Practicode IV (301-400)
MEDICAL RECORD
SEX: MALE Age: 63DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:
PRIMARY DEGENERATIVE JOINT DISEASE-RIGHT KNEE.PROCEDURES: RIGHT
TOTAL KNEE ARTHROPLASTY (ZIMMER).1. FEMORAL SIZE-SIZE E; RIGHT.2. TIBIAL
SIZE 6.3. ARTICULAR SURFACE-SIZE E-RIGHT; 10-MM HEIGHT.4. TAPER STEM PLUG
AND STEM EXTENSION SCREW.POSTOPERATIVE DIAGNOSIS: PRIMARY
DEGENERATIVE JOINT DISEASE-RIGHT KNEE.SURGEON: Stephanie Andrews
MDANESTHESIA: GENERAL.ANESTHESIOLOGIST:PROCEDURE: After adequate
induction with general anesthesia and the patient in the supine position, a
pneumatic tourniquet was applied to the high right thigh region and not inflated.
The right lower extremity was scrubbed, prepped with Betadine and draped in the
CaseID: OPD6931 usual manner for knee surgery. An Esmarch tourniquet was applied to the right
Primary Diagnosis: M17.11 lower extremity, which was elevated for a period of two minutes. The pneumatic
CPT: 27447-RT tourniquet was inflated to the appropriate level and the Esmarch removed.A linear
incision was made along the anterior aspect of the right knee from the distal
quadriceps to the tibial tubercle. The incision was brought to the subcutaneous
tissue and undermined medially. A medial parapatellar incision was made
extending from the quadriceps raphe to the medial tibial tubercle. The patella
was mobilized laterally and the infrapatellar fat pad was excised. The
anteromedial and the anterolateral capsule of the proximal tibia was released.
The knee was flexed and the patella everted.Advanced degenerative changes
of the interior of the right knee was observed, which was most advanced in the
patellofemoral and medial joints with exposure of subchondral bone. The
extramedullary alignment rod was applied to the tibia and fixed with pin. The
proximal cut was made with an oscillating saw, having determined the height by 10-
mm of the lateral tibial plateau. A drill hole
, MEDICAL RECORD
SEX: MALE Age: 55DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: LEFT
FEMUR FRACTURE.PROCEDURES: LEFT FEMUR INTERMEDULLARY
NAILINGPOSTOPERATIVE DIAGNOSIS: DISPLACED COMMUNITED LEFT FEMORAL
SHAFT FRACTURE.SURGEON:ANESTHESIA: GENERAL VIA ENDOTRACHEAL
TUBE.ESTIMATE BLOOD LOSS: 300 CC.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1
GM ANCEF POSTOP.COMPLICATIONS: NONE.INDICATIONS:
The patient is a male who was found on train tracks and on physical examine and x-
ray was found to have a displaced comminuted fracture of the left femur.
