A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam document distal neurovascular status concomitant and associated orthopaedic injuries 2 Interpret basic imaging studies triplanar films of the knee AP lateral oblique 3 Prescribes nonoperative management fracture brace long leg cast 4 Make informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit continue physical therapy and range of motion exercises discontinue DVT prophylaxis wound check staples/sutures removed diagnose and management of early complications continue toe partial weight-bearing at for additional for additional 6-9 weeks postop: ~ 3 month postoperative visit repeat radiographs advance to full weightbearing diagnosis and management of late complications<br /> postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Prioritizes the needs of the polytrauma patient works with consulting 2 Complex wound management and debridement understanding need for consultation for flap coverage 3 Capable of treating complications both intraoperatively and post-operatively manages post operative infection C Preoperative H & P 1 Performs focused orthopaedic exam check neurovascular status check for compartment syndrome check soft tissues 2 Appropriately orders basic imaging studies order triplanar radiographs of the knee AP lateral oblique 3 Perform operative consent describe complications of surgery including compartment syndrome infection superficial and deep wound problems residual knee joint instability DVT arthrosis loss of motion
E Preoperative Plan 1 Template fracture reductions draw key fragments of fracture and plan for reduction 2 Execute surgical walkthrough resident can describe key steps of the operation verbally to attending prior to beginning of case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation periarticular clamps K wires cancellous or cortical screws locking femoral condylar plate 2 Room setup and equipment radiolucent flat top table c-arm fluoroscopy 3 Patient positioning place patient supine place a sterile bump or triangle under the knee G Posteromedial Approach 1 Mark out and make the skin incision start the incision 1 cm posterior to the posteromedial edge of the tibial metaphysis 2 Identify the neurovascular structures identify the saphenous vein and the nerve H Deep Dissection 1 Dissect to fracture site expose the pes anserine tendons mobilize these tendons anteriorly or posteriorly 2 Mobilize the gastrocnemius dissect off the medial gastroc from the posteromedial tibia limit subperiosteal dissection to the fracture margins this will aid in the confirmation of the reduction I Lateral Approach 1 Identify and mark anatomy identify gerdys tubercle, the tibial crest,patella and fibular head 2 Mark and make the skin incision the incision should begin distally about 2 cm lateral to the tibial crest, curving over the tubercle of gerdy then proceed superiorly over the femoral epicondyle 3 Dissect through fascia dissect through the fascia without detaching the subcutaneous fat from the fascia 4 Split the IT band split the fibers of the IT band longitudinally parallel to the skin incision be careful not to the disrupt the capsule elevate the IT band off of Gerdys tubercle anteriorly and posteriorly J Reduction and Provisional Fixation 1 Identify fracture fragments indirectly reduce the metaphyseal fragments with fluoroscopy 2 Perform provisional fixation with K wires 3 Check reduction check reduction with fluoroscopy K Final Fixation 1 Apply plate apply a plate laterally to support the lateral split fragments and to support the depressed articular fragments 2 Create a raft effect with proximal screw placement to produce a raft effect, place multiple screws proximally in subchondral bone four screws are optimal for the rafting effect screws should be placed in the following fashion: fully threaded, partially threaded, fully threaded then partially threaded 3 Provide support of the medial fragment support of the medial side can be provided by a lateral plate if the medial fragment is large enough if fixation of the medial fragment cannot be achieved with a lateral locking plate, placement of a medial plate via the posterior approach is performed this is performed with posteromedial buttress fixation 4 Place locking screws these screws provide superior resistance to medial subsidence and are preferred over nonlocking screws for this application if compression is required, nonlocking screws should be placed before the application of locking screws across the fracture line 5 Fill subchondral defect all defects should be grafted with allograft, autograft or bone substitute use a tamp to impact the graft under the inferior surface of the depressed fragment 6 Elevate the fragment to its proper position 7 Check implant placement check placement of implants with fluoroscopy L Wound Closure 1 Irrigation, hemostasis, and drain copiously irrigate the wound irrigate until backflow is clear cauterize peripheral bleeding vessels 2 Deep closure use 0-vicryl to close the deep tissue 3 Superficial closure use 3-0 vicryl for subcutaneous tissue use 3-0 nylon for skin
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control prescribe appropriate DVT prophylaxis wound management remove dressings POD2 foley out when ambulating check appropriate labs antibiotics 2 Check radiographs in postop check placement of implants 3 Initiate physical therapy on POD 1 start CPM machine at 0 to 40 degrees advance 0 to 5 degrees during each PT session 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately pain meds outpatient physical therapy schedule 2 week follow up R Complex Patient Care 1 Develops unique, complex post-operative management plans