A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam check neurovascular status compare extremity to contralateral limb concomitant and associated orthopaedic injuries 2 Appropriately interprets basic imaging studies interpret AP pelvis and lateral radiographs of the affected hip 3 Recognition / evaluation of fragility fractures order appropriate workup and/or consult 4 Interacts with consultants regarding optimal patient management timing of surgery medical management assess risk for thromboembolic disease 5 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 6 Provides post-operative management and rehabilitation; WB status postop: 2-3 Week postoperative visit wound check diagnose and management of early complications<br /> staples/sutures removed continue physical therapy and range of motion exercises repeat xrays of femur postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> repeat xrays of femur postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Comprehensive assessment of fracture patterns on imaging studies recognizes reverse obliquity fractures 2 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral 3 Arranges for long term management of geriatric patients management of bone health discharge planning to long term care 4 Modifies and adjusts post-operative treatment plan as needed 5 Provides prohylaxis and manages thromboemblotic disease C Preoperative H & P 1 Perform focus orthopaedic history and physical perform careful extremity exam document distal neurovascular status identify associated injuries and comorbidities identify patient comorbidities and ASA status (predictor of mortality) screen medical studies to identify and contraindications for surgery 2 Order basic imaging studies order AP pelvis, ap and lateral of affected hip 3 Perform operative consent including lists potential complications describe complications of surgery including medical complications including death definitive stabilization within 48-72h associated with decreased pulmonary complications, thromboembolic events, length of hospital stay, and morbidity/mortality varus collapse with screw cut out AVN of the femoral head
E Preoperative Plan 1 Template intramedullary nail and cephalomedullary screws measure length of the hip screws 2 Surgical walkthrough resident can describe key steps of the operation verbally to attending prior to beginning of case. list potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation cannulated screws 2 Room setup and equipment radiolucent fracture table (Jackson fracture) c-arm fluoroscopy 3 Patient positioning make sure patient has Foley urinary catheter in place patient supine with feet padded with webril and placed firmly in fracture table boots if contralateral leg dropped down, if raising contralateral leg up 90° use thigh holder padded post deep into groin, move genitals and Foley catheter out of the way ipsilateral arm on stack of blankets over chest and taped down, contralateral arm on arm board prep and drape entire leg up to iliac crest to make sure adequate working area c-arm from contralateral side at 45° towards hip take initial fluoro AP/Lat of hip to examine femoral neck mark position of C-arm to ensure proper positioning during remainder of case (~15° tilt for correct AP xray of hip) G Closed Reduction 1 Perform a closed reduction apply gentle traction and internal rotation under fluoroscopic control 2 Verify the reduction is anatomic reduction is considered anatomic when the normal contours of the femoral neck have been re-established in both the AP and lateral views, the normal neck-shaft angle and neck length are restored the relative heights of the femoral head and trochanter should be symmetrical to the contralateral side and no gaps are seen in the fracture H Guidewire Placement 1 Position the guidewires these should be in line with the femoral neck axis through poke holes the standard placement is 3 pins in an inverted triangle position 2 Place guidepins place guidepins through stab incisions I Screw Placement 1 Place screws place cannulated screws over the guidepins the pin must lie along the axis of the femoral neck in both the AP and lateral views and parallel to the anteversion pin place the screws peripherally in the femoral neck with good cortical butrress espescially in the inferior and posterior neck avoid points below the lesser trochanter due to risk of subtrochanteric fracture postoperatively 2 Verify position of screws verify the position in two planes by fluoroscopy 3 Drill screws spread the soft tissues down to bone place self drilling, self tapping cannulated screws by power over the guidewires use washers in more proximal, metaphyseal locations 4 Confirm the length of the screws is appropriate the screws should be long enough so that all screw threads are on the proximal (head) side of the fracture J Wound Closure 1 Irrigation and hemostasis copiously irrigate the wounds 2 Close the skin subcutaneous and skin closure with 2-0 vicryl and staples
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 2 Inpatient physical therapy start range of motion exercises of the hip and knee 3 Appropriate medical management and medical consultation 4 Discharges patient appropriately pain meds outpatient PT schedule follow up appointment in 2 weeks R Complex Patient Care 1 Develops unique, complex post-operative management plans