A Outpatient Evaluation 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 DCP plating system 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 Dorsal Longitudinal Incision 1 Mark and make the incision make a skin incision over the center of the fractured metacarpal 2 Identify the neurovascular structures identify and protect the dorsal sensory nerve branches H Fracture Exposure 1 Expose the fracture extraperiosteally identify the radial and ulnar margins this helps in achieving appropriate reduction I Plate Placement 1 Measure the correct size DCP plate 2 Place the correct size plate J Provisional Fixation 1 Fix the plate provisionally fix the plate by clamping the plate to the bone proximally the most commonly used plates are 2.0 to 2.5 mm 2 Add a subtle concave bend to the plate before its application this helps compress the volar cortices 3 Check the alignment check the sagittal and coronal plane alignment by direct inspection of the fracture site assess the rotation clinically with the aid of tenodesis K Definitive Fixation 1 Place screws in compression mode achieve at least 4 cortices of fixation in both the proximal and distal fragments 2 Check the alignment and reduction check the anatomic fracture reduction with fluoroscopy 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 Superficial closure close the skin with 3-0 monocryl suture
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