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 Perifibular Approach 1 Mark the incision halfway between the fibula and the crest of the tibia make a 10 cm incision dircelty over the midportion of the fibula retract the skin anteriorly H Anterior and Lateral Compartment Release 1 Incise the anterior fascia release the fascia of the anterior and lateral compartment longitudinally in a proximal and distal direction retract the skin posteriorly I Superficial Posterior Compartment Release 1 Incise the lateral fascia release the fascia that overlies the lateral head of the gastrocnemius incise the fascia over the superficial posterior compartment for a distance of 15 cm evaluate the color, consistency, contractility and capillary refill J Deep Posterior Compartment Release 1 Expose and release the deep posterior compartment retract the anterior and lateral compartments anteriorly and the superficial posterior compartment posteriorly release the soleal bridge from the fibula identify the fascia over the FHL 2 Incise the fascia over the FHL 3 Retract the gastrocsoleus complex posterior retract the FHL laterally this exposes the posterior tibial artery, tibial nerve and peroneal artery that is overlying the tibialis posterior K FHL Release 1 Perform release incise the fascia around the tibialis posterior and the interval between the muscle and the origins of the flexor hallucis longus is widened if it is constrictive L 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