Dictation for LRTI

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  DESCRIPTION OF PROCEDURE: After induction of satisfactory axillary
  block anesthesia, patient's left upper extremity was prepped and
  draped in the usual sterile fashion.   After exsanguination of the
  draped in the usual sterile fashion.   After exsanguination of the
  left upper extremity with Esmarch, pneumatic tourniquet was placed
  at 300 mmHg.   Longitudinal incision was made over the volar radial
  aspect of the CMC joint of the left thumb extending volarly at its
  proximal aspect.   Dissection was carried down to the subcutaneous
  tissue.   Branches of the dorsal radial sensory nerve were identified
  and protected with Penrose drain loops.   The abductor pollicis
  longus and brevis was identified and incision was made along the
  volar aspect of these tendons and they were reflected ulnarly.   The
  capsule overlying the transtrapezial joint was identified and
  incised longitudinally.   The trapezium was resected en toto using
  sharp and blunt dissection and the FCR tendon was protected.   Next,
  two small transverse incisions were made in the forearm and
  overlying the FCR tendon.   The tendon was cut at its proximal aspect
  and retracted through the wound into the defect where t he trapezium
  had been resected.   Next, two 4-0 Vicryl sutures were placed in the
  periosteum and deep into the wound.   A drill hole was then made
  through the base of the thumb, 1 cm proximal on the dorsal radial
  aspect in line with the thumb nail and exiting the middle of the
  articular surface.   The hole was sequentially enlarged.   The FCR
  tendon was then passed through this hole and doubled over on itself
  and sutured in place using interrupted 4-0 Vicryl suture.   A 0.45
  K-wire was then placed across the thumb metacarpal into the index
  metacarpal after it had been reduced in anatomical position.   Next,
  a Keith needle was used to sphere the FCR tendon in accordian
  fashion.   This was done using two Keith needles.   The two deep 4-0
  Vicryl sutures were placed through the Keith needles.   The accordian
  tendon was sutured together using interrupted 4-0 Vicryl suture.
  The Keith needle was then passed through the accordian tendon and
  the tendon was passed deep into the wound and the deep sutures were
  tied over the top of the accordion tendon to hold it snugly in the
  defect.   Next, the dorsal and ulnar aspect of the capsule were
  repaired.   The skin was closed wit h 5-0 interrupted and running
  nylon suture over a TLS drain.   Next, attention was turned to the
  long finger dorsal DIP joint.   An incision was made through an old
  scar which was just distal to the recurrent tumor.   Dissection was
  carried around the tumor and it was excised en toto after extending
  the incision distally along the radial border.   A small amount of
  residual tumor was curetted off of the dorsal radial aspect of the
  distal phalanx proximally.   A small amount of the radial aspect of
  the terminal extensor tendon was resected also.   The wound was
  irrigated with sterile saline and the wound was closed with
  interrupted 5-0 nylon sutures.   Next, attention was turned to the
  carpal tunnel.   Longitudinal incision was made in line with the
  fourth ray.   Dissection was carried down through the subcutaneous
  tissue and bleeders were electrocoagulated.   The superficial palmar
  fascia was identified.   It was bluntly dissected distally and the
  superficial arch was identified in the wound.   Dissection was
  carried proximally using blunt and sharp dissection.   A Freer
  elevator was placed underneath the transverse carpal ligament and it
  was incised sharply.   The proximal aspect of the wound came to the
  distal palmar crease.   At this point, retractors were used to
  identify the distal aspect of the antebrachial fascia.   This was
  incised using blunt dissection for identification and then scissors
  for incision.   Small finger could be passed through here now.   The
  distal motor recurrent branch was identified and it was intact.   The
  wound was irrigated with sterile saline.   It was closed with
  interrupted 5-0 nylon suture over a TLS drain.   Next, the wounds
  were dressed with a bulky sterile dressing and splints were applied
  to the hand with a thumb spica splint.   The patient was transferred
  to the recovery room with stable vital signs.