Certificate of Attendance

Transcription

Certificate of Attendance
Advanced Clinic: Hand Surgery CPT Coding
May 13, 2004
_____________________________________
NAME
Lolita M. Jones, RHIA, CCS
Presenter
The American Health Information Management Association (AHIMA) has approved this program for
two (2) continuing education clock hours in the Clinical Data Management content area.
Retain this certificate as evidence of participation.
Advanced Clinic
Hand Surgery
Advanced Clinic:
Hand Surgery
CPT Coding
Author:
Lolita M. Jones, RHIA, CCS
Lolita M. Jones Consulting Services
1921 Taylor Avenue
Fort Washington, MD 20744
(V) 301-292-8027
(FAX) 301-292-8244
Coding Training: www.hcprofessor.com
E-mail: [email protected]
Distributed by HCPro
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Advanced Clinic
Hand Surgery
Table of Contents –
Disclaimer
1
About Lolita M. Jones Consulting Services
2
Objective
7
Clinical Coder: Tendon Surgery
8
Hand and Finger Tendons
8
CPT Coding Tips and Traps
11
Clinical Coders: Anatomy of the Hand
19
CPT Coding Guidelines
35
Exercises
36
Answer Key
96
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Disclaimer
Advanced Clinic: Hand Surgery is designed to provide accurate and authoritative
information in regard to the subject covered. Every reasonable effort has been made to
ensure the accuracy of the information within these pages. However, the ultimate
responsibility lies with the user.
Lolita M. Jones Consulting Services and staff make no representation, guarantee or
warranty, express or implied, that this compilation is error-free or that the use of this
publication will prevent differences of opinion or disputes with Medicare or other thirdparty payers, and will bear no responsibility or liability for the results or consequences of
its use.
Physician’s Current Procedural Terminology, Fourth Edition (CPT-4) is a copyrighted
coding system owned and maintained by the American Medical Association.
Please contact Lolita M. Jones, RHIA, CCS at:
(V) 301-292-8027
(Fax) 301-292-8244
© 2004 Lolita M. Jones Consulting Services
All five-digit number Physician’s Current Procedural Terminology, Fourth Edition
(CPT) codes, service description, instructions and/or guidelines are © 2003 American
Medical Association. All rights reserved.
All rights reserved. The author grants permission for photocopying for limited personal
use or internal use of the original purchaser. This consent does not extend to other kinds
of copying, such as for general distribution, for advertising or promotional purposes, for
creating new collective works, or for resale.
•
HAND
Advanced Clinic
Hand Surgery
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About Lolita M. Jones Consulting Services
HOSPITAL TRAINING PROGRAMS
(V) 301-292-8027
(FAX) 301-292-8244
BIOGRAPHY:
Lolita M. Jones, RHIA, CCS, is an independent consultant specializing in hospital
outpatient and ambulatory surgery center coding, billing, reimbursement, and operations.
Ms. Jones recently launched her web-based coding program at www.EZMedEd.com.
She has over 15 years of experience in publishing, training, and auditing for the hospital
outpatient and freestanding ambulatory surgery center (ASC) markets. Ms. Jones has
earned both the Registered Health Information Administrator and Certified Coding
Specialist credentials from the American Health Information Management Association
(AHIMA) in Chicago, IL. Ms. Jones resides in Fort Washington, Maryland, and she has
developed six (6) specialty manuals for freestanding ambulatory surgery centers (ASCs)
as well as comprehensive manuals for the following ambulatory payment classification
(APC) training programs:
Basic CPT Outpatient Coding Clinic: This 6.5 hour program is designed for
(Future/Beginning/Current) Coding Specialists, Coding Managers, Reimbursement
Specialists, Compliance Auditors, Hospital-Based Clinic Managers, and ALL hospital
staff responsible for outpatient coding including emergency room, ancillary department
and hospital-based clinic staff. The contents include general guidelines, steps for coding,
and official CPT guidelines for surgical procedures that are commonly performed in the
hospital outpatient setting. Exercises based on actual ambulatory surgery operative
reports will be used to strengthen the attendees’ understanding of the guidelines
presented.
APC Institute: Impact on Emergency Services: This 3 hour program is designed for
Emergency Department: Directors, Managers, Supervisors, and Nurses; Registration
Staff, Health Information Managers, Coding Specialists, and Cast Room Technicians.
The contents include APC Grouping Logic, Mapping Logic for ED Medical Visits,
APCs for Emergency Department Services, Modifiers –25 and –27, Emergency
Screening without Treatment, Critical Care, “Clotbuster” Drugs, Tissue Adhesive Wound
Closure, and Documentation Guidelines.
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Hand Surgery
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APC Institute: Outpatient Compliance Action Plan: This 6.5 hour program is
designed for Compliance Department Staff (Corporate Officers, Directors, Managers,
Analysts, Auditors); Health Information Management Staff (Directors, Coding
Managers/Supervisors, Coding Specialists); Risk Managers, APC Coordinators,
Reimbursement Specialists, Decision Support Analysts, Outpatient Billing Supervisors,
Outpatient Billing Specialists, Software Vendor Product Managers, ALL staff responsible
for facility component outpatient coding in: Registration, Hospital-Based Clinics,
Ancillary Departments, and the Emergency Department. The contents include: Brief
Overview of APCs; CPT Surgery Coding Compliance; and APC Compliance Issues: siteof-service billing, reason for visits, discontinued surgery, medical visits, “limited followup services,” colorectal cancer screening, observation stay without recovery, critical
care, interventional radiology, modifiers, unlisted procedure codes, units of service, UB92 claims data, and higher level APC groups.
APC Institute: Clinical Documentation Strategies: This 6.5 hour program is designed
for nursing, utilization management, case management, and other health care
professionals responsible for health records documentation. The contents include
ambulatory payment classification (APC)-related clinical documentation requirements
and management tips for the following sites of service: Emergency Room, Observation
Beds/Unit, Ambulatory Surgery, Hospital-Based Outpatient Departments/Clinics, Pain
Management Clinic, Series/Recurring Services, Partial Hospitalization Program, Cast
Room, Ancillary Testing Areas, and Utilization Management.
APC Institute: Coding Guidelines for Hospitals - This 1 or 2 day program is designed
for all technical, clinical and managerial staff responsible for facility component
outpatient coding that will directly impact ambulatory payment classification (APC)
payments. The contents include: Ambulatory Surgery Reimbursement under APCs, APC
Data Reporting Requirements, Medicare Hospital Outpatient Edits, Outpatient Billing
Procedures and Guidelines, Ambulatory Claims Rejection Monitors, Peer Review
Ambulatory Surgery Review, Coding System Reviews, How to Use ICD-9-CM, How to
Use CPT, and CPT Coding Guidelines By Body System (Integumentary,
Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic,
Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital,
Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).
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Modifier Clinic: Hospital Outpatient Issues: This 6.5 hour program is designed for
coding, reimbursement, compliance, billing, database management, ancillary, and clinic
staff responsible for modifier programming, reporting, billing, and auditing. The
contents include: Modifier Reporting Requirements, Official Medicare Guidelines,
Recommended Hospital Front-End Modifier Edits, Electronic/On-Line UB-92 Reporting
of Modifiers, Coding and Billing Aborted/Discontinued Procedures, ICD-9-CM vs.
Medicare Coding Guidelines, Unsuccessful vs. Aborted/Discontinued Procedures,
Documentation of Reduced/Discontinued Procedures, Testing Potential Coders, Software
Encoder Modifier Edits, Interventional Radiology Procedures, Information System
Upgrades, Data Quality Review, Radiology Modifier Reporting Issues, Ancillary
Department Modifier Reporting for Hospitals, and Exercises/Case Studies.
APC Institute: Hospital Financial and Operational Issues: This 6.5 hour program is
designed for hospital executives, directors, chargemaster coordinators,
coding/reimbursement staff, and information system/database managers who will
implement ambulatory payment classifications (APCs). The contents include: General
Overview of APCs, APC Data Reporting Requirements, APC Policy Issues, Developing
a Plan of Action, Conducting Hospital-Wide APC Education, and Assessing Current
Outpatient Operations for: Overall Hospital, Management Information Systems, Business
Office/Patient Accounts, Health Information Management, Ancillary
Departments/Chargemaster, Emergency Room, Hospital-Based Clinics, Hospital-Owned
Satellite Facilities, Hospital-Based Physician Coding and Billing, and Utilization
Management.
APC Institute: Billing and Reimbursement Issues. This 6.5 hour program is designed
for Chief Financial Officers, Vice Presidents of Finance, Controllers, Chargemaster
Coordinators, Database Managers, Software Vendor Product Managers, Coding
Managers, Reimbursement Specialists, Director of Patient Accounts/Business Office,
Outpatient Billing Supervisor/Coordinator, Outpatient Billing Specialists. The contents
include: Durable Medical Equipment and Prosthetics, Pre-operative Registration,
Outpatient Service “Red Flags,” Chargemaster/Charge Entry, Claims Preparation, Claims
Payment, Tracking and Reviewing Medicare Billing Guidelines.
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Lolita M. Jones Consulting Services
FREESTANDING
AMBUALTORY SURGERY CENTER
TRAINING PROGRAMS
ASC Clinic: Multi-Specialty Procedures - This 6.5 hour program is designed for
Freestanding ambulatory surgery center (ASC) Managers (Business, Nurse,
Reimbursement), Directors, Administrators, Coding Supervisors, Coding Specialists, and
Billers. The contents include: Current Freestanding ASC Structure, Proposed
Freestanding ASC Structure, Medicare Coding Requirements, Medicare Billing
Requirements, Coding Ambulatory Surgery, How To Use CPT When Coding
Ambulatory Surgery, and CPT Coding Guidelines By Body System (Integumentary,
Musculoskeletal, Respiratory, Cardiovascular and Lymphatic, Hemic and Lymphatic,
Digestive System, Urinary, Male Genital, Laparoscopy/Hysteroscopy, Female Genital,
Endocrine, Nervous, Eye and Ocular Adnexa, Auditory).
ASC Clinic: Dermatology & Plastic Surgery - This 6.5 hour program is designed for
all technical, clinical and managerial staff responsible for facility component freestanding
ASC coding and billing. The contents include: exercises based on actual outpatient
operative reports; and CPT coding guidelines for topics such as: tissue expander, pedicle
flap, pressure ulcer, skin grafts, nail avulsion and excision, scar revision, burn treatment,
lesion excisions, wound repair, adjacent tissue transfer/rearrangement, breast surgery,
free flaps with microvascular anastomosis.
ASC Clinic: Eye & Oculoplastic Surgery - This 6.5 hour program is designed for all
technical, clinical and managerial staff responsible for facility component freestanding
operative reports; and CPT coding guidelines for topics such as: cataracts. intraocular
lens, keratoplasty, trabeculectomy, strabismus surgery, punctum plugs, tarsorrhaphy,
trichiasis correction, retinal detachment repair, vitrectomy.
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ASC Clinic: Gastroenterology Procedures- This 6.5 hour program is designed for all
operative reports; and CPT coding guidelines for topics such as: hernia repair, nasogastric
intubation, percutaneous gastrostomy tube, hemorrhoidectomy, abscess/cyst drainage,
dental procedures, covered and noncovered colorectal cancer screening, gastrointestinal
endoscopy, esophageal dilation.
ASC Clinic: Orthopaedic Surgery - This 1 or 2 day program is designed for all
operative reports; and CPT coding guidelines for topics such as: ganglion cyst, joint
injections, decompression fasciotomy, treatment of fractures/dislocations, skeletal
anatomy of the hand and foot, surgical knee arthroscopy, bunionectomy, toe-to-hand
transfer with microvascular anastomosis.
ASC Clinic: Urology Procedures - This 6.5 hour program is designed for all technical,
clinical and managerial staff responsible for facility component freestanding ASC coding
and billing. The contents include: exercises based on actual outpatient operative reports;
and CPT coding guidelines for topics such as: retrograde pyelogram, ureter vs. urethra,
urethral dilation, ureteral stent, urethral stent, Burch Procedure,
vesicourethropexy/urethropexy, urodynamics, chemotherapy.
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OBJECTIVE: This program will first provide a detailed review of the hand surgery
CPT coding guidelines to assist the participants in their understanding of the numerous
techniques that are performed. “Real life” operative report case studies will also be
presented for many of the hand surgery techniques that are discussed.
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Clinical Coder: Tendon Surgery
Orthopaedics staff often find that selecting the appropriate CPT code for the repair
of a lacerated or ruptured tendon of the hand or finger can be as complex as the
surgery itself.
Tendon repairs of the hand or finger are classified to code range 26350–26504 in
the CPT manual. Code selection depends on the type of tendon and procedure
performed, and the anatomic site.
Understanding what the code narrative describes helps you translate the
procedure statement into accurate codes, the key to appropriate reimbursement.
This tool explains the medical terminology surgeons often use in the operative
report and details what each tendon repair code describes.
Before you review the information in the grid, you need to understand some basic
tendon anatomy, described below.
a. Hand and Finger Tendons
Tendons are fibrous connective tissues that attach muscles to bones, as well as to
other tissues. The type of tendon is classified according to the movement of the
associated muscle. That is, tendons associated with the muscle that causes a part
of the body, such as the hand or finger, to bend are called flexors. Those that
extend a part of the body are called extensors.
Tendons that are near the surface are described as “superficialis,” and those that
are deep seated are termed “profundus.”
When hand or finger tendons are lacerated or ruptured, the surgeon may perform a
primary or secondary repair. In the primary repair, the tendon is sutured or
reconstructed immediately after the injury.
