DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right clavicle fracture.
POSTOPERATIVE DIAGNOSIS: Right clavicle fracture.
OPERATION PERFORMED: Open reduction and internal fixation (ORIF) of right clavicle.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 100 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who flipped over the handlebars of his bicycle sustaining the above-stated injury. The fracture was significantly displaced, and it was thought that nonoperative treatment would likely lead to nonunion. Therefore, informed consent was obtained for operative fixation of his clavicle fracture.
DESCRIPTION OF OPERATION: The patient was brought to the OR and laid supine on the OR table. After general anesthesia was induced, the patient was positioned in the beach-chair position on the McConnell headrest. Next, the right upper extremity was prepped and draped in the usual sterile fashion, including the clavicle. Next, a standard incision was made directly overlying the clavicle, and the dissection was carried down to the deep layer exposing the clavicle fracture. The fascia was cleaned of hematoma and fibrin clot. The fracture was then reduced and held provisionally with a reduction clamp. Next, one lag screw was placed holding the fracture reduced. Next, a 7-hole plate from the Acumed Mayo sets was selected. The plate was fashioned over the clavicle and three screws were placed in the medial fragment and three screws in the lateral fragment in a standard AO fashion. All screws were then tightened. Plain films were obtained in the operating room showing good reduction of the fracture as well as placement of all screws and hardware. Next, the wound was closed in layers followed by dressings over the skin. The patient was placed into a sling postoperatively. The patient was then awakened from anesthesia, transferred back onto the stretcher, and taken to the PACU for recovery. There were no complications.
——————————————-
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right clavicle fracture.
POSTOPERATIVE DIAGNOSIS: Right clavicle fracture.
PROCEDURE PERFORMED: Open reduction and internal fixation (ORIF) of right clavicle.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 200 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who sustained a right clavicle fracture as well as both-bone forearm fracture approximately three weeks ago. The patient underwent operative fixation of his right forearm. The clavicle was initially treated nonoperatively but has shown significant displacement, and the patient has increased pain. Informed consent was obtained for operative fixation.
DESCRIPTION OF OPERATION: The patient was brought to the OR and laid supine on the OR table. After general anesthesia was induced, the patient was placed into a semi-beach chair position on the McConnell headrest. Next, the right clavicle and the right upper extremity were prepped and draped in the usual sterile fashion. A standard approach to the clavicle was performed. The fascia was cleaned of fibrin, clot and periosteum. Standard reduction clamps were used to perform reduction of the clavicle. Reduction was held provisionally with a K-wire.
Next, a plate from the Acumed clavicle plate set was selected and fashioned to the superior border of the clavicle. Three screws were placed on the medial fragment and three screws on the lateral fragment. Excellent reduction and fixation of the clavicle was obtained.
The wound was then thoroughly irrigated with normal saline, and the wound was closed in layers. Skin was closed with staples. Sterile dressings were applied. The patient was placed into a sling. He was then awakened from anesthesia and transferred back onto a stretcher and taken to the PACU for recovery. There were no complications.
