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--- resident:kia_washington [2019/10/06 12:32] – melissa
+++ resident:kia_washington [2021/08/04 15:21] (current) – [Table Saw Injury] jonathan
@@ Line 1: / Line 1: @@
-====Dr. Washington Introduction====
+=====Dr. Washington Introduction=====
   - Undergraduate: Stanford University, BA with Honors 1994-1998\\
@@ Line 11: / Line 11: @@
 [[https://drive.google.com/open?id=1Wj9SsNy7fyrXa3qs4VTK_1AsxdC26Agf|Dr. Washington Publication Link]]
+[[https://drive.google.com/open?id=1jhSJEgaqCdYZ6zTGClMI0xsX1svmlP57|Dr. Washington Recommended Papers]]
+===== Operative Reports =====
+Wide Awake Tips:\\
+\\
+For CTR, TFR, finger/hand mass excisions: close w/ 4-0 nylon and apply large bandaid. \\
+\\
+For Mucous cyst excisions: Close w/ 4-0 Chromic, dress w/ bandaid.\\
+\\
+ALL PATIENTS MAY REMOVE DRESSINGS AFTER 5 days and use hand as tolerated. No soaking or submerging.
+\\
+Any patient with more than 1 elective procedure (trigger and CTR, multiple triggers, etc.…) needs a first postop visit with hand therapy between 5-7 days.\\
 ====Distal Radius====
-Important notes: Transects brachioradialis unless elderly patient, does NOT repair pronator quadratus
-Sutures: 4-0 nylon for closure
-Dressing: xeroform
-Splint: If suspect DRUJ instability place sugar tong, otherwise volar splint.
-ASSISTANT:
+<WRAP group>
-ORIF left distal radius fracture; intraarticular in three parts
+<WRAP half column>
-Left distal ulnar styloid fracture
-.
+Operative Report:\\
-PREOPERATIVE DIAGNOSIS:
+. Open reduction and internal fixation distal radius fracture, intra-articular, and three fragments:\\
-Left Closed intra-articular distal radius fracture; in three parts
+\\
-Left distal ulnar styloid fracture
+His splint was removed and a tourniquet was placed onto his arm which was then sterilely prepped and draped. An Esmarch bandage was used to exsanguinate the limb before elevation of the tourniquet to 250 mmHg.\\
-POSTOPERATIVE DIAGNOSIS:
+ \\
-Left Closed intra-articular distal radius fracture; in three parts
+We began the procedure by making a 10 cm incision longitudinally over his FCR tendon extending from his wrist crease and proximally. We dissected through subcutaneous tissue and identified the FCR tendon. We incised the tendon sheath, retracted the tendon ulnarly, and incised the subsheath. The distal aspect of the FPL origin was  was retracted ulnarly to expose the pronator quadratus which was incised along its radial and distal borders and elevated subperiosteally. We released brachioradialis and identified the first dorsal compartment underneath. We identified the fracture site and cleaned the fracture of callus.  We then used fluoroscopic imaging in order to confirm the ability to reduce the fracture. \\
-Left distal ulnar styloid fracture
+ \\
-OPERATION PERFORMED:
+We then selected an long Acumed Acu-Loc 2 volar radius plate. The plate position was provisionally stabilized using 0.054 K-wires and then secured to the proximal fragment using a 3.5 mm compression screw. We then reduced the fracture onto the plate and stabilized the distal fragment using additional 0.054 K-wires. The position of the plate and the fracture reduction were confirmed using fluoroscopic imaging. We then secured the epiphysis and articular fragments to the plate using 2.8 mm locking screws. We completed stabilization of the plate to the proximal fragment using 3.5 mm locking screws. The final position of the plate and fracture reduction were confirmed using fluoroscopic imaging and we were happy with both. Clinical examination showed no impingement of his wrist range of motion and stability of the DRUJ in supination.\\
-Left Open reduction and internal fixation distal radius fracture, intra-articular, and three fragments.
