A Intermediate Evaluation and Management 1 Performs focused history and physical history mechanism of injury premorbid level of function history of malignancy occupation and hand dominance concomitant and associated orthopaedic injuries perform neurovascular exam physical exam inspection swelling soft tissue injury ecchymosis deformity 2 Orders and interprets required diagnostic studies 3 Knowledge of surgical indications 4 Post operative management postop: 2-3 week postoperative visit wound check check range of motion diagnose and management of early complications<br /> postop: ~ 6 week postoperative visit diagnosis and management of late complications<br /> check radiographs for healing of the tuberosities check range of motion the elbow motion should be near normal range start shoulder strengthening 3 month postoperative visit check that callus is present on the xrays if callus is not present, then repeat xrays every 6 weeks until radiographic evidence of healing B Advanced Evaluation and Management 1 Order appropriate imaging studies 2 Provides post-op management and rehabilitation C Preoperative H & P 1 Perform basic history and physical exam check neurovascular status identify medical co-morbidities that might impact surgical treatment 2 Ensure all studies are required to proceed with surgical intervention radiographs AP view and lateral views of the humerus 3 Perform operative consent describe complications of surgery including infection nonunion radial nerve palsy shoulder impingement elbow stiffness
E Preoperative Plan 1 Radiographic templating template fracture with instrumentation 2 Execute surgical walkthrough describe the steps of the procedure verbally prior to the start of the case 3 Description of potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation reduction clamps LCP and DCP plates K wires Cobb or periosteal elevator 2 Room setup and Equipment standard operating table fluoroscopy 3 Patient Positioning supine position with the extremity placed on a hand table G Anterolateral Approach 1 Identify and mark the incision mark the skin incision beginning proximally at the deltoid tubercle and continue distally just proximal to the antecubital crease 2 Make the skin incision 3 Identify neurovascular structures identify and protect the lateral antebrachial cutaneous nerve this usually will be seen in the distal aspect of the wound H Deep Dissection 1 Identify the interval between the biceps and the brachialis to enter this interval, sweep the finger from proximal to distal 2 Identify the musculocutaneous nerve at the level of the midhumerus, identify the musculocutaneous nerve that will be found on the undersurface of the biceps trace the nerve distally to protect the terminal branches the terminal branches form the lateral antebrachial cutaneous nerve 3 Expose and protect the radial nerve expose the radial nerve by dissecting the interval between the brachialis and the brachioradialis protect the radial nerve with a vessel loop so that it can be identified at all times 4 Expose the fracture split the brachialis in line with the fibers between the medial 2/3 and the lateral 1/3 this is an internervous plane between the radial nerve laterally and the musculocutaneous nerve medially I Fracture Preparation 1 Clear the fracture site expose the fracture site by sharp perioseal dissection clear the fracture site of hematoma and interfering soft tissue 2 Identify any degree of comminution 3 J Fracture Reduction 1 Reduce the fracture reduce the fracture by using gentle traction and rotation 2 Maintain the reduction use reduction clamps to maintain the reduction 3 place K wires to provisionally fix the fracture it is imperative to place the k wires so they do not interfere with plate fixation K Provisional Fixation 1 Place K wires to provisionally fix the fracture it is imperative to place the k wires so they do not interfere with plate fixation 2 Determine the length of the plate use a plate length that gives at least 6 cortices of fixation above and below the fracture if the bone is large, a 4.5 mm DCP should be used in smaller bones, a 4.5 mm LCP plate often provides a better fit 3 Template the plate on the shaft place the plate on the shaft of the humerus and hold with a plate holding clamp L Definitive Fixation 1 Place cortical screws place 4.5 mm cortical screws through the holes that are proximal and distal to the fracture site make sure that there is no soft tissue or nerve in between the bone and the plate make sure there is screw purchase in at least 6 cortices above and below the fracture 2 Test the stability of the fixation rotate, flex and extend the arm to test the stability of the fixation N Wound Closure 1 Irrigation copiously irrigate wound 2 Deep closure use 0-vicryl for fascia 3 Superficial closure use 2-0 vicryl for subcutaneous tissue use 3-0 monocryl for skin 4 Immobilization place in sling
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids order AP and lateral views to assess placement of implants DVT prophylaxis pain control advance diet as tolerated foley out when ambulating check appropriate labs wound care remove dressings POD 2 inpatient physical therapy remove in 1 to 2 days and start range of motion exercises weightbearing is allowed based on the patients comfort initial therapy should be elbow range of motion and shoulder pendulum exercises and passive self assist exercises Appropriate medical management and medical consultation 2 Discharges patient appropriately outpatient pt pain meds schedule follow up appointment in 2 weeks R Complex Patient Care 1 Comprehensive pre-op planning/alternatives. 2 Modify and adjust post-op plan as needed 3 Understand how to avoid and prevent complications 4 Treat simple complications intraoperatively and postoperatively