DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left Galeazzi fracture to necrotic and infected left ankle wound.
POSTOPERATIVE DIAGNOSIS: Left Galeazzi fracture to necrotic and infected left ankle wound.
PROCEDURES PERFORMED:
1. Left radius ORIF.
2. Irrigation and debridement of left ankle wound without placement of a VAC sponge.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Less than 200 mL.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and laid supine on the operating room table. General anesthesia was induced. The dressing on the patient’s left ankle was removed, and it was noted that the left ankle incision had a significant amount of necrotic skin associated with some purulent drainage. The patient had not been consented for irrigation and debridement of the ankle preoperatively; however, it was noted that the ankle did require irrigation and debridement of the necrotic skin. Attempts were made intraoperatively to contact the family; however, we were unable to do so. Due to the necessity of this procedure, we proceeded with irrigation and debridement.
The left lower extremity was therefore prepped and draped in the usual sterile fashion. The wound was covered. The left upper extremity was also prepped and draped in the usual sterile fashion after a tourniquet was placed high up on the left arm. Attention was first directed to the left upper extremity. A volar incision was made in the distal forearm. Dissection was carried out and the flexor carpi radialis tendon was retracted ulnarly. The flexor digitorum superficialis and the flexor pollicis longus muscles were retracted ulnarly as well. Care was taken to protect the radial artery during the dissection. Dissection was carried down to the bone. The fracture was easily reduced anatomically.
A Synthes small fragment locking plate was then contoured to sit flush on the volar aspect of the distal radius. Four screws were then placed proximal to the fracture followed by three screws distal to the fracture. Two of the distal screws were locking screws and two of the screws proximally were locking screws. All screws were placed in the standard AO fashion. Excellent reduction was obtained. C-arm fluoroscopy was used to confirm excellent position of all screws as well as the plate. Clinical examination of the distal radioulnar joint did not reveal any instability. Radiographs also did not show any instability of the distal radioulnar joint; therefore, the decision was made not to perform pinning of this joint. Next, the wound was thoroughly irrigated with normal saline. The pronator quadratus was reattached using 2-0 Vicryl suture.
The skin was closed in the subcutaneous layer with 2-0 Vicryl suture in inverted fashion. Staples were placed for the skin. Sterile dressings were applied and a volar splint was applied to the left forearm. Attention was then directed to the left ankle. The sutures were removed. A minimal amount of drainage was expressed from the wound. There was noted to be a large amount of necrotic skin; however, the extent of necrosis had not yet declared itself fully. Therefore, some of the necrotic skin was removed. The wound was thoroughly irrigated with 9 liters of normal saline, the middle 3 liters of which contained 100,000 units of bacitracin.
After thorough debridement of all necrotic tissue, a VAC sponge was placed and a vacuum-type seal was obtained. The plan is for the patient to return to the operating room in 48 hours for repeat irrigation and debridement of the left ankle wound. After the irrigation and debridement was completed, the patient was transferred back onto the stretcher and taken to the surgical intensive care unit for further recovery. There were no complications.
