A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam assess lower extremity compartments document distal neurovascular status check for associated orthopedic injuries 2 Interpret basic imaging studies biplanar radiographs of the leg 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<br /> postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Prioritizes the needs of the polytrauma patient timing of long bone fixation works with consulting 2 Complex wound management and debridement understanding need for consultation for flap coverage 3 Capable of treating complications both intraoperatively and post-operatively manages post operative infection C Preoperative H & P 1 Perform focused orthopedic exam assess lower extremity compartments document distal neurovascular status 2 Order basic imaging studies need biplanar radiographs of entire tibia/fibula, knee, and ankle 3 Perform operative consent describe complications of surgery including scarring injury to the superficial peroneal nerve
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 3 Patient positioning patient supine G Superificial Anterolateral Incision 1 Mark the incision halfway between the fibula and the crest of the tibia make the incision directly over the anterolateral intermuscular septum extend the incision 15 to 20 cm distally 2 Identify the superficial peroneal nerve the nerve is 10 to 12 cm proximal to the tip of the lateral malleolus H Anterior Compartment Release through Anterolateral Incision 1 Incise the anterior fascia localize the intermuscular septum at the proximal end of the wound make a short transverse incision anterior to the intermuscular septum the transverse incision should be long enough to fit the tip of curved mayo scissors for the fasciotomy 2 Perform the fasciotomy run the scissors cephalad and caudally 3 Assess the musculature of the anterior compartment evaluate the color, consistency, contractility and capillary refill I Lateral Compartment Release through Anterolateral Incision 1 Incise the lateral fascia localize the intermuscular septum at the proximal end of the wound make a short transverse incision posterior to the intermuscular septum the incision should be long enough to fit the tip of curved mayo scissors for the fasciotomy 2 Perform the fasciotomy run the scissors cephalad and caudally 3 Assess the musculature of the lateral compartment evaluate the color, consistency, contractility and capillary refill J Superficial and Deep Compartment Release 1 Mark the incision 2 cm medial to the posterior border of the tibia make an anteriormedial incision 2 cm medial to the posterior medial border of the tibia make incision 15-20 cm distally retract the saphenous vein and nerve anteriorly perform fasciotomy incise the fascia directly under the incision for a short distance place the tip of the curved mayo scissors into the incision direct the mayo scissors cephalad and caudally this decompresses the superficial posterior compartment 2 Assess the musculature of the superficial posterior compartment 3 Release the deep posterior compartment release the fascia distally and run mayo scissors proximally through and under the soleus bridge release the the soleus attachment to the tibia more than half way release the fascia over the posterior tibia muscle 4 Assess the musculature of the deep compartment K Superficial Compartment Release through the Anteromedial Incision 1 perform fasciotomy 2 incise the fascia directly under the incision for a short distance place the tip of the curved mayo scissors into the incision direct the mayo scissors cephalad and caudally this decompresses the superficial posterior compartment 3 Assess the musculature of the superficial compartment L Deep Compartment Release through Anteromedial Incision 1 Release the deep posterior compartment release the fascia distally and run mayo scissors proximally continue release through and under the soleus bridge release the the soleus attachment to the tibia more than half way 2 Assess the musculature of the deep compartment N Wound Closure 1 Place negative pressure dressings 2 Place in splint with the ankle in neutral this prevents equinus contracture 3 Return to OR in 48-96 hours for additional wound debridement 4 Return to OR in 5-7 days for primary wound closure
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 Physical therapy nonweightbearing 3 Appropriate medical management and medical consultation 4 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