DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Malunion, distal radial fracture, left wrist.
2. Rupture of the extensor pollicis longus, left.
POSTOPERATIVE DIAGNOSES:
1. Malunion, distal radial fracture, left wrist.
2. Rupture of the extensor pollicis longus, left.
OPERATION PERFORMED:
1. Osteotomy of left distal radius.
2. Reduced malunion with internal fixation and bone graft, left distal radius.
3. Tendon transfer, left extensor indicis proprius to the extensor pollicis longus.
SURGEON: John Doe, MD
ANESTHESIA: General.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, placed in the supine position and induced under general anesthesia. The left upper extremity was prepped with Betadine and draped in the usual sterile fashion. The areas to be incised were outlined with a marking pen with a zig-zag type border incision dorsally over the area of the fracture. In addition, a transverse incision was designed over the ulnar side of the MP joint and the left index finger and a transverse incision designed over the path of the extensor pollicis longus between the wrist and the MP joint of the left thumb. The arm was exsanguinated and the tourniquet was inflated to 250 mmHg.
A #15 blade was used to make an incision at the back of the wrist, down through the skin, through the subcutaneous tissue. The retinaculum was found by sharp and blunt dissection and it was opened and the fourth dorsal compartment was retracted. Using a Freer elevator, the volar surface of the compartment was carefully separated from the distal radius. The area that was injured was exposed and subsequent evaluation revealed that the dorsal tilt, which was opened from the fracture, was limited only to an area where the fracture had occurred. The fracture site was inspected and confirmed with C-arm and using a Freer elevator was carefully separated and rongeur was used to clean at the fracture site. Proximally, osteotomy was made in order to advance this large fragment. The fragment was then rotated in to a normal anatomic position, which was confirmed visually and also confirmed on x-ray. This appeared to give adequate alignment and it appeared to be near anatomic visually. The 2-hole 16 mm pin plate was then put in place by standard technique and secured. It was advanced approximately 2.5 mm dorsally. The hole was driven to secure the pin plate and it was approximately 18 mm in length and the pin plate was then held in place by standard technique in the TriMed System. X-rays were then taken and confirmed the normal tilt to the distal radius as well as the adequate alignment of the fragments.
The retinaculum was then repaired with 4-0 Vicryl suture material, allowing the volar portion of it to cover the area of plate fixation. The transverse incision was then made over the MP joint of the index finger down through the skin, down through the subcutaneous tissue, exposing the insertions of the extensor digitorum communis as well as the extensor indicis proprius. The tendon was then severed just on the ulnar side proximal to its insertion and was retracted into the wound. A tunnel was then made from the distal portion of extensor retinaculum to the wound using a tendon passer. This was in the same plane as the tendon which had ruptured. It was then passed distally and kept distally. The wound was irrigated over the dorsal aspect of the wrist and closed with 5-0 Vicryl to the derm layer and subcuticular 4-0 Prolene to the skin. Attention was then turned to the thumb, where tendon weaver was used to weave the extensor indicis proprius and the extensor pollicis longus. The extensor pollicis longus was cut proximally as the proximal portion of the tendon had scarred in. Tenolysis was performed in that area. Adequate tension was set and adequate weave was sewn in place with 4-0 Mersilene suture material.
The two distal wounds were then closed with 4-0 Prolene in a subcuticular fashion. Sensorcaine 0.5% plain was then injected in to all operative areas. A dry dressing was applied using Xeroform, fluffy gauze, hand wrap, and a thumb spica-type splint to keep the thumb in extension. The tourniquet had been released after 130 minutes of tourniquet time, after closing of the dorsal skin wound. It was then reinflated 15 minutes later and that is when the weave and wound closure was completed. The patient then had tourniquet released for the second time, that is approximately 50 minutes of tourniquet time and was taken from the operating room to the recovery room in satisfactory condition, having tolerated the procedure well.