Options, risks, and benefits were discussed with the brother, as the patient was
unable to give consent. He agreed with intramedullary nailing.PROCEDURE: The
CaseID: OPD6932 patient was brought to the operating room and anesthesia was induced via
Primary Diagnosis: S72.352A endotracheal tube. The patient was then positioned on the fracture table and
CPT: 27506-LT closed reduction was performed. The left hip and lower extremity were then
prepped and draped in sterile fashion.A longitudinal incision was made superior to
the greater trochanter and taken down through the subcutaneous tissue to the
tip of the trochanter. A guide rod was placed and centered in the AP and lateral
views. This was then over reamed, and a bead guide rod was placed down the
shaft across into the distal fragment. This was then sequentially reamed up to 10
and then a 10 x 400 Stryker nail was inserted and then the proximal interlock was
done with the guide in the static position. The distal interlocks were done in a
perfect circle technique.Clinically, he had good rotation compared to the other
side and x-ray showed anatomic reduction and good position of the hardware. The
wounds were then irrigated out. The gluteus fascia was closed with interrupted 0-
Vicryl. The subcutaneous tissue was closed with interrupted 2-0 Vicryl. Skin was
closed with skin clips as were the interloc
MEDICAL RECORD
Age 68Sex: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralPREOPERATIVE DIAGNOSIS: Arteriovenous malformation with severe
primary osteoarthritis of the right hip.POSTOPERATIVE DIAGNOSIS: Same.NAME OF
PROCEDURE: Right total hip arthroplasty.SURGEON:ANESTHESIA:
GeneralDESCRIPTION OF PROCEDURE: The patient was taken to the operating
room and after satisfactory general anesthesia the patient had an intrathecal block
performed for postoperative pain control he was placed in the lateral
decubitus position with his right hip uppermost. The right hip was then thoroughly
scrubbed, prepped and draped in the usual sterile manner. The hip was incised
CaseID: OPD6947 longitudinally down to the fascia lata which was also split. This was retracted and
Primary Diagnosis: M16.11 the hip identified. The anterior half of the abductors were incised at the insertion
Secondary Diagnosis: M85.451, Q27.30 of the greater trochanter. The leg was externally rotated. The capsule was then
CPT: 27130-RT identified and a t- shaped incision was made in the capsule. The hip was dislocated
anterolaterally. The femoral neck was the transected at the appropriate location to
hold the medial neck prosthesis. The acetabulum was curetted. The labrum was
removed and the acetabulum was then prepared with the combination reamers to
hold a size 60 Press- Fit bone ingrowth prosthesis. The dome of the acetabulum had
a large bone cyst. This was curetted. Kessel's node harvested from the patient's
femoral head. The Press-Fit 60 mm prosthesis was then impacted in position. The
Polyethylene liner was then inserted with the 10 degree buildup at the 10 o'clock
position. The femur was then prepared with the Stryker instrument to hold a size 10
Press-Fit bone ingrowth prosthesis. This was impacted down the femoral canal. Trial
reduction was performed with the -5 to -2.5 and 0 head and neck length. The -2.5
was selected. This
, MEDICAL RECORD
Age: 46 Sex: FEMALEDate of Service: 1/1/20XXService Department: Orthopedic
Group GeneralPREOPERATIVE DIAGNOSIS: Right shoulder chronic impingement,
AC joint primary arthritis.POSTOPERATIVE DIAGNOSIS: Same.NAME OF
PROCEDURE: Right shoulder examination under anesthesia, arthroscopy,
acromioplasty, distal clavicle excision.SURGEON: Dr. MDANESTHESIA: General with
scalene block.ESTIMATED BLOOD LOSS: Minimal.COMPLICATIONS:
None.DESCRIPTION OF PROCEDURE: After appropriate pre-operative marking
and time out the patient was given a scalene block. After time out the patient was
placed under endotracheal intubation and general anesthesia. The shoulder was
CaseID: OPD6949 examined. There was full range of motion and all ligaments were stable. The
Primary Diagnosis: M19.011 shoulder was then prepped and draped free in the usual manner.A posterior portal
Secondary Diagnosis: M75.41 was established after insufflating the joint with 50 mL of sterile saline. Within the
CPT: 29824-RT, 29826-RT shoulder joint we found completely normal cartilage on both articular surfaces. The
inferior recess was clear. The subscapularis inserted normally without tearing. The
biceps tendon proper was intact. The supraspinatus was intact with no signs of
degeneration or tearing. The infraspinatus and posterior bare area were normal. We
established a portal anteriorly in the interval above the subscapularis. There was a
normal insertion of the bicep tendon to the superior glenoid. The labrum was
attached solidly to bone.We placed the arthroscope into the subacromial space.
There were significant impingement findings with a lot of degeneration and
abrasion along the anterior edge of the acromion and superior cuff. There was
extensive adhesions and bursitis. There was no tearing of the bursal side of the cuff.