+ \\
+The incision was washed. The pronator quadratus was not closed and the skin was closed using 4-0 nylon sutures in a horizontal mattress with steri-strips. A sterile dressing and sugar tong splint  With the wrist in supination were applied. General anesthesia was reversed. He tolerated the procedure well. There were no complications. Final instrument count was correct.  The patient was taken out of the operating theater and to the PACU in stable condition.\\
-IMPLANTS: Acumed system
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+Important notes: Transects brachioradialis unless elderly patient, does NOT repair pronator quadratus\\
+Sutures: 4-0 nylon for closure\\
+Dressing: xeroform\\
+Splint: If suspect DRUJ instability place sugar tong, otherwise volar splint.\\
+OR tips: close ww/ 4-0 black nylon, xeroform/adaptiq, 4x4s, webrill, splint.\\
+If Short arm splint, wrap w/ ace. \\
+If long arm splint, wrap w/ bias.\\
+</WRAP>
+</WRAP>
+==== Carpal Tunnel Release ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Open Carpal Tunnel Release:\\
+\\
+Local anesthesia was achieved with 1% lidocaine with epinephrine to the palm.  The Right hand was then sterilely prepped and draped after placing a tourniquet. We exsanguinated with an esmarch and raised the tourniquet to 250 mm Hg. \\
+ \\
+A longitiunal incision was made 1 cm distal to the distal wrist crease in line with the 3rd web space,  extending  Kaplan's cardinal line. We dissected through the subcutaneous tissue and palmar fascia, and the palmaris brevis muscle fibers.  Care was taken to protect the ulnar neurovascular bundle in Guyon's canal. Next we palpated the hook of the hamate.  Next we identified the transverse carpal ligament which was divided longitudinally from the palmar fat pad and proximally into the antebrachial fascia approximate 1 cm proximal to the distal wrist crease under direct vision.  Complete release was ensured and the wound was irrigated with normal saline.  The skin was closed in a single layer using 4-0 nylon stitch.  A sterile dressing was applied.  Brandy tolerated the procedure well.  There were no complications.  The final instrument count was correct.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+Dr Washington always uses upper arm tourniquet. Webrill, tourniquet, 1000 drape.\\
+\\
+OR Tips: Close w/ 4-0 black nylon, xeroform or adaptiq, 2x2, webrill, 2” ace.
+If done in Wide Awake clinic, close w/ 4-0 nylon and just cover w/ large bandaid.\\
+\\
+Non-sterile tourniquet, on stretcher with arm table.\\
+No stockinette.\\
+Marking: Mark a dot at the ring finger tip. Flex into palm to transfer marker. Mark distal end of incision at Kaplan's, proximal end 1 cm distal to wrist crease. Use ragnelle, make sure incision is in-line with 3rd webspace.\\
+Local: On the field. Create wheal at wrist crease, inject distally along incision site (no median nerve block).\\
+Procedure: Uses scalpel through skin. Then use tenotomies to spread apart palmar fascia fibers. Cut TCL with 15 blade, then use tenotomies to complete TCL incision under direct visualization (lots of spreading before cutting).
