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CPC sample question # 1


Preoperative Diagnosis: Dupuytren’s contracture

Postoperative Diagnosis: Same

Procedure Performed: Biopsy of mass, volar aspect right hand

Anesthesia: Medial and ulnar nerve block

Findings: This 48-year-old white female has been struggling with a limp over the volar aspect of her right hand for several months. The mass is firm, fixed, and appears to getting larger. The patient notes discomfort in this region when she grasps objects such as a broom handle. Differential diagnosis includes early Dupuytren’s contracture vs. epidermoid inclusion cyst. Excision was recommended and the patient presents for same at this time. She is aware of the risks and benefits of the procedure and wishes to proceed.

Description of procedure: After adequate anesthesia was achieved, the right upper extremity was prepped and draped in the standard sterile orthopedic fashion. A modified Brunner incision was made over the fifth ray and dissection carried down through subcutaneous tissue. The neurovascular bundles of the fourth and fifth rays were identified and protected. The mass was isolated and noted to extend off the pretendinous fascia in a palmar direction. The pretendinous fascia was excised over the fifth ray for a distance of approximately 3 cm. The mass was mobilized off the subcutaneous tissue with a #69 Beaver blade. The remaining skin over this area was noted to be thin. Pretendinous fascia over the fourth ray was also partially excised as the mass was noted to be adhesed at this site as well. Flexor tendons were freed and intact. Further exploration of the wound revealed no evidence of significant involvement of the pretendinous fascia up into the MCP area distally of either the fourth or fifth ray.

Once all dissection was completed the wound was copiously irrigated with Kefzol solution. A 4-0 PDS suture was used to close the deep tissues and the skin was closed with 4-0 nylon. The tourniquet was released and the operative site was noted to turn appropriately pink with blood return. A sterile op site dressing was applied and the patient was returned to the recovery area is stable condition.

Pathology report returned with features consistent with Dupuytren’s contracture.

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