Anyone want to take a stab at this note and let me know what you think? I would really appreciate a second (or third, forth, fifth….) opinion!
Pre-operative Diagnosis:
Right hand, wrist, and forearm cellulitis with abscesses involving the DRUJ, radiocarpal joint, carpal joints, CMC joints, carpal tunnel, dorsum of the hand, palmar aspect of the hand and with apparent osteomyelitis on MRI involving the carpus, metacarpals, distal radius, and distal ulna.
Procedure Performed:
Irrigation and debridement of dorsal and volar forearm subcutaneous spaces, musculature, and extensor and flexor tendon sheaths
Arthrotomy and irrigation of debridement of distal radial ulnar joint
Arthrotomy and irrigation of debridement of radiocarpal joint and TFCC
Arthrotomy and irrigation of debridement of midcarpal joint
Arthrotomy and irrigation of debridement of second, third, fourth, and fifth CMC joints
Irrigation and debridement of intraosseous spaces between index and long, long and ring, and ring and small fingers
Irrigation and debridement of thenar space, hypothenar space
A1 pulley release and irrigation of long and ring finger flexor tendon sheaths
Once the hand and upper extremity had been prepped and draped in the usual sterile fashion the right upper extremity was held elevated and the tourniquet was inflated to 250 mmHg. Procedure was begun with removal of previously placed sutures and drains. Immediately after removing the dorsal sutures, seropurulent fluid was encountered within the subcutaneous space on the dorsum of the hand. The seropurulent fluid was tracked into the distal aspect of the forearm proximal to the incision, as well as distal into the hand and the decision was made to extend the incision proximally and distally to better obtain exposure. Incision was made with a 15 blade through skin only, with blunt dissection performed with tenotomy scissors thereafter. As dissection continued proximally, seropurulent fluid extended to the junction between the mid and distal thirds of the forearm. Dissection was carried through the extensor retinaculum which had been previously incised longitudinally between the third and fourth dorsal compartments. The seropurulent fluid extended down to the DRUJ which had been previously incised dorsally and the DRUJ continued to contain seropurulent fluid. Dissection continued being carried distally along the extensor tendons and tenotomy scissors were used to open the interosseous spaces between the thumb metacarpal and index metacarpal, between index and long metacarpals, between long and ring metacarpals, and between ring and small finger metacarpals. Seropurulent fluid was present between all metacarpal shafts, however frank purulence was present between the index and long metacarpals and long and ring metacarpals. A limited transverse arthrotomy was performed in the index and long finger CMC joints as well as between the fourth and fifth CMC joints with thin purulent fluid again present within these joints. Separate arthrotomies were made within the mid carpal joint, and again thin purulent fluid encountered. Standard portals were used for arthrotomies into the radiocarpal joint and TFCC joint, again with thin purulent fluid present. Extensive debridement was performed with a combination of 15 blade and tenotomy scissors within the subcutaneous spaces of the hand, wrist, and forearm and a curet was utilized to fully debride the interosseous spaces. Additionally, a freer was used in addition to tenotomy scissors to fully open and irrigate the CMC joints, midcarpal joint, radiocarpal joint and TFCC, and DRUJ.
We then turned our attention volarly and sutures overlying the carpal tunnel incision were removed. Again, immediate seropurulent fluid was encountered. Distally, the incision was extended and dissection was performed with tenotomy scissors. Frank purulence was present in the mid palmar space with purulence extending along the flexor tendons towards the long and ring finger MCP joints. With dissection proximally along the carpal tunnel, frank purulence was encountered within the volar forearm, and a separate standard FCR approach was utilized to reach the level of the pronator musculature. Incision was made within the pronator, and beneath the pronator musculature, frank purulence was encountered which extended towards the DRUJ. This was fully debrided with a curet, tenotomy scissors, and 15 blade. Concern existed for involvement of the hypothenar and thenar spaces, and 2 cm incisions were created overlying the thenar space and hyperthenar space with tenotomy scissors used to spread through the musculature. No purulence was encountered in thenar or hypothenar spaces. Incisions were made overlying the A1 pulley of the long finger and ring finger with dissection performed bluntly down to the A1 pulley with tenotomy scissors. Neurovascular bundles were identified and protected, the A1 pulleys were incised, and no purulence was encountered within the flexor tendon sheath of the long finger or ring finger. All incisions were aggressively debrided with 15 blade, tenotomy scissors, and curette involving the subcutaneous tissues, muscle bellies/tendon, and deep spaces. DRUJ was opened for irrigation with a freer. After aggressive debridements had been performed as above, and all spaces had been opened fully and debrided, copious irrigation was performed with 9 L of normal saline with polymyxin and bacitracin.
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