Report

Exam: MR of the brain with and without contrast.

Date: October 23, 2010

History: 26-year-old male, trauma with possible seizure.

Comparison: No prior MRI for comparison.

Technique: Routine pulse sequences were obtained with and without contrast. Scans were performed with axial T1, T2, FLAIR, sagittal T1, FLAIR, and axial diffusion weighted images. Axial and coronal T1-weighted images were obtained following the intravenous administration of 14 cc MultiHance.

In accordance with Clarian Radiology policies and procedures, a standard medication reconciliation was performed by the radiology technologist prior to the examination. No contraindications were identified. The examination was performed in accordance with the standard protocol. No significant acute adverse events occurred.

Findings:

The ventricles and cerebrospinal fluid spaces are normal in size and configuration for the patient's age. There is no evidence of mass-effect or midline shift. No abnormal areas of signal intensity or contrast enhancement are seen. No evidence of restricted diffusion is seen to suggest acute infarction. A tiny retention cyst is present in the left maxillary sinus. Other imaged paranasal sinuses and mastoid air cells are clear.

Note is made of a prominent pineal cyst, measuring approximately 1.1 cm in maximal diameter, without irregular internal enhancement.

IMPRESSION: MRI of the brain within normal limits.

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History of Present Illness

Per Clarian Arnett note: 26-year-old male presents by ambulance as a trauma one. that the patient was riding his bicycle this morning and hit by a vehicle. Patient was thrown fro the bicycle and hit the windshield of the pupil which shattered. Apparently there were some nurses at the scene who reported to the paramedics the patient was having a generalized tonic-clonic seizure when they found him on the ground. On paramedic arrival, the patient was awake, alert, and reportedly oriented x 3. Patient has obvious deformity to his left lower leg and right shoulder. He has a laceration to his right flank. He complains of right flank and low back pain, left leg pain, right shoulder pain, and some facial abrasions. He does report loss of consciousness. He has some headache. He denies nausea or vomiting. He denies severe neck pain. He has numbness in his left foot, but denies other focal weakness or numbness. Last tetanus is unknown.

Pt at Methodist mentions he was on cross country bike ride helmeted and was hit by car. No other recollections of event. +LOC. Taken to Clarian Arnett where images obtained showed multiple BLE fx's. HDS throughout GCS 15. C-collar cleared. Transferred to Methodist ED as Trauma 1 that was not called. Trauma resident seeing as consult.

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HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old male who is 5'9", 155 lb who was riding his bike around the road this morning approximately between 6 and 7 a.m. when he was struck by a car. He had a positive loss of consciousness. He states that he does not remember anything until the point in time when he woke up and had pain in his lower extremities bilaterally. He says that the pain is worse in his left leg, right leg, his right shoulder, right hip and left shoulder. Currently it is under control but at its worst it was 10/10. Also it is relieved by medications and he had decreased sensation on the lateral aspect and dorsum of his left foot.

ALLERGIES: IODINE.


PAST SURGICAL HISTORY: Left hand surgery, nasal surgery and abdominal surgery as an infant. The accident occurred between approximately 0600 and 0700. He last ate approximately 0500. He was taken to Clarian Arnett and transferred by ground to Methodist Hospital. He is right-hand dominant.

SOCIAL HISTORY: The patient is single. Drinks occasional ethyl alcohol. Denies tobacco or illicits and is a Ph.D. student.

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CT OF THE CERVICAL SPINE.
 IMPRESSION: Negative.


CT OF THE CHEST, ABDOMEN AND PELVIS.
IMPRESSION:
1. Fractures of the left scapula, right humeral head, right posterior 4th and 5th ribs, right anterior acetabulum, right superior pubic rami and right inferior pubic rami.
2. Subcutaneous and intramuscular air in the right lateralis muscle.
3. Probable right lung contusions.


CT1024
STUDY: CT the head, neck, chest, abdomen and pelvis without contrast.
10/18/2010.


HISTORY: Struck by car riding bike.