In the secondary repair, the suturing or reconstruction is delayed to allow the
tendon or sheath to heal before it is repaired. Secondary repairs may require a
tendon grafting, which may include induction of a sheath using silastic rods.
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Clinical Coder: Tendon Surgery – continued
FLEXOR TENDONS – HAND/FINGERS
flexor pollicis longus tendon
palmaris longus tendon
index finger flexor digitorum superificialis
middle finger flexor digitorum superficialis
ring finger flexor digitorum superficilias
little finger flexor digitorum superficialis
index finger flexor digitorum profundus
middle finger flexor digitorum profundus
ring finger flexor digitorum profundus
little finger flexor digitorum profundus
flexor pollicis longus
flexor carpi radialis
flexor carpi ulnaris
palmaris longus
pronator teres
EXTENSOR TENDONS
WRIST/FOREARM
extensor origin
brachioradialis tendon
supinator tendon
abductor pollicis longus tendon
extensor pollicis longus tendon
extensor pollicis brevis tendon
extensor indicis proprius tendon
extensor digitorum communis tendon of the index finger
extensor digitorum communis tendon of the middle finger
extensor digitorum communis tendon of the ring finger
extensor digitorum communis tendon of the little finger
extensor digiti minimi tendon
extensor carpi radialis longus tendon
extensor carpi radialis brevis tendon
extensor carpi ulnaris tendon
extensor pollicis brevis muscle
extensor carpi radialis longus muscle
extensor carpi radialis brevis muscle
extensor pollicis longus muscle
extensor indicis proprius muscle
extensor digiti minimi muscle
extensor carpi ulnaris muscle
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Clinical Coder: Tendon Surgery – continued
EXTENSOR TENDONS – DIGIT
extensor tendon of the index finger
extensor tendon of the middle finger
extensor tendon of the ring finger
extensor tendon of the littler finger
extensor mechanism of the index finger
extensor mechanism of the middle finger
extensor mechanism of the ring finger
extensor mechanism of the little finger
radial sagittal band of the index finger
radial sagittal band of the middle finger
radial sagittal band of the ring finger
radial sagittal band of the little finger
ulnar sagittal band of the index finger
ulnar sagittal band of the middle finger
ulnar sagittal band of the ring finger
ulnar sagittal band of the little finger
central slip of the index finger
central slip of the middle finger
central slip of the ring finger
central slip of the little finger
radial lateral band of the index finger
radial lateral band of the middle finger
radial lateral band of the ring finger
radial lateral band of the little finger
ulnar lateral band of the index finger
ulnar lateral band of the middle finger
ulnar lateral band of the ring finger
ulnar lateral band of the little finger
terminal extensor tendon of the index finger
terminal extensor tendon of the middle finger
terminal extensor tendon of the ring finger
terminal extensor tendon of the little finger
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b.
Hand Surgery
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CPT Coding Tips and Traps
Although knowing the ins and outs of tendon repairs is essential to coding them correctly,
it’s also important to follow a couple of reporting guidelines, which are often overlooked
by coders.
Read parenthetical notes: The note “includes obtaining graft” means that the
harvesting of a tendon graft, even from a distant site (code 20924) is an integral part of
the repair procedure and should not be coded separately. Other notes, such as
“boutonniere deformity,” describe the reason for the procedure. Closely reviewing the
code description for such diagnostic terms will ensure accurate code assignment.
Code all repairs: Another point to keep in mind is that each code describes surgery
performed on one tendon. Not reporting all tendons repaired could mean lost dollars for
the facility. If you are unsure of the number of tendons repaired, seek the surgeon’s
assistance.
Finally, keep in mind that not all third-party payers follow the same reporting and
reimbursement guidelines for tendon repairs. It is important to check with the payer in
question for its coding and reimbursement policies.
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Clinical Coder: Tendon Surgery—continued
CPT
Code
Procedure
Description
Diagnostic
Implications
26350
Simple suturing, or
advancing and suturing
of superficial or deep
(profundus) tendon
proximal or distal to
tendon sheath
Lacerations of palmar
surface of hand, forearm
or finger with tendon
involvement
This code describes
repairs or advancements
in areas of the hand
proximal to the midpalm
crease or distal to the
middle third of the middle
finger (not “no man’s
land”).
26352
Secondary
reconstruction with
flexor tendon grafting
of flexor superficial or
deep (profundus)
tendon proximal or
distal to tendon sheath
Inability to perform a
primary repair because
of treatment delay or
primary repair failure
Harvesting of free tendon
graft, locally or from a
distance, is included in
this procedure and should
not be coded separately.
26356
Suturing, or advancing
and suturing of
superficial or deep
(profundus) in “no
man’s land”
Injury in tendon sheath
“No man’s land” refers to
the critical area from the
midpalm crease to the
distal interphalangeal
(DIP) joint.
Comments
Many times, the diagnosis
is missed in the
emergency room, and the
patient is not evaluated
early in the course of the
disease. A portion of
tendon may still be intact
and then rupture a few
days later, delaying the
repair.
26357
Repair of flexor tendon
in sheath after scar
tissue has begun to
form around damaged
tendon or sheath
Sometimes called
“delayed primary repair.”
Can be performed if the
tendon has not retracted
and the sheath has few
adhesions—often seen
after clean lacerations
The term “delayed
primary repair” varies
among surgeons to mean
three to 21 days or more.
continued
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CPT
Code
Procedure
Description
Diagnostic
Implications
26358
Replacement of
damaged tendon in
tendon sheath after
reaction of injury has
subsided
Tendon has retracted too
far to make simple repair
Comments
This code describes onestage grafting without
prior creation of a sheath
by silicone rod. For twostage grafting, see codes
26390 and 26392.
Harvesting of a free
tendon graft, locally or
from a distance, is
included in this procedure
and should not be coded
separately.
26370
and suturing of deep
(profundus) flexor
tendon in flexor sheath
distal to intact flexor
digitorum superficialis
Performed if shortening
is less than 1 cm and
extreme flexion of finger
is not necessary to take
tension off repair
Occasionally, the
profundus tendon is cut
after it passes through
the superficialis tendon
decussation distal to the
proximal interphalangeal
(PIP) flexion crease. If the
profundus (deep) tendon
has been avulsed or
enough of the end is
damaged to require
resection of a small
amount, the tendon can
be advanced up to 1 cm
and be reattached directly
to the distal phalanx. If
the tendon is sharply
lacerated, an end-to-end
repair can be performed.
continued
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CPT
Code
Procedure
Description
26372
Replacement of
damaged deep
(profundus) tendon in
flexor sheath distal to
intact flexor digitorum
superficialis
Diagnostic
Implications
Comments
This procedure code
describes delayed repair
with a free tendon graft.
For delayed repair without
grafting, see code 26373.
Harvesting of a graft is
included in this code and
should not be coded
separately.
26373
and suturing of
damaged deep
(profundus) tendon in
flexor sheath distal to
intact flexor digitorum
superficialis
26390
Excision of flexor
tendon and
surrounding scar
tissue with insertion of
plastic (Hunter) rod or
tube to establish a
flexor sheath for
subsequent tendon
grafting
This procedure does not
include tendon grafting.
See code 26372.
Excessive scarring of
tendon bed, and joint
stiffness
This procedure is the first
stage of a two-stage
delayed tendon grafting.
In the first stage, a
silicone rod may be used
to create a tendon
sheath. In the second
stage, tendon grafting is
performed.
Delayed flexor tendon
grafting without rods to
create tendon channels is
classified as CPT codes
26352, 26358 and 26372.
continued
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CPT
Code
Procedure
Description
Diagnostic
Implications
26392
Delayed flexor tendon
grafting after creating
channels for tendon
sliding
This procedure includes
harvesting of a tendon
graft.
26410
and suturing of an
extensor tendon on
back of hand
Use code 26418 or 26420
to report the repair of
tendon dorsum of the
finger.
26412
and suturing of an
extensor tendon on
back of hand with
tendon graft
This procedure includes
harvesting of a tendon
graft.
26415
Insertion of plastic tube
or rod to create tendon
channel prior to tendon
grafting
26416
Delayed extensor
tendon grafting of hand
or finger
Heavy scarring on back
of hand
Comments
A plastic tube or rod is
inserted, allowing the
body to create a new
sheath into which a
tendon graft or transfer
can be placed for
extension of the fingers.
This is the second stage
of a delayed extensor
tendon grafting in which
the implanted rod or tube
is removed and a tendon
is grafted or transferred.
continued
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CPT
Code
Procedure
Description
Diagnostic
Implications
26418
and suturing of
extensor tendon on
back of finger
Laceration or rupture of
extensor tendon, finger
A simple laceration can
often be managed with
simple cleansing of a
wound and direct suture
or merely positioning
adjacent joints in full
extension for six weeks to
allow proper healing. If
treatment is delayed,
Mallet finger or
boutonniere deformity
may develop and require
more extensive surgery or
a graft.
26420
Repair of extensor
tendon by tendon graft
to replace portion of
tendon lost or
shortened due to delay
in treatment
Inability to straighten
finger
A graft can be required if
the tendon is shortened
due to a delay in
treatment of an injury or if
some tendon was lost
due to an injury. Normal
balance of the finger does
not tolerate a discrepancy
in length.
26426
Repair of extensor
tendon lost or
in treatment
Boutonniere deformity
(deformity of the finger
characterized by flexion
of PIP joint and
hyperextension of distal
joint)
If the injury is old, some
readjustments of local
tissue may provide
adequate extension. If
tissue is just shortened
and not lost, this
rearrangement may be
adequate. If tissue is lost,
a graft will be necessary.
26428
Repair of extensor
tendon by tendon graft
to replace portion of
tendon lost or
in treatment
Comments
Harvesting of the graft is
included and should not
be coded separately.
continued
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CPT
Code
Procedure
Description
Diagnostic
Implications
26432
Closed treatment of
extensor tendon,
laceration or rupture
of the distal insertion,
with or without
fracture of dorsal lip of
distal phalanx
Mallet finger (an avulsion
of the insertion of the
extensor tendon at the
base of the distal
phalanx). A fragment of
bone may be avulsed
along with the tendon.
26433
Open reattachment of
extensor tendon,
laceration or rupture
of the distal insertion,
using local tissues
only
26434
Open reattachment of
extensor tendon,
insertion laceration or
rupture, with tendon
graft
Comments
If there is no fracture, the
patient usually needs to
have the DIP joint
splinted in extension for
six or more weeks. If
there is a fracture,
percutaneous pinning—
placing a pin through the
fracture site or across the
DIP joint under x-ray
guidance—may be used
to stabilize the joint
without splinting.
This procedure is
performed rarely.
Shortening of tendon
caused by loss of tendon
or delay in treatment
Repair may include
pinning of the fracture or
joint to maintain
extension.
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Clinical Coders: Anatomy of the Hand
Source: Melloni, June L. et al. Melloni’s Illustrated Review of Human Anatomy.
Philadelphia: J.B. Lippincott Co., 1988.
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Source: A Manual of Orthopaedic Terminology, Carolyn Taliaferro
Blauvelt, Fred R. T. Nelson, Mosby Year Book, Inc., St. Louis, MO, 1994.
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Source: Surgical Exposures in Orthopaedics, The Anatomic Approach,
Stanley Hoppenfeld, MD, Piet deBoer, MA, FRCS, J.B. Lippincott
Company, Philadelphia, PA.
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CPT Coding Guidelines
See codes 20920 and 20922 (fascia lata graft) for application of an anchovy. This term is
used in microsurgery and hand surgery and refers to a rolled up piece of fascia lata (that
looks like an anchovy).
Carpometacarpal Joint Interposition Arthroplasty: Per the article “First
Carpometacarpal Joint Arthritis,” by Nathaniel P. Cohen, MD and Melvin Rosenwasser,
MD: “Carroll and Fromison have described excisional arthroplasty combined with a
rolled tendon interposition graft, the “anchovy procedure.” In this, a strip of tendon
from the flexor Carpi radialis or from the palmaris longus is rolled into a ball and placed
into the space created by the excision of the trapezium.” Code 25447 classifies a
carpometacarpal joint interposition arthroplasty. An additional CPT code should also be
assigned for the tendon transfer.
Sublimis or profundus flexor tendon transposition: assign 25310 (forearm/wrist
tendon transplantation or transfer) for sublimis or profundus flexor tendon transposition.
Source: June 2002 CPT Assistant newsletter, AMA.
Tenolysis and capsulotomy on the flexor tendon in the interphalangeal (IP) joint:
report both codes 26440, Tenolysis, flexor tendon; palm OR finger, each tendon, and
code 28272–59, Capsulotomy; interphalangeal joint, each joint (separate procedure). A
capsulotomy is performed on the joint in an attempt to increase the range of motion of the
joint and/or release a contracture. A tenolysis releases scar tissue, which binds a tendon
to surrounding structures, allowing for improved motion of the tendon. Capsulotomy and
tenolysis are distinct procedures, which can be performed independently, or in some
cases, together. Source: December 2002 CPT Assistant newsletter, AMA.
Code 26440, Tenolysis, flexor tendon; palm or finger; each tendon, includes
capsulectomy of the interphalangeal joint when performed. Source: April 2002 CPT
Assistant newsletter, AMA.
Advanced Clinic
Exercises
Hand Surgery
36
Advanced Clinic
Hand Surgery
37
Exercise 1. Please read the following clinical data and assign the appropriate
CPT code(s) - modifiers: ______________________________________________.
OPERATIVE REPORT
SURGEON:
ASSISTANT: None.
