Sample Operative Report printable pdf download

Sample Operative Reports for Common Orthopedic Procedures

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PATIENT NAME:

MEDICAL RECORD NUMBER:

DATE OF PROCEDURE:

SURGEON:

FIRST ASSISTANT:

SERVICE: Orthopedic Surgery

ANESTHESIOLOGIST:

ANESTHESIA: General

PREOPERATIVE DIAGNOSIS: Closed left femur fracture.

POSTOPERATIVE DIAGNOSIS: Closed left femur fracture.

OPERATION: Intramedullary nail fixation of left femur fracture.

ESTIMATED BLOOD LOSS:

BLOOD REPLACED:

DRAINS:

COMPLICATIONS:

INDICATION FOR SURGERY: This 22-year-old female sustained a closed left

femoral shaft fracture as a result of a motor vehicle crash last night. Surgery is indicated

in order to restore length and alignment to the limb and to facilitate functional rehabili-

tation. We discussed the operative and non-operative treatment options as well as the

relative risks and benefits of each with the patient. On our recommendation, she has

agreed to proceed with surgical treatment. All questions were answered.

PROCEDURE: The patient was brought to the operating room and placed on the

operating room table in the supine position where general anesthesia was induced and

an oral endotracheal tube was passed. She was then turned to the right lateral decubitus

position where bony prominences were well padded. The left lower extremity was then

prepared and draped sterilely. We used fluoroscopy for assistance throughout the case.

We passed a guide wire percutaneously through the skin proximally into the piriformis

fossa. Position of the guide wire was then confirmed using biplanar fluoroscopy. An

incision was made around the guide wire, and the soft tissues were spread. A 9-mm

drill bit was then passed over the guide wire and used to enlarge the opening into the

proximal femoral intramedullary canal. We passed the fracture reduction tool and a

guide wire into the proximal femoral intramedullary canal and then, using biplanar

fluoroscopy, reduced the fracture and passed the guide wire across the fracture site

into the distal fragment. We prepared the femur for nailing by reaming. We started

with a 9-mm endcutting reamer and progressed in 0.5-mm increments to 11.5 mm.

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Sample Operative Report