A Intermediate Evaluation and Management 1 Obtains focused history and performs focused exam document distal neurovascular status concomitant and associated orthopaedic injuries 2 Interpret basic imaging studies biplanar films of the knee and the shaft of the femur 3 Prescribes nonoperative management skeletal traction cast bracing knee immobilizer long leg casting 4 Make informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit continue physical therapy and range of motion exercises discontinue DVT prophylaxis wound check repeat radiographs of femur staples/sutures removed diagnose and management of early complications start toe partial weight-bearing at 8 weeks and continue for 4-6 weeks postop: ~ 3 month postoperative visit repeat radiographs of the femur 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 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 Performs focused orthopaedic exam check for ipsilateral femoral neck fracture check thigh compartments (anterior, posterior, adductor) 2 Appropriately orders basic imaging studies order biplanar radiographs of the knee and femur shaft 3 Perform operative consent describe complications of surgery including neurovascular injury infection delayed union nonunion infection
E Preoperative Plan 1 Template fracture reductions draw key fragments of fracture and plan forces required to obtain reductions obtain order of reduction for fracture fragments identify the main articular fragment identify fracture pattern and method of plate fixation for simple metaphyseal fracture pattern anatomic reduction and interfragmentary compression is performed using a neutralization plate with 4 cortices above the fracture with tensioning of the plate for multifragemted metadiaphyseal extension type fractures the plate should be much longer the plate should be two to three times the length of the fragmented section 50% of the holes in the shaft component of the plate should be filled apply as many screws as possible in the distal fragment to achieve stability 2 Template instrumentation template size of instrumentation 3 Execute surgical walkthrough resident can describe key steps of the operation verbally to attending prior to beginning of case. describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation periarticular clamps K wires cancellous or cortical screws locking femoral condylar plate 2 Room setup and equipment radiolucent flat top table c-arm fluoroscopy 3 Patient positioning place patient supine place a sterile bump or triangle under the knee G Midline Approach with an Extended Lateral Parapatellar Arthrotomy 1 Mark out the incision mark incision directly anterior starting 5 cm proximal to the superior pole of the patella 2 Make the skin incision 3 Develop the lateral skin flap 4 Perform arthrotomy be sure that there is a cuff of tissue on the lateral aspect of the patella as well as medially for the quadriceps 5 Expose the condyles sublux the patella medially or invert the patella during knee flexion 6 Perform periosteal elevation of the capsule off of the lateral condyle to prepare for the plate be sure to preserve the lateral collateral ligament the dissection should be limited to the anterior 2/3 of the lateral condyle H Reduction of the Articular Surfaces and Definitive Fixation of the Condyles 1 Evaluate the joint line determine the amount of articular comminution present assess each condyle for smaller fragments 2 Reduce the fracture fragments use large pointed reduction forceps to reduce the fragments assess each reduction under direct visualization at the trochlear region of the patellofemoral joint 3 Place temporary fixation place temporary K wires of guide pins for locking screws for provisional fixation 4 Place definitive fixation place screws in the periphery to avoid any interference with the plate placement itself if this is not possible, place screws from medial to lateral to avoid interference of plate placement I Reduction of the Shaft to the Distal Segment 1 Reduce the fracture with K wires place bumps under the leg to reduce extension of the distal segment to align it with the shaft of the femur if temporary external fixation has been placed, it should be loosened to aid in the reduction 2 Provisionally fix the distal segment to the shaft use K wires or steinmann pins for provisional fixation J Placement of the Plate 1 Place K wires all fixed angle plate systems are designed to restore valgus alignment of the distal femur place the guidewires for the screws in the distal portion of the plate parallel to the joint line placement of these screws in a parallel fashion ensures that when the shaft is brought to the plate, the anatomic axis of the femur will be restored 2 Insert the plate in a submuscular fashion in order to place the plate, drive the guidewires to the medial side of the knee place the plate submuscularly drive the guidewires back through the plate laterally align the plate to the distal segment and confirm that the screw trajectory is parallel to the joint 3 Confirm the placement of the plate proximally with fluoroscopy 4 Stabilize the plate to the bone distally place a guidewire in the center hole of the distal aspect of the plate 5 Confirm placement of the plate use lateral fluoroscopic imaging to confirm the anterior and posterior placement of the plate 6 Stabilize the plate to the bone proximally if no screw targeting guide is present, a percutaneous provisional fixation pin can be used to stabilize the plate 7 Check reduction check the flexion-extension reduction using fluoroscopy K Screw placement 1 Place screws use partially threaded or overdrilled fully threaded screws through the plate to provide interfragmentary compression once the articular surface is reduced, place two locking screws to secure the plate and the alignment 2 Evaluate the intercondylar notch use the notch view to ensure that penetration through the intercondylar notch did not occur L Attaching the Distal Segment to the Shaft and Placement of the Additional Screws 1 Assess placement of the plate before placing the locking screws check the length, rotation and the alignment through fluoroscopy the plate can be locked to the distal segment and then used to manipulate the distal segment relative to the shaft for flexion-extension reduction 2 Place additional screws proximally place additional screws percutaneously using freehand under fluoroscopic guidance if there is a targeting guide, place locking screws percutaneously 3 Check the final construct with lateral radiographs N Wound Closure 1 Irrigation, hemostasis, and drain copiously irrigate the wound irrigate until backflow is clear cauterize peripheral bleeding vessels 2 Deep closure close the arthrotomy with figure of eight 0 vicryl sutures reinforce with fiberwire suture 3 Superficial closure subcutaneous with 2-0 vicryl and skin closure with 3-0 vicryl and suture or staples 4 Dressings soft incision dressings over the distal femur
O Perioperative Inpatient Management 1 Write comprehensive admission orders advance diet as tolerated pain control prescribe appropriate DVT prophylaxis wound management remove dressings POD2 foley out when ambulating check appropriate labs antibiotics 2 Check radiographs in postop check placement of implants 3 Initiate physical therapy on POD 1 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately pain meds outpatient physical therapy schedule 2 week follow up R Complex Patient Care 1 Develops unique, complex post-operative management plans