Preoperative Patient Care A Outpatient Evaluation and Management 1 Obtain focused history and perform focused exam evaluate degree of soft tissue injury open wounds swelling (fracture blisters) deformity check soft tissue for wrinkles await return of skin wrinkles prior to ORIF to decrease wound complications for 10-14 days check compartments identify risk factors that correlate with complications and poor outcomes comorbidities diabetes social factors smoking 2 Appropriately interprets basic imaging studies AP/Lat/Mortise views of ankle, AP/Lat views of tibia/fibula characterize fracture pattern, amount of comminution, metaphyseal bone loss, shortening, and angulation commonly 3 fragments according to ankle ligaments: medial malleolar (deltoid), anterolateral (AITFL, Chaput), and posterolateral (PITFL, Volkmann) fragments 75% of fractures have associated fibula fractures location and angulation of fracture fragments influences surgical approach severely comminuted fractures with poor bone quality may require definitive management with external fixator vs. tibiotalar arthrodesis CT scan often performed after placement of spanning ankle external fixator to delineate fracture fragments once length restored 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation immediate Post-op non-weight bearing in splint vs. external fixator, crutches for ambulation 2 weeks post-op wound check repeat xrays of ankle and tibia/fibula 8-12 weeks postop xrays to evaluate union and fracture consolidation range of motion exercises to ankle advance weight bearing status and rehabilitation B Advanced Evaluation and Management 1 Provides comprehensive assessment of complex fracture patterns on imaging studies 2 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities noncompliance C Preoperative H & P 1 Obtain history and perform basic physical exam document neurovascular status check compartments 2 Order basic imaging studies order biplanar radiographs of the tibia and weight bearing triplanar radiographs of the ankle 3 Splint fracture appropriately place in posterior splint with stirrups 4 Perform preoperative consent wound breakdown (10%) superficial/deep infection (5-15%) malunion nonunion post-traumatic arthritis (30-70% depending on articular injury) ankle stiffness neurovascular injury Operative Techniques E Preoperative Plan 1 Template fracture template fracture pattern and instrumentation 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation external fixation system 2 Patient positioning patient supine with feet at the end of the bed, small bump under ipsilateral thigh, tourniquet on thigh if external fixator in place need to scrub down frame and pins thoroughly as this is a source of contamination 3 OR setup and C-arm radiolucent OR table c-arm from contralateral side perpendicular to bed G Tibial Pin Placement 1 Mark and make the incision at the site of tibial pin insertion 2 Bluntly dissect down to bone 3 Place the tibial pins place 2 Schanz pins into the midshaft of the tibia avoid placing the pins in comprosied soft tissue and any fracture extension 4 Confirm the location with fluoroscopy H Calcaneal Pin Placement 1 Mark and make a skin incision at the site of the calcaneus pin insertion 2 Perform blunt dissection down to bone 3 Place the calcaneal pin place a centrally threaded transfixation pin through the calcaneal tuberosity from medial to lateral placing the pin in this direction helps avoid the posterior tibial artery the location for this pin is 1.5 cm anterior to the posterior aspect of the heel and 1.5 cm proximal to the plantar aspect of the heel 4 Confirm the location with fluoroscopy I Bar Placement 1 Connect the tibial pins place a solitary bar to connect the tibial pins 2 Place bars on the calcaneal pins connect medial and lateral bars to each side of the heel this makes a triangular configuration J Reduction 1 Reduce the fracture perform longitudinal traction to obtain length be sure to obtain the appropriate anteroposterior reduction K Metatarsal Pin Placement 1 Place the metatarsal pin place a pin into the base of the first or second metatarsal this maintains a plantigrade foot along with alignment 2 Connect the metatarsal pin to the mainframe connect this forefoot pin to the main frame with connecting bar hold the foot in neutral dorsiflexion L Reduction Confirmation 1 Take final fluoro AP/Lat/Mortise of ankle and AP/Lat of tibia/fibula 2 Check limb length, rotation, and alignment Postoperative Patient Care O Perioperative Inpatient Management 1 Write comprehensive admission orders Serial compartment checks x24 hours IV fluids DVT prophylaxis pain control advance diet as tolerated check appropriate labs wound care pin care appropriately orders and interprets basic imaging studies xrays of the ankle in postop 2 Appropriate medical management and medical consultation 3 Inpatient physical therapy non weightbearing crutches for ambulation 4 Discharge home appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans
A Outpatient Evaluation and Management 1 Obtain focused history and perform focused exam evaluate degree of soft tissue injury open wounds swelling (fracture blisters) deformity check soft tissue for wrinkles await return of skin wrinkles prior to ORIF to decrease wound complications for 10-14 days check compartments identify risk factors that correlate with complications and poor outcomes comorbidities diabetes social factors smoking 2 Appropriately interprets basic imaging studies AP/Lat/Mortise views of ankle, AP/Lat views of tibia/fibula characterize fracture pattern, amount of comminution, metaphyseal bone loss, shortening, and angulation commonly 3 fragments according to ankle ligaments: medial malleolar (deltoid), anterolateral (AITFL, Chaput), and posterolateral (PITFL, Volkmann) fragments 75% of fractures have associated fibula fractures location and angulation of fracture fragments influences surgical approach severely comminuted fractures with poor bone quality may require definitive management with external fixator vs. tibiotalar arthrodesis CT scan often performed after placement of spanning ankle external fixator to delineate fracture fragments once length restored 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 4 Provides post-operative management and rehabilitation immediate Post-op non-weight bearing in splint vs. external fixator, crutches for ambulation 2 weeks post-op wound check repeat xrays of ankle and tibia/fibula 8-12 weeks postop xrays to evaluate union and fracture consolidation range of motion exercises to ankle advance weight bearing status and rehabilitation B Advanced Evaluation and Management 1 Provides comprehensive assessment of complex fracture patterns on imaging studies 2 Recognizes indications for and provides non-operative treatment of an unstable fracture diabetes medical comorbidities noncompliance C Preoperative H & P 1 Obtain history and perform basic physical exam document neurovascular status check compartments 2 Order basic imaging studies order biplanar radiographs of the tibia and weight bearing triplanar radiographs of the ankle 3 Splint fracture appropriately place in posterior splint with stirrups 4 Perform preoperative consent wound breakdown (10%) superficial/deep infection (5-15%) malunion nonunion post-traumatic arthritis (30-70% depending on articular injury) ankle stiffness neurovascular injury
E Preoperative Plan 1 Template fracture template fracture pattern and instrumentation 2 Execute surgical walkthrough describe steps of the procedure verbally to the attending prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation external fixation system 2 Patient positioning patient supine with feet at the end of the bed, small bump under ipsilateral thigh, tourniquet on thigh if external fixator in place need to scrub down frame and pins thoroughly as this is a source of contamination 3 OR setup and C-arm radiolucent OR table c-arm from contralateral side perpendicular to bed G Tibial Pin Placement 1 Mark and make the incision at the site of tibial pin insertion 2 Bluntly dissect down to bone 3 Place the tibial pins place 2 Schanz pins into the midshaft of the tibia avoid placing the pins in comprosied soft tissue and any fracture extension 4 Confirm the location with fluoroscopy H Calcaneal Pin Placement 1 Mark and make a skin incision at the site of the calcaneus pin insertion 2 Perform blunt dissection down to bone 3 Place the calcaneal pin place a centrally threaded transfixation pin through the calcaneal tuberosity from medial to lateral placing the pin in this direction helps avoid the posterior tibial artery the location for this pin is 1.5 cm anterior to the posterior aspect of the heel and 1.5 cm proximal to the plantar aspect of the heel 4 Confirm the location with fluoroscopy I Bar Placement 1 Connect the tibial pins place a solitary bar to connect the tibial pins 2 Place bars on the calcaneal pins connect medial and lateral bars to each side of the heel this makes a triangular configuration J Reduction 1 Reduce the fracture perform longitudinal traction to obtain length be sure to obtain the appropriate anteroposterior reduction K Metatarsal Pin Placement 1 Place the metatarsal pin place a pin into the base of the first or second metatarsal this maintains a plantigrade foot along with alignment 2 Connect the metatarsal pin to the mainframe connect this forefoot pin to the main frame with connecting bar hold the foot in neutral dorsiflexion L Reduction Confirmation 1 Take final fluoro AP/Lat/Mortise of ankle and AP/Lat of tibia/fibula 2 Check limb length, rotation, and alignment
O Perioperative Inpatient Management 1 Write comprehensive admission orders Serial compartment checks x24 hours IV fluids DVT prophylaxis pain control advance diet as tolerated check appropriate labs wound care pin care appropriately orders and interprets basic imaging studies xrays of the ankle in postop 2 Appropriate medical management and medical consultation 3 Inpatient physical therapy non weightbearing crutches for ambulation 4 Discharge home appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans