Plastics

• 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
• Has CTA runoff been obtained?
• 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.

No nicotine patch

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 5000U 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.

Dr. Gordon is particularly particular about these. You “wick” the wound, not pack it. He likes a 1/4 inch penrose drain, but he understands more practically, that a sliver of a glove is the easier option. Suture it to itself so it can't possibly fall out. ALWAYS get a culture if you would like to stay in this program. If the patient is compliant and able to care for themselves, he wants the patient to soak the hand once an hour for 10-20 minutes. If you are deciding between the OR, it's best to have inflammatory markers (WBC, ESR, CRP) and trend them.

Dr. Chong likes to take these

Dr. Chong also likes to take these

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

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