Preoperative Patient Care A Intermediate Evaluation and Management 1 Recognize vascular, nerve or other associated injuries document neurovascular status 2 Appropriately interprets basic imaging studies and recognizes fracture patterns interpret radiographs of the hip look for a widened physis on AP or lateral radiographs 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit check radiographs diagnose and management of early complications continue touch down weight bearing postop: 6 week postoperative visit check radiographs start weightbearing check radiographs yearly until skeletal maturity 5 Capable of diagnosis and early management of complications B Advanced Evaluation and Management 1 Recognizes factors that could predict difficult reduction and post-operative complication risk abnormal vascular examination neurological deficits 2 Appropriately orders and interprets advanced imaging studies 3 Completes comprehensive pre-operative planning with alternatives 4 Modifies and adjusts post-operative treatment plan as needed recognize deviations from typical postoperative course C Preoperative H & P 1 Obtains history and performs basic physical exam screen for risk factors for SCFE including obesity, renal disease, hypothyroidism, growth hormone usage, or prior radiation to the area perform neurovascular exam 2 Order basic imaging studies AP and frog leg lateral hip radiographs Measure slip angle and percent displacement 3 Perform operative consent describe complications of surgery including chondrolysis osteonecrosis further slippage Operative Techniques E Preoperative Plan 1 Template reduction determine the slip angle and percent displacement 2 Execute surgical walkthrough describe key steps of the operation verbally to attending prior to beginning of case. describe potential complications and the steps to avoid them F Room Preparation 1 Surgical instrumentation 6.5 or 7.3 mm cannulated screws 2 Room setup and equipment setup OR with standard radiolucent operating table fracture table is an option C-arm in from contralateral side of bed monitor in surgeon direct line of site at foot of bed flex the hip 90 degrees and abduct 45 degrees to obtain lateral views 3 Patient positioning supine pad the ipsilateral arm and position across the chest G Guidewire Placement 1 Identify the course of the guidewire use imaging to identify the femoral neck at its longest internally and externally rotate the hip until the femoral neck appears to be at its longest the femoral neck should be should be horizontal to the operating table and perpendicular to the image beam 2 Align the guidewire place a guidewire on the anterior hip and align the point of the guidewire over the center of the femoral head align the guidewire along the neck mark the skin along the guidewire to identify the planned trajectory of the wire this will represent the trajectory the guide pin should follow on the AP images H Determination of the Femoral Neck Entry Point 1 With unstable SCFEs, before manipulation of the leg for lateral views, consider initial temporary fixation of the epiphysis (usually with a guidewire). 2 Determine the path of the bone screw in the sagittal plane flex hip 90 degrees and abduct the hip 45 degrees align the guide wire along the neck over the center of the femoral head this represents the desired path of the screw in the sagittal plane the point that this line crosses the femoral neck is the entry point for the guidewire I Skin Entry Site Determination 1 Mark the skin incision example if the slip angle measured is 30 degrees, the entry point on the skin should be 30 degrees from the lateral palpable femoral shaft towards the femoral head 2 Make a skin incision make a 1 cm incision through the skin and spread with the hemostat down to the bone along the line that was previously drawn the point of the guidepin should be positioned on the anterolateral femoral neck where the entry was estimated entry point should be lateral to the intertrochanteric line (on AP view) to avoid screw head impingement J Guide Pin Insertion 1 Drill and advance the guidepin drill the guidepin into the midpoint of the femoral neck 2 Check pin placement confirm the position with imaging once the position of the guidepin is confirmed advance the guidepin to within 3 mm of the articular surface and the length is measured should be center center in the EPIPHYSIS 3 Confirm guide pin position confirm the final position of the guidepin with multiple radiographic images must be out of the joint on all images K Drilling and Cannulated Screw Placement 1 Measure the length of the cannulated screw measure the guidewire with the cannulated screw depth gauge to determine the desired screw length 2 Place cannulated screw use the cannulated drill over the guidewire stop the drill 1 or 2 mm before the tip of the guidewire drill must cross the physis place a 6.5 mm to a 7.3 mm cannulated screw over the guidewire remove the guidewire single screw fixation is usually favorable compared to multiple screws, lower risk of osteonecrosis and intraarticular penetration L Radiographic Evaluation 1 Ensure placement of the cannulated screw use spot AP and frog leg lateral fluoroscopy to ensure placement attempt if possible to have five threads of the screw within the epiphysis to decrease the risk of slip progression 2 Test for penetration into the joint use the "approach and withdraw" method to ensure that the screw tip remains in the femoral head under fluoroscopy range the hip from internal to external rotation at varying degrees of flexion watch to see if the screw tip approaches and withdraws from the subchondral bone N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Deep closure use 0-vicryl for deep closure 3 Superficial closure use 2-0 vicryl for the subcutaneous tissue use 3-0 monocryl for skin 4 Dressings and immobilization place a soft dressing on the incision Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated check appropriate labs wound care inpatient physical therapy 2 Discharge patient appropriately pain meds touch down weight bearing monitor neurological and vascular status schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Intermediate