DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Comminuted intra-articular fracture dislocation, right middle finger proximal phalanx.
POSTOPERATIVE DIAGNOSIS:
Comminuted intra-articular fracture dislocation, right middle finger proximal phalanx.
OPERATION PERFORMED:
ORIF of intra-articular fracture dislocation, right middle proximal phalanx.
SURGEON: John Doe, MD
ANESTHESIA: General.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The patient sustained a comminuted intra-articular fracture of the base of the right middle finger proximal phalanx with dislocation of the metacarpophalangeal joint. Exploration revealed extensive comminution of the articular surface with 4 main articular fragments. The largest fragment involved the dorsal ulnar aspect of the joint, which was dislocated dorsal ulnarly. The articular surface of the metacarpal head was intact. The fracture was displaced, comminuted and unstable.
DESCRIPTION OF PROCEDURE: Prophylactic IV antibiotic was given and the patient was taken to the operating room. An axillary block anesthetic was administered by the anesthesiologist and the right posterior limb was prepped and draped sterilely. A tourniquet was inflated at the upper arm following exsanguination of the limb. The right middle finger was viewed under fluoroscopy. Closed reduction could not be achieved. Therefore, open reduction was needed. A dorsal longitudinal incision was made over the right middle finger from the proximal phalanx across the metacarpophalangeal joint. Subcutaneous tissue was dissected. Superficial veins were ligated with bipolar cautery. The extensor mechanism was visualized. The capsule was disrupted with dislocation of the base of the proximal phalanx dorsal ulnarly.
The central slip of the extensor mechanism was incised longitudinally in the midline to permit exposure of the fracture site. The fracture fragments were debrided of hematoma and irrigated with antibiotic solution. The major articular fragments were retained. One fragment involving the dorsal central portion of the articular surface was a loose fragment devoid of any soft tissue attachment and impacted into the metaphyseal region. Another fragment involved the palmar ulnar aspect of the articular surface, attached to a remnant of the collateral ligament. The fracture was reduced provisionally, including the comminuted articular fragments. The alignment was checked radiographically using fluoroscopy. Fixation was then carried out using stainless steel 1.5 mm and 1.3 mm screws. The screws were first inserted transversely at the base of the proximal phalanx to stabilize the articular fragments. Additional screws were used in the metaphyseal and diaphyseal region to stabilize the 2 main fracture fragments in that region.
The fracture was viewed under fluoroscopy and the alignment of the articular surface appeared satisfactory. There was no significant articular step-off. The fracture was stable with range of motion and rotation of the finger was normal and symmetric. The palmar ulnar fragment of articular surface was too small to permit correct fixation. This was stabilized as the dorsal capsule was repaired using multiple Vicryl sutures.
The field was irrigated with antibiotic solution. Repeat fluoroscopy views were obtained, which showed stable fracture alignment and satisfactory fixation. The extensor mechanism was repaired using running 4-0 Supramid suture and the skin edges were reapproximated with 5-0 nylon sutures. Sterile bulky gauze dressing was applied followed by a forearm-based plaster splint for protection of the fracture. The tourniquet was deflated. Circulation returned to the right hand with normal capillary refill in all digits. The patient was transferred to the recovery room in stable condition. The patient tolerated the procedure well with no complications.
