Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam history: past history of cancer or radiation, prior treatments pre-existing pain smoking or chemical exposure constitutional symptoms fever physical exam notes lymph node involvement, lumps/nodules 2 Interprets basic imaging studies describe the radiographic appearance osteolytic osteoblastic 3 Prescribes and manages nonoperative treatment understand when to have the patient back to clinic for follow-up understand when to order new radiographic imaging studies 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check check radiographs start formal physical therapy diagnose and management of early complications infection DVT/PE wound breakdown neurovascular compromise hardware failure postop: 4-6 week postoperative visit check radiographs diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies/lab studies 3D radiographic studies to include CT MRI lab studies SPEP/UPEP PSA other tumor markers 2 Recommends complex non-operative treatment RFA or cryoablation Bisphosphonates Kyphoplasty or vertebroplasty 3 Nonoperative treatment infection wound breakdown DVT/PE) 4 Pre-operative preparation and consultation onc rad onc counseling C Preoperative H & P 1 Obtains history and performs basic physical exam history pain and function past medical/surgical/social/family history review of systems physical exam heart lungs extremity exam range of motion strength sensation skin changes tenderness 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies radiographs AP/lateral of the lesion Joint above and below the lesion 4 Prescribe non-operative treatment protected weightbearing bracing no intervention 5 Perform operative consent describe complications of surgery including Infection Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia Operative Techniques E Preoperative Plan 1 Template instrumentation template implant size 2 Execute surgical walkthrough describe the steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation Intramedullary humeral nail system 2 Room setup and Equipment standard OR table 3 Patient Positioning beach chair position place a small roll between the medial borders of the scapula turn the head to the contralateral side G Approach 1 Palpate and outline the anatomy of the humerus, clavicle and the humeral head identify and mark out the midline 2 Make the skin incision make a small longitudinal incision over the anterolateral corner of the acromion centered over the greater tuberosity extend the incision distally 3 cm 3 Perform skin incision use 10 blade for skin incision 4 Divide the deltoid split the deltoid fibers in line with the longitudinal incision do not extend the incision more than 4 cm because of the axillary nerve use knife down to fascia lata 5 Reflect the supraspinatus longitudinally incise the the supraspinatus in line with the skin incision for 1 to 2 cm just posterior to the bicipital tuberosity place suture tags H Canal Entry 1 Make the entry hole make the entry hole just medial to the to of the greater tuberosity, just lateral to the articular margin and 0.5 cm posterior to the bicipital groove make sure the entry hole is centered on AP and Lateral radiographs 2 Place the Kwire insert the kwire into the medullary canal to the level of the lesser tuberosity 3 Open the medullary canal use an awl or pass a cannulated drill bit over the kwire extend the shoulder to improve clearance of the acromion once the canal is opened, remove the kwire and place a ball tip guidewire 4 Advance the guidewire advance the guidewire until it is 1 to 2 cm proximal to the olecranon fossa I Determine Nail Length 1 Guide rod method with the distal end of the rod 1 to 2 cm proximal to the olecranon fossa, overlap a second guide rod extending proximally from the humeral entry portal subtract the length in mm of the overlapped guide rod from the total length of the identical guidewire to determine the nail length 2 Nail length gauge place the radioopaque gauge anterior to the humerus move the the C-arm to the proximal end of the humerus read the length from the stamped measurements on the gauge J Reaming and Nail Insertion 1 Ream the humeral shaft slowly ream the entire humerus over the ball tipped guidewire in 0.5 mm increments choose a nail that is 1 mm smaller than the last reamer used 2 Insert the nail attach the nail to an adaptor place the nail holding screw through the adaptor place the radiolucent targeting device onto the nail adaptor 3 Verify the nail assembly insert a drill bit through the assembled tissue protector placed in the required holes of the targeting device 4 Advance the nail manually advance the nail with sustained pressure insert the nail to at least the first circumferential groove on the nail adaptor but no deeper than the second groove countersink the nail 5 mm below the articular surface K Distal Locking Screws 1 Place the interlocking screws in a specific order place anterior, then posterior, then lateral then medial