DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left radiocarpal subluxation.
2. Left distal radius fracture.
POSTOPERATIVE DIAGNOSES:
1. Left radiocarpal subluxation.
2. Left distal radius fracture.
OPERATION PERFORMED:
1. Application of spanning external fixator to reduce the radiocarpal subluxation.
2. Open reduction and internal fixation of left distal radius fracture with a volar bearing plate, Tri-Med.
SURGEON: John Doe, M.D.
ASSISTANT: None.
ANESTHESIA: General endotracheal anesthesia.
ANESTHESIOLOGIST: Jane Doe, M.D.
COMPLICATIONS: None.
SPECIMENS: None.
DISPOSITION: To recovery room.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who sustained the above noted and was indicated for operative fixation. The risks, benefits, and alternatives of the procedure were discussed in detail with the patient, including but not limited to musculoskeletal or neurovascular damage, bleeding, infection, and also loss of life or limb. The patient was given the opportunity to ask questions, and all questions were answered to his satisfaction. Informed consent was obtained and placed on the chart.
FINDINGS AND DESCRIPTION OF OPERATION: The patient was taken to the operating room. Under endotracheal general anesthesia, the patient was placed in the supine position. The left distal radius was prepped and draped in the usual fashion. Radiocarpal subluxation was corrected with a spanning external fixator using 3.0 mm pins in the proximal radius and in the second and index metacarpal. Distraction was then used to reduce radiocarpal subluxation. Dissection was then carried down through flexor carpi radialis tendon sheath, through the pronator quadratus, and subsequently subperiosteal dissection. Intraarticular reduction was then achieved, held primarily with 0.62 K-wires. A volar bearing plate was then applied and secured with 3.2 and 2.3 screws respectively. Reduction was noted to be acceptable and anatomic in all planes. Prognosis for this patient is active and passive range of motion as tolerated with weightbearing restrictions for the first six weeks. We will follow up with x-rays at two weeks, eight weeks, and thereafter.