+Close: 4-0 Nylon horizontal mattress.\\
+Dressing: Adaptic, 4x4, webroll, 2" ACE. Off on POD#5. Will sometimes splint, depending on patient.\\
+</WRAP>
+</WRAP>
+==== CMC Arthroplasty====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Trapeziectomy and ligament reconstruction tissue interposition (Weilby technique):\\
+\\
+The patient was identified in the holding area, and the operative site was marked. He was brought to the operating theatre in stable condition, placed on to a regular OR table in the supine position with the operative arm on an arm board. Preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as operative location. Supraclavicular nerve block was performed, as well as moderate sedation. A tourniquet was placed onto the arm which was then sterilely prepped and draped. An Esmarch bandage was used to exsanguinate the limb for elevation of the tourniquet to 250 mmHg.\\
+\\
+We began the procedure by making a Wagner-type incision from the FCR tendon at the wrist crease and along the glabrous junction of the base of the thumb. We dissected through subcutaneous tissue and protected cutaneous nerves. The thenar origin was elevated, including the slip of the APL to the thenars. The CMC capsule was then incised and the trapezium identified. The trapezium was removed piece-wise using a rongeur. The FCR tendon was left intact.\\
+\\
+We then harvested a radial-sided slip of the FCR tendon and used this for our ligament reconstruction using the Weilby technique. In brief, the FCR tendon was passed through the APL insertion and back around the intact FCR slip to the index metacarpal. The remaining tendon was used for tissue interposition. The ligament reconstruction was secured using 3-0 Fiberwire suture. \\
+\\
+The wound was irrigated, and the thenar origin was repaired, as well as the APL slip, using 4-0 Monocryl suture. Skin was sutured using 4-0 Monocryl deep dermal sutures reinforced with Steri-Strips. Fluoroscopic imaging was used to confirm removal of the trapezium, as well as stability at the ligament reconstruction with stressing. A thumb spica splint was applied. The patient tolerated the procedure well. There were no complications. Final instrument count was correct.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+OR tips: Typically closes w/ 3-0/4-0 monocryl w/ dermabond, dress w/ 2x2, webril, plaster thumb spica splint, 2” ace\\
+</WRAP>
+</WRAP>
+====Cubital Tunnel Release====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. In situ decompression of ulnar nerve at the elbow:\\
+\\
+The patient was identified In the holding area and the operative site was marked. The patient was brought to the operating theatre in stable condition, placed on a regular table in supine position with right arm on an arm board. Preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. The patient received perioperative antibiotics. All bony prominences were well-padded. The right arm was sterilely prepped and draped.\\
+\\
+I began the procedure by making a longitudinal incision centered between his medial epicondyle and olecranon. I dissected through subcutaneous tissue and protected branches of the medial antebrachial cutaneous nerve. The ulnar nerve was identified just posterior to the medial intramuscular septum. The nerve was then decompressed through the cubital tunnel, as well as between the 2 heads of the FCU fascia. Complete decompression was ensured, both proximally and distally. Full elbow range of motion showed no subluxation and hemostasis was revised. \\
+\\
+The wound was irrigated and skin closed using 4-0 Monocryl deep dermal and running subcuticular stitch reinforced with Steri-Strips. Soft dressing was applied. The patient tolerated the procedure well. There were no complications. Marcaine 0.25% with 1% lidocaine and epinephrine was injected for postoperative anesthesia. The patinet left the operating room in stable condition.\\
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+Closes w/ 3-0/4-0 Monocryl, dermabond, dress w/ 4x4, webrill and 4” ace. \\
+</WRAP>
+</WRAP>
+====DeQuervain’s Release====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. 1st dorsal compartment release\\
+\\
+The patient was identified in the holding area and the operative site was marked. The patient was brought to the operating theatre in stable condition, placed onto a regular OR table with the arm on an arm board. A preoperative timeout was taken to ensure the patient's identity, the operative procedure, as well as operative location. Local anesthesia was achieved with 1% lidocaine mixed with 0.25% Marcaine plain. The hand was then sterilely prepped and draped. No tourniquet was required.
+I made a longitudinal incision just distal to the radial styloid and dissected through subcutaneous tissue and identified prominent branches of the superficial radial nerve, which were neurolysed and protected. We then identified the EPL and EPB tendons and followed them proximally back to the 1st dorsal compartment. The 1st dorsal compartment was then released at the dorsal most aspect of its insertion in order to prevent volar subluxation of the tendons. Complete release was ensured and sub-compartments were identified. The wound was irrigated and skin closed with 4-0 Monocryl suture. Steri-Strips and a sterile dressing were applied.
