Orthopaedic Surgery Essentials Series Hand and Wrist

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GRBT045-FM Doyle-2055G GRBT045-Doyle-v9.cls August 6, 2005 2:15

ORTHOPAEDIC SURGERY ESSENTIALS
HAND AND WRIST
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HAND AND WRIST
Adult Reconstruction
Daniel J. Berry, MD
Scott P. Steinmann, MD
Foot and Ankle
David B. Thordarson, MD
Hand and Wrist
James R. Doyle, MD
Oncology and Basic Science
Timothy A. Damron, MD
Carol D. Morris, MD
Pediatrics
Kathryn E. Cramer, MD
Susan A. Scherl, MD
Spine
Christopher M. Bono, MD
Steven R. Garn, MD
Sports Medicine
Anthony A. Schepsis, MD
Brian D. Busconi, MD
Trauma
Charles Court-Brown, MD
Margaret McQueen, MD
Paul Tornetta III, MD
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HAND AND WRIST
Series Editors
PAUL TORNETTA III, MD
Professor
Department of Orthopaedic Surgery
Boston University School of Medicine;
Director of Orthopaedic Trauma
Boston University Medical Center
Boston, Massachusetts
THOMAS A. EINHORN, MD
Professor and Chairman
Department of Orthopaedic Surgery
Boston University School of Medicine
Boston, Massachusetts
Author
JAMES R. DOYLE, MD
Emeritus Professor of Surgery (Orthopaedics)
John A. Burns School of Medicine
University of Hawaii
Honolulu, Hawaii
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Printed in the USA.
Library of Congress Cataloging-in-Publication Data
Hand and wrist / book editor, James R. Doyle.
p. ; cm.(Orthopaedic surgery essentials)
Includes bibliographical references and index.
ISBN 0-7817-5146-2 (case)
1. HandSurgery. 2. WristSurgery. 3. Orthopedic surgery. I. Doyle, James R. II. Series.
[DNLM: 1. HandsurgeryHandbooks. 2. Hand InjuriessurgeryHandbooks. 3. Wrist
surgeryHandbooks. 4. Wrist InjuriessurgeryHandbooks. WE 39 H235 2005] RD559.H35725
2005 617.5
75dc22
2005016072
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This textbook is dedicated to the orthopaedic teaching staff of the John A. Burns
School of Medicine at the University of Hawaii. It is dedicated to the memory of the
illustrious past chairs of the Division of Orthopaedics, Ivar Larson and Allen
Richardson, as well as a living emeritus chair, friend, and mentor,
Lawrence Gordon.
It is dedicated to the memory of those outstanding teachers, Eugene Lance and
Alan Pavel, who taught all of us the value of scholarship and excellence in surgery.
It is dedicated to those who continue the tradition of excellence in teaching,
Robert Atkinson, Daniel Singer, John Smith, and all those who continue to give
their time and energy to the advancement of the orthopaedic residency training
program at the University of Hawaii.
It is dedicated to those who made the paths to excellence straight and level in so
many ways, including Albert Chun Hoon, Tom Whelan, Ruth Ono,
Sue Arakaki Harada and Tori Marciel.
It is dedicated to my residentsthey taught me more than they will ever know.
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CONTENTS
Key to Abbreviations Inside Front Cover
Contributing Authors ix
Series Preface xi
Preface xiii
SECTION I: BASIC ANATOMY
1 Anatomy 1
1.1 Surface Anatomy 1
1.2 Systems Anatomy 7
1.3 Terminology of Movement 13
SECTION II: OUTPATIENT CLINIC
2 Congenital Deformities 14
3 Tumors 37
4 Dupuytrens Disease 64
5 Infections 78
6 Tenosynovitis and Epicondylitis 88
7 Entrapment Neuropathies 98
7.1 Median Nerve 98
7.2 Ulnar Nerve 106
7.3 Radial Nerve 111
SECTION III: EMERGENCY DEPARTMENT
8 Anesthesia 116
Charles L. McDowell and Kevin Cunningham
9 Hand Fractures and Fracture-Dislocations 128
10 Dislocation and Ligament Injuries 144
11 Carpal Injuries 158
11.1 Carpal Fractures 158
11.2 Carpal Instabilities and Fracture-Dislocations
of the Carpus 169
12 Tendon Injuries 179
12.1 Flexor Tendon 179
12.2 Extensor Tendon 190
13 Nerve Injuries 208
14 Amputations 226
15 Compartment Syndrome 242
16 Injection Injuries 250
Index 253
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CONTRIBUTING
AUTHORS
Kevin Cunningham, MD
Attending Anesthesiologist
McGuire Veterans Administration Hospital
Richmond, Virginia
Charles L. McDowell, MD
Clinical Professor of Orthopaedic
and Plastic (Hand) Surgery
Medical College of Virginia
Chief of Hand Surgery Service
McGuire Veterans Administration Hospital
Richmond, Virginia
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SERIES
PREFACE
Most of the available resources in orthopaedic surgery
are very good, but they either present information
exhaustivelyso the reader has to wade through too
many details to find what he or she seeksor they as-
sume too much knowledge, making the information dif-
ficult to understand. Moreover, as residency training has
advanced, it has become more focused on the individual
subspecialties. Our goal was to create a series at the basic
level that residents could read completely during a sub-
specialty rotation to obtain the essential information nec-
essary for a general understanding of the field. Once they
have survived those trials, we hope that the Orthopaedic
Surgery Essentials books will serve as a touchstone for
future learning and review.
Each volume is to be a manageable size that can be
read during a residents tour. As a series, they will have
a consistent style and template, with the authors voices
heard throughout. Content will be presented more visu-
ally than in most books on orthopaedic surgery, with a
liberal use of tables, boxes, bulleted lists, and algorithms
to aid in quick review. Each topic will be covered by one
or more authorities, and each volume will be edited by
experts in the broader field.
But most importantly, each volumePediatrics,
Spine, Sports Medicine, and so onwill focus on the req-
uisite knowledge in orthopaedics. Having the essential
information presented in one user-friendly source will
provide the reader with easy access to the basic knowl-
edge needed in the field; mastering this content will give
him or her an excellent foundation for additional infor-
mationfromcomprehensive references, atlases, journals,
and online resources.
We would like to thank the editors and contributors
who have generously shared their knowledge. We hope
that the reader will tell us what works and does not work.
Paul Tornetta III, MD
Thomas A. Einhorn, MD
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PREFACE
This volume is part of a series of focused and concise
textbook reviews designed to facilitate the learning pro-
cess for orthopaedic residents as they rotate through var-
ious subspecialty services in their training. I hope it will
serve as a tool that will facilitate the rapid acquisition of
knowledge so that the time spent on an upper extrem-
ity service will be as productive as possible. The concise
information in this text may also be useful to residents
in plastic surgery and general surgery as well as other
disciplines that may be involved in care of the hand and
wrist.
My aim was to cover basic core concepts and facts
that will act as building blocks or starting points for the
development of the readers own knowledge base of hand
and wrist care. Please note that this text is not designed
to be a comprehensive work on the hand and wrist but
rather an illustrated guide and outline that will give the
reader an overview of the field.
Much of the content reflects the work of friends
and mentors, colleagues, authors, professional organiza-
tions, and publishers that have generously shared their
knowledge of both published and unpublished work. Ref-
erences are not cited in the text, and the Suggested
Reading list may give only a hint of the sources of the
material utilized or presented by the writer. These lists
are at the end of each chapter, and are intended to ex-
pand on the basic information presented in the chapter
but are not intended to represent a comprehensive bib-
liography.
I made every effort to ensure that all these contribu-
tions (either reproduced or modified) have been recog-
nized. I owe a great debt to my past and present mentors
and colleagues for my own knowledge base and hope that
any failure to source appropriated concepts or facts will
be considered an unintentional oversight.
Textbooks require a joint effort. I thus am indebted
to Executive Editor Robert Hurley at Lippincott Williams
& Wilkins for his dedication to excellence and patient
and professional guidance, and to Grace Caputo, of
Dovetail Content Solutions, who saw me through this
process in such a delightful and professional manner. I
am also indebted to my long-time friend and colleague,
Charles McDowell, who wrote the chapter on anesthesia
techniques. It was Dr. McDowell who suggested that a
text such as this would be useful for residents. I greatly
appreciate his support and encouragement before and
during the writing of this textbook. Last, but certainly not
least, I wish to express my gratitude to Elizabeth Roselius
for her skillful interpretations of my many sketches
and for her excellent depictions of important points of
anatomy and technique.
Finally, I would like a parting word with the residents
who are the most likely readers of this text. Your resi-
dency years may be akin to the classic words that Charles
Dickens wrote in the opening of his book about the
French Revolution, A Tale of Two Cities: It was the best
of times. It was the worst of times. After your passage
through this experience you willas most have done
look back on it as the best time or experience of your life.
Find joy and meaning in your passage. Remember that
your learning process is based on the gift of knowledge
given to you by colleagues who have gone before you. Ap-
preciate and respect that knowledge, use it wisely, chal-
lenge it when needed, and add to it at every opportunity.
James R. Doyle, MD
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HAND AND WRIST
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1
ANATOMY
1.1 Surface
Anatomy 1
1.2 Systems
Anatomy 7
1.3 Terminology of
Movement 13
1.1 SURFACE ANATOMY
The most appropriate starting point is the hands surface
anatomy. Much can be learned about the deeper structures
in the hand by correlating external landmarks such as skin
creases and eminences to underlying anatomic structures.
PALMAR HAND
External Landmarks
The landmarks of the palmar side of the hand are depicted in
Figure 1.1-1. These landmarks are identified by inspection
of the skin creases and eminences, and by palpation for the
bony landmarks of the pisiform and the hook process of the
hamate bone.
Flexion Creases
The wrist, thenar, palmar, and digital flexioncreases are skin
flexion lines seen near synovial joints. These creases provide
folding points in the skin, similar to the creases in a road
map. Two creases are present over the proximal interpha-
langeal (PIP) joints, which account for the increased angles
of flexion at these joints. By comparison, only one crease
is found adjacent to the metacarpophalangeal (MCP) and
distal interphalangeal (DIP) joints. Flexion creases are usu-
ally at right angles to the long axis of the metacarpals and
phalanges, and parallel to the flexion-extension joint axis
of motion. The pronounced obliquity of the thenar crease
reflects the opposing movement of the thumb. It must be
noted, however, that only one of the 17 creases (the thumb
MCP joint) lies directly over the joint. Look at your own
hand and note that the MCP flexion crease lies at the mid-
point between the MCP and PIP joints.
Figure 1.1-2 depicts the relationship between these var-
ious skin creases and the underlying joints, and will allow
you to locate the underlying joint structures with a high
degree of confidence.
Thenar and Hypothenar Eminences
The thenar eminence is formed by the abductor pollicis bre-
vis (APB), the most superficial of the thenar group, and
the flexor pollicis brevis (FPB). Both overlie the deeper op-
ponens pollicis (OP). The ulnar-sided counterpart of the
thenar eminence is the hypothenar eminence, which is
formed by the abductor and flexor digiti minimi (ADM,
FDM) and the opponens digiti minimi (ODM).
Bony Landmarks
Pisiform Bone
This relatively superficial and easily palpated carpal bone
is located on the ulnar side of the base of the hand, and it
aids in the identification of the flexor carpi ulnaris (FCU)
tendon, the underlying ulnar neurovascular bundle, and
the more distal and radial hook process of the hamate
bone.
Hook Process of the Hamate Bone
This process of the hamate may be palpated approximately
2 cmdistal and 1 cmradial to the more prominent pisiform.
It marks the beginning of the oblique course of the motor
branch of the ulnar nerve.
Relationship of the Superficial Landmarks and
the Deeper Structures
A unique system of lines may be drawn on the hand that
will permit the examiner to accurately locate the underlying
deeper structures. These lines and the underlying structures
are depicted in Figure 1.1-3.
DORSAL HAND
External Landmarks
The external landmarks on the dorsum of the hand are il-
lustrated in Figure 1.1-4.
1
2 Section I / Basic Anatomy
Distal digital
crease
Middle digital
crease
Thenar
crease
Thenar
eminence
Distal wrist
flexion crease
Pisiform
Hypothenar
eminence
Proximal palmar
crease
Distal palmar
crease
Proximal digital
crease
Figure 1.1-1 Landmarks of the palmar hand.
Distal digital creases 7.8
2.6
14.4
10.3
19.6
19.2
16.3
7.9
6.9
9.1
2.2
9.2
11.7
21.1
18.7
19.4
22.6
13.5
7.7
1.9
1.6
2.6
7.0
7.3
Middle digital creases
Proximal digital creases
Thenar
crease
Distal wrist crease
Proximal
palmar crease
Distal
palmar crease
Figure 1.1-2 Wrist, thenar, palmar, and digital skin flexion creases
and their relationship to the underlying joints and bones.
Digital nerve
to index
Recurrent branch,
median nerve
Deep branch,
ulnar nerve
Deep palmar arch
Crest of trapezium
FCR tendon
Radial artery
Median nerve
Superf.
palmar
arch
1
4
2
3
A
B
Ulnar artery
Ulnar nerve
FCU tendon
Disiform
Cardinal
line
Hook
of hamate
Digital nerve
to little
finger
Figure 1.1-3 Kaplan described a unique system of lines that may be
drawn on the palmar side of the hand and that coincide with the
underlying structures.
Styloid process,
middle finger
metacarpal
ECU
Lunate fossa
Head of ulna
Listers tubercle
ECRB
ECRL
Radial styloid
process
APL
Anatomical
snuff box
EPB
EPL
1st DI
Figure 1.1-4 Landmarks on the dorsal hand.
Chapter 1 / Anatomy / Surface Anatomy 3
Bony Landmarks
Listers Tubercle
This bony landmark is located about 0.5 cm proximal to the
dorsal articular margin of the distal radius, in line with the
cleft between the index and middle finger metacarpals. It
Clavicle
Superior
angle
Sternal
end
Scapula
Medial
border
Inferior angle
Humerus
Medial
supracondylar
ridge
Medial epicondyle
Trochlea
Coronoid process
Tuberosity of ulna
Ulna
Head of ulna
Styloid process
Carpal bones
Metacarpal bones
(1st) Proximal phalanx
(2nd) Middle phalanx
(3rd) Distal phalanx
Distal
phalanx
Proximal
phalanx
Styloid process
Radius
Pronator teres
impression
Tuberosity
of radius
Capitulum
Head of radius
Lateral
epicondyle
Lateral
supracondylar
ridge
Deltoid
tuberosity
Surgical neck
Bicipital groove
Lesser tuberosity
Greater tuberosity
Coracoid process
Acromion
1
2 3
4
5
A
Figure 1.2-1 Bones of the upper limb: anterior (A) and posterior view (B). Figure continues.
is easily palpated and marks the fulcrum, or turning point,
for the extensor pollicis longus (EPL) tendon on its way to
the terminal phalanx of the thumb. It lies in a groove just
ulnar to Listers tubercle. The extensor carpi radial brevis
(ECRB) tendon is just radial to Listers tubercle in a similar
groove on the distal aspect of the radius.
Acromio-clavicular joint
Acromion
Head
Acromial angle
Greater tuberosity
Surgical neck
Deltoid tuberosity
Spiral groove
(sulcus for radial nerve)
Humerus
Lateral
supracondylar ridge
Lateral epicondyle
Olecranon process
Head of radius
Pronator teres
impression
Radius
Dorsal tubercle
(of Lister)
Styloid process
Proximal
phalanx
Distal
phalanx
Superior angle
Spine of scapula
Infraspinous
fossa
Medial
supracondylar ridge
Medial epicondyle
Posterior (sharp,
subcutaneous) border
Ulna
Head of ulna
Styloid process
Carpal bones
Metacarpal bones
(1st) Proximal phalanx
(2nd) Middle phalanx
(3rd) Distal phalanx
1
2
3
4
5
B
Figure 1.2-1 (continued)
Styloid Process of the Middle Finger Metacarpal
The styloid process of the middle finger metacarpal is lo-
cated on the metacarpals dorsal and radial base. It points to
the articular interface between the capitate and the trape-
zoid, and is just proximal to the point of insertion of the
ECRB tendon.
Radial Styloid
This distal projection of the radial side of the radius forms a
visible and easily examined landmark that is palpable both
palmar and dorsal to the abductor pollicis longus (APL)
and extensor pollicis brevis (EPB) tendons that run across
its apex.
ECRL (cut)
Common
extensor
tendon (cut)
Anconeus
Supinator
EPL
EIP
APL
EPB
Anconeus
(cut)
ECRL
ECRB
APL
EPB
EDC
EDM
ECU
Common
flexor
tendon
FDP
FCU (cut)
FDS (cut)
PL (cut)
FCR
(cut)
BR
(cut)
FPL
BR
(cut)
FCU
PL
(cut)
FPL
FDS
FCR
BR
PT
A B
Figure 1.2-2 (A) Flexor forearm muscles. (B) Extensor forearm muscles.
SDI
1
(cut)
SDI
2
(cut)
SDI
3
(cut)
SDI
4
(cut)
SDI
1
SDI
1
PI
1
PI
2
DDI
2
DDI
1
DDI
3
DDI
4
PI
3
SDI
2
SDI
3
SDI
4
ODM
PI
DI
DI
DI
DI
DI
AdP
(cut) APB
(cut)
PI
L1
L2
L3
L4
PI
FDM
PB OP
ADM
FCU
A B
Figure 1.2-3 (A) Palmar hand muscles. (B) Dorsal hand muscles.
5
Sup. thoracic a.
Subscapular a.
Lat. thoracic a.
Circumflex scapular a.
Profunda brachii a.
Thoracodorsal a.
Sup. ulnar collateral a.
Brachial a.
Ant. ulnar recurrent a.
Post. ulnar recurrent a.
Common interosseous a.
Ant. interosseous a.
Ulnar a.
Dorsal carpal branch
Palmar branch, AIA
Palmar radiocarpal arch
Branch to hypothenar ms.
Perforating branch
Palmar metacarpal a.
Common palmar digital a.
Proper palmar digital a.
Superf.
palmar arch
Deep
palmar arch
Recurrent
carpal a.
Superf. palmar
branch
Radial a.
Post.
interosseous a.
Radial recurrent a.
Radial collateral a.
Middle collateral a.
Post. and ant.
humeral circumflex as.
Axillary a.
Figure 1.2-4 Arteries of the upper
extremity.
Distal Head of the Ulna
The distal aspect of the ulna is slightly expanded and con-
tains a head and a comparatively small styloid process. The
head is most noticeable and prominent when the forearm
is pronated. The short styloid process is a rounded dorsoul-
nar projection from the ulnar head that is most palpable in
supination, and is about 1 cm proximal to the plane of the
radial styloid. The apex of the triangular fibrocartilage at-
taches to the palmar-radial base of the styloid process. The
extensor carpi ulnaris (ECU) tendon runs in a groove along
the dorsal aspect of the ulnar head.
Other Dorsal Landmarks
Anatomic Snuff Box
This depression on the radial side of the wrist is a narrow
triangle with its apex distal that is bordered dorsoulnarly
by the EPL, radially by the abductor pollicis longus (APL),
Chapter 1 / Anatomy / Systems Anatomy 7
Dorsal scapular
C4
C
5
C
6
C
7
C
8
T1
C5
C6
C7
T1
T2
Long
thoracic
G
F
C
A
B
D
C
E
Suprascapular U
p
p
e
r
t
r
u
n
k
L
o
w
e
r
t
r
u
n
k
M
i
d
d
l
e
t
r
u
n
k
L
a
t
e
r
a
l
c
o
r
d
P
o
s
t
e
r
i
o
r
c
o
r
d
M
u
sculocutaneous nerv
e
A
x
i
l
l
a
r
y
n
e
r
v
e
Radial ne
rv
e
M
e
d
ia
n
n
e
r
v
e
U
ln
a
r
n
e
r
v
e
Figure 1.2-5 Schematic illustration of the
brachial plexus, associated major branches,
peripheral branches and muscles they innervate. A,
nerve to subclavius; B, lateral pectoral nerve; C,
subscapular nerve; D, thoracodorsal nerve; E,
medial antebrachial cutaneous nerve; F, medial
brachial cutaneous nerve; G, medial pectoral nerve.
and extensor pollicis brevis (EPB) tendons, and proximally
by the distal margin of the extensor retinaculum. It contains
the dorsal branch of the radial artery; in its dorsoulnar cor-
ner, the tendonof the extensor carpi radialis longus (ECRL);
and superficially, one or more branches of the superficial
branch of the radial nerve. The carpal scaphoid bone lies be-
neaththis fossa and tenderness inthis area following trauma
may indicate an injury of this bone.
Lunate Fossa
The lunate fossa is a palpable central depression located on
the dorsum of the wrist, in line with the longitudinal axis of
the third metacarpal just ulnar and distal to Listers tuber-
cle, and beginning immediately distal to the dorsal margin
of the radius. It is, on average, approximately the size of the
pulp of your thumb, and it marks the location of the carpal
lunate in the proximal carpal row.
1.2 SYSTEMS ANATOMY
The following figures and discussion represent and are
designed to provide an overall perspective on the deeper
anatomythe skeletal, muscular, vascular, and neural
anatomyof the upper extremity. The perspective spans
from the shoulder and neck for discussions of the skele-
tal, neural, and vascular anatomy, and from the elbow for
the muscular system.
SKELETAL ANATOMY
The osseous structures of the upper limb include the
humerus, the radius and ulna, eight carpal bones, five
metacarpals, and 14 phalanges. The upper extremity skele-
ton is depicted in Figure 1.2-1.
To coracobrachialis
Lateral
cord
Medial
cord
Median nerve
To PT
To FCR
To PL
To FDS
To FDP
To FDS, index finger
To PQ
To lumbrical 2
To lumbrical 1
Recurrent nerve
Palmar cutaneous
nerve
To FDP
To FPL
Lat. antebrachial
cutaneous nerve
To radioulnar joint
To brachialis
To biceps
Musculocutaneous nerve
Chapter 1 / Anatomy / Systems Anatomy 9
Medial cord
Med. brachial
cutaneous nerve
Med. antebrachial
cutaneous nerve
Ulnar nerve
To FCU
Nerve of Henle
Palmar cutaneous nerve
Dorsal cutaneous branch,
to small finger
To PB
Sensory branch
Communicating branch
to median nerve
To AdP
To FPB
Deep motor
branch
D1
D1
P1
D1
L3
L4
D1
P1
To FDP, ring,
small fingers
To
long head,
triceps
To med. head, triceps
To anconeus
Superficial branch
To supinator
To APL
To EPL
To EPB
To EIP
To ECU
PIN
To ECRB
To EDC
To BR
To ECRL
To EDM
Communicating
branch, to ulnar
nerve
Deep branch
To lat. head, triceps
Radial nerve
Axillary nerve
Posterior cord
FOREARM
Pronation Supination
HAND
Flexion
Radial
deviation
Ulnar
deviation
Extension
DIGIT
Abduction
Adduction
Extension
Flexion
A
THUMB
Extension
Opposition
Flexion
Palmar
abduction
Opposition
Retro
position
Radial abduction
Radial
abduction
Palmar
abduction
B
Figure 1.3-1 Currently accepted terminology and depiction of
movement in the forearm, wrist, fingers: wrist, forearm (A), thumb (B).
11
TABLE 1.3-1 ANATOMIC BASIS FOR MOVEMENT
IN THE UPPER EXTREMITY
Joint/Motion Muscle Nerve Root
Elbow
Flexion Brachialis Musculocutaneous C5+C6+C7
Biceps Musculocutaneous C5+C6
Extension Triceps Radial C6+C7+C8
Forearm
Supination Biceps Musculocutaneous C5+C6
Supinator Radial C7+C8
Pronation Pronator teres Median C6+C7
Pronator quadratus Anterior interosseous
branch of median
C7+C8
Wrist
Flexion Flexor carpi radialis Median C6+C7
Flexor carpi ulnaris Ulnar C7+C8+T1
Extension Extensor carpi radialis longus Radial C6+C7
Extensor carpi radialis brevis Radial C7+C8
Extensor carpi ulnaris Radial C7+C8
Finger MCP
Flexion Medial two lumbricals Ulnar C8+T1
Lateral two lumbricals Median C8+T1
Extension Extensor digitorum communis, extensor
indicis, extensor digiti minimi
Posterior interosseous of
radial
C7+C8
Abduction Dorsal interossei
Ulnar C8+T1
Abductor digiti minimi Ulnar C8+T1
Adduction Palmar interossei
Ulnar C8+T1
Finger PIP
Flexion Flexor digitorum supercialis Median C8+T1
radial
C7+C8
Finger DIP
Flexion Flexor digitorum profundus Ulnar; anterior interosseous
of median
C8+T1
radial
C7+C8
Thumb
Palmar abduction Abductor pollicis longus Radial C7+C8
Abductor pollicis brevis Median C8+T1
Dorsal adduction Adductor pollicis Ulnar C8+T1
Thumb MCP
Flexion Flexor pollicis brevis deep head Ulnar C8+T1
Flexor pollicis brevis supercial head Median C8+T1
Extension Extensor pollicis brevis Radial C7+C8
Thumb IP
Flexion Flexor pollicis longus Median C7+C8
Extension Extensor pollicis longus Radial C7+C8
DIP, distal interphalangeal; IP, interphalangeal; MCP, metacarpophalangeal; PIP, proximal interphalangeal.
The dorsal and palmar interossei are abductors and adductors, respectively, of the ngers. They also ex the MCP joints and extend the PIP and DIP
joints. These so-called intrinsic muscles are the balancing and mediating forces between the powerful extrinsic exors and extensors of the ngers.
Loss of the intrinsic muscles results in signicant deformity in the hand and the reader is referred to the Doyle/Botte reference in Suggested Reading,
pages 581595 and chapter 13 of this text for a comprehensive discussion of the anatomy and function of these muscles.
Chapter 1 / Anatomy / Terminology of Movement 13
MUSCULAR ANATOMY
The muscles of the forearm are depicted in Figure 1.2-2
and the hand in Figure 1.2-3.
VASCULAR ANATOMY
The vascular anatomy from the axillary artery to the hand
is depicted in Figure 1.2-4.
NEURAL ANATOMY
The brachial plexus, median, ulnar, and radial nerves and
the muscles they innervate are depicted in Figure 1.2-5.
1.3 TERMINOLOGY OF
MOVEMENT
It is important to learn the language of movement as it re-
lates to forearm, wrist, fingers, and thumb functions. Figure
1.3-1 depicts the accepted terminology used to describe the
various movements seen and tested in the hand, wrist, and
forearm. Consistent use of these terms will allow all health
care providers to easily communicate their findings to each
other. Health workers might also develop a reasonable di-
agnosis and treatment plan if they note the absence of a
specific movement. Table 1.3-1 provides the anatomic ba-
sis for movement in the upper extremity; learning it will aid
TABLE 1.3-2 GRADING OF MUSCLE
STRENGTH
Grade Strength Description
5 Normal Complete ROM against gravity with
full resistance
4 Good Complete ROM against gravity with
some resistance
3 Fair Complete ROM against gravity
2 Poor Complete ROM with gravity
eliminated
1 Trace Evidence of slight contraction;
no joint motion
0 Zero No evidence of contraction
ROM, range of motion.
in making a diagnosis and help to establish the site and level
of an injury.
Table 1.3-2 covers the grading of muscle strength, which
helps to document the degree of disability as a baseline. It
is a useful tool in monitoring the presence or absence of
recovery.
SUGGESTED READING
Bugbee WD, Botte MJ. Surface anatomy of the hand. Clin Orthop
1993;296:122126.
Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity.
Philadelphia: Lippincott Williams & Wilkins, 2002.
Kaplan EB. Functional and surgical anatomy of the hand. 2nd Ed.
Philadelphia: JB Lippincott, 1965:265270.
PEARLS
Knowledge of anatomy is the key to diagnosis, treat-
ment, and surgery in the hand and wrist.
Continually review the anatomy of the hand, wrist,
and forearm; use the landmarks on your own hand
and wrist to visualize the deeper structures.
Remember that anatomy is three dimensional.
Dissect in the anatomy laboratory with your resident
colleagues.
Learn by repetition.
2
CONGENITAL
DEFORMITIES
Orthopaedics is both science and art. The art of or-
thopaedics includes the surgeons demeanor, which has
often been called bedside manner. The evaluation and
treatment of congenital deformities requires the appropri-
ate application of both science and art in order to effectively
deal with an infant or child with a congenital deformity, or
with his or her parents and extended family. We live in a
society where physical perfection is highly valued, so the
words of Robert E. Carroll in 1989 bear repeating:
Two body regions are constantly under scrutiny: the face and
the hands. These areas are rarely covered, and are perceived as
symbolic of the individual. Furthermore, they are very sensitive
areas used for communication. Since there is constant aware-
ness of these two body areas, what can be more important than
the functional and esthetic restoration of the upper extremi-
ties? The management of these complex problems carries with
it both great responsibility and rewards.
A congenital deformity may carry with it disappointment,
frustration, fear, and rejection. The initial doctor visit or
evaluation is often associated with anxiety or even guilt,
which can alter what might be considered normal responses
in other medical situations. Upper limb deformities are very
noticeable and are difficult to conceal. This often worsens
the deformitys social or emotional impact on the patient
and family.
The role of the upper extremity surgeon is to provide
support and information. Positive comments about other
physical attributes of the child are helpful to the parents
and to the patient. Your projection of a caring and accept-
ing caregiver will do much to help the parents along their
difficult path of acceptance of the deformity. Information
about support groups will be helpful to the family. Upper
extremity surgeons will need to offer more than technical ex-
pertise; they will need to become part of a team of thought-
ful and experienced professionals including pediatricians,
geneticists, and social workers. Finally, the use of inappro-
priate descriptive and potentially offensive terms such as
lobster claw hand or club hand should be abandoned. A
suitable and internationally accepted system of classifica-
tion and nomenclature has been developed and is best used
to write and speak about these deformities. Some have pro-
posed that congenital differences is a more appropriate
descriptive phrase than congenital deformities.
CLASSIFICATION
Being able to classify congenital deformities of the upper
limb is necessary to exchange ideas and concepts for diag-
nosing and treating them. The currently accepted classifi-
cation system is given in Box 2-1. It is based on embryonic
failure during development and relies on clinical diagnosis
for placement of the various and most prominent anomalies.
This system has been revised and adopted by the Congen-
ital Anomalies Committee of the International Federation
of Societies for Surgery of the Hand (IFSSH). Although
no classification system is perfect, the current system is the
best that exists at this time and is used worldwide. It has also
been observed that research on embryogenesis has rendered
some of the information outdated regarding pathogenesis
of limb malformations used in this classification. Although
many investigators have expressed difficulties in classifying
specific anomalies in this system, it has provided a frame-
work for discussion. Central deficiencies (cleft hand) and
brachysyndactyly, along with ulnar deficiencies in partic-
ular, have provided areas of controversy since the original
classification systemwas adopted, but it is beyond the scope
of this text to further define them. Defects in human limb
formation have been connected to gene mutations that may
encode signaling proteins, transcription factors, and recep-
tor proteins. Some limb defects have been mapped to a spe-
cific chromosomal segment and molecular defect. Table 2-1
provides a currently available genetic classification.
NORMAL UPPER LIMB DEVELOPMENT
1
Embryonic growth begins with fertilization of the egg fol-
lowed by attachment of the fertilized egg to the uterine
1
This section has been adapted with permission fromLight TR. Devel-
opment of the hand. In: Green DP, Hotckiss RN, Pederson WC, eds.
Greens operative hand surgery. 4th Ed. New York: Churchill Living-
stone, 1993.
14
Chapter 2 / Congenital Deformities 15
BOX 2-1 EMBRYOLOGIC CLASSIFICATION OF CONGENITAL DEFORMITIES OF THE UPPER
EXTREMITY
I. Failure of formation of parts (arrest of development)
A. Transverse arrest
1. Shoulder
2. Arm
3. Elbow
4. Forearm
5. Wrist
6. Carpal
7. Metacarpal
8. Phalanx
B. Longitudinal arrest
1. Radial ray deciency
2. Ulnar ray deciency
3. Central ray deciency
4. Intersegmental deciency (phocomelia)
II. Failure of differentiation of parts
A. Soft-tissue involvement
1. Disseminated
a. Arthrogryposis
2. Shoulder
3. Elbow and forearm
4. Wrist and hand
a. Cutaneous syndactyly
b. Camptodactyly
c. Thumb-in-palm deformity
d. Deviated/deformed digits
B. Skeletal involvement
1. Shoulder
2. Elbow
a. Elbow synostosis
3. Forearm
a. Proximal radioulnar synostosis
b. Distal radioulnar synostosis
4. Wrist and hand
a. Osseous syndactyly
b. Synostosis of carpal bones
c. Symphalangia
d. Clinodactyly
C. Congenital tumorous conditions
1. Hemangiotic
2. Lymphatic
3. Neurogenic
4. Connective tissue
5. Skeletal
III. Duplication
1. Whole limb
2. Humeral segment
3. Radial segment
4. Ulnar segment
a. Mirror hand
5. Digit
a. Polydactyly
1. Radial (preaxial)
2. Central
3. Ulnar (postaxial)
IV. Overgrowth
1. Whole limb
2. Partial limb
3. Digit
a. Macrodactyly
1. With brolipoma of nerve
2. No brolipoma of nerve
V. Undergrowth
1. Whole limb
2. Whole hand
3. Metacarpal
4. Digit
a. Brachysyndactyly
b. Brachydactyly
VI. Congenital constriction band syndrome
VII. Generalized skeletal abnormalities
A. Chromosomal
1. Madelungs deformity
Taken from Kozin, S. Congenital anomalies. In: Trumble T, ed. Hand surgery update 3, hand, elbow and shoulder. Rosemont, IL: American Society for
Surgery of the Hand, 2003:603604.
wall. The transition from embryo to fetus occurs at about
8 weeks, and is hallmarked by the appearance of the pri-
mary ossification center in the proximal humerus. Em-
bryogenesis is characterized by the appearance of new
organ systems and the fetal period by differentiation, mat-
uration, and enlargement of existing organs. The changes
in the early limb bud into the mature arm, forearm,
and hand rely on four interdependent developmental pro-
cesses: morphogenesis (the process by which a part as-
sumes a particular shape); cell differentiation (the pro-
cess by which individual cells, under genetic control,
become specialized for carrying out specific functions);
pattern formation (the process by which cellular differen-
tiation is spatially organized); and growth (the enlargement
of the structure reflecting both cell proliferation and matrix
elaboration).
Embryogenesis
Streeter identified 23 stages of embryonic development
based on his histological study of sectioned embryos (Ta-
ble 2-2). The upper limb develops from the arm bud, which
is an outgrowth from the ventrolateral body wall located
opposite the fifth through seventh cervical somites. The arm
bud first appears at approximately 26 to 27 days of gesta-
tion (3 to 5 mmcrown-rump length; Table 2-2 and Fig. 2-1).
Development in the arm bud occurs from proximal to distal
and is composed of a mass of somatic mesoderm-derived
mesenchyme covered by ectoderm. As the arm bud grows,
it assumes a flipper-like shape. At day 33, blood circulation
is established to the paddle-like arm bud.
At days 33 to 36 (7 to 9 mm crown-rump length), the
hand plates are evident as a flattened structure. Vessels
16 Section II / Outpatient Clinic
TABLE 2-1 GENETIC CLASSIFICATION OF LIMB DEFECTS
Molecular Defect Syndrome Limb Defect Gene Chromosome
Transcription factor Holt-Oram Radial deciency TBX5 12q24.1
Synpolydactyly Syndactyly, polydactyly,
brachydactyly HOXD13 2q31-q32
Townes-Brocks Polydactyly SALL1 16q12
Waardenburg types I and III Syndactyly PAX3 2q35
Hand-foot-genital Brachydactyly HOXA13 7p15-p14.2
Saethre-Chotzen Brachydactyly, syndactyly TWIST 7p21
Ulnar mammary Deciency and duplication TBX3 12q24.1
Pallister-Hall Polydactyly GL13 7p13
Creig cephalopoly syndactyly Syndactyly, polydactyly GL13 7p13
Signaling protein Grebe Severe brachydactyly CDMP1 20q11.2
Hunter-Thompson Brachydactyly CDMP1 20q11.2
Aarskog Brachydactyly FGD1 Xp11.2
Receptor protein Apert Syndactyly FGFR2 10q26
Pfeiffer Brachydactyly, syndactyly FGFR1 8p11.2-p11.1
FGFR2 8p11.2-p11.1
Jackson-Weiss Syndactyly, brachydactyly FGFR2 10q26
Unknown Split-hand-foot Syndactyly, fusion 7q21, Xq26, 10q24
Tarsal-carpal coalition Brachydactyly, fusions 17q
Nager Syndrome Posterior limb deciency 9q32
TABLE 2-2 STREETER STAGES OF HUMAN EMBRYONIC DEVELOPMENT
Stage Age (days) Crown-Rump Length Events
1 Fertilization
2 Zygote divides
3 Early blastocyte
4 6 Implantation begins
5 910 Complete blastocyte implantation
6 1115 Primary villi
7 1620 Notochord appears
8 2021 Neural plate develops
9 2122 Neural groove develops
10 23 2.03.5 mm Embryo straight; heart begins to beat
11 2425 2.54.5 mm Embryo curved
12 2627 3.05.0 mm Arm buds appear
13 2831 4.06.0 mm Arm buds are ipper-like
14 32 5.07.0 mm Forelimbs are paddle-shaped
15 3336 7.09.0 mm Hand plates formed
16 3740 8.011.0 mm Foot plates form
17 4143 1.11.4 cm Finger rays appear
18 4446 1.31.7 cm Notches between nger rays
19 4748 1.61.8 cm Fingers begin to separate
20 4951 1.82.2 cm Fingers separate and elongate
21 5253 2.22.4 cm
22 5455 2.32.8 cm Toes separate and elongate
23 56 2.73.1 cm Head rounded
Taken from Light TR. Development of the hand. In Green DP, Hotckiss RN, Pederson WC, eds. Greens
operative hand surgery.4th Ed. New York: Churchill Livingstone,1993:333338.
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+
E
M
AER
MS
MC
PCD
DR
IN
A B C
F E D
Figure 2-1 Normal limb bud
development. (A) At 28 days. (B) At
34 days. (C) At 36 days. (D) At 40
days with programmed cell death of
mesenchymal tissue between digital
ray mesenchymal condensations. (E)
At 42 days. (F) At 50 days showing
individual digits and well-defined
web spaces. AER, apical ectodermal
ridge; DR digital ray; E, ectoderm;
IN, interdigital notch; M, mesoderm;
MC, mesenchymal condensation;
MS, marginal sinus; PCD,
physiologic cell death. (Taken from
Yasuda M. Pathogenesis of preaxial
polydactyly of the hand in human
embryos. J Embryo Exp Morph
33:745756, 1975.)
grow into the limb from proximal to distal. At 5 weeks, a
constriction demarcates the arm from the forearm. A more
proximal depression will become the axillary fossa. At 41
to 43 days (11 to 14 mm crown-rump length), the finger
rays appear. At 50 days, individual digital metacarpal and
phalangeal mesenchymal condensations are histologically
visible. At day 52 or 53 (22 to 24 mm crown-rump length),
the fingers are entirely separate. In the seventh week, the
upper limb rotates 90 degrees on its longitudinal axis, so
that the elbow points dorsally. Embryogenesis ends during
the eighth week.
Limb Formation
Three interactions help guide limb formation. The first is
between the mesenchyme of the limb bud and the apical
ectodermal ridge (AER). This interaction influences and
guides proximal to distal axis limb differentiation, and is
the process that distinguishes the arm from the forearm
and the forearm from the hand. The second set of inter-
actions controls differentiation along the dorsal to palmar
axis, the distinction between the dorsum of the finger with
a fingernail, and the soft tissue of the pulp. The third set of
interactions controls cellular differentiation across the an-
teroposterior (AP) axis and causes the thumb to assume a
morphologic form distinctly different from the little finger.
The three critical regions of the limb bud that signal or
control outgrowth and pattern formation are the AER, the
dorsal ectoderm, and the zone of polarizing activity (ZPA).
The dorsal ectoderm controls palmar to dorsal differentia-
tion, which results in distinctly different flexor and extensor
surfaces.
The anteroposterior (AP) interactions are controlled by
a cluster of mesenchymal cells along the postaxial border
of the limb bud, the zone of polarizing activity (ZPA). The
morphogens elaborated within the ZPA diffuse and create a
gradient that helps control differentiation in the AP plane.
Retinoids are vitamin A-derived substances that may signal
digital differentiation from the polarizing region.
The AER is a transient ectodermal thickening at the tip
of the limb bud that is present during critical transitions
in limb development. The AER induces the differentiation
of the underlying mesoderm. The mesoderm elaborates
morphogens that maintain the AER. The progress zone is
a region of subectodermal mesoderm that defines proxi-
modistal relationships. The theory of positional information
suggests that the ultimate role or position of an individual
cell is determined by the length of time that a cell spends
in the progress zone, and by the number of times the cell
undergoes mitosis before exiting from the progress zone.
These interactions are critical for coordinating limb pattern
formation.
Apoptosis, or programmed cell death, is an integral ele-
ment of orderly limb embryogenesis. The resorption of tis-
sue between the digital mesenchymal condensations results
from the release of lysosomal enzymes from cells. The anti-
chondrogenic effects of the ectoderm and digital cartilage
inhibit interdigital mesenchymal cells from forming carti-
lage. As those interdigital cells migrate toward digital con-
densations to participate in chondrogenesis, the interdigital
zone experiences a decrease in cell density and cell death.
Genetic Control of Limb Differentiation
The four Hox genes (HoxAD) regulate patterning during
the development of the limbs, and help regulate the timing
and extent of local growth rates within the embryonic limb.
Mutation in the HoxDl3 position has been demonstrated
to lead to human synpolydactyly deformities in the hands
and feet. Three proteins (Sonic hedgehog [Shh], FGFs, and
Wnt-7a) are believed to establish the pattern of Hox gene
expression. The Hox code, in conjunction with other gene
products, is thought to provide more detailed positional and
morphogenic information to competent mesenchymal cells,
enabling themto formprecartilaginous skeletal cell conden-
sations of appropriate size and at appropriate sites.
Fetal Development
The upper limb is completely formed in miniature during
embryogenesis, and limbs growrapidly during fetal develop-
ment. Areas of cartilage are replaced by expanding primary
ossification centers, and joints move in utero in response to
muscle contraction.
Postnatal Development
After birth, the hand begins to explore its environment. Ini-
tial behaviors are shaped by subcortical reflexes. By the end
of the first year of life, the child begins to purposefully ma-
nipulate objects, using his or her hands in a coordinated
fashion. Hand preference or dominance is evident by 3 or
4 years of age.
ABNORMAL UPPER LIMB DEVELOPMENT
Abnormal limb development may be secondary to malfor-
mation (poor formation of tissue that initiates a chain of
additional abnormalities), deformation (from mechanical
forces applied to a normally formed embryo or fetus), dis-
ruption (destructive forces or problems such as infection
that affect normal embryos or fetuses), or dysplasia (condi-
tions that arise fromthe abnormal arrangement of cells into
tissues).
Causes of Common Congenital Deformities
Syndactyly
Digital ray separation is the result of the interactions be-
tween the AER and the underlying mesoderm. Syndactyly
+
+
+
+
+
+
+
+
+
+
+
+
+
+
AER
D
C
B
A
NC
AER
PCD
IPCD
Figure 2-2 Pathogenesis of limb deformities. (A) Mesenchymal cell
death leads to a reduction deformity of the hand. (B) Failure of cell
death results in syndactyly of adjacent digits. (C) Polydactyly results
from hyperplasia of the apical ectodermal ridge (AER). (D) Disrupted
ridge metabolism that results in failure of breakdown of the AER may
result in complete complex syndactyly. AER, apical ectodermal ridge;
IPCD, inhibited physiologic cell death; NC, necrotic cells; PCD,
physiologic cell death.
represents the failure of the normal separation of the digital
rays fromone another. When there is a failure of the normal
interdigital programmed cell death, interdigital webbing will
persist as syndactyly (Fig. 2-2).
Polydactyly
Polydactyly represents an inappropriate definition of digital
rays, reflecting an abnormality in the interaction between
limb bud ectoderm and mesoderm. Thumb polydactyly may
be related to prolonged ectodermal cells in the tip of the
limb bud that induce an abnormal notch in the radial mes-
enchymal tissue. Studies have shown that implantation on
the anterior side of the limb bud of FGF-soaked beads or of
portions of the ZPA will result in a mirror duplication of the
limb. In some instances, an inappropriate number of digital
condensations are formed. In other instances of polydactyly,
one of the five digital condensations becomes partially split
longitudinally. Digital definition occurs as the process of
interdigital apoptosis defines separate rays. If this process
occurs in an abnormal location, further splitting of the hand
plate results in polydactyly.
Dysplasia and Deciency
Necrosis of portions of the limb bud may be the result of
local injury or ischemia. The resulting hand may have a
corresponding area of dysplasia or deficiency. It has been
suggested on the basis of experimental studies that disrup-
tion of the AER may lead to transverse defects, whereas
loss of cells in the mesenchyme may result in longitudinal
deficiency patterns. Polands association, the occurrence of
brachysyndactyly with absence of the sternal costal portion
of the pectoralis major, may be related to unilaterally dimin-
ished vascular flow.
Thalidomide provided a vivid demonstration of the po-
tential effect of drug ingestion on limb morphogenesis.
Thalidomide was marketed outside the United States in the
late 1950s for the treatment of nausea associated with preg-
nancy. Administration of these drugs to pregnant rats has
been demonstrated to result in fetal anomalies. The spe-
cific anomalies are related to the dose and timing of the
drug administration.
Constriction Band Syndrome
Early amnion rupture sequence, also referred to as congen-
ital constriction band syndrome, is usually the result of in-
trauterine injury to a normally developed hand. In response
to the altered intrauterine environment, the fetus may be de-
formed, as fingers are forced together to create a secondary
syndactyly. The mechanical constriction of amniotic tissue
may disrupt or amputate fingers or toes.
IMPORTANT CLINICAL FACTS ABOUT
COMMON ANOMALIES
The following discussion will describe the important clinical
facts about some of the more common congenital anomalies
based on the currently accepted classification system. Not
all of the conditions listed in Box 2-1 will be presented.
FAILURE OF FORMATION OF PARTS
Failure of formation of parts may be transverse or longitudi-
nal. Transverse failure is represented by congenital amputa-
tion that may occur fromthe shoulder region to the phalanx.
Figure 2-3 An example of transverse arrest at the metacarpal level.
Longitudinal failure of development is characterized by ra-
dial, central, ulnar or intersegmental deficiency. Examples
of these deformities are complete or partial absence of the
radius, cleft hand, complete or partial absence of the ulna,
and phocomelia.
Transverse Arrest
The most common levels of amputation are proximal fore-
arm and mid-carpal, followed by metacarpal and humerus.
Figure 2-3 demonstrates the appearance of a transverse
arrest at the level of the metacarpal region. The condi-
tion is believed to be associated with severe hemorrhage
in the hand plate. These deficiencies differ from con-
striction ring amputations in that the proximal parts are
hypoplastic and the amputation is usually at or near a
joint.
Treatment
Treatment of arm and forearm amputations involves
prosthetic fitting of a dynamic or static device depend-
ing on the age of the patient and level of the amputa-
tion.
Transcarpal deficiency and foreshortened fingers (nub-
bins) are often present.
A palmar splint may provide rudimentary prehension.
Digital lengthening of one or more digits may be consid-
ered.
Separation of the radius and ulnar to form prehensile
appendages may be considered in bilateral transverse
arrest, especially if it is associated with visual impair-
ment.
Longitudinal Arrest
Radial Ray Deficiency
This condition involves absence or hypoplasia of the
thumb, radial carpal hypoplasia or absence and absence or
TABLE 2-3 RADIAL DEFICIENCY CLASSIFICATION
Type X-ray Findings Clinical Features
I. Short radius Distal radial epiphysis delayed in appearance Minor radial deviation of the hand
Normal proximal radial epiphysis Thumb hypoplasia is the prominent clinical feature
Mild shortening of radius without bowing requiring treatment
II. Hypoplastic Distal and proximal epiphysis present Miniature radius
Abnormal growth in both epiphyses Moderate radial deviation of the hand
Ulna thickened, shortened, and bowed
III. Partial absence Partial absence (distal, middle, proximal) Severe radial deviation of the hand
of radius
Distal one third to two thirds absence most common Most common type
Ulna thickened, shortened, and bowed
IV. Total absence No radius present
Ulna thickened, shortened, and bowed Severe radial deviation of the hand
hypoplasia of the radius. Four types have been classified
and are described in Table 2-3. A more recent and global
classification of radial longitudinal deficiency that includes
carpal and thumb anomalies is presented in Table 2-4. The
x-ray appearance of the four types listed in Table 2-3 is de-
picted in Figure 2-4. Ossification of the radius is delayed in
radial deficiency and the differentiation between types III
and IV may not be established until 3 years of age. The clin-
ical appearance of a type III patient is seen in Figure 2-5.
Syndromes associated with radial deficiency are presented
in Table 2-5.
Treatment
Treatment is aimed at improvement of appearance by
correcting the radial deviation of the wrist, balancing
the hand and wrist on the forearm, maintaining and
improving wrist and finger motion, promoting growth of
the forearm, and improving overall function of the upper
extremity.
This can be achieved by stabilizing the carpus on the end
of the ulna by centralization or ulnocarpal fusion. This
can be achieved with or without ulnar osteotomy and/or
tendon transfers.
These procedures work best in children, because func-
tional patterns developed over many years in adults are
best left unaltered.
The radial deviation deformity allows the hand to reach
the mouth. Bilateral conditions associated with non-
correctable stiff elbows should have only one side cor-
rected.
Surgery is most often needed in types II to IV.
Ulnar Ray Deficiency
This condition has four types; see Table 2-6 and Figure 2-6.
The classification system in Table 2-6 is based on the
status of the ulna and the humeral articulation. A more
recent classification system based on the characteristics of
TABLE 2-4 GLOBAL CLASSIFICATION OF RADIAL LONGITUDINAL DEFICIENCY
Type Thumb Anomaly Carpal Anomaly Distal Radius Proximal Radius
N Absent or hypoplasia Normal Normal Normal
O Absent or hypoplasia Absent, hypoplasia Normal Normal, radioulnar or radial head
or coalition dislocation synostosis
1 Absent or hypoplasia Absent, hypoplasia >2mm shorter than ulna Normal, radioulnar synostosis,
or coalition or radial head dislocation
2 Absent or hypoplasia Absent, hypoplasia Hypoplasia Hypoplasia
or coalition
3 Absent or hypoplasia Absent, hypoplasia Physis absent Variable hypoplasia
or coalition
4 Absent or hypoplasia Absent, hypoplasia Absent Absent
or coalition
Type I Type II
Type III Type IV
Figure 2-4 The osseous appearance of the four types of radial
deficiency: type I, type II, type III, and type IV. See Tables 2-2 and
2-3 for details.
the thumb and first web has been advocated due to the fact
that most surgeries for this condition involved the thumb
and first web (Table 2-7).
Treatment
Principles of treatment include splinting to correct any
significant ulnar deviation of the wrist and early excision
of the fibrous anlage of the ulna if it is not possible to
correct the ulnar deformity of the wrist.
The radial head may be excised in those patients with
minimal forearm rotation and elbow movement.
Creation of a one-bone forearm using the proximal ulna
and the distal radius may be indicated.
Hand function may be significantly improved by correc-
tive surgery to the thumb and first web when there is web
deficiency, absence of the thumb or thumb hypoplasia,
malposition, and loss of opposition.
Central Ray Deficiency
This includes typical cleft hand, which must be distin-
guished from atypical cleft hand, also known as brachysyn-
dactyly. Figure 2-7 represents a typical cleft hand, and
Figure 2-8 an atypical cleft hand or, more accurately,
brachysyndactyly. Table 2-8 compares the clinical features
of these two conditions.
Clinical Features
Typical cleft hand represents dysplasia of the central por-
tion of the hand, and is not seen in conjunction with
forearm or elbow anomalies.
The deformity is characterized by a V-shaped cleft in the
central aspect of the hand that may be associated with
absence of one or more digits.
Syndactyly may occur in the adjacent digits. The first web
space may be compromised.
Transverse bones may be noted on an x-ray, and there
may be an absence of multiple digits with only one digit
present (usually the little finger).
Some cleft hands may be caused by the split hand/split
foot gene localized on chromosome 7q21; see Table 2-1.
Treatment
Treatment of cleft hands should improve any compromise
of the first web space, close the cleft, and correct the
syndactyly if present.
Cleft closure may be achieved by transposition or translo-
cation of the appropriate ray.
In cases without a thumb, rotation of a radial ray, if
present, should be considered.
Intersegmental Deficiency
This deficiency, also known as phocomelia because of its
likeness to a seal limb, is distinguished fromtransverse defi-
ciencies because of the presence of digital structures. Three
types have been identified based on the presence or absence
of an intermediate segment between the shoulder and hand.
In type A, the hand is attached to the trunk, and there are
no limb bones; type B is characterized by the absence or
significant hypoplasia of the humerus so that the hand is
attached to the trunk by the forearm; type C is character-
ized by absence of the forearm, with the hand attached to
the humerus. Prosthetic or orthotic devices may be useful.
FAILURE OF DIFFERENTIATION OF PARTS
Soft Tissue Involvement
Disseminated
Arthrogryposis
The etiology of this condition is unknown. Although there
are multiple forms of this disorder, the one most likely to
be encountered on an orthopaedic service is known as amy-
oplasia congenita, or arthrogryposis.
Clinical Features
The classic patient with arthrogryposis demonstrates ad-
duction and internal rotation of the shoulders, extended
elbows, and pronated forearms.
A B
C
Figure 2-5 Type III radial deficiency. (A) Preoperative appearance.
(B) Postoperative appearance following transposition of the ulna. (C)
Improved appearance and function.
TABLE 2-5 SYNDROMES ASSOCIATED WITH
RADIAL DEFICIENCY
Syndrome Characteristics
Holt-Oram Heart defects, most commonly cardiac
septal defects
TAR Thrombocytopenia Absent Radius
syndrome.
Thrombocytopenia present at birth, but
improves over time.
VACTERL Vertebral abnormalities, Anal atresia,
Cardiac abnormalities,
Tracheoesophageal stula,
Esophageal atresia, Renal defects,
Radial dysplasia, Lower limb
abnormalities
Fanconis anemia Aplastic anemia not present at birth,
develops at about 6 years of age.
Fatal without bone marrow
transplant. Chromosomal challenge
test now available for early diagnosis.
Taken from Kozin, S. Congenital anomalies. In: Trumble T, ed. Hand
surgery update 3, hand, elbow and shoulder. Rosemont, IL: American
Society for Surgery of the Hand, 2003:610.
TABLE 2-6 CLASSIFICATION OF ULNAR
DEFICIENCIES
Type Grade Characteristics
I Hypoplasia Hypoplasia of the ulna with
presence of distal and proximal
ulnar epiphysis, minimal
shortening
II Partial aplasia Partial aplasia with absence of the
distal or middle one-third of the
ulna
III Complete aplasia Total agenesis of the ulna
IV Synostosis Fusion of the radius to the
humerus
The wrists are palmar flexed and the hands ulnar devi-
ated. The fingers are flexed and stiff. The thumb is flexed
into the palm.
This classic posture is demonstrated in Figure 2-9.
Treatment
As with all congenital anomalies, treatment is directed
toward the individual needs of each patient.
Type I
Type III
Type IV
Type II
A B
C D
Figure 2-6 The four types of ulnar deficiency: type I, type II,
type III, and type IV. See Table 2-6 for details.
The classic treatment goals include independent toilet
(perineal care) and self-feeding. In general, toilet care
requires an extended elbow; self-feeding requires some
degree of elbow flexion.
Early treatment is directed at passive movement and
static progressive splinting of joints to promote what
function may be present and as a useful precursor to sur-
gical intervention in the formof joint releases and tendon
transfers.
TABLE 2-7 CLASSIFICATION OF ULNAR
DEFICIENCY ACCORDING TO FIRST-WEB SPACE
ABNORMALITY
Type Grade Characteristics
A Normal Normal rst web space and normal
thumb
B Mild Mild rst web deciency and mild
thumb hypoplasia, with intact
opposition and extrinsic tendon
function.
C Moderate to
severe
Moderate-to-severe rst web
deciency and similar thumb
hypoplasia with malrotation into the
plane of the digits, loss of
opposition, and dysfunction of the
extrinsic tendons
D Absent Absence of the thumb
Many of these children develop trick motions to meet
their functional needs, and surgical intervention must be
calculated to improve and not diminish function.
Tendon transfers such as triceps to biceps, and pectoralis
major or latissimus dorsi to the front of the elbow, can re-
store active elbow flexion if a suitable muscle is available
for transfer.
A recent study of various transfers to achieve elbow flex-
ion revealed the following:
Exercises to obtain and maintain passive elbow flexion
are initiated at birth.
If at least 90 degrees of flexion has not been achieved
by 18 to 24 months of age after at least 6 months of
supervised therapy, an elbowcapsulotomy with triceps
lengthening is recommended.
Figure 2-7 Clinical appearance of a true cleft hand deformity.
Figure 2-8 Clinical appearance of an atypical cleft hand or
brachysyndactyly.
After the age of 4 years, tendon transfers for elbow
flexion on the dominant arm are recommended with
triceps to biceps transfer giving the most predictable
results.
The muscle to be transferred should have muscle
strength of at least grade 4.
A persistent wrist flexion deformity may require surgical
intervention. A proximal row carpectomy may be ben-
A B
Figure 2-9 Clinical appearance of arthrogryposis in the upper extremities.
TABLE 2-8 CLINICAL FEATURES OF TYPICAL
CLEFT HAND AND ATYPICAL CLEFT HAND
Atypical Cleft Hand
Typical Cleft Hand (Brachysyndactyly)
Familial, Autosomal dominant Sporadic, spontaneous
14 limbs involved 1 limb involved (no feet)
V-shaped cleft U-shaped cleft
No nger nubbins Finger nubbins may occur
Syndactyly (especially rst web) Unusual
Bilateral Unilateral
eficial in mild to moderate deformities, but more severe
flexiondeformities may require a dorsal wedge mid-carpal
osteotomy, along with a central transfer of the extensor
carpi ulnaris (ECU) to help the wrist extend.
The palm-clutched thumb may be repositioned, and the
fingers realigned, by osteotomy.
Wrist and Hand
Cutaneous Syndactyly
The webbing of the fingers may be spontaneous, inheri-
table, or associated with a syndrome. The conditions cur-
rently known to be associated with syndactyly are given
in Box 2-2. Inheritable syndactyly is associated with ge-
netic defects on certain regions of the second chromosome
BOX 2-2 CONDITIONS ASSOCIATED WITH SYNDACTYLY
Chromosomal
Trisomy 13
Trisomy 14
Trisomy 21
Partial trisomy 10q
Triploidy syndrome
Craniofacial Syndromes
Aglossia adactylia syndrome
Apert syndrome
Carpenter syndrome
Pfeiffer syndrome
Cohen syndrome
Cryptophthalmos syndrome
Ellis-van Creveld syndrome
Familial static Ophthalmoplegia syndrome
Glossopalatine ankylosis syndrome
Greig cephalopolysyndactyly syndrome
Hanhart syndrome
Hypertelorism and syndactyly syndrome
M obius syndrome
Noack syndrome
Oculodentodigital
Oculomandibulofacial syndrome
Oral-facial-digital
Oto-palato-digital
Pierre-Robin
Saethre-Chotzen
Other Syndromes
Acropectoral-vertebral dysplasia-F-form
(F syndrome)
Aarskog
Bloom syndrome
Brachydactyly A-2
Brachydactyly B
Chondrodysplasia punctata (Conradi) syndrome
Cornelia de Lange syndrome
EEC syndrome
Escobar syndrome
Fraser syndrome
Goltz focal dermal hypoplasia syndrome
Holt-Oram syndrome
Incontinentia pigmenti syndrome
Jarcho-Levin syndrome
Lawrence-Moon-Biedl syndrome
Lacrimoauriculodentodigital syndrome
Lenz-Majewski hyperostosis syndrome
Lenz microphthalmia syndrome
McKusick-Kaufman syndrome
Meckel syndrome
Miller syndrome
Neu-Laxova syndrome
Pallister-Hall syndrome
Pancytopenia dysmelia syndrome
Polands anomaly
Popliteal pterygium syndrome
Prader-Willi syndrome
Roberts-SC phocomelia syndrome
Rothmund-Thomson syndrome
Sclerostenosis syndrome
Scott craniodigital mental retardation syndrome
Short rib-polydactyly (Saldino-Noonan) syndrome
Smith-Lemli-Opitz syndrome
Spondylothoracic dysplasia syndrome
Summit syndrome
Thrombocytopenia-absent radius syndrome
Wardenberg syndrome
Taken from Ezaki MB. Syndactyly. In: Green DP, Hotckiss RN, Pederson WC, eds. Greens operative hand surgery. 4th Ed. New York: Churchill
Livingstone, 1999:414428.
(2q34q36). The mode of inheritable transmission is said
to be autosomal dominant, with variable expressivity and
incomplete penetrance.
Like most all congenital conditions, classification sys-
tems have evolved for syndactyly and the most simple system
is incomplete versus complete and simple versus complex. In
incomplete syndactyly, the interdigital web is extended, but
soft tissue union does not extend as far as the distal aspect of
the digits. Simple syndactyly involves only the skin and un-
derlying soft tissues, whereas complex syndactyly also mani-
fests some formof union of the underlying osseous terminal
phalanx. Another classification system has been developed
to guide the timing and extent of separation (Table 2-9).
This systemindicates the value of early (the first fewmonths
of life) separation of border digits (thumb-index and ring-
little finger web space) or digits with marked differences
in length. Separation prevents tethering of the longer digit
and may prevent flexion contracture or rotational deformity.
Surgery after 18 months of age has a lower incidence of
complications such as web advancement. Figure 2-10 shows
a case of complete, simple syndactyly, and Figure 2-11 is an
example of complex syndactyly as seen in Aperts syndrome.
Clinical Features
The most common site of webbing is between the middle
and ring finger.
Differential motion between the fingertips in com-
plete syndactyly indicates absence of bony involve-
ment.
Confluence of the nails (synechia) or the absence of dif-
ferential motion is most often associated with bony in-
volvement as seen in complex syndactyly.
Radiographs are an important part of the evaluation of
syndactyly. They assist in differentiating between com-
plex and simple syndactyly and in noting the presence or
absence of a hidden polydactyly.
The interdigital web has unique anatomy:
It is a three-dimensional space that allows normal fin-
ger movement in more than four planes.
It slopes from proximal to distal as viewed from the
dorsal aspect of the hand. This slope is most noticeable
when the digits are extended and abducted.
The web closes when the digits are flexed.
The web begins near the head of the metacarpal and
ends near the mid-portion of the proximal phalanx.
TABLE 2-9 SYNDACTYLY CLASSIFICATION
Type Description
Simple syndactyly (SS)
Standard (SSs) Straightforward, simple syndactyly of non-border digit. Surgery
can be delayed until 18 months of age.
Complicated (SSc) Simple syndactyly associated with additional soft tissue
interconnections, syndromes (such as Polands syndrome or
central deciency), or abnormal bony elements (such as
hypoplasia). Treatment must be individualized. Beware of
neurovascular anomalies.
Urgent (SSu) Soft tissue syndactyly of borders digits or digits of unequal
length, girth, or joint level. Requires early separation to
prevent angular and rotational deformity of tethered digit.
Complex syndactyly (CS)
Standard (CSs) Complex syndactyly of adjacent phalanges without additional
bony anomalies (such as delta phalanx or symphalangism).
Complicated (CSc) Complex syndactyly associated with additional bony
interconnections, (such as transverse phalanges,
symphalangism, or polysyndactyly), or syndromes (such as
constriction band syndrome). Treatment must be
individualized, and digits may function better as a unit.
Unachievable (CSu) Complex syndactyly with severe anomalies of the underlying
bony structures, which often prohibits formation of a
ve-digit hand without extensive surgical intervention.
Taken from Kozin, S. Congenital anomalies. In: Trumble T, ed. Hand surgery update 3, hand, elbow and
shoulder. Rosemont, IL: American Society for Surgery of the Hand, 2003:616.
Transversely oriented natatory fibers of the palmar fas-
cia span the mid and distal aspects of the web, and are
important support structures for the overlying skin and
subcutaneous tissues.
Treatment
The goals of treatment are to improve the overall appear-
ance of the hand and to improve function.
Contraindications include any condition that would pre-
clude general anesthesia (in children), the lack of ade-
quate vascular supply, soft tissue insufficiency, or lack of
a potentially stable skeleton for each digit.
Early separation at 4 to 6 months of age is advised for
complex syndactyly involving the border digits where con-
tinued growth may be expected to cause tethering or pro-
gressive deformity with growth.
Surgery is technically easier, and anesthesia is safer, after
1 year of age.
Surgical Techniques
Surgery is designed to try to reproduce this three-
dimensional space. Many methods have been designed to
achieve this, but the basic principles to achieve this goal
are based on the formation of a dorsally based flap that is
advanced to the palmar surface of the hand. The advance-
ment will form a new web in association with zigzag inci-
sions that run distally fromthe web area to the fingertips.
The zigzag incisions are used to prevent a linear scar and
its resultant contracture.
The triangular flaps thus formed are applied to the op-
posing surfaces of the separated digits; the gaps that
inevitably result are covered withfull thickness skingrafts
from a suitable donor site such as the hairless aspect of
the groin.
Figure 2-10 demonstrates the surgical technique used to
separate a case of simple, complete syndactyly.
A four-tailed Z-plasty may also be used to deepen the first
web, and is demonstrated in Figure 2-12.
Camptodactyly
Camptodactyly, meaning bent finger, is a congenital flex-
ion deformity of the proximal interphalangeal (PIP) joint
of the little finger. The term may be used less accurately
to describe any congenital flexion deformity of a digit. This
deformity has been noted in 70 or more syndromes.
Clinical Features
The finger assumes variable degrees of flexion contrac-
ture at the PIP joint. The neck and head of the proximal
phalanx at the PIP joint may be deformed.
The clinical and x-ray appearance of the condition is pre-
sented in Figure 2-13.
Etiology
The etiology is unknown, although various anatomic
abnormalities have been implicated, such as skin defi-
ciency, intrinsic and extrinsic tendon contracture, and
abnormal insertions, infection, and circulatory problems.
Abnormalities of insertion and contracture are most com-
monly found in the superficialis and or the lumbrical.
Treatment
Dynamic and static splinting may be useful if continued
through adolescence.
A
C
B
D
E
Figure 2-10 A case of simple, complete syndactyly showing the technique for release and web
formation using a dorsal pantaloon flap developed by L.D. Howard.
A B
Figure 2-11 An example of complex syndactyly as seen in Aperts syndrome.
A B
C
D
1 2
3 4
F
1
2
3
4
E
3
1
4
2
Figure 2-12 (AC) Clinical appearance of a child with Aperts syndrome in which a 4-tailed Z-plasty
was used to deepen the first web. (DF) Details of surgical technique.
28
Figure 2-13 Clinical appearance of camptodactyly.
Splinting is usually continued only at night once correc-
tion has been obtained.
Surgical intervention is not always required. It is indi-
cated for contractures of 30 degrees or more, or those
digits that have failed to improve with splinting.
Corrective procedures for this condition are quite vari-
able, but the basic principles relate to the release of the
intrinsic or extrinsic contractures in and about the PIP
joint. The principles also relate to the rebalancing of any
deforming forces.
A full-thickness skin graft or local flap is usually required
to treat the associated skin contracture.
Skeletal Involvement
Failure of differentiation as it relates to the skeleton is repre-
sented by synostosis. This condition may occur in the elbow,
forearm, wrist, and hand.
A B
Figure 2-14 (A) Clinical appearance of left sided forearm synostosis in a young child with the forearm
fixed in neutral. (B) X-ray showing coalition of the proximal radius and ulna (arrows).
Elbow Synostosis
Humeral radial synostosis has been identified or found in
three entities: as part of a systemic disorder manifested by
multiple synostosis; dysgenesis of the ulna; and as a part of
ulnar malformation and oligodactyly.
The position of the elbow may vary from full extension
to 90 degrees of flexion, and there may be associated
rotational deformities.
Treatment for this rare condition is directed at improving
the placement of the hand, which is sometimes directed
posteriorly.
A derotational osteotomy may be useful.
The exact procedure to be utilized will vary from patient
to patient, depending on whether or not the condition is
bilateral or unilateral.
The elbow is positioned to maximize hand function.
Forearm Synostosis
Forearm synostosis is often bilateral, and the forearm is
fixed in pronation. Figure 2-14 demonstrates the clinical
and x-ray appearance of a unilateral forearm synostosis in
the left upper extremity, which is fixed in neutral rotation.
A proximal rotational osteotomy may be performed based
on the functional needs of the patient (Figure 2-15). In
this patient, no treatment was required because the syn-
ostosis on the left was in neutral, and the opposite ex-
tremity had full pronation and supination.
Carpal Synostosis
This condition is more common in black populations. Luno-
triquetral coalitions are the most common. Figure 2-16
demonstrates the x-ray appearance of this condition. No
particular treatment is indicated.
Metacarpal Synostosis
This condition occurs most commonly between the ring and
little fingers, but may also present between the ring and
middle finger metacarpals. The most common form is rep-
resented by fusion of the ring and little finger metacarpals,
with abduction and hypoplasia of the little finger.
A
C
D
B
Figure 2-15 Surgical technique for proximal osteotomy in forearm
synostosis after Green and Mital, showing a proximal osteotomy and
reposition that is held in place by a longitudinal and a transverse
K-wire through the synostosis mass.
Indications for surgery include the need to improve the
appearance of the hand, but if severe little finger abduc-
tionis present this may interfere withfunctionas the little
finger may catch on things when the hand is used.
Osteotomy and realignment are designed to improve both
function and appearance.
Figure 2-16 X-ray appearance of a luno-triquetral coalition in the
wrist.
DUPLICATION
Digit
Polydactyly
Polydactyly may be divided into radial (preaxial), central,
and ulnar (postaxial).
Radial Polydactyly
Two classification systems have been used to categorize
thumb polydactyly. The first was by Wassel and the second
was by Buck-Gramko and Behrens. Both systems classify
the condition by the extent of bifurcation of the thumb. A
comparison of these two systems is given in Figure 2-17.
Wassel type IV thumbs are the most common. The preop-
erative and postoperative appearances of a type IV thumb
polydactyly are shown in Figure 2-18.
Central Polydactyly
Polydactyly of the central rays is often associated with syn-
dactyly. Ring ray involvement is the most common form.
Central polydactyly may be present in one hand, while
cleft hand is noted in the opposite extremity.
A radiograph is needed to adequately diagnose the con-
dition because the polydactylous digit may be concealed
within a syndactyly.
Treatment varies with the form of polydactyly encoun-
tered, but the goal is improved function and appearance.
In some instances, separation or excision may result in
lessened function and appearance.
The vascularity in synpolydacylous digits may be abnor-
mal, and digital separation may be associated with digital
ischemia.
Ulnar Polydactyly
Little finger polydactyly is common in black populations,
and may represent one of the most common hand malfor-
mations.
Small digits with a narrowstalk may be ligated when seen
in the newborn nursery. These digits will then necrose
and fall off.
Small nubbins may be ignored or surgically removed.
More substantial and formed digits may require a more
comprehensive approach to achieve better function and
appearance.
Wassel I
or
Type I Dist
Wassel II
or
Type IP
Wassel III
or
Type I Prox
Wassel IV
or
Type I MP
Wassel V
or
Type I MC
Wassel VI
or
Type I CM
Figure 2-17 The classification
systems for thumb polydactyly
demonstrating the systems of Wassel
and Buck-Gramcko and Behrens.
The first column depicts immature
thumbs, while the second shows
maturing thumbs. The metacarpal or
phalanges may partially or completely
separate at the epiphysis, metaphysis,
or diaphysis. (Taken from Light TR.
Congenital anomalies: syndactyly,
polydactyly and cleft hand. In:
Peimer CA, ed. Surgery of the hand
and upper extremity. New York:
McGraw-Hill, 1996:22112144.)
A B
C D
Figure 2-18 The preoperative (A, B) and postoperative (C, D) appearance of a type IV thumb
polydactyly treated by removal of the less dominant appendage.
A B
Figure 2-19 (A) Preoperative appearance of macrodactyly of the index finger (the middle finger was
amputated previously; note scar). (B) Enlarged digital nerves (arrows) and generalized fibrofatty
infiltration of the digit as seen at operation.
OVERGROWTH
Macrodactyly
The conditionof enlarged fingers (macrodactyly) presents in
two forms: static, with a single enlarged digit that is present
at birth and that grows proportionately to the other digits;
and progressive, with a digit that may not be enlarged at
birth but begins to enlarge in early childhood. Growth in
digits with this progressive type is much faster than the
normal digits, and may demonstrate angular deviation. The
progressive type is more common.
Clinical Features
The index finger is most commonly involved, and multiple
digits are frequently involved.
A B
Figure 2-20 The clinical appearance of brachydactyly. Note the comparatively normal thumb, but the
digits are represented as nubbins.
Motion in the affected digits becomes diminished with
age.
Phalangeal enlargement occurs in transverse and longi-
tudinal axes.
The digital nerves are thickened by fibrofatty tissue,
which renders identifying the conducting or functional
portions of the nerve difficult.
Both the median and ulnar nerve may enlarge proximal
to the digital nerve involvement.
Treatment
Treatment has included a variety of debulking, shorten-
ing procedures, including epiphyseal plate excision and
osteotomies, to correct angular and rotational deformi-
ties.
Debulking operations must be done in stages, and carry
the risk of vascular compromise if overly vigorous.
Growth of these digits is relentless.
Another form of treatment is amputation, usually in the
form of a ray amputation.
Amputation is often the last operation for a stiff, un-
sightly, and anesthetic digit.
Figure 2-19 shows a classic index finger macrodactyly.
UNDERGROWTH
Undergrowth may involve the whole limb, whole hand,
metacarpal, or digits. Brachysyndactyly and brachydactyly
(short fingers with and without webbing, respectively) will
be discussed. As previously noted, these two conditions
should not be confused with true cleft hand. Table 2-8
lists the features that differentiate atypical and typical cleft
hand.
Clinical Features
The affected hand is smaller in patients with brachy-
dactyly, which is a unilateral condition.
The thumb and little finger are often present and the
central digits are represented by nubbins of tissue
rather than fingers. Figure 2-20 depicts the clinical
appearance of brachydactyly in a child.
Brachysyndactyly is similar to brachydactyly in that the
condition is unilateral and the affected hand smaller.
The fingers are shorter than normal, and the webbing
of the digits may be simple and incomplete, or com-
plex.
Figure 2-21 is an example of brachysyndactyly as seen
in Polands syndrome.
Figure 2-22 represents a more complex form of
brachysyndactyly.
Treatment
In brachydactyly, treatment is directed at obtaining an
adequate first web and thumb reconstruction, if needed.
The thumb may be reconstructed by a toe transplant or
by lengthening, and the digits may be lengthened by free
toe phalangeal transfers into the small nubbins or skin
pockets.
In brachysyndactyly, if a thumb and adequate web are
present, treatment is focused on the release of the
webbed fingers.
CONSTRICTION BAND SYNDROME
Etiology
This condition is said to be a defect in the amnion (the
innermost layer of the placenta).
Strands or threads of this membrane detach and wrap
around digits or limbs.
Clinical Features
The end result of these constricting bands is intrauterine
amputation, constriction rings, and syndactyly.
B
A
Figure 2-21 Brachysyndactyly as seen in Polands syndrome.
(A) The pectoralis muscle is absent on the left side. (B) The index
and middle fingers are foreshortened, and the second and third web
spaces have partial (incomplete) webbing.
Secondary syndactyly results from abnormal tissue be-
tween the digits, which does allow separation.
If the ring does not result in amputation, the clinical
findings are present in the soft tissues.
Some rings are comparatively superficial, but some ex-
tend to the underlying osseous structures.
In the digits, the ring is deepest on the dorsal aspect.
Treatment
The surgeon must distinguish between shallow and deep
rings, because deep rings may have little or no venous
or lymphatic drainage. In these cases, the only venous
drainage is the vena comitantes of the digital arteries.
Minimal rings of little or no cosmetic consequence re-
quire no particular treatment, but deep rings are treated
with excision of the ring and closure by a series of con-
tinuous or interconnected Z-plasties.
A
C
B
D
Figure 2-22 (AB) A more complex form of brachysyndactyly. (C) Initial treatment by release of the
border fingers by dorsal flaps and skin grafts. (D) The early result.
Although some surgeons have corrected the deformity
in a one-stage procedure, it is customary to excise and
correct no more than half the ring at the first procedure.
The technique involves excision of the ring, followed by
mobilization of the skin and soft tissues as one composite
layer. This extends down to the level between the fat and
underlying fascia or vital structures.
A series of Z-plasties at angles of 60 degrees are then laid
out.
The length of each limb of the Z-plasty should be equal
to one-third to one-half the diameter of the digit or limb
being treated.
The flaps should be contoured and/or thinned to produce
a smooth nonbulging contour. Skin closure is with 5-0
or 6-0 chromic catgut (Fig. 2-23).
GENERALIZED SKELETAL
ABNORMALITIES
Madelungs Deformity
Etiology
Most cases of Madelungs deformity are caused by heredi-
tary dyschondrosteosis in the formof a lesion in the volar-
ulnar zone of the distal radial physis. This retards growth
asymmetrically, especially in late childhood.
Clinical Features
The condition is seen most often in females.
The distal ulna is very prominent.
B
A
1
1
3
3
5
2
2
4
4
6
6
5
C
Figure 2-23 Z-plasty technique for constriction ring syndrome.
