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Palmar Fasciectomy and Digital Fasciectomy Operative Example

DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed in supine position. After adequate anesthesia was obtained using a general anesthetic, the left arm was prepped and draped in the usual sterile manner. The left arm was then exsanguinated using Esmarch wrap and tourniquet and was inflated to 250 torr. I first turned my attention to the palmar fasciectomy. I made a curvilinear incision from the metacarpophalangeal joint area of the left index finger, curving across the palm and proximally to the carpometacarpal joint base of the small finger. I dissected down through the subcutaneous tissue to the Dupuytren's tissue and then I carefully separated the Dupuytren's tissue from the subcutaneous tissue and skin. I lifted this up so I could trace it back to just distal to the transverse carpal ligament. I then identified its limits on the radial side and the ulnar side of the palm and then identified each of the individual pretendinous cords that extended to the fingers. I released the Dupuytren's proximally and then followed each of the cords. I followed the cord to the index finger, where I preserved Skoog's fiber and followed it distally where it inserted into the skin and into the flexor sheath. I excised it at this point. On the middle finger, in a similar fashion, I followed it past Skoog's fibers, preserving the fibers and then it had a spiral cord that was extending ulnarly. I did follow this slightly more distal out to its attachment close to the base of the proximal phalanx. I protected the neurovascular bundle and released it from this location. I then followed the small finger out and it did extend again in a spiral cord towards the ulnar side. I was able to separate it from the neurovascular bundle and it was excised. I then followed the ring finger past Skoog's fibers and I continued the dissection distally. I released it from the flexor sheath and then I carefully identified the neurovascular bundles radially and ulnarly and traced these out towards the proximal flexion crease of the ring finger. I now did a modified Brunner incision over the palmar aspect of the ring finger and carefully separated the skin from the Dupuytren's tissue. I followed the dissection towards the radioulnar side, then identified over the middle aspect of the middle phalanx the digital nerve and vessel, and then used this to trace proximally to ensure that I protected the neurovascular bundle throughout its dissection. After exposing the digital nerve and vessel on both the radial and ulnar sides, I carefully separated the Dupuytren's disease from the flexor sheath and dissected it proximally. I then followed this underneath the proximal flap and removed it in one lump. I then checked for both lateral cords and retrovascular cords, which were identified and removed and again checked throughout the course of the dissection that the neurovascular bundles were protected. I then was able to demonstrate that I could fully extend the ring finger on both the metacarpophalangeal joint and the proximal interphalangeal joint and I checked to ensure that there were no remaining cords. I then irrigated out copiously and then deflated the tourniquet. I cauterized the small bleeding vessels, and then after irrigation checked to make sure that the flaps were pink and the finger tip was pink. I then irrigated again and extended points of Brunner incisions to the mid lateral line and then I used 5-0 nylon to close the skin. This was done in horizontal mattress stitches. I checked to ensure that again the flaps were all pink and then placed him in a compressive dressing and the fingers were placed in full extension with a splint holding that position. The patient was then taken to the recovery room in good condition.

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