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Arm Compartment Release - Anteromedial Approach

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

Antermodial Approach

1

Mark and make the incision

  • Make the incision from the medial epicondyle towards the axilla
H

Deep Dissection

1

Split the fascia

  • split the fascia that overlies the biceps and the triceps

2

Protect the neurovascular structures

  • isolate and protect the ulnar nerve

3

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

4

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

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

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

 

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