DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Extra-articular left distal radius fracture with ulnar styloid fracture.
POSTOPERATIVE DIAGNOSIS: Extra-articular left distal radius fracture with ulnar styloid fracture.
OPERATION PERFORMED: Open reduction and internal fixation (ORIF) of left extra-articular distal radius fracture, two part, with application of volar locking plate, and closed treatment of ulnar styloid fracture.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
SPECIMENS: None.
IMPLANTS: Synthes stainless steel volar distal radius locking plate.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic female who sustained a fall yesterday evening. The patient was evaluated, and the fracture was splinted temporarily overnight and arrangements were made for operative intervention. After discussion of risks and benefits, the patient elected to proceed with surgical intervention consisting of open reduction and internal fixation of the left distal radius fracture.
DESCRIPTION OF OPERATION: After obtaining informed consent, identifying the correct patient and correct operative site, the patient was taken to the operating suite and placed under adequate general anesthesia. Left hand and upper extremity was then prepped and draped in usual sterile fashion. She received preoperative IV antibiotics, then the limb was exsanguinated with an Esmarch bandage, and a well-padded brachial tourniquet was inflated to the appropriate arm pressure.
A standard volar approach to the distal radius was performed through the FCR sheath, the tendons retracted ulnarly, and the floor was opened. The FPL was retracted ulnarly protecting the median nerve. The pronator quadratus was then elevated off of its radial attachment thereby exposing the fracture. Hematoma was gently removed, and the fracture was manually reduced and provisionally stabilized with a percutaneously placed K-wire. Reduction was confirmed and adjusted as necessary under fluoroscopy until it was anatomic. A left stainless steel Synthes distal radius locking plate was then selected and applied to the volar surface of the radius in standard fashion. It was secured in the shaft with two nonlocking screws of appropriate length, then distally a row of locking screws was placed in a subchondral fashion stabilizing the fracture. The K-wire was removed and position and length of all hardware as well as the adequacy of the reduction was confirmed fluoroscopically. It was felt to be essentially anatomic. The distal radial ulnar joint was checked for stability and was felt to be stable in all positions of forearm rotation.
The bed was then thoroughly irrigated with normal saline, and the pronator was reapproximated with 0 Vicryl figure-of-eight sutures. The skin edges were closed with inverted buried 4-0 Vicryl and a running 4-0 Prolene reapproximating the skin. It was dressed with Xeroform and a bulky, lightly compressive short arm dressing with a volar plaster splint immobilizing the wrist in slight extension. The tourniquet was then released with excellent circulatory return to her hand. The patient was taken to the recovery room in stable condition, having tolerating the procedure without difficulty.