+The patient tolerated the procedure well. There were no complications. Final instrument count was correct.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+The most important part of this operation is ensuring both release of APL and EPB. They commonly run in separate subsheaths and failed operations are a result of incomplete release of the subsheaths.\\
+OR tips: close w/ 3-0/4-0 Monocryl, dermabond, 2x2, webrill and 2” ace. \\
+</WRAP>
+</WRAP>
+====Dorsal Wrist Ganglion Excision====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Dorsal wrist ganglion excisional biopsy:\\
+\\
+The patient was identified in the holding area and the operative site was marked.  The patient was brought to the operating theater in stable condition and placed onto regular OR table with the arm on an arm board. A preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as the operative location. Local anesthesia was achieved with 0.25% Marcaine mixed with 1% lidocaine with epinephrine. The hand was sterilely prepped and draped. \\
+\\
+A transverse incision was made over the ganglion. We dissected through subcutaneous tissue and exposed the extensor retinaculum which was divided longitudinally over the ganglion.  The ganglion was identified and traced to the radiocarpal joint.  A portion of the volar wrist capsule was excised around the stalk and this specimen was sent for pathology.\\
+\\
+The wound was irrigated and hemostasis was assured. Skin was closed with 4-0 Monocryl deep dermal sutures and reinforced with Steri-Strips. A sterile dressing was applied. The patient tolerated the procedure well. There were no complications. We did not require tourniquet. The patient left the operating room in stable condition.\\
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+OR tips: If VWG, usually closes w/ 4-0 Nylon. If DWG, close w/ 3-0/4-0 monocryl/dermabond. Splint until FU\\
+</WRAP>
+</WRAP>
+==== Volar Wrist Ganglion Excision ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Volar ganglion excisional biopsy:\\
+\\
+The patient was identified in the holding area and the operative site was marked. The patient was brought to the operating theater in stable condition and placed onto regular OR table with the operative arm on an arm board. A preoperative timeout was taken to ensure the patient's identity, operative procedure, as well as the operative location. Local anesthesia was achieved with 0.25% Marcaine mixed with 1% lidocaine with epinephrine. The hand was sterilely prepped and draped. The patient received mild sedation.\\
+\\
+We began the procedure by making a Chevron incision over the ganglion. We dissected through subcutaneous tissue and freed the radial artery from the ganglion and sacrificed the venae comitantes. The ganglion was traced down to the carpus and was found to originate from the scaphotrapeziotrapezoid joint. A portion of the volar wrist capsule was excised around the stalk and this specimen was sent for pathology.\\
+\\
+The wound was irrigated and hemostasis was assured. Skin was closed with 4-0 Monocryl deep dermal sutures and reinforced with Steri-Strips. A sterile dressing with a volar wrist splint was applied. The patient tolerated the procedure well. There were no complications. We did not require tourniquet. The patient left the operating room in stable condition.\\
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+OR tips: If VWG, usually closes w/ 4-0 Nylon. If DWG, close w/ 3-0/4-0 monocryl/dermabond. Splint until FU\\
+</WRAP>
+</WRAP>
+====Metacarpal Fractures s/p ORIF====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. CRPP Right first metacarpal base fracture:\\
+\\
+He was brought to the operating room and placed in a supine position. General anesthesia was induced and a time out performed.   An upper arm tourniquet was placed and the right upper extremity was prepped and draped in a standard sterile surgical fashion.  We first proceeded by exsanguinated and raising the tourniquet to 250 mm Hg.  We used the mini carm.  We reduced the fracture and placed two .045  kwires through the first metacarpal and one .045 k-wire through the first metacarpal to the second metacarpal. We burried the k wires underneath the skin.  We then placed a sterile dressing and a thumb spica splint.  The patient tolerated the procedure and went to the post operative care unit without complication.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+OR tips: Usually close w/ 4-0 nylon, adaptiq/xeroform, 4x4, ace. Usually places whole hand in forearm based intrinsic plus splint w/ IPs included\\
+</WRAP>
+</WRAP>
+====Trigger Finger Release====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Exact name of Operative Procedure:\\
+\\
+The patient was identified in the Holding Area, and the operative site was marked.  The patient was brought into the operative theater in stable condition, placed onto a regular OR table, with the arm on an arm board.  Preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as operative location.  Local anesthesia was achieved with 0.25 percent Marcaine mixed with 1 percent lidocaine with epinephrine.  The hand was then sterilely prepped and draped.\\
+\\
+I made a longitudinal incision extending from his distal palmar crease half way to the web spaces over the finger.  Dissection was proceeded with through the subcutaneous tissues protecting the digital neurovascular bundles.  I identified the A1 pulley which was divided longitudinally to expose the flexor tendons.  Complete release was performed distally and proximally with the Littler scissors.  Full release was confirmed by having the patient take a fist and completely extending to show no persistent triggering.  The wound was irrigated and closed with 4-0 nylon horizontal mattress sutures.  Sterile dressing was applied. The patient tolerated procedure well.  There were no complications.  Final instrument count was correct.  The patient left the operating theatre in stable condition.
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+Or tips: close w/ 4-0 nylon, xeroform/adaptiq, 4x4, webrill, 2” ace.
+If wide awake, just bandaid. \\
+</WRAP>
+</WRAP>
+====Nail Ablation====
+<WRAP group>
+<WRAP half column>
+was identified in the holding area and the operative site was marked.  He was brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with both operative extremity on an arm boards. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location.\\
+Tourniquets were placed and both arms were prepped and draped in a standard sterile surgical fashion. \\
+We first proceeded with the right hand. \\
+We exsanguinated the hand with an esmarch and raised the tourniquet to 250 mm Hg. \\
+We then proceeded with surgical ablation of the right index finger nail bed.  We used a freer elevator to remove the nail.  We then surgically removed the germinal matrix and sterile matrix with a # 15 blade.  We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed. \\
+We then proceeded with surgical ablation of the right long finger nail bed. We used a freer elevator to remove the nail.  We then surgically removed the germinal matrix and sterile matrix with a # 15 blade.  We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed. \\
+We then proceeded with the left hand procedures. \\
+We exsanguinated the hand with an esmarch and raised it to 250 mm Hg.  We then proceeded with surgical ablation of the left thumb nail.  We used a freer elevator to remove the nail.  We then surgically removed the germinal matrix and sterile matrix with a # 15 blade.  We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed. \\
+We then proceeded with surgical ablation of the left index finger.  We used a freer elevator to remove the nail.  We then surgically removed the germinal matrix and sterile matrix with a # 15 blade.  We then chemically ablated the nail bed with phenol, by using a q-tip to place it on the nail bed. \\
+We then elevated a full thickness skin graft from the left forearm that was 8 x 4 cm. \\
+We closed the incision with 3-0 vicryl and 4-0 monocyrl sutures after undermining the adjacent tissue. \\
+We then proceeded with the right index finger full thickness skin great to the nail bed.  We cut a 1x1 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding.  We sutured the skin graft with 4-0 chromic sutures. \\
+We then proceeded with the right long finger full thickness skin great to the nail bed. We cut a 1x1 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding.  We sutured the skin graft with 4-0 chromic sutures. \\
+We then proceeded with the left index finger full thickness skin great to the nail bed.  We cut a 1x1 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding.  We sutured the skin graft with 4-0 chromic sutures. \\
+We then proceeded with the left thumb full thickness skin great to the nail bed.  We cut a 2 x 2 cm full thickness skin graft and placed it on the nail bed after curretting the bed to get some bleeding.  We sutured the skin graft with 4-0 chromic sutures. \\
+We placed xeroform over the skin grafts, guaze 4x4, and we placed webroll, bilateral plaster splints, and bias dressing. \\
+</WRAP>
+<WRAP half column>
+Tourniquet: Yes\\
+Drain: No\\
+Sutures: Yes\\
+Dressing: Yes\\
+</WRAP>
+</WRAP>
+==== ORIF Lunate Dislocation ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Left ORIF of lunate dislocation\\
+. Left Luno triquetral ligament repair\\
+. Left scapho lunate ligament repair\\
+. EPL transposition\\
+. Left carpal tunnel release\\
+\\
+The patient was identified in the holding area and the operative site was marked.  He was brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with the operative extremity on an arm board. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location. A left arm tourniquet was placed and the arm was prepped and draped in a standard sterile surgical fashion.\\
+\\