PREOPERATIVE DIAGNOSIS: Right wrist ganglion cyst and left wrist ganglion cyst.
POSTOPERATIVE DIAGNOSIS: Right wrist ganglion cyst and left wrist ganglion cyst.
OPERATION: Right wrist excision of dorsal ganglion. Left wrist aspiration of dorsal
ganglion.
ANESTHESIA: Intravenous sedation.
INDICATIONS: This is a 39-year-old female who has had bilateral painful mass on the
wrists. Her right wrist has recurred multiple times after aspiration. The left wrist has
recently grown to about 2.5 cm and we had aspirated this today under local
anesthetic and sterile prep.
PROCEDURE/FINDINGS: The patient as placed in the supine position on the operating
room table. After adequate intravenous sedation was given, she had a block of 0.25%
Marcaine into the right wrist. She was prepped and draped in the usual sterile fashion.
The arm was elevated and tourniquet inflated to 250 mm Hg. Then a transverse incision
was made overlying the mass and carried down through the skin. The subcutaneous
tissue was carefully dissected. The sensory nerves were retracted medially and laterally.
The extensor mechanism was opened. I opened the retinaculum and the extensor tendons
were retracted medially and laterally. We then found the ganglion cyst. It was
approximately 3-cm in diameter and had a tract both radially and ulnarly. We dissected
around the cyst completely with the surrounding fibrofatty tissue and followed this
down to its origin in the dorsal wrist capsule at the region of the scaphoradial joint. We
excised it with a portion of the capsule and its serpiginous tail. We also excised a
portion of the posterior interosseous nerve, which was lying in direct contact with
this mass. We then copiously irrigated the wound. We obtained hemostasis and
cauterized the area of cyst excision. We closed this with a running 3-0 Prolene
subcuticular suture. Benzoin and Steri-Strips, 4 by 4’s, bulky dressing and plaster splint
were applied. The patient tolerated the procedure well and was discharged to the
recovery room in satisfactory condition.
Advanced Clinic
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Exercise 1 - continued
PATHOLOGY REPORT
Age/Sex: 39/F
PREOPERATIVGE DIAGNOSIS:
RIGHT WRIST GANGLION, BILATERAL
OPERATION PERFORMED:
RIGHT-EXCISION GANGLION WRIST; ASPIRATION CYST; REMOVAL
RIGHT WRIST, LEFT WRIST ASPIRATION GANGLION.
TISSUE REMOVED:
A. GANGLION RT WRIST
GROSS DESCRIPTION:
RECEIVED LABELED GANGLION RT WRIST. THE SPECIMEN CONSISTS OF A
RUBBERY FIRM PINK-TAN TISSUE MEASURING 1.5 X 0.5 X 0.3 CM. THE
SPECIMEN IS SERIALLY SECTIONED ON THE SHORT AXIS DIRECTION
REVEALING A RUBBERY FIRM PINK-TAN CUT SURFACE. ALL BLOCKED.
PATH PROCEDURES:
PROCEDURES: PATH DSM, A1 BLK
FINAL DIAGNOSIS:
SOFT TISSUE, RIGHT WRIST, EXCISION: FIBROADISPOSE TISSUE WITH
FOCAL MYXOID CHANGES PRESENT, CONSISTENT WITH GANGLION
CYST.
Signed ____________________
Advanced Clinic
Hand Surgery
39
OPERATIVE REPORT
Operation:
Release of long and ringer trigger fingers bilaterally.
Anesthesia:
Local 2% Xylocaine median and ulnar nerve blocks bilaterally.
Preoperative diagnosis:
Long and ring trigger fingers bilaterally.
Postoperative diagnosis: Long and ring trigger fingers bilaterally.
Operative Indications:
The 49-year-old patient developed triggering of the long and
ring fingers of both hands. Conservative treatment was unsuccessful. He had a closed
percutaneous release of the left ring trigger finger which was unsuccessful.
Operative Findings: There was some superficial fraying of the superficialis tendon of the
right long finger. There were some adhesions between the two flexor tendons in each of
the fingers. There was marked fraying of the superficialis and moderate fraying of the
profundus tendon in the left ring finger. The Al pulley was very tight. There was some
tenosynovitis proximal to the Al pulley. The Al pulley had been partially divided at its
proximal end. After the releases, the patient was able to fully flex and extend his fingers
without any catching or locking.
Operative Procedure: The right hand was done first. A transverse incision was made
between the proximal and distal palmar creases at the bases of the long and ring fingers.
The flexor sheaths were exposed. The Al pulleys were divided. The tendons were
inspected. The fraying of the superficialis tendon of the long finger was minimally
debrided. The skin was closed with #4-0 nylon sutures. A dry, sterile, bulky,
compressive type dressing was applied. The pneumatic tourniquet was released.
The left hand was then done. A transverse incision was made between the proximal
and distal palmar creases at the bases of the long and ring fingers. The flexor sheaths
were exposed. The Al pulley of the long finger was divided. A Transverse incision
was made in the proximal flexor crease of the ring finger to further expose the flexor
sheath and the tendon. The frayed edges of the tendons were debrided. Localized
tenosynovectomy was carried out. The patient was then able to fully flex and extend his
fingers without any catching or locking. The skin was closed with #4-0 nylon sutures. A
moist, bulky, compressive type dressing was applied. The pneumatic tourniquet was
released.
Advanced Clinic
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40
The patient tolerated the procedure well and was sent to the recovery room in satisfactory
condition.
Drains:
None.
Complications:
None.
Estimated Blood Loss: None.
I was present during the entire operation.
Advanced Clinic
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41
OPERATIVE REPORT
PREOPERATIVE DIAGNOSES:
1. Trigger finger, left ring.
2. Trigger finger, left little.
3. Trigger finger, right ring.
POSTOPERATIVE DIAGNOSES:
Same.
OPERATIVE PROCEDURES:
1. Release of trigger finger, left fourth finger.
2. Release of trigger finger, left fifth finger.
3. Injection of Kenalog 40 into tendon sheath of right ring finger.
INDICATIONS FOR OPERATION:
The patient is a 62-year-old man with stenosing tenosynovitis of the flexor tendons of his
right and left hands. He has had severe triggering of his left ring and little fingers. He
has moderate triggering of the right ring finger. Careful discussion has been
undertaken over the surgical procedures of releasing of the A-1 pulley of the flexor
tendons to alleviate triggering. He understands that there is a small possibility of
complications because of injury to the adjacent neurovascular bundles and that the
injection has no guarantee of success. Because he has symptoms of both right and left
hands, injections will be performed on the right hand and release will be performed on
the left. The following procedure was performed.
DESCRIPTION OF PROCEDURE: The patient was placed on the operating room
table in the supine position. Adequate intravenous sedation was given to allow for
anesthetization of the right and left palmar area with 0.5% Marcaine plain. A pneumatic
tourniquet was then placed on the left upper arm. The left arm and hand were then
prepped with Hibiclens solution and draped with sterile technique. The left arm and hand
were then exsanguinated with an Esmarch bandage and the pneumatic tourniquet was
elevated to 280 mmHg pressure. A transverse skin crease incision was made overlying
the metacarpal phalangeal joint on the palmar aspect of the left hand between the fourth
and fifth fingers. The skin and subcutaneous tissues were incised. The palmar
aponeurosis was divided in the direction of its fibers. The flexor tendon was then bluntly
exposed allowing the neurovascular bundles to deviate to the sides. The A-1 pulley of
the left ring finger was then divided longitudinally and the flexor tendon was
retracted to make sure that it was completely mobile within the canal. The same
technique was then used on the left fifth finger flexor tendon to divide the A-1 pulley
and to make sure that it was completely released.
Advanced Clinic
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The pneumatic tourniquet was then released with a total tourniquet time of 5 minutes.
The patient was asked to flex and extend his hand and was found to have no triggering of
the ring or little finger. Hemostasis was then obtained with pressure, elevation, and the
electrocautery. The wound was then closed with interrupted horizontal mattress and
continuous simple sutures of 5-0 nylon. Sterile dressings of Xeroform gauze and a volar
splint of 3 inch fiberglass were applied.
On the right palm, the anesthetization had been obtained with 0.5% Marcaine over the
metacarpal phalangeal joint of the right ring finger. A 25-gauze needle with a 3 cc
syringe and 0.5% Kenalog 40 were then used to inject into the flexor tendon sheath
of the right ring finger. The finger was then placed through a range of motion. The
wound was left undressed.
The patient was awakened and taken from the operating room in satisfactory condition
having tolerated the procedures well. Estimated blood loss was minimal. Sponge and
instrument counts were correct at the end of the operation.
Advanced Clinic
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Exercise 4 . Please read the following clinical data and assign the appropriate
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS:
Extensive adhesions left index finger flexor digitorum profundus and flexor digitorum
superficialis tendon, nine months status post flexor tendon repair tendon repair in zone 2.
POSTOPERATIVE DIAGNOSIS: Extensive adhesions left index finger flexor
digitorum profundus and flexor digitorum superficialis tendon, nine months status post
flexor tendon repair in zone 2.
OPERATION: Tenolysis left index finger flexor digitorum profundus and flexor
digitorum superficialis tendons.
ANESTHESIA: Bier block.
TOTAL TOURNIQUET TIME: 105 minutes at 250 mmHg.
BLOOD LOSS: Minimal.
INDICATIONS: The patient is a 59-year-old right hand dominant retired who has
become well known to me over the past nine months. She initially presented on January
23, 2003 after sustaining a laceration to the palmar aspect of the left index finger which
resulted in lacerations of both the FDP and FDS tendons and both digital nerves to the
index finger. Her tendons and nerves were repaired the same day. She initially did well
for the first five weeks postoperatively and motion was impressive. Unfortunately, at that
point, she went on vacation for a week and, despite having continued with exercises,
developed marked adhesions between weeks five and six. We have spent a great deal of
time performing therapy in the interim in order to try to free these adhesions. It
ultimately became clear that these were fixed and additional time was allowed for scar to
soften up. She has clearly plateaued in terms of therapy and in terms of scar remodeling
and is prepared at this time to undergo tenolysis.
She understands that tenolysis is designed to free the flexor tendons from the scar
that has formed between them and the adjoining structures. This will allow freer
gliding of the tendons. In order to maintain this motion, active therapy immediately
following the release is necessary. This is made possible by the fact that the tendons are
now strong and can withstand this stress. Without such early motion, adhesions will
reform and may in fact be worse.
Advanced Clinic
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44
She understands this. She understands that all surgery is attended by risk including the
risks of infection, wound healing difficulties, injury to the tendons themselves or to
adjacent nerves, the potential for rupture at or following the surgery, the potential for the
reformation of adhesions, and the certainty of a less than ideal result should she not
participate in postoperative rehabilitation aggressively. She understands and accepts
these risks and, after having all of her questions answered to her satisfaction, has signed
the appropriate consent forms in witness there of.
DESCRIPTION OF PROCEDURE: The patient was identified in the preoperative
holding area where an intravenous line was placed in her affected left hand by the
anesthesiologist. She was then transferred to the operating room where she was placed
supine on the operating table. At that point, her anesthesiologist, the doctor performed a
Bier block with my assistance. With this done, the intravenous line in the left hand was
removed and her left upper extremity was prepped and draped in the usual sterile fashion
with a Betadine scrub and paint from the fingertips to the tourniquet.
The case was performed under 2.5 x loupe magnification. I began by making a 2 cm long
incision in the distal palmar crease at the Al pulley level. The skin was incised sharply
and the subcutaneous tissue dissected bluntly to reveal the underlying flexor digitorum
profundus and flexor digitorum superficialis tendons. After isolating these, traction
was applied in an effort to effect a traction tenolysis. This was completely ineffective at
this level. It was clear that I was not going to be able to pull through the dense scar over
the proximal phalangeal level.
At this point, I proceeded to expose the palmar aspect of the finger. This was done
through a curved incision making every effort to avoid cutting across the palmar surface
of the finger as much as possible. Transverse limbs were placed in the flexion creases at
the MP, PIP and DIP joint and the longitudinal segments were kept as laterally as
possible. The skin was incised sharply here and careful blunt dissection was carried out
to divide the skin from the underlying scar. This was an arduous process as the scar was
quite dense and quite thick. With the skin flaps raised, care was then taken to identify the
radial and ulnar digital nerves. These were traced from the level of the MP flexion crease
out to the DIP flexion crease and were noted to be intact and healthy appearing. With the
nerves isolated, I began to address the scar overlying the flexor tendons. The scar
was debrided to reveal the A1 and A4 pulleys which were largely intact. The A3 pulley
had been damaged in the initial injury. With the superficial scarring removed, I was able
to use the A3 pulley window to bluntly divide scar deep to the flexor digitorum
superficialis. Finally, with this done, I returned to the palmar wound where traction was
applied and, at this point, having removed as much of the scar surgically, a traction
tenolysis was effective in completing the release of the adherent tendons.
Advanced Clinic
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45
At the completion of the procedure, I was able to bring the left index fingertip to within 7
mm of the distal palm via traction through the A1 pulley level. This was essentially the
passive limit or her joint motion. She has a 36 degree flexion contracture at the PIP joint,
but I decided that in the interest of allowing her the best chance at maintaining her flexion
I would not do a significant release at the PIP joint, which would cause her more pain and
likely inhibit her ability to perform active rehabilitation. We will do that at a later date if
she desires.
