A Basic Outpatient Evaluation and Management (including Post Op Care) 1 Perform focused history and physical exam recognizes implications of soft tissue injury 2 Orders/ interprets advanced imaging: CT scan 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention surgical indications pain with motion instability end stage osteoarthritis of the wrist 4 Modify and adjust post-op plan when indicated postop: 2-3 week postoperative visit wound check and remove sutures diagnose and management of early complications continue immobilization for 8-10 weeks continue non-weightbearing postop:3 months start strengthening exercises postop: 1 year postoperative visit C Preoperative H & P 1 Perform history and physical exam check radial/ulnar artery patency of operative extremity with Allen’s test 2 Orders and interprets basic imaging studies need biplanar films of wrist 3 Perform operative consent describe complications of surgery including neurovascular injury superficial and deep infections wound breakdown implant failure malunion and nonunion
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 steps to avoid them F Room Preparation 1 Surgical instrumentation fusion plate and screws 2 Room setup and equipment setup OR with standard operating table and radiolucent hand table turn table 90° so that operative extremity points away from anesthesia machines c-arm perpendicular to hand table with monitor in surgeon's direct line of site 3 Patient positioning supine with shoulder at edge of bed centered at level of patient’s shoulder hand centered on hand table, supinate arm arm tourniquet placed on arm with webril underneath (optional) G Superficial Dissection Between 3rd and 4th Extensor Compartment 1 Mark incision and make the incision make a standard dorsal longitudinal incision between the third and fourth extensor compartment use the tubercle of Lister as a landmark 2 Divide the third and fourth compartments incise the retinaculum over the third extensor compartment incised the radial septum of the fourth extensor compartment 3 Retract tendons retract the tendons ulnarly H Dorsal Wrist Capsulotomy and Joint Inspection 1 Expose the dorsal wrist capsule elevate the fourth and fifth extensor compartments ulnarly translocate the EPL tendon with the radial wrist extensor tendons radially 2 Expose the midcarpal joint and the radial half of the radiocarpal joint longitudinally split the dorsal radiocarpal and dorsal intercarpal ligaments with the apex of the triquetrum 3 Elevate the flap radially this will detach the dorsal capsule from the radius to the level of the styloid process 4 Expose the ulnocarpal joint split the dorsal radiocarpal ligament longitudinally incise the capsule along the ECU tendon subsheath proximally to the level of the TFCC with the apex of the triquetrum 5 Elevate this flap proximally 6 Inspect the radio lunate joint for articular cartilage wear I Scaphoid Excision 1 Excise the scaphoid identify and excise the scaphoid either in a piecemeal fashion with a rongeur or sharply using a scalpel take care to protect the volar radioscaphocapitate ligament J Fusion Preparation 1 Prepare the wrist for fusion decorticate the opposing joint surfaces of the lunate, triquetrum, capitate and hamate remove the volar third cartilage from the lunate and the capitate this corrects the pre-existing DISI deformity but will shorten the intercarpal bone distance 2 Harvest distal radius bone graft and place into the fusion bed K Carpal Reduction 1 Place Kwires place a .06 2K wire through the distal radius articular surface place another Kwire in the lunate use a separate K wire as a joystick to hold the lunate reduced and neutral alignment advanced the K wire across the radio lunate joint from dorsal to volar 2 Verify Kwire placement obtain images to verify the correction of the dorsally tilted lunate 3 Reduce the capitate applied dorsal pressure to volarly translate the capitate on the lunate this should fully correct the DISI deformity 4 Place 2 more Kwires secure the triquetrum to the hamate and the lunate to the capitate with two additional K wire place these K wire’s as volar as possible this prevents interference with rasping and plate placement 5 Place the rasp center the power rasp over the four bones in both the AP and lateral planes bury the rasp down to subchondral bone 6 Pack bone graft pack bone graft obtained from the distal radius between the four prepared bones L Plate Fixation 1 Position the plate center the plate over the four bones in the AP and lateral planes place the circular plate into the bony crater created by the rest rotate the plate to maximize screw purchase into each of the four bones 2 Set the plate place two screws in each of the four carpal bones place the screws unicortically place the first screw through the plate into the lunate do not tighten the screw completely place a second screw into the hole opposite the first screw the plate position should now be set 3 Check imaging for placement of the plate check a lateral x-ray to ensure the plate is well seated and there is no impingement with wrist extension 4 Fill the plate with screws fill the remainder of the holes with screws placing screws opposite one another and tightening them sequentially will help prevent Mal positioning of the plate 5 Obtain final imaging obtain final images to check screw links position carpal reduction and construct stability N Wound Closure 1 Irrigation, hemostasis, and drain irrigate wounds thoroughly and deflate tourniquet (if utilized) coagulate any bleeders carefully 2 Deep closure close the capsule with absorbable suture repair the extensor retinaculum leave the EPL tendon transposed subcutaneously 3 Superficial closure close skin close subcutaneous layer with 3-0 absorbable suture 3-0 nylon vertical/horizontal mattress for skin alternatively, can use running 4-0 or 5-0 Monocryl for subcuticular stitch 4 Dressing and splint place a short arm cast
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care prescribe outpatient physical therapy non-weightbearing