PREOPERATIVE DIAGNOSIS:
1. Closed Left Tibial Plateau Fracture
POSTOPERATIVE DIAGNOSIS:
1. Same
PROCEDURES PERFORMED:
1. Closed Reduction with placement of external fixator: Left tibial plateau
ANESTHESIA: General endotracheal
ESTIMATED BLOOD LOSS: Minimal
COMPLICATIONS: None.
DRAINS: None.
SPECIMENS: None.
TOURNIQUET: None.
HPI & INDICATIONS FOR PROCEDURE:
The patient is a who presented to the emergency department s/p motor vehicle collision. He was a restrained driver whose operatively in a vehicle that struck a pole at a high rate of speed. Presented to the ED with complaints of left knee pain. Imaging revealed a closed left tibial plateau fracture. There was significant swelling microarray coronal plane instability. Risks of operative or non operative stabilization were discussed patient in detail. Risks of non operative treatment included pain, bleeding, infection, development of compartment syndrome, neurovascular injury, loss of limb, loss of life. Patient elected to proceed with surgical intervention and stabilization in the form of closed reduction external fixation. Informed consents were obtained. Patient was given all opportunity to answer questions. Surgical site was verified and marked.
PROCEDURE IN DETAIL:
On the day of surgery patient was greeted in the preoperative holding area all last minute questions were answered to the patient’s satisfaction. Surgical consents were again verified and surgical marking was verified as well. Patient was taken to operating room 10 where he was placed supine on a radiolucent flat table. All bony prominences padded. Patient was then surrendered to general endotracheal anesthesia without incident. Operative extremity was then prepped and draped in the usual sterile fashion. A 13 point time-out was performed including correct patient, correct operative site, correct procedure. All those present were in agreement. Perioperative antibiotics given within 30 minutes of incision.
We have initially turned our attention to placement of 2 tibial pins. We 1st confirmed placement of the proximal pin on AP fluoroscopy. A small stab incision was made using a 15. Scalpel blade carried down sharply through skin and subcutaneous tissue. Pilot hole was then drilled and a 5 mm threaded Schanz pin was then inserted from an anterior to posterior direction appropriate placement was confirmed on AP and fluoroscopic imaging. The proximal pin was then placed in a similar manner the pins connected using a multi pin clamp.
We then turned our attention to placement of 2 femoral pins. We 1st confirmed our placement of the p distal pain on AP fluoroscopy. A small stab incision was made using a 15. Scalpel blade and dissection was carried sharply through skin subcutaneous tissue. The soft tissue was opened using hemostat and dissection carried bluntly down to bone. A pilot hole was then drilled from an anterior to posterior direction through both cortices of the femur. We then inserted a Synthes 5 mm threaded Schanz pin from anterior to posterior until we had good fixation both cortices of the bone. Proper placement was then confirmed on AP and lateral fluoroscopic imaging. We then placed a multi pin connector between both pins. Combi clamps were then applied to both multi pin connectors and 250 mm carbon fiber rods x2 then placed from the distal to the proximal pins and connected using a pin to bar clamp. We then provisionally reduced the tibial plateau fracture and confirmed reduction on AP and lateral fluoroscopy and then performed a provisional tightening of her fixator construct. We then final tightened our construct and confirmed reduction again on AP and lateral fluoroscopic imaging and determined that length, alignment, rotation was appropriate.
We then dressed our ex fix pin sites using a nonadhesive gauze dressing and overwrapped with Kerlix. At the conclusion of the case all needle, sponge, instrument counts were correct x3. Patient was then awakened from general endotracheal anesthesia and transferred post anesthesia care unit having suffered no untoward event.
CPT code 27532- LT Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction
20692 – Application of a multiplane (pins in more than one plane), unilateral, external fixation system.”
