surgery review booklet

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1 >uiciq Jcvicw |ookci (o u jcw oici inpoiiuri iicn- joi cxicir-ip-) CCJ|-C!> Cjjieci- oj 2oo Jc-iqpcd, Cdiicd, Opduicd bq ic lJ|> ir 2oo, 2 All pictures came from class notes / handouts. Most of the pictures were referenced from Dr. Hetheringtons book. 3 1ubc oj Coricri-. Topic Page # Charting Surgical Consult 6 Pre-Op Note 6 Post-Op Order 6 Admission Order & Note 6 Post-Op Note 7 Post-Op Visit 7 Layers of the Foot 8 Key Lab Values 8 Hospitalization Indications 9 Post-Op Fever Etiologies 9 Sutures Types 10 Selection 11 Technique 11 Classification Systems Stewart, Salter-Harris 12 Gustillo-Anderson, WatsonJones, Freiberg 13 Berndt-Hardy, Hawkin 14 Sneppen, Watson & Dobas, Kuwada 15 Rowe, Sanders 16 Hardcastle, Dias, Danis-Weber 17 Lauge-Hansen 18 MRI 19 Anesthesia Anesthetics 20 Dosing 20 Onset/Duration 20 Increasing Comfort 21 Ankle Block 21 Hemostasis = Tourniquet Pressures 21 4 1ubc oj Coricri- (Coriirucd). Topic Page # Corticosteroid Injections Types 22 Side Effects 22 Cocktails 22 Radiographic Data 23 Joint Deformities 24 Osteotomies Proximal 25-27 Shaft 29-30 Distal 31-33 Internal Fixation Principles 34 Rule of 2s 34 K-Wires 34 Steinmann Pins 34 Monofilament Wire 35 Tension Band Wiring 36 Staples 37 Screws Anatomy 38-39 Types 40-41 Fixation Technique 42-43 Selection 44 Soft Tissue Anchors 45 Plates 45-46 5 1ubc oj Coricri- (Coriirucd). Topic Page # External Fixation Principles 47 Complications 48 Types 48-49 Dynamics 50 Care & Management 50 Forefoot Pathologies / Surgical Procedures Hallux Limitus/Rigidus 51-52 Hammertoes 53-56 Etiologies for Contracted Digits 5th Digit Arthroplasty 57 Rearfoot Surgery Plantar Fasciotomy 58 Haglunds Deformity 59 Keck & Kelly Osteotomies 59 Tendon Transfers & Indications Adductor Hallucis 60 Abductor Hallucis 60 Extensor Hallucis Longus 60 Jones Suspension 60 Hibbs 60 Tibialis Anterior 61 STATT 61 Cobb 61 Tibialis Posterior 62 Peroneus Longus 62 Bunions based on Angles 63 Other things to know 67 6 CHARTING SURGICAL CONSULT 1. Chief Complaint 2. HPI (NLDOCAT) 3. Allergies 4. Medications 5. Social History 6. Medications 7. Family History 8. Primary Care Dr 9. Hospitalizations 10. RoS Vitals / Vascular / Neuro / Derm / Musculoskeletal 11. Ancillary (x-rays, labs, ect) PRE-OP NOTE Surgeon Pre-Op Dx Planned Procedure Medications Allergies Diagnostic Data Labs, x-rays, EKG, ect Consent Form: Describe Procedure & Care / Complications / Alleviations / Expected Outcomes / Arrange Pre-Op Testing Consent form was reviewed with patient, signed and placed in chart. All risks, possible complication and alternative treatments have been discussed with the patient in detail. All patients questions have been answered to satisfaction. No guarantees to the outcome have been made. POST-OPERATIVE ORDERS: VANDIMAX Date/Time/Signature Vitals Activities Nursing Diet Ins/Outs Meds Ancillary X-ray ADMISSION ORDERS & NOTE: ADC VAANDILMAX Date/Time/Signature Admit to Dx Condition - Vitals Activities Allergies Nursing Diet Ins/Outs Labs Meds Ancillary X-ray 7 POST-OP NOTE: SAPPA HEMI FC2P2 Surgeon Assistants Pre-Op Diagnosis Post-Op Diagnosis Procedure Anesthesia type / how much Hemostasis type Estimated Blood Loss Materials sutures/hardware Injectables any post-incision Findings Pathology Prophylaxis Complications Condition Patient tolerated procedure and anesthesia well. Patient transported to recovery by anesthesia with vitals stable and vascular status intact. Also may include.. Pathology bone, ST; Condition stable, guarded, fair, poor; Prophylaxis POST-OP VISIT: SOAP Subjective 1. POV # ______, PVD #_______ 2. Procedure 3. N,V,C,F,SOB 4. Activity status 5. Pain / How controlled 6. Other Complaints Objective 1. How patient presents walking, wheelchair 2. Vascular, Neuro, Derm, Musculoskeletal Assessment 1. Status Post-Op 2. Compliance Plan 1. Treatment 2. Dr & Residents 8 LAYER OF THE FOOT 1st Layer 1. Abductor Hallucis M. 2. Abductor Digiti Minimi M. 3. Flexor Digitorum Brevis M. 2nd Layer 1. Quadratus Plantae M. 2. Lumbricales M. 3rd Layer 1. Flexor Hallucis Brevis M. 2. Flexor Digiti Minimi M. 3. Adductor Hallucis M. 4th Layer 1. Dorsal Interossei M. (4) 2. Plantar Interossei M. (3) KEY LAB VALUES Chem 7 Na Cl BUN K CO Cr CBC HgB HCT Glucose Platelets WBC (23-29mmol/L) (5-20mg/dL) (M: 110o Parallel Pitch Lines most objective method of determining a Haglunds deformity Procedures: Longitudinal incision lateral to TA Dissection down to posterosuperior Calcaneus Aggressive removal of pathologic bone, but dont chase the bump If you need to reflect the TA, reattach with a soft tissue anchor and remain NWB for 3 weeks Keck & Kelly Osteotomy: Indicated for increased CIA angle with no Haglunds deformity Dorsal wedge osteotomy of the posterior Calcaneus Rotate posterior aspect of Calcaneus dorsally after wedge removal MAINTAIN PLANTAR HINGE Secure with cancellous screws NWB for 6 weeks 60 TENDON TRANSFERS Tendon Transfer detachment of the tendon from insertion then relocate to new position Tendon Transplantation / Translocation rerouting the tendon without detachment from its insertion Types: 1. Adductor Hallucis 9 Resect at insertion, pass under the joint capsule and reattach at medial aspect of the capsule 9 Indicated in HAV to realign the sesamoid apparatus 2. Abductor Hallucis 9 Transected at insertion, rerouted inner 1st met head and fixated at lateral base of proximal hallux 9 Indicated in Hallux Varus with an osteotomy 3. Extensor Hallux Longus 9 Transected at origin, rerouted under DTIL, fixated to lateral base of proximal hallux 9 IPJ needs fused 9 Indicated when have sagital component with Hallux Varus 4. Jones Suspension 9 EHL excised from insertion, drill a hole transversely through 1st met head, rerouted through hole and sutured on itself 9 Indicated with cock-up deformity, flexible cavus, lesser metatarsalgia, chronic ulcers, weak TA, flexible plantarflexion of 1st met 5. Hibb's Tenosuspension 9 EDL detached from insertion, bundled together and placed through midfoot at the base of the 3rd met or lateral cuneiform 9 Indicated to release retrograde buckling at MPJs, met equines, flexible cavus, claw toes 61 TENDON TRANSFERS CONTINUED Types Continued... 6. Tibialis Anterior Transfer 9 3 incisions at (1) proximal dorsal leg, (2) TA insertion at medial plantar cuneiform / tubercle 1st met, and (3) the new area of insertion in the midfoot 9 Release from insertion, reroute out the proximal incision, with tendon, with tendon passer brought to new insertion (usually 3rd cuneiform) 9 Indicated for recurrent clubfoot, flexible forefoot equines, dropfoot, tarsometatarsal amputation, Charcot Marie Tooth deformity 7. Split Tibialis Anterior Tendon Transfer (STATT) 9 3 incisions at (1) base of 1st met, (2) anterior leg over TA just lateral to medial malleolus and (3) over peroneus tertius at base of 5th met 9 Split tendon through proximal insertion, lateral slip passed through peroneus tertius sheath and sutured to tendon fixated to cuboid 9 Indicated for spastic RF equines, spastic equinovarus, fixed equinovarus, FF equines, flexible cavovarus deformity, DF weakness, excessive supination in gait 8. Cobb Procedure 9 STATT but reroute to TA to PA tendon 9 Indicated for PT dysfunction 62 TENDON TRANSFERS CONTINUED Types Continued... 9. Tibialis Posterior Tendon Transfer 9 3 incision (1) insertion of the PT at navicular tuberosity, (2) anterior leg, middle 1/3 just lateral to tibial crest and (3) one at new insertion at dorsal midfoot 9 Tendon released from navicular Tuberosity, dissected free at the medial leg insertion to expose the IM and the PT pulled through this opening then brought to new insertion level (usually 3rd cuneiform) 9 Indicated for weak anterior muscles, equinovarus, spastic equinovarus, recurrent clubfoot, dropfoot, complications from Charcot Marie Tooth, peroneal nerve plaste, leprosy, Duchennes MS 9 Muscle goes from a stance to a swing muscle during gait 10. Peroneus Longus Tendon Transfer 9 3 incisions (1) lateral, lower leg, (2) lateral cuboid and (3) base of 3rd met/lateral cuneiform 9 Suture the Peroneus Longus to the Brevis , cut the longus at the level of the cuboid and the tendon is brought through the proximal incision and back through the medical incision to the 3rd cuneiform 9 Indicated for anterior muscle weakness, dropfoot 63 BUNION PROCEDURES TO KNOW BASED ON ANGLES IM Angle Normal: 0-8o 12-16o Distal Osteotomy Austin Hohman (Neck) -- Trapaziodal Mitchell (Neck) Wilson (Neck) Reverdin Laird (Distal L) Short Z Waterman Youngswick >16o Proximal Osteotomy Base Wedge Lapidus (Met-Cuneiform Fusion)Hypermobile Cresentic Juavara Proximal V of Kotzengerb Comments: with a thin Met shaft may need to use a proximal procedure Mitchell shortens the length of met shaft used in Long Met Leng

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