We established a lateral portal and debrided the undersurface of the acromion of
soft tissue and performed an acromioplasty. We
MEDICAL RECORD
OPERATIVE NOTEAge: 56Sex: FEMALEDOS: 1/1/20XXPHYSICIAN:PREOPERATIVE:
Left Fourth, Third, and Second finger displaced proximal phalanx
fractures.POSTOPERATIVE: Left Fourth, Third, and Second finger displaced proximal
phalanx fractures.OPERATIVE PROCEDURE: (Code in order of procedures
listed)1. Closed reduction and percutaneous pin fixation left Fourth finger (fifth digit)
proximal phalanx base fracture.2. Closed reduction and percutaneous pin
fixation left Third finger (fourth digit) proximal phalanx fracture.3. Closed reduction
and percutaneous pin fixation left Second finger (third digit) proximal phalanx
fracture.SURGEON:ANESTHESIA: General.COMPLICATIONS: None.INDICATIONS:
CaseID: OPD6952 Ms. Smith is a female who presented to the clinic with comminuted proximal
Primary Diagnosis: S62.617A phalanx fractures near the metacarpal phalangeal joint. The patient had significant
Secondary Diagnosis: S62.615A, S62.613A angulation at the left small finger proximal phalanx. She did have fairly good
CPT: 26727-F4, 26727-F3, 26727-F2 range of motion, but obvious gross deformity to the long, small and ring finger. I
recommended either treatment closed in a cast, that she would likely lose some
flexion potentially at the metacarpal phalangeal joint. After considering options, the
patient wishes to proceed with closed reduction and percutaneous pin fixation
with possible open reduction if necessary. She agreed to surgery understanding
the alternatives, risks, and the benefits of the surgery.DESCRIPTION OF
PROCEDURE: The patient was brought back to the operating room where she
was placed in supine position. The left upper extremity was sterilely prepped and
draped in the usual fashion. Esmarch bandage was used to exsanguinate the left
upper extremity. The axial traction was placed on the left small finger. The
metacarpal phalangeal joint was flexed and pressure was placed along the volar
aspect of the proximal phalanx. The fracture r
, MEDICAL RECORD
OPERATIVE NOTEAGE: 63 Sex: FEMALEDOS: 1/1/20XXPREOPERATIVE DIAGNOSIS:
Arthrofibrosis, both knees.POSTOPERATIVE DIAGNOSIS: Arthrofibrosis, both
knees.OPERATIVE PROCEDURE: Manipulation under anesthesia, bilateral
knees.SURGEON: Dr. MDANESTHESIA: General with muscle
relaxation.COMPLICATIONS: None.CONDITION: Stable to recovery
room.INDICATIONS: Patient is a female status post bilateral total knee arthroplasty
approximately 4 months previous. She has considerable stiffness with her artificial
knee joints and wishes to proceed with manipulations. The surgeries were done by
CaseID: OPD6955
Dr. Kim Jones Possible and he asked me, because of timing, to perform these and
Primary Diagnosis: T84.82XA
patient agrees. The risks and benefits were thoroughly discussed with the patient
Secondary Diagnosis: Z96.653
and elected to proceed.FINDINGS: Preoperative range of motion on the right was 17
CPT: 27570-50
to 80; left was 15 to 83. Postoperative range of motion was 0 to 135
bilaterally.PROCEDURE: Patient was brought to the operating room. Preoperative
range of motion was documented. She was then placed under general anesthesia.
Muscle relaxation was used and then gentle manipulation was then done on both
knees, starting with the right. Audible breaking of scar tissue was done. It took a
normal amount of force for both extension and flexion and I was not concerned
that there were any fractures.
