1. Revision amputation left index finger, distal phalanx.
2. Repair of zone II flexor digitorum profundus laceration left middle finger.
3. Repair of ulnar digital nerve left third finger.
4. Repair of ulnar digital nerve left fourth finger.
OPERATIVE PROCEDURE: After consent was obtained, the patient was taken to the operating room and was given a general anesthetic. The left upper extremity was sterilely prepped and draped in normal fashion with Betadine scrub and paint. All wounds were copiously irrigated. The index finger essentially had the entire distal phalanx severely comminuted with the nail plate attached but the pulp essentially was skeletonized leaving a floppy distal fingertip. The third finger and the laceration at the level of the middle phalanx curved obliquely with an exposed ulnar neurovascular bundle which was completely transected and quite attenuated. The flexor digitorum profundus had 80% laceration of the tendon with only 15 to 20% of the fibers remaining radially. The ring finger and a complete ulnar neurovascular bundle transection with an intact flexor tendon system and intact radial side. At this point, we removed the bone fragments from the index finger, mobilized skin flaps, removed with sterile and germinal matrix, and then mobilized the volar skin flap, cleared the dog ears from the sides of the finger and then after copiously irrigation repaired the wounds, essentially a revision amputation of the index finger. The third finger was then addressed. A mid lateral incision was made over the ulnar portion of the digit exposing the neurovascular bundle proximal and distal. Using the microscope, we were able to repair the ulnar digital nerve. The nerve itself was severely attenuated and essentially been torn and we were able to mobilize some fascicles, at least two to three fascicles for the repair. Once we repaired with 8-0 nylon, the flexor tendon was then addressed using a 4-0 Ethibond suture in a figure-of-eight fashion approximating the remaining portion of the tendon. This did appear to stabilize the FDP to the third finger nicely. Attention was directed towards the ring finger where in a likewise fashion, an incision was enlarged allowing exposure of the neurovascular bundle. The ulnar digital nerve once identified was then repaired with 8-0 nylon under loupe magnification, and once repaired, it appeared to have reasonable continuity without significant tension. The wounds were irrigated and then the skin closed with 5-0 Prolene. The fingers were injected with 0.5% Marcaine for postoperative pain control. Dorsal blocking splint was applied. The patient was transferred to the recovery room in stable condition.
I think hands are the toughest for me and I am just beginning to learn them - then one like this sends my head in a whirl
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