DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Left hand crush injury involving left middle and left ring finger with amputation injury of left ring finger and crush injury of left middle finger.
POSTOPERATIVE DIAGNOSIS:
Subtotal amputation injury to the left middle finger with questionably viable distal part; amputation injury left ring finger through base of distal phalanx.
OPERATION PERFORMED:
1. Amputation revision of left ring finger.
2. Open reduction internal fixation, open distal phalanx fracture, left middle finger.
3. Repair of 5 cm complex subtotal amputation laceration, left middle finger.
4. Microscopic examination of neurovascular bundles of left middle finger at the level of trifurcation.
SURGEON: John Doe, MD
ANESTHESIA: Axillary block anesthesia.
DESCRIPTION OF OPERATION: The patient was evaluated preoperatively by Dr. Jane Doe and taken to the operating room where axillary block anesthesia was established. Dr. Jane Doe began the case which consisted of irrigation and debridement of the wounds. The patient had been advised preoperatively by Dr. Jane Doe about the nature of the injury and the potential risks and complications of the injury as well as the surgery. She obtained the consent and took the patient to the operating room. The patient will be admitted for 24 hour IV antibiotics given the nature of the crush injury.
After irrigation and debridement of the bone and soft tissue injuries of the middle and the ring fingers, an amputation revision of the right finger at the base of the distal phalanx was carried out. Once all parts had been repaired for the soft tissue coverage, local flaps were incised, elevated, rotated into place and sutured with half buried horizontal mattress sutures of 6-0 nylon suture. At this point, the tourniquet was elevated and the arm exsanguinated with the tourniquet set at 250 mmHg pressure. Under high power magnification, the neurovascular structures of the middle finger were examined. The neurovascular bundle on the radial side was missing distal to the trifurcation; on the ulnar side, they were intact. Flexor tendon was intact, although it was abraded. There was a comminuted fracture of the distal phalanx.
After thorough irrigation of all areas additionally with an additional liter of irrigation for both fingers and after the preliminary irrigation and debridement and after the amputation revision surgery was performed, the fracture of the distal phalanx of the middle finger was pinned under FluoroScan control with 0.045 inch K-wires. Soft tissue structures consisting of the skin and extensor tendon, where there was a partial laceration, were repaired with 5-0 nylon in each case. Full thickness debridement of the skin edges was required for an approximation without any tension. After soft tissue was closed, the tourniquet was released. After 30 seconds, there was capillary refill at the tip of the middle finger, although slow. Puncture of the skin with a suture needle showed bright red bleeding.
Prognosis for the left middle finger is guarded. It was not technically possible to do any additional microscopic repairs given the level of the injuries in the absence of the distal structures on the radial side. The patient will be observed postoperatively for IV antibiotics. Additional surgery in the future may be required pending the viability of the distal portion of the left middle finger. Needle and instrument counts were correct. Blood loss was less than 30 mL. Specimens consisted of the bone and tissue excised. Antibiotic ointment, Adaptic and a soft dressing were applied followed by application of a protective splint. The patient was stable intraoperatively and taken to the recovery room with stable vital signs.