+A longitiunal incision was made in line with the 3rd metacarpal on the dorsum of the hand.  We spread with tenotomy scissors down to the level of the extensor retinaculum.  We then made step cute incisions through the retinaculum the posterior interosseus nerve appeared to have been avulsed at the based of the 4th metacarpal.  We then made a dorsal sparing capsulotomy.  We pulled traction on the wrist with extension and then flexion while placing volar pressure on the lunate.  We placed two .054 k wires going from the scaphoid to capitate.  We then placed 2 crossed k wires across the scapho lunate interval and 2 k wires across the Luno triquetral interval.  We then repaired the LT ligament with 4-0 ethibond sutures and the scapho lunate ligament with a mini mitek anchor.  We then closed the capsule with 4-0 vicryl.\\
+ \\
+We transposed EPL and closed the extensor retinaculum in a vest over pants type fashion.  We closed the skin with 4-0 nylon sutures.\\
+ \\
+We then proceeded to the carpal tunnel release:\\
+A longitiunal incision was made 1 cm distal to the distal wrist crease in line with the 3rd web space,  extending  Kaplan's cardinal line and crossing the wrist crease. We dissected through the subcutaneous tissue and palmar fascia, and the palmaris brevis muscle fibers.  Care was taken to protect the ulnar neurovascular bundle in Guyon's canal. Next we palpated the hook of the hamate.  Next we identified the transverse carpal ligament which was divided longitudinally from the palmar fat pad and proximally into the antebrachial fascia approximate 1 cm proximal to the distal wrist crease under direct vision.  Complete release was ensured and the wound was irrigated with normal saline.  The skin was closed in a single layer using 4-0 nylon stitch.  \\
+ \\
+We placed a plaster sugar tong thumb spica splint and bias dressing.  He was extubated and went to the post operative care unit without complication.\\
+</WRAP>
+<WRAP half column>
+Photos\\
+Tourniquet: finger / forearm / arm\\
+Drain: Type of drain and placement\\
+Sutures: List all layers\\
+Dressing: What's preferred?\\
+Anatomy: Pertinent anatomy should be listed\\
+Post-operative care: Include restrictions, splints, etc...\\
+Attending Pearls (Learning points/Pimp Questions):\\
+</WRAP>
+</WRAP>
+==== Scaphoid Excision and 4-Corner Fusion ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. PIN neurectomy\\
+. EPL transposition\\
+. Scaphoid excision, 4 corner fusion\\
+. Carpal tunnel release\\
+. Diganostic wrist arthroscopy\\
+INDICATIONS FOR PROCEDURE: This patient is a _ - year old _ diagnosed with a chronic scapholunate ligament tear. We wanted to proceed with wrist arthroscopy for diagnosis and then definitive surgery as well as carpal tunnel release.
+ \\
+DESCRIPTION OF PROCEDURE:
+The patient was identified in the preoperative holding area and the operative site was marked.  They were brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with the operative extremity on an arm board. An upper arm tourniquet was placed and a preoperative time-out was performed to ensure the patient's identity, the operative procedure, as well as the operative location. The _ arm was sterilely prepped and draped in a standard sterile surgical fashion.\\
+ \\
+We first proceeded by exsanguinating the extremity and raising the tourniquet to 250 mm Hg.
+We first proceeded with the carpal tunnel release:
+ We made a longitudinal incision in the left palm in line with the 3rd webspace up to Kaplan's cardinal line. We incised through the skin down to the transverse carpal ligament and released it in its entirety.
+We then proceeded with our wrist arthroscopy. We hung the wrist in the Acumed traction tower. We entered the wrist through a dorsal 3/4 portal. We were able to visualize the space between the scaphoid and lunate and the proximal end of the capitate, indicative of a complete SL tear.
+We then proceed to scaphoid excision and four corner fusion, PIN neurectomy, and EPL transposition.
