krystim1109
Contributor
Im not quite sure how to code this I got 26390 26500 26500 I want to code 26356 but it was inclusive to 26390
PREOPERATIVE DIAGNOSIS: Left small finger zone 2 flexor tendon
laceration (flexor digitorum profundusand flexor tendondigitorum
superficialis).
POSTOPERATIVE DIAGNOSIS: Left small finger zone 2 flexor tendon
laceration (flexor digitorum profundus and flexor tendon digitorum
superficialis).
OPERATION:
1. Left small finger flexor tenolysis.
2. Left small finger partial flexor digitorum profundus excision.
3. Left small finger ulnar digital nerve repair, zone 2.
4. Left small finger A2 pulley reconstruction.
5. Left small finger A4 pulley reconstruction.
6. Left small finger Hunter rod insertion (passive 3 mm from distal
phalanx to the wrist crease).
7. Volar splint.
ANESTHESIA: General.
ASSISTANT: None.
IV FLUIDS: Crystalloid.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS: None.
FOLEY: None.
COMPLICATIONS: None.
FINDINGS/PROCEDURE: The patient was brought to the operating room
awake, alert, and in stable condition. Discussed the risks and
benefits of the surgery. She received a prophylactic dose of
antibiotics. Verbal time-out was performed confirming the operative
site, patient, and procedure. Tourniquet was applied on the left
upper arm. The left upper arm was sterilely prepped and draped. A
Brunner incision was marked over the volar aspect of the small finger
and palm. The limb was exsanguinated, tourniquet inflated to250 mmHg.
Under 3.5 loupe magnification, the above-marked skin incision was
made, full-thickness skin flaps elevated. At the site of the
laceration in zone 2 over the proximal phalanx, there was abundant
scar tissue along the ulnar border of the digit. The digital
neurovascular structure was identified. The ulnar digital nerve was
completely transected. This nerve was then mobilized. External
neurolysis was performed. With 2 viable ends of the nerve available,
I was able to do a nerve repair. I first performed a flexor tendon
tenolysis. The A2 pulley, A3 pulley, and A4 pulleys were completely
adherent to the bone; therefore, I opened up the flexor sheath in this
area. FDS tendon was identified just distal to the A1 pulley and was
adherent to some scar tissue. FDP was proximally migrated proximal to
the A1 pulley. The A1 pulley was actually in good condition and was
preserved. After the flexor tenolysis was performed, the remnants of
the FDS tendon which were about 1 cm in length were preserved, and I
actually used these to reconstruct the A4 pulley. The stump of the
FDP tendon was partially excised back to a reasonable length. This
waselevated. The wound was then thoroughly irrigated. The
tourniquet was deflated. Excellent hemostasis was obtainable. I then
moved forward with repairs.
The wound was then thoroughly irrigated. The ulnar digital nerve was
repaired with 9-0 nylon. Four simple sutures were placed. Excellent
apposition of the epineural repair was achievable without tension. I
then moved forward with placement of the Hunter rod. The Hunter rod
was first placed through the A1 pulley. I preserved the FDS tendon.
This would become an excellent source of amotor source for a tendon
repair for the second stage. The Hunter rod was then secured distally
beneath the FDP tendon insertion. This was performed with 3-0
FiberWire. This was secured. The A4 pulley was then reconstructed
using the 2radial and ulnar limbs of the FDS tendon. This was
secured with 4-0 Mersilene. This created an excellent pulley. The
remnants of the A3 pulley were repaired, and the A2 pulley was
repaired with a Mersilene suture. This was done by Z-plasting the
contracted A2 pulley. The A1 pulley was preserved. The Hunter rod
was then placed with a tendon passer proximal to the wrist flexion
crease beneath thetransverse carpal ligament. Intraoperative
fluoroscopic imagingconfirmed placement of the Hunter rod. The wound
was then thoroughly irrigated. The skin edges were then
reapproximated with 4-0 Prolene. Wounds were cleaned with wet-and-dry
dressing, Adaptic, Betadine, and fluffs. Marcaine was injected for
postoperative pain relief. The patient tolerated the procedure well
and was brought to the recovery room in an awake, alert, stable
condition to be discharged pending further evaluation.
