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Table of Contents
Lower Extremity Soft Tissue Coverage
Mechanism of wound
Size of wound
Prior surgeries
Existing hardware?
Current dressing/vac, etc
Weight bearing status
Infection? Osteo versus soft tissue only.
Antibiotics? Follow ALL cultures; know if they are soft tissue versus bone
CTA runoff
Needs to be on SQH 5000U TID and hold the AM dose if going to OR
Follow up CBCs especially after OR with ortho. If Hct is <28, will transfuse day BEFORE surgery.
If planning for poss free flap, need to T&C 2u RBC.
If going to surgery, need to make NPO, IVF, pre-op abx.
Example:
Soandso brokemyleg (MRN, Rm #, Ortho primary)
79F with open bimalleolar left ankle fx. 1/15: I&D, ex-fix. Now s/p I&D, ex-fix removal, ORIF 1/29.
Ortho plan for WV change today in OR. Will get pictures.
Plan for Left medial ankle coverage with free flap, possible wound vac, possible skin graft, possible vein graft.
Scheduled 2/5/20 12:00.
[ ] Mark and consent
[X] CTA runoff: L AT open to hardware, DP open. L PT open. L peroneal occluded in zone of injury.
[ ] Lovenox ppx: Change to SQH TID 500U after Ortho OR
[ ] F/u CBC- pending this AM (need pre-op trx?)
[ ] T&C 2u RBC for OR 2/5.
[ ] Need to hold SQH 2/5.
- OR cx 1/29: NGTD.
- Abx: none.
Chest Wall Recon after sternal dehisence of sternectomy
Dr. Chong likes to take these
Back Recon after spinal infection or dehisence
Dr. Chong also likes to take these
Sacral Decub
Following criteria must be met prior to flap reconstruction:
Nutrition: albumin > 2.5 gm/dl Prealbumin: normal >16 mg/dl. In general patients with osteo and inflammatory processes do not have a normal prealbumin. (negative acute phase reactant). However, if they can show consistent elevation in prealbumin over 3 weeks, they can be considered candidates for reconstruction.
The patient must have Source control: Adequate debridement and staged reconstruction after several weeks of IV antibiotics.
Flap reconstruction may be scheduled after the debridement with the patient managed with a wound vac.
Control of any spasms or release of fixed contractures that may impair flap mobilization.
Bowel regimen well established and urinary control. If necessary, diversion prior to surgery.
Plan for postoperative disposition: pressure relieving surface obtained prior to debridement, medical management and rehabilitation plan.
The patient is to follow up with Dr. *** in outpatient clinic.
OR
.PLASTICSPRESSURESORECONSULT
Distal radius fracture
Is it intraarticular or extra articular?
Is the patient neurovascularly Intact? (Check ulnar and radial pulses, sensation in radial, medial, and ulnar distributions) Motor exam as much as pain limits
The ED should have hand, wrist AND forearm X-rays ordered Ask the ED to have a mini C-arm ready, Ask them for Finger traps.
Be sure there is Lidocaine 1% without epi, and 18 G needle to draw, 27 or 30 G needle to inject, two 10 mL syringe, alcohol wipe.
Gather plaster roll (normally will fold into two sets 13-15 sheets each for a dorsal-volar splint, webril, a basin for warm water, bias wrap and an ACE to splint the patient after the reduction