Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Orthopedic
Sample Name: Pinning - Ulna

Description: Closed reduction and pinning of the right ulna with placement of a long-arm cast.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Right both bone forearm refracture.

POSTOPERATIVE DIAGNOSIS: Right both bone forearm refracture.

PROCEDURE: Closed reduction and pinning of the right ulna with placement of a long-arm cast.

ANESTHESIA: Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.25% Marcaine plain.

COMPLICATIONS: No intraoperative complications.

DRAINS: None.

SPECIMENS: None.

HARDWARE: Hardware was 0.79 K-wire.

HISTORY AND PHYSICAL: The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007. The patient was seen in the emergency room. The patient had a complete fracture of both bones with shortening bayonet apposition. Treatment options were offered to the family including casting versus closed reduction and pinning. The parents opted for the latter. Risks and benefits of surgery were discussed. Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness. All questions were answered, and the parents agreed to the above plan.

PROCEDURE IN DETAIL: The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was then administered. The patient received Ancef preoperatively. The right upper extremity was then prepped and draped in standard surgical fashion. A small incision was made at the tip of the olecranon. Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal. This was changed for a 0.79 K-wire. This was driven up to the fracture site. The fracture was manually reduced and then the K-wire passed through the distal segment. This demonstrated adequate fixation and reduction of both bones. The pin was then cut short. The fracture site and pin site was infiltrated with 0.25% Marcaine. The incision was closed using 4-0 Monocryl. The wounds were cleaned and dried. Dressed with Xeroform, 4 x 4. The patient was then placed in a well-moulded long-arm cast. He tolerated the procedure well. He was subsequently taken to Recovery in stable condition.

POSTOPERATIVE PLAN: The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal. X-rays of the right forearm will be taken. The patient may need additional mobilization time. Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months. Intraoperative findings were relayed to the parents. All questions were answered.

Keywords: orthopedic, closed reduction, pinning, forearm refracture, fracture site, arm cast,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples