PREOPERATIVE DIAGNOSIS: Right hand and forearm flexor compartment infection.
POSTOPERATIVE DIAGNOSIS: Right hand and forearm flexor compartment infection.
OPERATIVE PROCEDURE: Irrigation and debridement of right hand and forearm flexor compartment, including carpal tunnel.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, Mr. …. was brought to the operating room whereupon smooth induction of general anesthesia was performed by Dr. …... The patient was positioned in a supine fashion on the operating room table and all bony prominence were well padded. The patient’s right upper extremity was placed on an arm board and a tourniquet was placed on the right proximal arm. The right upper extremity was prepped and draped in the standard sterile fashion, including an alcohol preprep. A glove was placed over the fingernails.
The less than 1-inch incision over the base of the palm in the area of the previous carpal tunnel release by Dr. ….. was identified. This was incised and extended proximally to a length of approximately 1-1/2 inches. The subcutaneous tissue was easily split, revealing the released transverse carpal ligament and contents of the carpal tunnel. Extensive tenosynovitis surrounding the flexor tendons and the median nerve was encountered, as well as gross purulent material. The gross purulent material and tenosynovial biopsy were sent to the microbiology lab for culture and Gram stain. Because of the infection, which extended proximally, the carpal tunnel incision was lengthened to the distal volar forearm in a Z-type fashion over the wrist crease. The skin was dissected sharply and the subcutaneous tissue was dissected bluntly down to the level of the fascia. The fascia was split under direct visualization to reveal the flexor tendons. Again, extensive tenosynovitis was encountered and significant time and great care was taken to perform a thorough irrigation and debridement of the area, as well as a flexor tenosynovectomy. The median nerve was identified and the tenosynovium about the nerve was not removed as the palmar cutaneous branch of the nerve was not readily obvious, and given the distortion of the tissue it was judged that this likely could lead to injury of this branch of the nerve. Therefore the median nerve and its accompanying synovium was carefully retracted in a radial direction. Extensive tenosynovectomy about the flexor digitorum sublimis (FDS) and flexor digitorum profundus (FDP) tendons, as well as the flexor pollicis longus (FPL) tendon, was carried out. All of these tendons were identified and found to be basically normal looking and intact, once the abnormally inflamed synovium was removed.
The wound was then copiously irrigated with normal saline mixed with antibiotics one further time, and closed loosely over a 1/2 inch Penrose drain which was placed into the proximal forearm and laid down through the carpal tunnel and out the distal wound in the hand. The wound was loosely reapproximated only at the level of the skin with 3-0 nylon sutures in a simple fashion. A sterile dressing with a **__________** wrist splint was applied. The tourniquet was released and the patient was awakened from anesthesia and taken to the recovery room in stable condition.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: 55 minutes.
Postoperatively he will be on Unasyn and levofloxacin for broad spectrum coverage with elevation of the hand and adjustment of the antibiotics as indicated by the culture results. He will also begin occupational therapy for digital range of motion. He will be observed in house until his wound appears benign on p.o. antibiotics, and then he will be released.