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- Location
- Covina, CA
Hello everyone,
we are looking at 25280x2 for FDS, FDP lengthening in the forearm, 26593 Release of intrinsic muscle, but we are debating at the hand procedure 26170 (one or more digits). Thank you
Preoperative Diagnoses:
1. Left hand flexion contracture of the middle finger.
2. Left hand flexion contracture of the ring finger.
3. Left hand flexion contracture of the small finger.
4. Spasticity.
5. Hand wound.
Postoperative Diagnoses:
1. Left hand flexion contracture of the middle finger.
2. Left hand flexion contracture of the ring finger.
3. Left hand flexion contracture of the small finger.
4. Spasticity.
5. Hand wound.
Procedures Performed:
1. Excision left middle finger FDS tendon .
2. Excision left ring finger FDS tendon in hand.
3. Excision left little finger FDS tendon in hand .
4. Fractional lengthening left hand FDP tendon in the forearm .
5. Fractional lengthening left FDP ring finger in the forearm .
6. Fractional lengthening left FDP of the small finger in the forearm .
7. Release of intrinsic muscle left middle finger .
Complications: None.
Specimens: None.
Estimated Blood Loss: 20 mL.
Anesthesia: Local.
Indication: The patient has worsening flexion contractures of the left middle, ring and small fingers with inability to bring her fingers out of her palm and development of multiple wounds. She failed nonoperative treatment. She failed wound care and was having significant worsening. She complained that the ring and small fingers were fused together. I discussed the surgery with the patient and her daughter at length. Risks include infection, bleeding, neurovascular damage, stiffness, continued spasticity and poor wound healing as well as anesthetic risks. Given the patient age and multiple medical comorbidities, I discussed surgery under local anesthesia. Risks, benefits and alternatives were reviewed. The patient signed informed consent.
Procedure In Detail: The patient was met in the preoperative holding area where her identity was confirmed. Left hand was confirmed and marked. She was brought into the operating room. She was positioned supine with all bony prominences well padded. 20 mL of 1% lidocaine and 20 mL of 0.25% Marcaine were mixed and injected about the forearm at the musculotendinous junction and at the palm for digital nerve blocks. The forearm was addressed first and a longitudinal incision was made along the volar musculotendinous junction of the flexor tendons. The FDS was divided in a step-cut manner for the middle, ring and small fingers and the fingers were able to be slightly extended further out of the palm. Median and ulnar nerve blocks were performed in order to allow for comfortable manipulation of the fingers. There was mild improvement in MCP extension. Therefore, the FDP was likewise fractionally lengthened for the middle, ring and small fingers and the MCP extension improved to 110 degrees and the PIP extension improved to 70 degrees.
Given the mild improvement, attention was turned to the FDS at the level of the hand. The A1 pulleys of the middle, ring and small fingers were released and the FDP was identified. The FDS was excised starting at Camper's chiasm and as far proximally as retractable. The PIP extension was then improved to 50 degrees and the fingers could be brought out of the palm. The middle finger was crossing out of the ring finger. Therefore, the intrinsic muscle was released through a dorsal incision over the 3rd ulnar MCP joint. The lateral branch was released and this allowed for improved radial deviation of the middle finger at the MCP joint. All wounds were copiously irrigated and closed with 3-0 Vicryl for the subcutaneous tissue and 5-0 plain gut for the skin. A sterile dressing of Xeroform, 4 x 4, bacitracin, cast padding and a volar splint was applied. All sponge and needle counts were correct at the end of the case. The patient was transferred to the recovery room in stable condition.
we are looking at 25280x2 for FDS, FDP lengthening in the forearm, 26593 Release of intrinsic muscle, but we are debating at the hand procedure 26170 (one or more digits). Thank you
Preoperative Diagnoses:
1. Left hand flexion contracture of the middle finger.
2. Left hand flexion contracture of the ring finger.
3. Left hand flexion contracture of the small finger.
4. Spasticity.
5. Hand wound.
Postoperative Diagnoses:
1. Left hand flexion contracture of the middle finger.
2. Left hand flexion contracture of the ring finger.
3. Left hand flexion contracture of the small finger.
4. Spasticity.
5. Hand wound.
Procedures Performed:
1. Excision left middle finger FDS tendon .
2. Excision left ring finger FDS tendon in hand.
3. Excision left little finger FDS tendon in hand .
4. Fractional lengthening left hand FDP tendon in the forearm .
5. Fractional lengthening left FDP ring finger in the forearm .
6. Fractional lengthening left FDP of the small finger in the forearm .
7. Release of intrinsic muscle left middle finger .
Complications: None.
Specimens: None.
Estimated Blood Loss: 20 mL.
Anesthesia: Local.
Indication: The patient has worsening flexion contractures of the left middle, ring and small fingers with inability to bring her fingers out of her palm and development of multiple wounds. She failed nonoperative treatment. She failed wound care and was having significant worsening. She complained that the ring and small fingers were fused together. I discussed the surgery with the patient and her daughter at length. Risks include infection, bleeding, neurovascular damage, stiffness, continued spasticity and poor wound healing as well as anesthetic risks. Given the patient age and multiple medical comorbidities, I discussed surgery under local anesthesia. Risks, benefits and alternatives were reviewed. The patient signed informed consent.
Procedure In Detail: The patient was met in the preoperative holding area where her identity was confirmed. Left hand was confirmed and marked. She was brought into the operating room. She was positioned supine with all bony prominences well padded. 20 mL of 1% lidocaine and 20 mL of 0.25% Marcaine were mixed and injected about the forearm at the musculotendinous junction and at the palm for digital nerve blocks. The forearm was addressed first and a longitudinal incision was made along the volar musculotendinous junction of the flexor tendons. The FDS was divided in a step-cut manner for the middle, ring and small fingers and the fingers were able to be slightly extended further out of the palm. Median and ulnar nerve blocks were performed in order to allow for comfortable manipulation of the fingers. There was mild improvement in MCP extension. Therefore, the FDP was likewise fractionally lengthened for the middle, ring and small fingers and the MCP extension improved to 110 degrees and the PIP extension improved to 70 degrees.
Given the mild improvement, attention was turned to the FDS at the level of the hand. The A1 pulleys of the middle, ring and small fingers were released and the FDP was identified. The FDS was excised starting at Camper's chiasm and as far proximally as retractable. The PIP extension was then improved to 50 degrees and the fingers could be brought out of the palm. The middle finger was crossing out of the ring finger. Therefore, the intrinsic muscle was released through a dorsal incision over the 3rd ulnar MCP joint. The lateral branch was released and this allowed for improved radial deviation of the middle finger at the MCP joint. All wounds were copiously irrigated and closed with 3-0 Vicryl for the subcutaneous tissue and 5-0 plain gut for the skin. A sterile dressing of Xeroform, 4 x 4, bacitracin, cast padding and a volar splint was applied. All sponge and needle counts were correct at the end of the case. The patient was transferred to the recovery room in stable condition.