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--- resident:stephanie_malliaris [2021/08/02 18:29] – [Enchondroma Curettage] jonathan
+++ resident:stephanie_malliaris [2021/08/19 13:13] (current) – taylor
@@ Line 14: / Line 14: @@
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 ===== Hand =====
+==== Flexor Tendon Repair (Zones 1 and 2) ====
+<WRAP group>
+<WRAP half column>
+POSTOPERATIVE DIAGNOSES:
+.  Crush injury to hand.
+.  Complete transection of the flexor digitorum profundus, zone 2, right long
+finger.
+.  One slip, complete transection of flexor digitorum superficialis, zone 2 to
+right long finger.
+.  A 90% transection FDP to index finger, zone 1.
+.  Laceration to ring finger and small finger volar aspect.
+PROCEDURES:
+.  Washout and excisional debridement of crush wound to right hand index finger,
+long, ring, and small fingers.
+.  Repair of FDP tendon, right long finger, zone 2.
+.  Repair of FDP tendon in zone 1, right index finger.
+.  Closure of simple laceration, right ring finger and small finger.
+DESCRIPTION OF PROCEDURE:  The patient was brought to the operating room.  He
+remained on the stretcher.  The right upper extremity was put on a hand table.  Bony
+prominences were padded.  SCD boots were placed.  Preoperative antibiotics were
+given.  General anesthesia was administered.  The right upper extremity was prepped
+and draped in the usual sterile fashion with a tourniquet on the upper arm.
+Surgical pause was performed in accordance with hospital regulations.  The right
+upper extremity was elevated and exsanguinated using Esmarch bandage and the
+tourniquet was inflated to 250 mmHg.  We used a Tupper retractor and removed all the
+prior placed sutures and investigated the wounds.  We started with the long finger.
+A Bruner incision was used to extend the wound proximally and distally, and it was
+noted that the neurovascular bundles were grossly intact, but there was complete
+disruption of the FDP tendon in zone 2, as well as one of the slips of the FDS
+tendons.  The A3 pulley and part of the A4 were also injured and not in continuity.
+The tendon injury was actually more distal, and as such, we opened Bruner wires
+distally to the distal phalanx and located the distal end of the tendon through the
+A4-A5 area.  The remainder of the A4 pulley needed to be opened.  The proximal end
+of the tendon was brought through the A2 and A3 area pulleys.  We irrigated this
+with copious saline and used a 3-0 Supramid to do a modified Kessler repair of the
+FDP tendon.  This then had an epitendinous 6-0 Prolene placed circumferentially
+around the tendon.  The finger was ranged and it did achieve what appeared to be
+full flexion.  The other slip of the FDS tendon was trimmed and the radial slip
+remained intact and had not been injured in the accident.  The area was irrigated
+and the Bruner flaps were placed over the tendon.
+We turned our attention to the index finger.  The laceration was irrigated and
+excisional debridement was performed of skin and subcutaneous tissue.  This was done
+with scissors, and the area was 3 x 2 cm.  We explored the wound and found a 90%
+lacerated FDP tendon in zone 1.  As there was not much tendon distally, we elected
+to repair this with a suture anchor.  The area was cleaned off and a mini Mitek with
+-0 suture was drilled and placed into the volar aspect of the distal phalanx.  We
+then used the 2-0 suture to repair the tendon to the distal phalanx, and 6-0 Prolene
+was then used for further strength repair at the tendon laceration site.  This was
+then irrigated.
+We then did the excisional debridement of the skin and subcutaneous tissue of the
+long finger.  The nonviable edges were trimmed.  This was approximately 3 x 0.5 cm
+area.  The debridement was skin and subcutaneous tissue and it was done with an
+Adson.
+We then turned our attention to the ring and small fingers.  The 2 other lacerations
+were explored, tendons were intact in the ring finger and in the small finger.  It
+did not extend into the flexor sheath either.  Excisional debridements were
+performed, 1 cm x 0.5 cm for of these lacerations.
+The Irrisept wound irrigation system was used, 500 mL to irrigate all four of the
+lacerations.  We then released the tourniquet and normal perfusion returned to the
+hand and fingers.  Hemostasis was ensured and then the incisions were closed with
+interrupted 4-0 nylon sutures.
+A dorsal blocking splint was placed after bacitracin, Adaptic, and sterile Webril.
+</WRAP>
+<WRAP half column>
+Irrigation with Irrisept 500mL
+Tourniquet: Sterile; arm
+Drain: None
+Sutures:
+- Skin: 4-0 nylon
+- FDP zone 2: modified Kessler with 3-0 Supramid, epitendinous with 6-0 Prolene
+- FDP zone 1: mini Mitek with 2-0 suture was drilled and placed into volar aspect of distal phalanx, 2-0 suture to repair tendon to distal phalanx, 6-0 prolene to reinforce
+Dressing: Bacitracin, Adaptic, Webril, dorsal blocking splint\\
+Anatomy: FDP/FDS insertions, zones of injury, Camper's chiasm, neurovascular bundles\\
+Post-operative care: Elevate LUE, splint care, f/u 1-2 weeks, OT referral for flexor rehab protocol\\
+Attending Pearls (Learning points/Pimp Questions): N/A\\
+</WRAP>
+</WRAP>
 ==== Metacarpal Nail ====