DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left small finger puncture wound with infection and retained foreign body.
POSTOPERATIVE DIAGNOSIS: Left small finger puncture wound with infection and retained foreign body.
PROCEDURE PERFORMED:
1. Left small finger wound exploration with irrigation and debridement.
2. Removal of retained wooden splinter foreign body, left small finger.
SURGEON: John Doe, MD
SEDATION: General.
COMPLICATIONS: None.
OPERATIVE FINDINGS: The patient sustained a puncture on the palmar-ulnar surface of the left small finger at the level of the proximal interphalangeal flexion crease due to a wooden splinter. Exploration revealed no gross pus. There was surrounding induration and localized erythema at the wound margins. The wound measured approximately 3 mm. Exploration revealed a large, retained, linear, wooden, foreign body measuring approximately 2.5 cm in length and 2 to 3 mm in width. The splinter lay in the subcutaneous plane adjacent to the ulnar digital neurovascular bundle. The digital nerve was in continuity but may have been contused from the foreign body. The flexor tendon sheath was intact and beyond the zone of the injury.
DESCRIPTION OF PROCEDURE: Consent was signed by the patient, the patient was taken into the operating room, and general anesthesia was administered. The left arm was prepped and draped sterilely. A tourniquet was inflated on the upper arm without exsanguinating the limb due to the presence of infection.
A Brunner-type incision was made extending proximal and distal from the open wound on the palmar-ulnar aspect of the left small finger. Under loupe magnification, subcutaneous tissue was dissected. The jagged skin edge was debrided sharply. The wound cultures were obtained for aerobic and anaerobic organisms.
The wound was explored, and the foreign body was identified. This was dissected free from the surrounding fat, subcutaneous ligaments and removed. The foreign body was sent to Pathology as a specimen for identification. The digital neurovascular bundle was explored and found to be in continuity within the zone of injury. The wound was irrigated thoroughly with antibiotic solution. The patient was given empiric IV antibiotics with Ancef after cultures were obtained.
Tourniquet was deflated. Circulation returned to the left hand with normal capillary refill distally. Bleeding was controlled with direct pressure, and hemostasis was achieved. The skin edges were reapproximated with nylon sutures loosely, leaving the original punctured wound open to heal by secondary intention.
A sterile, bulky gauze dressing was applied. The patient was awakened and transported to recovery room in stable condition. The patient tolerated the procedure well with no complications. He will continue empiric antibiotic therapy postoperatively.