The post-manipulation range of motion was 0 to 135 bilaterally. Patient was
awakened from anesthesia. Large ice packs were placed on the knees. Patient was
to attend physical therapy later this day.Electronically signed by: MD 1/1/20XX
MEDICAL RECORD
AGE: 48SEX: MALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE DIAGNOSIS:
RIGHT MEDIAL COLUMN INTRAARTICULAR DISTAL HUMERUS
FRACTURE.PROCEDURES: RIGHT ELBOW ORIF, MEDIAL COLUMN IN
INTRAARTICULAR PORTION WITH ANTERIOR ULNAR NERVE
TRANSPOSITION.POSTOPERATIVE DIAGNOSIS: NONDISPLACED RIGHT MEDIAL
COLUMN INTRAARTICULAR DISTAL HUMERUS FRACTURE.SURGEON:
M.D.ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 20
CC.TOURNIQUET TIME: 90 MINUTES.ANTIBIOTICS: ANCEF 1 GM PREOP, 1 GM
ANCEF POSTOP.COMPLICATIONS: NONE.INDICATIONS: This patient is a right-
dominant male who fell at work getting off his truck, sustained a closed right medial
column nondisplaced intraarticular fracture of the distal humerus. Options, risks and
CaseID: OPD6964
benefits were discussed with the patient and he agreed with open reduction internal
Primary Diagnosis: S42.464A
fixation and ulnar nerve transposition and possible olecranon
CPT: 24579-RT
osteotomy.PROCEDURE: The patient was brought to the operating room and
anesthesia was induced via endotracheal tube. The patient was placed in the left
lateral decubitus position on a bean bag and the right upper extremity was
prepped and draped in sterile fashion. His limb was exsanguinated and the
tourniquet was inflated to 250.A longitudinal incision was made over the
olecranon and extended proximally and distally. The ulnar nerve was identified
along the medial triceps and traced up to the medial intermuscular septum. It was
traced distally down to the first branch to the flexor carpi ulnaris. A Penrose drain
was placed around the ulnar nerve and that was used to protect the nerve
throughout the case. The fracture surfaces were subperiosteally dissected irrigated
out and curetted.The trochlear fragment was reduced to the medial column and
held with 1.3 K-wires. It was reduced to the capitellum and viewed by performing
a partial triceps slide from m
MEDICAL RECORD
SEX: MALE Age: 63DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS:
PRIMARY DEGENERATIVE JOINT DISEASE-RIGHT KNEE.PROCEDURES: RIGHT
TOTAL KNEE ARTHROPLASTY (ZIMMER).1. FEMORAL SIZE-SIZE E; RIGHT.2. TIBIAL
SIZE 6.3. ARTICULAR SURFACE-SIZE E-RIGHT; 10-MM HEIGHT.4. TAPER STEM PLUG
AND STEM EXTENSION SCREW.POSTOPERATIVE DIAGNOSIS: PRIMARY
DEGENERATIVE JOINT DISEASE-RIGHT KNEE.SURGEON: Stephanie Andrews
MDANESTHESIA: GENERAL.ANESTHESIOLOGIST:PROCEDURE: After adequate
induction with general anesthesia and the patient in the supine position, a
pneumatic tourniquet was applied to the high right thigh region and not inflated.
The right lower extremity was scrubbed, prepped with Betadine and draped in the
CaseID: OPD6931 usual manner for knee surgery. An Esmarch tourniquet was applied to the right
Primary Diagnosis: M17.11 lower extremity, which was elevated for a period of two minutes. The pneumatic
CPT: 27447-RT tourniquet was inflated to the appropriate level and the Esmarch removed.A linear
incision was made along the anterior aspect of the right knee from the distal
quadriceps to the tibial tubercle. The incision was brought to the subcutaneous
tissue and undermined medially. A medial parapatellar incision was made
extending from the quadriceps raphe to the medial tibial tubercle. The patella
was mobilized laterally and the infrapatellar fat pad was excised. The
anteromedial and the anterolateral capsule of the proximal tibia was released.
