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Dictation for LRTI

 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 with 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.