(A) The constriction ring is excised down to the interval between the
fat and underlying vital structures or fascia. Redundant fat is excised
from the deep side of the flaps to achieve the appropriate contour. (B)
Sixty-degree interconnected Z-plasties are laid out and the major
arteries, veins, and nerves identified and preserved. (C) The flaps are
rotated and sutured in place with 5-0 or 6-0 chromic catgut. (Taken
from Doyle JR. Constriction ring reconstruction. In: Blair WF, Steyers
CM, eds. Techniques in hand surgery. Baltimore: Williams and
Wilkins, 1996.)
A B
C
Figure 2-24 Clinical and x-ray appearance of Madelungs deformity.
35
The hand is displaced palmarward along with the car-
pus, and is pronated in reference to the long axis of the
forearm.
The clinical and x-ray appearance is seen in Figure 2-24.
Treatment
Surgical treatment is indicated in those patients with
a significant and symptomatic deformity who are unre-
sponsive to conservative management.
In the adolescent, performing a physiolysis procedure in
the ulnar aspect of the distal radius and then filling the
defect created with fat may be considered as a possible
prophylactic procedure.
In the adult, surgical treatment is in the form of correc-
tive osteotomy of the distal radius, with shortening or
resection and stabilization of the distal ulna as needed.
SUGGESTED READING
Bayne LG, Klug MS. Long-term review of the surgical treatment of
radial deficiencies. J Hand Surg 1987;12A:169179.
Beatty E. Upper limb tissue differentiation in the human embryo. Hand
Clin 1985;1:391404.
Cole RJ, Manske PR. Classification of ulnar deficiency according to
the thumb and first web. J Hand Surg 1997;22A:479488.
Ezaki M. Treatment of the upper limb in the child with arthrogryposis.
Hand Clin 2000;16:703711.
Harley BJ, Carter PR, Ezaki M. Volar surgical correction of Madelungs
deformity. Techniques in Hand and Upper Extremity Surg
2002;6:3035.
James MA, McCarroll HR Jr, Manske PR. The spectrum of radial
longitudinal deficiency: a modified classification. J Hand Surg
1999;24A:11451155.
Jones KL. Smiths recognizable patterns of human malformation. 5th
Ed. Philadelphia: WE Saunders, 1997.
KozinS. Congenital anomalies. In: Trumble T, ed. Hand surgery update
3, hand, elbow and shoulder. Rosemont, IL: American Society for
Light TR. Congenital anomalies: syndactyly, polydactyly and cleft hand.
In: Surgery of the hand and upper extremity. New York: McGraw-
Hill, 1996:22112144.
Light TR. Development of the hand. In: Green DP, Hotckiss RN,
Pederson WC, eds. Greens operative hand surgery. 4th Ed. New
York: Churchill Livingstone, 1999:333338.
McCarroll HR Jr. Congenital anomalies: a 25 year review. J Hand Surg
2000;25A:10071037.
Moore KL. The developing human: clinically oriented embryology.
Philadelphia: WB Saunders, 1988.
Ogino T. Teratogenic relationship between polydactyly, syndactyly and
cleft hand. J Hand Surg 1990;15B:201209.
Taussig HB. A study of the German outbreak of phocomelia: the
thalidomide syndrome. JAMA 1962;180:11061114.
Van Heest A, Waters PM, Simmons BP. Surgical treatment of
arthrogryposis of the elbow. J Hand Surg 1998;23A:1063
1070.
Vickers D, Nielsen G. Madelung deformity: surgical prophylaxis (phys-
iolysis) during the late growth period by resection of the dyschon-
drosteosis lesion. J Hand Surg 1992;17B:401407.
Zaleske DJ. Development of the upper limb. Hand Clin 1985;1:383
390.
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3
TUMORS
In this chapter, the word tumor is used to describe any ab-
normal mass, or neoplastic growth or erosion, involving soft
tissue or bone that may be present in the hand or wrist.
Thus, benign soft tissue growths such as ganglion cysts,
giant cell tumors of the tendon sheath, pyogenic granulo-
mas, gouty deposits, and aneurysms will be discussed, along
with malignant lesions of soft tissue such as melanoma,
squamous cell carcinoma, and sarcomas of soft tissue and
bone.
All of these conditions are considered tumors under the
broad definition that a tumor is any swelling, tumefaction,
or erosive lesion of skin, soft tissue, or bone. The tumors
that will be discussed are representative of many of the le-
sions that may be commonly encountered. But this does not
represent a comprehensive compilation.
Tumors of the hand and wrist are more often than not
benign, but the wise practitioner will always be aware of
the need to consider all possibilities. This chapter will be
divided into benign and malignant categories, including le-
sions of the skin, soft tissue, and bone, as well as tumor-like
conditions.
The most important feature of this chapter is the sec-
tion on the basic principles of diagnosis, including imaging
techniques, tumor classification, biopsy, and staging of soft
tissue sarcomas.
PRINCIPLES OF DIAGNOSIS
Tumors that present with a history of rapid enlargement,
aching discomfort, or exceed 3 to 4 cm in size, war-
rant a careful evaluation of the mass and overlying skin,
and require palpation for enlarged lymph nodes in the
epitrochlear and axillary regions.
A plain radiograph is an appropriate initial study to ob-
tain. For suspicious soft tissue tumors, magnetic reso-
nance imaging (MRI) is advised with T1, T2, and short
tau inversion recovery (STIR).
T1 images are useful for anatomic detail.
T2 images show fluid collections, such as purulent
material and hematomas.
Gadolinium contrast may enhance the appearance of
soft tissue tumors.
If a malignancy is diagnosed, the workup should include
a chest radiograph and total-body scintigraphy (radioiso-
tope scans) to rule in or out metastatic spread.
Computed axial tomography (CT) of the chest, abdomen,
and pelvis is also utilized, along with routine hematology,
chemistry panel, and coagulation studies.
A medical oncologist and radiation therapist may be used
as indicated.
TUMOR CLASSIFICATION
The classification system developed by Enneking and
adopted by the Musculoskeletal Tumor Society is based on
the location (site) and extent of the lesion, and the histo-
logic grade. The site of the lesion can be either intracom-
partmental (T1) or extracompartmental (T2). The extent of
the tumor refers to the presence or absence of metastatic
lesions. The histologic grade may be benign (G0), low grade
(G1), or high grade (G2).
The Enneking system for staging of soft tissue and bone
sarcomas is given in Table 3-1.
BIOPSY
It has been recommended that the biopsy be performed at
the institution where subsequent treatment will be given,
as studies have suggested that this increases the ultimate
survival. Four dissection methods have been employed for
biopsy and are given in Table 3-2. All biopsies should be
carefully planned, and open biopsies are preferred over nee-
dle biopsies.
The biopsy is performed under tourniquet control, and
the limb is elevated but not exsanguinated with an Es-
march bandage prior to inflation of the tourniquet.
The resultant biopsy tract becomes a contaminated tract
of tumor cells, and will require removal en bloc if the
lesion is malignant.
Thus, the biopsy incision should be placed in such a way
that it facilitates future surgery. In general, longitudinal
incisions are preferred over transverse incisions.
37
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TABLE 3-1 ENNEKING SYSTEM FOR STAGING
OF SOFT TISSUE SARCOMA AND SARCOMA
OF THE BONE
Stage Grade Site Metastases
IA G1 T1 M0
IB G1 T2 M0
IIA G2 T1 M0
IIB G2 T2 M0
IIIA G1G2 T1T2 M1
IIIB G1G2 T1T2 M1
Characteristics
Grade (G)
G1 Low
G2 High
Site (T)
T1 Intracompartmental
T2 Extracompartmental
Metastases (M)
M0 No regional or distant metastases
M1 Regional or distant metastases present
Taken from Enneking WF, Spanier SS, Goodman MA. A system for
the surgical staging of musculoskeletal sarcoma. Clin Orthop Rel
Res 1980;153:106120.
Frozen sections may be used to determine that adequate
tissue has been removed for study, or for determining
margins. However, permanent sections are required for
definitive treatment.
CAVEATS ABOUT TUMOR TREATMENT
The brief discussion under each tumor presented is meant
to introduce the reader to some current concepts regarding
treatment options.
The following comments may be applied to all tumors,
but especially to malignant tumors and those tumors that
are benign but behave aggressively, such as giant cell tumor
of the bone.
The treatment options are not inclusive of all recom-
mended treatments, and are intended as an introduction
to the subject.
TABLE 3-2 MUSCULOSKELETAL TUMOR
DISSECTION METHOD
Type Description
Intralesional Dissection plane is through tumor
Marginal Dissection plane is through tumor reactive
zone
Wide Dissection plane well away from tumor in
normal tissue but within the compartment
Radical Dissection plane is extracompartmental
The treatment options may change as further experience
and knowledge are applied to a given tumor.
A team approach is ideal, and may include surgical spe-
cialists, pathologists, diagnostic and therapeutic radiolo-
gists, and oncologists.
In suspicious lesions, referral of the patient to a team or
center of experience for evaluation and treatment, even
before a biopsy is performed, may be considered.
BENIGN SOFT TISSUE TUMORS
Ganglion Cyst
Incidence and Location
Ganglion cysts are probably the most commonly encoun-
tered benign soft tissue tumor in the wrist and hand.
They occur most commonly over the dorsal aspect of the
wrist, the palmar and radial aspects of the wrist, the flexor
tendon sheath in the region of the A-1 pulley, and over
the distal interphalangeal (DIP) joint of the fingers and
the interphalangeal (IP) joint of the thumb.
In the flexor tendon sheath, they are termed volar reti-
nacular ganglia. Over the DIP joint of the digits and IP
joint of the thumb, they are termed mucous cysts.
Less common sites are about the PIP joint, the carpal
and ulnar canal, in the substance of extensor ten-
dons, from the extensor retinaculum, and in carpal
bones.
Diagnosis
Clinical Features
At the wrist, ganglion cysts may present as a firm, non-
tender mass that canbe up to several centimeters indiam-
eter (Figure 3-1). These cysts may transilluminate when
a bright light source, such as a penlight, is pressed against
them.
The size of the cyst may vary from time to time, and may
be related to physical activities.
The lesions are fixed to the underlying structures, and
do not move with flexion or extension of the wrist or
digits.
At the wrist, the diagnosis may be confirmed by aspiration
that yields a thick, jelly-like material that has no color.
At the radial and palmar aspects of the wrist, the gan-
glion cyst may lie beneath the radial artery and push it
up beneath the skin into a more prominent position. This
displacement of the radial artery must be remembered
if the ganglion cyst is treated by aspiration or excision
(Figure 3-2).
In the flexor sheath, they present as firm masses in the
palm at the level of the metacarpophalangeal joint, and
become more prominent with hyperextension of the fin-
gers (Figure 3-3).
In the digits, they may be seen as thin walled cysts that
overlie the DIP and IP joints and may often be associated
with osteoarthritis (Figure 3-4 and Figure 3-5).
Examples of a ganglion cyst in the carpal canal and in the
substance of the extensor tendon, respectively, are seen
in Figure 3-6 and Figure 3-7.
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Chapter 3 / Tumors 39
A B
Figure 3-1 (A) View of the dorsal aspect of the right wrist, showing a large cystic mass. (B) The mass
had the characteristic appearance of a ganglion cyst and was removed, along with a suitable portion of
the dorsal capsule.
Differential Diagnosis
At the dorsal aspect of the wrist, the ganglion should not
be confused with a carpal boss, rheumatoid synovitis, or
an accessory muscle called the extensor digitorum brevis
manus (EDBM).
The correct diagnosis is aided by noting that a carpal
boss occurs at the base of the middle finger metacarpal
and the adjacent capitate, is hard like bone, and is more
distal than the dorsal carpal ganglion that arises from
the region of the scapholunate capsule (Figure 3-8). For
a complete discussion of a carpal boss, see the section on
benign bone tumors.
Rheumatoid synovitis is usually softer to palpation than
the ganglion, and moves distal and proximal as the fingers
are flexed and extended. It flattens out when a complete
fist is made and presents with a tuck sign when the
fingers are extended (Figure 3-9).
The EDBM is a fusiform-shaped mass that occurs over
the metacarpals, does not transilluminate, and main-
tains its shape with finger flexion and extension (Fig-
ure 3-10).
An intratendinous ganglion of an extensor tendon may
occur over the wrist and hand, and is diagnosed by the
fact that it moves with flexion and extension of the fingers
and maintains its shape. Rheumatoid synovitis, however,
does not (see Figure 3-7 and Figure 3-9).
Treatment
Treatment for these lesions may be in the form of observa-
tion, aspiration (with or without an injection of cortisone),
multiple puncture technique, or surgical excision. While
the specifics of treatment are beyond the scope of this text,
note that for surgical intervention of the ganglion, current
A B
Figure 3-2 (A) View of the radial and palmar aspect of the right wrist showing a prominent mass.
(B) The mass arose beneath the radial artery; rubber bands have been placed about the artery proximal
and distal, to retract the artery out of harms way so that the ganglion may be excised. Remember that the
radial artery may be misidentified as a vein. It should be protected and preserved.
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A B
Figure 3-3 (A) Mass (arrow) at the base of the left index finger ray. (B) The volar retinacular ganglion
cyst (arrow) is arising from the first annular pulley and will be excised along with a small portion of the
pulley.
conventional wisdom recommends excision of a small por-
tion of the wrist capsule along with the cyst.
Excision of a recurrent or multilocular cyst may be aided
by careful injection of a dilute solution of methylene blue
into the cavity of the cyst using a 30-gauge needle.
The dye provides for excellent contrast of the cyst from
the surrounding structures, and aids in its complete
removal (Figure 3-11).
The intratendinous ganglion can usually be removed
fromthe substance of the extensor by longitudinally split-
ting its fibers and shelling out the cyst (see Figure 3-7).
A word of caution is warranted when aspirating or remov-
ing a volar carpal ganglion:
The radial artery is in close proximity, and is often
applied to the wall of the ganglion.
A preoperative assessment of the status of the radial
and ulnar arteries with an Allens test and/or Doppler
device will allow you to make appropriate decisions
should the radial artery be injured during the proce-
dure.
These lesions have no malignant potential, and may be
observed. Cosmetic rather than functional factors, or
concerns about cancer, may play a significant role in the
patients decision to remove a large cyst from the wrist.
In contrast, the volar retinacular cyst may interfere with
grip, and one or two punctures of the cyst often result in
its disappearance.
Patients may try to needle a mucous cyst at home, and
should be cautioned against this. Because the lesion
connects to the joint, any resulting infection may be dif-
ficult to treat.
Pathology
The diagnosis is seldom in doubt, based on the clinical
appearance and microscopic demonstration of a fibrous
capsule. That structure is often lined with a flattened
layer of epithelial-like cells and contains a mucinous ma-
terial that usually stains a pale blue on hematoxylin and
eosin sections.
Giant Cell Tumor of the Tendon Sheath
Aside from the ganglion cyst, this is probably the most
common benign soft tissue tumor encountered in the
upper extremity.
Giant cell tumor may not be a suitable termfor this lesion,
because it does not always contain giant cells and is not
always associated with the tendon sheath. This lesion has
also been called a fibrous tissue xanthoma.
It is the most common tumor in the palm and digits, and
appears to have a propensity for the radial three digits
and the DIP joint region.
It is usually on the palmar surface of the hand and fingers,
but may occur dorsally.
Clinical Features and Diagnosis
These tumors are slow growing, firm, nodular, and non-
tender.
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A
B
Figure 3-4 Characteristic appearance of the ganglion cyst (mucous
cyst) at the distal interphalangeal joint.
They are brown-yellow. In some instances, portions of
the lesion may lie just beneath the skin; a hint of this
color may show through in a thin-skinned patient.
In contrast to the ganglion, they do not transillumi-
nate.
They may occur as compound multinodular lesions.
Radiographs may demonstrate a soft tissue mass. In some
instances there may be erosion of the adjacent osseous
phalanx, or extension into the joint space.
Treatment
Treatment is surgical through an appropriate incision.
Because of their slow growth, these lesions may wrap
around nerves and other vital structures, and care must
be exercised in their removal. Figure 3-12 shows the pre-
operative, intraoperative, and microscopic appearance of
such a lesion.
At surgery, the lesions are moderately easy to remove.
A
B
Figure 3-5 Ganglion cyst arising from the PIP joint. Radiographs
(not shown) demonstrated significant degenerative arthritis in this
joint.
Failure to identify all satellite extensions or discover an
extension into the joint space, however, may be associ-
ated with a higher than normal recurrence rate. The same
comments would apply if the tumor has invaded the flexor
tendon sheath.
Pathology
The microscopic appearance often, but not always, re-
veals collections of giant cells in a dense and cellular
fibrous tissue matrix.
Hemosiderin collections are prominent, and may explain
the coloration of these lesions (Figure 3-12D).
Epidermal Inclusion Cyst
These cysts are found most commonly in the distal pha-
lanx, most often in males. They may be found following
amputation or injury of the fingertip.
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Figure 3-6 This large ganglion cyst arose from the volar aspect of
the carpal canal, and caused median nerve complaints. The ganglion
is to the left (arrows) and the probe is deflecting the median nerve.
A B
C
Figure 3-7 (A) Ganglions may arise in the substance of extensor
tendons, and present as a mass that moves distally with flexion of the
fingers. (B) The ganglion cyst is fusiformin shape. (C) It can be removed
without loss of integrity of the extensor tendon.
They are most commonly found on the palmar surface
of the digits, in contrast to sebaceous cysts (due to ob-
structed sebaceous glands) that occur on the dorsal as-
pect of the hand. Epidermal inclusion cysts are believed
to result from the traumatic implantation of epithelial
cells into the underlying soft tissue.
These slow-growing masses in the distal phalanx of the
fingers or thumb are firm and slightly moveable.
They are thick-walled white lesions that contain a white,
thick, cheesy material.
A history of trauma is not always present.
If the cyst has beenpresent for a long time, it may produce
a pressure defect on the adjacent osseous phalanx that is
visible on radiograph.
The typical appearance is shown in Figure 3-13.
Treatment
Epidermal inclusion cysts are easily removed from the
surrounding soft tissue.
They may often recur, and some surgeons have claimed
a lower recurrence rate by excising an ellipse of skin over
the cyst that may contain the site of the original traumatic
implantation.
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A
B
C
Figure 3-8 The carpal boss is often mistaken for a ganglion cyst. (AB) Prominent mass and scar
(arrows) following an attempted removal of a ganglion. (C) A radiograph clearly demonstrates the true
nature of this mass.
A B
Figure 3-9 This patient with
rheumatoid synovitis demonstrates the
fact that synovial lesions bunch-up
and become more prominent when the
fingers are extended (A), and flatten
out when a fist is made (B).
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Figure 3-10 This anomalous muscle called the extensor digitorum
brevis manus (EDBM) may also mimic the ganglion cyst; it is distal to
the typical ganglion location, and is more fusiform in shape.
Pathology
They have a wall of fibrous tissue on microscopic section,
and the white, cheesy material is keratin.
These lesions have no malignant potential.
Lipoma
Although lipoma is the most common benign soft tissue
tumor in the body, it is relatively uncommon in the wrist
or hand.
A
C
B
Figure 3-11 (A) This elongated compound ganglion cyst spanned a
considerable distance across the wrist and hand (arrows). (B) An
injection with a dilute solution of methylene blue demonstrated its true
extent. (C) That made its complete removal easier.
It may occur in any location in the hand and wrist, in-
cluding Guyons canal or the carpal tunnelwhere it may
produce nerve symptoms.
The typical lipoma is represented by a soft to firm non-
tender mass that does not transilluminate.
It may be firm if it has been growing for a long time in a
confined anatomic space.
It may be diagnosed on radiograph by its comparatively
diminished density (it appears darker) than the surround-
ing tissues.
This finding, called Bufalinis sign, demonstrates the
comparative diminished radio-density of fatty tissue.
Figure 3-14 demonstrates the preoperative, intraopera-
tive, and x-ray appearance of a large lipoma in the hand.
Treatment and Pathology
Lipomas are well demarcated and easily removed, and
recurrence is unusual.
Typical fat cells are seen on the histological sections, with
minimal amounts of fibrous tissue.
There is no malignant potential.
Neurilemmoma (Schwannoma)
Neurilemmoma is the most common benign nerve tumor
of the hand and wrist, and most often involves the median
nerve at the wrist.
It is most often seen in the 4th to 6th decades.
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A B
C D
Figure 3-12 (A) This compound giant cell tumor of the tendon sheath presented as a palmar hand
lesion (arrow). (B) It also presented as dorsally. (C) It was associated with several vital structures in the
palm, and invaded the metacarpophalangeal joint of the middle finger. (D) The characteristic histologic
features of giant cells in a cellular matrix with scattered hemosiderin deposits are noted. (Hematoxylin
and eosin, original magnification 160.)
Most often, patients present with a pain free mass on the
flexor side of the wrist.
Percussion over the mass may produce some distal pares-
thesias.
The mass is mobile side-to-side, but not longitudinally.
It does not transilluminate.
It is more medial in the wrist than the usual volar carpal
ganglion.
Treatment and Pathology
This lesion is easily differentiated from other nerve tu-
mors by the fact that it may be removed from the nerve
involved by shelling it out of the nerve.
The nerve fibers are separated longitudinally, and the
mass is removed (Figure 3-15A-D).
It is surprising to note that little or no nerve deficit is
present following its removal.
The histological appearance in Figure 3-15E is charac-
teristic, and recurrence is uncommon.
Neurofibroma
Neurofibromas are benign nerve lesions that arise from
nerve fasciculi.
They may be single or multiple, and are most common in
neurofibromatosis (von Recklinghausens disease).
They may present as subcutaneous masses about the
hand and wrist.
These lesions may be associated with caf e-au-lait spots
seen in neurofibromatosis.
The typical appearance of this lesion in a patient with
neurofibromatosis is shown in Figure 3-16.
Treatment
In contrast to the neurilemmoma, these lesions have a
nerve that enters and exits the mass, and that cannot be
freed from the mass.
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A
C
B
Figure 3-13 (A) The enlarged terminal phalanx (arrows) of this
carpenters thumb revealed a thick-walled cyst. (B) It was filled
with keratin material. (C) It was easily shelled out of the pulp of
the terminal phalanx.
If a small sensory nerve is involved, it may be excised
along with the lesionand little or no residuals will be
encountered. Note the afferent and efferent nerve fibers
from the neurofibroma in Figure 3-16C.
Progressively enlarging lesions that are symptomatic may
require removal.
Pathology
The characteristic histology is demonstrated in Figure
3-16D.
Malignant degeneration is possible in patients with neu-
rofibromatosis.
Digital Fibroma of Infancy
This is a benign but very aggressive lesion that occurs al-
most exclusively in the fingers and toes of children before
the age of one year.
In the hand, it is most often seen in the region of the IP
joint.
These lesions present as small raised masses that are non-
tender.
With growth, joint contracture and deformity may be
seen.
The lesions may growat an alarming rate, and may mimic
a malignancy (Figure 3-17).
Treatment
Treatment may include observation, limited and wide ex-
cision, and amputation.
Observation is indicated because spontaneous resolution
may occur. Progressive deformity may require surgical
intervention.
Wide excision and skin grafting may give the best local
control but recurrence is high (Figure 3-18).
Pathology
Intracytoplasmic inclusion bodies are present in the his-
tologic section, which suggests a viral or myofibroblast
origin.
Juvenile Aponeurotic Fibroma
This childhood and adolescent condition is a benign but
aggressive lesion seen most often in the palm.
The lesion presents as a small, pain free mass that may
be closely applied to the underlying vital structures in the
palm.
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A B
C
Figure 3-14 (A) This patient presented with a slow-growing, pain-free mass in the palm of her right
hand. (B) It was a classic lipoma. (C) The diagnosis was made preoperatively, based on the radiolucent
nature of the lesion on a radiograph (Bufalinis sign).
Treatment
Wide excision with sparing of the associated vital struc-
tures is the treatment of choice. Use skin grafts or flap
coverage as needed.
Pathology
The histologic appearance resembles fibrosarcoma; the
recurrence rate may be 50% or more.
Nodular Fasciitis
This condition is also known as pseudosarcomatous fasci-
itis, subcutaneous pseudosarcomatous fibromatosis, and
infiltrative fasciitis.
The lesion begins as a small nodule in the forearm or
hand.
The lesion is characterized by a small but rapidly growing
nodule that was only recently noted.
Figure 3-19 shows the intraoperative and histologic ap-
pearance of this lesion.
Treatment
The natural history of this lesion appears to be self-
limited, and even partially excised lesions do not reoccur.
The key to treatment of this lesion is to differentiate it
from a soft tissue sarcoma, and to avoid inappropriate
and aggressive treatment.
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A B
D C
E
Figure 3-15 (A) This patient presented with a slightly tender mass
(arrow) on the palmar side of her left forearm. (B) It was found to be
a large tumor involving the substance of the median nerve. (C) The
lesion was shelled-out under loupe magnification. (D) No residual
nerve deficits were noted following excision of this schwannoma.
(E) Microscopic view of the schwannoma. Note the dense and irregular
cellular pattern. (Hematoxylin and eosin, original magnification 160.)
Pathology
Its histologic appearance may resemble that of a fibrosar-
coma and myxoid liposarcoma.
Pyogenic Granuloma
These lesions most often involve the contact surface of
the digits.
These lesions present as dark red, raised, and small spher-
ical masses that are often associated with a history of
injury to the site of presentation.
They may appear to be sessile, but are usually peduncu-
lated and bleed easily.
Figure 3-20 shows two examples of pyogenic granuloma.
Treatment
In most cases, the condition is cured by severing the stalk
or pedicle flush with the skin, followed by applying silver
nitrate to the base of the pedicle on the digit.
Some have suggested that a small ellipse of skin be ex-
cised with the lesion, but this may not be necessary.
Pathology
This condition represents run-away angiogenesis, and
has no malignant potential. The histologic sections reveal
a collection of blood vessels.
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A B
C D
Figure 3-16 (A) This woman, age 24, presented with a small subcutaneous mass in the hypothenar
eminence of the left hand (arrow), which was associated with a caf e-au-lait spot on the dorsum of the
opposite hand (arrow). (BC) The lesion was a neurofibroma that arose from a small sensory fiber, and
complete removal was possible without significant deficit. (D) Histologic appearance of the
neurofibroma, demonstrating a moderately cellular matrix. (Hematoxylin and eosin, original
magnification 400.)
Glomus Tumor
This is a relatively uncommon lesion that occurs in the
distal phalanx and often under the fingernail.
It represents a neoplastic proliferation of the smooth
muscle cells of the normally occurring glomus, which
is a temperature regulating shunt.
The patient with this tumor presents a classic history of
pain that is often severe, cold sensitivity, and tenderness
over the distal phalanx.
Physical findings may include discoloration (reddish-
blue) beneath the fingernail, if the lesion is subungual;
ridging or deformity of the nail plate; and point tender-
ness.
Radiographs may reveal a bony defect in the osseous pha-
lanx because of pressure from the glomus tumor.
Although often subungual, any painful and tender sub-
cutaneous area in the digit with the above noted history
should be considered to be a glomus tumor.
Figure 3-21 demonstrates a patient with a longstanding
glomus that was being treated as an infection (note the
changes in the finger nail), and the intraoperative appear-
ance of the lesion. Figure 3-21Cshows the intraoperative
appearance of another glomus tumor, which is smaller.
Treatment
Excision of the lesion is the treatment of choice. It is
performed through a window in the nail, or by elevating
the nail proximally to expose the lesion.
Many of the lesions are in the soft tissues proximal to the
nail plate, and may be removed through an incision in
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Figure 3-17 A clinical example of digital fibroma of infancy. This
lesion enlarged rapidly in this infant of 1 year of age. Note the
enlarged little finger and the alarming appearance of the lesion.
this region without disturbing the nail plate (see Figure
3-21C).
Pathology
Histologic findings include endothelial pericyte and non-
myelinated nerve fibers.
Hemangioma
The majority of these tumors are seen within the first 4
weeks of life.
Females are affected three times as frequently as males.
Rapid growth may be noted in the first year of life, fol-
lowed by slower growth thereafter.
The final stage is represented by involution; by age 7,
70% of the lesions have involuted.
Noninvoluting lesions are capillary or cavernous.
The capillary hemangiomas are represented by the
port-wine stain.
The cavernous hemangiomas are represented by arte-
riovenous connections that may be either low or high
flow in nature.
The capillary hemangioma is represented by a minimally
raised port-wine stain lesion of variable size.
It presents as a bluish, raised subcutaneous mass that is
nontender, soft, and often multiloculated.
An MRI offers the diagnostic advantage of being nonin-
vasive, and may delineate the proximity of neural struc-
tures. It is especially useful in visualizing skeletal muscle
hemangiomas.
Radiographs of cavernous hemangiomas may show phle-
boliths (calcific deposits in a vein wall or thrombus).
The preoperative and intraoperative appearance of a cav-
ernous hemangioma is seen in Figure 3-22.
Treatment
Management of hemangiomas is usually conservative,
since most will involute by 7 years of age.
Surgical management may be indicated in noninvoluting
lesions if the diagnosis is in question, or if ulceration,
bleeding, or recurrent infection is a problem.
Surgery involves ligation of feeder vessels and complete
excision of the lesion.
Cryosurgery and YAG laser treatment has been used.
Keratoacanthoma
This is a fast-growing skin tumor that mimics the appear-
ance of squamous cell carcinoma.
It most often occurs on the hair-bearing dorsal skin of
the forearm, wrist, and hand.
In 1 to 2 months, it may grow from a small papule to a
raised lesion that is 2 to 3 cm in diameter.
A B
Figure 3-18 Another example of digital fibroma of infancy (proximal phalanx of the middle finger) in
another slightly-older child (A) who was treated with an excision and skin graft (B).
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A B
Figure 3-19 (A) Intraoperative appearance of this example of nodular fasciitis in the forearm.
(B) Histologic appearance of this benign lesion. Note the cellular nodule in the lower right.
(Hematoxylin and eosin, original magnification 160.)
The history of rapid growth, and its size and alarming
appearance, may make it difficult to distinguish it from
squamous cell carcinoma.
However, the central keratin plug in this lesion is in con-
trast to the small area of central necrosis seen in squa-
mous cell carcinoma.
Their rapid growth is in marked contrast to the slower
growth of squamous cell carcinoma.
Figure 3-23Ademonstrates the clinical appearance of the
lesion.
Treatment
Although the natural history of this lesion is spontaneous
regression after a latent phase of variable duration, the
lesion should be excised for an accurate diagnosis.
The resultant defect may be closed by skin grafts as
needed, and the resultant scar will, more often than not,
be less noticeable than the original lesion.
Figure 3-23Bdemonstrates the postoperative appearance
of this lesion following excision and split-thickness skin
grafting.
Pathology
The entire tumor must be evaluated. A pathologist ex-
perienced in skin tumors is useful in distinguishing this
lesion from squamous cell carcinoma.
Figure 3-23C shows the histologic appearance of the le-
sion at 35 magnification.
SOFT TISSUE TUMOR-LIKE CONDITIONS
Aneurysms (True and False)
Although not a neoplasm, an aneurysm may be appro-
priately included in a discussion of tumors of the hand
A B
Figure 3-20 Two examples of pyogenic granuloma, both of which were excised without recurrence.
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A B
C
Figure 3-21 (A) A soft tissue mass
(arrow) proximal to the fingernail,
with deformity of the fingernail.
(B) Surgery revealed a classic glomus
tumor. (C) Another example (arrow)
of a glomus tumor.
A B
Figure 3-22 (A) This patient presented
with a long-standing history of a soft and
pain-free mass over the index finger.
(B) At surgery, the grape-like clusters of
a cavernous hemangioma were noted
and excised.
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A B
C
Figure 3-23 (A) This elderly man presented with
this ominous-looking lesion that he said began as a
small bump only 6 weeks before. (B) The rapid growth
of this lesion indicated the probability that the
lesion was a keratoacanthoma, and excision followed
by skin graft was performed. (C) Note the histologic
appearance of the keratoacanthoma. (Hematoxylin
and eosin, original magnification 35.)
and wrist since it must be differentiated from a true neo-
plasm.
Aneurysms may be false or true.
False aneurysms result from a penetration of the
blood vessel wall, with subsequent hemorrhage and
hematoma formation that organizes to form a lumen
in continuity with the injured vessel. This often global-
shaped lesion does not have a true vascular endothelial
lining.
A true aneurysm results from an injury to the vessel
wall that permits gradual expansion or dilatation of the
vessel wall, and has a true vascular epithelial lining.
True aneurysms occur most frequently in areas subjected
to repetitive trauma, such as the ulnar artery and the
superficial arch in the palm. Mechanics, bakers, or others
that use their hypothenar eminence as a tool for forceful
pounding or pushing may experience such injuries.
False aneurysms are most often seen after penetrating
injuries, and are most common at the palmar side of the
wrist. They may occur in the radial artery in the anatomi-
cal snuffbox, the palmar arch, and the digits. Aneurysms
of the ulnar and digital vessels are evenly distributed be-
tween the false and true types.
Large aneurysms may present as visible and palpable
masses at the wrist, or in the palm of the hand.
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A
C
B
Figure 3-24 (A) This baker noted a slowly growing mass on the ulnar aspect of his right hand for
several months. It was believed that repetitive impact over the hypothenar eminence may have been
associated with the lesion. (B) Occlusion of the radial and ulnar arteries at the wrist diminished the size
of the mass. (C) At surgery, an aneurysm of the ulnar artery was identified and excised, and the resultant
arterial defect was bridged by a vein graft.
True aneurysms are usually fusiform-shaped, whereas
false aneurysms are global- or spherical-shaped.
Neurologic deficits may occur due to pressure on adja-
cent nerves.
Large aneurysms may have a bruit that is audible with a
stethoscope.
Doppler ultrasonography and arteriography are useful di-
agnostic aids.
Arteriography aids in preoperative planning and defines
the nature of collateral blood flow and thus may aid in
the method of treatment.
Figure 3-24 demonstrates a true aneurysm of the ulnar
artery in a 34-year-old baker.
Gouty Tophus
Gouty tophi, although not true neoplasms, may occur
throughout the hand and wrist, and may be associated
with joint and tendon dysfunction.
Gouty deposits may be small or large, and may oftenerode
through the skin over the extensor surfaces of the hand.
They are chalky white collections of a toothpaste-like ma-
terial that is unmistakable in appearance.
Figure 3-25 shows the clinical, x-ray, and intraoperative
appearance of gout in the left hand.
Treatment
Treatment is directed at the medical control of the gout.
Surgical intervention is directed at removal of large de-
posits that may compromise joint and/or tendon func-
tion.
MALIGNANT SOFT TISSUE TUMORS
Skin Tumors
Basal Cell Carcinoma
These lesions are located on the dorsum of the hand and
wrist in the areas of sun exposure.
They ultimately present as raised erosions, with an occa-
sional pearly border.
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A B
C
Figure 3-25 (A) This patient with a
longstanding history of gout presented
with gouty tophi and skin erosion over the
middle finger distal interphalangeal joint.
(B) Radiographs revealed bone erosions at
the metacarpophalangeal joint. (C)
Clinical appearance of the tophi at the
time of excision.
They are slowgrowing but may invade deeper tissues over
time.
There are many variations in the appearance of this
tumor, and they may present as areas of skin atro-
phy, pink discoloration, or telangiectatic changes. They
also may have a scar-like quality to their advancing
edges.
Treatment
Surgery is by excision of the lesion with a sufficient mar-
gin, followed by immediate histologic confirmation of the
adequacy of excision.
Closure may be by direct means in small lesions, or by
skin grafts or flaps in larger cases.
Squamous Cell Carcinoma
These lesions are the most common malignant tumor in
the hand.
They have the capacity to expand locally and to metasta-
size via the lymphatic or blood vessels.
They may vary fromwart-like, slow-growing lesions under
or near the fingernail, to large, ulcerated, or exophytic
growths most commonly over the dorsum of the finger
and hand.
They may also present as a red, scaly, and sometimes
ulcerated area. Figure 3-26 demonstrates the clinical and
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A B
Figure 3-26 (A) This patient was being treated for a chronic infection about his left index finger.
(B) X-rays demonstrated an erosion of the osseous phalanx, and surgery confirmed the presence of
squamous cell carcinoma of the nail bed.
x-ray appearance of this lesion that was treated initially
as an infection.
Treatment
Treatment will vary depending on the location, size,
and extent of the lesion, and presence or absence of
metastatic lesions.
In those lesions confined to the terminal phalanx, ampu-
tation at, or proximal to, the DIP joint may be an effective
treatment.
Malignant Melanoma
The incidence of these dangerous and insidious tumors
continues to increase, and a significant percentage of
these lesions involve the upper extremity.
They represent 5% of skin cancers, but are responsible
for 75% of deaths from skin cancer.
Sun exposure is considered to be the major cause for this
increase.
Four major types have been described.
Melanomas are cancers of the melanocytes.
Half arise from atypical moles; the other half arise de
novo.
Classication
Superficial Spreading Melanoma
This is the most common type in Caucasians, and repre-
sents 70% of all melanomas.
It is most likely to arise from, or adjacent to, a pre-existing
nevus.
It begins as a pigmented plaque, and has a radial growth
phase of months to years before vertical growth begins.
Metastatic spread is associated with the vertical growth
phase.
Nodular Melanoma
This type represents 15% of all melanomas, and has little
or no radial growth phase. It may metastasize early.
It grows rapidly, and usually arises de novo.
It is usually dark blue-black in color, but may be gray or
pink. If it is, it is called an amelanotic melanoma.
Acral Lentiginous Melanoma
This type represents 2% to 8% of all melanomas, and is
found on palmar surfaces and the fingernail.
It does not appear to be associated with sun exposure,
and is seen in all ethnic groups.
In those groups where melanoma is uncommon (African
American and Hispanics), it is the most common variant
found.
Aslow-growing radial growth phase occurs before vertical
growth. Because of its location, it is an area not routinely
examinedso the diagnosis may be delayed.
The subungual melanoma is in this category, and usually
affects the matrix of the thumbnail or great toenail.
Acral lentiginous melanomas must be differentiated from
subungual hematomas. A subungual hematoma is usu-
ally associated with a history of injury, and may progress
distally as nail growth occurs.
Lentigo Maligna Melanoma
This type represents 4% to 10% of all melanomas, and is
a type of de novo growth that is associated with long-term
sun exposure.
It is sometimes associated with actinic keratoses, and is
most common on the dorsal surface of the forearm.
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TABLE 3-3 BRESLOW SYSTEM FOR STAGING
MALIGNANT MELANOMA
Depth of Lesion (mm) 5-Year Survival Rate (%)
<0.76 89
0.761.49 75
1.52.49 58
2.53.99 46
>3.99 25
It begins as a tan, flat lesion that may have a radial growth
phase of 1 to 2 decades.
Surgical Staging
The Breslow system(Table 3-3) is based on the depth of the
lesion in millimeters, and 5-year survival rates are based on
this system.
Treatment
The depth of invasion of the malignant melanoma deter-
mines the recommended treatment.
Melanoma in situ that has not gone beyond the basement
membrane is excised with a 0.5 to 1.0 cm margin.
Tumors less than 1.0 mm deep should be excised with
a 1 cm margin. In the subungual location, this means
amputation at, or just proximal to, the DIP joint.
Melanomas 1 to 4 mm in depth should be excised with
a 2 cm margin, and the proximal lymph nodes should be
evaluated with scintigraphy and biopsy as indicated. If a
lymph node is positive, consideration may be given to a
chemotherapy protocol. That is beyond the scope of this
chapter.
Melanomas greater than 4 mm in depth have a very high
incidence of lymph node involvement.
Excision with a 3 cm margin is advised, and clinically
involved nodes should be resected.
Chemotherapy may be considered based upon the pa-
tients general medical condition.
Soft Tissue Sarcomas
Soft tissue sarcomas are relatively uncommon in the
hand.
Clinical Features
Most soft tissue sarcomas present as a painless mass that
has been present for a long time but has recently grown.
An epithelioid sarcoma is a notable exception, and may
present as an ulcerated nodule that has been treated as
an infection.
Diagnosis
In general, soft tissue sarcomas may be misdiagnosed as
infection, ganglion, or lipoma.
In addition to assessment of size, location, depth, and
mobility, the lymph nodes should be evaluated.
Plain radiographs may demonstrate regional calcification
and bone involvement.
An MRI is useful for determining abnormal anatomy and
the extent of disease. It also may lead to a suitable pre-
operative diagnosis and aid in pre-operative planning.
Although very small lesions may be excised with a sur-
rounding cuff of tissue, larger lesions may be evaluated
with an incisional biopsy.
The biopsy incision must be planned to meet the needs
of more extensive treatment later on, and transverse,
oblique, or similar incisions should be avoided.
It should be considered that biopsies will contaminate all
adjacent tissue planes.
Staging
After the diagnosis of a sarcoma has beenestablished, sys-
temic staging should be performed with CT of the chest
and axilla, as upper extremity sarcomas commonly spear
to the lungs and regional lymph nodes.
Staging is based on grade, size, and the presence or ab-
sence of metastatic lesions, as well as the histologic grade.
A useful guide is the system developed by Enneking
and adopted by the Musculoskeletal Tumor Society (see
Table 3-1).
Treatment
The management of soft tissue sarcomas is under constant
study, and changes to current recommendations and new
modalities may emerge as new or modified treatment pro-
tocols are developed and evaluated. Surgery is the primary
formof local treatment for soft tissue sarcoma. It is planned
as two distinct parts, and consists of resection and recon-
struction.
Excision is the initial form of treatment. Primary consid-
eration is for an appropriate resection, while secondary
consideration is for reconstruction.
The goal of surgery is to achieve complete resection of
the tumor, with a surrounding cuff (2 to 3 cm) of normal
tissue.
If these margins cannot be achieved, then amputation
should be considered.
Following wide excision of a large, high-grade lesion,
external radiation or radiation implants (brachytherapy)
therapy may be performed.
The role of chemotherapy in the preoperative or post-
operative period is still under investigation.
Patients withmetastases may be treated by chemotherapy
and/or resection of lung lesions.
Epithelioid Sarcoma
This tumor is said to be the most common soft tissue
sarcoma of the hand.
This tumor presents as a slow-growing, benign-looking,
firm nodule that may occur in the digits, palm, or volar
forearm in a young adult.
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The nodule may ulcerate. It tends to spread proximally
along the course of tendons, lymphatics, and fascial
planes, and does not respect fascial boundaries.
It is often misdiagnosed, and has a propensity for recur-
rence and regional lymph node involvement.
Treatment
This lesion must be treated aggressively, with a wide ex-
cision, radical resection, or amputation.
Lymph node biopsy is indicated even without clinical ev-
idence of involvement.
Marginal excision is not advised.
Radiation may be considered after wide excision of
large lesions; chemotherapy may be considered in those
patients with lymph node involvement, recurrence, or
metastatic lesions.
Pathology
Histologic features include formation of discrete nodules
of epithelial cells with areas of central necrosis.
Synovial Sarcoma
Synovial cell sarcoma is one of the more common sarco-
mas in the hand and wrist.
They typically occur over the wrist, are seldom seen in
the finger, and occur in the 15 to 40 age group.
They typically arise around joints, tendons, and bursae.
These tumors often present as slow growing, painless,
and firm masses that may have been present for several
years.
Soft tissue calcification may be seen on plain radio-
graphs.
Treatment
Surgery is the initial form of treatment. Primary consid-
eration is for an appropriate resection. Reconstruction is
a secondary consideration.
The goal of surgery is to achieve complete resection of
the tumor, with a surrounding cuff (2 to 3 cm) of normal
tissue.
If these margins cannot be achieved, amputation should
be considered.
Pathology
Small size may not be associated with a more favorable
prognosis.
Histologic sections reveal two cell types: epithelial cells
and spindle cells.
BENIGN BONE TUMORS
Enchondroma
These bone lesions are the most common primary bone
tumors of the hand, and 35% of all enchondromas arise
in the hand.
The proximal phalanx is the most common site of occur-
rence, followed by the metacarpal and middle phalanx.
Most lesions occur in patients 10 to 40 years of age.
The usual presentation is with a painless swelling over a
phalanx or metacarpal.
Pain and deformity may be the presenting complaint due
to a pathologic fracture through the enchondroma.
Pathological fractures in the hand are most often associ-
ated with enchondroma.
X-rays reveal a well-defined lytic lesion, with calcification
of the matrix in some cases.
The vast majority of cases may be diagnosed without CTs
or MRIs.
X-ray appearance, intraoperative findings, and histologic
appearance are depicted in Figure 3-27.
Treatment
Small lesions that are incidental findings on a radiograph
may be treated by observation.
Larger lesions, or those associated with fractures, may be
treated by curettage and bone grafting.
In patients with a pathologic fracture, it is best to reduce
the fracture as needed and allow the fracture to heal be-
fore curettage and bone grafting.
The osseous phalanx is often thin at the site of the le-
sion, and attempts at open reduction, fixation, and bone
grafting may be difficult because of the lack of sufficient
bone for anatomic reduction and fixation.
Shortening or deformity may be the end result.
After healing of the fracture, however, good bone stock is
present, and definitive curettage and bone grafting may
be achieved.
Pathology
Histologic sections reveal a characteristic cartilage matrix
with scattered lacunae that contain cartilage cells.
Multiple Enchondromatosis (Olliers Disease)
and Maffuccis Syndrome
Multiple enchondromatosis is an uncommon and non-
hereditary disorder manifested by multiple enchondro-
mas in the metaphysis and diaphysis of the long bones
and of the short, tubular bones of the hands and feet.
These benign lesions may become malignant chon-
drosarcoma or osteosarcoma in 30% of the patients,
so careful monitoring is indicated.
Maffuccis syndrome is a rare condition, and its x-ray
findings are similar to Olliers disease. However, patients
may also have multiple hemangiomas.
These patients may also develop sarcomas of the bone
and of the soft tissue.
Aneurysmal Bone Cyst
This lesion accounts for about 5% of all benign bone
tumors, but only 3% to 5% of these lesions occur in the
hand.
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B C
A
Figure 3-27 (A) This patients hand radiograph revealed an incidental finding of a lytic lesion of the
proximal phalanx of the index finger. (B) Biopsy, followed by curettage, revealed an enchondroma.
(C) The histologic appearance of an enchondroma. (Cartilage stain, original magnification 160.)
Hand lesions are most common in the second decade,
and metacarpal involvement is more common than in-
volvement of the phalanx.
These lesions often present as a rapidly enlarging,
alarming-appearing mass.
Radiographs demonstrate an expanding lesion on the
bone metaphysis/diaphysis, with thinning of the cortex.
An MRI may suggest a fluid-filled lesion.
Soft tissue extension is uncommon, and metastasis has
not been reported.
This lesion is demonstrated in Figure 3-28.
A biopsy and limited curettage was performed shortly af-
ter this depiction, and the lesion gradually diminished in
size over the next several months.
Treatment
An incisional biopsy is performed followed by curettage,
cryosurgery, and bone grafting, if sufficient bone stock is
available.
If bone stock is not available, wide excision and recon-
struction may be indicated. Cryosurgery may be associ-
ated with damage to the physis and subsequent growth
arrest.
Giant Cell Tumor of Bone
This lesion accounts for about 5% of all benign bone
tumors, but only 2% of these lesions occur in the hand.
This tumor occurs most commonly in the 4th decade
and may involve the distal radius, the metacarpals and
phalanges, and, rarely, the carpal bones.
The usual clinical presentation is with pain and swelling
in the affected region.
Radiographs demonstrate a lytic lesion with no matrix
and indistinct borders.
Cortical expansion, destruction, and soft tissue extension
are common.
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A B
Figure 3-28 (A) This otherwise healthy teenager presented with a rapidly enlarging mass in
her left thumb. (B) X-ray examination revealed an expanding osteolytic lesion of the thumb
metacarpal. Biopsy revealed an aneurysmal bone cyst, and curettage resulted in involution of the
lesion.
Treatment
Giant cell tumors of bone, although considered to be
benign bone lesions based on their histology, behave ag-
gressively, may metastasize, and may ultimately result in
death.
Lesions in the hand have a higher risk of local re-
currence. These lesions should be approached as ma-
lignant lesions, and should be staged following an
incisional biopsy with chest radiographs and a bone
scan.
Lesions in the metacarpals or phalanges that have pene-
trated the cortex may be treated with wide excision and
reconstruction, or amputation.
Distal radius lesions confined within the cortex may be
treated with curettage, burring, cryosurgery, and cemen-
tation if sufficient bone stock is available.
Those lesions that have pathologic fracture or cortical
perforation are treated by wide excision of the distal
radius, and reconstruction. Figure 3-29 depicts such a
lesion that was treated by wide soft-tissue and bone
A B C
Figure 3-29 (A) This giant cell tumor of bone had been initially treated by curettage, followed by
recurrence as noted here. (B) Wide excision of soft tissue and bone was performed. (C) The resultant
defect was treated with a large iliac crest bone graft and wrist fusion.
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resection, followed by an immediate bone graft from the
iliac crest, and wrist fusion.
Osteoid Osteoma
About 5% to 15% of these benign bone lesions appear in
the hand and wrist.
This lesion is most often seen in the carpal bones or prox-
imal phalanx. It mostly presents in the 2nd or 3rd decade.
Patients with this lesion often present with a history of a
dull ache in the affected region, which is often relieved
by nonsteroidal anti-inflammatory medication.
Swelling and tenderness is usually present. Radiographs
may demonstrate reactive and sclerotic bone, with or
without a small nidus surrounded by a radiolucent area.
A CT scan may further delineate the lesion.
Lesions in the distal phalanx may result in swelling in the
pulp and nail deformity.
The clinical and preoperative x-ray appearance, as well
as the intraoperative radiograph, are depicted in Figure
3-30A-C.
Treatment
Surgery in the form of excision of the nidus often results
in a cure.
Some have argued that treatment may be nonsurgical,
since nonsteroidal anti-inflammatory medication may re-
lieve the pain. Also, the natural history of this reactive
and benign bone lesion is one of gradual involution over
a several-year period.
Pathology
The histologic appearance of the dense bone is illustrated
in Figure 3-30D.
Carpal Boss
Although not a true neoplasm, this bony prominence is
often misdiagnosed as a ganglion cyst or other tumor over
the dorsal aspect of the wrist.
It is an osteophytic lesion that develops at the base of the
index and middle finger metacarpals and the adjacent
carpal capitate.
Carpal boss is most common in women, and usually
presents in the 3rd and 4th decades.
The lesion is bony, hard, nonmobile, and sometimes-
tender mass that is most noticeable when the wrist is
flexed.
Radiographs profiling the mass (30 to 40 degrees of
supination and 20 to 30 degrees of ulnar deviation) re-
veal a prominent, raised triangular bony mass that arises
from the opposing dorsal aspect of the metacarpal and
capitate.
An irregular and narrow pseudo-articulation is noted be-
tween the two opposing halves of the mass. The abutment
of the two opposing surfaces may be likened to an os-
teoarthritic joint, and may explain some of the symptoms
of tenderness and discomfort.
A small, thin-walled, bursa-like sac may develop over the
boss, and may be confused with a ganglion cyst.
This lesion is depicted in Figure 3-8.
Treatment
In patients with significant symptoms, the two sides of
the boss are removed down to normal articular cartilage.
Care is taken to avoid detachment of the extensor carpi
radialis brevis (ECRB) tendon insertion on the base of
the middle finger metacarpal.
MALIGNANT BONE TUMORS
Osteogenic Sarcoma
This is the most common malignant bone tumor in chil-
dren and adolescents, but is rarely seen in the hand.
When it does appear in the hand, it is usually in patients
in the 4th to 6th decades.
It is most often found in the proximal phalanges and
metacarpals, and rarely in the carpus.
The usual presentation is that of a rapidly enlarging mass
that is firm and painful.
Radiographs may reveal an expanding sclerotic tumor
with new bone formation or a lytic lesion and an associ-
ated soft tissue mass.
Treatment
Incisional biopsy should be performed with the antici-
pated need for limb salvage and amputation.
In the finger, wide excision or ray amputation may be
entertained along with neoadjuvant chemotherapy.
Chondrosarcoma
This lesion is the most common primary malignant bone
tumor that occurs in the hand.
The lesion occurs mainly in the proximal phalanges and
metacarpals in patients over the age of 60 years.
The lesion often presents as a firm, slow-growing, and
sometimes painful mass.
Radiographs show a lesion with poorly defined borders
and with areas of lysis and stippled calcification.
Cortical breakthrough and extension into the soft tissues
helps to distinguish it from enchondroma.
Chondrosarcomas are slow growing.
Metastasis of about 10% may be seen after local recur-
rence following intralesional treatment.
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A B
C
D
Figure 3-30 (A) This patient noted pain and progressive swelling in the proximal phalanx of the right
ring finger, which was relieved by aspirin. (B) X-rays revealed an osteoblastic lesion that appeared to
have a segment (nidus) that was denser in its distal aspect. (C) This dense area was removed using a
high-speed burr, and the symptoms resolved. (D) Review of the specimen by the pathologist confirmed
the preoperative diagnosis of osteoid osteoma. (Hematoxylin and eosin, original magnification 160.)
Treatment
Incisional biopsy is performed and reviewed by a pathol-
ogist very familiar with cartilage lesions.
Preoperative treatment includes a chest CT, because
these lesions most often metastasize to the lungs.
Treatment is by wide excision, including digit or ray am-
putation.
Metastatic Tumors
Metastatic lesions in the hand (acrometastases) are un-
common and the incidence is less than 0.3%.
When it does occur, the phalanges and metacarpals are
equally involved, and involvement of the carpal bones is
said to be rare.
P1: JDW
A B
Figure 3-31 Metastatic carcinoma of the wrist. (A) This man, age 62, with bronchogenic carcinoma of
the lung complained of pain and swelling in the right wrist. (B) Radiographs demonstrated an osteolytic
metastatic lesion (arrows) in the radial aspect of the wrist.
Bronchogenic carcinoma of the lung is said to be the
primary malignancy in about 50% of the cases.
Other primary sources are renal, esophageal, breast,
colon, prostate, thyroid gland, and bone cancer.
Clinical findings sometimes mimic an infection with
pain, swelling, and erythema being present.
Radiographs usually reveal a lytic lesion, although
metastatic prostate cancer can appear as a sclerotic le-
sion.
If the metastatic lesion appears without a history of prior
tumor, then a suitable workup is performed to identify
the primary site.
Biopsy and cultures of the lesion will usually confirm the
diagnosis.
Figure 3-31 shows clinical and x-ray views of a 62-year-
old man with bronchogenic carcinoma of the lung that
has metastasized to the wrist.
Treatment
Treatment is usually palliative and is based on the needs
of the patient.
SUGGESTED READING
Aletikiar K, Leung D, Zelefsky M, et al. Adjuvant brachytherapy for
primary high-grade soft-tissue sarcoma of the upper extremity. Ann
Surg Oncol 2002;9:4156.
Al-Qattan MM. Giant cell tumors of tendon sheath: classification and
recurrence rate. J Hand Surg 2001; 26B:7275.
Athanasian, E. Tumors. In: Trumble, TE, ed. Hand surgery update 3,
hand, elbow, shoulder. Rosemont, IL: American Society for Surgery
of the Hand, 2003:555588.
Carroll RE, Bowers WH. Keratoacanthoma: an unusual hand tumor.
Clin Orthop 176;118:173179.
Cheng CY HN, Su KY, Hsu RWW. Treatment of giant cell tumor of
the distal radius. Clin Orthop 2001;383:221228.
Enneking WF, Spanier SS, Goodman MA. A system for the surgical
staging of musculoskeletal sarcoma. Clin Orthop 1980;153:106
120.
Gustafson P, Arner M. Soft-tissue sarcoma of the upper extremity:
descriptive data and outcome in a population-based series of 108
adult patients. J Hand Surg 1999;24A:668674.
Kang HJ, Shin SJ, Kang ES. Schwannomas of the upper extremity. J
Hand Surg 2000;25B:604607.
Marcuzzi A, Acciaro A, Landi A. Osteoid osteoma of the hand and
wrist. J Hand Surg 2002;27B:440.
Stephen AB, Lyons AR, Davis TR. A prospective study of two conserva-
tive treatments for ganglia of the wrist. J Hand Surg 1999;24B:104
105.
Warso M, Gray T, et al. Melanoma of the hand. J Hand Surg
1997;24A:354360.
4
DUPUYTRENS
DISEASE
Dupuytrens disease (DD) is a well-known but poorly under-
stood clinical entity involving the palmar and digital fascia
of the hand. From the patients perspective, this disease be-
gins as small nodules or lumps in the palmor fingers, which
may eventually develop into longitudinally oriented cords or
bands that contract. When this happens, a condition known
as Dupuytrens contracture results (Figure 4-1).
HISTORICAL FEATURES
Henry Cline in 1777 was the first to recognize that
the disease involved the palmar fascia. He recommended
fasciotomyas did his student, Astley Cooper of London.
However, it was in 1831, at the Hotel Dieu in Paris, that
Dupuytren presented a lecture, later transcribed by one of
his students, that described the disease within the palmar
fascia. Dupuytren recommended open fasciotomy through
a transverse incision, and also recommended it be left open
to heal.
EPIDEMIOLOGY AND ETIOLOGY
The condition is most often seen in patients with Northern
European and Scandinavian ancestry, and is more common
in males than females. It has a genetic etiology and has
been associated with seizure disorders, alcohol and tobacco
use, and HIV. Hormones such as peptides (cytokines) may
play a role in the development of DD and may promote
transformation of fibroblasts into myofibroblasts.
PATHOPHYSIOLOGY
DD begins in the perivascular fibroblasts within the fibrous
bundles of the fascia. During the active stage of the disease
when progressive joint contracture occurs, myofibroblasts
are the predominant cells. These cells demonstrate cell-
to-cell and cell-to-stroma attachments. The myofibroblasts
contain contractile elements called alpha smooth muscle
actin. Figure 4-2 depicts the cellular model of contracture
in DD.
Histologically, DD resembles scar tissue, and the colla-
gen found in DDis type III. Thats the same type of collagen
identified in scar tissue. Normal palmar fascia is mainly type
I collagen with only small amounts of type III collagen. Type
IV and VI collagen with fibronectin are seen in early stages
of DD, when myofibroblasts proliferate.
NORMAL ANATOMY
Palmar Aponeurosis (PA)
The PA is the specialized structure in the central portion of
the palm with longitudinal, transverse, and vertical fibers.
It is distinguished from the covering of the thenar and
hypothenar eminences by its triangular shape and greater
thickness. The longitudinal fibers of the palmar fascia rep-
resent the distal continuation of the palmaris longus (when
present). These fibers, which begin as a conjoined apex at
the base of the palm, form bundles in the middle and distal
palmthat run to the corresponding four fingers and, in some
instances, to the thumb. The longitudinal fibers are essen-
tially parallel to the deeper flexor tendons; because of this ar-
rangement, they are sometimes called pretendinous bands.
The four bundles of longitudinally oriented fibers overlay
transverse fibers in the palm, which are located at the junc-
tion of the middle and distal thirds of the palm and over the
metacarpophalangeal (MCP) joints. The transverse fibers of
the PA course beneath the longitudinal cords, from the ul-
nar side of the small finger to the radial side of the index fin-
ger. In the thumb-index finger web space, the proximal com-
missural ligament (PCL) is the radial continuation of these
transverse fibers. The more distal counterpart of the PCL
is the distal commissural ligament (DCL), which is more
longitudinally oriented and which spans the space between
the MCP joint of the thumb and index finger. Both the PCL
and DCL course toward the thumbs MCP joint, where they
send attachments to the undersurface of the skin. The deep
portion of the DCL sends fibers to attach on both sides of
the flexor pollicis longus (FPL) sheath. The more longitudi-
nal orientation of the DCL may be a factor in its more likely
involvement in DD, although both the DCL and PCL may
be involved in Dupuytrens contracture. The PCL and DCL
64
A
B
Figure 4-1 Clinical appearance of Dupuytrens
disease. (A) An elderly male with a several year
history of progressive drawing down of his left
little finger. Note the prominent cord that begins in
the palm and extends into the finger and that limits
passive and active extension of the finger. (B)
Another patient with recurrent Dupuytrens disease
showing contracture of the web space between the
left ring and little finger (arrow), and dimpling of
the skin (arrow) in the palm on the right hand.
A B C D
Figure 4-2 Diagrammatic depiction of the pathogenesis of Dupuytrens disease. (A) The perivascular
fibroblast in an early nodule, surrounded by fibrillary material penetrating into the palmar fascia. (B)
The myofibroblast that appears when clinical contracture is apparent. (C) The myofibroblasts have
cell-to-cell and cell-to-stroma connections. (D) The mature cord consists of longitudinally oriented type
III collagen, with a few residual cells of fibroblasts and myofibroblasts. (Redrawn after Chiu HF,
McFarlane RM. Pathogenesis of Dupuytrens contracture: a correlative clinical-pathological study.
J Hand Surg 1978;3A:110.)
65
Pretendinous
fibers
Proximal
commissural ligament
Palmaris longus
Longitudinal fibers
Transverse fibers
Spiral bands
Natatory
ligament
Distal
commissural
ligament
Figure 4-3 The palmar fascia and its associated
ligaments. See the text for details.
are usually thinner and less noticeable than the transverse
fibers between the fingers. Both the longitudinal and trans-
verse fibers course through the vertical septa to reach the
transverse metacarpal ligament. The third component of the
palmar fascia consists of the nine vertical (sagittal) septa,
called the fibers of Legueu and Juvara, which are located
deep to the transverse fibers. They form the sides of eight
canals, four of which contain the underlying finger flexor
tendons, and four adjacent ones that contain the lumbrical
muscles and neurovascular bundles. These paratendinous
septa, along with the transverse palmar aponeurosis, form a
fibrous tunnel systemthat has been described as the palmar
aponeurosis pulley. These nine vertical septa are anchored
to the transverse metacarpal ligament, palmar interosseous,
and adductor fascia, and they divide the distal portion of the
central palmar space into eight canals. The normal anatomy
of the palmar fascia is depicted in Figure 4-3.
Function
Compression Loading/Shock Absorbing. Any discus-
sion of the role of the palmar retinacular structures must
note that these structures are only a part of a complex
tissue consortium designed to meet a variety of functional
demands. This complex three-dimensional network may
be considered a fibrous skeleton or framework designed
to assist in the hands mechanical functions. Compression
loading is a common force applied to the hand, and requires
a system of shock absorption. In the hand, one method of
shock absorption is to contain somewhat compliant tissues,
such as fat or muscle, in compartments that can change
shape but not volume. This is amply demonstrated in the
palm, with its various layers of multidirectional fascia
that contain and compartmentalize fat and muscle while
conforming to the shape or contour of the object being
grasped or manipulated.
Skin Anchorage. Skin is retained by fascial elements that
allow the hand to flex while maintaining the skin in posi-
tion. The skin folds at prominent creases that are minimally
anchored; this contrasts to the skin on the adjacent sides
of the crease, which possess multiple strong anchor points.
This allows the relatively unanchored skin to fold, while the
anchored skin is held in place. These fascial anchors may
be vertical, horizontal, or oblique, depending on the specific
need of the skin envelope. A good example is the horizon-
tal attachments of the superficial fibers of the pretendinous
bands, which attach to the dermis of the distal palm. This
arrangement resists horizontal shearing forces in gripping
actions, such as holding a hammer or a golf club. The PA,
which includes the nine vertical septa anchored to the deep
transverse metacarpal ligament, is tensed with power grip
and thus anchors the skin to the skeleton of the hand.
Skeletal Stability. Although not a part of the palmar fas-
cia, the previously mentioned transverse metacarpal liga-
ment that attaches to the palmar plates of the MCP joints
plays a role in maintaining the transverse metacarpal arch,
as do the transverse fibers of the palmar fascia and the nata-
tory ligaments.
Joint Stability. The fascial ligaments in the web space of
the finger and thumb may play a role in limiting abduc-
tion, and thus may indirectly limit the impact of potentially
destabilizing forces that might be applied to the digits.
Chapter 4 / Dupuytrens Disease 67
Pulley Function. The transverse fibers of the palmar fas-
cia, supported by the vertical septa, form what is called the
palmar aponeurosis pulley.
Vascular Protection and Pumping Action, and Nerve
Protection. Vascular structures in the palm are protected
by surrounding substantial fibrous tissue and fat pads.
When the hand is compressed, as in making a fist, the in-
compressible fascia may act as a venous pumping mecha-
nism. This is in contrast to the large dorsal veins on the
dorsum of the hand, which are surrounded by loose areo-
lar tissue. The nerves in the palm are protected by fascial
structures; those near the base of the fingers are protected
by fat pads.
Distal Palmar and Digital Fascia
The longitudinal fibers of the PA divide into three layers in
the distal palm. Layer one, the most superficial, inserts into
the skin of the distal palm and onto the proximal aspect
of the flexor sheath. Layer two splits and passes on each
side of the flexor sheath, where it continues distally as the
spiral band beneath the neurovascular bundle and natatory
ligaments. It then inserts on the lateral digital sheet. Layer
three passes on each side of the flexor sheath to the region
of the MCP joint. The natatory ligaments have transverse
as well as curved fibers that follow for the contour of the
webs. The curved or distal continuations of these fibers join
the lateral digital sheet. The lateral digital sheet is a con-
densation of the superficial digital fascia on each side of
the finger; it receives fibers from the natatory ligament, the
spiral band, and Graysons ligament. The retaining skin lig-
aments of Grayson and Cleland stabilize the skin during
flexion and extension of the finger. Graysons ligaments are
palmar to the neurovascular bundles, and pass from the
skin to the flexor tendon sheath. These ligaments form a
tube from the proximal aspect of the finger to the distal
interphalangeal joint, where the digital nerves and vessels
always can be found during surgical dissection. The distal
palmar and digital fascia is depicted in Figure 4-4.
PATHOLOGIC ANATOMY
In this discussion the word band is used to describe a nor-
mal palmar or digital fascial structure and the word cord to
describe its pathological counterpart. Thus, a diseased band
is a cord.
DD begins in the palm as a nodule that represents the
early manifestation of the disease in the longitudinal
fibers of the PA.
Histologically, nodules are a collection of fibroblasts and
myoblasts in a fibrous tissue matrix.
These nodules may coalesce to form cords that contract
and produce the characteristic contracture deformity.
This may appear clinically as a nontender nodule in the
palm, or a skin dimple of retracted skin.
The nodules form in and along the longitudinal axis of
the rays. The ring and little finger are most commonly
involved.
Graysons ligament
Lateral digital sheet
NV bundle
Natatory ligament
Spiral band
Transverse fibers, PA
Longitudinal fibers, PA
Transverse MC
ligament
Clelands ligament
Figure 4-4 Distal palmar and digital fascia. See the text for details.
As the disease progresses, it spreads to the fingers and
produces the typical contracture of the MCP and often
the proximal interphalangeal (PIP) joints.
Recognition of the distinct anatomic separation of
the longitudinal (involved) and transverse (noninvolved)
fibers of the PA, and the distal separation of the lon-
gitudinal fibers into three layers, allows the surgeon to
selectively excise the diseased tissue instead of all fascial
tissue.
Pretendinous Bands
The pretendinous bands of the PA are the most common
places for Dupuytrens contracture to occur.
A palpable nodule may progress to a prominent pretendi-
nous cord, which may produce a flexion contracture of
the MCP joint.
Although the pretendinous cord is the primary cause of
flexion contracture of the MCP joint, it may join the cen-
tral cord of the finger that extends well beyond the PIP
joint.
The central cord originates fromthe superficial fibrofatty
digital fascia on the flexor side of the finger.
The central cord always is in continuity with the pre-
tendinous cord.
Transverse Fibers
Only the longitudinal fibers (pretendinous bands) of the
PA are involved; the transverse fibers are ideally left be-
hind during excision of the diseased palmar fascia.
The transverse fibers to the thumb web, the PCL, and
the DCL, which are more obliquely oriented and sub-
ject to tension, may contract. The loss of abduction and
extension of the thumb can result.
Natatory Ligament
The natatory ligaments frequently are diseased. Because
they not only span the finger web space but also send
fibers distally into the fingers, they may be responsible for
web space contracture as well as PIP joint contracture.
Finger Fascia
The fibers in the finger that may become diseased are the
fibrofatty fascia on the flexor aspect of the fingers; the dis-
tal continuation of the pretendinous fibers, called the spiral
band; the distal (longitudinal) extension of the natatory lig-
aments; Graysons ligament (as terminal attachment for the
spiral bands); and the lateral digital sheet.
Fibrofatty Fascia
This tissue forms the central cord in the finger, joining
the pretendinous cord of the palm to form a continuous
cord from the palm to the middle phalanx.
It often divides into two tails that attach to the flexor
sheath and osseous middle phalanx.
Spiral Band
The fibers (layer two) are the deep and distal continua-
tion of the pretendinous band on each side of the flexor
sheath.
They pass deep to the neurovascular bundle as they pro-
ceed to the lateral side of the finger, and then migrate
superficial to the neurovascular bundle to attach to the
middle phalanx by means of Graysons ligament.
This configuration progressively displaces the neurovas-
cular bundle with increasing PIP joint contracture, first
toward the midline, then proximally, and then superfi-
cially. This places the neurovascular bundle at consider-
able risk during surgery because the neurovascular bun-
dle spirals around this fascial structure, called the spiral
cord.
The spiral cord is either a continuation of the spiral band
or arises from the musculotendinous junction of an in-
trinsic muscle; it attaches distally to the flexor sheath and
bone in the middle phalanx.
Natatory Ligament
Disease and contracture of the transverse elements of
the natatory ligaments form the natatory cords that pro-
duce contracture of the finger web spaces, with loss of
abduction of the fingers.
The distal digital extension of the natatory ligament joins
the spiral band, and these two bands subsequently join
the lateral digital sheet to form the lateral cord.
Graysons Ligaments
Graysons ligaments, located in the middle and proximal
phalanges, pass from the digital flexor sheath, palmar
to the neurovascular bundle, to the lateral digital sheet.
They are in the same fascial plane as the natatory liga-
ments.
They provide attachment for the spiral cords to the mid-
dle phalanx.
Lateral Digital Sheet
The lateral digital sheet is a condensation of the superfi-
cial fascia on either side of the finger.
It receives fibers from the natatory and spiral ligaments,
as well as from Graysons and Clelands ligaments.
When diseased, it is known as the lateral cord.
Lateral Cord
The lateral cord runs from the natatory ligament to the
lateral digital sheet.
It usually does not cause PIP joint contracture, except
on the ulnar side of the small finger. There it attaches to
an abductor cord overlying the ADM and can cause PIP
joint contracture.
Retrovascular Cord
This cord lies deep to the neurovascular bundle. It arises
from the periosteum of the lateral base of the proximal
phalanx, passes close to the PIP joint, and ends at the
lateral aspect of the distal phalanx.
It is the usual cause of DIP joint contracture, and an
occasional cause of PIP joint contracture.
Isolated Digital Cord
Isolated cords may arise in the fingers as single or double
cords without any attachments in the palm.
These cords arise from the periosteum at the base of the
proximal phalanx in conjunction with adjacent ligaments.
They pass distally to displace and then cross the neuro-
vascular bundle, inserting on the tendon sheath or bone
of the middle phalanx.
These cords may result in a significant loss of extension
of the PIP joint, and cause isolated contractures.
Figure 4-5 demonstrates the pathologic tissues in the dis-
tal palm and finger in DD.
First Web Space
Although only the longitudinal fibers (pretendinous
bands) of the palmar fascia are involved in the hand, the
transverse fibers to the thumb web, PCL, and DCL are
more obliquely oriented and are subject to tension.
If diseased, they may contract and be responsible for loss
of abduction and extension of the thumb (Figure 4-6).
B A
Lateral
cord
Spiral
cord
Natatory
cord
Pretendinous
cord
NV bundle
Central cord
Graysons lig.
Lateral cord
Graysons lig.
Isolated
digital
cord
Retrovascular
cord
Figure 4-5 Pathological anatomy of the distal palmar and digital
anatomy. (A) The more superficial diseased elements. (B) The deeper
diseased elements.
Proximal and distal
commissural cords
Figure 4-6 Fascial involvement in the first web.
Table 4-1 summarizes the relationship between fascial
bands/ligaments, cords, and the clinical result of cord for-
mation. The convention adopted here is that fascial bands
or ligaments are normal structures and that cords are their
pathological counterparts.
TREATMENT
DDcannot be cured by surgery or any other means currently
available. Recurrence is likely, and surgery may be associ-
ated with complications such as vascular compromise to a
digit, skin necrosis, hematoma, infection, nerve injury, fail-
ure to completely relieve the contracture, and irreversible
stiffness with or without reflex sympathetic dystrophy. DD
that presents at an early age carries a greater potential for re-
currence. Contractures in younger patients are often more
severe, and repeated surgery is often required. The long-
term prognosis for a suitable result is diminished when the
disease begins at an early age.
Operative indications must be clearly understood by both
the surgeon and the patient, and are based on the progres-
sion of the disease and the loss of function. Manifestations
of functional loss may include difficulty or embarrassment
while shaking hands, placing the hand in tight places, such
as the pocket, or a variety of functional activities related to
everyday use. Some surgeons use a certain or set degree of
contracture to propose surgery. This may be useful in some
circumstances, but must be tailored to the individual needs
of the patient.
In terms of prognosis, contracture of the PIP joint is the
most difficult to treat and obtain a satisfactory release. How-
ever, the MCP joint seldommanifests a permanent contrac-
ture after release. An experienced DD surgeon has noted
that when the PIP joint contracture was less than 30 de-
grees, the patient was more often made worse with surgery
than made better.
The current and accepted treatment for DD is a surgical
approach employing fasciotomy or partial fasciectomy. The
effect of clostridial collagenase injection into the cords that
are causing contracture is currently under study. The tech-
nique involves injection of the material into the substance
of the cord, followed by passive extension of the affected
joint to stretch or rupture the cord.
It may be argued that fasciotomy is not a definitive pro-
cedure. It may, however, serve the needs of some selected
patients. It can serve as a preliminary procedure to release
a finger from the palm for hygiene purposes prior to a more
comprehensive fasciectomy. Fasciotomy may also be used as
a definitive procedure in those patients who have associated
medical problems that would dictate a less comprehensive
approach. A fasciotomy may be performed under local anes-
thesia and the wound left open followed by early motion.
This approach may serve the needs of some patients better
than a more comprehensive procedure. Although closed or
blind fasciotomy was used in the past, open fasciotomy is
more commonly used today.
Total fasciectomy has been abandoned in favor of limited
or partial fasciectomy. Prophylactic removal of normal or
nondiseased fascia is not indicated, and may increase the
probability of postoperative complications.
TABLE 4-1 DUPUYTRENS DISEASE: FASCIAL BANDS THAT MAY FORM
CONTRACTURE CORDS
Fascial Bands/Ligaments Cords Result
Palm
Pretendinous bands of palmar fascia Pretendinous cord MCP joint contracture
Commissure
Natatory ligaments Natatory cords Digital web contracture
Proximal commissure ligament First commissure cords Thumb web contracture
Distal commissure ligament First commissure cords Thumb web contracture
Finger
Spiral band Spiral cord Displaces neurovascular bundle,
PIP contracture
Fibrofatty fascia Central cord PIP joint contracture
Natatory ligament and lateral digital sheet Lateral cord PIP joint contracture
Periosteum of proximal phalanx Retrovascular cord DIP contracture
Periosteum of proximal phalanx Isolated digital cord PIP contracture
PIP, proximal interphalangeal; MCP, metacarpophalangeal; DIP, distal interphalangeal.
The surgeon must have a comprehensive plan for deal-
ing with DD in each patient. Such plans must include man-
agement of the skin, of the diseased fascia, and of joint
contracture. Various techniques will be used based on the
surgeons experience and the needs of the patient. Open
techniques, skin grafts, Z-plasties, and PIPjoint release may
be required.
Surgical Technique
Fasciotomy
The diseased fascia is incised rather than excised, and the
wounds are left open to heal by secondary intention.
Sterile dressings protect the incisions and healing usually
occurs within 3 weeks.
Immediate closure of the incisions would result in a
recurrence of the flexion posture, especially at the MCP
joints.
Exercises are initiated immediately after surgery.
An open fasciotomy is illustrated in Figure 4-7.
Open (McCash) Technique
This technique was first published in 1964, and has
proved to be a useful method for dealing with apparent
skin loss following palmar, or even digital, fasciotomy or
fasciectomy.
Closure of these incisions often results in a flexed pos-
ture at the MCP and/or the PIP joints because of skin
contracture.
Leaving the incisions open avoids this problem of, or the
necessity for, a skin graft.
The method is used based on the experience of the sur-
geon and the needs of the patient.
Figure 4-8 depicts the preoperative and postoperative
healing sequence using this method.
A
B
Figure 4-7 Open fasciotomy. (A) Preoperative appearance showing significant contractures at the
MCP and PIP joints of the ring and little fingers. (B) Release of the contractures. The incisions were left
open, and kept covered with nonadherent sterile dressings until healed at 3 weeks. This technique is
useful for patients that may not tolerate a more comprehensive procedure.
A B
C
D
E
G
F
H
Figure 4-8 The open (or McCash) technique. (A) Preoperative appearance. (B) Appearance immediately
after fasciectomy and just before application of the non-adherent sterile dressing. (C) Appearance at
postoperative day 6, (D) day 10, (E) day 14, and (F) day 20. (GH) Postoperative appearance at 2 months
showing good extension and flexion.
71
A B
C D
Figure 4-9 The longitudinal skin incision with Z-plasty closure. (A) Note the isolated diseased cord of
palmar fascia elevated by the scissors. (B) A double-running Z-plasty has been laid out in proximity to
the distal palmar crease and the MCP flexion crease of the little finger. (C) The flaps are rotated and
sutured in place. (D) The result 2 months postoperatively.
Longitudinal Incision with Z-Plasty Closure
In addition to the transverse incisions previously noted in
Figures 4-7 and 4-8, longitudinal incisions with Z-plasty
closures may be used to excise the diseased fascia in the
palm and digit.
Suchincisions are ideally suited for single ray involvement
(Figure 4-9).
The longitudinal incision with a Z-plasty closure may also
be used for more than one ray involvement of disease
confined to the palm.
Figure 4-10 illustrates the use of a longitudinal incision in
the palm, with Z-plasty closure for involvement of two rays.
The Z-plasty should be laid out with reference to the
palmar and digital flexion creases.
