DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left humeral shaft fracture.
2. Right lateral malleolus fracture.
3. Right pantalar dislocation.
POSTOPERATIVE DIAGNOSES:
1. Left humeral shaft fracture.
2. Right lateral malleolus fracture.
3. Right pantalar dislocation.
PROCEDURES PERFORMED:
1. ORIF of left humeral shaft.
2. Open reduction and internal fixation of right lateral malleolus.
3. Removal of K-wire, right foot, with placement of K-wire across talonavicular joint.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 400 mL.
DESCRIPTION OF OPERATION: The patient was brought to the OR and laid supine on the OR table. General anesthesia was induced. Tourniquet was placed high up on the right thigh. Right lower extremity and left upper extremity were then prepped and draped in the usual sterile fashion. An anterolateral approach to the humeral shaft was performed. Dissection was carried down to the brachialis, which was split in the midline taking care to protect the musculocutaneous nerve. The fracture was exposed proximally and distally. Next, using tenaculums and standard reduction clamps, the fracture was reduced and held together with reduction clamps provisionally.
Next, a lag screw was placed across the fracture in standard AO fashion. Next, a 9-hole large fragment LCDC plate was fashioned to the anterior aspect of the humerus. Four screws were placed proximal and four screws distal to the fracture. All screws were placed in standard AO fashion. Next, plain films were obtained in the OR, which showed good length of all screws and excellent reduction of the fracture. The wound was then thoroughly irrigated with normal saline. The deep layer was closed with 0 Vicryl suture in figure-of-eight fashion followed by 3-0 Vicryl suture for the subcutaneous layer and staples for the skin. Sterile dressing was applied to the left upper extremity.
Next, the right lateral malleolus fracture was addressed, which was operated on simultaneously by another surgical team. A standard lateral approach to the ankle was performed. The lateral malleolus fracture was exposed and cleaned of periosteum and fibrin clot. There was noted to be a comminuted segment and no lag screws could be placed. Next, a 7-hole LCDC plate was contoured to the distal fibula. Three holes were placed proximal and three holes distal to the lateral malleolus fracture. Excellent fixation was obtained. The wound was then thoroughly irrigated with normal saline and closed in layers with staples to the skin. Next, attention was directed to the pantalar dislocation, which had previously been reduced approximately 2 days ago. One of the K-wires across the talonavicular joint had held the midfoot in plantar flexion; this K-wire was removed. The midfoot was then dorsiflexed and another K-wire was placed across the navicula into the talus stabilizing the talonavicular joint.
Plain films were then obtained in the OR and sterile dressings were applied to the right lower extremity followed by an AO splint. Plain films showed excellent reduction of the ankle mortise and good placement of all hardware. The patient was then awakened from anesthesia and transferred back onto the stretcher and taken to the PACU for recovery. The patient will remain nonweightbearing on bilateral lower extremities.
