DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left femoral shaft fracture.
2. Compartment syndrome, left thigh.
3. Compartment syndrome, left leg.
POSTOPERATIVE DIAGNOSES:
1. Left femoral shaft fracture.
2. Compartment syndrome, left thigh.
3. Compartment syndrome, left leg.
OPERATION PERFORMED:
1. Application of external fixator, left femur.
2. Fasciotomy, left thigh.
3. Fasciotomy, left leg.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 200 mL.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male, who was a pedestrian, run over by a car today. The patient was initially seen at an outside hospital and was transferred here for further care. On arrival to the emergency department here, the patient was noted to have diminished pulses in his left lower extremity, both DP and PT pulses. He had a clinical evidence of thigh and calf compartment syndrome. The patient was initially evaluated by the trauma service and was cleared for emergent fasciotomies with left thigh and calf as well as for fixation of his femur fracture. Vascular surgery was also consulted, and after stabilization of the femur, they will perform either direct exploration of the artery or perform an angiogram to rule out arterial injury.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and laid supine on the OR table. After general anesthesia was induced, the left lower extremity was prepped and draped in the usual sterile fashion. Approximately, a 16 inch incision was made along the lateral aspect of the left thigh. A large amount of hematoma was evacuated. The lateral and the posterior compartments of the thigh were decompressed through the lateral incision.
Next, attention was directed towards the left calf. Medial and lateral incisions were made decompressing all four compartments in the left leg. After fasciotomies were performed, attention was directed towards stabilizing the left femur fracture with an external fixator. Two 5 mm pins were placed in the proximal fragments and two pins in distal fragment. Bars were assembled, and the fracture was reduced anatomically using direct palpation through the lateral fasciotomy wound. The clamp was applied to obtain anatomic reduction. The clamps were then tightened, and another set of clamps with bars was placed for further stability. All clamps were tightened.
At this point, the vascular surgery team scrubbed in, and they will further evaluate the need for an angiogram in the operating room. As mentioned, the patient had diminished pulses preoperatively and was thoroughly evaluated by the vascular surgery service for potential dysvascular limb. Their portion of the procedure will be dictated in a separate operative note. There were no complications for the orthopedic portion of the procedure.
