Operative Report Assign Question & Answer Guide (With Explanation)

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Original Question

18. OPERATIVE REPORT- ASSIGN CPT CODE PREOPERATIVE DIAGNOSIS: COMMINUTED FRACTURE , RIGHT OLECRANON PROCESS OF THE ULNA. POSTOPERATIVE DIAGNOSIS; COMMINUTED FRACTURE, RIGHT OLECRANON PROCESS OF THE ULNA PROCEDURE PERFORMED: OPEN REDUCTION INTERNAL FIXATION RIGHT OLETRANON FRACTURE ANESTHESIA : GENERAL FINDINGS: THE PATIENT HAD A MARKEDLY COMMINUTED DISPLACED FRACTURE OF HIS RIGHT OLECRANTON. HE HAD INVOLVED A SIGNIFICANT PORTION OF THE ARTICULAR SURFACE. WE WERE ABLE TO REASSEMBLE THE MAJOR FRAGMENTS; HOWEVER WE DID HAVE TO DEVRUDE SOME OF THE ARTICULAR CARTILAGE FROM THE JOINT, WHICH RESULTED IN A DEFECT IN THE ARTICULAR CARTILAGE OF SOME SIGNIFICANCE. PROCEDURE: WHILE UNDER A GENERAL ANESTHETIC , THE PATIENT WAS PLACED IN A SUPINE POSTION ON THE OPERATING ROOM TABLE, WHERE HIS RIGHT ARM WAS PREPPED WITH BETADIE AND DRAPED IN A STERILE FASHION. WE USED AN ESMARCH BANDAGE TO EXSANGUINATE THE ARM, AND A TOURNIQUET ON THE LIMB WAS INFLATED TO 250 mm HG. THE TOTAL TOURNIQUET TIME ENDED UP BEING 43 MINUTES. WE CREATED A LONGITUDAL INCISION OVER THE POSTERIOR ASPECT OF THE ELBOW, SKIRTING TO THE RADIAL SIDE OF THE OLECRANON. WE CARRIED THE DISSECTION DOWN THROUGH THE SUBCATENEOUS TISSUE AND EASILY IDENTIFIED THE FRACTURE SITE AS THE PERIOSTEUM WAS TORN OVER THIS AREA. WE USED SUCTION TO IRRIGATE THE HEMATOMA , SEVERAL PIECES OF ARTICULAR CARTILAGE LAY IN JOINT, WHICH WE DEBRIDED, AS WELL BECAUSE IT WAS LAYING LOOSE IN THE JOINT. WE THEN THOROUGHLY IRRIGATED THE AREA WITH SALINE TO LOOK FOR ANY REMAINING LOOSE FRAGMENTS. WE HELD THIS IN PLACE WITH A TOWEL CLIP AS WE DRILLED A TRANSVERSE HOLE THROUGH THE ULNA, PERHAPHS 2.5 CM DISTAL TO THE FRACTURE SITE. WE PASSED AN 18-GAUGE WIRE THROUGH THIS TRANSVERSE TUNNEL THROUGH THE ULNA , AND THEN WE PASSED TWO SMOOTH STEINMANN PINS ACROSS THE FRACTURE SITE. WE STARTED THE STEINMANN PINS FROM THE PROXIMAL FRAGMENT AND DRILLED ACROSS THE FRACTURE SITE INTO THE DISTAL ULNAR SHAFT. AFTER WE HAD COMPLETED THE SECOND STEINMANN PINS ACROSS THE FRACTURE SITE AND AROUND THE STEINMANN PINS. WE THEN TIGHTENED THIS WITH A HARRIS WIRE TIGHTENER. THE COMBINATION OF THE STEINMANN PINS AND THE FIGURE OF EIGHT WIRE SEEMED TO SECURE THE FRACTURE QUIET NICELY. THERE WAS NO MOVEMENT OF THE FRACTURE SITE WITH PLACING THE ELBOW THROUGH A RANGE OF MOTION. WE LEFT THE STEINMANN PINS LONG UNTIL WE HAD OBTAINED AN INTRAOPERATIVE XRAY CONFIRMING AN ACCEPTABLE ALIGNMENT OF THE FRAGMENT. THE XRAY DID CONFIRM A SIGNIFICANT LOSS OF THE ARTICULAR CARTILAGE, HOWEVER IT WAS ELECTED TO ACCEPT THIS BECAUSE THE FRAGMENTS APPEARED TO BE RELATIVELY STABLE CLINICALLY. WE THEN BENT THE STEINMANN PINS AT 90 DEGREES AND CUT THEM OFF AND THEN TAPED THE STEINMANN PINS SO THAT THEY WERE BURIED INTO THE TRICEPS MUSCLE. WE PLACED THE ELBOW THROUGH A RANGE OF MOTION AND FOUND THAT NO CREPITUD WAS NOTED, THE FRACTURE APPEARED TO BE IN A GOOD CONDITION, AND WE THEREFORE IRRIGATED THE AREA WITH SALINE AND CLOSED THE SUBCUTANEOUS TISSUE USING 2-0 VICYL AND THE SKIN WITH 3-0 NYLON. A XERFORM DRESSING WAS APPLIED, AND A LONG ARM SPLINT WAS APPLIED WITH THE ELBOW FLEXED ABOUT 60 DEGREES. HE WAS TAKEN FROM THE OPERATING ROOM IN GOOD CONDITION AND BREATHING SPOTANEOUSLY. TOURNIQUET RELEASED AFTER 43 MINUTES OF TOURNIQUET TIME, AND WR RELEASED THIS JUST AFTER THE XRAYS, HE WAS GIVEN IV KEFZOL PREOPERATIVE AS WELL . THE FINAL SPONGE AND NEEDLE COUNTS WERE CORRECT.

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