DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left small finger open fracture, distal phalanx, with complex laceration.
POSTOPERATIVE DIAGNOSES:
1. Left small finger open fracture, distal phalanx, with complex laceration.
2. Laceration of flexor tendon, radial digital nerve and radial digital artery, left small finger.
OPERATION PERFORMED:
1. Left small finger wound exploration with irrigation and debridement.
2. Left small finger irrigation and debridement of open fracture, distal pharynx, with open reduction internal fixation.
3. Left small finger repair of flexor digitorum profundus tendon laceration.
4. Small finger microscopic repair of radial digital nerve and radial digital artery lacerations.
SURGEON: John Doe, MD
ANESTHESIA: Axillary block.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The patient sustained a near circumferential laceration involving the distal aspect of the left small finger extending from the eponychium across the radial surface of the distal phalanx onto the palmar ulnar aspect of the distal interphalangeal joint. There was an intact dorsoulnar skin bridge, including the terminal neurovascular structures on the ulnar side of the finger tip.
Exploration revealed a comminuted oblique fracture of the base of the distal phalanx with displacement and contamination of the bone surface. The fracture occurred at the level of the insertion of the flexor digitorum profundus tendon. The radial digital nerve was found to have one intact fascicle group with two lacerated terminal branches. The radial digital artery was completely transected.
DESCRIPTION OF OPERATION: Consent was signed. The patient was taken to the operating room on an emergency basis. Axillary block anesthetic was administered by the anesthesiologist to the left upper extremity, which was then prepped and draped sterilely. A tourniquet was inflated on the upper arm following exsanguination of the limb.
The left small finger wound was explored under loupe magnification. The jagged skin edges were debrided sharply. The wound was irrigated thoroughly with antibiotic solution.
The fracture site was debrided using a curette and rongeur and irrigated with additional IV antibiotic solution. The fracture was then reduced and stabilized using a 0.035 inch K-wire placed in retrograde fashion across the fracture site. The alignment was checked clinically and by fluoroscopy and found to be satisfactory.
A K-wire was then driven across the distal interphalangeal joint, maintaining the joint in a slightly flexed position for protection of the soft tissue repairs. The end of the K-wire was then cut short beneath the skin following confirmation of its position via fluoroscopy.
Next, the flexor tendon was repaired using multiple sutures of 4-0 Supramid. A portion of the tendon insertion was intact at the proximal fracture fragment. The remaining distal fibers were repaired securely to the distal stump of the profundus tendon.
Next, the operating microscope was brought in. The terminal branches of the radial digital nerve were repaired using 9-0 nylon epineural sutures. The radial digital artery was dissected and prepared for repair. This appeared to be the larger of the two digital arteries measuring approximately 1.5 mm in diameter. The artery ends were debrided and irrigated with heparin solution. Anastomosis was performed using circumferential sutures of 10-0 nylon without excessive tension.
The field was again irrigated with antibiotic solution. The skin edges were reapproximated with nylon sutures. The tourniquet was deflated. Circulation returned to the left hand with normal capillary refill distally in the small finger. Bleeding was controlled with pressure, and hemostasis was achieved. A sterile bulky gauze dressing was applied followed by a forearm-based ulnar gutter plaster splint. The patient was transferred to recovery in stable condition. He tolerated the procedure well with no complications. Prior to application of the splint, the small finger was observed and perfusion remained intact distally with normal capillary refill and pink color.
The patient was given IV antibiotic prophylaxis and baby aspirin in the recovery room. The patient tolerated the procedure well with no complications.
