Procedure Performed:
Left index finger amputation consisting of disarticulation at the MCP joint
Irrigation and debridement of the mid palmar space
Irrigation and debridement of the thenar space
Irrigation and debridement of the status post dorsal subcutaneous space
Irrigation and debridement of the webspaces between the thumb and index finger and index finger and long finger
Procedure was begun with an incision along the mid axial line at the level of the distal phalanx. Immediate and extensive purulence was encountered and the decision was made to proceed with amputation at the level of the DIP joint. A fishmouth incision was created the DIP was amputated, and septic joint involving the DIP was identified. One drill was then used to debride the distal aspect of the DIP joint which did demonstrate osteomyelitis within the middle phalanx we then turned our attention to the A1 pulley as extensive swelling was present along the radial aspect of the hand and longitudinal incision was made at the level of the A1 pulley and immediately upon entering the subcutaneous tissues, extensive purulence was encountered in the soft tissues overlying the A1 pulley. Dissection was carried down to the level of the A1 pulley, pulley was incised, and purulence was identified within the flexor tendon sheath. Tendon demonstrated extensive fraying consistent with chronic infection and the tendons were retracted to expose the joint capsule incision was made within the joint capsule and extensive septic arthritis involving the MCP joint was identified with involvement of the base of the proximal phalanx. An additional incision was made overlying the thenar musculature and immediately upon spreading within the subcutaneous tissues with tenotomy scissors, a large amount of purulence was encountered within the thenar space and upon further dissection, purulence was encountered within the mid palmar space. As extensive purulence continued to be encountered along the radial aspect of the hand, we turned our attention to the dorsum of the hand, an incision was made in the webspace of the thumb and index finger, again with purulence encountered within the webspace with purulence tracking dorsally into the subcutaneous space of the hand finally, an incision was made in the interosseous space between the second and third digits, again with purulence involving the webspace between the index and long finger and also with purulence tracking through the palm of the hand between the second and third metacarpal to the palmar aspect of the hand. At this point, with osteomyelitis extensively involving the distal, middle, and proximal phalanx as well as the DIP and MCP joints and the flexor tendon sheath of the index finger, the decision was made to perform a disarticulation of the index finger. A fishmouth style incision was created, the index finger was disarticulated, and the finger sent to pathology. We then turned our attention to further dissection through the multiply named incisions prepared previously with care taken to spread through muscle compartments and deep spaces with tenotomy scissors to prevent iatrogenic injury to nerves or vessels of the hand. Purulence did not extend beyond the third metacarpal palmarly or dorsally approximately 15 cc of purulence was encountered dorsally and volarly between the long finger and thumb. Any devitalized tissues were removed including bone, tendon, flexor tendon sheath, subcutaneous tissues, and skin. Instrumentation used to perform this debridement included 15 blade, tenotomy scissors, and curettes. After debridement had been completed, 6 L of normal saline with polymyxin and bacitracin were utilized with cystoscopy tubing in an attempt to fully irrigate the wounds and remove any remaining purulence all wounds were again spread with tenotomy scissors to ensure that no further pockets of purulence remained, and after we had confirmed that all abscesses have been broken up, all deep spaces drained, and purulence and necrotic material removed to the best of our ability, the tourniquet was deflated. Hemostasis was then obtained with a combination of bipolar electrocautery and Bovie electrocautery and all incisions were loosely closed with interrupted 3-0 Prolene. 3 1/4 inch Penrose drains were placed him a 1 within the amputation site, 1 within the thenar space of the hand, and 1 within the dorsal subcutaneous space of the hand. Both wounds closed and drains placed, dressings were applied which consisted of Xeroform, 4 x 4’s, Kling, Kerlix, and an Ace wrap. Patient was then awakened from general anesthesia and transported the holding area in stable condition.
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