After cleaning up the remnants of the scar and assuring that both digital nerves remained
intact, the wound was irrigated copiously with dilute Betadine saline solution. The skin
over the finger was closed and again traction was placed at the palmar wound. The
fingertip actually came slightly closer to the palm approximately 6 mm from the distal
palm. Satisfied with the release, the finger closure was completed with interrupted
sutures of #5-0 nylon and the palmar wound was closed with interrupted horizontal
mattress sutures of #5-0 nylon. A soft dressing consisting of Xeroform over the incision
and a Kling wrap was applied and secured with an Ace bandage.
At the completion of the case, sponge, needle and instrument counts were correct. Total
tourniquet time was 105 minutes at 250 mmHg. There were no complications. At the
completion of the case, the patient was accompanied to the PACU awake and in stable
condition.
COMPLICATIONS:
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OPERATIVE RECORD
PREOPERATIVE DIAGNOSIS: Dupuytren disease, left palm.
POSTOPERATIVE DIAGNOSIS: Dupuytren disease, left palm, pathology pending.
OPERATION:
Palmar fasciectomy, left palm.
ANESTHESIA: Local.
INDICATIONS: This is a 66-year-old female with a painful pretendinous band in the
left palm who presents for definitive treatment.
PROCEDURE: The patient was taken to the operating room and placed in the supine
position. A tourniquet was placed high on the left upper extremity, and the left upper
extremity was prepped and draped in the usual sterile fashion. Infiltration with 0.5%
Marcaine with epinephrine was performed for anesthesia using a field block. Next, the
arm was elevated and exsanguinated. The tourniquet inflated to 250 mmHg. The total
tourniquet time was less than 2 hours.
Using a chevron-shaped incision, the skin was incised. The skin was sharply taken
down off of the underlying diseased fascia. The pretendinous band was exposed.
The proximal extent of it was identified and cut. The mass was excised incorporating
normal superficial palmar fascia. The mass was sent to pathology for appropriate
study after releasing it from its most distal end in the palm.
The wound was copiously irrigated. Hemostasis obtained with electrocautery. The skin
was gently approximated with 5-0 nylon. Xeroform and a bulky dressing were applied
and held with Kerlix and an Ace wrap.
Estimated blood loss was minimal. The IV fluid replaced was none. Drains and packs
were none. Complications were none. The patient tolerated the procedure well and was
taken to the recovery room in a good postoperative condition.
Advanced Clinic
Hand Surgery
SURGICAL PATHOLOGY REPORT
Age: 1/17/37
Sex: F
CLINICAL DIAGNOSIS: Deep Mass Left Palm
TISSUE SUBMITTED:
Mass Left Palm
IMPORTANT CLINICAL DATA:
GROSS: MASS LEFT PALM. The specimen is received in formalin and consists
of a shaggy, partially cystic structure measuring 1.3 x 0.6 x 0.5 cm. The
specimen will be bisected and submitted in toto.
DIAGNOSIS: TISSUE FROM LEFT PALM: FIBROTENDINOUS TISSUE
SHOWING FIBROBLASTIC PROLIFERATION, COMPATIBLE
WITH PALMAR FIBROMATOSIS.
47
Advanced Clinic
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OPERATIVE REPORT
OPERATION: Left little finger palmar and digital fasciectomies for Dupuytren’s.
ANESTHESIA: Axillary block.
PREOPERATIVE DIAGNOSIS: Moderate to severe left little finger Dupuytren’s.
POSTOPERATIVE DIAGNOSIS: Moderate to severe left little finger Dupuytren’s.
OPERATIVE INDICATIONS: The patient is a 74-year-old male who has left little
finger Dupuytren’s primarily of the proximal interphalangeal and distal
interphalangeal joints. He has significant contracture across both of these joints.
OPERATIVE FINDINGS: Moderate severe palmar disease and severe proximal
interphalangeal and distal interphalangeal joint disease involving the left little finger.
OPERATIVE PROCEDURE: With consent from the patient, he was taken to the
operating room. In the supine position, an axillary block was placed by anesthesia.
Anesthesia administered intravenous sedation. Anesthesia monitored the patient
continuously during the procedure.
The extremity was prepared with Betadine and draped out. With adequate anesthesia, the
preoperative markings were marked out. The extremity was exsanguinated.
The incision was made with a #15 Bard-Parker. Carefully and delicately, the dermis was
dissected off the overlying diseased fascia. The ulnar and radial neurovascular bundles
were identified out distally. These were dissected out carefully with a Beaver blade and
Stevens’ scissors. The ulnar and radial neurovascular bundles were then dissected back
proximally exposing them along their length of the finger to the palm.
In doing this, the diseased fascia was carefully dissected aware from the surrounding
dermis and soft tissue. The diseased fascia was also dissected away from the flexor
sheath. Ulnarly, the disease inserted beyond the distal interphalangeal joint into the
flexor sheath. Significant insertions of the diseased fascia were dissected off the
distal interphalangeal joint and proximal interphalangeal joint areas. Additionally,
proximally the diseased fascia was dissected off the musculotendinous origin of the
abductor digiti minimi.
Bleeding was controlled with bipolar cautery.
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The tourniquet was released. The little finger remained well perfused. The wound was
irrigated out. Bleeding was controlled with bipolar cautery. A Z-plasty was performed
across the metacarpophalangeal crease. The skin edges were reapproximated with #50 nylon.
The wound was dressed with Xeroform, fluffs, Webril and ulnar gutter splints with the
wrist extended 20 degrees, metacarpophalangeal joint at 70 degrees and interphalangeal
joint at 0.
SPECIMEN: Bacteriological: None. Pathological: The palmar and digital diseased
fascia was submitted.
PROSTHETIC DEVICE OR IMPLANT: None.
ESTIMATED BLOOD LOSS: Less than 10 milliliters/blood given, none.
FLUIDS: Crystalloid.
SPONGE COUNT: Correct.
POSTOPERATIVE CONDITION: Fair, stable.
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SURGICAL PATHOLOGY
FINAL DIAGNOSIS:
LITTLE FINGER (EXCISION) - FIBROMATOSIS (DUPUYTRENS
CONTRACTURE)
************************************************************************
*****
SPECIMEN(S) SUBMITTED:
LEFT LITTLE FINGER DUPUYTRENS
CLINICAL DATA:
Left little finger contracture
GROSS DESCRIPTION:
A. Received fresh are two pieces of soft irregular shaped white fibrous
tissue with attached fibroadipose tissue which measure in aggregate
5 x 1 x 0.5 cm. Specimens are serially sectioned and representative
sections are submitted.
(Age: 74) M
Advanced Clinic
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OPERATIVE REPORT
Recurrent Dupuytren’s contracture of the left little finger with significant proximal
interphalangeal joint contracture of 80 degrees.
POSTOPERATIVE DIAGNOSIS:
Recurrent Dupuytren’s contracture of the left little finger with significant proximal
interphalangeal joint contracture of 80 degrees.
OPERATION:
1. Excision of digital palmar fascia with skin grafting from the ulnar border of the
hand to the proximal interphalangeal joint level.
2. Release of volar plate and joint contracture of the proximal interphalangeal joint.
INDICATIONS:
This is a 64-year-old female who had had excision of digital palmar fascia several years
ago on left little finger. She was noncompliant with the brace and rehab protocol initially
postop, and she had progressed down from approximately 35- to 40- degree contracture
when she was last seen to almost 80 degrees at this point in time. To try to stop any
bridging fascial cords, it was elected that we would skin graft at the PIP joint with this
release.
PROCEDURE:
The patient was placed in the supine position on the operating table. After adequate
intravenous sedation was given, she had a block of the ulnar nerve at the wrist with
0.25% Marcaine and 2% Xylocaine plain. She was prepped and draped in the usual
sterile fashion. The arm was elevated, and the tourniquet was inflated to 250 mmHg.
Then a Bruner zigzag incision was made overlying the finger and was carried down to
the skin, carefully dissecting the subcutaneous tissue and lifting a flap. We exposed and
protected the neurovascular bundles and excised the diseased cords. Then we opened
the tendon sheath and excised a portion of the volar plate and released the accessory
and collateral ligaments to the finger at the PIP joint. We obtained full extension
intraoperatively. We measured the size for the proposed skin graft and removed a 2.5 x
1.5 cm skin graft from the lateral margin of the hand. The skin was carefully
dissected, and a full-thickness graft was obtained. The flaps were elevated.
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Hemostasis was achieved, and the graft site was closed primarily with 5-0 Prolene
sutures. The finger was closed with 5-0 Prolene sutures as the graft was interposed
at the PIP joint level. Once this was completed, we applied Xeroform, soft bulky
dressing, and a plaster splint to keep the finger in full extension. The patient tolerated the
procedure well and was discharged to the recovery room in satisfactory condition.
Advanced Clinic
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OPERATIVE REPORT
Dupuytren disease, right hand.
POSTOPERATIVE DIAGNOSIS: Dupuytren disease, right hand.
OPERATION: Excision of Dupuytren disease, right hand from right thumb, right middle
finger, and right palm.
ANESTHESIA: General.
INDICATIONS: This is a 56-year-old female with painful and large Dupuytren nodules
at the aspect of the first webbed space by the thumb also at the PIP joint of the middle
finger with approximately 30% contracture and at the A1 pulley area in line with the ring
finger. She desires definitive treatment and presents for excision.
position. After general anesthesia was obtained, a tourniquet was placed high on the right
upper extremity, and the right upper extremity was prepped and draped in the usual
sterile fashion. First, the arm was exsanguinated and the tourniquet inflated to 250
mmHg. The total tourniquet time was less than 2 hours.
Infiltration was 0.5% Marcaine was performed at each of the sites where the Dupuytren
disease was present for postoperative anesthesia.
First, attention was directed to the palmar area in line with the ring finger.
A transverse incision was made at the distal/palmar crease where the disease was
present. The skin was sharply dissected away from the disease. Circumferential
dissection of the disease was completed. It was cut distally and dissected proximally.
Careful attention paid to protect the underlying neurovascular bundles and flexor tendon.
The disease was completely excised and sent to Pathology. The wound was copiously
irrigated. Hemostasis was obtained with electrocautery. The skin gently approximated
with 5-0 nylon.
Next, attention was paid to the PIP joint of the middle finger, where again a
transverse incision was made at the PIP crease. Circumferential dissection was
carried out around the ulnar aspect of the digit. The ulnar neurovascular bundle was
first identified and then dissection carried out and completed around the disease. It was
also released proximally and dissected distally. It was taken off of the middle phalanx,
and this helped correct the 30% contracture of the PIP joint.
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Next, attention was paid to the first webbed space just below the thumb. A
transverse incision was made over longitudinal disease. And again, circumferential
dissection was carried out around the disease protecting underlying neurovascular
structures.
The disease was able to be excised in toto. This wound was also gently approximated
with 5-0 nylon after copious irrigation, and hemostasis being obtained with
electrocautery. All wounds were dressed with Xeroform and dressing sponges. This was
held with Kerlix and then an Ace wrap.
Estimated blood loss was minimal. The IV fluids replaced was less than 2000 cc of
crystalloid. Drains and packs were none. Complications were none.
The patient tolerated the procedure well and was taken to the recovery room in a good
postoperative condition.
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Age 6/04/46
Sex: F
CLINICAL DIAGNOSIS: Dupuytren’s Disease Right Thumb, Middle and Ring Finger
TISSUE SUBMITTED:
Fascia Right Thumb, Middle and Ring Fingers
IMPORTANT CLINICAL DATEA:
GROSS: FASCIA RIGHT THUMB, MIDDLE RING FINGER. The specimen is
received in formalin and consists of three fragments of firm, rubbery
whitish yellow partially friable tissue, ranging in size from 1.0 x 0.8 x
0.5 cm up to 1.5 x 1.0 x 1.0 cm. Representative sections will be submitted
in one cassette.
DIAGNOSIS: TISSUE FROM RIGHT HAND: FRAGMENTS OF ADIPOSE
TISSUE WITH FIBROVASCULAR TISSUE AND FIBROTENDINOUS COMPONENTS SHOWING FIBROBLASTIC
CELLULAR PROLIFERATIVE CHANGES COMPATIBLE
WITH A FIBROMATOSIS OF DUPUTYREN’S CONTRACTURE.
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PROCEDURE NOTE
PREOPERATIVE DIAGNOSIS: Extensor tendon injury zone 5, right index finger.
POSTOPERATIVE DIAGNOSIS: Same.
OPERATIVE PROCEDURE: Repair of right index finger extensor tendon zone 5.
ANESTHESIA: Marcaine 0.25% and sedation.
DRAINS: None.
COMPLICATIONS: None.
INDICATION FOR PROCEDURE: This patient has a history of an extensor tendon
injury to his right index finger over zone 5. It was felt best amenable to operative
intervention.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite and 1
gram of Ancef was administered. The right upper extremity was prepped and draped in a
normal sterile fashion. Marcaine 0.25% had been infiltrated about the proposed incision.
The arm was exsanguinated of blood and tourniquet was inflated to 250 mmHg.
There was noted to be an oblique laceration over zone 5 of the right index finger of 1
cm. This was extended distally and proximally in a Brunner type fashion. Skin flaps
were elevated and retracted with 4-0 silk. The wound was copiously irrigated. The
extensor mechanism was completely transected including the ulnar sagittal bands.
A running 6-0 nylon epitendinous suture was applied to coapt the tendon. We then
placed 3-0 Ethibond suture of Kessler type configuration as a core suture. Excellent
coaptation of the tendon was achieved. When we flexed the finger, there was no gaping
at the tendon juncture. The wound was irrigated and closed with 4-0 nylon. A sterile
dressing and splint were applied with the wrist in extension and the MP at 0 degrees. The
IP joints were left free. The patient was transferred to the recovery room in good
condition.
