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ORIF Orbital Floor Fracture Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right orbital floor fracture.

POSTOPERATIVE DIAGNOSIS:
Right orbital floor fracture.

OPERATION PERFORMED:
Open reduction internal fixation of right orbital floor fracture.

SURGEON:  John Doe, DDS

EBL:  Minimal.

IV FLUIDS:  950 mL.

URINE OUTPUT:  Not recorded.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female who was playing hockey approximately eight days ago when she was head-butted in the right face. She immediately noted difficulty with vision and in fact experienced double vision. She also experienced significant rapid onset of periorbital swelling. She presented to the emergency department for evaluation. A CT scan was obtained, which revealed a right orbital floor fracture.

Oral and Maxillofacial Surgery was consulted. Given the patient's significant swelling, surgical intervention was deferred at that time. She was followed up in clinic and continued to display significant diplopia and upward gaze. For correction of her orbital floor fracture, she was then taken to the operating room for the aforementioned procedure under general anesthesia.

SIGNIFICANT FINDINGS:  Right orbital floor fracture.

DESCRIPTION OF OPERATION:  Once the oral endotracheal tube was placed, the patient was turned for surgery.  The patient was prepped and draped in the usual sterile fashion.  The surgeon gowned and gloved after scrubbing.  Three mL of 1% lidocaine with 1:100,000 of epinephrine was locally administered in the right lateral canthal region as well as in the right lower eyelid.  Approximately 1 mL was deposited in the middle, medial, and lateral infraorbital fat pads.  A forced duction test was performed and the eye was noted to be mobile.  A corneal shield was placed after applying ophthalmic ointment.

A subciliary incision was performed with a #15 blade and this was carried lateroinferiorly at the lateral canthus.  Tenotomy scissors were used to dissect approximately 4 to 5 mm inferiorly under the skin.  They were then used to perform a blunt dissection laterally over the lateral orbital rim.  At this point, dissection was carried inferiorly just anterior to the infraorbital rim, medially along the orbital rim.  The incision in the tunneled dissection plane was then opened with the tenotomy scissors in a preseptal fashion.  The periosteum was then incised approximately 3 to 5 mm inferior to the infraorbital rim.

Periosteal elevators were used to then dissect superiorly and then the periorbita was dissected free from the orbital floor.  This was gently teased from the fractured floor segments and held in a retracted manner with malleable retractors.  Once a medial and lateral stable bony segment had been identified, the Synthes medium-sized orbital floor plate was then adapted.  The arms of this plate were then folded inferiorly over the infraorbital rim.  The middle arm had to be removed as this was impinging on the infraorbital nerve.  The medial and lateral arms were each secured with a single 4 mm x 1.3 mm Synthes screw.

The wound was explored again and the periorbita was noted to be free from all edges of the plate.  A forced duction test was performed again and the eye was noted to be freely mobile.  The wound site was irrigated with copious normal saline.  The periosteum was closed with multiple interrupted 4-0 Vicryl sutures and the skin incision was closed with a running 5-0 nylon suture.  The eyes were washed with balanced salt solution and the patient was returned to the care of the anesthesia service prior to awakening.  Pressure was held in the infraorbital area to prevent hematoma formation.  The patient was extubated in the operating room and tolerated extubation well.  The patient was taken to the postanesthesia care unit to continue recovery.

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