Surgeons should handle the flaps carefully, keeping them
as thick as possible to preserve their blood supply.
These longitudinal incisions that cross the flexion creases
should never be used without Z-plasty closure, because a
pronounced scar that is associated with significant con-
tracture will result.
B
D
C A
Figure 4-10 The longitudinal incision and Z-plasty closure for disease
encompassing two rays in the palm. (A) The longitudinal incision is laid out
between the ring and little finger rays. The cross-hatched marks denote the
underlying fascial cords. (B) The cords have been removed and the Z-plasty is
laid out centered about the distal palmar crease. Note that the oblique limbs of
the Z are carried to the distal palmar crease, and that the incision axis and two
oblique limbs are equidistant. (C) The flaps are rotated and the distal palmar
crease is restored. (D) The result at 8 days postoperative, showing that the flaps
are viable and healing satisfactorily.
Zigzag Incision
This incision is widely used to expose palmar and digital
diseased cords.
Although it resembles a longitudinal incision, its multidi-
rectional configuration avoids longitudinal tension lines
and is well tolerated by the palmar and digital tissues.
Figure 4-11 shows the zigzag incision and the postoper-
ative result.
Skin Grafts
Skin grafts may be used to replace badly diseased skin or
to fill a skin defect following fasciectomy.
Full-thickness skin grafts are used most often because
they are less likely to contract.
Figure 4-12 shows a patient with severe contracture in
whom skin closure was facilitated by full thickness skin
grafts.
The Skoog Principle
In 1967, Skoog published his findings and recommenda-
tions regarding the noninvolved nature of the transverse
elements of the palmar fascia in patients with DD. This
concept focused the attention of surgeons on the need
to remove only those tissues that are diseased. In many
instances, this results in less trauma to the hand, and
preserves the parts of the palmar fascia that could con-
tinue to play an important role in the hand. Figure 4-13
A B
Figure 4-11 The zigzag incision for Dupuytrens disease. (A) Comprehensive incision from the proximal
palm to the DIP joint for removal of the single-ray palmar and digital cords in Dupuytrens disease. (B)
The end result at 3 months with nearly full extension and good skin healing in the palm and finger.
A B
C
D
Figure 4-12 Full-thickness skin graft to facilitate closure in Dupuytrens disease. (A) The preoperative
appearance of severe Dupuytrens disease, with contracture in the left hand. (B) Intraoperative
appearance as the procedure progresses. (C) A palmar skin graft has been applied in the palm, while a
second graft (not shown) will be applied to the defect in the proximal phalanx of the little finger. The
ring finger was left open. (D) The end result at 3 months.
74
A
C
B
Figure 4-13 The Skoog principle of preservation of the transverse
fibers of the palmar fascia in fasciectomy. (A) Clinical appearance of
Dupuytrens disease in the right little finger ray. (B) The transverse
fibers (open arrow) can be seen between and beneath the longitudinal
cords (solid arrow) of the palmar fascia. (C) The end result after
removal of the longitudinal cords. Note the preserved transverse fibers
(arrow) and the underlying nerves and vessels.
demonstrates the relationship of the diseased longitudinal
cords to the underlying transverse fibers of the palmar
fascia.
Structures at Risk During Surgery
One of the principles in DD surgery is to begin the dissec-
tion in relatively normal tissue and progress to the site of
maximum disease involvement. Thus, dissection often be-
gins in the proximal palm, where the cords are more easily
identified and their relationship to associated structures is
more evident. Wise and experienced surgeons look for vital
structures such as the common and proper digital vessels
and nerves in the palm. Surgeons focus on this as the dis-
section enters the region of the distal palm and fingers, in
order to avoid injury to these structures.
A review of the normally occurring bands in the distal
palmand finger is appropriate here. The pretendinous band
splits into two spiral bands just proximal to the first annu-
lar pulley. These bands then continue distally as the spiral
band, where they join the lateral digital sheet. That sheet
in turn may join the fibers of Graysons ligament (Figure
4-14).
With contracture the spiral band, lateral sheet and
Graysons fibers join to form the spiral cord. It is this com-
posite structure that spirals around the digital nerve and
vessel and, with increasing contracture, progressively draws
the neurovascular bundle toward the midline, proximally
and superficially (Figure 4-15). It is here, in the region of
the proximal phalanx and PIP joint, that the neurovascular
bundle is at risk. The digital nerve and cord are not easily
distinguished because they are similar in color. The nerve
is soft compared to the firmer nature of the cord, and the
color of the blood vessel (even under tourniquet control)
may provide some distinguishing features. A useful tech-
nique is to identify the nerve and vessel in the distal palm,
and then trace them distally.
Other cords adjacent to the neurovascular bundles in
the finger are the lateral and central cord, which may also
produce PIP joint contracture, along with the spiral cord.
Figure 4-16 shows the clinical appearance of the neuro-
vascular bundle and adjacent cords in the fingers of two
patients.
Pretendinous band
Graysons ligament at PIP
Lateral digital sheet
Neurovascular bundle
Spiral band
Figure 4-14 The anatomy of the normal tissues that may form the
spiral cord: Pretendinous band; spiral band; lateral digital sheet; and
Graysons ligament.
A B
Figure 4-16 Clinical examples of cords and their relationship to the neurovascular bundles in the
finger. (A) Note the proximity of the digital nerves (retraction loops) to the cords (arrow) in this little
finger. (B) Note the proximity of the digital nerves and vessels (open arrows) to the digital cord (closed
arrow) in this ring finger.
Spiral cord
Graysons ligament
Lateral cord
Figure 4-15 The spiral cord and its relationship to the
neurovascular bundle.
76
SUGGESTED READING
Baldalamente MA, Hurst LC. Enzyme injection as nonsurgical
treatment in Dupuytrens disease. J Hand Surg 2000;25A:629
636.
Chiu HF, McFarlane RM. Pathogenesis of Dupuytrens contracture:
a correlative clinical-pathological study. J Hand Surg 1978;3A:
110.
Doyle JR. Palmar Hand. In: Doyle JR, Botte MJ, eds. Surgical anatomy
of the hand and upper extremity. Philadelphia: Lippincott Williams
& Wilkins, 2002:532641.
McCash CR. The open palm technique in Dupuytrens contracture.
Br. J Plastic Surg 1964;17:271280.
McFarlane RM. On the origin and spread of Dupuytrens disease.
J Hand Surg 2002;27A:385390.
McGrouther DA. The microanatomy of Dupuytrens contracture. Hand
1982;14:215236.
McGrouther DA. Dupuytrens contracture. In: Green DP, Hotchkiss
RN, Pederson WC, eds. Greens operative hand surgery. 4
th
Ed.
New York: Churchill Livingstone, 1999:563591.
Skoog T. The transverse elements of the palmar aponeurosis in
Dupuytrens contracture. Their pathological and surgical signifi-
cance. Scand J Plast Reconstr Surg 1967;1:5163.
Tomasek J, Rayan GM. Correlation of alpha-smooth muscle actin ex-
pression and contracture in Dupuytrens disease fibroblasts. J Hand
Surg 1995;20A:450455.
Lubahn, JD. Dupuytrens disease. In: Trumble, TE, ed. Hand surgery
update 3, hand, elbow, shoulder. Rosemont, IL: American Society
for Surgery of the Hand, 2003:393401.
Zachariae L. Dupuytrens contracture. The aetiological role of trauma.
Scand J Plast Reconstr Surg 1971;5:116119.
5
INFECTIONS
This chapter will present the basic principles involved in the
diagnosis and treatment of common infections in the hand.
Discussion will begin with the more common bacterial in-
fections involving soft tissue and bone that may be seen in
an acute situation.
Prior to the antibiotic era, infections in the hand and
their sequelae could be disabling, and in some cases fatal.
Antibiotics have changed that, but early diagnosis and treat-
ment is a necessary part of the management equation in or-
der to minimize the potential disability that may result from
infections that are diagnosed late or treated inappropriately.
The specifics of the pertinent anatomy as it relates to each
infection will be addressed under each type of infection.
The effect of antibiotics is most pronounced in the early
phases of an infection. Antibiotics may in some instances
cure certain types of infections if they are administered early
and are organismspecific. Many infections, however, do not
present in a timely fashion. Some infections may begin as
cellulitis; at this stage a more serious or deep infection may
be averted by prompt treatment including antibiotics, and
elevation and rest of the affected part.
The patients history of injury or onset is often critical to
making the correct diagnosis. Not all patients will be forth-
coming with the true details of the circumstances surround-
ing the infection. Human bite wounds are a prime example:
most patients will not admit that the problemoccurred from
a fistfight, but rather say it resulted from a fall.
A basic principle of the treatment of deep or closed-
space infections is to provide open drainage in a suitable
and timely fashion. Drainage of an infection is accompanied
by a culture of the material obtained, and includes routine
bacterial and fungal cultures. A smear and gramstain of the
drained material may allow a presumptive or tentative iden-
tification of the organism involved. Antibiotics are started
based on the most likely organism involved. Table 5-1
includes examples of selected antibiotic agents, and their
class, spectrum, use, and cost.
Immobilizing the affected part and allowing it to rest are
also important aspects of treatment. Elevation means that
the affected part is at least 30 cmabove the level of the heart,
a posture that is most easily obtained by recumbency. Sitting
in a chair with the hand at or below the level of the heart
is not elevation. Immobilization by use of a splint or cast
provides rest to the part and will also prevent inappropriate
inspection or manipulation of the lesion by the patient.
Remember that infections in diabetic, debilitated, mal-
nourished, or immunocompromised patients will be more
difficult to treat, and will sometimes present as chronic,
rather than acute, infections. Infections in these patients
sometimes require amputation of digits.
The following discussion will include some of the more
common infections that may be encountered in the outpa-
tient clinic or the emergency department.
Felon
The felon is a subcutaneous infection that occurs in the
distal pulp of the fingers or thumb.
Pertinent Anatomy
The distal pulp of digits is covered by thick skin that is
tethered to the osseous phalanx by multiple fibrous tissue
septae. This three-dimensional space is filled with fat, and
contains numerous vessels and nerves and their specialized
end organs. These septae stabilize the pulp for pinching
and grasping, and form compartments that may prevent ad-
equate drainage unless incised (Figure 5-1).
Clinical Appearance and Diagnosis
The felon presents as a swollen, red, painful, and tender
terminal phalanx that may or may not have a history of a
penetrating injury (Figure 5-2).
Spontaneous drainage or pointing of the abscess may oc-
cur (Figure 5-3). This indicates a late and neglected in-
fection, and diagnosis and treatment should have been
started in a more timely fashion.
The felon may also migrate to the distal interphalangeal
(DIP) joint and to the adjacent flexor sheath in untreated
cases.
Treatment
Treatment is aimed at decompression of the abscess,
which is often under tension.
Surgical drainage is indicated if there is evidence of a pu-
rulent collection under pressure. This may occur within
2 to 3 days of the onset of the condition.
78
Chapter 5 / Infections 79
TABLE 5-1 CLASS, SPECTRUM, USE, AND COST OF SELECTED ANTIBIOTIC AGENTS
Class Spectrum Notes Cost
a
Penicillins
Natural penicillins Penicillin G, penicillin V Most streptococci, gram(+) anaerobes,
some Staphylococci; poor gram()
Effective for S. viridans,
Pasteurella in bite
infections
$$$
Penicillinase-
resistant
Nafcillin, methicillin,
dicloxacillin
Similar to natural penicillins, but better
Staphylococcus coverage
Nafcillin effective for
septic arthritis,
osteomyelitis
$$$
Extended spectrum Ampicillin, amoxicillin Similar to natural penicillins, but better
gram() coverage
$
With -lactamase
inhibitors
Amoxicillin/clavulanate
(Augmentin),
ampicillin/
sulbactam (Unasyn)
Similar to extended-spectrum penicillins, but
better coverage of -lactamase-producing
Staphylococci, gram()
Good rst line
coverage for diabetic
hand infections
$$$
Cephalosporins
First generation Cephalexin (Keex),
cefazolin (Ancef,
Kefzol)
Similar to penicillinase-resistant penicillins
against gram(+); some gram()
Recommended
prophylaxis against
wound infections
$$$
Second generation Cefuroxime, cefotetan Similar to penicillinase-resistant penicillins
against gram(+); more gram()
Third generation Ceftriaxone,
ceftazidime
Similar to second generation but including
Pseudomonas
Ceftriaxone effective
against gonococcus
$$$
Fourth generation Cefepime Similar to third generation cephalosporins
Other -lactams
Carbapenems Imipenem, meropenem Broad-spectrum against most gram(+) and
gram() bacteria, some Pseudomonas
Reserved for severe,
polymicrobial
infections
$$$$$
Monobactam Aztreonam Some gram(), no anaerobes or gram(+)
cocci
$$$$$
Glycopeptides Vancomycin Gram(+), including MRSA; no gram()
coverage
IV only, can cause
red-man syndrome if
infused quickly
$$$
Polypeptides Bacitracin, polymyxin Bacitracin covers only gram(+), polymyxin
only covers gram()
Topical use only $
Aminoglycosides Gentamicin,
tobramycin,
amikacin
Gram(), including Pseudomonas Monitor levels, screen
for nephrotoxicity,
ototoxicity
$$$
Tetracyclines Tetracycline,
doxycycline
Most gram(+), some gram() Do not use in children
(stains teeth, bones)
$
Macrolides Erythromycin,
clarithromycin
Most gram(+), some gram(), clarithromycin
active against mycobacteria
GI side effects
common
$$$
Oxazolidinones Linezolid (Zyvox) All Staphylococci (incl MRSA, all
Streptococci, all enterococci (incl. VRE)
Good PO
bioavailability,
bone/joint
penetration
$$$$
Lincosamides Clindamycin Staphylococci, some gram() anaerobes High incidence of GI
side-effects
$$
Streptogramins Quinupristin-
dalfopristin
(Synercid)
Staphylococci, Streptococci, enterococci
(including VRE)
IV only, good bone/joint
penetration
$$$$$
Fluoroquinolones
Broad-spectrum Ciprooxacin (Cipro),
levooxacin
(Levaquin)
Broad gram(+) and gram() coverage Good PO bioavailability
for bone and joint
infections
$$$$$$
Expanded-
spectrum
Gatioxacin (Tequin),
moxioxacin
(Avelox)
Similar to broad-spectrum uoroquinolones,
but better gram(+) coverage
Good PO
bioavailability, limited
FDA approval
$$$$$
(continued)
TABLE 5-1 Continued
Class Spectrum Notes Cost
a
Other -lactams
Metronidazole Metronidazole (Flagyl) Parasites, anaerobes, including C. difcile Drug of choice for
C. difcile
$
Sulfonamides Trimethoprim-
sulfamethoxazole
(TMP-SMX, Bactrim)
Broad range of gram(+) and gram() Commonly used for
urinary tract
infections
$
Antimycobacterials Isoniazid (INH),
ethambutol,
cycloserine,
rifampin,
pyrazinamide (PZA)
Mycobacteria; rifampin also effective against
gram(+) cocci
Usually used in
combinations;
consult infectious
disease specialist
$$$$$
a
Costs for recommended courses of treatment: $, $110; $$, $1050; $$$, $50200; $$$$, $2001000; $$$$$, $100020,000; FDA, US Food and Drug
Administration; GI, gastrointestinal; gram(), gram negative; gram(+), gram positive; IV, intravenous; MRSA, methicillin-resistant Staphylococcus
aureus; PO, by mouth; VRE, vancomycin-resistant Enterococcus. (From Cornwall R, Bednar MS. Infections. In: Trumble, TE, ed. Hand surgery
update-3, hand, shoulder & elbow. Rosemont, IL: American Society for Surgery of the Hand, 2003:433457.)
Nail plate
Distal phalanx
Fibrous septae
Figure 5-1 The anatomy of the terminal phalanx.
A B
Figure 5-2 (A) Clinical appearance (swelling) of a felon in the thumb. The pulp was firm and tender to
palpation. (B) Felon of the left middle finger. Note the swelling in the pulp and the proposed midlateral
incision of the noncontact side of the digit.
The aim of surgery is to produce immediate and contin-
uous drainage of the abscess.
The usual organism is Staphylococcus aureus, although
opportunistic gram-negative and mixed organisms may
be encountered in the immuno-compromised patient.
This requires an appropriate incision and division of the
fibrous septae to promote drainage.
Appropriate and inappropriate incisions for drainage of
the felon are depicted in Figure 5-4.
Incisions that extend on both sides of the pulp (fish-
mouth incisions) are to be avoided. They result in unsuit-
able scars, may result in vascular or neurological compro-
mise of the resultant flap, and in general alter the shape
and function of the pulp.
The preferred surgical incision is a lateral midaxial inci-
sion that begins distal to the DIP joint flexion crease and
continues distally at a level adjacent to the free edge of
the nail plate.
Figure 5-3 A felon that was neglected and drained spontaneously
(or pointed).
This incision maintains the architectural integrity of
the pulp, while at the same time providing adequate
exposure and drainage.
Oblique or longitudinal volar incisions may be used if the
abscess is pointing in that direction (volar), but should be
relatively short and should avoid injuring the underlying
digital nerves.
This volar incision may be most suitable when the ab-
scess has spontaneously drained in that direction.
These incisions should not cross the flexion crease.
The incisions are placed on the non-contact side of the
digit.
In the index, middle, and ring fingers, the incisions are
on the ulnar side and in the thumb and little finger they
are on the radial side.
Drains, Antibiotic Therapy and Splints
A small drain is inserted into the wound to keep it open
and promote drainage.
Figure 5-4 Inappropriate (marked with an X) and appropriate
incisions for drainage of the felon.
Matrix cells
Eponychial fold
Paronychia
Nail plate
Figure 5-5 The anatomy of the distal phalanx showing the finger
nail components, nail plate, matrix, and eponychium, with an artists
depiction of a lateral fold infection called a paronychia.
An alternative to this drain is to place a small catheter
in the wound for irrigation and drainage.
Antibiotic therapy, along with rest (a plaster splint is ef-
fective) and elevation of the extremity, is instituted.
Prompt drainage, suitable incisions, and antibiotic ther-
apy usually result in a satisfactory outcome that will pre-
serve the function of the pulp and avoid a disabling scar.
These actions also tend to prevent the spread of the in-
fection to bone or to the flexor tendon sheath.
Acute Paronychia
Pertinent Anatomy
A paronychia is an infection of the lateral soft tissue fold
surrounding the nail plate. The interface between the nail
plate and the overlying skin is a unique anatomic arrange-
ment that allows for growth of the nail plate from ma-
trix cells (Figure 5-5). This interface or seal however may
be penetrated by foreign bodies that introduce bacteria
into an otherwise sterile interface. Over-vigorous mani-
cures and nail biting may be associated with these infec-
tions.
The initial infection usually involves half or less of the
eponychia fold, and in such instances is called an epony-
chia.
A neglected infection may involve the entire fold, and is
called a run-around infection (Figure 5-6A).
These neglected lesions may spread to the insertion of
the adjacent extensor tendon. This can result in a mallet
finger deformity and can deformthe fingernail secondary
to injury to the germinal nail matrix (Figure 5-6B).
Staphylococcus aureus is the usual organisminvolved, but
Streptococcus and oral anaerobes may be seen in infec-
tions caused by nail biting.
A B
Figure 5-6 (A) The run-around form of paronychia. (B) The end result of delayed treatment of a
severe paronychium with chronic mallet finger and nail deformity.
Treatment
Early cases (before fluctuance and an abscess have de-
veloped) may be treated by warm water soaks, splinting,
and cephalosporins.
If an abscess is identified, it must be drained by one of
several methods, including elevation of the eponychial
fold to drain the purulent material, followed by insertion
of a small drain; or an oblique incision in the eponychial
fold centered over the site of maximum involvement. In
more chronic cases, a margin of the nail plate is removed,
followed by a drain insertion.
Chronic Paronychia
The term chronic paronychia is used to describe non-
bacterial infection of the eponychial fold caused, most
commonly, by a Candida albicans infection. Other organ-
isms such as tuberculosis, syphilis, atypical mycobacte-
ria, gram-negative rods, and cocci have also been identi-
fied, however.
It is most often associated with chronic maceration, and
occurs in patients such as dishwashers, homemakers,
bartenders, and others that have their hands in water
that contain irritants.
Some have concluded that this condition is a type of hand
dermatitis and not onychomycosis.
Treatment
Treatment is difficult and not always successful.
Nonsurgical treatment includes topical corticosteroids
and systemic antifungal agents.
Treatment that removes the patient from constant expo-
sure to water may be as important as medications.
In patients who do not respond to conservative treatment,
surgical marsupialization with or without plate removal
may be effective.
A crescent of skin that is 3 to 4 mm wide is excised proxi-
mal and parallel to the eponychium, which includes skin,
fat, and nail platebut not the nail matrix (Figure 5-7).
Herpes Simplex (Herpetic Whitlow)
This condition represents an important differential diag-
nosis of both pyogenic paronychia and felon.
It is an infection caused by the herpes simplex virus (types
1 or 2) and is usually seen in medical and dental person-
nel.
The affected digit is swollen, painful, and red.
The infection may involve more than one digit and is
often less tender than a bacterial lesion.
Figure 5-8 shows the typical appearance of the herpes
simplex lesion in the digit.
Small vesicles may appear early on, and the fluid in them
is clear and not purulent.
These lesions then involute and desquamate, and the
cycle resolves in 3 to 4 weeks.
The diagnosis is usually made by taking a history and
performing an examination.
Nail plate
Matrix cells
Area of chronic paronychia
A B
Figure 5-7 Marsupialization technique for surgical management of
chronic paronychia.
A
C
B
Figure 5-8 The clinical appearance of a herpes simplex infection in the
digit. (A) The erythematous phase. (B) The pustular phase. (C) The
desquamation phase. (Courtesy of Dean S. Louis, University of Michigan.)
Treatment
Surgery is not necessary and is contraindicated since bac-
terial infections may contaminate the incision site. Sys-
temic dissemination with a secondary viral encephalitis
can also occur.
Pyogenic Flexor Tenosynovitis
Pertinent Anatomy
The flexor tendons are enclosed in a double-walled synovial
sheath that extends from the region of the DIP joint to the
midpalm in the index, middle, and ring fingers; from the
DIP joint to the wrist in the little finger; and from the in-
terphalangeal (IP) joint to the wrist in the thumb. The most
common arrangement of the synovial sheath of the digits
is shown in Figure 5-9. This sheath represents a closed
space that, if infected, can produce severe disability in the
digit. Such infections require early diagnosis and appropri-
ate treatment. The relationship of the pulley system that
must be preserved during surgical drainage is depicted in
Figure 5-10.
Kanavel described four characteristic findings in pyo-
genic flexor tenosynovitis:
Flexed posture of the finger.
Swelling of the finger (Figure 5-11).
Tenderness along the course of the sheath.
Significant pain with passive extension of the flexed
finger.
The most common organism is Staphylococcus aureus.
Figure 5-9 The most common arrangement of the synovial sheaths
in the hand. This configuration gives anatomic support to the concept
of the horseshoe abscess, which is a flexor sheath synovial infection
that may communicate from thumb to little finger and vice versa
through Paronas space. See Figure 5-12 for depiction of Paronas
space.
A2 Oblique A1
B
Radial bursa
Synovial sheath
A5
A
C3 A4 C2 A3 C1 A2
A1
Figure 5-10 The digital pulley system. (A) The finger pulleys.
(B) The thumb pulleys.
Figure 5-11 The clinical appearance of pyogenic flexor
tenosynovitis in the little finger following an untreated laceration at
the PIP flexion crease. Note the swelling and erythema in the finger
and palm.
Treatment
If seen early (within 24 to 48 hours), it may be feasible to
treat to the condition by hospitalization with intravenous
antibiotics, bed rest and elevation of the hand, and im-
mobilization with a splintwith the hand and wrist in
the position of function (wrist in moderate extension and
the fingers slightly flexed).
The patient should be evaluated twice daily; if the con-
dition is not resolved within 24 to 48 hours, surgical
drainage should be performed.
Most cases will be in the late category. Surgical drainage
is performed along with the modalities listed for early
conservative treatment.
Open drainage through midaxial and palmar incisions has
been employed in the past for these infections, but when
compared to closed catheter irrigation, the former tech-
nique may be associated with a higher incidence of com-
plication and reoperation.
The current trend for recommended treatment is for
closed catheter irrigation.
Closed catheter irrigation consists of insertion of a 16-
gauge polyethylene catheter into the sheath just proximal
to the first annular pulley through a transverse, oblique,
or zigzag incision.
The catheter is passed under the A1 pulley distally for
about 2 cm (see Figure 5-10).
The catheter is sutured to the skin, and the wound is
closed.
A second incision is made distally, either on the noncon-
tact side of the digit in the midaxial plane or volarly distal
to the A4 pulley.
The sheath distal to the A4 pulley is excised, and a small
drain is sutured in place to ensure that the distal wound
stays open.
The patency and drainage of the construct is tested by the
injection of sterile saline through the proximally placed
catheter.
A variation on this technique is to bring the distal end of
the catheter out the distal wound and allow passage of
saline in the sheath by two to three openings made in the
catheter within the sheath.
Intermediate septa
Radial marginal
septum
Paronas space
FCR
PQ
FCU
Ulnar marginal
septum
Transverse
MC ligament
Central palmar
space
Figure 5-12 The palmar space and Paronas
space (see text for details).
The proximal portion of the catheter is brought out
through the dressings, and attached to a sterile 50-mL
syringe.
The distal wound is left exposed in the splint and dress-
ings for visual verification of patency of the system.
The system is flushed with sterile saline every 2 hours
for 48 hours, and then the finger is inspected. Compara-
ble end results might be achieved without postoperative
irrigation.
If the infection has abated, the catheter should be re-
moved and gentle range of motion exercises should
begin.
If there is some question about the status of the infection,
the irrigation can be continued for another 24 hours.
General principles in this technique include preservation
of the annular pulleys during placement of the catheter,
and concomitant intravenous antibiotic therapy.
Central Palmar Space Infections
Pertinent Anatomy
I recommend that the following concept regarding the
palmar space, based on the work of Bojsen-Moeller and
Schmidt, be accepted as valid.
The central palmar space is bounded radially and ulnarly
by marginal septae that begin as an expansion of the side-
walls of the carpal canal.
The floor is formed by the palmar interosseous fascia,
transverse metacarpal ligaments, and adductor fascia.
The roof is formed by the palmar aponeurosis.
The radial marginal septum extends distally to the proxi-
mal phalanx of the index finger, and forms the radial wall
of the lumbrical canal.
The ulnar margin septum is attached to the shaft of the
small finger metacarpal.
Between these two marginal septae are seven interme-
diate septae that divide the distal aspect of the central
palmar space into four canals for the flexor tendons and
four canals to accommodate the lumbrical muscle and
neurovascular bundles.
Thus, the historical concepts of a thenar and midpal-
mar or, as later modified, an adductor and deep palmar
ulnar space should be abandoned in my opinion (Fig-
ure 5-12).
An infection of the central palmar space may result from
a penetrating injury to the space or an extension of an
infected digital synovial sheath.
There may be swelling, redness, and tenderness in the
central aspect of the palm, and active and passive move-
ment of the fingers may be painful.
Treatment
Surgical drainage may be performed through an incision
in or parallel to the proximal palmar crease or thenar
crease to correspond to the site of maximum fluctuance.
A drain is placed to promote continuous egress, and a
splint is applied.
Elevation of the extremity, bed rest, and appropriate an-
tibiotics complete the treatment regimen.
SPECIAL SITUATIONS
Several conditions may present as unique situations and
may seem somewhat out of the ordinary.
Horseshoe Abscess
This term is used to describe an infection that may begin
in the thumb or little finger flexor sheath and that may
infect the opposing digit.
This occurs when sufficient pressure in the respective
sheath results in passage of the infected material into
Paronas space in the wrist and then into the opposing
tendon sheath. (see Figure 5-9 and Figure 5-12)
The treatment principles described for flexor tenosynovi-
tis are used, and drainage is required for both of the digits
involved and at the wrist (Paronas space).
Collar Button Abscess
This term has been used to describe interdigital web-
space infections.
The infections usually begin in the palm.
The palmar fascia attachments to the skin provide re-
sistance to superficial palmar spread, and the infection
will spread dorsally in the path of least resistance. Thus,
the lesion presents in the shape of a collar button or an
hourglass.
Patients present with painful swelling in the web space
and distal palm.
Palmar and dorsal drainage is effective treatment through
appropriate incisions such as a zigzag palmar incision and
a longitudinal web incision dorsally.
Osteomyelitis
Although osteomyelitis may be seen in the hand by direct
extension from an adjacent soft tissue infection, it may
also result from direct penetration. It seldom occurs by the
hematogenous route. Staphylococcus aureus and S. epider-
midis are the usual organisms involved.
Osteomyelitis should be suspected in any longstanding or
deep infection that is adjacent to bone, or in an infection
following a deep, penetrating wound.
Chronic swelling and infections that fail to resolve with
standard treatment may indicate osteomyelitis.
Elevation, increased thickness of the periosteum, or an
osteolytic lesion in the bone, seen on radiograph, are
signs of bone infection.
A foreign body with an osteolytic halo is also suggestive
of osteomyelitis.
C-reactive protein may be elevated.
A technetium bone scan may be diagnostic.
Figure 5-13 This neglected glass laceration resulted in a chronic
infection of the middle finger involving soft tissues, bone, and joint.
The problem could not be resolved with elevation, rest to the part,
and antibiotics. An amputation was performed with resolution of the
infection.
Treatment
Drainage of the bone is indicated through drill holes in
the cortex or a small window.
Necrotic bone (sequestrum) is removed if it is present.
The wound may be packed open, or the catheter irrigation
method may be used.
Figure 5-14 Human bite wound. This policeman sustained a
penetrating tooth wound (arrow) to the MCP joint of the left middle
finger, and shortly thereafter noted pain and swelling in the hand.
Incision and drainage was required, along with hospitalization and
intravenous antibiotics.
Figure 5-15 This cat owner sustained multiple scratches and bites
to the dorsum of her hand that resulted in cellulitis, with swelling,
redness, and pain. The infection developed overnight. The organism
was Pasteurella multocida, and the condition quickly resolved with
intravenous penicillin.
In some cases with severe bone and soft tissue involve-
ment, amputation may be the best treatment (Figure
5-13).
Human Bite Wounds
These wounds are most often seen over the metacarpopha-
langeal (MCP) joint and are due to a fist blow to an oppo-
nents mouth. The history of injury is not often forthcoming
due to embarrassment.
These wounds are often small and may initially appear
very benign.
The opponents tooth penetrates the MCP joint space
and inoculates this closed space with a variety of or-
ganisms, including Staphylococcus aureus, Streptococcus
viridans, and Eikenella corrodens.
Later on there is swelling, redness, and increasing pain
(Figure 5-14).
A radiograph of the injured hand may reveal a fracture or
a piece of the opponents tooth in the joint.
Treatment
These injuries should never be closed primarily.
They should be opened and debrided extensively. This
includes excision of the initial wound margins and exten-
sion of the wound to allow proper exposure, inspection,
and irrigation of the joint involved.
The wound is cultured prior to irrigation and debride-
ment.
It is left open and the hand is dressed and splinted.
Appropriate antibiotics are started after cultures have
been obtained.
Patients with bite wounds from humans may not always
keep their follow-up appointments, and serious consid-
eration should be given to hospitalization until the con-
dition is resolved.
Animal Bites
Domestic animal bites or scratches may result inthe rapid
onset of cellulitis and lymphangitis.
The most commonly isolated organisms fromdog and cat
bites are Streptococcus viridans, Pasteurella multocida, S.
aureus, and anaerobes.
Figure 5-15 represents a case of P. multocida (a small
gram-negative coccus) cellulitis following a bite from the
patients house cat.
The condition must be distinguished fromcat scratch dis-
ease or fever, which is usually associated with small red
lesions on the hand or wrist, lymphadenopathy, and a his-
tory of cat scratch. The organism is Rochalimaea hense-
lae, a gram-negative bacillus.
A skin test may be confirmatory.
Treatment
Penicillin is the antibiotic of choice for animal bites.
The treatment for cat scratch disease is said to be con-
troversial because it is a self-limiting disease.
Ciprofloxacin has been used.
SUGGESTED READING
Bojsen-Moeller F, Schmidt L. The palmar aponeurosis and the central
spaces of the hand. J Anat 1974;117:5568.
Cornwall R, Bednar MS. Infections. In: Trumble TE, ed. Hand surgery
update-3, hand, elbow&shoulder. Rosemont, IL: American Society
for Surgery of the Hand, 2003:433457.
Jebson PJL, Louis DS, eds. Hand infections. Hand Clinics
1998;14(4):511711.
Neviaser RL. Acute infections. In: Green DP, Hotchkiss RN, Peder-
son WC, eds. Greens operative hand surgery. 4th Ed. New York:
Churchhill Livingstone, 1999:10331047.
Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus
systemic antifungals in the treatment of chronic paronychia: an
open, randomized double-blind study and double dummy study. J
Am Acad Dermatol 2002;47:7376.
Wright PE II. Hand infections. In: Canale ST, Dougherty K, Jones L,
eds. Campbells operative orthopedics. vol. IV, 10th Ed. Philadel-
phia: Mosby, 2003:38093825.
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6
TENOSYNOVITIS
AND
EPICONDYLITIS
This chapter discusses some of the most common clinical
entities in the fingers, thumb, and wrist (stenosing tenosyn-
ovitis), as well as medial and lateral epicondylitis of the el-
bow.
Epicondylitis, although anatomically not in the hand or
wrist, is commonly seen on a Hand and Upper Extremity
Service and is appropriately included in this text on the
hand and wrist.
Trigger digits and de Quervains tenosynovitis may be
classified as inflammatory conditions that involve the re-
spective tendon sheaths and retinacular structures.
Stenosing tenosynovitis is an apt term to describe trigger
digits and de Quervains, since narrowing of the channel
through which the respective tendons travel is the common
denominator in these conditions. There may not be agree-
ment as to the relative role of tendon, retinacular, or synovial
tissues in causing this narrowing, but perhaps all three play
varying roles. The fact that the problem may be relieved by
rest, medication, or surgery indicates that stenosis is a valid
concept when discussing this disorder.
Epicondylitis, in contrast, may have multiple pathophys-
iologic factors in its etiology.
TRIGGER DIGIT (ADULT)
Pertinent Anatomy
This condition involves the first annular pulley (A1) of
the fingers and thumb. These structures are depicted in
Figure 6-1.
The A1 pulley in the finger arises from the metacar-
pophalangeal (MCP) joint palmar plate and, to a lesser ex-
tent, from the base of the proximal phalanx. It is located in
the distal palmand not the finger. In the thumb, the A1 pul-
ley arises from the MCP joint palmar plate and, to a lesser
extent, from the base of the proximal phalanx.
History, Clinical Appearance, and Diagnosis
This condition is more common in women, with the peak
incidence at 40 to 60 years of age.
The ring finger is most commonly involved, followed by
the thumb and middle finger.
Single or multiple digits may be involved.
Patients give a history of a clicking sensation with mo-
tion of the affected finger or thumb.
Sometimes a lump is described in the palm, and
anatomically this lump corresponds to the A1 pulley.
The clicking may progress to locking of the digit.
This locking is in the flexed position. Attempts at
extension of the digit are often painful.
The locked position in a trigger digit is with both
the MCP and proximal interphalangeal (PIP) joint
flexed.
Sometimes the patient must use the other hand to
passively extend, or unlock, the digit.
Repetitive use or overuse of the hand may be associated
with the onset of the condition.
Commonly associated conditions are rheumatoid arthri-
tis, diabetes mellitus, and gout.
Other reported causes of trigger digit include localized
enlargement of the flexor digitorum profundus (FDP) in
the region of the A3 pulley. In patients with rheuma-
toid arthritis, the triggering may be due to proliferative
synovium about the profundus tendon and subsequent
trapping at the flexor digitorum superficialis (FDS) de-
cussation.
Stenosing tenosynovitis does not usually result in a fixed
or permanently locked position.
If a trigger finger cannot be passively extended, it
is probable that true locking of the finger is present
due to a cause such as a spur from the metacarpal
that is trapped in a small fenestration in the palmar
plate.
The posture of true locking is with varying degrees of
flexion at the MCP joint, whereas the PIP joint is in
full extension and actively and passively mobile.
The locked trigger finger is in a flexed posture at both
the PIP and MCP joints (Figure 6-2).
In early or mild cases, crepitation with flexion of the digit
and tenderness over the region of the A1 pulley may be
the most prominent findings.
As the conditionprogresses, definite locking and catching
may occur. This is usually painful.
88
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Chapter 6 / Tenosynovitis and Epicondylitis 89
A1
Figure 6-1 The arrangement of the finger and thumb flexor tendon
sheath and pulleys.
The patient may become apprehensive when asked to flex
the finger, because the locking and release of the locked
digit are painful.
Treatment
Nonsurgical Treatment
Conservative management in the formof rest to the hand,
splinting, and anti-inflammatory medication may be of
benefit in mild or early cases.
Figure 6-2 The clinical appearance of a typical locked trigger
finger. Note that flexion is present in the MCP, PIP, and DIP joints.
The next level of treatment includes a steroid injection
into the flexor sheath.
One injection (or a second 2 weeks later) may result in
relief.
Patients with a discrete palpable nodule, single digit in-
volvement, and a short duration of symptoms appear to
have the best response to injections.
Injection Technique
The site to be injected is prepped with Betadine or a
similar solution, and the skin at the injection site is anes-
thetized with ethyl chloride spray.
A short, 25-gauge needle attached to a 1-mL syringe with
0.5 mL of corticosteroid designed for intrasynovial use
(Kenalog-40 or similar agent) is introduced through the
skin and into the proximal synovial sheath.
The ideal injection site is just proximal to the A1 pulley
into the synovial sheath.
Entering at a slight angle aids in placement of the needle.
Marked resistance indicates that the needle may be in
the substance of the tendon, and the needle should be
withdrawn slightly or repositioned.
As the steroid is injected into the sheath, the filling of the
sheath may be palpated by the injectors finger positioned
over the proximal or middle phalanx.
Serial injections in the anatomy laboratory by the author
have demonstrated that a fluid volume of 0.5 mL is more
than sufficient to fill the sheath in most digits.
Figure 6-3 shows the injection technique.
Surgical Treatment
The goal of surgical treatment is to incise (release) the
first annular pulley through a transverse or longitudinal
incision.
In general, the incisions should not cross a palmar or
digital flexion crease at right angles.
Some suitable longitudinal incisions for the fingers and
the recommended transverse thumb incisionare depicted
in Figure 6-4.
My preference for longitudinal finger incisions is based
on the ease of exposure. The line of incision parallels
the underlying tendons, nerves, and blood vessels (they
are less likely to be injured), and is oriented in a more
suitable plane to facilitate postoperative exercises.
The proximal part of the incision over the middle finger is
angled slightly, to parallel the distal palmar flexioncrease.
Four digits may be released simultaneously with these
incisions without compromise to the skin.
The soft tissues are retracted with two vein retractors
that protect the neurovascular bundles. The A1 pulley is
incised with a no. 15 blade under direct vision.
All of the A1 pulley is incised and, if necessary, so are
a few millimeters of the proximal portion of the A2
pulley.
The flexor tendons may be pulled up into the wound to
verify complete release. In the thumb, the radial digi-
tal sensory nerve crosses the flexor pollicis longus (FPL)
sheath fromulnar to radial at or proximal to the A1 pulley
and must be identified and protected.
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Figure 6-3 Injection technique for trigger fingers.
The A1 pulley is incised, but the oblique pulley is pre-
served.
Percutaneous release has been developed for trigger fin-
ger release and, in experienced, operators may be a useful
adjunct to the open technique.
CONGENITAL TRIGGER THUMB
Trigger digits in infants and children usually involve the
thumb rather than fingers.
These children are usually brought to the pediatrician or
other caregiver when the family notes that the thumb in-
terphalangeal (IP) joint is in a flexed posture and cannot
be passively extended.
The child presents with a locked IP joint that cannot be
actively or passively extended.
A prominent but nontender nodule is noted in the region
of the palmar aspect of the thumb MCP joint. It may be
bilateral in 25% to 33% of patients diagnosed.
The wise practitioner will not attempt to passively extend
the IP joint with undue force, because such a maneuver
may be painful.
The diagnosis is usually made by the clinical appearance
and physical findings.
Other diagnoses may be considered, such as congenital
clasped thumb, absent extensor tendons, arthrogryposis,
or spasticity.
Figure 6-5 shows the clinical appearance of bilateral con-
genital trigger thumbs.
Treatment
Spontaneous resolution of this condition has been reported
in some series with or without conservative treatment, such
as splinting, massage, and passive extension exercises to the
IP joint. It is unknown how many of these thumbs sponta-
neously resolve without ever being diagnosed. Conservative
treatment may be tried based on the perceived needs of the
family and the age of the child. Little or no harm will re-
sult from delaying the trigger thumb release should it be
required.
Surgical Treatment
The first annular pulley is incised through a transverse
incision that is centered over the nodule.
The neurovascular bundles are close by and must be pro-
tected.
In contrast to the adult trigger thumb, the FPL tendon
has a prominent nodule (Nottas node).
This nodule is not excised because it will resolve following
release of the first annular pulley (Figure 6-6).
CONGENITAL TRIGGER FINGER
Trigger fingers in children are much less common than
trigger thumbs.
Pathologic findings may include a nodule in the FDP and
FDS, and a bunching up or buckling of one or more slips
of the FDS.
Treatment
In contrast to congenital trigger thumb release, release
of the first annular pulley in congenital trigger finger may
be inadequate.
The incision should be extensile, because correction, in
addition to release of the A1 pulley, may require excision
of tendon nodules, one or both slips of the FDS, and
release of the A3 pulley.
A Bruner zigzag incision is useful for this more compre-
hensive exposure.
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Figure 6-4 Suitable longitudinal incisions for
trigger finger release, and the recommended
transverse incision for release of the thumb A1
pulley.
Figure 6-5 Bilateral congenital trigger thumbs in a child. Note the
flexed posture of the interphalangeal joints of the thumbs.
Figure 6-6 Congenital trigger thumb. Intraoperative photo showing
release of the first annular pulley, and the prominent nodule (arrows)
in the FPL called Nottas node.
91
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Sagittal band
Juncturae
tendinum
EDC
APL
EPL
1
2
L
3
4
5
6
EIP
EPB
EDM
ECU
ECRL &
ECRB
Figure 6-7 The six dorsal extensor compartments.
DE QUERVAINS TENOSYNOVITIS
Pertinent Anatomy
The first extensor compartment contains the abductor pol-
licis longus (APL) and the extensor pollicis brevis (EPB)
tendons (Figure 6-7). The wrist, thumb, and finger exten-
sor tendons enter the hand beneath a fibrous tissue reti-
naculum that contains six tunnels. Five of these tunnels
are fibroosseous and one (the fifth) is fibrous. This extensor
retinaculum(ER) is a wide fibrous tissue band that prevents
bowstringing of the tendons and improves their mechanical
advantage. At this level, the extensor tendons are covered
by a synovial sheath. The ER has two distinct layers: the
supratendinous layer and the infratendinous one. The latter
is limited to the area deep to the ulnar three compartments.
The tendons in the first extensor compartment are vari-
able in their number of slips and tunnels. The APL may
have two, and up to four, tendon slips, whereas the EPB
usually has only one and may be absent in 5% to 7% of
cases. Anatomic studies have revealed that the first com-
partment may consist of two distinct compartments in as
many as 33% of patients. These two tunnels are an ulnar
tunnel for the EPB, and a more radial one for the abduc-
tor pollicis longus (APL). Even a third tunnel containing an
anomalous tendon has been reported. Failure to recognize
these variations may lead to treatment failure (Figure 6-8).
The anatomic relationship of the radial artery and nerve
to this region must be recognized to prevent injury to
these structures (see Figure 6-8). The radial artery passes
obliquely across the anatomical snuff box from the palmar
aspect of the wrist deep to the APL and the radial wrist
extensors (extensor carpi radialis longus [ECRL] and ex-
tensor carpi radialis brevis [ECRB]). Two or more sensory
branches of the radial nerve are immediately superficial to
the first extensor compartment.
A history of radial-sided wrist pain of variable duration
may be identified, in association with overuse of the wrist
and thumb. The condition may be associated with dia-
betes or pregnancy.
There is tenderness over the first extensor compartment,
and there may be swelling and redness over the region of
the radial styloid.
Flexion and extension of the thumb is usually painful,
and crepitation may be noted.
Finkelsteins test is pathognomonic and is properly per-
formed as described.
The thumb is grasped by the examiner, and the hand
is quickly abducted (bent ulnarward).
The test is inappropriately performed by placing the
thumb in the palm before wrist abduction, because
this may produce pain even in a normal wrist (Figure
6-9).
A positive test is manifested by pain over the radial
styloid due to stretching of the inflamed tendons.
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1st extensor
compartment
Sensory branches
of radial nerve
Radial artery
APL
EPB
Figure 6-8 Relevant anatomy for de Quervains tenosynovitis. The
APL and EPB ordinarily share a common fibroosseous canal, but in
33% of cases a separate canal may be present that contains the EPB.
Failure to recognize and release this second compartment will result
in an incomplete release. Note the relationship of the radial artery
and radial nerve to the first extensor compartment.
De Quervains tenosynovitis must be distinguished from
arthritis of the trapeziometacarpal joint of the thumb.
Tenderness and swelling over this joint, along with
pain and crepitation, are signs of arthritis.
This arthritic condition may co-exist with de Quer-
vains tenosynovitis.
Treatment
Rest to the thumb and wrist by means of a splint that
immobilizes both, along with anti-inflammatory medica-
tion, may be useful in mild cases.
If these simple measures are not successful, a steroid
injection into the first extensor compartment should be
considered.
A B
Figure 6-9 Finkelsteins test. (A) The incorrect technique. (B) The
correct technique. The test is appropriately performed by grasping
the patients thumb, and then ulnar deviating the hand. A
false-positive test may result if the thumb is flexed into the palm and
grasped by the patients fingers followed by ulnar deviation of the
wrist (see text).
This is performed under sterile techniques and local
anesthesia (1% Xylocaine without epinephrine).
Ethyl chloride spray is a suitable alternative to tem-
porarily anesthetize the skin.
An intrasynovial steroid injection is placed into the first
compartment using a short 25- or 27-gauge needle.
The injection site is about 1 cm proximal to the tip of the
radial styloid.
The needle is guided by palpation of the tendons in the
first compartment. Needle placement may be verified by
noting enlargement of the sheath with instillation of the
cortisone.
The injectionmay be repeated in4 to 6 weeks if symptoms
are not relieved.
Water-soluble steroid preparations in volumes of 1 mL or
less are preferred. Informed consent prior to the injection
includes the possibility of depigmentation of the skin and
atrophy of the subcutaneous fat.
Surgical Treatment
If conservative treatment fails, surgery by release of the
first extensor compartment is performed.
A 2 cm transverse incision is made about 1 cm proximal
to the tip of the radial styloid.
Branches of the radial sensory nerve are identified and
carefully retracted.
The retinaculum is incised longitudinally, all compart-
ments released, and the respective tendons are gently
lifted from the wound to verify complete release.
Traction on one of the unroofed tendons must result in
extension of the MCP joint, indicating release of the EPB
tendon.
If this does not occur, then a second compartment must
be searched for and released.
INTERSECTION SYNDROME
(CROSSOVER TENDONITIS)
Pertinent Anatomy
This condition is a type of tenosynovitis of the second dor-
sal compartment. The APL and EPB muscle bellies cross
over the tendons of the ECRL and ECRB, and this is the
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EPB
APL
ECRB
ECRL
4 cm
Site of physical
findings
Site of
tenosynovitis
Figure 6-10 Intersection syndrome. Although the symptoms of
swelling and tenderness present in the crossover area 4 cm proximal
to the radial styloid, the true pathology is distal in the second extensor
compartment.
site of physical findings. The pathology, however, is located
distally in the synovial sheath of the second compartment.
The ECRL and ECRB are encased in a tight compartment,
and the symptoms and the physical findings of swelling and
tenderness do not present at this site. Rather they present
about 4 cm proximal to the radial styloid. Surgical release
of the second compartment distal to the area of symptoms
and findings reveal characteristic synovitis (Figure 6-10).
Pain and swelling about the muscle bellies of the APL
and EPB at the dorsal and radial aspect of the wrist are
characteristic of this syndrome.
This area is about 4 cm proximal to the radial styloid.
It may be seen after overuse of the wrist, and is often
associated with sports activities such as rowing or weight
lifting.
Treatment
If conservative measures including splinting and/or
steroid injections into the second compartment fail, then
surgical release of the second dorsal compartment is
performed through an incision centered over the radial
wrist extensors (ECRL and ECRB).
The extensor pollicis longus (EPL) tendon and sensory
branches of the radial nerve are in the area and are iden-
tified and protected.
EXTENSOR INDICIS PROPRIUS (EIP)
SYNDROME
Pertinent Anatomy
The muscle belly of the EIP may extend into the relatively
small (8 to 10 mm wide) fourth compartment when the
wrist is flexed. This produces relative occlusion or compro-
mise of the already limited space. Hypertrophy of this mus-
cle, or synovitis of the surrounding tendon sheath, may be
implicated.
This condition may manifest itself as swelling and ten-
derness in the radial side of the fourth extensor compart-
ment, which is most noticeable in wrist flexion.
With the wrist in full flexion, the patient is asked to ex-
tend the index finger against resistance.
The production of pain that is adjacent to Listers tuber-
cle represents a positive test for EIP syndrome.
Treatment
Partial release of the extensor retinaculum or partial ex-
cision of a hypertrophied EIP muscle belly may be indi-
cated if conservative measures fail.
EXTENSOR POLLICIS LONGUS
TENOSYNOVITIS
Pertinent Anatomy
The EPL curves around Listers tubercle in the third exten-
sor compartment. Its movement is through a relatively long
osseous groove and Listers tubercle acts as a turning fair-
lead to change its initial course that is parallel to the long
axis of the forearm to an oblique axis to reach the thumb.
Any condition that compromises the osseous groove or in-
flames the surrounding synovial sheath will result in pain,
swelling, and tenderness.
EPL tenosynovitis is often seen following a Colles frac-
ture, and its tendency to rupture may be related to local
ischemia in an unyielding fibro-osseous groove.
Tenderness, swelling, and crepitation may be noted along
the course of the tendon.
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Treatment
Attritional rupture of the EPL may occur in these cir-
cumstances, and steroid injections are not advised.
Re-routing of the tendon radial to its anatomic tunnel is
recommended.
CALCIFIC TENDONITIS
Etiology, Clinical Appearance, and Diagnosis
Release of calcium salts into the synovial and peritendi-
nous space results in acute pain, swelling, redness, and
tenderness.
The onset is sudden and is not usually associated with a
precipitating incident.
The redness and swelling may mimic infection.
Gouty tenosynovitis may present in a similar fashion and
may be diagnosed by history or laboratory studies.
A high index of suspicion and a radiograph more of-
ten than not lead to the diagnosis of acute calcific
tendonitis.
The lesions may occur anywhere in the hand or wrist, and
the region of the flexor carpi ulnaris (FCU) and pisiform
bone is the most common site (Figure 6-11).
Treatment
This condition is usually self-limited and may resolve in
a matter of days.
Symptomatic treatment is indicated inthe formof splints,
mild anodynes, and anti-inflammatories as needed.
LATERAL EPICONDYLITIS
Pertinent Anatomy and Possible Etiology
Most treaters of lateral epicondylitis have focused on the
ECRB muscle and its fibrous tissue origins from the lateral
epicondyle. It arises from the common extensor origin from
the lateral epicondyle, radial collateral ligament of the el-
bow joint, and the intermuscular septum. Various entities
have been implicated, and include such conditions as an
inflamed synovial fringe, fibrositis of the annular ligament
around the radial head and neck, periostitis of the ECRBori-
gin, and angiofibroblastic hyperplasia of the ECRB tendon
of origin. Most now agree that some form of noninflam-
matory degeneration of the ECRB tendon is responsible,
because acute inflammatory cells are not often present in
the specimens removed.
The findings at surgery have identified a grayish and
edematous ECRB origin and rupture of portions of the
ECRB origin in about one-third of the patients treated.
Specialized stains of these abnormal tissues have demon-
strated myofibroblast cells that are not normally found in
tendons.
A
B
Figure 6-11 Acute calcific tendonitis. (A) This young reporter noted
the sudden onset of pain, swelling, and redness on the flexor aspect of
his wrist (arrows). (B) Radiographs demonstrated a calcium deposit in
the region of the FCU tendon and pisiform bone (arrow).
Patients with this condition present with the insidious
onset of pain on the outer aspect of the elbow that may
radiate into the extensor surface of the forearm.
Racket sports have been implicated, especially in those
that play often or have faulty technique.
Repetitive use of the wrist and finger extensor muscles
is often noted. Swelling is not a usual feature, but point
tenderness over the lateral epicondyle and the tendon of
origin of the ECRB is present.
Symptoms are reproduced by resisted dorsiflexion of the
wrist with the elbow extended.
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Differential diagnosis may include cervical disc disease,
radial tunnel syndrome, posterior interosseous nerve syn-
drome, radiocapitellar arthritis, or osteochondral injury.
Radiographs should be obtained to rule out bone pathol-
ogy.
Treatment
Initial treatment is conservative in the form of activ-
ity modification, rehabilitation exercises, ice, and anti-
inflammatories.
Some patients will benefit from a so-called tennis elbow
brace that applies pressure to the extensor tendon origin
on the proximal forearm.
Steroid injection, directed to the osseous origin of the
ECRB tendon, may be beneficial.
Surgical Treatment
Surgery is indicated for those patients that have failed to
improve after several months of conservative treatment,
and who, for a variety of reasons, cannot or chose not to
live with the condition.
Most current surgical approaches to this problem are
extra-articular, and consist of debridement of the abnor-
mal tissue on the deep or underside of the ECRB and
adjacent tendons.
In open techniques, the interval between the ECRL and
ECRB is exposed through a lateral incision.
Diseased tissue is removed from the ECRB after detach-
ing it from its epicondylar origin.
Other sites of diseased tissue are looked for and removed
from the ECRL or common extensor origin.
Reattachment of these tendons is facilitated by roughen-
ing of the adjacent bone or by mini-epicondylectomy.
The collateral ligament is protected during the procedure
to avoid the postoperative complication of posterolateral
rotatory instability of the elbow (Figure 6-12).
Arthroscopic debridement of the ECRB has also shown
favorable results.
MEDIAL EPICONDYLITIS
Pertinent Anatomy and Possible Etiology
The flexor-pronator muscle group originates from the me-
dial epicondyle and supracondylar ridge, and include the
pronator teres (PT), flexor carpi radialis (FCR), palmaris
longus (PL), flexor digitorum superficialis (FDS), and the
FCU. The PT (humeral head) and FCR share a common
tendon origin from the epicondylar ridge, and are the usual
muscles involved. The anterior elements of the medial col-
lateral ligament (A-MCL) are the major ligamentous stabi-
lizers of the medial aspect of the elbow, and must be pro-
tected during any surgical releases in this area. The A-MCL
originates from the inferior and anterior aspect of the me-
dial epicondyle (Figure 6-13).
Figure 6-12 The lateral elbow ligaments. LUCL, lateral ulnar
collateral ligament; RCL, radial collateral ligament.
History, Physical Examination, and Diagnosis
Medial epicondylitis is the most common cause of me-
dial elbow pain, but it is much less common than lateral
epicondylitis.
The onset, like lateral epicondylitis, is insidious in the
majority of cases.
The patients often describe activity-related pain asso-
ciated with repetitive and forceful forearm pronation
and/or wrist flexion.
Many cases are associated with occupational activities.
Sports-related activities such as throwing and golfing are
often associated with this condition.
Posterior
Transverse
Annular ligament
of radius
Anterior
Figure 6-13 The medial elbow ligaments.
P1: JDW
The sites of maximum tenderness are over the medial
epicondyle and just distal at the tendinous origin of the
flexor-pronator muscles.
Resisted pronation and wrist flexion often reproduce the
symptoms.
Symptoms of cubital tunnel syndrome may also be
present, and are manifested by tenderness and a pos-
itive Tinels sign over the ulnar nerve in the cubital
tunnel.
Additional differential diagnostic entities include ul-
nar nerve subluxation, subluxing medial head of the
triceps, medial collateral ligament insufficiency (es-
pecially in throwers), elbow arthritis, and cervical
radiculitis.
Treatment
Conservative treatment is represented by activity modifi-
cation, ice, and anti-inflammatory medication.
A steroid injection deep to the site of the origin of the
flexor-pronator group may also be tried.
If symptoms resolve in a timely fashion, flexor-pronator
stretching exercises are performed.
Surgical Treatment
Surgery is indicated for those patients that have failed to
improve after several months of conservative treatment,
and who, for a variety of reasons, cannot or chose not to
live with the condition.
The commonly recommended treatment is debridement
and reattachment of the flexor-pronator origin through
an incision just anterior to the medial epicondyle.
A small cuff of tissue may be left proximally to facilitate
reattachment.
Pathological tissue on the underside of the PT or
FCR, or elsewhere in the flexor-pronator origin, is
excised.
Some surgeons perform a limited epicondylectomy to fa-
cilitate reattachment of the flexor-pronator muscles.
The ulnar nerve in the cubital tunnel, and the branches of
the medial antebrachial cutaneous nerve, must be iden-
tified and preserved during the procedure.
SUGGESTED READING
Baker CL Jr, Murphy KP, Gottlob CA, Curd DT. Arthroscopic clas-
sification and treatment of lateral epicondylitis: two-year clinical
results. J Shoulder Elbow Surg 2000;9:475482.
Cardon LJ, Ezaki M, Carter PR. Trigger finger in children. J Hand Surg
1999;24:11561161.
Carroll RE, Sinton W, Garcia A. Acute calcium deposits in the hand.
JAMA 1950;157:422426.
Carrozzella J, Stern PJ, Von Kuster LC. Transection of radial dig-
ital nerve of the thumb during trigger release. J Hand Surg
1989;14A:198200.
Doyle JR. The Elbow. In: Doyle JR, Botte MJ, Surgical anatomy of the
hand and upper extremity. Philadelphia: Lippincott, Williams &
Wilkins: 2002:371402.
Doyle JR. Palmar Hand. In: Doyle JR, Botte MJ, Surgical anatomy of
the hand and upper extremity. Philadelphia: Lippincott, Williams &
Wilkins: 2002:532641.
Dunsmuir RA, Sherlock DA. The outcome of treatment of trigger
thumb in children. J Bone Joint Surg 2000;82B:736738.
Elliott BG. Finkelsteins test: a descriptive error that can produce a
false positive. J Hand Surg (Br) 1992;17:48182.
Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J
Bone Joint Surg 1930;12:509540.
Gabel GT, Morrey BF. Operative treatment of medial epicondylitis:
influence of concomitant ulnar neuropathy at the elbow. J Bone
Joint Surg 1995;77A:1065.
Grundborg AB, Reagan DS. Pathologic anatomy of the forearm: inter-
section syndrome. J Hand Surg 1985;10A:299302.
Morrey BF, An K-N. Functional anatomy of the ligaments of the elbow.
Clin Orthop 1985;201:8490.
Musgrave DS, Sotereanos DG. Tenosynovitis, de Quervains syndrome
and epicondylitis, In: Trumble, TE, ed. Hand surgery update-3,
hand, elbow, shoulder. Rosemont, IL: American Society for Surgery
of the Hand, 2003:271284.
Pate MD, Bassini LB. Trigger fingers and thumb: when to splint, inject
or operate. J Hand Surg 1992;17A:110113.
Ritter WA, Inglis AE. The extensor indicis proprius syndrome. J Bone
Joint Surg 1969;51-A:16451648.
Weiss APC, Akelman E, Tabatabai M. Treatment of de Quervains
disease. J Hand Surg 1994;19A:59598.
Wolfe S. Tenosynovitis. In: Green DP, Hotchkiss RN, Pederson WC,
eds. Greens operative hand surgery. 4th Ed. New York: Churchill
Livingstone, 1999:20222044.
P1: JYT/... P2: IML/OVY QC: IML/OVY T1: IML
7
ENTRAPMENT
NEUROPATHIES
7.1 Median
Nerve 98
7.2 Ulnar
Nerve 106
7.3 Radial
Nerve 111
Common entrapment neuropathies or nerve compression
syndromes of the sensory and motor nerves in the arm, el-
bow, forearm, and wrist will be presented in this chapter.
Compression syndromes that occur in the arm, elbow, and
forearm are included because their major manifestations
are often in the hand.
The term compression neuropathy is an appropriate de-
scription of abnormal pressure on a nerve from an adjacent
anatomic structure. The underlying pathophysiology, how-
ever, is not understood as well, but may be related to me-
chanical factors and abnormal fluid homeostasis associated
with conditions such as diabetes, chronic renal failure, hy-
pothyroidism, or pregnancy. The role of mechanical factors
is easily appreciated in those diseases or tumors that re-
sult in a space-occupying lesion. Rheumatoid arthritis that
produces inflammation, and proliferation of the synovium
and ganglion cyst, may be extrinsic mechanical factors that
result in nerve compression.
The pertinent anatomy will be presented with each clini-
cal entity. Important features in the history, pertinent phys-
ical findings, and treatment options will be given for each
condition.
7.1 MEDIAN NERVE
Carpal Tunnel Syndrome (CTS)
Compression of the median nerve in the carpal canal is
more often than not seen as a chronic condition related to
a variety of causes. Some have placed it in the category of
repetitive stress syndrome, but it is beyond the scope of
this chapter to discuss this issue. This chronic condition is
appropriately contrasted to acute median nerve compression
seen most commonly in association with fractures about the
wrist.
Pertinent Anatomy
The median nerve enters the hand from the forearm and
wrist through a fibroosseous canal or tunnel. The floor and
sides of this tunnel are formed by the pronator quadratus
muscle and the carpal bones. Figure 7.1-1 shows the roof
of this structure, which is formed by the flexor retinaculum.
The flexor retinaculum is composed of the following:
1. Proximally, the antebrachial fascia and deep investing
forearm fascia.
2. The central portion is the transverse carpal ligament that
is defined by its attachments to the pisiform and hook
process of the hamate ulnarly, and radially to the tuberos-
ity of the scaphoid and ridge of the trapezium.
3. The distal portion is the aponeurosis between the thenar
and hypothenar muscles.
Nine flexor tendons accompany the median nerve through
this canal. These tendons are covered by a synovial sheath
called the ulnar and radial bursa (Figure 7.1-2). The reader
is referred to the suggested reading list for details of the
complex anatomy of this region.
Pathophysiology
Although the carpal canal is open proximally and distally, it
acts as a closed compartment. Chronic median nerve com-
pression results when pressure levels exceed those normally
tolerated by the median nerve. Carpal tunnel (CT) pressure
levels innormal subjects have beenrecorded at 2.5 to 10 mm
Hg, whereas CTS patients may exhibit levels of approxi-
mately 30 mm Hg. It is unclear, and experts have debated,
if the underlying cause of nerve dysfunction is the relation-
ship between mechanical factors or ischemia. It has been
observed that nerve compression of 20 to 30 mm Hg will
block venous blood flowand axonal transport, and compres-
sion of 60 to 80 mm Hg will block intraneural blood flow.
Nerve conduction block occurs at 130 to 150 mm Hg.
Pressure catheters placed in the CT of both CTS pa-
tients and normal subjects have revealed that CT pressures
98
Chapter 7 / Entrapment Neuropathies / Median Nerve 99
Hypothenar muscle
Thenar muscle
Radial artery
FCR
FCU
TCL
1
2
P S
H
T
3
Median nerve
Ulnar nerve
& artery (cut)
Antebrachial
fascia
Deep investing
fascia
Figure 7.1-1 The anatomy of the flexor
retinaculum. 1, antebrachial and deep investing
forearm fascia; 2, central portion of the transverse
carpal ligament (TCL); 3, distal aponeurosis. H,
hook process of hamate; P, pisiform; S, scaphoid;
T, thenar eminence.
are affected by finger, wrist, and forearm position, and ac-
tivities such as pinching and grasping. Carpal tunnel (CT)
pressure increases with wrist flexion and with extension.
Anatomic studies have noted incursion of the distal muscle
bellies of the FDS when the fingers are extended. They have
also noted similar incursion of the lumbrical muscles when
the fingers are flexed. This may partly explain the pressure
changes noted in various finger and wrist positions.
A2
Oblique
A1
Radial bursa
Ulnar
bursa
Figure 7.1-2 The synovial tissue that surrounds the nine flexor
tendons as they pass through the carpal tunnel is called the ulnar and
radial bursa.
Abnormal fluid homeostasis and carpal canal edema
are also factors leading to CTS in patients with diabetes,
chronic renal failure, hypothyroidism, and pregnancy.
Rheumatoid, gouty, or other inflammatory arthritis can
cause hyperplasia of the tenosynovium, which can dimin-
ish the space available in the carpal canal for the median
nerve. This compresses the nerve. Diabetic patients have a
predilection to develop CTS because of increased nerve sus-
ceptibility to injury, and because of a lower pressure thresh-
old for blockage of fast axonal transport.
Acute Carpal Tunnel Syndrome
Fractures about the wrist, including the distal radius and the
carpus, are the most common causes of acute compression
of the median nerve. These injuries are often characterized
as space-occupying lesions in terms of the carpal canal and
the median nerve. Avolarly displaced lunate or a fragment of
a Colles fracture may significantly compromise the volume
of the CT. This may compress the median nerve against the
flexor retinaculum. As part of a Colles fracture treatment, a
hematoma block and extreme wrist flexion have both been
shown to further increase pressure within the canal. Post-
traumatic edema associated with these injuries also plays a
significant role in the production of acute CTS.
Diagnosis
Patient History
Patients with CTS often present with multiple com-
plaints, but the most common is numbness and tingling
in the fingers and thumb.
The patient is often unable to tell the examiner which
digits tingle.
The numbness may be constant or intermittent, and
commonly occurs 2 to 3 hours after retiring for the
night. These nocturnal symptoms have been ascribed
to the fact that the normal use of the hand during
the day promotes the flow of well-oxygenated blood
to the median nerve. At night, however, venous stasis
occurs, and oxygen tension in the nerve decreases to
a level that promotes or triggers the symptoms. This
concept is supported by the fact that patients often
relieve the numbness through vigorous massage or by
shaking their hands.
Patients often complain of dropping things, and they
sometimes complain of pinch or grip weakness.
Predisposing or associated conditions should be asked
about. Those include occupational and sports activi-
ties, as well as associated disorders such as rheumatoid
arthritis, diabetes, and thyroid disease. Other peripheral
neurological disorders that may produce hand numbness
are cervical radiculopathy, brachial plexopathy, thoracic
outlet syndrome, apical lung tumor, pronator syndrome,
cubital and ulnar tunnel syndrome, and peripheral neu-
ropathy.
Bilateral CTS in a young male should prompt an investi-
gation for acromegaly.
Physical Examination
Sensory Tests
Sensory evaluation may be by static or moving two-point
discrimination (2PD) and Semmes-Weinstein (SW)
monofilaments.
The static 2PD evaluates the status of slowly adapting
large myelinated fibers, while the moving 2PD evalu-
ates the fast adapting large myelinated fibers.
SW monofilaments are threshold tests that evaluate
sensory end organ function.
The SW test is more sensitive in identifying compressive
neuropathy than 2PD; when abnormal 2PD is present,
the disease is more severe.
Motor Evaluation
Motor evaluation consists of looking for thenar atrophy
and strength testing the abductor pollicis brevis.
The disease is considered severe and is usually longstand-
ing when there is thenar muscle atrophy.
Atrophy is seldom, if ever, recovered following CT re-
lease.
Provocative Tests
Commonly used provocative tests for CTS include
Phalens and Tinels signs, the CT compression test
(Durkans sign), the tourniquet test, and a combined
Phalens maneuver withSWmonofilament testing. These
and other useful tests are given in Table 7.1-1.
Electrodiagnostic Tests
Electrodiagnostic studies include nerve conduction ve-
locity (NCV) and electromyography (EMG).
An abnormal nerve conduction result includes decreased
action potential amplitude, increased distal latency, and
decreased velocity.
A distal motor latency of >4.5 ms and a sensory latency
of >3.5 ms constitute and abnormal result. These mea-
surements are achieved using an orthodromic stimulus
and recording across the wrist.
Additional diagnostic accuracy has been shown with
nerve conduction measurements assessing short nerve
segments (such as the inching technique or the compar-
ison of palm-to-digit and wrist-to-digit latencies). In the
case of CTS, measurements are made by isolating the
wrist segment.
Electromyography measures insertional activity, resting
potential, and muscle activation.
Increased insertional activity, fibrillations at rest, pos-
itive sharp waves, complex repetitive discharges, and
decreased motor unit recruitment are all consistent
with nerve compromise.
Diagnostic Reliability. Szabo and co-workers noted that
the accuracy with which a patient can be diagnosed with
CTS depends on the population being studied. They ob-
served that a combination of findings in the history and
physical exam was more accurate than the same findings
in isolation. The CTS was accurately diagnosed 86% of the
time when night pain, a positive SW monofilament test, a
positive Durkans test, and a positive Brighamhand diagram
were all present; the probability of having CTS was 0.68%
when all of these tests were negative. These authors noted
that electrodiagnostic studies did not add to the diagnostic
power of this combination of tests.
Some believe that electrodiagnostic studies provide the
only objective evidence, and equate it to the gold standard
for diagnosis of CTS. But not all agree. These tests may be
positive in asymptomatic individuals, and negative in indi-
viduals with classic signs and symptoms. Some observers
have noted that a significant number of patients diagnosed
with CTS on clinical groundsbut with negative electrodi-
agnostic studieshave improved following a CTR.
Median Nerve Contusion
It is important to distinguish median nerve contusion from
acute CTS, because delayed release of an acute CTS may
result in a poor outcome. Contusion may be treated by ob-
servation, whereas acute CT syndrome requires immediate
release.
Signs and symptoms of contusion appear immediately, in
contrast to those of compression that may occur later,
as swelling increases. Thus, initial and careful sensory
evaluation is mandatory.
SW or 2PD tests are useful.
In some cases, direct pressure measurements are indi-
cated. Pressure greater than 40 mm Hg as measured by a
wick catheter in the CT indicates the need for immediate
CT release.
Treatment
Nonsurgical Treatment. Conservative or nonoperative
treatment is indicated for mild CTS, and is initially indi-
cated for moderate cases. Any associated conditions should
be identified and treated as indicated.
Treatment is aimed at the underlying process, and may
include activity modification such as ergonomic studies
and corrections, splints that immobilize the wrist in a
neutral position, and oral nonsteroidal medication. In
some cases, treatment includes a short course of steroidal
anti-inflammatory medication.
TABLE 7.1-1 TESTS FOR CARPAL TUNNEL SYNDROME (CTS)
Interpretation of
Test How Performed Condition Tested Positive Result Positive Result
Phalens test Elbows on table, forearms
vertical, wrists exed
Paresthesia in
response to
position
Numbness or tingling
on radial digits within
60 seconds
Probable CTS (sens
0.75, spec 0.47)
Percussion test
(Tinel sign)
Lightly tap along median
nerve from proximal to
distal
Site of nerve lesion Electric tingling
response in ngers
Probable CTS if positive
at the wrist (sens 0.60,
spec 0.67)
Carpal tunnel
compression test
(Durkan)
Direct compression of
median nerve at carpal
tunnel
Paresthesia in
response to
compression
Paresthesia within
30 seconds
Probable CTS (sens
0.87, spec 0.90)
Hand diagram Patient marks site of pain
or altered sensation on
outlined hand diagram
Patients perception
of symptoms
Markings on palmar side
of radial digits, without
markings in palm
Probable CTS (sens
0.96, spec 0.73,
negative predictive
value 0.91)
Hand volume stress
test
Hand volume measured
by displacement, repeat
after 7-minute stress
test and a rest of
10 minutes
Hand volume Hand volume increased
by 10 mL or greater
Probable dynamic CTS
Direct measurement
of carpal tunnel
pressure
Wick or infusion catheter
placed in carpal tunnel
Hydrostatic pressure
in resting and
provocative
positioning
Resting pressure 25 mm
Hg or more (variable
and technique related)
Hydrostatic compression
is felt to be probable
cause of CTS
Static 2-point
discrimination
Determine minimum
separation of two
distinct points when
applied to palmar
ngertip
Innervation density
of slow-adapting
bers
Failure to determine
separation of at least
5 mm
Advanced nerve
dysfunction
Moving 2-point
discrimination
As above, with movement
of the points
Innervation density
of fast-adapting
bers
Failure to determine
separation of at least
4 mm
Advanced nerve
dysfunction
Vibrometry Vibrometer placed on
palmar side of digit,
amplitude set to
120 Hz, and increase to
threshold of perception;
compare median and
ulnar bilaterally
Threshold of
fast-adapting
bers
Asymmetry compared to
contralateral hand or
median to ulnar in
ipsilateral hand
Probable CTS
(sens 0.87)
Semmes-Weinstein
monolaments
Monolaments of
increasing diameter
touched to palmar side
of digit until patient can
determine which digit is
touched
Threshold of slowly
adapting bers
Value greater than 2.83 Median nerve
impairment (sens 0.83)
Distal sensory
latency and
conduction
velocity
Orthodromic stimulus and
recording across wrist
Latency, conduction
of sensory bers
Latency greater than
3.5 msec, or asymmetry
of conduction velocity
of greater than 0.5 msec
versus opposite hand
Probable CTS
Distal motor latency
and conduction
velocity
Orthodromic stimulus and
recording across wrist
Latency, conduction
velocity of motor
bers of median
nerve
Latency greater than
4.5 msec, or asymmetry
of conduction velocity
of greater than 1.0 msec
Probable CTS
Electromyography Needle electrodes placed
in muscle
Denervation of
thenar muscles
Fibrillation potentials,
sharp waves, increased
insertional activity
Advanced motor median
nerve compression
Sens, sensitivity; spec, specicity. (From Abrams R, Meunier, M. Carpal tunnel syndrome. In: Trumble TE, ed. Hand surgery update 3, hand, elbow,
shoulder. Rosemont, IL: American Society for Surgery of the Hand, 2003:299312.)
Steroid injection or steroid iontophoresis into the CT,
along with splinting, may give short-term benefit. It oc-
casionally gives long-term benefit.
A positive response affirms the diagnosis, and may be a
predictor of a satisfactory surgical outcome, if required.
Stretching, strengthening, and flexibility exercises may
also play a significant role in recovery and avoidance of
surgery in selected patients.
Surgical Treatment
Indications
Surgical treatment of CTS is indicated for patients who
have failed conservative treatment, and for patients with
thenar muscle weakness, atrophy, or with signs of motor
denervation on electrodiagnostic studies.
Open Surgical Technique
Incision
The incision for open CT release is a longitudinal inci-
sion that begins at the wrist flexion crease and ends about
1 cm proximal to the proximal palmar crease. Its axis
is somewhat parallel to the radial border of the ring
finger.
Others have tried to identify the ideal site of place-
ment, and have noted that the depression between the
thenar and hypothenar eminence is the ideal site for
the incision.
This sought-after zone is the zone in which the least
number of superficial nerves are present. But there is
no true internervous or nerve-free zone for this inci-
sion (Figure 7.1-3).
The incision just described places the dissection to
the ulnar side of the CT, which is considered to be the
relatively safe side for entering the canal and releasing
the TCL.
Some surgeons have used smaller, single- or two-portal
incisions to accomplish exposure and release of the TCL.
Many of these techniques use special blade-guide instru-
ments to facilitate section of the TCL.
Deep Dissection. The goal of this operation is to com-
pletely release the ulnar margin of the TCL without in-
jury to vital structures such as the median nerve and its
branchesincluding the recurrent or motor branchand
the superficial palmar arch that is just distal to the dis-
tal end of the TCL. The technical details of the vari-
ous CT release techniques are beyond the scope of this
text.
Endoscopic Release of the Carpal Canal. A variety of
techniques have been developed that utilize the arthroscope
to assist in TCL section. Single- and two-portal techniques
have been used with success.
Open Versus Endoscopic CT Release. Studies compar-
ing these two basic techniques have suggested that there
is earlier functional recovery in the endoscopic technique
compared to open techniques. However, there is no current
evidence available to show that the endoscopic technique
is superior in terms of final outcome to the open technique.
PCBMN
Nerve of Henle
PCBUN
Trans. PCBUN
P
Figure 7.1-3 Cutaneous innervation of the palm as it relates to
open carpal tunnel release. Four nerves are at risk (all nerves that
may be cut or pass within 2 mm of the incision): the palmar
cutaneous branch of the median nerve (PCBMN); the palmar
cutaneous branch of the ulnar nerve (PCBUN); the nerve of Henle;
and transverse palmar branches (Trans. PCBUN) from the ulnar
nerve in Guyons canal.
Caveat: CT release by any means, including open,
limited-open with or without special guide instruments, and
endoscopic release, have all been associated with complica-
tions.
Ancillary Procedures With CT Release. Studies have
shown that there is no added benefit fromtenosynovectomy,
epineurotomy, or internal neurolysis in idiopathic CTS.
Pronator Teres Syndrome and Proximal Sites
of Median Nerve Compression
Sites of Compression
There are five potential sites of proximal median nerve com-
pression: two are in the distal arm and three are in the prox-
imal forearm (Figure 7.1-4).
The first distal arm site is an abnormal proximal origin of
the superficial head of the pronator teres from the supra-
condylar ridge rather than the medial epicondyle. This ab-
normal muscle positionresults inlateral displacement of the
neurovascular bundle, and has the potential for compres-
sion of the underlying median nerve and brachial artery.
The second distal arm site is represented by a supra-
condylar process and a ligament of Struthers, which
spans between the supracondylar process and the me-
dial epicondyle, thus creating an arcade that contains
the median nerve and brachial artery. The supracondy-
lar process is a hook-shaped projection of bone from the
A B
C D
Figure 7.1-4 Sites of compression of the median nerve in the
arm/forearm. (A) The ligament of Struthers from an anomalous
supracondylar process to the medial epicondyle. (B) The pronator
teres. (C) The lacertus fibrosus (the least common cause). (D) A
fibrous arch in the flexor digitorum superficialis of the middle finger.
anteromedial aspect of the distal humerus. It arises 3 to 5 cm
proximal to the medial epicondyle and is 2 to 20 mm in
length. Its incidence is approximately 1%, and it is a rare
cause of pressure on the under lying median nerve and
brachial artery.
