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Table of Contents
Dr. Washington Introduction
- Undergraduate: Stanford University, BA with Honors 1994-1998
- Graduate: Duke University School of Medicine 1999-2003
- Post Graduate:
- University of Pittsburgh Medical Center, Internship, General Surgery 2003-2004
- University of Pittsburgh Medical Center, Residency, Plastic and Reconstructive Surgery 2004-2011
- University of Pittsburgh Medical Center, Post Doctoral Fellow, Plastic Surgery Research Laboratory, 2006-2008
- University of Pittsburgh Medical Center, Fellowship, Hand and Microsurgery, 2011-2012
Operative Reports
Wide Awake Tips:
For CTR, TFR, finger/hand mass excisions: close w/ 4-0 nylon and apply large bandaid.
For Mucous cyst excisions: Close w/ 4-0 Chromic, dress w/ bandaid.
ALL PATIENTS MAY REMOVE DRESSINGS AFTER 5 days and use hand as tolerated. No soaking or submerging.
Distal Radius
Important notes: Transects brachioradialis unless elderly patient, does NOT repair pronator quadratus Sutures: 4-0 nylon for closure Dressing: xeroform Splint: If suspect DRUJ instability place sugar tong, otherwise volar splint.
ASSISTANT: ORIF left distal radius fracture; intraarticular in three parts Left distal ulnar styloid fracture . PREOPERATIVE DIAGNOSIS: Left Closed intra-articular distal radius fracture; in three parts Left distal ulnar styloid fracture POSTOPERATIVE DIAGNOSIS: Left Closed intra-articular distal radius fracture; in three parts Left distal ulnar styloid fracture OPERATION PERFORMED: Left Open reduction and internal fixation distal radius fracture, intra-articular, and three fragments. IMPLANTS: Acumed system DESCRIPTION OF OPERATION: x was identified in the Holding Area and the operative site was marked. He was brought to the operating theater in stable condition and placed onto a regular OR table with his operative arm on an arm board. A preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. His splint was removed and a tourniquet was placed onto his arm which was then sterilely prepped and draped. An Esmarch bandage was used to exsanguinate the limb before elevation of the tourniquet to 250 mmHg. We began the procedure by making a 10 cm incision longitudinally over his FCR tendon extending from his wrist crease and proximally. We dissected through subcutaneous tissue and identified the FCR tendon. We incised the tendon sheath, retracted the tendon ulnarly, and incised the subsheath. The distal aspect of the FPL origin was was retracted ulnarly to expose the pronator quadratus which was incised along its radial and distal borders and elevated subperiosteally. We released brachioradialis and identified the first dorsal compartment underneath. We identified the fracture site and cleaned the fracture of callus. We then used fluoroscopic imaging in order to confirm the ability to reduce the fracture. We then selected an long Acumed Acu-Loc 2 volar radius plate. The plate position was provisionally stabilized using 0.054 K-wires and then secured to the proximal fragment using a 3.5 mm compression screw. We then reduced the fracture onto the plate and stabilized the distal fragment using additional 0.054 K-wires. The position of the plate and the fracture reduction were confirmed using fluoroscopic imaging. We then secured the epiphysis and articular fragments to the plate using 2.8 mm locking screws. We completed stabilization of the plate to the proximal fragment using 3.5 mm locking screws. The final position of the plate and fracture reduction were confirmed using fluoroscopic imaging and we were happy with both. Clinical examination showed no impingement of his wrist range of motion and stability of the DRUJ in supination. The incision was washed. The pronator quadratus was not closed and the skin was closed using 4-0 nylon sutures in a horizontal mattress with steri-strips. A sterile dressing and sugar tong splint With the wrist in supination were applied. General anesthesia was reversed. He tolerated the procedure well. There were no complications. Final instrument count was correct. x was taken out of the operating theater and to the PACU in stable condition. POSTOPERATIVE PLAN: x will go home from the hospital today with arrangements made to follow up with me in clinic in two weeks. He will be transitioned into a short arm removable splint, which will be worn continuously for an additional four weeks with protected range of motion of his wrist initiated by Hand Therapy. He has been told to strictly elevate his hand at all times as well as move his fingers to prevent stiffness. If he has any difficulty or concerns between now and followup, he has been told to contact me, and I would be happy to see him sooner.
Carpal Tunnel Release
Any patient with more than 1 elective procedure (trigger and CTR, multiple triggers, etc.…) needs a first postop visit with hand therapy between 5-7 days.
Dr Washington always uses upper arm tourniquet. Webrill, tourniquet, 1000 drape.
Dr. Washington– Carpal Tunnel Release
OR Tips: Close w/ 4-0 black nylon, xeroform or adaptiq, 2×2, webrill, 2” ace.
