DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left closed distal tibia/fibula fracture.
2. Second and third left finger nail bed injuries.
POSTOPERATIVE DIAGNOSES:
1. Grade 1 open left distal tibia/fibula fracture.
2. Foot wound laceration.
3. Second and third left finger nail bed injuries.
OPERATION PERFORMED:
1. IM nailing of left tibia.
2. I and D of open fracture.
3. Repair of nail bed, second and third left finger.
4. Layered closure of complicated left foot wound for approximately 20 cm.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed under general anesthesia. Preoperative antibiotics were given. A time-out was performed to identify the correct extremity. The patient’s left upper and left lower extremities were sterilely prepped and draped in the usual fashion.
The patient had a complex wound with a proximally-based flap involving the dorsum of his foot. Upon further inspection, he had three small punctate wounds of approximately 1 cm in length separately in the posterior aspect of his calf. This was at the level of the fracture itself. The wound was copiously irrigated first with three liters of sterile saline. Due to the wound posteriorly, an anterior wound was made for us to directly visualize the fracture. The fracture edge of the distal fragment was then debrided. The bony edges on the proximal end were also debrided. There was significant comminution that involved the anterolateral cortex of the tibia. The wound itself was also debrided of devitalized subcutaneous tissue.
Once the debridement was completed, attention was turned to the procedure of the IM nailing of the left tibia. A patella-splitting approach was carried out. The incision was made. The starting hole was established using the C-arm. Once that was done, the guidewire was able to pass down through the canal through the open wound that we were creating anteriorly for the I and D. We were able to pass the guidewire down to the distal fragment. Sequential reaming was carried out. We encountered chattering at 10.5, thus it was reamed up to 12 mm. The length of the nail was measured to be 375 mm. The nail was then inserted and stabilized proximally and distally with two screws each. Good compression was able to be placed across the posterior cortex. The anterior cortex was comminuted. The fibula was out to length.
Once that was done, all the wounds were copiously further irrigated again. The traumatic wound of the foot was reapproximated with 0 Prolene and 3-0 nylon. There was definitely a large avulsion flap with a proximal base. We were hoping that the skin flap would survive. Otherwise, the patient will need a skin graft in the future. All the other surgical wounds were able to be closed tightly with Vicryl and staples. Sterile dressing was then placed, and the patient was placed in a well-padded short leg posterior splint.
Attention was turned to the left upper extremity. He had a nail bed injury involving the left second and third fingertips. The second fingertip had to be removed, and the nail bed was able to be repaired using 6-0 chromic. The third nail was able to be saved, and the nail bed was also decompressed and repaired with chromic suture. Once that was done, foil was placed on the second finger as a temporizing nail bed. A sterile dressing was then placed. The patient’s index and third fingers were splinted.
Once we were done with that, the patient was awoken and taken to the recovery room. The patient will be toe-touch weightbearing on the left lower extremity. His left second and third fingers will be immobilized for a short period; however, he can weight bear to the left upper extremity.
