DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Bilateral trigger thumbs.
POSTOPERATIVE DIAGNOSIS:
Bilateral trigger thumbs.
OPERATION PERFORMED:
Bilateral trigger thumbs, A1 pulley release.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Local MAC.
INDICATION FOR OPERATION: The patient is a (XX)-year-old Hispanic female with history of bilateral trigger thumbs for an extended period of time. She had an attempt at steroid injection to treat the triggered thumbs. The patient’s symptoms did not resolve; therefore, recommendation for bilateral trigger thumb release of the A1 pulley was offered to the patient to alleviate her symptoms. Risks, benefits, and alternatives of the surgery were discussed.
Risk including but not limited to scar, infection, bleeding, nerve or vessel injury, persistent triggering and/or recurrence, need for further surgeries were discussed in detail. Questions were answered and consent was obtained prior to the surgery.
DESCRIPTION OF OPERATION: After informed consent was obtained from the patient, he was taken to the operating theater for bilateral trigger thumbs and A1 pulley release. He was transferred from the gurney to the operating table and placed in supine position. IV sedation was administered by the anesthesia staff, and he was monitored throughout the procedure. After the patient was sedated using a half-half mixture of 1% Xylocaine and 0.5% Marcaine with epinephrine, 6 mL of local anesthetic was injected into the left thumb overlying the A1 pulley to provide operative anesthesia. Five mL was injected into the right thumb overlying the A1 pulley as well. The bilateral upper extremities had well-padded tourniquets placed in the forearms. The bilateral upper extremities were then sterilely prepped and draped in usual fashion. Esmarch bandage was used to exsanguinate the right upper extremity and tourniquet was inflated to 250 mmHg prior to incision.
Using a #15 scalpel blade, a transverse incision just distal to the digital palmar crease overlying the A1 pulley was made approximately 1.5 to 2 cm. Incision was made just through the dermis. The subcutaneous tissues were gently dissected in a blunt fashion with Littler dissecting scissors. Ragnell retractors were placed, both radially and ulnarly to protect the neurovascular structures. Under direct visualization, the A1 pulley was identified, and using a #15 blade, a small nick was made in the A1 pulley. There was thickening of this pulley and hourglass appearance to the flexor pollicis longus tendon was noted underneath the pulley.
Using Littler dissecting scissors, the A1 pulley was opened both distally and extended proximally. The left thumb IP joint could then go through the full range of excursion with improved extension of the thumb. Passively palpitating, with full flexion and extension, no significant locking or triggering was identified. The wound was irrigated with copious amount of sterile normal saline. The wound edges were reapproximated with 5-0 nylon suture in interrupted horizontal mattress fashion. The tourniquet was deflated on the right upper extremity at approximately 10 minutes of use. Adequate perfusion to the right hand was noted after tourniquet was deflated, less than 2 seconds capillary refill of all digits.
Next, attention was directed to the left trigger thumb. An Esmarch bandage was used to exsanguinate the left hand and tourniquet was inflated to 250 mmHg prior to incision. A #15 scalpel blade was used to make a transverse incision approximately 1.5 to 2 cm in length just distal to the palmar digital crease on the volar aspect of the thumb. The incision was made shallow just through the dermis. The subcutaneous tissues were dissected bluntly with Littler dissecting scissors. Ragnell retractors were placed ulnarly and radially protecting the neurovascular structures.
The A1 pulley was identified and was opened longitudinally with a nick using a #15 scalpel blade, then extending the incision through the pulley with the Littler dissecting scissors both distally and proximally. Care was taken to protect the oblique ligament in the thumb.
Again, there was thickening of A1 pulley and a slight bulbous appearance to the flexor pollicis longus tendon just proximal to the constricting portion of the pulley. The thumb was able to go through full excursion. Following release with the A1 pulley, there was no triggering or locking of the thumb. The wound was irrigated with copious amounts of sterile normal saline.
The skin was then closed with 5-0 nylon suture in interrupted horizontal mattress fashion. Tourniquet was deflated at approximately 9 minutes of use with adequate perfusion in the left noted with less than 2 seconds capillary refill felt in thumb and other digits. Xeroform was placed over the wounds and sterile 4 x 4 and a Kling was used to dress the area. Dressings were held in place with 2-inch Coban wrapped lightly about the thumb, hand, and wrist.
The patient tolerated the procedure without complications and was returned to the recovery room in stable condition, appearing comfortable.
