2011 Cengage Learning. All Rights Reserved.

May not be copied, scanned, or duplicated, in whole or in part,

except for use as permitted in a license distributed with a certain product or service or otherwise on a password-
protected website for classroom use.

SURGICAL PROCEDURE____________________________________

Patient Name: Paul G. Catrou PCP: Marie Aaron, DO

Patient ID: 010220 DOB: 10 Jan ---- Age: 37 Sex: Male

Date of Admission: 28 June ----

Date of Procedure: 30 June ----

Surgeon: Max L. Hirsch, MD Assistant: Markus LeRoy Johnson, PA-C

Preoperative Diagnoses
1. Left distal radius fracture.
2. Left elbow fracture dislocation (type I coronoid fracture).

Postoperative Diagnoses
1. Left distal radius fracture.
2. Left elbow fracture dislocation (type I coronoid fracture).

Operative Procedures
1. Open reduction, internal fixation, left distal radius.
2. Left elbow lateral ligament repair.
3. Left elbow loose body removal.
4. Left elbow hinged external fixator application.

IV Fluids: See nurses notes.

Estimated Blood Loss: See nurses notes.

Urine Output: See nurses notes.

Complications: None.

INDICATIONS
Mr. Catrou is a 37-year-old male who sustained a left distal radius fracture
and left elbow fracture-dislocation approximately 2 weeks ago after jumping
from a second-story building. The patient was initially monitored by
Psychiatry for suicidal ideation. Patient initially had ORIF and was placed in
a splint with adequate reduction. However, the patient was noncompliant

(Continued)

2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part,
except for use as permitted in a license distributed with a certain product or service or otherwise on a password-
protected website for classroom use.

SURGICAL PROCEDURE

Patient Name: Paul G. Catrou
Patient ID: 010220
Date of Procedure: 30 June ----
Page 2



and removed the splint application. Followup x-rays demonstrated
instability. Patient was subsequently transferred to Forrest General Hospital
and stabilized mentally by Dr. Stella Rose Dickinson and her team. Dr.
Hirsch was consulted from Orthopaedics and monitored the patient there.
Patient was subsequently sent back to Hillcrest for definitive management.

DESCRIPTION OF OPERATION
The patient was identified, brought to the operating room, and placed supine
on the operating room table. Preoperative antibiotics were given. General
anesthesia was obtained. The patient's left upper extremity was then prepped
and draped in the standard sterile fashion. A sterile tourniquet was applied.
Extremity was exsanguinated and tourniquet inflated to 250 mmHg. Utilizing
an FCR approach to the distal radius, careful dissection was made through skin
and subcutaneous tissue with good hemostasis obtained with bipolar cautery.
The FCR sheath was identified and incised. The FCR tendon was then retracted
ulnarly. FCR subsheath was divided to expose pronator quadratus and FPL
tendon. The pronator quadratus was then released distally to expose the distal
radius. Fracture site was identified. Significant comminution noted radially as
well as on the ulnar aspect. Callus formation as well as soft tissue were noted
to be interposed. This was removed with a small rongeur and curettes. The
fracture site was reduced. Utilizing the AcroMed AccuLock plate, the distal
radius was then stabilized. Five locking screws used distally and 3 cortical
screws used proximally.

Intraoperative imaging confirmed proper placement of all hardware as well
as an adequate reduction of the fracture site. Wrist range of motion
demonstrated no evidence of significant crepitus. The distal radioulnar joint
was stable. Tourniquet was released after 88 minutes. Hemostasis was
obtained with bipolar cautery. Wound thoroughly irrigated with NSS. Skin
was closed with 4-0 nylon suture in interrupted fashion.

(Continued)


2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part,
except for use as permitted in a license distributed with a certain product or service or otherwise on a password-
protected website for classroom use.

SURGICAL PROCEDURE

Patient Name: Paul G. Catrou
Patient ID: 010220
Date of Procedure: 30 June ----
Page 3



Attention was then turned to the left elbow. Tourniquet was down for
20 minutes. Extremity was then reexsanguinated, and tourniquet was
inflated to 250 mmHg. Utilizing a lateral Kocher approach to the elbow,
careful dissection made through skin and subcutaneous tissue with good
hemostasis obtained with Bovie cautery. Interval between the ECU and
anconeus was identified. This was split to expose the ruptured capsule.
There is an avulsion of the lateral ligament complex off the lateral
epicondyle. Incision was then carried more proximally. The anterior capsule
was also released partially laterally to expose the elbow joint. Significant
hematoma was noted. Loose body was also noted in the posterior
compartment of the elbow. This was removed with a small rongeur.

Elbow joint was thoroughly irrigated with normal saline solution. Some
condylar injury noted of the coronoid as well as the posterior aspect of the
trochlea. Radial head and capitulum were noted to be intact. The lateral
ligament complex was then repaired with No. 2 FiberWire suture. An
attempt was made to use 2 Arthrex suture anchors; however, there was
little purchase. A Mitek Panalok suture was then utilized to repair the lateral
collateral ligament to its lateral epicondylar insertion site. The elbow was
then ranged with the forearm in pronation. Good stability was noted with an
arc of 80 to 130 degrees of flexion. Additional stability was provided with
the Stryker hinged elbow fixator. The epicondylar access was identified
under intraoperative imaging. Guidewire was placed. The hinged external
fixator was then applied with two 4.0 mm half pins in the distal humerus and
two 3.0 mm half pins in the ulna. Intraoperative imaging confirmed
adequate placement of all hardware as well as good stability of the elbow.
Range of motion was approximately 30 to 135 degrees of flexion. The
wounds were then copiously irrigated with normal saline solution. The
remainder of the lateral ligament complex was augmented with
No. 2 FiberWire suture in interrupted fashion, fascial layer closed with
2-0 Vicryl suture in interrupted fashion, subcutaneous layer closed with
2-0 Vicryl suture in interrupted fashion. Skin closed with 3-0 nylon in

(Continued)
2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part,
except for use as permitted in a license distributed with a certain product or service or otherwise on a password-
protected website for classroom use.

SURGICAL PROCEDURE

Patient Name: Paul G. Catrou
Patient ID: 010220
Date of Procedure: 30 June ----
Page 4



interrupted fashion. Elbow was then placed at 90 degrees. A rod-to-bar
construct was also created to lock the elbow at 90 degrees. Dry sterile
dressings applied. Tourniquet released after 86 minutes. A posterior splint
with an additional side splint was used to further stabilize the elbow.
Awakened from anesthesia, patient had no complications and was taken to
recovery in stable condition.

DISPOSITION: To be seen in my office 3 days postop and by Dr. Dickinson
2 weeks postop. Patient is to call the office if there are any problems or
concerns prior to his postop visit.



____________________________
Max L. Hirsch, MD, Orthopedics

MLH:xx
D:6/30/----
T:6/31/----

C: Stella Rose Dickinson, PhD, Psychology
Marie Aaron, DO, Family Practice