CT BRAIN.


FINDINGS: Multiple computed axial tomographic images through the brain without intravenous contrast was obtained. The ventricles and sulci are within normal limits. The brain parenchyma has a normal appearance. There is no evidence of intracranial hemorrhage, mass effect, or acute major vessel infarct. The cranium is intact.


XR SHOULDER: IMPRESSION: Comminuted fracture of the right shoulder


XR ANKLE: IMPRESSION:
1. Comminuted fracture of the distal fibula with disruption of the ankle mortise.
2. Fracture of the distal fibula.

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GENERAL: The patient denies fatigue, weakness, fevers or chills.

HEENT: No blurry vision, double vision, otorrhea, earaches, rhinorrhea or epistaxis, bleeding gums ________ swelling.

RESPIRATORY: No shortness of breath, wheezing or asthma.

CARDIAC: No chest pain, orthopnea, paroxysmal nocturnal dyspnea, peripheral edema.

GASTROINTESTINAL: No nausea, vomiting or diarrhea. No hematemesis, hematochezia or melena.

GENITOURINARY: Denies dysuria, hematuria, nocturia, polyuria, frequency or urgency.

PSYCH: Denies any depression or anxiety.

HEMATOLOGIC: Denies any bleeding, bruising or history of coagulating disorders.

ENDOCRINE: Denies diabetes or thyroid disorder.

RADIOGRAPHIC DATA: X-rays were reviewed. Right upper extremity demonstrates a four-part proximal humerus fracture, shortened angulated into varus, right lower extremity demonstrates a minimally displaced pilon fracture. The joint surface is widened. The talus is centered under the plafond. Left lower extremity demonstrates a middle distal third junction tibial shaft and fibular fracture, comminuted, displaced and laterally in flexion and externally rotated. CT scan of chest, abdomen and pelvis was reviewed which shows a left scapular body fracture as well as a right superior and inferior pubic rami fractures, a right pubic root fracture and right fourth and fifth rib fractures.

PHYSICAL EXAMINATION:

GENERAL APPEARANCE: The patient is alert and oriented times three. He is in no apparent distress.

HEENT: His head is traumatic. He has a laceration to the bridge of his nose. Pupils are equally round and reactive to light. Narest patent. Buccal mucosa is moist. Extraocular muscles are intact.

NECK: Supple, no jugular venous distention.

RESPIRATORY: No wheezes, no respiratory diseases. Clear to auscultation bilaterally.

CARDIAC: Regular rate and rhythm.

ABDOMEN: Soft, nontender.

PELVIS: Stable to AP and lateral compression.

SPINE: Cervical spine is nontender to cervical palpation.

EXTREMITIES: Left upper extremity the patient has full range of motion of the shoulder, elbow and wrist. Motor is intact to his auxiliary, musculocutaneous and ulnar nerve distribution. Sensation intact to his axillary, musculocutaneous, radial ulnar and median nerve distribution. Pulses 2/4 in his radial artery. Right upper extremity is tenderness to palpation in his shoulder. 3-cm transverse laceration along his deltoid, superficial in nature. He has superficial abrasions on his neck, across his trapezius on the right side. As well as motor is intact to his axillary and ulnar and PI nerve distributions. Sensation is intact to his axial, musculocutaneous, radial, ulnar and median nerve distribution. Pulses are 2/4 in his radial artery. Right lower extremity pulses 2/4 in his dorsalis pedis and posterior tibialis arteries. He has superficial abrasions over his lateral malleolus. Motor is intact to toe movements. Sensation is intact L3 through S1. He has a 5-cm oblique laceration along the course of his iliac crest. No fracture fragments were palpated with the sterile Q-tip or stepoff. Left lower extremity is +2/4 dorsalis pedis and posterior tibialis arteries. His motor is intact to toe movement and he has a superficial abrasion over his VMO. He has lacerations over his first metatarsophalangeal joint and distal first phalanx with the nail being avulsed from his first toe. He has positive motor to toe movement and he has decreased sensation in the distributions of his deep peroneal, superficial peroneal nerves. Sensation is intact to tibial, saphenous and sural nerve distributions.