Evaluation and Management 1 Recognize vascular, nerve or other associated injuries document neurovascular status 2 Appropriately interprets basic imaging studies and recognizes fracture patterns interpret radiographs of the hip look for a widened physis on AP or lateral radiographs 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit check radiographs diagnose and management of early complications continue touch down weight bearing postop: 6 week postoperative visit check radiographs start weightbearing check radiographs yearly until skeletal maturity 5 Capable of diagnosis and early management of complications B Advanced Evaluation and Management 1 Recognizes factors that could predict difficult reduction and post-operative complication risk abnormal vascular examination neurological deficits 2 Appropriately orders and interprets advanced imaging studies 3 Completes comprehensive pre-operative planning with alternatives 4 Modifies and adjusts post-operative treatment plan as needed recognize deviations from typical postoperative course C Preoperative H & P 1 Obtains history and performs basic physical exam screen for risk factors for SCFE including obesity, renal disease, hypothyroidism, growth hormone usage, or prior radiation to the area perform neurovascular exam 2 Order basic imaging studies AP and frog leg lateral hip radiographs Measure slip angle and percent displacement 3 Perform operative consent describe complications of surgery including chondrolysis osteonecrosis further slippage
E Preoperative Plan 1 Template reduction determine the slip angle and percent displacement 2 Execute surgical walkthrough describe key steps of the operation verbally to attending prior to beginning of case. describe potential complications and the steps to avoid them F Room Preparation 1 Surgical instrumentation 6.5 or 7.3 mm cannulated screws 2 Room setup and equipment setup OR with standard radiolucent operating table fracture table is an option C-arm in from contralateral side of bed monitor in surgeon direct line of site at foot of bed flex the hip 90 degrees and abduct 45 degrees to obtain lateral views 3 Patient positioning supine pad the ipsilateral arm and position across the chest G Guidewire Placement 1 Identify the course of the guidewire use imaging to identify the femoral neck at its longest internally and externally rotate the hip until the femoral neck appears to be at its longest the femoral neck should be should be horizontal to the operating table and perpendicular to the image beam 2 Align the guidewire place a guidewire on the anterior hip and align the point of the guidewire over the center of the femoral head align the guidewire along the neck mark the skin along the guidewire to identify the planned trajectory of the wire this will represent the trajectory the guide pin should follow on the AP images H Determination of the Femoral Neck Entry Point 1 With unstable SCFEs, before manipulation of the leg for lateral views, consider initial temporary fixation of the epiphysis (usually with a guidewire). 2 Determine the path of the bone screw in the sagittal plane flex hip 90 degrees and abduct the hip 45 degrees align the guide wire along the neck over the center of the femoral head this represents the desired path of the screw in the sagittal plane the point that this line crosses the femoral neck is the entry point for the guidewire I Skin Entry Site Determination 1 Mark the skin incision example if the slip angle measured is 30 degrees, the entry point on the skin should be 30 degrees from the lateral palpable femoral shaft towards the femoral head 2 Make a skin incision make a 1 cm incision through the skin and spread with the hemostat down to the bone along the line that was previously drawn the point of the guidepin should be positioned on the anterolateral femoral neck where the entry was estimated entry point should be lateral to the intertrochanteric line (on AP view) to avoid screw head impingement J Guide Pin Insertion 1 Drill and advance the guidepin drill the guidepin into the midpoint of the femoral neck 2 Check pin placement confirm the position with imaging once the position of the guidepin is confirmed advance the guidepin to within 3 mm of the articular surface and the length is measured should be center center in the EPIPHYSIS 3 Confirm guide pin position confirm the final position of the guidepin with multiple radiographic images must be out of the joint on all images K Drilling and Cannulated Screw Placement 1 Measure the length of the cannulated screw measure the guidewire with the cannulated screw depth gauge to determine the desired screw length 2 Place cannulated screw use the cannulated drill over the guidewire stop the drill 1 or 2 mm before the tip of the guidewire drill must cross the physis place a 6.5 mm to a 7.3 mm cannulated screw over the guidewire remove the guidewire single screw fixation is usually favorable compared to multiple screws, lower risk of osteonecrosis and intraarticular penetration L Radiographic Evaluation 1 Ensure placement of the cannulated screw use spot AP and frog leg lateral fluoroscopy to ensure placement attempt if possible to have five threads of the screw within the epiphysis to decrease the risk of slip progression 2 Test for penetration into the joint use the "approach and withdraw" method to ensure that the screw tip remains in the femoral head under fluoroscopy range the hip from internal to external rotation at varying degrees of flexion watch to see if the screw tip approaches and withdraws from the subchondral bone N Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Deep closure use 0-vicryl for deep closure 3 Superficial closure use 2-0 vicryl for the subcutaneous tissue use 3-0 monocryl for skin 4 Dressings and immobilization place a soft dressing on the incision
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated check appropriate labs wound care inpatient physical therapy 2 Discharge patient appropriately pain meds touch down weight bearing monitor neurological and vascular status schedule follow up in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans