Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam document distal neurovascular status check for associated orthopedic injuries 2 Interpret basic imaging studies biplanar radiographs of the forearm 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 wound check staples/sutures removed start range of motion exercises diagnose and management of early complications postop: ~ 3 month postoperative visit diagnosis and management of late complications 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 Perform focused orthopedic exam assess the forearm compartments document distal neurovascular status 2 Order basic imaging studies need biplanar radiographs of entire upper extremity 3 Perform operative consent describe complications of surgery including scarring neurovascular injury Operative Techniques E Preoperative Plan 1 Execute surgical walkthrough describe key steps of the procedure to the attending verbally prior to the start of the case describe potential complications and the steps to avoid them F Room Preparation 1 Surgical instrumentation curved mayo scissors 2 Room setup and equipment standard OR table hand table 3 Patient positioning patient supine G Ulnar Volar Incision 1 Mark and make the incision make a straight line incision over the first third of the ulnar aspect of the volar forearm start the incision just proximal to the wrist crease and extend the incision to just distal to the ulnar aspect of the elbow flexion crease 2 Identify the volar compartment carry the incision down through the fascia into the volar compartment H Deep Dissection 1 Open the fascia open the fascia along the length of the compartment 2 Examine the soft tissues examine the deep and the superficial muscles I Radial Incision 1 Mark and make the second volar incision make a second incision starting with a middorsal straight line incision that begins 3 to 4 cm proximal to the wrist crease 2 Extend the incision extend the incision down to the radial aspect of the flexion crease J Fascial Release 1 Release the compartments release the mobile wad and dorsal compartment 2 Incise the fascia incise the fascia for both compartments over the entire length of the incision examine the muscles in both compartments after release of the fascia, the muscles should bulge out of the incision do not debride any muscle during this procedure some muscles with questionable viability may recover after the fascial release K Wound Management 1 Pack the wounds pack the wounds with moist dressing until the second look procedure L 2nd Look Procedure 1 Debride necrotic tissue aggressively debride any necrotic tissue with a no. 10 blade in a tangential manner until bleeding tissue is seen 2 Cover the wounds place moist dressings over large wounds with exposed deep structures of neurovascular structures until coverage can be performed if coverage is not needed, perform moist dressing changes for the next 7 to 14 days once the edema subsides, perform primary closure or skin grafting as needed Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders serial compartment checks x 24 hours advance diet as tolerated pain control wound management return to the OR in 48-96 hours for repeat compartment check and wound debridement foley out when ambulating check appropriate labs antibiotics prescribe DVT prophyhlaxis 2 Physical therapy nonweightbearing 3 Appropriate medical management and medical consultation 4 Discharges patient appropriately pain meds outpatient PT schedule follow up in 2 weeks wound care R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam document distal neurovascular status check for associated orthopedic injuries 2 Interpret basic imaging studies biplanar radiographs of the forearm 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 wound check staples/sutures removed start range of motion exercises diagnose and management of early complications postop: ~ 3 month postoperative visit diagnosis and management of late complications 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 Perform focused orthopedic exam assess the forearm compartments document distal neurovascular status 2 Order basic imaging studies need biplanar radiographs of entire upper extremity 3 Perform operative consent describe complications of surgery including scarring neurovascular injury
E Preoperative Plan 1 Execute surgical walkthrough describe key steps of the procedure to the attending verbally prior to the start of the case describe potential complications and the steps to avoid them F Room Preparation 1 Surgical instrumentation curved mayo scissors 2 Room setup and equipment standard OR table hand table 3 Patient positioning patient supine G Ulnar Volar Incision 1 Mark and make the incision make a straight line incision over the first third of the ulnar aspect of the volar forearm start the incision just proximal to the wrist crease and extend the incision to just distal to the ulnar aspect of the elbow flexion crease 2 Identify the volar compartment carry the incision down through the fascia into the volar compartment H Deep Dissection 1 Open the fascia open the fascia along the length of the compartment 2 Examine the soft tissues examine the deep and the superficial muscles I Radial Incision 1 Mark and make the second volar incision make a second incision starting with a middorsal straight line incision that begins 3 to 4 cm proximal to the wrist crease 2 Extend the incision extend the incision down to the radial aspect of the flexion crease J Fascial Release 1 Release the compartments release the mobile wad and dorsal compartment 2 Incise the fascia incise the fascia for both compartments over the entire length of the incision examine the muscles in both compartments after release of the fascia, the muscles should bulge out of the incision do not debride any muscle during this procedure some muscles with questionable viability may recover after the fascial release K Wound Management 1 Pack the wounds pack the wounds with moist dressing until the second look procedure L 2nd Look Procedure 1 Debride necrotic tissue aggressively debride any necrotic tissue with a no. 10 blade in a tangential manner until bleeding tissue is seen 2 Cover the wounds place moist dressings over large wounds with exposed deep structures of neurovascular structures until coverage can be performed if coverage is not needed, perform moist dressing changes for the next 7 to 14 days once the edema subsides, perform primary closure or skin grafting as needed
O Perioperative Inpatient Management 1 Write comprehensive admission orders serial compartment checks x 24 hours advance diet as tolerated pain control wound management return to the OR in 48-96 hours for repeat compartment check and wound debridement foley out when ambulating check appropriate labs antibiotics prescribe DVT prophyhlaxis 2 Physical therapy nonweightbearing 3 Appropriate medical management and medical consultation 4 Discharges patient appropriately pain meds outpatient PT schedule follow up in 2 weeks wound care R Complex Patient Care 1 Develops unique, complex post-operative management plans