The knee was flexed and the patella everted.Advanced degenerative changes
of the interior of the right knee was observed, which was most advanced in the
patellofemoral and medial joints with exposure of subchondral bone. The
extramedullary alignment rod was applied to the tibia and fixed with pin. The
proximal cut was made with an oscillating saw, having determined the height by 10-
mm of the lateral tibial plateau. A drill hole
, MEDICAL RECORD
SEX: MALE Age: 55DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: LEFT
FEMUR FRACTURE.PROCEDURES: LEFT FEMUR INTERMEDULLARY
NAILINGPOSTOPERATIVE DIAGNOSIS: DISPLACED COMMUNITED LEFT FEMORAL
SHAFT FRACTURE.SURGEON:ANESTHESIA: GENERAL VIA ENDOTRACHEAL
TUBE.ESTIMATE BLOOD LOSS: 300 CC.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1
GM ANCEF POSTOP.COMPLICATIONS: NONE.INDICATIONS:
The patient is a male who was found on train tracks and on physical examine and x-
ray was found to have a displaced comminuted fracture of the left femur.
Options, risks, and benefits were discussed with the brother, as the patient was
unable to give consent. He agreed with intramedullary nailing.PROCEDURE: The
CaseID: OPD6932 patient was brought to the operating room and anesthesia was induced via
Primary Diagnosis: S72.352A endotracheal tube. The patient was then positioned on the fracture table and
CPT: 27506-LT closed reduction was performed. The left hip and lower extremity were then
prepped and draped in sterile fashion.A longitudinal incision was made superior to
the greater trochanter and taken down through the subcutaneous tissue to the
tip of the trochanter. A guide rod was placed and centered in the AP and lateral
views. This was then over reamed, and a bead guide rod was placed down the
shaft across into the distal fragment. This was then sequentially reamed up to 10
and then a 10 x 400 Stryker nail was inserted and then the proximal interlock was
done with the guide in the static position. The distal interlocks were done in a
perfect circle technique.Clinically, he had good rotation compared to the other
side and x-ray showed anatomic reduction and good position of the hardware. The
wounds were then irrigated out. The gluteus fascia was closed with interrupted 0-
Vicryl. The subcutaneous tissue was closed with interrupted 2-0 Vicryl. Skin was
closed with skin clips as were the interloc
MEDICAL RECORD
Age 68Sex: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group
GeneralPREOPERATIVE DIAGNOSIS: Arteriovenous malformation with severe
primary osteoarthritis of the right hip.POSTOPERATIVE DIAGNOSIS: Same.NAME OF
PROCEDURE: Right total hip arthroplasty.SURGEON:ANESTHESIA:
GeneralDESCRIPTION OF PROCEDURE: The patient was taken to the operating
room and after satisfactory general anesthesia the patient had an intrathecal block
performed for postoperative pain control he was placed in the lateral
decubitus position with his right hip uppermost. The right hip was then thoroughly
scrubbed, prepped and draped in the usual sterile manner. The hip was incised
CaseID: OPD6947 longitudinally down to the fascia lata which was also split. This was retracted and
Primary Diagnosis: M16.11 the hip identified. The anterior half of the abductors were incised at the insertion
Secondary Diagnosis: M85.451, Q27.30 of the greater trochanter. The leg was externally rotated. The capsule was then
CPT: 27130-RT identified and a t- shaped incision was made in the capsule. The hip was dislocated
anterolaterally. The femoral neck was the transected at the appropriate location to
hold the medial neck prosthesis. The acetabulum was curetted. The labrum was
removed and the acetabulum was then prepared with the combination reamers to
hold a size 60 Press- Fit bone ingrowth prosthesis. The dome of the acetabulum had
a large bone cyst. This was curetted. Kessel's node harvested from the patient's
femoral head. The Press-Fit 60 mm prosthesis was then impacted in position. The
