Plastics

1. Undergraduate: Stanford University, BA with Honors 1994-1998
   
2. Graduate: Duke University School of Medicine 1999-2003
   
3. Post Graduate:

• University of Pittsburgh Medical Center, Internship, General Surgery 2003-2004
  
• University of Pittsburgh Medical Center, Residency, Plastic and Reconstructive Surgery 2004-2011
  
• University of Pittsburgh Medical Center, Post Doctoral Fellow, Plastic Surgery Research Laboratory, 2006-2008
  
• University of Pittsburgh Medical Center, Fellowship, Hand and Microsurgery, 2011-2012
  

Dr. Washington Publication Link

Important notes: Transects brachioradialis unless elderly patient, does NOT repair pronator quadratus Sutures: 4-0 nylon for closure Dressing: xeroform Splint: If suspect DRUJ instability place sugar tong, otherwise volar splint.

ASSISTANT: ORIF left distal radius fracture; intraarticular in three parts Left distal ulnar styloid fracture . PREOPERATIVE DIAGNOSIS: Left Closed intra-articular distal radius fracture; in three parts Left distal ulnar styloid fracture POSTOPERATIVE DIAGNOSIS: Left Closed intra-articular distal radius fracture; in three parts Left distal ulnar styloid fracture OPERATION PERFORMED: Left Open reduction and internal fixation distal radius fracture, intra-articular, and three fragments.   IMPLANTS: Acumed system     DESCRIPTION OF OPERATION: x was identified in the Holding Area and the operative site was marked. He was brought to the operating theater in stable condition and placed onto a regular OR table with his operative arm on an arm board. A preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. His splint was removed and a tourniquet was placed onto his arm which was then sterilely prepped and draped. An Esmarch bandage was used to exsanguinate the limb before elevation of the tourniquet to 250 mmHg.   We began the procedure by making a 10 cm incision longitudinally over his FCR tendon extending from his wrist crease and proximally. We dissected through subcutaneous tissue and identified the FCR tendon. We incised the tendon sheath, retracted the tendon ulnarly, and incised the subsheath. The distal aspect of the FPL origin was was retracted ulnarly to expose the pronator quadratus which was incised along its radial and distal borders and elevated subperiosteally. We released brachioradialis and identified the first dorsal compartment underneath. We identified the fracture site and cleaned the fracture of callus. We then used fluoroscopic imaging in order to confirm the ability to reduce the fracture.   We then selected an long Acumed Acu-Loc 2 volar radius plate. The plate position was provisionally stabilized using 0.054 K-wires and then secured to the proximal fragment using a 3.5 mm compression screw. We then reduced the fracture onto the plate and stabilized the distal fragment using additional 0.054 K-wires. The position of the plate and the fracture reduction were confirmed using fluoroscopic imaging. We then secured the epiphysis and articular fragments to the plate using 2.8 mm locking screws. We completed stabilization of the plate to the proximal fragment using 3.5 mm locking screws. The final position of the plate and fracture reduction were confirmed using fluoroscopic imaging and we were happy with both. Clinical examination showed no impingement of his wrist range of motion and stability of the DRUJ in supination.   The incision was washed. The pronator quadratus was not closed and the skin was closed using 4-0 nylon sutures in a horizontal mattress with steri-strips. A sterile dressing and sugar tong splint With the wrist in supination were applied. General anesthesia was reversed. He tolerated the procedure well. There were no complications. Final instrument count was correct. x was taken out of the operating theater and to the PACU in stable condition.   POSTOPERATIVE PLAN: x will go home from the hospital today with arrangements made to follow up with me in clinic in two weeks. He will be transitioned into a short arm removable splint, which will be worn continuously for an additional four weeks with protected range of motion of his wrist initiated by Hand Therapy. He has been told to strictly elevate his hand at all times as well as move his fingers to prevent stiffness. If he has any difficulty or concerns between now and followup, he has been told to contact me, and I would be happy to see him sooner.