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OPERATIVE REPORT
1. Laceration left index finger at proximal phalanx dorsally.
2. Extensor tendon laceration left index finger.
3. Laceration left index finger to bone.
Same.
PROCEDURE:
1. Irrigation, debridement, exploration of left index finger laceration including
violation of cortical bone.
2. Repair of extensor tendon laceration. Total length of repaired laceration is 3.5
centimeters.
ANESTHESIA:
Monitored anesthesia care.
FLUIDS DELIVERED INTRAOPERATIVELY:
300 CC Ringer’s Lactate.
ESTIMATED BLOOD LOSS:
Minimal.
TOTAL TOURNIQUET TIME OF THE CASE:
7 minutes at 250 mmHg.
COMPLICATIONS:
None.
INDICATIONS: The patient is a 50-year-old right-handed dominant female who
sustained a laceration to her left index finger a couple of days ago as a result of a
knife wound, self-infected while cutting or slicing turkey. She was seen in the
emergency room at General Hospital where the extensor tendon was seen in the wound
and noticed to be lacerated. The patient is being taken to the operating room to
undergo formal evaluation, irrigation, debridement and repair of structures as indicated at
the left index finger laceration site at the dorsal radial aspect of the proximal phalanx.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and
placed on the OR table in the supine position under IV sedation, augmented with local
digital block anesthesia using a 50/50 mix of 0.5% Marcaine and 2% Xylocaine.
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The extremity was prepped and draped in the usual fashion for surgery. A tourniquet was
applied to the arm. The extremity was exsanguinated with an Esmarch bandage. The
tourniquet was inflated to 250 mmHg. The total tourniquet time for the case is 7 minutes.
The total tourniquet time for the case is 7 minutes. The procedure was begun by
extending the excision proximally and distally in a gentle S shape. The original incision
is approximately 1.5 centimeters in length, it is roughly transverse at the dorsal radial
portion of the proximal phalanx at about its halfway mark. The total incision length is
3.5 centimeters. The entire surgical procedure was performed under 3.5 power loupe
magnification. The flaps were elevated. The extensor tendon mechanism is evaluated.
There is a 1-centimeter transverse incision in the extensor tendon hood. The palmar most
edge of the radial lateral band remains intact. There is approximately 4 millimeters
distanced from that edge to the beginning of the incision. The incision then carried
over ulnad to about the mid portion of the extensor hood. The periosteum is
evaluated deep to the tendon. The lacerate had gone to bone. This area of exposed
bone is then debrided with a curet and thoroughly irrigated with antibiotic
irrigation. The tendon laceration is repaired using 3-0 Ethibond suture with
multiple figure-of-eight stitches. The tourniquet is released. Hemostasis is obtained by
direct pressures and elevation, followed by bipolar electrocautery Bovie. The skin is
closed with 5-0 nylon sutures. Xeroform and sterile gauze dressing is applied. A finger
extension splint is applied and held in place with an Ace wrap. The dressing includes the
wrist and distal forearm. The patient is returned to the recovery area in good condition.
there were no preoperative, intraoperative or postoperative complications.
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OPERATIVE RECORD
PREOPERATIVE DIAGNOSIS: Radial collateral ligament injury, right thumb.
POSTOPERATIVE DIAGNOSIS: Radial collateral ligament injury, right thumb.
OPERATION: Radial collateral ligament reconstruction with advancement of
abductor tendon.
INDICATIONS: This 28-year-old police officer was injured in an altercation. He has
done well with conservative treatment and by physical examination and x-ray has
complete rupture of his radial collateral ligament. He presents for definitive
treatment.
upper extremity. The right upper extremity was prepped and draped in the usual sterile
fashion.
An incision was made along the radial side of the MIP joint at the thumb. In the
subcutaneous tissues, the dorsal central branch radial nerve was identified and protected.
The extensor mechanism was also gently retracted ulnar ward.
An incision was made along the radial side of the joint. There was obvious complete
rupture of the ligament. A remnant ligament was fortunately still present. Using a
ronguer, bony troughs were made on the radial side of the proximal phalanx and
the radial side of the metacarpal head. Bone anchors were applied to each area.
The joint was reduced. The remnant ligaments were sewn into our bony troughs on
either end. The sutures from the bone anchors were then used to advance the
abductor into the radial side of the joint for added stability.
With this completely sewn in then, radial stability was once again restored to the joint
with the ulnar deviation. There was no gapping of the joint on the radial side. Passive
flexion-extension was attacked as well. The wound was copiously irrigated. Hemostasis
obtained with bipolar electrocautery. The skin was gently approximated with 5-0 nylon.
The area was infiltrated with 0.5% Marcaine with epinephrine for postoperative
anesthesia. Xeroform and a bulky dressing were applied and held with Kerlix. A radial
thumb spica splint was applied and held with Kerlix. A radial thumb spica splint was
applied and held with Kerlix and an Ace wrap.
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The estimated blood loss: Minimal. The IV fluid replaced: Less than 3000 cc of
crystalloid. Drains and packs: None.
Complications: None.
The patient tolerated the procedure well and was taken to the recovery room in good
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OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Right hook of hamate nonunion.
POSTOPERATIVE DIAGNOSIS: Right hook of hamate nonunion.
OPERATION: Excision right hoot of hamate.
ANESTHESIA: General endotracheal.
INDICATIONS: The patient is a 34-year-old gentleman with trauma to his right hand
sustained a hook of hamate fracture, which has developed a nonunion. Given persistent
discomfort, the patient is brought for hook of hamate excision.
PROCEDURE/FINDINGS
The patient was brought to the operating room and after successful induction of general
anesthesia with endotracheal intubation, the patient was positioned supinely on the
operating room table. The tourniquet was placed around the right upper extremity and
the limb prepped and draped in a sterile fashion. After exsanguination with elevation, the
tourniquet was inflated to 250 mmHg. A curvilinear incision based in the right
palmar overlying Guyon canal was made with a #15-blade scalpel. Subcutaneous
tissue was divided bluntly with Stevens tenotomy scissors. The ulnar nerve vascular
bundle was identified and retracted ulnarly and the tip of the hamate were palpated. The
fascia was split longitudinally and dissected subperiosteally around the hook of the
hamate. At its base there was a nonunion with gross motion. The hook was
removed and the base was smoothed with a rongeur and small rasp. Bone was
placed over the cancellous portion. The flexor tendons were visualized showing no
evidence of fraying or irritation. The tourniquet was then deflated. Hemostasis was
assured with bipolar cautery and the wound irrigated with normal saline. The wound
edges re-approximated with 4-0 nylon suture. Xeroform followed by sterile dressing was
applied. Prior to dressing the wound area was infiltrated with 0.25% Marcaine plain for
postoperative pain relief. A short arm splint was ultimately applied.
Estimated blood loss 5 cc. Tourniquet time 17 minutes. Drains: none. Complications:
none.
DISPOSITION: The patient tolerated the procedure well and was taken to the recovery
room in good condition.
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OPERATIVE RECORD
PREOPERATIVE DIAGNOSIS: Right thumb, metacarpophalangeal joint arthritis.
POSTOPERATIVE DIAGNOSSI: Right thumb, metacarpophalangeal joint arthritis.
OPERATION:
graft.
Right thumb metacarpophalangeal joint arthrodesis with local bone
INDICATIONS: This 50-year-old female has been followed with MP joint arthrosis of
her thumb for some time. She has failed conservative treatment including splinting and
presents for definitive treatment.
PROCEDURE: The patient was taken to the operating room and placed in a supine
upper extremity. The right upper extremity was prepped and draped in the usual sterile
fashion.
Using a radially based flap semi-curved incision over the MP joint, the skin was
incised. The dorsal central branch of the radial nerve was protected. The EPL was
identified and, at the level of the MP joint, the joint was entered between the EPL and
other extensor tendons.
The collateral ligaments were taken down. There were large osteophytes present on
both medial and lateral side. These were debrided with a rongeur. There was a
complete loss of cartilage down to denuded bone on the metacarpal side of the MTP joint
as well as on the proximal phalanx side.
Next, using a Conex reamer, the green reamer was used to prepare both the
metacarpal head and the proximal portion of the proximal phalanx. This was taken
down to good bleeding cancellous bone and local bone was harvested for graft.
Next, using bold screws over a K-wire, a K-wire was placed holding the joint in about 25
degrees flex. Our graft was packed into the joint site, and a 32-mm screw was
measured the appropriate size. A 32-mm screw was placed giving excellent
compression of our fusion site. This was supplemented with an anti-rotational K-wire.
The hardware positions were checked on AP, lateral and oblique views of the C-arm, and
excellent position noted. Good apposition of the bony ends was obtained.
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The K-wire was cut off at the level of the bone. A 3-0 undyed Vicryl was used to repair
the capsule, and the retinaculum over the extensor tendons was also repaired with a 3-0
undyed Vicryl. The skin was approximated with 5-0 nylon. The area was infiltrated with
0.5% Marcaine for post-op anesthesia.
Xeroform and a bulky dressing were applied and held with Kerlix. A radial thumb spica
splint was applied and held with Kerlix and an Ace wrap.
The estimated blood loss was minimal. The IV fluid replaced was less than 2000 cc of
The patient tolerated the procedure well and she was taken to the recovery room in a
good postoperative condition.
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OPERATIVE RECORD
1. Chronic painful mallet deformity, left little finger.
2. Distal interphalangeal joint arthritis, left little finger.
OPERATION: Distal interphalangeal joint fusion, left little finger with autograft.
ANESTHESIA: Local.
INDICATIONS: This is a 46-year-old female who suffered an injury to her little
finger DIP joint and has had pain, redness, and irritation in that joint since July of this
year.
On physical exam, she had a chronic mallet deformity, but on exam she also had pain at
the DIP joint consistent with possible early osteoarthritis. She presented for definitive
treatment.
position. A digital block was performed with 0.5% Marcaine plain. A tourniquet was
placed high on the left upper extremity. The left upper extremity was prepped and draped
in the usual sterile fashion. The arm was exsanguinated. The tourniquet was inflated to
250 mmHg. The total tourniquet time was less than 2 hours.
First, an S-shaped incision was made on the dorsum of the DIP joint, taken down to
the level of the extensor mechanisms where flaps were raised. The previous disruption of
the extensor mechanism was identified. The DIP joint was entered, and there was
significant loss of cartilage off of the middle phalanx as well as the distal phalanx.
Because of these findings, it was elected to perform a DIP joint fusion.
Using a rongeur, a lot of bone was removed from the ends of the middle phalanx as
well as from the proximal end of the distal tufts down to good cancellous bleeding
bone. Local bone graft was also harvested from the middle phalanx.
Next, using Acutrak fusion set, the distal phalanx and middle phalanx were prepared. A
24-mm screw was placed with our graft interposed between the 2 ends. Good
compression of the distal tuft on the middle phalanx was noted. Good placement of
the hardware and alignment of the digit were noted on AP and lateral views of the C-arm.
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This being the case, the wound was copiously irrigated. Hemostasis obtained with
bipolar electrocautery. Using vertical mattress sutures over the extensor mechanism
using full-thickness sutures, the wound was repaired. This was supplemented with
horizontal mattress sutures medially and laterally for the skin edges.
The blood loss was minimal. The IV fluid replaced was none. Drains and packs were
none. Complications were none.
The patient tolerated the procedure well and was taken to the recovery room after
Xeroform and a bulky dressing were placed and held with tube gauze.
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OPERATIVE REPORT
Age: 43
OPERATION: Right thumb CMC joint arthrodesis with internal fixation.
ANESTHESIA: General endotracheal anesthesia.
PREOPERATIVE DIAGNOSIS: Right thumb CMC arthritis.
POSTOPERATIVE DIAGNOSIS: Right thumb CMC arthritis.
OPERATIVE INDICATIONS: The patient has for some time had pain about the right
basilar thumb region. History and physical examination as well as radiographic studies
were all consistent with degenerative arthritis at that joint. Conservative treatment was
attempted, however, the patient still had significant pain limiting daily activities. For that
reason, the patient wished to pursue the surgical option. We discussed in detail the
alternatives for treatment, the recommended surgical treatment and the risks and benefits
associated with surgery. With full understanding, the patient wished to proceed with the
operation as described below.
OPERATIVE PROCEDURE: The patient was brought into operating room #4 at the
ambulatory surgical center. He was placed supine on the operating room table and a right
proximal arm tourniquet applied. It was isolated with a sterile drape. The right upper
extremity was prepped with Betadine and draped in a free and sterile fashion after the
patient was anesthetized by the anesthesia department. Also, the patient was given 1
gram of Ancef intravenously. The extremity was exsanguinated with an Esmarch
bandage and the tourniquet inflated to 250 mmHg where it remained for less than two
hours.
A 3 cm longitudinal incision was made over the first extensor compartment beginning
just distal to the radial styloid and proceeding over the dorsal surface of the thumb
metacarpal base. Dissection was primarily sharp with a 15 blade. The capsule over the
thumb CMC joint was incised. There was noted to be a significant amount of synovial
fluid present. The joint was inspected and the cartilaginous surfaces were extremely
worn. We also inspected the scaphotrapezial joint through a small arthrotomy and the
cartilage surfaces seemed to be well maintained. It should be noted that during the
initial dissection, the dorsal branch of the radial artery was isolated and protected
throughout the case.
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At this point, we chose to proceed with arthrodesis of the thumb CMC joint as described.
