DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Closed left distal radius fracture.
2. Closed Schatzker V bicondylar left tibial plateau fracture.
POSTOPERATIVE DIAGNOSES:
1. Closed left distal radius fracture.
2. Closed Schatzker V bicondylar left tibial plateau fracture.
OPERATIONS PERFORMED:
1. Open reduction and internal fixation, ORIF, left distal radius.
2. Spanning ex-fix, left tibial plateau.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 10 mL.
INDICATIONS FOR OPERATION: This is a (XX)-year-old Hispanic male who fell from a height and landed on his left hand and leg, sustained a left distal radius fracture as well as comminuted tibial plateau fracture. The patient was seen and evaluated initially at an outside hospital where he had x-rays and CT scan done. He was then transferred to this hospital for definitive surgical fixation. All the risks and benefits of the procedure for spanning ex-fix and ORIF of the left radius were discussed with the patient, and informed consent was obtained.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in the supine position. Then, 1 g of vancomycin was given preoperatively. After satisfactory general endotracheal anesthesia was administrated, the left upper extremity and the left lower extremity were prepped and draped in regular sterile routine fashion. A tourniquet, well padded, was placed on the left upper arm. The distal radius was addressed simultaneously with the lower extremity.
For the distal radius, the volar approach was performed. The FCR tendon was identified and was retraced ulnarly. The fascia was then opened, and the pronator quadratus was incised sharply from the lateral border of the distal radius. The fracture was identified and was cleaned with the rongeur. We were able to anatomically reduce the distal radius fracture and provisionally fix with one K-wire. The mini C-arm confirmed anatomic reduction and good alignment of the radial height as well as the inclination. The fracture was extraarticular.
We decided to place the extra-articular plate. Accordingly, Synthes extra-articular locking plate was placed and was locked distally with four locking screws and proximally with three cortical screws. Again, the mini C-arm confirmed good anatomic alignment. The tourniquet was deflated, and hemostasis was secured. The subcu was then closed with 3-0 Vicryl and the skin with 4-0 nylon. Intraoperative x-ray was taken, which confirmed the anatomic alignment and reduction and good placement of the plate and screws. Dressing was then applied in the form of Adaptic, 4 x 4, sterile Webril, and a volar splint was applied.
With regard to the left tibial plateau, the spanning ex-fix was placed using a 5-0 Synthes AO large Ex-Fix. The pins were predrilled with the 3.5 and then followed by placement of the proximal pins. Two pins were placed in the proximal femur anteriorly and two in the distal tibia. The fracture was then reduced, and the bars were tightened at this point. Also, intraoperative x-ray of the knee was taken, which showed good alignment of the fracture of the tibial plateau. The patient tolerated the procedure well and was taken to recovery in stable condition.