In the proximal forearm, the median nerve may be com-
pressed at one of three levels, in the following order of
frequency: the pronator teres, the flexor superficialis arch,
and the lacertus fibrosus.
Pronator Teres (PT). Dissections of the proximal forearm
have revealed either a fibrous band on the dorsum of the
superficial head of the pronator overlying the median nerve,
or a fibrous band as a component of the deep ulnar head of
the pronator when the latter was present, or, when the deep
head was absent, a separate fibrous band attached to the
coronoid process of the ulna proximally. In some instances,
fibrous bands were noted on both heads, which formed a
definite fibrous arcade.
Flexor Superficialis Arch. A fibrous arcade was observed
in approximately one third of the dissections spanning from
the proximal margin of the FDS to the middle finger.
Lacertus Fibrosus. Entrapment of the median nerve be-
neath the lacertus fibrosus is the least common cause of
median nerve entrapment in the proximal forearm. It may
be secondary to hypertrophy or enlargement of the lacertus.
Diagnosis
Functional muscle testing may give some indication of the
site of compression (Figure 7.1-5).
If complaints are produced by flexion of the elbowagainst
resistance between 120 and 135 degrees of elbowflexion,
compression may be in the distal arm beneath a ligament
of Struthers.
Compression by the lacertus fibrosus may be aggravated
by active flexion of the elbow against resistance when the
arm is pronated.
If symptoms are increased by resisted pronation of the
forearm (usually combined with wrist flexion to relax the
FDS), the nerve may be compressed between the prona-
tor.
If the symptoms are aggravated by resisted flexion of the
FDS to the middle finger, compression may be at the
FDS proximal arch.
Treatment
The operative technique for treatment of pronator syn-
drome includes complete exploration of the median
nerve, from the distal arm to the proximal forearm.
The mediannerve is explored fromthe regionof a possible
anomalous supracondylar process and an associated lig-
ament of Struthers to the proximal edge of the FDS, with
release of all potentially constricting structures, includ-
ing the ligament of Struthers and the lacertus fibrosus.
At the level of the PT, compression may be because of
muscle hypertrophy or constricting muscle fascial bands.
Further decompression of the median nerve is achieved
by tracing the median nerve into the substance of the PT,
and then releasing any areas of constriction.
The final site of possible constriction is in the proximal
edge of the FDS, which may be exposed by entering the
interval between the FCR and the PT.
The median nerve may be constricted here beneath a
fibrous tissue arch along the leading edge of the FDS.
A persistent median artery has also been observed as a
cause of pronator syndrome. Reported cases have demon-
strated penetration of the median nerve by the median
artery, and constriction of the nerve by vascular leashes
from the median artery.
FDS proximal arch
C
B A
Lacertus fibrosus
& pronator
Struthers
ligament
120135
Figure 7.1-5 Localizing tests for
median nerve compression in the
proximal forearm. (A) Test for
presence of a ligament of Struthers.
(B) Test for lacertus fibrosus and
pronator teres compression. (C) Test
for median nerve compression by
fibrous tissue arch of flexor
digitorum superficialis of the middle
finger (see text).
Anterior Interosseus Nerve Syndrome
Compression of the anterior interosseus nerve (AIN) char-
acteristically results in complete or partial loss of function
of the FPL and the flexor digitorum profundus (FDP) of
the index finger and long fingers, as well as of the PQ. This
occurs without any sensory deficits. These findings may be
associated with vague complaints of discomfort in the prox-
imal forearm. In the complete AIN syndrome (AINS), the
affected patient assumes an unusual pinch posture with the
distal joint of the index and thumb in extension. Although
the FPL and FDP of the index are innervated exclusively
by the AIN, the FDP of the long finger is exclusively inner-
vated by the AIN only 50% of the time. In the remaining
50%, the long finger FDP is at least partially innervated by
the ulnar nerve. Variations from the classic AINS include
isolated paresis or paralysis in either the index profundus or
the FPL. In both complete and partial types, there is often
an antecedent history of unusual muscular exertion, blunt
trauma, or edema in the extremity.
Diagnosis
AINS, especially the incomplete type, must be distin-
guished from flexor tendon rupture, flexor tendon ad-
hesion, and stenosing tenosynovitis.
If a Martin-Gruber connection is present between the
AIN and the ulnar nerve, there may be intrinsic muscle
paresis or atrophy.
The incomplete type of AINS may be distinguished from
rupture of the FPL by noting passive flexion of the in-
terphalangeal joint of the thumb with wrist and metacar-
pophalangeal (MCP) joint hyperextension in AINS, in
contrast to absence of thumb interphalangeal joint flex-
ion in rupture of the FPL.
Compression Sites
The nerve is usually compressed by fibrous bands that
run from the deep (most common) or superficial head of
the PT to the brachialis fascia (Figure 7.1-6).
Other sites of compression have been identified, includ-
ing the fibrous tissue arcade of the FDS, which the
AIN passes beneath to sit on the interosseous membrane
(IOM).
Other reported causes of compression include enlarged
bursae or tumors, aberrant or thrombosed vessels, a dou-
ble lacertus fibrosus overlying the nerve, compression of
the nerve as it runs deep to both heads of the PT, and
fractures of the forearm and distal humerus.
Three aberrant muscles have been identified in associa-
tion with AINS, including an accessory head of the FPL
called Gantzers muscle, the palmaris profundus, and the
flexor carpi radialis brevis (FCRB).
Although an accessory head of the FPL (Gantzers
muscle) has been identified as a cause of AINS, some
observers have noted that Gantzers muscle always is
posterior to the median nerve and AIN. However, in
dissections of the forearm in which Gantzers muscle
was present, the authors demonstrated the possibility
of a pincer-like effect between this abnormal poste-
rior head and the adjacent anterior FDS. This could
produce compression of the median nerve, as well as
the AIN. The median nerve and AIN passed through
the interval between these two muscles, which share
a common origin on the medial epicondyle.
The common denominator in this condition appears to
be localized edema, superimposed on an anatomic abnor-
mality that is either congenital or acquired.
Treatment
Nonsurgical Treatment. Patients who present with pare-
sis may be observed, because most improve spontaneously
Deep head,
pronator teres
FCRB
A B C
D E
Palmaris profundus
Fibrous arch,
FDS
Gantzers muscle
Figure 7.1-6 Anterior interosseous nerve
compression sites. (A) Deep head of the pronator
teres. (B) Fibrous arch of the middle finger flexor
digitorum superficialis. (C) Gantzers muscle. (D)
Abnormal flexor carpi radialis brevis (FCRB). (E)
Abnormal palmaris profundus muscle. FDS, flexor
digitorum superficialis.
without surgery. This is especially true in children with
AINS associated with fractures of the forearm and elbow
region.
Surgical Treatment
Exploration and decompressionis advised in patients who
present with complete paralysis of either muscle tendon
unit and who have shownno improvement, as determined
by physical examination or repeat EMG after 12 weeks
of observation.
The AIN is exposed through a curved incision beginning
at the antecubital flexion crease just medial to the biceps
tendon.
The median nerve is traced distally to its entrance be-
tween the two heads of the PT, and the superficial head
of the PT is mobilized and retracted to reveal the usual
site of origin of the AIN, from the posterior aspect of the
median nerve.
The site of compression may be identified by noting a pale
discoloration in the nerve, with or without a concomitant
indentation of the nerve.
All potential sites of compression are released; it is not
necessary to perform an internal neurolysis.
It may be necessary to divide the insertion of the PT, in
order to facilitate exposure of the AIN at the superficialis
fibrous arcade.
7.2 ULNAR NERVE
Ulnar Nerve Compression (Wrist)
Compression of the ulnar nerve at the wrist is significantly
less common than compression at the elbow.
Subjective complaints include loss of dexterity in the
hand, which results in clumsiness, dropping things, or
weakness.
Numbness in the ring and little fingers may be prominent
symptoms, and may be verified on physical examination.
Motor weakness of the intrinsic muscle may be present in
early cases, and atrophy of the intrinsic muscles may be
present in late cases or severe compression of the motor
component of the nerve.
A characteristic claw deformity of the ring and little fin-
gers may be observed with motor deficit.
Pertinent Anatomy
Ulnar Tunnel (Guyons Canal). Guyons canal, or the
ulnar tunnel, is the space that the ulnar nerve and artery
traverse to gain entrance to the hand from the forearm.
Little finger
tendon sheath
To superficial arch
To deep arch
Fibrous arch
Motor branch
Branch to
hypothenar
muscles
Ulnar artery
Ulnar nerve
Branch to
ulnar side
of little finger
ODM
FDM
ADM
PB
H
P
FCU
Figure 7.2-1 The ulnar nerve in Guyons canal.
The ulnar nerve may divide into motor and sensory
components proximal to, at, or in Guyons canal,
but the most common configuration is division
in Guyons canal an average of 8.6 mm (range,
015 mm) from the proximal edge of the pisiform.
H, hook process of hamate; P, pisiform.
Guyons canal begins at the proximal edge of the palmar
carpal ligament and ends at or beyond the fibrous arch of
the hypothenar muscles. Beginning from proximal to distal,
the roof of the canal is formed by the palmar carpal ligament,
portions of the palmar aponeurosis, and the palmaris brevis
muscle. The floor is formed by the TCL, the pisohamate and
pisometacarpal ligaments, and the FDM. The ulnar wall is
composed of the flexor carpi ulnaris (FCU), the pisiform,
and the ADM. The radial wall is formed by the tendons of
the extrinsic flexors, the TCL, and the hook process of the
hamate. The average length of Guyons canal is 27 mm,
with a range from 20 to 34 mm. The ulnar nerve and artery
branches in this region are covered by the palmaris brevis
muscle, and are surrounded by a thick fat pad.
Ulnar Nerve in Guyons Canal. The ulnar nerve, accom-
panied by the ulnar artery on its radial side, enters the hand
on the radial side of the pisiform bone through Guyons
canal (Figure 7.2-1). The ulnar nerve may divide into mo-
tor and sensory components proximal to, at, or in Guyons
canal, but the most common configuration is division in
Chapter 7 / Entrapment Neuropathies / Ulnar Nerve 107
Guyons canal at an average of 8.6 mm (with a range of 0
to 15 mm) from the proximal edge of the pisiform.
Ulnar Motor Branches. The motor component of the nerve
at the level of the pisiform is ulnar and dorsal. The mo-
tor branch gives off one to three (usually two) branches to
the hypothenar muscles before it enters the depths of the
palm. Its course into the palm has been variously described
as passing between the origin of the FDM and ODM, or
beneath the proximal origin of the FDM. It then courses
around the ulnar and distal aspect of the base of the hook
process of the hamate. The proximal edge of the FDMoften
demonstrates a fibrous arcade, where the motor branch may
become entrapped. It then traverses the hand to innervate
the ring and small finger lumbricals, the palmar and dorsal
interossei, the adductor pollicis, and the deep head of the
FPB (Figure 7.2-2).
Ulnar Sensory Branches. After division into a sensory trunk
and a motor branch in Guyons canal, the sensory compo-
nent divides into the sensory branch to the ulnar side of the
little finger, and the common sensory nerve to the fourth
web space, which subsequently divides into the PDN to
the radial side of the little finger and the ulnar side of the
ring finger. The motor branch to the palmaris brevis usually
arises from the sensory branch to the little finger.
The Zones of Guyons Canal. Guyons canal has been di-
vided into three zones to aid in identification of the most
common or likely causes of nerve compression in the ulnar
tunnel. Zone 1 is from the proximal edge of the proximal
commissural ligament (PCL) to the bifurcation of the ul-
nar nerve. Zones 2 and 3 are parallel zones that begin at
the bifurcation of the nerve and that end at the region just
beyond the fibrous tissue arch of the hypothenar muscles.
Zone 2 contains the motor branch of the ulnar nerve, and
zone 3 contains the sensory branch of the nerve. Zones 2
and 3 are not divided by an anatomic structure, but rather
are arbitrary divisions that have useful clinical applications.
FPB,
deep head
FPB
FPB
APB
PB
P1
L
L
L L
P1
P1
D1
D1
D1
D1
D1
FDM
AdP
Figure 7.2-2 The deep motor branch of the ulnar nerve in the palm.
See text for details.
Diagnosis
The clinical relevance of these zones is apparent in Table
7.2-1. These zones are useful for the localization and cor-
rect prediction of the cause of ulnar neuropathy in Guyons
canal. This information, along with a careful history, sen-
sory and motor examination, careful palpation, Allens test,
and radiographs of the wrist, may lead to an accurate pre-
diction of the cause of the ulnar deficit.
Treatment
Decompressionof the ulnar nerve inGuyons canal is per-
formed through a longitudinal zigzag incision centered
over the interval between the pisiform and the hook pro-
cess of the hamate (Figure 7.2-3).
The roof of the canal is incised to reveal the underlying
nerve and artery on the radial side of the FCU tendon.
TABLE 7.2-1 AREAS AND CAUSES OF ULNAR NERVE COMPRESSION IN GUYONS
CANAL
Decit Zone 1 Zone 2 Zone 3 Causes Occurrence (%)
Motor and sensory 42 Ganglions 45
Fractures 36
Anomalous muscles 7
Motor alone 1 42 Ganglions 60
Fractures 12
Thickened pisohamate
ligament
7
Sensory alone 7 10 Thrombosis 30
Synovitis 24
Anomalous muscles 12
These represent the most frequent causes of ulnar nerve compression, and do not add up to 100%. Those patients
with combined motor and sensory loss without a history of trauma had a ganglion as the cause of the ulnar decit 45%
of the time. Isolated motor decits occurred most frequently in zone 2 and were due to a ganglion 60% of the time.
Isolated sensory decits occurred most commonly from compression in zone 3, but also may occur in zone 1;
thrombosis of the ulnar artery was the most frequent cause. (Taken from Doyle JR, Botte MJ. Palmar hand. In: Surgical
anatomy of the hand and upper extremity. Philadelphia: Lippincott Williams & Wilkins, 2002:578.)
B A
C
Figure 7.2-3 Surgical approach to Guyons canal. (A) A longitudinal
zigzag incision is used in the interval between the pisiform and hook
process of the hamate (dots) in order to unroof the canal. (BC) Note
the arrangement of the artery, nerve, and tendon (ANT) from radial
to ulnar, and also note the relationship of the nerve to the FCU
tendon, pisiform, and hook process of the hamate bone.
Cubital Tunnel Syndrome (Elbow)
The term cubital tunnel syndrome was proposed in 1958
to identify a specific site of entrapment of the ulnar nerve,
and to distinguish it fromtardy ulnar palsy that is associated
with posttraumatic cubitus valgus.
Pertinent Anatomy
The ulnar nerve enters the posterior aspect of the armat ap-
proximately the midpoint of the arm, and continues distally
toward the elbow behind the medial intermuscular septum
on the medial head of the triceps muscle. The nerve con-
tinues to the elbow, where it enters the fibroosseous cubital
tunnel. The tunnel can be divided into three parts. The
first part of the cubital tunnel is the entrance of the tunnel
formed by the ulnar groove in the medial epicondyle. At this
level, the ulnar nerve usually provides one or several small
articular branches to the elbow joint, and these branches
usually are proximal to the branches given off to innervate
the FCU.
The second, and middle, part of the tunnel consists of
a fascial arcade that is a fan shaped ligament covering the
tunnel. It attaches to the medial epicondyle and to the ole-
cranon, and connects the ulnar and humeral heads of the
origin of the FCU muscle. In this area, the nerve lies on the
posterior and oblique portions of the ulnar collateral liga-
ment, and usually gives off two branches to innervate the
FCU. One branch usually supplies the humeral head, and
one supplies the ulnar head. The first branch exits the main
nerve trunk horizontally. The second branch continues dis-
tally for several centimeters before entering the FCU. Up to
four motor branches to the FCU may be given off, exiting
the main nerve at a point between 4 cmproximal and 10 cm
distal to the medial epicondyle. The motor branches enter
the FCU on its deep surface. The distance between the me-
dial humeral epicondyle and the olecranon is shortest with
elbowextension. This distance increases with elbowflexion.
The roof or fascial arcade becomes taut with elbow flexion.
The third, and most distal, part of the tunnel consists of
the muscle bellies of the FCU. The FCU provides a portion
of the roof in this area. The nerve courses through the in-
terval between the humeral and ulnar heads of the FCU, or
between the FCU and the FDP muscles. It continues dis-
tally in the forearm between the FDP, located dorsally and
laterally to the nerve, and the FCU, located anteriorly and
medially. The volume of the tunnel decreases with elbow
flexion, and the pressure within it increaseseven in the
normal elbow when the aponeurotic arch or surrounding
soft tissues are not thickened.
Pathophysiology
The ulnar nerve at the elbow is subcutaneous through-
out much of its course, and also is partially fixed in a fi-
broosseous canal. Because of its exposed position, and the
fact that it wraps around the medial condyle in flexion, pro-
longed elbow flexionwhich stretches the nerve and nar-
rows the tunnelcombined with resting the elbowon a hard
surface may result in paresthesias in the ring and little fin-
gers. This occurs even in normal people. When swelling of,
or elbow inflammation or congestion of, the flexor-pronator
Chapter 7 / Entrapment Neuropathies / Ulnar Nerve 109
muscles is added to this stretchcompression, the vascular
supply of the ulnar nerve may be compromised, and nerve
symptoms may result. Sustained elbow flexion combined
with vigorous finger and wrist motionsuch as that which
a musician might performcan also result in ulnar nerve
symptoms. The motions used to throw a ball and for a ten-
nis serve are similar, and can place significant stress on the
ulnar nerve. They may be associated with ulnar nerve symp-
toms. Perioperative ulnar neuropathies are more common
in men than in women. Although there is no gross anatomic
difference between the sexes regarding the course of the ul-
nar nerve in the upper extremity, there is a significantly
larger (2 to 19 times greater) fat content on the medial as-
pect of the elbow in women compared to men. Also, the
tubercle of the coronoid process on the ulna is 1.5 times
larger in men.
Surgical treatment of cubital tunnel syndrome is facilitated
by knowledge of the potential sites of compression, and of
the anatomy specific to each of those areas.
Arcade of Struthers. Although recently contested by
some observers as to its name and occurrence, there is a
potential site of entrapment of the ulnar nerve that lies 8 cm
proximal to the medial epicondyle called the arcade of
Struthers. When the arcade is present, both the ulnar nerve
and the superior ulnar collateral vessels pass through it. In
a study of 25 arms, the arcade of Struthers was present
68% of the time. The arcade has a medial-facing roof,
formed by the deep investing fascia of the arm, superfi-
cial muscle fibers from the medial head of the triceps,
and the internal brachial ligament arising from the cora-
cobrachialis tendon. The floor, which is lateral, is formed
by the medial aspect of the humerus, and is covered by
the deep muscular fibers of the medial head of the triceps.
The anterior border is the medial intermuscular septum
(Figure 7.2-4).
Medial Head Triceps. The ulnar nerve may be buried in
the medial head of the triceps muscle, and this overlying
muscle roof may be a source of compression. When it is, it
should be incised.
8 cm
Medial
intermuscular
septum
Medial
intermuscular
septum
Arcade of Struthers
Ulnar nerve
Medial head,
triceps
Medial
epicondyle
Arm fascia
Internal br.
ligaments
Superior
fibers
TRICEPS
A
B
Figure 7.2-4 Fresh cadaver dissection of the
so-called arcade of Struthers. (A) The
appearance of the arcade over the ulnar nerve
and its relationship to the medial intermuscular
septum (MIMS). Here, the upper vertical arrow
marks the MIMS, the lower vertical arrow marks
the ulnar nerve, and the opposed horizontal
arrows mark the arcade. (B) Artists depiction of
the relationship of the arcade to the MIMS and
the medial epicondyle.
Figure 7.2-5 Fresh cadaver dissection of the medial aspect of the
arm and elbow. Note the probe under the cubital tunnel retinaculum.
Medial Intermuscular Septum. The ulnar nerve lies pos-
terior to the medial intermuscular septum (MIMS)and
when the ulnar nerve is transposed anteriorlyit can repre-
sent a sharp edge that may cause impingement of the nerve.
The MIMS should be excised as part of ulnar transposition,
as discussed under the treatment section (see Figure 7.2-4).
Elbow (Cubital Tunnel). The ulnar nerve in its passage
from the arm to the forearm transits the cubital tunnel,
which is an osseous canal formed by the medial epicondyle
and the proximal ulna. It is covered by a retinaculumformed
by the deep investing fascia of the arm that is attached to
the medial epicondyle and the olecranon. This cubital tun-
nel retinaculum (CTR) is 2 to 3 cm wide from proximal
to distal, and 0.5 to 0.75 mm thickand its distal margin
blends with the investing fascia of both the humeral and
ulnar heads of the FCU. Osbornes band and the arcuate
ligament are other names often used to describe this fibrous
tissue roof of the ulnar tunnel (Figure 7.2-5). Because of
the somewhat eccentric origin of this fascial roof, the cu-
bital tunnel changes contour and volume during elbow flex-
ion and extension. In flexion, the cross-sectional contour
changes from slightly ovoid to elliptical (Figure 7.2-6). Any
swelling in the canalor inflammation or thickening of the
fascial roofmay compress the nerve or its vasculature.
Forearm. At the distal end of the cubital tunnel the ulnar
nerve enters the forearm through the flexor pronator group
of muscles, usually between the humeral and ulnar heads of
the FCU. The flexor-pronator muscles are arranged in two
groups. The superficial group is formed by five muscles (the
PT, FCR, PL, FDS, and FCU) that originate from a com-
mon origin created by the fusion of several fibrous septae.
Those septae arise from the anterior surface of the medial
humeral epicondyle, the ulnar collateral ligament, and me-
dial surface of the coronoid process. They formwell-defined
fascial compartments for the muscles, as well as a common
aponeurosis from which adjacent muscles originate. These
septae fuse, beginning approximately 3.5 to 4 cm distal to
the epicondyle. This fused structure is commonly known as
EXTENSION
FLEXION
Figure 7.2-6 Changes in the cubital tunnel with flexion and
extension.
the flexor-pronator origin, or the flexor-pronator aponeuro-
sis. Anadditional aponeurosis inthis area is present between
the FDS to the ring finger and the humeral head of the
FCU that did not fuse with the previously described com-
mon flexor pronator origin but rather arose from the medial
surface of the coronoid process 0.3 to 0.5 cmmedial to it. If
present, it may not be possible to transpose the ulnar nerve
adjacent to the median nerve in a relatively straight course
unless this septum is detached along with the radial two-
thirds of the flexor-pronator group. Others have identified a
structure deep to the FDS, and superficial to both the FDP
and the FCU, that provided a point of origin for all of these
muscles. That structure extended approximately 5 cmdistal
to the epicondyle. This deep aponeurosis of the FCU, which
bridges and forms a common origin for muscle fibers of the
FCU, FDS, and FDP, should be released by separating the
two heads of the FCU and exploring the deep surface of the
muscle for at least 5 cm distal to the epicondyle.
Diagnosis
Clinical findings include complaints of medial elbow
pain, numbness and tinglingor burningin the ring
and little fingers, hand clumsiness, and weakness of
pinch.
Physical findings may include tenderness behind the me-
dial condyle over the course of the ulnar nerve, as well as
a positive Tinels sign over the nerve 2 cm proximal and
distal to the cubital tunnel.
Other physical findings include decreased sensibility in
the ring and little fingers, as well as decreased pinch and
grip strength.
Claw deformity of the ring and little fingers, as well as in-
trinsic muscle atrophy, are seen in severe and prolonged
cases.
Physical findings that aid in the diagnosis are tenderness
over the ulnar nerve at the elbow, reproduction of the pa-
tients symptoms with elbowflexion, and positive findings
with sensory evaluation.
Chapter 7 / Entrapment Neuropathies / Radial Nerve 111
Electrodiagnostic studies have a high rate of false nega-
tives.
Other causes of symptoms that mimic cubital tunnel syn-
drome (such as thoracic outlet syndrome) should be elim-
inated by appropriate tests.
Weakness of the FDS to the little finger may be present
in cubital tunnel syndrome, but not in ulnar nerve com-
pression at the wrist. This finding may be helpful in dis-
tinguishing these two conditions.
Treatment
Conservative treatment is appropriate for mild and early
cases of cubital tunnel that present without motor deficit.
Avoidance of elbow flexion and pressure over the point
or medial aspectof the elbow, along with oral anti-
inflammatories, may be beneficial.
Surgical Treatment
Common to all ulnar nerve transpositions is elimina-
tion of compression or traction problems by removing
the nerve from the fibroosseous tunnel and permanently
transposing it to an anterior location.
Permanent transposition has been achieved by subcuta-
neous transposition, subcutaneous transposition with
some form of tether to prevent the nerve from assum-
ing its original position, or submuscular or intramuscular
transposition.
The sine qua non of ulnar nerve transposition is perma-
nent realignment of the ulnar nerve in an anterior po-
sition, without entrapment (absence of compression) or
fixation (traction). Such complications would prevent the
nerve from gliding.
It also must be recognized that the ulnar nerve remains
subcutaneous throughout most of its new course, and
that even submuscular or intramuscular transposition
eliminates only a portion of this subcutaneous posi-
tion.
The effectiveness of transposition is based on decompres-
sion of the nerve and on elimination of any potential for
traction injury.
A factor in the avoidance of secondary entrapment fol-
lowing transposition might be early and protected mobi-
lization of the elbow joint.
The debate concerning the best technique for ulnar nerve
transposition and the role of in situ ulnar nerve neurolysis
without transposition (with or without medial epicondylec-
tomy) is not addressed in this text. Rather, the reader is
referred to the suggested reading list at the end of this
chapter.
7.3 RADIAL NERVE
Although this is a text on the hand and wrist, radial nerve
palsy originating in the armwill be encountered on an upper
extremity service and it is appropriate to discuss it in the
context of this book.
Radial Nerve Palsy with Fracture of the Humerus
Radial nerve palsy in the arm is associated most often with
fractures of the humerus in the middle third or at the junc-
tion of the middle and distal thirds. Radial nerve palsy at
this location is distinguished from the more proximal Sat-
urday night palsy and crutch palsy seen in the upper arm
and axilla, respectively. These more proximal lesions usually
recover spontaneously in 60 to 90 days and are not the topic
of discussion here.
Pertinent Anatomy
At the level in the humerus under discussion, the radial
nerve is subject to injury based on at least two anatomic
factors:
1. The proximity of the radial nerve to bone in the spiral
groove.
2. The relative fixation of the radial nerve in the spiral
groove and at the site of penetration of the nerve through
the lateral intermuscular septumon its way fromthe pos-
terior to the anterior aspect of the arm.
Based on these anatomic findings, it is appropriate to
postulate the etiology of the neurapraxia based on traction,
contusion, or hematoma.
Surgical Exploration
Although much discussion has been generated around the
issue of early versus late exploration of radial nerve palsy as-
sociated with humeral fracture, most palsies recover spon-
taneously, and early surgical exploration is recommended in
only three circumstances: (1) open fractures, (2) fractures
that require open reduction and or fixation, and (3) frac-
tures with associated vascular injuries. The onset of radial
nerve palsy after fracture manipulation is not an indication
for early nerve exploration.
Holstein-Lewis Fracture
In 1963, Holstein and Lewis described a spiral oblique frac-
ture of the distal humerus in seven patients, five with radial
nerve paralysis and two with paresis. They noted radial an-
gulation and overriding at the fracture site. As the radial
nerve courses anteriorly through the lateral intermuscular
septum, it is less mobile and subject to being injured by the
movement of the distal fracture fragment. Because of the
high incidence of radial nerve dysfunction, early operative
intervention was advised.
In a larger and more recent study of this fracture associ-
ated with radial nerve palsy, 11 of 15 patients were treated
without exploration of the radial nerve and had complete re-
covery; in the 4 patients who were explored, the nerve was
in continuity. They also demonstrated complete recovery.
Radial Nerve Entrapment in the Arm
Pathophysiology
Radial nerve entrapment in the arm is rare compared with
trauma-related palsy. A fibrous arch and accessory part of
the lateral head of the triceps has been associated with nerve
compression secondary to swelling of the muscle after mus-
cular effort. Some cases of radial nerve entrapment in this
regionof the lateral head of the triceps have beenreported as
spontaneous in onset and some following strenuous mus-
cular activity. What appears to be a familial radial nerve
entrapment syndrome has been reported in a 15-year-old
girl with a total and spontaneous radial nerve palsy. Her
sister had recently sustained an identical lesion that im-
proved spontaneously, and her father also suffered from in-
termittent radial nerve palsy. These cases appear to repre-
sent a genetically determined defect in Schwann cell myelin
metabolism.
Treatment
Although a patient with entrapment neuropathy with an
acute onset after overactivity sometimes recovers spon-
taneously, entrapment in the advanced stage should be
surgically decompressed because prolonged compression
might result in intraneural fibrotic changes secondary to
long-term compression.
The surgical approach of choice is posterior between the
long and lateral heads of the triceps.
Radial Sensory Nerve Entrapment at the Wrist
Wartenberg in 1932 described an isolated neuritis of the
superficial radial nerve at the wrist that he called cheiralgia
paresthetica. The condition is characterized by pain, burn-
ing, or numbness on the dorsal and radial aspect of the distal
forearm and wrist that radiates into the thumb, index, and
middle fingers. The symptoms are often associated with a
history of a variety of traumatic and iatrogenic causes, in-
cluding a direct blow to the nerve, a tight wristwatch band
or bracelet, handcuffs, or an injury due to laceration or com-
pression from retraction during surgery. Although Warten-
berg classified it as neuritis, it is a form of nerve entrap-
ment.
Pertinent Anatomy
The sensory branch of the radial nerve (SBRN) is positioned
beneath the BRmuscle as it travels towards the wrist, where
it exits frombeneath the BR tendon and between the ECRL
tendon to pierce the antebrachial fascia. In 10% of speci-
mens, the nerve may pierce the tendon of the BR. It be-
comes subcutaneous at a mean of 9 cm (with a range of 7
to 10.8 cm) proximal to the radial styloid. In supination the
SBRN lies beneath the fascia, but without compression. In
pronation, the ECRL crosses over the BR and may create a
scissoring or pinching effect on the SBRN.
Diagnosis
A useful provocative test is to ask the patient to fully
pronate the forearm. A positive test is manifested by
paresthesia or dysesthesia on the dorsoradial aspect of
the hand.
In addition to this provocative test, a positive Tinels sign
may be noted over the nerve distal to the BR muscle belly
as well as altered moving touch and vibratory sense.
Treatment
Treatment is based on the particular cause, and is usu-
ally conservative in the formof splinting, altered physical
activities, and physical therapy including stretching and
tissue gliding exercises.
In patients who require surgery, release of the deep fas-
cia and the fascia joining the BR and ECRL, as well as
neurolysis of the SBRN, may be utilized in selected cases.
Radial Tunnel Syndrome
Pertinent Anatomy
In the mid-portion of the arm, the radial nerve passes
through the spiral groove to enter the anterolateral aspect
of the distal third of the arm on its way to the forearm,
where it lies between the brachioradialis laterally and the
brachialis medially. The ECRL covers it anterolaterally, and
the capitellum of the humerus is posterior. The radial tun-
nel begins at the level of the radiohumeral joint and extends
through the arcade of Frohse to end at the distal end of the
supinator. Division of the radial nerve into motor (posterior
interosseous) and sensory (superficial radial) components
may occur at any level within a 5.5-cmsegment, from2.5 cm
above to 3 cm below Hueters or the interepicondylar line
(a line drawn through the tips of the epicondyles of the
humerus). The superficial radial nerve remains on the un-
derside of the brachioradialis until it reaches the mid-
portion of the forearm and is not subject to compression
in the radial tunnel.
The five structures in the radial tunnel that represent po-
tential sites of compression may be recalled by a useful
mnemonic FREAS (Figure 7.3-1). The structures, from
proximal to distal, are Fibrous bands, Recurrent radial ves-
sels (the leash of Henry), Extensor carpi radialis brevis,
Arcade of Frohse, and Supinator (the distal border). The
fibrous bands are anterior to the radial head at the begin-
ning of the radial tunnel, and are the least likely cause of
compression. The radial recurrent vessels cross the PIN to
supply the adjacent brachioradialis and ECR muscles, and
it is postulated that engorgement of these vessels with exer-
cise may compress the nerve. The tendinous proximal mar-
gin of the ECRB also may compress the PIN, and may be
mistakenly identified as the arcade of Frohse, which lies
deep to the proximal margin of the ECRB muscle. The ar-
cade of Frohse is the fibrous proximal border of the super-
ficial portion of the supinator. It is the most common site
of compression of the PIN, and is located from 3 to 5 cm
below Hueters line (Figure 7.3-2). Sometimes the tendi-
nous margin of the ECRB and the arcade of Frohse may
overlap and form a scissors-like pincer effect on the radial
Hook on
ECRB
S
A
E
R
F
Brachialis
Hueters
line
Sensory branch,
radial nerve
Radial recurrent
artery
PIN
Figure 7.3-1 Potential sites of compression of the
radial nerve in radial tunnel syndrome (RTS).
F, fibrous tissue bands; R, radial recurrent vessels;
E, fibrous edge of ECRB; A, arcade of Frohse;
S, supinator (see text).
A B
Figure 7.3-2 Fresh cadaver dissection of the ECRB and supinator. (A) The fibrous tissue edges of the
ECRB and the supinator are in close proximity to the PIN as it enters the supinator. (B) The ECRB has
been reflected superiorly. Fat has been removed from around the supinator to reveal its two heads and to
reveal the fibrous tissue edge of the superficial head that forms the arcade of Frohse.
nerve in this area. It is appropriate to continue the explo-
ration to the distal border of the supinator, although it is
a rare site of compression. More often, a mass, such as a
ganglion, may be found beneath the superficial portion of
the supinator.
Diagnosis
The radial tunnel syndrome (RTS) must be distinguished
from PIN syndrome (PINS).
RTS is a subjective symptom complex without motor
deficit, which involves a motor nerve. This is in con-
trast to PINS, which is an objective complex with mo-
tor deficit affecting a motor nerve.
The symptoms in RTS are similar to lateral epicondyli-
tis, with complaints of pain over the lateral aspect of
the elbow that sometimes radiates to the wrist. Be-
cause compression of a motor nerve is believed to
cause the pain, the description of the pain as a deep
ache is not surprising.
A dynamic state may exist in which pronation, elbow
extension, and wrist flexion are combined with con-
traction of the wrist and finger extensors to produce
compression of the PIN.
Physical findings may include point tenderness 5 cm dis-
tal to the lateral epicondyle.
The absence of sensory or motor disturbances in RTS is
characteristic.
To a limited extent, provocative tests may give some indi-
cation of the anatomic location of the compression, but
are not always reliable.
The so-called middle finger test involves extension of the
middle finger with the elbow in extension and the wrist
in neutral. The test is considered to be positive if pain
is produced in the region of the proximal portion of the
ECRB. Sanders has modified this test as follows:
With the elbow in full extension, the forearm in full
pronation, and the wrist held in flexion by the exam-
iner, the patient is asked to actively extend the long
and ring fingers against resistance.
According to Sanders, these positional modifications
produce maximum compression on the PIN, and rep-
resent a more reliable form of the test.
If symptoms are reproduced with the elbowin full flex-
ion, the forearmin supination, and the wrist in neutral,
then fibrous bands are suspected.
Reproduction of symptoms by passive pronation of the
forearmwith the elbow in 45 to 90 degrees of flexion
and the wrist in full flexionindicates entrapment by
the ECRB.
Compression at the arcade of Frohse is suspected if
the symptoms are reproduced by isometric supination
of the forearm in the fully pronated position.
The most reliable test is the injection of 2 to 3 mL of
1% lidocaine without epinephrine into the radial tunnel.
Relief of pain and a PIN palsy confirms the diagnosis.
A prior injection into the lateral epicondylar region that
did not relieve pain also supports the diagnosis.
Electrodiagnostic studies to date have not been useful in
the diagnosis because there are no motor deficits, and
studies of conduction velocity through the radial tunnel
are unreliable.
Treatment
Treatment may be nonoperative, in the formof rest to the
extremity and avoidance of the activities that aggravate
the condition.
The judicious injection of steroids about the site or sites
of possible compression may result in some relief.
Surgical intervention is in the form of release of all pos-
sible points of compression of the nerve.
Posterior Interosseus Nerve Syndrome
In contrast to RTS, PINSis characterized by objective motor
signs of entrapment of the PIN manifested by weakness or
complete palsy of the finger and thumb extensors. There
usually is no history of antecedent trauma.
Diagnosis
In complete PINS, active extension of the wrist occurs
with radial deviation owing to loss of the ECRB, whereas
the more proximally innervated ECRL remains intact.
There is associated loss of finger and thumb extension.
Partial loss of function is more common, with lack of
extension of one or more fingers or isolated loss of thumb
extension.
Sensation always is intact.
Diagnostic Tests
In contrast to RTS, EMG is positive in the muscles in-
nervated by the PIN.
Computed tomography scans or magnetic resonance
imaging may show a mass in the radial tunnel.
Treatment
The reader is referred to the sections on RTS, since
the approaches and principles of decompression are very
similar.
The nerve should be explored from the arm to the distal
aspect of the supinator, based upon the clinical findings
and the findings at surgery.
Bowlers Thumb and Cherry Pitters Thumb
Bowlers thumb is a neuroma in continuity of the ulnar dig-
ital nerve of the thumb. It results from external pressure
from the margin of the thumb hole in a bowling ball. It usu-
ally involves the ulnar nerve, and is characterized by pain,
paresthesias, and a tender mass on the ulnar aspect of the
proximal phalanx of the thumb. A variation known as cherry
pitters thumb has been described by Viegas.
Treatment
Both conditions may be treated by activity modification,
and, in the case of bowlers thumb, by enlarging the
thumb hole in the bowling ball.
SUGGESTED READING
Abrams R, Meunier M. Chapter 21. Carpal tunnel syndrome. In: Trum-
ble, TE, ed. Hand surgery update 3, hand, elbow & shoulder. Rose-
mont, IL: American Society for Surgery of the Hand, 2003:299
312.
Cobb TK, Dalley BK, Posteraro RH, et al. Anatomy of the flexor reti-
naculum. J Hand Surg 1993;18:9199.
Dellon AL, Chiu DTW. Chapter 22. Cubital and radial tunnel syn-
dromes. In: Trumble, TE, ed. Hand surgery update 3, hand,
elbow & shoulder. Rosemont, IL: American Society for Surgery
of the Hand, 2003:313323.
Dellon AL. Diagnosis and treatment of ulnar nerve compression of
the elbow. Techniques in Hand and Upper Extremity Surgery
2000;4:127136.
Dellon AL, Mackinnon SE. Radial sensory entrapment in the forearm.
J Hand Surg 1986;11A:199205.
Dobyns JH, OBrien ET, Linscheid RL, et al. Bowlers thumb: diagno-
sis and treatment. A review of seventeen cases. J Bone Joint Surg
1972;54:751.
Doyle JR, Botte MJ. Elbow. In: Surgical anatomy of the hand and
upper extremity. Philadelphia: Lippincott Williams & Williams,
2002:365406.
Doyle JR, Botte MJ. Forearm. In: Surgical anatomy of the hand and
upper extremity. Philadelphia: Lippincott Williams & Williams,
2002:407485.
Doyle JR, Botte MJ. Palmar hand. In: Surgical anatomy of the hand
and upper extremity. Philadelphia: Lippincott Williams &Williams,
2002:532641.
Ehrlich W, Dellon AL, Mackinnon SE. Cheiralgia paresthetica (entrap-
ment of the radial sensory nerve). J Hand Surg 1986;11:196199.
Gelberman RH, Eaton R, Urbaniak JR. Peripheral nerve compression.
J Bone Joint Surg 1993;75:185478.
Gross NS, Gelberman RH. The anatomy of the distal ulnar tunnel.
Clin Orthop 1984;196:238247.
Sanders WE. Letter. J Bone and Joint Surg 1992;309310.
Szabo RM. Acute carpal tunnel syndrome. Hand Clinics 1998;14:419
429.
Szabo RM, Slater RR, Farver TB, et al. The value of diagnostic testing
in CT syndrome. J Hand Surg 1999;24A:704714.
Szalay EA, Rockwood CA Jr. The Holstein-Lewis fracture revisited.
Orthop Trans 1983;7:516.
8
ANESTHESIA
CHARLES L. MCDOWELL
KEVI N CUNNI NGHAM
Relief from pain delivered with a minimum of discomfort
and a high degree of safety is a building block of patient reas-
surance and a hallmark of modern outpatient surgery. The
methods to be described are effective and safe in emergency
rooms, outpatient settings, as well as in more formalized
operating theaters. Emphasis upon outpatient surgery has
dramatically increased the desirability of effective regional
and local anesthesia methods that can be used by operat-
ing surgeons and anesthesiologists. In many of the settings
where surgery is performed today, there is not an anesthe-
siologist availableor even necessary. This is an additional
stimulus to the operating surgeon to become proficient in
the administration of local and regional anesthesia.
GUIDELINES
1. Determine the patients allergy status to the drugs.
Despite the fact that genuine allergies to local anes-
thetics are exceedingly rare, if the patient describes
an allergy to a local anesthetic, the surgeon should
not use it, even if the history is inconclusive or vague.
If the patient is right, and a reaction occurs, the
physical and legal consequences can be serious.
If a local anesthetic agent is necessary for medical or
other reasons, the surgeon should consider using an
alternative drug or skin testing.
Of the two types of local anesthetics, esters, being
derived from para-aminobenzoic acid (PABA), are
far more likely to produce an allergic reaction than
amide-type agents are.
Symptoms of allergic reactions include itching, burn-
ing, tingling, hives, erythema, angioedema, dysp-
nea, chest discomfort, wheezing, coughing, sneezing,
shock, and tachycardia.
Much more commonly, the patient will not have had
a true allergic reaction to the local anesthetic, but
rather symptoms associated with one of the follow-
ing:
Inadvertent direct intravenous or arterial injec-
tion of the agent or a drug overdose. These symp-
toms can include convulsions, disordered speech,
tachycardia, or bradycardia.
Reaction to local agents containing epinephrine
(palpitations, severe anxiety, tachycardia).
A vasovagal reaction.
An anxiety-hyperventilation event.
One can choose another type and performa skin test.
Otherwise, consult an anesthesiologist and proceed
with another method.
2. Ensure the site of injection is sterile.
3. Do not inject directly into a wound. This increases the
risk of implanting and spreading bacteria.
4. Inject more proximally to avoid multiple needle sticks
and the resulting multiple punctures and patient dis-
comfort.
Block a peripheral nerve well proximal to the site of
surgery.
This will result in less needle sticks and a larger area
of anesthesia.
5. Know the anatomy.
Knowing the location of peripheral nerves is neces-
sary to accomplish a successful regional nerve block.
The sensory distribution of peripheral nerves is rea-
sonably consistent.
Figure 8-1 represents the distribution of the three
major peripheral nerves in the upper extremity.
It is important to know this anatomy so as to be able
to perform a neurologic examination prior to induc-
ing anesthesia for the purpose of making a proper
diagnosis.
A patients injury may have resulted in damage to a
nerve, and that fact should be known before surgery
so that one can select a proper treatment plan and
choose the appropriate peripheral nerve, or nerves,
to block.
6. Take care in choosing the needle bore and type.
One has to balance the issues of pain versus effec-
tiveness and safety.
We tend to assume that needles of small diame-
ter cause less pain. However, the disposable nee-
dles we use are so sharp that patients cannot tell
the difference between one with a gauge of 25 or
22.
There are several advantages to using a larger-bore
needle.
116
Chapter 8 / Anesthesia 117
To coracobrachialis
Lateral
cord
Medial
cord
Median nerve
To PT
To FCR
To PL
To FDS
To FDP
To PQ
To lumbrical 2
To lumbrical 1
Recurrent nerve
Palmar cutaneous
nerve
To FDP
To FPL
Lat. antebrachial
cutaneous nerve
To radioulnar joint
To brachialis
To biceps
A
Figure 8-1 The anatomy of the major
nerves of the upper extremity, showing
their sensory and motor components.
(A) Median nerve.
Figure continues.
Increased stiffness of the needle allows the sur-
geon to direct it more effectively.
There is less chance of breaking it or having to
deal with retrieving a broken needle.
One obtains useful information feedback from
rate of flow.
N Because there is greater resistance to flow in a
small-bore than in a large-bore needle, one has
to push harder on the plunger.
N If the surgeon inadvertently places the needle
into the substance of a tendon or ligament, it
would be more difficult to push the plunger
118 Section III / Emergency Department
Medial cord
Med. brachial
cutaneous nerve
Med. antebrachial
cutaneous nerve
Ulnar nerve
To FCU
Nerve of Henle
to small finger
To PB
Sensory branch
to median nerve
To AdP
To FPB
Deep motor
branch
D1
D1
P1
D1
L3
L4
D1
P1
To FDP, ring,
small fingers
B
Figure 8-1 (continued) (B) Ulnar
nerve.
To
long head,
triceps
To anconeus
Superficial branch
To supinator
To APL
To EPL
To EPB
To EIP
To ECU
PIN
To ECRB
To EDC
To BR
To ECRL
To EDM
Communicating
branch, to ulnar
nerve
Deep branch
Radial nerve
Axillary nerve
Posterior cord
C
Figure 8-1 (continued) (C) Radial nerve.
than if the needle had been placed in a space
such as the ulnar bursa, which contains the me-
dian nerve.
N If the surgeon uses a small-bore needle, he or she
may not be able to distinguish between being in
a tendon or the space around a peripheral nerve.
N A large-bore needle will give the surgeon impor-
tant information about the location of the end
of the needle.
Smaller diameter needles will penetrate the sub-
stance of a peripheral nerve more easily thanlarger
diameter needles.
N Axons will be damaged if a needle is inserted
into the substance of a peripheral nerve.
N Also, the patient will usually have severe pain
upon penetration.
When the surgeon and the patient both move vio-
lently because of pain or surprise, additional damage
can be done to the nerve.
For all peripheral nerve blocks, one should use nee-
dles designated blunt tip, when available.
This is especially important when doing infraclav-
icular and axillary blocks.
The angle of the bevel is 30 to 45 degrees instead
of the usual sharp tip needles, which are beveled
at 12 to 15 degrees.
Using a blunt-tip needle further reduces the
chance of penetrating the epineurium and inject-
ing into the substance of the nerve.
Experience has shown that the blunt-tip needle is
more likely to push or roll the nerve out of the way,
rather than perforating or impaling it.
Injecting into the substance of a peripheral nerve
may cause significant mechanical injury.
7. Inject the local anesthetic slowly and steadily.
Avoid fast and forceful injections, especially with
larger volume blocks.
Remember, nerves can usually recover frommechan-
ical trauma fromneedle contact, but needle insertion
plus deposition of local anesthetic injected under
high pressure can significantly damage nerve fascicle
architecture and compromise its microvasculature,
with devastating permanent results.
Always inject smaller volumes of local anesthetic (3
to 5 mL) at a time, with intermittent aspiration to
rule out a direct intravascular injection.
When aspirating on a syringe for blood, some smaller
veins may collapse, even with the tip of the needle in
the lumen of the vessel.
Patient response is the key to diagnosis of intravas-
cular injection of local anesthetic agent.
Never inject local anesthetic when high resistance to
the injection is encountered.
Withdraw the needle, reassess surface landmarks,
reinsert the needle, and try again.
Painful paresthesias and resistance to injection
strongly suggest an intraneural injection.
8. Do not inject into a vein or artery.
Many peripheral nerves are in close association with
veins and arteries.
In some locations, such as the axillary sheath, the
median nerve at the elbow, and the ulnar nerve at
the wrist, the relationships are intimate.
The old and true admonition to withdraw the
plunger of a syringe before injecting applies yet
again.
9. Consider the time it takes for local or regional anesthe-
sia to become effective, and use this period to further
your relationship with the patient.
Because anesthetic materials take a few minutes to
become fully effective, there is a potential time gap
in the operating room schedule.
Anesthesia should preferably be administered in
an anteroom to the operating room.
Nurses in this setting can prepare the patient so
that the surgeon can administer the anesthetic im-
mediately after the preceding operation.
The anesthetic will be acting while the paperwork
and room preparation is proceeding.
If one assumes a 20-minute turnover time, there
will be adequate time for the anesthetic to become
effective.
This is an important time to establish a doctor-
patient relationship in the surgical environment, be-
fore the patient is separated from the operating team
by a wall of draping cloth.
Giving the anesthetic well before the operation
gives the surgeon time to reassure the patient and
to discuss the process.
When administering the anesthetic, the surgeon
has time to chat, describe the process, and answer
questions that all patients have.
The patient may remember the surgeon only in a
white coat in an office. Often, patients will not
even recognize the surgeon in a scrub suit.
Preoperative contact with the operating surgeon
is in itself reassuring to patients, even though an
anesthetic agent is being injected.
The patient will be reassured by knowing that
anesthesia is complete before being rolled into the
operating room.
If the surgeon has to administer additional injec-
tions after the patient has been blinded to the pro-
cess by drapes and other items, the patient may
lose confidence and become anxious.
Making the patient as comfortable as possible in the
operating room can enhance the feeling of reassur-
ance.
Keeping the environment warm and quiet is help-
ful.
A pillow for the head and behind the knees adds
comfort.
The arm board should be placed so that the arm
is not abducted more than perpendicular to the
trunk, in order to reduce shoulder stiffness or
pain.
10. Confirm that anesthesia is accomplished by using light
touch.
Pinching or sticking skin merely produces more pain
and unnecessary anxiety in the patient.
If the patient feels light touch, the anesthetic is not
adequate. If the patient does not feel light touch,
anesthesia is complete.
This method must be used in children, or the addi-
tional pain or threat thereof will bar any possibility
of cooperation. Adults appreciate the same consid-
eration.
The examiner has to be careful to not stimulate
a proprioceptive response from the patient by mov-
ing skin or joints in an area not anesthetized. Many
patients will respond if they feel anything, including
a proprioceptive sensation.
11. Remember that managing anesthesia for children is dif-
ferent from that for adults.
Children have minimal tolerance for pain and threat-
ening surgeons. And one is wise to assume that they
have food in their stomachs.
In many emergency situations, local anesthesia is the
safest method for obtaining anesthesia for children,
but successful administration requires the surgeon
to be skilled at management of the psychological and
technical issues.
In the more controlled operating room environ-
ment, anesthesiologists, equipment, and premedica-
tion are available. Adults appreciate efficient, mini-
mally painful, and effective anesthesia, too.
12. Consider use of a pneumatic tourniquet when more
distal blocks (wrist and digits) are used.
Most patients can tolerate a tourniquet without par-
enteral drugs for up to 20 minutes.
The pressure should not exceed 225 to 250 mm Hg.
If the systolic pressure is so high that bleeding occurs
in spite of the tourniquet pressure set as described,
one should probably not be doing surgery except in
an emergency situation.
The tourniquet can be deflated and reinflated 5 to
10 minutes later if necessary, but one should care-
fully choose operations that can be performed with
confidence within the 10 to 20 minute time limit.
Planning approaches, reviewing radiographs, and
other such procedures should be done before inflat-
ing the tourniquet, and wound irrigation, bleeding
control, and closure can be done after the tourni-
quet has been deflated.
COMMONLY AVAILABLE AGENTS AND
THEIR USES
Lidocaine
Lidocaine (Xylocaine) without epinephrine produces rapid
onset of anesthesia but is short acting. Using epinephrine
can increase the time of effective anesthesia. The latter drug
may produce some unpleasant side effects to deal with in
an outpatient setting, including drowsiness, lightheaded-
ness, and vertigo. If blood concentration continues to rise,
one sees agitation and excitement, and then, seizures. For-
tunately, these symptoms are not common, but one must
be prepared. One complication reported from the use of
epinephrine with local anesthetic agents when used for dig-
ital nerve blocks is ischemia of the digit caused by vasocon-
striction of the digital arteries. Most of these unfortunate
effects can be avoided by using mepivacaine, which has a
longer effect without using epinephrine.
Mepivacaine
Mepivacaine (Polocaine/Carbocaine) is ideal for an outpa-
tient setting. Its time of effectiveness is adequate for most
upper extremity operations, and it doesnt act so long that it
interferes with postoperative evaluation of pain symptoms.
The safety record for this drug is excellent.
Marcaine
Marcaine (Bupivicaine) can produce anesthesia for up to
12 hours. During that time, the patient will be relieved of
pain from the injury or operation. However, the surgeon
will have placed the patient at risk. Consider, for example,
if the operation were performed successfully and a dressing
or cast applied after wound closureand then the patient
developed a compartment syndrome. By the time the pa-
tient and surgeon were aware that there was a problem, it
would be too late to prevent necrosis of soft tissue. Surgeons
depend on careful observations to warn of an impending
compartment syndrome. Usually, the first warnings come
from the patient who complains of inordinate pain. If that
information is not available because of the anesthetic, the
first indication that a problem exists will come too late to
reverse the course of the injury. A better choice of agent
is mepivacaine. It will provide adequate anesthesia for an
operation and recovery up to 3 to 4 hours. Then the patient
will be able to alert the surgeon if the pain is so severe that it
cannot be adequately controlled by 30 to 60 mg of codeine,
or its equivalent. There will be sufficient time to relieve
pressure from the cast or dressing, or to do a fasciotomy if
needed, to prevent soft tissue necrosis.
INDICATIONS AND OPERATIVE SITES
When the site or sites are in the same upper extremity,
and if the sites to be operated upon are located within the
digits or palm, a wrist block would suffice. However, the
surgeon must be aware of the tourniquet time. An axillary
or infraclavicular block is usually more comfortable for the
patient, and provides better flexibility for the surgeon if the
tourniquet time will extend beyond 10 to 20 minutes.
When the procedure requires an additional surgical site
in addition to the operated extremity for skin, bone, vessel,
or tendon graft material or distant skin flap, one could still
use regional anesthesia if the patient and anesthesia services
are prepared to use a general anesthetic when needed, or
if the other site can be anesthetized with regional or lo-
cal anesthesia. Otherwise, proceed with general anesthesia
from the outset.
When one is doing a procedure where the patients coop-
eration is required or useful, such as tenolysis of adhesions
to tendons or tendon balancing, as in quadregia, a combina-
tion of regional anesthesia (wrist block) and sedation/pain
relief to control tourniquet pain (ischemia) is used. This
requires coordination with anesthesiology. The tourniquet
time must be monitored so that the extremity is not par-
alyzed at the time one needs the patient to contract mus-
cles. Paralysis occurs about 30 minutes after a tourniquet
is applied. If the tourniquet is deflated for 5 minutes, pa-
tients can respond to commands to contract muscles. For
example, if you were doing a tenolysis of a profundus ten-
don in a digital flexor sheath, you should ask the patient to
slowly make a fist. If the regional anesthesia is adequate and
sufficient analgesia has been supplied by the anesthesiol-
ogist to block pain from the tourniquet, then the patient
should be able to contract the muscles and move the tendon
being tenolysed. The procedure described is exceptionally
useful when orchestrated properly.
METHODS
Intravenous Regional Anesthesia
This method is mentioned here only to discourage its use.
There are four reasons why the procedure should be aban-
doned. Any procedure that places the patient at unnecessary
risk, places the surgeon in the disadvantageous position of
restricting options unnecessarily, or favors the person giving
the anesthesia over the patient and the surgeon, should not
remain in use. The person administering the anesthetic is
assured of rapid and easily obtained success, but if an error
is made, it can be fatal to the patient. The surgeon can-
not consider deflating the tourniquet to evaluate bleeding
potential, or for any other reason, before the operation is
completed, as anesthesia will be lost as soon as the tourni-
quet is deflated. Bleeding control, wound closure, and other
end-of-operation procedures will have to be done with sup-
plemental anesthetic injected locally, and with attendant
discomfort and anxiety for the patient. These are sufficient
reasons to discourage the use of intravenous regional anes-
thesia. Lets add a fourth and more important reason: there
are other methods that are safer for the patient and can be
performed quickly and easily if the surgeon takes the time
to become proficient and efficient using them.
Supraclavicular Blocks of the Brachial Plexus
These should be performed only in an operating room en-
vironment because of the risk of pneumothorax (reported
up to 6%)and the resulting need for assistance, positive
pressure breathing, and the possibility that a chest tube may
have to be inserted. These methods can be used effectively
for shoulder operations, as well as for upper extremity op-
erations when experienced personnel and proper facilities
are available.
Infraclavicular Blocks of the Brachial Plexus
Blockade of the brachial plexus at the level of the cords can
be obtained by an infraclavicular approach.
Anatomy and Technique
The length of the clavicle is palpated from its manubrial
attachment to the coracoid process, and bisected in half.
The axillary artery pulsation is palpated in the apex of the
axilla.
The surgeon stands on the patients side opposite the
side to be blocked, with the patients head turned later-
ally away from that side, with his or her arm abducted
90 degrees at the shoulder, and with the forearm supine.
The infraclavicular area is prepped and draped.
A skin wheal is raised 2 to 3 cm below the inferior border
of the midpoint of the clavicle.
Midclavicular
point
A
B
Axillary artery
Radial nerve
Ulnar nerve
Axillary vein
Median nerve
Anterior
Musculocutaneous
nerve
Axillary artery
Figure 8-2 The technique of a brachial plexus block, by the
infraclavicular approach.
A nerve stimulator is used to more precisely localize the
plexus, usually at a depth of 6 to 8 cm.
A 10 cm insulated nerve-stimulating needle is then ad-
vanced through the skin wheal oriented laterally at a 45
degree angle. It enters tangentially, and away from the
rib cage (to reduce the risk of a pneumothorax), and is
inserted in the direction of the axillary artery pulsation
(Figure 8-2).
Initial muscle twitches elicited will be from the pec-
toralis major/minor.
Once the needle has traversed the pectoralis muscles,
stimulation of the brachial plexus cords will produce
characteristic muscle contractions at the wrist, and
will indicate entry of the needle into the sheath.
Stimulation of median nerve twitches in particular
seems to yield consistently higher success rates.
The surgeon stabilizes the needle, aspirates carefully for
blood, and injects an appropriate volume and concentra-
tion of local anesthetic.
Preferred Agent and Volume
Mepivacaine 1.25% to 1.5% (35 to 45 mL) will provide 3
to 4 hours of anesthesia.
Axillary Block
Axillary block can be undertaken either with or without elec-
trical stimulation. Safety, effectiveness, and ease of perfor-
mance make this the method of choice in an outpatient
setting and in the emergency room. If electrical stimulation
is not available, one should use the axillary approach instead
of the infraclavicular approach. (Compare with other meth-
ods: simplicity, repeatability, effectiveness, risks, effect of
obesity on the process, etc.) Also, the axillary approach to
the brachial plexus can be used more safely than the supra-
clavicular and infraclavicular approaches in an outpatient
setting.
All effective proximal nerve blocks are produced by plac-
ing the anesthetic agent within the perivascular space
(axillary sheath).
It does not matter where one enters the space. If the
volume is sufficient, the anesthetic agent will infiltrate
to all four nerves in the sheath.
The T2 nerve is not located within the axillary sheath.
Since it supplies sensibility to the medial arm, one should
consider placing a weal of anesthetic material trans-
versely across the proximal arm on the medial surface to
relieve pain that could be caused by tourniquet pressure.
Confirmation of proper needle placement within the axil-
lary sheath can be achieved by any of the following meth-
ods:
Eliciting paresthesias in the distribution of the me-
dian, ulnar, and radial nerves
Using a nerve stimulator
Dividing the neurovascular bundle into four quad-
rants, and depositing four aliquots of local anesthetic
in each sector around the artery after fascial clicks
have been obtained. Such clicks are the feedback re-
sistance felt on perforating the axillary sheath, which
is more noticeable if one uses a blunt needle.
Anatomy and Techniques
No matter which technique is used, one must always withdraw
the plunger to be certain that there is no blood returning
through the needle.
The patient lies supine with the upper extremity abducted
90 degrees with or without elbow flexion.
The axillary artery pulse is palpated as far proximal as
possible in the apex of the axilla. Overzealous digital pres-
sure, or having the patient rest the hand behind the head,
can obscure the pulse.
The axillary fold is prepped with Betadine or chlorhexi-
dine solution, and the area is draped with sterile towels.
The two-finger fixation technique (using the tips of the
non-dominant index and long fingers) is used to identify
the margins of the pulse, retract the overlying skin and
soft tissue, and help immobilize the needle prior to and
during the injection.
A skin wheal is raised over the most prominent area of
the axillary artery pulse.
With the two fingertips gently applied over the pulse, a
22-gauge, 3-to-5-cm conventional needle connected to
an intravenous extension set tubing (or alternatively, a
21-gauge butterfly needle with such tubing already at-
tached) is advanced either perpendicular to, or at a more
oblique angle with, the needle tip oriented toward the
axilla. The needle should intentionally puncture the an-
terior wall of the axillary artery until bright red blood with
a pulsatile pressure head can be seen entering the exten-
sion tubing or can be readily aspirated into the syringe.
A
Median nerve,
axillary artery,
ulnar nerve
B
Musculocutaneous
nerve
Axillary artery
Median nerve
Basilic vein
Ulnar nerve
Radial nerve
Figure 8-3 Technique of a brachial plexus block, by the axillary
approach.
The needle is then slowly advanced 1 cmor more to delib-
erately puncture the posterior wall of the artery until no
more blood flows into the tubing or syringe (Figure 8-3).
The needle tip can then be assumed to be residing in the
posterior part of the neurovascular sheath.
Because the axillary sheath is believed to have discontin-
uous connective tissue septae that compartmentalize or
impede the free diffusion of local anesthetic, one should
inject half of the total dose of local anesthetic at this lo-
cation. Do so after careful confirmation that the needle
tip is not inside the axillary artery lumen.
One slowly withdraws the needle through the artery while
aspirating for blood into the syringe. The reappearance
of blood in the tubing or syringe confirms that the needle
tip is back in the lumen of the axillary artery.
The surgeon continues withdrawing the needle until it
exits the artery. At this location one should inject the
remaining one-half of the dose of local anesthetic agent.
After the needle is withdrawn completely, the patients
arm is adducted to the side, and continuous digital pres-
sure is applied to the injection site to promote spread of
the anesthetic agent.
A single needle puncture into the axillary sheath often
results in an adequate axillary block, but it is not as fre-
quently effective as either the transarterial or the two-
needle methods.
To use the single needle method, it is only necessary
to place the needle into the axillary sheath and then
inject 35 to 45 mL of mepivacaine slowly.
In the process of inserting the needle into the sheath,
one may inadvertently puncture the axillary artery. In
case this happens, merely adjust the technique to a
transarterial method.
When performing a transarterial axillary block, one de-
liberately pushes the needle toward the axillary artery,
passes through it, and, after withdrawing the plunger to
be certain that the tip of the needle is not in either artery
or vein, injects the sheath as described above.
This method yields a high degree of success. Experi-
ence with it suggests that there are not often compli-
cations unless one injects the agent into the artery.
If this happens, seizures and other complications can
occur.
A technique that is preferred to either of the above is the
two-needle method. It is especially useful in urgent and
outpatient settings where there may not be expert help
available to help deal with the complications from other
techniques. The advantage of the two-needle method is
that one can avoid the need to search for landmarks af-
ter the first injection, which would hide and distort the
anatomy because of tissue inflation.
A short 22-gauge blunt-tip needle is attached to a sy-
ringe to use as a handle, and, for aspiration, to be sure
that the needle tip is not in a vessel.
The two needles are directed into the axillary sheath,
one above and one below the artery. A click is often
felt when penetrating the axillary sheath.
The axillary artery is superficial and should be iden-
tified as far proximal in the axilla as possible. This is
the best site for injection. All four major nerves are
located within the axillary sheath at this level. Recall
from our previous discussion that there is a need for a
block of T2 nerve root.
1% or 1.5% mepivacaine (Polocaine/Carbocaine), 30 to
40 mL.
When injecting, one can apply digital pressure distal to
the site of injection to force more of the fluid into the
proximal portion of the perivascular space.
It takes about 20 to 30 minutes for the anesthetic to
become effective, so one should arrange to use the time
efficiently.
If the anesthesia department is planning to perform the
block, the patient should be sent for in plenty of time
for the anesthesiologist to prepare for and perform the
block.
If the surgeon is doing the block, he should do it imme-
diately following the proceeding case, and then do other
paper work, surgical preparations, and other things after-
ward.
Expected Outcome
A successful outcome will produce complete anesthesia in
the upper extremity high enough to prevent pain from a
tourniquet. It will also give the surgeon the flexibility to
inflate and deflate the tourniquet as needed, do surgery for
2 to 3 hours, and still have sufficient pain relief to last for
an additional hour after surgery. Complications from infra-
clavicular and axillary blocks are rare and are related to
intravascular injection of the anesthetic agent.
Blocking Major Nerves in the Arm
There are very few indications for blocking only one or two
major nerves in the arm. It would be a rare event that would
call for such blocks to be used instead of an axillary or other
more proximal block. The median and radial nerves in the
arm and forearm are deep within the tissue, and lack easily
identifiable landmarks. Multiple punctures and anelectrical
Figure 8-4 Ulnar nerve block at the elbow. The mark on the skin is
over the medial epicondyle.
stimulator would be needed to be successful. It is more
comfortable for the patient if the axillary block method is
used. Also, the success rate is higher.
The ulnar nerve proximal to the medial epicondyle of the
elbow is an exception because it is accessible. In this
situation, the nerve is easily palpated just proximal to the
medial epicondyle.
Inserting the needle about 2 to 3 cm proximal to the
medial epicondyle and parallel to the nerve, and injecting
the agent along side of the nerve at this site, will block it
successfully.
One should not inject posterior to the epicondyle because
the nerve is often fixed in the cubital tunnel. Injecting
into the cubital tunnel increases the risk that the needle
might penetrate the substance of the nerve and cause
permanent damage. Also, the hydraulic pressure that is
produced by injecting into the partially closed space of
the cubital tunnel may cause permanent damage to the
ulnar nerve by acute severe compression.
Anatomy and Techniques
The anesthetic agent is injected proximal to the cubital tun-
nel, and the needle tip is located adjacent to the easily pal-
pated ulnar nerve at this site (Figure 8-4).
Mepivacaine, 1%, 5 to 7 mL.
Wrist Block
One may wish to use a tourniquet on the arm to control
bleeding during a procedure on the hand when some type
of peripheral block has been performed. It is possible for the
surgeon to inflate a tourniquet to 25 to 50 mm Hg above
systolic pressure for about 20 minutes. If more time is re-
quired, one will have to deflate the tourniquet, wait about
5 minutes to restore comfort, and begin again. This can
be repeated, but the surgeon is likely to push the patient
beyond his or her tolerance of pain caused by ischemia.
One should reserve this method for operations that can be
performed safely within the 20-minute time limit. The sur-
geon should not let overconfidence dictate his choice to use
this method. If one anticipates that more than 20 minutes
will be required to performan operation with care within the
time limit, an axillary block should be undertaken instead.
It is a very unhappy scene in the operating room when the
surgeon is trying to complete an operation while the patient
is complaining of pain, moving around on the table, and
threatening to get off the table and leave.
Technique
The first step is to raise a subcutaneous wheal across the
flexor surface of the distal forearm about 2 cm proximal
to the wrist flexion crease (Figure 8-5A).
At this location, the anesthetic material will block the
last branch of the lateral antibrachial cutaneous nerve
and the palmar sensory branch of the median nerve, pro-
ducing a numb area for the subsequent injection to block
the median and ulnar nerves.
A second wheal should be raised over the radial styloid
to block the sensory branches of the radial nerve (Figure
8-5B).
One can return to the volar site and inject through the
first wheal to block the median and ulnar nerves.
The median nerve block is accomplished by inserting a
22-gauge needle tip at a location 1.5 to 2 cm proximal to
the wrist flexion crease and 1 cm ulnar to the palmaris
longus.
The needle tip is inserted perpendicular to the skin about
1.5 cm and is located within the ulnar bursa. Thus, the
median nerve is bathed by the agent and not put at risk
of perforation (Figure 8-5C).
About 5 to 7 mL of mepivacaine is injected.
The ulnar nerve is blocked by inserting the needle at the
same distance proximal to the wrist flexion crease as the
median nerve block.
The insertion should be at the radial edge of the flexor
carpi ulnaris (FCU) tendon, to a depth of about 1.5 cm
(Figure 8-5D).
Aspiration is especially important before injecting the
agent because the ulnar artery and veins are very close to
the nerve.
About 5 to 7 mL of mepivacaine will be sufficient.
A complete wrist block using this method will ensue
within about 20 minutes.
A wrist block will, of course, paralyze all of the intrinsic
muscles. There may be occasions when preserving func-
tion of the small muscles is useful, as in reconstructive
operations on the extensor hood mechanism.
In such cases, digital blocks and use of an arm tourni-
quet for a short time will be a better choice.
Also, one can coordinate the anesthetic with anesthe-
siologist as mentioned above, so that the tourniquet
can be kept in place for longer than 20 minutes.
Five to 7 mL of 1% mepivacaine is used at the median
and ulnar nerve sites, and 3 to 4 mL is administered in a
weal raised over the radial sensory nerve and the dorsal
sensory nerve from the ulnar nerve (Figure 8-5B and E).
A
C
B
D
E
Figure 8-5 Wrist block. (A) A wheal is raised to block the sensory branch of the median nerve and
produce a numb area for subsequent injection of the median and ulnar nerves. (B) Technique to block
the sensory branch of the radial nerve. (C) Block of the median nerve (X). (D) Block of ulnar nerve
(second X). (E) Block of the dorsal sensory branch of the ulnar nerve ( mark on skin indicates distal
ulna). See text for details of injection techniques.
Expected Outcome
The wrist block described will anesthetize all of the hand
except for a small quarter-size area at the base of the thumb
on the volar side of the thenar eminence supplied by the
branches of the lateral antebrachial cutaneous nerve. A
weal placed proximal to this site just proximal to the wrist
flexion crease will complete the block if needed. The pur-
pose of this subcutaneous injection of 3 to 5 mL is to block
the branches of the medial antebrachial cutaneous nerves
and the sensory branch of the median nerve that supply
sensation to the base of the thumb and palm, and to anes-
thetize the sites of injection for the median and ulnar nerve
blocks. Some examples of operations that lend themselves to
this type of anesthesia are carpal tunnel release and trigger
finger release. Longer operations where patient cooperation
is necessary, such as tenolysis in digits and palm, should be
performed using a wrist block, with sedation and pain con-
trol by anesthesia, so that the tourniquet can be used as
A B
Figure 8-6 (A) Technique for finger nerve block. (B) Palmar view of the finger nerve block, showing
technique for palpating the flow of the anesthetic material into the web space and lumbrical canal.
needed and the patient can move the tendons undergoing
tenolysis at the surgeons request.
Finger Nerve Blocks
Web space injections are easy to perform, and give a wide
area of anesthesia. This approach avoids circumferential
digital block, with its implied risk of arterial spasm and
necrosis of the digit. Epinephrine is not used in any type
of finger or thumb nerve block because of its potential
for vasoconstriction and circulatory compromise. Polocaine/
Carbocaine may be injected with a 22-gauge needle.
Technique
Assuming the person administering the anesthetic is right
handed, he or she should grasp the finger or fingers on
the left side of the web space to be injected, place the
pulp of his or her index finger in the patients palm be-
tween the metacarpal heads (over the lumbrical canal),
insert the 22-gauge needle parallel to the metacarpals
and into the lumbrical canal, and inject about 3 mL of
Polocaine/Carbocaine into the lumbrical canal (Figure
8-6A).
With the index finger, the surgeon should feel the lumbri-
cal canal inflate (Figure 8-6B), confirming that the agent
is in the correct space volar to the transverse metacarpal
ligament.
The next web space is injected in the same manner.
Thus, there is a block of both digital nerves to the digit, as
well as numbness on the contiguous sides of the adjacent
digits. This reduces the sensory feedback that the patient
has to tolerate.
Additional anesthesia to the digit is produced by raising
a weal transversely across the base of the digit about 1
cm proximal to the MCP joint as described elsewhere.
The radial digital nerve to the index finger is also superfi-
cial enough to be easily palpated over the first lumbrical
muscle belly.
Two or 3 mL of anesthetic agent placed in a transversely
oriented wheal located about 1 to 2 cm proximal to the
metacarpal head will accomplish the block.
The situation is a bit different in the case of the ul-
nar digital nerve to the little finger, as it is under fat
resting upon the short flexor muscles of the hypothenar
group.
One cannot palpate the nerve, so the injection should
be done fromthe ulnar side of the palmwith the needle
directed volar to the hypothenar muscles and into the
fat between the muscles and the skin.
Two to 3 mL of anesthetic agent will produce a suc-
cessful block.
Thumb Nerve Blocks
Technique
In the case of the thumb, the weal can be placed at the
level of the mid shaft of the metacarpal or more proximal.
This includes doing so at the wrist in order to completely
block the radial sensory nerve at the level of the radial
styloid.
The digital nerves to the thumb are so superficial that
they are easily palpated beneath the skin on either side
of the flexor pollicis longus.
Raising a weal transversely across the flexor surface of
the thumb at or just proximal to the MCP joint flexion
crease easily blocks them (Figure 8-7).
Three mL of mepivacaine is used at each site, and a weal
is placed on the dorsum of the palm about 1 cm proximal
to the metacarpal head.
Expected Outcome
A satisfactory digital block using mepivacaine will produce
pain relief for about 3 hours. Some examples of operations
that lend themselves to this type of anesthesia are any
operation at or distal to the PIP joint (so there is space for
a tourniquet at the base of the digit). A surgeon could use a
A B
Figure 8-7 Technique for thumb nerve block. (A) Note the convenient and less painful site of injection
for a digital nerve block of the thumb. (B) The digital nerves of the thumb are located in the
subcutaneous tissue, and are easily anesthetized by injecting a wheal of anesthetic across the flexor
surface of the thumb at the MCP joint flexion crease.
tourniquet applied more proximally if he or she was very
confident that the procedure would take no longer than 20
minutes.
Use of Digital Tourniquets
Murphys Lawis always in force. Only those who either have
not heard of the law or think they are above the law would
use rubber bands for a temporary tourniquet for bleeding
control during operation on a digit. The rest of us know
that there is a considerable risk that we could put a dressing
over the bands and forget themand if this happens, when
the anesthetic has worn off, the patient will complain of
inordinate painbecause the digit has beenrendered necrotic
by prolonged ischemia. We reduce our risk of this happening
by using a wider Penrose drain clamped with a hemostat,
which will remind us to remove it before applying a dressing.
The hemostat is too large to fit inside of most dressings.
There is a device being marketed that looks like a finger cot.
The device will exsanguinate the digit as it is rolled into place
on the digit and provide ischemia during the operation. It
has the same inherent drawback that a rubber band has. It
can be hidden by dressings, and is not recommended.
CONCLUSION
Both surgeon and patient gain confidence when anesthe-
sia is appropriate, relatively painless, and complete. One
must arrange the sequencing of care so that the process is
efficient, unhurried, and sufficient time is allowed for the
anesthetic agent to become effective.
SUGGESTED READING
Barash P, Cullen B, Stoelting R, eds. Clinical anesthesia. 5th Ed.
Hahn MB, McQuillan PM. Regional anesthesia, an atlas of anatomy
and techniques. St. Louis: Mosby, 1996.
Kirby RR, et al., eds. Clinical anesthesia practice. 2nd Ed. Philadelphia:
W.B. Saunders, 2002.
Miller RD, ed. Millers anesthesia. 6th Ed. Philadelphia: Elsevier
Churchill Livingstone, 2004.
Raj, PP. Pain medicine: a comprehensive review. St. Louis: Mosby,
1996.
Winnie, AP. Perivascular techniques of brachial plexus block.
In: Plexus anesthesia. vol I. Philadelphia: W.B. Saunders,
1993.
GRG045-09 Doyle-2055G GRBT045-Doyle-v9.cls July 15, 2005 22:9
9
HAND
FRACTURES
AND FRACTURE-
DISLOCATIONS
This chapter will discuss the general principles of treating
fractures of the phalanges and metacarpals and of treating
fracture-dislocations in the hand. Fractures of the hand are
relatively common, and are second in incidence to lacera-
tions of the hand.
Treatment goals include restoring the bony anatomy, and
leaving it with acceptable alignment, length, and rotation.
Dislocations and ligament injuries in the hand are presented
in Chapter 10.
GENERAL PRINCIPLES
Although restoration of the original anatomic configuration
is the goal of treatment, it should not be obtained at the
risk of soft-tissue scarring and joint stiffness, or at the risk
of altering the blood supply to the bone. This may result in
non-union.
Fractures in the hand are considered to be stable or un-
stable. Stable fractures may require minimal immobiliza-
tion, whereas unstable fractures may require special im-
mobilization techniques and or internal fixation. Unstable
fractures of the metacarpal diaphysis most often angulate
with the apex dorsal whereas fractures of the midaspect of
the proximal phalanx angulate with the apex volar. The ac-
tion of the wrist extensors that insert proximally extend the
proximal portion of the metacarpal, and the interosseous
muscles and the long-finger flexors flex the distal segment.
Unstable fractures of the proximal phalanx are deformed
by the extensor mechanism and the intrinsic muscles
(Figure 9-1).
The classic fracture deformities described above are not
representative of all fracture deformities that may be seen,
but they do serve to introduce the concept that unstable
fractures angulate and deform.
DIAGNOSIS
Patient History
The history of injury with a hand fracture is usu-
ally straightforward, but fractures associated with a
laceration over the metacarpophalangeal (MCP) or prox-
imal interphalangeal (PIP) joints should raise the ques-
tion of a human bite wound that requires a different treat-
ment approach.
To treat a human bite wound, refer to the section of
Chapter 5 that deals with human bite wounds.
Physical signs of fracture include swelling, tenderness,
ecchymosis, skin abrasions, and deformityincluding
malrotation.
