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Is there anyone that can help with this note? I have 27216, 25605, 11012 but could use some help on if this is correct. Thank you in advanced!!
Indications: Patient is a xx y.o. male with multiple injuries after an MVA in which he had presented as a level 1 trauma earlier in the week with the follow orthopedic injuries: OPEN left tibia fracture, OPEN left femoral shaft fracture, left intertrochanteric femur fracture, left thigh compartment syndrome, left Zone 2 sacral fracture with left superior and inferior pubic rami fractures, and a closed distal radius fracture. Patient was temporized initially by Dr. on night of arrival and then Dr.r assumed care of the patient and his left femur, IT fracture, and tibia were definitively fixed on 10/4/24. On 10/4/24 the lateral thigh fasciotomy site was extended and a wound vac was applied.
Procedure Details:
The patient was seen in the preoperative holding area. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The risks and potential complications of their problem and purposed treatment include but are not limited to infection, nerve injury, vascular injury, persistent pain, potential skin necrosis, deep vein thrombosis, possible pulmonary embolus, complications of the anesthetics and failure of the implant. The patient concurred with the proposed plan, giving informed consent. The site of surgery properly noted/marked. The patient was taken to Operating Room, identified as xxxxx and the procedure verified. A Time Out was held and the above information confirmed.
The patient was brought to the operating room, placed on the operating table in a supine position.. Following the successful induction of anesthesia, the operative extremity was scrubbed, prepped and draped in the usual sterile fashion.
We first decided to address the sacral fracture:
The C-arm was positioned to come into the field from the contralateral side. An antero-posterior view of the pelvis was obtained to center the pubic symphysis over the center of the sacrum. An inlet view of the pelvis was then obtained by tilting the image intensifier until the anterior cortical ring of S1 and S2 were superimposed as concentric circles. The position of the C-arm was then recorded. An outlet view was then obtained by tilting the C-arm 90° caudal and visualizing the superior aspect of the pubic symphysis over the S2 vertebral body. The position of the C-arm was then recorded.
A free guide wire was then used to find our starting point on the outlet view. A 1 cm longitudinal incision was then made over the guidewire and spread down to the lateral ilium. A modified cannulated guide was then inserted onto the lateral ilium and the position relative to the window for the S1 foramen was checked radiographically. A guide wire was then placed through the cannulated guide and the outlet view was evaluated for the wire position in the superior– inferior orientation. Minor adjustments were made and the wire was then evaluated with the inlet view for the AP orientation. After confirming proper alignment, the guide wire was advanced directed into the body of the S1 and across the SI joint.
The same process was then repeated for a screw within the S2 sacral body, with the guidewire stopping just short of the contralateral SI joint. Then We then used the opening reamer to bore the near cortex. We then removed the smooth wire and inserted the centering cannula and the balltip guidewire which was then advanced from the left ilium, across the SI joint, through the S2 body and to the SI joint. When the wire was in the area of the foramen, both the outlet and inlet views were evaluated to confirm proper position. The length of the wire was measured and the path was drilled over the wire sequentially starting with a 6mm reamer up to 7.5 mm reamer. A 7.5 x 130 mm curvafix was inserted, but found to be too long, and it was removed and replaced with a 7.5 x110mm curvafix to the appropriate depth and then locked in position. The insertion handle was removed.
After the S2 screw was placed, we then returned our attention to the S1 screw. We then used the opening reamer to bore the near cortex. We then removed the smooth wire and inserted the centering cannula and the balltip guidewire which was then advanced from the left ilium, across the SI joint, through the S1 body and across the SI joint. When the wire was in the area of the foramen, both the outlet and inlet views were evaluated to confirm proper position. The length of the wire was measured and the path was drilled over the wire sequentially starting with a 8mm reamer up to 9.5 mm reamer. A 9.5 x 120 mm curvafix was inserted to the appropriate depth and then locked in position. The insertion handle was removed. Final fluoroscopic images were obtained and we were happy with the position of the screws.
Subcutaneous tissue was closed with 2-0 PDS and sin was closed with staples.
We then turned our attention to the left lateral thigh fasciotomy site:
The lateral musculature was still herniated through the skin significantly. All muscle was pink and viable with no evidence of necrosis. The muscle and open wound were irrigated thoroughly with a total of 6L of normal saline, 2L of the saline did have additional betadine added). The muscle was debrided with a cobb elevator. After irrigation, we attempted closure of the proximal aspect of the fasciotomy site that was still open after surgery on 10/4/24. Due to the amount of swelling of the muscle and skin tension, we were only able to close an additional 4cm of the wound proximal with 2-0 PDS in subcutaneous tissue and then 2-0 prolene was used with skin closure. The remaining aspect of the thigh fasciotomy site remained open due to swelling, measuring approximately 26 x 11cm of remaining open wound with exposed muscle. Ioban was then used to boarder the wound site and proximal incision sites from precious surgery on 10/4/24 and the curvafix screws. A large black wound vac sponge was applied to the wound and additional black sponge was placed over the closed more proximal aspect of the incision. A lilly pad was placed and the vac was to suction with no evidence of leaks.
After the removal of the drapes, all of the patients previously incisions and wound on the left lower extremity were then dressed with xeroform, 4x4s, ABD, kerlix, and ACE wrap.
We then turned our attention to the right distal radius.
Fluoroscopic images were obtained and showed maintained alignment of the right distal radius fracture in adequate position. A well molded long arm cast was then applied to the arm. Final XR showed maintained alignment of the distal radius fracture.
Instrument, sponge, and needle counts were correct prior to wound closure and at the conclusion of the case.
Dr. Tucker was present for all critical aspects of the case.
