DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right medial malleolus fracture.
POSTOPERATIVE DIAGNOSIS: Right medial malleolus fracture.
OPERATION PERFORMED: Open reduction and internal fixation, right medial malleolus.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None apparent.
DISPOSITION: To the PACU for recovery.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid supine on the OR table. After general anesthesia was induced, the right lower extremity was prepped and draped in the usual sterile fashion. Tourniquet was not used during the case.
Next, a standard medial approach to the medial malleolus was performed. The fracture was identified and cleaned of periosteum. The fracture was noted to be minimally displaced. Upon opening the fracture, approximately 5 x 5 mm osteochondral fragment was identified; loose fragments in the joint. These fragments were part of medial and profound impaction injury, which was excised due to its small size. Next, the fracture was reduced anatomically and held provisionally with K-wires.
Next, a 5-hole one-third tubular plate was fashioned to the medial aspect of the medial malleolus. Two screws were placed in the proximal fragments followed by two screws in the distal fracture fragment. The most distal screw was placed in the lag fashion obtaining excellent compression across the fracture.
Next, the wound was thoroughly irrigated and closed in layers. Plain films were obtained in the OR, which showed excellent reduction of the fracture on both the AP, mortise, and lateral plains. All hardware that was placed was in good position. Next, sterile dressings were applied, and the patient was placed into an AO splint, awakened from anesthesia, and transferred back onto a stretcher and taken to the PACU for recovery. There were no complications.
