History: Three days ago this 23-year-old woman fell off the third step of a ladder and landed on her right wrist. Since then she has had pain and swelling in the wrist.

Exam: She is alert and oriented with stable vital signs. Her right wrist is diffusely swollen with dorsal tenderness. Motor and sensory exams are intact along the radial, ulnar, and median nerve distributions. X-ray reveals a nondisplaced fracture of the distal radius.

Treatment: The patient was placed in a dorsal plaster splint. X-ray of the radius through the splint showed maintenance of excellent anatomic alignment. It was explained to the patient that she will need to remain in her splint for approximately 3-4 weeks in order to stabilize her fracture as it heals. She was given Anaprox for pain and told to elevate her arm above her heart to reduce pain and swelling. She will return for follow up in one week.

Preoperative Diagnosis: Displaced olecranon process fracture left elbow

Postoperative Diagnosis: Same

Procedure: ORIF with tension band, left elbow

Indications for Surgery: The patient is a 14-year-old boy who was struck on the elbow by another player’s stick while playing lacrosse. X-ray of his left elbow revealed a displaced olecranon fracture. He presents to the ambulatory surgery unit today for the above definitive procedure.

Description: The patient was brought to the OR, anesthetized and intubated. The right upper extremity was prepped with Betadine scrub and draped free in the usual sterile orthopedic manner. The arm was then elevated and exsanguinated and the tourniquet inflated to 250 mm./Hg.

A 5 inch incision was made with the scalpel on the extensor side of the elbow beginning distally and proceeding in an oblique fashion up the proximal forearm. Dissection was carried down through subcutaneous tissue and fascia and bleeding was controlled with electrocautery. We then subperiosteally exposed the proximal ulna and olecranon to visualize the fracture site. The fracture could be seen at the base of the olecranon process. We irrigated the site thoroughly and reduced the fracture fragments without difficulty.

Extending the elbow we inserted two smooth K-wires across the fracture site. Next through a drill hole in the proximal ulnar shaft we threaded an 18 gauge wire through it and wrapped it around the K-wires in a figure-of-eight manner to further stabilize the fixation. Wires were then twisted and placed into soft tissues. The K-wires in the olecranon were advanced slightly after being bent and cut. Bleeding was controlled with electrocautery.

The tourniquet was deflated and the wound was closed with 2-0 interrupted sutures. Sterile dressings applied to the operative site. The patient was extubated and taken to the Recovery Room having tolerated the procedure well.

History: The patient is a 19-year-old college student who sustained an open, comminuted fracture of the right proximal tibia with a proximal fibular diaphyseal fracture when he was struck by a car while crossing the street. He is admitted emergently for fracture debridement and stabilization. He understands the need for debridement to minimize infection, however he and his family prefer that he return home for restorative care. It was my recommendation to wait approximately ten days post-operatively until the wound and soft tissues had healed completely with no infectious process and then discuss definitive fracture treatment.

Procedure: The patient was brought to the OR and placed on the table in the supine position. A spinal anesthetic was administered. After adequate anesthesia had been achieved, a well-padded tourniquet was placed in the right groin and inflated. The patient’s right lower extremity was prepped and draped in the usual sterile manner. Examination of the right leg revealed a deep puncture wound on the medial aspect where the distal tibial spike poked through the skin. The leg was neurovascularly intact and had no signs of compartment syndrome. The puncture wound was extended approximately one cm above and below. The skin incision was deepened with the dissecting scissors. The distal tibial spike was immediately encountered and exposed. The skin edges, fascia and muscle were debrided sharply with a #15 blade. The spike of tibial bone was then sharply debrided followed by extensive irrigation and pulse lavage. Following this aerobic and anaerobic wound cultures were obtained. Then the surgically extended wound was closed with 3-0 nylon in a simple fashion leaving the puncture wound open. Sterile bandage was applied. The tourniquet was deflated and the fracture fragments manipulated. Following reduction a well-padded long leg fiberglass cast was applied with the knee in flexed position. Post-casting radiographs revealed no angulation in the lateral projection. AP radiographs revealed fracture lines extending proximally with a nondisplaced butterfly fragment. The fracture site itself was gapped and there was 50% apposition of the fibula with over 90% apposition of the tibial fracture. The patient was placed on the stretcher and taken to the recovery room in stable condition.