Indications: Patient is a xx y.o. male with multiple injuries after an MVA in which he had presented as a level 1 trauma earlier in the week with the follow orthopedic injuries: OPEN left tibia fracture, OPEN left femoral shaft fracture, left intertrochanteric femur fracture, left thigh compartment syndrome, left Zone 2 sacral fracture with left superior and inferior pubic rami fractures, and a closed distal radius fracture. Patient was temporized initially by Dr. on night of arrival and then Dr.r assumed care of the patient and his left femur, IT fracture, and tibia were definitively fixed on 10/4/24. On 10/4/24 the lateral thigh fasciotomy site was extended and a wound vac was applied.
Procedure Details:
The patient was seen in the preoperative holding area. The risks, benefits, complications, treatment options, and expected outcomes were discussed with the patient. The risks and potential complications of their problem and purposed treatment include but are not limited to infection, nerve injury, vascular injury, persistent pain, potential skin necrosis, deep vein thrombosis, possible pulmonary embolus, complications of the anesthetics and failure of the implant. The patient concurred with the proposed plan, giving informed consent. The site of surgery properly noted/marked. The patient was taken to Operating Room, identified as xxxxx and the procedure verified. A Time Out was held and the above information confirmed.
The patient was brought to the operating room, placed on the operating table in a supine position.. Following the successful induction of anesthesia, the operative extremity was scrubbed, prepped and draped in the usual sterile fashion.
We first decided to address the sacral fracture:
The C-arm was positioned to come into the field from the contralateral side. An antero-posterior view of the pelvis was obtained to center the pubic symphysis over the center of the sacrum. An inlet view of the pelvis was then obtained by tilting the image intensifier until the anterior cortical ring of S1 and S2 were superimposed as concentric circles. The position of the C-arm was then recorded. An outlet view was then obtained by tilting the C-arm 90° caudal and visualizing the superior aspect of the pubic symphysis over the S2 vertebral body. The position of the C-arm was then recorded.
A free guide wire was then used to find our starting point on the outlet view. A 1 cm longitudinal incision was then made over the guidewire and spread down to the lateral ilium. A modified cannulated guide was then inserted onto the lateral ilium and the position relative to the window for the S1 foramen was checked radiographically. A guide wire was then placed through the cannulated guide and the outlet view was evaluated for the wire position in the superior– inferior orientation. Minor adjustments were made and the wire was then evaluated with the inlet view for the AP orientation. After confirming proper alignment, the guide wire was advanced directed into the body of the S1 and across the SI joint.
The same process was then repeated for a screw within the S2 sacral body, with the guidewire stopping just short of the contralateral SI joint. Then We then used the opening reamer to bore the near cortex. We then removed the smooth wire and inserted the centering cannula and the balltip guidewire which was then advanced from the left ilium, across the SI joint, through the S2 body and to the SI joint. When the wire was in the area of the foramen, both the outlet and inlet views were evaluated to confirm proper position. The length of the wire was measured and the path was drilled over the wire sequentially starting with a 6mm reamer up to 7.5 mm reamer. A 7.5 x 130 mm curvafix was inserted, but found to be too long, and it was removed and replaced with a 7.5 x110mm curvafix to the appropriate depth and then locked in position. The insertion handle was removed.
After the S2 screw was placed, we then returned our attention to the S1 screw. We then used the opening reamer to bore the near cortex. We then removed the smooth wire and inserted the centering cannula and the balltip guidewire which was then advanced from the left ilium, across the SI joint, through the S1 body and across the SI joint. When the wire was in the area of the foramen, both the outlet and inlet views were evaluated to confirm proper position. The length of the wire was measured and the path was drilled over the wire sequentially starting with a 8mm reamer up to 9.5 mm reamer. A 9.5 x 120 mm curvafix was inserted to the appropriate depth and then locked in position. The insertion handle was removed. Final fluoroscopic images were obtained and we were happy with the position of the screws.
Subcutaneous tissue was closed with 2-0 PDS and sin was closed with staples.
We then turned our attention to the left lateral thigh fasciotomy site:
The lateral musculature was still herniated through the skin significantly. All muscle was pink and viable with no evidence of necrosis. The muscle and open wound were irrigated thoroughly with a total of 6L of normal saline, 2L of the saline did have additional betadine added). The muscle was debrided with a cobb elevator. After irrigation, we attempted closure of the proximal aspect of the fasciotomy site that was still open after surgery on 10/4/24. Due to the amount of swelling of the muscle and skin tension, we were only able to close an additional 4cm of the wound proximal with 2-0 PDS in subcutaneous tissue and then 2-0 prolene was used with skin closure. The remaining aspect of the thigh fasciotomy site remained open due to swelling, measuring approximately 26 x 11cm of remaining open wound with exposed muscle. Ioban was then used to boarder the wound site and proximal incision sites from precious surgery on 10/4/24 and the curvafix screws. A large black wound vac sponge was applied to the wound and additional black sponge was placed over the closed more proximal aspect of the incision. A lilly pad was placed and the vac was to suction with no evidence of leaks.
After the removal of the drapes, all of the patients previously incisions and wound on the left lower extremity were then dressed with xeroform, 4x4s, ABD, kerlix, and ACE wrap.
We then turned our attention to the right distal radius.
Fluoroscopic images were obtained and showed maintained alignment of the right distal radius fracture in adequate position. A well molded long arm cast was then applied to the arm. Final XR showed maintained alignment of the distal radius fracture.
Instrument, sponge, and needle counts were correct prior to wound closure and at the conclusion of the case.
Dr. Tucker was present for all critical aspects of the case.