Polyethylene liner was then inserted with the 10 degree buildup at the 10 o'clock
position. The femur was then prepared with the Stryker instrument to hold a size 10
Press-Fit bone ingrowth prosthesis. This was impacted down the femoral canal. Trial
reduction was performed with the -5 to -2.5 and 0 head and neck length. The -2.5
was selected. This
, MEDICAL RECORD
Age: 46 Sex: FEMALEDate of Service: 1/1/20XXService Department: Orthopedic
Group GeneralPREOPERATIVE DIAGNOSIS: Right shoulder chronic impingement,
AC joint primary arthritis.POSTOPERATIVE DIAGNOSIS: Same.NAME OF
PROCEDURE: Right shoulder examination under anesthesia, arthroscopy,
acromioplasty, distal clavicle excision.SURGEON: Dr. MDANESTHESIA: General with
scalene block.ESTIMATED BLOOD LOSS: Minimal.COMPLICATIONS:
None.DESCRIPTION OF PROCEDURE: After appropriate pre-operative marking
and time out the patient was given a scalene block. After time out the patient was
placed under endotracheal intubation and general anesthesia. The shoulder was
CaseID: OPD6949 examined. There was full range of motion and all ligaments were stable. The
Primary Diagnosis: M19.011 shoulder was then prepped and draped free in the usual manner.A posterior portal
Secondary Diagnosis: M75.41 was established after insufflating the joint with 50 mL of sterile saline. Within the
CPT: 29824-RT, 29826-RT shoulder joint we found completely normal cartilage on both articular surfaces. The
inferior recess was clear. The subscapularis inserted normally without tearing. The
biceps tendon proper was intact. The supraspinatus was intact with no signs of
degeneration or tearing. The infraspinatus and posterior bare area were normal. We
established a portal anteriorly in the interval above the subscapularis. There was a
normal insertion of the bicep tendon to the superior glenoid. The labrum was
attached solidly to bone.We placed the arthroscope into the subacromial space.
There were significant impingement findings with a lot of degeneration and
abrasion along the anterior edge of the acromion and superior cuff. There was
extensive adhesions and bursitis. There was no tearing of the bursal side of the cuff.
We established a lateral portal and debrided the undersurface of the acromion of
soft tissue and performed an acromioplasty. We
MEDICAL RECORD
OPERATIVE NOTEAge: 56Sex: FEMALEDOS: 1/1/20XXPHYSICIAN:PREOPERATIVE:
Left Fourth, Third, and Second finger displaced proximal phalanx
fractures.POSTOPERATIVE: Left Fourth, Third, and Second finger displaced proximal
phalanx fractures.OPERATIVE PROCEDURE: (Code in order of procedures
listed)1. Closed reduction and percutaneous pin fixation left Fourth finger (fifth digit)
proximal phalanx base fracture.2. Closed reduction and percutaneous pin
fixation left Third finger (fourth digit) proximal phalanx fracture.3. Closed reduction
and percutaneous pin fixation left Second finger (third digit) proximal phalanx
fracture.SURGEON:ANESTHESIA: General.COMPLICATIONS: None.INDICATIONS:
CaseID: OPD6952 Ms. Smith is a female who presented to the clinic with comminuted proximal
Primary Diagnosis: S62.617A phalanx fractures near the metacarpal phalangeal joint. The patient had significant
Secondary Diagnosis: S62.615A, S62.613A angulation at the left small finger proximal phalanx. She did have fairly good
CPT: 26727-F4, 26727-F3, 26727-F2 range of motion, but obvious gross deformity to the long, small and ring finger. I
recommended either treatment closed in a cast, that she would likely lose some
flexion potentially at the metacarpal phalangeal joint. After considering options, the
patient wishes to proceed with closed reduction and percutaneous pin fixation
with possible open reduction if necessary. She agreed to surgery understanding
the alternatives, risks, and the benefits of the surgery.DESCRIPTION OF
PROCEDURE: The patient was brought back to the operating room where she