directed interlocking screws 2 Place the anterior-posterior screws advance the C arm over the distal humerus until the oval slot is seen in a perfect circle use a scalpel over the skin to precisely determine the location of the incision keep incision lateral to the biceps tendon after skin incision use a blunt hemostat to spread under the brachialis muscle insert a short drill bit through a soft tissue protector center the drill bit in the locking hole hole attach the drill and penetrate the near cortex detach the drill bit then use a mallet to advance the drill bit to the far cortex reattach the drill and penetrate the far cortex place a depth gauge and measure the length of the interlocking screws place the interlocking screws use C arm to confirm placement and length 3 Place the lateral-medial screws advance the C arm over the distal humerus until the oval slot is seen in a perfect circle use a scalpel over the skin to precisely determine the location of the incision after skin incision use a blunt hemostat to spread to the bone insert a short drill bit through a soft tissue protector center the drill bit in the locking hole hole attach the drill and penetrate the near cortex detach the drill bit then use a mallet to advance the drill bit to the far cortex reattach the drill and penetrate the far cortex place a depth gauge and measure the length of the interlocking screws place the interlocking screws use C arm to confirm placement and length L Wound Closure 1 Repair the supraspinatus and deltoid use nonabsobable suture to perform a side to side repair 2 Close the deep fascia use 0 vicryl for deep fascia 3 Perform superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressings place soft dressings place in sling or shoulder immobilizer Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 2 Appropriately orders and interprets basic imaging studies post-op xrays of the humerus in post-op 3 Appropriate medical management and medical consultation 4 Inpatient physical therapy start pendulum and elbow ROM exercises 5 Discharges patient appropriately pain meds outpatient pt schedule follow up appointment in 2 weeks R Complex Patient Care 1 Recommends appropriate biopsy including biopsy alternatives and appropriate techniques understand role of open biopsy vs needle biopsy 2 Develops unique, complex post-operative management plans
A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam history: past history of cancer or radiation, prior treatments pre-existing pain smoking or chemical exposure constitutional symptoms fever physical exam notes lymph node involvement, lumps/nodules 2 Interprets basic imaging studies describe the radiographic appearance osteolytic osteoblastic 3 Prescribes and manages nonoperative treatment understand when to have the patient back to clinic for follow-up understand when to order new radiographic imaging studies 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check check radiographs start formal physical therapy diagnose and management of early complications infection DVT/PE wound breakdown neurovascular compromise hardware failure postop: 4-6 week postoperative visit check radiographs diagnosis and management of late complications postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Appropriately orders and interprets advanced imaging studies/lab studies 3D radiographic studies to include CT MRI lab studies SPEP/UPEP PSA other tumor markers 2 Recommends complex non-operative treatment RFA or cryoablation Bisphosphonates Kyphoplasty or vertebroplasty 3 Nonoperative treatment infection wound breakdown DVT/PE) 4 Pre-operative preparation and consultation onc rad onc counseling C Preoperative H & P 1 Obtains history and performs basic physical exam history pain and function past medical/surgical/social/family history review of systems physical exam heart lungs extremity exam range of motion strength sensation skin changes tenderness 2 Screen medical studies to identify and contraindications for surgery 3 Orders basic imaging studies radiographs AP/lateral of the lesion Joint above and below the lesion 4 Prescribe non-operative treatment protected weightbearing bracing no intervention 5 Perform operative consent describe complications of surgery including Infection Wound complications Neurovascular compromise Tumor progression DVT/PE Pneumonia
