OT notes · Orthopaedics

ORIF of metacarpal and phalangeal fractures

Usual anaesthesia
Regional anaesthesia (brachial plexus block or local nerve blocks) with sedation; general if needed
Position
Supine, arm on a hand table, upper arm tourniquet
Setting
urgent

Operative note template for fixation of metacarpal and phalangeal fractures (percutaneous K-wires, intramedullary wires, lag screws or plates), with a filled example for dorsal compression plating of a displaced transverse ring finger metacarpal shaft fracture with rotational deformity.

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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

  • stiffness of the finger joints
  • extensor tendon adhesions needing therapy or release
  • malrotation (finger overlap) or malunion
  • non-union or loss of fixation
  • pin-site infection (K-wires)
  • injury to dorsal sensory nerve branches (numbness)
  • prominent plate or wires needing removal
  • cold intolerance

Pre-operative details for this operation

  1. Fracturebone (metacarpal / proximal / middle phalanx), digit, side, level (base, shaft, neck, head), pattern (transverse, short oblique, long oblique / spiral, comminuted, intra-articular), open or closed
  2. IndicationRotational deformityAngulation beyond accepted limitShortening more than 5 mmMultiple metacarpal fracturesIrreducible / unstableOpen fracturewrite the measured angle and the digit
  3. Clinical rotation checkdigits in flexion point to the scaphoid tubercle; scissoring present / absent
  4. Skin and woundsdorsal wounds, swelling; tetanus status if open
  5. X-raysPA, oblique and lateral
  6. Hand dominance and occupation
  7. Implants availableK-wires 0.9 to 1.6 mm, hand set with 1.5 to 2.4 mm screws and plates, mini C-arm

Anaesthesia and position

  1. AnaesthesiaBrachial plexus blockLocal nerve block with sedationGeneral
  2. PositionSupine, arm on hand table
  3. TourniquetUpper armForearm (sterile)pressure, inflation and deflation times
  4. Image intensifierMini C-armStandard C-arm

Operative findings

  1. Fracture pattern at surgeryas expected / extra fragment / comminution; soft tissue interposed
  2. Extensor tendons and juncturaeintact / injured; juncturae divided
  3. Sensory nerve branchesdorsal branch of ulnar nerve, superficial radial nerve branches seen and protected
  4. Rotation and alignment after fixationtenodesis test / forearm squeeze: digits converge on scaphoid tubercle, no scissoring

Procedure (steps)

  1. TechniqueClosed reduction + percutaneous K-wiresIntramedullary wires / deviceOpen reduction + lag screwsOpen reduction + plate
  2. IncisionDorsal longitudinal over the metacarpal (not over the tendon)Between two metacarpals (adjacent fractures)Midaxial (phalanx)Small incision at metacarpal base (IM wire)length
  3. Exposuresensory nerves protected; extensor tendon retracted, paratenon kept; periosteum and interosseous fascia raised as one layer; lateral band retracted or partly excised (phalanx)
  4. Reductionhaematoma cleared; traction, Jahss manoeuvre, reduction clamp; rotation checked before fixing
  5. Provisional fixationK-wire or clamp
  6. Definitive fixationK-wires: number, size, direction (longitudinal / transverse), bent and capped; lag screws: number and size, at least two, two screw-diameters from the edge; plate: type, holes, screw size, compression technique, plate slightly over-bent
  7. Rotation and alignment check after fixationtenodesis or forearm squeeze; image in PA, oblique, lateral
  8. Extensor gliding checkedpassive finger flexion and extension; no tendon catching on implant

Closure, drains and dressing

  1. Periosteum / interosseous fascia over the plateRepairedNot possible
  2. Juncturae tendinumRepairedNot repairedNot divided
  3. Tourniquet released and haemostasistotal tourniquet time
  4. Skinlayered closure; suture used
  5. SplintVolar splint, wrist and MCP joints (intrinsic plus)Forearm-based intrinsic-plus splint with neighbouring digitpin sites padded

Specimens and implants

  1. Platesystem (1.5 / 2.0 / 2.4 mm), shape, holes, make, batch/lot, sticker pasted
  2. Screwsnumber, diameter, lengths, lag / neutral / locking
  3. K-wires / IM devicenumber, diameter, left out of skin or buried
  4. SpecimensNone

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. Elevationhand above heart level; finger circulation checks
  2. Analgesiadrug, dose, frequency
  3. Pin-site careif wires out of skin: dressing plan, watch for infection
  4. Early motionrigid fixation: active motion of all finger joints within 1 week; K-wires: uninvolved digits from review at 7 to 10 days; avoid immobilisation beyond 4 weeks
  5. Splintremovable orthosis with MCP flexion and IP extension between exercises; buddy strapping if needed
  6. Check X-raysPA, oblique and lateral
  7. Follow-upwound check and suture removal at the review visit; K-wire removal at about 4 weeks when fracture non-tender; splint weaning and strengthening once healing is seen, around 6 weeks

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. N.D., 26 years, right-handed electrician, punched a wall 2 days ago. X-ray: displaced transverse fracture of the right ring finger metacarpal shaft with apex-dorsal angulation of 25 degrees. On flexion the ring finger overlaps the little finger.

Case details

Date: 15/09/2026. Urgent ORIF right ring finger metacarpal. Minor OT 2.

In OT 14:00. Tourniquet up 14:30. Tourniquet down 15:25. Out of OT 15:45.

