A Outpatient Evaluation and Management 1 Obtain focused history and performs focused exam concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests 2 Prescribes and manages nonoperative treatment orders appropriate orthosis 3 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 4 Provides postoperative management and rehabilitation 2 week postoperative visit remove sutures check for consolidation on radiographs diagnose and management of early complications B Advanced Evaluation and Management 1 Provides post-op management and rehabilitation C Preoperative H & P 1 Perform basic medical and orthopaedic history and physical check neurovascular status check range of motion 2 Perform operative consent describe complications of surgery including malunion delayed union or nonunion pin site or surgical wound infection extensor tendon adhesions or ruptures MCP or interphalangeal capsular contractures
E Preoperative Plan 1 Execute surgical walkthrough describe the steps of the procedure verbally prior to the start of the case 2 Description of potential complications and steps to avoid them F Room Preparation 1 Surgical Instrumentation headless screws guidewires 2 Room setup and Equipment standard operating table hand table 3 Patient Positioning patient placed in the supine position with hand on hand table place tourniquet high on the affected extremity G Incision 1 Mark and make the incision make a longitudinal or curvilinear incision over the metacarpal head 2 Bluntly dissect to the extensor mechanism H Soft Tissue Dissection 1 Expose the fracture site split the extensor mechanism longitudinally incise the capsule I Fracture Reduction 1 Manipulate the MCP joint flex the MCP joint this will facilitate the exposure of the fracture 2 Reduce the fracture use a dental pick or small pointed reduction forceps to reduce the fracture J Provisional Fixation 1 Place guidewires insert guidewires from a cannulated headless screw set K Definitive Fixation 1 Place headless screws insert headless screws over the guidewires 2 Confirm placement and reduction check the screw placement and fracture reduction radiographically L Wound Closure 1 Close the periosteum and soft tissues close the periosteum and the interosseous muscle fascia over the plate this provides a smooth gliding surface for the extensor mechanism 2 Repair the extensor mechanism close the extensor mechanism with 4-0 nonabsorbable suture 3 Superficial closure close the skin with 3-0 monocryl suture N Wound Closure
O Perioperative Inpatient Management 1 Write comprehensive postoperative orders 2 Orders appropriate inpatient occupational and physical therapy 3 Discharges patient appropriately write for 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