Fractures may be associated with collateral ligament in-
juries, tendon avulsion, and nerve or vascular injury.
These structures should be evaluated by physical exami-
nation.
Radiologic Examination
Posterior-anterior, lateral, and oblique x-ray views are ob-
tained, along with accurate lateral profile views of the
phalanges.
Comparison views of the uninjured hand or digit are ob-
tained as needed.
TREATMENT
Closed Treatment
Closed treatment and external forms of immobilization
are best used in stable rather than unstable fractures.
Stability is defined in this context as the maintenance of
reduction following manipulation and external immobi-
lization.
This concept is amplified by noting that a transverse fracture
is intrinsically more stable than an oblique fracture.
Techniques of Closed Reduction
The following comments about closed reduction are most
appropriately applied to stable fractures of the diaphysis
of the middle and proximal phalanges, and the diaphysis
128
Chapter 9 / Hand Fractures and Fracture-Dislocations 129
FDP & FDS
Extensor carpi
Interosseous muscle
Lumbrical muscle
Figure 9-1 Classic fracture deformity in unstable
fractures of the metacarpals and phalanges (see
text for details).
of the metacarpals. They apply to fractures that are stable
(usually transverse fractures) and reducible.
Specific fractures of a more problematic nature that re-
quire operative intervention or special techniques will be
discussed later.
Proximal and Middle Phalanges
Anesthesia prior to fracture reduction in the hand may
be achieved by appropriate nerve blocks. Refer to Chap-
ter 8.
Following suitable anesthesia, longitudinal traction is
performed, followed by correction of the deformity.
This axial traction may be aided by the use of finger traps,
and the entire procedure is performed most comfortably
for the patient and surgeon by having the patient lay
supine with the elbow flexed to 90 degrees.
In digital fractures, the potentially deforming forces of
the intrinsics are relaxed by flexion of the MCP joints.
Wrist extension facilitates flexion of the MCP joints and
longitudinal traction of the finger or fingers.
After reduction, stability of the reduction is determined
along with rotational alignment.
Rotational alignment is evaluated by sighting down the
plane of the finger nails (from distal to proximal) to note
the relative tilt of the nail plate of the injured finger in
comparison to the adjacent fingers and using the unin-
jured hand for comparison as needed.
Rotation may also be checked by noting absence of
crossing over of the digit during flexion, and by not-
ing its normal parallel alignment with the adjacent
fingers.
Post reduction radiographs are made in sufficient num-
ber and detail to verify and document the reduction.
Depending on the digits fractured, a radial or ulnar gutter
splint is used to immobilize the injured digits.
The so-called intrinsic plus position is utilized with the
wrist in extension, the MCP joints in 90 degrees of flex-
ion, and the PIP joints in extension.
Ninety degrees of flexion at the MCP joints may not al-
ways be achieved. It has been noted that 60 degrees of
flexion of the MCP joint may be adequate.
This position results in relaxation of the potential de-
forming force of the intrinsic muscles, and avoids con-
tracture of the collateral ligaments of the MCP and PIP
joints.
An alternative to the radial or ulnar gutter splint is
to immobilize the wrist and hand in extension, and
place the reduced digit on an outrigger splint with the
MCP joint flexed to 90 degrees and the PIP joint in
extension.
This method allows visual evaluation of the alignment;
this may be confirmed as indicated by radiograph (Fig-
ure 9-2).
Protected motion of the fractured digit may begin at 3
to 4 weeks after reduction, with continued splinting as
needed and based on the experience of the surgeon.
In selected patients, some minimally displaced, stable,
and suitably aligned fractures of the proximal and mid-
dle phalanges may be treated by strapping the injured
digit to an adjacent finger and allowing early protected
motion.
Appropriate x-ray views should be obtained 1 week or less
after reduction, and weekly or biweekly thereafter based
on the fracture and the experience of the surgeon.
Metacarpal Fractures
The same comments about patient positioning and anes-
thesia apply as noted for phalangeal fractures.
The wrist is extended, and longitudinal traction achieved
by grasping the flexed proximal phalanx as a lever for dis-
tal traction and aligning and rotating the distal segment
of the metacarpal.
A cobra splint or cast may be used to immobilize these
fractures with the wrist in extension and the MCP joints
flexed 80 to 90 degrees (Figure 9-3).
The PIP joints are left free for flexion; if malrotation is
a potential problem, the injured digit may be taped to an
adjacent uninjured digit.
Splinting may be performed for 3 to 4 weeks based upon
the nature of the fracture and the experience of the sur-
geon.
Figure 9-2 Artists depiction of a Bohler-type
outrigger splint used for postreduction
immobilization of fractures of the proximal and
middle phalanges.
Early Motion in Hand Fractures
Fractures that are secondary to high-energy trauma, such
as crush injuries or those associated with joint injuries,
are more likely to develop residual stiffness and loss of
function.
Early mobilization and measures to reduce edema (eleva-
tion of the injured part) may be useful adjuncts to avoid
this complication.
Think of edema and swelling as internal glue that is
associated with stiffness.
True elevation of the hand requires it to be 30 cm or
higher than the level of the heart. This is best achieved
by lying down and elevating the hand on some form of
support.
Maintaining the hand in an arm sling (although better
than letting the hand hang at the side) is not elevation.
Figure 9-3 An example of a cobra cast used to immobilize a
fracture of the metacarpal. The carefully padded cast is molded to the
contours of the hand and the position of the wrist and MCP joints
neutralize the deforming force of the interosseous muscles.
Early motion is believed to lessen harmful adhesions of
the soft tissues, including the extensor and flexor tendon
systems and joint capsules.
Early motion along with proper joint positioning may
lessen these complications.
Some surgeons have noted that immobilization of fingers
beyond 4 weeks will lead to long-term stiffness due to
tendon adhesions and joint contracture.
Thus, fractures treated with closed reduction and
splinting are usually mobilized after 3 to 4 weeks, even
in the absence of osseous union by radiograph.
Stability of the fracture at this stage is due to fibrous
union that most often proceeds to osseous union.
In general, only splint the joints that are absolutely
needed, in order to allowearly motion of uninjured joints.
The PIP joint does not need to be immobilized in frac-
tures of the distal phalanx or distal interphalangeal (DIP)
joint.
Open Treatment
The indication for closed versus open reduction may de-
pend on many factors, including the special needs of the
patient and the experience and preferences of the sur-
geon.
Fractures with articular step-off, open fractures (espe-
cially in those with bone loss and significant soft-tissue
injury), fractures with significant shortening or bone loss,
and fractures that fail closed reduction are indications for
surgical treatment.
Other surgical indications include multiple fractures,
fractures that are intrinsically unstable, fractures with ro-
tational malalignment as seen in spiral and oblique frac-
tures, and fractures associated with joint subluxation or
dislocation.
Internal fixation should be achieved with minimal soft-
tissue disruption in order to limit scarring and disruption
of the blood supply of the fractured bone.
Ideally, the fixation should be rigid enough to allow im-
mediate active motion.
If this is not possible, protected motion should begin as
soon as possible based upon the nature of the fracture
and the surgeons experience.
Surgical intervention may be associated with stiffness
unless early mobilization is used.
Minimum surgical dissection will favor recovery of mo-
tion.
Many fractures that require reduction and fixa-
tion can be treated with percutaneous fixation tech-
niques.
Phalangeal fractures treated with plates and screws (most
likely because of wider surgical dissection) have a higher
incidence of stiffness.
Percutaneous fixation can be performed with Kirschner
wires.
Screws may be placed in selected cases through limited
incisions.
Oblique fractures are prone to rotational malalignment,
and stabilization is achieved by compression screws or
0.045-inch Kirschner wires placed perpendicular to the
fracture line.
The fixation devices are positioned to avoid compro-
mise to the tendons, so that early motion is not compro-
mised.
Figure 9-4 demonstrates an unstable spiral-oblique frac-
ture of the proximal phalanx fixed with two mini-
screws.
The fracture was exposed through a longitudinal incision
in the extensor tendon, which gave excellent exposure;
this stable construct allowed protected motion early.
The aftercare and supervised rehabilitation program is
very important to achieve maximum recovery and func-
tion.
Dynamic external fixation methods have been developed
for treatment of difficult articular fractures, especially
about the PIP joint.
These methods are technically challenging but may be
used based on the surgeons experience and preference.
Operating room fluoroscopy units are useful aids in re-
duction and placement of fixation devices.
Figure 9-4 An unstable, spiral-oblique fracture of the proximal
phalanx exposed through an extensor tendon splitting approach and
fixed with two mini screws.
Arthroscopic evaluation of joint surfaces has allowed
some surgeons to more accurately reduce and fix certain
intra-articular fractures.
Some Caveats about Kirschner Wires
Kirschner wires should be placed with understanding
that they will be removed at some point in the future.
They may be cut off beneath the skin, or left protruding
from the skin for ease of removal.
Infection may be avoided by keeping the exit sites of the
K-wires clean and dry.
Inappropriately placed K-wires may damage vital struc-
tures such as nerve, blood vessel, or tendon.
They should be placed so that soft-tissue gliding may oc-
cur during rehabilitation, without any impingement or
compromise to the soft tissues.
K-wires that cross joints may break, and their broken ends
may erode and damage articular cartilage.
When broken in this manner they are difficult to re-
move without causing additional joint damage.
Transarticular K-wires should be protected with a splint or
cast until their timely removal.
Making a right-angle bend on the exposed end of the K-
wire and cutting it off about 2 to 3 mm beyond the bend
may prevent excessive migration. In some instances, this
facilitates removal.
Threaded K-wires are prone to wrap-up adjacent soft
tissues; for that reason, smooth wires are preferred.
Specific Fractures of the
Phalanges and Metacarpals
DISTAL PHALANX
Fractures of the Tuft
Fractures of the distal phalanx are the most common
hand fracture.
Tuft fractures are usually due to a crush injury, and are
often associated with a subungual hematoma and some-
times a nail bed laceration.
Initial treatment consists of drainage of the subungual
hematoma, if present.
In patients with a disrupted nail and significant lac-
eration or disruption of the nail bed, consider re-
pairing the underlying nail bed with fine absorbable
sutures.
If a suitable nail plate is present, it may be replaced as a
biologic stent.
Splinting of the DIP joint for 2 to 3 weeks may protect
the soft-tissue injury and give symptomatic relief for the
fracture. Nonunion of one or more fracture fragments is
common, and requires no particular treatment.
Fractures of the Shaft
Fractures of the diaphysis may be transverse or longitu-
dinal.
A
B
C
Figure 9-5 Clinical and x-ray appearance of a displaced fracture of the proximal metaphysis of the
distal phalanx with K-wire fixation. A. Note the displaced fingernail. B. Radiographs showing
displacement of the fracture. C. Longitudinal K-wire fixation.
Most are minimally displaced and respond well to 2 to 3
weeks of DIP joint splinting. Fractures from high-energy
injuries may damage the germinal matrix.
Fractures of the Proximal Metaphysis
These injuries often displace the proximal nail from its
bed, and the nail should be anatomically reduced and
held in place with sutures. A transfracture K-wire may
be used to stabilize the fracture, and is often more ad-
vantageous in maintaining the reduction (Figure 9-5).
Fractures of the Base of the Distal Phalanx
Three types of these fractures exist. See Table 9-1.
Type I
The extensor mechanism is attached to the basal epi-
physis, and closed reduction of the fracture results in
correction of the deformity.
Continuous external splinting of the distal joint in full
extension for 3 to 4 weeks results in union of the fracture
and correction of the deformity.
Type II
This fracture is not to be confused withthe more common
small bone fragment associated with a tendon avulsion
and mallet-finger deformity that is treated as a soft-tissue
injury.
Operative treatment has been recommended for fracture
fragments involving more than one-third of the articular
surface.
TABLE 9-1 TYPES OF FRACTURES OF THE BASE
OF THE DISTAL PHALANX
Type Description
I. Transepiphyseal fracture as seen in children.
II. Hyperexion injury that usually results in a fracture
of the articular surface that involves 2050% of
the articular surface (the so-called mallet fracture).
III. Hyperextension injury with fracture of the articular
surface that usually involves >50% of the articular
surface and is sometimes associated with late
volar subluxation of the distal phalanx.
A
B
C
Figure 9-6 Artists depiction of a method to
reduce and fix a mallet fracture. A. A zigzag dorsal
incision is used to expose the fracture. B. A
0.035-inch, double-ended K-wire is drilled
longitudinally through the distal phalanx. C. The
joint is reduced, the K-wire is driven proximally
across the joint, and the fracture fragment is
reduced. If the fracture fragment cannot be
maintained in position, a loop of 4-0 wire is passed
through the fragment and distal phalanx and is tied
over a padded button. Intraoperative radiographs
are made to determine anatomic reduction. The
transarticular K-wire is protected with a splint for
6 weeks. The pullout wire may be removed in 3 or
4 weeks.
An accurate reduction is advocated to prevent joint de-
formity with secondary arthritis and stiffness.
This fracture may be treated as depicted in Figure 9-6.
The reader should note that this is a technically chal-
lenging operation, and not all surgeons recommend its
use.
Many surgeons advise closed splinting for this injury.
Operative repair of a mallet fracture is a technically dif-
ficult operation.
Attempted fixation of the fracture fragment by K-wire or
wire loop may result in comminution of the fragment and
loss of attachment of the extensor mechanism.
Type III
Figure 9-7 shows a radiograph of a type III hyperexten-
sion injury.
Treatment for this fracture is the same as for type II frac-
tures.
Both type I and II injuries have been treated successfully
by closed means, and the reader is advised to note the
following caveats regarding this fracture.
Caveats
Wehbe and Schneider recommended nonoperative treat-
ment by extensionsplinting of all mallet fractures, includ-
ing the hyperextension type with subluxation of the distal
phalanx.
Figure 9-7 Lateral x-ray view of a type III mallet finger fracture (see
text for details).
They believe that restoring joint congruity does not influ-
ence the end result, because remodeling of the articular
surface is reported to lead to a near-normal painless joint
in spite of persistent joint subluxation.
A further caveat about hyperextension mallet fractures
with volar subluxation is that splinting of the deformity
in hyperextension at the DIP joint should be avoided to
prevent volar subluxation of the distal phalanx.
MIDDLE PHALANX
Nondisplaced and Extra-Articular Fractures
Most nondisplaced extra-articular fractures can be
treated with buddy taping for 3 to 4 weeks.
Spiral fractures or others with potential for instability
may be splinted for 3 to 4 weeks, with timely follow-up
including radiographs.
If displacement occurs, the fractures should be treated
as noted for unstable displaced fractures (see discussion
that follows).
Displaced and Articular Fractures
Displaced fractures should be considered to be intrinsi-
cally unstable, and even when anatomically reduced they
may redisplace. This is especially true in oblique or com-
minuted fractures.
Dorsal Fracture Subluxation of the PIP Joint
This fracture involves the volar aspect of the articular
surface of the base of the middle phalanx, and is one of
the most disabling injuries to the finger.
Diagnosis and treatment are often delayed.
Figure 9-8 demonstrates the x-ray appearance of such an
injury.
These comminuted and unstable fractures may be treated
by some form of dynamic traction that maintains reduc-
tion and allows simultaneous movement of the injured
joint.
Another treatment option is that of dorsal block splinting,
in which the PIP joint is reduced and held in the degree
A B
Figure 9-8 X-ray appearance of a comminuted and displaced fracture subluxation of the base of the
middle phalanx.
of flexion that results in and maintains a concentric re-
duction.
Active flexion of the joint is performed and the dorsal
blocking splint gradually extended over a 4 to 5 week
period.
When seen late, these injuries may be salvaged by a volar
plate arthroplasty.
An example of a similar injury in the proximal phalanx
of the thumb demonstrates the use of balanced dynamic
traction to treat such an injury (Figure 9-9).
This method requires careful monitoring and balanc-
ing of the forces involved.
Some surgeons may elect to treat this injury by a thumb
spica cast or splint, and others may choose an open re-
duction and fixation with K-wires, plates and/or screws.
These first two examples are contrasted to an unstable
fracture-dislocation of the PIP joint with a relative large
and non-comminuted fragment that can be reduced and
fixed.
Such an anatomic reduction is stable and with early pro-
tected motion, an excellent outcome may be anticipated
(Figure 9-10).
PROXIMAL PHALANX
Peri-Articular Fractures
At the PIP Joint
Fractures that involve the articular surface of the proxi-
mal phalanx at the PIP joint are intrinsically unstable. If
they are not reduced and internally stabilized, deformity
and arthrosis will result.
Figure 9-11 demonstrates a neglected oblique fracture
of the proximal phalanx that healed with an articular off-
set and subsequent deformity. A realignment osteotomy
corrected the deformity.
At the MCP Joint
Fractures of the articular surface of the proximal pha-
lanx at the MCP joint are best treated by internal fixation
followed by protected early motion. Figure 9-12 demon-
strates such a case.
Diaphyseal Fractures of the Proximal Phalanx
Injuries at this level are prone to angulate with the apex
volar due to the action of the intrinsic muscles and ex-
tensor mechanism.
Treatment by closed means, or internal fixation with K-
wires or screws, is based on the anticipated stability of
the fracture and the preferences of the surgeon.
Reduction of phalangeal fractures is performed by flexing
the MCP joint to relax the intrinsic muscles, followed by
axial traction, digital pressure, and accentuation of the
deformity to disengage the fracture fragments as needed.
METACARPAL
Fractures of the Neck
These injuries are relatively common, and most often in-
volve the little finger metacarpal.
They often occur from punching various things with a
tightly clenched fist, and the eponym boxers fracture is
often used to describe these injuries.
C
E
D
A B
Figure 9-9 A dynamic traction method for treatment of a
comminuted and displaced fracture of the proximal phalanx of the
thumb. A, B. Pretreatment x-ray appearance; note the comminution
and volar subluxation of the proximal phalanx. C. The traction device
in place demonstrating a dorsal lifting K-wire in the base of the
proximal phalanx, and a longitudinal traction K-wire in the distal
phalanx. Traction was achieved by rubber bands between the outrigger
device and the K-wires. The device was left in place for 6 weeks.
(DE) The x-ray appearance of the fracture at 3 months.
A B
Figure 9-10 A noncomminuted but unstable volar lip fracture-dislocation of the base of the proximal phalanx that is amenable to
fixation.
Some surgeons consider all of these fractures as stable
and impacted ones that are not easily reduced.
Patients do not always present in a timely fashion, and
if seen even after 7 to 10 days, these fractures may be
impossible to move even under appropriate anesthesia
and vigorous manipulation.
The most controversial aspect of these injuries is deter-
mining which require treatment.
The basis of treatment for surgeons who treat these more
aggressively is determined by the degree of angulation
of the fracture as noted on a radiograph. The published
acceptable ranges of deformity vary with the finger in-
volved.
The little finger appears to tolerate a flexion deformity
at the metacarpal neck better than the other fingers
due to its hypermobility.
Thirty degrees of flexion seems to have no appreciable
effect on function in biomechanical studies.
Some authors will allow up to 50 degrees of angula-
tion, while others allow up to 70 degrees.
It has been argued that laborers and athletes that grip
bats or racquets may be candidates for more aggressive
management.
Treatment of these fractures is based on the surgeons
experience and the perceived needs of the patient. Most
single-bone fractures are treated by closed reduction and
some level of immobilization.
Figure 9-13 demonstrates a useful technique for reduc-
tion.
It is performed by using the cup or proximal articular
surface of the proximal phalanx as a pusher to reduce
the volar flexed aspect of the head and neck of the
metacarpal.
Multiple displaced fractures may indicate more aggres-
sive treatment.
In single bone fractures, two parallel percutaneous pins
that pass through the reduced distal aspect of the frac-
ture into the adjacent metacarpal keep the fracture in
alignment, are minimally invasive, and are easily re-
moved.
Figure 9-14 shows a patient with significant displace-
ment of fractures of the neck of the metacarpals of the
little and ring fingers.
Some surgeons would suggest that open reduction and
internal fixation is indicated.
Closed reduction would no doubt be difficult, if not
impossible.
Fractures of the Diaphysis
Although the ring and little fingers may tolerate up to
40 degrees of angulation of a fractured metacarpal shaft
due to carpometacarpal (CMC) motion at the hamate ar-
ticulation, this amount of angulation leaves a prominent
bump on the back of the handwhich most patients find
unacceptable.
Angulation beyond acceptable tolerances requires reduc-
tion and some form of fixation or immobilization based
upon the patients needs and the surgeons preferences.
Current thinking about the acceptable amount of short-
ening in metacarpal fractures is said to have decreased
from 1 cm to less than 5 mm.
Extensor lag associated with shortening of the metacarpal
may be accommodated by MCP hyperextension in the
absence of musculotendinous shortening.
Although some shortening is acceptable, rotation is not.
A
C
B
Figure 9-11 A neglected oblique
fracture of the articular surface of the
neck of the proximal phalanx. A, B. Note
the clinical and x-ray deformity.
C. Realignment was obtained by
osteotomy.
Figure 9-15 demonstrates the clinical appearance of a
malrotated index finger following an open reduction and
internal fixation.
Caveat: It does not take much rotation or malalignment
at the fracture site to yield a malrotated finger.
Treatment of metacarpal shaft fractures may vary from
a closed reduction, a well-applied cobra cast (see Fig-
ure 9-3), and a careful follow-up including radiographs,
to various forms of fixation, including K-wires, screws,
screws and plates, and external fixation devices.
Minimum profile plates may be used in certain cases.
Figure 9-16 shows such a plate in place.
Soft-tissue dissection should be kept to a minimum,
and although such techniques allow early protected
motion, they should be used in carefully selected
patients.
A B
Figure 9-12 An unstable fracture at the base of the proximal phalanx. A. Note the displaced and slightly
comminuted fracture at the base of the proximal phalanx. B. A single K-wire was used to fix the fragment
to the phalanx, and a longitudinal K-wire was used to stabilize the joint. The longitudinal K-wire was
removed at 3 weeks, and protected motion was started by strapping the middle finger to the index finger.
Compression screws placed at right angles to oblique
fractures may also be used.
K-wires may be used in selected cases, either in crossed
or parallel configuration.
Bi-cortical passage of the K-wires promotes better fixa-
tion and prevent rotation.
Stabilization of metacarpal fractures with external fixa-
tors, as well as transversely oriented K-wires from an in-
tact metacarpal to one with a fracture or bone loss defect,
may be especially useful when severe soft-tissue injuries
are present.
Figure 9-13 Closed reduction technique for boxers fracture.
Fracture of the Finger Metacarpal Base
Injuries to the finger metacarpal base most often involve
the ring and little fingers.
They are often associated with fractures of the adjacent
carpal bones.
These fractures may be missed on routine radiographs,
and the diagnosis may be aided by an oblique supination
view.
Open reduction and internal fixation is required to re-
store the normal alignment of the articular surfaces of
the CMC joints.
Figure 9-17 shows such an injury to the base of the little
finger metacarpal and an associated fracture of the ring
finger metacarpal.
Treatment was by open reduction and K-wire fixation
of the CMC dislocation, with parallel K-wires across
the ring finger metacarpal fracture.
THUMB METACARPAL
Fractures of the Diaphysis
Fractures of the diaphysis are relatively uncommon, and
fractures about the thumb metacarpal usually involve the
base.
The thumb has significant CMC motion, and dorsal an-
gulation of fractures of the diaphysis of the metacarpal
may be better tolerated than angulatory deformity in the
fingers (especially the index and middle).
A B
C
Figure 9-14 AC. X-ray appearance
in three views of severely displaced
boxers fractures of the ring and little
finger metacarpals.
A B
Figure 9-15 Malrotation deformity of an internally fixed index metacarpal fracture. A. Note the scar
over the dorsal aspect of the index finger, and the subtle supination deformity seen in the index
fingernail. B. The deformity is most pronounced during flexion. A corrective derotational osteotomy was
performed.
Figure 9-16 Intraoperative view of a miniplate and
screws for treatment of a metacarpal fracture.
C D
A B
Figure 9-17 CMC joint dislocation of the little finger and fracture of the ring finger metacarpal. A, B.
X-ray appearance of the injury. Note the CMC dorsal dislocation of the little finger metacarpal and
fracture of the ring finger metacarpal. Note also that the oblique view is more revealing than the AP
view. C, D. Postoperative appearance showing anatomic reduction and fixation with K-wires. Note the
bent ends of the K-wires (see text).
Although dorsal angulation of some degree may be func-
tionally acceptable (some surgeons accept up to 30 de-
grees), it may not always be acceptable from the patients
perspective.
Both closed and operative methods may be used for re-
duction and fixation of diaphyseal fractures, as previously
described.
The most suitable position for immobilization of the
thumb is abduction and extension of the CMCjoint, with
minimal flexion of the MCP joint and extension of the IP
joint.
This position may be demonstrated on your own hand by
noting the posture of the thumb when it lightly touches
the tip of the semi-flexed index finger.
Fractures of the Base
Extra-articular fractures of the base of the thumb
metacarpal are treated like fractures of the diaphysis, and
most can be managed by closed means.
It is the intra-articular fracturesclassified as Bennetts
or Rolandos fracturesthat are most problematic and
challenging for the surgeon.
Bennetts Fracture
Pertinent Anatomy and Pathomechanics
The volar projection of the base of the thumb metacarpal
is firmly held to the adjacent trapezium by the superficial
anterior oblique ligament (SOAL) and the deep anterior
oblique ligament (DOAL).
The latter is also known as the beak ligament.
These ligaments firmly hold the volar projection of the
thumb metacarpal in place, and in the presence of axial
loading, a fracture occurs rather than a dislocation of the
CMC joint.
The resultant fracture is oblique and is displaced by the
proximal and dorsal pull of the abductor pollicis longus
(APL) tendon that inserts on the dorsal base of the thumb
metacarpal.
In addition, the adductor pollicis (AP) places a radially
deforming force on the metacarpal.
Diagnosis
This injury is most accurately diagnosed by a true lateral
radiograph of the CMC joint.
A true lateral is obtained by placing the radial border
of the thumb flat on the x-ray plate with the wrist and
forearm pronated 15 to 35 degrees.
Placing the wrist and hand in this position naturally ex-
tends the wrist and hand. This position is maintained
with a foam wedge placed under the ulnar border of the
hand.
The x-ray beam is centered over the CMC joint and di-
rected at a 15-degree angle from distal to proximal.
Treatment
An anatomical reduction and maintenance of that reduc-
tion is required.
This is an unstable fracture, and it is highly unlikely that
a closed reduction can be maintained by a cast or a
splint.
Figure 9-18 Technique for percutaneous fixation of a Bennetts
fracture of the thumb (see text for details).
Some surgeons, however, recommend closed reduction
and casting provided a stable reduction can be main-
tained and provided there is less than 1 mmdisplacement
or articular step-off.
Maintenance of the reduction is best achieved by some
form of fixation, either by closed percutaneous pinning
or by open reduction and fixation.
A B
Figure 9-19 Technique for screw fixation of Bennetts fracture. A.
The incision. B. Reduction and screw fixation.
C D
A B
Figure 9-20 X-ray appearance of Bennetts fracture with K-wire fixation. A, B. Prereduction
appearance. C, D. Note the anatomic reduction and K-wire fixation of the fracture fragment, and a
second transarticular K-wire across the CMC joint. Question to the reader: What would you have done
differently in terms of the cut off ends of the K-wires? Answer: A 90-degree bend prior to cutting off the
K-wires would have prevented migration of the ends of the pins beneath the dorsal cortex of the metacarpal
and made pin removal at 6 weeks a less complex procedure.
Some surgeons base their decision for closed versus open
methods based on the size of the volar lip (articular) frag-
ment.
If the fragment is less than 15% to 20% of the articular
surface, closed reduction and percutaneous pinning is
elected.
If the articular fragment is greater than 25%to 30%, open
reduction is performed.
Management of this fracture by percutaneous fixation is
performed by longitudinal traction on the thumb, simul-
taneous pressure over the dorsal aspect of the base of
the thumb metacarpal, and pronation of the thumb fol-
lowed by insertion of a transarticular K-wire across the
dorsal base of the metacarpal into the trapezium (Fig-
ure 9-18).
This construct is protected by a secure cast or splint,
the pin is removed at 5 weeks, and motion starts based
on the clinical and x-ray findings.
Open reduction is performed through a J-shaped incision
that reflects the base of the thenar muscles away from
the CMC joint.
This approach allows a profile view of the fracture and
CMC joint.
The fracture fragment is reduced anatomically and
fixed to the main body of the metacarpal by one or
two K-wires or screws, based on the surgeons choice
and experience.
This construct is protected with a cast or splint, and
motion is started based on the nature and stability of
the fixation (Figure 9-19).
Figure 9-20 demonstrates the x-ray appearance of a
Bennetts fracture and its reduction and fixation with
K-wires.
Rolandos Fracture
This fracture was originally described as a fracture of
the base of the thumb metacarpal with a Y- or T-shaped
intra-articular component.
The term has now come to include any comminuted
intra-articular fracture of the base of the thumb meta-
carpal.
Treatment
In those fractures that meet Rolandos original descrip-
tion, treatment is by open reduction and internal fixation
with K-wires, plates, and screws.
In those more comminuted fractures, treatment tech-
niques have included skeletal traction and mini-external
fixators.
The goals of treatment for these comminuted fractures is
to maintain thumb length and as much congruity of the
articular surface as possible.
SUGGESTED READING
Eaton RG, Malerich MW. Volar plate arthroplasty of the proximal in-
terphalangeal joint: a review of thirty years experience. J Hand Surg
1980;5:260268.
Glickel SZ, BarronOA, Eaton RG. Dislocations and ligament injuries in
the digits. In: Green DP, Hotchkiss RN, Pederson WC, eds. Greens
operative hand surgery. 4th Ed. New York: Churchill Livingstone,
1999:772808.
Gutow AP, Slade JF, Mahoney JD. Phalangeal injuries. In Trumble T,
ed. Hand surgery update 3, hand, elbow and shoulder. Rosemont,
IL: American Society for Surgery of the Hand, 2003:127.
Markiewitz AD. Metacarpal fractures. In Trumble T, ed. Hand surgery
update 3, hand, elbowand shoulder. Rosemont, IL: Amer. Soc Surg
Hand, 2003:2935.
Stern PJ: Fractures of the metacarpals and phalanges. In: Green DP,
Hotchkiss RN, Pederson WC, eds. Greens operative hand surgery.
4th Ed. New York: Churchill Livingstone, 1999:711771.
Wehbe MA, Schneider LH. Mallet fractures. J Bone Joint Surg 1984;
66A:658669.
10
DISLOCATION
AND LIGAMENT
INJURIES
The ligaments of the hand, in conjunction with the con-
figuration of the bone components of the joints, provide
for stable yet mobile joints that allow the digits to perform
precise movements. These stabilizing ligaments, however,
are subject to stresses that sometimes exceed their toler-
ance. When this happens, they fail. The end result is loss of
stability and function due to mechanical factors and pain.
Timely recognition and appropriate treatment of these in-
juries is mandatory in the management of hand injuries.
Certain patterns of injury have been identified, and the most
common and clinically significant forms of ligament injuries
based on their respective joints will be discussed. By defi-
nition, the discussion of ligament injuries in this chapter
includes joint instability, subluxation, and dislocation. Dis-
locations may occur without destabilizing injury or chronic
instability to the respective ligaments involved. However, it
is mandatory that the examiner clearly distinguishes those
dislocations and subluxations that will inevitably result
in instability, and those that are intrinsically stable after
reduction.
Our discussion in this chapter will be directed at liga-
ment injuries rather than fracture dislocations. However,
some ligament injuries may be associated with an avulsion-
type fracture, but the main focus is on the ligament injury
and not the fracture. Chapter 9, which focuses on frac-
tures and fracture dislocations, discussed these injuries, and
the reader may recognize that some arbitrary divisions have
been made in these two chapters for the sake of conve-
nience.
FINGER DISTAL INTERPHALANGEAL
JOINT AND THUMB INTERPHALANGEAL
JOINT
Incidence and Treatment
Dislocations of the distal joints of the fingers and thumb
are relatively uncommon.
The distal phalanx of these joints has a shorter lever
arm, and additional stability is present due to the ad-
jacent insertions of the flexor and extensor tendons.
When dislocations do occur they are most likely to be
dorsal or lateral and may be open due to the compar-
atively diminished skin coverage over this joint (Fig-
ure 10-1A).
Reduction is achieved by longitudinal traction and ma-
nipulation of the base of the phalanx into its anatomical
bed.
As in all reductions, joint stability is evaluated by gentle
passive and active motion.
Postreduction radiographs are taken to verify the reduc-
tion.
The joint is splinted in a few degrees of flexion, and mo-
tion may be started in 7 to 10 days (Figure 10-1B).
These dislocations are usually reducible, and reported
causes for failed reduction are interposed soft tissue,
such as the palmar plate or the flexor tendon.
Surgery is indicated for those dislocations that cannot be
reduced.
PROXIMAL INTERPHALANGEAL JOINT
Pertinent Anatomy
In terms of bony architecture, the PIP joint may be likened
to two coffee cups in their respective saucers that have been
placed side-by-side, with both cups and saucers firmly at-
tached together. This analogy serves to illustrate the fact
that the bicondylar end of the proximal phalanx (the cof-
fee cups) articulates with a saucer-like component at the
base of the middle phalanx, and thus has a certain element
of stability or resistance against radial or ulnar deviation.
Figure 10-2 depicts the anatomic arrangement of the PIP
joint. Add to this fact that the radial and ulnar collateral lig-
aments are substantial cord-like structures that are firmly
attached to the neck of the proximal phalanx and the base
of the middle phalanx. It is not surprising to recognize that
the majority of dislocations of the PIP joint occur in the
dorsal (most common) or palmar plane. Additional stability
is added to the PIP joint by the palmar plate and its prox-
imal and distal attachments, and the accessory collateral
ligament. Figure 10-3 depicts the soft tissue anatomy of the
PIP joint.
144
Chapter 10 / Dislocation and Ligament Injuries 145
A B
Figure 10-1 (A) X-ray appearance of a dorsal dislocation of the IP joint of the thumb. (B) X-ray
appearance after reduction and splinting.
Dorsal Dislocation
Mechanism of Injury and Pathologic Anatomy
This injury is most commonly associated with a blow to the
end of the digit that results in an obvious deformity. The
attachments of the palmar plate are disrupted (usually dis-
tally). There are also longitudinal but nondestabilizing tears
of the collateral ligaments in the zone between the proper
(cord-like) and accessory (fan-like) region of the collateral
ligament complex.
Diagnosis
These sports injuries are often reduced shortly after the
injury by the patient, a teammate, or coach, and the
Figure 10-2 The bicondylar arrangement of the PIP joint accounts
for its intrinsic bony stability.
patient usually presents to the examining physician with
a swollen but reduced PIP joint.
Profile radiographs in the anterior-posterior (AP) and
true lateral planes are obtained to note any fractures.
C1
A3
Palmar plate
Palmar tubercle
Collateral
ligaments
Digital
vessel
Check-rein
ligament
A2
Proper collateral
ligament
Palmar plate Accessory
collateral ligament
B
A
Figure 10-3 Artists depiction of the arrangement of the palmar
plate and its proximal and distal attachments, along with the proper
and accessory collateral ligaments.
Figure 10-4 X-ray appearance of a dorsal PIP joint dislocation.
In the unreduced state, these radiographs most often re-
veal that the base of the middle phalanx is resting on the
dorsal neck of the proximal phalanx (Figure 10-4).
Sometimes a small fragment of bone is avulsed from the
palmar base of the middle phalanx, which indicates that
the plane of disruption was through the base of the mid-
dle phalanx rather than at the attachment of the palmar
plate. This fragment remains attached to the palmar plate
volarly.
Treatment
Closed reduction of the dislocation is performed un-
der digital block anesthesia, followed by longitudinal
traction and pushing the base of the middle phalanx
distally.
After reduction, stability of the joint is determined by
active and passive movements of the joint.
Satisfactory active movement without redislocation or
deformity indicates that sufficient soft tissue stability re-
mains to allow early protected movement.
Passive stability is confirmed by stress testing of the col-
lateral ligaments with the PIP joint in full extension and
at 30 degrees of flexion, and comparing this to an unin-
jured but otherwise comparable digit.
Increased mobility in the AP plane is tested by gentle
shear testing, by stabilizing the proximal phalanx and
moving the middle phalanx.
This injury is seldom associated with a destabilizing col-
lateral ligament or other soft tissue injury, and the re-
duced digit may be buddy taped to an adjacent digit for
protected exercise.
A large fracture fragment noted on radiograph (usually
40% or more of the articular base of the middle phalanx)
indicates a fracture-dislocation and represents a desta-
bilizing injury. These injuries are often treated by open
reduction and fixation, or other forms of stabilization.
Instability results due to the fact that the majority, if not
all, of the stabilizing collateral ligaments are attached
to this fragment and no longer act as stabilizers to the
middle phalanx. This topic is discussed in the chapter on
Fractures and FractureDislocations.
Figure 10-5 X-ray appearance of a lateral dislocation of the PIP
joint.
Lateral Dislocation
A mechanism of injury is a direct lateral force on the PIP
joint that exceeds the tolerance of the collateral ligament
complex (Figure 10-5).
This injury is less common than dorsal PIP joint disloca-
tion. It involves disruption of the origin or insertion of the
collateral ligament, disruption of the interval between the
proper collateral ligament and the accessory collateral liga-
ment, and partial disruption of the palmar plate attachment.
Diagnosis
Complete lateral dislocations are clinically apparent, but
subluxations may not be as obvious because of swelling.
Stress testing of the collateral ligament and accessory sta-
bilizers is performed with the PIP joint in full extension.
An angular deformity of 20 degrees or more on the
stress test is diagnostic of significant instability.
Treatment
If stability is present with active and passive flexion, and
extension of the PIP joint and radiographs demonstrate
joint congruity, treatment is through protected motion
by buddy taping the injured digit to an adjacent digit.
Surgery is indicated for soft tissue interposition or a dis-
placed fracture.
Palmar Dislocations
Three types of palmar PIP dislocation have been identified.
All are rare.
Rotatory Palmar Subluxation
This condition represents a longitudinal rent in the extensor
mechanism between the lateral band and the central slip of
the extensor tendon, which allows the head of the proximal
phalanx to enter the separation and be trapped. The
Central slip
Radial lateral band
Torn ext.
expansion
Figure 10-6 Rotatory subluxation of the proximal interphalangeal
joint. This lesion occurs due to a longitudinal rent in the extensor
mechanism between the lateral band and the central slip of the
extensor tendon. This allows the head of the proximal phalanx to
enter the separation and be trapped and rotated between the
displaced lateral band and the central slip.
displaced lateral band is trapped behind the palmar aspect
of the condyle, resulting in a rotatory deformity of the mid-
dle and distal segment of the finger (Figure 10-6).
The mechanism of injury is due to a combination of
forces, including rotation, flexion, and lateral deviation. The
PIP joint is most susceptible to torsional force at 55 degrees
of flexion, when the lateral bands shift palmar to the mid-
axis of the proximal phalanx. Thus, the injury probably is
sustained with the PIP joint in moderate flexion. The term
subluxation seems appropriate because the PIP joint is not
widely separated.
Diagnosis
The PIPjoint is in moderate flexion, the middle and distal
phalanges are rotated, and there is swelling about the PIP
joint.
A true lateral radiograph of the proximal phalanx demon-
strates partial separation of the PIP joint and obliquity
of the middle phalanx due to the rotatory component of
this injury.
Treatment
Although this condition has been reported to be irre-
ducible, closed reduction under appropriate anesthesia
may be attempted by simultaneous flexionof the metacar-
pophalangeal (MCP) and PIP joints to relax the lat-
eral band, followed by gradual extension accompanied
by rotation of the middle phalanx that is opposite to the
deformity.
If this maneuver is not successful, open reduction is
performed.
Irreducible Rotatory Palmar
Dislocation
This condition is the more complete or severe form of rota-
tory palmar subluxation.
Intact radial collateral ligament
Torn ext. expansion
Central slip, ulnar
lateral band &
avulsed ulnar
collateral
ligament
Figure 10-7 Irreducible rotatory palmar dislocation of the PIP joint.
The clinical appearance is characterized by almost 90 degrees of
flexion at the PIP joint, supination of the distal aspect of the finger,
and inability to reduce the deformity.
Irreducibility is due to soft tissue interposition of the
central slip, which, along with the ulnar lateral band, is
displaced palmar to the neck of the proximal phalanx (Fig-
ure 10-7). Findings at surgery reveal the head of the prox-
imal phalanx projecting through an oblique tear in the ex-
tensor expansion between the central slip and the radial
lateral band. Findings also reveal the central slip and ulnar
lateral band displaced to lie together in front of the neck
of the proximal phalanx, where they act as a block to re-
duction. The UCL is avulsed and the RCL is intact. As in
rotatory palmar subluxation, the mechanism of injury is a
predominantly rotational force. A common cause of injury
is a full-spin clothes dryer that catches a finger while it is
still moving; the finger most often involved is the index.
Diagnosis
The clinical appearance is characterized by almost 90
degrees of flexion at the PIP joint, supination of the distal
aspect of the finger, and inability to reduce the deformity.
Treatment
The PIP joint is exposed through a dorsal approach. Re-
duction is achieved by replacement of the displaced cen-
tral slip and lateral band, followed by repair of the rent
in the extensor mechanism.
Reducible Palmar Dislocation
Based on clinical studies and cadaver experiments, the re-
ducible type of palmar dislocation is associated with injury
to one collateral ligament, the palmar plate, and the ex-
tensor mechanism (usually the central slip insertion of the
extensor tendon). Although usually reducible, it is unstable
because of loss of dorsal support fromthe central slip. More
Figure 10-8 X-ray appearance of a palmar dislocation
of the PIP joint.
importantly, if not recognized and treated properly, this re-
sults in a boutonniere deformity because of the central slip
disruption. Unilateral injury to the collateral ligament re-
sults in a rotatory deformity because of the suspensory ef-
fect of the intact collateral ligament. The mechanism of
injury is a varus or valgus stress followed by a palmar force
that dislocates the middle phalanx palmarly. Cadaver ex-
periments that used only an anterior force without varus or
valgus force resulted in avulsion of the central slip, usually
with a fracture fragment and a lesser incidence of collateral
ligament rupture. Figure 10-8 depicts the x-ray appearance
of reducible palmar dislocation.
Clinical Caveats
If an anterior dislocation can be reduced, it is important
to recognize that an injury to the central slip has occurred
and requires appropriate treatment.
It has been noted that palmar dislocations of the PIP
joint always injured the extensor mechanism (most often
a tear of the central slip), a collateral ligament, and the
palmar plate.
The associated ligament and tendon injury, if not treated,
will result inloss of bothstatic and dynamic PIPjoint sup-
port, which is manifested by palmar subluxation, malro-
tation, boutonniere deformity, and fixed flexion contrac-
ture.
Figure 10-9 demonstrates the clinical and x-ray ap-
pearance of such a neglected case involving the PIP
joint of the ring finger.
Although the joint was reduced and soft tissue recon-
struction was performed, the end result was a stiff
finger.
Irreducible palmar dislocations are not usually associ-
ated with central slip disruption, and may have a more
favorable prognosis.
Inability to reduce an anterior dislocation is most likely
due to interposition of a part of the extensor mechanism,
which can be corrected by surgery.
There are two forms or stages of progression in rotatory
injuries.
The first, or stage I, is a subluxation injury; the second,
or stage II, is an irreducible dislocation.
Closed reduction of stage I injuries may be attempted
in acute cases.
In stage II or complete dislocations, closed reduction
is not advised.
A B
Figure 10-9 Clinical and x-ray appearance of a neglected palmar dislocation of the ring finger PIP joint.
FINGER METACARPOPHALANGEAL
JOINT AND COLLATERAL LIGAMENTS
Pertinent Anatomy
In contrast to the PIP joint architecture, the MCP joints of
the fingers may be described as a single coffee cup that is
loosely placed in its saucer. The rounded coffee cup (the
metacarpal head) sits in its flat saucer (the base of the
proximal phalanx) and although the two joint surfaces are
joined together, their shape and ligamentous constraints
permit mutiplanar movements including flexion, extension,
abduction, adduction, and limited pronation and supination
(Figure 10-10). Like the PIP joints, they are supported by
primary and accessory collateral ligaments. The MCP joint
palmar plate is less rigidly fixed proximally, and although a
type of checkrein ligament exists, it is less substantial than
the one found at the PIP joint. This may explain the normal
ability of the MCP joint to hyperextend, whereas the PIP
joint is less prone to do so. One collateral ligament injury
and two dislocations have been recognized at the MCP joint
finger joints.
Finger Metacarpophalangeal Ligament Injuries
The overall incidence of rupture of the collateral ligaments
of the fingers is much lower than the incidence of rupture of
C D
Proper coll. lig.
Accessory coll. lig.
A2 pulley
A1 pulley
A1 pulley
Palmar plate
Palmar plate
Extensor
tendon
Sagittal
band
Proper
coll. lig.
Accessory
coll. lig.
MC
MC
B
A
Figure 10-10 Anatomy of the finger MCP joint collateral ligaments. (A) A cross section of the MCP
joint showing the various stabilizing structures of the joint. (B) Lateral view of the finger MCP joint.
(C) Fresh cadaver dissection of the MCP collateral ligaments showing their comparatively relaxed
tension in MCP joint extension. (D) Note the increased tension of the collateral ligaments in flexion.
Figure 10-11 Intraoperative appearance of a
complete tear of the RCL of the index MCP joint. The
curved clamp is on the proximal end of the RCL. The
first dorsal interosseous muscle (1st DI) expansion was
retracted, and the two ends of the ligament
reapproximated with a Bunnell-type pullout suture.
Excellent healing and stability was achieved.
either the UCL or RCL of the thumb. Ruptures most often
occur in the little and index fingers, and involve the RCL.
These fingers are most commonly involved because of their
position as border digits, but finger MCP joint RCL rup-
tures have been reported in all the fingers. The usual mech-
anism of injury is forced ulnar deviation with the fingers
flexed.
Diagnosis
There is usually tenderness along the radial side of the
joint, and pain on ulnar stress of the joint.
An arthrogram may aid in diagnosis.
Treatment
Treatment should be based on functional need, and may
include primary reattachment, repair, or reconstruction
by tendon graft as needed (Figure 10-11).
Dorsal Dislocation of the Finger
Metacarpophalangeal Joint
Dorsal dislocation of the finger MCP joints is unusual. The
most common digit to be involved is the index, followed by
the small finger.
The usual mechanism of injury is hyperextension of the
finger, often due to a fall on the outstretched hand. The
proximal attachment of the palmar plate is torn, and
the suspensory effect of the collateral ligaments allows the
hyperextension force to thrust the proximal phalanx and pal-
mar plate dorsally to rest on the dorsal aspect of the meta-
carpal.
Kaplan identified a four-sided complex of structures that
played a role in trapping the metacarpal head in the palm
(Figure 10-12). These structures are as follows:
1. Radially, the lumbrical
2. Proximally, the transverse fibers of the palmar aponeu-
rosis
3. Ulnarly, the flexor tendons
4. Distally, the natatory ligaments and the palmar plate
Diagnosis
It is important to distinguish between complete ir-
reducible dislocations and reducible subluxations, be-
cause a subluxation can be converted to a complete
and irreducible lesion by inappropriate reduction maneu-
vers.
In complete dislocation (the irreducible lesion), the MCP
joint is held in slight to moderate extension; MCP
joint flexion is impossible and the finger is ulnarly
deviated.
A prominence may be palpated in the palm that cor-
responds to the metacarpal head, and the skin may be
puckered. Figure 10-13 demonstrates the clinical ap-
pearance of complete dislocation of the MCP joint of
the index finger.
In subluxation (the reducible lesion), the findings are
similar except that the proximal phalanx is usually more
hyperextendedoften 60 to 80 degrees.
Radiographic Findings
In complete dislocations, the radiographic findings may
be minimal in the anteroposterior view.
The oblique view usually demonstrates widening of the
joint space, and the lateral view may show the complete
dislocation.
Lateral or dorsal displacement of the sesamoid in the
oblique and lateral views also is an important finding.
A tangential or Brewerton view of the metacarpal head
may aid in the detection of an avulsion or other fractures
in the region of the metacarpal head (Figure 10-14).
Treatment
Distinction must be made between subluxation and com-
plete dislocation because the former is reducible by
closed means and the latter is not.
A
C
Natatory
ligament
Palmar plate
Digital
nerve
Lumbrical
Flexor
tendons
Transverse
fibers
Pretendinous
band
B
Figure 10-12 Complete dorsal
dislocation of the index finger joint.
(AB) Extended and ulnar-deviated
index finger. (C) The head and neck
of the dislocated metacarpal is
trapped by the transverse fibers of the
palmar fascia, the flexor tendons,
natatory ligaments, and the palmar
plate, and the lumbrical.
In subluxation, the proximal edge of the palmar plate
remains palmar to the metacarpal head.
If either hyperextension or traction is used as part
of the reduction technique, the palmar plate may be
drawn dorsally and result in a complete and irreducible
dislocation.
The proper reduction maneuver is performed by flex-
ion of the wrist, and distal and palmar force on the
base of the proximal phalanx that slides the phalanx
over the metacarpal head.
Irreducible dislocations are treated by open reduction.
Kaplan described a palmar approach for this condition,
and others have described a dorsal approach.
THUMB METACARPOPHALANGEAL
JOINT AND COLLATERAL LIGAMENTS
Joint Dislocations
Most dorsal dislocations of the thumb MCP joint are re-
ducible; irreducible dislocations are due to a variety of
A B
Figure 10-13 (A) Clinical appearance of a complete and locked dorsal dislocation of the MCP joint of
the index finger. (B) Hyperextension at the MCP joint, and ulnar deviation of the index finger.
A
C
B
Figure 10-14 X-ray appearance of a dorsal dislocation of the index
finger MCP joint. (A) The AP view shows only minimal changes at
the MCP joint (arrow). (B) The oblique view shows a widened MCP
joint space and some dorsal displacement of the proximal phalanx
(arrow). (C) The lateral view shows a complete dislocation (arrow).
interposed structures that either block or trap the proximal
phalanx from returning to its anatomic position.
If the thumb collateral ligaments are visualized as struc-
tures that suspend the proximal phalanx during flexion and
extension, it is easy to speculate that any disruption of the
proximal attachments or restraints to hyperextension may
result in the proximal phalanx going over the top with
a sufficient hyperextension force, and becoming locked or
trapped on the dorsal surface of the metacarpal. For this to
occur, the palmar plate attachment must be disrupted ei-
ther at its proximal aspect or at its insertion into the base of
the proximal phalanx. If the palmar plate is disrupted dis-
tally, the accessory collateral ligaments are torn, and this
allows the proximal phalanx and the collateral ligaments to
swing dorsally to the top of the metacarpal. If the palmar
plate is detached proximally, it and its imbedded sesamoid
bones are carried dorsally along with the proximal phalanx.
In addition to the palmar plate, other structures that may
be pulled along in this excursion are the adductor pollicis
aponeurosis, including the bony insertion on the ulnar base
of the proximal phalanx; the abductor expansion; and the
two heads of the FPB, which, along with the intact proper
collateral ligaments, may forman entrapment noose around
the neck of the thumb metacarpal and prevent reduction.
The FPL may be entrapped in the joint but usually remains
in the sheath.
Diagnosis
A radiograph that demonstrates sesamoid bones on the
dorsal aspect of the metacarpal and adjacent to the base
of the proximal phalanx usually indicates a complex irre-
ducible dislocation of this joint (Figure 10-15).
A B
Figure 10-15 Locked dorsal dislocation of the MCP joint of the
thumb. (A) The sesamoid bones are resting on the dorsal aspect of
the neck of the thumb metacarpal (arrow). (B) An open reduction
was required to reduce this locked dislocation.
Treatment
Closed reduction may be attempted, under appropriate
anesthesia, by flexing the wrist and thumb interpha-
langeal joint and then pushing the hyperextended proxi-
mal phalanx distalward.
Longitudinal traction is avoided because it may tighten
the noose represented by the various soft tissues around
the neck of the metacarpal and prevent reduction.
If closed means are not successful, open reduction is
indicated through a dorsal or palmar approach.
Figure 10-16 shows the clinical and x-ray appearance of
a dorsal dislocation of the MCP joint of the thumb, and
A
C
B
Figure 10-16 Clinical and x-ray appearance of an MCP thumb
dorsal dislocation, and technique of reduction. (A) Note the
hyperextension of the MCP joint. (B) The radiograph demonstrates
that the proximal phalanx is perched on the dorsal aspect of the
metacarpal. (C) Reduction under suitable anesthesia is achieved by
hyperextension of the proximal phalanx and by pushing or sweeping
it off the neck of the metacarpal.
the hyperextension and distal slide technique to reduce
the dislocation.
Collateral Ligament Injuries
Ulnar Collateral Ligament
Rupture or Avulsion
This injury is due to sudden and forceful radial deviation
(abduction) of the proximal phalanx of the thumb, often
secondary to a fall on the out stretched hand with the thumb
abducted. It may be associated with activities such as skiing
or ball sports.
Disruption of the UCL at the distal insertion (with or
without a bone fragment) is five times more common than
proximal tears or disruptions. Tears in the substance of the
UCL occur with less frequency. Associated injuries include
tears of the dorsal capsule, partial avulsion of the palmar
plate, or a tear in the adductor aponeurosis. In addition to
providing lateral stability to the MCP joint, the UCL and
RCL play a role in suspending the proximal phalanx. There-
fore, disruption of the UCL may result in palmar migration
and rotation (supination) of the proximal and distal phalanx
on the intact RCL.
Stener Lesion
In 1962, Stener described complete rupture of the UCL
with interposition of the adductor aponeurosis between the
distally avulsed UCL and its site of insertion. This configu-
ration is easy to understand based on the fact that the UCL
is deep to the adductor aponeurosis. Also, with avulsion it
is carried proximally, while the leading edge of the adduc-
tor aponeurosis is carried distally by the deforming force
of injury. When the force abates and the proximal phalanx
returns to its normal alignment, the UCL is external rather
than deep to the adductor aponeurosis. Even if this config-
uration did not occur, the natural tension in the ligament
and subsequent contracture would place it well proximal
to its distal attachment, and beneath the aponeurosis. The
Stener lesion is depicted in Figure 10-17.
Diagnosis
The diagnosis is made by noting the mechanismof injury;
identifying tenderness, swelling, or ecchymoses over the
ulnar side of the MCP joint; and noting laxity of the UCL
with stress testing.
Local anesthesia may be used to facilitate the stress
test.
Aradiographis made as part of the stress test to document
the degree of opening of the joint. Comparison stress
films may be made of the opposite side, as needed.
It is beyond the scope of this text to discuss the methods
of stress testing in detail, except to note that with com-
plete UCLdisruption, the MCPjoint may be opened with
minimal resistance.
EPL
UCL
A
B
Adductor pollicis
Figure 10-17 The Stener lesion. (A) The UCL lies beneath the
adductor aponeurosis. (B) Rupture of the UCL occurs with sufficient
abduction force. When the MCP joint resumes its anatomic position,
the proximal portions of the UCL are trapped proximal and
superficial to the adductor aponeurosis. The aponeurosis must be
surgically reflected, and the UCL rejoined in its anatomic position, to
restore stability to the joint.
Treatment
The basic principle of treatment in complete ruptures of
the UCL is to reattach the UCL to its anatomic site of
attachment.
If the anatomic sites of attachment are not duplicated,
there may be less range of motion than normal of the
MCP joint.
Caveat About Associated Fractures in UCL Injuries
Conventional wisdom has indicated that the position of the
so-called avulsion fractures that may be seen with UCL in-
juries marks the distal aspect of the disrupted UCL. Awidely
displaced fracture fragment would indicate significant dis-
placement of the UCL, and would suggest the need for sur-
gical intervention. A recent case study reevaluated this con-
cept and found that the location of the fracture fragment
did not always indicate the location of the ruptured collat-
eral ligament. The author of this study, quoting reports by
Stener in 1963 and 1969, noted that fractures of this type
A B
Figure 10-18 Radial collateral ligament disruption at the MCP joint of the thumb. (A) Positive stress
test manifested by abnormal deviation of the proximal phalanx. (B) The complete avulsion of the RCL
was repaired by reattachment of its proximal origin using a small screw. The repair was protected by an
oblique transarticular Kirschner wire until healing occurred.
are either avulsion fractures due to UCL disruption, or shear
fractures at the base of the proximal phalanx by the palmar
portion of the radial condyle of the metacarpal. If the frac-
ture seen on radiographs is a shear fracture, its position is
unrelated to the location of the distal end of the avulsed
UCL. A displaced ligament may occur in the presence of an
undisplaced fracture.
Radial Collateral Ligament
Disruption
Although injuries to the RCL are less common than UCL
injuries, they also are associated with significant disabil-
ity.
The mechanismof injury indisruptionof the RCLis forceful
adduction or torsion on the flexed MCP joint.
Because the abductor aponeurosis is relatively broader
compared to the narrower adductor aponeurosis, there is
no potential for soft tissue interposition (the Stener le-
sion) with an RCL avulsion. In contrast to the UCL, the
RCL is torn with almost equal frequency proximally and
distally, and mid-substance disruption is more common in
the RCL than in the UCL. The abductor aponeurosis may
be disrupted, in addition to the RCL. Disruption of the
RCL results in palmar migration and pronation of the prox-
imal phalanx and dorsoradial prominence of the metacarpal
head. In my experience, these findings may not be as notice-
able immediately after the injury, possibly because initial
swelling might mask the deformities, or because these find-
ings may occur progressively and thus may not be prominent
in the early phase of this condition.
Diagnosis
Diagnosis of the acute injury is made based on the history
of the injury, findings of ecchymosis or tenderness, and
a positive instability test.
Figure 10-18 demonstrates a positive stress test in an
acute RCL avulsion that was repaired by reattachment
of the ligament at its proximal attachment.
In my experience, RCL injuries tend to be diagnosed late
rather than early, when compared to UCL injuries.
This may be because a complete disruption of the UCL
results in immediate and significant disability owing to
the functional demands placed on the ulnar side of the
thumb, leading to early evaluation.
The RCL injury and subsequent dysfunction does not
seemto be as disabling, at least in the beginning, but as
time passes, it becomes increasingly bothersome and
is in fact a significant source of patient complaint and
disability.
Treatment
The basic principle of treatment in complete ruptures is
to reattach the RCL to its anatomic site of insertion or
repair the tear.
Late diagnosis may require ligament reconstruction by a
tendon graft.
Dorsoradial Capsule Injury
The mechanism of injury includes a direct blow, sports ac-
tivities, or breaking a fall. Possible predisposing factors are
an anatomic variation in the collateral ligaments that al-
low greater MCP flexion, and an area of relative thinness
and weakness in the dorsoradial capsule compared with the
ulnar side of the joint.
Diagnosis
The primary complaint is pain over the dorsum of the
thumb and limited use of the thumb. This diagnosis
should be considered in patients with persistent pain at
the thumb MCP joint.
A B
Figure 10-19 Dorsoradial capsular injury at the thumb MCP joint. (A) Flexed posture of the thumb
MCP joint that represents maximum extension for this patient. (B) Repair was achieved by reefing the
dorsoradial capsule of the MCP joint, and by advancing the extensor pollicis brevis tendon about 0.5 cm
distal to its insertion.
A
C
B
Figure 10-20 X-ray appearance in three views of a dorsal
dislocation of the CMC joint of the ring and little fingers
(arrows). Note that the dislocation is most apparent in the
oblique and lateral views.
A B
Figure 10-21 Dorsal dislocation of the thumb MCP joint. (A) Dorsal prominence at the base of the
thumb metacarpal (arrow). (B) The radiograph reveals complete dislocation without fracture.
Patients typically demonstrate tenderness over the dor-
soradial aspect of the thumb MCP joint in the absence
of laxity of either the RCL or UCL.
In some instances, there is minimal palmar subluxation
of the proximal phalanx.
Some patients experience loss of full active extension of
the proximal phalanx.
Treatment
Some patients can be treated successfully by immo-
bilization if no palmar subluxation or extensor lag
exists.
Surgery is indicated for persistent activity-limiting com-
plaints over the dorsoradial capsule, or if findings of pal-
mar subluxation and extensor lag exist.
Findings at the time of surgery include thinning or redun-
dancy of the dorsoradial capsule, or an obvious defect in
the capsule.
Treatment is by reefing (imbrication) or direct closure of
the defect in the dorsoradial capsule, and advancement
of the insertion of the EPB tendon, if an extensor lag
is present. An appropriate period of immobilization to
protect the repair should follow.
Figure 10-19 shows a patient with this lesion and the
surgical intervention that was performed.
CARPOMETACARPAL JOINT
DISLOCATIONS
Mechanism of Injury
True dislocations of the carpometacarpal (CMC) joint of
the thumb and fingers have been reported, but they are
rare. Most are fracturedislocations, and these injuries have
been discussed in the chapter on fractures of the hand.
When isolated dislocations of the CMCjoint occur, they are
usually dorsal and are caused by a longitudinal compression
force that produces simultaneous flexion and compression
of the metacarpal that drives the metacarpal base from its
carpal articulation. Most occur in the little and ring fingers
and are even more rare in the thumb.
Diagnosis
Figure 10-20 shows the x-ray appearance of a dorsal dis-
location of the CMC joint of the ring and little fingers.
Figure 10-21 shows the clinical and x-ray appearance of
a dislocation of the thumb CMC joint.
SUGGESTED READING
Bean CHG, Tencer AF, Trumble TE. The effect of thumb metacar-
pophalangeal ulnar collateral ligament attachment site on joint
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11
CARPAL
INJURIES
11.1 Carpal
Fractures 158
11.2 Carpal
Instabilities
and Fracture-
Dislocations of
the Carpus 169
11.1 CARPAL FRACTURES
PERTINENT ANATOMY
The Carpal Bones
The carpus consists of eight carpal bones arranged in a
proximal and a distal row, with each row containing four
bones. The proximal row includes (from radial to ulnar) the
scaphoid, lunate, triquetrum, and pisiform. The pisiform is
located palmar to the plane of the remaining three carpal
bones of the proximal row, and the pisotriquetral joint is
separated fromthe adjacent articulations. The distal rowin-
cludes (from radial to ulnar) the trapezium, trapezoid, capi-
tate, and hamate. The carpus is divided into the radiocarpal
joint and the midcarpal joints. The proximal row is convex
proximally and concave distally. The proximal row articu-
lates proximally withthe distal radius and withthe triangular
fibrocartilage complex, forming the radiocarpal and ulno-
carpal joint. The proximal row articulates distally with the
distal carpal row, forming the midcarpal joint (Figure11.1-1).
The four bones of the distal row articulate distally with
the five metacarpal bones and with each other. The bones
of the distal carpal row are straighter in alignment across
the wrist than the proximal row, especially at their distal
articulations with the metacarpal bones.
On the dorsal surface of the carpus, a gentle convex arch
is formed by the arrangement of the proximal and distal
rows. On the palmar surface, however, a deep concavity is
formed, designated as the carpal groove. The carpal groove
is accentuated by the palmar projection of the pisiform and
hook of the hamate ulnarly, and by the projection of the
scaphoid tuberosity and trapezial ridge radially. The mid-
carpal joint and the radiocarpal joint usually do not com-
municate with each other; if communication does occur, as
seen through the flow of dye from an arthrogram, there is a
tear or rent in the scapholunate or lunotriquetral ligaments.
Useful External Landmarks and Their
Relationships to the Underlying Structures
Figure 11.1-2 is a depiction of the thenar and wrist flexion
creases and their relationship to some of the underlying
structures.
Listers Tubercle
The extensor pollicis longus (EPL) tendon courses along
the ulnar side of Listers tubercle on its way from the wrist
to the distal phalanx of the thumb. The extensor carpi radial
brevis (ECRB) is to the radial side of this tubercle. Listers
tubercle is located 0.5 cm from the radiocarpal joint and is
in line with the cleft between the index and middle finger
metacarpals. The interval between the proximal pole of the
scaphoid and its articulationwiththe lunate and the scapho-
lunate ligament is just ulnar and distal to Listers tubercle.
Styloid Process of the Middle Finger Metacarpal
This process, located on the dorsal and radial aspect of the
middle finger metacarpal, points to the articular interface
between the capitate and trapezoid, and is just proximal to
the insertion of the ECRB tendon.
Lunate Fossa
This palpable central depression on the back of the wrist
is in line with the middle finger metacarpal, is just distal
and ulnar to Listers tubercle, and marks the location of the
carpal lunate.
Radial Styloid
This visible and easily palpated landmark is both palmar and
dorsal to the abductor pollicis longus (APL) and extensor
pollicis brevis (EPB) tendons that course across its apex.
158
Chapter 11 / Carpal Injuries / Carpal Fractures 159
Distal
phalanges
Middle
phalanges
Proximal
phalanges
Metacarpals
Hook of hamate
Triquetrum
Pisiform
Lunate
Ulna Radius
Trapezoid
Trapezium
Capitate
Scaphoid
Trapezoid
Hamate
Styloid
process
Pisiform
Triquetrum
Lunate
Ulna
Trapezium
Capitate
Scaphoid
Lister's tubercle
Radius
B A
Figure 11.1-1 A. Skeletal anatomy of the wrist, palmar aspect. B. Skeletal anatomy of the wrist, dorsal
aspect.
Distal Head of the Ulna
The slightly expanded distal end of the ulna has a head and
styloid process. The head is most visible and palpable when
the forearm is in pronation; the posteroulnar styloid is most
readily palpable in supination and is approximately 1 cm
proximal to the plane of the radial styloid.
Pisiform Bone
The pisiform bone, located on the ulnar and palmar aspect
of the base of the hand, provides a visible and palpable land-
mark that aids in the identification and location of the flexor
carpi ulnaris (FCU) tendon, the underlying ulnar neurovas-
cular bundle, and the hook process of the hamate.
Hook Process of the Hamate
The hook of the hamate, located on the ulnar and palmar
aspect of the distal carpus, can be palpated approximately
1 cm radial and distal to the pisiform. Because of its deep
location, it may be difficult to palpate in some individu-
als. The hook of the hamate lies between the ulnar tunnel
(Guyons canal) and the carpal tunnel. It thus provides a
landmark for the ulnar nerve and artery (located just ulnar
to the hook), and the ulnar boundary of the carpal tunnel.
Point tenderness in this area may indicate a fracture of the
hook process, a somewhat common injury in sports that use
racquets, clubs, or bats, such as tennis, golf, or baseball.
Scaphoid Tubercle
The scaphoid tubercle is in the distal palmar aspect of the
scaphoid. It projects into the palm, and the tubercle is pal-
pable on the radial aspect of the base of the hand, usu-
ally just distal to the distal palmar wrist crease. It becomes
more prominent with the wrist positioned in radial devia-
tion, since the scaphoid assumes a position of more palmar
flexion in this position. Conversely, the scaphoid tubercle is
less prominent and possibly not palpable when the wrist is
in ulnar deviation, since the scaphoid assumes a position of
decreased palmar flexion and lies more in the plane of the
radius and ulna.
Distal wrist
crease
18.7
22.6
19.4
11.7
9.2
13.5
21.1
Proximal palmar
crease
Thenar crease
Figure 11.1-2 Flexion crease
landmarks. Relationship of the carpal
bones and other bony landmarks to
the thenar and distal wrist creases.
The number indicate the mean
distance (in mm) of the structures
depicted from the respective creases.
Distal Wrist Flexion Crease
The distal wrist crease is located over the proximal carpal
row and passes over the waist of the scaphoid and, 80% of
the time, over the pisiform bone. The lunate is proximal to
the distal wrist crease with its center an average of 9.2 mm
from the crease. The radiocarpal joint is 13.5 mm proximal
to the crease and the center point of the distal radioulnar
joint (DRUJ) is 21.1 mm proximal to the wrist crease. The
base of the ulnar styloid is on average 11.7 mm proximal to
the wrist crease.
Anatomic Snuff Box
The anatomic snuffbox is a narrow triangle, with its apex
distal, that is bounded dorsoulnarly by the EPL, radially
by the APL and EPB tendons, and proximally by the distal
margin of the extensor retinaculum. It contains the dorsal
branch of the radial artery in the dorsoulnar corner, the
tendon of the extensor carpi radialis longus (ECRL) and
one or more branches of the superficial branch of the radial
nerve. Tenderness in the anatomical snuffbox is associated
with fractures of the scaphoid.
Vascular Anatomy of the Carpus
The vascular supply to the carpus is through two main sys-
tems, the dorsal carpal vascular systemand the palmar carpal
vascular system (Figure 11.1-3). The dorsal and palmar sys-
tems consist of a series of dorsal and palmar transverse
arches that are connected by anastomoses formed by the
radial, ulnar, and anterior interosseous arteries.
Vascular Supply of the Scaphoid
The scaphoid receives its vascular supply mainly from the
radial artery (Figure 11.1-4). Vessels enter the scaphoid in
limited areas dorsally and palmarly at nonarticular zones of
ligamentous attachment. The dorsal vascular supply to the
scaphoid accounts for 70%to 80%of the internal vascularity
of the bone, all in the proximal region. The major dorsal
vessels enter the bone through small foramina located at a
dorsal ridge in the region of the scaphoid waist.
At the level of the intercarpal joint, the radial artery gives
off the intercarpal artery, which immediately divides into
two branches. One branch runs transverse to the dorsum
of the wrist. The other branch runs vertically and distally
over the index metacarpal. Approximately 5 mmproximal to
the origin of the intercarpal vessel at the level of the styloid
process of the radius, another vessel is given off that runs
over the radiocarpal ligament to enter the scaphoid through
its waist along the dorsal ridge.
There are consistent major communications between the
dorsal scaphoid branch of the radial artery and the dorsal
branch of the anterior interosseous artery. No vessels enter
the proximal dorsal region of the scaphoid through the dor-
sal scapholunate ligament, and no vessels enter through the
dorsal cartilaginous areas. The dorsal vessels usually divide
into two or three branches soon after entering the scaphoid.
These branches run palmarly and proximally, dividing into
smaller branches to supply the proximal pole as far as the
subchondral region.
The palmar vascular supply accounts for 20% to 30% of
the internal vascularity, all in the region of the distal pole. At
Dorsal pollicis artery
DMCA
DMCA
DMCA
DMCA
DMCA
Basal metacarpal arch
Dorsal intercarpal arch
Dorsal carpal branch,
ulnar artery
Branch to triquetrum
and pisiform
Ulnar artery
Branch to dorsal
radiocarpal arch
from ulnar artery
Dorsal branch, AIA
A
Dorsal
radiocarpal arch
Radial artery
Branch to palmar
radiocarpal arch
Branch to scaphoid
and trapezium
Branch to dorsal
ridge of scaphoid
Figure 11.1-3 A, B. Anatomy of the arterial supply to the dorsal and palmar aspect of the wrist.
Figure continues.
the level of the radioscaphoid joint, the radial artery gives off
the superficial palmar branch. Just distal to the origin of the
superficial palmar branch, several smaller branches course
obliquely and distally over the palmar aspect of the scaphoid
to enter through the region of the tubercle. These branches,
the palmar scaphoid branches, divide into several smaller
branches just before penetrating the bone. In 75% of spec-
imens, these arteries arise directly from the radial artery.
Specific Fractures of
the Carpus
The majority (80%) of carpal fractures involve the scaphoid,
followed by (in descending order of incidence) the tri-
quetrum, trapezium, hamate, lunate, pisiform, capitate, and
trapezoid.
SCAPHOID
Mechanism of Injury
The usual history is a fall on the extended wrist. Experi-
mental studies have shown that fractures of the scaphoid
can be produced consistently by forces applied to a hyper-
extended (90 degrees or more) and radially deviated wrist.
Progressively less extension resulted in fractures of the dis-
tal radius and forearm.
Diagnosis
Initial findings include a history of a fall, complaints of
persistent discomfort or pain in the wrist, and tenderness
on palpation in the anatomical snuffbox.
X-rays are taken in four views: one posterior-anterior
(PA), one lateral, and two oblique views.
PDA
PDA
PDA
PDA
PDA PDA
CPDA
CPDA
CPDA
PMA
PMA
PMA
PMA
PMA
PF
PF
PF
Superficial palmar arch
Deep palmar arch
Radial
recurrent
artery
Dorsal pollicis
artery
Branch to dorsal
ridge, scaphoid
Branch to scaphoid
and trapezium
Branch to dorsal
radiocarpal arch
Superficial
palmar branch
Palmar radiocarpal
arch
Radial artery
Palmar branch, AIA
Ulnar artery
Branch to dorsal
radiocarpal arch
Branch to pisiform
and triquetrum
Palmar intercarpal arch
Branch to dorsal
intercarpal arch
Branch to hypothenar
muscles (cut)
Branch to basal
metacarpal arch
Ulnar recurrent artery
B
The PA radiograph is best performed with the patient
making a fist.
The fist posture results in slight wrist extension, and
promotes ulnar deviation of the wrist that may be use-
ful in opening up the fracture interface.
This position also places the longitudinal axis of the
scaphoid parallel to the plane of the x-ray plate.
Figure 11.1-5 demonstrates a fracture of the carpal
scaphoid.
If radiograph studies do not demonstrate a definite frac-
ture, the wrist is immobilized in a short-arm thumb spica
cast, and repeat radiographs made in 2 to 3 weeks.
If radiograph studies at 2 to 3 weeks are inconclusive,
and positive physical findings are present, a bone scan
may be used to further assist in the diagnosis.
Some surgeons may use magnetic resonance imaging
(MRI) rather than a bone scan, because MRI may de-
tect an occult fracture sooner than a bone scan.
MRI with gadolinium is useful for evaluating vascu-
larity of the scaphoid.
Computerized tomography (CT) is a useful method to
define bone anatomy, and may aid in the diagnosis of an
angular deformity that may require surgical correction.
Treatment
Treatment options may be based on a number of different
classification systems that in turn are based on the loca-
tion of the fracture (distal, middle, or proximal pole), sta-
bility, whether the fracture is displaced or nondisplaced,
Dorsal intercarpal arch Dorsal radiocarpal arch
Radial artery
Superficial
palmar artery
Branch to dorsal
ridge of scaphoid
Figure 11.1-4 Anatomy of the arterial
supply to the scaphoid and the radial
aspect of the wrist.
whether it is angulated or nonangulated, and the plane
of the fracture relative to the long axis of the scaphoid.
The simplest treatment related classification is based on
the location of the fracture.
Distal-Third Fractures
Fractures of the tuberosity and distal third may be treated
with a short-arm thumb spica cast until union is evident
by radiograph or other studies.
If the fracture is intra-articular and displaced, an open
reduction and internal fixation may be considered.
Figure 11.1-5 X-ray view of a fracture of the carpal scaphoid.
(Courtesy of H. Relton McCarroll, Jr., MD, San Francisco)
Middle-Third Fractures
Recent, stable, and undisplaced fractures are managed
with a short-arm thumb spica cast.
Recent undisplaced but potentially unstable fractures, in-
cluding vertical oblique or reduced trans-scaphoid per-
ilunate fracture dislocations, should be managed with
a long-arm (above the elbow) thumb spica cast. Some
surgeons consider a reduced trans-scaphoid perilunate
dislocation to be inherently unstable, and advise internal
fixation.
Displaced or angulated fractures require open reduction
and internal fixation by techniques based on the sur-
geons experience and choice, including K-wires and or
Herbert screws.
Proximal-Third Fractures
Recent fractures are treated with a Herbert screw fol-
lowed by a long-arm thumb spica cast.
Delayed or nonunion and avascular necrosis is highly
likely in spite of the above-recommended treatment,
and may require one or more secondary operations
including bone grafting, vascularized bone grafting,
excision of the proximal pole, or proximal row carpec-
tomy.
The length of immobilization will vary from injury to in-
jury, and is based on the experience of the surgeon, clin-
ical findings, and suitable diagnostic studies.
Additional Treatment Principles
Fractures of the scaphoid treated more than 4 weeks after
injury are less successfully treated by cast immobilization.
Percutaneous fixation may be a useful technique for fix-
ation of undisplaced fractures.
Stable and nondisplaced fractures will most likely heal
with cast immobilization; unstable and displaced frac-
tures are best treated with some formof internal fixation.
A gap or fracture offset of 1 mm or greater is considered
to be a reliable indicator of instability, and is associated
with a higher incidence of nonunion and malunion.
Open reduction and internal fixation are indicated in
these fractures.
Internal fixation of the surgeons choice is usually indi-
cated in fractures involving the proximal pole due to their
propensity for delayed and nonunion.
The initial determination of stability status may not al-
ways be correct.
Differences of opinion exist regarding the necessity for
immobilization of the thumb and elbow in scaphoid frac-
tures, and may vary with the experience and preference
of the surgeon.
Palmar Versus Dorsal Surgical Approaches to the Scaphoid
The major blood supply to the scaphoid enters at the
dorsal and distal aspect of the bone; based on this fact,
palmar or anterior surgical approaches to this bone are fa-
vored for management of distal pole and waist fractures.
The blood supply to the distal and middle aspects of the
bone is abundant in comparison to the proximal pole
whose blood supply is precarious.
This poor blood supply is a significant factor in the
high rate of nonunion in scaphoid fractures of the
proximal pole.
The palmar approach is recommended for correction of
the humpback deformity (dorsal angulation and col-
lapse of the scaphoid).
The dorsal approach is preferred for ease of screw place-
ment in proximal pole fractures, and does not compro-
mise the dorsal blood supply if dissection is confined to
the proximal pole.
It is also the approach of choice for insertion of vas-
cularized bone grafts.
Other Treatment Options
The treatment of established nonunion (including bone
graft techniques), the use of electrical stimulation for
delayed or nonunion, and procedures for secondary re-
construction of nonunion or malunion of the scaphoid is
beyond the scope of this chapter.
Late Complications of Scaphoid Fracture Nonunion
If untreated, scaphoid nonunions lead to a predictable
pattern of arthrosis in the wrist.
Scaphoid nonunion may exist with or without avascular
necrosis (AVN) of the proximal aspect of the scaphoid;
if present, AVN lessens the chances of success in recon-
structive procedures.
