Status post fourth metacarpal fracture with retained hardware and adhesions.
POSTOPERATIVE DIAGNOSIS: Status post fourth metacarpal fracture with retained hardware and adhesions.
PROCEDURES: Open debridement, lysis of adhesions, attempted removal of a 2.0 mm Synthes plate and screw.
ANTIBIOTICS: Ancef 1 gm.
INDICATIONS: This is a 23-year-old, white male who approximately 5 years ago had a fifth metacarpal fracture treated with open reduction. Recently, he has noted slight decreased range of motion and evidence of slight extension lag and pain over the plate. Prior to surgery, the risks and benefits of surgery, including the possibility that the plate may be left in due to the fact that the screw heads may be stripped were all clearly explained, and he understood. Midway through the case when it became apparent that the plate could not be removed, I had a discussion with the mother who agreed that the lysis of adhesions should take care of the problem, and that it would cause more damage to the bony structures to take the plate out than the benefits that would be received from it.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room in the supine position. General anesthesia was administered, and 1 gm of Ancef given preoperatively. The hand was prepped and draped in sterile fashion. A proximal tourniquet was applied and inflated to a pressure of 250 mmHg. The hand was prepped and draped in sterile fashion. The previous incision was then used. Dissection was carried down to subcutaneous tissue. Again, we noted adhesions both to the tendon to the underlying subcutaneous tissue. We went ahead and lysed these in an open fashion. In addition, there were adhesions to the muscle layer underneath. These were also incised and lysed, allowing improved passive range of motion. At this point, we went ahead and identified the plate which was a modular Synthes 2.0 mm. We went ahead and attempted to remove the screws. The screws were partly stripped and as we attempted to remove them, this further stripped the screws. To remove them, we would have had to do extensive bony debridement, possibly causing further injury to the bone.
At this point, I broke scrub and went to the mother and discussed the case with her. We went over the risks and benefits of being aggressive and removing the plate, versus just doing a lysis of adhesions. She concurred that lysis of adhesions would be the best course of treatment, especially in light of the fact that trying to remove the screws and the plate would cause further damage to the bone.
At this point, I went back in and scrubbed sterilely. I went ahead and proceeded with lysis of adhesions. At this point, we copiously irrigated with normal saline. We closed using 4-0 Vicryl in running fashion for the muscle layer, 4-0 Vicryl in running fashion for the tendinous layer, and 4-0 Vicryl with a running 4-0 PDS and Steri-Strips for the skin. A bulky dressing with a volar splint was applied. The patient was awakened and taken to the recovery room in good condition.
Yikes. I read, and reread this note.. and am still not totally sure how to advise you.
I code for a Hand Center, and typically when they do these types of procedures they list out the tendons involved, and I bill based on the tenolysis work done. 26440-26449. I have never quite seen one described like this. I would recommend going back to the physician for further guidance (or addendum!!).
Good LUCK! (let us know how this bills out.. i would like to know how it settles out....)