Friday, November 11, 2011

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Open reduction, right intra-articular distal radius fracture -OP Report

PREOPERATIVE DIAGNOSIS: Right intra-articular distal radius fracture.

POSTOPERATIVE DIAGNOSIS: Right intra-articular distal radius fracture.

OPERATION PERFORMED: Open reduction, right intra-articular distal radius fracture, greater than or equal to 3 fragments.

ANESTHESIA: Is general.

BLOOD LOSS: Minimal.

COMPLICATIONS: None.

SPECIMENS: None.

FINDINGS:
Comminuted intra-articular distal radius fracture following a volar plating. The DRUJ was restored to acceptable stability and the fracture was restored to acceptable alignment.

INDICATIONS:

OPERATION:
Patient was met preoperatively, and this operative site marked by the operative team. Patient was then brought back to the operating room, transferred to the operating room table. SCDs were placed on her bilateral lower extremities. IV Ancef was given preoperatively. General anesthesia was then induced by the anesthesia team. A well-padded tourniquet was placed about her right upper extremity. Her right arm was pre-cleaned with chlorhexidine, prepped with ChloraPrep, and draped in the usual sterile fashion. A preoperative time-out confirming patient identification, surgical site, surgery to be performed, and presence of needed equipment was carried out prior to initiation of the procedure.

Under fluoroscopic imaging, traction was held across the fracture. It was felt that the distal fragments were large enough to tolerate a volar plate rather than a dorsal bridge plate with the use of a dorsal bridge plate as a salvage should a fixation be marginal. As such, the arm was exsanguinated with an Esmarch bandage, and a longitudinal incision along the radial aspect of the FCR tendon was carried through skin. Blunt dissection was carried through subcutaneous tissue. The radial artery was identified just radial to the FCR and dissected along its length. It was mobilized radially. Several perforating branches were coagulated using bipolar electrocautery to allow for appropriate mobilization of the artery. The floor of the radial artery sheath was then incised and blunt dissection carried down to the pronator quadratus. A small portion of the first dorsal compartment was then opened and the brachioradialis identified in the floor of the first dorsal compartment and released to allow for reduction. The pronator quadratus fascia was then incised, and the muscle fibers of the pronator quadratus elevated in a radial-to-ulnar direction to expose the fracture. The fracture was then cleaned of intervening tissue. A fracture reduction forceps was then used to reduce the radial shaft in a radial direction and a K-wire was placed percutaneously from the radial styloid into the shaft. A fluoroscopic imaging was then obtained which showed acceptable reduction of the fracture. A Synthes 6-hole head, 3-hole shaft, variable angle distal radius plate was then selected and positioned on the volar aspect of the distal radius. It was positioned with K-wires. Appropriate positioning of the plate was then confirmed under orthogonal fluoroscopic images. It was then affixed to the radial shaft with a 2.7-mm cortical screw. The distal row was then filled with a subchondrally placed 2.4-mm locking screws in a combination of a variable angle and standard locking as dictated by the plate position and fracture. After each distal screw was placed, orthogonal fluoroscopic images were obtained which showed that the screw was placed into an extra-articular position. The most ulnar screw was confirmed to be outside of the DRUJ. After this, the plate was affixed to the radial shaft with an additional two 2.7-mm cortical screws. Following this, final fluoroscopic images were obtained which showed acceptable position of the hardware, acceptable length of the hardware, and acceptable alignment of the fracture. The wound was thoroughly irrigated. The pronator quadratus was then closed using 3-0 Vicryl partially over the plate. The tourniquet was then deflated and hemostasis achieved using bipolar electrocautery. The wound was once again thoroughly irrigated. The fascia of the forearm was released subcutaneously proximally due to the patient's swelling. The skin was then closed using 3-0 Monocryl subcutaneous layer and 3-0 nylon skin sutures. At the conclusion of closure, the forearm compartments were compressible. The DRUJ was then tested and found to be stable in supination, stable in pronation but did have some laxity in neutral. As such, it was elected to immobilize her temporarily in supination. A dry sterile dressing of Xeroform, 4 x 4s, and sterile Webril was placed, and the patient was placed into a long arm splint in supination. She was then awakened from general anesthesia, transferred to a stretcher, and taken to PACU in stable condition. All sponge and instrument counts were correct at the conclusion of the case.

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