OT notes · Orthopaedics

ORIF of radius and ulna shaft with plating

Usual anaesthesia
General anaesthesia or brachial plexus block (the book advises against a regional block in the first few days or when the forearm is very swollen, as it can mask compartment syndrome)
Position
Supine with the arm on a radiolucent arm table, tourniquet on the upper arm
Setting
emergency

Operative note template for open reduction and plate fixation of diaphyseal radius and ulna fractures, with a filled example for a closed both-bone forearm fracture in an adult fixed with 3.5 mm compression plates.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • compartment syndrome after surgery
  • injury to the posterior interosseous, anterior interosseous or superficial radial nerve
  • radial artery injury
  • wound infection
  • non-union or malunion with loss of forearm rotation
  • cross-union (radioulnar synostosis)
  • prominent or painful implant, later removal
  • refracture after implant removal
  • skin may have to be left open and closed later

Pre-operative details for this operation

  1. Side and fracture descriptionright / left, level (proximal / middle / distal third) of each bone, pattern (transverse, oblique, butterfly, comminuted), open or closed
  2. Associated joint injury ruled outDRUJ and radiocapitellar joint normal on X-rayGaleazzi patternMonteggia pattern
  3. Pre-op distal neurovascular statusradial and ulnar pulse, capillary refill, median / ulnar / radial nerve sensation and motor, AIN (thumb IP and index DIP flexion), PIN (finger and thumb extension)
  4. CompartmentsSoft, no pain on passive finger stretchTense: plan fasciotomyrecord even when normal
  5. X-raysAP and lateral forearm with wrist and elbow; X-ray of the normal side if comminuted (length and ulnar variance)
  6. Implants and C-arm available3.5 mm plates (LC-DCP / locking), mini-fragment screws, bone graft plan if any

Anaesthesia and position

  1. AnaesthesiaGeneralSupraclavicular / infraclavicular blockGeneral with blockif block, note swelling and compartment status first
  2. PositionSupine, arm on radiolucent arm table
  3. Tourniquetsite (upper arm), pressure in mmHg, inflation time, deflation time, total minutes
  4. C-armposition of machine, operator

Operative findings

  1. Radius fracture pattern at surgerylevel, transverse / oblique / butterfly / comminuted, bone loss
  2. Ulna fracture pattern at surgery
  3. Soft tissue and nerves seensuperficial radial nerve, PIN, radial artery: intact / injured
  4. DRUJ stability after fixationStable in neutral, supination and pronationUnstable: fixed with K-wires
  5. Forearm rotation after fixationfull pronation-supination, no plate impingement at DRUJ or proximal radioulnar joint

Procedure (steps)

  1. Order of fixationRadius firstUlna first (less comminuted bone first)
  2. Exsanguination and tourniquet inflationElevationLoose elastic wrapEsmarchpressure and time
  3. Approach to radiusVolar (Henry)Dorsal (Thompson)incision length; radial artery and superficial radial nerve protected; PIN protected in dorsal approach
  4. Muscles released from radiuspronator teres, FPL, pronator quadratus, supinator: which, and whether reattached
  5. Fracture ends cleaned and reducedhaematoma cleared, periosteum preserved, clamp used
  6. Lag screw / butterfly fixationNot needed2.0 / 2.4 / 2.7 mm lag screw outside plateLag screw through plate
  7. Radius plate3.5 mm LC-DCP compression3.5 mm locking compression plateNeutralisation plateBridge platenumber of holes, screws each side, cortices each side, locking or non-locking, contoured for radial bow
  8. Approach to ulnaalong subcutaneous border, between FCU and ECU; dorsal ulnar cutaneous branch protected in distal third
  9. Ulna platesurface (dorsal / volar / subcutaneous), type, holes, screws and cortices each side
  10. Bone graftNot usedIliac crest autograftAllograft / substitute
  11. C-arm checkAP and lateral of whole forearm, screw length, DRUJ and radiocapitellar joint; number of images saved
  12. DRUJ stress and rotation testelbow at 90 degrees, forearm in neutral, supination and pronation
  13. Tourniquet released and haemostasistime of release; bipolar used

