Hand Surgery: Tricks of the Trade [Illustrated] 1626234795, 9781626234796

Citation preview

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Hand Surgery Tricks of the Trade

Pedro K. Beredjiklian, MD Senior Vice President of Clinical Affairs Chief of the Hand Service Rothman Orthopaedic Institute; Professor of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania, USA

976 illustrations

Thieme New York • Stuttgart • Delhi • Rio de Janeiro

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Library of Congress Cataloging-in-Publication Data Names: Beredjiklian, Pedro K., editor. Title: Hand surgery : tricks of the trade / [edited by] Pedro K. Beredjiklian. Other titles: Hand surgery (Beredjiklian) Description: New York : Thieme, [2020] | Includes bibliographical references and index. Identifiers: LCCN 2020024182 (print) | LCCN 2020024183 (ebook) | ISBN 9781626234796 (hardback) | ISBN 9781626234802 (eISBN) Subjects: MESH: Hand–surgery | Hand Injuries–surgery | Hand Deformities–surgery | Orthopedic Procedures | Reconstructive Surgical Procedures Classification: LCC RD778 (print) | LCC RD778 (ebook) | NLM WE 830 | DDC 617.5/75059–dc23 LC record available at https://lccn.loc.gov/2020024182 LC ebook record available at https://lccn.loc.gov/2020024183

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

© 2020. Thieme. All rights reserved. Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001, USA +1-800-782-3488, [email protected] Georg Thieme Verlag KG, Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, [email protected] Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00, [email protected] Thieme Publishers Rio, Thieme Publicações Ltda. Edifício Rodolpho de Paoli, 25º andar Av. Nilo Peçanha, 50 – Sala 2508 Rio de Janeiro 20020-906 Brasil +55 21 3172 2297 / +55 21 3172 1896 Cover design: Thieme Publishing Group Typesetting by TNQ Technologies, India Printed in USA by King Printing Company, Inc. ISBN 978-1-62623-479-6 Also available as e-book: eISBN 978-1-62623-480-2

54321

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

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To my great sons, Peter and Kirk, and my lovely wife, Mary, who inspire me, and without whose support, patience, dedication, and understanding, none of this work would be possible.

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Contents Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xxxiii

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xxxiv

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xxxv

Part I: Tendon Injuries 1.

Extensor Tendon Repair (Zone 1, 3, 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

Kevin D. Han and Matthew L. Iorio 1.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

1.2

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3

1.3

Repair Indications and Contraindications . . .

4

1.4

2.

Caveats, Pearls, and Lessons Learned (Extensor Zone 1, 3, 5) . . . . . . . . . . . . . . . . . . . .

4

Zone 1: Terminal Tendon Injuries (Mallet Finger). . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zone 3: Central Slip Injuries . . . . . . . . . . . . . . . . . Zone 5: MCP Joint Injuries . . . . . . . . . . . . . . . . . .

4 5 7

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

7

Extensor Tendon Repair (Zones 2, 4, 6–9) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4

1.5 1.5.1 1.5.2 1.5.3

Kirk Wong 2.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

2.2

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

2.3

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8

2.3.1 2.3.2 2.3.3

8 9

2.3.4 2.3.5

General Treatment Guidelines. . . . . . . . . . . . . . . . Repair Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . Zone 2 (Proximal Phalanx (Pinning) Phalanx) Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zone 4 (Proximal Phalanx) Injuries . . . . . . . . . . . Zone 6 (Metacarpal) Injuries . . . . . . . . . . . . . . . . .

3.

2.3.6 2.3.7 2.3.8

Zone 7 (Carpus) Injuries . . . . . . . . . . . . . . . . . . . . Zone 8 (Distal Forearm) Injuries. . . . . . . . . . . . . . Zone 9 (Proximal Forearm) Injuries . . . . . . . . . . .

10 10 10

2.4

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10

2.5

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

11

Flexor Tendon Repair (Zone 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

9 9 10

Brian A. Tinsley 3.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

3.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

3.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12

3.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

12

3.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

12

3.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13

3.7

Tips, Pearls, and Lessons Learned . . . . . . . . . .

13

3.8

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

13

3.8.1 3.8.2

Distal Stump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Distal Phalanx Fractures . . . . . . . . . . . . . . . . . . . .

13 13

3.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

13

3.9.1 3.9.2 3.9.3 3.9.4

Initial Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . Tendon-to-Tendon Repair . . . . . . . . . . . . . . . . . . . Tendon to Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone to Bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 14 14 14

3.10

Bailout, Rescue, and Salvage Procedures . . .

15

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15

vii

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Contents

4.

Flexor Tendon Repair (Zone 2)

..................................................................

16

David W. Lee, Stephen Ros, and Christopher Doumas Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

4.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

17

4.9

Key procedural steps . . . . . . . . . . . . . . . . . . . . . .

18

4.10

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . .

18

4.11

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19

..............................................................

20

4.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

16

4.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

4.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

4.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

17

4.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

17

4.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

17

5.

Flexor Tendon Injuries (Zone 3–5)

4.7

Derek L. Masden 5.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

5.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

21

5.2

Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

5.10

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

5.3

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20

5.11

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

22

5.4

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.12

Special Considerations . . . . . . . . . . . . . . . . . . . . .

22

5.5

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.6

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.12.1 5.12.2

Wide-Awake Flexor Tendon Repair. . . . . . . . . . . . Primary Repair with Intercalary Defects . . . . . . .

22 22

5.7

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

21

5.13

Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

5.8

Timing of Repair . . . . . . . . . . . . . . . . . . . . . . . . . .

21

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

23

........................................................

27

Part II: Tendon Reconstruction 6.

Flexor Tendon Reconstruction (Zone 2)

Ryan A. Hoffman, Katharine Criner Woozley, and James S. Raphael

viii

6.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

27

6.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28

6.3

Single-Stage Flexor Tendon Reconstruction .

28

6.3.1 6.3.2 6.3.3 6.3.4 6.3.5 6.3.6

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . Special Instructions, Position, and Anesthesia . . Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Course . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28 28 28 28 28 28

6.4

Two-Stage Flexor Tendon Reconstruction . . . .

28

6.4.1 6.4.2 6.4.3 6.4.4 6.4.5

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . Special Instructions, Position, and Anesthesia . . Tips, Pearls, and Lessons Learned . . . . . . . . . . . . .

28 29 29 31 31

6.4.6 6.4.7 6.4.8

Postoperative Course. . . . . . . . . . . . . . . . . . . . . . . . Bailout, Rescue, and Salvage Procedures . . . . . . . Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31 31 31

6.5

Pulley Reconstruction . . . . . . . . . . . . . . . . . . . . .

32

6.5.1 6.5.2 6.5.3 6.5.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . .

32 32 32 32

6.6

Flexor Tenolysis . . . . . . . . . . . . . . . . . . . . . . . . . . .

32

6.6.1 6.6.2 6.6.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . .

32 32 33

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

33

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Contents

7.

Radial Nerve Palsy Tendon Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

Charles E. Hoffler, Hari Om Gupta, and Menar Wahood 7.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

7.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

7.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

7.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34

7.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

7.6 7.7

7.8.7 7.8.8 7.8.9

EDC Recipient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . EPL Recipient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . .

35 35 35

7.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

38

34

7.9.1 7.9.2

Contractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tensioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38 38

Special Considerations . . . . . . . . . . . . . . . . . . . .

35

7.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

38

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35

7.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

35

7.8.1 7.8.2 7.8.3 7.8.4 7.8.5 7.8.6

PT Donor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FCU Donor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FCR Donor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . FDS Donor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PL Donor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ECRB Recipient. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35 35 35 35 35 35

7.10.1 7.10.2 7.10.3 7.10.4 7.10.5 7.10.6

Number of Incisions . . . . . . . . . . . . . . . . . . . . . . . . Tendon Preparation . . . . . . . . . . . . . . . . . . . . . . . . Weaving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tensioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dangers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . .

38 38 38 38 39 39

7.11

Bailout, Rescue, and Salvage Procedures . . .

39

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39

8.

Low Median Nerve Palsy Tendon Transfers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40

Valeriy Shubinets, Benjamin Chang, and David J. Bozentka 8.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40

8.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

43

8.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40

8.2.1 8.2.2

General Principles of Tendon Transfers . . . . . . . . Considerations Specific to Low Median Nerve Palsy Tendon Transfers . . . . . . . . . . . . . . . . . . . . . .

40 40

8.8.1 8.8.2 8.8.3 8.8.4

EIP Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PL (Camitz) Transfer . . . . . . . . . . . . . . . . . . . . . . . . FDS Transfer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADM (Huber) Transfer . . . . . . . . . . . . . . . . . . . . . .

43 43 43 44

8.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41

8.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

45

8.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42

8.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

45

8.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

42

8.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

42

8.10.1 8.10.2 8.10.3 8.10.4

EIP Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PL (Camitz) Transfer . . . . . . . . . . . . . . . . . . . . . . . . FDS Transfer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADM (Huber) Transfer . . . . . . . . . . . . . . . . . . . . . .

45 45 47 47

8.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

43

8.11

Bailout, Rescue, and Salvage Procedures . . .

48

8.12

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

48

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

49

..................................................

50

9.

Tendon Transfers for Low Ulnar Nerve Palsy Daniel A. Seigerman and Amir R. Kachooei

9.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50

9.2

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50

9.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50

9.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

50

9.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

51

9.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

51

9.7

Tips, Pearls, and Lessons Learned . . . . . . . . . .

51

9.7.1 9.7.2

Correction of Clawing . . . . . . . . . . . . . . . . . . . . . . Loss of Pinch Strength . . . . . . . . . . . . . . . . . . . . . .

51 53

ix

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Contents 9.8

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

53

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

55

9.9

Bailout, Rescue, and Salvage Procedures . . .

55

10.

Extensor Indicis Proprius Tendon Transfer for Rupture of the Extensor Pollicis Longus Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56

Christopher Jones 10.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56

10.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

57

10.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56

10.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

57

10.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56

10.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

57

10.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56

10.11

Bailout, Rescue, and Salvage Procedures . . . .

59

10.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

56

10.12

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

59

10.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

56

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

59

10.7

Special Instructions, Positioning, Anesthesia

56

11.

Extensor Indicis Proprius to Extensor Digitorum Comminus Tendon Transfer. . . . . . . . . . . . . .

60

Robert B. Carrigan Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60

11.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

60

11.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

60

11.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

60

11.11

Bailout, Rescue, and Salvage Procedures . . . .

62

Superficialis Transfer for Rupture of the Flexor Pollicis Longus Tendon . . . . . . . . . . . . . . . . . . . . .

63

11.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60

11.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60

11.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60

11.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60

11.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

60

11.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

60

12.

11.7

Alexandria L. Case, R. Glenn Gaston, and Joshua M. Abzug 12.1

Preoperative Work-up . . . . . . . . . . . . . . . . . . . .

63

12.3

Postoperative Management . . . . . . . . . . . . . . . .

65

12.1.1

Indications and Contraindications . . . . . . . . . . . .

63

12.4

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

65

12.2

Surgical Technique. . . . . . . . . . . . . . . . . . . . . . . .

64

12.5

Summary/Functional Outcomes . . . . . . . . . . . .

66

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

66

Trigger Finger/Thumb Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69

Part III: Tendinopathies 13.

Jack Abboudi

x

13.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69

13.6

Special Considerations . . . . . . . . . . . . . . . . . . . . .

69

13.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69

13.7

13.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

70

69

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

70

69

13.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

13.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

71

69

13.10

Key Procedure Steps . . . . . . . . . . . . . . . . . . . . . . .

71

| 02.06.20 - 23:21

Contents 13.11

Bailout, Rescue, and Salvage Procedures . . . .

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

73

14.

DeQuervain Tenosynovitis

......................................................................

74

72

George L. Yeh 14.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

74

14.4

Treatment Surgical . . . . . . . . . . . . . . . . . . . . . . .

75

14.2

Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

74

14.2.1 14.2.2 14.2.3 14.2.4

Patient History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Examination . . . . . . . . . . . . . . . . . . . . . . . Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis . . . . . . . . . . . . . . . . . . . . . . .

74 75 75 75

14.3

Nonoperative Treatment . . . . . . . . . . . . . . . . . .

75

14.4.1 14.4.2 14.4.3 14.4.4 14.4.5 14.4.6 14.4.7

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Outcome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75 75 75 76 77 78 78

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

78

Extensor Carpi Ulnaris Tenosynovectomy/Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

79

15.

Kevin F. Lutsky 15.1

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

79

15.5

Surgical Approach . . . . . . . . . . . . . . . . . . . . . . . .

80

15.2

Mechanism of Injury . . . . . . . . . . . . . . . . . . . . . .

79

15.6

Tenosynovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80

15.3

Evaluation and Exam . . . . . . . . . . . . . . . . . . . . . .

79

15.7

Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

81

15.4

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

80

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

81

16.

Intersection Syndrome

..........................................................................

82

Julia A. Kenniston 16.1

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

82

16.6.2

Magnetic Resonance Imaging . . . . . . . . . . . . . . . .

83

16.2

Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

82

16.7

Nonoperative Management . . . . . . . . . . . . . . .

83

16.3

Pathoanatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

82

16.8

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

83

16.4

Clinical Presentation . . . . . . . . . . . . . . . . . . . . . .

82

16.5

Differential Diagnosis . . . . . . . . . . . . . . . . . . . . .

82

16.6

Radiographic Features . . . . . . . . . . . . . . . . . . . . .

83

16.8.1 16.8.2 16.8.3 16.8.4

Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . Pitfalls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

83 83 84 84

16.6.1

Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

83

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

84

17.

Lateral Epicondylar Debridement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85

Frederic E. Liss 17.1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85

17.5.2

17.2

Nonoperative Treatment . . . . . . . . . . . . . . . . . .

85

17.2.1

Author’s Preferred Method for Nonoperative Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85

17.3

Differential Diagnosis . . . . . . . . . . . . . . . . . . . . .

85

17.4

Surgical Indications . . . . . . . . . . . . . . . . . . . . . . .

86

17.5

Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . .

86

17.5.1

Arthroscopic Debridement . . . . . . . . . . . . . . . . . .

86

17.5.3

Author’s Preferred Technique: Open Release and Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Rehabilitation . . . . . . . . . . . . . . . . .

86 86

17.6

Potential Complications and Pitfalls . . . . . . . .

86

17.7

Pearls, Tips, and Lessons Learned . . . . . . . . . .

87

17.7.1 17.7.2 17.7.3 17.7.4 17.7.5

Surface Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . Positioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Lateral Collateral Ligament and Joint Capsule . . Radial Nerve and Branches . . . . . . . . . . . . . . . . . . Vascular Considerations for the Capitellum . . . .

87 87 88 88 88

xi

| 02.06.20 - 23:21

Contents 17.7.6

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

88 89

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

89

17.8

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

18.

Medial Epicondylar Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

90

Lance M. Brunton 18.1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

90

18.4

Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . .

91

18.2

Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . .

90

18.5

Ulnar Neuropathy . . . . . . . . . . . . . . . . . . . . . . . . .

91

18.3

Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

91

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

92

........................................................................

95

Part IV: Nerve Repair/Reconstruction 19.

Nerve Repair in the Hand Patricia M. Kallemeier

19.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

95

19.7

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

97

19.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

95

19.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

96

19.7.1 19.7.2

Primary Nerve Repair . . . . . . . . . . . . . . . . . . . . . . . Nerve Reconstruction . . . . . . . . . . . . . . . . . . . . . . .

97 98

19.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

96

19.8

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

98

19.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

96

19.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

98

19.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19.10

Bailout, Rescue, and Salvage Procedures . . . .

99

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

99

20.

96

Peripheral Nerve Injury and Repair using Autograft or Allograft

............................

100

Santiago Rodriguez, Craig Rodner, and Anthony Parrino 20.1

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

100

20.5

Repair Methods . . . . . . . . . . . . . . . . . . . . . . . . . . .

101

20.2

Nerve Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . .

100

20.3

Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . .

100

20.5.1 20.5.2 20.5.3

Direct Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Autograft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Allograft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

101 101 102

20.4

Injury Classification . . . . . . . . . . . . . . . . . . . . . . .

101

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

103

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

103

.............................................

104

21.

Nerve Conduits for Nerve Repair/Reconstruction Eon K. Shin

xii

21.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

104

21.6

Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . .

106

21.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

104

21.3

Nerve Conduit Characteristics . . . . . . . . . . . . .

104

21.6.1 21.6.2 21.6.3

Preparation of Nerve Ends . . . . . . . . . . . . . . . . . . . Suturing of Nerve Ends . . . . . . . . . . . . . . . . . . . . . . Final Surgical Considerations . . . . . . . . . . . . . . . . .

106 106 106

21.3.1 21.3.2

Advantages of Nerve Conduits . . . . . . . . . . . . . . . Materials for Nerve Conduits . . . . . . . . . . . . . . . .

104 104

21.7

Postoperative Rehabilitation . . . . . . . . . . . . . . .

106

21.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

105

21.8

Special Considerations . . . . . . . . . . . . . . . . . . . . .

107

21.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

105

21.8.1 21.8.2

Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107 107

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

107

| 02.06.20 - 23:21

Contents

22.

Oberlin Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108

Juan M. Giugale and John R. Fowler Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

109

22.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

109

22.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

109

22.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

109

22.11

Bailout, Rescue, and Salvage Procedures . . .

110

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

112

Open Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115

22.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108

22.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108

22.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

108

22.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

109

22.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

109

22.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

109

22.7

Part V: Nerve Compression 23.

Violeta Gutierrez Sherman and Jennifer Moriatis Wolf 23.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115

23.7

Tips, Pearls, and Pitfalls . . . . . . . . . . . . . . . . . . .

115

23.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115

23.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115

23.7.1 23.7.2 23.7.3

Incision Marking . . . . . . . . . . . . . . . . . . . . . . . . . . . Tissue Handling. . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgeon Positioning . . . . . . . . . . . . . . . . . . . . . . . .

115 116 116

23.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

115

23.8

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

116

23.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

115

23.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

116

23.6

Instructions, Positioning, and Anesthesia . . . .

115

23.10

Postoperative Management . . . . . . . . . . . . . . .

118

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

118

Endoscopic Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119

24.

Jonas L. Matzon 24.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119

24.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119

24.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119

24.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119

24.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

119

24.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

119

25.

24.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

119

24.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

119

24.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

120

24.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

120

24.11

Bailout, Rescue, and Salvage Procedures . . .

120

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

121

Proximal Median Nerve Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

122

Michael Aversano, Mikhail Zusmanovich, Michael E. Rettig, and Nader Paksima 25.1

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

122

25.4

Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

126

25.1.1

Anomalous Anatomy . . . . . . . . . . . . . . . . . . . . . . .

123

25.2

Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . .

123

25.3

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

124

25.4.1 25.4.2 25.4.3 25.4.4 25.4.5

Nonoperative Management . . . . . . . . . . . . . . . . . Surgical Decompression . . . . . . . . . . . . . . . . . . . . Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . Postop Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . Potential pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . .

126 126 126 126 126

25.3.1 25.3.2

Clinical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

124 124

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

128

xiii

| 02.06.20 - 23:21

Contents

26.

Open Ulnar Nerve Decompression at the Wrist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

130

Daniel B. Polatsch, Steven Beldner, and Remy V. Rabinovich 26.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

130

26.7

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

133

26.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

130

26.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

135

26.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

132

26.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

136

26.4

Indications and Contraindications. . . . . . . . . .

132

26.10

Bailout, Rescue, and Salvage Options . . . . . . .

136

26.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

133

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

136

26.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

133 .......................................................

137

27.

Endoscopic Ulnar Nerve Decompression

Claudia de Cristo, Ludovico Lucenti, and Pedro K. Beredjiklian 27.1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137

27.6

Operative Detail . . . . . . . . . . . . . . . . . . . . . . . . . . .

137

27.2

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137

27.3

Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137

27.4

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137

27.6.1 27.6.2 27.6.3 27.6.4 27.6.5

Preparation—Planning/Special Equipment. . . . . . Technique/Key Steps . . . . . . . . . . . . . . . . . . . . . . . . Risks/What to Avoid . . . . . . . . . . . . . . . . . . . . . . . . Salvage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tips/Pearls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

137 138 138 139 139

27.5

Indications and Contraindications. . . . . . . . . .

137

27.7

Postoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

139

27.5.1 27.5.2 27.5.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . Alternate Procedures . . . . . . . . . . . . . . . . . . . . . . .

137 137 137

27.7.1 27.7.2

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . . Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

139 139

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

139

Open Ulnar Nerve Decompression/Subcutaneous Transposition at the Elbow . . . . . . . . . . . . .

140

28.

Na Cao and David E. Ruchelsman 28.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

140

28.2

Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

140

28.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

140

28.4

Positioning and Anesthesia . . . . . . . . . . . . . . . .

28.5 28.5.1 28.5.2

29.

28.5.3

Key Procedural Steps: Pearls, Pitfalls, and Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . .

142

28.6

Postoperative Rehabilitation . . . . . . . . . . . . . . .

142

140

28.7

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

142

Operative Techniques . . . . . . . . . . . . . . . . . . . . .

140

28.8

Failed Ulnar Nerve Decompression at the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

142

Open In Situ Ulnar Nerve Decompression. . . . . . Subcutaneous Ulnar Nerve Transposition and Z-Lengthening of the Flexor-Pronator Mass . . . .

140

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

143

Submuscular Ulnar Nerve Transposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

144

141

Marc J. Richard and Patrick A. Holt

xiv

29.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

144

29.2

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

144

29.3

Clinical Findings and Indications . . . . . . . . . . .

144

29.4

Contraindications and Considerations . . . . . .

144

29.5

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

144

29.6

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

145

29.7

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

145

| 02.06.20 - 23:21

Contents Transposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

145 146

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

146

Partial Wrist Denervation for Chronic Wrist Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

147

29.8

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

145

29.8.1 29.8.2

Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Decompression . . . . . . . . . . . . . . . . . . . . . . . . . . . .

145 145

30.

29.8.3 29.8.4

Mikhail Zusmanovich, Michael Aversano, Nader Paksima, and Michael E. Rettig 30.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

147

30.7

Presurgical Diagnostic Testing . . . . . . . . . . . . .

148

30.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

147

30.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

147

30.7.1 30.7.2

Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

149 149

30.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

148

30.8

Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . .

149

30.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

148

30.6

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

148

30.8.1 30.8.2 30.8.3

Dorsal Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . Volar Henry Approach . . . . . . . . . . . . . . . . . . . . . . Volar Ulnar Approach. . . . . . . . . . . . . . . . . . . . . . .

149 149 149

30.6.1 30.6.2

Anterior Interosseous Nerve . . . . . . . . . . . . . . . . . Posterior Interosseous Nerve. . . . . . . . . . . . . . . . .

148 148

30.9

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

150

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

151

Distal Phalanx Fractures: Percutaneous Pinning and Open Reduction Internal Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

155

Part VI: Hand Fractures 31.

Carl M. Harper 31.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

155

31.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

155

31.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

156

31.4

Operative Indications . . . . . . . . . . . . . . . . . . . . .

156

31.4.1 31.4.2 31.4.3 31.4.4

Seymour Fractures . . . . . . . . . . . . . . . . . . . . . . . . . Mallet Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . Open Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Unstable Fractures with Nail Plate Loss . . . . . . . .

156 156 156 157

31.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

157

31.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

157

31.6.1 31.6.2

Open Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Associated Nailbed Injury . . . . . . . . . . . . . . . . . . .

157 157

32.

Middle/Proximal Phalanx (Pinning)

31.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

157

31.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

157

31.8.1 31.8.2 31.8.3 31.8.4 31.8.5

Mallet Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suture Anchor Fixation . . . . . . . . . . . . . . . . . . . . . ORIF with a Compression Screw. . . . . . . . . . . . . . Seymour Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . Shaft Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

157 158 158 158 158

31.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

158

31.9.1 31.9.2

Seymour Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . Mallet Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . .

158 158

31.10

Difficulties Encountered, Bailouts, and Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

159

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

159

............................................................

160

Salah Aldekhayel and MM. Al-Qattan 32.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160

32.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

160

32.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160

32.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

161

32.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

160

32.7

32.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

161

160

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xv

| 02.06.20 - 23:21

Contents 32.8

Individual Fractures Discussing Tips, Key Procedural Steps, and Expected Outcomes .

161

32.9

Bailout, Rescue, and Salvage Procedures . . . .

164

32.8.1 32.8.2

Extra-Articular Fractures. . . . . . . . . . . . . . . . . . . . Intra-Articular Fractures . . . . . . . . . . . . . . . . . . . .

161 163

32.10

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

165

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

165

33.

Middle/Proximal Phalanx (Open Reduction and Internal Fixation)

..........................

166

Michael Rivlin 33.1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

166

33.7

Salvage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

168

33.2

Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

166

33.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

166

33.7.1 33.7.2

Corrective Osteotomy . . . . . . . . . . . . . . . . . . . . . . . Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

168 168

33.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

166

33.8

Tips/Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169

33.5

Alternate Procedures . . . . . . . . . . . . . . . . . . . . .

166

33.9

Postoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169

33.6

Operative Detail . . . . . . . . . . . . . . . . . . . . . . . . . .

167

33.10

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . .

169

33.6.1 33.6.2 33.6.3 33.6.4 33.6.5 33.6.6

Preparation: Planning/Special Equipment . . . . . Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Open Reduction and Lag Screw Fixation . . . . . . . Open Reduction and Plate Fixation . . . . . . . . . . . Risks/What to Avoid . . . . . . . . . . . . . . . . . . . . . . . .

167 167 167 167 167 168

33.11

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

169

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

169

34.

Fixation of Uni and Bicondylar Phalangeal Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

170

J. Michael Hendry and Martin Dolan 34.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

170

34.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

171

34.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

170

34.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

171

34.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

170

34.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

170

34.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

170

34.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

170

34.10.1 Closed Reduction and Percutaneous K-wire Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34.10.2 ORIF through Midlateral Approach . . . . . . . . . . . . 34.10.3 Osteochondral Graft Reconstruction through Volar Approach (Shotgun) . . . . . . . . . . . . . . . . . . . 34.10.4 Dorsal Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . .

34.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

170

34.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

170

35.

34.11

171 171 172 172

Bailout, Rescue, and Salvage Procedures . . . .

172

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

172

Bony Mallet Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

173

Genghis E. Niver

xvi

35.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

173

35.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

174

35.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

173

35.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

173

35.8.1 35.8.2

Percutaneous Fixation . . . . . . . . . . . . . . . . . . . . . . . Internal Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . .

174 174

35.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

173

35.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

174

35.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

173

35.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

174

35.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

173

35.11

Bailout, Salvage, and Rescue Procedures . . . .

175

35.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

175

173

| 02.06.20 - 23:21

Contents

36.

Proximal Interphalangeal Joint Fracture-Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

176

William J. Knaus, J. Michael Hendry, and Joseph Upton 36.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

176

36.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

177

36.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

176

36.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

177

36.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

176

36.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

176

36.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

176

36.10.1 36.10.2 36.10.3 36.10.4 36.10.5

Extension Block Pinning . . . . . . . . . . . . . . . . . . . . Dynamic External Fixation . . . . . . . . . . . . . . . . . . Open Reduction and Internal Fixation. . . . . . . . . Volar Plate Arthroplasty . . . . . . . . . . . . . . . . . . . . Hemi-Hamate Arthroplasty . . . . . . . . . . . . . . . . .

177 177 177 178 178

36.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

176

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36.11

Bailout, Rescue, and Salvage Procedures . . .

180

36.7

176

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

180

36.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

176

37.

Metacarpals (Pinning) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

181

Philip S. Brazio and Jacques A. Machol 37.1

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

181

37.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

181

37.2.1 37.2.2 37.2.3

For Operative Fixation . . . . . . . . . . . . . . . . . . . . . . For Pinning over Internal Fixation . . . . . . . . . . . . Contraindications (Indications for Plating) . . . . .

181 181 181

37.3

Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

181

37.3.1 37.3.2 37.3.3 37.3.4

Diagnostic Studies . . . . . . . . . . . . . . . . . . . . . . . . . . Equipment and Hardware . . . . . . . . . . . . . . . . . . . Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Assistants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

181 181 181 181

37.4

Approach to Specific Fracture Patterns . . . . .

181 181

37.4.2 37.4.3

Metacarpal Neck Fracture (Boxer Fracture) . . . . Comminuted Fractures . . . . . . . . . . . . . . . . . . . . .

182 183

37.5

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . .

184

37.5.1 37.5.2 37.5.3

Splinting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pin Removal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

184 184 184

37.6

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .

184

37.6.1 37.6.2 37.6.3

Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pin Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Stiffness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

184 184 184

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

185

37.4.1

Bennett Fracture Dislocation . . . . . . . . . . . . . . . . .

38.

Metacarpal Fracture Open Reduction and Internal Fixation (ORIF) . . . . . . . . . . . . . . . . . . . . . . . . . .

186

Edward S. Lee and Haripriya S. Ayyala 38.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

186

38.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

188

38.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

186

38.7

38.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

188

186

Special Instruments, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38.3.1 38.3.2 38.3.3

Metacarpal Head Fractures . . . . . . . . . . . . . . . . . . Metacarpal Neck Fractures. . . . . . . . . . . . . . . . . . . Metacarpal Shaft Fractures . . . . . . . . . . . . . . . . . .

186 186 187

38.7.1 38.7.2

Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

188 188

38.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

188

38.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

187

38.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

189

38.4.1 38.4.2 38.4.3

General Indications . . . . . . . . . . . . . . . . . . . . . . . . . Metacarpal Neck fractures . . . . . . . . . . . . . . . . . . . Metacarpal Shaft Fractures . . . . . . . . . . . . . . . . . .

187 187 187

38.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

189

38.11

Bailouts, Rescue, and Salvage Procedure . . .

190

38.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

187

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

193

xvii

| 02.06.20 - 23:21

Contents

39.

Limited-Open Retrograde Intramedullary Headless Screw Fixation of Metacarpal Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

194

David E. Ruchelsman and Chaitanya S. Mudgal 39.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

194

39.6

Special Considerations . . . . . . . . . . . . . . . . . . . . .

195

39.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

194

39.7

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

195

39.3

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

194

39.8

Postoperative Rehabilitation . . . . . . . . . . . . . . .

196

39.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

195

39.9

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

196

39.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

195

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

198

40.

First Metacarpal Base Fractures (Bennett and Rolando Fractures) . . . . . . . . . . . . . . . . . . . . . . . . . . .

199

Brandon Rogalski and Richard Tosti 40.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

199

40.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

199

40.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

199

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

199

40.8.3 40.8.4

Closed Reduction and Percutaneous Pinning. . . . Open Reduction Internal Fixation with Interfragmentary Screw . . . . . . . . . . . . . . . . . . . . . Open Reduction Internal Fixation with A Plate . . Arthroscopic Assisted Reduction . . . . . . . . . . . . . .

199

40.3

40.8.1 40.8.2

199 200 201

40.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

201

40.10

Key Procedural Steps During Open Reduction and Internal Fixation (ORIF) . . . . . .

201

Bailout, Rescue, and Salvage Procedures . . . . .

201

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

202

Scaphoid Pinning/ORIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

205

40.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

199

40.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

199

40.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

199

40.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

199

40.11

Part VII: Wrist Fractures 41.

Joseph D. Galloway and Irfan H. Ahmed 41.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

205

41.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

205

41.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

205

41.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

205

41.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

41.6

41.7.2 41.7.3 41.7.4

Tips, Pearls, and Lessons Learned . . . . . . . . . . . . . Difficulties Encountered . . . . . . . . . . . . . . . . . . . . . Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

206 207 208

41.8

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

209

205

41.8.1 41.8.2

Volar Open. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dorsal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

209 209

Special Considerations . . . . . . . . . . . . . . . . . . . .

205

41.9

Bailout, Rescue, and Salvage Procedures . . . .

210

41.7

Operative Treatment . . . . . . . . . . . . . . . . . . . . . .

206

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

211

41.7.1

Special Instructions, Positioning, and Anesthesia

206

42.

Percutaneous/Kapandji Pinning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

212

A. Samandar Dowlatshahi

xviii

42.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

212

42.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

212

42.2

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

212

42.5

Special Considerations . . . . . . . . . . . . . . . . . . . . .

212

42.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

212

| 02.06.20 - 23:21

Contents 42.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

212

42.10

42.7

Tips, Pearls, and Lessons Learned . . . . . . . . . .

212

42.7.1 42.7.2

To Incise or Not to Incise Skin . . . . . . . . . . . . . . . . Pinning Sequence . . . . . . . . . . . . . . . . . . . . . . . . . .

212 212

42.8

Postoperative Management . . . . . . . . . . . . . . .

213

42.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

213

43.

Distal Radius: Volar Approach

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

42.10.1 If Anatomic Reduction Is Achieved by Closed Manipulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42.10.2 If Anatomic Reduction Is Not Achieved by Closed Manipulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42.11

213

213 214

Bailout, Rescue, and Salvage Procedures . . .

215

..................................................................

216

Juana Medina 43.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

216

43.8

Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

216

43.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

216

43.3

Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

216

43.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

216

43.8.1 43.8.2 43.8.3 43.8.4

Henry Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . The Trans-FCR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The Volar-Extensile Approach . . . . . . . . . . . . . . . Modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

216 216 216 216

43.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

216

43.9

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

218

43.6

Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . .

216

43.10

Bailout and Salvage Procedures . . . . . . . . . . . .

219

43.7

Requirements, Positioning, and Anesthesia .

216

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

219

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

219

Dorsal Approach to Distal Radius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

220

44.

Rohit Garg and Jesse B. Jupiter 44.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

220

44.3.5

Case 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

226

44.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

220

44.4

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

226

44.3

Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . .

221

44.5

Tips and Tricks. . . . . . . . . . . . . . . . . . . . . . . . . . . .

226

44.3.1 44.3.2 44.3.3 44.3.4

Case 1 Case 2 Case 3 Case 4

221 223 224 225

44.6

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

227

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

227

45.

Bridge Plating of Distal Radius Fractures

......................................................

228

.................................... .................................... .................................... ....................................

Jonathan W. Shearin and Van Thuc Nguyen 45.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

228

45.6

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

231

45.2

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

228

45.7

Special Considerations . . . . . . . . . . . . . . . . . . . .

231

45.2.1 45.2.2 45.2.3 45.2.4

Bones. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Biomechanics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiographic Parameters . . . . . . . . . . . . . . . . . . . . Extensor Compartments . . . . . . . . . . . . . . . . . . . .

228 228 228 229

45.8

Biomechanical Stability . . . . . . . . . . . . . . . . . . .

231

45.9

Surgical Management . . . . . . . . . . . . . . . . . . . . .

231

45.3

Definition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

230

45.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

230

45.9.1 45.9.2 45.9.3 45.9.4 45.9.5

Planning, Positioning, and Anesthesia . . . . . . . . . Closed Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Approach/Plate Placement . . . . . . . . . . . Plate Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . .

231 231 231 233 233

45.5

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

231

45.10

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

235

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| 02.06.20 - 23:21

Contents References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

46.

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

235

External Fixation of Distal Radius Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

236

235

William H. Kirkpatrick 46.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

236

46.7

Surgical Management . . . . . . . . . . . . . . . . . . . . .

236

46.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

236

46.7.1

Planning, Positioning, and Anesthesia . . . . . . . . .

236

46.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

236

46.8

Tips and Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . .

237

46.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

236

46.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

237

46.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

236

46.10

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

237

46.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

236

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

238

Phalangeal Osteotomies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

241

Part VIII: Bone Reconstruction 47.

Mark Snoddy and Philip E. Blazar 47.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

241

47.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

241

47.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

241

47.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

241

47.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

241

47.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

241

47.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

242

47.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

242

47.8.1

Preoperative Planning . . . . . . . . . . . . . . . . . . . . . .

242

48.

Corrective Osteotomy of Metacarpal Malunion

47.8.2 47.8.3 47.8.4 47.8.5 47.8.6

Osteotomy Location and Type . . . . . . . . . . . . . . . . Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tenolysis and Capsulectomy . . . . . . . . . . . . . . . . . Articular Malunions. . . . . . . . . . . . . . . . . . . . . . . . . Types of Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . .

242 242 243 243 244

47.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

245

47.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

245

47.11

Bailout, Rescue, and Salvage Procedures . . . .

245

47.12

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

245

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

245

...............................................

246

Pranay M. Parikh

xx

48.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

246

48.7

Positioning, Anesthesia . . . . . . . . . . . . . . . . . . . .

247

48.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

246

48.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

247

48.2.1 48.2.2 48.2.3

Treat the Patient, Not the Radiograph . . . . . . . . . Diagnose Before Initiating Treatment . . . . . . . . . Measure Twice, Cut Once. . . . . . . . . . . . . . . . . . . .

246 246 246

48.9

Challenges/Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . .

247

48.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

247

48.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

246

48.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

246

48.10.1 48.10.2 48.10.3 48.10.4

Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Deangulation Osteotomy . . . . . . . . . . . . . . . . . . . . Derotation Osteotomy . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . . .

247 247 248 249

48.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

246

48.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

246

48.11

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

249

48.6.1 48.6.2

Hardware Selection . . . . . . . . . . . . . . . . . . . . . . . . Bone Graft Selection. . . . . . . . . . . . . . . . . . . . . . . .

246 247

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

249

| 02.06.20 - 23:21

Contents

49.

