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ORIF of Radius Fracture IM Nail Fixation Hip Fracture Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Left distal radius comminuted fracture.
2.  Left intertrochanteric comminuted fracture.

POSTOPERATIVE DIAGNOSES:
1.  Left distal radius comminuted fracture.
2.  Left intertrochanteric comminuted fracture.

OPERATION PERFORMED:
1.  Open reduction and internal fixation of the left distal radius comminuted fracture.
2.  Intramedullary nail fixation of the left intertrochanteric hip fracture.

SURGEON:  John Doe, MD

ESTIMATED BLOOD LOSS:  100 mL

ANESTHESIA:  General endotracheal intubation.

INDICATIONS FOR PROCEDURE:  The patient is an (XX)-year-old who sustained a fall yesterday.  She fell to the ground, landing on the hip and left wrist, with complaints of isolated pain in the hip and left wrist. Clinical examination demonstrated a deformity of the left distal radius, marked tenderness of the left distal radius.  Sensation to light touch was intact and the patient had good capillary refill.  The patient was able to dorsiflex and plantar flex the ankle and toes and the foot was warm.  Radiographs were reviewed, demonstrating comminuted distal radius fracture with substantial compromise of the bone.  The examination of hip demonstrated a comminuted intertrochanteric hip fracture. The plan was for an intramedullary rod fixation of the left intertrochanteric hip fracture and an open reduction and internal fixation of the left radius.  The patient was informed of the risks and benefits of the surgical procedures and signed informed consent.

DESCRIPTION OF PROCEDURE:  The patient received antibiotics in the preoperative holding area and was brought to the operating room where anesthesia was administered.  We started initially with the left hip.  The patient was placed on the fracture table.  Both feet were placed in traction boots after padding with Webril and ABD pads.  We put the right lower extremity in the lithotomy position and then the left lower extremity was placed in longitudinal traction.  Under direct fluoroscopic evaluation, we placed traction, internal rotation on the limb, until the fracture was lined up.  We then scrubbed and draped the limb in the usual fashion.  We made a small puncture wound and introduced a guidewire into the intramedullary canal of the femur under fluoroscopy.  We expanded the size of the incision and introduced a soft tissue guide and proceeded to drill over the wire for the rod.  We then placed the intramedullary guidewire into the femur further, distally past the rod, lined the sliding screw up with the center of the femoral head, passed the guidewire through the nail up to the center of the femoral head.  This was checked on both AP and lateral views.  We then measured the length and after drilling placed the appropriate length screw up through the nail into the femoral head.  We then placed a locking screw, tightened it fully and reversed it one-fourth turn.  We then used the distal fixation jig, marked the skin, made a small incision and proceeded to drill through the nail and bone.  We measured that length and placed the appropriate length screw through the nail.  We then irrigated out the wound and closed with a 2-0 Vicryl and stapled once again.  Nonadherent dressings, 4 x 4s, ABD pads and tape were applied.  We then scrubbed and draped the left upper extremity.  A tourniquet was applied, exsanguinated the limb and elevated the tourniquet.  We used the approach of Henry, dissected down through skin and subcutaneous tissue.  We identified the radial artery, flexor carpi radialis; this was retracted radially.  We identified the fracture of the pronator quadratus with the arm pronated; this was removed off the distal radius.  We placed retractors using Hohmann, being careful to avoid injury to the median nerve or the radial artery.  Once we had adequate exposure, we identified that there was significant bony deficit in the distal radius.  There was marked osteoporosis.  We confirmed that the plates that we had were long enough.  We placed the longest plate up against the bone, proceeded to pin the plate to the bone, reduced the wrist and obtained images to confirm placement.  We then proceeded to drill, measure and placed appropriate length screws.  We used the short peg locking screws and nonlocking screws to affix the plate to the bone.  The reduction was acceptable.  We identified a very large bony deficit over the distal radius.  We chose to use the Wright Medical AlloMatrix to fill this defect.  After irrigation, the AlloMatrix was mixed and then packed into this.  We then placed moistened sponges in the wound, dropped the tourniquet, wrapped the arm in an Ace wrap and checked the position of the fixation on both AP and lateral views.  We were happy with the fixation.  We irrigated out the wound using bipolar for coagulation.  The wrist was closed using 2-0 at the pronator quadratus and then we used an interrupted 4-0 nylon in a vertical mattress stitch.  The wound was loosely approximated to minimize the risk of soft tissue tension and formation of compartment.  A nonadherent dressing, 4 x 4s, Webril and a short arm splint were applied.  The patient was then brought to the recovery room.  In recovery room, the patient was able to move the fingertips and light touch sensation was intact.  The patient was also able to dorsiflex and plantar flex the ankle and toes.  Intraoperative images of the distal radius found the fixation and fracture to be in acceptable position.  Images of the hip also were in an acceptable position, with good fixation with the hardware.