Closure, drains and dressing

  1. Deep fasciaLeft open
  2. Subcutaneous tissueabsorbable suture, size
  3. SkinPrimary closure, nylon 3-0Left open for delayed primary closure
  4. DrainNoneSuction drain
  5. Dressing and splintSoft bulky dressing, slingLong arm posterior splint, fingers freeno tight circular bandage
  6. Distal neurovascular status at endpulses, capillary refill, finger movement, compartments soft

Specimens and implants

  1. Radius implantplate type, material (SS / titanium), holes, number and length of screws each side, make, lot/batch number, sticker pasted
  2. Ulna implantas above
  3. Other implantslag screws, K-wires across DRUJ, graft; size, number, lot/batch
  4. C-arm images savednumber of images, saved / printed

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevationon pillow above heart level
  2. Distal neurovascular and compartment watchpulse, capillary refill, finger movement, pain on passive finger stretch: hourly for the first 24 h
  3. Loosen dressingif pain increases out of proportion or fingers swell; inform surgeon at once
  4. Analgesiadrug, dose, frequency
  5. Finger, shoulder and elbow movementactive movement from day 1
  6. Check X-rayAP and lateral forearm
  7. Wound check and suture removaldressing check day 2 to 3; suture removal day as per unit
  8. Follow-up and physiotherapysupervised pronation-supination exercises

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. S.K., 32 years, right-hand dominant, fell from a two-wheeler. Closed displaced transverse fractures of the middle third of right radius and ulna. Operated on day 2.

Case details

Date: 14/05/2026. Emergency list. OT 3.

In OT 10:05. GA induced 10:15. Tourniquet inflated 10:32. Incision 10:34. Tourniquet released 11:48. Closure completed 12:05.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E. C-arm technician: Mr F.

Indication and pre-op

Closed displaced transverse fractures, middle third right radius and ulna. DRUJ and radiocapitellar joint normal on X-ray.

Pre-op: radial and ulnar pulses palpable, capillary refill under 2 s. Median, ulnar and radial nerve sensation normal. AIN intact (thumb IP and index DIP flex). PIN intact (fingers and thumb extend). Forearm swollen, compartments soft, no pain on passive finger stretch.

Consent: general, procedure-specific and anaesthesia consent taken in Marathi. Site marked. WHO checklist sign in and time out done.

Inj cefazolin 2 g IV at 10:18, before tourniquet inflation.

Anaesthesia and position

General anaesthesia (regional block not used because of swelling on day 2).

Supine, right arm on radiolucent arm table. Pneumatic tourniquet on right upper arm over padding. C-arm from the head end.

Parts painted with povidone-iodine and draped. Limb exsanguinated by elevation. Tourniquet inflated to 250 mmHg at 10:32.

Procedure

Radius fixed first. Volar Henry approach, 10 cm incision. Lateral antebrachial cutaneous nerve and superficial radial nerve protected. Radial artery mobilised medially.

Pronator teres insertion elevated subperiosteally. Fracture ends cleared of haematoma, periosteum kept on the fragments. Transverse fracture, no comminution.

Radius: 3.5 mm LC-DCP, 7 holes, stainless steel, contoured to keep the radial bow. Fixed in compression with 3 bicortical 3.5 mm cortical screws on each side (6 cortices each side). Hole over fracture left empty. Pronator teres sutured back.

Ulna: incision along the subcutaneous border, interval between FCU and ECU. Transverse fracture reduced with a pointed reduction clamp.

Ulna: 3.5 mm LC-DCP, 7 holes, stainless steel, on the dorsal surface. 3 bicortical screws on each side (6 cortices each side) in compression.

C-arm: AP and lateral of whole forearm. Fractures reduced, radial bow kept, screw lengths correct, DRUJ and radiocapitellar joint congruent. 4 images saved.

DRUJ stable with elbow at 90 degrees in neutral, supination and pronation. Full forearm rotation, no plate impingement.

