tube and prevent rotation 3 Repeat the same steps for the distal stump fill the tube with saline using a fine cannula K Wound Closure and Immobilization 1 Expose the posterior face of the nerve 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