PREOPERATIVE DIAGNOSIS: Left small finger zone 2 flexor tendon
laceration (flexor digitorum profundusand flexor tendondigitorum
superficialis).
POSTOPERATIVE DIAGNOSIS: Left small finger zone 2 flexor tendon
laceration (flexor digitorum profundus and flexor tendon digitorum
superficialis).
OPERATION:
1. Left small finger flexor tenolysis.
2. Left small finger partial flexor digitorum profundus excision.
3. Left small finger ulnar digital nerve repair, zone 2.
4. Left small finger A2 pulley reconstruction.
5. Left small finger A4 pulley reconstruction.
6. Left small finger Hunter rod insertion (passive 3 mm from distal
phalanx to the wrist crease).
7. Volar splint.
ANESTHESIA: General.
ASSISTANT: None.
IV FLUIDS: Crystalloid.
ESTIMATED BLOOD LOSS: Minimal.
DRAINS: None.
FOLEY: None.
COMPLICATIONS: None.
FINDINGS/PROCEDURE: The patient was brought to the operating room
awake, alert, and in stable condition. Discussed the risks and
benefits of the surgery. She received a prophylactic dose of
antibiotics. Verbal time-out was performed confirming the operative
site, patient, and procedure. Tourniquet was applied on the left
upper arm. The left upper arm was sterilely prepped and draped. A
Brunner incision was marked over the volar aspect of the small finger
and palm. The limb was exsanguinated, tourniquet inflated to250 mmHg.
Under 3.5 loupe magnification, the above-marked skin incision was
made, full-thickness skin flaps elevated. At the site of the
laceration in zone 2 over the proximal phalanx, there was abundant
scar tissue along the ulnar border of the digit. The digital
neurovascular structure was identified. The ulnar digital nerve was
completely transected. This nerve was then mobilized. External
neurolysis was performed. With 2 viable ends of the nerve available,
I was able to do a nerve repair. I first performed a flexor tendon
tenolysis. The A2 pulley, A3 pulley, and A4 pulleys were completely
adherent to the bone; therefore, I opened up the flexor sheath in this
area. FDS tendon was identified just distal to the A1 pulley and was
adherent to some scar tissue. FDP was proximally migrated proximal to
the A1 pulley. The A1 pulley was actually in good condition and was
preserved. After the flexor tenolysis was performed, the remnants of
the FDS tendon which were about 1 cm in length were preserved, and I
actually used these to reconstruct the A4 pulley. The stump of the
FDP tendon was partially excised back to a reasonable length. This
waselevated. The wound was then thoroughly irrigated. The
tourniquet was deflated. Excellent hemostasis was obtainable. I then
moved forward with repairs.
The wound was then thoroughly irrigated. The ulnar digital nerve was
repaired with 9-0 nylon. Four simple sutures were placed. Excellent
apposition of the epineural repair was achievable without tension. I
then moved forward with placement of the Hunter rod. The Hunter rod
was first placed through the A1 pulley. I preserved the FDS tendon.
This would become an excellent source of amotor source for a tendon
repair for the second stage. The Hunter rod was then secured distally
beneath the FDP tendon insertion. This was performed with 3-0
FiberWire. This was secured. The A4 pulley was then reconstructed
using the 2radial and ulnar limbs of the FDS tendon. This was
secured with 4-0 Mersilene. This created an excellent pulley. The
remnants of the A3 pulley were repaired, and the A2 pulley was
repaired with a Mersilene suture. This was done by Z-plasting the
contracted A2 pulley. The A1 pulley was preserved. The Hunter rod
was then placed with a tendon passer proximal to the wrist flexion
crease beneath thetransverse carpal ligament. Intraoperative
fluoroscopic imagingconfirmed placement of the Hunter rod. The wound
was then thoroughly irrigated. The skin edges were then
reapproximated with 4-0 Prolene. Wounds were cleaned with wet-and-dry
dressing, Adaptic, Betadine, and fluffs. Marcaine was injected for
postoperative pain relief. The patient tolerated the procedure well
and was brought to the recovery room in an awake, alert, stable
condition to be discharged pending further evaluation.