Intrinsic release of the index middle ring and small finger/opponens pollicis release

kmuth

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Rothbury, MI
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I am not 100% sure on how I should code this, but I am thinking 26593x4 and 26440 for the opponens release. Any advice is appreciated!

POSTOPERATIVE DIAGNOSIS(ES):
Volkman's contracture of the left hand

PROCEDURE:
Intrinsic release of the index middle ring and small finger and release of the opponents pollicis of the left hand



INDICATIONS:
The patient had a decubitus injury to the hand which led to compartment syndrome, although he had a compartment release he has an intrinsic contracture. He has good neurological function therefore contracture release is indicated



DESCRIPTION OF PROCEDURE:
The patient is brought into the operating room under a regional block and sedation. He is supine on the operating room table and his left arm is on an armboard. The patient is now prepped and draped in sterile fashion. Preoperative markings are visible. Preoperative timeout is carried out.

The arm is exsanguinated using an Esmarch bandage and the tourniquet inflated to 250 mmHg.

We began by making incisions over the second and fourth web spaces where the patient had previously had incisions for fasciectomy. We then mobilized the extensor tendons so we can go to the fourth webspace.

We released the dorsal intrinsic off of the fourth and fifth metacarpals, we identify the palmar intrinsic which is very contracted and we release it off of the bone. Even with the release of the tendon off the bone we are still unable to fully extend the MP joint with the IP joints flexed for the small finger. We do need to lengthen the palmar intrinsic tendon distally.

We repeat the procedure for the ulnar intrinsic tendon on the ring finger and then we mobilize the dorsal intrinsics off of the fourth and third metacarpals. We identified the palmar intrinsics and we resect the damaged tissue we released the palmar intrinsic tendon and we are now able to mobilize the ring and small fingers. We go to the radial incision and mobilize the tendons in the second webspace off of the muscle we then released the palmar intrinsics. Dissection is very slow and tedious as we have to contend with the pedicles to the intrinsic muscles which we need to protect.

Now we are now able to fully extend and the MP joints and flex the IP joints. The thumb is still very contracted and we can feel that the opponens pollicis is the culprit. We make an incision along the carpal tunnel incision the patient previously had we dissect down through the subcutaneous tissue and expose the palmar fascia which we resect.

We identify the neurovascular structures and carefully protected. We find the tight components pollicis tendon and we carefully release it until the retracts slightly. We are not able to retract it fully as there is some degree of capsular contraction and due to the patient's poor thenar musculature I do not want to give him a fully retracted thumb.
 
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