E Preoperative Plan 1 Template instrumentation template implant size 2 Execute surgical walkthrough describe the steps of the procedure to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation Intramedullary humeral nail system 2 Room setup and Equipment standard OR table 3 Patient Positioning beach chair position place a small roll between the medial borders of the scapula turn the head to the contralateral side G Approach 1 Palpate and outline the anatomy of the humerus, clavicle and the humeral head identify and mark out the midline 2 Make the skin incision make a small longitudinal incision over the anterolateral corner of the acromion centered over the greater tuberosity extend the incision distally 3 cm 3 Perform skin incision use 10 blade for skin incision 4 Divide the deltoid split the deltoid fibers in line with the longitudinal incision do not extend the incision more than 4 cm because of the axillary nerve use knife down to fascia lata 5 Reflect the supraspinatus longitudinally incise the the supraspinatus in line with the skin incision for 1 to 2 cm just posterior to the bicipital tuberosity place suture tags H Canal Entry 1 Make the entry hole make the entry hole just medial to the to of the greater tuberosity, just lateral to the articular margin and 0.5 cm posterior to the bicipital groove make sure the entry hole is centered on AP and Lateral radiographs 2 Place the Kwire insert the kwire into the medullary canal to the level of the lesser tuberosity 3 Open the medullary canal use an awl or pass a cannulated drill bit over the kwire extend the shoulder to improve clearance of the acromion once the canal is opened, remove the kwire and place a ball tip guidewire 4 Advance the guidewire advance the guidewire until it is 1 to 2 cm proximal to the olecranon fossa I Determine Nail Length 1 Guide rod method with the distal end of the rod 1 to 2 cm proximal to the olecranon fossa, overlap a second guide rod extending proximally from the humeral entry portal subtract the length in mm of the overlapped guide rod from the total length of the identical guidewire to determine the nail length 2 Nail length gauge place the radioopaque gauge anterior to the humerus move the the C-arm to the proximal end of the humerus read the length from the stamped measurements on the gauge J Reaming and Nail Insertion 1 Ream the humeral shaft slowly ream the entire humerus over the ball tipped guidewire in 0.5 mm increments choose a nail that is 1 mm smaller than the last reamer used 2 Insert the nail attach the nail to an adaptor place the nail holding screw through the adaptor place the radiolucent targeting device onto the nail adaptor 3 Verify the nail assembly insert a drill bit through the assembled tissue protector placed in the required holes of the targeting device 4 Advance the nail manually advance the nail with sustained pressure insert the nail to at least the first circumferential groove on the nail adaptor but no deeper than the second groove countersink the nail 5 mm below the articular surface K Distal Locking Screws 1 Place the interlocking screws in a specific order place anterior, then posterior, then lateral then medial directed interlocking screws 2 Place the anterior-posterior screws advance the C arm over the distal humerus until the oval slot is seen in a perfect circle use a scalpel over the skin to precisely determine the location of the incision keep incision lateral to the biceps tendon after skin incision use a blunt hemostat to spread under the brachialis muscle insert a short drill bit through a soft tissue protector center the drill bit in the locking hole hole attach the drill and penetrate the near cortex detach the drill bit then use a mallet to advance the drill bit to the far cortex reattach the drill and penetrate the far cortex place a depth gauge and measure the length of the interlocking screws place the interlocking screws use C arm to confirm placement and length 3 Place the lateral-medial screws advance the C arm over the distal humerus until the oval slot is seen in a perfect circle use a scalpel over the skin to precisely determine the location of the incision after skin incision use a blunt hemostat to spread to the bone insert a short drill bit through a soft tissue protector center the drill bit in the locking hole hole attach the drill and penetrate the near cortex detach the drill bit then use a mallet to advance the drill bit to the far cortex reattach the drill and penetrate the far cortex place a depth gauge and measure the length of the interlocking screws place the interlocking screws use C arm to confirm placement and length L Wound Closure 1 Repair the supraspinatus and deltoid use nonabsobable suture to perform a side to side repair 2 Close the deep fascia use 0 vicryl for deep fascia 3 Perform superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin 4 Dressings place soft dressings place in sling or shoulder immobilizer
O Perioperative Inpatient Management 1 Write comprehensive admission orders DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 2 Appropriately orders and interprets basic imaging studies post-op xrays of the humerus in post-op 3 Appropriate medical management and medical consultation 4 Inpatient physical therapy start pendulum and elbow ROM exercises 5 Discharges patient appropriately pain meds outpatient pt schedule follow up appointment in 2 weeks R Complex Patient Care 1 Recommends appropriate biopsy including biopsy alternatives and appropriate techniques understand role of open biopsy vs needle biopsy 2 Develops unique, complex post-operative management plans