Pre-operative diagnosis: Left thumb flexor pollicis longus tendon laceration and associated structures
Post-operative diagnosis: Same
Procedure/description: Left thumb exploration with the following procedures:
1.) foreign body removal and washout (removed a piece of ceramic tile)
2.) repair of the flexor pollicis longus tendon per the left thumb using primary tendon repair (6 core strand repair with additional epitendinous repair)
3.) repair of the left thumb oblique pulley structure
Operative findings: Complete laceration of the left thumb flexor pollicis longus tendon with retraction of the proximal end of the tendon deep into the palm, complete laceration of the A1 pulley, and partial significant laceration of the oblique thumb pulley per the left hand. Foreign body of ceramic removed. Washout performed. Sutures used for pulley repair - 5-0 prolene for the oblique pulley, and sutures for FPL tendon repair - 3-0 ethibond (core) and 5-0 prolene (epitendinous).
Specimens: None, foreign body removed
Fluids/Blood: See record
Estimated Blood Loss: 15 cc
Drains/Packs: None
TT: 1 hr 53 minutes at 250 mmHg.
Patient's condition: Stable
History: 32 yo male with a history of a left thumb deep laceration that resulted in a FPL (flexor pollicis longus tendon) injury and associated injuries as named above. He also had a remnant of ceramic tile embedded still in his finger from his ED washout. He understood informed consent details and we discussed relevant repair risks such as tendon surgery repair risks, bow stringing, tendon rupture and/or suture failure, scarring, need for future tenolysis as a risk, contracture, stiffness, digital neurovascular structural injury, wound issues, and standard hand risks. He voiced understanding. We discussed the importance of good compliance with splinting, post-op protocol and hand therapy. He voiced understanding.
Procedure: After timeout, standard protocol measures, marking confirmation, isolation, prep/drape, and sterile protocol we proceeded. Local anesthesia was used at the end of the case using local per a median nerve block and per a radial nerve block, along with a local site block. Once we began, we first assessed our placement of incisions and confirmed them. We used a modified brunner incisional pattern per the thumb and extending into the palm, and would open them accordingly based on intraoperative needs. We began by first opening his native laceration along this mcp flexion crease that was closed by the ED. This had sutures removed. Tourniquet was used with escmarch preparation. Once we opened this, we easily saw the significant foreign body that was ceramic and it was a large piece and removed this well and completely. We then explored the wound directly in the midline of the thumb to see the tendon sheath tunnel was vacant and saw hematoma clot. We then washed this area out and evacuated the clot and didn't find tendon in this space. The proximal end and distal end had both retracted back from what we could see. We then continued with our modified brunner access incisions along the thumb and the palm, starting with the palm first to identify the proximal tendon end. This was done in a careful manner, with us identifying the neurovascular bundles on both sides to preserve them, and we made efforts to do this well. Then tracing the pattern of injury into the palm, we were able to identify the proximal end and place the beginning portion of our 6 strand repair using a modified kessler type technique into the tendon's proximal stump end, after minor tendon end trimming to get a smooth surface for good repair. We had evaluated the A1 pulley per the left thumb and it was lacerated completely. We also evaluated the oblique pulley and it was partially lacerated but significantly injured. Based on this we marked the oblique pulley's ends to try to preserve this should we need to divide this temporarily. We feed the ethibond suture through the oblique pulley's tunnel to deliver the proximal tendon end more distally. We also dissected free the distal tendon stump end. We attempted delivery of the distal tendon stump's end through that same space beneath the oblique pulley. This did not deliver easily, so we had to divide the oblique pulley completely for rearrangement and re-establishment of the oblique pulley, which was done later in the case to try to minimize bowstringing by repair of the oblique pulley. We then used our 3-0 ethibond, as we felt 4-0 was not holding as well as we preferred, so we used 3-0 ethibond for our core sutures. We used our 3-0 ethibond to establish our core sutures using a 6 strand repair. We made sure to provide a tendon end-to-end repair that was gap free and well opposed with a good repair. Once this was done, we felt a epitendinous repair was in order, and given the tendon's size we felt a 5-0 prolene would work best. We placed this as a running 5-0 epitendinous repair. Once the FPL (flexor pollicis longus tendon) was repaired, we once again evaluated to see if there were any other significant injuries, and from what we could see the remaining injuries were pulley based. Based on the desire to provide the oblique pulley restoration, we provided repair of the left thumb oblique pulley by repairing it using 5-0 prolene. We took efforts to do this in a careful manner. Once this oblique pulley was repaired, we surveyed once again, and felt it was appropriate to release the tourniquet. We let down the tourniquet and held pressure for 5 minutes to help minimize slow oozing, and found hemostasis to be reasonable. We used irrigation to throughly wash out the hand wounds and inspected once more to make sure no foreign body remained from what we could see and also to washout out well. Once washed out, we used the bipolar forcep to control skin edge associated bleeding. We evaluated our perfusion per the left thumb and it was good with good warmth, cap refill, color and bleed well distally to pin prick. Then, with hemostasis well controlled we proceeded to close by using a few sparing 4-0 vicryl sutures to reorient the closure at the modified brunner extension points and then proceeded to close using 4-0 nylon closure per the skin. The left thumb was appropriate and appeared well in viability without issues. We then proceeded with dressings, and splinting for protection. No issues. The procedure was well tolerated
Post-operative diagnosis: Same
Procedure/description: Left thumb exploration with the following procedures:
1.) foreign body removal and washout (removed a piece of ceramic tile)
2.) repair of the flexor pollicis longus tendon per the left thumb using primary tendon repair (6 core strand repair with additional epitendinous repair)
3.) repair of the left thumb oblique pulley structure
Operative findings: Complete laceration of the left thumb flexor pollicis longus tendon with retraction of the proximal end of the tendon deep into the palm, complete laceration of the A1 pulley, and partial significant laceration of the oblique thumb pulley per the left hand. Foreign body of ceramic removed. Washout performed. Sutures used for pulley repair - 5-0 prolene for the oblique pulley, and sutures for FPL tendon repair - 3-0 ethibond (core) and 5-0 prolene (epitendinous).
Specimens: None, foreign body removed
Fluids/Blood: See record
Estimated Blood Loss: 15 cc
Drains/Packs: None
TT: 1 hr 53 minutes at 250 mmHg.
Patient's condition: Stable
History: 32 yo male with a history of a left thumb deep laceration that resulted in a FPL (flexor pollicis longus tendon) injury and associated injuries as named above. He also had a remnant of ceramic tile embedded still in his finger from his ED washout. He understood informed consent details and we discussed relevant repair risks such as tendon surgery repair risks, bow stringing, tendon rupture and/or suture failure, scarring, need for future tenolysis as a risk, contracture, stiffness, digital neurovascular structural injury, wound issues, and standard hand risks. He voiced understanding. We discussed the importance of good compliance with splinting, post-op protocol and hand therapy. He voiced understanding.
Procedure: After timeout, standard protocol measures, marking confirmation, isolation, prep/drape, and sterile protocol we proceeded. Local anesthesia was used at the end of the case using local per a median nerve block and per a radial nerve block, along with a local site block. Once we began, we first assessed our placement of incisions and confirmed them. We used a modified brunner incisional pattern per the thumb and extending into the palm, and would open them accordingly based on intraoperative needs. We began by first opening his native laceration along this mcp flexion crease that was closed by the ED. This had sutures removed. Tourniquet was used with escmarch preparation. Once we opened this, we easily saw the significant foreign body that was ceramic and it was a large piece and removed this well and completely. We then explored the wound directly in the midline of the thumb to see the tendon sheath tunnel was vacant and saw hematoma clot. We then washed this area out and evacuated the clot and didn't find tendon in this space. The proximal end and distal end had both retracted back from what we could see. We then continued with our modified brunner access incisions along the thumb and the palm, starting with the palm first to identify the proximal tendon end. This was done in a careful manner, with us identifying the neurovascular bundles on both sides to preserve them, and we made efforts to do this well. Then tracing the pattern of injury into the palm, we were able to identify the proximal end and place the beginning portion of our 6 strand repair using a modified kessler type technique into the tendon's proximal stump end, after minor tendon end trimming to get a smooth surface for good repair. We had evaluated the A1 pulley per the left thumb and it was lacerated completely. We also evaluated the oblique pulley and it was partially lacerated but significantly injured. Based on this we marked the oblique pulley's ends to try to preserve this should we need to divide this temporarily. We feed the ethibond suture through the oblique pulley's tunnel to deliver the proximal tendon end more distally. We also dissected free the distal tendon stump end. We attempted delivery of the distal tendon stump's end through that same space beneath the oblique pulley. This did not deliver easily, so we had to divide the oblique pulley completely for rearrangement and re-establishment of the oblique pulley, which was done later in the case to try to minimize bowstringing by repair of the oblique pulley. We then used our 3-0 ethibond, as we felt 4-0 was not holding as well as we preferred, so we used 3-0 ethibond for our core sutures. We used our 3-0 ethibond to establish our core sutures using a 6 strand repair. We made sure to provide a tendon end-to-end repair that was gap free and well opposed with a good repair. Once this was done, we felt a epitendinous repair was in order, and given the tendon's size we felt a 5-0 prolene would work best. We placed this as a running 5-0 epitendinous repair. Once the FPL (flexor pollicis longus tendon) was repaired, we once again evaluated to see if there were any other significant injuries, and from what we could see the remaining injuries were pulley based. Based on the desire to provide the oblique pulley restoration, we provided repair of the left thumb oblique pulley by repairing it using 5-0 prolene. We took efforts to do this in a careful manner. Once this oblique pulley was repaired, we surveyed once again, and felt it was appropriate to release the tourniquet. We let down the tourniquet and held pressure for 5 minutes to help minimize slow oozing, and found hemostasis to be reasonable. We used irrigation to throughly wash out the hand wounds and inspected once more to make sure no foreign body remained from what we could see and also to washout out well. Once washed out, we used the bipolar forcep to control skin edge associated bleeding. We evaluated our perfusion per the left thumb and it was good with good warmth, cap refill, color and bleed well distally to pin prick. Then, with hemostasis well controlled we proceeded to close by using a few sparing 4-0 vicryl sutures to reorient the closure at the modified brunner extension points and then proceeded to close using 4-0 nylon closure per the skin. The left thumb was appropriate and appeared well in viability without issues. We then proceeded with dressings, and splinting for protection. No issues. The procedure was well tolerated