Scaphoid Nonunion: Medial Femoral Condyle Vascularized Bone Graft

....................

250

49.6.3 49.6.4 49.6.5

Flap Harvest Surgical Technique . . . . . . . . . . . . . Graft Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Microvascular Anastomosis. . . . . . . . . . . . . . . . . .

251 252 252

49.7

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

252

49.8

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .

252

49.9

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . .

252

49.9.1 49.9.2

Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wrist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

252 252

49.10

Donor Site Postoperative Morbidity . . . . . . . .

253

Megan R. Miles and James P. Higgins 49.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

250

49.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

250

49.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

250

49.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

250

49.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

251

49.5.1 49.5.2

Avascular Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . Preoperative Imaging . . . . . . . . . . . . . . . . . . . . . . .

251 251

49.6

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

251

49.6.1 49.6.2

Anesthesia and Positioning . . . . . . . . . . . . . . . . . . Volar Wrist Surgical Technique . . . . . . . . . . . . . . .

251 251

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

253

50.

Scaphoid Nonunion-ORIF and Bone Graft for Humpback Deformity . . . . . . . . . . . . . . . . . . . . . . . .

254

Lee M. Reichel and David Ring 50.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

254

50.7

Tips, Pearls, and Lessons Learned . . . . . . . . . .

255

50.2

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

254

50.7.1

50.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

254

50.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

254

50.7.2 50.7.3

Reduction of the Lunate Prior to Scaphoid Correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Graft Procurement and Placement. . . . . . . . . . . . Immobilization after Surgery . . . . . . . . . . . . . . . .

255 255 256

50.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

254

50.8

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

256

50.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

50.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

257

254

50.10

Bailout, Rescue, and Salvage Procedures . . .

257

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

259

Capitate Shortening Osteotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

260

51.

Matthew B. Cantlon 51.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

260

51.5

Operative Technique Alternatives . . . . . . . . . .

260

51.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

260

51.6

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

261

51.3

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

260

51.7

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .

261

51.4

Operative Technique . . . . . . . . . . . . . . . . . . . . . .

260

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

261

52.

Distal Radius Osteotomy for Malunion (Volar Approach) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

262

Kevin D. Han and Peter S. Kim 52.1

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

262

52.5

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

263

52.2

Basic Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

262

52.6

Caveats, Pearls, and Lessons Learned. . . . . . .

263

52.3

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

262

52.4

Indications and Contraindications . . . . . . . . . .

262

52.4.1 52.4.2 52.4.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . Timing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

262 263 263

52.6.1 52.6.2 52.6.3 52.6.4 52.6.5 52.6.6

Preoperative Assessment. . . . . . . . . . . . . . . . . . . . History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Examination . . . . . . . . . . . . . . . . . . . . . . . Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Volar Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Operative Steps . . . . . . . . . . . . . . . . . . . . . . . .

263 263 263 263 263 263

xxi

| 02.06.20 - 23:21

Contents 52.6.7

Special Considerations . . . . . . . . . . . . . . . . . . . . . .

265

52.6.8

Difficulties and Complications . . . . . . . . . . . . . . . .

53.

Distal Radius Osteotomy for Malunion: Dorsal Approach

265

....................................

266

Ludovico Lucenti, Claudia de Cristo, and Pedro K. Beredjiklian 53.1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

266

53.8

Operative Details . . . . . . . . . . . . . . . . . . . . . . . . . .

268

53.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

266

53.3

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

266

53.4

Special Considerations . . . . . . . . . . . . . . . . . . . .

266

53.5

Indications and Contraindications. . . . . . . . . .

266

53.8.1 53.8.2 53.8.3 53.8.4 53.8.5 53.8.6 53.8.7

Preparation—Planning/Special Equipment. . . . . . Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Technique/Key Steps . . . . . . . . . . . . . . . . . . . . . . . . Risks/What to avoid. . . . . . . . . . . . . . . . . . . . . . . . . Salvage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tips/Pearls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

268 270 270 272 274 274 274

53.5.1 53.5.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . .

266 267

53.9

Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . .

275

53.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

53.10

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . .

275

268

53.11

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

275

53.6.1 53.6.2

Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

268 268

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

275

53.7

Preoperative Planning . . . . . . . . . . . . . . . . . . . .

268

Distal Interphalangeal Joint Arthrodesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

279

Part IX: Arthritis 54.

Ryan D. Katz 54.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

279

54.7

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

281

54.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

279

54.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

279

54.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

280

54.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

280

54.7.1 54.7.2 54.7.3 54.7.4 54.7.5 54.7.6

Headless Compression Screw. . . . . . . . . . . . . . . . . Kirschner Wires . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90 × 90 Wires/Wires and Pins. . . . . . . . . . . . . . . . . Bone Loss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Failure of Fixation . . . . . . . . . . . . . . . . . . . . . . . . . . Failure of Union . . . . . . . . . . . . . . . . . . . . . . . . . . . .

281 283 283 283 283 283

54.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

280

54.8

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

283

54.6.1

Special Instructions, Positioning, and Anesthesia

280

54.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

283

54.10

Bailout, Rescue, and Salvage Procedures . . . .

283

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

284

Thumb Basal Joint Arthroplasty: Trapeziectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

285

55.

Jessica Hawken and Kenneth R. Means

xxii

55.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

285

55.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

285

55.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

285

55.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

285

55.5

Relative Contraindications . . . . . . . . . . . . . . . .

285

55.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

285

55.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

285

55.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

285

55.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

286

55.10

Salvage Procedures . . . . . . . . . . . . . . . . . . . . . . . .

289

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

289

| 02.06.20 - 23:21

Contents

56.

Ligament Reconstruction Tendon Interposition (LRTI)

.......................................

290

292 292 292 292 293 294

Charles A. Daly and Christopher L. Forthman 56.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

290

56.8.3

56.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

290

56.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

290

56.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

290

56.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

56.8.4 56.8.5 56.8.6 56.8.7 56.8.8

Inspection of Scaphotrapeziotrapezoid (STT) Joint and Partial Trapeziectomy . . . . . . . . . . . . . . Tunnel Placement . . . . . . . . . . . . . . . . . . . . . . . . . . Harvesting FCR . . . . . . . . . . . . . . . . . . . . . . . . . . . . Passing FCR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Securing MC Suspension . . . . . . . . . . . . . . . . . . . . Capsular Closure . . . . . . . . . . . . . . . . . . . . . . . . . . .

290

56.6

Special considerations . . . . . . . . . . . . . . . . . . . . .

290

56.9

Bailout, Rescue, and Salvage Procedures . . .

294

56.7

Special Instructions, Positioning, Anesthesia

290

56.9.1 56.9.2

FCR Transection . . . . . . . . . . . . . . . . . . . . . . . . . . . Tunnel Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . .

294 294

56.8

Tips, Pearls, and Lessons Learned. . . . . . . . . . .

290

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

294

56.8.1 56.8.2

Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Trapeziectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

290 291

57.

Total Wrist Arthrodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

295

John C. Dunn, Curt Hanenbaum, and Keith A. Segalman 57.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

295

57.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

295

57.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

295

57.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

296

57.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

295

57.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

296

57.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

295

57.11

Bailout, Rescue, and Salvage Procedures . . .

298

57.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

295

57.12

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

299

57.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

295

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

299

57.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

295

Proximal Row Carpectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300

58.

Laura Lewallen and Dawn M. LaPorte 58.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300

58.6

Special Instructions, Positioning, Anesthesia

301

58.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300

58.7

Tips, Pearls, and Lessons Learned . . . . . . . . . .

301

58.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

300

58.8

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

301

58.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

300

58.9

Bailout, Rescue, and Salvage Procedures . . .

302

58.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

300

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

303

59.

Scaphoidectomy and Four-Corner Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

304

David R. Steinberg and Oded Ben-Amotz 59.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

304

59.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

304

59.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

304

59.7

Positioning and Anesthesia . . . . . . . . . . . . . . . .

304

59.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

304

59.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

305

59.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

304

59.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

304

59.8.1 59.8.2 59.8.3

Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Arthrotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scaphoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .

305 305 305

xxiii

| 02.06.20 - 23:21

Contents 59.8.4 59.8.5 59.8.6

Styloidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

305 305 305

59.9.3

Ensuring Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . .

305

59.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

305

59.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

305

59.11

Bailout, Rescue, and Salvage Procedures . . . .

308

59.9.1 59.9.2

Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Scaphoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . .

305 305

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

308

60.

Partial Distal Ulna Resection (Wafer, Hemiresection) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

309

Jason D. Wink and Ines C. Lin 60.1

Wafer Procedure . . . . . . . . . . . . . . . . . . . . . . . . .

309

60.2

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . Special Considerations . . . . . . . . . . . . . . . . . . . . . . Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.1.8 Tips, Pearls, and Lessons Learned . . . . . . . . . . . . . 60.1.9 Difficulties Encountered . . . . . . . . . . . . . . . . . . . . 60.1.10 Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . . . 60.1.11 Bailout, Rescue, and Salvage Procedures . . . . . . .

309 309 309 309 309 309

60.2.1 60.2.2 60.2.3 60.2.4 60.2.5 60.2.6 60.2.7

60.1.1 60.1.2 60.1.3 60.1.4 60.1.5 60.1.6 60.1.7

61.

Ulnar Hemiresection Arthroplasty . . . . . . . . . .

312

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contraindications. . . . . . . . . . . . . . . . . . . . . . . . . . . Special Considerations . . . . . . . . . . . . . . . . . . . . . . Special Instructions, Positioning, and Anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60.2.8 Tips, Pearls, and Lessons Learned . . . . . . . . . . . . . 60.2.9 Difficulties Encountered . . . . . . . . . . . . . . . . . . . . . 60.2.10 Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . . . . 60.2.11 Bailout, Rescue, and Salvage Procedures . . . . . . .

312 312 312 312 312 312 313 313 313 313 314

60.3

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . .

314

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

314

.......................................................

315

310 310 310 310 312

Complete Distal Ulna Excision (Darrach) Dominic J. Mintalucci

61.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

315

61.9

Surgical Procedure . . . . . . . . . . . . . . . . . . . . . . . .

316

61.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

315

61.3

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

315

61.9.1 61.9.2 61.9.3

Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Osteotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Closure and Stabilization . . . . . . . . . . . . . . . . . . . .

316 316 317

61.4

Pertinent Anatomy . . . . . . . . . . . . . . . . . . . . . . .

315

61.10

Postoperative Management . . . . . . . . . . . . . . . .

317

61.5

Clinical History and Physical Examination . .

316

61.11

Functional Outcomes . . . . . . . . . . . . . . . . . . . . . .

317

61.6

Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

316

61.12

61.7

Nonoperative Management . . . . . . . . . . . . . . .

316

Radioulnar Convergence/Stump Instability and Salvage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

317

61.8

Positioning and Anesthesia . . . . . . . . . . . . . . . .

316

Pearls and Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . .

318

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

319

Finger (PIP/DIP) Collateral Ligament Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

323

61.13

Part X: Instability 62.

Meredith N. Osterman

xxiv

62.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

323

62.4

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

323

62.2

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

323

62.5

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

325

62.3

Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

323

| 02.06.20 - 23:21

Contents 62.6

Indications for Surgery . . . . . . . . . . . . . . . . . . . .

325

62.6.1 62.6.2

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . .

325 325

63.

62.7

Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

325

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

325

Finger Metacarpophalangeal Joint Collateral Ligament Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

326

Gregory G. Gallant 63.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

326

63.9

Indications for Surgical Treatment . . . . . . . . .

327

63.2

Anatomy/Physiology . . . . . . . . . . . . . . . . . . . . . .

326

63.10

Contraindications to Surgery . . . . . . . . . . . . . .

327

63.3

Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

326

63.11

Positioning and Anesthesia . . . . . . . . . . . . . . . .

327

63.4

Clinical Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . .

326

63.12

Surgical Techniques . . . . . . . . . . . . . . . . . . . . . . .

328

63.5

Ligament Injury Grades/Classification . . . . . .

326

63.5.1 63.5.2 63.5.3 63.5.4

Grade 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grade 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Grade 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

326 327 327 327

63.12.1 63.12.2 63.12.3 63.12.4

Acute Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic Injuries. . . . . . . . . . . . . . . . . . . . . . . . . . . . Small Displaced Avulsion Fractures . . . . . . . . . . . Larger Displaced Fractures . . . . . . . . . . . . . . . . . .

328 329 329 329

63.13

Postoperative Treatment . . . . . . . . . . . . . . . . . .

329

63.6

Location of Ligament Injury . . . . . . . . . . . . . . . .

327

63.14

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

329

63.7

Radiographic Studies . . . . . . . . . . . . . . . . . . . . . .

327

63.15

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

330

63.8

Conservative Treatment . . . . . . . . . . . . . . . . . . .

327

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

330

64.

Thumb Metacarpophalangeal Joint Collateral Ligament Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

332

Megan L. Jimenez and Bruce A. Monaghan Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

334

64.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

334

64.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

335

64.10

Key Procedural Steps (UCL Repair) . . . . . . . . .

335

64.11

Bailout, Rescue, and Salvage Procedures . . .

337

64.12

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

337

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

337

Thumb Metacarpophalangeal Joint Collateral Ligament Reconstruction . . . . . . . . . . . . . . . . . . .

338

64.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

332

64.1.1

Anatomy/Physiology . . . . . . . . . . . . . . . . . . . . . . . .

332

64.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

333

64.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

333

64.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

333

64.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

334

64.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

334

65.

64.7

Armin Badre and Ruby Grewal 65.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

338

65.2

Relevant Anatomy . . . . . . . . . . . . . . . . . . . . . . . .

338

65.3

Clinical Presentation . . . . . . . . . . . . . . . . . . . . . .

338

65.3.1 65.3.2 65.3.3

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical Examination . . . . . . . . . . . . . . . . . . . . . . . Radiographic Evaluation. . . . . . . . . . . . . . . . . . . . .

338 338 338

65.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

338

65.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

339

65.6

Surgical Technique of UCL Reconstruction: Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

339

65.6.1 65.6.2 65.6.3 65.6.4 65.6.5 65.6.6 65.6.7

Setup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bone Tunnel Preparation . . . . . . . . . . . . . . . . . . . . Tendon Harvest. . . . . . . . . . . . . . . . . . . . . . . . . . . . Tendon Graft Passage and Tensioning . . . . . . . . . Other Fixation Techniques. . . . . . . . . . . . . . . . . . . Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

339 339 340 341 341 342 342

65.7

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

342

xxv

| 02.06.20 - 23:21

Contents Phase III: > 12 weeks . . . . . . . . . . . . . . . . . . . . . . . .

342

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

342

Scapholunate Ligament Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

344

65.8

Rehabilitation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

342

65.8.1 65.8.2

Phase I: 0–6 weeks . . . . . . . . . . . . . . . . . . . . . . . . . Phase II: 6–12 weeks . . . . . . . . . . . . . . . . . . . . . . .

342 342

66.

65.8.3

Daniel A. Seigerman and Michael J. Pensak 66.1

Description and Diagnosis . . . . . . . . . . . . . . . . .

344

66.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

344

66.3

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

345

66.3.1 66.3.2

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Special Considerations . . . . . . . . . . . . . . . . . . . . . .

345 345

66.4

Surgical Technique for Scapholunate Ligament Repair with Capsulodesis Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . .

345 345

66.4.2 66.4.3 66.4.4 66.4.5 66.4.6

Diagnostic Arthroscopy. . . . . . . . . . . . . . . . . . . . . . Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reducing the SL Interval . . . . . . . . . . . . . . . . . . . . . Repair of the Ligament . . . . . . . . . . . . . . . . . . . . . . Capsulodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

345 346 346 346 346

66.5

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . .

346

66.6

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

346

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

347

66.4.1

Special Instructions and Positioning . . . . . . . . . .

67.

Scapholunate Capsulodesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

348

Moody Kwok 67.1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

348

67.8

Special Considerations . . . . . . . . . . . . . . . . . . . . .

350

67.2

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

348

67.9

67.3

Pathophysiology, Nonoperative Treatment, and Natural History . . . . . . . . . . . . . . . . . . . . . . .

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

350

348

67.10

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

350

67.4

Clinical and Imaging Evaluation . . . . . . . . . . . .

348

67.11

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

350

67.5

Operative Treatment . . . . . . . . . . . . . . . . . . . . . .

349

67.11.1 Postoperative Course. . . . . . . . . . . . . . . . . . . . . . . .

350

67.5.1 67.5.2 67.5.3

General Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . Blatt Capsulodesis (Historical Perspective) . . . . . Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

349 349 349

67.12

Bailout, Rescue, and Salvage Procedures . . . .

350

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

351

67.6

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

349

Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . .

351

67.7

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

349

68.

Scapholunate Ligament Reconstruction (Brunelli Types) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

352

Bryan A. Hozack and Asif M. Ilyas 68.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

352

68.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

353

68.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

352

68.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

353

68.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

352

68.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

352

68.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

352

68.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

352

68.10.1 68.10.2 68.10.3 68.10.4 68.10.5 68.10.6

Volar Approach and Graft Harvest. . . . . . . . . . . . . Dorsal Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . Tunnel Placement. . . . . . . . . . . . . . . . . . . . . . . . . . . Graft Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reduction and Fixation . . . . . . . . . . . . . . . . . . . . . . Postoperative Course. . . . . . . . . . . . . . . . . . . . . . . .

353 353 353 354 354 355

68.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

68.11

Bailout, Rescue, and Salvage Procedures . . . .

355

352

Tips, Pearls, and Lessons Learned . . . . . . . . . .

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

355

353

68.8

xxvi

| 02.06.20 - 23:21

Contents

69.

Distal Radioulnar Ligament Repair/Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

356

A. Samandar Dowlatshahi and Tamara D. Rozental 69.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

356

69.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

356

69.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69.4

69.8.1 69.8.2

TFCC Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ligament Reconstruction. . . . . . . . . . . . . . . . . . . .

356 357

356

69.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

357

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

356

69.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

357

69.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

356

69.11

Bailout, Rescue, and Salvage Procedures . . .

358

69.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

356

69.12

Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

358

69.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

69.13

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

358

356

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

358

Tips, Pearls, and Lessons Learned . . . . . . . . . .

356

.......................................................................

363

69.8

Part XI: Skin 70.

Split Thickness Skin Graft Rosemary Yi and Virak Tan

70.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

363

70.2.3

Salvage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

365

70.1.1 70.1.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alternatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

363 363

70.3

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . .

365

70.4

Complication . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

365

70.2

Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . .

363

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

366

70.2.1 70.2.2

Preparation—Planning and Special Equipment. . Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

363 363

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

366

71.

Full Thickness Skin Graft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

367

Aaron Rubinstein and Jonathan Keith 71.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

367

71.6

Technique, Positioning, and Anesthesia . . . .

368

71.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

367

71.7

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . .

368

71.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

368

71.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

369

71.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

368

71.9

Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . .

370

71.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

368

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

370

72.

V–Y Advancement Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

371

Michael J. Pensak and Daniel A. Seigerman 72.1

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

371

72.5

Tips, Pearls, and Lessons . . . . . . . . . . . . . . . . . .

371

72.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

371

72.6

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

373

72.3

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

371

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

373

72.4

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

371

xxvii

| 02.06.20 - 23:21

Contents

73.

Volar Advancement Flaps—Moberg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

374

John E. Nolan III, Nathan T. Morrell, and Adam B. Shafritz 73.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

374

73.8

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

375

73.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

374

73.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

374

73.8.1 73.8.2

Moberg Advancement Flap Technique . . . . . . . . . V–Y Advancement Flap Technique . . . . . . . . . . . .

375 375

73.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

374

73.9

Technical Difficulties. . . . . . . . . . . . . . . . . . . . . . .

375

73.4.1 73.4.2

Moberg Advancement Flap Indications . . . . . . . . V–Y Advancement Flap Indications . . . . . . . . . . .

374 374

73.10

Procedural Modifications . . . . . . . . . . . . . . . . . .

375

73.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

374

73.10.1 Moberg Modifications . . . . . . . . . . . . . . . . . . . . . . . 73.10.2 V–Y Modifications . . . . . . . . . . . . . . . . . . . . . . . . . .

375 376

73.5.1 73.5.2

Moberg Advancement Flap Contraindications . . V-Y Advancement Flap Contraindications. . . . . .

374 374

73.11

Expected Outcomes . . . . . . . . . . . . . . . . . . . . . . .

376

73.12

Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

378

73.6

Vascular Considerations . . . . . . . . . . . . . . . . . . .

374

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

378

73.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

375

Cross Finger (and Reverse) Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

74.

Justin M. Miller, John M. Yingling, and John T. Capo 74.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

74.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

74.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

74.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

74.4.1 74.4.2

Cross-Finger Flap . . . . . . . . . . . . . . . . . . . . . . . . . . Reverse Cross-Finger Flap . . . . . . . . . . . . . . . . . . .

379 379

74.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

379

74.5.1

Both Cross-Finger and Reverse Flaps . . . . . . . . . .

379

74.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

379

75.

74.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

74.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

379

74.9

Difficulties and Complications Encountered .

380

74.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

380

74.10.1 Cross-Finger Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . 74.10.2 Reverse Cross-Finger Flap . . . . . . . . . . . . . . . . . . . .

380 381

74.11

Bailout, Rescue, and Salvage Procedures . . . .

383

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

385

Thenar Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

386

Stephen Ros and James Monica

xxviii

75.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

386

75.8

Tips, Pearls, and Lessons Learned . . . . . . . . . . .

387

75.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

386

75.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

387

75.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

387

75.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

387

75.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

387

75.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

387

75.10.1 Stage 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75.10.2 Stage 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

387 388

75.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

387

75.11

Bailout, Rescue, and Salvage Procedures . . . .

389

75.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

75.12

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

389

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

389

387

| 02.06.20 - 23:21

Contents

76.

Axial Flag Flap and First Dorsal Metacarpal Artery Flap (Kite Flap)

.........................

390

Roger B. Gaskins III and Zhongyu Li 76.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

390

76.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

391

76.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

390

76.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

390

76.8.1 76.8.2 76.8.3

Pedicle Dissection. . . . . . . . . . . . . . . . . . . . . . . . . . Flap Sizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

391 391 391

76.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

390

76.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

391

76.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

390

76.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

391

76.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

391

76.11

Bailout, Rescue, and Salvage Procedures . . .

391

76.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

391

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

393

Z-plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

394

77.

Rosemary Yi 77.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

394

77.1.1 77.1.2

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

394 394

77.2

Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

395 396

77.4

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . .

397

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

397

Suggested Readings . . . . . . . . . . . . . . . . . . . . . .

397

77.3

Modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

78.

Radial Forearm Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

398

Takintope Akinbiyi and Benjamin Chang 78.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

398

78.10

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . .

400

78.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

398

400

78.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

398

78.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

398

78.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

398

78.6

Special Considerations . . . . . . . . . . . . . . . . . . . .

398

78.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

398

78.10.1 Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.10.2 Antegrade Fasciocutaneous Pedicled Flap and Free Flap. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.10.3 Retrograde (Reverse) Fasciocutaneous Pedicled Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.10.4 Radial Artery Sparing Perforator-based Pedicled Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.10.5 Adipofascial Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . 78.10.6 Osteocutaneous Flap . . . . . . . . . . . . . . . . . . . . . . . 78.10.7 Other Flap Considerations . . . . . . . . . . . . . . . . . . .

78.8

Tips, Pearls, and Lessons Learned . . . . . . . . . .

398

78.11

Bailout, Rescue, and Salvage Procedures . . .

402

78.8.1 78.8.2 78.8.3

Radial Artery Perforator Location . . . . . . . . . . . . . Composite Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tunneling a Pedicled Flap Under a Skin Bridge . .

398 399 399

78.12

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

402

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

402

78.9

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

Suggested Reading . . . . . . . . . . . . . . . . . . . . . . .

403

399

Needle Aponeurotomy for Dupuytren's Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

407

400 401 402 402 402 402

Part XII: Dupuytren’s Disease 79.

Charles F. Leinberry 79.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

407

79.3

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

407

79.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

407

79.4

Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

407

xxix

| 02.06.20 - 23:21

Contents 79.5

Technical Tip/Pearl . . . . . . . . . . . . . . . . . . . . . . . .

409

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

410

79.5.1 79.5.2

Breaking the Cord . . . . . . . . . . . . . . . . . . . . . . . . . . Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

409 410

80.

Subtotal Fasciectomy for Dupuytren's Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

411

Craig S. Phillips and Grigory E. Gershkovich 80.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

411

80.2

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

411

80.3

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

412

80.3.1

Relative Contraindication . . . . . . . . . . . . . . . . . . .

412

80.4

Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

412

80.4.1 80.4.2 80.4.3 80.4.4

Skin Incision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Subtotal Fasciectomy . . . . . . . . . . . . . . . . . . . . . . . . Contracture Release. . . . . . . . . . . . . . . . . . . . . . . . . Recurrence and Complications . . . . . . . . . . . . . . .

412 413 413 415

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

416

Thumb CMC and MCP Joint Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

419

Part XIII: Arthroscopy 81.

Mark L. Wang and Pedro K. Beredjiklian 81.1

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

419

81.7

Joint Surface Resection . . . . . . . . . . . . . . . . . . . .

420

81.2

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

419

81.8

81.3

Procedural Setup . . . . . . . . . . . . . . . . . . . . . . . . .

420

419

First Metacarpal Intra-Articular Fracture Reduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

81.9

Septic Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . .

420

81.3.1

Establishing Portals . . . . . . . . . . . . . . . . . . . . . . . .

419

81.10

MCP Joint Arthroscopy . . . . . . . . . . . . . . . . . . . . .

421

81.4

Diagnostic Arthroscopy . . . . . . . . . . . . . . . . . . .

419

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

421

81.5

Arthroscopic-Assisted Synovectomy . . . . . . .

420

81.6

Joint Capsular Shrinkage . . . . . . . . . . . . . . . . . .

420

82.

Diagnostic Wrist Arthroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

422

Joseph Said III and Donald Mazur 82.1

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

422

82.2

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

422

82.3

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

422

82.4

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

422

82.5

Special Considerations . . . . . . . . . . . . . . . . . . . .

422

82.6

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

422

82.6.1

Tips, Pearls, and Lessons Learned . . . . . . . . . . . . .

423

83.

Arthroscopic Triangular Fibrocartilage Complex/Ligament Debridement

82.6.2 82.6.3 82.6.4

Portal Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . Radiocarpal Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . Midcarpal Joint. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

423 423 425

82.7

Difficulties Encountered . . . . . . . . . . . . . . . . . . .

425

82.8

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

426

82.9

Bailout, Rescue, and Salvage Procedures . . . .

426

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

426

..................

428

Matthew L. Drake

xxx

83.1

Description. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

428

83.4

Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

428

83.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . .

428

83.5

Contraindications . . . . . . . . . . . . . . . . . . . . . . . . .

428

83.3

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

428

83.6

Special Considerations . . . . . . . . . . . . . . . . . . . . .

428

| 02.06.20 - 23:21

Contents 83.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

428

83.10

Bailout, Rescue, and Salvage Procedures . . .

431

83.8

Tips, Pearls, and Lessons Learned. . . . . . . . . . .

429

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

431

83.9

Key Procedural Steps . . . . . . . . . . . . . . . . . . . . . .

429

84.

TFCC Outside-In Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

432

Sara Low and Christopher Williamson 84.1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

432

84.2

Key Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

432

84.3

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

432

84.4

Special Considerations. . . . . . . . . . . . . . . . . . . . .

433

84.5

Indications and Contraindications . . . . . . . . . .

434

84.6

Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

434

84.7

Special Instructions, Positioning, and Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

434

84.8

Key Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

434

84.9

Postoperative Care . . . . . . . . . . . . . . . . . . . . . . .

436

84.10

Tips/Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

436

84.11

Pearls and Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . .

436

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

437

Paronychia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

441

Part XIV: Infection 85.

T. Robert Takei 85.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

441

85.2

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

441

85.3

Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . .

441

85.4

Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

441

85.5

Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

85.6

85.7.2 85.7.3

Chronic Paronychia. . . . . . . . . . . . . . . . . . . . . . . . . Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

443 443

85.8

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

443

441

85.8.1 85.8.2 85.8.3

Acute Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chronic Infection . . . . . . . . . . . . . . . . . . . . . . . . . .

443 443 444

Differential Diagnosis . . . . . . . . . . . . . . . . . . . . .

442

85.9

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

444

85.7

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

442

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

444

85.7.1

Acute Paronychia . . . . . . . . . . . . . . . . . . . . . . . . . . .

442

86.

Felon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

445

Brian Katt, Daren Aita, and Daniel Fletcher 86.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

445

86.7

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

445

86.2

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

445

86.8

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

446

86.3

Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . .

445

86.4

Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

445

86.8.1 86.8.2 86.8.3

Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antibiotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Felon Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

446 446 446

86.5

Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

445

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

447

86.6

Differential Diagnosis . . . . . . . . . . . . . . . . . . . . .

445

87.

Flexor Tenosynovitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

448

Jason M. Rovak 87.1

Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

448

87.2

History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

448

87.3

Differential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

448

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| 02.06.20 - 23:21

Contents 87.4

Work-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

448

87.6

Antibiotic Management . . . . . . . . . . . . . . . . . . .

450

87.4.1 87.4.2 87.4.3

Physical Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Laboratory Findings . . . . . . . . . . . . . . . . . . . . . . . . Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

448 448 448

87.7

Inpatient versus Outpatient Treatment . . . . .

450

87.8

Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

450

87.5

Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

449

87.9

Pitfalls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

450

87.5.1 87.5.2 87.5.3

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . Postoperative Care . . . . . . . . . . . . . . . . . . . . . . . . .

449 449 450

Suggested Readings . . . . . . . . . . . . . . . . . . . . . . .

450

88.

Septic Joint

........................................................................................

451

Samir Sodha

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88.1

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

451

88.2

Clinical Presentation . . . . . . . . . . . . . . . . . . . . . .

451

88.3

Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

451

88.3.1 88.3.2 88.3.3

Physical Examination . . . . . . . . . . . . . . . . . . . . . . . Differential Diagnosis. . . . . . . . . . . . . . . . . . . . . . . Laboratory and Diagnostic Testing. . . . . . . . . . . .

451 451 451

88.4

Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . .

452

88.4.1

Septic Distal Interphalangeal Joint . . . . . . . . . . . .

452

88.4.2 88.4.3 88.4.4

Septic Proximal Interphalangeal Joint . . . . . . . . . Septic Metacarpophalangeal Joint . . . . . . . . . . . . . Septic Wrist Joint . . . . . . . . . . . . . . . . . . . . . . . . . . .

452 453 453

88.5

Postsurgical Care . . . . . . . . . . . . . . . . . . . . . . . . . .

453

88.5.1 88.5.2

Surgical Wound Management . . . . . . . . . . . . . . . . Antibiotic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . .

453 454

88.6

Septic Joint Sequelae . . . . . . . . . . . . . . . . . . . . . .

455

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

455

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

457

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Foreword Dr. Pedro K. Beredjiklian, the Chief of Hand Service at Rothman Institute in Philadelphia, one of the most highly regarded academic orthopaedic programs in the country, has committed his career to the education and training of residents and fellows. That commitment is clearly evident in this textbook, Hand Surgery: Tricks of the Trade. Despite the proliferation of written and video information readily available on the Internet, this textbook is an important and timely educational resource. All the major topics in relation to hand surgery are discussed in 88 chapters, which are arranged across 14 sections. Each chapter, and many are co-authored, is written by recognized authorities on the subject. Dr. Beredjiklian and his six co-editors have insured that the information in each chapter is both current and accurate. Chapters include the operative treatment for acute and chronic tendon, nerve, ligament and bone injuries in the wrist and hand, and the reconstructive procedures required for the sequelae of problems such as tendon transfers, ligament reconstructions, arthroplasties, osteotomies, and arthrodeses. Surgery for chronic tendinopathies and compressive neuropathies in the hand elbow, wrist, and hand are also covered; surgical techniques for arthritic problems, skin coverage deficits, Dupuytren’s disease, and pyogenic hand infections are captured in detail. Endoscopic median

nerve decompression in the carpal tunnel and arthroscopic wrist techniques are also discussed. Dr. Beredjiklian’s textbook is comprehensive and organized in an uncomplicated “how-to” fashion that includes a concise description of the topic, key principles pertaining to the operative procedure, potential risks and complications and, most importantly, “Tips, Pearls, and Lessons Learned” by the authors. Each chapter provides a list of references which is limited to those deemed most important, as well as several suggestions for further reading on the topic. Residents and fellows will certainly benefit from this textbook as an important go-to reference. Experienced hand surgeons will also benefit as it is a useful guide to review problems and operative procedures they do not commonly encounter in their practice. Our patients, of course, will be the ultimate benefactors. Hand Surgery: Tricks of the Trade should be in the library of every hand surgeon. Martin A. Posner, M.D. Professor of Orthopedic Surgery NYU School of Medicine Chief: Division of Hand Surgery NYU– Langone Orthopedic Hospital New York City, New York, USA

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Preface There are many books available in the field of hand surgery which cover a wide range of topics, primarily from a didactic standpoint. However, despite the depth of detail present in these books, specific information on the precise steps that need to be followed in the operating room is limited. The idea for this text came as a response to these concerns. This work is designed to cover the basic surgical aspects of commonly performed hand procedures in a clear and reproducible manner. The chapters are designed to allow the reader to review the basic steps and important issues associated with each procedure. In other words, this is a “how-to” textbook that has been created keeping in mind medical students, surgical trainees, and practicing hand surgeons. One of the key features of this book is the consistent organization of each chapter. The structure is designed to allow the reader to quickly read through an operative

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procedure and review the salient features associated with the procedure, with special emphasis on the operative technique. We have integrated information involving a wide range of topics in hand surgery to create an all-inclusive procedure reference. To complement the information, each chapter is heavily illustrated to convey not only important anatomic considerations but also intraoperative tips and tricks that will help as procedural keys during surgery. We would like to thank the chapter authors for their dedication to the field and commitment to sharing their knowledge and experience. In addition, much gratitude to the section editors who tirelessly engaged in organizing and compiling a large amount of information. Pedro K. Beredjiklian, MD

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Contributors Editor Pedro K. Beredjiklian, MD Senior Vice President of Clinical Affairs Chief of the Hand Service Rothman Orthopaedic Institute Professor of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania, USA Associate Editors Ludovico Lucenti, MD Orthopaedic surgeon Department of Orthopaedics and Traumatology Policlinico Casilino Hospital Rome, Italy Kevin F. Lutsky, MD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania; Research Director Division of Hand Surgery Rothman Orthopaedic Institute Egg Harbor Township, New Jersey, USA Jonas L. Matzon, MD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania; Rothman Orthopaedic Institute–Hand, Wrist, Elbow, & Microvascular Surgery Washington Township, New Jersey, USA Michael Rivlin, MD Associate Professor Department of Hand and Orthopaedic Surgery Rothman Institute of Orthopaedics Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania, USA Virak Tan, MD Clinical Professor of Orthopedics Rutgers–New Jersey Medical School Institute for Hand and Arm Surgery Madison, New Jersey, USA

Michael M. Vosbikian, MD Assistant Professor Department of Orthopaedic Surgery Rutgers–New Jersey Medical School Newark, New Jersey, USA Contributors Jack Abboudi, MD Assistant Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania; Rothman Orthopaedic Institute–Hand, Wrist, Elbow, & Microvascular Surgery Malvern, Pennsylvania, USA Joshua M. Abzug, MD Associate Professor Departments of Orthopedics and Pediatrics University of Maryland School of Medicine; Director, University of Maryland Brachial Plexus Practice Director of Pediatric Orthopedics University of Maryland Medical Center; Deputy Surgeon-in-Chief University of Maryland Children's Hospital; Director and Founder, Camp Open Arms Timonium, Maryland, USA Irfan H. Ahmed, MD Associate Professor Director, Hand Surgery Fellowship Chief, Hand and Upper Extremity Surgery Department of Orthopaedics, University Hospital New Jersey Medical School Rutgers, The State University of New Jersey Newark, New Jersey, USA Daren Aita, MD Orthopaedic Surgeon Rothman Orthopaedic Institute–Hand, Wrist, Elbow, & Microvascular Surgery Trenton, New Jersey, USA Takintope Akinbiyi, MD, MSc Chief Resident Division of Plastic Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania, USA

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Contributors Salah Aldekhayel, MD, MEd, FRCSC Assistant Professor of Plastic Surgery Division of Plastic and Reconstructive Surgery King Saud bin Abdulaziz University for Health Sciences Riyadh, Saudi Arabia MM. Al-Qattan, MD Consultant Plastic Surgeon and Professor of Surgery Head, Division of Plastic Surgery King Saud University Riyadh, Saudi Arabia Director, College of Medicine Research Center (CMRC) Medical College King Saud University, Riyadh Michael Aversano, MD Orthopedic surgeon Department of Pediatric Orthopaedic Surgery Division of Pediatric Hand & Upper Extremity Surgery Joe DiMaggio Children's Hospital Hollywood, Florida, USA Haripriya S. Ayyala, MD Resident Division of Plastic Surgery Rutgers–New Jersey Medical School Newark, New Jersey, USA Armin Badre, MD, MSc, FRCSC Assistant Clinical Professor Western Upper Limb Facility (WULF) Division of Orthopaedic Surgery, Department of Surgery University of Alberta Edmonton, Alberta, Canada Steven Beldner, MD Assistant Professor Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Department of Orthopaedic Surgery Lenox Hill Hospital–Northwell Health New York, New York, USA Oded Ben-Amotz, MD Hand surgeon Penn Musculoskeletal Center Penn Medicine University City Philadelphia, Pennsylvania, USA Pedro K. Beredjiklian, MD Senior Vice President of Clinical Affairs Chief of the Hand Service Rothman Orthopaedic Institute Professor of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania, USA

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Philip E. Blazar, MD Chief Division of Hand Surgery Associate Professor of Orthopaedic Surgery Harvard Medical School Brigham Health Boston, Massachusetts, USA David J. Bozentka, MD Chief, Orthopaedic Surgery Penn Presbyterian Medical Center; Chief, Hand Surgery Section Department of Orthopedic Surgery; Associate Professor Perelman School of Medicine of the University of Pennsylvania Philadelphia, Pennsylvania, USA Philip S. Brazio, MD Clinical Instructor, Microsurgery Division of Plastic and Reconstructive Surgery Stanford University Palo Alto, California, USA Lance M. Brunton, MD Excela Health Orthopaedics and Sports Medicine Latrobe, Pennsylvania, USA Matthew B. Cantlon, MD Orthopaedic Hand and Upper Extremity Surgeon Orthopaedic and Neurosurgery Specialists Greenwich, Connecticut, USA Na Cao, MD Resident Department of Orthopaedic Surgery Tufts Medical Center Boston, Massachusetts, USA John T. Capo, MD Chief of Hand Surgery Vice Chairman of Orthopaedics Residency Program Director RWJ Barnabas Health Jersey City Medical Center Jersey City, New Jersey, USA Robert B. Carrigan, MD Attending Orthopaedic Surgeon Division of Orthopaedic Surgery Children's Hospital of Philadelphia Philadelphia, Pennsylvania, USA Alexandria L. Case, MS Orthopaedic Clinical Research Coordinator Department of Orthopaedics University of Maryland School of Medicine Timonium, Maryland, USA

| 02.06.20 - 23:21

Contributors Benjamin Chang, MD Professor of Clinical Surgery Associate Chief, Division of Plastic Surgery University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania, USA Claudia de Cristo, MD Orthopaedic surgeon Department of Orthopaedics and Traumatology University Hospital "Policlinico-Vittorio Emanuele" University of Catania Catania, Sicily, Italy Charles A. Daly, MD Consultant Shoulder, Elbow, Hand & Wrist Surgery Emory Upper Extremity Center; Department of Orthopaedic Surgery Emory University Atlanta, Georgia, USA Martin Dolan, MD Orthopedic surgeon Harvard Vanguard Medical Associates Boston, Massachusetts, USA Christopher Doumas, MD Clinical Assistant Professor Rutgers Robert Wood Johnson Medical School Chief of Hand Surgery Jersey Shore University Medical Center University Orthopaedic Associates, LLC Somerset, New Jersey, USA A. Samandar Dowlatshahi, MD Instructor, Harvard Medical School Division of Hand Surgery, Department of Orthopaedics Division of Plastic Surgery, Department of Surgery Beth Israel Deaconess Medical Center Boston, Massachusetts, USA Matthew L. Drake, MD Orthopedic Hand Surgeon Olathe Health Johnson County Orthopedics and Sports Medicine Olathe, Kansas, USA John C. Dunn, MD Walter Reed National Military Medical Center Bethesda, Maryland, USA Curtis National Hand Center Baltimore, Maryland, USA

Daniel Fletcher, MD, ABOS, CAQSH, ASSH Hand, Upper Extremity, and Shoulder Surgeon Member, Rothman Institute Board of Councils President, Trenton Orthopaedic Group at Rothman Institute President, New Jersey Surgery Center Trenton, New Jersey, USA Christopher L. Forthman, MD Consultant Shoulder, Elbow, Hand & Wrist Surgery Greater Chesapeake Hand to Shoulder Specialists Curtis National Hand Center Medstar Union Memorial Hospital Baltimore, Maryland, USA John R. Fowler, MD Assistant Dean and Associate Professor Department of Orthopaedics University of Pittsburgh Pittsburgh, Pennsylvania, USA Gregory G. Gallant, MD, MBA Rothman Orthopaedic Institute Orthopaedic Surgeon Hand, Wrist, Elbow, and Shoulder Specialist Microvascular Surgeon Doylestown, Pennsylvania, USA Joseph D. Galloway, MD Resident Physician Department of Orthopaedic Surgery Rutgers–New Jersey Medical School Newark, New Jersey, USA Rohit Garg, MD Orthopaedic Hand Surgeon Massachusetts General Hospital Boston, Massachusetts, USA Roger B. Gaskins, III, MD Hand & Upper Extremity Surgeon Florida Medical Clinic Tampa, Florida, USA R. Glenn Gaston, MD Fellowship Director Ortho Carolina Hand and Upper Extremity Fellowship Chief of Hand Surgery Atrium Musculoskeletal Institute Charlotte, North Carolina, USA

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Contributors Grigory E. Gershkovich, MD Orthopaedic Surgeon Tower Health Medical Group Hand & Upper Extremity Surgery Division of Orthopaedic Surgery Phoenixville Hospital Phoenixville, Pennsylvania, USA Juan M. Giugale, MD Hand and Upper Extremity Fellow Department of Orthopaedics University of Pittsburgh Pittsburgh, Pennsylvania, USA Ruby Grewal, MD Associate Professor Roth|McFarlane Hand and Upper Limb Center University of Western Ontario St. Joseph's Health Center London, Ontario, Canada Hari Om Gupta, DO, MSc Orthopaedic Surgeon LECOMT–Larkin Community Hospital Miami Hand and Upper Extremity Institute Miami, Florida, USA Kevin D. Han, MD Faculty Physician, BUMC-P University of Arizona College of Medicine Arizona Center for Hand Surgery Phoenix, Arizona, USA Curt Hanenbaum, MS IV Medical Student University of Connecticut Storrs, Connecticut, USA

Charles E. Hoffler, II, PhD, MD Associate Professor of Orthopaedic Surgery at Larkin Nova Southeastern University Miami Hand and Upper Extremity Institute Miami, Florida, USA Ryan A. Hoffman, MD Orthopedic Surgery Resident Department of Orthopedic Surgery Einstein Healthcare Network Philadelphia, Pennsylvania, USA Patrick A. Holt, MD, PhD Orthopedic Surgeon Peninsula Orthopaedic Associates Salisbury, Maryland, USA Bryan A. Hozack, MD Chief Resident Department of Orthopaedic Surgery Thomas Jefferson University Hospital Rothman Orthopaedics Philadelphia, Pennsylvania, USA Asif M. Ilyas, MD, MBA, FACS Professor & Fellowship Program Director Rothman Orthopaedic Institute Thomas Jefferson University Philadelphia, Pennsylvania, USA

Carl M. Harper, MD, FAAOS Assistant Professor Department of Orthopedic Surgery Division of Hand & Upper Extremity Surgery Harvard Medical School Boston, Massachusetts, USA

Matthew L. Iorio, MD Associate Professor Director, PRS Hand Surgery Service Co-Director, Extremity Microsurgical Reconstruction Co-Director, Wound Care Program Division of Plastic Surgery University of Colorado Hospital Aurora, Colorado, USA

Jessica Hawken, MD Orthopaedic Surgery Resident Curtis National Hand Center MedStar Union Memorial Hospital Baltimore, Maryland, USA

Megan L. Jimenez, DO Fellow Sports Medicine and Surgery Washington University St. Louis, Missouri, USA

J. Michael Hendry, MD, MSc Assistant Professor, Queen’s University Division of Plastic Surgery Kingston Health Sciences Centre Kingston, Ontario, Canada

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James P. Higgins, MD Chief of Hand Surgery Curtis National Hand Center Medstar Union Memorial Hospital Baltimore, Maryland, USA

| 02.06.20 - 23:21

Contributors Christopher Jones, MD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Rothman Orthopaedic Institute–Hand, Wrist, Elbow, & Microvascular Surgery Philadelphia, Pennsylvania, USA Jesse B. Jupiter, MD Past President, American Shoulder and Elbow Surgeons Hansjoerg Wyss/AO Professor Harvard Medical School Visiting Orthopedic Surgeon Massachusetts General Hospital Boston, Massachusetts, USA Amir R. Kachooei, MD Assistant Professor and Surgeon Department of Orthopedic Hand and Elbow Orthopedic Research Center Mashhad University of Medical Sciences Ghaem Hospital, Ahmad-Abad Street Mashhad, Iran Patricia M. Kallemeier, MD Orthopaedic Surgeon Hand, Wrist and Elbow Surgery DMOS Orthopaedic Centers West Des Moines, Iowa, USA Brian Katt, MD Hand and Upper Extremity Surgeon Division of Hand Surgery Rothman Institute Philadelphia, Pennsylvania, USA Ryan D. Katz, MD Attending Hand Surgeon Curtis National Hand Center MedStar Union Memorial Hospital Baltimore, Maryland, USA Jonathan Keith, MD, FACS Associate Professor Division of Plastic Surgery Rutgers New Jersey Medical School Newark, NewJersey, USA Julia A. Kenniston, MD Orthopedic Hand Surgeon Plymouth Bay Orthopedic Associates, Inc. Plymouth, Massachusetts, USA

Peter S. Kim, MD Orthopedic hand surgeon Orthopedics and Sports Medicine, Atrius Health Instructor of Surgery Harvard Medical School Boston, Massachusetts, USA William H. Kirkpatrick, MD Clinical Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Rothman Orthopedic Institute Division of Hand Surgery Philadelphia, Pennsylvania, USA William J. Knaus, MD Assistant Professor of Surgery, Plastic and Reconstructive Surgery Department of Surgery Emory University School of Medicine Atlanta, Georgia, USA Moody Kwok, MD Orthopedic hand surgeon Rothman Institute Willow Grove, Pennsylvania, USA Dawn M. LaPorte, MD Professor and Vice Chair Education Department of Orthopaedic Surgery Johns Hopkins University School of Medicine Baltimore, Maryland, USA David W. Lee, MD Orthopedic Surgery Resident Department of Orthopedic Surgery Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey, USA Edward S. Lee, MD, MS Chief Division of Plastic Surgery Rutgers–New Jersey Medical School Newark, New Jersey, USA Charles F. Leinberry, MD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Hand and Wrist Specialist Rothman Orthopaedic Institute Bensalem, Pennsylvania, USA

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Contributors Laura Lewallen, MD Assistant Professor Department of Orthopaedic Surgery Johns Hopkins University School of Medicine Baltimore, Maryland, USA Zhongyu Li, MD, PhD Professor Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center Wake Forest School of Medicine Winston-Salem, North Carolina, USA Ines C. Lin, MD, MSEd Assistant Professor of Surgery Department of Surgery Division of Plastic Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania, USA Frederic E. Liss, MD Clinical Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University; Hand, Wrist, Elbow and Shoulder Surgery Rothman Orthopaedic Institute Philadelphia, Pennsylvania, USA Sara Low, MD Einstein Orthopedic Specialists Einstein Healthcare Network Philadelphia, Pennsylvania, USA Ludovico Lucenti, MD Orthopaedic surgeon Department of Orthopaedics and Traumatology Policlinico Casilino Hospital Rome, Italy Kevin F. Lutsky, MD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania; Research Director Division of Hand Surgery Rothman Orthopaedic Institute Egg Harbor Township, New Jersey, USA

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Jacques A. Machol, IV, MD, FACS Clinical Assistant Professor USC Division of Plastic Surgery Department of Plastic Surgery Southern California Permanente Group Los Angeles, California, USA Derek L. Masden, MD, FACS Vice Chairman of Plastic Surgery, MedStar Washington Hospital Center Plastic Surgery/Hand Surgery, MedStar Washington Hospital Center; Assistant Clinical Professor Department of Plastic Surgery, MedStar Georgetown University Hospital Washington, DC, USA Jonas L. Matzon, MD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania; Rothman Orthopaedic Institute–Hand, Wrist, Elbow, & Microvascular Surgery Washington Township, New Jersey, USA Donald Mazur, MD Orthopaedic Sports Medicine Rothman Orthopaedics Philadelphia, Pennsylvania, USA Kenneth R. Means, Jr. MD Vice-Chief Curtis National Hand Center MedStar Union Memorial Hospital Baltimore, Maryland, USA Juana Medina, MD Orthopedic surgeon Hand Surgery Unidad Ortopedica de Colombia Bogota, Colombia Megan R. Miles, MD Orthopaedic Surgery Resident The Curtis National Hand Center MedStar Union Memorial Hospital Baltimore, Maryland, USA Justin M. Miller, DO Orthopaedic Co-Chief Resident RWJ Barnabas Health Jersey City Medical Center Jersey City, New Jersey, USA

| 02.06.20 - 23:21

Contributors Dominic J. Mintalucci, MD Hand & Upper Extremity Surgeon Co-Director, The Hand Center at Santa Rosa Orthopaedics Santa Rosa Orthopaedic Medical Group Santa Rosa, California, USA

Nader Paksima, DO, MPH Clinical Professor of Orthopedic Surgery Associate Chief of Hand Service NYU School of Medicine New York, New York, USA

Bruce A. Monaghan, MD Chairman Department of Surgery Inspira Medical Center Mullica Hill Premier Orthopaedic Associates of Southern New Jersey Mullica Hill, New Jersey, USA

Pranay M. Parikh, MD Chief, Section of Hand Surgery Chief, Division of Plastic & Reconstructive Surgery Assistant Professor of Surgery University of Massachusetts Medical School Baystate Medical Center Springfield, Massachusetts, USA

James Monica, MD Clinical Assistant Professor Rutgers University/University Orthopaedic Associates Somerset, New Jersey, USA Nathan T. Morrell, MD Assistant Professor, Orthopaedic Surgery Orthopaedic Hand & Upper Extremity Surgery University of New Mexico Health Sciences Center Albuquerque, New Mexico, USA Chaitanya S. Mudgal, MD, MS, MCh Associate Professor in Orthopaedic Surgery Harvard Medical School Department of Orthopaedic Surgery Hand Surgery Service Massachusetts General Hospital Boston, Massachusetts, USA Van Thuc Nguyen, DO Resident Department of General Surgery Arnot Ogden Medical Center Elmira, New York, USA Genghis E. Niver, MD Hand and Upper Extremity Surgeon Summit Medical Group Florham Park, New Jersey, USA

Anthony Parrino, MD Orthopedic surgeon Department of Orthopaedic Surgery University of Connecticut Health Center Farmington, Connecticut, USA Michael J. Pensak, MD President Ocean Orthopedic Associates Toms River, New Jersey, USA Craig S. Phillips, MD Hand and Upper Extremity Surgeon The Illinois Bone & Joint Institute; Clinical Assistant Professor of Surgery Department of Orthopaedic Surgery The University of Chicago Hospitals Pritzker School of Medicine Chicago, Illinois, USA Daniel B. Polatsch, MD Assistant Professor Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Department of Orthopaedic Surgery Lenox Hill Hospital–Northwell Health New York, New York, USA

John E. Nolan, III, MD, MS Orthopaedic Surgery Resident University of Vermont Medical Center Burlington, Vermont, USA

Remy V. Rabinovich, MD Attending Physician Department of Orthopaedic Surgery Lenox Hill Hospital–Northwell Health New York, New York USA

Meredith N. Osterman, MD Assistant Professor Upper extremity and Microvascular Surgery Thomas Jefferson University Hospital The Philadelphia Hand to Shoulder Center King of Prussia, Pennsylvania, USA

James S. Raphael, MD Chairman Department of Orthopedic Surgery Director of Hand & Upper Extremity Surgery Einstein Healthcare Network Philadelphia, Pennsylvania, USA

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Contributors Lee M. Reichel, MD Orthopaedic Surgeon Austin Regional Clinic; Associate Professor UT Austin, Dell Medical School Austin, Texas, USA Michael E. Rettig, MD Clinical Professor Department of Orthopedic Surgery New York University Langone Medical Center New York, New York, USA Marc J. Richard, MD Associate Professor Hand, Upper Extremity, and Microvascular Surgery Department of Orthopaedic Surgery Duke University Medical Center Durham, North Carolina, USA David Ring, MD, PhD Associate Dean for Comprehensive Care Professor of Surgery and Psychiatry Dell Medical School The University of Texas at Austin Austin, Texas, USA Michael Rivlin, MD Associate Professor Department of Hand and Orthopaedic Surgery Rothman Institute of Orthopaedics Sidney Kimmel Medical College Thomas Jefferson University Philadelphia, Pennsylvania, USA Craig Rodner, MD Associate professor Department of Orthopaedic Surgery University of Connecticut Health Center Farmington, Connecticut, USA Santiago Rodriguez, MD Resident Department of Orthopaedic Surgery University of Connecticut Health Center Farmington, Connecticut, USA Brandon Rogalski, MD Orthopedic Surgery Resident The Philadelphia Hand Center King of Prussia, Pennsylvania, USA Stephen Ros, MD, PhD Orthopedic Surgery Resident Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey, USA

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Jason M. Rovak, MD Hand Surgeon Hand Surgery Associates, P.C Denver, Colorado, USA Tamara D. Rozental, MD Chief, Hand and Upper Extremity Surgery Professor of Orthopaedic Surgery Harvard Medical School Beth Israel Deaconess Medical Center Boston, Massachusetts, USA Aaron Rubinstein, MD Orthopaedic surgeon Division of Orthopaedic Surgery Rutgers New Jersey Medical School Newark, New Jersey, USA David E. Ruchelsman, MD, FAAOS Chief of Hand Surgery Director, Hand Surgery Research & Education Foundation Clinical Associate Professor of Orthopaedic Surgery NWH Department of Orthopaedic Surgery Boston, Massachusetts, USA Joseph Said III, MD Orthopedic Hand and Upper Extremity Surgeon Summit Medical Group Westfield, New Jersey, USA Keith A. Segalman, MD Attending Physician Curtis National Hand Center Assistant Clinical Professor Department of Orthopedic Surgery Johns Hopkins Hospital Baltimore Maryland, USA Daniel A. Seigerman, MD Rothman Orthopedic Institute; Assistant Professor Department of Orthopedic Surgery Zucker School of Medicine, Hofstra/Northwell; Chief of Hand Surgery, Phelps Hospital New York, New York, USA Adam B. Shafritz, MD Professor of Orthopaedics and Rehabilitation University of Vermont Robert Larner, MD College of Medicine Burlington, Vermont, USA

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Contributors Jonathan W. Shearin, MD Hand and Upper Extremity Surgeon Tri-County Orthopaedics Cedar Knolls, New Jersey, USA Violeta Gutierrez Sherman, MD Orthopaedic Surgeon Kaiser Permanente Hand & Upper Extremity Surgery Kaiser Fresno Medical Center Fresno, California, USA Eon K. Shin, MD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Philadelphia Hand to Shoulder Center Langhorne, Pennsylvania, USA Valeriy Shubinets, MD Hand Surgery Fellow Curtis National Hand Center Union Memorial Hospital Baltimore, Maryland, USA Mark Snoddy, MD Hand and Upper Extremity Fellow Department of Orthopaedics Brigham and Womens Hospital Boston, Massachusetts, USA Samir Sodha, MD Chief of Hand Surgery Assistant Professor Department of Orthopaedic Surgery Hackensack-Meridian School of Medicine at Seton Hall University Rothman Orthopedic Institute Hackensack, New Jersey, USA David R. Steinberg, MD Professor Director, Hand and Upper Extremity Fellowship Department of Orthopaedic Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania, USA T. Robert Takei, MD Hand and Upper Extremity Surgeon Rothman Orthopedic Institute; Chief, Hand Surgery Abington Memorial Hospital Abington, Pennsylvania, USA

Virak Tan, MD Clinical Professor of Orthopedics Rutgers–New Jersey Medical School Institute for Hand and Arm Surgery Madison, New Jersey, USA Brian A. Tinsley, MD Orthopaedic surgeon Orthopaedic Associates of Reading Wyomissing, Pennsylvania, USA Richard Tosti, MD Hand, Wrist, Elbow, and Microvascular Surgeon Philadelphia Hand to Shoulder Center; Assistant Professor Department of Orthopaedic Surgery Thomas Jefferson University King of Prussia, Pennsylvania, USA Joseph Upton, MD Hand and microvascular surgery Childrens Hospital Boston Boston Shriners Hospital Beth Israel Deaconess Hospital; Professor of Surgery Harvard Medical School Boston, Massachusetts, USA Menar Wahood, DO Orthopaedic surgeon Larkin Community Hospital Miami Hand and Upper Extremity Institute Miami, Florida, USA Mark L. Wang, MD, PhD Associate Professor Department of Orthopaedic Surgery Sidney Kimmel Medical College Thomas Jefferson University Division of Hand Surgery Rothman Orthopaedic Institute Philadelphia, Pennsylvania, USA Christopher Williamson, MD Orthopaedic surgeon Einstein Orthopedic Specialists Einstein Healthcare Network King of Prussia, Pennsylvania, USA Jason D. Wink, MD, MS Chief Resident Division of Plastic Surgery University of Pennsylvania Philadelphia, Pennsylvania, USA

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Contributors Jennifer Moriatis Wolf, MD Professor Department of Orthopaedic Surgery The University of Chicago Chicago, Illinois, USA Kirk Wong, MD Orthopedic surgeon Rebound Orthopedics Vancouver, Washington, USA Katharine Criner Woozley, MD Associate Professor Department of Orthopaedic Surgery Einstein Healthcare Network Philadelphia, Pennsylvania, USA George L. Yeh, MD Orthopedic Surgeon Potomac Valley Orthopaedic Associates Olney, Maryland, USA

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Rosemary Yi, MD Clinical Instructor Orthopedic Surgery Division Rutgers University–New Jersey Medical School RWJ Barnabas Health Institute for Hand and Arm Surgery Harrison, New Jersey, USA John M. Yingling, DO Orthopaedic Co-Chief Resident RWJ Barnabas Health Jersey City Medical Center Jersey City, New Jersey, USA Mikhail Zusmanovich, MD Orthopedic surgeon Department of Orthopaedic Surgery New York University/Hospital for Joint Diseases New York, New York, USA

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Part I Tendon Injuries

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1 Extensor Tendon Repair (Zones 1, 3, 5)

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2 Extensor Tendon Repair (Zones 2, 4, 6–9)

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3 Flexor Tendon Repair (Zone 1)

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4 Flexor Tendon Repair (Zone 2)

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5 Flexor Tendon Injuries (Zone 3–5)

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1 Extensor Tendon Repair (Zone 1, 3, 5) Kevin D. Han and Matthew L. Iorio Abstract Extensor tendon injuries are more common than flexor tendon injuries and require similar precision in diagnosis and treatment. Closed injuries without an open injury can be treated with splints or casts, whereas those resulting from an open injury (e.g., laceration) should be treated with an open repair. In addition, chronic injuries, or those involving significant bony avulsions, often require surgical intervention. Soft tissue mallet injuries may have similar outcomes following splinting in either acute or chronic phase. Central slip injuries must be monitored closely to prevent development of a Boutonnière deformity. For zone 5 “fight bite” injuries, tendon repair should be delayed until any infection is cleared. Postoperative therapy for zones 1 and 3 injuries should focus on immobilization. However, isolated zone 5 injuries may benefit from early gliding with relative motion splinting.

include sagittal hood and sagittal band injuries, resulting in subluxation of the extensor tendon into the intermetacarpal recess. The extensor mechanism of the digits is governed by two separate and neurologically independent systems. The radial nerves innervate the extrinsic extensors (extensor digitorum communis [EDC], extensor indicis proprius [EIP], and extensor digiti minimi [EDM]) and the ulnar and median nerves innervate the intrinsic extensors (lumbricals, interossei). The extrinsic extensors originate in the proximal forearm and are responsible for MCP joint extension. Within the intrinsic system, the lumbricals originate on the flexor digitorum profundus (FDP) tendon, though the third and fourth lumbricals may have an accessory head on the ulnar side of the neighboring flexor tendon. The interossei originate on

Keywords: extensor tendon, mallet finger, central slip, sagittal band, zones of injury, fight bite

1.1 Key Principles Extensor tendons are thinner and flatter than flexor tendons, and are therefore less likely to hold core sutures. Repair methods should focus on maximizing strength while minimizing shortening. As such, mattress or figure-of-eight-type sutures may be better suited for repair. Given the frequency of contamination, absorbable suture material with a prolonged degradation time such as polydioxanone (up to 6 weeks) should be considered in lieu of permanent sutures that may harbor prolonged bacterial colonization or represent a nidus for breakdown or pain in the thin dorsal skin envelope. The extensor mechanism is largely extrasynovial and any instrumentation can cause potential scarring to skin and bone. In the setting of an associated fracture, periosteal stripping can cause dense adherence of the extensor tendon to the underlying cortical bone. This should be considered when choosing techniques of osteosynthesis to allow for early mobilization and gliding of the tendon. Extensor tendon injuries are often associated with damage to neighboring structures, such as metacarpophalangeal (MCP) joint penetration in the setting of “fight bite” injuries in zone 5, or germinal matrix and physeal injuries in zone 1.

1.2 Anatomy Extensor tendon injuries are classified by zones, with “odd” number designations occurring over joints (▶ Fig. 1.1). So, zone 1 injuries are over the distal interphalangeal (DIP) joint and represent disruption of the terminal extensor, zone 3 are at the level of the proximal interphalangeal (PIP) joint with an injury to the central slip, and zone 5 designate injuries at the MCP joint. It should be noted that zone 5 injuries, in addition to disruption of the joint or metacarpal head, may

Fig. 1.1 Extensor tendon zones. Modified nomenclature: The zones of the extensor tendons of the fingers are designated as Dd1-Dd8 and those of the thumb as Pd1-Pd5. D=Digit (fingers; second through fifth digits). P= Pollex (thumb; first digit). d= dorsal. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

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Extensor Tendon Repair (Zone 1, 3, 5) the metacarpal and attach to the extensor mechanism at the level of the proximal phalanx. Given the volar position of the intrinsic extensor, relative to the axis of rotation of the MCP joint, they are responsible for MCP joint flexion and IP joint extension.

1.3 Repair Indications and Contraindications Generally, the indications of closed or open treatment of extensor tendon injuries in the fingers depend on whether the disruption is due to a closed or open (wound) injury. Closed injuries without an open injury can be treated with splints or casts, whereas those resulting from an open injury (e.g., laceration) should be treated with an open repair. In addition, chronic injuries, even when closed, often require surgical intervention. Open injuries, chronic extensor deficiencies, or complex traumas typically warrant operative intervention. Active infection, loss of dorsal soft tissue coverage, or chronic injuries with joint stiffness or ankylosis may represent relative contraindications to operative repair.

1.4 Anesthesia Extensor injuries in zones 1 and 3 can be repaired under digital block, while a wrist block may be needed for zone 5. However, general anesthesia may be required in some patients, especially pediatrics, to allow appropriate exploration and irrigation of the wound. Wide awake local anesthesia using a local anesthetic with epinephrine obviates the need for a tourniquet and is an increasingly popular and effective method for acute repairs.

prevent skin necrosis. For patients that present in a delayed fashion, it is still reasonable to offer splinting, with reports of chronic injuries up to 3 months demonstrating satisfactory outcomes. Tendon avulsions with a fracture fragment (i.e., bony mallet) are also correctable with a splint. Joint subluxation may be present in injuries involving 50% or more of the joint surface, and in order to establish a congruent joint, surgical repair may be needed. In cases where a large articular fragment is involved but the joint is stable through range of motion, operative indications may be based upon function as opposed to the absolute presence of a fracture. Closed reduction and percutaneous pining can be performed for delayed or open injuries. Mild hypertension of the DIP joint improves clinical joint reduction, which is visualized under fluoroscopy. A slight bend of the k-wire may help prevent migration or extrusion during the treatment period (▶ Fig. 1.2). Regardless of the repair technique, the patient should be counseled that a slight extension lag, swan neck deformity, or joint stiffness may persist.

Soft Tissue Mallet Repair A soft tissue mallet may require operative treatment if open from a laceration or a crush injury, or for those that have failed conservative treatment with splinting. A recent systematic review demonstrated similar outcomes in either splinting or operative repair. Therefore, operative repair may be best suited for failed splinting or a secondary rupture. Several repair techniques have been reported, but we prefer the use of a small anchor placed at the dorsal ridge of the distal phalanx to avoid injury to the joint or germinal matrix. If desired, the repair can be augmented through dermatotenodesis, where the skin closure sutures include the underlying extensor tendon to

1.5 Caveats, Pearls, and Lessons Learned (Extensor Zone 1, 3, 5) 1.5.1 Zone 1: Terminal Tendon Injuries (Mallet Finger) Anatomy The lateral bands are formed from contributions of the intrinsic muscles (lumbricals, interossei) and the EDC tendon. The two lateral bands come together just proximal to the DIP joint to form the terminal tendon that attaches onto the dorsal aspect of the distal phalanx. The action of the terminal tendon is to effect extension at the DIP joint, and a disruption of the tendonbone juncture leads to loss of active extension of the DIP joint. The finger then assumes a flexion position at the joint due to the unopposed pull of the flexor tendons.

Treatment Most closed zone 1 tendon avulsions (i.e., soft tissue mallet) can be treated with extension splinting of the DIP joint. We recommend uninterrupted splinting for 6 weeks followed by gradual weaning of 2 additional weeks of nighttime splinting. It is important to avoid hyperextension of the DIP joint in the splint to

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Fig. 1.2 A chronic central slip deficiency treated with dorsal mobilization of the lateral bands, and reconstruction of the central slip with a crossed palmaris tendon graft.

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Caveats, Pearls, and Lessons Learned (Extensor Zone 1, 3, 5) encourage scarring of the two tissue planes. Following repair, a retrograde k-wire should be placed across the joint for 4 to 6 weeks to maximize tendon adherence.

Bony Mallet Repair Operative treatment for a chronic bony mallet can be challenging. Percutaneous techniques involve flexing the DIP joint and placing a k-wire perpendicular to a tangent at the dorsal joint line. The joint is then extended and the wire functions as a blockade to proximal migration of the bony fragment, encouraging fracture reduction. A retrograde wire through the DIP is then placed to hold the reduction. Open repair of the bony mallet may involve placement of a small headed compression screw, or if the joint is stable, excision of the fragment and attachment of the tendon through the use of an anchor.

Special Considerations ●

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Pediatric transepiphyseal fractures (i.e., Seymour fractures) may require operative treatment to remove the interposed germinal matrix from the open physis. For patients who are unable to comply with an external splint (e.g., health care providers who wash their hands several times daily), a buried transarticular wire may be a favorable alternative.

Difficulties and Complications Closed treatment can have complications related to the splint, with dorsal skin maceration or ulceration. Most frequently, however, poor patient compliance is responsible for failure of treatment. Additionally, pin track infections can result in premature loss of internal splinting, or in severe cases, cause deep track infections and osteomyelitis. For chronic injuries, surgery to rebalance the extensor mechanism finger should not be considered until splinting has been attempted and any joint stiffness corrected. The PIP joint should be splinted in 40° to 60° of flexion in the setting of secondary swan neck deformities. Operative treatment options can include extensor tendon reconstruction and central slip tenotomy. However, we have found that DIP arthrodesis is the simplest and most successful treatment option in this situation.

1.5.2 Zone 3: Central Slip Injuries Anatomy (▶ Fig. 1.3) The central slip is formed from contributions of the intrinsic muscles (lumbricals, interossei) and the EDC tendon. The central slip attaches onto the dorsal aspect of the middle phalanx. The action of the central slip is to effect extension at the PIP joint, and a disruption of the tendon-bone juncture leads to loss of active extension of the PIP joint. The finger then assumes a flexion position at the joint due to the unopposed pull of the flexor tendons. If palmar subluxation of lateral bands occurs, subsequent flexion of the PIP joint and hypertension of DIP joint results (i.e., Boutonnière finger). On examination in the acute setting, the Elson’s test can be used to identify disruption of the central slip. To perform the

Fig. 1.3 Closed rupture of the medial part of the intermediate band in zone Dd3. There is loss of active extension in the proximal interphalangeal joint: (1) Tendon of the flexor digitorum profundus. (2) Dorsal aponeurosis. (2.1) Oblique retinacular ligament. (2.2) Lateral part of the lateral band. (2.3) Medial part of the intermediate band. (2.4) Lateral part of the intermediate band. (3) Tendon of the flexor digitorum superficialis. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

examination, the injured finger is held by the examiner in 90° of flexion at the PIP joint. The patient is then asked to extend the finger and DIP joint. If the DIP joint remains supple or “floppy,” the central slip is intact and limiting proximal excursion of the lateral bands. If, however, the DIP joint becomes rigidly extended, the central slip has lost its advantage over the lateral bands and is most likely transected.

Treatment Most closed zone 3 tendon avulsions can be treated with extension splinting of the PIP joint. We recommend uninterrupted splinting for 6 weeks followed by gradual weaning of 2 additional weeks of nighttime splinting. The DIP joint is typically left unsplinted and range of motion is recommended to allow gliding of the lateral bands. Tendon avulsions with a fracture fragment are typically treated surgically with pinning of the PIP joint in extension, and pin or screw fixation of the bone fragment is large enough.

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Extensor Tendon Repair (Zone 1, 3, 5)

Central Slip Repair A central slip injury may require operative treatment if open from a laceration or a crush injury, or for those that have failed conservative treatment with splinting. Several repair techniques have been reported, but we prefer the use of a small anchor placed at the dorsal ridge of the middle phalanx. Following repair, a retrograde k-wire should be placed across the joint for 4 to 6 weeks to maximize tendon adherence (▶ Fig. 1.4). Open repair of the central slip can be challenging, especially in delayed cases where the proximal tendon stump may be indurated or fibrotic. Limited proximal migration is typically seen, however, owing to the several points of insertion throughout the dorsal finger. It should be noted that a very tight or tenuous repair of the central slip at the base of the middle phalanx may represent a hindrance to motion during recovery, or go on to early rupture. If the repair is tight or difficult due to chronicity

or loss of tissue, a dorsal tendon turnover, lateral band transfer, or free graft should be considered (▶ Fig. 1.5).

Difficulties and Complications Closed treatment can have complications due to poor patient compliance. Stiffness of the PIP joint is seen with frequency especially after surgical management, and treatment with physical and occupational therapy is often required to address this problem. Additionally, pin track infections can result in premature loss of internal splinting, or in severe cases, cause deep track infections and osteomyelitis. A Boutonnière deformity may develop following a central slip injury at various time points, including as early as a week post-injury. However, if the contracture is associated with joint fibrosis, we prefer to release the joint or employ serial extension casting to create a supple joint prior to reconstruction. In severe or late cases, joint arthrodesis may be required to restore function.

Fig. 1.4 (a, b) Laceration of the intermediate band, lateral band, and oblique retinacular ligament treated by repairing the tendon with core sutures and transfixing the proximal interphalangeal joint. The individual tendon segments are selectively sutured: (1) Dorsal aponeurosis. (1.1) Lateral part of the lateral band. (1.2) Medial part of the intermediate band. (1.3) Lateral part of the intermediate band. (1.4) Oblique retinacular ligament. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

Fig. 1.5 (a, b) A slight bend at the tip of the k-wire and mild hyperextension of the DIP joint is demonstrated under fluoroscopy.

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Caveats, Pearls, and Lessons Learned (Extensor Zone 1, 3, 5)

Fig. 1.6 (a) Ulnar subluxation of the extensor in zone 5 indicating an injury to the radial sagittal band. (b) The EDC to the finger is split and proximally transected. It is then woven through the junction of the tendon and sagittal hood to prevent propagation of the split. (c) The split portion is tunneled deep to the intermetacarpal ligament to reconstruct the radial sagittal band and centralize the tendon.

1.5.3 Zone 5: MCP Joint Injuries

EDC Tendon Repair

Anatomy

Repair from tendon disruption is technically easier in zone 5, as the tendon becomes thicker and may accommodate a more robust suture repair. Following repair, the wrist should be splinted in slight extension to decrease tension on the repair. Our preference after operative repair is to employ a relative motion splint, which places the injured digit in hyperextension at the MCP relative to the neighboring fingers. This may allow for early motion with decreased joint stiffness or extensor lag. In the setting of traumatic injuries incurred from punching another person, a high suspicion for joint bacterial inoculation and attendant injuries of the metacarpal head or sagittal bands should be carefully considered. Tendon repair can be delayed in this setting until infection has been cleared.

The EDC tendon is innervated by the posterior interosseous nerve proximally. Proximal to the MCP joint, the juncturae tendinum interlink the extrinsic extensors and limit independent extension and permit assisted extension. Juncturae are more prevalent in the ulnar digits. The index finger and the small finger can have its own extensor, the EIP and EDM, respectively. The proprius tendons are usually ulnar to the EDC tendon on the dorsum of the hand. The EDC tendons are stabilized over the MCP joint by the radial and ulnar sagittal bands, and it is the mechanism responsible for MCP joint extension. Rupture of the sagittal bands can lead to tendon instability over the MCP joints. On physical examination, injury is manifested as subluxation of the extensor tendon into the intermetacarpal recess.

Treatment Injury to the EDC tendon in zone 5 can be divided into a disruption of the actual tendon and sagittal band injuries. Tendon disruptions are typically the result of open injuries (lacerations, punching, or fight bite injuries), while sagittal band injuries are often closed and the result of blunt trauma. As such, tendon disruptions typically involve surgical repair, while sagittal band injuries are initially treated with a splint or cast for 4 to 6 weeks. Patients that fail immobilization or present in delayed fashion with a closed rupture of sagittal band are candidates for surgical repair. If primary repair of sagittal band is not possible, such as commonly seen with chronic or attritional ruptures, a portion of the EDC can be split and wrapped deep to the intermetacarpal ligament to recapitulate the sagittal band and prevent tendon subluxation (▶ Fig. 1.6).

Difficulties and Complications In the setting of human fight bites or serious infections, the initial goals are infection control, surgical debridement, and soft tissue equilibrium prior to any definitive tendon repair. However, longterm immobilization can lead to adhesions and joint stiffness.

Suggested Readings Brzezienski MA, Schneider LH. Extensor tendon injuries at the distal interphalangeal joint. Hand Clin. 1995; 11(3):373–386 Cheung JP, Fung B, Ip WY. Review on mallet finger treatment. Hand Surg. 2012; 17 (3):439–447 Hashizume H, Nishida K, Mizumoto D, Takagoshi H, Inoue H. Dorsally displaced epiphyseal fracture of the phalangeal base. J Hand Surg [Br]. 1996; 21(1):136–138 Lin JS, Samora JB. Surgical and nonsurgical management of mallet finger: a systematic review. J Hand Surg Am. 2018; 43(2):146–163.e2 McKeon KE, Lee DH. Posttraumatic Boutonnière and swan neck deformities. J Am Acad Orthop Surg. 2015; 23(10):623–632 Shewring DJ, Trickett RW, Subramanian KN, Hnyda R. The management of clenched fist “fight bite” injuries of the hand. J Hand Surg Eur Vol. 2015; 40 (8):819–824

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2 Extensor Tendon Repair (Zones 2, 4, 6–9) Kirk Wong Abstract This chapter focuses on extensor tendon injuries from zone 2 to 9 excluding zones 1, 3, and 5. Surgical repair is favored for complete injuries or partial ones which involve more than 50% of the width of the tendon. Various techniques have been described to lessen the chance of tendon shortening and gap formation and to improve the ease of the technique. Traditionally, the modified Becker technique is superior over the modified Kessler, figure of 8, or modified Bunnell suture technique. The RITM (running, interlocking, horizontal mattress) technique provides greater strength, less shortening, and faster operative time compared to the modified Becker stitch, especially for zone 2 to 4 repairs. Rehabilitation for zone 4 to 7 repairs can consist of the Wyndell Merritt protocol that allows for early active motion. Complications such as tendon adhesion, rupture, and limited flexion can be mitigated by optimal repair technique and appropriate rehabilitation. Keywords: Becker, Bunnell, extensor tendons, RITM, Kessler, ICAM, Wyndell Merritt

2.1 Introduction Extensor tendon injuries can be divided in to nine zones (▶ Fig. 2.1). Zone 1 includes the distal interphalangeal (DIP) joint, zone 2 the middle phalanx, zone 3 the proximal interphalangeal (PIP) joint, zone 4 the proximal phalanx, zone 5 the metacarpophalangeal (MCP) joint, zone 6 the metacarpals, zone 7 the carpus, zone 8 the musculotendinous junction, and zone 9 the muscles of the extensors. Thumb zone 1 is over the interphalangeal joint, zone 2 the proximal phalanx, zone 3 the MCP joint, zone 4 the thumb metacarpal, and zone 5 the thumb carpometacarpal (CMC) joint. This chapter will discuss initial evaluation, treatment, rehabilitation, and complications related to extensor tendon injuries in zones 2, 4, 6, 7, 8, and 9. Zones 1, 3, and 5 are described in Chapter 1.

2.2 Evaluation Examination starts with observing the normal cascade of the hand. The examiner needs to test each finger individually for extension lag or weakness to prevent the juncturae tendinum from masking a tendon injury. Associated bony and soft tissue injuries need to be addressed at the same time or in a staged fashion.

2.3 Treatment 2.3.1 General Treatment Guidelines When examining a patient with an extensor tendon laceration, it is important to assess active and passive motion of the finger and wrist. Radiographs should be obtained to rule out bony

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Fig. 2.1 Extensor tendon zones of injury. (Modified with permission from Baratz M, Schmidt C, Hughes T. Extensor tendon injuries. In Green DP, Hotchkiss RN, Pederson WC, eds. Green’s operative hand surgery. 5th ed. New York: Churchill Livingstone, 2005: 187–217. Copyright 2005, with permission from Elsevier.)

injuries or radiopaque foreign bodies. Neurovascular status should be documented. With open fractures, appropriate washout, debridement, and antibiotics should be administered, and tetanus should be updated. It is also important to test each extensor compartment for zone 7 injuries. In grossly contaminated wounds, repair is delayed until the contamination is under control. Despite better repair techniques and rehabilitation, patients should be advised that some extensor lag may persist, and full flexion may not be possible despite successful treatment.

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Treatment

2.3.2 Repair Techniques Repair techniques include modified Becker, modified Bunnell (▶ Fig. 2.2), modified Kessler, or running, interlocking, horizontal mattress (RITM) stitch as described by Lee et al1 (▶ Fig. 2.3 and ▶ Fig. 2.4). The augmented or modified Becker suture method was performed with two rows of laterally placed crisscrossing sutures initiated 1 cm from the edge of the tendon with three crosses for each side of the tendon margin. The modified Bunnell suture method consists of four core sutures with the second core suture placed next to the first as described by Howard et al.2 For the RITM suture configuration, a simple running suture is placed followed by a mattress configuration that is locked by passing the suture needle underneath the preceding crossing suture. Woo et al3 reported four different extension repair techniques comparing modified Kessler, modified Becker, figure of 8, and double loop technique. They found that the modified Becker technique failed solely by suture breakage instead of pull out, with the highest resistance to gapping. They suggested that sutures applied to the lateral edge of the extensor tendon perpendicular to the orientation of the fibers provided the strongest repair, especially for zone 2 and 4 injuries. In addition, with the modified Becker technique the crisscross lattice creates a finger trap effect around the tendon to strengthen the repair.3 Chung et al4 performed a biomechanical study investigating the strength of 1, 2, or 3 cross-stitches using the modified Becker technique and found that a single cross-stitch had increased stiffness, yield load, and less gap formation than multiple cross-stitches. However, a single

Fig. 2.2 Modified Becker and Bunnell technique. (Modified with permission from Howard RF, Ondrovic L, Greeenwald DP. Biomechanical analysis of four-strand extensor tendon repair techniques. J Hand Surg 1997;22A:838–842.)

cross-stitch had a lower ultimate load to failure compared with three cross stitches. The tendon distal to the MCP joint (zones 2–4) are generally thinner and best repaired with RITM technique using 4–0 nonabsorbable braided sutures, whereas the tendon proximal to zone 5 can accommodate a core suture better and can be better secured with a modified Kessler or modified Becker stitch using 3–0 nonabsorbable braided sutures.

2.3.3 Zone 2 (Proximal Phalanx (Pinning) Phalanx) Injuries Extensor tendons in zone 2 have a bilobe-shaped cross-section configuration. The lateral bands on either side are held together by triangular ligament. Separate sutures placed over the lateral band provide more secure repair than suture placement centrally. Partial tendon lacerations involving less than 50% of the width without extensor lag can be treated with 3 weeks of DIP joint splinting in extension. Tendon laceration involving more than 50% with weak DIP joint extension or extensor lag is best treated with figure of 8 suture, modified Becker stitch, or RITM technique with pinning of the DIP joint. If a tendon gap precludes primary repair, one can consider turndown flap described by Kochever (▶ Fig. 2.5).

2.3.4 Zone 4 (Proximal Phalanx) Injuries In zone 4, the extensor digitorum communis (EDC) splits into the central slip that inserts into base of middle phalanx. The lateral slips join the interosseous on both sides and the lumbrical tendon on the radial side to form the lateral bands. The tendon in this zone is thin, flat and broad. Because of the surface area and location adjacent to the proximal phalanx, this zone is prone to tendon adhesion, especially injuries associated with fractures. Patients need to be aware of potential

Fig. 2.3 How to perform the new extensor tendon running, interlocking, horizontal mattress (RITM) repair technique: begin the simple running suture at the near end. (Modified with permission from Lee, SK, Dubey A, Kim BH, Zingman A, Landa J, Paksima N. A biomechanical study of extensor tendon repair methods: introduction to the runninginterlocking horizontal mattress extensor tendon repair technique. J Hand Surg 2010;35A:19–23. Copyright 2010, with permission from Elsevier.)

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Extensor Tendon Repair (Zones 2, 4, 6–9)

Fig. 2.4 How to perform the new extensor tendon running, interlocking, horizontal mattress (RITM) repair technique: run the interlocking horizontal mattress suture by starting at the far end. The suture needle passes underneath the prior crossing suture to lock each throw. (Modified with permission from Lee, SK, Dubey A, Kim BH, Zingman A, Landa J, Paksima N. A biomechanical study of extensor tendon repair methods: introduction to the running-interlocking horizontal mattress extensor tendon repair technique. J Hand Surg 2010;35A:19–23. Copyright 2010, with permission from Elsevier.)

extension lag of the digit despite optimal repair. Since the injury usually is partial because the tendon is broad, patients with good PIP extension against resistance can be treated with a PIP joint extension splint for 4 weeks. Complete lacerations can be treated with modified Becker, modified Bunnell, or the RITM stitch. Lee et al reported greater stiffness, less time to perform, and less tendon shortening with the RITM stitch than the modified Becker or Bunnell techniques. If a tendon gap precludes primary repair, one can consider turndown flap described by Kochever similar to zone 2. Zone 4 thumb injuries can involve branches of the superficial radial nerve, so detailed examination and exploration is necessary to rule out concomitant nerve injuries

2.3.5 Zone 6 (Metacarpal) Injuries The EDC to the small finger can be absent with only the extensor digitorum minimi (EDM) present. Extensor indicis proprius is ulnar to EDC index, and EDM ulnar to EDC small. With increased tendon diameter and less associated injuries, the prognosis is usually better over the metacarpals than distally in the finger. In addition to the increased diameter, the modified Becker stitch allows for early active motion.

2.3.6 Zone 7 (Carpus) Injuries With six compartments under the extensor retinaculum, this zone is prone to adhesions. Meticulous repair of the retinaculum is important to prevent bowstringing. If excessive tension is encountered after the tendon repair, one can perform a z-lengthening of the retinaculum to improve tendon glide. The fifth compartment contains the EDM tendon which overlies the distal radioulnar joint. Injury to this zone can be secondary to

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Fig. 2.5 Extensor tendon reconstruction using a proximally based tendon flap as described by Kochevar et al. (Reproduced with permission from Kochevar A, Rayan G, Angel M. Extensor tendon reconstruction for zones II and IV using local tendon flap: a cadaver study. J Hand Surg Am. 2009;34(7):1269–1275. Copyright 2009, with permission from Elsevier.)

lacerations, nondisplaced distal radius fractures, prominent screws from volar locking plate fixation, or prominent osteophytes from the distal radioulnar joint. Acute injuries can be repaired with the techniques mentioned above. Chronic injuries require tendon transfers or grafting.

2.3.7 Zone 8 (Distal Forearm) Injuries Injury to this zone involves the musculotendinous junction. The fibrous raphe of the musculotendinous junction may be amendable to repair.

2.3.8 Zone 9 (Proximal Forearm) Injuries Zone 9 involves the extensor musculature. Repair of muscle fibers usually is not feasible. In patients with incomplete EDC muscle lacerations with an intact digit, one can consider tendon transfers. For complete muscle laceration, tendon transfers from flexor digitorum superficialis or flexor carpi radialis should be considered. It is important to immobilize the elbow in 90 degrees of flexion after repair of this zone to lessen the chance of failure. A thorough neurovascular examination should be performed due to the potential injury to the neurovascular structures, specifically the posterior interosseous nerve.

2.4 Complications Complications related to extensor tendon repair include adhesion, re-rupture, and stiffness. For zones 6 to 8 re-ruptures, options include side-to-side tendon transfer, tendon graft, or tendon transfers. Extensor tendon adhesions can develop after primary tendon repair and result in stiffness with lack of full

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References

Fig. 2.6 (a,b) Digital component of Wyndell Merritt yolk splint.

flexion of the involved joints. Long-term hand therapy (4–6 months) is necessary before operative intervention. With concomitant joint contracture release, results are less predictable. The main factor to prevent complications is to adhere to a structured hand therapy program that minimizes tendon rupture and maximizes tendon gliding.

2.5 Rehabilitation Extensor tendon repair for zone 2 is best protected with straight extension splint or DIP joint pinning for 4 to 6 weeks while allowing unrestricted PIP motion similar to zone 1 injuries. Rehabilitation for zone 4 to 7 repairs consists of immediate controlled active motion (ICAM) protocol described by Wyndell Merritt.5,6 With this protocol the repaired digit MCP joint is held in 15 to 20 degrees of extension compared with adjacent digits. A thermoplastic yolk splint is used for 6 weeks, and a forearm-based wrist splint in 30 degrees of extension is used for the first 3 weeks (▶ Fig. 2.6). Other authors reported similar results with the use of yolk splint alone without the wrist component. Berry and Neumeister7 compared two groups using this protocol. Group A was placed in the digital yoke orthosis only without wrist immobilization. Group B was treated with the traditional protocol with the digital yolk splint and wrist immobilization. They reported no ruptures in either group with comparable range of motion.

References [1] Lee SK, Dubey A, Kim BH, Zingman A, Landa J, Paksima N. A biomechanical study of extensor tendon repair methods: introduction to the running-interlocking horizontal mattress extensor tendon repair technique. J Hand Surg Am. 2010; 35(1):19–23 [2] Howard RF, Ondrovic L, Greenwald DP. Biomechanical analysis of four-strand extensor tendon repair techniques. J Hand Surg Am. 1997; 22(5):838–842 [3] Woo SH, Tsai TM, Kleinert HE, Chew WY, Voor MJ. A biomechanical comparison of four extensor tendon repair techniques in zone IV. Plast Reconstr Surg. 2005; 115(6):1674–1681, discussion 1682–1683 [4] Chung KC, Jun BJ, McGarry MH, Lee TQ. The effect of the number of crossstitches on the biomechanical properties of the modified Becker extensor tendon repair. J Hand Surg Am. 2012; 37(2):231–236 [5] Howell JW, Merritt WH, Robinson SJ. Immediate controlled active motion following zone 4–7 extensor tendon repair. J Hand Ther. 2005; 18(2):182–190 [6] Merritt WH. Relative motion splint: active motion after extensor tendon injury and repair. J Hand Surg Am. 2014; 39(6):1187–1194 [7] Berry N, Neumeister M. Analysis of limited Wyndell Merritt Splint for extensor tendon injuries to hand immobilization. Abstract: Presented at American Association for Hand Surgery annual meeting Beverly Hills, CA Jan 2008

Suggested Readings Burns MC, Derby B, Neumeister MW. Wyndell Merritt immediate controlled active motion (ICAM) protocol following extensor tendon repairs in zone IV-VII: review of literature, orthosis design, and case study-a multimedia article. Hand (N Y). 2013; 8(1):17–22 Izadpanah A, Hayakawa T, Murray KA, Islur A. Modified Merritt splint in proximal zone IV and zone V extensor tendon injuries: nine years rehabilitation experience in a single center. Presented at American Association for Hand Surgery Annual Meeting 2015

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3 Flexor Tendon Repair (Zone 1) Brian A. Tinsley Abstract Zone 1 flexor tendon injuries encompass several different types of repair techniques. Considerations for zone 1 flexor tendon injuries include surgical approach, tendon retrieval, and tendon repair. Depending on the injury pattern, fracture fixation, tendon-to-bone repair, or tendon-to-tendon repair may be required. When repair fails or is not feasible, additional salvage techniques may be necessary. Keywords: flexor tendon repair, flexor tendon injury, zone 1, Jersey finger

3.1 Description A zone 1 flexor tendon injury is an injury to the flexor digitorum profundus (FDP) tendon that is between the flexor digitorum superficialis (FDS) insertion on the middle phalanx and the FDP insertion on the distal phalanx (▶ Fig. 3.1). There are several techniques and methods of fixation for zone 1 flexor tendon lacerations. Fixation options include direct tendon-totendon repair, use of bone tunnel, or a bone anchor. The method of repair is dependent on the presence of an adequate distal tendon stump, presence and size of segmental tendon defect, and surgeon preference.

3.2 Key Principles The flexor tendon should be repaired without tendon advancement of more than 1 cm, which may result in the quadriga effect (inability to completely flex the fingers due to the tethering of one, preventing full excursion of the adjacent fingers). The goal is to achieve fixation able to withstand early motion rehabilitation.

3.3 Indications Zone 1 flexor tendon injuries should be repaired in the majority of patients with a viable digit. In patients with severe or chronic injuries, an FDS-only digit can be managed with distal interphalangeal (DIP) joint fusion; however, most cases allow for an attempted FDP repair or reconstruction.

3.4 Contraindications Primary zone 1 FDP repair is contraindicated in otherwise nonviable digits. Relative contraindications include patients with severe segmental tendon damage as well as patients that cannot participate in therapy. Primary repair may not be technically feasible in patients with a chronic FDP laceration with significant retraction.

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Fig. 3.1 Diagram of flexor tendon zones within the hand and wrist: (1) Distal to FDS insertion; (2) Proximal edge of pulley system to insertion of FDS. (3) Distal end of carpal tunnel at A1 pulley. (4) Length of the carpal tunnel. (5) Musculotendinous junction to the carpal tunnel. (T1) Distal to the interphalangeal joint (IP). (T2) Distal to the metacarpaphalangeal joint (MP). (T3) Distal edge of carpal tunnel to proximal edge of A1 pulley. (Modified with permission from Gunter G, Levin LS, Sherman, R. Reconstructive Surgery of the Hand and Upper Extremity. 1st ed. Thieme; 2018.)

3.5 Special Considerations Patients with acute flexor tendon injuries should be treated surgically within 1 week of the injury, if possible. Delay in repair can result in adhesion formation and may reduce tendon excursion. This may make mobilization for repair more difficult intraoperatively and limit motion postoperatively. Adequate repair technique allowing for early postoperative motion is important to maximize outcome after surgery.1,2 This should be monitored and therapy protocols adjusted depending on patient progress.

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Key Procedural Steps

3.6 Special Instructions, Positioning, and Anesthesia The patient should be positioned supine with the extremity on a hand table. Wide awake local anesthesia with no tourniquet allows for patient participation to actively test the repair, tendon gliding, and joint motion, which minimizes the risk of postoperative rupture.3 With sedation, the patient may be awoken enough to test the repair. General anesthesia is also an option, although the surgeon will not be able to evaluate the repair integrity intraoperatively.

3.7 Tips, Pearls, and Lessons Learned If the tendon is retracted within or proximal to the A4 pulley, incising the flexor sheath proximal to the area of retraction allows access to the tendon stump. The tendon can be advanced by carefully pushing the tendon forward through the sheath. This can be done by using two forceps to alternately grasp and advance the tendon to feed it distally. Alternatively, a passing suture can be placed through the tendon and retrieved with a suture passer through the A4 pulley. A milking maneuver with the wrist in flexion can help advance the tendon distally. When this is ineffective, a separate zone 3 incision may be required. A suture passer or pediatric feeding tube can be passed from distal to proximal through the flexor sheath. The proximal tendon stump can be sutured to the feeding tube or looped through the suture passer, which is then pulled back through, thus pulling the tendon distally. Trimming the end of the tendon, if frayed or bulbous, may allow for easier passage through the sheath or pulley. The tendon can be held in place with a syringe needle placed transversely through the A4 pulley capturing the tendon within the pulley. This will help prevent retraction of the tendon for an easier repair. If the level of repair is close to the A4 pulley, the tendon must not be too bulky in order to glide through A4 easily. If there is difficulty, the distal aspect of A4 can be vented with a longitudinal incision without significant functional consequences.4,5 This is best assessed with the patient wide awake and actively flexing the digit.

fixation should be limited to the distal phalanx in order to allow for early range of motion. In the setting of a significant distal phalanx comminution, K-wire fixation may have to cross the DIP joint. This may result in stiffness and require additional procedures to improve motion. Suture anchors may not have purchase in a significantly comminuted distal phalanx. Suturing the tendon with 2–0 proline suture and passing the suture around the distal phalanx through the nail, and tying over a button is an option.

3.9 Key Procedural Steps 3.9.1 Initial Approach There are several different approaches that may be used including a Bruner (palm zigzag) approach or mid-axial incision. The choice of approach is influenced by the wound pattern for a laceration and is helpful to include the laceration in the surgical incision if possible. For optimal visualization of a zone 1 injury, a volar midline longitudinal incision can be made from the volar DIP joint flexion crease about 0.5 to 1 cm distal. Only the skin should be incised and then carefully spread in a transverse direction to prevent damage to the terminal branches of the digital nerves. At the level of the proximal interphalangeal (PIP) joint, this is extended proximally as a Bruner incision (▶ Fig. 3.2). Careful dissection and gentle soft tissue handling is essential to minimize tissue trauma.

3.8 Difficulties Encountered 3.8.1 Distal Stump If the remaining distal tendon stump is over 1 cm and significantly damaged, it may not allow for adequate distal suture purchase. This is more common when the tendon is ripped or torn, such as in snow blower injuries, rather than sharp lacerations. If this is the case, the proximal aspect of the volar plate can be detached from the middle phalanx and used to reinforce the distal stump. The distal attachment is left intact and the volar plate is incorporated into the suture fixation.6

3.8.2 Distal Phalanx Fractures A zone 1 flexor tendon injury in the setting of a concomitant distal phalanx fracture can be challenging. If the fracture allows,

Fig. 3.2 A midline longitudinal incision just distal to the distal interphalangeal (DIP) joint flexion crease allows for excellent visualization of the flexor digitorum profundus (FDP) insertion. After skin incision, the subcutaneous tissue should be spread carefully with scissors to minimize trauma to the radial and ulnar digital nerve branches. This is connected to a Bruner incision more proximally as needed for extensile exposure.

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Flexor Tendon Repair (Zone 1) If the tendon is retracted, but still distal to A2, it can be identified through a separate tendon sheath incision distal to the pulley and advanced distally using forceps. If the tendon is difficult to pass, a suture can be passed through the tendon and retrieved through A4 with a suture passer. When the tendon is retracted to the palm, a separate zone 3 incision is made to identify the tendon and pass it distally. An additional incision just distal to A2 is helpful in advancing the tendon in stages. Once the tendon has been passed through the A4 pulley, flexing the wrist allows further tendon excursion to reduce tension during repair. Once the tendon is in position, it can be held with a 22-gauge needle. This can be placed through the A4 pulley and tendon within, preventing tendon retraction to facilitate repair. This must be placed carefully to avoid inadvertent damage to the neurovascular bundles. A small snap can be clamped onto the end after placement to avoid inadvertent needle stick injury.

3.9.2 Tendon-to-Tendon Repair When the distal stump of the tendon is over 1 cm, performing a tendon-to-bone repair may result in the quadriga effect (inability to completely flex the fingers due to the tethering of one, preventing full excursion of the adjacent fingers). In this case, a tendon-to-tendon repair is recommended. While there are many suture configurations, the author typically uses an 8-strand core suture repair with 4–0 looped braided caprolactam

suture and 6–0 monofilament epitendinous suture. This provides enough repair strength to allow for early motion (▶ Fig. 3.3).

3.9.3 Tendon to Bone Using an anchor for direct repair of the tendon to the distal phalanx is appropriate when there is 1 cm or less of distal tendon stump. This allows for adequate fixation without causing over excursion of the FDP tendon. The repair site is prepared first by removing overlying tissue prior to placement of the anchor. Remaining tendon stump can be preserved and sutured into the anchored tendon. A micro-sized anchor is typically appropriate for the distal phalanx.7 Take care when drilling and placing the anchor to prevent dorsal penetration of the distal phalanx and damage to the nail bed (▶ Fig. 3.4a,b). Alternatively, the tendon can be secured with suture that is passed around the distal phalanx or through the bone. This is then passed through the nail and tied over a button.8,9 Care must be taken to pass the sutures distal to the germinal matrix to avoid damage and nail deformity (▶ Fig. 3.5a,b).

3.9.4 Bone to Bone If there is a boney avulsion fragment, this can be directly repaired for bone-to-bone healing. Fixation depends on the size of the fragment. For small fragments, a micro-sized anchor or suture and button can be used as in a tendon-to-bone repair. If

Fig. 3.3 An 8-strand Gelberman-Winters technique using a 4–0 looped braided caprolactam suture spanning about 1 cm from the repair site on each side. A running 6–0 proline epitendinous suture is placed.

Fig. 3.4 (a,b) A micro-sized anchor can be placed in the midline at the footprint of the flexor digitorum profundus (FDP) insertion. When drilling, avoid penetration of the dorsal cortex.

Fig. 3.5 (a,b) A modified Kessler technique with a 2–0 proline pullout suture can be used to secure the distal tendon. The ends are passed through the bone and nail with a Keith needle, avoiding the germinal matrix. The ends are then passed through a button and tied. Make sure that when tying the sutures, there is appropriate tension to avoid any gapping at the repair site with active motion.

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References

Fig. 3.6 (a,b) If the fragment is large enough for screw fixation, a 1.3-mm or 1.5-mm screw can be used. A small pointed reduction clamp or sharp towel clip with the opposite tine placed percutaneously at the level of the terminal tendon insertion can be used to hold the fragment reduced.

the fragment is large enough for fixation, a 1.3- or 1.5-mm screw can be used from volar to dorsal (▶ Fig. 3.6a,b). During screw placement, avoid a long screw as this can damage the germinal matrix of the nail.

3.10 Bailout, Rescue, and Salvage Procedures During repair of a bony avulsion, a screw may comminute the fragment. One can supplement this fixation by using a bone anchor or using a pullout suture and button technique. Similarly, during anchor placement, if the bone anchor pulls out, one can fall back on the suture button technique. If there is a large segmental defect in the tendon or if surgery is delayed with a retracted tendon, there may be insufficient tendon length for a primary repair. One technique for a retracted tendon is to gently pull and hold longitudinal traction on the tendon for several minutes after it is passed distally. In some cases, this will allow for enough excursion to enable primary repair. In the case of a large defect or severely retracted chronic tear, a tendon reconstruction using tendon graft may be necessary. A free tendon graft such as a palmaris longus or a toe flexor can be used in a one-stage grafting procedure. If there is significant soft tissue injury, and the tendon sheath is disrupted and unable to provide a healing, lubricating surface to allow tendon gliding, a two-stage reconstruction can then be performed. In the first procedure, a silastic tendon rod is inserted to allow re-creation of the digital sheath and kept in place for about three months to allow restoration of the gliding surface of the sheath. The second procedure involves the removal of the silicone rod and replacement with a free tendon autograft. The outcomes of the two-stage reconstruction are unpredictable. If a tendon graft reconstruction is performed, one must make sure that there is not too much length on the tendon graft. This

is best done with wide awake anesthesia as the motion can be intraoperatively assessed. If there is too much length on the graft, the lumbrical origin is translated proximally. This lengthens the lumbrical that may overpower the FDP, resulting in a lumbrical plus digit. In patients with severe FDP damage that is not reparable or in the setting of repair failure, salvaging with an FDS-only digit is an option. In the case of an FDS-only digit, a DIP fusion in flexion can restore function to the digit.

References [1] Starr HM, Snoddy M, Hammond KE, Seiler JG, III. Flexor tendon repair rehabilitation protocols: a systematic review. J Hand Surg Am. 2013; 38(9): 1712–7.e1, 14 [2] Frueh FS, Kunz VS, Gravestock IJ, et al. Primary flexor tendon repair in zones 1 and 2: early passive mobilization versus controlled active motion. J Hand Surg Am. 2014; 39(7):1344–1350 [3] Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010; 126(3):941–945 [4] Chow JC, Sensinger J, McNeal D, Chow B, Amirouche F, Gonzalez M. Importance of proximal A2 and A4 pulleys to maintaining kinematics in the hand: a biomechanical study. Hand (N Y). 2014; 9(1):105–111 [5] Moriya K, Yoshizu T, Tsubokawa N, et al. Outcomes of release of the entire A4 pulley after flexor tendon repairs in zone 2A followed by early active mobilization. J Hand Surg Eur Vol. 2016; 41(4):461 [6] Al-Qattan MM. Use of the volar plate of the distal interphalangeal joint as a distally based flap in flexor tendon surgery. J Hand Surg Am. 2016; 41(2): 287–290 [7] Huq S, George S, Boyce DE. The outcomes of zone 1 flexor tendon injuries treated using micro bone suture anchors. J Hand Surg Eur Vol. 2013; 38(9): 973–978 [8] Chu JY, Chen T, Awad HA, Elfar J, Hammert WC. Comparison of an all-inside suture technique with traditional pull-out suture and suture anchor repair techniques for flexor digitorum profundus attachment to bone. J Hand Surg Am. 2013; 38(6):1084–1090 [9] McCallister WV, Ambrose HC, Katolik LI, Trumble TE, MCallister WV. Comparison of pullout button versus suture anchor for zone I flexor tendon repair. J Hand Surg Am. 2006; 31(2):246–251

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4 Flexor Tendon Repair (Zone 2) David W. Lee, Stephen Ros, and Christopher Doumas Abstract Zone 2 flexor tendon lacerations are notoriously difficult injuries to manage and have historically led to poor outcomes after attempted repair. Even with excellent tendon repair, complications such as adhesion formation, rupture, and stiffness remain possible. Thus, a thorough understanding of surgical anatomy and technique is required. The goal of repair is accurate coaptation of the tendon ends with sufficient strength to allow early postoperative rehabilitation; a strong and smooth surgical repair will also reduce the likelihood of adhesion formation. Because of the importance of postoperative therapy, patient selection, compliance, and education must not be overlooked. Keywords: flexor tendon injury, zone 2, tendon repair, tendon sheath, pulley, laceration

4.1 Description Zone 2 flexor tendon injuries occur between the A1 pulley proximally and the flexor digitorum superficialis insertion distally (▶ Fig. 4.1). In this region, the flexor digitorum superficialis and profundus tendons lie within a tight fibro-osseous sheath with a series of pulleys that prevent bowstringing (▶ Fig. 4.2). Within this sheath, the two tendons are covered by

fibrous epitenon. Together, the fibro-osseous sheath and epitenon play a critical role in the smooth gliding of the tendon. The superficialis is split by the profundus and its two slips turn sideways and insert on the middle phalanx in an upside-down manner. Zone 2 was historically named “no man’s land” because injuries here invariably led to adhesion formation and poor outcomes. However, in the 1960s, Kleinert and others first reported good outcomes after primary repair, stressing the importance of meticulous atraumatic surgical technique and early postoperative rehabilitation.1 Subsequent advancements in suture technique, design, and postoperative therapy have drastically improved outcomes.2,3,4,5 As described by Strickland, core sutures should have the following characteristics: easy placement, secured knots, smooth juncture at tendon ends, minimal gapping, minimal interference with vascularity, and sufficient strength to permit early motion.6 Although there are many core suture techniques, it is known that multiple suture strands (≥ 4) provide superior load to gapping and failure.7 Classic suture techniques such as the Kirchmayr and modified Kessler are still common; however, newer techniques such as the Strickland, Cruciate, Becker, and Winters-Gelberman are becoming more common due to increased repair site strength7 (▶ Fig. 4.3). A peripheral epitendinous suture is recommended to increase repair site strength and reduce gapping.8

Fig. 4.1 Diagram of flexor tendon zones within the hand and wrist. (Data from Kleinert HE, Schepel S, Gill T. Flexor tendon injuries. Surg Clin North Am 1981; 61:267–286.)

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Tips, Pearls, and Lessons Learned therapy. Stiffness is the most common complication owing to adhesions and contractures after surgical repair.

4.4 Indications ● ●

●

Lacerations involving > 50% of tendon cross-sectional area. A compliant patient who is willing and able to participate in postoperative rehabilitation. Emergent repair if digital nerves and arteries are also lacerated and the finger is dysvascular; otherwise, repair is preferably done within 1 week of injury. Chronic injuries (> 6 weeks) are likely to have poor results and are more amenable to reconstruction.

4.5 Contraindications ● ● ●

Significant soft tissue and/or bone loss. Neurovascular compromise. Noncompliant patient unable to participate in therapy.

4.6 Special Considerations ●

●

●

Fig. 4.2 Flexor tendon sheath of a finger (Lateral aspect). (1) Palmar ligament (volar plate). (2) Deep transverse metacarpal ligament (resection site). (3) Tendon of the flexor digitorum superficialis. (4) Tendon of the flexor digitorum profundus. (5) Radial collateral ligament. (6) Accessory radial collateral ligament. (7) Phalangoglenoidal ligament. (8) Check rein ligament. [A1-A5] Annular parts of flexor tendon sheath [A1-A5 pulleys]. (C1) Cruciform part of flexor tendon sheath [C1 pulley]. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, 1st eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

4.2 Key Principles The goal of flexor tendon repair is the accurate anastomosis of the lacerated ends using meticulous and atraumatic technique that result in a smooth and nonbulky repair. A precise repair of sufficient strength will restore tendon gliding and allow optimal range of motion, thus reducing complications.

4.3 Expectations Good outcomes can be expected if a strong tendon repair is achieved and the patient participates in early postoperative

Preoperative evaluation includes a thorough examination, including testing of each tendon in each finger. The flexor digitorum superficialis is examined by holding the remaining fingers in full extension; the profundus is examined by extending the finger and immobilizing the proximal interphalangeal (PIP) joint. Plain radiographs are obtained to ensure no other injuries are overlooked. Ultrasound may be useful in determining the extent of partial tears. Patient selection is critical as compliance in postoperative rehabilitation is key to obtaining a good outcome.

4.7 Special Instructions, Positioning, and Anesthesia ●

●

●

The patient is placed supine on an operating table with the operative extremity placed on a hand table. A well-padded tourniquet is placed on the upper arm. A 2 to 4x magnification surgical loupe is used to optimize tissue handling and technique. Wide awake local anesthesia without a tourniquet can be used to allow intraoperative assessment of repair strength, gliding, and gap formation.

4.8 Tips, Pearls, and Lessons Learned ●

●

Atraumatic technique must be used when handling the tendon and its sheath; excessive handling of the epitenon, including pinching or crushing, should be avoided as much as possible. When retrieving the proximal tendon stumps, avoid repeated blind grasps through the tendon sheath, which will cause traumatic damage to the pulleys and tendon, thus promoting adhesions and/or rupture.

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Flexor Tendon Repair (Zone 2)

Fig. 4.3 Common suture techniques. (a) Cruciate. (b) Strickland. (c) Winters-Gelberman. (Reproduced with permission from Germann G, Levin LS, Sherman R, eds. Reconstructive Surgery of the Hand and Upper Extremity. © Thieme; 2018.)

●

Special care must be taken to protect the A2 and A4 pulleys; injury to these structures can result in bow-stringing, loss of motion, and contractures.

4.9 Key Procedural Steps The wound is extended with Bruner incisions to allow full exposure proximally and distally; the addition of midlateral incisions are used in order to achieve robust skin flaps to cover the tendon repair site. Skin flaps are raised with sharp dissection, preserving subcutaneous tissue attachment to the flap, thereby maintaining vascularity and viability. Dissection is carried down to the tendon sheath, and the digital nerves and vessels are identified and protected. A window in the tendon sheath is made between the A2 and A4 pulleys using a radial or ulnarbased flap that can be repaired later. Distal tendon stumps are retrieved beyond the A4 pulley and pulled through proximally. Flexion of the distal interphalangeal (DIP) and PIP joints can help deliver the tendons proximally if not readily accessible. Core sutures are then placed in the profundus and superficialis tendons and clamped for later use. Dilation of the A4 pulley, partial division, or venting may be necessary to allow smooth passage of the stump. Proximal stumps, if visible, are grasped and held in place using a 25-gauge needle inserted through one of the proximal annular pulleys and tendon. If not readily visible, the tendons can be manually “milked” from proximal to distal with the wrist and MCP joints in flexion. If still unsuccessful and the tendon is visible within the sheath, a tendon retriever or grasper is used. Alternatively, using the method described by Sourmelis and McGrouther, a small catheter or similar device is passed into the tendon sheath proximally and pulled through the window distally3. The tendon is left in-situ, and the catheter is sutured to the tendon proximally; the suture is placed roughly 1cm proximal to the A1 pulley and the catheter is pulled distally to deliver the tendon stumps. Once the tendon is secured with a needle as above, the suture and catheter can be removed. Core sutures are then placed in the proximal superficialis and profundus tendon ends; care must be taken to ensure the correct orientation of the tendons. The profundus is often more robust

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and, at minimum, a four-strand core suture of 3–0 or 4–0 braided polyester is used with locking loops. Suture purchase should be at least 1 cm on either side. An epitendinous repair using 6–0 nonabsorbable suture is then placed beginning on the volar surface and run circumferentially using a running lock or cross-stitch technique. Depending on the location, the superficialis tendon may not be large enough to accommodate a core suture and may be repaired using a standard modified Kessler technique. A repair of one slip of the flexor digitorum superficialis (FDS) should be done as a repair of both may cause overcrowding. The tendon sheath is then repaired and stability is assessed by moving the digits through a full range of motion, ensuring smooth gliding through the tendon sheath and pulleys. Additional sheath excision or venting should be limited to prevent bowstringing.

