Sample Type / Medical Specialty: Orthopedic
Sample Name: Hardware Removal - Elbow
Description: Hardware removal in the left elbow.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Retained hardware in left elbow.
POSTOPERATIVE DIAGNOSIS: Retained hardware in left elbow.
PROCEDURE: Hardware removal in the left elbow.
ANESTHESIA: Procedure done under general anesthesia. The patient also received 4 mL of 0.25% Marcaine of local anesthetic.
TOURNIQUET: There is no tourniquet time.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: No intraoperative complications.
HISTORY AND PHYSICAL: The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture. He underwent screw compression for the fracture in October 2007. The fracture has subsequently healed and the patient presents for hardware removal. The risks and benefits of surgery were discussed. The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion. All questions were answered and the family agreed to the above plan.
PROCEDURE: The patient was taken to the operating room, placed supine on the operating table. General anesthesia was then administered. The patient's left upper extremity was then prepped and draped in standard surgical fashion. Using his previous incision, dissection was carried down through the screw. A guide wire was placed inside the screw and the screw was removed without incident. The patient had an extension lag of about 15 to 20 degrees. Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex. The washer was also removed without incident. Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl. Wound was injected with 0.25% Marcaine. The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias. The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.
DISCHARGE NOTE: The patient will be discharged on date of surgery. He is to follow up in one week's time for a wound check. This can be done at his primary care physician's office. The patient should keep his postop dressing for about 4 to 5 days. He may then wet the wound, but not scrub it. The patient may resume regular activities in about 2 weeks. The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.
Keywords: orthopedic, retained hardware, hardware removal, tourniquet, elbow, hardware,