Fractures of the waist may collapse, and dorsally angulate
to produce the humpback deformity.
Four progressive stages of scaphoid nonunion and ad-
vanced collapse (SNAC) have been identified: (1) arthritis
of the radial styloid, (2) spread of the arthritis to include
the scaphoid fossa of the radius, (3) the addition of capi-
tolunate arthritis, and (4) diffuse carpal arthritis.
Triquetrum
Incidence and Types of Fracture
Triquetral fractures are the most common carpal fractures
exclusive of the scaphoid. Two types have been identified:
dorsal rim chip fractures (the most common) and fractures
of the body.
Mechanism of Injury
Chip Fractures. Although the exact mechanism of injury
is unknown, these injuries may be due to avulsionof the con-
joined insertion of the dorsal radiocarpal (dorsal radiotri-
quetral) and dorsal intercarpal ligaments during hyperflex-
ion and radial deviation of the wrist, or due to impaction
from the ulnar styloid or hamate during axial loading and
hyperextension of the wrist.
Body Fractures. These injuries are usually the result of a
direct blow to the ulnar aspect of the wrist, which results in
a medial tuberosity fracture. Triquetral fractures are often
associated with other carpal injuries such as a perilunate
dislocation. An anteroposterior crushing injury may result
in sagittal fracture. Lunate or perilunate dislocation may
cause proximal pole fracture, as the palmar lunotriquetral
ligament avulses the proximal pole of the triquetrum. Trans-
verse fractures are usually the result of shear force, and
often are associated with scaphoid fractures.
Treatment
Small nondisplaced or even displaced chip fractures are
usually treated symptomatically with a short period of
immobilization as needed.
Larger chip fractures, due to their potential for nonunion
or instability if untreated, are immobilized in a cast.
Open reduction and fixation may be required to restore
the insertions of the DRC and DIC ligaments to prevent
persistent pain and instability that is sometimes seen in
injuries with larger fragments.
Fractures of the triquetral body or palmar radial fractures
are usually minimally displaced, and are treated by cast
immobilizationbut they may be associated with lunotri-
quetral or other ligament tears.
Palmar radial fractures have been associated with volar
intercalated segment instability (VISI) collapse, and may
warrant fixation and repair or reconstruction of the
lunotriquetral ligament complex.
Trapezium
Incidence and Types of Fracture
Fractures of the trapezium are the second-most common
nonscaphoid fracture. Five types have been identified, in-
cluding vertical transarticular (the most common), horizon-
tal, dorsoradial tuberosity, anteromedial ridge, and commin-
uted. Fractures of the trapeziumoften occur in combination
with thumb metacarpal or distal radius fractures.
Mechanism of Injury
Vertical transarticular fractures are due to a longitudinal ax-
ial force transmitted by the thumb metacarpal. Horizontal
fractures are due to direct shearing forces, and dorsoradial
fractures are the result of vertical shearing as the metacarpal
impacts the trapezium into the radial styloid. An object
held in the web space (such as the handlebars of a bicy-
cle or motorcycle) may produce a similar injury. Anterome-
dial ridge fractures result froman anteroposterior force that
flattens the transverse carpal arch and causes an avulsion
through the transverse carpal ligament of the anteromedial
ridge. This fracture may occur in conjunction with a frac-
ture of the hook process of the hamate.
Treatment
Displaced intra-articular fractures are best treated by
open reduction and fixation, but most other fractures are
treated by 4 to 6 weeks of cast immobilization.
The articulation with the adjacent thumb metacarpal is
very critical for thumb function, and post-injury arthrosis
may be avoided by anatomic reduction of intra-articular
fractures.
Hamate
Incidence and Types of Injury
Hamate injuries are most common in stick or racquet sports
such as golf, baseball, or tennis. Fracture of the hamate
hook presents with pain (and often, point tenderness) dis-
tal and radial to the pisiform. Nonunion and the resultant
irregularity of the fracture interface may cause attritional
rupture of the flexors, and this loss of flexion in the little
and ring fingers may be the presenting complaint (Figure
11.1-6).
Two major types of fractures have been identified, and
involve the hook process and the body of the hamate. Hook
fractures may involve the tip, waist, or base. Fractures of
the body may involve the proximal pole, medial tuberosity,
or (in the body), be oriented in the sagittal oblique plane or
dorsal coronal plane.
Mechanism of Injury
Hook fractures may result from a sudden forceful blow,
or from repetitive impacts that may cause a stress frac-
ture. An avulsion fracture may occur by means of traction
from the FCU tendon and its extension through the pisoha-
mate ligament. A crush injury in the AP plane may result in
an avulsion-type fracture mediated through the transverse
carpal ligament. Fractures of the body of the hamate may
result from direct blows to the ulnar aspect of the hand
(medial tuberosity fracture), anteroposterior crush injury
(sagittal oblique fracture), or carpometacarpal dislocation
of the ring and little fingers that results in a dorsal coronal
fracture.
Treatment
Hook fractures may be treated based on location, degree
of displacement, and time from injury.
Recent nondisplaced fractures, regardless of location,
may be treated with immobilization, with the wrist in
radial deviation to lessen the possible deforming force of
the ulnar finger flexors.
Displaced avulsion fractures that involve only the super-
ficial tip of the hook may be treated symptomatically.
The fragment may be excised if it remains symptomatic
after several weeks.
Fractures of the waist or base of the hook may be excised.
Some surgeons advise preservation of the hook by means
of ORIF and bone grafting, believing that the hook is
important as a mechanical pulley that maintains flexor
tendon function.
Nondisplaced body fractures may be treated by cast im-
mobilization, but displaced fractures, especially those
seen with metacarpal subluxation or instability, should
be anatomically reduced and fixed.
The motor branch of the ulnar nerve courses around the
base of the hook process, and is at risk during surgery in
this region.
Lunate
Incidence, Vascular Supply and Types
Lunate fractures are said to represent about 1%of all carpal
fractures, excluding fractures associated with Kienbocks
disease.
True lunate fractures are often associated with fractures
of the distal radius, scaphoid, capitate, and triquetrum.
A B
Figure 11.1-6 Attritional rupture of flexor tendons due to fracture of the hook process of hamate.
A. Loss of flexion in the left little finger. B. Fracture of the base of the hook process (open arrows) and
frayed margin (solid arrow) of the flexor tendon.
Twenty percent of lunate bones are vascularized by a sin-
gle palmar supply, and in the remaining 80%, the vascular
supply arises fromboth palmar and dorsal vessels that anas-
tomose in the body of the lunate.
The five types of fractures that have been identified are
based on their location and vascular supply: (1) palmar pole
fractures (the most common) affecting the palmar nutrient
artery, (2) osteochondral (chip) fractures of the proximal ar-
ticular surface but not affecting vascularity, (3) dorsal pole
fractures possibly affecting the dorsal nutrient artery, (4)
sagittal-oblique fractures through the body, and (5) coronal
split of the body.
Mechanism of Injury
Type I palmar pole fractures are due to wrist hyperex-
tension and compression from the capitate and radius,
combined with tension on the radiolunate and lunotri-
quetral ligaments. The palmar pole is avulsed by the
lunotriquetral ligaments, and this may produce flexion
of the lunate.
Type II osteochondral fractures may occur following
shear-related injuries, as seen in lunate dislocations, sub-
luxations, or in patients with Kienbocks disease.
Type III dorsal pole fractures result from shear forces in
perilunate dislocations (as the capitate displaces dorsally)
or from avulsion of the scapholunate ligament in acute
rotatory subluxation of the scaphoid.
Type IV sagittal-oblique fractures between the proximal
and distal articular surfaces result from shear forces pro-
duced by radiocarpal fracture-dislocation.
Type V coronal fractures result from wrist hyperexten-
sion, which produces tension on the short radiolunate
ligament that avulses the palmar pole. This fracture may
also be seen following a palmar perilunate dislocation of
the capitate.
Treatment
Most lunate fractures require surgical treatment based
on the fracture and its associated ligamentous injury.
Type I fractures may require correction of a lunate rota-
tory component if present.
Type II injuries may require debridement if symptomatic.
The specific treatment recommendations are outlined
above.
Type III fractures associated with acute scapholunate
dissociation may require operative stabilization of the
scapholunate joint.
Type IV fractures that are displaced require fixation.
Type V fractures may require surgical intervention, de-
pending on the degree of displacement and the associated
carpal instability.
Kienbocks disease of the lunate should be considered in
the absence of significant trauma.
Pisiform
Fractures of the pisiform are uncommon, but four types
have been identified: transverse (the most common),
parasagittal, comminuted, and pisotriquetral impaction.
Mechanism of Injury
The usual cause of this fracture is a fall or direct impaction
on the pisiform, with the wrist extended. Active contrac-
tion of the FCUmuscle-tendon unit may play a role in sepa-
ration of the fracture interface. Incongruity of the pisiform
may result in pisotriquetral incongruity and degenerative
arthritis. As well, a shearing injury may result in intra-
articular loose bodies, which may remain symptomatic.
Treatment
Most fractures may be treated with immobilization, with
the expectation that union or fibrous union will occur.
Wide separation of the fragments may indicate some de-
gree of discontinuity of the FCU, and may be an indica-
tion for exploration.
Some surgeons prefer to excise widely separated or com-
minuted fractures and restore the integrity of the FCU
by suture techniques of their choice.
Parasagittal and comminuted fractures, as well as pisotri-
quetral impaction conditions (if symptomatic) may be
treated by pisiform excision.
Capitate
Fortunately, capitate fractures are uncommon. They are
difficult to treat due to the fact that the proximal pole
is entirely intra-articular and without soft-tissue attach-
ment. AVN is likely if the fracture is displaced. Four
fracture types have been reported: transverse fracture of
the body (the most common), transverse fracture of the
proximal pole, and coronal oblique and parasagittal frac-
tures.
Mechanism of Injury
The first two types occur due to compression loading of the
hyperextended wrist, which forces the capitate against the
dorsal edge of the radius. This mechanism of injury may
also produce a concomitant fracture of the scaphoid, and is
called the scaphocapitate fracture syndrome. The scaphoid
fracture may be the only injury evident on the initial radio-
graphs, and the wise examiner will look for clinical evidence
of injury to the capitate in addition to the scaphoid injury.
Types III and IV usually result from hyperextension and
axial loading injuries.
Treatment
CT is often required to make the diagnosis. MRI is used
to evaluate the vascularity of the proximal pole.
The treatment of capitate fractures requires prompt diag-
nosis and stabilization. If diagnosed early and it is nondis-
placed, cast immobilization may be used.
If the fracture is displaced or part of scaphocapitate frac-
ture syndrome, open reduction and internal fixation is
indicated.
Vascularity of the proximal pole may be evaluated in-
traoperatively.
Restoration of distal carpal row height, anatomic reduc-
tion, and careful evaluation for associated injuries are the
primary goals of treatment.
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168
Chapter 11 / Carpal Injuries / Carpal Instabilities and Fracture-Dislocations of the Carpus 169
Late Results of Nonunion of the Capitate
Capitate osteonecrosis may occur due to loss of vascular-
ity. This in turn may lead to distal-row collapse, scaphoid
rotatory subluxation, and progressive carpal arthritis with
persistent pain and stiffness.
Trapezoid
Incidence and Types
The trapezoid is the least commonly fractured carpal
bone. Trapezoid fractures rarely occur alone, and are usu-
ally associated with fracture-dislocations involving dislo-
cation of the index metacarpal or the trapezoid itself.
Diagnosis may be aided by CT or MRI, since radio-
graphs may not show the fracture. Two types have been
identified; they include fractures of the dorsal rim and
body.
Mechanism of Injury
This fracture usually results from an axially directed force
along the index metacarpal. These fractures are often diffi-
cult to identify on plain films, and thus require a high index
of suspicion. As noted above, a CT scan or MRI will best
characterize this fracture.
Treatment
Minimally displaced trapezoid fractures are treated with
cast immobilization for 4 to 6 weeks, but displaced frac-
tures may require ORIF or closed reduction and immo-
bilization.
Osteonecrosis may occur in the trapezoid due to its
poor blood supply. Trapezoid-index metacarpal arthrode-
sis may be indicated for late arthrosis.
Table 11.1-1 depicts the fracture type, treatment, asso-
ciated injuries, and treatment PEARLS, and is repro-
duced with permission of the authors and publisher.
11.2 CARPAL INSTABILITIES
AND FRACTURE-
DISLOCATIONS OF
THE CARPUS
DEFINITION
Carpal instability is defined as loss of carpal ligament in-
tegrity due to acute traumatic dislocations or ligamentous
laxity. It implies the loss of the ability to maintain normal
kinematic and kinetic functions and relationships under
static conditions and or functional loads between the ra-
dius, carpal bones and metacarpals. In the broader defini-
tion of carpal instabilities used in this chapter, they may
be associated with certain fracture dislocations of the car-
pus, and include isolated carpal dislocations and adaptive
instabilities secondary to malunions of distal radius frac-
tures.
Carpal instability is further divided into static and dy-
namic forms. Static instability refers to carpal malalignment
that is detectable on standard x-ray views, whereas dynamic
instability refers to carpal instability that is reproduced or
demonstrated on physical examination maneuvers, and may
often be demonstrated on stress radiographs. Static insta-
bilities are usually associated with complete ligamentous
disruption, whereas dynamic instabilities are usually asso-
ciated with a partial or incomplete ligamentous disruption.
Dynamic carpal instability is said to be the most common
cause of wrist pain and carpal instability in adolescents and
young adults. It is most likely due to attenuation of the
palmar radioscaphoid and scapholunate interosseous liga-
ments.
Dorsal wrist ganglions that most often arise from the
region of the SL ligament have been shown to be associated
with symptoms and signs of dynamic scapholunate insta-
bility.
The Ring Concept
A current theory of carpal kinematics characterizes the car-
pus as a ring that allows reciprocal motion between the
proximal and distal rows during radial and ulnar deviation,
and during flexion and extension. The scaphoid is consid-
ered to be the stabilizing link between these two rows, and
the triquetrum is said to be the pivot point for carpal rota-
tion. Any interruption of the ring in the proximal carpal row
results in carpal instability.
The Intercalated Segment
This term is used to describe the relationship or position of
the proximal carpal row that is interposed, or suspended be-
tween the radius/ulna and the distal carpal row/hand. Some
have called the proximal carpal row a free body in space.
This oversimplification is amplified by noting that the radius
Palmar radioulnar
Ulnotriquetral
Triquetrocapitate
Pisohamate
P
H
C
Td
Tm
S
L
Radioscapho-
capitate
Long radio-
lunate
Radioscapho-
lunate
Short radio-
lunate
Ulnocapitate
Figure 11.2-1 The palmar radiocarpal ligaments (see text for
details).
of curvature of the proximal pole of the scaphoid and the
lunate are different (the lunate has a greater radius). This
finding fits with the interosseous scapholunate ligament
anatomy that demonstrates thick and unyielding fibers dor-
sally compared to the palmar portions of the ligament that
are less dense and more elastic. These two facts (among
others) account for the different rates or ratios of move-
ment that demonstrate equal rotation of these two bones in
wrist extension, but showgreater rotation of the scaphoid in
wrist flexion. This observation is but a small example of the
complexity of the kinematics of the wrist, and the reader is
referred to the Suggested Reading list for additional study.
PERTINENT ANATOMY
The readers understanding of carpal instability and the
concepts of carpal kinematics will be enhanced by a review
of the current description and terminology of the carpal
ligaments.
Palmar Radiocarpal Ligaments
Figure 11.2-1 shows these ligaments, including the ra-
dioscaphocapitate, long radiolunate (previously named the
radiotriquetral and also the radiolunotriquetral) and short
radiolunate, radioscapholunate, pisohamate, triquetrocap-
itate, ulnocapitate, ulnotriquetral and palmar radioulnar
ligaments.
Dorsal Radiocarpal Ligaments
Figure 11.2-2 shows these ligaments, including the dorsal
intercarpal, dorsal scaphotriquetral, and dorsoradiocarpal
(sometimes called the dorsal radiotriquetral) ligaments.
Palmar Midcarpal and Proximal and Distal-Row
Interosseous Ligaments
Figure 11.2-3 shows the capitohamate, triquetrohamate,
triquetrocapitate, lunotriquetral, scapholunate, scaphocap-
itate, scaphotrapezium-trapezoid, trapeziotrapezoid, and
trapeziocapitate ligaments. The scapholunate (SL) ligament
is divided into three parts: dorsal (the most substantial
part), proximal, and palmar. It is the main stabilizer of the
scaphoid that prevents it from flexing under load. In con-
trast to the SL ligament, the lunotriquetral (LT) ligament is
more substantial in its palmar aspect.
CLASSIFICATION
Acurrently accepted classification systemis presented as an
aid to understanding some of the more common patterns of
carpal instability.
Carpal Instability Dissociative (CID)
This compound term is used to describe an injury to one of
the major interosseous ligaments involving the same carpal
row. It is termed dissociative because there is separation or
dissociation between at least two carpal bones. Common
examples of CID are scapholunate dissociation, lunotri-
quetral dissociation, unstable scaphoid fracture, and per-
ilunate dislocation. Examples of scapholunate dissociation
and lunotriquetral dissociation are given in Figures 11.2-4
and 11.2-5.
The introduction of scapholunate and lunotriquetral
dissociation allows us to add two other compound terms
that the reader will encounter in descriptions of these
injuries.
S
Dorsal
scaphotriquetral
Dorsal
intercarpal
Tm
Td
C
H
Tq
P
Dorsal radiocarpal
(Dorsal radiotriquetral) L
Figure 11.2-2 The dorsal radiocarpal ligaments (see text for
details).
Dorsal Intercalated Segment Instability (DISI)
In SL dissociation, a collapse deformity occurs in which
the lunate and triquetrum usually rotate into an extended
posture (they face dorsally) that is combined with supination
and radial deviation. Figure 11.2-6 demonstrates a chronic
scapholunate dissociation showing a DISI deformity.
Volar Intercalated Segment Instability (VISI)
In lunotriquetral dissociation, the lunate rotates into a
flexed posture (it faces palmarward, or volar).
Late Results of Untreated SL Dissociation
Untreated SL dissociation may often be associated with a
condition called scapholunate advanced collapse or SLAC
deformity. If scapholunate dissociation is present for a pro-
longed period of time, it will result in a scapholunate ad-
vanced collapse deformity, with severe arthritis in the ra-
dioscaphoid and midcarpal region.
The articular surface of the distal radius that articu-
lates with the scaphoid is elliptical, and dorsal scaphoid
dissociation or subluxation results in incongruity between
the scaphoid and the scaphoid fossa in the radius. This is
LT
Lunotriquetral
TRIC
Triquetrocapitate
TH
Triquetrohamate
CH
Capitohamate
TRAC
Trapeziocapitate
TT
Trapezio - trapezoid
STT
Scaphotrapezium - trapezoid
SC
Scaphocapitate
SL
Scapholunate
S
L
P
Tq
H
C
Td
Tm
Figure 11.2-3 Palmar midcarpal and
proximal- and distal-row interosseous
ligaments (see text for details).
A B
Figure 11.2-4 Comparison of x-ray
findings in a normal wrist and in one
with a scapholunate dissociation. A.
The normal appearance of the wrist in
the AP view. Note the uniform spacing
of the carpal bones, and more
specifically, the parallel alignment of
the articular interface between the
proximal pole of the scaphoid and the
lunate (parallel vertical arrows). B. A
scapholunate dissociation showing a
widened and nonparallel space
between the scaphoid and lunate, a
foreshortened scaphoid, and a
positive ring sign (arrows in a circle).
analogous to two superimposed and co-linear tea spoons
that normally are co-linear but then one spoon (scaphoid)
rotates into noncolinear alignment. The result of this incon-
gruous alignment is arthritis. Figure 11.2-7 demonstrates
the mechanism for development of a SLAC arthrosis.
Figure 11.2-5 A lunotriquetral dissociation as shown by an
arthrogram. Note the presence of radio-opaque dye in the space
between the lunate and triquetrum (opposing arrows), indicating
disruption of the lunotriquetral ligament.
Carpal Instability Nondissociative (CIND)
It is called nondissociative because there is no scapholu-
nate separation or dissociation between the proximal pole
of the scaphoid and the adjacent lunate or between the lu-
nate and the triquetrum. CIND is often referred to as mid-
carpal instability. This condition refers to carpal instability
that is characterized by a major noninterosseous ligament
injury that could be seen in dorsal or palmar carpal sublux-
ation/dislocation and ulnar translation. It is termed radio-
carpal CIND. Figure 11.2-8 represents an example of CIND
in a patient with palmar radiocarpal dislocation.
Midcarpal CIND is characterized by midcarpal instabil-
ity, such as capitate lunate instability (CLIP wrist), pal-
mar or dorsal midcarpal instability, and medial antero-
medial instability (MAMI). Symptoms are often present as
a painful wrist clunk that is reproduced by pronation, axial
compression, and ulnar deviation. The sequence of events
is as follows: with radial deviation, the proximal row palmar
flexes; during ulnar deviation, there is loss of the normal
synchronous (or smooth) movement of the proximal row,
and it jumps rather than glides into extension; this precip-
itous catch-up movement or clunk reproduces the patients
symptoms.
Carpal Instability Complex (CIC)
A useful definition of these injuries is when the instability
involves or impairs the relationship of the bones in the same
row (CID type) and the relationship between rows (CIND
type). Dorsal perilunate dislocation, trans-scaphoid perilu-
nate fracture dislocation, trans-scaphoid trans-capitate dis-
location, and trans-triquetrum perilunate fracture disloca-
tion are all types of CIC injuries. The first two injuries are
the most common.
A B
Figure 11.2-6 DISI deformity as seen in an established scapholunate dissociation. A. AP view of the
wrist showing a widened scapholunate space (vertical arrows). B. Note the dorsally rotated lunate
(arrows) on the lateral view.
Further division of these injuries may be made into lesser
and greater arc injuries (Figure 11.2-9). Lesser arc injuries
are defined as purely ligamentous injuries without fracture,
and greater arc injuries share the same mechanismof injury
but are associated with a fracture through a carpal bone. A
classic example of the latter is the trans-scaphoid perilu-
nate fracture dislocation (Figure 11.2-10). Slower loading
forces (injuries) are usually associated with carpal fractures,
in contrast to faster loading forces that usually produce a
purely ligamentous injury.
Figure 11.2-7 Artists depiction of the
pathomechanics of the SLAC arthrosis (see text for
details).
Carpal Instability Adaptive (CIA)
The termextrinsic midcarpal instability has been used to de-
scribe this secondary carpal instability that results from dor-
sal angulation of the distal radius in malunited fractures of
the distal radius. This term is used to differentiate or distin-
guish this instability from those midcarpal instabilities that
are intrinsic to the carpus. The deformity in the radius leads
to a secondary malalignment of the proximal carpal row, loss
of wrist flexion and radiocarpal or midcarpal instability.
Figure 11.2-8 Lateral x-ray view, showing a radiocarpal palmar
subluxation. This was a stress radiograph (arrows).
Clinical Findings. These patients present with com-
plaints of pain in the wrist, and there is tenderness over the
radiocarpal and midcarpal region, along with an obvious de-
formity of the wrist. Corrective osteotomy of the radius may
help in re-alignment of the carpus.
DIAGNOSIS
Watsons Scaphoid Shift Maneuver
This maneuver is a physical examination technique that
aids in the diagnosis of scapholunate dissociation. It is
performed with the forearm in slight pronation.
This maneuver is performed by applying pressure over the
palmar tubercle of the scaphoid by the examiners thumb
with the wrist in ulnar deviation and slight extension.
Pressure is maintained on the distal pole of the scaphoid
and then the wrist is brought into radial deviation and
slight flexion.
S
S
L
L
Figure 11.2-9 The lesser and greater carpal arcs
(see text for details).
In wrists with this form of instability (SL), the proximal
pole of the scaphoid is displaced dorsally over the lip of
the radius.
Release of the thumb pressure causes the scaphoids
dorsally displaced proximal pole to return to its anatomic
position in the scaphoid fossa of the radius, and a palpa-
ble (and usually painful) clunk or pop may be noted
(Figure 11.2-11).
Ballottement Test
The ballottement test or maneuver is used to identify ab-
normal motion or tenderness at the lunotriquetral junc-
tion.
It is done by firmly fixing the lunate with the examiners
thumb and index finger of one hand while the pisiform
and triquetrumare displaced dorsally and volarly with the
other hands thumb and index finger (Figure 11.2-12).
A positive test is revealed by pain, and indicates lunotri-
quetral instability.
Other Tests
Various forms of compression, distraction, and transla-
tion may reveal abnormal mobility or pain patterns with
these motions, and can be indicative of various types of
instability about the wrist as previously described.
Some patients may be able to reproduce various clunks
and abnormal movements about the wrist that may some-
times aid the astute examiner in establishing a diagnosis.
Radiologic Examination
Imaging techniques include standard x-ray views such as
the PA and lateral, PA in radial and ulnar deviation, and
lateral views in flexion and extension, as well as AP and
lateral views with a fist.
The Moneim view is taken with the wrist elevated on the
ulnar side by a sponge pad.
This view facilitates observation of the space between
the proximal pole of the scaphoid and the adjacent
lunate, and will often reveal a scapholunate separation
that may not be seen on the regular PA films.
A
C
B
D
Figure 11.2-10 Trans-scaphoid-perilunate fracture dislocation. A. PA view showing the loss of
continuity of the carpal arcs described by Gilula (see Figure 11.2-13). B. Lateral view of the
palmar-flexed lunate (vertical open arrow) and dorsal displacement of the remaining carpus around the
lunate. C, D. Internal fixation techniques used to restore the architectural integrity of the carpus.
(Courtesy of H. Relton McCarroll, Jr., MD, San Francisco)
A B
Figure 11.2-11 The scaphoid shift maneuver for a SL dissociation (see text for details).
Similarly, PA views with radial and ulnar deviation may
show a separation that may not be seen on regular
films.
Axial loading or compression of the carpus by making a
fist often demonstrates a scapholunate separation that
might not be present on routine radiographs.
P
T
Q
L
Figure 11.2-12 Ballottement maneuver for LTD (see text for
details).
Additional imaging techniques include arthrography with
or without videofluoroscopy, bone scans, tomograms, and
a CT or MRI.
A tomogram or CT is a useful aid in evaluating asso-
ciated fractures. At this point in time, an MRI is less
helpful.
An arthrogramis cost effective and, when done as a triple
phase injection, may provide useful information about
the midcarpal, radiocarpal, and distal radioulnar articu-
lation.
Contrast material injected into the midcarpal joint
should not extend into the radiocarpal joint unless
there is a ligament disruption in the proximal row (see
Figure 11.2-5).
An arthrogram is easy to obtain, and has been most help-
ful in terms of revealing disruption of the interosseous
ligaments.
Arthroscopy of the wrist is preferred over an arthro-
gram by some surgeons, and may be more accurate
in determining the extent of ligament injury and the
status of the cartilage surface.
A bone scan is nonspecific, although it may reveal in-
flammatory changes about the joint.
Defining Normal Carpal Alignment
Carpal Arcs, Carpal Spacing and Lunate Conguration
Gilula identified three unbroken arcs that mark the ar-
ticular margins of the proximal and distal carpal row in
the PA x-ray view of the wrist. A set-off in any of these
arcs or lines indicates an intercarpal derangement at the
site where the line is offset (Figure 11.2-13).
Most articulating bones have a space between them that
is usually 2 mm or less, and any overlap greater than
4 mm is suggestive of a carpal joint abnormality.
Figure 11.2-13 Gilula lines demarcating the proximal and distal
carpal rows.
In PA-neutral x-ray views of the wrist, the lunate nor-
mally has a trapezoidal shape. If the lunate is triangular
in shape, it suggests a malrotated lunate (either flexed or
extended).
Measurement of Carpal Bone Alignment
Commonly used measurements made from lateral wrist
radiographs are the scapholunate angle, the capitolunate
angle, the radiolunate angle, and the lunotriquetral an-
gle.
These angles are depicted in Figure 11.2-14.
The SL Angle
The SL angle is measured by a line drawn through the
longitudinal axis of the scaphoid from the distal to proxi-
mal pole, and by a line drawn through the horizontal axis
of the lunate.
Normal values range from 30 to 60 degrees, with an av-
erage of 47 degrees.
Angles greater than 70 to 80 degrees are a definite indi-
cation of SL dissociation.
The Capitolunate (CL) Angle
Although the longitudinal axes of the radius, lunate, cap-
itate, and third metacarpal are not usually colinear, the
CL angle is useful when studying midcarpal (CIND) in-
stabilities.
A line is drawn that is perpendicular to a line that con-
nects the palmar and dorsal tips of the lunate.
>80
o
-16
o
30
o
- 60
o
15
o
14
o
Scapholunate
Capitolunate
Radiolunate
Lunotriquetral
NORMAL ABNORMAL
Figure 11.2-14 Useful carpal
angles (see text for details).
The capitate axis is represented by a line drawn from a
point in the center of the convexity of the capitate head
to a point at the center of its distal articular surface.
Theoretically, the normal CL axis should be 0 degrees
with the wrist in neutral, but what is considered normal
ranges to 15 degrees.
The Radiolunate (RL) Angle
A line is drawn that is perpendicular to a line that con-
nects the palmar and dorsal tips of the lunate.
The angle formed by this line and the longitudinal axis
of the radius is the RL angle.
An RL angle greater than 15 degrees is abnormal, and
such a finding is associated with DISI and VISI deformi-
ties.
The Lunotriquetral (LT) Angle
The lunotriquetral angle represents that angle formed by
a line drawn through the horizontal (longitudinal axis)
axis of the lunate and a line drawn through the longitu-
dinal axis of the triquetrum.
The accurate assessment of these axes is difficult to de-
termine.
The average normal angle is 14 degrees.
In lunotriquetral dissociation, the angle averages 16
degrees.
Other Useful Diagnostic Findings
Scapholunate dissociation is one of the most common
forms of carpal instability.
Common findings that may be noted on plain radiographs
are foreshortening of the scaphoid, the appearance of a
ring in the distal pole of the scaphoid, lack of parallel ap-
position of the adjacent articular surfaces of the scaphoid
and lunate, widening of the space between the proximal
pole of the scaphoid and the lunate, and an increased
scapholunate angle (Figure 11.2-4).
TREATMENT
Treatment options may vary according to many factors,
which include the location of the instability, the underly-
ing cause, the length of time frominjury to treatment, the
presence or absence of secondary deformities and arthro-
sis, and whether the instability is static or dynamic.
In general, surgical treatment is based on the principles
of carpal realignment and restoration of normal carpal
kinematics.
Attempts to achieve these two principles have included
ligamentous reconstruction and capsulodesis of various
forms, arthrodesis of various types, carpectomy and re-
alignment osteotomy of the radius in CIA types of insta-
bility.
A detailed discussion of these techniques is beyond the
scope of this text. New techniques and methods will no
doubt evolve as the understanding of this complex joint
grows.
SUGGESTED READING
Amadio PC, Taleisnik J. Fractures of the carpal bones. In: Green DP,
Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal capsu-
lodesis for the unstable scaphoid and volar capsulodesis following
excision of the distal ulna. Hand Clin 1987;3:81102.
Brahin B, Allieu Y. Compensatory carpal malalignments. Ann Chir
Main, 1984;3:357363.
Burge P. Closed cast treatment of scaphoid fractures. Hand Clinics
2001;17:541552.
Dovan TT, Gelberman RH, Cooney WP. Carpal Instability. In Trumble
TE, ed. Hand surgery update 3, hand, elbow and shoulder. Rose-
mont, IL: Amer. Soc Surg Hand, 2003:205216.
Doyle JR, Botte MJ. Surgical anatomy of the hand and upper ex-
tremity. Chapter 1, Skeletal anatomy, pp. 191; Chapter 4, Vas-
cular anatomy, pp. 237293; Chapter 9, The wrist, pp. 486531,
Garcia-Elias M. Carpal instabilities and dislocations. In: Green DP,
Gilula LA, et al. Roentgenographic diagnosis of the painful wrist. Clin
Orthop 1984;187:5264.
Imbriglia JE, Broudy AS, et al. Proximal row carpectomy: clinical eval-
uation. J Hand Surg 1990;15:426430.
Kleinman WB. Dynamics of carpal instability. In: Watson HK,
Weinzweig J, eds. The wrist. Philadelphia: Lippincott, Williams and
Wilkins, 2001:456481.
Kleinman WB, Carroll CT. Scapho-trapeziotrapezoid arthrodesis for
treatment of chronic static and dynamic scapho-lunate instability:
a 10-year perspective on pitfalls and complications. J Hand Surg
1990;15:408414.
Knoll VD, Trumble TE: Scaphoid fractures and nonunions. In Trumble
TE, ed. Hand surgery update 3, hand, elbow and shoulder. Rose-
mont, IL: Amer. Soc Surg Hand, 2003:161173.
Park MJ, Cooney WP III, Hahn ME, et al. The effects of dorsally
angulated distal radius fractures on carpal kinematics. J Hand Surg
1990;15:721727.
Putnam MD, Meyer NJ. Carpal fractures excluding the scaphoid. In
Trumble T, ed. Hand surgery update 3, hand, elbow and shoulder.
Rosemont, IL: Amer. Soc Surg Hand, 2003:175187.
Taleisnik J, Watson HK. Midcarpal instability caused by malu-
nited fractures of the distal radius. J Hand Surg 1984;9A:350
357.
Tolo ET, Shin AY. Fracture dislocations of the carpus. In Trumble T,
ed. Hand surgery update 3, hand, elbow and shoulder. Rosemont,
IL: Amer. Soc Surg Hand, 2003:189204.
Watson HK, Ashmead DT, et al. Examination of the scaphoid. J Hand
Surg 1988;13:657660.
Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced col-
lapse pattern of degenerative arthritis. J Hand Surg 1984;9:358
365.
12
TENDON
INJURIES
12.1 Flexor
Tendon 179
12.2 Extensor
Tendon 190
12.1 FLEXOR TENDON
The results of flexor tendon surgery have improved signif-
icantly over the last 40 years, based on an improved un-
derstanding of the anatomy and biology of the flexor ten-
don system, improved sutures and suture techniques, and
the development of rehabilitation protocols that facilitated
early recovery and improved functional results. Currently
accepted general principles of treatment include primary
repair of recent clean injuries in the operating room, with
repair of both flexor tendons using suture techniques at the
repair site that minimally distort the anatomy of the tendons
and that are strong enough to allow early protected move-
ment. Additional factors in a successful outcome relate to
preservation of the critical portions of the pulley system.
PERTINENT ANATOMY
Figure 12.1-1 depicts the most common anatomical ar-
rangement of the synovial sheaths and flexor tendon pulleys
in the thumb and fingers.
Digital Flexor Sheath
The digital flexor tendon sheath is composed of synovial
(membranous) and retinacular (pulley) tissue components.
It is a system that allows a tendon to turn a corner and
maximize the available tendon excursion to produce a sig-
nificant arc of flexion. Loss of this pulley system results in
bowstringing of the tendon and loss of flexion.
Membranous Portion
The membranous portion is a synovial tube sealed at both
ends. The floor or dorsal aspect of this tunnel is composed
of the transverse metacarpal ligament, the palmar plates of
the metacarpophalangeal (MCP), proximal interphalangeal
(PIP), and distal interphalangeal (DIP) joints, and the pal-
mar surfaces of the proximal and middle phalanges. In the
index, long, and ring fingers, the membranous portion of
the sheath begins at the neck of the metacarpals and con-
tinues distally to end at the DIP joint. In most instances,
the small finger synovial sheath continues proximally to the
wrist.
Visceral and parietal synovial layers are present, and a
prominent synovial pouch is present proximally that rep-
resents the confluence of the visceral and parietal layers.
A visceral layer reflection or pouch is also noted between
the two flexors at the neck of the metacarpal, but is 4
to 5 mm distal to the more visible proximal and super-
ficial portions of the synovial sheath. The membranous
or synovial portions of the sheath are most noticeable in
the spaces between the pulleys, where they form plicae
and pouches to accommodate flexion and extension of the
digits.
Retinacular Portion
The retinacular (pulley) portion is a series of transverse (the
palmar aponeurosis pulley), annular, and cruciform fibrous
tissue condensations, which begin in the distal palm and
end at the DIP joint.
With the exception of the third annular pulley, the pul-
leys are located between joints; this fact, along with some
element of compressibility, allows a large arc of flexion with-
out impingement. The finger pulley system consists of the
palmar aponeurosis pulley, five annular, and three cruci-
form pulleys. The second and fourth annular pulleys are
the most important to preserve or reconstruct in flexor ten-
don surgery. In the thumb, two annular and one oblique
pulley are present, and it is the oblique pulley that is most
important from a functional perspective.
The reader is referred to the Suggested Reading list
at the end of this chapter for references that detail addi-
tional anatomic features of the flexor tendon sheath and
the biomechanical principles of muscle/tendon excursion,
moment arms, radians, work of flexion, lubrication factors,
tendon nutrition and healing.
179
Ulnar bursa
Radial bursa
A1
Oblique
A2
PA
A1
A2
C1
A3
C2
A4
C3
A5
Figure 12.1-1 Composite view of the synovial
sheaths and pulleys system of the thumb and fingers
(see text for details).
Vascular Supply of the Flexor Tendons
Sources of vascular supply to the flexor tendons are from
intrinsic longitudinal vessels that continue from the palm,
synovial attachments to the enclosed flexor tendons in
the proximal sheath, and specialized forms of mesotendon
called the vincula, located inside the sheath (Figure 12.1-2).
Clinical Signicance
Removal of the flexor digitorum superficialis (FDS) for a
tendon transfer is best performed proximal to or at the prox-
imal edge of Campers chiasma, since this will preserve the
vinculum breve superficialis (VBS) and vinculum longum
profundus (VLP). This may have the incidental side bene-
fit of avoiding the potential for hyperextension at the PIP
joint, as well as preserving the blood supply of the FDS
and flexor digitorum profundus (FDP). See Figure 12.1-3.
Core intratendinous sutures are ideally placed in the rel-
atively avascular palmar aspect of the profundus tendon,
when practical. The comparative role of synovial nutrition
and the vascular supply in tendon healing will not be de-
bated here except to put into context the value of avoiding
damage to the vascularity of the tendons in the sheath.
ZONES OF FLEXOR TENDON INJURY
Finger Zones
The naming of five zones of injury in the fingers has aided
in comparison of results, and to some extent is of prognostic
value. The zones are depicted in Figure 12.1-4.
Zone I is just beyond the insertion of the FDS to the
insertion of the FDP. This zone is occupied only by the
FDP.
Zone II is from the distal palmar crease to the distal in-
sertion of the FDS, and injuries in this zone more likely
than not involve both flexor tendons.
Zone III begins just distal to the distal edge of the trans-
verse carpal ligament (at the origin of the lumbrical mus-
cles) and ends at the distal palmar crease.
Zone IV is the region of the carpal tunnel.
Zone V is at the wrist and distal forearm.
Thumb Zones
The thumb zones of injury are depicted in Figure 12.1-4.
Chapter 12 / Tendon Injuries / Flexor Tendon 181
VLP
VLS
VBP
VBS
A-3 Pulley
B
Proximal zone
of vascularization
FDS
FDP
Branch to VLS
VLS
Proximal trans.
digital artery
VBS
Interphalangeal
trans. digital artery
Distal bone
of vascularization
VBP
VLP
Distal trans.
digital artery
Distal zone
of vascularization
Intermediate zone
of vascularization
A
Figure 12.1-2 A. Artists depiction of the blood
supply of the finger flexor tendons. B. Fresh
cadaver dissection of the flexor tendons showing
the vincula. VBP, vinculum breve profundus;
VLP, vinculum longum profundus; VLS,
vinculum longum superficialis; VBS, vinculum
breve superficialis.
DIAGNOSIS
The Finger Cascade
Many flexor tendon injuries may be diagnosed by noting
the posture of the injured hand/digit, and comparing it to
that in the opposite hand or adjacent digits.
The normal posture of the fingers reveals a progressive
flexion posture, or cascade, with the little finger being the
most flexed, and the index being the least flexed.
Figure 12.1-5 demonstrates the loss of the normal finger
cascade in this young male with a laceration to the medial
side of the left ring finger.
Findings at surgery confirmed complete laceration of
the FDS and FDP in this zone II injury.
Figure 12.1-3 Fresh cadaver dissection showing Campers
chiasma (opposing arrows) in the FDS tendon in the region
of the PIP joint (see text for details).
Zone I
Zone II
Zone TI
Zone V
Zone IV
Zone III
Zone TII
Zone TIII
Figure 12.1-4 The zones of flexor tendon injury (see text for details).
Figure 12.1-6 demonstrates a more subtle loss of the nor-
mal finger cascade associated with a rupture of the inser-
tion of the FDP (zone I injury) in this teenage flag ball
player.
There is a comparative lack of flexion in the ring finger
(loss of cascade) compared with the adjacent fingers,
and a lack of flexion at the DIP joint when making a
fist.
This is an avulsion of the insertion of the FDP of the
ring finger.
Direct Testing of FDS and FDP
Figure 12.1-7 demonstrates the techniques used to
demonstrate the function of the FDS and FDP.
B A
Figure 12.1-6 FDP tendon rupture in a flagball player. A. Note the loss of normal finger cascade and
the increased extension posture of the right ring finger. B. Note the loss of flexion in the DIP joint while
making a complete fist.
Figure 12.1-5 Note the loss of the normal finger cascade in this
young male with a laceration of the proximal phalanx. The
preoperative diagnosis of laceration of both flexor tendons was
confirmed at surgery.
Trapping the adjacent fingers in extension permits only
the FDS to flex the PIP joint.
This maneuver works because the FDS is functionally
characterized as four independent muscle bellies with
four separate tendons.
The FDP is easily isolated by blocking motion at the PIP
joint.
TREATMENT
Laceration of the flexor tendons represents a significant
and serious injury.
Surgical repair is best performed by experienced surgeons
who have suitable facilities and instruments available for
repair.
Flexor tendon injuries are not considered to be true
emergencies, and best results are obtained when such
A B
Figure 12.1-7 Testing for function of the FDS and FDP tendons. A. Holding the adjacent fingers in
extension permits only the FDS to act on the PIP joint of this middle finger. B. Holding the PIP joint in
extension permits isolation of the FDP tendon function.
surgeries are performed in a timely fashion but on an
elective basis.
If both tendons are lacerated, both tendons are repaired.
Zone II injuries are the most likely to result in adhesions
and loss of function.
The post-operative management of these injuries is very
important, and should be considered a part of the surgical
protocol.
Surgical Exposures
Most flexor tendon injuries are due to lacerations of the
palmar surface of the digits or palm.
These lacerations are more often than not transverse in
orientation.
Figure 12.1-8 demonstrates how these traumatic inci-
sions may be appropriately extended to achieve surgical
exposure and at the same time avoid a pernicious scar
that might produce a contracture.
These elective extensions of the transverse wounds are
positioned to utilize the fact that midaxial incisions do
not contract and allow the elevation of a thick and well-
vascularized flap for exposure.
The wounds may also be extended by using oblique
limbs of extension that also meet the same needs.
Suture Materials
Tendon sutures have been fabricated from various mate-
rials, including stainless steel, nylon, polypropylene, and
polyester.
Because of its ease of use, strength, and minimal elastic-
ity, 3-0 and 4-0 braided polyester sutures are commonly
used for flexor tendon repairs.
Suture Techniques
Many techniques have been developed for reapproxi-
mation of the lacerated flexor tendons since Bunnell
developed his well-known tendon-grasping suture more
than 50 years ago.
Although there may not be an ideal suture technique,
there are some underlying principles in all suture
techniques: ease of suture placement, secure knots that
will not slip or stretch out, a smooth suture junction with-
out gapping or bunching, and sufficient strength to allow
early supervised motion programs (see the section on re-
habilitation that follows).
A suture technique developed by Strickland is depicted
in Figure 12.1-9. It begins as a two-strand, core-grasping
technique supplemented by a second-core suture and a
running and locking epitendinous suture.
The strength of a given suture repair is nearly directly
proportional to the number of strands of suture material
that cross the repair site, and to the size of the suture
material.
A four-strand repair is stronger that a two-strand re-
pair.
The addition of a peripheral epitendinous suture to the
core sutures has been found to increase the strength of
the repair site in a significant fashion. This helps prevent
gap formation that may lead to adhesions and failure to
recover useful motion in the digit.
The epitendinous suture may also tidy up, reconform,
and debulk the repair site to permit easy passage of the
repair site through the critical pulleys.
Some Points of Intraoperative Technique
Atraumatic technique is a useful descriptive term to note
that careful meticulous dissection and gentle handling of
all tissues is very important in the management of flexor
tendon injuries.
After extending the wound and opening the sheath at the
anticipated repair site, it is necessary to retrieve the two
tendon ends. The distal end is usually retrieved by flexing
the digit.
The proximal end retracts due to the physiologic tension
of the muscle, and if not retracted too far proximally by
Figure 12.1-8 Useful skin incisions for the extension of traumatic wounds associated with flexor
tendon injuries. The solid lines represent the traumatic wound, and the dotted lines represent the safe
extensions of these wounds for exposure and repair.
A
B
Figure 12.1-9 A useful four-strand, core-grasping suture developed
by Strickland.
C
D
intact vincula, may be grasped with fine tooth forceps
and brought distally.
Blind repeated probing up the proximal sheath with a
grasping instrument is to be avoided. If the proximal end
cannot be easily grasped or milked down by digital mas-
sage, then a small and moistened feeding tube catheter
is passed proximally (usually into the palm), and the re-
tracted tendon is sutured to the catheter at this level.
The catheter is then brought distally into the repair site,
carrying with it the proximal tendon stump. When the
two stumps are adjacent, a 22-gauge hypodermic needle
is passed transversely through the sheath to impale and
fix the proximal tendon.
A repair of the surgeons choice and experience is per-
formed.
Indiscriminant excision of the membranous or retinacu-
lar portions of the sheath is to be avoided, but portions
of the sheath may be incised or excised to promote place-
ment of the sutures.
Repair of the incised sheath has been advocated by some
surgeons, but such repair should not compromise the
gliding movement of the repaired tendons in the sheath.
Rehabilitation
Rationale
Early passive motion is designed to change an unfavor-
able scar to a favorable one by altering the biologic pro-
cess of collagen synthesis and degradation.
Early passive motion by applying small but frequent
forces in opposite directions modifies and elongates
restrictive tendon adhesions.
Studies have shown that early motion stress to repaired
flexor tendons results in more rapid recovery of tensile
Figure 12.1-10 Active extension-elastic band
flexion rehabilitation method for flexor tendon
repairs.
strength, less adhesions, better tendon excursion, and
minimal repair site deformation.
Load at failure of mobilized tendons tested at 3 weeks
was twice that of immobilized tendons, and the fa-
vorable differences continued at all intervals through
12 weeks.
Studies have revealed that passive MCP joint move-
ment results in little or no motion of the flexor tendons,
whereas DIP joint motion results in FDP excursion of 1
to 2 mm/10 degrees of joint flexion.
Each 10 degrees of PIP flexion results in FDP and the
FDS excursion of about 1.5 mm.
Some Practical Applications of These Principles
These and other studies and experience have led to the
progressive evolution and development of tendon mobi-
lization protocols and techniques that focus on promot-
ing motion at the PIP joint.
Active Extension-Elastic Band Flexion Method
The first technique is the most widely used at this time.
An orthotic device maintains the wrist and MCP joints
in slight flexion.
An elastic band is attached to the fingernail of the in-
volved digit, this elastic band is passed beneath a midpal-
mar bar and is anchored proximally on a portion of the
orthotic device.
Figure 12.1-10 demonstrates an example of a currently
used method.
Controlled Passive Motion Method
This method involves immobilization of the wrist and dig-
its in a similar orthotic device, but movement is achieved
by serial passive movement of the DIP, PIP, and MCP
joints.
Those that use this method state that it is less likely to
result in flexion contracture when compared to the elastic
band traction method.
Controlled Active Motion Method
The introduction and use of 4-6 strand tendon repair
methods has made it possible to use this method with a
certain level of safety in terms of its major complication
of tendon rupture.
In any splinting program, it is best to maintain the inter-
digital joints in extension to minimize the likelihood of
flexion contractures.
The specific details of these three methods are beyond the
scope of this text and will no doubt evolve and change.
Also, completely new methods may be developed in re-
sponse to the need for better final results.
Caveats
Utilization of any of these methods requires a team ap-
proach with a surgeon and therapist.
A cooperative patient is mandatory for success when us-
ing any of these methods.
Investigative Methods to Limit
Peritendinous Adhesions
The methods of early excursion of the tendon repair site
just reviewed are a form of extrinsic mechanical means
to limit adhesions.
Investigative methods have included the insertion of
polyvinyl alcohol shields (PVA) as an intrinsic mechanical
shield to limit peritendinous adhesions following flexor
tendon repair.
The material is semipermeable, allowing passage of
synovial fluid nutrients to the tendon repair sitebut
unfortunately, the method was associated with an in-
creased rupture rate and a diminished strength of site
repair.
Hyaluronic acid is a glycosaminoglycan normally found
in the synovial fluid of the sheath.
Studies have suggested that hyaluronic acid (HA) may
limit the formation of adhesions following zone II
flexor tendon repair, and a recent study found that an
HA membrane applied circumferentially around the
tendon repair site inhibited the formation of restric-
tive adhesions.
Histologic examination of the tendon repair sites did
not demonstrate any interference withintrinsic tendon
repair.
The application of 5-fluorouracil to the repair site has
been reported to result in diminished adhesions, without
an increased risk of rupture.
Late Reconstruction
Tenolysis
Not all tendon repairs result in useful recovery of func-
tion; lysis of adhesions may be required in selected cases.
The indications for this procedure are when the patient
has reached a plateau in their progress fromsplinting and
therapy.
The needs of the patients, as well as their age, occupation,
and the digit involved, may aid in the decision-making
process.
The wise surgeon will recognize that a tenolysis operation
may sometimes reveal a disrupted tendon and a severely
compromised bed that only a staged tendon reconstruc-
tion can solve. Both the surgeon and patient must be
prepared for this eventuality.
Surgeons vary in their opinion regarding the timing of
tenolysis. Most would wait several months after primary
repair or tendon grafting before considering this op-
tion.
Technique
Active participation of the patient is critical to the success
of the operation and local anesthesia with intravenous
sedation as needed is used.
A generous zigzag incision is laid out from the fingertip
to the proximal palm, and is used as needed.
All adhesions are excised, and the critical portions of
the pulley system are preserved.
A staged tendon reconstruction should be considered
when an adequate pulley system cannot be preserved.
During the procedure, the active pull-through of the
tendon is noted by having the patient actively flex the
digit.
The procedure ends when an adequate level of flexion
is achieved.
Aftercare includes a splint that permits immediate and
continued flexion of the digit.
In selected patients, an indwelling catheter may be left in
place for 4 to 5 days for the instillation of small amounts
of local anesthetic during exercise periods.
Any concomitant surgical procedures, such as capsulot-
omy, increase the risk for a poor result.
Two-Stage Tendon Reconstruction
Indications and Contraindications
Primary tendon repairs that have failed after repair and
tenolysis are associated with joint contracture, have a
known loss of critical pulleys, and, in patients in whom
conventional tendon grafting is likely to fail, are candi-
dates for two-stage tendon reconstruction.
The insertion of a silastic Hunter-tendon prosthesis per-
mits the formation of a scar-free bed and sheath for sub-
sequent insertion of a free tendon graft.
Contraindications include those digits with marginal cir-
culation and sensibility, and patients unwilling or unable
to engage in a prolonged, often tedious, and difficult re-
habilitation process.
First Stage
The first stage consists of wide exposure of the flexor
sheath and pulley system through a zigzag incision.
All useful portions of the pulley systemare preserved, the
flexor tendons excised, and a 1 cm stump of profundus
tendon is left distally.
D
C
B
A
Figure 12.1-11 Methods of digital pulley
reconstruction. A, B. Hemi-FDS to pulley
remnant and to bone. C, D. Pulleys formed by
single loop or loop and a half around phalanges,
using tendon remnants of free tendon grafts. E.
Pulley formed by using extensor retinaculum. F,
G. Pulleys formed in palmar plate (Karev pulley)
and using free graft tunneled through palmar
plate. H. Pulley formed by graft interweave
through remnants of tendon. Figure continues.
The excised tendon material is kept moist for possible use
as material to reconstruct pulleys.
If available, one or two slips of the superficialis are left
attached to use in pulley reconstruction.
If any joint contractures are present and not corrected by
excision of the flexor tendons, then joint release is per-
formed by a palmar plate release and a collateral ligament
incision.
Dissection in the palm is carried to the level of the lum-
brical origin.
A second incision is made at the flexor aspect of the wrist
to accept the proximal end of the silastic Hunter-tendon
prosthesis.
Asuitably sized prosthesis (3 to 6 mmin width) is inserted
from the fingertip to the wrist.
The end of the Hunter tendon is sutured beneath the
distal stump of the profundus.
Pulleys are reconstructed to obtain a minimum of two
pulleys (in the A2 and A4 positions) but more than two
pulleys are desirable if possible.
Some methods of pulley reconstruction are illustrated
in Figure 12.1-11.
Prior to closure the tendon is pulled at its proximal
end to note that it glides freely and does not bow-
string.
The tendon should also glide freely when the digit is
extended. It should not buckle or bulge.
Aftercare includes a bulky dressing, followed by a super-
vised passive exercise program.
Second Stage
This stage is performed when satisfactory passive mo-
tion has been obtained. It usually takes 3 or more
months.
A suitable tendon graft (usually the plantaris, or, if not
available, one of the long toe extensors) is attached to
the proximal end of the Hunter tendon. The distal end
of the Hunter tendon is detached and pulled distally to
atraumatically insert the tendon graft into the new flexor
sheath.
H
G
F
E
The distal anastomosis (first) is made into the stump of
the profundus at the DIP joint, and the proximal anasto-
mosis (at the wrist) made by joining the graft to a suitable
donorsuch as the profundusto one of the central dig-
its. An interweave technique is used to place the graft in
the substance of the donor motor.
Tension is adjusted prior to insertion of the proximal su-
tures to match the normal finger cascade.
Appropriate tension may be verified by noting exten-
sion of the operated digit when the wrist is flexed and
flexion of the digit when the wrist is extended.
Rehabilitation following the second stage reconstruction
is via an active extension-elastic band flexion method, as
previously described.
Figure 12.1-12 demonstrates a two-stage Hunter tendon
reconstruction sequence.
SPECIAL SITUATIONS
Partial Tendon Lacerations
Although adequate tendon strength and function may be
maintained after partial tendon lacerations, some partial
lacerations may result in entrapment and triggering of
the tendon against an adjacent pulley.
Current recommendations are for repair of lacerations
greater than 50% of the tendon, and debridement of the
tendon edges in those less than 50%.
Under no circumstances should the tendon ends be
excised or squared-up to make the repair techni-
cally easier or more tidy. Any shortening of a flexor
tendon may result in the loss of extension of the
digit.
A B
C
D
Figure 12.1-12 Two-stage Hunter tendon reconstruction for a fixed-flexion contracture of the ring
finger following a failed flexor tendon repair. A. Note the fixed flexion contracture of the ring finger;
passive extension was not possible. B. Insertion of a free tendon graft using the plantaris tendon. The
plantaris tendon graft (left) is being drawn into the new flexor sheath by the Hunter tendon (right),
following joint release, pulley reconstruction, and insertion of a Hunter tendon 4 months prior. C, D.
Note the active flexion and nearly complete extension of the reconstructed finger.
Profundus Tendon Avulsion
This injury is likely to occur in certain sports such as flag
or regular football, in which forceful grasping is used to
grab a flag or jersey of an opponent.
The FDP of the ring finger is most often injured, and may
be misdiagnosed by coaches and others as a sprained
finger. Radiographs are often negative.
Figure 12.1-6 shows a classic clinical case that was diag-
nosed and treated a few days after injury. Function was
restored.
The avulsion may occur with a small or substantial bone
fragment. The prognosis is based on the level to which the
FDP retracts, the remaining blood supply of the tendon,
the length of time between the injury and treatment, and
the presence and size of the bone fragment.
There are three types.
Type I is characterized by retraction of the profundus
tendon into the palm.
N If seen early, it may be threaded back down the
flexor sheath and reattached, followed by routine
mobilization.
N If not, the treatment choices include leaving it alone
(or trimming the tendon stump in the palm if it
is symptomatic and interferes with function), per-
forming an arthrodesis of the DIP joint, or perform-
ing a tendon graft.
N The latter choice carries with it the risk of compro-
mise to the intact FDS, and may not always be a
suitable alternative.
Type II is characterized by retraction of the tendon to
the region of the PIP joint, and a small bone chip may
be present in the distal tendon stump.
N These injuries may be reattached as late as
6 weeks after the injury, with satisfactory re-
sults.
Type III injuries present with a large bone fragment
that becomes trapped at the distal edge of the A4 pul-
ley, and are comparatively easy to reattach due to the
lack of significant retraction, as well as a sizeable bone
fragment.
The key to a successful outcome in this injury is early
diagnosis and treatment.
12.2 EXTENSOR TENDON
The extensor mechanismin the finger, in comparison to that
of the flexors, is thinner, less substantial, and less likely to
hold sutures well. At the wrist and forearm, however, the ex-
tensors substance and cross-sectional area are much more
like the flexor tendons. Injuries to the extensor tendons are
common, owing to their relatively exposed and superficial
location. The dorsal aspect of the hand and wrist is covered
with a thin layer of supple skin, with minimal subcutaneous
tissue. In many areas, such as the distal finger joint, the ten-
don is very thin and subject to rupture with sufficient force.
Injury may be secondary to laceration, deep abrasion, crush,
or avulsion, and the majority of extensor tendon injuries are
at joint levels. Penetrating wounds that disrupt the tendon
are also prone to enter the joint; this is true not only at
the interphalangeal joints, but also at the MCP joint. The
degree of joint contamination must be evaluated and con-
sidered in the treatment plan.
Unlike the flexor tendons, loss of continuity of the exten-
sor mechanismin the hand and fingers is usually not associ-
ated with immediate retraction of the tendon ends because
of the multiple soft-tissue attachments and interconnec-
tions at various levels. Furthermore, the extensor mecha-
nism in the hand is extrasynovial, except at the wrist, where
the tendons are covered with a synovial sheath. Paratenon
surrounds the extensor tendons over the dorsum of the
hand, and tendons covered with paratenon do not separate
widely when lacerated. Therefore, divided extensor tendons
are usually free to retract only on the dorsum of the wrist.
Because of this, many tendon injuries, especially in the fin-
gers, may be treated successfully by splinting alone. In the
hand and fingers, any gap in the tendon following lacera-
tion or avulsion is usually caused by unopposed flexion of
the joints rather than retraction of the tendon.
PERTINENT ANATOMY
Extension of the finger is a complex act and is considered
to be more intricate than finger flexion. This mechanism
is composed of two separate and neurologically indepen-
dent systems: the extrinsic extensors innervated by the ra-
dial nerve, and the intrinsic systems supplied by the ulnar
and median nerves.
The extensor mechanism arises from multiple muscle
bellies in the forearm. The extensor pollicis longus (EPL),
extensor pollicis brevis (EPB), extensor indicis proprius
(EIP), and extensor digiti minimi (EDM) have a compar-
atively independent origin and action. The proprius ten-
dons at the MCP joint level are usually to the ulnar side
of the communis tendons. The little finger proprius tendon
(EDM) over the metacarpal and wrist level is usually repre-
sented by two distinct tendinous structures (Figure 12.2-1).
The extensor digitorum communis (EDC) tendon to the lit-
tle finger is present less than 50% of the time. When it is
absent, it is almost always replaced by a junctura tendinum
from the ring finger to the extensor aponeurosis of the little
finger.
Traditional knowledge suggested that independent ex-
tension of the index and little fingers was caused solely by
the proprius tendons to these digits. Loss of independent ex-
tension, especially of the index finger, was said to be likely,
but in the majority of patients, independent extension of the
index is still possible if the EIP is absent due to injury or
transfer. Extension lag in the index finger may be avoided
when taking the EIP as a transfer by sectioning the EIP
proximal to the hood.
The wrist, thumb, and finger extensors gain entrance to
the hand beneath the extensor retinaculum through a se-
ries of six tunnelsfive fibro-osseous and one fibrous (the
fifth dorsal compartment, which contains the EDM). The
extensor retinaculum is a wide fibrous band that prevents
bowstringing of the tendons across the wrist joint. Its aver-
age width is 4.9 cm (with a range of 2.9 to 8.4 cm), as mea-
sured over the fourth compartment (see Figure 12.2-1). At
this level, the extensor tendons are covered with a synovial
sheath. The extensor retinaculumconsists of two layers: the
supratendinous and the infratendinous. The infratendinous
layer is limited to an area deep to the three ulnar compart-
ments. The six dorsal compartments are separated by septa
that arise from the supratendinous retinaculum and insert
onto the radius.
Just proximal to the MCP joint level, the communis ten-
dons are joined together by oblique interconnections called
juncturae tendinum. These connecting bands usually run in
a distal direction from the ring finger communis to the little
and middle fingers, and fromthe middle to the index finger.
The EDM tendon receives a junctura from the ring finger
extensor if the little finger EDC is absent. It is because of
these interconnections that laceration of the middle finger
communis tendon just proximal to this junctura may result
in only partial extension loss of the middle finger. The junc-
turae tendinum have considerable interaction between ad-
jacent fingers, and may also decrease the stress on the web.
Sectioning the web virtually abolishes any movement be-
tween adjacent fingers, in contrast to transection of the long
extensors, which has no effect on the interaction between
the fingers. This finding is of significance when evaluating
an injured hand, because a lacerated tendon may be over-
looked if finger extension is partially maintained through
juncturae, intertendinous fascia, or the web structures be-
tween the adjacent fingers.
The extensor tendon at the level of the MCP joint is
held in place over the dorsum of the joint by the conjoined
tendons of the intrinsic muscles and the transverse lamina
or sagittal band, which together tether and keep the exten-
sor tendons centralized over the joint (Figure 12.2-2). The
sagittal band arises from the palmar plate and the inter-
metacarpal ligaments at the neck of the metacarpals. Any
injury to this extensor hood or expansion may result in sub-
luxation or dislocation of the extensor tendon. The extensor
Chapter 12 / Tendon Injuries / Extensor Tendon 191
EIP
EPL
EPB
APL
Listers tubercle
ECRB
ECRL
EDC
6
5
4 3
2
1
Retinaculum
ECU
EDM
Juncturae
tendinum
Figure 12.2-1 The extensor mechanism at the
wrist, fingers, and thumb. Note the six
compartments or canals.
mechanism at the level of the proximal aspect of the fin-
ger is composed of a layered, crisscrossed fiber pattern that
changes its geometric arrangement as the finger flexes and
extends. This arrangement allows the lateral bands to be
displaced volarly in flexion and to return to the dorsum of
the finger in extension.
The intrinsic tendons from the lumbrical muscles join
the extensor mechanism at about the level of the proximal
and midportion of the proximal phalanx, and continue dis-
tally to the DIP joint of the finger.
At the MCP-joint level, the intrinsic muscles and ten-
dons are palmar to the joint axis of rotation and act as flexors
of the MCP joint. At the PIP joint, however, they are dorsal
to the joint axis, and aid in the extension of the PIP joint.
The extensor mechanism at the PIP joint is best de-
scribed as a trifurcation of the extensor tendon into the
central slip, which attaches to the dorsal base of the mid-
dle phalanx, and the two lateral bands. The lateral bands
pass on either side of the PIP joint and continue distally
to insert at the dorsal base of the distal phalanx. The ex-
tensor mechanism is maintained in place over the PIP
joint by the transverse retinacular ligaments. The extensor
tendon achieves simultaneous extension of the two finger
joints by a mechanism in which the central slip extends the
middle phalanx, and the lateral bands bypass the PIP joint
to extend the distal phalanx. The fibers overlying the PIP
joint are differentially loaded as the finger moves. In the
flexed position, the most central fibers are tensed, whereas
in extension, the lateral fibers are tensed. The most impor-
tant feature of this mechanismis that the three elements are
in balance. Specifically, the lengths of the central slip and
two lateral bands must be such that extension of the PIP
and DIP joints takes place together, so that when the middle
phalanx is brought up into alignment with the proximal pha-
lanx, the distal phalanx reaches alignment at the same time.
This mechanism depends on the relative length of the cen-
tral slip and two lateral bands. This precise and consistent
length relationship is what is so difficult to restore when
the mechanism has been damaged. Loss of this critical re-
lationship at the PIP joint level, with relative lengthening
of the central slip, results in the characteristic boutonniere
deformity. A unique arrangement is present at the dorsal as-
pect of the PIP joint, where the central slip of the extensor
tendon invests a fibrocartilage plate prior to its attachment
to the dorsal base of the middle phalanx. The average thick-
ness of the central slip at this level is 0.5 mm, but because
of the presence of this fibrocartilage plate, the thickness
is doubled over the PIP joint. This structure is called the
A
B
Sagittal band
MP
Central slip
PIP
Transverse
retinacular ligament
DIP
Terminal
tendon
Oblique
Lateral band
Transverse
ligament
Deep MC
Lumbrical
Dorsal & volar
interosseous
muscles
Triangular ligament
Transverse
retinacular
ligament (cut)
Oblique retinacular
ligament (cut)
Central slip
Lateral band
Sagittal band
MP
DIP
PIP
Figure 12.2-2 The extensor
mechanism at the MCP, PIP, and
DIP joints of the finger.
dorsal plate, and adds to the stability of the extensor ten-
don and PIP joint. It also increases the moment arm of the
extensor tendon at the PIP joint, and prevents attrition of
the central slip at the PIP joint. The similarity of the dor-
sal plate and the patella is striking. In my experience, this
dorsal plate adds relative thickness and substance to the ex-
tensor mechanism, and aids in the placement of sutures for
lacerations in this area.
Zones of Extensor Tendon Injury
The zones of injury are given in Table 12.2-1 and are based
on the anatomic characteristics of the extensor mechanism
in each zone. This provides a useful basis for establishing a
treatment plan and comparing end results following various
forms of treatment.
Zone 1 Injuries (DIP Joint;
Mallet Finger)
Four types of mallet deformity have been identified, and
the classification in Table 12.2-2 is useful in establishing a
treatment plan. Type IVinjuries are discussed in the chapter
on fractures.
TABLE 12.2-1 THE ZONES OF EXTENSOR
TENDON INJURY IN THE FINGERS, THUMB,
AND FOREARM
Zone Finger Thumb
I DIP joint Interphalangeal joint
II Middle phalanx Proximal phalanx
III PIP joint MCP joint
IV Proximal phalanx Metacarpal
V MCP joint Carpometacarpal joint/radial
styloid
VI Metacarpal
VII Dorsal retinaculum
VIII Distal forearm
IX Mid and proximal
forearm
DIP, distal interphalangeal; MCP, metacarpophalangeal; PIP, proximal
interphalangeal.
TABLE 12.2-2 MALLET FINGER
CLASSIFICATION
Type Description
I Closed or blunt trauma to the tip of the digit,
resulting in sudden forceful exion of the joint
with loss of tendon continuity with or without a
small avulsion fracture from the dorsal base of
the distal phalanx.
II Laceration at or proximal to the DIP joint, with loss
of tendon continuity.
III Deep abrasion with loss of skin, subcutaneous
cover, and tendon substance.
IV
A Transepiphyseal plate fracture in children.
B Hyperexion injury with fracture of the articular
surface of 2050%.
C Hyperextension injury with fracture of the articular
surface usually >50% and with early or late volar
subluxation of the distal phalanx.
PATHOLOGIC ANATOMY AND DIAGNOSIS
The most common type of mallet finger is type I, which
is caused by loss of continuityeither from tearing the
substance of the tendon just proximal to the joint, or from
avulsion of the tendon from its insertion, with or without
a small piece of bone.
The degree of deformity in this injury may vary from
a few degrees of extension loss to a 75 to 80 degree
flexion posture of the DIP joint (Figure 12.2-3).
A laceration (type II) over or near the DIP joint that tran-
sects the tendon also produces a characteristic mallet
deformity.
Lacerations directly over the joint more often than not
enter the joint; this must be considered in treatment
because of the potential for joint contamination.
Figure 12.2-3 Clinical appearance of a mallet finger deformity,
type I, obtained when a ball struck the tip of the finger.
Deep abrasion injuries (type III) over the distal joint may
result in significant loss of soft-tissue cover, and a loss
of a portion or all of the underlying tendon mechanism.
The joint is almost always exposed.
TREATMENT
Type I
Closed type I injuries are treated by continuous splinting
of the DIP joint in full extension.
Only the DIP joint needs to be splinted, but the splinting
must be continuous. Removal of the splint during the
treatment interval and flexing the DIP joint may reverse
the healing process.
When the DIP joint is capable of active extension (usu-
ally after 6 to 8 weeks), the splint may be removed, and
cautious flexion activity may be started.
If any recurrence of the deformity occurs, the splint is
reapplied for another 2 to 3 weeks.
Various forms of splinting have been used, and my fa-
vorite splints include the commercially available Stack
splint, which comes in multiple sizes, and dorsal or
palmar splints made from padded aluminum (Fig-
ure 12.2-4).
Reconstitution of the tendon occurs by fibroblastic pro-
liferation, which produces a tendon callus that subse-
quently contracts and re-forms into a type of tendon that
restores continuity.
The success of this method depends on continuous coap-
tation of the tendon ends, and avoidance of stretching or
tearing of the tendon callus.
The precarious nature of this healing process is further
amplified by noting that the microvascular anatomy of
the distal digital extensor tendon often demonstrates an
area of minimal or deficient blood supply in this zone.
Type II
Lacerations over the DIP joint may produce a mallet de-
formity, and an appropriate suture technique that may
be used is given in Figure 12.2-5.
Splinting is continuous for 6 weeks following surgical
repair.
Type III
The management of this injury is far different from that
of a simple closed mallet deformity, and staged surgical
reconstruction is required.
Zone II Injuries
DIAGNOSIS
Injuries in this zone are usually due to lacerations.
Lacerations over the dorsal aspect of the middle phalanx
may result in partial rather than complete laceration of
Figure 12.2-4 Useful splints for the treatment of
type I closed mallet finger deformity. Note that the
PIP joint is left free for motion.
1
2
3
Figure 12.2-5 Suture technique for repairing an
extensor tendon laceration over the DIP joint.
the extensor mechanism, due to its increased breadth and
curved shape.
Incomplete lacerations may not be associated with a mal-
let deformity.
TREATMENT
All wounds in this area should be carefully inspected,
and the underlying extensor mechanism evaluated and
repaired as indicated.
Partial lacerations involving less than 50% of the sub-
stance of the extensor may be treated by wound care
and skin suture followed by protected range of mo-
tion.
More extensive or complete lacerations are repaired by
a running suture near the cut edge, followed by a cross
stitch proximal and distal to the running suture (Figure
12.2-6).
Splinting of the DIP joint is performed for 4 to 6 weeks,
based on the nature of the laceration and the integrity of
the repair.
2
1
3
Figure 12.2-6 Extensor tendon suture technique for lacerations
over the middle phalanx (zone II).
Zone III Injuries
MECHANISM OF INJURY AND
PATHOLOGIC ANATOMY
Injuries to the extensor mechanism in zone III are usually
due to closed blunt trauma with acute forceful flexion of
the PIP joint, producing avulsion of the central slip from
its insertion on the dorsal base of the middle phalanx, with
or without fracture and laceration of the extensor tendon at
or near its insertion. Volar dislocation of the PIP joint may
also result in avulsion of the central slip and subsequent
boutonniere deformity. Loss of integrity of the central slip
attachment at the dorsal base of the middle phalanx, ei-
ther from avulsion or laceration, starts a cascade of tendon
imbalance that results in a characteristic deformity of flex-
ion at the PIP joint and hyperextension of the DIP joint.
This deformity, called the boutonniere deformity, illustrates
the problem of imbalance in the finger, which is a chain
of joints with multiple tendon attachments. This chain col-
lapses into an abnormal posture or deformity when there is
an imbalance of the critical forces maintaining equilibrium.
This abnormal cascade or sequence begins with flexion of
the PIP joint, owing to loss of the central slip and the unop-
posed force of the flexor digitorum superficialis. Next, with
stretching of the expansion (transverse retinacular ligament
and triangular ligament) between the central and lateral
slips, the lateral bands migrate volarward to a position volar
to the axis of joint rotation. Finally, in this position of the
lateral bands, the pull of the intrinsic muscles is directed
exclusively to the distal joint, which progressively hyperex-
tends. The MCP joint is also hyperextended by action of the
long extensor tendon.
DIAGNOSIS
Figure 12.2-7 demonstrates the appearance of the bou-
tonniere deformity.
Figure 12.2-7 The clinical appearance of the boutonniere
deformity. Note the flexed posture of the PIP joint and the
hyperextension of the DIP joint of the middle finger.
Figure 12.2-8 The Elson test for diagnosis of
boutonniere deformity.
In closed injuries, the characteristic boutonniere defor-
mity may not be present at the time of injury, and usually
develops over a 10- to 21-day period following injury.
This condition is often missed, even in an open wound.
A painful, tender, and swollen PIP joint that has been
recently injured should arouse suspicion. Active motion
is decreased, and the finger is held semiflexed.
Diagnostic maneuvers include holding the PIP joint in
full extension and testing the amount of passive flexion
of the distal joint.
With disruption of the central slip and volar migration of
the lateral bands, flexion of the distal joint is markedly
decreased.
Another useful test is the Elson test depicted in Figure
12.2-8.
The finger to be examined by the Elson test is flexed
comfortably to a right angle at the PIP joint over the
edge of a table, and firmly held in place by the exam-
iner. The patient is then asked to extend the PIP joint
against resistance.
Any pressure felt by the examiner over the middle pha-
lanx can only be exerted by an intact central slip.
Further proof is that the DIP joint remains flail during
the effort because the competent central slip prevents
the lateral bands from acting distally. In the presence
of a complete rupture of the central slip, any exten-
sion effort perceived by the examiner is accompanied
by rigidity at the DIP joint with a tendency toward
extension. This is produced by the extensor action of
the lateral bands.
This test, however, does not demonstrate the presence
of a partial rupture of the central slip, and it may be
impeded by pain or lack of patient cooperation.
Consideration may be given to nerve block for pain relief,
as indicated.
TREATMENT
Closed Boutonniere
Correction of this deformity is dependent on restoration
of the normal tendon balance, and on the precise length
relationship of the central slip and lateral bands.
In acute cases, before fixed contractures have occurred,
this may be achieved by two basic means:
Progressively splinting the PIP joint into full exten-
sion.
Insertion of an oblique transarticular K-wire to main-
tain the PIP joint in full extension.
At the same time, active and passive flexion exercises of
the distal joint are performed.
Splinting of the PIP joint, and active flexion of the DIP
joint, are believed to draw the lateral bands distally and
dorsally, and to reduce the separation of the torn ends of
the central slip of the extensor tendon.
A B
C D
E F
Figure 12.2-9 Various forms of static and dynamic splints used to treat a closed-boutonniere deformity.
This allows repair by contracture of the disrupted ten-
don ends at their anatomic length, and by migration
of the lateral bands to their normal anatomic position
above the joint axis of rotation at the PIP joint.
Positioning and maintaining the PIP joint in extension
has been achieved by dynamic and static splinting, K-wire
fixation of the joint, and serial plaster casts.
When the distal joint can be fully flexed with the PIP
joint extended, all components of the extensor mecha-
nism have been restored to their normal relationships
and balance. At this point, the splint may be discon-
tinued.
This may take 6 weeks or more of continuous splinting
and DIP joint exercise.
Various forms of splints used for treatment of closed bou-
tonniere deformity are depicted in Figure 12.2-9.
In closed boutonniere deformity, operative treatment is
undertaken in two circumstances:
The central slip has been avulsed with a bone frag-
ment, and is lying free over the PIP joint. In this case,
it should be replaced or excised, and the tendon should
be reattached with a pullout suture.
There is a long-standing boutonni ` ere deformity in a
young person.
In closed volar dislocations of the PIP joint, there is usu-
ally a rupture of the central slip, along with a rupture of
a collateral ligament and volar plate and a subsequent
boutonniere deformity.
These potentially disabling soft-tissue injuries must be
recognized and repaired by prompt reduction and primary
repair of all ruptured structures (central slip, collateral
ligament, and volar plate), combined with stabilization
of the PIP joint in extension with a K-wire for 3 weeks,
followed by gradual mobilization over the next 3 to 4
weeks while the PIP joint is protected.
Motion of the distal joint is encouraged in the early post-
operative period.
It can be anticipated that this method will produce satis-
factory results, although joint stiffness can be a problem
because of extensive soft-tissue injury.
Reconstructions of a chronic, closed boutonniere de-
formity or of boutonniere lesions caused by burns or
rheumatoid disease are beyond the scope of this text.
Laceration of Central Slip at PIP Joint
Laceration of the extensor mechanism at the PIP joint
will result in loss of extension at that joint, which may in
turn develop into a secondary boutonniere deformity if
not properly treated.
The average thickness of the central slip just proximal to
the PIP joint is 0.5 mm, but this measurement is dou-
bled by the fibrocartilaginous dorsal plate at the point of
insertion of the central slip into the dorsal base of the
middle phalanx.
This dorsal plate provides a more substantial substance
for suture retention.
The lateral bands at this level also are approximately twice
the thickness of the central slip portion of the extensor
tendon, and are likely to retain sutures better than the
proximal portion of the central slip.
A useful repair technique is a modified Kessler suture of
4-0 synthetic suture beginning 1 cm from the lacerated
tendon edge.
The knot is tied in the substance of the tendon so that
two intact strands cross the laceration.
This suture begins in the substance of the lateral bands
on each side, and ends in the confluence of the lateral
bands and the dorsal plate over the PIP joint.
Next, a 5-0 synthetic suture is used to perform a cross
stitch, as described by Silfverskiold. This is not a cir-
cumferential suture, as is used for flexor tendons, be-
cause the tendon is flat and thin, but it is placed from
margin to margin of the extensor.
Both the Kessler and the cross-stitch sutures are
placed so that little or no shortening or side-to-side
deformity of the extensor mechanism is produced.