Immediate Post Op Orders And Restrictions

Goals:

• Elevate wrist above elbow x 2-3 days
• Finger and motion and typing as tolerated
• Remove dressing at POD 5
• Work status: depends on job type
• 0-2 weeks: 5-10 lb. lifting limit, no pushing or pulling
• 2-4 week: <20 lbs., then no restrictions

10-14 Days Post-surgery

Goals:

• Schedule 1st post op visit as Physician Extender w/ either Washington or Kathryn; if PE unavailable, schedule w/ Kathryn as POV
  
• Wound Check
  
• Suture Removal
  
• Range of motion and edema control
  
• OT PRN
  

OT (if ordered beyond PE duties on 1st post op visit)

Goals:

• 2-4 weeks post op

Finger and wrist ROM, scar massage

• 4+ weeks post op

Scar desensitization/massage
Putty use
Strengthening and ROM as tolerated

Any patient with more than 1 elective procedure (trigger and CTR, multiple triggers, etc.…) needs a first postop visit with hand therapy between 5-7 days.

Dr. Washington - CMC Arthroplasty

Immediate Post Op Orders

Goals:

• Keep splint/dressing intact until follow up
  
• Elevate until follow-up
  
• Move fingers as splint allows
  
• Work status depends
  

Work Restrictions

• 0-3 days: OFF work
  
• 0-2 weeks: Limited use of operative hand to tolerance
  
• 4-8 weeks: 3-5pound limit, light use of thumb
  
• 8-12 weeks, no weight limit
  

10-14 Days Post-surgery

• 1st follow up visit (Schedule with Physician Extender)
  
• Wound Check
  
• Suture Removal PRN (often does dissolvable sutures)
  
• Xray 3 View thumb
  
• Forearm based thumb spica cast
  

4 weeks

• 2nd post op follow up visit w/ MD
  
• Remove cast
  
• Transition to forearm based thumb spica zipper
  
• Xray 3 view Thumb
  
• Order therapy to begin at 6 weeks post op
  

OT (start at 6 weeks) - FU w/ MD/PA at 8 weeks

• Begin OT at 6 weeks
  
• Gentle circumduction, flexion, extension, abduction, opposition, retroposition of thumb as well as AROM of wrist
  
• Desensitization
  
• May remove splint for exercises and showering/light activity
  

OT Progression (10 weeks) - FU w/ MD at Post op week 12

• Wean from splint – use only for heavy activity
  
• Start light strengthening with putty
  
• Ok to have splint off in home/controlled environment, splint on when out in community
  
• If no problems, d/c from OT to HEP
  

Immediate Post Op Orders

Goals:

• Dressing to remain on until Post op.
  
• May move fingers, wrist, and elbow as tolerated
  
• Work status depends
  

Work Restrictions

• Limited use of operative extremity to tolerance
  
• 0-3 weeks: May use arm as tolerated; 5lb weight restriction
  
• 3-4 weeks: 10-15lbs as tolerated
  
• >5 weeks: no restrictions
  

10-14 Days Post-surgery

• Schedule 1st post op visit with Physician Extender Washington or Kathryn; if PE unavailable, schedule w/ Kathryn as POV
  
• Wound Check
  
• Suture Removal(PRN, usually dissolvable
  
• Review HEP for strengthening
  
• OT Order (PRN)
  

OT (if ordered beyond PE duties on 1st post op visit)

• Scar massage, desensitization, strengthening
  

8 weeks

• 2nd follow up visit scheduled with MD/PA
  

Immediate Post Op Orders

Goals:

• Remove dressing at POD 5
  
• Elevate wrist x 3 days
  
• May move fingers as splint allows
  
• Work status depends
  

Work Restrictions

• 0-2 weeks: OK light use for typing and paperwork
  
• 0-2 weeks: 5 pound lifting limit, no pushing or pulling
  
• 2-4 wk.: no restriction
  

10-14 Days Post-surgery

• Schedule 1st post op visit w/ Physician Extender Washington or Kathryn; if PE unavailable, schedule w/ Kathryn
  
• Wound Check
  
• Suture Removal
  
• OT Order (PRN)
  

OT (if ordered beyond PE duties on 1st post op visit)

• ROM, Scar massage, desensitization
  

6 weeks

• 2nd follow up visit scheduled with PA
  

Immediate Post Op Orders

Goals:

• Keep splint/dressing intact until follow up
  
• Elevate wrist until follow up
  
• May move fingers as splint allows
  
• Work status depends
  

Work Restrictions

• During casting period: No lifting, pushing or pulling more than 5 pounds in casted extremity.
  

10-14 Days Post-surgery

• 1st post-op visit as Physician Extender w/ Washington or Kathryn; If PE unavailable, schedule w/ Kathryn as POV
  
• X-rays (3 views of wrist)
  
• Wound Check
  
• Suture Removal
  
• Short arm cast vs. Muenster- MD/PA to specify
  

4 weeks post op

• Schedule 2nd post op visit MD or PA unless otherwise specified
  
• Repeat cast vs. Delta splint at ~4 weeks
  

6 weeks post op w/ PA

• 3rd follow up visit with PA, transition to Delta vs. Zipper
  
• Begin GAROM of wrist once transitioned into splint (6 weeks)
  

8 weeks w/ MD

• 4th Follow up visit w/ MD
  
• Wean splint while at home (i.e. May remove to for ADLS)
  

12 weeks

• Final Physician visit w/ MD
  

Immediate Post Op Orders

Goals:

• Leave splint on until FU
  
• Elevate wrist x 5 days
  
• May move fingers as splint allows
  
• Work status depends
  

Work Restrictions

• 0-2 weeks: may use as tolerated; 5 lbs. weight restriction
  
• 3-6 weeks: full use
  

10-14 Days Post-surgery

• Schedule 1st post op visit with Physician Extender w/ Washington or Kathryn; if PE unavailable, schedule w/ Kathryn as POV
  
• Wound Check
  
• Suture Removal
  
• Review HEP for ROM, scar management
  
• OT Order (PRN)
  

6-8 weeks

• 2nd Follow up w/ MD or PA
  

Immediate Post Op Orders

Goals:

• Keep splint/dressing intact until follow up
  
• Elevate wrist until follow-up
  
• May move fingers as splint allows
  
• Work status depends
  

Work Restrictions

• During casting period: No lifting, pushing or pulling more than 5 pounds in casted extremity.
  
• For 2 wks. post cast removal: May lift, push, or pull up to 10 pounds with splint ON
  
• For 2-6 wks. post cast removal: May gradually increase weight-bearing as tolerated, with splint always on when lifting more than 10 pounds.
  
• May d/c splint at 6 wks. following cast removal
  

10-14 Days Post-surgery

• Schedule 1st post op visit with Physician Extender w/ Washington or Kathryn; If PE unavailable, schedule w/ Kathryn as POV
  
• X-rays (3 view hand)
  
• Wound Check
  
• Suture Removal
  
• OT Order (PRN)
  
• Discussion with physician/PA to determine type of short arm cast or splint
  

OT (if ordered beyond PE duties on 1st post op visit)

• If in splint – begin AROM, edema and scar management
  

4 weeks w/ PA

• 2nd follow up visit scheduled with PA
  
• Repeat Xrays 3 V Hand
  
• Cast vs. Splint
  

6 weeks w/ MD

• 3rd follow up w/ MD
  
• Repeat Xrays 3 V Hand
  
• Begin OT for ROM, unless otherwise specified
  

Immediate Post Op Orders

Goals:

• Remove dressing 5 days post op
  
• Apply Band-Aid
  
• Keep wound dry, no ointments
  
• Motion as tolerated to digits, wrist
  
• Work status depends
  

Work Restrictions

• 0-2 weeks: OK light use of hand for typing, paperwork, 5 pound lifting limit
  
• 3-4 weeks: No restrictions
  

10-14 Days Post-surgery

• Schedule 1st post op visit with Physician Extender w/ Washington or Kathryn; If PE unavailable, schedule w/ Kathryn as POV
  
• Wound Check
  
• Suture Removal
  
• Review HEP for ROM and strengthening, scar management
  
• OT Order (PRN/if >1 TFR)
  

OT (if ordered beyond PE duties on 1st post op visit)

• ROM and strengthening
  
• Edema control
  
• Scar massage
  

6-8 weeks

• 2nd follow up visit scheduled with MD/PA
  

If Multiple Trigger finger releases, begin OT for GAROM, tendon gliding at Post Op day 5. Post op order to be placed when Surgery Request is placed.