4.10 Postoperative Care ●

●

●

A dorsal blocking splint is applied postoperatively to maintain 20-30° of wrist flexion and 50-60° of MCP flexion. A graded rehabilitation protocol is initiated with a qualified hand therapist. The therapist should be informed of the quality of repair, and a treatment regimen is decided between the surgeon and therapist. Therapy must be individualized based on patient characteristics. If a strong primary repair has been performed, early range of motion therapy can be initiated with “place and hold” exercises.

4.11 Complications ●

●

Repair site rupture should be diagnosed and managed as soon as possible. If rupture occurs within 3 weeks postoperatively, revision repair should be attempted promptly for the best chance of successful outcome. Otherwise, a staged tendon reconstruction will likely provide a better result. Stiffness may develop from interphalangeal joint contracture. The majority of contractures can be corrected with a combination of passive stretching exercises and static progressive splinting.

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References ●

Adhesion formation is a common complication that can occur despite appropriate rehabilitation and therapy. Tenolysis should be considered at the 3- to 6-month period if the patient is no longer improving. Achieving full passive range of motion prior to tenolysis provides the best outcomes postoperatively.

References [1] Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg Am. 1977; 2(6): 441–451

[2] Groth GN. Pyramid of progressive force exercises to the injured flexor tendon. J Hand Ther. 2004; 17(1):31–42 [3] Sourmelis SG, McGrouther DA. Retrieval of the retracted flexor tendon. J Hand Surg [Br]. 1987; 12(1):109–111 [4] Strickland JW. Flexor Tendon Injuries: II. Operative Technique. J Am Acad Orthop Surg. 1995; 3(1):55–62 [5] Strickland JW, Glogovac SV. Digital function following flexor tendon repair in Zone II: A comparison of immobilization and controlled passive motion techniques. J Hand Surg Am. 1980; 5(6):537–543 [6] Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am. 2000; 25(2):214–235 [7] Chauhan A, Palmer BA, Merrell GA. Flexor tendon repairs: techniques, eponyms, and evidence. J Hand Surg Am. 2014; 39(9):1846–1853 [8] Diao E, Hariharan JS, Soejima O, Lotz JC. Effect of peripheral suture depth on strength of tendon repairs. J Hand Surg Am. 1996; 21(2):234–239

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5 Flexor Tendon Injuries (Zone 3–5) Derek L. Masden Abstract Flexor tendon injuries within zones 3 to 5 represent those confined to the palm and distal forearm. They can be debilitating with resultant loss of basic hand function. A thorough understanding of the anatomy, surgical approach, reconstructive options, and rehabilitation is required to provide the best opportunity for functional recovery in these anatomic regions. Proper exposure with identification and repair of neurovascular structures and repair of injured tendons with sound surgical technique can ensure successful outcomes and recovery. Keywords: flexor tendon repair, zone 3, zone 4, zone 5, tendon injury

5.1 Description The majority of literature on flexor tendon injury focuses on the management of zone 2 lacerations. Although much of this is applicable to flexor tendon injuries in other zones, several key differences exist between zones. Surgeons must be familiar with these differences when evaluating, treating, and rehabilitating patients with zones 3 to 5 flexor tendon injuries.

5.2 Classification The classification of the zone of injury is through the following standard anatomical boundaries: zone 3 marks the area of the palm between the carpal tunnel and the flexor tendon sheath, or from the distal aspect of the transverse carpal ligament to the proximal border of the A1 pulley; zone 4 describes the area within the carpal tunnel; and zone 5 is from the proximal border of the transverse carpal ligament to the musculotendinous junction in the proximal forearm See Fig. 4.1.

5.3 Key Principles Given the close proximity of tendons, nerves, and blood vessels in the hand and forearm, combined injuries are common, and there should be a low threshold for surgical exploration and identification of the surrounding neurovascular structures. Primary tendon repair is preferred and possible in the majority of zones 3 to 5 injuries. A minimum of a four-strand repair and an epitendinous suture is recommended (▶ Fig. 5.1). Early active motion rehabilitation protocols should be employed to optimize functional outcomes after these injuries.

Fig. 5.1 (a) Original Kirchmayer/Kessler: Two sutures (two-strand) with knots buried in the tendon outside the suture line. A two-strand core suture with knots. In the suture line or burled in the tendon outside the suture line. lntratendinous knots may have better gliding properties, but have more suture material in the tendon gap. Theoretically, sutures should be placed insofar as possible at the volar aspect of the tendon to avoid disturbance of the dorsally situated vessels. Too much compression at the suture line should be avoided to prevent bulging of the tendon repair with subsequent impairment of gliding. (b–e) Modified Kessler: One or two sutures (two-strand) with intratendinous knots. Cross section demonstrates optimal position of core sutures (continued). (f) Strickland’s “double grasp” modification of the Kirchmayer-Kessler technique (two-strand). (g) “Double grasp” technique with an additional rectangular mattress suture (four-strand). (h,i) Tsuge’s loop technique: Double loop (six-strand). (j) Pulvertaft technique: The tendon stumps are connected in a braided pattern—excellent tensile strength, allows early active mobilization. (k,l) Epitenon sutures: Epitenon sutures add considerable tensile strength to the tendon repair. They also smooth the contour of the tendon repair, thereby improving gliding properties. The two most commonly used patterns are running stitches (5–0) or interlocking sutures (5–0). A modification is a crisscross pattern that may increase tensile strength. (Modified with permission from Günter Germann, L. Scott Levin, Randolph Sherman. Reconstructive Surgery of the Hand and Upper Extremity, 1st edition. © 2018 Thieme.)

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Key Procedural Steps

5.4 Expectations Zones 3 to 5 injuries are more forgiving than zone 2 injuries due to excellent tendon nutrition, a bed that is less prone to adhesions, and fewer surrounding retinacular structures, thereby easing repair and promoting tendon gliding. As such, good to excellent outcomes in range of motion and tendon function should be expected. However, concomitant neurovascular injury can complicate recovery and functional outcomes after such combined injuries.1,2

5.5 Indications Complete lacerations or > 60% transection of the flexor tendons in zones 3 to 5.

5.6 Contraindications Contraindications include severe multitissue injuries to the hand and fingers, contaminated wounds, significant soft tissue loss over the flexor system, and patients that are unable to participate in rehabilitation. These instances may require staged tendon repair or reconstruction after an adequate wound bed and soft tissue coverage have been established.

5.7 Diagnosis Similar to other zones, complete transection of a flexor tendon in zones 3 to 5 will present with inability to flex the digit at the interphalangeal joints along with loss of the natural resting cascade of the hand (▶ Fig. 5.2). Given the close proximity of the vascular palmar arch and neurovascular bundles, detailed examination of the peripheral nerves and vessels around the zone of injury and distally is imperative. The Allen’s test must be performed when examining pulses as retrograde flow through palmar arches may mask vascular injuries. There should be a

Fig. 5.2 Intra-op photo of a zone 3 laceration of both flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons to the index finger with resultant loss of resting cascade of the finger. Note the extended posture in comparison to the other un-injured digits.

low threshold for surgical exploration as innocuous lacerations may hide the extent of deep structural injury, and the preoperative examination is often unreliable in these patients.3

5.8 Timing of Repair Tendon repair should occur within 2 to 3 weeks of injury to facilitate primary repair, though animal studies have suggested that acute repair as soon as possible after injury may be ideal.4

5.9 Key Procedural Steps General or upper extremity regional anesthesia and tourniquet control are used. Existing lacerations should be lengthened proximally and distally for improved exposure. Incisions should cross flexion creases at an angle. Extreme care must be taken to identify and protect the palmar arch as well as the branches of the median and ulnar nerve that lie superficial to the flexor tendons. The transverse carpal ligament must be released in zone 4 injuries. Carpal tunnel release is often required in zone 3 injuries to gain exposure to the proximal tendon stumps and in zone 5 injuries to gain access to the distal tendon stumps. There is a low threshold to release the A1 pulley in zone 3 injuries both for exposure of the distal tendon stump and to allow room for tendon glide after repair (▶ Fig. 5.3a). Distal tendon stumps can be retrieved with finger flexion to deliver the tendons into the wound. Proximal tendon ends in zone 3 injuries may be retrieved by a milking maneuver with the wrist in flexion. If this is not successful, the incision should be extended and the transverse carpal ligament released. A 25-gauge needle may be placed transversely across the proximal tendon stump to prevent re-retraction (▶ Fig. 5.3b). Injured and uninjured structures are identified and tagged for repair from deep to superficial. In general tendons are repaired first, followed by neurovascular structures. However, if the deep motor branch of the ulnar nerve has been lacerated in zone 3, this is repaired first, as it lies deep to the flexor tendons. Digital flexor tendons are repaired next in a deep to superficial sequence. A 3–0 or 4–0 nonabsorbable suture is used in a locking fashion to provide at least a four-strand repair. The authors prefer the locked cruciate repair due to its favorable biomechanical profile and resistance to gap formation.5 Core sutures should be placed 7 to 10 mm from the tendon edge and dorsal placement is biomechanically advantageous6 (▶ Fig. 5.3c). If the repair site of the tendon will be gliding through the flexor tendon sheath, an epitendinous suture is recommended to improve contour at the repair site and decrease resistance within. It has also been shown to increase repair strength by 10 to 50%, substantially reduce gap formation, and decrease rate of reoperation.6 This is done prior to the core suture in order to better line up the tendon ends for maximum streamlining of the repair. A running locking epitendious suture with a 6–0 monofilament is used. Partial and complete lacerations of digital, median, and ulnar nerves are then repaired with 8–0 or 9–0 nylon under magnification using an epineural technique. Lumbricals, if lacerated, do not need to be repaired.

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Flexor Tendon Injuries (Zone 3–5)

Fig. 5.3 (a) Intra-op photos of zone 3 flexor tendon laceration with proximal extension into carpal tunnel to gain exposure of proximal tendon ends and release of the A1 pulley for distal tendon exposure. (b) 25-gauge hypodermic needles can be used to secure tendons to facilitate repair without tension. (c) Repair of both flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons, note the return of the resting cascade of the index finger.

There is a lack of literature examining the significance of arterial injury in a viable hand. Repair of single artery lacerations is controversial, but it is the authors’ practice to perform these repairs using microsurgical technique when feasible.

5.10 Rehabilitation After surgery, patients are placed in a dorsal extension-blocking splint with the wrist in 20 to 40 degrees of flexion, the metacarpophalangeal joints in 40 to 60 degrees of flexion, and the interphalangeal joints in flexion. Compared to zone 2 repairs, zones 3 to 5 repairs have less risk of adhesion formation due to improved vascularity and more space around the tendon bed. However, an early active motion protocol should be used to improve the results of flexor tendon repair in any zone when compared with more conservative passive motion protocols.7

5.11 Complications When compared to zone 2, tendon-related complications in zones 3 to 5 are less common. Tendon ruptures are rare and tenolysis is infrequently required.8

5.12 Special Considerations 5.12.1 Wide-Awake Flexor Tendon Repair Recent literature has advocated for “wide-awake” tendon surgery using local anesthesia with epinephrine. Patients can participate intraoperatively after tendon repair, allowing the surgeon to assess active motion for gapping, tendon gliding, and entrapment while still in the operating room. Unlike in zone 2, flexor tendons in zones 3 to 5 generally do not run within the flexor sheath and there is more space for gliding of the repaired tendon. As such “wide-awake” surgery may not provide as much benefit and is not routinely recommended for zones 3 to 5 repairs.

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5.12.2 Primary Repair with Intercalary Defects In the event that tendon injuries in zones 3 to 5 cannot be primarily repaired, due to either loss of tendon substance or to retraction of frayed tendon ends in delayed cases, the defects can be repaired with either interposition tendon grafts or side-to-side transfers. With these more extensive injuries, priority is given to repairing the terminal flexor [flexor digitorum profundus (FDP)] tendons over the flexor digitorum superficialis (FDS).

Interposition Grafts If present, the palmaris longus tendon is the preferred interposition graft as it can be easily accessed through existing exposures for zones 3 to 5 injuries. After appropriate debridement to clean tendon ends, the harvested palmaris longus tendon is sutured to the proximal and distal stumps of the damaged flexor tendon using the Pulvertaft weave technique. The graft should be sutured with excess tension such that the interphalangeal joints of the affected digit are more flexed than the surrounding normal fingers9 (▶ Fig. 5.4a, b). If palmaris longus is not present, the plantaris tendon from the lower leg may be utilized.

End to Side Transfers Significant gaps in tendon continuity in the palm can be corrected with use of a primary FDS to FDP transfer. The goal is to restore terminal flexion by re-routing an intact FDS volarly to the distal FDP stump.

Side-to-Side Transfers The distal FDP stump can also be sewn to an adjacent FDP tendon in a side-to-side fashion. This should be done by weaving the distal FDP stump into the adjacent FDP tendon and securing with nonabsorbable braided suture. This provides simultaneous flexion of the two digits and works best in more proximal injuries.

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References

Fig. 5.4 (a) Intra-op photo of interpositional palmaris longus tendon graft used in flexor pollicis longus (FPL) tendon reconstruction. Following Pulvertaft weave, the patient is instructed to flex the digit to test excursion and tension. (b) Intra-op photo of patient with full active flexion of thumb following FPL interposition graft (done under minimal sedation anesthesia to test active flexion).

5.13 Pearls ●

●

●

Low threshold for surgical exploration due to concomitant neurovascular injury that is difficult to elicit on physical exam Low threshold to release A1 pulley and transverse carpal ligament for exposure Early active motion rehabilitation protocols should be used postoperatively

References [1] Weinzweig N, Chin G, Mead M, Gonzalez M. “Spaghetti wrist”: management and results. Plast Reconstr Surg. 1998; 102(1):96–102

[2] Hudson DA, de Jager LT. The spaghetti wrist: simultaneous laceration of the median and ulnar nerves with flexor tendons at the wrist. J Hand Surg [Br]. 1993; 18(2):171–173 [3] Gibson TW, Schnall SB, Ashley EM, Stevanovic M. Accuracy of the preoperative examination in zone 5 wrist lacerations. Clin Orthop Relat Res. 1999(365):104–110 [4] Tang J, Shi D, Gu Y. Flexor tendon repair: timing of surgery and sheath management. Zhonghua Wai Ke Za Zhi. 1995; 33(9):532–535 [5] McLarney E, Hoffman H, Wolfe SW. Biomechanical analysis of the cruciate four-strand flexor tendon repair. J Hand Surg Am. 1999; 24(2):295–301 [6] Klifto CS, Capo JT, Sapienza A, Yang SS, Paksima N. Flexor tendon injuries. J Am Acad Orthop Surg. 2018; 26(2):e26–e35 [7] Athwal GS, Wolfe SW. Treatment of acute flexor tendon injury: zones III-V. Hand Clin. 2005; 21(2):181–186 [8] Yii NW, Urban M, Elliot D. A prospective study of flexor tendon repair in zone 5. J Hand Surg [Br]. 1998; 23(5):642–648 [9] Kim YJ, Baek JH, Park JS, Lee JH. Interposition tendon graft and tension in the repair of closed rupture of the flexor digitorum profundus in zone III or IV. Ann Plast Surg. 2018; Mar;80(3):238–241

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Part II Tendon Reconstruction

II

6 Flexor Tendon Reconstruction (Zone 2)

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7 Radial Nerve Palsy Tendon Transfers

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8 Low Median Nerve Palsy Tendon Transfers

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9 Tendon Transfers for Low Ulnar Nerve Palsy

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10 Extensor Indicis Proprius Tendon Transfer for Rupture of the Extensor Pollicis Longus Tendon

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11 Extensor Indicis Proprius to Extensor Digitorum Comminus Tendon Transfer

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12 Superficialis Transfer for Rupture of the Flexor Pollicis Longus Tendon

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6 Flexor Tendon Reconstruction (Zone 2) Ryan A. Hoffman, Katharine Criner Woozley, and James S. Raphael Abstract Compared with primary repair, flexor tendon reconstruction poses an alternative treatment to flexor tendon injury. Termed “no man’s land,” zone 2 of the hand poses serious challenges to tendon repair. Owing to the complexity of the tendon sheaths and small margin for error, postoperative swelling, adhesion formation, or infection outcomes can be variable and the prognosis guarded. With these features in mind, one must be careful and consider the clinical picture when deciding between primary repair, single-stage, or two-stage flexor tendon reconstruction. In these instances, the entire environment must be considered so as to decrease tendon rupture, pulley failure, or adhesion formation. With close observation, the orthopaedic surgeon can utilize this information toward deciding on the most appropriate treatment as well as preoperative plan toward achieving recovery of maximum active range of motion. Keywords: flexor tendon, reconstruction, silicone rod, tendon graft

6.1 Description Flexor tendon injuries to the hand are classified into five zones for the fingers (▶ Fig. 6.1). Zone 1 is distal to the insertion of the flexor digitorum superficialis (FDS) tendon. Zone 2 is from the FDS insertion site to the distal palmar crease. Zone 3 extends from the distal palmar crease, proximally into the palm. Zone 4 consists of the carpal tunnel. Zone 5 is proximal to the carpal tunnel. Special focus will be placed on zone 2 flexor tendon reconstruction. The flexor mechanism of each finger involves two tendons: the FDS and the flexor digitorum profundus (FDP). The FDS tendon enters the A1 pulley, then splits into two tendon slips and rotates 180 degrees in a dorsolateral direction around the FDP tendon. The FDP tendon passes through this split, also known as Camper’s chiasm. The tendinous sheath that the FDS and FDP course through begins approximately at the level of the metacarpal heads and spans to the distal phalanges. It is important to understand the roles of the digital flexor sheath, as well as the pulley systems involved. There are three pulley systems that offer a mechanical advantage to flexion by allowing for force multiplication with less expenditure of energy. There are three pulley systems in the hand: 1. Annular 2. Cruciate 3. Palmar aponeurosis There are five annular and three cruciate pulleys, and the palmar aponeurosis pulley system (▶ Fig. 6.2). When the pulleys are damaged, bowstringing of the flexor tendons occurs, which increases work needed at the expense of reduced tendon excursion. The A2 and A4 pulleys are believed to be the most important in maintaining adequate flexor tendon function. Located over the proximal and middle phalanges, respectively, they serve primarily to anchor the tendons close to the bone. In doing so, they help translate excursion into angular motion. In addition to the pulley systems, the digital sheath helps facilitate smooth gliding of the tendons.

Fig. 6.1 A depiction of the five zones within the hand. (Modified with permission from Kamal R, Weiss A, ed. Comprehensive Board Review in Orthopaedic Surgery. 1st Edition. Thieme; 2016.)

Fig. 6.2 A depiction of the five annular and three cruciate pulleys present on flexor tendons within the digital sheath. (Reproduced with permission from Stern S, ed. Key Techniques in Orthopaedic Surgery. 2nd Edition. Thieme; 2018.)

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Flexor Tendon Reconstruction (Zone 2) cleaned in a sterile fashion and remainder of the body draped. There are several methods of anesthesia that may be utilized. In certain situations, the patient may be administered general anesthesia with or without a brachial plexus block; however, recent trends have shifted toward wide-awake surgery using lidocaine and epinephrine. Benefits of local anesthetic include the ability to have the patient interact during the procedure, which is particularly helpful during tensioning of the tendon graft.

6.3.4 Surgical Technique

Fig. 6.3 Abnormal resting flexion cascade indicative of FDS and FDP tendon lacerations to the long finger.

6.2 Key Principles When assessing subacute or chronic flexor tendon injuries, frequent findings in flexor tendon injuries include soft tissue damage, loss of flexor function, development of adhesions, injury to one or more pulleys, joint contracture, scar tissue formation, and neurovascular injury. The Boye’s preoperative classification is frequently used to assess for probability of improved postoperative outcome. In addition to assessing degree of tendon injury, one must also identify the appropriateness of a single- or two-stage reconstruction in the setting of an inability to perform a primary repair.

6.3 Single-Stage Flexor Tendon Reconstruction 6.3.1 Indications Single-stage flexor tendon reconstruction is generally appropriate in the setting of a subacute or chronic, unrepairable flexor tendons (both FDS and FDP), intact flexor tendon sheath, absence of scar tissue, and functional pulley system (▶ Fig. 6.3). The decision to perform a single-stage reconstruction, in the setting of an intact FDS, is controversial due to the potential for adhesion development and scarring around the FDS tendon.

6.3.2 Contraindications Single-stage reconstruction should be avoided in patients with excessive adhesions, lack of at least one digital nerve to the digit, joint contracture, loss of multiple pulleys, and poor compliance.

6.3.3 Special Instructions, Position, and Anesthesia The patient is generally positioned in the supine position with the afflicted arm extended on a hand table. The extremity is

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A midlateral or Bruner (zigzag) approach is typically utilized to gain access to the digital sheath (▶ Fig. 6.4). Once exposed, the damaged tendons are excised and a tendon graft is prepared. Some controversy exists as to whether to utilize intra or extrasynovial tendon grafts. Intrasynovial grafts (FDS, toe flexors) may limit adhesion formation. Extrasynovial tendon grafts (palmaris longus, plantaris) are also often used. Once harvested, the tendon graft is attached both proximally (either in the wrist or palm) to the proximal stump of the injured tendon and to the distal phalanx.

6.3.5 Postoperative Course Postoperatively, a bulky dressing and plaster dorsal blocking splint are applied. The metacarpophalangeal (MCP) joints are ideally maintained in 90 degrees of flexion with the interphalangeal (IP) joints at neutral position. Depending on surgeon preference, the patient is seen several days after surgery and fitted for a custom dorsal blocking splint. At this time, patients begin an extensive course of both physical and occupation therapy. Rehabilitation initially consists of early passive range of motion that progresses to strengthening exercises anywhere from 6 to 10 weeks later. Depending on the stability of the distal juncture, an active range of motion may be initiated earlier.

6.3.6 Complications In single-stage reconstruction, it is not uncommon for patients to develop adhesions that may require staged tenolysis. In addition, rupture of the reconstructed tendon may also be seen. Depending on the time period postoperatively, the grafted tendon may either be repaired primarily, or converted to a two-stage flexor tendon reconstruction.

6.4 Two-Stage Flexor Tendon Reconstruction 6.4.1 Indications While flexor tendon reconstruction is a widely accepted management of tendon injuries, indications are somewhat controversial. Currently, failed zone 2 tendon repairs and chronic flexor tendon injuries with a scarred and mechanically incompetent pulley mechanism are generally accepted as indications for reconstruction. Patients must have realistic expectations and be reliable in terms of follow-up and compliance with postoperative instructions, as rehabilitation is a strenuous and long process.

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Two-Stage Flexor Tendon Reconstruction

Fig. 6.4 Stage 2 flexor tendon reconstruction: Bruner incisions over the palm and DIP joint.

6.4.2 Contraindications

Paneva-Holevich Method

Patients with a history of infection or compromised neurovascular function are poor candidates for staged tendon reconstruction. In addition, those with intractable fixed flexion contractures are generally contraindicated for reconstruction. Due to the extensive rehabilitation involved with this type of procedure, patients who are not reliable are generally excluded from consideration. Generally, patients presenting with a functioning FDS (“superficialis finger”) are poor candidates for surgical intervention as flexion is maintained at the proximal IP joint.

The procedure consists of two stages. During stage I, key steps include creating a Bruner (zigzag) incision down into the palm so as to avoid creation of unnecessary scar tissue and later contraction. It is important to remove any excess scar tissue on incision. Next, an end-to-end coaptation loop is generally created using the proximal FDS/FDP while preserving the distal FDP as an anchor for later use. While attempting to preserve the A2 and A4 pulleys, a silicon rod is pulled through the pulley system, extending down into the palm of the hand. This rod is maintained for 8 to 12 weeks to allow for a synovial membrane/sheath to form in anticipation for stage II. During stage II, adhesions are dissected away to free up the repair site. The proximal FDS site is incised and the tendon is reflected to the distal phalanx. Since this tendon is attached to the former FDP stump, a native tendon spans the entirety of the phalanx.

6.4.3 Surgical Technique Most commonly utilizing a Bruner’s (zigzag) incision, the first stage of the procedure consists of the implantation of a silicone or Dacron-reinforced silicone gliding implant into the scarred tendon bed. The purpose of the method is to allow for creation of mesothelial cells to form and create a new synovial cavity. Formation of a new synovial sheath allows for the gliding motion necessary for optimal tendinous activity. The implant is generally anchored to the distal phalangeal area, passed through the available synovial sheath, and anchored into the palm or distal forearm depending on the condition and location of the proximal stump of the injured tendon. Intensive rehabilitation is then started to promote the formation of the new digital sheath and maintain maximum passive range of motion. Approximately 3 months later, the silicone implant is removed from the newly created synovial cavity and the tendon graft is placed into the new sheath and anchored into the distal phalanx and anastomosed to the proximal tendon stump in the palm or forearm.

Hunter-Salisbury Method Another reconstructive method is the Hunter-Salisbury twostage technique. Similar to stage I of the Paneva-Holevich technique, a silicon rod is placed to allow for creation of a pseudosheath; however, rather than using the FDS-FDP conduit, a tendon graft is weaved through the pulley system in stage II. Commonly used grafts include the palmaris longus (present in 85% of individuals), plantaris, and long toe extensor. Desired graft length must be factored in for proper graft selection as plantaris tendons are generally considered in cases requiring longer grafts (▶ Fig. 6.5, ▶ Fig. 6.6, ▶ Fig. 6.7, ▶ Fig. 6.8, ▶ Fig. 6.9, ▶ Fig. 6.10, ▶ Fig. 6.11). Regardless of procedure selection, proper pulley assessment must occur to ensure an adequate pulley system exists. If damage is visible, the native pulleys should be repaired.

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Flexor Tendon Reconstruction (Zone 2)

Fig. 6.5 Stage 1 of flexor tendon reconstruction seen in the Hunter-Salisbury method. A Brunner zigzag is used to display the exposed tendon sheath which contains a silicone rod anchored distally to the distal aspect of the flexor digitorum superficialis (FDS) tendon.

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Fig. 6.6 The proximal edge of the Silicone rod is exposed in zone 5.

Fig. 6.7 The proximal edge of the rod is buried, frequently anchored to flexor digitorum superficialis (FDS) in zone 5.

Fig. 6.8 Stage 2 flexor tendon reconstruction: Silastic rod in the pseudosheath.

Fig. 6.9 Stage 2 flexor tendon reconstruction: Palmaris longus tendon graft harvest with multiple transverse incisions in the forearm.

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Two-Stage Flexor Tendon Reconstruction

Fig. 6.10 Stage 2 flexor tendon reconstruction: Palmaris tendon graft sutured to a Silastic rod and passed into the pseudosheath of the finger.

6.4.4 Special Instructions, Position, and Anesthesia The patient is positioned in the supine position with the arm extended on a hand table. The patient procedure can be performed under general anesthesia or a brachial plexus block. Wide-awake surgery using lidocaine and epinephrine allows the patient to interact during the procedure, facilitating adequate tensioning of the tendon graft.

6.4.5 Tips, Pearls, and Lessons Learned Range of motion must be thoroughly emphasized during the postoperative phase. After stage I, early passive ROM is pivotal toward development of latent function. These measures help reduce formation of scar tissue as well as improve the success of the graft. Furthermore, location of graft origin is crucial toward proper selection. If the graft is to be anchored in the forearm, a longer device will be necessary. On the contrary, assuming no trauma has occurred in the palm, should this location be selected as origin, a shorter graft would need to be selected. Graft length is essential as it dictates the degree of tension that must be placed in order to allow for maximal excursion.

6.4.6 Postoperative Course After stage I, a bulky dressing is applied and the hand/wrist placed in a dorsal blocking splint. The wrist, MCP, and IP joints are kept in 35 degrees of flexion, 60 to 70 degrees of flexion, and relaxed in an extended position, respectively. Passive range of motion is initiated at the first postoperative visit, generally post-op day 1 to 3. The goal is to maximize motion to both prevent formation of adhesions and improve the soft tissue environment for stage II, typically performed about 3 months later. At the completion of stage II, a bulky dressing and dorsal blocking splint are applied. The splint is molded to maintain neutral position for the wrist, 45 degrees of MCP flexion, and IP neutral position. Early formal therapy is initiated with early protected weight bearing and active motion begun within days

Fig. 6.11 Stage 2 flexor tendon reconstruction: Palmaris longus tendon graft secured to the FDP tendon motor in the palm via Pulvertaft weave.

of surgery. Active range of motion is enhanced to abbreviated flexion/extension 2 weeks postoperatively. Barring complications, patients are encouraged to progress to resistance exercises at 4 to 6 weeks’ time. Each program is formatted to the degree of initial contracture and compliance of the patient to facilitate optimal return of function. Less compliant patients may be encouraged to maintain splinting for a prolonged period of time in comparison to more compliant patients. Dynamic splinting may be encouraged in patients with past or high risk of developing adhesive contractures.

6.4.7 Bailout, Rescue, and Salvage Procedures Occasionally, circumstances arise where graft placement cannot be anchored to the distal phalanx. In these situations, primary focus is directed toward establishing function at the PIP joint. Under the following three circumstances, motion at the PIP rather than distal interphalangeal (DIP) joint is the aim: 1. Articular damage to or extensor mechanism dysfunction across the DIP 2. Inadequate flexor tendon excursion arising due to the presence of bowstringing, usually secondary to pulley dysfunction or absence 3. Digits in which the distal insertion ruptured after tendon grafting In situations where circumstance 1 is present, anchoring of the tendon graft to the middle phalanx is considered for salvage of function. Similar to type 1, in type 2 and 3 situations, function is primarily aimed toward the PIP rather than DIP joints. Unlike type 1, the FDP may be salvaged in types 2 and 3, with type 2 necessitating pulley reconstructions.

6.4.8 Pitfalls The most common complication associated with flexor tendon reconstruction is the development of adhesions. Early postoperative therapy can help avoid adhesions, and tenolysis may be

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Flexor Tendon Reconstruction (Zone 2) of motion idealized after stage I reconstruction. Whereas the tendon is passed volar to the extensor mechanism in the proximal phalanx, in the middle phalanx, the tendon is passed dorsal. In addition, the graft may be weaved in a shoe-lace-like fashion through existing annular tissue to mimic the native pulley. Furthermore, the native FDS tendon may be tensioned from its distal slip and tethered to the contralateral periosteum or pulley material.

6.5.3 Pitfalls

Fig. 6.12 A tendon graft that has been wrapped around the phalanx two times in a Bunnell fashion to facilitate pulley reconstruction.

attempted in cases refractory to therapy. While silicon rods help form a membranous sheath to facilitate gliding of the native tendon, their use can lead to development of synovitis or infection. Synovitis may present as warmth, swelling, or pain in the digit. This issue must be identified and treated accordingly as it may result in a thickened, less suitable environment for stage II. Loose or unstable pulleys are one cause of this complication. Proper identification of compromised pulleys during initial procedure is essential to minimize postoperative complications. During stage I, improper anchoring of the silicon rod to the distal phalanx may also lead toward irritation and subsequent synovitis. Once present, synovitis may impair range of motion secondary to pain, diminishing early function and potentiating formation of adhesions. Initially, anti-inflammatory medication may be used to attempt to improve physical symptoms; however, if refractory, the graft may need to be removed. Graft rupture and infection are other common complications of the procedure.

6.5 Pulley Reconstruction 6.5.1 Indications The pulley system is essential to allow for the tendon to remain in close proximity to the bone in order to minimize bowstringing phenomenon. Incompetent pulleys may result in a joint flexure contractures, compromising function. Injury or scarring of the A2 and A4 annular pulleys must be assessed during the stage 1 procedure. In pulley reconstruction during the stage I procedure, free tendon grafts are used. While some debate exists, intrasynovial tendons decrease the amount of work for adequate tendon excursion, thus facilitating maximal angular motion.

6.5.2 Surgical Technique Wrapping of tendons around the phalanges as developed by Bunnell, rather than drilling through bone for support, as described by Doyle and Blythe, may be preferable (▶ Fig. 6.12). Two or three loops around the tendon may facilitate early range

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While passing the tendinous grafts around the phalanges, damage to the neurovascular bundle may occur. In addition, inappropriate tensioning of the pulley may lead to failure of the construct and eventual bowstringing. In efforts to mitigate these issues, tendons are generally passed by hand to ensure accuracy. In addition, tendons should be checked intraoperatively for adequate pulley tension.

6.5.4 Postoperative Care Postoperatively, a protective external pulley ring is worn for 4 to 6 weeks. It is essential for the physical therapist to support this structure during initial passive or active range of motion.

6.6 Flexor Tenolysis 6.6.1 Indications Tenolysis involves removing adhesions from tendons. As mentioned above, zone 2 reconstruction is a tedious and technically demanding task as there is an increased propensity for adhesion formation. In the initial evaluation of flexor tendons, one must first assess the range of motion. Patients presenting with adhesions commonly complain of discrepancies between passive and active digital range of motion, with active being the diminished component. If occurring after prior surgery, it is important to optimize function of the afflicted hand prior to intervention. It is typical to wait approximately 4 to 6 months after a surgical procedure to allow soft tissue and tendinous healing. Throughout this time, rigorous occupational therapy is performed to ensure optimal range of motion of the digits. If after this period of time, and if there is failure of progression with therapy, patients may be indicated for surgical intervention. Patients with good passive range of motion in the absence of functional active flexion are the best candidates. Those with limited passive range of motion are likely to have contractures of the joints, in which case the articular adhesions must be also addressed to improve digital range of motion postoperatively.

6.6.2 Surgical Technique Most tenolysis procedures are conducted under local anesthesia, with general reserved for anxious patients or those with

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Flexor Tenolysis extensive adhesion formation. Surgical incisions consist of either a Brunner zigzag or a midlateral technique. The tendon sheath is incised, and adhesions are removed through sharp dissection. Care should be taken to preserve the reconstructed tendon and the pulley system.

6.6.3 Postoperative Care Postoperatively, bulky dressings are applied with guidance toward participating in early range of motion. This procedure is associated with a high level of success; however, patients must be cautioned for the possibility of adhesion recurrence, which is the most common pitfall following tenolysis procedures.

Suggested Readings Fletcher DR, McClinton MA. Single-stage flexor tendon grafting: refining the steps. J Hand Surg Am. 2015; 40(7):1452–1460 Inkellis E, Altman E, Wolfe SW. Management of flexor pulley injuries with proximal interphalangeal joint contracture. Hand Clin. 2018; 34(2):251–266 Samora JB, Klinefelter RD. Flexor tendon reconstruction. J Am Acad Orthop Surg. 2016; 24(1):28–36 Sandvall BK, Kuhlman-Wood K, Recor C, Friedrich JB. Flexor tendon repair, rehabilitation, and reconstruction. Plast Reconstr Surg. 2013; 132(6):1493–1503 Strickland JW. Flexor tendon injuries. Part 4. Staged flexor tendon reconstruction and restoration of the flexor pulley. Orthop Rev. 1987; 16(2):78–90 Strickland JW. Flexor tendon surgery. Part 2. Free tendon grafts and tenolysis. J Hand Surg [Br]. 1989; 14(4):368–382 Tang JB. Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer. Clin Orthop Surg. 2015; 7(3):275–281 Wehbé MA, Mawr B, Hunter JM, Schneider LH, Goodwyn BL. Two-stage flexor-tendon reconstruction: ten-year experience. J Bone Joint Surg Am. 1986; 68(5):752–763

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7 Radial Nerve Palsy Tendon Transfers Charles E. Hoffler, Hari Om Gupta, and Menar Wahood Abstract Various tendon transfer options exist to restore hand and wrist function following radial nerve palsy. Donor selection principles are critical to successful transfers. Tendon transfer principles are applied including an expendable donor, synergistic function, similar excursion and power, straight line of pull, and one transfer for one function. Surgical indications, tips, recommended techniques, and salvage procedures are reviewed in detail. Keywords: radial nerve palsy, radial nerve injury, posterior interosseous nerve palsy, tendon transfer

7.1 Description Various tendon transfer options are available for radial nerve palsy in the setting of proper functioning median and ulnar nerves (▶ Table 7.1).1 The aim is to restore wrist, metacarpophalangeal (MCP) joint, and thumb extension. Interphalangeal (IP) joint extension is typically preserved with the unaffected intrinsic muscles.

7.2 Key Principles The level of radial nerve injury dictates the interventions necessary to restore functional motion. In low radial nerve or posterior interosseous nerve injury, where extensor carpi radialis longus (ECRL) wrist extension is spared, reconstruction should focus on restoring finger and thumb extension. In pre-radial bifurcation nerve injury, wrist extension should also be restored. In order for a muscle group to be considered transferable, it must follow these basic principles2: ● The donor muscle must be expendable and loss of its primary function should not significantly compromise the patient’s residual functional motion and strength. ● The donor unit must have at least full active motion against resistance, since transfer causes an expected loss of at least one grade of strength. Ideally, the force generation of the donor should be equal to or greater than the recipient it is replacing. ● Donor transfers must have sufficient amplitude of tendon excursion similar to the recipient and be in a straight vector, ideally crossing a single joint.

