DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right fifth digit proximal phalanx fracture.
POSTOPERATIVE DIAGNOSIS:
Right fifth digit proximal phalanx fracture.
OPERATION PERFORMED:
Percutaneous pinning of the right fifth digit.
SURGEON: John Doe, DPM
ASSISTANT: Jane Doe, DPM
ANESTHESIA: Combination of MAC with local, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain was infiltrated preoperatively.
SPECIMENS: There were no specimens sent to pathology.
HEMOSTASIS: Maintained using a pneumatic ankle tourniquet infiltrated to 250 mmHg.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: Consists of one 0.062 K-wire.
COMPLICATIONS: There were no complications in the perioperative period.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old female who presents today with a right fifth digit proximal phalanx fracture. This is an oblique fracture and at this time very unstable and malaligned. This occurred approximately 3 days ago. The patient now presents for surgery due to the inability to reduce this using more conservative measures. Consent has been signed. The patient has been medically cleared and n.p.o. for the appropriate time. There are no contraindications to surgery and all questions regarding surgery have been answered for the patient prior to the procedure.
DESCRIPTION OF OPERATION: The patient was brought into the operating room lightly sedated and placed in the supine position on the operating room table under monitored anesthesia care. Then, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain was infiltrated preoperatively. A pneumatic ankle tourniquet was placed upon the right ankle. The right leg was draped and prepped in a normal sterile fashion, elevated and exsanguinated using Esmarch bandage, at which time pneumatic ankle tourniquet was inflated to 250 mmHg.
Attention was directed to the right fifth digit, where under XiScan, it was evaluated that this fracture had caused the distal aspect of the proximal phalanx and remaining phalanx to be laterally dislocated. Percutaneous pinning was then done after manually relocating the proximal phalanx and doing so allowed for this percutaneous pinning to create a straight digit. XiScan was once again used and anatomical alignment was indeed satisfactory.
Once this was finished, the pneumatic ankle tourniquet was deflated and removed and the patient finished the procedure with vital signs stable and neurovascular status intact to digits 1-5 of the right foot. The patient was sent to recovery, where vitals are to be taken per routine. The patient is to keep surgical shoe clean, dry and intact and to ice and elevate this right lower extremity.