Figure 12.2-10 demonstrates some useful suture tech-
niques for repair of lacerations in the region of the PIP
joint.
Passive motion of the PIP joint in the operating room
to 30 degrees, without gapping of the repair site, usually
indicates that the repair is satisfactory.
Some lacerations of the extensor mechanism over the
PIP joint are so near the insertion of the central slip that
inadequate length is present distally to place or retain the
suture material.
In these cases, the distal aspect of the suture must
be placed through a small transverse tunnel made in
the dorsal base of the proximal phalanx with a 0.35
K-wire.
A5-0 cross stitchis placed as space permits to augment
the repair (see Figure 12.2-10D, E).
Care is taken to ensure that the various components
are neither foreshortened nor lengthened, as this may
result in contracture or extensor lag, respectively.
The PIP joint is splinted in full extension.
Under ideal circumstances, and when a hand therapist
is available, the short arc motion protocol is begun (see
Rehabilitation Protocol for Zone IIIIV Injuries).
An alternative treatment option is as follows:
A safety-pin splint or a molded, palmar, thermoplast
splint, as described for treatment of the closed bouton-
niere deformity, is applied, and active flexion exercises
of the distal joint are started.
The splint is maintained on a continuous basis for 5 to
6 weeks with the PIP joint in full extension, and active
flexion exercises of the distal joint are performed.
When active exercises to the PIP joint are started at 5
to 6 weeks, the patient is advised to support the prox-
imal phalanx in flexion as the PIP joint is extended.
This directs the force of the extensor tendon more dis-
tally, and the finger is in a more effective position for
extension.
The PIP joint is splinted in extension between these
exercise sessions for another 2 to 4 weeks.
At 8 to 10 weeks, active flexion and extension exercises
are increased.
Dynamic flexion splinting of the PIP joint can be used
to augment recovery of flexion if there is no extensor
lag at the PIP joint.
The recovery of flexion in the DIP joint can be aug-
mented by gentle and intermittent rubber band trac-
tion between a dress hook attached to the fingernail
distally and a small proximal hook attached to a plaster
finger cylinder cast.
Zone IV Injuries (Proximal
Phalanx)
DIAGNOSIS
Injuries at this level are usually partial lacerations of the
extensor mechanism, because of the broad configuration
of the tendon over the curved shape of the underlying
phalanx and consequent protection of the lateral bands.
Functional loss may be minimal due to this fact.
These lesions are diagnosed by direct inspection of the
wound.
TREATMENT
Laceration of an isolated lateral band may be repaired
with a 5-0 cross stitch, and early protected motion may
be started.
B
D E
C A
Figure 12.2-10 Suture techniques
for repair of lacerations of the
central slip at the PIP joint. AC. A
Kessler stitch with a crisscross
overlay is used if there is sufficient
tendon at each end for repair. D, E.
If sufficient tendon is not available
distally, the tails of the Kessler
suture are tied through a transverse
tunnel made with a 0.035 K-wire
through the dorsal base of the
middle phalanx. The crisscross stitch
is used to complete the repair. The
Kessler suture is tied with suitable
tension to avoid gapping or undue
shortening of the tendon. The
distance between the longitudinal
components of the suture is adjusted
to avoid side-to-side bunching or
shortening.
Complete lacerations of the central tendon should be
repaired using a modified Kessler suture of 4-0 nonab-
sorbable material, with a crisscross suture of 5-0 (see
Figure 12.2-10A, C).
Care is taken to avoid relative lengthening or short-
ening of the central tendon, because this may result
in imbalance between the central slip and the lateral
bands.
Because of the relatively large interface between the
extensor mechanism and osseous phalanx, and the re-
sultant potential for adhesions, it is ideal to begin
short arc motion exercises as described for zone III
injuries.
Zone V Open Injuries
(MCP Joint)
HUMAN BITE WOUNDS
Mechanism of Injury and Diagnosis
Tendon injuries at this level are most often associated
with open wounds.
A small, penetrating wound over the MCP joint may be
caused by striking someone in the mouth with a clenched
fist.
Although many patients deny this mechanism of in-
jury, a careful history must be taken.
This is a contaminated wound, and the organisms in-
volved are capable of producing significant wound infec-
tion.
Gram-positive bacteria (usually staphylococci) alone,
or in combination with gram-negative organisms, are
most frequently cultured.
The incidence of complications is directly related to the
time span from injury to treatment.
Treatment
A radiograph is obtained to note the presence or absence
of a fracture or foreign body.
The wound must be extended proximally and distally to
permit inspection of the joint, and a culture is taken.
The wound is debrided, irrigated, and left open.
Appropriate antibiotics are started immediately (prefer-
ably preoperatively).
Under no circumstances should a human bite wound be
closed.
Most tendon injuries associated with this type of wound
are partial, and need not be repaired immediately.
The hand is splinted, with the wrist in 40 to 45 degrees ex-
tension and the MCP joints in 15 to 20 degrees of flexion.
The soft tissues, including the capsule and extensor hood,
are allowed to seek their own position over the joint.
Partial or even complete lacerations are seldomif
everassociated with significant retraction at this
level.
The tendon laceration may be repaired secondarily as
needed in 5 to 7 days, or even later depending on the
nature of the wound at the time of inspection.
When the infection is under control, dynamic splinting
is started.
LACERATIONS
Treatment
Lacerations of the extensor tendon or hood at the MCP
joint level are repaired using core-type sutures of 4-0 non-
absorbable material.
Injuries of the extensor tendon at this level are not asso-
ciated with retraction of the ends, and a modified Kessler
with a cross-stitch is used (see Figure 12.2-10A, C).
Postoperative management includes dynamic splinting
using the methods described in the section on Rehabili-
tation of Extensor Tendon Injuries.
Zone V Closed Injuries
(MCP Joint)
CLOSED SAGITTAL BAND INJURIES
Pathologic Anatomy and Diagnosis
Spontaneous rupture of the radial sagittal band with
subsequent ulnarward subluxation or dislocation of the
extensor tendon in the nonrheumatoid patient may
occur following forceful flexion or extension of the
finger.
The lesion is secondary to a tear of the sagittal band and
oblique fibers of the hood, usually on the radial side,
although rupture of the ulnar sagittal band and radial
dislocation have been reported.
Ulnar subluxation or dislocation of the extensor tendon,
sometimes accompanied by painful snapping of the ex-
tensor tendon when making a fist, is the usual find-
ing.
In some cases, this may be associated with incomplete
finger extension and ulnar deviation of the involved digit
(Figure 12.2-11).
The middle finger is the most commonly involved.
This may be the result of an inherent anatomic weak-
ness, because the extensor tendon of the long finger
is situated on top of the transverse fibers, and has a
comparatively loose attachment at this level.
Treatment
Patients seen within 2 weeks of the injury may be treated
by closed means using a plaster or orthotic device that
maintains the MCP joint in a flexion block splint (Fig-
ure 12.2-12). The splint maintains the finger in neutral
abduction-adduction, allowing full extension but block-
ing flexion at 10 to 20 degrees.
The splint is used for 6 weeks.
Dislocations that are diagnosed long after the injury, or
that fail initial splinting, are best treated with surgical
release and realignment of the extensor mechanism by
one of the methods depicted in Figure 12.2-13.
OPEN SAGITTAL BAND INJURIES
Treatment
Lacerations of the hood or sagittal bands at this level
must be repaired so that the extensor tendon will remain
centralized over the dorsum of the joint.
Failure to repair this type of injury may result in sublux-
ation of the extensor tendon and an associated loss of
extension.
A cross stitch of 4-0 or 5-0 nylon is used to repair these
lacerations.
Gentle flexion and extension exercises are started in 3 to
5 days.
Abduction and adduction motions are avoided, and these
forces are minimized by buddy strapping the injured
finger to an adjacent finger.
Zone VI Injuries (Metacarpal)
Zone VI injuries have a better prognosis than more distal
lesions (zones II to V) for several reasons:
They are unlikely to have associated joint injuries.
The decreased tendon surface area in zone VI lessens
the potential for adhesion formation.
A B
C
Figure 12.2-11 Traumatic ulnar dislocation of the extensor tendon
at the MCP joint. A. Note the lack of complete extension of the
middle finger. B. There is ulnar deviation of the middle finger when
the patient attempts to extend the finger. C. Operative appearance of
the dislocated extensor tendon (arrows) and the anatomic or normal
position of the extensor (dotted lines).
The increased subcutaneous tissue lessens the poten-
tial for adhesions.
There is greater tendon excursion in zone VI.
Complex tendon imbalances are less likely to occur.
TREATMENT
The extensor tendons in this zone have sufficient sub-
stance to accept core-type sutures of the surgeons
choice, and dynamic splinting can be performed with
the assurance that disruption of the suture site is un-
likely.
Postoperative management includes dynamic splinting
beginning at 3 to 5 days with the wrist in 40 to 45 degrees
of extension and the MCP joints in 0 to 15 degrees flex-
ion. This lasts for 5 weeks. See the section on extensor
tendon rehabilitation.
SECRETANS DISORDER
(PERITENDINOUS FIBROSIS)
This condition is included under extensor tendon injuries
in zone VI since it may mimic tendon injuries in this zone.
In 1901, Henri-Francois Secretan described 11 cases of
persistent hard edema on the dorsum of the hand, all asso-
ciated with work-related injuries. All patients were covered
by workers compensation insurance, had sustained trauma
insufficient to produce fracture, and had prolonged symp-
toms and findings. This condition has been called dorsal
hard edema of the hand, peritendinous fibrosis of the dor-
sum of the hand, and factitious lymphedema of the hand.
Typically, a worker, usually male, describes a blow to the
dorsum of the hand without fracture or laceration and then
develops firm, persistent swelling over the back of the hand
with subsequent loss of finger flexion and resulting pro-
longed time out of work.
A
B
Figure 12.2-12 Orthotic device for treatment of extensor tendon
dislocation at the MCP joint. (Courtesy of Inoue and Tamara, from
Inoue G, Tamura Y. Dislocation of the extensor tendon over the
metacarpophalangeal joints. J Hand Surg 1996;21A:464469.)
Etiology
A number of factors have been reported in association with
this disorder, including proven or suspected self-inflicted
trauma, such as repeated blows to the back of the hand or
application of tourniquets, compensable work-related in-
juries, and neurosis, psychosis, or suicidal tendency. Al-
though abnormal tissues have been removed in Secretans
disorder, these tissues are merely the natural response to
trauma, and the pathology reports on the tissue specimens
and MRI findings are not unexpected. Such findings do not
indicate an etiology other than self-inflicted trauma.
Controversy still surrounds this disorder as to etiology
and treatment. In my opinion, Secretans is a disorder with
a known etiology and pathogenesis, and it is not a disease,
which implies some unique pathologic process that occurs
for some as yet undiscovered reason.
Diagnosis
Diagnosis is based on the history and on physical find-
ings.
Both T1- and T2-weighted MRI have shown soft-tissue
and tendon edema in combination with diffuse peritendi-
nous fibrosis extending to the fascia of the interosseous
muscles.
Operative findings (not advised) have shown fibroadipose
tissue with areas of focal myxoid or cystic degeneration
similar to ganglion tissue.
Treatment
Most experts advise nonoperative management of this
condition, which has included studious neglect and
avoidance of passive manipulation, heat, and massage.
They do, however, encourage the patient to exercise by
voluntary means.
The condition may improve by plaster-cast protec-
tion.
This condition must be recognized as a factitious dis-
order.
Patients with factitious disorders are not feigning the
disorder; they are causing it.
Confrontation in the form of accusation can poten-
tially be harmful to both the patient and the doctor,
and should be avoided.
The physical problemor lesion may resolve when com-
pensation is terminated. This condition is not a surgi-
cal lesion.
Best results have been achieved by psychotherapy.
Protective casting, although it may result in immedi-
ate improvement and can confirm the diagnosis, may
not be effective as a definitive treatment, as this disor-
der is self-inflicted and is characterized by recidivism.
However, this technique may somehow demonstrate,
in a conscious or unconscious way, the self-inflicted
nature of the problem.
Active physical therapy may be useful in many cases
when combined with psychotherapy.
Zone VII Injuries (Wrist)
ANATOMY
Injuries of the extensor mechanism at the wrist level are
associated with damage to the retinaculum. The retinac-
ulum prevents bowstringing of the extensor tendons, and
lacerations of the extensors at this level are thought to be
associated with subsequent adhesions to the overlying reti-
naculum. For this reason, many authors in the past advised
that portions of the extensor retinaculum located over the
site of tendon repair be excised to prevent adhesions. How-
ever, some surgeons have noted no statistical differences
in their results when comparing zones VI, VII, and VIII.
They repaired each retinacular rent primarily, and used tra-
ditional postoperative immobilization. The excellent results
with early dynamic splinting suggest that excision of por-
tions of the retinaculum over the tendon repair site may not
be as important as previously believed. However, limited ex-
cision of portions of the retinaculumdoes no harm, and may
facilitate tendon exposure and gliding, especially in repairs
Ulnar
subluxation
MP
Junctura
tendinum
Lumbrical
RCL
Figure 12.2-13 Techniques for
secondary reconstruction of extensor
tendon dislocation at the MCP joint.
in which there might be some impingement between the
suture site and the adjacent retinaculum.
TREATMENT
If the surgeon is concerned about maintaining the
anatomic integrity of the retinaculum, the traumatic
openings in the retinaculummay be extended distally and
proximally at each end of the retinacular laceration to fa-
cilitate tendon repair and then reapproximated.
The tendon is repaired using a standard core-type suture
of appropriate nonabsorbable material.
The adequacy of the retinacular restraint is verified by
passive flexion and extension of the fingers and wrist.
Multiple tendon injuries at this level may be dealt with
by appropriate excision of the retinaculum as needed.
Portions of the retinaculum should be preserved either
proximal or distal to the suture line to prevent bowstring-
ing; this is usually technically feasible.
Although it has been recommended that complete exci-
sion of the extensor retinaculum be performed in lacer-
ations at multiple levels, it is my opinion that complete
excision of the retinaculum is seldom, if ever, necessary,
even in this type of injury. Some portion of the retinac-
ulum can usually be preserved, and adhesions that limit
function are unlikely, especially if early dynamic splinting
is used.
Tendons lacerated at this level retract, and traumatic
wounds must be extended proximally and distally to find
the tendon ends.
In many instances, the surgeon must deal with multiple
tendon lacerations, and the sorting out and matching of
these tendon ends for later suture may be quite tedious
and time consuming.
A method of intraoperative tendon labeling has been de-
scribed, and avoids the repetitive identification of tendon
ends and thus saves operative time.
The method involves the placement of a 4-0 nonab-
sorbable suture into each cut end using a grasping
suture technique such as the two-suture, modified
Kessler.
The free ends of the suture material are then clamped
in a hemostat and a Steri-Strip is placed through the
thumb or finger hole, or around one of the proximal
shanks of the hemostat. It is then folded on itself.
A sterile marking pen is used to write the name of the
tendon on the Steri-Strip.
After all tendons have been labeled, they are easily
matched and repaired using the same suture that ini-
tially tagged the tendon ends.
EXTENSOR TENDON RUPTURE
Mechanism of Injury
In addition to injury by laceration, the extensor tendons
may rupture following a closed fracture or may dislocate
following injury to the retinaculum. The EPL and EDC
tendons may rupture following a Colles fracture, and the
extensor carpi ulnaris (ECU) tendon may dislocate ulnar-
ward with forceful supination, palmar flexion, and ulnar
deviation. The radially situated extensor tendons (EIP and
EDC to index and EPL to the thumb) may be entrapped,
and may rupture in Smiths and Galeazzis fractures. In
Galeazzis fracture, the ECU may be trapped between the
dorsally displaced ulnar head and avulsed ulnar styloid, or
the extensor digiti minimi (EDM) tendon may be caught
beneath the radial border of the dorsally dislocated ulnar
head.
Treatment
Impending rupture of the EPL has been treated by sub-
cutaneous transposition from its canal.
Treatment of acute ruptures of the EPL tendon is by
transfer of the EIP tendon (or intercalary graft) and the
ruptured communis tendons by intercalary graft, or by
suturing the distal tendon stump to the adjacent extensor
tendons.
Dislocation of the ECUtendon is treated by repairing the
fibro-osseous sheath with a free tendon graft or a portion
of the extensor retinaculum.
Zone VIII Injuries (Distal
Forearm)
MECHANISM OF INJURY
Injuries at the musculotendinous junction may be caused by
laceration or traumatic rupture. Although extensor tendon
rupture at the musculotendinous junction is rare, such in-
juries may be due to sudden, forceful traction forces caused
by gloves caught in revolving machines.
TREATMENT
In lacerations, the distal aspect of the junction (the ten-
don) accepts and holds sutures satisfactorily, but the
muscle component is less likely to retain the suture.
Although it is theoretically possible to place the sutures
in the muscle through the fibrous tissue origins of the
tendon in the muscle belly, it is not always possible to
obtain a suitable repair.
If such repairs are tenuous, the surgeon may elect to
restore function by tendon transfer or by side-to-side su-
ture, as recommended for management of musculotendi-
nous ruptures.
Zone IX Injuries (Proximal
Forearm)
PATHOLOGIC ANATOMY
The wrist and common finger extensors, as well as the little-
finger proprius, arise from the region of the lateral epi-
condyle at the elbow. The thumb extensors and abductors,
along with the proprius tendon of the index finger, arise
from the forearm below the elbow. Injuries at this level are
usually caused by penetrating wounds with knives or pieces
of broken glass. The size of the skin wound may give little
indication of the magnitude of the injury. Single or multi-
ple functional units may be injured. The demonstrated loss
of function may be the result of muscle transection, nerve
injury, or both. Such loss of function in a penetrating injury
in the proximal forearm may defy accurate preoperative di-
agnosis. The radial nerve at the level of the distal arm gives
off branches to the brachialis, brachioradialis, and the ex-
tensor carpi radialis longus (ECRL). A major division of this
nerve then occurs into the sensory branch and the posterior
interosseous nerve (PIN). The superficial (sensory) branch
continues distally under cover of the brachioradialis into the
forearm, wrist, and hand areas. The posterior interosseous
nerve gives branches to the extensor carpi radialis brevis
(ECRB) and supinator, which it penetrates and supplies,
and then innervates the remainder of the extensor muscle
group.
TREATMENT
Experimental data onrepaired muscle lacerations inlabo-
ratory animals (rabbits) imply that useful but incomplete
function can be restored with adequate repair of skeletal
muscle.
A muscle segment totally isolated from its motor point
may not contribute to the contractile function of the in-
nervated muscle.
In a series of patients with forearm flexor muscle lacera-
tions, it was noted that tendon grafting was an effective
method of repair to overcome extensive defects.
The indication for this technique is laceration of two or
more muscle bellies with at least 50% of the muscle sub-
stance lacerated.
A penetrating wound with functional loss in the proxi-
mal third of the forearm must be carefully explored to
determine the exact etiology of the loss.
Under tourniquet control and appropriate anesthesia, the
wound margins are debrided and then extended proxi-
mally and distally and the extent of damage noted.
If it can be determined that the wounds extend only
into the muscle belly, a careful repair of the muscle
belly is performed with multiple figure-of-eight sutures
of polyglactin (Vicryl, Ethicon).
For muscle grafting, the palmaris longus and long toe
extensor tendons are used and passed through the su-
perficial epimysium, muscle belly, and deep epimysium
proximally and distally and sutured to themselves with a
Pulvertaft side-weave technique.
One to three grafts are used, as required.
The limb is immobilized for 3 weeks, with the elbow at
90 degrees.
Protected motion is started at 3 weeks, and progressive
motion is started at 6 weeks.
NERVE INVOLVEMENT
Diagnosis
Many times it is impossible to determine nerve damage
at the time of surgery in the immediate postinjury period.
After 7 to 10 days, however, a denervated muscle will
spontaneously contract for several minutes under the in-
fluence of succinylcholine used during induction of gen-
eral anesthesia.
Additional information may be gained by electrodiagnos-
tic studies at 3 to 4 weeks postinjury.
Treatment
The decision to undertake secondary nerve repair or re-
construction versus tendon transfer depends on the judg-
ment and experience of the surgeon.
If there is evidence of nerve involvement, the appropriate
branches are identified and traced out to their insertions.
Penetrating wounds often injure the nerve at or near its
entrance into the muscle belly.
Retraction of the distal nerve stump into the muscle
belly may occur, and may defy location and subsequent
repair.
If the lesion is confined to the muscle belly, definitive
repair is carried out using sutures or tendon grafts and
sutures, as previously described.
The muscle is usually quite hemorrhagic, and muscle
planes are difficult to identify.
Identification is aided by evacuation of the hematoma,
irrigation, and gentle sponging of the cut muscle ends.
Identifying intramuscular fibrous septa and fascia for
the placement of sutures aids in preventing the sutures
from pulling out of the muscle.
Coaptation of the cut ends of those muscles that arise at
or distal to the elbow is aided by wrist extension.
If suitable repair cannot be obtained by these methods,
tendon transfers may be required.
Postoperative Management
Postoperatively, the extremity is supported in a plaster
splint or cast that maintains the wrist in 45 degrees
of extension and the MCP joints in 15 to 20 degrees
flexion.
The elbow joint is immobilized in 90 degrees of flexion
if the muscles involved arise at or above the lateral epi-
condyle.
Immobilization is continued for 4 weeks postinjury, and
then protected range of motion is permittedbut a night
splint is used to maintain the wrist in extension for an-
other 2 weeks.
Rehabilitation of Extensor
Tendon Injuries
HISTORY AND GENERAL PRINCIPLES
Repaired extensor tendon injuries have traditionally been
immobilized in extension for 3 to 4 weeks. However, in
some instances, this has resulted in adhesions between the
extensor tendon and the surrounding tissues. This has been
especially true when the tendon injury was associated with
a crush injury, surrounding soft-tissue loss, infection, un-
derlying fracture, or joint-capsule or flexor-tendon injury.
Significant and extensive research (both basic and clinical)
has focused on the best methods of postoperative manage-
ment of flexor tendon injuries, and controlled and early
passive motion of the tendon suture site provided by dy-
namic splinting has proved to be a useful method to pro-
mote a well-healed, smooth, nonadherent, gliding flexor
tendon surface, with improved tensile strength. This body
of evidence regarding the rehabilitation of flexor tendon in-
juries with dynamic splinting is applicable to extensor ten-
don injuries, and many clinical studies have supported this
concept.
At this time, there are many accepted protocols for dy-
namic splinting and early active motion in extensor tendon
injuries, even in the most problematic zone III injuries. At
this time, only zone I and II injuries and zone III closed
boutonniere injuries are treated by static splinting. The pro-
tocols that follow have proven to be useful in my practice.
However, the reader should note that improvements and
changes might be made to these protocols in the future as
more experience is gained.
These principles of dynamic splinting may be especially
applicable when multiple extensor tendons are injured be-
neath the extensor retinaculum and when there are asso-
ciated injuries. The extensor tendons at the wrist level are
surrounded by a synovial sheath and constrained by fibro-
osseous and fibrous tunnels. Indiscriminate sacrifice of the
extensor retinaculum results in altered biomechanics and
poor function. The use of controlled passive motion has
been clearly shown to improve results in flexor tendon in-
juries, and these principles are now applied to extensor ten-
don injuries:
Extensor tendon injuries can be placed in an outrig-
ger splint that maintains passive extension using elas-
tic traction, but that allows limited active flexion (Fig-
ure 12.2-14).
Excursion of the repaired extensor tendon is achieved by
active flexion.
Figure 12.2-14 Dynamic splint for early motion of
extensor tendon injuries in zones V to VI.
Splinting is started 3 to 5 days after surgery and is main-
tained for 5 weeks.
Active flexion is performed 10 times an hour.
REHABILITATION PROTOCOLS
Zone III and IV Injuries
Extensor tendon injuries in zones III and IVhave historically
demonstrated higher percentages of extensor lag and loss
of flexion. This led to the development of a rehabilitation
protocol based on protected movement of the injured finger.
The efficacy of the short arc motion for zone III extensor
injuries was based on the fact that 30 degrees of flexion
at the PIP joint results in a calculated tendon excursion of
3.75 mm.
In this protocol, developed by Evans, a thermoplastic pal-
mar static splint is used to immobilize the PIP and DIP
joints in full extension, except during exercise.
The splint is taped directly over the PIPand DIPjoints.
Two thermoplastic exercise splints are used:
N Type I, for PIP joint motion, is a palmar splint with
30 degrees of PIP flexion and 20 to 25 degrees for
the DIP joint.
N Type II, for DIP flexion, is a palmar static splint that
maintains the PIP joint in full extension and keeps
the DIP joint free.
The exercise regimen is as follows:
First 2 weeks:
N The static splint is removed on the hour for 20 repe-
titions of PIP and DIP joint exercise, with the wrist
at 30 degrees of flexion and the MCP joint at or
near 0 degrees of extension.
N The patient holds the type I splint in place beneath
the proximal phalanx, maintains the MCP joint in
full extension, and, beginning from full extension,
actively flexes the PIP and DIP joints to the re-
straints of the splint.
N Each exercise is performed slowly and sustained
briefly in full extension for 20 repetitions.
N The type II splint is then held in place to maintain
the PIP joint in full extension, and the DIP joint is
fully flexed and extended.
N If lateral band repair was required, the flexion is
limited to 30 to 35 degrees.
N The patient is instructed in what Evans terms min-
imal active muscle tendon tension, which repre-
sents a force of about 300 g.
Third week:
N The type I splint is altered to allow 40 degrees flex-
ion at the PIP joint if no extensor lag has developed.
Fourth week:
N The type I splint is altered to allow 50 degrees of
flexion if no extensor lag is present.
N This is increased to 70 to 80 degrees by the end of
the 4th week if the PIP joint is actively extending to
0 degrees.
N If an extensor lag develops, flexion increments
should be less, and active extension exercises and
extension splinting should be emphasized.
Zone V to VII Injuries
Caveat: This protocol, along with other dynamic protocols
for extensor tendoninjuries, is most suitably used inpatients
who are reliable and well-motivated, and is based on the
availability of an experienced and capable hand therapist.
Studies have found that 5 mm of passive tendon glide is
safe as well as effective in limiting adhesions after extensor
tendon injury. This amount of gliding is achieved by active
MCP-joint flexion ranging from 27.5 degrees to 40.9 de-
grees (index, 28.3 degrees; long, 27.5 degrees; ring, 40.9
degrees; little, 38.3 degrees).
The method of postoperative management for extensor
tendon injuries in finger zones V to VII begins with dy-
namic splinting 3 to 5 days after surgery.
The wrist is positioned in an appropriate amount of ex-
tension to relieve tension at the repair site. This is usually
40 to 45 degrees.
The MCP and IP joints are supported at 0 degrees in
elastic traction slings attached to an outrigger device (see
Figure 12.2-14).
A palmar block limits MCP flexion to the arc of motion
previously noted to result in 5 mm of extensor tendon
excursion.
The patient is instructed to actively flex the MCP joints,
but to allow the elastic traction on the outrigger device
to passively return the digital joints to 0 degrees. This
exercise is done 10 times per hour.
Dynamic splinting is discontinued between the 3rd and
4th weeks; active motion is then started using gentle ac-
tive and active assistive exercises that emphasized exten-
sion at the MCP joint with the wrist supported in exten-
sion.
Between 4 and 5 weeks postsurgery, individual finger ex-
tension and the claw position are emphasized to direct
controlled stress to the adhesions.
At 5 to 6 weeks, finger flexion is emphasized.
At 7 weeks, resistance, functional electric stimulation,
and dynamic flexion splinting are used as needed to en-
courage full finger flexion.
During the phase of dynamic splinting, resting the digi-
tal joints at 0 degrees prevents extensor lag. Controlled
MCP motion prevents extension contractures, maintains
the integrity of the collateral ligaments, and lessens the
effects of adhesions at the repair site.
With the wrist and MCP joints fully extended, passive
movement of the IP joints may be performed without
affecting tendon excursion in zones V, VI, and VII, thus
avoiding stiffness in these joints.
Wrist Extensor Tendon Injuries in Zone VII
Postoperative management of lacerations of the ECRL,
ECRB, and ECU includes immobilization of the wrist
at 40 to 45 degrees extension for 4 to 5 weeks with the
fingers free.
Progressive active and gentle passive range of motion is
started after 4 to 5 weeks, and a night splint that keeps
the wrist in 40 to 45 degrees of extension is used for an
additional 2 weeks.
Zone VIII Injuries
Postoperative management includes static immobiliza-
tion of the wrist in 40 to 45 degrees of extension and the
MCP joints in 15 to 20 degrees of flexion for 4 weeks,
followed by a static night splint that maintains the wrist
in extension for an additional 2 weeks.
Flexion of the MCP joints may be started at 2 weeks
against elastic traction resistance.
SUGGESTED READING
Angeles JG, Heminger H, Mass D. Comparative biomechanical per-
formance of 4-strand core suture repairs for zone II flexor tendon
lacerations. J Hand Surg 2002;27:508517.
Botte MJ, Cohen MS, von Schroeder HP. Method of tendon labeling
in forearm injuries. J Hand Surg 1991;16A:763764.
Botte MJ, Gelberman RH, Smith DG, Silver MA, Gellman H. Repair
of severe muscle belly lacerations using a tendon graft. J Hand Surg
1987;l2A:406412.
Diao E. Experimental studies of tendon injuries. In: Trumble TE, ed.
Hand surgery update 3, hand, elbow and shoulder. Rosemont, Il:
Amer. Soc Surg Hand, 2003:233251.
Doyle JR. Boutonniere deformity. In: Strickland JW, ed. Master tech-
niques in orthopedic surgery: the hand. 2nd Ed. Philadelphia: Lip-
pincott Williams & Wilkins, 2005.
Doyle JR. Extensor tendons-acute injuries. In: Green DP, Hotchkiss
RN, Pederson WC, eds. Greens operative hand surgery. 4th Ed.
Doyle JR. Palmar and digital flexor tendon pulleys. Clin Orthop Rel
Res, 2001;383:8496.
Doyle JR, Botte MJ. Palmar hand. In: Surgical anatomy of the hand
and upper extremity. Philadelphia: Lippincott Williams & Wilkins,
2002:532641.
Doyle JR, Semenza J, Gilling B. The effect of succinylcholine on den-
ervated skeletal muscle. J Hand Surg 1981;6:4042.
Evans RB. An update on extensor tendon management. In: Hunter JM,
Schneider LH, Mackin EJ, et al., eds. Rehabilitation of the hand,
4th Ed. St. Louis: CV Mosby, 1996:655706.
Evans RB. Early active short arc motion for the repaired central slip. J
Hand Surg 1994;19A:991997.
Evans RB, Thompson DE. An analysis of factors that support early
active short arc motion of the repaired central slip. J Hand Ther
1992;5:187210.
Inoue G, Tamura Y. Dislocation of the extensor tendon over
the metacarpophalangeal joints. J Hand Surg 1996;21A:464
469.
Leddy JP, Packer JW. Avulsion of the profundus tendon insertion in
athletes. J Hand Surg 1977;2:6669.
Newport ML. Extensor tendon injuries in the hand. J Acad Orthop
Surg 1997;5:5966.
Peterson WW, Manske PR, Bollinger BA, et al. Effect of pulley ex-
cision on flexor tendon biomechanics. J Orthop Res 1986;4:96
101.
Rayan GM, Murray D. Classification and treatment of closed sagittal
band injuries. J Hand Surg 1994;19A:590594.
Schneider LH. Flexor tendons-late reconstruction. In: Green DP,
Hotchkiss RN, Pederson WC, eds. Greens operative hand
surgery. 4th Ed. New York: Churchill Livingstone, 1999:1898
1949.
Secretan H. Oedeme sur et hyperplasie traumatique du metacarpe dor-
sal. Rev Med Suisse Romande 1901;21:409.
Seiler JG. Flexor tendon repair. In: Trumble TE, ed. Hand surgery
update 3, hand, elbow and shoulder. Rosemont, Il: Amer. Soc Surg
Hand, 2003:253259.
Silfverskiold KL, Andersson CH. Two new methods of tendon repair:
an in vitro evaluation of tensile strength and gap formation. J Hand
Surg 1993;18A:5865.
Strickland JW. Flexor tendons-acute injuries. In: Green DP, Hotchkiss
RN, Pederson WC, eds. Greens operative hand surgery. 4th Ed.
Widstrom CJ, Johnson G, Doyle JR, et al. A mechanical study of six
digital pulley reconstruction techniques: part I. Mechanical effec-
tiveness. J Hand Surg1989;14A:821825.
13
NERVE
INJURIES
Our peripheral nervous system is our mediator to, and in-
terpreter of, our external environment. This system, along
with the optic nervous system, makes it possible for us to
not only survive, but to flourish in our environment.
This chapter will discuss the evaluation and treatment of
acute nerve injuries as seen in the hand, wrist, and forearm,
and will emphasize the diagnosis of acute nerve injuries and
the management of commonly encountered injuries of the
three major upper extremity nerves and their branches.
This chapter will also describe the classic hand defor-
mities, and findings seen following nerve injuries, repair
techniques, and some of the tendon transfers used to treat
irreparable nerve injuries.
The discussion of nerve injuries begins with the pertinent
anatomy and physiology of nerve injury and repair.
PERTINENT ANATOMY
Gross Anatomy of the Nerves of the
Upper Extremity
The anatomic configuration and relationships of the me-
dian, ulnar, and radial nerves in the upper extremity are
depicted in Figure 13-1. These figures represent the most
usual or common arrangement of the nerves, and do not de-
pict anatomic variations. The distribution of the cutaneous
nerves in the upper extremity given in Figure 13-2 and Fig-
ure 13-3 indicates the most common distribution of the
cutaneous branches of the three major nerves in the hand.
Peripheral Nerves
Neural Components
The peripheral nerves contain motor, sensory, and auto-
nomic fibers. The motor fibers originate from the motor
neurons in the anterior horn of the spinal cord. The sen-
sory fibers originate from the sensory neurons in the dorsal
root ganglia. The autonomic fibers are either preganglionic,
arising from the neurons in the brainstem/spinal cord, or
postganglionic, arising from the neurons in paravertebral
ganglia.
Spatial Organization
There is a significant degree of topographical localization in
the peripheral nerve trunk that correlates to distal function.
Motor neurons serving a single muscle are found grouped
together within the anterior horn of the spinal cord.
Macroscopic and Microscopic Anatomy
Figure 13-4 illustrates the macroscopic anatomy of a typ-
ical peripheral nerve as seen in the upper extremity. The
following descriptive terms are useful anatomic points of
understanding about nerve injury and repair.
The Three Concentric Layers
Epineurium. Epineurium is a loose, collagenous connec-
tive tissue that represents the outermost layer of the nerve
as well as an internal investing layer that surrounds fascicles
and groups of fascicles. The epineurium is an elongation of
the dural sleeve of the spinal nerve roots, and is divided into
external and internal layers. The external epineurium sur-
rounds the peripheral nerve, and anchors blood vessels en-
tering fromthe surrounding tissue. The internal epineurium
is present between fascicles, and cushions them from exter-
nal force. It also contains blood vessels. The percentage of
nerve cross-sectional area represented by the epineurium
may vary, and greater amounts may be found in the nerves
in the region of joints and in more exposed locations. This
layer may thicken or enlarge in response to trauma, and
may represent a large portion of the scar seen after nerve
injury. The epineurium is surrounded by a loose collection
of areolar tissue that under normal circumstances (absence
of extrinsic scar tissue) accounts for the longitudinal excur-
sion of the nerve and the avoidance of traction injuries.
Perineurium. The perineurium surrounds individual fas-
cicles, and is composed of up to 10 concentric lamellae of
flattened cells, with prominent basement membranes that
are linked tightly together. Longitudinally and obliquely ori-
ented collagen fibers are present between these lamellae.
The perineurium functions as an extension of the blood-
brain barrier, controlling the intraneural ionic environment
by limiting diffusion, blocking the spread of infection to the
endoneurium, and maintaining a slightly positive intrafas-
cicular pressure. The perineurium surrounds each fascicle
208
Chapter 13 / Nerve Injuries 209
To coracobrachialis
Lateral
cord
Medial
cord
Median nerve
To PT
To FCR
To PL
To FDP
To FDP
To PQ
To lumbrical 2
To lumbrical 1
Recurrent nerve
Palmar cutaneous
nerve
To FDP
To FPL
Lat. antebrachial
cutaneous nerve
To radioulnar joint
To brachialis
To biceps
Figure 13-1 The configuration and
anatomic relationships of the three
major nerves of the upper extremity,
and their branches showing
distribution and muscles innervated.
Figure continues.
Medial cord
Med. brachial
cutaneous nerve
Med. antebrachial
cutaneous nerve
Ulnar nerve
To FCU
Nerve of Henle
to small finger
To PB
Sensory branch
to median nerve
To AdP
To FPB
Deep motor
branch
D1
D1
P1
D1
L3
L4
D1
P1
To FDP, ring,
small fingers
Figure 13-1 (continued)
To
long head,
triceps
To anconeus
Superficial branch
To supinator
To APL
To EPL
To EPB
To EIP
To ECU
ECRB
PIN
To EDC
To BR
To ECRL
To EDM
Communicating
branch, to ulnar
nerve
Deep branch
Radial nerve
Axillary nerve
Posterior cord
Lower lateral brachial cutaneous n.
Medial brachial cutaneous n.
Medial antebrachial cutaneous n.
Anterior branch
Posterior branch
Dorsal cutaneous branch of ulnar n.
Palmar cutaneous branch of ulnar nerve
Palmar cutaneous branch of median nerve
Superficial branch of radial n.
Lateral antebrachial cutaneous n.
Anterior branch
Posterior branch
Posterior antebrachial cutaneous n.
A
Figure 13-2 The cutaneous nerves
of the upper extremity of the (A)
anterior and (B) posterior aspects of
the upper extremity. Figure continues.
and provides a diffusion barrier. This layer maintains a pos-
itive pressure gradient that is manifested by the bulging fas-
cicles of a freshly cut nerve.
Endoneurium. The endoneurium is the collagenous tis-
sue that acts as packing among axons within the per-
ineurium. The endoneuriumparticipates in formation of the
Schwann cell tube that contains the myelinated axon and its
associated Schwann cells. Schwann cells formmembranous
expansions around axons, and form the myelin sheath that,
in oversimplified terms, represents the insulation around
the axon and promotes efficient conduction and velocity of
action potentials. Large myelinated axons have two layers
of collagen (endoneurium); the outer is longitudinally ori-
ented and the inner is arranged randomly and is associated
with reticulin. Small myelinated axons have only the outer,
longitudinal layer. The Schwann cell basement membrane
forms the inner lining of this tubular structure. Endoneurial
collagen resists longitudinal stress, and the Schwann cell
participates in a complex homeostatic relationship with the
axon.
The Fascicle
The fascicle is the smallest unit of nerve tissue than can be
manipulated surgically; it contains axons enclosed by en-
doneurium and is in turn wrapped in perineurium (Figure
13-4). The number of fascicles in a given nerve may vary in
number and size. Interconnections may occur between fas-
cicles. Fascicular group mapping has permitted more accu-
rate reapproximation of nerves, and identification of these
fascicular groups as to size and axial orientation may allow
the surgeon to more appropriately reconnect or join severed
nerves either primarily or with nerve grafts.
Vascular Supply
Peripheral nerves are very vascular, and segmental nutrient
vessels join a plexus of predominantly longitudinal vessels
in the epineurium. These, in turn, supply a second plexus
that lies among the lamellae of the perineurium. Perineurial
vessels may travel for long distances before entering the en-
doneurium. This longitudinal plexus of blood vessels allows
a nerve to be mobilized for a significant distance without
ischemic compromise.
Intercostal brachial n.
Upper lateral brachial cutaneous n.
Lower lateral brachial
cutaneous n.
Posterior antebrachial
cutaneous n.
Posterior antebrachial cutaneous n.
Cutaneous branches
of radial n.
Posterior branch of
lateral antebrachial cutaneous n.
Superficial branch of radial n.
Dorsal cutaneous branch of ulnar n.
Medial antebrachial
cutaneous n. (ulnar
posterior branches)
Posterior brachial
cutaneous n.
(of radial n.)
B
Ulnar Nerve
Median Nerve Median Nerve
Radial Nerve Radial Nerve
Figure 13-3 The terminal (cutaneous) distribution of the median, ulnar, and radial nerves in the palm
and back of the hand.
Epineurium
Vessel
Perineurium
Fascicle
Endoneurium
Myelinated fiber
Axon
Node of
Ranvier
Schwann cell
Figure 13-4 Typical cross-sectional anatomy of a
peripheral nerve showing the nerve axons
surrounded by the investing layers of endoneurium,
perineurium, and epineurium. Note the grossly
visible vascular network in the perineurium (see
text for details).
The Neuron
The neuron is the basic functional and morphological unit
of the peripheral nerve. Each neuron consists of a cell body
with cytoplasmic extensions, called dendrites, and an axon
(Figure 13-5).
The cell body contains a single nucleus with one or
more nucleoli, ribosomes, endoplasmic reticulum, and the
Dendrites
Nucleolus
Nucleus
Schwann cell
Axolemma
Myelin
Axon hillock
Axon
Nissl
bodies
Figure 13-5 The basic functional unit of the peripheral nerve is the
neuron, which consists of a cell body, an axon, and dendrites. The
axon and dendrites are protoplasmic extensions of the cell body.
Some axons are unmyelinated and some are myelinated.
Golgi apparatus. It synthesizes structural components of the
neuron.
The axon is a special cylindrical extension arising from
the neuron at a confluence of cytoplasm called the axonal
hillock. The axon contains axoplasm, microtubules, and
neurofilaments surrounded by the axolemma, which serves
as the surface membrane. The axon functions as a means
of bidirectional axonal transport and nerve conduction.
In general, Schwann cells surround all axonsbut only
the larger axons have a myelin sheath. In larger myelinated
axons, Schwann cells are present along the entire length,
and are said to be the glial cells of the peripheral ner-
vous system. The myelinated axon has characteristic inden-
tations at uniform intervals; these are called the nodes of
Ranvier and are myelin-free zones that facilitate ionic ex-
change and propagation of electric conduction. The diame-
ter of the axon is one factor that may determine the presence
or absence of myelin. The size of the axon may determine
the thickness of the myelin layer. Motor fibers have thicker
myelin sheaths than sensory fibers.
In an unmyelinated nerve, each Schwann cell surrounds
several small axons, and in a myelinated nerve, Schwann
cells surround a single axon. The myelin sheath is a complex
proteophospholipid that promotes conduction efficiency
and the velocity of action potentials. Myelinated axons have
four distinctive regions: the node of Ranvier, paranode, jux-
taparanode, and internode. Each of these zones is charac-
terized by a specific set of axonal proteins. Voltage-gated
sodium channels are clustered at the nodes, whereas potas-
sium channels are concentrated at juxtaparanodal regions.
Sensory Receptors
There are three common types of mechanoreceptors, and
their roles in sensory perception are noted as follows.
Merkel Cell
The Merkel cell is a disc-shaped cell that is clustered around
the sweat duct. This complex consists of several receptors
served by the branches of a single axon.
This receptor is slowly adapting, and is very sensitive to
the perpendicular indentation of the skin. The Merkel cell
has a well-circumscribed receptive field of 2 to 4 mm, and
responds to a small area of skin pressure, such as static
2-point discrimination.
Meissner Corpuscle
The Meissner corpuscles are located in the superficial der-
mis, and are most highly developed in the finger pulp
or pads. They are egg-shaped lamellar structures situated
closely below the dermis at the sides of the intermediate
ridge, and are anchored by thin strands of connective tis-
sue.
These receptors are innervated by several terminal axons,
and are rapidly adapting. They provide information about
rapidly fluctuating mechanical forces acting on the palmar
surfaces of the hands and feet.
They fire briefly at the start of stimulus and at times
at the end, and respond to flutter vibration at 30 cps. The
Meissner corpuscle is well equipped for analysis of motion,
such as moving 2-point discrimination.
Pacinian Corpuscle
The Pacinian corpuscle lies in the subcutaneous tissue of
the palmar and plantar surfaces, and is visible to the naked
eye; it reaches up to 2 mm in length.
A single axon innervates the corpuscle and is surrounded
by 40 to 60 concentric lamellae.
The Pacinian corpuscle is rapidly adapting, and is espe-
cially sensitive to vibration with a receptive field that is up
to several centimeters in diameter.
PHYSIOLOGY OF NERVE INJURY
AND REPAIR
Classification of Injury
Sir Herbert Seddon and Sir Sydney Sunderland both de-
vised a classification system of nerve injury based on degree
of disruption of the internal structures of the peripheral
nerve. These systems are simple and widely used today be-
cause of their correlation to the degree of nerve injury and
thus provide a useful basis for comparison of results with
various treatments and lend themselves, to some degree,
as prognostic factors following nerve injuries. Sunderland
noted that nerve injuries may be represented by more than
one degree of injury, and that a nerve injury may not always
fall into a single category. Table 13-1 compares these two
classification systems.
Degeneration and Regeneration
Events in the Neuron and Proximal Axon Following
Nerve Injury
The following sequence represents a cursory summary of
the events that may occur in the neuron and proximal axon
after axotomy.
1. Signals from the periphery turn on the genes in the neu-
ron for successful reinnervation. The neuron receives
specific signals from the axonal injury site, which in turn
prime the cell to initiate the process of degeneration and
subsequent regeneration.
2. The first phase is characterized by the arrival of action
potentials generated at the injury site. This burst of ac-
tion potentials opens gated calciumchannels, causing an
influx of calciumions that activate calcium-sensitive pro-
tein kinases. These kinases regulate various transcription
factors.
3. In the second phase, protein kinases and other intrinsic
constituents activated at the injury site are transported
retrograde, promoting synthesis of proteins required for
TABLE 13-1 COMPARISON OF SUNDERLAND AND SEDDON CLASSIFICATION OF
NERVE INJURIES
Author Descriptive Term Nature of Injury/Neuropathology
Sunderland First Degree Injury Demyelinating injury with a temporary conduction block
Seddon Neurapraxia
Seddon
Sunderland
Second Degree Injury
Axonotmesis
Distal degeneration of the injured axon but with almost always
complete regeneration due to intact endoneurium
Sunderland
Seddon
Third Degree Injury
Neurotmesis
Sunderlands third degree injury is less severe than the neurotmesis
category of Seddon since the perineurial layer is intact.
Regeneration occurs but is incomplete due to endoneurial
scarring and loss of end-organ specicity within the fascicle
Sunderland Fourth Degree Injury Axon, endoneurium, perineurium are disrupted with extensive
scarring that blocks axonal regeneration and often results in a
neuroma-in-continuity.
Sunderland Fifth Degree Injury Severed nerve trunk without possibility of spontaneous regeneration.
Degeneration of axon and myelin
Schwann cell
Schwann cell
Schwann cell
Schwann cell
A
B
C
D
Endoneurium
New axonal growth
New
axon
New myelin
Macrophage
Figure 13-6 Wallerian degeneration and
regeneration. A. Breakdown of axoplasm and
cytoskeletons into granular, ovoid particles.
B. Macrophages appear, and in 2 to 3 days they
phagocytize and clear away these particles.
C. Schwann cells proliferate by mitosis, and form a
line known as Bungers band. D. Schwann cells
wrap around and myelinate newly regenerating
axons. (After Chiu DTW, Choi M, Dellon AL.
Nerve Physiology and Repair. In: Trumble TE, ed.
Hand surgery update 3: hand, elbow & shoulder.
Rosemont, IL: American Society for Surgery of the
Hand, 2003:287297).
regeneration. Growth-specific proteins are synthesized,
and are transported distally.
4. The third phase is mediated by neurotrophic factors,
growth-promoting surface molecules, and cytokines re-
leased by the extrinsic cells, such as the macrophages
and Schwann cells at the injury site. These are then
taken up by the injured axon and transported back to the
neuron.
5. The last phase marks the end of regeneration. Growth
factors produced by the target organ arrive.
Axon Sprouting
Within hours of an injury, so-called collateral sprouts begin
to develop from the most distal node of Ranvier proximal to
the site of injury. The sprout formation site may be close to
the injury site (in a sharp transection) or farther away (in
an avulsion/crush-type injury). Terminal sprouts arise from
the tip of the surviving axon.
Events in the Distal Axon Following Nerve Injury
Wallerian Degeneration. Wallerian degeneration is a
breakdown and cleanup process that occurs in the distal
axon in response to nerve injury (Figure 13-6). It is summa-
rized as:
1. Axoplasm and cytoskeletons break down.
2. Macrophages appear in the injured area and begin to
phagocytize the breakdown material.
3. Schwann cells proliferate by mitosis, forming a line
known as Bungers band.
4. Schwann cells envelope and form myelin around new
regenerating axons.
Step one is initiated by the influx of calcium ions imme-
diately following an injury. Circulating macrophages and
those within the nerve are attracted to the injured area in
large numbers. After 2 or 3 days, they start to phagocytize
these particles and clear them away.
Schwann cells start to proliferate by mitosis, forming
a line known as Bungers band. This degenerative process
takes at least 1 to 2 weeks, and electrodiagnostic tests per-
formed during this period may not pick up any abnormality.
The known key players for Wallerian degeneration are
macrophages, Schwann cells, various neurotrophic factors,
the injured neuron, and end organs. They influence each
other in an intricate interplay, which is currently only par-
tially understood.
If an axon does not regenerate in a timely fashion, the
distal endoneurial tube may collapse, rendering regenera-
tion of the axon difficult, if not impossible.
This may be the main reason that muscles fail to be rein-
nervated following a delayed surgical nerve repair, rather
than due to degeneration of muscle fibers and motor end
plates, as previously thought.
Regeneration. During regeneration, Schwann cells and
neurons are interdependent. This relationship is mediated
by both neurotrophic factors and neurite outgrowth pro-
moting factors.
Neurotrophic factors facilitate bidirectional communi-
cation between neurons and Schwann cells. Neurite out-
growth promoting factors facilitate attachment of growing
axons to other axons and/or Schwann cells, and thus guide
nerve regeneration.
Neurotrophic factors are peptides, three major groups of
which have been identified: neurotrophins, neurokines, and
the transforming growth factor (TGF).
The details of axoplasmic transport, nerve conduction,
and neuromuscular transmission are beyond the scope of
this text. For more details of these complex processes,
refer to the Suggested Readingsparticularly the chap-
ter on Nerve Physiology and Repair in Hand Surgery
Update.
DIAGNOSIS
Peripheral nerves are most always mixed nerves (they
contain both motor and sensory nerve fibers), but the
injury may not always involve both components of the
nerve.
Nerve injuries may be partial, and may spare some vital
nerve pathways while injuring others.
The appraisal of peripheral nerve injuries involves the
examination of both sensory and motor components of
the nerve that is being evaluated.
Sensory evaluation is based on examination of a nerves
autonomous zone of innervation (the anatomic site least
likely to have any overlap with another nerve).
Motor evaluation is focused on the functional motor unit
that is the last or most terminal muscle to be innervated
by the nerve under evaluation, or sometimes by the ease
of examination of a muscle known to be innervated by
that nerve.
In an acute situation in the emergency room, the sen-
sory evaluation of an injured nerve is best determined by
light touch rather than by a pin or needle (especially in
children). Two-point discrimination is a valuable tool for
evaluation of sensation, but it may be difficult to achieve
in an acute injury in the emergency room.
Both sensory and motor evaluations are made before any
form of local anesthesia is given.
In most, if not all instances, the diagnosis of a peripheral
nerve injury may be made without inappropriate explo-
ration of the wound in an emergency room setting. The
diagnosis is made based on knowledge of the anatomy
involved and on a focused examination that utilizes that
knowledge.
When in doubt as to the extent or nature of injuries to
the nerve from lacerations, explore the wound under ap-
propriate anesthesia in an operating room.
The Hoffman-Tinel Sign
This is a clinical sign thats useful for determining the
level of nerve injury or recovery based on the presence of
injured or regenerating axons.
The test is performed by digital percussion of the nerve
distal to the site of nerve injury, with proximal advance-
ment of the percussion until the site of injury is reached
or the zone of regeneration is identified.
The percussion, performed gently with the examiners
fingertip, progresses along the course of the nerve until
the endpoint is identified by paresthesia localized either
to the zone of injury in cases of complete nerve interrup-
tion, or distally into the zone of cutaneous innervation.
Some clinicians prefer to percuss from proximal to distal
to the site of the lesion downward until the paresthesia
disappears.
The paresthesia, or pins and needles sensation, is
caused by the regenerating axons that are sensitive to per-
cussion, in part because of the loss of the myelin sheath
as part of Wallerian degeneration.
A positive response over a long segment of nerve may be
due to unequal growth rates of various sensory fibers.
The sign may be absent in the first 4 to 6 weeks after
nerve suture, and the onset and progress of the sign may
be inversely proportional to the severity of the injury.
Steady distal progression of the endpoint is a favorable
sign in nerve regeneration, but it must be recognized that
the sign is qualitative, not quantitative.
CONVENTIONAL TERMS USED
IN PERIPHERAL NERVE INJURIES
A nerve laceration is said to be high or low (proximal or
distal).
More than one nerve may be injured in a combined injury.
An example is a median and ulnar nerve laceration at the
wrist.
Combined injuries are often associated with injuries
to the vascular supply, which may complicate treat-
ment and recovery. Furthermore, in some unusual in-
stances, the injured nerves may be at different anatomic
levels.
SPECIFIC NERVE INJURIES
Figures 13-1 and 13-3 show the classic patterns of mo-
tor innervation and sensory distribution of the specific
nerves.
The three major nerves may be injured at any level, but
our discussion is confined to nerve injuries in the fore-
arm, wrist, or hand.
The loss of motor function and sensation will depend on
the level of injury.
Lesions may be represented by contusion, crush, or par-
tial or complete lacerations.
Our discussion will assume that the injuries are com-
plete, and that motor and sensory components are com-
pletely lacerated.
Median Nerve
High Lesions
Sensory Deficits
Sensory deficit in the flexor aspect of the thumb, index
finger, middle finger, and radial half of the ring finger.
The autonomous zone of deficit evaluation is the flexor
aspect of the terminal phalanx of the index finger (Figure
13-7).
Motor Deficits
Loss of pronation of the forearm, flexion at the in-
terphalangeal (IP) joint of the thumb, distal interpha-
langeal (DIP) joints of the index and middle fingers,
R
M
U
Figure 13-7 The three autonomous zones of sensation in the hand.
These are the areas least likely to have any sensory nerve overlap, and
thus may be considered reliable areas to test for sensation of the
respective nerves involved. M, median, flexor aspect of the terminal
phalanx of the index finger; R, radial, web space between the thumb
and index finger; U, ulnar, flexor aspect of the terminal phalanx of the
little finger.
Figure 13-8 Several week old median nerve laceration showing loss
of opposition of thumb, and atrophy of the thenar muscles.
proximal interphalangeal (PIP) joints of the four fingers,
and abduction-opposition of the thumb.
Dynamic Posture
Ulnar deviation of wrist with wrist flexion.
There is also an inability to perform pulp-to-pulp contact
between the thumb and the adjacent digits (opposition).
The thumb stays adducted in the palm during attempted
opposition (Figure 13-8).
Low Lesions
Sensory Deficit
Sensory deficit in the flexor aspect of the thumb, and in-
dex finger, middle finger, and ulnar half of the ring finger.
The autonomous zone of deficit is the flexor aspect of
terminal phalanx of the index finger (see Figure 13-7).
Motor Deficit
Loss of abduction-opposition of thumb.
Isolated injury of the motor branch of the median nerve
will result in loss of thumb abduction-opposition without
sensory deficit (Figure 13-8).
Ulnar Nerve
High Lesions
Sensory Deficit
Loss of sensation in the flexor/dorsal aspect of the lit-
tle finger, ulnar half of the ring finger, and flexor/dorsal
aspect of ulnar half of the hand.
The autonomous zone of deficit is the flexor aspect of the
terminal phalanx of the little finger (Figure 13-7).
Motor Deficit
Loss of flexion of the flexor digitorumprofundus (FDP) of
the ring and little fingers; loss of function in all intrinsic
muscles except for the lumbricals of the index and mid-
dle fingers; and loss of flexion in the flexor carpi ulnaris
(FCU).
Profound wasting of the intrinsic muscles is noted (Fig-
ure 13-9).
Dynamic Posture
Wrist flexion is associated with slight radial deviation.
Attempts to extend the ring and little fingers result in hy-
perextension at the metacarpophalangeal (MCP) joints,
Figure 13-9 High ulnar nerve laceration showing profound atrophy
of the intrinsic muscles of the hand.
and in flexion at the PIP joints. This is called Duchennes
sign (Figure 13-10).
Pressure or force over the proximal phalanges of these
digits by the examiner promotes extension of the PIP
joints; this is called Bouviers sign or maneuver (Figure
13-11).
A weak and unstable pinch, with hyperextension of the
thumb MCP joint (Jeannes sign) and with hyperflexion
of IP joint (Froments sign), are also classic signs of ulnar
nerve palsy (Figure 13-12).
There is an inability to cross the middle finger over the
index finger or to cross the index over the middle finger.
This indicates a loss of function in the second and first
dorsal interosseous muscles, respectively.
Figure 13-10 Note the claw deformity of the ring and little fingers
in this patient with a low ulnar nerve lesion. This deformity is
characterized by hyperextension of the ring and little finger MCP
joints and flexion of the PIP joints, and is called Duchennes sign. The
deformity is due to loss of the ulnar-nerve-innervated lumbricals and
the dorsal and palmar interosseous muscles that normally flex the
MCP joints and extend the PIP joints, and thus balance the effects
of the extrinsic flexors of the fingers.
Figure 13-11 Pressure or downward force over the proximal
phalanges of the clawed ring and little fingers (low ulnar nerve palsy)
reproduces the action of the intrinsic muscles and corrects most of
the claw deformity. This finding is called Bouviers maneuver.
The clawdeformity may not be as prominent in high ulnar
lesions compared to low lesions since both the flexor dig-
itorum superficialis (FDS) and the FDP extrinsic finger
flexors are intact in low lesions, and since they account
for a stronger flexion deformity in the ring and little fin-
gers.
Low Lesions
Sensory Deficit
Loss of sensation in the flexor/dorsal aspect of the lit-
tle finger, ulnar half of the ring finger, and flexor/dorsal
aspect of the ulnar half of the hand.
The autonomous zone of deficit is the flexor aspect of the
terminal phalanx of the little finger.
Figure 13-12 Froments and Jeannes signs as seen in ulnar nerve
palsy in the left hand. Note the compensatory hyperflexion of the IP
joint (Froments sign) and hyperextension of the MCP joint of the
thumb (Jeannes sign) during pinch. This posture is due to loss of the
stabilizing force of the adductor muscle on the MCP joint of the
thumb and compensatory hyperflexion of the thumb IP joint. Note
also the atrophy of the first dorsal interosseous muscle in the
thumb-index web space.
Figure 13-13 This patient demonstrates a high radial nerve palsy.
Note the loss of extension of the wrist, thumb, and fingers secondary
to a laceration of the radial nerve above the elbow.
Motor Deficit
Motor deficits are the same as in high ulnar nerve lesions,
except that the FDP function to ring and little fingers is
intact, and may accentuate the claw deformity.
Dynamic Posture
The dynamic posture is the same as in high ulnar nerve
lesions.
Radial Nerve
High Lesions
Sensory Deficit
There is loss of sensation over the dorsal radial aspect of
the hand and thumb.
The autonomous zone is in the web space between the
thumb and index finger.
Motor Deficit
There is loss of extension of the wrist, fingers, and thumb
mediated by the EDC, EDM, EIP, ECRB, ECRL, ECU,
EPL, EPB and APL.
Dynamic Posture
A high radial nerve lesion results in the loss of wrist,
finger, and thumb extension, and is commonly called a
wrist drop (Figure 13-13).
This represents a total and high radial nerve lesion before
its division into the motor and sensory components.
This division may occur in a region that is 2.5 cm above
or 3.0 cm below a line drawn in the coronal plane be-
tween the medial and lateral epicondyle of the humerus
(Hueters line).
Low Radial Nerve Palsy
Sensory Deficit
The high and low lesion convention has worked well for
the median and ulnar nerves, but works less well for the
radial nerve because the motor and sensory components
are widely separated in the proximal forearm.
The sensory component of the radial nerve may be injured
in a high or low anatomic position. This results in the
same clinical manifestations that are noted for the high
lesion.
Motor Deficit
The motor deficit will vary according to the level of injury
and the sequence or order of innervation of the respective
muscles.
The sequence of innervation order is quite variable, but
Figure 13-1 shows a common one.
A common sequence is the innervation of the ECRL,
supinator, and ECRB, in that order.
The EDC is most always innervated before the EIP,
APL, and EPL.
The EDM is usually innervated before the EIP, and
the APL before the EPL.
PRINCIPLES OF NERVE REPAIR
Primary, Delayed Primary, and Secondary Repair
Primary repair is defined as repair within hours of injury.
Delayed primary repair is repair performed 5 to 7 days
after injury.
Arepair performed more than 1 week after injury is called
a secondary repair.
Primary nerve repair has emerged as the treatment of
choice when conditions permit (Box 13-1). If these con-
ditions cannot be met, it is better to delay repair.
Secondary repair under favorable conditions is usually
associated with improved outcomes compared to nerve
repair done under less than ideal circumstances.
In cases where timely repair cannot be performed, the
nerve ends should be sutured together to prevent retrac-
tion. This will facilitate a future definitive repair.
Techniques of Nerve Suture
Epineurial Suture
Magnification improves the results of nerve suture and
the operating microscope is a useful tool to facilitate
nerve suture.
BOX 13-1 CONDITIONS THAT FAVOR PRIMARY
REPAIR
Sharp transections without any element of crush injury
Absence of signicant tension at the repair site when the
ends are joined
Minimal wound contamination; a suitable bed of viable
muscle, fat, or tenosynovium
Absence of other injuries that preclude timely restoration
of circulation, skeletal stability, or soft tissue cover
A suitable operating room and equipment, including
magnication
A patient in suitable metabolic and emotional condition to
undergo surgery
An intoxicated patient or a patient who has just
attempted suicide is not an ideal candidate for primary
repair.
Placement of the proximal and distal nerve stumps on
suitable background material in a bloodless field aids in
visualization.
Correct rotational orientation is obtained by matching
the fascicular bundles with respect to size and position,
and matching the orientation of the vascular landmarks.
The cut ends are trimmed perpendicular to their long axis
to remove any damaged tissues and to form a uniform
surface for contact between the ends.
A smooth and uniform transection prior to repair may be
achieved by devices that hold or stabilize the nerve during
the transection.
A single suture is placed to join the epineurial edges fur-
thest from the surgeon.
A second suture is then placed at 180 degrees from the
first to form equal halves.
Done properly, this will result in matching opposing
surfaces, without bulging, retraction, or twisting of the
individual fascicles.
An 8-0 or 9-0 suture is used for these two critical stitches
in a major peripheral nerve, and the tails are left long to
permit rotation of the nerve.
The inability to bring the nerves ends together with 8-0
sutures indicates excessive tension, and further mobiliza-
tion or grafting should be considered.
Additional interrupted sutures of 10-0 are used to bisect
the 180-degree arc formed by the first two sutures.
Additional sutures are added in a similar fashion to com-
plete the repair but a watertight repair is neither nec-
essary nor desired.
Group Fascicular Suture
Group fascicular suture requires greater magnification
and is technically more challenging than epineurial su-
ture.
This suture technique is less tolerant of repair under ten-
sion due to the less substantial nature of the internal
epineurium and perineurium.
The proximal and distal stump surfaces are inspected to
identify fascicular groups. Fascicular groups tend to sep-
arate from other fascicular groups, and with gentle trac-
tion and dissection with curved microscissors, fascicular
groups may be identified.
Matching fascicular groups are trimmed at right angles
to their longitudinal axis and separated for a distance of
3 to 4 mm in the proximal and distal stumps.
A retention suture placed in the posterior epineurium is
useful to control tension and permit rotation of the nerve
to aid in placement of sutures in the various fascicular
groups.
The fascicular groups are joined fromback to front by su-
tures placed in the internal epineurium or perineurium.
Only the minimum number of sutures necessary to pro-
duce uniformcoaptation of the fascicular group is placed.
Individual Fascicular Suture
The separation of individual fascicles is technically chal-
lenging and is less commonly used for nerve suture.
Large fascicles may accept two 10-0 sutures, but a single
suture may be appropriate for smaller fascicles.
Epineurial
Group fascicular
Individual fascicular
Figure 13-14 The three techniques of peripheral nerve repair.
This technique may be most useful in partial nerve lacer-
ations where only a portion of a group fascicle has been
lacerated.
Figure 13-14 demonstrates the three techniques of pe-
ripheral nerve repair.
Fascicle-Matching Techniques
Accurate matching of sensory and motor components of
a severed nerve is an important factor in the outcome of
nerve repair.
Techniques that aid in matching include using intraneu-
ral mapping, intraoperative nerve stimulation, and histo-
chemical identification of the motor and sensory compo-
nents.
The later two techniques have time constraints and tech-
nical aspects in their performance that limits their use.
They may be most useful in secondary nerve reconstruc-
tion.
The details of these techniques are beyond the scope of this
chapter.
Nerve Grafting
There are many instances in nerve repair where loss of
nerve substance does not permit a tension free rejoining
of the injured nerve.
A
B
D C
Figure 13-15 A. This 22-year-old man sustained a deep laceration to the inner aspect of his left arm.
B, C. This resulted in sensory deficits in the median and ulnar distribution and a median and ulnar claw
hand (a combined high median and ulnar palsy). D. He was treated with fascicular bundle nerve grafts
(sural nerves) to the median and ulnar nerves, with recovery of wrist and finger flexion and protective
sensation in the hand.
This is most oftenseeninsecondary nerve repair where
excision of the scarred and damaged nerve ends results
ina significant gap that mitigates against a tension-free
union.
Earlier efforts at nerve graft included interposition of
trunk grafts that matched the size of the injured nerve; ca-
ble grafts composed of smaller nerves, bundled together,
to fill the gap; and a pedicle nerve graft in which one
major nerve was sacrificed and used to replace what was
considered to be a more important nerve.
The current technique to restore continuity in a nerve
with a significant gap is called group fascicular nerve
grafting.
The technique consists of removing all interposed scar
tissue between the two ends of the involved nerve, and in-
terposing autogenous nerve grafts (usually the sural nerve
or nerves) to matching fascicles in the proximal and distal
stumps.
Matching of fascicles is most easily achieved in gaps of 4
to 6 cm, although larger gaps may be filled and suitable
results obtained (Figure 13-15).
The lateral antebrachial cutaneous nerve in the forearm
may be used to fill gaps in digital nerves.
A discussion of the role of free vascularized nerve grafts,
nerve conduits, and neurotropism is beyond the scope of
this chapter.
Prognosis and Timing of Nerve Repairs
In general terms, the results following nerve repair are
best within the first 3 months after injurybut reinner-
vation may be expected within 1 year following injury.
No reinnervation can be expected after 3 years.
Tendon Transfers in Nerve Injury
In some instances, nerve repair is not possiblebut use-
ful upper extremity function may be restored by tendon
transfers.
In some instances following nerve repair, a useful level
of sensory recovery (protective sensation or better) may
be anticipated without motor recovery. It is in these cases
that tendon transfer may be most useful.
Tendon transfers work best in supple joints without fixed
contracture and when suitable soft tissue beds are avail-
able for passage of the tendons.
A
B
Figure 13-16 A. Wrist scar, loss of opposition, and thenar eminence
atrophy can be seen in this 65-year-old male with complete sensory
loss in the median nerve distribution. B. Epineurial repair of the
median nerve was performed along with a FDS opponensplasty.
A
B C
Figure 13-17 Intermediate level radial nerve palsy. A. Preoperative appearance of an injury to the
posterior interosseous branch of the radial nerve (PIN) with loss of thumb and finger extension. B, C.
Function was restored by transfer of the PL to the rerouted EPL and transfer of the FCR to the EDC
tendons.
A
C
E
B
D
Figure 13-18 A. Clinical appearance of an ulnar claw hand. B. Secondary epineurial repair of the
ulnar nerve was performed. C, D. The EIP tendon was split into two tails, passed through the
interosseous spaces beneath the axis of rotation of the MCP joints, and sutured to the radial lateral
bands of the ring and little fingers. E. This transfer replaced the function of the interosseous muscles,
rebalanced the extrinsic flexors and extensors, and corrected the claw deformity.
The simple treatment algorithm is: (1) what function is
lost, and (2) what expendable muscle/tendon units are
available for transfer.
Selection of an appropriate muscle tendon unit is based
on its cross-sectional area (strength) and excursion (fiber
length), in order to mimic as much as possible the muscle
tendon/unit being replaced.
Mechanical factors include orientation of the transfer for
a straight-line pull, one transfer to performone function,
appropriate tension, placing the transfer in the proper
relationship to the joint axis, and when needed, a strong
and suitably placed pulley or fulcrum.
Examples
These transfers are only examples of the many tendon trans-
fers used to restore function in the upper extremity. Refer
to the Suggested Reading list for a more comprehensive dis-
cussion of the topic.
Low Median Nerve Palsy. Figure 13-16 demonstrates
the preoperative appearance of a 65-year-old male with a
one-year-old laceration of the flexor aspect of the left wrist.
There was loss of sensation in the median nerve distribution
and loss of opposition of the thumb. Treatment included ex-
cision of the median nerve neuroma, epineurial repair, and
opponensplasty using the FDS of the ring finger to the ab-
ductor position of the thumb. Opposition was restored along
with protective sensation in the median nerve distribution.
Intermediate Level Radial Nerve Palsy. Figure 13-17
demonstrates the preoperative appearance of an injury to
the posterior interosseous branch of the radial nerve (PIN),
with loss of thumb and finger extension. The level of injury
was distal to the innervation of the wrist extensors, so wrist
extension was maintained. Restoration of thumb and finger
extension was achieved by transfer of the PL to the rerouted
EPL and transfer of the FCR to the EDC tendons.
Low Ulnar Nerve Palsy. Figure 13-18 demonstrates a
typical claw deformity of the ulnar nerve. It resulted from
a laceration of the ulnar nerve at the distal forearm. Treat-
ment was by secondary ulnar nerve repair (epineurial) and
transfer of a two-tailed tendon graft using the EIP sutured
to the radial side of the lateral bands in the ring- and little-
finger proximal phalanges.
SUGGESTED READING
Brushart TM. Nerve repair and grafting. In: Green DP, Hotchkiss RN,
Pederson WC, eds. Greens operative hand surgery. 4th Ed. New
York: Churchill Livingstone, 1999:13811403.
Buck-Gramcko D, Lubahn JD. The Hoffmann-Tinel sign. J Hand Surg
1993;18B:800805.
Chiu DTW, Choi M, Dellon AL. Nerve physiology and repair. In:
Trumble TE, ed. Hand surgery update-3, hand, elbow and shoul-
der. Rosemont, IL: American Society for Surgery of the Hand,
2003:287297.
Jabaley ME. Internal anatomy of the peripheral nerve. In: Hunter JM,
Schneider LH, Mackin EJ, eds. Tendon and nerve surgery in the
hand. St. Louis: Mosby-Year Book, 1996:1925.
Millesi H, Meissl G, Berger A. Further experience with intrafascicular
grafting of the median, ulnar, and radial nerves. J Bone Joint Surg
1976;58A:209218.
Omer G. Combined nerve palsies. In: Green DP, Hotchkiss RN, Ped-
erson WC, eds. Greens operative hand surgery. 4th Ed. New York:
Churchill Livingstone, 1999:15421555.
Seddon HJ. Surgical disorders of the peripheral nerves. Baltimore:
Williams and Wilkins, 1972.
Sheppard JE. Tendon transfers. In: Trumble TE, ed. Hand surgery
update-3, hand, elbow and shoulder. Rosemont, IL: American
Smith KL. Anatomy of the peripheral nerve. In: Hunter JM, Schneider
LH, Mackin EJ, eds. Tendon and nerve surgery in the hand. St.
Louis: Mosby-Year Books, 1996:1118.
Sunderland S. Nerve and nerve injuries. 2nd Ed. New York: Churchill
Livingstone, 1978.
Williams PL. Grays anatomy, 38th Ed. New York: Churchill Living-
stone, 1995, Chapter 8, The nervous system.
14
AMPUTATIONS
GENERAL PRINCIPLES
The management of thumb or finger amputation is a com-
plex topic with many variable methods of treatment. Digital
amputations may involve the terminal aspect of the digit or
a substantial portion of the ray, and general principles of
management will be presented in this chapter. This chapter
will also include a section on replantation.
The goals of treatment include restoration of adequate
sensibility without hypersensitivity, good function and ap-
pearance, and a short period of recovery.
The treatment of each case is based on the patients age,
occupation, functional needs, the digit injured, and the sur-
geons experience with various techniques.
Treatment methods range from healing by secondary in-
tention with dressing changes, to primary closure (without
tension) with local tissue, to split-thickness or full-thickness
skin grafts, to various forms of local or distant flaps.
PERTINENT ANATOMY
Terminal Phalanx
Most amputations in the hand involve the terminal pha-
lanx, and this chapter will focus on that level of amputation.
The anatomy of the terminal phalanx represents a complex
functional unit that consists of bone and soft tissue in the
form of thick skin that covers a fat pad with fibrous tis-
sue elements that separate the fat into compartments. This
complex structure includes nerves and specialized end or-
gans that provide sensibility to the digital tip in the form of
pressure, pain, temperature, and identification of form and
texture.
It is the hand, through the digital tips, that obtains infor-
mation from the environment, which it passes to the brain
and ultimately executes a given function in conjunction with
the remaining components of the upper extremity. The hand
is under central control, mediated by specialized end organs
and nerve endings in and beneath the skin, as well as by joint
receptors. Although the hand also may be under visual con-
trol, this modality is a less effective control method com-
pared to the modalities of sensibility and proprioception:
compare the effective use of the hand by a blind person to
the relatively poor hand function in a sighted person who
has lost sensibility due to Hansens disease. Thus, it should
be readily apparent that the tips of our digits are critically
important to hand function. The contour of the terminal
phalanx with its nail is multiplanar and its shape and spe-
cialized end organs can never be restored surgically in spite
of our best efforts at reconstruction.
Nail Unit
The nail unit consists of the nail plate, the nail fold, the
nail bed (sterile and germinal matrix), a vascular supply,
and nerves. The nail unit assists in digital pad sensibility by
providing support and counter pressure for the digital pad.
Grasping and pinching are aided by the nail unit, which
provides dorsal and peripheral anchoring, and provides sta-
bility to the palmar pad. The functional spectrum may in-
clude everything from scratching an itch to picking up and
manipulating small objects. The anatomy and terminology
of the nail unit is depicted in Figure 14-1.
Nail Plate
The hard, often shiny, fingernail or thumbnail is called
the nail plate. The nail plate is homologous to the stra-
tum corneum of the epidermis, and consists of compacted,
anucleate, keratin-filled squames with dorsal, intermediate,
and palmar layers. It is slightly convex in the longitudinal
axis and more convex in the transverse axis. The lunula is a
white opacity immediately distal to the central aspect of the
proximal nail fold, and is said to be due to comparatively
poor vascularization of the germinal matrix.
Nail Fold
Proximally, the nail plate extends under the semilunar nail
fold, which is lined with dorsal and palmar epidermis. The
stratum corneum layer of the dorsal layer of epidermis ex-
tends distally over the nail plate to form the cuticle or epo-
nychium.
226
Chapter 14 / Amputations 227
Hyponychium
Lateral nail fold
Nail plate
Sterile matrix
of nail bed
Lunula
Eponychium
Proximal
nail fold
Germinal
matrix of
nail bed
Stratum corneum
Insertion,
extensor
tendon
Insertion,
flexor tendon
Figure 14-1 The anatomy and terminology of the
nail unit and terminal phalanx.
Nail Bed
The nail plate rests on the nail bed (sterile and germinal
matrix), which is defined as all the soft tissue immediately
beneath the nail plate that participates in nail generation
and migration. The nail bed is a specialized form of epithe-
lium, with a proximal zone of germinal matrix and a dis-
tal zone of sterile matrix. The germinal matrix is proximal,
and the distal margin of the lunula is approximately at the
junction between the germinal and sterile matrix. A sagittal
section of the distal phalanx reveals a wedge-shaped col-
lection of germinal cells within the proximal portion of the
nail bed. Dorsal and palmar components of the matrix are
noted. The palmar matrix cells are continuous distally with
the nail bed. The nail bed is grooved and ridged longitudi-
nally, which matches a similar pattern on the undersurface
of the nail plate, and which may help stabilize the nail for
functional demands. Beneath the epitheliumof the nail bed
is a dermis layer that is anchored to the underlying perios-
teum of the distal phalanx by fibrous tissue. Keratinized
cells are extruded from the dorsal and palmar germinal ma-
trix cells to produce the nail plate, with the major production
coming from the palmar cells. The area of epidermis under
the distal edge of the nail plate is called the hyponychium.
The stratum corneum layer is undulant and constantly be-
ing shed. The hyponychium provides an important barrier
against entry of bacteria.
Clinical Signicance
A smooth nail bed is essential for the regrowth of a normal
nail plate. In nail-bed injuries, primary healing cannot occur
if the bed is not accurately reapproximated. If the scar is in
the dorsal matrix, a dull streak may appear in the nail plate;
if the scar is in the intermediate portion of the germinal
matrix, a split or absent nail may occur; if the scar is in the
palmar nail or sterile matrix, a split or nonadherence of the
nail beyond the scar may occur.
Blood Supply and Drainage
The arterial blood supply to the nail bed comes from two
dorsal branches from the common palmar digital artery;
the proximal vessel is a dorsal branch to the nail fold, and
the second courses along the lateral nail plate margin and
sends branches to the nail bed (Figure 14-2). These ves-
sels anastomose dorsally with their counterparts to form
arcades.
