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 upper arm 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 the need for skin grafting 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 arm 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 arm board 3 Patient positioning patient supine G Lateral Approach 1 Mark and make the incision start the incision at the deltoid insertion extend the incision down to the lateral epicondyle H Deep Dissection 1 Split the fascia split the fascia that is over the biceps anteriorly and posteriorly 2 Check the integrity of the soft tissue check the viability of the muscle check the muscle tone, contractility, color and bleeding if viability of the muscle tissue is not clear, reinspect the muscle in 24 to 48 hours 3 Leave the incision open I Wound Management 1 Copiously irrigate the wound 2 Cover the incision with wet saline dressings another option is to use a wound vac this can be done to facilitate care, reduce the edema and decrease the pain that is associated with frequent dressing changes J 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 Periooerative 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 Appropriate medical management and medical consultation 3 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 upper arm 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 the need for skin grafting 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 arm 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 arm board 3 Patient positioning patient supine G Lateral Approach 1 Mark and make the incision start the incision at the deltoid insertion extend the incision down to the lateral epicondyle H Deep Dissection 1 Split the fascia split the fascia that is over the biceps anteriorly and posteriorly 2 Check the integrity of the soft tissue check the viability of the muscle check the muscle tone, contractility, color and bleeding if viability of the muscle tissue is not clear, reinspect the muscle in 24 to 48 hours 3 Leave the incision open I Wound Management 1 Copiously irrigate the wound 2 Cover the incision with wet saline dressings another option is to use a wound vac this can be done to facilitate care, reduce the edema and decrease the pain that is associated with frequent dressing changes J 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 Periooerative 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 Appropriate medical management and medical consultation 3 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