sienamt
New
Can someone help me out with a CPT and Dx for this op? I am thinking 26115 for the procedure but I'm at a loss for the diagnosis!
Post Op Dx- RT middle finger mass, possible foreign body granuloma
Procedure Performed- RT middle finger mass excision
Indications- Patient sustained a presumed puncture injury to the middle finger more than one month prior to surgery while gardening. Patient was treated for cellulitis, which resolved. But continued to note pain and sensation of a retained foreign body in the digit. After failure of conservative management, they wish to have this area explored and any abnormal tissue excised.
Description of Procedure- A small Brunner zigzag incision was made centered at the MP flexion crease, which represented the area of maximal tenderness and swelling. Subcutaneous dissection was carried out bluntly. No foreign body was identified, but there was an area of extensive scar tissue formation, possibly consistent with a foreign body granuloma. For additional visualization, a Brunner incision was extended proximally and distally. The radial and ulnar neurovascular bundles were identified and mobilized away from the soft tissue mass. The soft tissue mass appeared to be adherent to the A2 pulley. It was mobilized off the A2 pulley with no disruption of the pulley itself. The mass was excised and sent to pathology for analysis.
Pathology- Soft tissue, right middle finger, excision; Fibrous tissue with patchy chronic inflammation and giant cells.
Comment- No birefringent foreign material could be identified on polarized light microscopic examination, but the histologic features are suggestive of a foreign-body reaction, possibly to non-birefringent material, supporting the clinical impression. Correlation with clinical findings is recommended.
Post Op Dx- RT middle finger mass, possible foreign body granuloma
Procedure Performed- RT middle finger mass excision
Indications- Patient sustained a presumed puncture injury to the middle finger more than one month prior to surgery while gardening. Patient was treated for cellulitis, which resolved. But continued to note pain and sensation of a retained foreign body in the digit. After failure of conservative management, they wish to have this area explored and any abnormal tissue excised.
Description of Procedure- A small Brunner zigzag incision was made centered at the MP flexion crease, which represented the area of maximal tenderness and swelling. Subcutaneous dissection was carried out bluntly. No foreign body was identified, but there was an area of extensive scar tissue formation, possibly consistent with a foreign body granuloma. For additional visualization, a Brunner incision was extended proximally and distally. The radial and ulnar neurovascular bundles were identified and mobilized away from the soft tissue mass. The soft tissue mass appeared to be adherent to the A2 pulley. It was mobilized off the A2 pulley with no disruption of the pulley itself. The mass was excised and sent to pathology for analysis.
Pathology- Soft tissue, right middle finger, excision; Fibrous tissue with patchy chronic inflammation and giant cells.
Comment- No birefringent foreign material could be identified on polarized light microscopic examination, but the histologic features are suggestive of a foreign-body reaction, possibly to non-birefringent material, supporting the clinical impression. Correlation with clinical findings is recommended.