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One tendon transfer should be considered for one specific function.

Knowledge of available muscle units is important as well. Always assess and prioritize which functions need to be restored and which muscle-tendon units are viable donors. In partial radial nerve palsies, some extensor groups are spared and attention should be directed to restoring the remaining functional deficits. Alternatively, if the patient is missing a muscle group from a concurrent injury, prior transfer, or congenital absence (i.e., palmaris longus [PL]), then alternative donors should be investigated. Synergistic muscles are preferred due to ease of rehabilitation. For example, wrist flexors and digit MCP extensors are usually contracting simultaneously, so postoperative occupational therapy is more intuitive than a finger flexor to finger extensor transfer.

7.3 Expectations Injuries proximal to the elbow cause high radial nerve palsies, and tendon transfers are used to restore the resulting motor deficits in wrist extension, lesser digit MCP extension, and thumb extension. Injuries distal to the elbow cause low radial nerve palsies, often with preserved wrist extension from the ECRL. In low radial nerve injuries, tendon transfers restore lesser digit extension at the MCP joints and thumb extension. The pronator teres (PT) is typically transferred to the extensor carpi radialis brevis (ECRB) as it inserts centrally on the hand at the base of the third metacarpal, which can create more neutral extension than the ECRL insertion on the second metacarpal. Flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) are common donors for lesser digit extension. PL or the ring finger flexor digitorum superficialis (FDS) can be transferred to the extensor pollicis longus (EPL). FCR transfer to the first compartment extensors is less common.2

7.4 Indications Tendon transfers should be considered when there is loss of wrist extension, finger extension at the MCP joint, and thumb extension secondary to radial nerve injury with a poor prognosis for functional recovery due to known anatomic features, electrophysiologic, or minimal clinical improvement by 6 months after the injury.

Table 7.1 Most common radial nerve palsy tendon transfers FCR transfers ● ● ●

PT to ECRB FCR to EDC PL to rerouted EPL

FCU transfers ● ● ●

PT to ECRB FCU to EDC PL to rerouted EPL

Superficialis transfers ● ●

PT to ECRB FDS III to EDC – FDS IV to EPL – FCR to APL and EPB

Abbreviations: APL, abductor pollicis longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDS, flexor digitorum superficialis; PL, palmaris longus; PT, pronator teres.

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7.5 Contraindications Absolute: ● Lack of appropriate donors tendon/muscle (which may be from concomitant median and ulnar nerve injury) ● Muscle-tendon units with less than grade 4 strength ● Severe joint contractures and ankylosis ● Active infection ● Inability to cooperate with postoperative restrictions and rehabilitation

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Tips, Pearls, and Lessons Learned Relative: ● Donor muscle-tendon units with less than grade 5 strength ● Moderate joint contractures ● Soft tissue bed inflammation and sclerosis

7.6 Special Considerations EMG and nerve conduction studies may be helpful 3 months following the injury in order to confirm radial nerve deficits or failure of spontaneous recovery. If clinical or electrophysiologic evidence of recovery is not present at 4 to 6 months, the prognosis for robust nerve recovery is poor. Preoperative passive range of motion should be assessed to ensure supple joints are present to accept tendon transfers. Patients with progressive neurological disorders affecting peripheral nervous system may be a poor candidate for tendon transfer due to possible neighboring involvement of nerves. It is also necessary to determine patient’s functional needs to ensure appropriate affected motions are restored.

7.8.3 FCR Donor Release the FCR tendon as distal as possible. If a split FCR is planned, proximal dissection must identify the two motor branches and divide the muscle accordingly.4

7.8.4 FDS Donor The long finger FDS may be transferred to the EPL and extensor indicis proprius (EIP), and the ring finger FDS is transferred to the extensor digitorum communis (EDC). The opposite transfer pairing has also been described. The tendons should be divided immediately proximal to the decussation and passed through generous distal holes in the interosseous membrane (IOM) on either side of the interosseous neurovascular structures. The tendon to the EDC is divided into four slips. The tendon is passed distally under the retinaculum and woven to the EDC as distal as possible.

7.8.5 PL Donor

7.7 Special Instructions, Positioning, and Anesthesia ●

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● ●

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A regional nerve block may be helpful in reducing amount of general anesthesia Supine position with operative extremity extended on a hand table Careful preoperative observation and assessment of particular donor muscle strength Determine particular muscle units available for transfer If multiple incisions are necessary, leave ample distance between them for primary closure If soft tissue deficits are present and primary closure is unobtainable, consider rotational or free flap coverage at the time of tendon transfer Preoperative occupational therapy may be used to keep the wrist and hand joints supple

7.8 Tips, Pearls, and Lessons Learned 7.8.1 PT Donor Harvest the tendon with a 3-cm extension of periosteum from the radial shaft to increase the effective tendon length for weaving. Routing the PT subcutaneously and superficial to the brachioradialis (BR) and ECRL can minimize adhesions (▶ Fig. 7.1).

7.8.2 FCU Donor Harvest the tendon immediately proximal to the pisiform; 5 cm of FCU tendon should be separated from the distal muscle belly to improve gliding (▶ Fig. 7.2). Mobilize the FCU proximally until its primary vascular pedicle is identified 6 cm from the tip of the medial epicondyle.3

Mobilize the muscle as proximal as possible to generate a more radial vector of tension and less thumb adduction once transferred to the EPL5 (▶ Fig. 7.3).

7.8.6 ECRB Recipient If radial nerve recovery remains possible, consider using an end-to-side transfer to preserve ECRB continuity for more anatomic function recovery.

7.8.7 EDC Recipient Pass the donor tendon through the EDC as distal as possible. Resect the tendons near the musculotendinous junction. Remove a 2- to 3-cm segment of tendon to minimize adhesions. Tension each digit individually to recreate the natural cascade of progressively decreasing MCP extension from the index finger to the small finger.

7.8.8 EPL Recipient Transpose the EPL subcutaneously and radially to avoid thumb adduction. The EPL may be rerouted in a retrograde fashion through the first dorsal compartment if the patient has a specific need for more thumb abduction. An abductor pollicis longus (APL) slip may need to be resected to accommodate the EPL. The weave should be proximal to the extensor retinaculum.5

7.8.9 Postoperative Care The importance of an experienced occupational therapist cannot be understated. Patients often require encouragement and consistent re-education to adhere to the postoperative protocol necessary for a successful outcome.

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Radial Nerve Palsy Tendon Transfers

Fig. 7.1 Pronator Teres (PT) to Extensor Carpi Radialis Longus/Brevis (ECRL/ECRB) Transfer. (a) With the forearm pronated, a straight dorsal incision is made over the distal forearm to identify the tendons of ECRL (2) and ECRB (7). (1) Superficial branch of the radial nerve. (2) Extensor carpi radialis longus. (3) Brachioradialis. (4) Radius. (5) Abductor pollicis longus. (6) Extensor digitorum. (7) Extensor carpi radialis brevis. (b) Identify and safely retract the superficial radial nerve (2) away from ECRL/ECRB (6,7) and define the radial insertion of PT (5). (1) Cephalic vein. (2) Superficial branch of the radial nerve. (3) Brachioradialis. (4) Radial artery. (5) Pronator teres. 6 Extensor carpi radialis brevis. 7 Extensor carpi radialis longus. (8) Supinator. (c) The PT tendon (5) along with a strip of periosteum of PT is carefully dissected off of the radius and shuttled through the tendons of ECRL and ECRB (3,4) under tension. (1) Superficial branch of the radial nerve. (2) Brachioradialis. (3) Tendon of the extensor carpi radialis longus. (4) Tendon of the extensor carpi radialis brevis. (5) Tendon of the pronator teres with strip of periosteum. (6) Supinator. (d) Under balanced wrist extension, the PT (4) is sutured to the extensor tendons (1,3). (1) Tendon of the extensor carpi radialis longus. (2) Brachioradialis. (3) Tendon of the extensor carpi radialis brevis. (4) Tendon of the pronator teres. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

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Tips, Pearls, and Lessons Learned

Fig. 7.2 Flexor Carpi Ulnaris (FCU) to Extensor Digitorum Communis (EDC) Transfer. (a) Schematic diagram of the FCU. (1) Flexor carpi ulnaris. (b) Skin incisions: ulnar distal wrist crease overlying the FCU tendon, proximally at the musculotendinous junction of FCU, and dorsally where the FCU tendon will pass subcutaneously through the EDC tendons. (c) A transverse incision proximal to FCU insertion is made over the distal wrist crease; the tendon is transected, mobilized via the proximal incision, and brought subcutaneously to the dorsally forearm. (1) Tendon of flexor carpi ulnaris. (d) The EDC is identified within the fourth dorsal compartment and the FCU is passed obliquely through the EDC tendons under tension. (1) Tendon of flexor carpi ulnaris. (2) Tendons of extensor digitorum communis. (e) The FCU tendon is obliquely sutured to the EDC tendons under tension. (1) Tendon of flexor carpi ulnaris. (2) Tendons of extensor digitorum communis. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

Fig. 7.3 Palmaris Longus (PL) to Extensor Pollicis Longus Transfer (EPL). (a) Schematic diagram of the PL and EPL (1) Palmaris longus (2) Tendon of extensor pollicis longus (b) Skin incisions: midline volar at the level of the distal wrist crease overlying the PL, proximally at the musculotendinous junction of PL, ulnar to Lister's tubercle over the third dorsal compartment, proximal to the EPL insertion at the level of the metacarpophalangeal (MCP) joint, and midpoint between the released PL and EPL. (c) The PL tendon is released distally through a wrist crease incision and then mobilized proximally in line with the tendon through a transverse incision. The EPL is identified and transected at the level of the third dorsal compartment and then mobilized to the MCP. (1) Tendon of the extensor pollicis longus. (2) Tendon of the palmaris longus. (d) An incision is made over the midpoint between the PL/EPL tendons, ensuring a straight line of pull, and then sutured together under tension. (1) Tendon of the palmaris longus. (2) Tendon of the extensor pollicis longus. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

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Radial Nerve Palsy Tendon Transfers

7.9 Difficulties Encountered 7.9.1 Contractures Radial nerve palsy can produce an adduction deformity if the inactive EPL becomes adherent within its fibro-osseous canal at the wrist.6 This is more prevalent with a concomitant medial nerve palsy and needs to be corrected before any tendon transfers are performed. Initial treatment is with an active abduction traction splint followed by releasing the EPL from its fibro-osseous canal and transposing it subcutaneously.

7.9.2 Tensioning Appropriate tensioning is based on the Blix curve for optimal sarcomere length.1 Attention should be paid to reproducing the donor muscle preoperative length in order to maximize force generation. Intraoperatively, the surgeon may mark the donor muscle with sutures at fixed intervals before detaching its tendon and ensuring that these fixed intervals are maintained after the tendon weave is performed.

7.10 Key Procedural Steps 7.10.1 Number of Incisions For the most common tendon transfer combinations, three donor tendons from the volar side are transferred to recipient tendons on the dorsal side. This translates to at least one incision for transfers using the FCR as a donor to the EDC, 2 for the FCU, and 3 for the FDS. If rerouting of the EPL through the first extensor compartment, an additional incision on the dorsum of the thumb MCP joint may be necessary. Skin incisions should be planned so that the tendon weaves do not lie directly under the incisions.1

7.10.2 Tendon Preparation All tendons for transfers should be explored initially to confirm their integrity before proceeding with any of the releases or weaves. If the PT is used for wrist extension, it is important to harvest a 3-cm distal periosteal strip of tissue to allow sufficient length for tendon transfer. Subcutaneous routing of the PT is preferred to minimize adhesions to the underlying radius. For the FCR-type and FCU-type transfers, the usual route to the EDC is around the subcutaneous border of the radius and ulna, respectively. The tendon should be harvested as distal as possible. The FCR transfer, as well as the FDS, can also be routed to the EDC via windows on either side of the interosseous neurovascular structures proximal to the pronator quadratus. To minimize adhesions, the tunnels should be large, and part of the FDS muscular origin may be detached from the IOM. At least 5 cm of FCU tendon should be dissected free of distal muscle belly to improve gliding. In addition, the FCU should be mobilized proximally until its primary vascular pedicle is identified 6 cm from the tip of the medial epicondyle.7 The PL is identified at the wrist crease through the same incision for the FCR. A subcutaneous tunnel is made to the dorsal thumb to the EPL, staying deep to the cutaneous nerves. If the

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PL is absent, the options include the FDS from the long or ring finger,8 split FCR,4 or single FCU3 tendon transfers. Long finger FDS is transferred to the EIP/EPL and ring finger FDS to EDC. The ECRB and EDC tendons can be prepared for end-to-end or end-to-side transfer; end-to-side is usually performed if doing an early tendon transfer and hoping for recovery of radial nerve function. The EPL should be removed from the third extensor compartment and incised at its musculotendinous junction to prepare for an end-to-end transfer.5 The EPL is typically rerouted subcutaneously toward PL to prevent adduction of the thumb when the PL contracts. It can also be rerouted in a retrograde fashion through the first extensor compartment to enhance abduction. A slip of the APL may need to be excised to accommodate the EPL.

7.10.3 Weaving The Pulvertaft weave is the most common type of repair using 2–0, 3–0, or 4–0 nonabsorbable horizontal mattress sutures. Its pullout strength can be increased by using corner stitches. Other options include the spiral, lasso, and doubleloop, which offer the benefit of increased pullout strength with the disadvantage of greater bulk. The side-to-side technique has comparable bulk to the Pulvertaft weave and greater strength when compared to the horizontal mattress suture technique.9,10 To minimize bow-stringing and ensure tendon gliding, the fascia around extensor compartments I, II, and IV must be cleared, while making sure to preserve the extensor retinaculum; the weaves and sutures should be located proximal to the extensor retinaculum as to not contact the retinaculum during tendon excursion. Donors should be woven into recipients as distal as possible without impinging. If using FDS to restore lesser digit extension, the tendon is divided into four slips, passed anterograde through the fourth compartment and woven to the EDC, as distal as possible from the retinaculum.

7.10.4 Tensioning As reviewed above, reproducing the donor muscle preoperative length may maximize force generation. If wrist transfer is performed first, the PT is woven into the ECRB with the wrist in slight extension (30°–45°). The wrist is then brought to neutral and the FCR/FCU/FDS is woven into the EDC with the MCP joints in full extension. Lastly, with the EPL under full tension, the PL is woven into the EPL with the wrist in neutral. If wrist transfer is performed last, the donors (FCR/FCU/FDS) to the EDC and EPL are woven with the wrist in neutral or 45° extension with the fingers and thumb in full extension. Tension is then adjusted until 30° of wrist flexion results in adequate extension of the thumb and finger MCP joints, and wrist extension allows for full passive finger flexion. The PT is woven last into the ECRB until a 30° resting posture of the wrist is attained with the MCP joints of the fingers slightly flexed. The normal finger cascade of the MCP joints is when the fingers are progressively less extended from radial to ulnar, which is achieved by individually tensioning each EDC to the donor tendon.

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References

The radial artery and the ulnar neurovascular bundle must be identified and protected during the harvest of the FCR and FCU tendons, respectively. The PL should be identified superficial to the deep forearm fascia, and not confused with the median nerve deep to the fascia. If a split FCR transfer is planned, care should be taken not to damage their neurovascular pedicles.4 During routing, priority should be given to identifying and protecting cutaneous nerves, such as the superficial branch of the radial nerve, dorsal sensory branch of the ulnar nerve, and the palmar cutaneous branch of the median nerve. If a tunnel is used through the IOM for the PL transfer, the anterior and posterior interosseous nerves and arteries must be protected. It is important to stay deep to the superficial branch of the radial nerve and the palmar cutaneous branch of the median nerve.

The FCU is mobilized through a volar incision and subcutaneously tunneled around the ulnar forearm to the dorsum. A dorsal incision is used to weave the FCU through the EDC, EIP, and EDM tendons in an oblique direction, and as distal as possible, while the wrist is held in 30° extension, MCP joints at 20°, and IP joints in full extension. After suturing the individual lesser digit extensor tendons, the FCU is woven into the EPL with thumb in full extension. If tensioning is appropriate, the wrist extension tenodesis effect will create digit flexion within 2 cm of the palm. The wrist is immobilized in 40° of extension with 10° of MCP hyperextension for 3 to 4 weeks with immediate active and passive flexion/extension of IP joints. Adhesions can develop after any tendon transfer surgery, and physical therapy should be modified to address these concerns.1 Tenolysis should be delayed for at least 6 to 9 months.

7.10.6 Postoperative Care

References

7.10.5 Dangers

Most authors recommend an above elbow splint with the elbow in 90° of flexion and the forearm in moderate to full pronation. The wrist should be in 30° to 50° of extension, the lesser digit MCP joints in full extension with the IP joints free, and the thumb fully extended and abducted. Immobilization is maintained for 4 to 6 weeks with immediate active and passive flexion/extension of IP joints.

7.11 Bailout, Rescue, and Salvage Procedures A single FCU tendon transfer can be used to restore wrist, finger, and thumb extension.3 Advantages of this include simplicity, shorter operative time, less donor tendon loss of function, and less incisions. Primary indications include a high radial nerve or concomitant high median nerve injury. If the FCU tendon is not sufficiently strong, PT can still be transferred to the ECRB for restoration of wrist extension.

[1] Cheah AE, Etcheson J, Yao J. Radial nerve tendon transfers. Hand Clin. 2016; 32(3):323–338 [2] Sammer DM, Chung KC. Tendon transfers: part I. Principles of transfer and transfers for radial nerve palsy. Plast Reconstr Surg. 2009; 123(5):169e–177e [3] Gousheh J, Arasteh E. Transfer of a single flexor carpi ulnaris tendon for treatment of radial nerve palsy. J Hand Surg [Br]. 2006; 31(5):542–546 [4] Lim AY, Lahiri A, Pereira BP, Kumar VP, Tan LL. Independent function in a split flexor carpi radialis transfer. J Hand Surg Am. 2004; 29(1):28–31 [5] Colantoni Woodside J, Bindra RR. Rerouting extensor pollicis longus tendon transfer. J Hand Surg Am. 2015; 40(4):822–825 [6] Omer GE, Jr. Reconstruction of a balanced thumb through tendon transfers. Clin Orthop Relat Res. 1985(195):104–116 [7] Tubiana R. Problems and solutions in palliative tendon transfer surgery for radial nerve palsy. Tech Hand Up Extrem Surg. 2002; 6(3):104–113 [8] Chuinard RG, Boyes JH, Stark HH, Ashworth CR. Tendon transfers for radial nerve palsy: use of superficialis tendons for digital extension. J Hand Surg Am. 1978; 3(6):560–570 [9] Brown SH, Hentzen ER, Kwan A, Ward SR, Fridén J, Lieber RL. Mechanical strength of the side-to-side versus Pulvertaft weave tendon repair. J Hand Surg Am. 2010; 35(4):540–545 [10] Jeon SH, Chung MS, Baek GH, Lee YH, Kim SH, Gong HS. Comparison of looptendon versus end-weave methods for tendon transfer or grafting in rabbits. J Hand Surg Am. 2009; 34(6):1074–1079

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8 Low Median Nerve Palsy Tendon Transfers Valeriy Shubinets, Benjamin Chang, and David J. Bozentka Abstract The main goal of tendon transfers in the setting of low median nerve palsy is restoration of thumb opposition. Four classic low median nerve palsy tendon transfers exist: extensor indicis pollicis, palmaris longus (PL) (Camitz), flexor digitorum superficialis (FDS), and abductor digiti minimi (ADS) (Huber). Each has a unique set of features and considerations. This chapter describes the preoperative evaluation, intraoperative execution, and postoperative follow-up involved with these transfers. The importance of a thorough assessment of the patient’s deficits and goals is emphasized, along with proper management of expectations and associated risks. Technical details of tendon harvest, tendon tunneling, pulley formation, and tension-setting are outlined. Helpful tips and tricks are included to streamline the steps and avoid pitfalls. Common modifications to optimize function are also discussed. At the end of this chapter, the reader should be familiar with the key features of low median nerve palsy tendon transfers, the unique advantages and disadvantages of each, and the judicious use of preoperative evaluation and intraoperative decision-making to increase the likelihood of success.

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Keywords: opponensplasty, low median nerve palsy, tendon transfer, thumb opposition, Camitz, Huber, Bunnell, RoyleThompson ●

8.1 Description Low median nerve palsy tendon transfers are directed toward restoring thumb opposition, a critical primate function for both power and precision manipulation.

8.2 Key Principles 8.2.1 General Principles of Tendon Transfers The following set of “rules” or principles represents an essential guide to performing tendon transfers and optimizing the likelihood of success1,2: ● Supple joints: A tendon transfer will not move a stiff joint. After nerve injury, the joints must be kept supple with the aid of supervised hand therapy and home exercises. If a joint contracture develops, it must be corrected prior to tendon transfer, as the latter requires a period of postoperative immobilization, while contracture release dictates immediate mobilization.1 ● Soft tissue equilibrium: The surrounding soft tissues must reach a state of equilibrium: there should be no active open wounds, no inflammation, and all scars should be soft and mature. Generally, the path for tendon transfer is established in the subcutaneous plane. If excessive scar is present, it may have to be excised and replaced with new soft tissue via

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regional or free tissue transfer. Alternatively, the tendon transfer is re-routed along a different path. Adequate strength of tendon: The transferred tendon should be strong enough to move the desired joint. Typically, the process of transfer weakens the tendon by one grade.1 Adequate excursion of tendon: Every attempt should be made at matching the excursion amplitude of the transferred tendon to that of the tendon it replaces. Excursion amplitude represents the linear motion of the muscle-tendon unit as it contracts. In general, extrinsic finger flexors have an excursion amplitude of 70 mm, extrinsic finger extensors of 50 mm, and extrinsic wrist flexors and extensors of 30 mm.1 If the donorrecipient tendon excursion cannot be matched, one can supplement the active range of motion by tenodesis effect. Straight line of pull: The transferred tendon should ideally run in a straight line from its origin to its new insertion. If this is not possible, pulleys should be utilized. One tendon, one function: Tendon transfers are generally most successful when the transferred tendon performs one function. Expendable donor: Loss of function associated with donor tendon sacrifice should not be critical to hand function. For example, extensor indicis proprius (EIP) opponensplasty does not sacrifice index finger extension given the presence of a separate extensor digitorum communis (EDC) tendon to the index finger. Synergy: Tendon transfer by default necessitates a period of re-education for the patient (i.e., in EIP opponensplasty, EIP tendon’s new function is to move the thumb rather than the index finger). This process may be easier if “synergistic” tendons are used. For example, wrist flexion and finger extension work in unison when grabbing and gripping objects, i.e., wrist flexors and finger extensors are said to be synergistic. Therefore, in the setting of a radial nerve palsy, a wrist flexor is transferred to restore finger extension. Similarly, in low median nerve palsy tendon transfers, rehabilitation is easier if the transferred muscle-tendon unit is synergistic with abductor pollicis brevis (APB), as is the case with the EIP transfer.

8.2.2 Considerations Specific to Low Median Nerve Palsy Tendon Transfers Median nerve injuries are divided into high and low depending on whether the injury is proximal or distal to the forearm muscle innervation.1 In high median nerve injuries, the injury is proximal to the forearm muscle innervation, whereas in low median nerve injuries, the injury is distal to the innervation. Thus, in the low median nerve palsy, pronator quadratus, pronator teres, flexor carpi radialis (FCR), all four FDS, flexor pollicis longus (FPL), and index/middle finger flexor digitorum profundus (FDP) muscles are usually intact and functional, unless also traumatically injured. The muscles affected by the palsy are the thenar muscles and the radial two lumbricals. The

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Expectations intact ulnar-innervated interossei can compensate for the lumbricals, whereas loss of thenar muscles may significantly impact the ability to oppose the thumb. As such, the main goal of tendon transfers in the setting of a low median nerve palsy is restoring

Fig. 8.1 Thumb opposition is a complex movement that consists of flexion, palmar abduction, and pronation. For tendon transfers, the ideal vector to reproduce opposition starts at the pisiform. If the vector is more distal, greater degree of flexion is produced, which may be useful in cases of combined ulnar-median nerve palsy. If the vector is more proximal, greater degree of palmar abduction is produced.

thumb opposition, and these transfers, accordingly, are often referred to as opponensplasties or opposition tendon transfers. Thumb opposition is a complex movement that consists of palmar abduction, pronation, and flexion.1,2 There are three muscles in the thenar eminence that contribute to opposition: APB, opponens pollicis (OP), and flexor pollicis brevis (FPB). Of these muscles, APB is recognized as the most important for opposition.3 In cases of an isolated median nerve palsy, the APB insertion on the radial side of the thumb metacarpophalangeal (MCP) joint is a commonly used insertion site for opposition tendon transfers. The ideal line of pull for these transfers starts at the pisiform (▶ Fig. 8.1). If the line of pull is more distal to the pisiform, a greater degree of thumb flexion is achieved, which can be useful in cases of a combined ulnar and median nerve palsy.3 If the line of pull is more proximal to the pisiform, a greater degree of thumb abduction is achieved.3 Assessing the soft tissue environment around the thumb is critical for success with opponensplasties. Particular attention should be directed at the status of the dorsal skin and web space. In a long-standing low median nerve palsy, shortening of the dorsal skin and fascia may occur, especially if the patient develops a habit of lateral squeeze pinch.4 If the contracture is not corrected, the dorsal skin will limit thumb abduction and, especially, pronation.4 Crank action may develop, which will result in a progressive supination deformity of the thumb with loss of metacarpal abduction and pronation.4 Thus, before any tendon transfer procedure, the thumb should be assessed for its full ability to oppose passively without limitation. If restrained, passive stretching and splinting will be needed.4 In more severe cases, a sliding webplasty, Z-plasty, or even free tissue transfer is considered (▶ Fig. 8.2).4

8.3 Expectations Setting reasonable expectations for patients is of paramount importance. Patients should have a good understanding of the

Fig. 8.2 A 5-year-old patient is shown with right thumb hypoplasia and absence of thenar muscles, as well as narrowing of first web space. If the first web space is not corrected, it will limit the thumb’s abduction and pronation after abductor digiti minimi (ADM) (Huber) transfer. (a) Markings for 4-flap z-plasty to widen first web space. (b) Harvest of ADM. (c) The ADM is subcutaneously tunneled across the palm to the thumb metacarpophalangeal (MCP) joint and secured to the periosteum of proximal phalanx. (d) The incisions for the 4-flap z-plasty were then made and the flaps transposed. (These images are provided courtesy of Benjamin Chang MD, Philadelphia, PA.)

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Low Median Nerve Palsy Tendon Transfers reason for surgery and the severity of their injury, specifically the irrecoverable nature of nerve damage that often leads to the need for tendon transfers. A well-executed tendon transfer will at best approximate the original degree of function, not restore it completely. Even if good range of motion and strength are achieved, the act and coordination of a particular movement is never the same as in the premorbid state. The tendons are taken out of their natural context and re-routed to perform a different task, which requires a period of re-education and retraining. Hand therapy, with persistent repetitions, is critical to achieving success. The patient’s willingness and ability to engage in the strenuous rehabilitation process should thus be confirmed prior to surgery.2 Specific risks associated with each opponensplasty should be discussed. After an FDS transfer, for example, a patient may develop a weakened grip due to ring finger donor tendon sacrifice.2,3 After an EIP tendon transfer, a patient may not be able to independently extend the index finger developing a small degree of extensor lag.2,3 The patient should understand the potential need for an additional tendon graft if the transferred tendon is too short.

8.4 Indications Historically, polio was one of the earliest and most common indications for tendon transfers, including opponensplasties as a result of thenar muscle paralysis.1,2,3 Today, the most common indication for a tendon transfer is a nerve injury that has littleto-no chance of recovery.1 This can happen in the context of a traumatic injury (i.e., median nerve laceration, failed median nerve reconstruction/recovery) or a compressive neuropathy (i.e., severe carpal tunnel syndrome).1,2,3 By default, high median nerve palsies include low median nerve deficits; therefore, pronator syndrome, cervical radiculopathy, or brachial plexopathy may lead to thenar atrophy and the need for restoration of thumb opposition. Congenital absence of thenar muscles is also possible.1,2,3 Finally, low median nerve palsy can occur in the context of specific neurologic maladies such as hereditary spastic paraplegia, cerebral palsy, Charcot-Marie-Tooth disease, or spinal cord injury.1,2,3 Although currently not as pertinent, leprosy affects peripheral nerves and may also necessitate tendon transfers.1 A thorough assessment of a patient’s functional impairment is essential prior to committing to surgery. If the low median nerve palsy is limited to the nondominant hand, a patient may compensate fairly well without an opponensplasty, depending on the required daily activities and demand level.2 If there is associated loss of sensation, the hand surgeon must make sure that the loss of opposition is not due to sensory deficit.2 Even if a true lack of motor function exists, a well-executed tendon transfer will not reach maximal potential if the patient cannot sense the moving parts. Sensory nerve transfers may have to be considered.5,6 Finally, not all patients with a low median nerve palsy have significant loss of opposition. Jensen et al noted that only 14% of patients with a median nerve injury required an opponensplasty.7 Similarly, Foucher et al found that only 6.6% of patients with an operative carpal tunnel syndrome had a severe enough deficit to require treatment for thumb opposition weakness.8 This may be related to cross-innervation from the

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ulnar nerve and the resulting compensation by the FPB muscle. The superficial head of FPB, in fact, receives dual innervation by the median and ulnar nerves in 30% of cases, whereas the deep head receives dual innervation in 79% of cases.9,10 Additional anatomic means of compensation exist, through volar slips of abductor pollicis longus (APL) (the so-called digastric muscle of Wood11,12,13,14), recruitment of APL with increasing effort,15 or action of other radial-innervated muscles such as extensor pollicis brevis.15,16 A recent appraisal of clinical deficits following high median nerve injuries showed that patients still averaged a fairly high 7.5 out of 10 score on the Kapandji opposition scale.17

8.5 Contraindications A tendon transfer will not work in the setting of excessive scar, joint contracture, active wound, or inflammation. The procedure is also contraindicated in a patient who refuses to participate in the required hand therapy following surgery, including both the supervised component with a dedicated therapist and the obligatory home exercises. As discussed above, every effort should be made to truly assess the patient’s deficit, as not every case of median nerve palsy has a significant enough opposition defect to require a tendon transfer; the clinical experience of many, in fact, argues otherwise.7,8,17,18 Particular caution should be taken in unilateral nondominant hand cases or cases that involve a sensory deficit where the disability may be due to loss of sensation rather than true motor loss of opposition.2

8.6 Special Considerations Unique considerations exist for each type of opponensplasty. The EIP tendon transfer, for example, is an attractive option in a high median nerve palsy or traumatic injuries that simultaneously affect the extrinsic flexor tendons, precluding the use of FDS.2,3 Furthermore, there is less risk of grip strength loss compared to an FDS transfer. No separate pulley creation is required; the distal ulna itself plays the role of the pulley, which is fairly stable, limiting the propensity of the tendon transfer to migrate.2 One potential drawback of the transfer is that patients may develop an extensor lag or lose the ability to independently extend the index finger.3 The former risk presumably can be mitigated by not harvesting any part of the extensor hood with the EIP tendon.19 Rarely, a tendon autograft may be needed if the harvested EIP tendon has insufficient length. EIP also has a shorter muscle-fiber length compared to APB and the ring FDS, which may limit the resulting degree of thumb motion.2 In the FDS transfer, the ring finger FDS is typically used. This, however, carries a risk of grip strength weakness, which has led some to favor the middle finger FDS.2 The middle finger FDS is also considered in combined median-ulnar nerve injuries, as the ring FDP is ulnar-innervated and harvesting the ring FDS may deprive the ring finger of all its extrinsic flexor function.3 FDS transfer is contraindicated in high median nerve palsies, given the muscle’s median nerve innervation. PL transfer is very convenient when performing a simultaneous carpal tunnel release.2,3,20 Additionally, there is no functional morbidity associated with this tendon sacrifice. In about

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Tips, Pearls, and Lessons Learned 15 to 20% of individuals, however, PL is congenitally absent.3 Special caution should be exercised in traumatic wrist or forearm injuries where PL may have been transected or the surrounding soft tissue and overlying skin have become too scarred for successful harvest and re-routing of the tendon.2 It is reasonable to ask whether a Camitz transfer is truly indicated at the time of carpal tunnel release, as some thenar muscle function may recover after median nerve decompression. However, the amount of recovery is unpredictable and even if successful, the recovery may take significant time.2 Given the convenience of the transfer and its low functional morbidity, our preference is to perform the transfer at the same time as the carpal tunnel release rather than wait for recovery if there is a true opposition deficit. ADM transfer is a very practical transfer. It limits the operation to the palm, does not involve significant re-routing or pulley formation, and replaces an absent or atrophied thenar APB with a similarly sized hypothenar muscle.2,3 As such, it is particularly useful in forearm trauma cases, where harvest of palmaris or FDS may not be possible and EIP may not be successfully tunneled through the forearm scar. If APB is congenitally absent or severely atrophied, ADM can add bulk to the thenar eminence, thus restoring not only function but form.2,3 ADM also contracts and shortens throughout its length, not relying on tendon gliding as much as the other transfers. Because it is an intrinsic muscle and does not cross the wrist joint, it also avoids issues associated with tenodesis.21

8.7 Special Instructions, Positioning, and Anesthesia The patient is placed in a supine position on the operating table. General endotracheal anesthesia is administered. Alternatively, a regional block may be used with intravenous sedation. The arm is placed on a hand table, which is attached as an extension to the operating bed. A padded pneumatic tourniquet is placed around the upper arm. The hand and arm are then prepped and draped in a sterile fashion. The arm is exsanguinated with an Esmarch bandage and the tourniquet is inflated to 250 mm Hg pressure.

8.8 Tips, Pearls, and Lessons Learned 8.8.1 EIP Transfer ●

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The EIP transfer can be lengthened 1 to 2 mm by taking part of the extensor hood distally. The extra length may be used in the Riordan variation of the transfer, as described below.22 The defect in the extensor hood should be repaired to avoid an extensor lag. In isolated median nerve palsies, the transferred EIP tendon is attached only to the distal APB. In combined ulnar-median nerve injuries, the EIP tendon may also be attached to the MCP joint capsule and the extensor pollicis longus (EPL) tendon near the proximal phalanx (Riordan variation).22 This modification restricts IP joint flexion and allows FPL to flex

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the MCP joint more effectively, thus substituting for the paralyzed FPB.2,23 Because the EIP tendon may have attachments in the dorsal hand, the tendon should be dissected as far proximally as possible at the dorsal index finger MCP incision using the Littler scissors. More proximally, where the Littler scissors cannot reach under direct visualization, a tendon stripper may be used. Dissection and mobilization of the tendon is then completed at the wrist incision. Alternatively, another incision can be made halfway between the MCP joint and the wrist incisions if there is an added degree of difficulty with releasing the attachments.2,3 When passing the tendon from the dorsal wrist to the ulnar incision, a useful trick is to first place a 4–0 prolene suture at the distal end of the harvested tendon. A subcutaneous tunnel is then developed with a hemostat or a Schnidt clamp from the dorsal wrist to the ulnar incision. Littler scissors are placed at the tip of the clamp and guided from the ulnar incision to the dorsal wrist incision. The prolene suture at the end of harvested EIP tendon is then inserted into the hole in the Littler scissors and the scissors are used to draw the prolene suture through the subcutaneous tunnel with the tendon (▶ Fig. 8.3). This operative technique can be used in other transfers, not just EIP. Alternatively, clamping the end of the tendon with a hemostat or a Schnidt clamp may be sufficient to guide the tendon through the tunnel.

8.8.2 PL (Camitz) Transfer ●

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To obtain appropriate tendon length for transfer, the palmar fascia is harvested as an extension of PL. The palmar fascia is transected at the distal palmar crease. To obtain appropriate width, a 1 to 1.5 cm width of fascia is typically included.3 Alternatively, we just gather the fascia in the palm from index, middle, and ring fingers. In its standard form, the Camitz transfer restores palmar abduction. A variation can be performed where a window is made in the distal transverse carpal ligament and the tendon is passed through this window, creating a vector of pull that adds a degree of pronation.3,24 Another means of adding pronation is to attach the transferred tendon to the extensor apparatus or the dorsal MCP joint capsule.2,8,24

8.8.3 FDS Transfer ●

The FDS tendon should be divided at the level of Camper’s chiasm, just proximal to the bifurcation. Alternatively, another incision can be made more distally at the level of the proximal interphalangeal (PIP) joint, dividing the FDS at its insertion into the middle phalanx. Two slips of FDS are then obtained. One slip can be used for APB attachment and the other for MCP joint capsule stabilization if needed. This method of harvest, however, carries a risk of PIP stiffness, hyperextension, and swan neck deformity. In addition, there is a risk of FDP tendon devascularization through injury to the vincula.25 Since in most cases sufficient length is obtained by dividing FDS at the level of Camper’s chiasm, the more distal incision at the PIP joint is avoided.

