DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Crush avulsion, near amputation, right upper extremity through the elbow joint.
POSTOPERATIVE DIAGNOSIS: Crush avulsion, near amputation, right upper extremity through the elbow joint.
OPERATION PERFORMED: Revascularization, right upper extremity, with microvascular repair, brachial artery and venae comitantes.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: 100 mL.
COMPLICATIONS: None apparent.
DISPOSITION: To recovery in stable condition.
INDICATION FOR OPERATION: The patient presented to the emergency room following a work-related crush injury to his right upper extremity that resulted in an open dislocation of the elbow and disruption of the brachial artery and vascular supply to the right hand. He appeared to have some intact ulnar sensation in the emergency room. He was taken to the operating room for emergency exploration and repair. There were no other apparent major injuries.
DESCRIPTION OF OPERATION: After induction of general anesthesia, the right upper extremity was cleaned of gross debris, painted, and then draped in a sterile manner with the donor on the right leg just for grafts, if necessary. Six liters of saline was used to Pulsavac the wound. The neurovascular structures were identified and protected, and the skin and muscle were debrided of all questionable nonviable tissue.
Volar forearm fasciotomies were performed. We identified that all the radial, median, and ulnar nerves were intact but contused and stretched. The brachial artery and venae comitantes were completely disrupted. There was an area where the periosteum was stripped for the distal 4-6 cm of the humerus with the elbow joint completely disrupted and the cartilage of the humerus eburnated. We performed this identification, exploration with orthopedic service and Dr. (XX). Dr. (XX) then proceeded to shorten the humerus and perform an elbow fusion with reconstruction plates.
Following this stability, we examined the radial artery and veins under magnification and found them to be satisfactory for primary repair. We established good inflow and then under the operating room microscope performed an end-to-end coaptation of the brachial artery with interrupted 8-0 Ethilon. We released the clamps. The warm ischemia time was approximately seven hours. This was seven hours from the date of the reported injury.
The hand pinked up immediately, and there was never a subsequent problem with the arterial anastomosis. We identified appropriate venae comitantes and then performed an end-to-end coaptation with no tension with one of the larger venae comitantes. The contralateral one was ligated, several other veins were ligated. The nerves were freed so that they were not in contact with the bone or reconstruction plate and were well covered by the arm and forearm musculature. The pedicle was covered with brachialis muscle. The skin was loosely reapproximated, and a large area of the fasciotomy in the posterolateral arm was left open. This was covered with bacitracin and Adaptic. He was placed in a supportive splint and awakened and transported to recovery in stable condition. At the end of the case, the hand was viable with a palpable radial pulse.
