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Femur Fracture Intramedullary Nailing Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Right femur fracture.
2.  Right patella fracture.
3.  Left base of fifth metacarpal fracture.

POSTOPERATIVE DIAGNOSES:
1.  Right femur fracture.
2.  Right patella fracture.
3.  Left base of fifth metacarpal fracture.

OPERATIONS PERFORMED:
1.  Intramedullary nailing, right femur fracture.
2.  Open reduction internal fixation, right patellar fracture, with cerclage wiring.
3.  Closed treatment of left fifth metacarpal fracture.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General endotracheal.

COMPLICATIONS:  None.

SPECIMENS REMOVED:  None.

ESTIMATED BLOOD LOSS:  350 mL.

TOURNIQUET TIME:  Not used.

INDICATION FOR OPERATION:  The patient is a (XX)-year-old female involved in a motor vehicle accident, who was seen and evaluated the day before surgery and noted to have the above new orthopedic injuries. Informed consent was obtained for surgery, and she was brought to the operating room at the earliest convenience for fixation of these fractures.

DESCRIPTION OF OPERATION:  The patient was brought back to the operating room and placed supine on the operating table. The right hip was bumped up. Anesthesia was induced by the anesthesia team. Informed consent was obtained prior to the procedure. A time-out was performed, and the patient's name, medical record number, operative site and operation to be performed were verified by the entire operative team. The patient was then prepped with ChloraPrep and draped in the usual standard sterile fashion. Preoperative antibiotics in the form of one gram of Ancef was given prior to the procedure being performed.

An incision was carried down in the midline, over the knee, from the tibial tubercle, approximately 12 cm long. The incision was carried down sharply through skin and subcutaneous tissues until the fascia above the patella and prepatellar bursa was identified. It was noted to be markedly hemorrhagic.

A median parapatellar arthrotomy was then performed from the level of the tibial tubercle up proximal to the pole of the patella. The patella was then brought laterally and inspected and noted to have a nondisplaced fracture through the mid part of the patellar articular surface, and alignment was noted to be excellent.

Attention was turned to the femur fracture. A guidewire was placed under direct visualization and fluoroscopic guidance up through the notch. Using biplane fluoroscopy, there was noted to be bone in both views. The starting reamer was then utilized to penetrate the subchondral bone. The long guidewire and ball-tipped guidewire were threaded up through the canal. The fracture was reduced and the guidewire was passed without complication. It was checked under biplanar fluoroscopy as well, and the alignment was noted to be acceptable.

Reaming was begun starting at 8, then 9, 10, 10.5, 11, 11.5 and 12. A 11 x 380 retrograde intramedullary Stryker nail was placed without complication and threaded up through the fracture up to proximally. Once this was done, the distal locking guide was placed and the distal locking screws were placed without complication.

The fracture rotation was then checked, and it was noted to be acceptable with adequate rotation and angulation. The proximal locking screws were then placed, one dynamically and one statically, without complication. The wounds were irrigated and attention was turned to the patella.

A 16 gauge wire was utilized to make a cerclage around the patella through the subcutaneous cuff. This was revised several times until x-rays and visual inspection noted it to be in excellent position without any wire in the joint or displacement of the fracture. This was tightened down and wounds irrigated copiously.

X-rays were obtained, biplane fluoroscopy, noting that patellar alignment was excellent and all screw lengths were adequate. The wounds were sutured closed. The median parapatellar arthrotomy was closed with interrupted 0 Vicryl sutures and the skin closed with 2-0 Vicryl sutures and staples.

The locking screw holes were covered with 2-0 Vicryl sutures and staples. The patient's leg was washed and dried. Bacitracin, Adaptic gauze and dry gauze dressings were placed. Drapes were removed and x-rays were taken while the patient was still asleep. A well-padded splint was placed for the patient's ankle and calcaneus fractures.

Attention was turned to the left hand and x-ray showed the base of the fifth metacarpal fracture was minimally placed. It was checked under fluoroscopy and noted to be adequate. The splint was replaced. The patient was awakened from anesthesia and taken to the PACU in stable condition.

PLAN:  The patient will convalesce in the hospital and will likely return to the operating room for definitive operative fixation of the calcaneus and lateral malleolus fractures once the soft tissues have improved.