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Low Median Nerve Palsy Tendon Transfers

Fig. 8.3 EIP transfer in a 15-year-old with Charcot-Marie-Tooth disease. (a–c) extensor indicis proprius (EIP) tendon is harvested at the metacarpophalangeal (MCP) joint, then mobilized into the dorsal wrist incision. The tendon is passed to the ulnar incision using Littler scissors and a 4–0 prolene suture passed through the hole in the scissors. (d–e) Tension is set such that the thumb can be palmar-abducted with wrist extension and then brought back into adduction with wrist flexion. (f) Postoperatively, patient demonstrates thumb abduction in the operated left hand. Disease is bilateral and patient ultimately required an EIP transfer on the right side too. (These images are provided courtesy of Benjamin Chang MD, Philadelphia, PA.)

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The Royle-Thompson variation of the FDS transfer restores a greater degree of thumb flexion than palmar abduction, which can be useful when the goal of the tendon transfer is to have the thumb reach the small finger.2,26,27 This is often the case in combined ulnar-median nerve palsies. In contrast, the Bunnell variation creates a pulley effect that starts proximal to the pisiform.2,28 As such, it primarily targets the palmar abduction component of opposition. Based on the patient’s needs, the surgeon can design and range the pulley anywhere in between the Bunnell and Royle-Thompson variations.2,29 In the Bunnell variation, the pulley can either be a simple slit in flexor carpi ulnaris (FCU) or a loop carefully crafted out of a distally based longitudinal slip of FCU. If a slit option is chosen, a stitch has to be placed at the proximal end of the slit, which prevents proximal migration of the transferred FDS tendon.3 If the loop option is chosen, the transferred tendon can be first passed ulnar to the intact FCU half and then through the loop for greater stability.3 In patients with MCP joint instability, the extra length of transferred FDS tendon can be used to reconstruct collateral ligaments.3

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8.8.4 ADM (Huber) Transfer ●

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The ADM transfer is thought to be one of the more challenging and technically demanding opponensplasty options.30 Two reasons for the added degree of difficulty are (1) the need to preserve the neurovascular pedicle and

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(2) the need to achieve adequate rotation and reach of the transfer. The neurovascular pedicle can be identified proximally, on the dorsoradial side of the muscle, as the muscle is dissected in a retrograde fashion from distal to proximal.2,3 Excess tension on the pedicle should be avoided. Typically, turning the ADM muscle over 180 degrees like a page of a book puts the least tension on the pedicle.2,3 If there is difficulty in visualizing the pedicle, the incision can be extended more proximally to identify the ulnar artery and nerve, and then tracing them more distally to the pedicle.2 Variations exist regarding how much ADM can be released proximally to allow adequate rotation and reach of the muscle. One reasonable strategy is to divide some of the attachments to the pisiform, while preserving the muscle’s attachments to the FCU tendon, although this can potentially compromise the muscle’s blood supply.2,21,31 Yet others have described completely releasing ADM from the pisiform and FCU.32 As with other opponensplasties, ADM is typically inserted into the distal APB. Since the Huber transfer is particularly appealing in cases of congenital thenar muscle hypoplasia to restore thenar bulk, APB may be absent. In such cases, ADM can be secured to the periosteum of the proximal phalanx base using a 4–0 Mersilene suture. Free tendon grafting may be needed if ADM does not have adequate reach. This is particularly relevant in cases where ADM is not released from the pisiform.

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Key Procedural Steps

8.9 Difficulties Encountered ●

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Setting the tension on the transferred tendon is a critical step. If the tension is too loose, the transferred tendon will fail to achieve the desired range of motion. If the tension is too tight, the transfer will overcompensate and misbalance the hand. In the EIP, Camitz, and FDS opponensplasties, we rely on the tenodesis effect to determine appropriate tension. The tension is set such that the thumb is in maximal palmar abduction or opposition with wrist in extension, while with the wrist flexed, the thumb is able to be brought back (adducted) into the plane of the palm. Others have described setting the tension such that the thumb is in full palmar abduction or opposition when the wrist is neutral.2,3 The Huber transfer typically results in just enough muscle harvested, leaving little room for adjusting the tension. Caution should still be exercised to ensure appropriate tension when the ADM is attached to APB or thumb proximal phalanx base. Unlike the extrinsic tendon-based transfers, the ADM transfer does not rely on wrist motion or tenodesis for function. Care and time must be taken when creating subcutaneous tunnels for transfers. Nearby neurovascular structures can be at risk for iatrogenic injury such as the dorsal branch of the ulnar nerve in the EIP transfer. In the palm, the skin and underlying palmar fascia are tightly adherent, which makes subcutaneous plane development particularly tedious. Unlike other opponensplasties, the Huber transfer necessitates identification and protection of the pedicle. When the muscle is tunneled to the thumb, the tension on the pedicle should be checked prior to securing the transfer.

should be kept proximal to the extensor retinaculum for adequate length and line of pull.2 Two more incisions are then made: at the distal ulna and on the radial side of the thumb MCP joint. EIP is first tunneled subcutaneously from the dorsal wrist to the distal ulna incision, making sure that the tendon stays superficial to FCU, as otherwise it may lead to compression of the ulnar nerve in the future.2 The distal ulna acts as a functional pulley for the EIP tendon, although some have also described making a slit in the FCU through which the EIP can be passed.19 Care should be taken to avoid injury to the dorsal sensory branch of the ulnar nerve.3 A subcutaneous tunnel is then created using a Schnidt clamp from the distal ulna to the radial thumb MCP joint. The end of the EIP tendon is clamped and passed to the thumb incision. The end of the tendon is then weaved through the tendinous portion of the distal APB and sutured in place with a figure-of-eight 4–0 Mersilene suture. The tension is set such that the thumb is in maximal palmar abduction with the wrist in extension, while allowing the thumb to be brought back into the plane of the palm with the wrist in flexion. A second figure-of-eight 4–0 Mersilene suture is used to collapse the end of the tendon onto itself or secure it to the side of the proximal phalanx base. The tourniquet is released, hemostasis is obtained, and the incisions are closed. Postoperatively, the hand is immobilized in a thumb spica cast for 4 weeks, keeping the thumb in maximal palmar abduction. After 4 weeks, the cast is removed and a range of motion exercises are started. A custom-made thumb spica orthosis is typically used that maintains thumb in palmar abduction. Eight weeks postoperatively, the orthosis is discontinued and the patient gradually returns to full activity. This postoperative protocol is used for the other opponensplasties.

8.10 Key Procedural Steps

8.10.2 PL (Camitz) Transfer

8.10.1 EIP Transfer

This tendon transfer is typically performed in combination with open carpal tunnel release (▶ Fig. 8.4 and ▶ Fig. 8.5). Starting from the wrist flexion crease, the standard carpal tunnel incision is extended distally to the distal palmar crease. If necessary, the incision can also be extended proximally several centimeters across the wrist in a zigzag fashion, staying ulnar to avoid injury to the palmar cutaneous branch of the median nerve that typically runs radial to PL.3 Skin flaps are raised taking care to preserve the palmar fascia, which is essential to obtaining appropriate length for tendon transfer. Once exposed, the palmar fascia over the index, middle, and ring fingers is transected distally at the level of the distal palmar crease and reflected off the deeper tissues using sharp dissection proceeding cautiously in a distal-to-proximal direction. The superficial palmar arch and the common digital nerves are protected at all times (▶ Fig. 8.5). Small perforating vessels are cauterized using bipolar electrocautery. As the palmar fascia is raised, care is taken to leave it connected to the PL tendon proximally. The fascia is separated from the underlying transverse carpal ligament. The PL tendon is also dissected off the surrounding subcutaneous tissues, including proximally for about 3 cm into the distal forearm. Once the fascia and PL are adequately mobilized, the fascia is folded onto itself as an extension of the PL tendon and secured longitudinally with a running suture. A 4–0 prolene is placed as a traction stitch at the distal end. At this time, the transverse carpal tunnel may be released.

A triangular incision is made on the ulnar side of the index finger metacarpal head on the dorsum of the hand, creating a radially based skin flap (▶ Fig. 8.3). The flap is elevated to expose the extensor hood. EIP is identified ulnar and deep to EDC, although variations may exist including radial position, presence of multiple slips, and even congenital absence of EIP.3,33,34 EIP is harvested just proximal to the extensor hood, as this usually achieves sufficient length and avoids the associated risk of subluxation and extensor lag with sacrifice of the hood. Alternatively, a small portion of the extensor hood may be taken to lengthen the tendon by 1 to 2 mm; if so, the defect is closed with a figure-of-eight absorbable suture. The EIP tendon is dissected and mobilized off the surrounding soft tissues all the way to the dorsum of the wrist, first starting with Littler scissors and if needed, a tendon stripper more proximally. A counter incision is then made transversely across the dorsum of the wrist, at the level of Lister tubercle. The extensor retinaculum is divided over the fourth compartment and the EIP tendon is identified by traction on the distal end. EIP typically has the most distal muscle belly of any muscle in the fourth compartment, which can also help with identification.3 At the wrist incision, the tendon is dissected further proximally to its musculotendinous junction to free it up from the surrounding tissues. Once the EIP tendon is delivered into the wrist incision, it

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Low Median Nerve Palsy Tendon Transfers

Fig. 8.4 (a–c) A 16-year-old with severe carpal tunnel and thenar muscle atrophy in the right hand (top row). (d–f) Compared to the contralateral normal hand (bottom row), patient shows poor opposition, particularly in the palmar abduction component of movement. (These images are provided courtesy of Benjamin Chang MD, Philadelphia, PA.)

Fig. 8.5 Camitz transfer in the patient from ▶ Fig. 8.4. (a,b) Harvest of the palmaris longus (PL) tendon and the distal palmar fascia. A 4–0 prolene stitch may be placed through the distal end of the palmar fascia once the fascia is folded onto itself to create an extension of PL tendon. (c) Creation of a subcutaneous tunnel between the carpal tunnel incision and the incision over the radial side of thumb metacarpophalangeal (MCP) joint. The PL tendon and the palmar fascia may be passed through this tunnel with the aid of Littler scissors and the prolene suture passed through the hole of the scissors. (d) The transferred tendon is sutured to distal insertion of abductor pollicis brevis (APB). (These images are provided courtesy of Benjamin Chang MD, Philadelphia, PA.)

A V-shaped incision is made over the radial side of the thumb MCP joint creating a dorsally based triangular flap. The distal end of the APB tendon is identified. A subcutaneous tunnel is created between this incision and the proximal end of the carpal tunnel incision. The PL tendon can be directed through this subcutaneous tunnel with the aid of Littler scissors, passing the prolene suture through a hole in the scissors first and then guiding the scissors with the prolene suture and the tendon through the tunnel. Once the PL tendon is delivered to the

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thumb MCP joint, the prolene suture is removed and the tendon is passed through the distal APB using a tendon weaver. A figure-of-eight 4–0 Mersilene suture is used to secure the transferred tendon to the APB tendon, setting the tension. A second 4–0 Mersilene suture is used to collapse the distal end of the transferred tendon onto itself. The tourniquet is deflated and hemostasis is obtained. The skin is closed with either absorbable monocryl or nonabsorbable nylon sutures. A thumb spica cast maintains the thumb in full palmar abduction for 4 weeks.

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Key Procedural Steps

8.10.3 FDS Transfer A small longitudinal incision is made in the distal palm overlying the A1 pulley of the ring finger. The FDS tendon is identified between the A1 and A2 pulleys. The finger is flexed and FDS is divided at the level of Camper’s chiasm, just proximal to the bifurcation. Division of FDS more distally at its insertion into the middle phalanx carries the risk of destabilizing the PIP joint and devascularizing the FDP tendon.25 Once FDS is harvested, two options are available for pulley creation and rerouting of the FDS tendon to the thumb, which include the Royle-Thompson and the Bunnell variations. In the Royle-Thompson opponensplasty, a 3-cm incision is made in the proximal palm on the radial border of hypothenar eminence.26,27 The ring FDS tendon is identified just distal to the carpal tunnel and proximal to the superficial palmar arch. The palmar aponeurosis and the transverse carpal ligament lie radial and proximal to the tendon, respectively. The angle created by these two structures will function as the de facto pulley once the ring FDS tendon is rerouted to the thumb. After transecting the tendon distally at Camper’s chiasm, it is freed and delivered into the hypothenar eminence incision. A third and final incision is then made on the radial side of the thumb MCP joint, where the APB tendon is identified. The ring FDS tendon is delivered to this location through a subcutaneous tunnel in the palm; care and time are taken when creating this tunnel, as the skin here is very adherent to the palmar fascia. The transferred FDS tendon is secured to the distal APB as previously described. Because the line of pull created by this transfer is distal to the pisiform, one criticism of the Royle-Thompson opponensplasty is that it achieves more thumb flexion than abduction and

Fig. 8.6 Schematic drawing of the flexor digitorum superficialis (FDS) transfer (Bunnell variation).

opposition. Accordingly, it is thought to be most useful in the setting of combined ulnar-median nerve injuries or when the major goal of surgery is to allow approximation of thumb and small finger.2 In the Bunnell opponensplasty, the pulley is created more proximally at the level of the FCU insertion onto the pisiform.28 Two common options exist: (1) a slit in the FCU tendon or (2) a loop created with half of FCU split as a 5-cm longitudinal distally based segment.2,3 In the former, a stitch has to be placed at the proximal edge of the vertical slit to prevent migration of the transferred FDS tendon more proximally.3 In the latter, a 5-cm vertical incision is made that longitudinally splits the distal FCU tendon, being careful to preserve the insertion of both halves onto the pisiform. The radial half is then transected horizontally at its proximal end and is sutured to the intact FCU distally, creating a loop (▶ Fig. 8.6). The nearby ulnar neurovascular bundle is visualized and protected.3 The FDS tendon is passed through the loop, and ultimately to the radial MCP joint into the APB insertion. Some also advocate passing the FDS tendon ulnar to the FCU tendon first before threading it through the loop, creating a more stable construct and pulley.3 In contrast to the Royle-Thompson opponensplasty, the Bunnell variation creates a vector of pull that originates more proximally and thus, more successfully restores palmar abduction.

8.10.4 ADM (Huber) Transfer An ulnar hand incision is made from the base of the small finger to the pisiform (▶ Fig. 8.7 and ▶ Fig. 8.8). ADM muscle is exposed and visualized in its entirety. ADM is transected distally from its two insertions (on the fifth proximal phalanx base and the extensor mechanism), making sure to maintain as much length as possible. If necessary, a small strip of periosteum may be taken for length.3 ADM is then dissected free from the

Fig. 8.7 Schematic drawing of the abductor digiti minimi (ADM) transfer.

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Low Median Nerve Palsy Tendon Transfers

Fig. 8.8 Huber transfer. (a,b) Harvest of abductor digiti minimi (ADM) through an ulnar hand incision. Proximally, care is taken not to inadvertently injury the pedicle to the ADM. (c,d) The muscle is tunneled across the palm and secured to the periosteum of proximal phalanx or the distal insertion of APB depending on whether abductor pollicis brevis (APB) is congenitally present or absent. (These images are provided courtesy of Benjamin Chang MD, Philadelphia, PA.)

underlying flexor digiti minimi and surrounding soft tissue in a retrograde direction. Proximally, care is taken to preserve the neurovascular pedicle to ADM. The muscle is supplied by the deep palmar branch of the ulnar artery, which enters the muscle dorsoradially a few millimeters distal to the pisiform.3 If needed, the ulnar artery and nerve can be identified proximal to the wrist and then traced distally to help visualize the pedicle.2 With the pedicle protected, proximal attachments of the ADM to the pisiform can be divided, while preserving the attachments to FCU allowing adequate rotation and reach for transfer.2,3 Some, however, prefer to leave the pisiform insertion intact, as its division has been shown to reduce the muscle’s blood supply in primate studies.2,31 In this case, a tendon graft may be needed to lengthen the transferred tendon. Interestingly, some prefer to completely release ADM, dividing all of its proximal attachments including those to the FCU, and then allowing it to scar back down.32 The latter technique was, in fact, developed with the intent of preventing ulnar nerve compression by the ADM transposition.32 A radial incision is made on the thumb MCP joint and a subcutaneous tunnel is created between this incision and the proximal ADM insertion. When ADM is passed through the tunnel, it needs to be turned 180 degrees along its longitudinal axis like a page of a book.2,3 This reduces tension on the neurovascular bundle. ADM is sutured into the distal APB or the periosteum of the proximal phalanx base (if APB is congenitally absent), tensioning the transfer such that the thumb is in maximum opposition with the wrist extended.

8.11 Bailout, Rescue, and Salvage Procedures ●

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Development of adhesions postoperatively is always a risk when performing tendon transfers. The adhesions will restrict tendon motion and interfere with function. If this

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limited excursion persists despite hand therapy, return to the operating room and tenolysis may be needed to re-establish proper motion. The tension on the transfer may become too loose, in which case return to the operating room to reset the tension will be necessary. If insufficient tendon length is harvested during the original procedure, a free tendon interposition graft can be used to extend the transfer intraoperatively. This may occur with the Huber transfer and occasionally, with the EIP transfer. In the Huber transfer, a few proximal attachments to the pisiform may also be divided to gain extra length. Occasionally, despite the best technical execution, the transfer fails to function properly. If after completion of hand therapy, the patient has little or no motion, another transfer is considered. Fortunately, multiple options are available for an opponensplasty.

8.12 Pitfalls ●

Failure to assess patient’s deficits and need for opponensplasty: Not every patient with a median nerve palsy will need an opponensplasty. In fact, a significant percentage seems to be able to compensate through dual-innervation of FPB or by action of the radial nerve-directed APL and extensor muscles. Special caution should be exercised in unilateral, nondominant hand cases, which may have limited impact on a patient’s livelihood.2 A thorough sensory exam is key because lack of opposition may be due to absence of sensation, in which case a tendon transfer will not solve the problem.2 Even if a true motor component is present, the results of opponensplasties in the absence of sensation will not be as effective. Patients may be able to compensate by visualizing the moving hand, but this compensation is lost in the dark or when the hand is inside a pocket or a bag.2 As such, every effort should be made to repair the median nerve in hope of

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References

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restoring at least some form of sensation, even in the setting where motor restoration is no longer possible.1 Sensory nerve transfers may also have to be considered.5,6 Noncompliance with hand therapy: A formal hand therapy program is an important factor in obtaining optimal function of a tendon transfer. Hand therapy is helpful in restoring range of motion as the patient is immobilized for 4 weeks after the tendon transfer. In addition, a fairly intense course of exercises is required to re-educate and re-train the transferred tendon to perform a new function. Failure to follow general principles of tendon transfers: A tendon transfer should not be attempted in the setting of a stiff joint, excess scar, active inflammation, or an open unhealed wound. In low median nerve transfers specifically, the thumb has to be supple enough in its ability to passively reach full opposition. If the dorsal skin and fascia are tight, the thumb will not be able to abduct and pronate fully. The index finger will contact the thumb on its ulnar border and not the pulp, potentially leading to crank action and severe supination deformity.4 Failure to protect the neurovascular structures: Caution should be exercised to prevent iatrogenic injury to the nearby nerves or vessels while harvesting tendons, creating subcutaneous tunnels or designing pulleys. In the Bunnell opponensplasty, for example, the ulnar nerve and artery must be protected while making a pulley in the distal FCU. In the EIP tendon transfer, injury to the dorsal sensory branch of the ulnar nerve must be avoided while creating a tunnel from the dorsal wrist to the distal ulna. The neurovascular bundle to ADM is at risk for injury or excess tension when either dissecting ADM proximally or tunneling the muscle to the thumb. Similarly, the entire superficial palmar arch is at risk for injury while harvesting and elevating palmar fascia as an extension of the PL transfer. Failure to set the tension correctly: The tension on the transferred tendon cannot be too loose or too tight. The first stitch that secures the transferred tendon to the distal APB sets the tension. A second stitch is placed to provide additional security and/or collapse the distal end of the transferred tendon onto itself.

References [1] Sammer DM. Principles of Tendon Transfers. In: Thorne CH (editor-in-chief), Gurtner GC, Chung KC, Gosain AK, et al, eds. Grabb and Smith's Plastic Surgery. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:807–816 [2] Davis TRC. Principles of Tendon Transfers of Median R, and Ulnar Nerves. In: Wolfe SW (editor-in-chief), Hotchkiss RN, Kozin SH, Pederson WC, Cohen MS, eds. Green's Operative Hand Surgery. 7th ed. Philadelphia, PA: Elsevier; 2017:1023–1079 [3] Chadderdon RC, Gaston RG. Low median nerve transfers (opponensplasty). Hand Clin. 2016; 32(3):349–359 [4] Brand PWHA, ed. Clinical Mechanics of the Hand. 3rd ed. St. Louis, Missouri: Mosby; 1999 [5] Ozkan T, Ozer K, Gülgönen A. Restoration of sensibility in irreparable ulnar and median nerve lesions with use of sensory nerve transfer: long-term follow-up of 20 cases. J Hand Surg Am. 2001; 26(1):44–51

[6] Bertelli JA, Ghizoni MF. Very distal sensory nerve transfers in high median nerve lesions. J Hand Surg Am. 2011; 36(3):387–393 [7] Jensen EG. Restoration of opposition of the thumb. Hand. 1978; 10(2): 161–167 [8] Foucher G, Malizos C, Sammut D, Braun FM, Michon J. Primary palmaris longus transfer as an opponensplasty in carpal tunnel release: a series of 73 cases. J Hand Surg [Br]. 1991; 16(1):56–60 [9] Zancolli EA, Ziadenberg C, Zancolli E, Jr. Biomechanics of the trapeziometacarpal joint. Clin Orthop Relat Res. 1987(220):14–26 [10] Olave E, Prates JC, Del Sol M, Sarmento A, Gabrielli C. Distribution patterns of the muscular branch of the median nerve in the thenar region. J Anat. 1995; 186(Pt 2):441–446 [11] Marshall VC, Marshall RD. Movements of the thumb in relation to peripheral nerve injuries. Postgrad Med J. 1963; 39:518–525 [12] Khoury Z, Bertelli J, Gilbert A. The subtendons of the abductor pollicis longus muscle. Surg Radiol Anat. 1991; 13(3):245–246 [13] Roh MS, Strauch RJ, Xu L, Rosenwasser MP, Pawluk RJ, Mow VC. Thenar insertion of abductor pollicis longus accessory tendons and thumb carpometacarpal osteoarthritis. J Hand Surg Am. 2000; 25(3):458–463 [14] El-Beshbishy RA, Abdel-Hamid GA. Variations of the abductor pollicis longus tendon: an anatomic study. Folia Morphol (Warsz). 2013; 72(2): 161–166 [15] Cooney WP, Linscheid RL, An KN. Opposition of the thumb: an anatomic and biomechanical study of tendon transfers. J Hand Surg Am. 1984; 9(6): 777–786 [16] Cooney WP, III, An KN, Daube JR, Askew LJ. Electromyographic analysis of the thumb: a study of isometric forces in pinch and grasp. J Hand Surg Am. 1985; 10(2):202–210 [17] Bertelli JA, Soldado F, Lehn VL, Ghizoni MF. Reappraisal of clinical deficits following high median nerve injuries. J Hand Surg Am. 2016; 41(1):13–19 [18] Boatright JR, Kiebzak GM. The effects of low median nerve block on thumb abduction strength. J Hand Surg Am. 1997; 22(5):849–852 [19] Al-Qattan MM. Extensor indicis proprius opponensplasty for isolated traumatic low median nerve palsy: a case series. Can J Plast Surg. 2012; 20(4): 255–257 [20] Camitz H. Surgical treatment of paralysis of opponens muscle of thumbs. Acta Chir Scand. 1929; 65:77–81 [21] Latimer J, Shah M, Kay S. Abductor digiti minimi transfer for the restoration of opposition in children. J Hand Surg [Br]. 1994; 19(5):653–658 [22] Riordan DC. Tendon transfers for nerve paralysis of the hand and wrist. Curr Pract Orthop Surg. 1964; 23:17–40 [23] Burkhalter W, Christensen RC, Brown P. Extensor indicis proprius opponensplasty. J Bone Joint Surg Am. 1973; 55(4):725–732 [24] MacDougal BA. Palmaris longus opponensplasty. Plast Reconstr Surg. 1995; 96(4):982–984 [25] North ER, Littler JW. Transferring the flexor superficialis tendon: technical considerations in the prevention of proximal interphalangeal joint disability. J Hand Surg Am. 1980; 5(5):498–501 [26] Royle ND. An operation for paralysis of the intrinsic muscles of the thumb. JAMA. 1938; 111:612–613 [27] Thompson TC. A modified operation for opponens paralysis. J Bone Joint Surg Am. 1942; 24:632–640 [28] Bunnell S. Opposition of the thumb. J Bone Joint Surg. 1938; 20:269–284 [29] Lee DH, Oakes JE, Ferlic RJ. Tendon transfers for thumb opposition: a biomechanical study of pulley location and two insertion sites. J Hand Surg Am. 2003; 28(6):1002–1008 [30] Littler JW, Cooley SG. Opposition of the thumb and its restoration by abductor digiti quinti transfer. J Bone Joint Surg Am. 1963; 45:1389–1396 [31] Dunlap J, Manske PR, McCarthy JA. Perfusion of the abductor digiti quinti after transfer on a neurovascular pedicle. J Hand Surg Am. 1989; 14(6): 992–995 [32] Cawrse NH, Sammut D. A modification in technique of abductor digiti minimi (Huber) opponensplasty. J Hand Surg [Br]. 2003; 28(3):233–237 [33] Trivedi S, Siddiqui AU, Sinha TP, Sinha MB, Rathore M. Absence of extensor indicis: a rare anatomical variant. Int J Biol Res. 2014; 05(01):61–62 [34] Gonzalez MH, Weinzweig N, Kay T, Grindel S. Anatomy of the extensor tendons to the index finger. J Hand Surg Am. 1996; 21(6):988–991

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9 Tendon Transfers for Low Ulnar Nerve Palsy Daniel A. Seigerman and Amir R. Kachooei Abstract Various tendon transfer procedures have been described to help compensate and reestablish function in patients who have suffered low ulnar nerve palsy. Tendon transfer principles include using an expendable donor, synergistic function, similar excursion and power, straight line of pull, and one transfer for one function. While tendon transfers can help to improve function, the physician and patient should understand that permanent limitations are likely.

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Keywords: low ulnar nerve palsy, tendon transfer, intrinsic minus, claw hand

9.1 Key Principles ●

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It is critical to understand the various deficits caused by a low ulnar nerve palsy and understand which tendon transfers restore which lost function. There should be an individualized treatment plan for each patient. The muscles affected in a low ulnar nerve palsy include the ulnar two lumbrical muscles, all interossei muscles, the adductor pollicis, deep head of the flexor pollicis brevis, and the hypothenar muscles. Lumbricals and interossei muscles normally cause flexion of the metacarpophalangeal (MCP), extension of the proximal interphalangeal (PIP), and extension of the distal interphalangeal (DIP) joints. Paralysis of the intrinsic muscles causes inversion of the function causing clawing (MCP extension, PIP and DIP flexion) due to unbalanced contraction of the long digital extensor and flexors. Clawing of the ring and small fingers: This occurs due to paralysis of both the interossei and lumbrical muscles to these

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two fingers, whereas the index and middle fingers remain unaffected because the lumbricals to these two fingers are left innervated by the median nerve. Grip strength is also decreased because of the clawing in the fourth and fifth fingers. Froment sign: when the adductor policis brevis is paralyzed, the force of the secondary thumb adductor—extensor policis longus (EPL)—results in thumb adduction and MCP extension. This causes stretching of the flexor policis longus (FPL) causing thumb IP flexion. This position with the thumb in adduction, MCP extension, and thumb IP flexion is called the Froment sign. Pinch is affected due to the paralysis of thumb adductor and the first dorsal interosseous both of which stabilize the thumb for pinching (▶ Fig. 9.1). Wartenberg sign: paralysis of the third-volar interosseous, which normally adducts the digit, along with the unopposed abduction force of the extensor digiti minimi (EDM), causes abduction of the fifth finger called Wartenberg sign.

9.2 Expectations The goal of surgery is to improve function. Communication with the patient to understand his or her functional deficits and shared decision making can help to construct the most appropriate surgical plan. The patient should understand that normal function cannot be restored. Small improvements in patients with catastrophic injuries or complete nerve palsy can be relatively impactful. At best, the patient will have noticeable weakness when comparing the repaired and unaffected side.

9.3 Indications ●

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It is important to remember that patients treated with nerve repair may take 12 or more months to demonstrate improvement. Electromyographic (EMG) testing may help to evaluate nerve recovery, if any, after repair. The neuromuscular junction is irreversible after 12 months from nerve injury. Within this period is considered appropriate for nerve repair/transfer, after which tendon transfers are indicated. Transfers for low ulnar nerve palsy are indicated for correcting the claw deformity in the fourth and fifth digits, increasing the pinch power, and preventing thumb adduction.

9.4 Contraindications ●

Fig. 9.1 Example of classic ulnar palsy with interosseous muscle atrophy, with “claw” deformity of the ring and small fingers and atrophy of the thumb adductors. (Reproduced with permission from Beasley RW. Beasley’s Surgery of the Hand. 1st ed. © 2003 Thieme.)

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Contracture: Patients with contractures within the motor groups affected by the ulnar nerve injury or contracture within the donor group is an absolute contraindication for tendon transfer surgery. Polyneuropathy or no adequate donor tendon: There needs to be an acceptable donor muscle group. Muscle force drops

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Tips, Pearls, and Lessons Learned

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at least one grade after transfer (based on the muscle force grading of 0–5); thus, the transferring muscle must not be compromised. Infection: Active infection is a contraindication for tendon transfer surgery. Spasticity: Patients with central nervous system deficits may be contraindicated for specific tendon transfers.

interphalangeal joints (▶ Fig. 9.2). A positive test is demonstrated when the patient can extend the IP joints, and confirms the competence of the extensor mechanism.

Static Procedures ●

9.5 Special Considerations ●

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MP hyperextension occurs with lack of intrinsic flexion against an unopposed and intact extensor digitorum communis. Clawing is typically worst in the small and ring fingers due to median innervated lumbricals. With a low ulnar nerve injury, the flexor digitorum profundus (FDP) to the small and ring fingers are intact, and therefore, can make the appearance of clawing more severe when compared to higher ulnar nerve injuries.

9.6 Special Instructions, Positioning, and Anesthesia ● ● ●

Regional anesthesia with sedation or with general anesthesia Supine on hand table Upper arm tourniquet

9.7 Tips, Pearls, and Lessons Learned 9.7.1 Correction of Clawing Bouvier Maneuver ●

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Static procedures are successful only if the Bouvier maneuver is positive. These procedures include MCP joint volar plate advancements and capsulodesis, pulley advancements, bone blocks, and others utilizing the normal anatomy of the MCP joint (▶ Fig. 9.3). Zancolli described a static capsular shortening of the volar plate by cutting the volar plate with a distal base, advancing proximally and suture back more proximally to the metacarpal neck to hinder MP joint hyperextension (▶ Fig. 9.4). Alternatively, a modified MP joint capsulodesis has also been described (▶ Fig. 9.5).

Dynamic Procedures ●

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Dynamic transfers include those that help restore the function of the intrinsic musculature to improve MP flexion and IP extension. For MP flexion, the donor tendon should pass volar to the transverse metacarpal ligament to cause flexion at the MP joint. The donor tendon should be anchored distally into the extensor mechanism such that an extension moment is created at the PIP joint. The most widely used donor tendon to correct clawing is the FDS tendon.1 The FDS tendon to the middle finger is selected, as to not cause further weakness in the ring and small fingers (▶ Fig. 9.6). A Bruner incision is made over the PIP joint, and the FDS tendon is isolated and transected close to its insertion,

Prior to addressing a clawing deformity, it is important to perform a Bouvier maneuver. To perform this test, hold the MP joints in slight flexion, and ask the patient to extend the

Fig. 9.2 If MP joint hyperextension is blocked, radial innervated muscles provide full active proximal interphalangeal (PIP) extension through the extensor’s central slips. MP, metacarpophalangeal. (Reproduced with permission from Beasley RW. Beasley’s Surgery of the Hand. 1st ed. © 2003 Thieme.)

Fig. 9.3 Anatomic diagram of the volar plate of the metacarpophalangeal joint and the A1 and A2 pulleys. (a) Volar aspect. (b) Dorsal ulnar; (1) A2 pulley. (2) Volar plate. (3) Insertion of the volar plate. (4) A1 pulley. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

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Fig. 9.4 (a) Skin incision over the metacarpophalangeal joints of the ring finger and little finger for capsulodesis of the metacarpophalangeal joints to correct a hyperextension deformity. (b-e) Zancolli capsulodesis of the metacarpophalangeal joint (figure shows the ring finger) to correct a hyperextension deformity. (b) A1 pulley is exposed and incised longitudinally prior to resection. (1) A1 pulley. (2) Common palmar digital nerve. (3) Common palmar digital artery and vein. (4) Tendon of the flexor digitorum profundus of the ring finger. (5) Tendon of the flexor digitorum superficialis of the ring finger. (c) The volar plate of the metacarpophalangeal joint of the ring finger is exposed. (1) Tendon of the flexor digitorum superficialis of the ring finger. (2) Tendon of the flexor digitorum profundus of the ring finger. (3) Palmar interosseous. (4) A1 pulley (partially resected). (5) Volar plate. (6) Lumbrical. (d) A portion of the volar plate is excised. (1) A1 pulley (mobilized). (2) Volar plate (partially resected). (e) A partial resection is performed to shorten the volar plate of the metacarpophalangeal joint of the ring finger, which is then securely closed with interrupted sutures. (1) volar plate. (f-g) Schematic diagram of the incision of the A1 pulley in a hyperextension deformity of the metacarpophalangeal joint. (f) Incision for resection of the A1 pulley and partial resection of the volar plate. (1) A1 pulley. (2) Volar plate. (g) The metacarpophalangeal joint is flexed 20° following resection of the A1 pulley and partial resection of the volar plate. Removing the A1 pulley shifts the effect of flexion to the proximal phalanx and provides an additional dynamic correction of the hyperextension deformity. (1) Margin of the resection in the A1 pulley. (2) Volar plate (suture) after partial resection. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

leaving a stump of FDS to decrease the likelihood of iatrogenic swan neck deformity. The distal palmar crease is then opened, the FDS tendon is identified at this level, and the tendon is brought proximally. The tendon is sectioned into two slips and each is passed on the radial border of the ring and small fingers, respectively, through the lumbrical canals. The tendon is then passed volar to the axis of rotation of the MP joint to apply a flexion moment. A radial-sided midlateral or dorsal

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incision is then made on the ring and small fingers to expose the radial lateral band. The donor tendon is then brought into the field and sutured directly to the lateral band using a pulvertaft weave technique secured with a braided suture. Anchorage to the lateral band is indicated if the Bouvier maneuver is negative. The disadvantage of this anchorage is hyperextension of the PIP joint, especially if the Bouvier test is positive. Alternatively,

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Difficulties Encountered

Fig. 9.5 Capsulodesis of the metacarpophalangeal joint (figure shows ring finger) to correct a hyperextension deformity (alternative method). (a,b) The insertion of the volar plate is dissected off the metacarpal and shifted proximally. (1) A2 pulley. (2) A1 pulley (partially resected). (3) Volar plate. (4) Proximal insertion of the volar plate. (5) Collateral ligament. (6) Phalangoglenoidal ligament. (7) Accessory collateral ligament. (c) The volar plate is mobilized and two holes are drilled to permit refixing it in the desired position. (1) Volar plate. (2) Drill holes. (d,e) Bone sutures are placed to refix the volar plate with the metacarpophalangeal joint in 20-degree flexion. (1) A2 pulley. (2) A1 pulley (partially resected). (3) Volar plate. (f) Skin incisions for bone suture. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

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the Zancolli lasso procedure can be performed where the FDS tendon is anchored to the flexor tendon sheath either at the A1 pulley or between the A1 and A2 pulleys (▶ Fig. 9.7). This is done by passing the donor tendon through an incision in the flexor sheath, and sutured back to itself (lasso), to the A2 pulley, or passed through a bone tunnel proximally using the flexor sheath as an anchor point.2 This procedure is effective and relatively simple, but requires a positive Bouvier test.3 Postoperatively, active flexion of the IP joints is started in the first day, and active extension is started after 3 weeks. To prevent MCP extension, splint is used for 3 months.

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9.7.2 Loss of Pinch Strength ●

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Loss of the adductor pollicis longus muscle and first dorsal interosseous can cause weakness with pinch strength. The extensor carpi radialis brevis (ECRB) is commonly used as the tendon for this transfer.4 The ECRB is released from its insertion at the middle finger metacarpal base.

The tendon is then exposed and brought proximal and superficial to the extensor retinaculum in the distal third of the forearm. This transfer commonly requires to be lengthened by an interposition autograft such as the palmaris longus tendon. The tendon is then routed between the second and third metacarpal base where the second metacarpal base acts as a pulley corresponding to the direction of pull of the adductor policis. A dorsal/ulnar incision over the thumb metacarpal is then made exposing the thumb adductor pollicis tendon. The ECRB is inserted into the adductor pollicis insertion via a pulvertaft weave.

9.8 Difficulties Encountered ●

Over-tensioning of the FDS to lateral band, coupled with distal release of the FDS tendon can lead to a swan neck deformity because the flexor power is decreased and added to the extensor power.

