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Distal Radius Fracture ORIF Medical Transcription Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left distal radius fracture.

POSTOPERATIVE DIAGNOSIS:  Left distal radius fracture.

OPERATION PERFORMED:  Open reduction and internal fixation of left distal radius fracture.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  General.

ESTIMATED BLOOD LOSS:  Minimal.

SPECIMENS:  None.

DRAINS:  None.

COMPLICATIONS:  None.

DESCRIPTION OF OPERATION:  Risks and benefits of the operation were explained to the patient. Alternatives were also discussed with the patient. The patient elected to proceed. Consent for surgery was obtained. The patient was brought to the operating room and placed on the operating table in the supine position. After administration of general anesthesia, the left upper extremity was prepped and draped in the usual sterile fashion. The extremity was exsanguinated with an Esmarch and tourniquet on the upper arm was inflated.

An incision was made on the volar aspect of the wrist over the distal flexor carpi radialis tendon. Dissection was taken through the subcutaneous tissues to the tendon sheath. The tendon sheath was incised longitudinally and the tendon was retracted. The floor of the sheath was then incised longitudinally. Distal fascia was also incised. The pronator was exposed. The fracture was seen disrupting a portion of the pronator. The pronator was detached radially and distally and reflected off of the volar surface of the distal radius. The fracture was then reduced. Manipulation of all fragments produced excellent reduction of the fracture. A 0.062 K-wire was then passed percutaneously to the radial styloid. This pin was then passed across the fracture and engaged the more proximal ulnar cortex of the radius, maintaining reduction of the fracture. A volar distal radial plate was then applied to the bone and positioned under the image intensifier. A proximal screw was then placed to secure the plate. Distally, locking screws were placed through the plate into the distal fragment. Each of these was placed under fluoroscopic guidance. The radial-most screw was placed at the styloid. The ulnar-most screw captured dorsal ulnar corner of the distal radius. The K-wire was then removed. Two additional proximal screws were placed through the plate. Reduction of the fracture was near anatomic. Position of the plate and all screws were visualized in multiple projections with the image intensifier. The fracture was stable with fixation.

The wound was irrigated with copious amounts of sterile solution. Pronator was repaired to the radial side with 3-0 PDS suture. The floor of the FCR sheath was also repaired with PDS suture. The subcutaneous tissues and skin were then closed with Monocryl suture. A dressing was applied. The tourniquet was deflated. Splint was applied. The patient was awoken from anesthesia and taken to the recovery room in stable condition.