Branches from these vessels and the arcades form si-
nuses surrounded by muscle fibers, and help to regulate the
blood pressure and blood supply to the extremities. These
networks have been identified as papillary, reticular, and
subdermal, and correspond to the general architecture of
the vessels of the skin. The dermis of the nail bed is well vas-
cularized, and includes large arteriovenous shunts (glom-
era). There is reduced vascular density in the region of the
germinal matrix, in contrast to an increased vascular density
in the sterile matrix. The comparatively less-vascularized
germinal matrix demonstrates a well-developed subdermal
network located near a zone of loose connective tissue that
is poorly vascularized near the proximal part of the distal
phalanx. This zone may be a sliding apparatus between the
nail and the distal attachment of the extensor tendon. A
coalescence of veins in the skin, proximal to the nail fold,
that course proximally in a random fashion over the dorsum
of the digit, provides venous drainage. These veins are of
sufficient size for microvascular anastomosis.
Nerve Supply
Branches from the paired digital nerves innervate the nail
unit. The most common pattern (70%) is represented by
a branch that passes beneath the nail plate and into the
nail bed at approximately the level of the lunula and a sec-
ond branch that passes distally to end at the hyponychial
area. There are numerous sensory nerve endings, including
Merkel discs and Meissner corpuscles.
1
1
2
2
3
3
Digital artery
Papillary network
Reticular network
Subdermal network
Figure 14-2 Arterial supply of the distal phalanx. 1, Network of nail wall; 2, arcade of germinal matrix;
3, arcade of sterile matrix. See text for details.
Nail Plate Growth
Growth rate is determined by the turnover rate of the ger-
minal matrix, which varies with age, digit (the long fin-
ger nail grows faster than the small fingernail), environ-
mental temperature, season, time of day, and nutritional
status. Rate of growth in the long finger is approximately
0.1 mm/day. As the matrix cells enlarge, they grow distally
due to the confinement of the nail fold, and they are flat-
tened by the pressure of newly forming cells beneath them.
This pressure and confinement result in a nail plate that is
flat and grows distally. The dorsal layer of the germinal ma-
trix produces nail cells that are relatively shiny, and if these
cells are removed or damaged, the nail surface will appear
dull.
Relationship of the Germinal Matrix to the
Extensor Tendon Insertion
Based on microscopic dissection, the distance from the ter-
minal aspect of insertion of the extensor tendon and the
proximal edge of the germinal matrix was found to average
1.2 mm, with a range of 0.9 to 1.8 mm.
The clinical significance of this fact is that when the ex-
tensor tendon insertion is visualized during operative pro-
cedures on the dorsum of the distal phalanx, care should be
taken to avoid damage to the germinal matrix. Conversely,
when the germinal matrix is being removed for total ablation
of a nail, dissection does not need to be carried proximal to
the most distal fibers of the extensor tendon.
TREATMENT
Digital Tip Amputations With or Without
Bone Involvement
These injuries may occur in a variety of planes in rela-
tionship to the long axis of the digit. The osseous phalanx
may or may not be exposed.
The following discussion and case presentations illus-
trate various techniques that may be used based on the
nature of the injury.
The reader should understand that there is no ideal treat-
ment for fingertip amputations, and that differences of
opinion exist among the surgeons who treat these in-
juries.
Many of the following procedures are technically chal-
lenging, and most, if not all, may have cosmetic and func-
tional issues related to the procedure.
The choice of a given technique may relate to the sur-
geons experience and preference.
The procedure should be matched to each patient and his
or her cosmetic and functional needs.
Fingertip avulsions in children may be treated by sterile
dressing changes as the primary form of treatment.
Most, if not all, soft tissue avulsions of the digit tips in
children will rapidly regrow the lost skin. This may be the
only treatment required.
A B
C
Figure 14-3 A. Significant loss of the terminal pulp
of the thumb as a result of a power saw injury to the
non-dominant left thumb. B, C. Treatment was via
primary closure, by folding over the remaining local
tissues. This provided for excellent tissue coverage
with good sensibility and circulation. Rapid healing
occurred in this unemployed elderly male.
In some instances the avulsed part may be reapplied as
a biologic dressing with the understanding that it may or
may not survive.
Significant bone protrusion, if evident, may need to be
trimmed back.
Secondary reconstruction may be used as necessary.
Surgical Treatment
Primary Closure by Local Tissue
Suitable local tissues, if present, may provide very satis-
factory tissue for primary coverage of amputation defects.
The advantage of this method includes rapid healing with
minimal and acceptable shortening, and coverage of the
defect with substantial and sensate skin.
This technique is illustrated in Figure 14-3 and Figure
14-4.
Primary Closure With Shortening of the Bone. The
shortening of the osseous phalanx to obtain satisfactory soft
tissue coverage is illustrated in Figure 14-5.
After shortening the bone and smoothing its edges
with a rasp to round its contour, dorsal and palmar
flaps are fashioned and then closed in the coronal
plane.
The key to closure by this method is to shorten the bone
sufficiently to achieve closure of the skin and soft tissues
without tension.
Prior to closure, the digital nerves are identified and gen-
tly retracted distally and cut with a scalpel so that they
retract proximally into the soft tissues.
Closure by Skin Graft
Split-thickness skin graft may be used to promote rapid
healing of fingertip amputations.
The use of a split-thickness skin graft removed from the
forearm with a sterile razor blade and sutured into place
over the defect is shown in Figure 14-6. Rapid healing
occurred.
It might be argued that sterile dressings (without a skin
graft) might have achieved the same end result, but it
may have taken a little longer.
Caveat: Figure 14-7 illustrates the result of a skin graft re-
moved from the forearm of an African American and su-
tured to a skin loss defect at the tip of his index finger.
This resulted in a poor color match, and should be avoided.
Figure 14-7B shows a suitable location for removal of a full-
thickness skin graft with a suitable color match. The longi-
tudinal axis of the graft is parallel and in the proximal pal-
mar crease. The resultant defect may be closed after limited
A B
C
Figure 14-4 A, B. A high-speed router blade removed the distal and dorsal
aspect of this self-employed carpenters left middle finger. C. Rapid healing
with good tissue coverage was achieved by folding over the remaining
portions of the terminal phalanx.
excision of the palmar fascia in the base of the wound and
minimal undermining of the edges. Another suitable source
of skin graft is fromthe instep region of the plantar surface
of the foot.
Figure 14-8 shows a young African American female with
skin loss at the tip of her left thumb, which was treated by
application of a full-thickness skin graft from the instep
on the plantar surface of her foot. The skin graft and donor
site healed with minimal scarring, and a good color match
was achieved.
Closure by Local Flaps. Local flaps include the VY-
plasty, the Kutler, and the Moberg advancement flaps.
VY-Plasty
This flap is used for closing transversely oriented ampu-
tations, and is an alternative to the fishmouth closure.
Figure 14-9 shows a patient with a three-finger ampu-
tation who was treated with a VY-plasty in the ring and
index fingers and with a fishmouth closure in the middle
finger.
A V-shaped flap is developed as shown in Figure 14-9B,
and is mobilized and advanced distally to forma Y-shaped
configuration.
Mobilization of the V is carefully performed to avoid loss
of its blood supply.
Bone shortening is used as required.
Figure 14-9C demonstrates the end result of the VY-
plasty in the index and ring fingers, and the end result of
the fishmouth closure in the middle finger.
The VY technique is depicted in Figure 14-10.
The Kutler Bilateral VY Advancement Flaps
This bilateral flap is also a VY advancement flap that is
formed on both sides of the digit.
The flaps are advanced to meet in the midline of the
amputation.
Figure 14-11 illustrates the technique, and Figure 14-12
shows a clinical example.
The Volar Advancement Flap
This flap is also known as the Moberg flap.
It is a palmar neurovascular advancement flap that has
the potential for excellent sensibility for, and substantial
coverage of, an amputated digit.
D
A B
C
Figure 14-5 A, B. Preoperative and injury views of a crush injury to the terminal phalanx of the right
middle finger. C, D. Revision was accomplished by shortening the osseous phalanx and closing the
wound using the fishmouth technique, which consists of the formation of dorsal and palmar flaps that
are sutured together in the midline.
It is ideally used in the thumb, and may not be successful
in the fingers for a variety of reasons, including flexion
contracture and occasional loss of vascularity in the flap.
Figure 14-13 shows the excellent coverage that can be
obtained with this advancement flap.
The details of the technique are depicted in Figure 14-14.
Closure by Distant Pedicle Flaps
Thenar Flap
This distant pedicle flap is useful for covering the distal
aspect of the index and middle fingers, and, like other
distant pedicle flaps, is intended to maintain the length
of the digit.
This flap is best used in those patients who do not have
any proclivity for joint stiffness. Some have indicated that
it is best used in younger patients who do not have as
significant a potential for stiffness as older patients.
Figure 14-15 shows a clinical sequence of a male Pacific
Islander with amputations of the tips of the middle and ring
fingers. Significant loss of pulp was noted in the middle fin-
ger. A thenar flap was used to restore the pad on the middle
finger, and a full-thickness skin graft from the hypothenar
eminence was used to cover the amputation at the tip of the
ring finger. This graft site was selected as a ready source of
full-thickness skin that provided durable coverage for the
palmar side of the finger. It also provided an excellent color
match for this dark-skinned patient. The end result is noted
inFigure 14-15D. Agood color matchis noted inbothdigits,
the flap and full-thickness donor sites are barely noticeable,
and good hand function was recovered. Figure 14-16 is an
artists depiction of the technique.
Cross-Finger Flap
The cross-finger flap is another technique to cover the
tip of an amputated finger; as with other flaps, it is de-
signed to maintain finger length and cover the defect with
durable and sensate skin.
It is very useful for restoring the loss of the pulp on the
flexor aspect of the finger.
Figure 14-17 depicts the sequence of a cross-finger flap
used to restore an avulsion of the pulp lost on the flexor
surface of the terminal phalanx on the left little finger.
B A
C D
Figure 14-6 A. The clinical appearance of a skin defect on the ulnar side of the terminal phalanx of the
left ring finger. B. A sterile razor blade is used to remove a split-thickness skin graft from the forearm.
C. The skin graft is sutured into place, and the tails of the suture are left long enough to tie over a cotton
stent (not shown) in order to keep the graft firmly applied to its bed. D. A complete take of the graft was
noted at 10 days.
A B
Figure 14-7 A. This African American male had a split-thickness skin graft removed from his forearm
and applied to a defect at the tip of his left index finger. Note the poor color match. B. Area of a more
suitable donor site.
A B
C
Figure 14-8 A. This young African American female had a skin
defect on the tip of her left thumb. B. A full-thickness skin graft
was removed from the instep region of the plantar surface of her
foot and closed primarily. C. The graft was sutured in place over
the defect beneath a stent, with excellent healing and color match.
The pedicle flap is raised from the dorsum of the adja-
cent ring finger down to the paratenon of the extensor
mechanism, and it includes the skin and subcutaneous
tissue.
The flap is hinged on the ulnar side of the ring finger,
and then sutured to the defect on the little finger.
The defect on the ring finger is covered with a moderately
thick, split-thickness skin graft.
The flap is divided in 12 to 14 days, and the free margin
further inset into the defect.
Figure 14-18 is an artists depiction of the cross finger
pedicle flap.
Nail Bed Injuries
Subungual Hematoma
Subungual hematoma may occur following crushing-type
injuries due to the abundant blood supply of the nail bed.
It may cause severe pain in the digit. It is discussed here
because of its association with fingertip injuries.
Drainage of the hematoma with the incandescent end of
a paper clip is a painless way to relieve this condition.
A radiograph to rule out an associated fracture is useful.
Some have argued that draining a subungual hematoma
in the presence of a fracture may result in an open frac-
ture, but if a fracture is present by radiograph, sterile
dressings may be used until the drainage site closes.
Lacerations and Avulsions
Nail-bed injuries may occur in conjunction with digit am-
putations.
They may occur as simple or complex lacerations and
avulsions.
The nail plate may be present in whole or part, and should
not be discarded. Instead, it should be used as a stent
following the repair of the nail bed.
Secondary or delayed reconstruction of these injuries is
unpredictable, and the best results are achieved by treat-
ment at the time of the initial injury.
Lacerations
Some surgeons advocate removal of an attached or par-
tially intact nail plate to facilitate the repair of the un-
derlying nail bed.
In most cases, however, it may be left in place, where
it will act as a biologic stent to recontour and promote
the healing of the underlying laceration. Often, the nail is
partially avulsed and elevated fromits bed. In those cases,
the nail may be removed and saved for later reapplication
as a biologic stent.
Simple lacerations of the nail bed are repaired under dig-
ital anesthesia and a suitable tourniquet.
Loupe magnification is useful, and the laceration is su-
tured with 6-0 or 7-0 chromic or plain gut.
Following repair, the nail plate is replaced over the re-
paired nail bed and under the proximal nail fold.
A
B
C
Figure 14-9 A. Triple amputation in a patients right hand. B. A VY-plasty
has been performed on the index and ring fingers, and a fish-mouth closure
has been performed on the middle finger. C. Note the final result in the
three fingers.
1
2
3
Figure 14-10 Artists depiction of
the VY-plasty technique. The
technique is most useful in
transverse amputations. Bone
shortening is performed as required.
1
2
3
Figure 14-11 Artists depiction of the
Kutler bilateral VY-plasty technique for
fingertip amputations.
This will act as a biologic stent, and will help to contour
the nail bed.
Replacement of the nail plate will prevent scar formation
between the proximal nail fold and the bed.
If the nail is not available, a thin piece of sterile silicone
sheet may be cut to duplicate its shape and may be in-
serted as a replacement.
The replaced nail will be pushed out as the new nail
grows.
Local wound care and dressings are used to pro-
tect the nail bed until the new nail plate covers the
matrix.
Avulsions
Small avulsion defects may be repaired by undermining
and advancing the surrounding nail bed to close the de-
fect.
If a portion of the nail bed remains attached to the under-
surface of the nail, it may be reapplied to fill the defect
as a free graft.
If insufficient tissue is available, the great toe can be used
with minimal morbidity. The toenail is removed, and a
split graft is removed from the nail bed.
A split graft satisfies the needs of the injured nail bed,
and allows healing of the great toe nail bed without side
effects.
The graft is sutured into the defect with fine absorbable
sutures as previously described.
Late Reconstruction
Nail deformities may occur in spite of appropriate treat-
ment, and may be related more to the nature of the orig-
inal injury than the treatment.
Common deformities seen are hook nails, split nails and
non-adherent nails.
Hook Nail
Loss of bony support to the distal aspect of the nail bed
and plate often results in hooking, in which the distal
aspect of the nail grows towards the palm.
A B
Figure 14-12 A clinical example of the Kutler bilateral VY-plasty.
A B
E
C D
Figure 14-13 The Moberg advancement flap for thumb tip amputations. A. Note the transverse
amputation through the distal aspect of the left thumb. B. A skin hook is used to gently advance the flap
that has been incised bilaterally. The flap includes the neurovascular bundles, and is released down to
the level of the flexor sheath. C. The distal margin of the flap has been advanced to meet the distal edge
of the thumbnail, and has been sutured in place with slight flexion of the interphalangeal (IP) joint to
facilitate a tension-free closure. D, E. Note the excellent pad over the tip of the thumb.
Flexor tendon
1
2
3
Figure 14-14 Artists depiction of the Moberg
advancement flap. The bilateral midaxial incision is
carried to the region of the osseous structures and
flexor sheath, and the neurovascular bundle is
protected in the flap.
This can be corrected by removing the nail and trimming
the matrix back to the level of the bony support.
The defect is then closed with an advancement flap with-
out placing any tension on the matrix.
Split and Nonadherent Nail
Split nails result from a longitudinal scar in the matrix,
with an absence of nail-producing cells.
If the scar is in the dorsal matrix, only a dull streak may
appear in the nail plate. If the scar is in the intermediate
portion of the germinal matrix, a split or absent nail may
occur. If the scar is in the palmar nail or sterile matrix,
a split or non-adherence of the nail beyond the scar may
occur.
Nonadherent nails may result from scarring of the ger-
minal matrix, or from a scar in the sterile matrix.
Treatment involves excising the scar and replacing it with
nail matrix.
Typically, if the defect is large enough to cause a split
nail, it cannot be closed primarily and will need a graft.
If the defect is in the sterile matrix, it can be treated
with a split-thickness graft.
The germinal matrix requires a full-thickness graft,
which can be taken from the second toe. This will
result in a cosmetic defect of a lesser degree than by
using the great toe, and still provide adequate matrix
for nail regeneration.
A nonadherent nail typically results from scar in the ster-
ile matrix.
This is similarly treated with excision of the scar and
placement of a split-thickness matrix graft.
In severely deformed or bothersome split or loose nails,
another option is to remove the entire nail unit and re-
place it with a split-thickness skin graft.
REPLANTATION
Indications
Indications for replantation have been refined since the first
successful limb reattachment was performed in 1962. The
current indications for digital replantation are patients with
multiple digit amputations, thumb amputations, pediatric
patients with amputations, and single digit amputations dis-
tal to the insertion of the flexor digitorum superficialis ten-
don. Multilevel amputations offer a greater technical chal-
lenge, but may not represent an absolute contraindication
to replantation.
Factors such as associated injuries, age, and associated
systemic illness all play a role in the decision-making pro-
cess. Avulsion injuries, and those with massive contamina-
tion, may preclude a successful result.
Timing
Muscle tissue is susceptible to irreversible changes after
6 hours of ischemia at room temperature. Digits do not
contain muscle, and thus their warmischemia time is much
longer. Successful replantations in digits have occurred af-
ter 33 hours of warm ischemia time, and after 94 hours
of cold ischemia. These recorded times are at the extreme
end of the spectrum of allowable elapsed times prior to re-
plantation; do not take them as an acceptable norm. Thus,
transportation of the patient and the amputated part should
be as rapid as possible to a center with a replantation capa-
bility. When the part has been properly cooled, successful
replantation has been achieved in patients after 24 to 30
hours.
D
A B
C
Figure 14-15 The thenar flap and color-matched, full-thickness skin graft. A. Note the significant loss
of pulp in the middle finger, and the loss of skin over the tip of the ring finger. B. A full-thickness skin
graft was harvested from the hypothenar eminence, the defect closed, and the graft sutured to the ring
finger; note the generous length of the thenar flap. C. The thenar flap has been elevated and attached to
the tip of the middle finger. D. Note the excellent functional and cosmetic result.
Palmar fascia
1 2
the technique for the thenar flap.
A B
C D
E F
Figure 14-17 The cross-finger pedicle flap.
Steps in Replantation
The amputated part must be located and sent with the
patient to the most appropriate emergency room. Placing
the amputated part in a small plastic bag and laying it on
ice is advisable. The part should not be frozen (no dry ice)
or otherwise manipulated.
Ideally, after the patient arrives at the emergency room,
an on-call replantation team would divide into two treat-
ment units.
One team takes the amputated part to the operating
room where it is cleaned as needed and kept cool
and moist. This team debrides the amputated part as
needed and identifies and tags vital structures, includ-
ing nerves, veins, arteries and tendons.
The other team should assess the patient with a med-
ical history and physical examination, obtain appro-
priate laboratory studies, and start general supportive
measures as indicated.
The details of the replantation procedure is beyond the
scope of this text, but they include the shortening and
fixation of the bone, repairing flexor and extensor ten-
dons, anastomosis of one or more arteries and two veins,
repairing the nerves, and skin coverage.
Radial
midlateral line
2 1
Split-thickness
graft
the cross finger flap.
A B
C
Figure 14-19 Four-finger amputation and successful replantation. A. This 34-year-old print shop
worker sustained a traumatic amputation of four fingers in a paper cutter. B. Successful reattachment
was achieved of all four digits. C. He regained useful function and sensibility in the hand and returned
to work in the print shop.
Postoperative care includes aspirin for its antiplatelet
effect, and some form of anticoagulant therapy of the
surgeons choice. The patient should not be allowed to
smoke or drink caffeinated beverages.
Postoperative monitoring may be accomplished by noting
clinical signs such as color, pulp turgor, and capillary
refill. However, skin temperature measurements or pulse
oximetry may be more reliable.
Figure 14-19 illustrates a typical replantation patient.
SUGGESTED READING
Atasoy E, Godfrey A, Kalisman M. The antenna procedure for the
hook-nail deformity. J Hand Surg 1983;8:5558.
Atasoy E, Ioalimidis, Kasdan ML, Kutz JE. Reconstruction of the am-
putated fingertip with a triangular volar flap. J Bone Joint Surg
1970;52A:921926.
Chang J, Jones N. Twelve simple maneuvers to optimize digital re-
plantation and revascularization. Tech in Hand Upper Extremity
Surgery 2004;8:161166.
Chow SP, Ho E. Open treatment of fingertip injuries in adults. J Hand
Surg 1982;7:470476.
Cronin TD. The cross finger flap: a new method of repair. Am Surg
1951;17:419425.
Das SK, Brown HG. Management of lost finger tips in children. Hand
1978;10:1627.
Flatt AE. The thenar flap. J Bone Joint Surg 1957;39B:8085.
Graham B. Major replantation versus revision amputation and pros-
thetic fitting in the upper extremity: a late functional outcomes
study. J Hand Surg 1998;23:783791.
Kumar VP, Satku K. Treatment and prevention of hook nail deformity
with anatomic correlation. J Hand Surg 1993;18A:617620.
Kutler W. A new method for finger tip amputation. JAMA 1947;
133:2930.
Moberg E. Aspects of sensation in reconstructive surgery of the upper
extremity. J Bone Joint Surg 1964; 46A:817825.
Yong FC, Teoh LC. Nail bed reconstruction with split-thickness nail
bed grafts. J Hand Surg 1992;17B:193197.
15
COMPARTMENT
SYNDROME
DEFINITIONS
Anatomic Compartments
An anatomic compartment is defined as an enclosed space
formed by fascia, or a combination of fascia and bone, that
contains one or more muscles. An exception to this defini-
tion is the carpal tunnel, which contains nine flexor tendons
but no muscleexcept for those individuals with low-lying
muscle fibers from the flexor digitorum superficialis (FDS)
that sometimes extend into the carpal canal. The contents
of an anatomic compartment are muscles, arteries, veins,
and nerves.
Compartment Syndrome
Compartment syndrome is defined as a symptomcomplex re-
sulting fromincreased tissue pressure within a limited space
that compromises the circulation and function of the con-
tents of that space. This occurs when intramuscular pres-
sure is elevated to a level, and for a period of time, sufficient
to reduce capillary perfusion.
The muscle component of the various compartments is
the primary target of the pathological process; the nerves
are the secondary targets.
Following sustained vascular compromise, the muscle
undergoes necrosis, fibrosis, and contracture; associated
nerve injury causes further muscle dysfunction, sensibility
deficits, or chronic pain. The end result is a dysfunctional
muscle compartment with local and distant manifestations
that depend upon the compartment involved and the degree
of muscle contracture and nerve dysfunction.
Types
Acute. An acute compartment syndrome results when in-
tramuscular pressure (IMP) exceeds capillary blood pres-
sure for a prolonged period of time. In this circumstance,
immediate decompression is required to prevent muscle
necrosis.
Chronic or Exertional. This condition occurs when exer-
cise increases IMP enough to cause ischemia, pain, and in
some instances, diminished sensibility or neurological dys-
function.
If a particular compartment is hypertrophied or confined
by tighter-than-normal fascia, small increases of volume as-
sociated with exercise may significantly increase IMP.
Symptoms usually disappear with cessation of the activ-
ity but appear again with resumption of the activity. If the
activity is continued in spite of pain and neurologic deficit
for a sufficient period of time, an acute compartment syn-
drome may result. This condition is seen most often in the
lower extremity, but it also may occur in the upper extremity.
Volkmanns Ischemic Contracture
This condition is defined as the end result of irreversible hy-
poxic damage to muscles, nerves, and vascular endothelium
of an anatomic compartment. It may be categorized as mild,
moderate, or severe. In its mild form, portions of normal
muscle are replaced by contractile scar tissue that shortens
or contracts the affected muscle. The adjacent nerves are
not affected and the resultant deformity may be minimal.
In the moderate form the muscle or muscles are more
severely involved, and the adjacent nerves may be affected to
some degree. The end result is a more significant deformity
involving the FDS and flexor pollicis longus (FPL)and
in some instances, portions of the FDS muscles and the
median nerve.
In the severe type, all of the digital flexors are involved,
along with the extrinsic wrist flexors. In some cases, the
muscles in the extensor and mobile wad compartment are
also involved. The median nerve is severely compromised,
and often degenerates into a fibrous tissue thread at its mid-
aspect. Although less likely to be involved, the ulnar nerve
may also be compromised. The end result is a severe flexion
contracture of the wrist and digits, with significant sensory
deficit. Figure 15-1 depicts the clinical and intraoperative
appearance of Volkmanns ischemic contracture.
ANATOMIC COMPARTMENTS IN THE
UPPER EXTREMITY
There are 13 compartments in the upper extremity fromthe
shoulder to the hand. They are the deltoid, anterior arm,
posterior arm, mobile wad of the forearm, flexor forearm,
extensor forearm, and pronator quadratus. In the hand they
242
Chapter 15 / Compartment Syndrome 243
A
C
B
Figure 15-1 Clinical and intraoperative appearance of Volkmanns ischemic contracture in an elderly
alcoholic. A. Note the fixed and flexed wrist, the adduction contracture of the thumb, and the claw
deformity of the fingers. B. Note the necrotic muscle at the tip of the forceps. C. The median nerve was
surrounded by necrotic muscle (Penrose drain).
VOLAR
PT
BR
AN
PL
FCR
ECU
EDC
R
U
ECRB
ECRL
FDS
FCU
FDP
MOBILE WAD
DORSAL
Supinator
Figure 15-2 The three forearm compartments: the flexor containing
the finger, thumb, and wrist flexors; the extensor containing the
finger, thumb, and ulnar wrist extensor (ECU); and the mobile wad of
three, which is represented by the brachioradialis and the ECRL and
ECRB (radial wrist extensors). R, radius; U, ulna.
include the central palmar, adductor, thenar, hypothenar,
interosseous, and finger compartments. The central palmar
compartment contains the lumbrical muscles, and thus
meets the definition of a compartment. The finger or digits,
although not a definite compartment, may require release
if they are significantly compromised by both internal and
external pressure. The flexor forearm (Figure 15-2) and the
interosseous (Figure 15-3) compartments have the greatest
clinical significance, since development of a compartment
Thenar
Adductor
Interosseous
Hypothenar
Mid-palmar
Figure 15-3 Cross section of the midpalm, depicting the thenar,
adductor, interosseous, midpalmar, and hypothenar spaces.
INCREASED INTRACOMPARTMENTAL PRESSURE
Increased
venous
pressure
Increased
capillary
pressure
Increased compartmental content Decreased compartmental size
Vasospasm Shock
Increased
exudation
Increased
capillary
permeability
Decreased
perfusion
pressure
Elevation of
extremity
Decreased arteriolar pressure
Decreased arteriolar transmural
pressure difference
Closure of arterioles
Decreased tissue perfusion
Progressive death of muscle and nerve
Figure 15-4 Matsens unified concept of compartment syndrome (see text for details).
syndrome in these two locations probably results in the most
significant functional loss and deformity.
ETIOLOGY AND PATHOPHYSIOLOGY
Compartment syndrome is caused by elevated pressure
inside a closed compartment.
Matsens unified concept of compartment syndrome is
presented in Figure 15-4.
Increased pressure within a compartment may be caused
by either an increased volume within the compartment
(such as fracture, hemorrhage, soft-tissue injury, and
snake bite) or a decrease in the size of the compartment
(such as a tight cast or dressing, burn eschar, or pro-
longed external limb pressure during anesthesia or during
an unconscious state resulting from drugs or alcohol).
In children, supracondylar fractures of the humerus are
a frequent cause because of a cast that fits tightly, or an
injury or occlusion of the brachial artery.
Because of the relatively noncompliant nature of the fas-
cia around the specific anatomic compartments, either of
these two situations will result in an increase in pressure.
Increased pressure within a compartment decreases the
blood supply to the soft tissues, resulting in tissue hypoxia
and damage.
The blood flowis determined by several factors, including
arterial pressure, venous pressure, resistance within the
vessel, and local tissue pressure.
The difference between the arterial and venous pressures
is the arteriovenous gradient.
This gradient, and therefore blood flow, will be de-
creased if venous pressure is increased or if the in-
coming arterial blood pressure is decreased (such as
in shock, hemorrhage, or limb elevation).
All blood vessels, but particularly the microcirculation
and veins, are collapsible. Blood flow, therefore, also
can be decreased if the surrounding tissue pressure
exceeds both the strength of the vessel wall and the
pressure within the vessel.
Tissue pressure affects both the flow through a vessel,
and the fluid equilibrium and exchange across the walls
of the microcirculation.
Both the fluid pressure within the capillary and the sur-
rounding tissues, and the respective osmotic pressures
within the tissue and plasma, determine fluid exchange.
DIAGNOSIS
The discussion of diagnosis will be focused on the forearm
and hand compartments, and will include acute carpal tun-
nel syndrome.
The six Ps of diagnosis of acute compartment syndrome
are given in Box 15-1. Compartment syndrome must be dis-
tinguished fromarterial injury and nerve injury. Table 15-1,
based on five of the six Ps, helps to differentiate compart-
ment syndrome from the ischemia associated with arterial
injury or from the findings in nerve injury that might mimic
some of the components of compartment syndrome.
Acute Compartment Syndrome of the Forearm
The diagnosis of forearmcompartment syndrome is made
by clinical findings, and may be confirmed by measure-
ment of intracompartmental pressure.
BOX 15-1 THE SIX PS OF DIAGNOSIS OF
ACUTE COMPARTMENT SYNDROME
Pressure (elevated)
Pain (especially with passive stretch of the involved
muscle[s])
Paresthesia
Paresis or Paralysis
Pink skin color
Pulse (usually intact)
Clinical Findings
Clinical findings include the following:
A swollen, tense, tender compartment with overlying
skin that is often pink or red (Figure 15-5).
Pain that may seem out of proportion to the injury.
Sensory deficits or paresthesias.
Paresis or paralysis.
Distal pulses are usually intact.
Pain is usually increased by passive stretch of the muscles
in the affected compartment. For pain in the flexor fore-
arm compartment, stretching regimens would include
passive extension of the wrist and finger flexors.
This finding may not be specific or reliable if there is
an associated fracture or blunt trauma.
Sensory changes usually occur before motor deficits.
Radial and ulnar pulses are usually intact, since sys-
tolic arterial pressure (+/ 120 mm Hg) exceeds the
pressure within the involved compartment.
If the extremity is swollen, Doppler examination may be
useful to determine the status of the pulse.
Pink or red discoloration of the skin may be absent,
and temperature, capillary refill, and compartment tur-
gor may not be reliable signs in many instances.
In children, anxiety associated with an increasing analgesic
requirement is a very reliable indicator of compartment
syndrome.
TABLE 15-1 DIFFERENTIAL DIAGNOSIS OF
COMPARTMENT SYNDROME, ARTERIAL INJURY,
AND NERVE INJURY BASED ON FIVE PS
Compartment Arterial Nerve
Syndrome Injury Injury
Pressure in compartment +
Pain with stretch + +
Paresthesia or anesthesia + + +
Paresis or paralysis + + +
Pulses intact + +
Note: Taken from Hargens AR, Mubarak SJ. Current concepts in
pathophysiology, evaluation, and diagnosis of compartment syndrome.
Hand Clinics 1998;14:371384.
Intracompartmental Pressure Measurements
Although the diagnosis of compartment syndrome may
be made clinically, the measurement of the intracompart-
mental pressure is an additional diagnostic tool that may
aid in confirmation of the diagnosis.
Compartment pressures can be measured by the needle
manometer technique, continuous infusion technique,
the wick or slit catheter technique, or with transducers
that measure pressures digitally.
Self-contained devices with instructions for use, such as
the Stryker and Whitesides pressure monitor, are com-
mercially available.
It is important to become familiar with at least one of
these techniques or devices so that the necessary tools
may be readily located in your emergency department,
clinic, or hospital, and utilized in a timely fashion.
The threshold pressures considered consistent with a
compartment syndrome range from 45 mm Hg to 20 mm
Hg below diastolic pressure.
Animal studies of compartment syndrome have indicated
that clinical signs along with compartment pressures of
30 mm Hg or greater are consistent with compartment
syndrome.
A B
Figure 15-5 Acute compartment syndrome of the forearm. A. This patient was obtunded from drugs. He
lay on his left arm/forearm for an unknown length of time; note the swelling in the forearm and arm. He
complained of severe pain. B. He was immediately taken to the operating room, where a comprehensive
fasciotomy was performed, which revealed swollen and edematous forearm muscles.
Figure 15-6 demonstrates ulnar and dorsal approaches
for needle placement in the flexor aspect of the forearm.
Acute Compartment Syndrome of the Hand
Clinical Findings
The carpal tunnel, although not a true compartment, may
act as a closed space, and the median nerve may be sub-
ject to the adverse effects of increased pressure.
The hand compartments that may be involved in com-
partment syndrome are the interosseous (both dorsal and
palmar), the thenar and hypothenar, the adductor, and
the fingers.
The clinical findings in compartment syndrome in the
hand are similar to the previously described findings in
the forearm, and include paininthe region, painwithpas-
sive stretch of the involved muscles, localized swelling,
paresthesia in the involved nerve distribution, and mus-
cle paresis.
In the hand, all the intrinsic muscles may be evaluated
by passively abducting and adducting the digits with the
metacarpophalangeal (MCP) joints in extension and the
proximal interphalangeal (PIP) joints in flexion.
The adductor compartment in the thumb is tested by
positioning the thumb in palmar abduction to produce
stretching of the adductor.
The thenar muscles are stretched by abduction and ex-
tension of the thumb, and the hypothenar muscles are
stretched by abduction and extension of the little finger.
T
H
MP
A B
Figure 15-7 Portals for compartment pressure measurements in the hand. A. Interosseous
compartment pressures may be measured through these four portals on the dorsum of the hand. B. The
thenar (T), midpalmar (MP), and hypothenar (H) compartments may be measured through these portals.
PL
ECR
FDS
BR
PT
ECRB
EDC
ECU
U
EPL
APL
R
FPL
FDP
FCU
B
A
Figure 15-6 Ulnar and dorsal approaches for needle/catheter
placement in the flexor forearm to obtain intracompartmental
pressure. The starting point for both approaches is at the junction of
the proximal and middle third of the supinated forearm. A. The ulnar
approach inserts the needle/catheter into the deep or profundus
compartment using the ulna as a guide. B. The dorsal approach
permits measurement of the dorsal compartment pressures, as well as
the deep compartment depending on the depth of insertion. R,
radius; U, ulna.
Swelling and increased tissue turgor may be noted over
the individual involved compartments.
In the fingers, the amount of swelling and the nature of
the injuryas well as the presence of a nonyielding burn
escharmay indicate increased pressure and the need
for a fasciotomy.
Potential compartments are present in the finger due to
the presence of fascial bands around the neurovascular
bundles, including Graysons and Clelands ligaments.
Measurement of Intracompartmental Pressures in the Hand
Figure 15-7 depicts the sites of needle placement for
measurement of compartment pressures in the hand.
TREATMENT OF ACUTE COMPARTMENT
SYNDROMES
Forearm Compartment Syndrome
The goals of treatment are to restore microcirculation to
the compartment through decompression.
This includes splitting or removing a tight cast, includ-
ing the removal of cast padding and tight dressings or
bandages of any type down to the level of the skin.
If these maneuvers fail to resolve the problem, then im-
mediate operative decompression is performed.
Decompression is typically achieved by fasciotomy.
Surgical Treatment
Flexor Forearm Compartment Syndrome
The forearm compartments (involving the forearm flexor
compartment and the mobile wad compartment) are de-
compressed by a comprehensive incision from the dis-
tal arm to the midpalm, as noted in Figure 15-8 and
15-5B.
The deep fascia is incised from the region of the distal
arm to, and including, the carpal canal.
The underlying flexor muscles will often bulge dramat-
ically into the wound.
The median nerve is at risk at four locations: the lacertus
fibrosus, the pronator teres, the deep fascial arcade of
the flexor digitorum superficialis, and the carpal tunnel.
If preoperative findings indicate that the ulnar nerve is
involved, it is also decompressed as indicated at the cu-
bital tunnel, forearm, and Guyons canal at the wrist and
hand.
Figure 15-8 Comprehensive incision for release of the volar
forearm compartment syndrome. Note that the incision includes the
distal arm and should include the carpal tunnel.
If signs of radial nerve dysfunction are present, decom-
pression of the radial tunnel may also be indicated (see
Chapter 7, Entrapment Neuropathies, for details of ra-
dial nerve decompression).
Coexisting forearm fractures are usually stabilized oper-
atively at the time of fasciotomy.
Skin incisions are left open to accommodate swelling, but
are loosely reapproximated to cover the nerves.
If fractures are open and contaminated, fasciotomy is
performed, wounds debrided, and fractures stabilized.
In contaminated wounds, external fixation or limited in-
ternal fixation may be preferable to standard internal fix-
ation methods.
Skin grafting and limited secondary closure is performed
when wounds demonstrate clean granulation tissue.
Release of Extensor Forearm Compartment
Compartment syndromes involving the forearm extensor
compartment are released through a dorsal incision.
When both the flexor and extensor compartments are in-
volved, it is preferable to release the flexor compartment
first; the relaxation afforded by the skin and fascia often
decompresses the dorsal compartments.
Dorsal compartment pressures are used to determine
whether or not to release the extensor compartment.
If required, it is released through a longitudinal inci-
sion 2 cm lateral and distal to the lateral epicondyle.
The incision is continued distally to the myotendinous
junction of the extensor muscles in the midforearm.
Fasciotomy is also indicated at the time of limb revascu-
larization if the duration of ischemia has been as much
as 4 to 6 hours.
Post revascularization edema may precipitate compart-
ment syndrome, and prophylactic fasciotomy is indi-
cated.
Hand Compartment Syndrome
The principles of treatment of hand compartment syn-
dromes are similar to those of the forearm.
The appropriate incisions for decompression of the vari-
ous hand compartments are depicted in Figure 15-9.
The essentials of the deeper dissection for decompression
of the hand compartments are given in Figure 15-10.
Release of swollen fingers may be required based on the
amount of swelling and the nature of the skin envelope.
If a significant burn eschar or swelling is present, digital
fasciotomies are performed through midlateral incisions
on the nondominant or noncontact side of the digits.
The incisions are dorsal to the neurovascular bundles;
Clelands and Graysons ligaments are incised.
The dissection usually ends at the flexor sheath.
The incision is centered over the PIP joint and may ex-
tend 2 cm proximal and 2 cm distal to the PIP joint, as
described in Figure 15-11.
Prognosis and Caveats for Acute
Compartment Syndrome
The prognosis depends on the intensity and duration of
the elevated compartment pressure.
T
H
MP
B A
Figure 15-9 Appropriate incisions for release of the hand compartments. A. The thenar (T), midpalmar
(MP), and hypothenar (H) incisions. B. Suitable incisions for release of the interosseous compartments.
Therefore, time is of the essence in the management of
compartment syndrome.
If clinical findings and/or pressure readings are sugges-
tive, but not conclusive, remember that the scar from a
fasciotomy incision is of relatively minimal consequence
compared to an untreated compartment syndrome that
results in a Volkmanns ischemic contracture.
Hypothenar
Lumbrical, mid-palmar, &
adductor
Thenar
Dorsal & palmar interosseous
Figure 15-10 Depiction of the details of the deeper dissection for
release of the interosseous muscle compartments, the thenar
compartment, the midpalmar and adductor compartments (both of
which may be released through a midpalmar incision), and the
hypothenar compartment.
TREATMENT OF VOLKMANNS ISCHEMIC
CONTRACTURE
Treatment goals are to increase function, decrease as-
sociated pain factors if present, and, if possible, restore
limb sensibility.
Transverse
Clelands
ligament
Clelands
ligament Graysons
ligament
NV
bundle
Figure 15-11 Midaxial incision for release of compromised digits in
compartment syndrome.
Treatment of mild contractures depends upon the sever-
ity of the deformity and the time interval between injury
and initiation of treatment.
Contractures of the deep forearm flexors, with normal
hand sensibility and preservation of remaining extrin-
sic muscle strength, are treated by a comprehensive
hand rehabilitation program that includes active and
passive mobilization, strengthening, and static and dy-
namic extensionsplinting. This regimenworks to improve
thumb web space width, strengthen weak thumb intrinsic
muscles, and correct or improve digital flexion contrac-
tures.
Surgical Treatment
Treatment of moderate to severe contractures is based on
elimination of contractures, release of secondary nerve
compression, and tendon transfers to recover some of
the lost function.
The surgical procedures employed include excision of
the muscle infarct, tendon lengthening, muscles slides,
neurolysis (or nerve graft in very severe cases), and
various tendon transfers to restore balance and func-
tion.
Microvascular free tissue transfers of nerve and muscle
have been promising in severe cases of Volkmanns con-
tracture.
SUGGESTED READING
Botte MJ, Gelberman RH. Acute compartment syndrome of the fore-
arm. Hand Clinics 1998;14:391403.
Botte MJ, Keenan MAE, Gelberman RH. Volkmanns ischemic con-
tracture of the upper extremity. Hand Clinics 1998;14:483497.
Doyle JR. Anatomy of the upper extremity muscle compartments. Hand
Clinics 1998;14:343364.
Hargens AR, Mubarak SJ. Current concepts in the pathophysiology,
evaluation and diagnosis of compartment syndrome. Hand Clinics
1998;14:371383.
Kadiyala RK, Waters PM. Upper extremity pediatric compartment syn-
dromes. Hand Clinics 1998;14:467475.
Matsen FA III, Clawson DK. Compartment syndromes: a unified con-
cept. Clin Orthop 1975; 113:814.
McDougal CG, Johnson GHF. A new technique of catheter place-
ment for measurement of forearmcompartment pressure. J Trauma
1991;31:14041408.
Mubarak SJ, Hargens AR, Owen CA, et al. The wick-catheter technique
for measurement of intramuscular pressure. A new clinical and
research tool. J Bone Joint Surg 1976;58A:10161020.
Ortiz JA, Berger RA. Compartment syndrome of the hand and wrist.
Hand Clinics 1998;14:405418.
Szabo RM. Acute carpal tunnel syndrome. Hand Clinics 1998;14:419
429.
Tsuge K. Management of established Volkmanns Contracture. In:
Green DP, Hotchkiss RN, Pederson WC, eds. Greens oper-
ative hand surgery. 4th Ed. New York: Churchill Livingstone,
1999:593603.
Von Schroeder HP, Botte MJ. Definitions and terminology of com-
partment syndrome and Volkmanns ischemic contracture of the
upper extremity. Hand Clin 1998;14:331341.
Whitesides TE Jr, Heckman MM. Acute compartment syndrome:
update on diagnosis and treatment. J Am Acad Orthop Surg
1996;4:209218.
16
INJECTION
INJURIES
Injection injuries may occur secondary to penetration of the
skin by fluids under high pressure, therapeutic injections
(infusions) of chemotherapeutic agents, or self-injection of
various narcotic agents in addiction.
HIGH-PRESSURE INJECTION INJURIES
History
These injuries are most often seen in commercial painters,
mechanics, heavy equipment operators, and others who
work with various fluids under high pressure. The fluids
or materials involved may be paint or paint solvents, grease,
or hydraulic fluids under high pressure. A common history
is that of a painter cleaning his spray gun at the end of the
day and checks to see if the gun is clean by spraying the tip
of his finger to see if the resultant spray is clear. A similar
scenario is that of a heavy equipment operator who notes a
leak in a hydraulic line and tries to correct it by holding a
rag around the leak. Yet another scenario is the mechanic
who wants to know if he still has some grease in his gun,
and therefore places the tip of the grease gun on the tip of
his finger and pulls the release trigger.
Pathomechanics of Injury
All of the above described scenarios result in the easy pen-
etration of the skin envelope by the various high-pressure
fluids. The materials fill the tissue spaces and travel along
fascial planes in the line of least resistance. They are very
injurious to the tissues, and thatcombined with the me-
chanical factors of increased tissue pressureproduces is-
chemia and tissue necrosis. Latex or water-based paint is the
least noxious of the listed materials, but are still associated
with significant soft tissue changes.
Diagnosis and Physical Findings
The diagnosis is made by the history of what at first may
seem a very minimal injury that later develops into a ma-
jor problem with pain that may be out of proportion to the
physical findings.
These patients may be seen in an emergency room set-
ting. The initial findings may not be very striking in terms
of appearance of the digit or hand, but as the condition
develops they may be associated with severe pain.
The worker may be hesitant to admit the true mechanism
of the injury due to embarrassment.
The initial physical findings may be negligible, with little
or no evidence of penetration except for some swelling in
the digit or palm.
As the chemical irritation develops, there is increased
swelling and signs of inflammation. Painbecomes a major
factor.
Treatment
Treatment consists of early decompression through ap-
propriate incisions.
The aimis to decompress the involved area and to remove
as much of the injected material as possible.
Amputation may be avoided by early treatment that in-
cludes wide debridement, open drainage, repeat debride-
ment as indicated, and delayed wound closure (Figure
16-1).
Prognosis
These injuries result in severe tissue ischemia with necro-
sis, which may result in amputation.
Rates of amputation vary from 16% to 48%.
The outcome from these injuries depends on the type
and amount of material injected, the presence of infec-
tion, and the interval between injury and removal of the
injected material.
Stiffness is a recognized complication, and the overall
prognosis is guarded in these injuries.
THERAPEUTIC INJECTION INJURIES
Injections or infusions are ordinarily safe, but may lead to
serious problems because of incorrect placement of nee-
dles or catheters, or because of fluid extravasation with
tissue necrosis. The latter complication may be seen with
250
Chapter 16 / Injection Injuries 251
A B
C
Figure 16-1 A, B. This 25-year-old, left-handed backhoe operator
detected a small leak in one of the hydraulic lines on the machine, and
attempted to stop it by forcibly holding an oil rag over the leak. He felt
a stinging sensation in his hand and let go of the line. About 2 hours
later he had increasing pain in his left hand and went to a local
emergency room, where his pain was considered to be inappropriate.
He was sent home with pain pills. Later that night he was diagnosed
with a hydraulic fluid injection injury; the site of entry at the thenar
eminence was opened through a small incision, and a small drain
inserted. C. Further consultation revealed the extensive nature of the
injury, and a comprehensive decompression was performed both to
remove additional hydraulic fluid and to debride the wound. Delayed
wound closure was performed at a later date, and his residuals were
those of mild to moderate stiffness in the left thumb.
intravenous chemotherapeutic agents used in cancer ther-
apy, and may result in significant soft tissue loss that re-
quires appropriate soft tissue coverage.
Medications designed for intravenous use mistakenly
placed into an artery may result in arterial spasm with mus-
cle ischemia and necrosis. Nerve injuries have been ob-
served in the forearm following extravasation of physiologic
intravenous fluids used for rehydration, due to increased
hydrostatic pressure rather than any toxicity specific to the
fluid. Steroid injection used for treatment of carpal tunnel
syndrome, if placed intrafascicularly, may have an adverse
effect on nerve function.
SELF-INFLICTED INJECTION INJURIES
These injuries may present ina variety of ways because many
different agents may be used. The portal may or may not be
readily evident. Manifestations include infection, edema,
and chronic induration of soft tissues. Portals may be intra-
venous or intra-arterial. If sufficient changes are produced
in the arterial lining or wall, ischemia or necrosis may be
seen.
SUGGESTED READING
Frederick HA, Carter PR, Littler JW. Injection injuries to the me-
dian and ulnar nerves at the wrist. J Hand Surg 1992;17A:645
647.
MacKinnon SE, Hudson AR, Gentili F, et al. Peripheral nerve injec-
tion injury with steroid agents. Plastic Reconstr Surg 1982;69:482
489.
Pinto MR, Turkula-Pinto LD, Cooney WP, et al. High-pressure injec-
tion injuries of the hand: review of 25 patients managed by open
wound technique. J Hand Surg 1993;18A:125130.
Stanley D, Connolly WB. Iatrogenic injection injuries of the hand and
upper limb. J Hand Surg 1992;17B:44246.
252
P1: JDW
GRBT045-INDEX Doyle-2055G GRBT045-Doyle-v9.cls July 20, 2005 16:13
INDEX
Note: Page numbers followed by f indicate figures; those followed by t indicate tables.
A
Abscess
collar button, 86
horseshoe, 86
Acral lentiginous melanoma, 56
Acute carpal tunnel syndrome, 99102
median nerve contusion, 100
tests for, 100, 101t
Acute compartment syndrome
prognosis for, 247248
treatment of, 247248
Acute paronychia, 8182
AER. See Apical ectodermal ridge
(AER)
AIN. See Anterior interosseus nerve
(AIN)
Amputations, 226241
anatomy of, 226228
avulsions, 233
bone shortening primary closure, 229
digital, 228233
distant pedicle flap closure,
231232
lacerations, 233
local flap closure, 230
local tissue primary closure, 229
nail bed, 226
nail bed injuries, 233235
nail fold, 226
nail plate, 226
nail unit, 226
replantation, 237241
indications, 237
timing, 237
skin graft closure, 229230
subungual hematoma, 233
terminal phalanx, 226
triple, 234f
Anatomic compartment
definition of, 242
Anatomic snuff box, 67, 160
Anatomy of, 113
Anesthesia, 116127
agents for, 120121
guidelines for, 116117
indications for, 121
methods for, 121127
operative sites for, 121
Aneurysmal bone cyst, 5859, 60f
Aneurysms, 5154
false, 53
true, 53
Animal bites, 87, 87f
Anterior interosseus nerve (AIN)
compression sites, 105f
syndrome, 104
Antibiotics
classification of, 79t80t
cost of, 79t80t
use of, 79t80t
Aperts syndrome, 28f
Apical ectodermal ridge (AER), 17
Apoptosis, 18
Arcade of Struthers, 109
dissection of, 109f
Arm
blocking major nerves,
123124
medial aspect of, 110f
Arthrogryposis, 2129
clinical appearance of, 24f
Atypical cleft hand
clinical features of, 24f
Axillary block, 122123, 123f
B
Ballottement test, 174, 175f
Basal cell carcinoma, 5455
Benign bone tumors, 5861
Benign soft tissue tumors, 3840
Bennetts fracture of thumb, 141143
K-wire fixation of, 142f
percutaneous fixation of, 141f
screw fixation of, 141f
Beta lactams
classification of, 79t
cost of, 79t
use of, 79t
Bites
animal, 87, 87f
human, 86f
Bohler-type outrigger splint,
130f
Bone cyst
aneurysmal, 5859, 60f
Bone tumors
benign, 5861
malignant, 6163
Boutonniere deformity, 195f
Elson test for, 196, 196f
Bouviers maneuver, 219f
Bowlers thumb, 114
Boxers fracture
closed reduction of, 138f
Brachydactyly, 32f
Brachysyndactyly, 24f, 33f, 34f
Bupivicaine, 121
C
Calcific tendonitis, 95
Campers chiasma, 181f
Camptodactyly, 2629, 29f
Capitate fractures, 166169, 168t
Capitolunate (CL) angle, 177178
Carbocaine. See Mepivacaine
(Polocaine/Carbocaine)
Carpal alignment
defining normal, 175176
measurement of, 177
Carpal angles, 177f
Carpal arcs, 174f, 175176
Carpal bones, 43f, 61
anatomy of, 158, 170
Carpal fractures, 158169
Carpal groove, 158
Carpal injuries, 158178
anatomy of, 158160
Carpal instability
classification of, 170175
definition of, 169
diagnosis of, 174178
physical examination of, 174
radiologic examination of,
174175
treatment of, 178
Carpal instability adaptive (CIA),
173174
Carpal instability complex (CIC),
172173
Carpal instability dissociative (CID),
170172
Carpal instability nondissociative
(CIND), 172
Carpal scaphoid fracture, 163f
Carpal spacing, 175176
Carpal synostosis, 29
Carpal tunnel compression test,
101t
Carpal tunnel syndrome (CTS),
98103
acute, 99102
median nerve contusion, 100
tests for, 100, 101t
Carpometacarpal (CMC) joint
dislocation, 157
dorsal dislocation of, 156f
253
P1: JDW
254 Index
Carpus
fractures, 161165
intercalated segment, 169170
ring concept, 169
vascular anatomy of, 160161
Cast
cobra, 130f
Cavernous hemangioma, 52f
Central palmar space infections,
8586
Central polydactyly, 30
Central ray deficiency, 21
Cephalosporins
cost of, 79t
use of, 79t
Cherry pitters thumb, 114
Chondrosarcoma, 6162
Chronic paronychia, 82
Marsupialization technique, 82f
CIA. See Carpal instability adaptive
(CIA)
CIC. See Carpal instability complex
(CIC)
CID. See Carpal instability dissociative
(CID)
CIND. See Carpal instability
nondissociative (CIND)
CL. See Capitolunate (CL) angle
Claw deformity
ulnar nerve, 219f
Cleft hand, 23f
atypical, 24f
deformity, 24f
Closed boutonniere deformity,
196198, 197f
Closed sagittal band injuries, 200
Clostridial collagenase injection, 69
CMC. See Carpometacarpal (CMC)
joint
Cobra cast, 130f
Collar button abscess, 86
Collateral ligament injuries, 154155
Compartment pressure measurements
hand, 246f
Compartment syndrome, 242249
acute
prognosis for, 247248
definition of, 242
differential diagnosis of, 245t
digital release, 248f
etiology of, 244
pathophysiology, 244
Congenital deformities, 1436
abnormal upper limb development,
18
constriction band syndrome,
3334
duplication, 3031
etiology of, 18
failure of differentiation of parts,
2130
skeletal involvement, 2930
generalized skeletal abnormalities,
3436
longitudinal arrest, 1920
normal upper limb development,
1417
embryogenesis, 1518, 16t
fetal development, 18
limb differentiation genetic
control, 18
limb formation, 1718
postnatal development, 18
overgrowth, 3233
part formation failure, 1923
transverse arrest, 19, 19f
undergrowth, 33
of upper extremity
embryologic classification of, 15t
Congenital trigger finger, 90
Congenital trigger thumb, 90
Constriction band syndrome, 3334
etiology of, 18
Z-plasty technique, 35f
Cross-finger flap, 231233, 239f, 240f
Crossover tendonitis, 9394, 94f
CTS. See Carpal tunnel syndrome (CTS)
Cubital tunnel syndrome
elbow, 108109, 110
Cutaneous syndactyly, 2426
D
DCL. See Distal commissural ligament
(DCL)
De Quervains tenosynovitis, 9293, 93f
Digital fascia, 67, 67f
Digital fibroma of infancy, 46, 50f
Digital pulley system, 84f
flexor tendon injuries, 187f188f
Digital tourniquets, 127
Digits
duplication, 3031
DIP. See Distal interphalangeal (DIP)
joint
DISI. See Dorsal intercalated segment
instability (DISI)
Distal commissural ligament (DCL), 64
Distal forearm injuries, 204
Distal interphalangeal (DIP) joint, 38
extensor mechanism, 192f
extensor tendon injuries, 192193,
194f
Distal motor latency, 101t
Distal palmar fascia, 67, 67f
Distal phalanx
anatomy of, 81f
arterial supply, 228f
Distal phalanx fractures, 131133
base, 132, 132t
Distal sensory latency, 101t
Distal wrist flexion crease, 159160
Dorsal extensor compartments, 92f
Dorsal hand, 13
bony landmark, 34
external landmarks, 13
landmarks of, 2f
Dorsal intercalated segment instability
(DISI), 171
deformity, 173f
Dorsal radiocarpal ligaments, 170, 171f
Dorsoradial capsule injury, 155157
Duchennes sign
ulnar nerve, 219f
Duplication
digits, 3031
Dupuytrens disease, 6476, 65f
epidemiology of, 64
etiology of, 64
fascial bands, 70t
fasciotomy, 70
full-thickness skin graft, 74f
historical features of, 64
normal anatomy of, 6465
open (McCash) technique, 70, 71f
pathologic anatomy of, 6769
pathophysiology of, 64
skin grafts, 73
Skoog principle, 7375, 75f
structures at risk during surgery, 75
surgical technique, 7071, 70f
treatment of, 6976
zigzag incision, 73, 74f
Z-plasty closure, 72, 72f, 73f
Dysplasia
etiology of, 19
E
ECRB. See Extensor carpi radial brevis
(ECRB)
EDBM. See Extensor digitorum brevis
manus (EDBM)
EDM. See Extensor digiti minimi
(EDM)
EIP. See Extensor indicis proprius (EIP)
Elbow
cubital tunnel syndrome, 108109,
110
lateral ligaments, 96f
medial aspect of, 110f
medial ligaments, 96f
movement in
anatomic basis for, 12t
Electromyography, 101t
Elson test
for boutonniere deformity, 196, 196f
Enchondroma, 59f
Endoneurium, 212
Entrapment neuropathies, 98114
EPB. See Extensor pollicis brevis (EPB)
Epicondylitis, 8897
lateral, 9596
medial, 9697
Epidermal inclusion cyst, 4144
Epineurium, 208
Epithelioid sarcoma, 5758
EPL. See Extensor pollicis longus (EPL)
ER. See Extensor retinaculum (ER)
Extensor carpi radial brevis (ECRB),
158
Extensor digiti minimi (EDM), 190
Extensor digitorum brevis manus
(EDBM), 39, 44f
Extensor indicis proprius (EIP), 190
syndrome, 94
Extensor pollicis brevis (EPB), 92
anatomy of, 190
P1: JDW
Index 255
Extensor pollicis longus (EPL), 158
anatomy of, 190
tenosynovitis, 9495
Extensor retinaculum (ER), 92
Extensor tendon injuries, 190207
anatomy of, 190193
dynamic splint, 206f
history, 205206
rehabilitation of, 205207, 206207
sutures, 195f
zones of, 192193, 192t
Extensor tendon rupture, 204
Extremities. See Upper extremities
F
False aneurysm, 53
Fascicle-matching techniques
peripheral nerves, 221
Fascicular sutures
Fasciectomy
partial, 69
total, 69
Fasciotomy, 69
Dupuytrens disease, 70
FDP. See Flexor digitorum profundus
(FDP)
FDS. See Flexor digitorum superficialis
(FDS) tendons
Felon
anatomy of, 78
clinical appearance of, 80f
diagnosis of, 78
drainage, 81f
neglected, 81f
treatment of, 78
Fibrofatty fascia, 68
Fibroma
juvenile aponeurotic, 4647
Finger. See also Mallet finger; Trigger finger
arrangement of, 89f
congenital trigger, 90
index
skin graft, 232f
locked trigger, 89f
middle
amputation, 230f
movement, 11f
neurovascular bundles, 76f
ring
two-stage Hunter tendon
reconstruction, 189f
synovial sheaths and pulley systems,
180f
Finger distal interphalangeal joint
anatomic basis for movement, 12t
dislocations of, 144
Finger fascia, 68
Finger flexor tendons
blood supply of, 181f
Finger metacarpophalangeal joint
collateral ligaments
anatomy of, 149, 149f
dorsal dislocation of, 150151
movement in
Finger metacarpophalangeal ligaments
injuries, 149150
Finger nerve block, 126, 126f
Finger proximal interphalangeal joint
Finger zones
of flexor tendon injuries, 180
Finkelsteins test, 92, 93f
First web space, 6869, 69f
Fish-mouth closure, 234f
Flexion creases, 1, 2f
Flexor digitorum profundus (FDP)
tendon
functional testing, 183f
rupture, 182f
Flexor digitorum superficialis (FDS)
tendons
functional testing, 183f
Flexor forearm
catheter placement, 246f
muscles, 5f
Flexor pollicis longus (FPL), 242
Flexor retinaculum
anatomy of, 99f
Flexor superficial arch, 103
Flexor tendons, 179190
anatomy of, 179180
attritional rupture, 165f
digital flexor sheath, 179180
injuries
active extension-elastic band
flexion rehabilitation, 185, 185f
adhesions, 186
controlled active motion
rehabilitation, 186
controlled passive motion
rehabilitation, 185186
digital pulley system, 187f188f
intraoperative techniques,
183185
late reconstruction, 186
partial lacerations, 188
profundus tendon avulsion, 189
rehabilitation, 185186
skin incisions, 184f
surgical exposure, 183
sutures, 183
two-stage tendon reconstruction,
186188
zones of, 180, 182f
laceration, 182f
synovial tissue surrounding, 99f
vascular supply of, 180
Forearm
acute compartment syndrome of,
244246, 245b, 245f
compartments of, 243f
CTS compression, 110
distal injuries of, 204
movement, 11f
Forearm compartment syndrome
treatment of, 247
Forearm injuries. See Proximal forearm
injuries
Forearm synostosis, 29, 29f
proximal osteotomy in, 30f
Forefinger amputations
replantation timing, 240f
FPL. See Flexor pollicis longus (FPL)
Froments sign
ulnar nerve palsy, 219f
Full-thickness skin graft
Dupuytrens disease, 74f
G
Ganglion cyst, 3840, 39f, 40f, 41f,
42f, 44f
Germinal matrix
extensor tendon insertion, 228
Giant cell tumor
of bone, 5961, 60f
of tendon sheath, 4041, 45f
Gilula lines, 177f
Glomus tumor, 4950, 52f
Gout, 55f
Gouty tophus, 54
Graysons ligament, 67, 68
Group fascicular sutures
Guyons canal
surgical approach to, 108f
zones of, 107
H
Hamate bone
fractures of, 165, 168t
hook process of, 1, 159
Hand. See also Dorsal hand
compartment pressure
measurements, 246f
compartment syndrome, 246247
incisions, 248f
treatment of, 247
diagram, 101t
fractures, 128143
closed reduction, 128129
closed treatment of, 128130
diagnosis of, 128
early motion in, 130
open treatment of, 130131
patient history, 128
radiological examination of, 128
ligament injuries, 144147
metastatic tumors, 6263
synovial sheath, 84f
volume stress test, 101t
Hemangioma, 50
Hematoma
subungual
amputations, 233
Herpes simplex (Herpetic Whitlow), 82,
83f
High-pressure injection injuries, 250
Hoffman-Tinel sign, 217
Holstein-Lewis fracture, 111112
Hook nail, 235236
Horseshoe abscess, 86
Human bite wounds, 86f, 87, 199200
Hypothenar eminences, 1
P1: JDW
256 Index
I
Index finger
joint
dorsal dislocation of, 151f, 152f
skin graft, 232f
Index metacarpophalangeal joint
RCL tear, 150f
Infancy
digital fibroma of, 46, 50f
Infections, 7887
acute paronychia, 8182
chronic paronychia, 82
felon, 7881
herpes simplex, 82
pyogenic flexor tenosynovitis, 8385
special situations, 8687
Infraclavicular blocks
brachial plexus, 120121, 122f
Injection injuries, 250251
Internode, 214
Interphalangeal (IP) joint, 38
dislocation of, 144, 145f
movement in
Intersection syndrome (crossover
tendonitis), 9394, 94f
Intersegmental deficiency, 2123
Intravenous regional anesthesia, 120
Intrinsic plus position, 129
IP. See Interphalangeal (IP) joint
Irreducible rotary palmar dislocation,
147148
Isolated digital cord, 68
J
Jeannes sign
ulnar nerve palsy, 219f
Juvenile aponeurotic fibroma, 4647
Juxtaparanode, 214
K
Keratoacanthoma, 5051, 53f
Kirschner wires, 131
Kutler bilateral VY advancement flaps,
230
Kutler bilateral VY-plasty, 235f
L
Lacertus fibrosus, 103
test for, 104f
Lateral cord, 68
Lateral digital sheet, 68
Lateral elbow ligaments, 96f
Lateral epicondylitis, 9596
Lentigo maligna melanoma, 56
Lidocaine (Xylocaine), 120
Ligament of Struthers
test for, 104f
Limb deformities. See also Upper
extremities
genetic classification of, 16t
pathogenesis of, 18f
Limbs
normal bud, 17f
Lipoma, 44, 47f
Listers tubercle, 3, 158
Little finger carpometacarpal joint
Locked trigger finger, 89f
LT. See Lunotriquetral (LT) angle
Lunate configuration, 175176
Lunate fossa, 7, 158
Lunate fractures, 165166, 167t
Lunotriquetral (LT) angle, 178
Lunotriquetral dissociation, 172f
M
Macrodactyly, 3233
Madelungs deformity, 3436, 35f
Maffuccis syndrome, 58
Malignant bone tumors, 6163
Malignant melanoma, 5657
Breslow system for staging, 57t
Malignant soft tissue tumors, 5458
Mallet finger, 193f, 194f
extensor tendon injuries, 192193
fracture of, 132f
pathologic anatomy of and diagnosis
of, 193
treatment of, 193
Marcaine (Bupivicaine), 121
Matsens unified concept of
compartment syndrome, 244f
MCP. See Metacarpophalangeal (MCP)
joint
Medial elbow ligaments, 96f
Medial epicondylitis, 9697
Medial head triceps, 109
Medial intermuscular septum, 110
Median nerve
compression
localizing tests for, 104f
proximal sites of, 102103, 103f
test for, 104f
cutaneous distribution of, 213f
entrapment neuropathies, 98105
epineurial repair, 223f
injuries, 218
palsy, 224225
Megalodactyly, 32f
Meissner corpuscle, 215
Melanoma, 5657
Mepivacaine (Polocaine/Carbocaine),
120121
for axillary block, 123
for thumb nerve block, 124
for wrist block, 124
Merkel cells, 215
Metacarpal fractures, 129f, 134138
base, 138
boxers fracture, 139f
CMC joint dislocation, 140f
diaphysis, 136138
malrotation deformity, 139f
miniplate for, 140f
neck, 134136
screws for, 140f
Metacarpal injuries, 200202
Metacarpal synostosis, 2930
Metacarpophalangeal (MCP) joint
closed injuries, 200
collateral ligaments
anatomy of, 149, 149f
dislocations, 151154
diagnosis of, 152
treatment of, 153
dorsal dislocation of, 150151, 151f,
153f, 157f
dorsoradial capsular injury, 156f
extensor tendon
dislocation, 203f
traumatic ulnar dislocation, 201f
lacerations, 200
movement in
open injuries, 199200
orthotic device, 202f
periarticular fractures, 134
RCL disruption, 155f
RCL tear, 150f
Metacarpophalangeal (MCP) ligaments
injuries, 149150
Metaphysis fractures
proximal, 132
Midcarpal joints, 158
Middle finger
amputation, 230f
metacarpal
styloid process, 4, 158
Middle phalanx fractures, 129f, 131f,
133134
base, 134f
displaced and articular, 133
dorsal subluxation of PIP joint,
133134
nondisplaced and extraarticular, 133
Midpalm
cross section of, 243f
Moberg advancement flap, 237f
thumb tip amputation, 236f
Modified Kessler suture, 198
Movement
terminology of, 13
Multiple enchondromatosis (Olliers
Disease), 58
Muscles
strength grading, 13t
Musculoskeletal tumor
dissection method, 38t
N
Nail
anatomy of, 227f
Nail bed
blood supply of, 227
nerve supply of, 227
Natatory ligaments, 68
Nerve(s)
skeleton, 7f10f
Nerve injuries, 208225
anatomy of, 208215
axon sprouting, 216
degeneration and regeneration,
215217
distal axon, 216217
P1: JDW
Index 257
physiology of, 215217
Sunderland vs. Seddon classification
of, 215t
Neural anatomy of, 13
Neurilemmoma (schwannoma),
4445
Neurofibroma, 4546, 49f
Neuron, 214f
Node of Ranvier, 214
Nodular fasciitis, 4748, 51f
Nodular melanoma, 56
Normal limb bud, 17f
O
Olliers Disease, 58
Open sagittal band injuries, 200
Osteogenic sarcoma, 61
Osteoid osteoma, 61, 62f
Osteoma
osteoid, 61, 62f
Osteomyelitis, 8687, 86f
P
Pacinian corpuscles, 215
Palm
cutaneous innervation of, 102f
nerves
Palmar aponeurosis, 6465
compression loading/shock absorbing,
66
function of, 6667
joint stability, 66
pulley function, 67
skeletal stability, 66
skin anchorage, 66
vascular protection, 67
Palmar distal-row interosseous
ligaments, 170
Palmar fascia, 66f
distal, 67, 67f
Palmar hand, 1
bony landmarks of, 1
external landmarks of, 1
landmarks of, 2f
muscles, 5f
Palmar midcarpal interosseous
ligaments, 170, 171f
Palmar plate, 145f
Palmar proximal interosseous
ligaments, 170, 171f
Palmar radiocarpal ligaments, 170, 170f
Palmar space, 85f
Palm-clutched thumb, 24
Paranode, 214
Paronas space, 85f
Paronychia, 82f
acute, 8182
chronic, 82
Marsupialization technique, 82f
Partial fasciectomy, 69
PCL. See Proximal commissural
ligament (PCL)
Penicillins
classification of, 79t80t
cost of, 79t80t
use of, 79t80t
Percussion test, 101t
Perineurium, 208212
Peripheral nerves
concentric layers of, 208209
cross-sectional anatomy of, 214f
fascicle, 212
fascicle-matching techniques, 221
fascicular bundle nerve grafts,
222f
fascicular sutures, 221
injuries
diagnosis of, 217
median nerve, 218
nerve grafts, 221222
radial nerve, 220, 220f
repair, 220225, 220b, 221f
suture, 220221
terminology, 217
ulnar nerve, 218220
macroscopic anatomy of, 208
microscopic anatomy of, 208
neural component, 208
neuron, 214215, 214f
repair
timing, 222
sensory receptors, 215
spatial organization, 208
tendon transfers, 222225
Peritendinous fibrosis, 201202
Phalanx. See also Terminal phalanx
distal
anatomy of, 81f
arterial supply, 228f
Phalanx fractures. See also Proximal
phalanx fractures
distal, 131133
base, 132, 132t
Phalens test, 101t
PIP. See Proximal interphalangeal (PIP)
joint
Pisiform bone, 1, 159
Pisiform bone fractures, 166, 168t
Polocaine/Carbocaine. See Mepivacaine
(Polocaine/Carbocaine)
Polydactyly, 30
etiology of, 19
Posterior interosseus nerve syndrome,
114
Pretendinous bands, 64, 6768
Programmed cell death, 18
Pronator teres (PT), 103
syndrome, 102103
Proximal commissural ligament (PCL),
64
Proximal forearm injuries, 204205
nerves, 205
Proximal interphalangeal (PIP) joint
anatomy of, 144
bicondylar arrangement of, 145f
central slip lacerations, 198
dorsal dislocation, 145146
dorsal location, 146f
irreducible rotary palmar dislocation,
147f
lateral dislocation, 146
palmar dislocation, 146, 148f
rotary subluxation of, 147f
Proximal metaphysis fractures, 132,
132f
Proximal phalanx fractures, 129f, 131f,
134
base, 136f, 138f
diaphyseal, 134
neck, 137f
traction, 135f
Proximal phalanx injuries, 198199
Proximal phalanx laceration, 182f
sutures, 199f
PT. See Pronator teres (PT)
Pyogenic flexor tenosynovitis, 8385,
84f
Pyogenic granuloma, 48, 51f
R
Radial collateral ligament (RCL)
disruption, 155
Radial deficiency, 21f
osseous appearance of, 21f
syndromes associated with, 22t
Radial longitudinal deficiency
global classification of, 20t
Radial nerve, 111114
entrapment in arm, 112
injuries, 220, 220f
palsy, 223f
with humeral fracture, 111112
Radial polydactyly, 30
Radial ray deficiency, 1920
treatment of, 20
Radial sensory nerve
entrapment at wrist, 112
Radial styloid, 4, 158
Radial tunnel syndrome, 112114,
113f
vs. PINS, 114
Radiocarpal joint, 158
Radiocarpal ligaments
dorsal, 170, 171f
Radiocarpal palmar subluxation, 174f
Radiolunate (RL) angle, 178
RCL. See Radial collateral ligament
(RCL) disruption
Regional anesthesia
intravenous, 120
Retrovascular cord, 68
Rheumatoid synovitis, 43f
Ring carpometacarpal joint
Ring finger
fixed-flexion contracture
two-stage Hunter tendon
reconstruction, 189f
RL. See Radiolunate (RL) angle
Rotary palmar subluxation, 146147
P1: JDW
258 Index
S
Safety-pin splint, 198
Sagittal band injuries
open, 200
Sarcoma
epithelioid, 5758
osteogenic, 61
soft tissue, 57
staging of, 38t
staging of, 38t
synovial, 58
Scaphoid
arterial supply to, 163f
fractures, 161164
distal-third, 163
middle-third, 163
nonunion complications, 164
palmar vs. dorsal surgical
approaches to, 164
proximal-third, 163
tubercle, 159
Scaphoid lift (SL)
angle, 177
Scapholunate advanced collapse
(SLAC), 171172
arthrosis, 173f
Scapholunate dissociation
x-ray, 172f
Schwann cells, 212
Schwannoma, 4445, 48f
Secretans disorder, 201202
Self-inflicted injection injuries, 251,
251f
Semmes-Weinstein monofilaments,
101t
Sensation
autonomous zones, 218f
Shaft fractures, 131132
Single needle puncture
Skeleton
anatomy of, 712, 9f12f
nerves, 7f10f
Skin grafts
Dupuytrens disease, 73
Skin tumors, 5455
SL. See Scaphoid lift (SL)
SLAC. See Scapholunate advanced
collapse (SLAC)
Soft tissue sarcoma, 57
staging of, 38t
Soft tissue tumor-like conditions, 5154
Soft tissue tumors
benign, 3840
malignant, 5458
Spiral band, 68
Splint
Bohler-type outrigger, 130f
safety-pin, 198
thermoplast, 198
Squamous cell carcinoma, 5556, 56f
Stener lesion, 154, 154f
Strickland suture, 184f
Subungual hematoma
amputations, 233
Superficial spreading melanoma, 56
Supraclavicular blocks
brachial plexus, 120
Surface anatomy, 17
Syndactyly, 27f, 28f
conditions associated with, 25t
cutaneous, 2426
etiology of, 18
Synovial sarcoma, 58
Systems anatomy, 713
T
Tendon injuries, 179207. See also
Extensor tendon injuries; Flexor
tendons, injuries
Tendonitis
calcific, 95
Tenosynovitis, 8897
De Quervains, 9293, 93f
EPL, 9495
pyogenic flexor, 8385, 84f
Terminal phalanx
amputations, 226
anatomy of, 80f, 227f
crush injuries, 231f
skin defect, 232f
Thenar eminences, 1
Thenar flap, 231, 238f
Therapeutic injection injuries, 250251
Thermoplast splint, 198
Thumb
Bennetts fracture of, 141143
K-wire fixation, 142f
percutaneous fixation of, 141f
screw fixation of, 141f
Bowlers, 114
cherry pitters, 114
congenital trigger, 90
cyst, 46f
flexor tendon sheath, 89f
movement in, 11f
skin graft, 233f
synovial sheaths and pulley systems,
180f
terminal pulp loss, 229f
Thumb interphalangeal joint
dislocations, 144
movement in
Thumb metacarpal fractures,
138143
base, 141142
diaphysis, 138141
Rolandos, 143
Thumb metacarpophalangeal joint
dislocations, 151154
diagnosis of, 152
treatment of, 153
dorsal dislocation of, 153f, 157f
dorsoradial capsular injury, 156f
movement in
RCL disruption, 155f
Thumb nerve blocks, 126127, 127f
Thumb polydactyly, 31f
Thumb zones
of flexor tendon injuries, 180
Tinel sign, 101t
Total fasciectomy, 69
Tourniquets
digital, 127
Transarterial axillary block, 123
Trans-scaphoid-perilunate fracture
dislocation, 175f
Transverse fibers, 68
Trapezium fractures, 164165, 167t
Trapezoid fractures, 167t, 169
Trigger digit, 8890
Trigger finger
congenital, 90
incisions for, 91f
injection technique for, 90f
locked, 89f
Trigger thumb
congenital, 90
Triquetral fractures, 164, 167t
True aneurysms, 53
True cleft hand deformity, 23f
Tuft fractures, 131
Tumors, 3763
biopsy, 3751
classification of, 37, 38t
diagnosis of, 37
treatment of, 38
Two needle puncture
U
Ulna
distal head of, 6, 158159
Ulnar artery
aneurysm, 54f
Ulnar claw hand, 224f
Ulnar collateral ligament rupture or
avulsion, 154155
Ulnar deficiencies, 23f
classification of, 22t, 23t
Ulnar nerve, 106111
block, 124
at elbow, 124f
claw deformity, 219f
compression
diagnosis of, 107
in Guyons canal, 106107, 106f,
107t
treatment of, 107
wrist, 106107
cubital tunnel syndrome
elbow, 108109
deep motor branch of, 107f
Duchennes sign, 219f
injuries, 218220
laceration, 219f
motor branches, 107
palsy
Froments sign, 219f
Jeannes sign, 219f
sensory branches, 107
P1: JDW
Index 259
Ulnar polydactyly, 30
Ulnar ray deficiency, 2021
Upper extremities
abnormal development of, 18
anatomic compartments in,
242243
arteries of, 6f
bones of, 3f4f
cutaneous nerves, 212f
movement in
nerves, 209f211f
anatomy of, 117f119f
gross anatomy of, 208
normal development of,
1417
embryogenesis, 1518, 16t
fetal development, 18
limb differentiation genetic
control, 18
limb formation, 1718
postnatal development, 18
V
Vascular anatomy, 13
Vibrometry, 101t
VISI. See Volar intercalated segment
instability (VISI)
Volar advancement flaps, 230231
Volar intercalated segment instability
(VISI), 171
Volkmanns ischemic contracture, 242,
243f
VY-plasty, 230, 234f
W
Wallerian degeneration and
regeneration, 216f
Watsons scaphoid lift maneuver, 174,
175f
Wrist
arterial supply to, 161f162f
block, 124126, 125f
outcomes, 125126
calcium deposit, 95f
and hand
failure of differentiation of parts,
2429
injuries, 202204
luno-triquetral coalition in, 30f
movement in, 11f
osteolytic lesion, 63f
skeletal anatomy of, 159f
superficial anatomic landmarks
about, 160f
X
Xylocaine, 120
Z
Zone of polarizing activity (ZPA), 17

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GRBT045-FM Doyle-2055G GRBT045-Doyle-v9.cls August 6, 2005 2:15

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