LABORATORY DATA: White blood cell count 13.2, hemoglobin 13, hematocrit 13.3, platelets 255,000, sodium 137, potassium 2.8, chloride 101, CO2 31, BUN 21, creatinine 0.87.

IMPRESSION:

1. Right pilon fracture

2. Right four-part proximal humerus fracture.

3. Left tibial fibula fractures.

4. Right open iliac wing fracture.

5. Left scapular body fracture.

6. Right pubic root fracture.

7. Right superior and inferior pubic rami fractures.

8. Right fourth and fifth rib fractures.

PLAN: The patient will be placed in bilateral lower extremity splints, the left being a long-leg sugar-tong and the right a short-leg sugar tong. He has been given Ancef, gentamicin and tetanus shots. We will continue his pain control. Will take him to the operating room for an incision and drainage of this right hip, intramedullary nailing of the left tibia and external fixation of his right pilon. Will perform staged treatment and bring him back in the near future for open reduction and internal fixation of his right proximal humerus. This was discussed with Dr. Jelen who is in agreement.

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HISTORY OF PRESENT ILLNESS: This is a 26-year-old male patient who was struck by a motor vehicle while riding his bike earlier in the day near Lafayette, Indiana. He was brought by the squad to Arnett Hospital. Apparently, he was thrown from his bicycle and hit the windshield. Upon arrival to Arnett, he was awake and oriented x3. Apparently, he had some questionable loss of consciuosness there at the scene, but was alert and oriented in the emergency department. He was seen by the orthopedist there who felt he should be treated at a trauma center due to the complex nature of his injuries. He was accepted by the emergency department who asked us to see the patient once he arrived.

The patient was initially evaluated by Dr. C. Luke Wilcox from the Orthopedic Trauma Service who had completed his H P, which was available for my review. I also had the opportunity to evaluate the patient. He has splints on his bilateral lower extremities. They are neurovascularly intact. He has a moderate amount of welling about the right ankle. He has an abrasion about the medical aspect of his left knee. He has an open wound about his right iliac crest. He has an abrasion about his right shoulder. Examination of his radiographs reveals a four-part fracture of the right proximal humerus with a located right shoulder. He has a displaced fracture of the midshaft of the left tibia. He has an impacted comminuted fracture of the right tibial plafond.

IMPRESSION AND PLAN: I discussed treatment options with the patient. We will have him evaluated by the Trauma Team. I recommended that we perform debridement of his right iliac crest wound, which does not appear to associate with any fracture. He does have a nondisplaced parasymphysial fracture; but I see no posterior injury on the CT scan. I have recommended intramedullary nailing of his left tibia fracture, external fixation of his tibial pilon fracture, as it appears to be quite swollen at this time. He has fairly significant amount of swelling about his shoulder and will likely delay treatment there for a couple of days or when we do definitive fixation of his pilon. I have discussed this with him. He wishes to proceed with this plan. He has been given the appropriate antibiotics and tetanus vaccine in the emergency department. His compartments are soft and compressible. He has no evidence of compartment syndrome. We will proceed when he has been evaluated by the Trauma Service.

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OPERATIVE NOTE

Dictated by Bradley A. Jelen, D.O.             Juarez, Antonio L.

Dictated 10/19/2010    432503     3229857      73-411-234

Transcribed 10/21/2010 08:01 P      gin        MH   A4S 4094-P

cc:  Bradley A. Jelen, D.O.

DATE OF OPERATION: 10/18/2010

DATE OF BIRTH: 02/29/1984

PREOPERATIVE DIAGNOSES:

1. Open pelvic right iliac crest wound.

2. Right distal tibia/tibial plafond fracture.

3. Left tibial shaft fracture.

4. Left scapula fracture.

5. Right pelvis fracture.

PROCEDURE(S) PERFORMED:

1. Open treatment of left tibial shaft fracture with intramedullary nailing.

2. Application of uniplane external fixator, right lower extremity for a tibial plafond fracture.

3. D bridement of traumatic wound, right iliac crest, with d bridement of skin, subcutaneous tissue, muscle, fascia and bone.

SURGEON: Dr. Bradley A. Jelen

ASSISTANT: Dr. Michael T. Krosin, who assisted with patient positioning, prepping and draping, wound retraction, wound suction, placement of orthopedic hardware and wound closure.

ANESTHESIA: General.

ANESTHESIOLOGIST: Dr. Ryan C. Thomas

ANTIBIOTICS: Kefzol 2 gm IV.

ESTIMATED BLOOD LOSS: 200 cc.

COMPLICATIONS: None.

CONDITION TO THE RECOVERY ROOM: Stable.

INDICATIONS FOR PROCEDURE: This can be found within the patient's chart. However, in summary, the patient is a 26-year-old-male who was involved in a bicycle versus motor vehicle accident near Lafayette, Indiana. There was some questionable loss of consciousness. He was seen at Clarian Arnett, there evaluated by the Emergency Department staff. The orthopedist there felt that the injuries were too difficult to take care of at Clarian Arnett, and thus he was transferred to Methodist Hospital. The patient was evaluated by the Trauma Team as well as by myself. He was noted to have multiple musculoskeletal injuries, including a right tibial plafond fracture, a left mid shaft tibia fracture, a left minimally displaced scapula fracture, an open wound about his right iliac crest.

I had the opportunity to examine the patient, review his radiographs and discuss treatment options with him. Given that he has a fairly significant amount of swelling about his shoulder, will delay treatment of that until later in the week, as well as his tibial plafond fracture. I recommend today that we perform d bridement of his open wound, reduce and perform intramedullary nailing of his left tibial shaft fracture, and spanning external fixation of his right tibial plafond. The treatment goals, plan, risks, benefits, complications and alternative treatments were reviewed with the patient. and after this discussion he wished to proceed. Informed consent was obtained.

DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite, placed on the operating table in the supine position, induced under general anesthesia. After an adequate means of general anesthesia, the patient was secured to the operating table, where all bony neurovascular structures were appropriately padded. His left and right lower extremities were then prepped and draped in a standard orthopedic fashion. He received an additional dose of IV antibiotic in the operative suite.

We proceeded first with intramedullary nailing of the left tibia. The procedure was begun by performing close reduction of the tibia fracture, which aligned well with traction and appropriate manipulation. We utilized a suprapatellar portal for placement of the intramedullary nail, this was done through approximately a 3-cm incision at the superior pole of the patella. The quadriceps tendon was identified, split in its mid substance, and then blunt dissection was utilized to develop the interval between the patella and the trochlea. The Smith Nephew protection sleeve was then placed through this interval down to the proximal tibia, where utilizing orthogonal imaging intensifier views, the desired starting point for the intramedullary nail was identified. The initial guidewire was then placed down the proximal tibia. With the protection sleeve in place, and once we were satisfied with placement of the initial guidewire, the 12-mm rigid reamer was utilized to open the intramedullary canal.

I then utilized a Charnley reamer to open the canal distally. A ball-tipped guidewire was utilized under fluoroscopic guidance to cross the fracture site, and this was held reduced down to the physeal scar. With the protection sleeve again in place, the guidewire traversing the fracture site, and the fracture held reduced, a gentle intramedullary reaming beginning with 8.5 mm, increasing in 0.5-mm increments up to 10 mm was performed. An 8.5-mm  nail, 360 cm in length was then selected. This was then inserted over the ball-tipped guidewire, down to the physeal scar. The guidewire was then removed. I was satisfied with the radiographic and clinical appearance of the leg. Two distal interlocking screws were utilized distally. The nail was then back-slapped, compressing the fracture. There was a slight amount of translation on the lateral view, but otherwise well aligned. A single proximal dynamic screw was then placed utilizing the aiming arm on the insertion handle. The insertion handle was removed. All the wounds were thoroughly irrigated. The quadriceps tendon was closed with 0-Vicryl suture. The remainder of the wounds were closed with a combination of 0-Vicryl and 2-0 Vicryl suture and skin staples.

Our attention was then next drawn to the right ankle. A transcalcaneal pin was then placed under fluoroscopic guidance, and 2 medial-placed tibial pins were applied. A Delta frame was then constructed. Traction and slight valgus force were applied. Bars and pins were tightened, clamps were tightened, and I was satisfied that the fracture was brought out to length in an appropriate alignment on both the AP and lateral image intensifier views. Sterile dressings were placed around each of the pin sites.

Our attention was next drawn to the iliac crest. This area was then separately prepped and draped. There was a significant amount of abrasion, and this was scrubbed with a sterile scrub brush. Sharp excisional d bridement of the wound including skin, subcutaneous tissue, muscle and fascia, was undertaken. There was a portion of the iliac crest that was denuded of some soft tissue, and this was thoroughly curettaged, followed by pulsatile lavage until all devitalized and foreign tissue was removed. Once this was confirmed, the wound was again thoroughly irrigated with pulsatile lavage, closed over a Hemovac drain that had been placed deep into the wound. The wound was closed with multiple 3-0 Ethilon sutures in a vertical mattress-type fashion.

Sterile dressings were then applied to all wounds. The patient's general anesthesia was reversed, and he was transported to the Post Anesthesia Care Unit in stable condition.

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OPERATIVE REPORT     20-Oct-10   11:59 PM CASE#: OP101020-3236517

NEW DOCUMENT: OPERATIVE NOTE

Dictated by Bradley A. Jelen, D.O.         Juarez, Antonio L.

Dictated 10/27/2010   439870   3236517         73-411-234

Transcribed 10/28/2010 07:19 P  429          MH   A4S 4094-P

cc: Bradley A. Jelen, D.O.

DATE OF OPERATION: 10/20/2010

DATE OF BIRTH: 02/29/1984

PREOPERATIVE DIAGNOSIS: Four-part fracture right proximal humerus.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURES PERFORMED: Open treatment of right proximal humerus fracture with internal fixation.

SURGEON: Dr. Bradley Jelen.

FIRST ASSISTANT: Dr. Jason Wild, who assisted in patient positioning, prepping and draping, wound retraction, wound suction, traction on the extremity, obtaining and maintaining reduction, placement of orthopedic hardware, and wound closure.

SECOND ASSISTANTS:

1.  Dr. Luke Wilcox, visiting orthopedic resident.

2.  Matthew Yentes, CST/CFA.

ANESTHESIA: General, per Dr. Stark.

ESTIMATED BLOOD LOSS: 300 mL.

ANTIBIOTICS: Kefzol 2 gm IV.

COMPLICATIONS: None.

CONDITION TO RECOVERY ROOM: Stable.

SURGICAL FINDINGS: Comminuted fracture right proximal humerus.

INDICATIONS FOR PROCEDURE: These can be found within the patient's chart. However, in summary, this is a 26-year-old-male patient who was involved in a bicycle versus motor vehicle accident in which he sustained multiple fractures including left tibial shaft fracture, right tibial plafond fracture, left scapular fracture, and pelvic ring fracture, as well as this proximal humerus fracture. He has previously undergone intramedullary nailing of his tibia, debridement and closure of the wound about his right iliac crest, and spanning external fixation of his right lower extremity. The planned operation today was to perform definitive fixation of his right proximal humerus and his right tibial plafond fracture. However, when he was examined preoperatively, he was noted still to have fairly significant swelling to the right lower extremity with some fracture blisters. At that point, I recommended to proceed with operative fixation of his proximal humerus fracture and definitively delay definitive fixation of his pilon fracture until the soft tissues were amenable. I discussed treatment options with the patient, as well as the risks, benefits, alternative treatments, and potential complications including but not limited to, nerve and vessel injury, nonunion, malunion, and potential need for further surgery. After the discussion, he wished to proceed. and informed consent was obtained.

DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite, placed on the operating room table in the supine position, and induced under general anesthesia. After adequate means of general anesthesia, the patient was secured to the operating table, where all bony and neurovascular structures were padded. A soft roll was placed under the right scapula and his right upper extremity was then prepped and draped in the standard orthopedic fashion. He received prophylactic antibiotics.

The procedure was begun. Following prepping and draping, I utilized the deltopectoral approach to the right proximal humerus. This was performed with an incision of approximately 15 cm in length, beginning just superior and lateral to the coracoid, extending in an anterolateral direction over the anterior arm. This was taken through the subcutaneous tissue with a combination of sharp and blunt dissection utilizing electrocautery for hemostasis. The cephalic vein was identified. This interval was then bluntly developed, developing the deltopectoral interval. The upper one-third of the pectoralis major was then elevated off the proximal humerus. The subdeltoid and subacromial spaces were bluntly developed, mobilizing the proximal humerus.

Utilizing traction and positioning, the fragments then were identified. A suture __________ the greater tuberosity, as well as the lesser tuberosity placement to gain control of these. Utilizing a combination of direct manipulation and positioning of the extremity, the fracture was reduced and help temporarily with multiple K-wires. The image intensifier was brought in. I was satisfied with the alignment of the fracture and reduction with the temporary K-wires. We then applied a Smith Nephew proximal humerus locking plate with multiple lock screws in the humeral head and nonlocked screws in the shaft. I was satisfied with the position. All of the K-wires were removed. The sutures between the lesser and greater tuberosities were tied underneath the plate. The shoulder was placed through a range of motion. The fracture was noted to be quite stable. Utilizing the image intensifier with live fluoroscopy, we were able to identify that none of the screws penetrated the humeral head.

The wound was then thoroughly irrigated and closed with a combination of 0 and 2-0 Vicryl suture and skin staples. Sterile dressings were applied and the patient's general anesthesia was reversed. He was transported to the post anesthesia care unit in stable condition.

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OPERATIVE REPORT     27-Oct-10   11:59 PM CASE#: OP101027-3236236

NEW DOCUMENT: OPERATIVE NOTE

Dictated by Bradley A. Jelen, D.O.         Juarez, Antonio L.

Dictated 10/27/2010   439863   3236236         73-411-234

Transcribed 10/28/2010 03:35 P  s18          MH   A4S 4094-P

cc: Bradley A. Jelen, D.O.

DATE OF OPERATION: 10/27/2010

DATE OF BIRTH: 02/29/1984

PREOPERATIVE DIAGNOSIS: Fracture weight bearing surface right distal tibia with fibula fracture.

POSTOPERATIVE DIAGNOSIS: Same.

PROCEDURES PERFORMED:
1. Open treatment of weight bearing surface of right distal tibia with fixation of tibia and fibula utilizing external fixation.
2. Removal of external fixator right lower extremity.

SURGEON: Dr. Bradley Jelen.

FIRST ASSISTANT: Dr. Michael Krosin who assisted in patient positioning, prepping and draping, wound retraction, wound suction, traction on the extremity to obtain and maintain reduction, placement of orthopedic hardware, and wound closure.

SECOND ASSISTANTS: Dr. Jason Wild, Dr. C. Luke Wilcox

ANESTHESIA: General, Dr. Taylor.

ANTIBIOTICS: Kefzol 2 gm IV.

BLOOD LOSS: 100 mL.

TOURNIQUET: 250 mmHg for 90 minutes.


COMPLICATIONS: None.

CONDITION TO RECOVERY ROOM: Stable.

INDICATIONS FOR PROCEDURE: These can be found within the patient's chart. However, in summary, the patient is a 26-year-old-male patient who was involved in a bicycle versus motor vehicle accident back on 10/18. He sustained multiple injuries including pelvic ring fracture, left scapular fracture, right proximal humerus fracture, left tibial shaft fracture, as well as distal tibial plafond fracture. The scapula and the pelvic ring we have elected to treat non-operatively. He has undergone operative fixation of his left tibial shaft fracture with intramedullary nailing as well as operative fixation of his right proximal humerus fracture with internal fixation. In addition, he had a traumatic wound about his right iliac crest, which was debrided and closed. He also had a spanning external fixator applied to the right lower extremity. He returns to the operative suite today for definitive fixation of his right tibial plafond fracture. I have discussed specific risks, benefits, complications, and alternative treatments. He has been examined preoperatively. He has positive wrinkle signs. Swelling is dramatically decreased from where it was previously, and the soft tissues are amenable to operative treatment. He wishes to proceed. Informed consent was obtained.

DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite, placed on the operating room table, in supine position, and induced under general anesthesia. After adequate maintenance of general anesthesia, the patient was secured to the operating room table where all bony and neurovascular structures were appropriately padded. His right lower extremity was then prepped and draped in standard orthopedic fashion after the external fixator had been removed except for the calcaneal pin, which was used for traction during this case.

Pneumatic tourniquet was utilized. The lower extremity was exsanguinated. The pneumatic tourniquet was insufflated to 250 mmHg. The procedure was begun by first exposing the lateral aspect of the distal fibula as well as the tibia with approximately a 12 cm incision along the lateral fibula, then extending toward the 4th ray. This was taken through the subcutaneous tissues with a combination of sharp and blunt dissection utilizing electrocautery for hemostasis.


The distal tibial fracture was easily identified. The extensor retinaculum was elevated off the lateral aspect of the distal fibula, and this allowed us to mobilize the extensor tendon from the neurovascular bundle anteriorly. This allowed direct exposure of the anterolateral fragment. This was booked open. We were able to identify the intercalary articular fragments. These were removed and cleaned.


Once the hematoma had been suctioned from the fracture on the anterolateral fragment, I then made an approximately 5-6 cm incision over the medial malleolus extending slightly proximally. This was taken through the subcutaneous tissue with a combination of sharp and blunt dissection utilizing electrocautery for hemostasis. The large medial malleolar fragment was identified. The was some comminution here, which was removed. This fracture was _____________________ with two 0.062 K-wires. Reduction was confirmed both through visual inspection as well as with the image intensifier.


There, moving back to the anterolateral aspect and wound, this fragment was booked open. The interarticular fragments were then replaced, held with K-wires, and then the large anterolateral fragment was then reduced to the medial aspect of the distal tibia with a reduction clamp, which was compressed and then held temporarily with K-wires.


The image intensifier was brought in. The fracture was noted to be essentially anatomically reduced. I then placed the Smith-Nephew anterior BLP plate utilizing two non-locked screws in the distal tibial diaphysis. Three lag screws in anterior to posterior fashion were then placed through this plate stabilizing this large fragment.


At this time, I also placed a medial BLP plate with two lag screws in the distal articular portion and two non-locked screws in the diaphysis.


Orthogonal image intensifier views revealed acceptable widening and reduction of the articular surface without hardware-related complication.


My attention was then turned to the distal fibula fracture, which was just a transverse fracture at the joint surface. The hematoma from this was cleaned out of the fracture. This was reduced and held with a reduction clamp, and a single 3/5 intramedullary screw was placed up the canal stabilizing this fracture.


All temporary K-wires were removed. Final image intensifier views including AP mortise and lateral view were obtained and revealed acceptable reduction of fracture and placement of all hardware. The wounds were thoroughly irrigated. The lateral wound of the extensor retinaculum was closed loosely with 0-Vicryl. 2-0 Vicryl and 3-0 Ethilon were then utilized on the subcutaneous tissues of the remainder of both the medial and lateral wounds. Sterile dressings were then applied. Postoperative splint was applied. The patient's general anesthesia was then reversed, and he was transported to the Post Anesthesia Care Unit, in stable condition.