Tourniquet released at 11:48 (total 76 minutes). Haemostasis with bipolar cautery.

Closure

Deep fascia left open over both wounds.

Subcutaneous tissue closed with interrupted polyglactin 910 (Vicryl) 3-0. Skin closed with interrupted nylon (Ethilon) 3-0. No drain.

Soft bulky dressing with loose cast padding. Arm sling.

At end: radial pulse palpable, capillary refill under 2 s, all fingers moving, compartments soft.

Specimens and implants

No specimen.

Radius: 3.5 mm LC-DCP 7-hole SS, 6 screws 3.5 mm cortical (14, 14, 16 mm proximal; 14, 14, 14 mm distal). Make and lot/batch no. as on sticker, sticker pasted in case sheet and implant register.

Ulna: 3.5 mm LC-DCP 7-hole SS, 6 screws 3.5 mm cortical (16 mm x 3 proximal; 14 mm x 3 distal). Sticker pasted.

C-arm: 4 images saved to the machine and printed for the file.

End of procedure

Estimated blood loss 100 ml. No transfusion.

Mop, needle and instrument count correct.

No intra-operative complications.

Patient shifted to recovery in stable condition. Pulse 84/min, BP 124/78 mmHg.

Post-op orders

Limb elevated on pillow. Check radial pulse, capillary refill, finger movement and pain on passive finger stretch hourly for 24 h. Inform on-call resident if pain increases.

Analgesia as per the anaesthesia chart.

Active finger, elbow and shoulder movement from today.

Check X-ray AP and lateral right forearm tomorrow. Dressing check on POD 2. Suture removal at first follow-up.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 14/05/2026, 12:20.

Must document for this operation

  • Distal neurovascular status, including anterior interosseous nerve (AIN) and posterior interosseous nerve (PIN), before and after surgery. A nerve palsy found after surgery cannot be called iatrogenic or pre-existing unless the pre-op state is written down.
  • Compartment status before and at the end of surgery. Compartment syndrome is a known complication of forearm fixation and a common medicolegal claim; a documented normal check shows it was looked for.
  • Implant details for each bone: plate type, holes, screws and cortices on each side, make, lot/batch number, sticker. Needed for implant recall, for the surgeon who removes the plate later, and for the implant register.
  • Tourniquet pressure, inflation and release times. Tourniquet palsy and ischaemia are judged against the recorded pressure and duration.
  • Whether the fascia was left open and whether skin was closed or left for delayed closure. The ward team needs to know the plan for the wound and the risk of compartment syndrome.
  • DRUJ stability and forearm rotation checked after fixation, and C-arm images saved. A missed Galeazzi or Monteggia injury or plate impingement is found only if the check is recorded, and saved images show the reduction at the time of surgery.

Common mistakes in these notes

  • Writing 'distal neurovascular status intact' without naming the pulses and the nerves checked.
  • Writing 'plating done' with no plate length, number of screws or cortices on each side.
  • No tourniquet time or pressure.
  • Not recording the order of fixation or the approach used for each bone.
  • Leaving out the implant sticker or lot number.

Indian practice and paperwork

  • Record the batch and serial number of every implant in the case sheet; NABH also asks for it in the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))

Sources

  • Campbell's Core Orthopaedic Procedures. Elsevier; 2024, Technique 31, Open reduction and internal fixation of both-bone forearm fractures (Cosgrove CT), pp. 149-151.
  • Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 2, Open reduction and internal fixation of diaphyseal forearm fractures (Reichel LM, Dawson JR), pp. e-book markers P.10-P.20.
  • Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 62, Fractures of the shafts of the radius and ulna; Ch 2, Tourniquets, pp. 2819-2821; 137-138.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision; cefazolin recommended for implantation of internal fixation devices. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, pp. 137-138: tourniquet time kept to 2 hours or less in healthy adults under 50; pressure 50-75 mmHg above limb occlusion pressure, 135-255 mmHg found satisfactory for the upper limb.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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