Using a curet and water cooled burs, a “cup and cone” tight fit was fashioned. We
made certain that we had excellent apposition between cancellous surfaces at the
base of the thumb metacarpal and the trapezium. We placed the thumb in
approximately 40 degrees of palmar abduction and 20 degrees of extension. We utilized
the flexed index finger as a guide making certain that the pulp of the thumb nicely met
the index finger middle phalanx on its radial aspect. Once this was assured, we then
compressed the arthrodesis site and two 0.062 smooth K-wires were introduced. Both Kwires gained excellent fixation in both bones. The K-wires were cut below the level
of the skin. The position of the arthrodesis was assessed clinically as was
radiolographically. Also, the reduction and stabilization was assessed. We were very
happy with the position and the stability.
The wound was thoroughly irrigated as it had been throughout the case and the capsule
repaired with 3-0 Ethibond suture. The skin was then closed with 5-0 Prolene suture.
Adaptic and sterile dressings were applied together with a thumb spica splint. The
patient was given pain medications, instructions and a follow-up appointment. There
were no operative complications.
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OPERATIVE REPORT
Age: 75
OPERATION: Left index finger revision-amputation at the P3 level. Left middle
finger distal interphalangeal arthrodesis with cortical cancellous distal radial bone
graft.
PREOPERATIVE DIAGNOSIS: Left index finger snow blower injury, with non
healing wounds. Left middle finger snow blower injury, with T3-distal
interphalangeal non union.
OPERATIVE PROCEDURE: With consent from the patient, he was taken to the
Operating Room. In the supine position, anesthesia placed an axillary block.
The extremity was prepared with Betadine and draped out. The extremity was
exsanguinated. The tourniquet was inflated to 250 millimeters of mercury. Total
tourniquet time was approximately 1 hour and 20 minutes.
The left index finger was approached first. The necrotic soft tissue from the tip was
debrided away. The underlying P-3 that was comminuted and non united was
debrided away. The proximal most shaft of the P-3 was debrided down too. The
bone was healthy at this point. This wound was irrigated out copiously with saline. The
laterally based skin flap that was viable was debrided back to healthy tissue and
preserved. This would provide coverage for the tip.
Perpendicular incisions were made at the eponychial fold, and the nail bed was dissected
out. The nail bed was then resected in its entirety. The wound was again irrigated out
with saline.
The lateral flap was brought around and trimmed to fit the index stump. The flap was
sutured in place with simple interrupted Nylon sutures.
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The left middle finger P-3, distal interphalangeal non union was approached through a
dorsal incision. The incision was made with a #15 Bard Parker. The extensor tendon
was incised and lifted up from the distal P-2 area out distally. The comminuted, non
united P3-distal interphalangeal was rongeured away. This was irrigated out with
saline.
The nail and soft tissue of the middle finger had healed well.
A distal radial bone graft was harvested from beneath the third extensor compartment.
Cortical cancellous bone was harvested. The harvest site was packed with Gelfoam.
The periosteum here was reapproximated with simple interrupted Ticron. The skin here
was reapproximated with simple interrupted #5-0 Nylon.
The cortical cancellous bone was packed into the distal interphalangeal/P-3 fracture
site. The cancellous bone was placed underneath the nail bed for support. Two 0.045 K
pins were fired through the remnant P-3 and P-2 head. The distal interphalangeal
was arthrodesed in 10 degrees of flexion.
This would was irrigated out with saline. The tendon was repaired with simple
interrupted #3-0 Ticron. The skin was repaired with simple interrupted #5-0 Nylon.
The wounds were dressed with Xeroform fluffs, casting passing, and a protective plaster
slab splint.
ESTIMATED BLOOD LOSS: Less than 10 ml, no blood given.
FLUIDS GIVEN:
Crystalloid.
SPONGE COUNT: Correct.
POSTOPERATIVE CONDITION: Stable.
SPECIMEN: Bacteriological-Soft tissue and bone, gram stain and bacterial cultures were
submitted. Pathological-Skin, soft tissue and bone were submitted.
PROSTETIC DEVICE OR IMPLANTS: 0.045 K pins x 2.
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(Age: 75) M
Part A: LEFT INDEX FINGER DEBRIDEMENT
Part B: MIDDLE FINGER DEBRIDEMENT
*****************************************************************
FINAL DIAGNOSIS
1. FINGER (DEBRIDEMENT, LEFT INDEX FINGER) - NECROSIS, ACUTE
INFLAMMATION, CHRONIC INFLAMMATION, GRANULATION TISSUE
AND
FOCAL IMPACTION OF OSSEOUS SEGMENTS IN FIBROUS TISSUE.
2. BONE AND FIBROUS TISSUE (DEBRIDEMENT, LEFT MIDDLE FINGER,
B) - GRANULATION TISSUE AND FIBROSIS.
******************************************************************
CLINICAL DATA:
1. Left middle and index finger snowblower injury.
GROSS DESCRIPTION:
A. Received in formalin are multiple fragments of red-tan-gray soft tissue
and bone aggregating to 4.0 x 2.5 x 0.2 cm. A fingernail is present with the
specimen. Representative sections are submitted in formalin.
B. Received in formalin are multiple minute fragments of gray-white soft
tissue and bone aggregating to 0.2 x 0.1 x 0.1 cm. The specimen is entirely
submitted in formalin.
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OPERATIVE REPORT
Rheumatoid arthritis—severe of the right hand with subluxation and dislocations of
all of her MP joints and instability.
Rheumatoid arthritis—severe of the right hand with subluxation and dislocations of
all of her MP joints and instability.
OPERATION:
Right hand metacarpophalangeal joint arthroplasties with silicone implants to the index,
middle, ring and little fingers, tendon transverse and realignments, capsule release of the
index, ring and little fingers and arthrodesis of the metacarpophalangeal joint of the right
thumb.
IMPLANTS USED
Size 4 for the index finger.
Size 5 for the middle finger.
Size 3 for the ring and little finger.
Right medical silicone implants.
There was one Acutrak 30-mm screw placed for the arthrodesis of the thumb.
INDICATIONS:
This is a 47-year-old female who presents because of a progressive deformity from
rheumatoid arthritis. She has been on Prednisone, methotrexate, folic acid, Remicade
which has really helped reduce some of her rheumatoid nodules to the digits, so we have
already completely reconstructed the contralateral hand, is here fore the right hand.
PROCEDURE/FINDINGS
The patient was placed in the supine position on the operating room table. After adequate
general endotracheal anesthesia was obtained, she was prepped and draped in the usual
sterile fashion. A transverse incision was made at the MP joint level. This was carried
down through skin and subcutaneous tissue, carefully dissected and flaps created.
Protecting the vasculature in the web space to preserve that throughout the course of
dissection. We then opened up the extensor mechanism. All of the extensors were
dislocated ulnarly, and we released them on their radial border. Mobilized the sagittal
bands on the ulnar side and on the radial side opened the capsular tissue, debrided the
synovitis and we proceeded to do the same procedure on all digits.
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We released the tight intrinsic on the ulnar side, mobilized the extensor tendon,
debrided the joint and then using oscillating saw removed whatever was remaining of
the metacarpal head and flattened the surface of the proximal phalanx. We then used
the _______ instruments. First an initial probe was placed and then the size was
successfully enlarged both proximally and distally, basing our size on the distal degree of
tolerance. Once both canals were rasped free and the MP joint was mobilized so that the
proximal phalanx completely brought out dorsal to the metacarpal cut, we knew we had
adequate release and the digits were straight. We then trialed all the prosthesis and
assessed the mobility and stability of the fingers. Once we were happy with this, using a
no-touch technique, we placed the implant arthroplasties, first the #4 in the index
finger, the #5 in the middle finger, the 33 in the ring and little finger. Closing the
capsular tissue with 4-0 PDS and then we transposed the extensor and performed a pantsover-vest type of repair to the sagittal bands, centralizing and to some degree radializing
the extensor mechanism with multiple Tycron sutures. We had good alignment and
balance of the fingers once this was completed. We confirmed the position of the
prosthesis radiographically. Once this part was completed we opened the thumb which
had a previous attempt at arthrodesis a number of years earlier. Dr. __________
was unsuccessful. The extensor mechanism was split, the joint opened, the capsule
opened and the synovitis debrided. Using a rongeur we contoured the head of the
metacarpal and some good cancellous bone. We used a small K-wire to make some
holes at the edge of the articular surface cortical bone interface of the proximal
phalanx using small osteotome and a curette to debride the sclerotic area. We then
were able to reduce this, placed one oblique K-wire, keeping the MP joint in
approximately 20 degrees of flexion. We drilled, tapped and placed the appropriate
length Acutrak screw. We used a 30 mm headless Acutrak screw, obtained good
arthrodesis with some supination to the thumb for easier pinch. Once this was
completed, we let down the tourniquet, obtained meticulous hemostasis, copiously
irrigated the sounds and closed all the wounds with 5-0 Prolene suture. Xeroform, 4 x
4’s, bulky dressing and plaster splint applied. The patient tolerated the procedure well
and was discharged to the recovery room in satisfactory condition.
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OPERATIVE REPORT
OPERATION: Repair of abductor pollicis first dorsal interosseous and primary repair of
the common digital nerve to the left thumb.
ANESTHESIA: General endotracheal anesthesia.
PREOPERATIVE DIAGNOSIS: Laceration to left first web space.
POSTOPERATIVE DIAGNOSIS: Laceration to the left first web space.
OPERATION INDICATIONS: This is a patient who was seen in the Emergency Room
after a knife laceration to his first web space involving the left hand. He was examined in
the Emergency Room and found to have a sensory deficit to the left thumb as well as
division of his abductor pollicis and first dorsal interosseous. He presents now for
repair.
OPERATIVE PROCEDURE: The patient was brought to the operating room, placed in
the supine position. IV access was established and he was given a general endotracheal
anesthetic. The left arm was then prepped and draped in a sterile fashion. The old
sutures were removed and the wound was opened up. The wound was then thoroughly
irrigated with saline solution and inspected. We found that the abductor pollicis and first
dorsal interosseous were divided and this was expected from his prior evaluation in the
Emergency Room. Careful dissection was carried out and the common digital nerve to
the thumb was identified and was found to be divided at the level just proximal to the
first metacarpal. The digital nerve to the radial aspect of the index was dissected and was
not injured and was in continuity. The abductor pollicis and the first dorsal
interosseous were then reapproximated using interrupted 3-0 Vicryl sutures to the
fascia. After this was done, the common digital nerve to the thumb was repaired
under the microscope using interrupted 9-0 nylon stitches suturing the epineurium
to the epineurium. After this was completed, the wound was once again irrigated with
saline solution and this irrigant was sucked out. The skin was then closed using
interrupted Ethilon stitches. A dorsal splint was then placed and situated such that the
thumb would be kept in IP flexion at the operation and at the conclusion of the operation,
it was let down without incident. The tourniquet time was 215 minutes. The general
endotracheal anesthetic was reversed and the patient was transported to the recovery
room in satisfactory condition.
ESTIMATED BLOOD LOSS: Approximately 20 cc.
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OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Left extensor pollicis longus tendon rupture.
POSTOPERATIVE DIAGNOSIS: Left extensor pollicis longus tendon rupture.
PROCEDURE PERFORMED: Left extensor indicis proprius to extensor pollicis longus
tendon transfer.
PROCEDURE: The patient was brought to the operating room and placed supine and
given general anesthesia. A well-padded pneumatic tourniquet was applied and set at
250. The arm was prepped and draped sterilely. The arm was exsanguinated and
tourniquet inflated. A 0.5 cm incision was made over the distal second metacarpal over
the extensor indicis proprius and the tendon was identified and was harvested. The gap in
the extensor hood was closed using #4-0 Mersilene. We then made a 2 cm transverse
incision over the third and fourth dorsal compartment and the extensor indicis proprius
was retrieved from this location. We then made a 1.5 cm incision over the distal first
metacarpal and the extensor hood of the thumb was visualized. The extensor
pollicis longus tendon was then seen. We then transferred the EIP tendon to
adjacent to the EPL and using an interweaver technique the EIP was attached to the
EPL distally. This was done while getting tension on the repair such that there was
an extended posture of the MCP with the wrist in neutral. Excellent excursion was
appreciated and the repair was reinforced using #4-0 Vicryl. The tourniquet was
released. The wounds were irrigated using normal saline and the wounds were closed
using #4-0 Vicryl and #4-0 Prolene. Sterile bulky dressing was applied. The patient was
placed in thumb-spika posture splint. The patient tolerated the procedure well without
any complications.
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OPERATIVE REPORT
Right thumb pan trapezial arthritis.
Same.
Right thumb trapeziectomy and ligament reconstruction tendon interposition. (LRTI).
INDICATIONS FOR OPERATION: The patient is a 69-year-old gentleman with a long
history of bilateral thumb pain. He’s been treated nonoperatively for pan trapezial
arthritis with splints and anti-inflammatory drugs and has been unresponsive and he now
is scheduled for surgical intervention.
DESCRIPTION OF OPERATION: The patient is brought to the operating room and
axillary block anesthesia was performed. After adequate anesthesia the right upper
extremity was prepped and draped in the usual sterile manner. The limb was
exsanguinated with an ACE wrap, tourniquet brought to 275 mm of mercury.
Longitudinal incision was made over the base of the thumb, metacarpal, carried
sharply down through the skin and subcutaneous tissue. Superficial radial nerve was
identified and protected. The capsule over the trapeziometacarpal joint was then
sharply incised. The radial nerve was identified and retracted approximately and
perforators were cauterized. Subperiosteal dissection was then carried around the
trapezium. It was split with a sagittal saw and removed piecemeal. A flexor
carpiradialis tendon was then harvested in the proximal forearm and pulled through
the defect left by the trapezium. The base of the metacarpal was then removed using
the oscillating saw. A 4 mm bur was then used to make a tunnel through the
metacarpal at the base. The tendon was then passed up through this hole and
folded on down itself and held in place with 4-0 Ti-Cron incorporating the lower
capsule. The remaining tendon was then woven in an Anchovy type fashion and
placed in the defect.
The capsule was then closed using 4-0 Ti-Cron. Tendon interval closed with 4-0 Vicryl.
Tendon interval closed with 4-0 Vicryl. Skin closed with 4-0 vicryl and 4-0 Nylon. The
patient was placed in a standard postoperative bulky dressing with a splint. He tolerated
the procedure well and was brought to the recovery room in stable condition.
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OPERATIVE REPORT
OPERATION: Trapezium resection, ligament reconstruction and tendon interposition
arthroplasty, left thumb. Excision of nodule, dorsum of left index finger.
PREOPERATIVE DIAGNOSIS: Pan trapezial arthritis, left wrist. Nodule dorsum of
left index finger.
OPERATIVE INDICATIONS: Pain at the base of the right thumb, unrelieved by
conservative treatment, and secondary to x-ray confirmed arthritis. There was a small,
slightly tender nodule over the dorsum of the left index finger, of undetermined etiology.
OPERATIVE FINDINGS: There was extensive arthritis on both sides of the trapezium,
and in the joint between the scaphoid and trapezoid. There was a small solid nodule
sitting on the extensor tendon just distal to the proximal interphalangeal joint over the
dorsum of the left index finger. The nodule was well circumscribed.
OPERATIVE PROCEDURE: A longitudinal incision was made over the dorsal radial
aspect of the base of the left thumb. Care was taken to identify and protect the branches
of the superficial radial nerve. The extensor retinaculum over the first extensor
compartment was divided longitudinally, completely releasing the EPL and EPB tendons.
A longitudinal capsular incision was made between the EPL and EPB tendons. The
capsule was carefully dissected from the trapezium, and from a portion of the base of the
first metacarpal. The trapezium was removed piecemeal. The opposing surfaces of
the scaphoid and trapezoid were also removed down to cancellous bone. A drill hole
was then made traversely across the base of the first metacarpal, emerging at the deep
volar beak of the metacarpal. A longitudinal strip of the extensor carpi radialis
tendon was removed through multiple transverse forearm incisions. The tendon strip
was transected proximally, and left attached distally. It was delivered into the trapezial
cavity, and dissected to the base of the second metacarpal. The tendon strip comprised
approximately 75% of the tendon. The tendon strip was passed through the hole at
the base of the first metacarpal, looped back around itself and then pulled tightly,
and secured with #3-0 Tycron sutures. A portion of the remaining tendon implant was
placed in the space between the scaphoid and trapezoid, and held there with a #3-0
Tycron suture, placed through some soft tissue in the depths of the wound. This appeared
to hold the tendon in a good position. The remaining portion of the tendon that was
harvested was tied in multiple knots, which were secured with #3-0 Tycron sutures.
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This implant was then placed in the trapezial cavity, and was held there with a #3-0
Tycron suture that had been placed through the remaining portion of the FCR tendon in
the depths of the cavity. This held the tendon implants in good position. The capsule
was carefully repaired with #3-0 Tycron sutures. The skin incisions were closed with #40 Nylon sutures.
A transverse incision was made over the dorsum of the index finger, just distal to the
proximal interphalangeal joint, and directly over the nodule. The nodule was dissected
free from the surrounding tissues and completely removed, and sent to pathology.
The skin was closed with #4-0 nylon sutures.
Then 5 cc of 2% Xylocaine with epinephrine mixed with 5 cc of 0.5% marcaine was used
for median and radial nerve blocks at the wrist. A moist, bulky compressive type
dressing was applied, and anterior and posterior plaster splints. The pneumatic tourniquet
was used during the procedure. The patient tolerated the procedure well, and was sent to
the recovery room in satisfactory condition.
DRAINS: None.
ESTIMATED BLOOD LOSS: None.
I was present during the entire operation.
Advanced Clinic
Hand Surgery
PATHOLOGY REPORT
FINAL DIAGNOSIS:
1. LEFT INDEX FINGER, EXCISION (B) - GIANT CELL TUMOR
OF TENDON SHEATH.
Comment: An addendum will be issued following decalcification of the
specimen from part A.
** Report Electronically Signed Out**
**************************************************************
Part A: LEFT SYNOVIUM
Part B: NODULE LEFT INDEX FINGER
CLINICAL DATA:
LEFT THUMB ARTHRITIS
GROSS DESCRIPTION:
A. Received fresh are multiple, tan-pink, bony fragments aggregating to
2 x 2 x 0.6 cm. The specimen is entirely submitted in formalin for
decalcification at A1.
B. Received fresh is a rubbery, pink-tan, oval-shaped nodule that
measures 0.6 x 0.3 x 0.3 cm. Specimen is submitted in entirety in
formalin in cassette B1.
Addendum:
** SIGNED OUT 04/21/98**
*** REPORT OF DECALCIFIED TISSUE***
LEFT INDEX FINGER REGION, EXCISION (A)
SYNOVIUM WITH FIBROSIS AND OSTEOCARTILAGENOUS
TISSUE SEGMENTS.
(Age: 71) F
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OPERATIVE REPORT
1. Degenerative osteoarthritis, carpometacarpal joint, left thumb.
2. Carpal tunnel syndrome, left hand.
3. Stenosing tenosynovitis, left long finger.
1. Degenerative osteoarthritis, carpometacarpal joint, left thumb.
2. Carpal tunnel syndrome, left hand.
3. Stenosing tenosynovitis, left long finger.
1. Trapezium resection arthroplasty, left thumb, with flexor carpi radialis
interpositional graft.
2. Carpal tunnel release, left hand.
3. Release of flexor tendon sheath, left long finger.
ANESTHESIA:
General.
PROCEDURE: The patient was placed supine on the operating table at which time she
was put to sleep under general anesthesia. Following this the left arm was prepped with
Betadine Solution for a full five-minute prep. The area was then draped in a sterile
fashion and a tourniquet applied.
Attention was turned first to the volar aspect of the long finger. Here a transverse
incision was made and carried down through skin and subcutaneous tissue. Careful blunt
dissection was made down to the underlying flexor tendon sheath. The sheath was
opened longitudinally and the flexor tendons exposed. Once opened it was noted that
the tendons could glide smoothly with no further impingement. The area was then
irrigated with saline solution. The skin edges were anesthetized with Marcaine and
closed with #5-0 nylon suture.
Attention was then turned to the palmar aspect of the hand where a curved incision
was made over the palmar aspect and carried down through skin and subcutaneous tissue.
Careful blunt dissection was made down to the underlying transverse carpal ligament.
The ligament was opened longitudinally and the underlying median nerve exposed.
The area was explored and no other evidence of significant abnormalities could be noted.
The area was irrigated with saline solution. The skin edges were anesthetized with
Marcaine and the skin closed with #5-0 nylon suture.
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Next, two small transverse incisions were made over the palmar aspect of the wrist
and in the mid forearm. These were over the areas of the flexor carpi radialis tendon.
The tendon was then transected at its musculotendinous junction and pulled through
into the distal wound.
Attention was then turned to the radial aspect of the wrist. Here an S-shaped incision
was made and carried down through skin and subcutaneous tissue. Blunt dissection was
made down to the underlying capsule. The capsule was then opened and the
carpometacarpal joint exposed. There was noted to be evidence of marked
degenerative changes with marked erosion of the articular surfaces. Multiple loose
bodies were encountered and removed. Once the capsule was opened, the saw was
then used to transect the trapezium. This was then removed piecemeal. Once
adequately exposed and cleared, the flexor carpi radialis tendon was then grasped in
the wound and pulled through. An oblique hole was then made through the base of the
metacarpal and the tendon was pulled through this. The tendon was then brought back
and sutured in on itself to maintain the position of the metacarpal. There was good
stability once done. The tendon was then rolled and placed in to the space left by the
trapezium. This was sutured into the position. Following this the capsule was closed
over this. The areas were irrigated with saline solution, following which then the
subcutaneous tissues were closed with #3-0 Vicryl, skin edges were anesthetized with
Marcaine and closed with #5-0 Vicryl suture.
All wounds were then dressed in a sterile fashion and a short-arm cast with a thumb spica
was applied. The tourniquet was released and the patient returned to the Recovery Room
in satisfactory condition.
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OPERATIVE RECORD
PREOPERATIVE DIAGNOSIS: Arthritis, right and left hands.
POSTOPERATIVE DIAGNOSIS: Arthritis, right and left hands.
OPERATION: 1. Injection of left thumb carpometacarpal joint.
2. Right thumb carpometacarpal arthroplasty with flexor carpi
radialis tendon transfer.
3. Right middle finger distal interphalangeal joint arthrodesis.
INDICATIONS: This 55-year-old female with severe arthritis of both hands presents for
definitive treatment after failure of conservative treatment.
position. After general anesthesia was obtained and 600 mg IV clindamycin given, the
left thumb was prepped sterilely and the CMC joint injected with 1 cc of 40 mg DepoMedrol and 1 cc of 0.5% Marcaine with epinephrine.
Next, a tourniquet was placed high on the right upper extremity, and the right upper
extremity was prepped and draped in the usual sterile fashion. The arm was then elevated
and exsanguinated and the tourniquet inflated to 250 mmHg. The total tourniquet time
was less than 2 hours.
First, the middle finger was addressed using a S-shaped incision over the dorsum of the
DIP joint. The skin was incised. Dissection was carried out down to the extensor
mechanism where distal and proximal flaps were raised. The extensor mechanism was
incised exposing the joint. The collateral ligaments were taken down. There was severe
arthritis noted. Using a rongeur both ends of the joint were prepared down to good
cancellous bleeding bone.
Next, using the Accu-Chek fusion set, the bone was prepared and a 24-mm screw was
placed given excellent fixation and good apposition of the 2 fusion sites. No graft was
used. Good placement of the hardware and alignment of the joint were noted on AP,
lateral, and oblique view of the C-arm.
Next, using a 5-0 nylon the extensor mechanism and skin closed in one large layer. A
digital block was then performed with 0.5% Marcaine plain for postoperative anesthesia.
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Next, using a modified Wagner incision, the skin was incised. In the subcutaneous tissue,
the dorsal central branch of the radial nerve was identified and protected. First, the dorsal
compartment was identified. First dorsal compartment release was performed and
released from the dorsal side.
Next, using a #15 blade, arthrotomy was made into the CMC joint as well as the STT
joint isolating the trapezium. Subperiosteal dissection was carried out around as much of
the trapezium as possible.
Next, using an osteotome and mallet, the trapezium was broken up into 4 quadrants.
Using a rongeur, the trapezium was then removed completely. Careful attention was
paid to protect the underlying flexor carpi radialis tendon.
Once complete removal of the trapezium was obtained, the FCR was identified at the
base of our wound, and the sheath was entered. It was released proximally and distally.
Next, with tension placed on the flexor carpi radialis tendon, a counter incision was made
proximally over the tendon. The incision was taken down to the level of the flexor carpi
radialis sheath. The sheath was also opened and opened proximally and distally by
exposing the tendon. Another incision approximately 15 cm above the wrist crease was
also made. The tendon was circumferentially dissected free.
Using a #15 blade the tendon was released and brought forth all the way sequentially
through each of our incisions up into and including the CMC joint. With the tendon
in place them, a bur was used to make an entry hole into the proximal end of the
metacarpal. A dorsal ulnar hole was made connecting this to the entry hole in the base of
the metacarpal.
Next, our tendon was woven through the end of the metacarpal out the dorsal ulnar
hole and back onto itself where it was sewn down with 2-0 PDS suture. The
metacarpal was held distracted and slightly opposed while sewing this in.
With this completed then the remainder of the tendon was rolled up into an anchovy
and sewn together with the 2-0 PDS suture. This was then placed as a spacer between
the metacarpal and the scaphoid.
Next, the 2-0 PDS was used to repair the capsule of the CMC and STT areas. A 3-0
undyed Vicryl was used to repair the remaining deep tissues. Through the procedure,
copious irrigation was performed and hemostasis was obtained with bipolar
electrocautery.
Finally, all wounds were approximated with 5-0 nylon suture. All areas were infiltrated
with 0.5% Marcaine with epinephrine for post-op anesthesia.
Advanced Clinic
Hand Surgery
Next, for the middle finger, dry sterile dressing was placed and held with tube gauze.
Xeroform was placed over all wounds, and bulky dressing was applied and held with
Kerlix. A radial thumb spica splint was then applied and held with Kerlix and an Ace
wrap.
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OPERATIVE RECORD
1. Right thumb carpometacarpal arthritis.
2. Right thumb metacarpal phalangeal joint arthritis.
3. Right carpal tunnel syndrome.
1. Right thumb carpometacarpal arthritis.
2. Right thumb metacarpal phalangeal joint arthritis.
OPERATION:
1. Right endoscopic carpal tunnel release.
2. Right carpometacarpal arthroplasty with flexor carpi radialis tendon transfer.
3. Metacarpal phalangeal joint arthrodesis with local graft.
INDICATIONS: This is a 70-year-old female with significant cardiac history who has
the above problems. We have been treating her conservatively. She has failed
conservative treatment which has included injections and splints. She presents for
definitive treatment.
PROCEDURE: The patient was brought to the operating room and placed in the supine
position. Local infiltration with 0.5% Marcaine plain was performed for anesthesia. A
tourniquet was placed high on the right upper extremity, and the right upper extremity
was prepped and draped in the usual sterile fashion. The arm was exsanguinated and the
tourniquet inflated to 250 mmHg. The total tourniquet time was less than 2 hours.
A transverse incision was made at the proximal wrist crease. Dissection was carried
out down to the distal antebrachial fascia. A distally based flap was made. The proximal
portion of the distal fascia was released under direct vision with the scissors.
Using the Agee system, the undersurface of the transverse carpal ligament was
identified. First using the synovial spoon, then the small and then large dilators were
placed within the carpal canal. The Agee system was placed in the canal, and the distal
aspect of the ligament was identified, the blade elevated, and the distal one-third of the
ligament was released. The blade was retracted, and our distal release was checked.
Good release was noted. The blade was brought back to the level of the previous release
site, re-elevated, and the remainder of the ligament was released under direct vision.
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Our release was checked one more time with the blade retracted, and good release again
was appreciated. No pulsatile bleeding was noted. the wound was copiously irrigated.
Hemostasis was obtained with electrocautery. The wound was gently approximated with
#5-0 nylon.
Next, using a modified Wagner incision, the skin was incised. In the subcutaneous tissue,
the dorsal central branch of the radial nerve was identified and protected. First, the dorsal
compartment was identified. First dorsal compartment release was performed and
released from the dorsal side.
Next, using a #15 blade, arthrotomy was made into the CMC joint as well as the STT
joint isolating the trapezium. Subperiosteal dissection was carried out around as much of
the trapezium as possible.
Next, using an osteotome and mallet, the trapezium was broken up into 4 quadrants.
Using a rongeur, the trapezium was then removed completely. Careful attention was
paid to protect the underlying flexor carpi radialis tendon.
Once complete removal of the trapezium was obtained, the FCR was identified at the
base of our wound, and the sheath was entered. It was released proximally and distally.
Next, with tension placed on the flexor carpi radialis tendon, a counter incision was made
proximally over the tendon. The incision was taken down to the level of the flexor carpi
radialis sheath. The sheath was also opened and opened proximally and distally by
exposing the tendon. Another incision approximately 15 cm above the wrist crease was
also made. The tendon was circumferentially dissected free.
Using a #15 blade the tendon was released and brought forth all the way sequentially
through each of our incisions up into an including the CMC joint. With the tendon in
place the, a bur was used to make an entry hole into the proximal end of the metacarpal.
A dorso-ulnar hole was made connecting this to the entry hole in the base of the
metacarpal.
Next, our tendon was woven through the end of the metacarpal out the dorso-ulnar
hole and back onto itself where it was sewn down with 2-0 PDS suture. The
metacarpal was held distracted and slightly opposed while sewing this in.
With this completed then the remainder of the tendon was rolled up into an anchovy
and sewn together with the 2-0 PDS suture. This was then placed as a spacer between
the metacarpal and the scaphoid.
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Next, the 2-0 PDS was used to repair the capsule of the CMC and STT areas. A 3-0
undyed Vicryl was used to repair the remaining deep tissues. Throughout the procedure,
copious irrigation was performed and hemostasis was obtained with bipolar
electrocautery.
Finally, the MP joint was addressed. Dissection was carried down to the MP joint.
Careful attention being paid to protect the dorsal-central branch radial nerve. Arthrotomy
was made dorsally. The carotid ligaments were taken down. Using a rongeur, the end
of the metacarpal as well as the proximal portion of the proximal phalanx were
denuded over the sclerotic bone, which was present, down to good bleeding cancellous
bone.
Next, two 0.045-mm K-wires were placed through the metacarpal down into the
proximal phalanx with the MP joint held at approximately 25% of flexion. There
was good opposition of the cancellous bony surfaces. Local graft from the excised
trapezium from the previous arthroplasty was harvested and added as local graft
filling all the areas nicely.
With this completed then, 3-0 Vicryl was used to repair the capsule with the retinaculum.
The skin was approximated with 5-0 nylon. The whole area was infiltrated with 0.5%
Marcaine with epinephrine for postoperative anesthesia.
Xeroform and a bulky dressing were applied and a radial thumb spica splint was applied
immobilizing the thumb and wrist. This was held with Kerlix and an Ace wrap.
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OPERATIVE REPORT
1. Severe right pantrapezial arthritis.
Same.
PROCEDURE:
1. Right thumb basilar joint tendon interpositional arthroplasty and
reconstruction of the palmar oblique carpal metacarpal ligament
with a distally based flexor carpal radialis tendon transfer.
2. Right carpal tunnel release.
SKIN PREPARATION: Hibiclens.
FINDINGS: This lady presents with established right carpal tunnel syndrome and severe
basilar joint arthritis.
PROCEDURE: General anesthesia was given, right hand and forearm were scrubbed
with Hibiclens and draped as usual. Extremity was exsanginated and the tourniquet was
inflated. An incision was made in the proximal palm along the access of the ring finger.
The skin and subcutaneous tissues were separated and palmar fascia was incised and a
transverse carpal ligament was transected. A distal brachial fasciotomy was
subcutaneously performed. Contents of the carpal tunnel were explored. Some
thickening of the synovium was noted but did not appear pathological. The basilar joint
of the thumb was approached through a dorsal incision. Skin and subcutaneous tissues
were separated. The radial sensory nerves were carefully retracted. The dorsal capsule
was transversely opened. The trapezium was removed piecemeal preserving the soft
tissue connections. The peroneus longus was harvested through three transverse
incisions as a free graft. The radial part of the flexor carpal radialis was harvested
as the distally based tendon transfer passed into the trapezial area. A drill hole was
created in the base of the thumb metacarpal. A wire loop was passed to pass the flexor
carpal radialis through the drill hole and back onto the insertion of the tendon. The
extra tendinous tissue was fashioned in the form of a bowel which was placed at the site
of the trapezium. The capsule was meticulously repaired. The tendon transfer was
tightened and sutured to itself. The tourniquet was released.
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Hemostasis was obtained with electrocoagulation. The wounds were closed with 6-0
Prolene interrupted and continuous sutures after obtaining hemostasis. Sterile dressings
with a thumb Spica cast were applied and the patient was sent to the recovery room in
satisfactory condition. Sponge, needle and instrument counts were correct.
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OPERATIVE REPORT
OPERATION: Radical debridement of extensor tenosynovium with preparation of
extensor pollicis longus for extensor indicis proprius to extensor pollicis longus transfer,
and metacarpophalangeal joint arthrotomy and synovectomy of the second ray.
PREOPERATIVE DIAGNOSIS: Right hand rheumatoid deformities: specifically,
extensor pollicis longus rupture and florid tenosynovectomy.
POSTOPERATIVE DIAGNOSIS: Right hand rheumatoid deformities: specifically,
extensor pollicis longus rupture and florid tenosynovectomy, plus infiltrative
tenosynovitis of fourth and second dorsal compartments accompanying the ruptured
extensor pollicis longus.
OPERATIVE INDICATIONS: The patient is a 46-year-old, left hand-dominant project
coordinator. He is an avid golfer. He was seen by my colleague in rheumatology. He
noted the inability to extend his dominant right thumb and quite a bit of dorsal swelling.
For these reasons, my colleague made a consultation to me, which I appreciate greatly.
I admitted the patient and had a long discussion with him. We talked about the
patholophysiology of rheumatoid disease and the fact that these tendon ruptures may
herald more significant disease and possible further problems. We talked about the risks,
benefits and alternatives of the above-mentioned procedures, and he understood them
implicitly, including the risks and benefits of infection, bleeding, damage to skin, nerves,
blood vessels, bone, and soft tissues, failure of the operation, need for more operation and
the risks of anesthesia. He consented to the performance of the above-mentioned
procedures.
OPERATIVE PROCEDURE: The patient was taken to the operating room and placed on
the table in the supine position after a successful axillary block anesthesia. A pneumatic
tourniquet encircled the proximal brachium and was inflated to 250 mmHg for 36
minutes. Through a longitudinal incision based on the dorsal aspect of the wrist, great
care was taken to dissect down without injury to subcutaneous neurovascular structures.
Thick flaps were raised. The third dorsal compartment was opened to find a tremendous
amount of tenosynovium, and it was empty and devoid of the extensor pollicis longus.
The proximal and distal stumps were located and controlled. Notably, there was
extensive tenosynovium of an infiltrative nature in the second dorsal compartment.
Careful tenosynovectomy of the extensor carpi radialis longus and brevis tendons
was undertaken.
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The fourth compartment was opened for the same purpose, and this was debrided .
Smoothing of the dorsal aspect of the wrist, especially around Lister’s tubercle, was
performed with a rongeur and rasps.
Our previous plan was to assess the integrity of the extensor pollicis longus and likely
transfer for it. The extensor indicis proprius was the tendon that we wished to transfer,
and the patient understood that.
With an incision over the metacarpophalangeal joint, great care was taken to dissect
down without injury to the subcutaneous neurovascular structures. The extensor indicis
proprius was located on the ulnar border of the joint, ulnarward of the proper
extensor. A tremendous amount of tenosynovium at that level was encountered so that in
addition to the harvest of the tendon, debridement and capsular reconstruction of
the second metacarpophalangeal joint was performed. A tremendous amount of
hypertrophic synovium was recovered. The erosions were smoothed locally. The
articular surface looked reasonably good, although there was quite a bit of peripheral
erosion and some cartilage softening. Copious irrigation and meticulous hemostasis was
obtained. The wound was closed, and then the tendon was nicely centralized.
Attention was turned toward the thumb, where the incision was extended over the
carpal-metacarpophalangeal joint. The distal aspect of the extensor pollicis longus
stump was controlled and utilizing a Pulver-Taft type weave with the Jacobson
instruments, a nice tension was placed between the transferred EIP to the distal
aspect of the EPL. Tension was assessed in fullest extension. The interphalangeal joint
was in about neutral, and in flexion. There was extension at the IP joint of the thumb.
Copious irrigation and meticulous hemostasis was maintained. The dorsal retinaculum
was split to protect both the transferred tendons and the indwelling fourth compartment
tendons. All wounds were closed in layers.
Careful application of a sterile bulky dressing with a thumb spica attachment was
performed.
SPECIMENS: Resected tissue.
DISPOSITION: The patient leaves the operating room alive and well, having tolerated
the procedure without complication or complaint. He will stay overnight for pain control
and IV antibiotics. He will return to me in approximately two to 14 days. We will likely
deep him casted for a total of four weeks, and then start a motion program.
Advanced Clinic
Hand Surgery
PATHOLOGY REPORT
FINAL DIAGNOSIS:
TENDON AND SYNOVIUM, RIGHT WRIST, EXCISION - SEVERE CHRONIC
EXUDATIVE SYNOVITIS WITH RHEUMATOID NODULE FORMATION
COMPATIBLE WITH ACTIVE RHEUMATOID SYNOVITIS.
** Report Electronically Signed Out **
*******************************************************************
SYNOVITIS DORSAL RIGHT WRIST
CLINICAL DATA:
RHEUMATOID ARTHRITIS, RIGHT EXTENSOR POLLICIS LONGUS, HAND
GROSS DESCRIPTION:
A. Received in formalin are multiple irregularly shaped fragments of pink-white
fibrous tissue, fibroadipose tissue, and soft, pink-white tissue aggregating to 8 x 3
x 0.6 cm. The specimens are serially sectioned and representative sections are
submitted in formalin in one cassette.
(Age: 46) M
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Advanced Clinic
Answer Key
Exercise 1
20612-LT
25111-RT
Exercise 2
26055-F2
26055-F3
26055-F7
26055-F8
Exercise 3
26055-F3
26055-F4
20550-F8
Exercise 4
26440-LT
26440-LT-59
Exercise 5
26121-LT
Exercise 6
26123-F4
Exercise 7
26123-F4
Hand Surgery
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Advanced Clinic
Exercise 8
26123-F5
26125-F7
Exercise 9
26418-F6
Exercise 10
26418-F1
Exercise 11
26542-F5
Exercise 12
25431-RT
Exercise 13
26852-F5
Exercise 14
26862-F4
Exercise 15
26841-RT
Hand Surgery
97
Advanced Clinic
Exercise 16
26952-F1
26862-F2
Exercise 17
26531-F6
26531-F7
26531-F8
26531-F9
26850-F5
Exercise 18
26591-LT
26989
64831
Exercise 19
26480-LT
Exercise 20
25447-RT
25310-RT
Exercise 21
25310-RT
25447-RT
26160-F1
Hand Surgery
98
Advanced Clinic
Hand Surgery
Exercise 22
25310-LT
25447-LT
26055-LT
Per the Complete Global Service Data for Orthopaedic Surgery, American Academy of
Orthopaedic Surgeons, code 25310 includes a “neuroplasty.” So code 64721 (open
carpal tunnel release) was not assigned to this case.
Exercise 23
25447-RT
25310-RT
26860-F7
Exercise 24
26852-RT
25310-RT
25447-RT
Orthopaedic Surgeons, code 25310 includes a “neuroplasty.” So code 29848
(arthroscopic carpal tunnel release) was not assigned to this case.
Exercise 25
25447-RT
25310-RT
Orthopaedic Surgeons, code 25310 includes a “neuroplasty.” So code 64721 (open
carpal tunnel release) was not assigned to this case.
Exercise 26
26483-RT
99
Advanced Clinic
Exercise 27
26356-LT
26356-LT-59
64831-LT
Exercise 28
26356-F8
26350-F8
Hand Surgery 100

Certificate of Attendance

Transcription

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