A Intermediate Evaluation and Management 1 Performs focused history and physical determine the mechanism and date of the injury concomitant and associated orthopaedic injuries perform neurovascular exam evaluate the soft tissue look for tenting of the skin 2 Interprets basic imaging studies AP apical oblique 3 Prescribes nonoperative management place in sling or figure of eight brace patient to keep arm to side and limit activity for 4 to 6 weeks 4 Knowledge of surgical indications open fracture tenting of the skin unstable Group II fractures (Type IIA, Type IIB, Type V) subclavian artery or vein injury floating shoulder (clavicle and scapula neck fracture) symptomatic nonunion posteriorly displaced Group III fractures displaced group I (middle third) with >2cm shortening 5 Post operative management postop: 2-3 week postoperative visit wound check diagnose and management of early complications<br /> start shoulder exercises at 4-6 weeks postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> check radiographs for fracture consolidation B Advanced Evalaution and Management 1 Order appropriate imaging studies C Preoperative H & P 1 Perform basic history and physical exam identify medical co-morbidities that might impact surgical treatment 2 Order basic imaging studies radiographs AP apical oblique 3 Perform operative consent describe complications of surgery including prominence of hardware wound complications infection nonunion
E Preoperative Plan 1 Radiographic templating template fracture with instrumentation 2 Execute surgical walkthrough describe the steps of the procedure verbally prior to the start of the case 3 Description of potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation appropriate precontoured plate or LCP 2 Room setup and equipment standard operating table fluoroscopy 3 Patient positioning place in the supine or modified beach chair position place a bump on the medial portion of the scapula on the operative shoulder G Approach 1 Identify and mark the fracture infiltrate area with dilute epinephrine to minimize bleeding make a longitudinal incision just inferior to and in line with the clavicle 2 Identify critical structures identify the supraclavicular nerves these nerves cross the clavicle at the level of the platysma minimize removal of muscle attachments and periosteum as much as possible H Fracture Reduction and Provisional Fixation 1 Reduce the fracture realign the fracture with a distractor use clamps and kwires to reduce comminuted fractures I Superior Plate Final Fixation 1 Place the superior plate place a LCP or precontoured plate to the superior aspect of the clavicle 2 Prepare screw placement drill the clavicle in a superior to inferior direction 3 Place screws use depth gauge to measure the length of each screw a minimum of three screws should be placed bicortically in each major fragment of the fracture place interfragmentary screw this screw greatly enhances the stability of the construct J Anterior Plate Final Fixation (alternative placement) 1 Prepare the fracture site partially remove the origins of the deltoid and the pectoralis major 2 Place the plate anteriorly place a LCP or precontoured plate on the anterior aspect of the clavicle 3 Prepare screw placement drill the clavicle from an anterior to posterior direction 4 Place screws use the depth gauge to measure the appropriate length screw a minimum of three screws should be placed in each major fragment place interfragmentary screw this screw greatly enhances the stability of the construct K Wound Closure 1 Irrigation and hemostasis copiously irrigate the wound 2 Deep closure close the platysma with 0-vicryl 3 Superficial closure close the subcutaneous tissue with 3-0 vicryl close the skin with 3-0 monocryl
O Perioperative Inpatient Management 1 Discharge the patient appropriately outpatient pt remove dressing POD 2 pain meds schedule follow up appointment in 2 weeks R Complex Patient Care 1 Comprehensive pre-op planning/alternatives 2 Modify and adjust post-op plan as needed 3 Understand how to avoid and prevent complications 4 Treat simple complications intraoperatively and postoperatively