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 shoulder 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: 1-2 week postoperative visit check radiographs diagnose and management of early complications<br /> check pin sites postop:4 week postoperative visit check radiographs remove pins with a battery powered hand drill start active assisted range of motion exercises of the shoulder once radiographic healing is observed, formal physical therapy is started 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 injury mechanism check pulses 2 Order basic imaging studies radiographs of the shoulder 3 Perform operative consent describe complications of surgery including nerve injury pin tract infection or osteomyelitis persistent stiffness growth disturbance fracture through pin hole in cortex
E Preoperative Plan 1 Template fracture identify fracture pattern 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 flexible intramedullary nail fracture table 2 Room setup and equipment setup OR with standard operating table c-arm brought in from the head of the bed 3 Patient positioning modified beach chair position with the back elevated 30 degrees place a bean bag under the head, neck and upper torso to allow the patient to hang over the chair slightly place a chest pad attached to the table to prevent the patient from being pulled off of the bed when tract is applied to the arm G Closed Reduction 1 Reduce the fracture abduct and externally rotate the arm have an assistant stabilize the torso apply traction to the arm for disengagement of the fracture fragments 2 Correct angulation typical angulation that needs to be corrected is varus and apex anterior push down on the proximal end of the shaft to correct angulation maintain abduction to correct the varus H Placement of the First Pin 1 Place first pin from distal lateral to proximal medial start the pin perpendicular to the shaft drop the hand to the correct angle it is important that the initial approach down to the bone along the final angle of the pin insertion to avoid possible skin tension problems 2 Advance the pin advance the pin into the head stopping several millimeters below the subchondral bone I Placement of the Second Pin 1 Place the second pin placement of the second pin is placed more proximal and anterior than the first pin if the first pin is aimed at the inferior border of the head , the second should be aimed more superior for greater pin divergence across the fracture J Fixation Test 1 Perform the advance withdrawal test rotate the shoulder and the tips of the should appear to approach the joint then withdraw with continued rotation if the pins appear to long, they should be pulled back K Wound Closure 1 Place soft dressings over the pin sites
O Perioperative Inpatient Management 1 Discharge patient appropriately pain meds pin care non weightbearing manage swelling monitor neurological and vascular status schedule follow up in 1-2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans