DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right trimalleolar ankle fracture.
POSTOPERATIVE DIAGNOSIS: Right trimalleolar ankle fracture.
OPERATION PERFORMED: Open treatment of trimalleolar ankle fracture with fixation of the fibula.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Less than 50 mL.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old who sustained an injury to his right ankle resulting in a trimalleolar ankle fracture. The patient had a significant displacement of his fibula fracture and concern for ankle instability. Therefore, he was felt to be a candidate for open reduction and internal fixation of his ankle.
DESCRIPTION OF OPERATION: Following informed consent, the patient was taken to the operating room and placed supine on the operating room table. Following adequate induction of general anesthesia, the tourniquet was applied to the right lower extremity. The extremity was then exsanguinated with the use of an Esmarch, and the tourniquet was inflated to 300 mmHg.
At this time, a lateral-based incision was made. A fibular fracture was palpated. Incision was centered over this. The skin was incised. Dissection was carried down through the subcutaneous tissue. The superficial peroneal nerve was not encountered in our field.
Dissection was carried down directly to the periosteum, which was sharply divided in line with the skin incision revealing his fracture. It was a very long oblique fracture. The fracture hematoma was removed. The fracture site was debrided in a point to point reduction. Clamp was then used to obtain initial reduction of the fracture. This was in anatomic reduction.
C-arm was brought in and confirmed the anatomic reduction of the fibula. An anterior to posterior lag screw was then placed in a standard fashion, which allowed excellent compression and reduction of the fracture. The clamp was removed. The fracture was stable. Going to the significantly long fracture, a 10-hole one-third tubular plate was then placed laterally as a neutralization plate. The screw holes were filled with appropriate length 3.5 cortical screws and a 4.0 cancellous screw distally to avoid penetration into the talofibular joint.
C-arm views, including an AP, mortise as well as a lateral, confirmed anatomic reduction of the fibula. Mortise view showed that the mortise was symmetric. The syndesmosis was then stressed manually, and there was no opening of the medial joint space indicating no injury to the syndesmosis.
Of note, the patient did have a nondisplaced medial malleolus fracture that was seen preoperatively. This was examined closely under fluoroscopy. After plating the fibula, it was completely nondisplaced. The decision was made not to treat this with internal fixation.
The wounds were copiously irrigated followed by closure with 0 Vicryl, 2-0 Vicryl and a 4-0 Monocryl suture for the skin. There was minimal tension on the skin upon closure. Steri-Strips were applied as well as a sterile compressive dressing and a well-padded, well-molded splint. Tourniquet was let down. The toes pinked up nicely. The patient tolerated the procedure well.