was placed in supine position. The left upper extremity was sterilely prepped and
draped in the usual fashion. Esmarch bandage was used to exsanguinate the left
upper extremity. The axial traction was placed on the left small finger. The
metacarpal phalangeal joint was flexed and pressure was placed along the volar
aspect of the proximal phalanx. The fracture r
, MEDICAL RECORD
OPERATIVE NOTEAGE: 63 Sex: FEMALEDOS: 1/1/20XXPREOPERATIVE DIAGNOSIS:
Arthrofibrosis, both knees.POSTOPERATIVE DIAGNOSIS: Arthrofibrosis, both
knees.OPERATIVE PROCEDURE: Manipulation under anesthesia, bilateral
knees.SURGEON: Dr. MDANESTHESIA: General with muscle
relaxation.COMPLICATIONS: None.CONDITION: Stable to recovery
room.INDICATIONS: Patient is a female status post bilateral total knee arthroplasty
approximately 4 months previous. She has considerable stiffness with her artificial
knee joints and wishes to proceed with manipulations. The surgeries were done by
CaseID: OPD6955
Dr. Kim Jones Possible and he asked me, because of timing, to perform these and
Primary Diagnosis: T84.82XA
patient agrees. The risks and benefits were thoroughly discussed with the patient
Secondary Diagnosis: Z96.653
and elected to proceed.FINDINGS: Preoperative range of motion on the right was 17
CPT: 27570-50
to 80; left was 15 to 83. Postoperative range of motion was 0 to 135
bilaterally.PROCEDURE: Patient was brought to the operating room. Preoperative
range of motion was documented. She was then placed under general anesthesia.
Muscle relaxation was used and then gentle manipulation was then done on both
knees, starting with the right. Audible breaking of scar tissue was done. It took a
normal amount of force for both extension and flexion and I was not concerned
that there were any fractures.
The post-manipulation range of motion was 0 to 135 bilaterally. Patient was
awakened from anesthesia. Large ice packs were placed on the knees. Patient was
to attend physical therapy later this day.Electronically signed by: MD 1/1/20XX
MEDICAL RECORD
AGE: 48SEX: MALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE DIAGNOSIS:
RIGHT MEDIAL COLUMN INTRAARTICULAR DISTAL HUMERUS
FRACTURE.PROCEDURES: RIGHT ELBOW ORIF, MEDIAL COLUMN IN
INTRAARTICULAR PORTION WITH ANTERIOR ULNAR NERVE
TRANSPOSITION.POSTOPERATIVE DIAGNOSIS: NONDISPLACED RIGHT MEDIAL
COLUMN INTRAARTICULAR DISTAL HUMERUS FRACTURE.SURGEON:
M.D.ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 20
CC.TOURNIQUET TIME: 90 MINUTES.ANTIBIOTICS: ANCEF 1 GM PREOP, 1 GM
ANCEF POSTOP.COMPLICATIONS: NONE.INDICATIONS: This patient is a right-
dominant male who fell at work getting off his truck, sustained a closed right medial
column nondisplaced intraarticular fracture of the distal humerus. Options, risks and
CaseID: OPD6964
benefits were discussed with the patient and he agreed with open reduction internal
Primary Diagnosis: S42.464A
fixation and ulnar nerve transposition and possible olecranon
CPT: 24579-RT
osteotomy.PROCEDURE: The patient was brought to the operating room and
anesthesia was induced via endotracheal tube. The patient was placed in the left
lateral decubitus position on a bean bag and the right upper extremity was
prepped and draped in sterile fashion. His limb was exsanguinated and the
tourniquet was inflated to 250.A longitudinal incision was made over the
olecranon and extended proximally and distally. The ulnar nerve was identified
along the medial triceps and traced up to the medial intermuscular septum. It was
traced distally down to the first branch to the flexor carpi ulnaris. A Penrose drain
was placed around the ulnar nerve and that was used to protect the nerve
throughout the case. The fracture surfaces were subperiosteally dissected irrigated
out and curetted.The trochlear fragment was reduced to the medial column and
held with 1.3 K-wires. It was reduced to the capitellum and viewed by performing
a partial triceps slide from m
