Please help, -patient had decompression fasciotomy of forearm two days earlier

PROCEDURE:

Washout of right forearm fasciotomy site

OPERATIVE FINDINGS:

The flexor and pronator group of muscles remained extremely edematous and do not react to electrocautery.  There is concern in some areas for necrosis, however, most of this is indeterminate at this point and no muscle was debrided at this time.  I was unable to close any skin due to the continued significant edema.  The extensor muscles, specifically the dorsal wad, did react to cautery.  The patient does have signals in the palmar arch and radial artery and ulnar artery still.  She has some discoloration in the tips of her fingers, which is unchanged.  She does have capillary refill at approximately 1 second in each finger.

  HISTORY: The patient presented with acute ischemia of the right upper extremity.  This was not provoked.  She was found to have an aberrant right subclavian artery with thrombus at the take off.  She underwent thrombectomy with reperfusion of the forearm and developed a compartment syndrome.  48 hours ago, she went for emergent upper extremity fasciotomy and she presents today for dressing change and washout.   DESCRIPTION OF PROCEDURE: Written informed consent was obtained from the patient, site was marked, and she was taken from the preop staging area to the operating room suite, placed supine on the operating room table.  General endotracheal anesthesia was introduced.  Antibiotics were infused.  Right arm was circumferentially prepped and draped in normal sterile fashion.  Time-out was called.  We elected to proceed.  The wound was examined with findings as above.  The muscle bellies were extremely edematous and no skin can be closed in this setting.  She will likely require skin grafts in the future.  The muscle bellies were all carefully examined and ensured that she had adequate fasciotomy in all the muscle bellies.  I did extend the incision distally and to ensure that there was an adequate release of the carpal tunnel, I made counter incisions over the thenar and hypothenar eminences as well as 3 incisions over the posterior hand over the interosseous muscles.  There was not significant muscle edema in the interosseous or hypothenar eminence.  There was, however, significant edema in the thenar eminence, which was released as we performed the fasciotomies on the hand.  The dorsal compartment remained soft and the anterior and posterior compartments of the upper arm also remained soft.  We irrigated thoroughly with warm normal saline.  There were some patchy areas of ischemia in the flexor muscle groups in the forearm, however, nothing was frankly necrotic, and therefore, no debridement was performed in this setting.  We will need to continue dressing changes and arm elevation and see how much neurologic recovery we can gain.  Preop exam showed no flexion or extension of the wrists or fingers, although she does have some sensation in the hand.  The wound was then dressed with moistened Kerlix followed by ABDs and Kerlix wraps.  The patient was awoken from anesthesia and taken to recovery room in stable condition.  

Comments

  • I think 26037 is supported for the hand, it seems the forearm wounds were explored only with a dressing change...hope this helps!
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