Surgeon: Dr A. (3rd-year resident, orthopaedics), assisted and supervised by Dr B. (consultant). Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Indication: rotational deformity with scissoring of the ring finger over the little finger, and shaft angulation of 25 degrees (above the 20-degree limit for the ring finger).

Closed injury. Skin intact over the dorsum, moderate swelling. Finger sensation normal.

Consent: general, procedure-specific and anaesthesia consent in Marathi from patient. Stiffness, tendon adhesions, plate removal and nerve numbness explained.

Right hand marked. WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 14:15, before tourniquet inflation.

Anaesthesia and position

Right brachial plexus block by anaesthetist, with light sedation.

Supine, right arm on hand table. Upper arm tourniquet inflated to 250 mmHg after exsanguination. Parts painted with povidone-iodine and draped. Mini C-arm used.

Procedure

Dorsal longitudinal incision 4 cm over the ring metacarpal shaft, placed off the line of the extensor tendon.

Dorsal sensory branches of the ulnar nerve seen in the subcutaneous layer and protected. Extensor tendon to the ring finger retracted with its paratenon kept. Periosteum and interosseous fascia raised as one layer.

Findings: transverse shaft fracture with a small dorsal comminuted fragment. No soft tissue interposed. Extensor tendon intact.

Fracture ends cleared of haematoma. Reduced with a reduction clamp. Rotation checked with the fingers in a composite fist before fixation.

4-hole 2.0 mm compression plate bent slightly more than the dorsal curve of the metacarpal. First screw next to the fracture placed eccentrically, second screw across the fracture drilled in the far part of the hole to compress. Remaining two screws neutral. All four 2.0 mm bicortical screws.

Tenodesis test: fingers extend with wrist flexion and flex towards the scaphoid tubercle with wrist extension. No scissoring. Mini C-arm PA, oblique and lateral: fracture reduced, no volar gap, screw lengths correct.

Passive finger flexion and extension: extensor tendon glides freely over the plate.

Closure

Periosteum and interosseous fascia closed over the plate with absorbable suture. Juncturae not divided.

Tourniquet released at 15:25, total 55 min. Haemostasis secured. Skin closed in layers with interrupted sutures.

Well-padded volar splint holding the wrist and MCP joints in the intrinsic-plus position, IP joints free. Fingers pink, capillary refill normal.

Specimens and implants

4-hole 2.0 mm straight compression plate with four 2.0 mm cortical screws. Make, batch and lot recorded; stickers pasted.

No specimen.

End of procedure

Estimated blood loss under 20 ml. No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to recovery in stable condition. Pulse 78/min, BP 122/76 mmHg.

Post-op orders

Right hand elevated above heart level. Finger colour and capillary refill checked by nursing staff; inform on-call resident if a finger is pale, blue or numb.

Active IP joint movements from POD 1 in the splint. Hand therapy review within 1 week for active motion of all finger joints and a removable orthosis.

Check X-ray right hand PA, oblique and lateral before discharge.

Wound check and suture removal at the review visit. X-ray at 6 weeks; splint weaning and strengthening once healing is seen. No heavy lifting till then.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 15/09/2026, 16:00. Seen by Dr B.

Must document for this operation

  • The indication with numbers: rotation, angle, shortening. Most metacarpal fractures are treated without surgery, so the note must show why this one needed fixation.
  • Rotation checked after fixation, and how. Malrotation of even 10 degrees causes finger overlap, and it is hard to correct once the plate is on.
  • Implants: plate size, screw number and size, K-wire number and diameter, and whether wires were buried. The removal surgeon and the clinic need this to plan wire or plate removal.
  • Sensory nerves and extensor tendons seen and protected, and tendon gliding checked. Numbness and tendon adhesions are the common complaints after hand fixation.
  • Splint position and the motion plan. Immobilisation beyond 4 weeks causes stiffness, and the hand therapist starts from the written plan.

Common mistakes in these notes

  • Writing 'ORIF 4th metacarpal' without the digit name and side (ring finger, right).
  • Not recording a rotation check after fixation.
  • No K-wire count or diameter, so clinic removal misses a wire.
  • Leaving out the tourniquet time.
  • Writing 'splint applied' without the joint positions.

Indian practice and paperwork

  • Record the batch and lot number of the plate and screws in the case sheet; NABH also expects them in the OT implant master logbook and the discharge summary. (NABH Hospital Standards 5th ed., MOM.10(d))
  • In an audit of 153 orthopaedic op notes at a Mumbai hospital, tourniquet time was recorded in only 41.8 percent of notes. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227)

Sources

  • Chung KC. Operative Techniques: Hand and Wrist Surgery. 3rd ed. Elsevier; 2018, Procedures 12-14: closed reduction and K-wire fixation of metacarpal neck and shaft fractures; percutaneous intramedullary fixation of metacarpal head and neck fractures; ORIF of metacarpal shaft fractures (Saito T, Haase SC, Chung KC), pp. 99-117.
  • Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds. Green's Operative Hand Surgery. 7th ed. Elsevier; 2017, Ch 7, Fractures of the metacarpals and phalanges, pp. 231-277.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV within 60 min before incision; recommended for internal fixation devices. Clean hand surgery without implants needs no prophylaxis. academic.oup.com/ajhp/article/70/3/195/5112717
  • Campbell's Operative Orthopaedics 15e, Ch 2, Tourniquets, printed pp. 137-138 (pdf 162-163): 135-255 mmHg satisfactory for the upper limb; 2 hours or less in healthy adults under 50.

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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