Surgical and Procedural Management
Domain 5: Surgical and Procedural Management
This domain tests perioperative risk assessment, sterile technique, and recognition of procedure-related complications.
Core rules
- Preoperative assessment: cardiac risk, diabetes control (HbA1c), anticoagulation plan, anemia, nutrition, and smoking status. Document allergies, prior anesthesia problems, and functional baseline.
- Informed consent requires capacity, discussion of alternatives, risks, benefits, and documented patient questions.
- Surgical site infection prevention: chlorhexidine-alcohol skin prep, appropriate antibiotic within 60 minutes, normothermia, glucose control, and minimal traffic.
- Arthroplasty versus ORIF depends on fracture pattern, bone quality, and patient function; displaced femoral neck fractures in older adults often favor arthroplasty.
- Joint aspiration and injection: landmark, sterile technique, avoid injection through cellulitis, and check anticoagulation status. Send aspirate for cell count, crystals, and culture when infection is suspected.
- Postoperative monitoring includes neurovascular checks, wound assessment, pain control, and VTE prevention.
Worked example
A patient requests a cortisone injection for a painful knee, but the skin is warm and erythematous. Do not inject. Aspirate for culture and cell count, and treat possible septic arthritis. Injecting through infected skin can seed the joint.
Traps
Obtaining consent for an incapacitated patient without a surrogate; missing coagulopathy before injection; and attributing postoperative fever to atelectasis without assessing the wound.