A Outpatient Evaluation and Management 1 Obtains focused history and performs physical examination provocative tests differential diagnosis and physical exam tests 2 Orders basic imaging studies radiographs AP true AP with active shoulder abduction Axillary lateral Scapular Y view 3 Prescribes non-operative treatment physical therapy anti-inflammatory medication 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 Provide basic post op management postop: 2-3 week postoperative visit wound check remove sutures diagnose and management of early complications<br /> B Advanced Evaluation and Management 1 Interpret basic imaging studies radiographs MRI labral tears arthritis C Preoperative H & P 1 Obtain history and perform physical exam history age gender smoker trauma physical exam check range of motion weakness of the extremity inspect for atrophy identify medical co-morbidities that might impact surgical treatment 2 Perform operative consent describe complications of surgery including infection damage to the suprascapular nerve and vessels incomplete decompression
E Preoperative Plan 1 Radiographic templating 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Make sure tower working 30° arthroscope fluid pump system standard arthroscopic instruments arthroscopic scissors 2 Room setup and Equipment standard OR table for lateral decubitus position 3 Patient Positioning lateral decubitus position pad any prominences of the extremities position the head and neck in neutral alignment G Scope Insertion 1 Outline landmarks Outline the acromion, distal clavicle, coracoid process and portal placement 2 Place posterior portal mark portal 1 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion make small skin incision place blunt trocar with the arm in 15° of abduction and 30° of forward flexion use lateral traction to avoid damage to the articular surface place the 30° arthroscope. 3 Place anterior portal halfway between acromioclavicular joint and the lateral aspect of the coracoid pierce the anterior fibers of the deltoid and enter the joint in the interval between the supraspinatus and subscapularis 4 Place lateral portal place laterally in line with the mid clavicle and 2 to 3 cm lateral to its lateral edge 5 Place medial portal place 3-3.5 cm medial to the bisecting line at the midclavicle H Diagnostic Arthroscopy 1 Visualize the anatomy articular cartridge of the humeral head and glenoid labrum biceps tendon inferior recess articular surface insertion of the subscapularis, supraspinatus, infraspinatus and teres minor 2 Establish anterior portal localize portal with an 18 gauge spinal needle placement place a seven millimeter cannula using the outside-in technique I Subacromial Bursectomy 1 Maneuver the arthroscope view through the lateral portal 2 Visualize pertinent anatomy use the anterior portal as the working portal visualize the coracoacromial ligament to the coracoid tip and posterior to it 3 Perform a subacromial bursectomy this is to visualize the coracoacromial ligament follow the coracoacromial ligament to the coracoid process perform additional posteromedial dissection place retractors through the superior portal to help retract and dissect medially the bursectomy should allow visualization from the AC joint and CC ligament anteriorly to the scapular spine posteriorly J Decompression 1 Identify the suprascapular structures identify the suprascapular ligament identify the suprascapular nerve and artery the suprascapular nerve is inferior to the ligament 2 Place the arthroscopic scissors into the suprascapular portal remove the extrinsic pathology that is compressing the nerve K Wound Closure 1 Irrigation and hemostasis irrigate the portals 2 Deep closure use 3-0 biosyn for closure 3 Superficial closure use 4-0 biosyn for skin 4 Dressing and immediate immobilization place sling
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care schedule follow up orders and interprets basic imaging studies order postoperative radiographs of the shoulder to ensure appropriate implant placement 2 outpatient PT sling for 2-3 days for comfort pendulum exercises POD 1 increase active motion as tolerated R Complex Patient Care 1 Modifies and adjusts post operative rehabilitation plan as needed post-operative stiffness 2 Order and interpret advanced imaging studies MRI 3 Treats intra-operative and post operative complications irrigation and debridement for infection proper infection treatment infectious disease consultation