Sample Name: ORIF & Closed Reduction
Description: Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSES: Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.
POSTOPERATIVE DIAGNOSES: Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.
1. Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.
2. Closed reduction casting of the right forearm.
ANESTHESIA: Surgery performed under general anesthesia. Local anesthetic was 10 mL of 0.5% Marcaine.
COMPLICATIONS: There were no intraoperative complications.
HISTORY AND PHYSICAL: The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today. The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow. After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure. Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve. At that same time, the patient's mildly angulated radial shaft fracture will be reduced. This was explained to the father. The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms. All questions were answered. The father agreed to the above plan.
POSTOPERATIVE PLAN: The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days. The father was made aware of the intraoperative findings. All questions answered.
Keywords: orthopedic, orif, elbow fracture, dislocation, open reduction internal fixation, closed reduction, left medial epicondyle fracture, long-arm posterior well-molded splint, splint, radial shaft fracture, volar apex angulation, medial epicondyle fracture, medial epicondyle, internal fixation, epicondyle fracture, ulnar nerve, epicondyle, fracture, reduction, tourniquet, ulnar, nerve,