+We made a dorsal midline incision overlying the radiocarpal joint in line with the 3rd metacarpal.  We spread with our tenotomy scissors down to the level of the extensor retinaculum. We made a step cut incision in the retinaculum and raised thick retinacular flaps. We then located the posterior interosseous nerve and removed the distal end and cauterized the remainder at the level of the radiocarpal joint. We then made a ligament sparing incision in the dorsal wrist capsule. We raised the capsular flap and located the scaphoid and lunate. There was a complete chronic tear of the SL ligament and the cartilage on the capitate was worn, so we made the decision to do a scaphoid excision, 4 corner fusion.
+We excised the scaphoid in its entirety. We then used a joystick to bring the lunate out of the DISI deformity. We removed the cartilage from the capitate and lunate and used bone graft from the scaphoid. We placed a 22 mm Acumed screw in the capitolunate interval and a 16 mm screw in the hamate capitate interval.  We then closed the remaining capsule with 4-0 Vicryl suture. We then transposed the EPL tendon and then closed the extensor retinaculum and a vest over pants type fashion with 4-0 Vicryl.
+We closed the incisions with 4-0 nylon suture in a horizontal mattress fashion.
+We placed a sterile dressing and a well-padded sugar tong splint.
+The patient tolerated the procedure and awoke from anesthesia without known complications.
+\\
+</WRAP>
+<WRAP half column>
+Tourniquet: Upper arm – 250 mmHg\\
+Drain: None\\
+Sutures: Drain stitches: 4-0 Vicryls/Nylons\\
+Dressing: Sugar tong splint, well-padded. 10 sheets thick. Bias/tape.\\
+Anatomy: Arthroscopic port entry sites. Anatomy of the carpus.\\
+Post-operative care:\\
+- Maintain splint until clinic follow-up.\\
+- Okay to use sling while arm is numb from block; remove when sensation returns to avoid stiffness/contralateral shoulder pain.\\
+Learning points/Pimp Questions:
+-	Know arthroscopic port entry sites, how to obtain appropriate intraoperative views with a C-arm.\\
+-	Know how to place a sugar tong splint.\\
+</WRAP>
+</WRAP>
+==== Table Saw Injury ====
+<WRAP group>
+<WRAP half column>
+Operative Report:\\
+. Right open carpal tunnel release\\
+. Right flexor pollicus longus repair\\
+. Complex closure right hand\\
+\\
+OPERATIVE INDICATIONS:
+XXX　is a 65 y.o.　male　who had a table saw injury to the palm of his hand and injured his FPL tendons as well as the digital nerves. We wanted to proceed with operative intervention.
 DESCRIPTION OF OPERATION:
-x was identified in the Holding Area and the operative site was marked. He was brought to the operating theater in stable condition and placed onto a regular OR table with his operative arm on an arm board. A preoperative time-out was taken to ensure the patient's identity, operative procedure, as well as the operative location. General anesthesia was administered. His splint was removed and a tourniquet was placed onto his arm which was then sterilely prepped and draped. An Esmarch bandage was used to exsanguinate the limb before elevation of the tourniquet to 250 mmHg.
+XXX　was identified in the holding area and the operative site was marked. He　was brought to the operating theater in stable condition, placed onto a regular OR table in the supine position with the operative extremity on an arm board. A preoperative time-out was taken to ensure the patient's identity, the operative procedure, as well as the operative location.　A regional block was performed in preoperative holding.
-We began the procedure by making a 10 cm incision longitudinally over his FCR tendon extending from his wrist crease and proximally. We dissected through subcutaneous tissue and identified the FCR tendon. We incised the tendon sheath, retracted the tendon ulnarly, and incised the subsheath. The distal aspect of the FPL origin was  was retracted ulnarly to expose the pronator quadratus which was incised along its radial and distal borders and elevated subperiosteally. We released brachioradialis and identified the first dorsal compartment underneath. We identified the fracture site and cleaned the fracture of callus.  We then used fluoroscopic imaging in order to confirm the ability to reduce the fracture.
