DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left small finger open Salter-Harris II distal phalanx fracture with nail bed laceration.
POSTOPERATIVE DIAGNOSIS: Left small finger open Salter-Harris II distal phalanx fracture with nail bed laceration.
PROCEDURES PERFORMED:
1. Irrigation and debridement of open distal phalanx fracture, left small finger.
2. Nail bed repair, left small finger.
3. Open reduction internal fixation of distal phalanx fracture, left small finger.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General with local.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
TOURNIQUET TIME: 30 minutes.
CONDITION: Stable to recovery room.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old male who sustained this injury to his left small finger at school earlier today. He had an open distal phalanx fracture through the physis of the distal phalanx with disruption of the nail bed and exposed bone. We saw him in the OR holding area. We discussed risks and benefits, pros and cons of surgery. The patient and family understood these and elected to proceed with the procedure.
DESCRIPTION OF PROCEDURE: We met the patient in the OR holding area preoperatively and marked his extremity. He was given 1 gram of IV Ancef for infection prophylaxis and taken to the operating room and placed supine on the operating room table. All bony prominences were well padded. The operative extremity was confirmed by the nursing staff, anesthesia staff, and myself. Tourniquet was applied to the most proximal aspect of the left forearm, settings were 250 mmHg. The patient was placed under general anesthetic with an LMA for anesthesia. Once adequate anesthetic was on board, we prepped and draped the hand and the forearm in the standard surgical fashion. We then used an Esmarch bandage to exsanguinate the extremity and inflated the tourniquet.
We began by preinjecting and performing a digital block to the left small finger with 6 mL total of 0.5% Marcaine plain. Following this, we then used the Freer elevator and were able to elevate the nail plate and separate it gently from the sterile matrix beneath. This was passed off to the back table where it was placed in a cup of sterile Betadine.
Following this, we were able to examine the finger and noted that the exposed distal phalanx was fractured through the growth plate. The entire paronychia and eponychium were intact with the nail plate and fracture avulsed out from underneath the eponychial fold. Considering the extent of laceration to the nail bed, we used a 15 blade and made two oblique incisions from the eponychial fold proximally and elevated the large skin flap to expose the proximal aspect of the sterile matrix and the germinal matrix. Care was taken to protect these structures beneath the skin. Skin hook was used to retract the eponychial fold.
We copiously irrigated the exposed fracture. This was through the growth plate. We used a small curette and debrided any residual hematoma and foreign debris that were in the area. We used saline and a bulb syringe and cleaned the exposed bony surfaces. Once they were adequately and sterilely debrided, we were then able to visualize the transverse laceration through the sterile matrix. We were able to remove any interposed soft tissue and then manually reduce the fracture.
Once we felt this was easily reduced, we then took a 0.035 inch K-wire and then in antegrade fashion sent the pin out from the fracture through the tip of the finger. We brought the pin flush to the fracture site, performed a manual reduction making certain the sterile matrix was not interposed in the fracture site and then in the retrograde fashion sent the pin across the physis of the distal phalanx and then across the DIP joint.
Once this was completed, we then used intraoperative fluoroscopy in AP and lateral views, confirmed that the pin was well positioned and the fracture was anatomically aligned and the DIP joint was anatomically aligned and congruent. We were satisfied with pin placement and fracture reduction. We then copiously irrigated and chose a 5-0 chromic and in an interrupted fashion were able to close the sterile matrix laceration over the distal phalanx in an interrupted fashion. We were able to anatomically reduce this.
Following this, we were able to place the flap of eponychial fold back into its normal anatomic position. We then used a 5-0 chromic in an interrupted fashion and closed the two incisions we made in the skin and eponychial fold and reapproximated these to an anatomic alignment. We then placed the cleaned nail plate back under the eponychial fold between the matrix and the proximal nail fold to prevent any scarring.
Following this, we let the tourniquet down. There was no pulsatile bleeding. Tourniquet time was 30 minutes. Finger was pink with normal capillary refill at the end of the case. We bent and cut the pin just as it exited from the tip of the finger. We placed sterile Xeroform over the nail itself followed by sterile 4 x 4s loosely around the finger and then a bulky soft dressing was applied, followed by an ulnar gutter-type plaster splint, forearm based, to the end of the small and ring finger, followed loosely by an Ace bandage. The patient was awoken from his anesthetic. There were no complications. Again, the finger was pink with normal capillary refill at the end of the case. He was transferred stable to the recovery room.
Plan is for discharge to home. The patient will keep the splint in place until we see him in one week in the outpatient setting.
