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--- resident:kia_washington [2021/02/14 14:14] – [ORIF Lunate Dislocation] jonathan
+++ resident:kia_washington [2021/08/04 15:21] (current) – [Table Saw Injury] jonathan
@@ Line 476: / Line 476: @@
-==== Scaphoid Excision, 4-Corner Fusion ====
+==== Scaphoid Excision and 4-Corner Fusion ====
 <WRAP group>
@@ Line 531: / Line 531: @@
+==== 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:
+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 first proceeded with a carpal tunnel release:
+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.
+We then proceeded with repair of the FPL tendon:
+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.
+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>