Sample Name: Elbow Manipulation
Description: Left elbow manipulation and hardware removal of left elbow.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Left elbow with retained hardware.
POSTOPERATIVE DIAGNOSIS: Left elbow with retained hardware.
1. Left elbow manipulation.
2. Hardware removal of left elbow.
ANESTHESIA: Surgery was performed under general anesthesia.
INTRAOPERATIVE FINDING: Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees. We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.
LOCAL ANESTHETIC: 10 mL of 0.25% Marcaine.
PROCEDURE: The patient was taken to the operating room and placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in a standard surgical fashion. Using fluoroscopy, the patient's K-wire was located. An incision was made over his previous scar. A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles. The K-wires were easily palpable. A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident. The wound was then irrigated. The triceps split was now closed using #2-0 Vicryl. The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl. The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias. A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line. At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.
DIAGNOSTIC IMPRESSION: The postoperative films demonstrated no fracture, no retained hardware. The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.
POSTOPERATIVE PLAN: The patient will restart physical therapy and Dynasplint in 3 days. The patient is to follow up in 1 week's time for a wound check. The patient was given Tylenol No. 3 for pain.
Keywords: orthopedic, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware,