Updated: 10/4/2016

Conduit Repair

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Questions
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Cases
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Techniques
2

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

 

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