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POSTOPERATIVE DIAGNOSES: Right median nerve injury at the wrist and laceration to the flexor tendons of the right ring finger and first webspace contracture.
OPERATIONS PERFORMED:
1. Cable grafting to the median nerve using three segments of 10 cm in length each.
2. Tendon graft to the ring finger using the flexor digitorum superficialis tendon.
3. Tenolysis of flexor digitorum superficialis and flexor digitorum profundus to the ring finger.
4. Soft tissue rearrangement with contracture release measuring 10 cm2 of the first webspace.
FINDINGS: Lacerated median nerve just proximal to the transverse carpal ligament and the lacerated ends were found just beneath the superficial palmar arch.
INDICATIONS: The patient is a 20-year-old gentleman with an industrial accident with median nerve injury and right ring finger flexor tendon injury that were treated at the University Hospital about three months ago. He has developed webspace contracture since. Upon reviewing the operative notes to that surgery, they were unable to find the median nerve proximally or distally, and so nothing was done with this, and then they apparently repaired flexor tendon injury in zone II. He has no motion of the ring finger and is insensate in the median nerve distribution. I have discussed with the patient at length the risks, benefits, and options for surgery. The risks to include but not limited to infection, bleeding, injury, blood vessels, tendons, or nerves, need for further surgery, chronic pain, stiffness, and swelling. He notes understanding and gives informed consent to proceed.
DESCRIPTION OF PROCEDURE: The patient was correctly identified and brought to the operating room in the supine position, and monitors were placed. After adequate general anesthesia, he was intubated without difficulty. He was then prepped and draped in normal sterile fashion in the region of the right upper extremity and left lower extremity. Skin incisions were planned. The extremity was exsanguinated with an Ace wrap and the tourniquet was inflated to 250 mmHg. A longitudinal skin incision was made through the prior incision. The median nerve was found just proximal to the wrist in the subcutaneous tissues. This was taken proximally to free up from the surrounding tissues and get the healthy nerve. Careful dissection was then taken distally. The nerve endings were not found as I approached the superficial volar arch. So, incisions were made more distally. The common digital nerves were found distally and traced proximally. The common digitals to the second and third webspace were found and the proper radial digital to the index was found. The sural nerve was then harvested from the left leg in its entirety and then used as a cable graft. The nerve was turned around and using the operating microscope in standard microvascular technique cable grafting of 10 cm was done for three grafting, one to the common digit of the right index, one to the second webspace, and one to the third webspace common digital nerves. Fibrin glue was used then to reinforce these repairs. The tenolysis was then performed to the flexor digitorum superficialis and flexor digitorum profundus to the ring finger. The pulleys were cut out and destroyed and there was absolutely no motion and the tendon had gaps greater than 3 cm. Therefore, a portion of flexor digitorum superficialis was resected and used a tendon graft and sutured in place using a bone anchor into the distal phalanx of the ring finger. It was then sutured to the flexor digitorum profundus of the ring finger using a Pulvertaft weave to finish with a nice normal cascade. The webspace contracture was then released using a double opposing Z-plasties measuring about 10 cm2. The adductor musculature was released and freed. The tourniquet was released. Hemostasis was achieved with bipolar cautery. The wounds were closed in layers. Sterile dressings were placed. The patient tolerated the procedure well, was extubated in the operating room, and taken to the recovery room in stable condition.
POSTOPERATIVE DIAGNOSES: Right median nerve injury at the wrist and laceration to the flexor tendons of the right ring finger and first webspace contracture.
OPERATIONS PERFORMED:
1. Cable grafting to the median nerve using three segments of 10 cm in length each.
2. Tendon graft to the ring finger using the flexor digitorum superficialis tendon.
3. Tenolysis of flexor digitorum superficialis and flexor digitorum profundus to the ring finger.
4. Soft tissue rearrangement with contracture release measuring 10 cm2 of the first webspace.
FINDINGS: Lacerated median nerve just proximal to the transverse carpal ligament and the lacerated ends were found just beneath the superficial palmar arch.
INDICATIONS: The patient is a 20-year-old gentleman with an industrial accident with median nerve injury and right ring finger flexor tendon injury that were treated at the University Hospital about three months ago. He has developed webspace contracture since. Upon reviewing the operative notes to that surgery, they were unable to find the median nerve proximally or distally, and so nothing was done with this, and then they apparently repaired flexor tendon injury in zone II. He has no motion of the ring finger and is insensate in the median nerve distribution. I have discussed with the patient at length the risks, benefits, and options for surgery. The risks to include but not limited to infection, bleeding, injury, blood vessels, tendons, or nerves, need for further surgery, chronic pain, stiffness, and swelling. He notes understanding and gives informed consent to proceed.
DESCRIPTION OF PROCEDURE: The patient was correctly identified and brought to the operating room in the supine position, and monitors were placed. After adequate general anesthesia, he was intubated without difficulty. He was then prepped and draped in normal sterile fashion in the region of the right upper extremity and left lower extremity. Skin incisions were planned. The extremity was exsanguinated with an Ace wrap and the tourniquet was inflated to 250 mmHg. A longitudinal skin incision was made through the prior incision. The median nerve was found just proximal to the wrist in the subcutaneous tissues. This was taken proximally to free up from the surrounding tissues and get the healthy nerve. Careful dissection was then taken distally. The nerve endings were not found as I approached the superficial volar arch. So, incisions were made more distally. The common digital nerves were found distally and traced proximally. The common digitals to the second and third webspace were found and the proper radial digital to the index was found. The sural nerve was then harvested from the left leg in its entirety and then used as a cable graft. The nerve was turned around and using the operating microscope in standard microvascular technique cable grafting of 10 cm was done for three grafting, one to the common digit of the right index, one to the second webspace, and one to the third webspace common digital nerves. Fibrin glue was used then to reinforce these repairs. The tenolysis was then performed to the flexor digitorum superficialis and flexor digitorum profundus to the ring finger. The pulleys were cut out and destroyed and there was absolutely no motion and the tendon had gaps greater than 3 cm. Therefore, a portion of flexor digitorum superficialis was resected and used a tendon graft and sutured in place using a bone anchor into the distal phalanx of the ring finger. It was then sutured to the flexor digitorum profundus of the ring finger using a Pulvertaft weave to finish with a nice normal cascade. The webspace contracture was then released using a double opposing Z-plasties measuring about 10 cm2. The adductor musculature was released and freed. The tourniquet was released. Hemostasis was achieved with bipolar cautery. The wounds were closed in layers. Sterile dressings were placed. The patient tolerated the procedure well, was extubated in the operating room, and taken to the recovery room in stable condition.