+We first proceeded with a carpal tunnel release:
-We then selected an long Acumed Acu-Loc 2 volar radius plate. The plate position was provisionally stabilized using 0.054 K-wires and then secured to the proximal fragment using a 3.5 mm compression screw. We then reduced the fracture onto the plate and stabilized the distal fragment using additional 0.054 K-wires. The position of the plate and the fracture reduction were confirmed using fluoroscopic imaging. We then secured the epiphysis and articular fragments to the plate using 2.8 mm locking screws. We completed stabilization of the plate to the proximal fragment using 3.5 mm locking screws. The final position of the plate and fracture reduction were confirmed using fluoroscopic imaging and we were happy with both. Clinical examination showed no impingement of his wrist range of motion and stability of the DRUJ in supination.
+A longitidunal incision was made 1 cm distal to the distal wrist crease in line with the 3rd web space, extending Kaplan's　cardinal line. We dissected through the subcutaneous tissue and palmar fascia, and the palmaris brevis muscle fibers. Care was taken to protect the ulnar neurovascular bundle in Guyon's canal. Next we palpated the hook of the hamate. Next we identified the transverse carpal ligament　which was divided longitudinally from the palmar fat pad and proximally into the antebrachial fascia approximate 1 cm proximal to the distal wrist crease under direct vision. Complete release was ensured and the wound was irrigated with normal saline.
-The incision was washed. The pronator quadratus was not closed and the skin was closed using 4-0 nylon sutures in a horizontal mattress with steri-strips. A sterile dressing and sugar tong splint  With the wrist in supination were applied. General anesthesia was reversed. He tolerated the procedure well. There were no complications. Final instrument count was correct.  x was taken out of the operating theater and to the PACU in stable condition.
+We then proceeded with repair of the FPL tendon:
-POSTOPERATIVE PLAN:
+The proximal and distal ends of the FPL tendon were identified. We repaired the tendon with a 4-core strand repair with a modified Kessler stitch and an epitendinous repair.
-x will go home from the hospital today with arrangements made to follow up with me in clinic in two weeks. He will be transitioned into a short arm removable splint, which will be worn continuously for an additional four weeks with protected range of motion of his wrist initiated by Hand Therapy. He has been told to strictly elevate his hand at all times as well as move his fingers to prevent stiffness. If he has any difficulty or concerns between now and followup, he has been told to contact me, and I would be happy to see him sooner.
+We then isolated the digital nerves, which appeared to be avulsed. We tagged them with 5-0 Prolene suture and burried them underneath the thenar muscles.
+We then proceeded to irrigated the wounds extensively. We undermined the tissue with tenotomy scissors. We then sutured the incision closed with 4-0 Nylon suture in an interrupted horizontal mattress fashion. The length of the incision was 30 centimeters.
+A sterile dressing and thumb spica splint were applied. The patient tolerated the procedure and went to the post operative care unit without complication.
+</WRAP>
+<WRAP half column>
+Photos:\\
+{{:resident:img_4872.png?400|}}
+{{:resident:img_4871.png?400|}}
+{{:resident:img_4870.png?200|}}
+{{:resident:img_4869.png?200|}}
+\\
+Tourniquet: Arm\\
+Drain: None\\
+Sutures: Modified Kessler = 4-0 Fiberwire, Epitendinous = 6-0 Prolene, Skin = 4-0 Nylon horizontal mattress, 5-0 Prolene to tag the nerves\\
+Dressing: Xeroform on suture line, then 4x4 gauze, well-padded plaster splint with Webril, 4x15, x12 thick, (thumb spica, in this case) - she generally splits the plaster longitudinally, with an extra piece to mold around the thumb\\
+Anatomy: Obviously for a mangaled hand all hand and forearm anatomy is critical. Usually attending will explore the injury and then write out what needs to be repaired with check boxes. Usually the order is bony fixation, tendon repair and then nerve. If the hand is dysvascular, then that needs to be addressed to prevent muscle necrosis.\\
+Post-operative care:\\
+Immobilization in splint until clinic. Depending on repair may attempt early mobilization.\\
+Attending Pearls (Learning points/Pimp Questions): Known how to draw a modified Kessler prior to performing the suture repair. Know relevant anatomy of the hand and palm.\\
+</WRAP>
+</WRAP>