Plastics

Operative Report:
1. Open reduction and internal fixation distal radius fracture, intra-articular, and three fragments:

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 The distal aspect of the FPL origin was was retracted ulnarly to expose the pronator quadratus which was incised along its radial and distal borders and elevated subperiosteally.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. The patient was taken out of the operating theater and to the PACU in stable condition.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Attending Pearls (Learning points/Pimp Questions):
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.

Operative Report:
1. Open Carpal Tunnel Release:

Local anesthesia was achieved with 1% lidocaine with epinephrine to the palm. The Right hand was then sterilely prepped and draped after placing a tourniquet. We exsanguinated with an esmarch and raised the tourniquet to 250 mm Hg.
 
A longitiunal incision was made 1 cm distal to the distal wrist crease in line with the 3rd web space, extending Kaplan's cardinal line. We dissected through the subcutaneous tissue and palmar fascia, and the palmaris brevis muscle fibers. Care was taken to protect the ulnar neurovascular bundle in Guyon's canal. Next we palpated the hook of the hamate. Next we identified the transverse carpal ligament which was divided longitudinally from the palmar fat pad and proximally into the antebrachial fascia approximate 1 cm proximal to the distal wrist crease under direct vision. Complete release was ensured and the wound was irrigated with normal saline. The skin was closed in a single layer using 4-0 nylon stitch. A sterile dressing was applied. Brandy tolerated the procedure well. There were no complications. The final instrument count was correct.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Attending Pearls (Learning points/Pimp Questions):
Dr Washington always uses upper arm tourniquet. Webrill, tourniquet, 1000 drape.

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.

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.

Operative Report:
1. 1st dorsal compartment release

The patient was identified in the holding area and the operative site was marked. @CAPHE@ was brought to the operating theatre in stable condition, placed onto a regular OR table with the arm on an arm board. A preoperative timeout was taken to ensure the patient's identity, the operative procedure, as well as operative location. Local anesthesia was achieved with 1% lidocaine mixed with 0.25% Marcaine plain. The hand was then sterilely prepped and draped. No tourniquet was required.   I made a longitudinal incision just distal to the radial styloid and dissected through subcutaneous tissue and identified prominent branches of the superficial radial nerve, which were neurolysed and protected. We then identified the EPL and EPB tendons and followed them proximally back to the 1st dorsal compartment. The 1st dorsal compartment was then released at the dorsal most aspect of its insertion in order to prevent volar subluxation of the tendons. Complete release was ensured and sub-compartments were identified. The wound was irrigated and skin closed with 4-0 Monocryl suture. Steri-Strips and a sterile dressing were applied.

The patient tolerated the procedure well. There were no complications. Final instrument count was correct.

Photos

Tourniquet: finger / forearm / arm
Drain: Type of drain and placement
Sutures: List all layers
Dressing: What's preferred?

Anatomy: Pertinent anatomy should be listed

Post-operative care: Include restrictions, splints, etc…

Attending Pearls (Learning points/Pimp Questions):
The most important part of this operation is ensuring both release of APL and EPB. They commonly run in separate subsheaths and failed operations are a result of incomplete release of the subsheaths.

OR tips: close w/ 3-0/4-0 Monocryl, dermabond, 2×2, webrill and 2” ace.

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