If done in Wide Awake clinic, close w/ 4-0 nylon and just cover w/ large bandaid.
Any patient with more than 1 elective procedure (trigger and CTR, multiple triggers, etc.…) needs a first postop visit with hand therapy between 5-7 days.
Carpal Tunnel (OR)
Non-sterile tourniquet, on stretcher with arm table.
No stockinette.
Marking: Mark a dot at the ring finger tip. Flex into palm to transfer marker. Mark distal end of incision at Kaplan's, proximal end 1 cm distal to wrist crease. Use ragnelle, make sure incision is in-line with 3rd webspace.
Local: On the field. Create wheal at wrist crease, inject distally along incision site (no median nerve block).
Procedure: Uses scalpel through skin. Then use tenotomies to spread apart palmar fascia fibers. Cut TCL with 15 blade, then use tenotomies to complete TCL incision under direct visualization (lots of spreading before cutting).
Close: 4-0 Nylon horizontal mattress.
Dressing: Adaptic, 4×4, webroll, 2“ ACE. Off on POD#5. Will sometimes splint, depending on patient.
CMC Arthroplasty
OR tips: Typically closes w/ 3-0/4-0 monocryl w/ dermabond, dress w/ 2×2, webril, plaster thumb spica splint, 2” ace
Cubital Tunnel Release
Closes w/ 3-0/4-0 Monocryl, dermabond, dress w/ 4×4, webrill and 4” ace.
DeQuervain’s Release
OR tips: close w/ 3-0/4-0 Monocryl, dermabond, 2×2, webrill and 2” ace.
Distal Radius Fracture s/p ORIF
OR tips: close ww/ 4-0 black nylon, xeroform/adaptiq, 4x4s, webrill, splint.
If Short arm splint, wrap w/ ace. If long arm splint, wrap w/ bias.
Dorsal/Volar Wrist Ganglion Excision
OR tips: If VWG, usually closes w/ 4-0 Nylon. If DWG, close w/ 3-0/4-0 monocryl/dermabond. Splint until FU
Metacarpal Fractures s/p ORIF
OR tips: Usually close w/ 4-0 nylon, adaptiq/xeroform, 4×4, ace. Usually places whole hand in forearm based intrinsic plus splint w/ IPs included
Trigger Finger Release
Or tips: close w/ 4-0 nylon, xeroform/adaptiq, 4×4, webrill, 2” ace.
If wide awake, just bandaid.
Nail Ablation
was identified in the holding area and the operative site was marked. He was brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with both operative extremity on an arm boards. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location.
Tourniquets were placed and both arms were prepped and draped in a standard sterile surgical fashion.
We first proceeded with the right hand.
We exsanguinated the hand with an esmarch and raised the tourniquet to 250 mm Hg.
We then proceeded with surgical ablation of the right index finger nail bed. We used a freer elevator to remove the nail. We then surgically removed the germinal matrix and sterile matrix with a # 15 blade. We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed.
We then proceeded with surgical ablation of the right long finger nail bed. We used a freer elevator to remove the nail. We then surgically removed the germinal matrix and sterile matrix with a # 15 blade. We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed.
We then proceeded with the left hand procedures.
We exsanguinated the hand with an esmarch and raised it to 250 mm Hg. We then proceeded with surgical ablation of the left thumb nail. We used a freer elevator to remove the nail. We then surgically removed the germinal matrix and sterile matrix with a # 15 blade. We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed.
We then proceeded with surgical ablation of the left index finger. We used a freer elevator to remove the nail. We then surgically removed the germinal matrix and sterile matrix with a # 15 blade. We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed.
We then elevated a full thickness skin graft from the left forearm that was 8 x 4 cm.
We closed the incision with 3-0 vicryl and 4-0 monocyrl sutures after undermining the adjacent tissue.
We then proceeded with the right index finger full thickness skin great to the nail bed. We cut a 1×1 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding. We sutured the skin graft with 4-0 chromic sutures.
We then proceeded with the right long finger full thickness skin great to the nail bed. We cut a 1×1 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding. We sutured the skin graft with 4-0 chromic sutures.
We then proceeded with the left index finger full thickness skin great to the nail bed. We cut a 1×1 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding. We sutured the skin graft with 4-0 chromic sutures.
We then proceeded with the left thumb full thickness skin great to the nail bed. We cut a 2 x 2 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding. We sutured the skin graft with 4-0 chromic sutures.
We placed xeroform over the skin grafts, guaze 4×4, and we placed webroll, bilateral plaster splints, and bias dressing.
Tourniquet: Yes
Drain: No
Sutures: Yes
Dressing: Yes