DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left long and ring finger stenosing tenosynovitis.
2. Ring finger palmar Dupuytren contracture.
OPERATION PERFORMED:
1. Left long and ring finger first annular pulley release.
2. Ring finger palmar subtotal fasciectomy.
SURGEON: John Doe, MD
ANESTHESIA: Bier block.
TOURNIQUET TIME: 34 minutes.
COMPLICATIONS: None
DISPOSITION: At the end of the procedure, all sponge and needle counts were correct. The patient was transported to the recovery room in good condition.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old man who has symptomatic trigger finger of the long and ring fingers and has a symptomatic palmar Dupuytren contracture in the axis of the ring and small fingers, most prominently in that of the ring finger. We have discussed risks, potential complications, and treatment alternatives relating to his Dupuytren contractures as well as his trigger fingers. He has failed conservative management. We have discussed the risks and potential complications which include, but are not limited to, bleeding, infection, injury to nerves and blood vessels which may cause potentially permanent numbness, tingling, pain, stiffness, regional pain syndromes, and that he may actually be worse off or require additional surgery at some point down the road. The patient was also told that he may have recurrence of his Dupuytren contracture and this may occur rapidly and that he may have or develop trigger fingers at the long and ring fingers as a recurrence or at other digits on either hand, and he may be worse off than he was before surgery or require additional surgery. The patient understands these risks.
DESCRIPTION OF OPERATION: The patient was transported to the operating room where the anesthesia service administered antibiotic and placed Bier block after applying a well-padded tourniquet to the left brachium. Two incisions were made; one was approximately 1 cm in length, transverse incision, roughly at the level of the distal palmar crease in the axis of the long finger. Through that incision, dissection was sharp through skin, blunt to subcutaneous tissue, being careful to expose the first annular pulley as well as the A0 pulley. These were divided. A traction tenolysis was performed. Tenosynovial adhesions between the flexor digitorum profundus and superficialis were released, and at the completion of the procedure, after the tourniquet was deflated, the patient was asked to flex and extend all of his digits, which he was able to do without evidence of hesitation or triggering. Hesitation and triggering were noted at the long as well as the ring finger prior to surgery.
Attention was turned to the ring finger, where a volar Bruner-type incision was made from roughly the level of the interval between the proximal digital crease and the distal palmar crease and proximally the distal extent of the transverse carpal ligament. Through this incision, Dupuytren cord in the palm was identified and excised, being careful to protect the common neurovascular bundle to the long ring finger as well as that to the ring and small finger. The palmar cord was excised and sent as a pathology specimen. The first annular pulley was then released. Traction tenolysis was performed. Adhesions between the flexor digitorum and superficialis were resected. Tourniquet was deflated. His motion was observed, and his wounds were closed. The long finger axis wound was closed with a combination of simple and horizontal mattress sutures, whereas the volar Bruner incision was loosely reapproximated with simple interrupted stitches. Sterile dressings were applied, including Adaptic, 4 x 4, sterile Webril and Ace wrap.
The patient has been advised to actively range his digits as much and as often as possible with the idea of evacuating hematoma through manual motion and flexion extension. He is to call for any problems, in particular dramatic escalation of pain which may represent infection or other problem. Given his diabetes, we may leave his sutures in longer than usual; however, assessment of that will be made at the time of suture removal, which is anticipated to be around 10-14 days postop. He will be discharged to home with p.o. pain medications, antibiotics, and antiemetic.