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Fig. 9.6 (a) A volar incision over the metacarpophalangeal joints of the ring finger and little finger and a medioradial incision on the ring finger are made to transfer the tendon of the flexor digitorum superficialis of the ring finger. (b) Schematic diagram of the tendon of the flexor digitorum superficialis of the ring finger. The tendon of the flexor digitorum superficialis of the ring finger is transected at its insertions, further divided longitudinally, and transferred to the lateral extensors of the ring finger and little finger. (1) Transected insertion of the tendon of the flexor digitorum superficialis of the ring finger. (2) Tendon of the flexor digitorum superficialis of the ring finger. (3) Middle and ring finger lumbricals. (c,d) Transfer of the tendon of the flexor digitorum superficialis of the ring finger. (c) After it is transected at its insertions, the tendon is further divided longitudinally into two slips. (1) Tendon of the flexor digitorum superficialis of the ring finger. (d) The divided slips of the tendon are fed through the middle and ring finger lumbricals and reinserted. (1) Tendon of the flexor digitorum superficialis of the ring finger (longitudinally divided). (2) Common palmar digital artery and vein and proper palmar digital nerve. (3) Canals of the middle and ring finger lumbricals. (4) Tendon of the flexor digitorum profundus of the ring finger. (5) Ring finger lumbrical. (6) A1 pulley. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

Fig. 9.7 Variations in reinsertion of the tendon of the flexor digitorum superficialis of the ring finger after transfer. (a) The tendon is fixed to the A2 pulley (“lasso” fixation). (1) A2 pulley. (2) Tendon of the flexor digitorum superficialis. (b) A loop is passed through the proximal portion of the proximal phalanx and sutured. (1) Proximal phalanx. (2) Tendon of the flexor digitorum superficialis. (c) The tendon is sutured to the dorsal aponeurosis. (1) Dorsal aponeurosis. (2) Tendon of the flexor digitorum superficialis. (3) Deep transverse metacarpal ligament. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

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References ●

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It is critical to not over-tighten this tendon transfer, and the MP joint should be tensioned at approximately 60 degrees of flexion, and the IP joints should be straight. Anchorage to the lateral band is preferred when Bouvier test is negative. With positive Bouvier test, the Zancolli lasso procedure is the preferred method to avoid PIP hyperextension.

9.9 Bailout, Rescue, and Salvage Procedures ●

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Transfer of the FDS of the third digit does not improve grip strength but even might compromise it. Transfer of FCR, ECRL, and ECRB are the other options, which improve the grip strength. The drawback is that tendon graft is required for the sufficient length. In patients with longstanding claw deformities, bone blocks can be used to prevent MP hyperextension. This is

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useful in patients where tendon transfer will not be successful, including those where extrinsic muscle function is weak. Functional arthrodesis can also be considered in those patients with arthrosis, or longstanding complex clawing.5

References [1] Bunnell S. Surgery of the intrinsic muscles of the hand other than those producing opposition of the thumb. J Bone Joint Surg. 1942; 24: 1–3 [2] Hastings H, II, McCollam SM. Flexor digitorum superficialis lasso tendon transfer in isolated ulnar nerve palsy: a functional evaluation. J Hand Surg Am. 1994; 19(2):275–280 [3] Sapienza A, Green S. Correction of the claw hand. Hand Clin. 2012; 28(1): 53–66 [4] Smith RJ. Extensor carpi radialis brevis tendon transfer for thumb adduction: a study of power pinch. J Hand Surg Am. 1983; 8(1):4–15 [5] Littler JW. Tendon transfers and arthrodeses in combined median and ulnar nerve paralysis. J Bone Joint Surg Am. 1949; 31A(2):225–234

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10 Extensor Indicis Proprius Tendon Transfer for Rupture of the Extensor Pollicis Longus Tendon Christopher Jones Abstract Transfer of the extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon is a reliable procedure to restore thumb extension for a ruptured or otherwise irreparable EPL tendon. The EPL can rupture from attritional wear after distal radius fracture or due to osteophytes and chronic inflammation from wrist arthritis. Tendon transfer principles that are applied include an expendable donor (EIP), synergistic function, similar excursion and power, straight line of pull, and one transfer for one function—thumb extension. The procedure can be performed under wide-awake local anesthesia with no tourniquet (WALANT) to ensure proper tendon tension, glide, and repair strength. Proper tensioning of the transfer is critical, with slight over-tensioning preferable to provide optimal motion and strength. A Pulvertaft or similar tendon weave should provide adequate repair strength to start therapy early in the postoperative period. As with all tendon transfers, some loss of thumb extension strength is expected but otherwise a good range of motion, coordination, and function are the norm. There usually is a loss of independent index finger extension, and diminished index finger extension strength is expected, which is well tolerated from a functional standpoint. Keywords: extensor pollicis longus, extensor indicis proprius, tendon rupture, tendon transfer, distal radius fracture

10.3 Expectations The surgery should recreate the ability to extend the thumb out of the palm and posterior to the plane of the hand, to facilitate pinch and grasp. As with any tendon transfer, a slight decrease in strength (four out of five MRC grade) is expected, but otherwise, a good range of motion, coordination, and function are the norm (Lemmen et al 1999; Meads and Bogoch 2004). Additionally, there will be loss of index finger independent extension and some loss of index finger extension strength, which are well tolerated (Magnussen et al 1990).

10.4 Indications EPL tendon rupture is typically a consequence of distal radius fracture or wrist arthritis that places the rupture site at the level of the carpus. Ruptures or lacerations distal to this level may not leave enough EPL tendon to connect the EIP transfer. In general, EIP to EPL tendon transfer is indicated if EPL primary repair is not possible due to attritional rupture (poor tendon quality), segmental tendon loss (unable to bridge gap), or an old injury where the EPL muscle and tendon unit have irreversibly retracted.

10.5 Contraindications ●

10.1 Description

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Tendon transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) for ruptured or lacerated and irreparable EPL tendon at the wrist level.

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10.2 Key Principles ●

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Tendon transfer basic principles, as applied to EIP to EPL transfer: – EIP is an expendable donor of similar excursion and power – This transfer performs only one function: thumb extension – Synergistic transfer – Though a straight line of pull is recommended, this procedure (as described later) provides a similar line of pull to the EPL tendon that changes course at Lister tubercle – Expect one MRC grade of motor strength loss Proper tensioning of the tendon transfer is critical for an optimally functioning thumb A strong repair allows immediate initiation of therapy to accelerate rehabilitation and decrease risk of tendon adhesions (Giessler et al; Germann et al 2008). Occupations therapy is helpful for muscle re-education/ cortical remapping.

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Absent or non-function EIP or extensor digitorum communis tendon to index finger (EDCI) Poor soft tissue coverage Very distal EPL rupture such that EIP is not long enough for transfer Joint contracture that would limit motion

10.6 Special Considerations Assure that the patient has full passive thumb range of motion and functioning EDCI and EIP tendons to permit the sacrifice of the EIP tendon. To verify EIP function, the patient should demonstrate independent index finger extension with the other fingers clenched in a tight fist. The EDCI tendon will visibly buckle with this maneuver.

10.7 Special Instructions, Positioning, Anesthesia The procedure is best performed with the patient awake to assure proper tendon tensioning, repair strength, and tendon glide. Wide-awake local anesthesia with no tourniquet (WALANT) is preferred to avoid the influence of ischemia and muscle constriction from the tourniquet on the patient’s ability to move the thumb. The patient is positioned supine with their

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Key Procedural Steps

Fig. 10.2 Ruptured extensor pollicis longus (EPL) tendon after debridement and secured with a 2–0 silk traction stitch. Note the dorsal radial sensory nerve branch crossing the tendon at the most distal aspect of the incision.

Fig. 10.1 Lister tubercle and both incisions are marked on the hand. Note the abnormal resting position of the thumb in full flexion at the interphalangeal (IP) joint.

10.9 Difficulties Encountered arm on a hand table. A tendon passer can simplify subcutaneous passage of the tendon and a “pig sticker” is used to perform the tendon weave.

10.8 Tips, Pearls, and Lessons Learned ●

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The EIP and the other accessory extensor tendon, the small finger extensor digiti quinti (EDQ) are always more ulnar at the metacarpophalangeal (MP) joint. An easy way to remember this fact is that with the index and small fingers only extended, the hand forms the shape of a “U” for ulnar. It is helpful to thoroughly release any EIP soft tissue attachments over the dorsum of the hand before dividing it distally. It is important to assure that the EIP tendon has a clear line of pull from the exit of the fourth dorsal extensor compartment to the EPL without intervening soft tissue which could bind tendon glide. Setting the proper transfer tension is critical. A good rule of thumb (literally) is to tension the tendons so that the thumb interphalangeal (IP) joint sits in full extension with the wrist in neutral (Low et al 2001). However, the final decision on proper tension should be based on the patient’s active range of motion at surgery. With the wrist in the functional position of 30 degrees of extension, the patient should be able to actively fully extend the thumb and oppose to at least the mid-portion of the small finger (Lalonde 2014). You will have to ask the patient to extend the index finger (EIP), not the thumb, to test thumb extension. In general, it is better to err on the side of overtightening the transfer since the tension tends to lessen slightly over the first few months after surgery as the patient “works out the slack in the system” (Lee et al 2015; Jung et al 2014).

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A Pulvertaft weave can sometimes be bulky and hinder smooth tendon glide. Be sure to trim any thickened, tendinotic EPL tendon prior to performing the weave to minimize bulk. Also, there are other described methods to join the tendons, such as a side-to-side transfer, which can minimize tendon bulk (Brown et al 2010). Dividing the EIP tendon too distally can destabilize the extensor hood and lead to EDCI subluxation. Therefore, always divide the tendon proximal to the MP extensor hood and place a stitch from the EDCI edge to the ulnar sagittal band to secure its position centered over the MP joint.

10.10 Key Procedural Steps Local anesthesia (WALANT technique) is best performed in the holding area to allow at least 20 minutes for the vasoconstriction effect. A tourniquet is placed on the upper arm for backup, if needed. Lister tubercle is palpated and marked as a reference. This bony structure functions as a pulley for the EPL to direct its pull radially toward the thumb (▶ Fig. 10.1). A 3-cm incision is made over the course of the EPL tendon centered between Lister tubercle and the thumb MP joint. Spread with a scissor down to the extensor sheath, being mindful of radial sensory nerve branches that usually traverse this field. The tendon sheath is opened longitudinally and a ruptured EPL tendon is verified. Typically, the rupture occurs at the level of the carpus with about 3 cm of tendon intact up to the MP joint. The proximal tendon stump retracts and does not need to be identified. The EPL tendon is debrided of thickened, tendinotic, and frayed tendon, back to healthy-appearing tendon. A 2–0 silk traction stitch is placed in the end of the tendon to facilitate tensioning (▶ Fig. 10.2). Make a 1.5-cm transverse incision over the index finger extensor tendons at the metacarpal neck level. Dissect with scissors down to the EIP and EDCI tendons. The EIP is always more ulnar of the two. Sharply separate the two tendons (▶ Fig. 10.3).

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Extensor Indicis Proprius Tendon Transfer for Rupture of the Extensor Pollicis Longus Tendon

Fig. 10.3 Index finger extensor tendons, extensor indicis proprius (EIP) and extensor digitorum communis tendon to index finger (EDCI). The more ulnar tendon held with the retractor is the EIP.

Fig. 10.5 A “pig sticker” is used to pass the extensor indicis proprius (EIP) tendon through the central portion of the extensor pollicis longus (EPL).

Use a small scissor to carefully dissect on all four sides of the EIP proximally, over the dorsum of the hand, to release any tethering attachments. Then place a 2–0 silk traction stitch in the EIP at the metacarpal neck level and divide it transversely just distal to the stitch. Place a 6–0 Prolene figure-of-8 stitch from the extensor hood to the edge of the EDC to center it over the metacarpal head and decrease risk of subluxation. A tendon passer, or similar instrument, is placed on top of the deep fascia of the first dorsal interosseous muscle and tunneled subcutaneously out of the EIP incision (▶ Fig. 10.4). Shuttle the tendon using the silk stitch to the EPL incision. Once passed, the tendon usually needs to be freed from tethering soft tissues to allow a straight line of pull from the fourth dorsal compartment exit. Use a “pig sticker” to pass EIP through EPL tendon centrally (▶ Fig. 10.5). Set the initial tension so that the thumb IP joint is brought into full extension with the wrist in neutral. Secure the weave with one mattress stitch passed through both tendons (▶ Fig. 10.6). Ask the patient to gently flex and extend the thumb and index finger with the wrist in a

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Fig. 10.4 A tendon passer is tunneled subcutaneously from the extensor pollicis longus (EPL) to the extensor indicis proprius (EIP) incision in order to shuttle the tendon to the EPL incision.

Fig. 10.6 The tendons are secured with one mattress stitch to assess the tension. Note the thumb interphalangeal (IP) joint in full extension with the wrist in neutral.

functional position of 30 degrees of extension. (Remember that thumb extension is now controlled by the EIP tendon and will occur with attempted index finger, not thumb, extension.) Proper tensioning will allow for active full thumb extension and flexion to about the mid small finger level. Assure the tendon weave glides smoothly, especially proximally. Reset the tendon tension as necessary by removing the preliminary stitch and re-tensioning. Perform three more passes of the tendon weave securing each loop with at least one mattress stitch using a 4–0 braided nonabsorbable stitch (▶ Fig. 10.7). Tendon overlap should extend approximately 2 cm long. The skin is closed per personal preference. In the author’s experience, a 5.0 running monocryl subcuticular stitch, Dermabond, and steristrips works well. A thumb spica splint is applied with the wrist and thumb in slight extension. The patient starts hand therapy for active and active assist thumb range of motion (ROM) within 3 days of surgery. Start strengthening at approximately 4 weeks after

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Pitfalls

Suggested Readings

Fig. 10.7 Pulvertaft tendon weave complete.

surgery. An orthoplast thumb spica splint is worn for protection with activities of daily living for the first 8 weeks after surgery.

10.11 Bailout, Rescue, and Salvage Procedures If the EIP does not reach the EPL tendon stump, the EIP can be transposed out of the fourth extensor compartment to provide a more direct line of pull and provide slightly more length. An interposition tendon autograft of your choice (i.e., palmaris longus, abductor pollicis longus [APL], extensor carpi radialis brevis [ECRB]) can also be used. In the event the EIP tendon is not viable or ruptures during tensioning, transferring the ECRB or a slip of the APL can be used as a backup (Cui et al 2017; Chetta et al 2012; Bullón et al 2007; Chitnis and Evans 1993).

Brown SH, Hentzen ER, Kwan A, Ward SR, Fridén J, Lieber RL. Mechanical strength of the side-to-side versus Pulvertaft weave tendon repair. J Hand Surg Am. 2010; 35(4):540–545 Bullón A, Bravo E, Zarbahsh S, Barco R. Reconstruction after chronic extensor pollicis longus ruptures: a new technique. Clin Orthop Relat Res. 2007; 462(462): 93–98 Chetta MD, Ono S, Chung KC. Partial extensor carpi radialis longus turnover tendon transfer for reconstruction of the extensor pollicis longus tendon in the rheumatoid hand: case report. J Hand Surg Am. 2012; 37(6): 1217–1220 Chitnis SL, Evans DM. Tendon transfer to restore extension of the thumb using abductor pollicis longus. J Hand Surg [Br]. 1993; 18(2):234–238 Cui S, Yang G, Li Q, et al. Tendon transfer to restore the extension of the thumb using the extensor carpi radialis brevis: a long-term follow-up. J Plast Reconstr Aesthet Surg. 2017; 70(11):1577–1581 Germann G, Wagner H, Blome-Eberwein S, Karle B, Wittemann M. Early dynamic motion versus postoperative immobilization in patients with extensor indicis proprius transfer to restore thumb extension: a prospective randomized study. J Hand Surg Am. 2001; 26(6):1111–1115 Giessler GA, Przybilski M, Germann G, Sauerbier M, Megerle K. Early free active versus dynamic extension splinting after extensor indicis proprius tendon transfer to restore thumb extension: a prospective randomized study. J Hand Surg Am. 2008; 33(6):864–868 Jung SW, Kim CK, Ahn BW, Kim DH, Kang SH, Kang SS. Standard versus over-tensioning in the transfer of extensor indicis proprius to extensor pollicis longus for chronic rupture of the thumb extensor. J Plast Reconstr Aesthet Surg. 2014; 67 (7):979–985 Lalonde DH. Wide-awake extensor indicis proprius to extensor pollicis longus tendon transfer. J Hand Surg Am. 2014; 39(11):2297–2299 Lee JH, Cho YJ, Chung DW. A new method to control tendon tension in the transfer of extensor indicis proprius to extensor pollicis longus rupture. Ann Plast Surg. 2015; 75(6):607–609 Lemmen MH, Schreuders TA, Stam HJ, Hovius SE. Evaluation of restoration of extensor pollicis function by transfer of the extensor indicis. J Hand Surg [Br]. 1999; 24 (1):46–49 Low CK, Pereira BP, Chao VT. Optimum tensioning position for extensor indicis to extensor pollicis longus transfer. Clin Orthop Relat Res. 2001(388): 225–232 Magnussen PA, Harvey FJ, Tonkin MA. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon. J Bone Joint Surg Br. 1990; 72(5): 881–883 Meads BM, Bogoch ER. Transfer of either index finger extensor tendon to the extensor pollicis longus tendon. Can J Plast Surg. 2004; 12(1):31–34

10.12 Pitfalls Under-tensioning the tendon transfer will limit thumb extension strength and the ability to fully extend the thumb out of the palm. It’s better to slightly over-, rather than under-tension the transfer.

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11 Extensor Indicis Proprius to Extensor Digitorum Communis Tendon Transfer Robert B. Carrigan Abstract Transfer of the extensor indicis proprius (EIP) to the extensor digitorum communis (EDC) tendons can restore finger extension for ruptured tendons. The EDC tendons, especially those of the lesser digits, most commonly rupture from attritional wear due to chronic inflammatory changes from distal radioulnar joint arthritis. Tendon transfer principles are applied, including an expendable donor, synergistic function, similar excursion and power, straight line of pull, and one transfer for one function—thumb extension. Proper tensioning of the transfer is important, with slight over-tensioning preferable. A Pulvertaft or similar tendon weave should provide adequate repair strength to start therapy early in the postoperative period. Addressing the degenerative changes in the distal radioulnar joint is critical to prevent re-rupture. Keywords: extensor indicis proprius, extensor digitorum communis, tendon rupture, distal radioulnar joint

11.1 Description Transfer of the extensor indicis proprius (EIP) tendon to the extensor digitorum communis (EDC) tendon is an in-phase tendon transfer for the treatment of chronic or attritional ruptures of the EDC tendons to the middle, ring, or small fingers.

11.2 Key Principles When considering tendon transfers for the upper extremity, various factors should be considered. The finger joints should be supple and the soft tissue bed should be adequate enough to allow for tendon gliding. When selecting a tendon for transfer, one should consider if the tendon for transfer is expendable, what is the strength of the muscle tendon unit, and if there is a straight line of pull. When the rupture is caused by inflammatory changes in the distal radioulnar joint, addressing the degenerative changes in the distal radioulnar joint is critical to prevent re-rupture.

11.3 Expectations Good-to-excellent results can be achieved with proper execution of the tendon transfer. Patients can expect to achieve good digital extension after surgery and appropriate hand therapy, although some weakness in finger extension and a slight extensor lag are often seen.

11.4 Indications EIP to EDC tendon transfer should be considered for patients with a single chronic digital extensor tendon rupture.

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11.5 Contraindications ● ● ● ● ●

Stiff finger joints Soft tissue envelope that would not allow for tendon gliding Lack of EIP tendon for transfer Multiple tendon ruptures Cognitive impairment that would adversely affect the patient’s ability to participate in occupational therapy

11.6 Special Considerations This is a fairly straightforward procedure without the need for special instrumentation or equipment.

11.7 Special Instructions, Positioning, and Anesthesia Patients are positioned supine with a hand table extension. A padded tourniquet may be considered for hemostasis. Considerations regarding anesthesia vary, and confer benefits and trade-offs. Wide-awake hand surgery may be considered with the use of local anesthetic and epinephrine. This offers the benefit of patient participation during the tensioning of the tendon transfer. Regional anesthesia in the form of an axillary block may be considered. General anesthesia is an alternative option.

11.8 Tips, Pearls, and Lessons Learned When harvesting the EIP tendon, make sure that all connections between the tendon and the soft tissues are divided so that the tendon is easily mobilized for the transfer. It is better for the tension of the tendon transfer to be a little tight rather than a little loose. Snug transfers will often stretch out over time with therapy.

11.9 Difficulties Encountered Anomalous extensor tendon anatomy may be observed. Multiple slips of the EIP or a complete absence may be encountered.

11.10 Key Procedural Steps Once the patient is anesthetized, the arm is prepped and draped in the standard fashion. A 3-cm longitudinal incision is made along the dorsum of the hand in line with the affected finger. Skin and subcutaneous tissue are dissected with scissors; careful attention is paid to avoid injury to the dorsal ulnar sensory nerve. The distal end of the EDC tendon is identified

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Key Procedural Steps

Fig. 11.1 Illustration depicting the technical steps in performing a Pulvertaft weave. (a) Tendon is passed through longitudinal split made in recipient tendon. (b) Tendon is passed once again through the recipient tendon. (c) Tendon is sutured and trimmed. (d) Completed Pulvertaft tendon weave. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

and dissected free of any scar tissue. Traction is applied to the distal extent of the tendon to make sure it extends the affected finger. A transverse incision is made just proximal to the metacarpalphalangeal (MP) joint of the index finger. The EIP tendon is identified along the ulnar aspect of the extensor hood. A second transverse incision is made at the dorsal wrist crease, just distal to the extensor retinaculum. The proximal aspect of the EIP tendon is identified in the fourth extensor compartment. The distal aspect of the EIP tendon is harvested sharply and pulled through the proximal wrist crease incision. A subcutaneous tunnel is developed with blunt dissection between the proximal dorsal wrist crease incision and first longitudinal incision. The EIP tendon is then passed. The EIP tendon is then sutured to the EDC tendon. Several important technical points are to be considered at this step. First is the suturing of the tendon repair. Where possible a strong tendon repair such as a Pulvertaft weave should be considered (▶ Fig. 11.1 and ▶ Fig. 11.2). The second is the tension of the transfer. The surgeon should check the resting cascade of the hand with the wrist in flexion and extension and adjust the tension of the repair accordingly (▶ Fig. 11.3). If the surgery is being performed under local anesthetic with the patient awake, the patient can be asked to flex and extend the digit and tension can be adjusted to achieve full active range of motion.

Fig. 11.2 Clinical photograph of suturing of extensor indicis proprius (EIP) to extensor digitorum communis (EDC) tendon transfer for chronic tendon laceration of the digital extensors to the ring and middle fingers.

Skin is closed in the standard fashion and the hand splinted with a volar resting splint from the fingertips to the forearm with the wrist and fingers in extension.

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Extensor Indicis Proprius to Extensor Digitorum Communis Tendon Transfer Duration of immobilization is dependent on the security of the tendon transfer repair. In trustworthy patients with securely repaired tendon transfers, initiation of early motion rehabilitation may commence. In less trustworthy patients, longer periods of immobilization may be warranted before the initiation of therapy. Therapy should focus on restoration of range of motion, tendon gliding, and cognitive rehabilitation, and continue till full active extension is achieved (▶ Fig. 11.4a, b).

11.11 Bailout, Rescue, and Salvage Procedures

Fig. 11.3 Clinical photograph demonstrating restoration of the resting digital cascade with the wrist in flexion following tendon transfer.

In cases where the EIP is not present or multiple finger extension transfers are necessary, one should be open to considering alternative donor options such as flexor carpi radialis (FCR) or flexor carpi ulnaris (FCU). While these are not in phase donor tendons, they are of sufficient strength and have appropriate line of pull to provide satisfactory finger extension. In addition, if more than one tendon is ruptured, a side-to-side repair can help augment the transfer.

Fig. 11.4 (a,b) Clinical photographs demonstrating postoperative digital extension and flexion following extensor indicis proprius (EIP) to extensor digitorum communis (EDC) tendon transfer.

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12 Superficialis Transfer for Rupture of the Flexor Pollicis Longus Tendon Alexandria L. Case, R. Glenn Gaston, and Joshua M. Abzug Abstract Flexor pollicis longus (FPL) tendon ruptures are observed as a result of Mannerfelt lesions in patients with rheumatoid arthritis (RA) and are also associated with excessive tendon wear following distal radius fractures requiring open reduction and internal fixation. These tendon ruptures present clinically as a thumb with normal motion except for active flexion at the interphalangeal (IP) joint, although in patients with RA or those with limited functionality of the thumb at baseline, these injuries are more difficult to identify. Radiographic views of the hand and wrist should be taken as a part of the clinical examination to identify any causes of attrition to the tendon and to aid in preoperative planning, as bony deformities may need to be addressed during the procedure to avoid future rupture of the transferred tendon. The procedure may also be performed for patients with an anterior interosseous nerve (AIN) palsy, thus causing the FPL to become nonfunctional. The ruptured tendon will need to be debrided to allow for adequate motion of the transferred tendon. The flexor digitorum superficialis (FDS) tendon of either the long or ring finger is commonly the source of the tendon for transfer during this procedure. The source tendon is tagged and withdrawn through the wrist into an incision in the forearm, then transferred to the thumb where it is secured to finalize the transfer. In cases of an AIN palsy, the FDS to the ring finger should be utilized, although this procedure is not an option for high median palsies.

completed as part of the physical examination, as tenosynovitis may be indicative of a rupture in a low or nonfunctional rheumatoid hand.5 Three radiographic views of the hand and wrist should be ordered to assess for any bony deformation or displacement that may have caused attrition of the tendon. Additionally, imaging of the thumb IP joint is important to assess for arthritic change as this may influence a decision for IP arthrodesis in lieu of tendon reconstruction. In patients with RA, bony spicules can form on the scaphoid and lead to increased wear of the tendon. Similarly, volar displacement of the scaphoid can also contribute to tendon attrition and should be noted during radiographic assessment.

12.1.1 Indications and Contraindications Indications for a tendon transfer include tendon rupture or an AIN palsy. The procedure is ideal for patients with these

Keywords: flexor pollicis longus rupture, flexor digitorum superficialis transfer, tendon transfer, rheumatoid arthritis, Mannerfelt lesion, distal radius fracture

12.1 Preoperative Work-up Flexor pollicis longus (FPL) tendon ruptures are marked by full passive range of motion with no active flexion of the interphalangeal (IP) joint of the thumb.1 The remainder of the digit typically demonstrates normal abduction, adduction, extension, and strength.1 The use of a tenodesis test or forearm squeeze test (in addition to assessing flexor digitorum profundus [FDP] function of the index and long finger) can help differentiate anterior interosseous nerve (AIN) palsy from FPL rupture. Closed FPL ruptures are often associated with distal radius fractures, particularly those with internal fixation in which the plate is fixed too distally to the watershed line as the raised profile of the hardware can cause excessive wear on the tendon2,3,4 (▶ Fig. 12.1). In addition, FPL tendon ruptures are also observed in patients with rheumatoid arthritis (RA), as bony deformity typically at the scaphotrapeziotrapezoid (STT) joint may contribute to unusual amounts of tendon wear and predispose the patient to tendon rupture.5,6 Given the pathology, preventative care in patients with RA is crucial. Detailed inspection of rheumatoid hands and wrists for signs of tenosynovitis should be

Fig. 12.1 Flexor pollicis longus (FPL) tendon rupture. (Image credit: R. Glenn Gaston, MD.)

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Superficialis Transfer for Rupture of the Flexor Pollicis Longus Tendon conditions who desire functional improvements. Alternative treatments to tendon transfer include nonoperative management, tendon reconstruction, two-stage tendon reconstruction, bridge graft, and arthrodesis. In cases where the thumb is stable, and the carpometacarpal (CMC) and metacarpophalangeal (MCP) joints are functioning normally, particularly in the elderly population, it is appropriate to manage the rupture conservatively. If the FPL rupture is identified within 4 to 6 weeks of initial rupture, it may be feasible to perform a tendon grafting procedure, provided that the IP joint has satisfactory motion and that no myostatic contracture of the FPL muscle is observed.6 If both tendon ends can be identified at the level of the wrist in an RA patient and these ends are in good condition, a bridge graft with simultaneous resection of the offending bony pathology may be performed.5 In patients with severe scarring of the tendon sheath bed and/or destruction of the pulley system, an arthrodesis or a two-stage tendon reconstruction would be a better approach than a tendon transfer.5

12.2 Surgical Technique In preparation for the procedure, one should be sure that there is access to a pneumatic tourniquet, a basic handset including additional Allis clamps (Jarit, Hawthorne, NY) and casting/ splinting materials. In addition, the patient should be examined to determine whether the flexor digitorum superficialis (FDS) tendon is stronger on the third or fourth finger. If the procedure is being performed for AIN palsy, then the FDS tendon to the fourth finger must be utilized. The procedure may be performed under wide-awake local anesthesia no tourniquet (WALANT), general, or regional anesthesia at the discretion of the patient and surgeon. The patient should be in a supine position on the operating room table with a hand table. A nonsterile pneumatic tourniquet is placed, and the limb is prepped and draped; however, if WALANT is being utilized, no tourniquet is necessary. The planned incisions are drawn, and the tourniquet is inflated. The cause of the rupture should be ascertained, and management of the offending structure addressed. If the FPL

Fig. 12.2 Isolation of flexor digitorum superficialis (FDS) of the proximal incision on the fourth finger with extension at the distal interphalangeal (IP) joint and flexion at the proximal IP joint. (Image credit: Shriners Hospital for Children, Philadelphia.)

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rupture was caused by a bony prominence on the scaphoid associated with RA, this bone should be shaved down to eliminate potential for future tendon attrition. Following the removal of this bony spur, soft tissue should be manipulated to cover the recently shaved bone before moving onto the tendon transfer. Alternatively, if the rupture occurred due to placement of a volar distal radius plate, the plate should be removed prior to performing the tendon transfer. Often the proximal FPL tendon stump retracts into the distal forearm and the distal stump may be found within the pulley system of the thumb necessitating a wider exposure. To locate the distal stump, passive IP and MP joint flexion can often “deliver” the tendon end into view. Alternatively, more distal exposure is required with care taken to preserve the oblique pulley. To isolate the FDS tendon, make a short, oblique incision along the A1 pulley of either the third or fourth digit. Through this incision, identify the FDS tendon and isolate it using a vessel loop or an Allis clamp (Jarit, Hawthorne, NY) (▶ Fig. 12.2). Within the volar forearm incision, identify the same FDS tendon and isolate it. By twirling the Allis clamps, one should see the FDS tendon glide between the two incisions, verifying that the FDS tendon is isolated both proximally and distally (▶ Fig. 12.3). Traction should be applied to the FDS confirming PIP flexion to avoid inadvertent FDP harvest. A tag suture is then placed into the FDS tendon and it is transected distally. Proximal traction on the FDS tendon through the forearm incision allows the tendon to be delivered (▶ Fig. 12.4). If difficulty is encountered with proximal traction on the FDS tendon, adhesions between the FDS and FDP distally should be released and the division of Camper chiasm should be assessed. From the forearm incision, redirect the FDS tendon toward the incision on the thumb (▶ Fig. 12.5). A Pulvertaft weave is now performed to transfer the FDS tendon to the distal stump of the ruptured FPL tendon (▶ Fig. 12.6). Before placing the definitive sutures, a temporary stitch can be utilized to assess the tension of the transfer. Tenodesis effect can be utilized to assess the tension and ensure the thumb IP joint flexes with wrist extension (▶ Fig. 12.7) and extends with wrist flexion (▶ Fig. 12.8). Once the definitive sutures are placed, any extra tendon length can be doubled back upon itself to form a double-stranded repair as long as it is kept outside of the pulley system.

Fig. 12.3 Two Allis clamps ensuring isolation of the same tendon distally and proximally. (Image credit: Joshua M. Abzug, MD.)

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Complications

Fig. 12.5 Flexor digitorum superficialis (FDS) tendon is redirected toward the thumb. (Image credit: R. Glenn Gaston, MD.) Fig. 12.4 Flexor digitorum superficialis (FDS) tendon rolled into volar forearm incision. (Image credit: Shriners Hospital for Children, Philadelphia.)

Fig. 12.6 Appearance of the thumb demonstrating interphalangeal (IP) flexion following appropriate tensioning of the tendon transfer. (Image credit: R. Glenn Gaston, MD.)

Fig. 12.7 Flexion of the interphalangeal (IP) joint with wrist extension during the tenodesis effect. (Image credit: R. Glenn Gaston, MD.)

12.3 Postoperative Management Splinting is recommended for 7 to 10 days postoperatively. At this time, the patient should begin therapy to improve range of motion for tendon strengthening and relearning following the tendon transfer. Up to 2 or 3 months postoperatively, splinting is recommended to protect the transfer.

12.4 Complications

Fig. 12.8 Extension of the interphalangeal (IP) joint with wrist flexion during the tenodesis effect. (Image credit: R. Glenn Gaston, MD.)

It is not uncommon for patients undergoing an FDS transfer to experience increased stiffness at the MCP joint, although this complication has limited functional impact. Using the FDS tendon as the source of the transfer, diminished or weakened flexion, or a swan neck deformity can result.7 In some instances, vasculature may be comprised during the

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Superficialis Transfer for Rupture of the Flexor Pollicis Longus Tendon procedure if the princeps pollicis artery is damaged. If the transfer is unsuccessful, the patient may continue to experience decreased range of motion and/or weakness. In a small cohort study of patients undergoing FDS IV transfers following FPL tendon ruptures by Schmitt et al, 20% of patients experienced contracture of the thumb IP joint, while another 20% experienced contracture of the fourth finger proximal IP joint.8 Additionally, as with any operative procedure, infection is a potential risk.

12.5 Summary/Functional Outcomes In summary, tendon transfers of the FDS tendon to supplement function in cases of FPL rupture are generally successful and yield satisfactory results. In Schmitt et al’s 2013 study, 80% of patients stated that they would undergo the procedure again.8 The most frequent complication is joint stiffness, which can be addressed by therapy.

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References [1] Klug RA, Press CM, Gonzalez MH. Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius fracture: a case report. J Hand Surg Am. 2007; 32(7):984–988 [2] Azzi AJ, Aldekhayel S, Boehm KS, Zadeh T. Tendon rupture and tenosynovitis following internal fixation of distal radius fractures: a systematic review. Plast Reconstr Surg. 2017; 139(3):717e–724e [3] Kara A, Celik H, Oc Y, Uzun M, Erdil M, Tetik C. Flexor tendon complications in comminuted distal radius fractures treated with anatomic volar rim locking plates. Acta Orthop Traumatol Turc. 2016; 50(6):665–669 [4] Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011; 93(4): 328–335 [5] Murray PM. Flexor tendon ruptures in the rheumatoid patient. Oper Tech Orthop. 1998; 8(2):92–97 [6] Kozlow JH, Chung KC. Current concepts in the surgical management of rheumatoid and osteoarthritic hands and wrists. Hand Clin. 2011; 27(1):31–41 [7] Carlo J, Dell PC, Matthias R, Wright TW. Collateral ligament reconstruction of the proximal interphalangeal joint. J Hand Surg Am. 2016; 41(1):129–132 [8] Schmitt S, Mühldorfer-Fodor M, van Schoonhoven J, Prommersberger KJ. Restoration of thumb flexion at the interphalangeal joint by transposition of the flexor digitorum superficialis tendon from the ring finger. Oper Orthop Traumatol. 2013; 25(4):321–330

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Part III Tendinopathies

III

13 Trigger Finger/Thumb Release

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14 DeQuervain Tenosynovitis

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15 Extensor Carpi Ulnaris Tenosynovectomy/Instability

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16 Intersection Syndrome

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17 Lateral Epicondylar Debridement

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18 Medial Epicondylar Debridement

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13 Trigger Finger/Thumb Release Jack Abboudi Abstract Release of the A1 pulley relieves the triggering phenomena and allows for improved range of motion of the digit in cases of limited and restricted flexor tendon excursion. This condition is also termed stenosing tenosynovitis or tendovaginitis. This procedure can, in most cases, relieve finger locking, catching, and allows for improved range of motion of the digit. The indication for this procedure is a triggering finger or thumb that is refractory to conservative treatment in the form of activity modification, anti-inflammatory medication, and corticosteroid injections. Keywords: trigger finger, A1 pulley, stenosing flexor tenosynovitis, trigger finger release.

13.1 Description Technique for the surgical correction of triggering fingers and thumbs with release of the A1 pulley.

13.2 Key Principles Identifying proper external and internal landmarks will keep this routine procedure consistent and avoid pitfalls.

13.3 Expectations This procedure can, in most cases, relieve finger locking, catching, and allows for improved range of motion of the digit in cases of limited and restricted flexor tendon excursion. Some patients with triggering fingers may develop flexion contractures of the proximal interphalangeal (PIP) joint of the same digit. Such contractures will not directly correct with this procedure, but may have an opportunity to improve with postoperative stretching exercises once the restriction of the flexor tendon excursion has been relieved with surgery. For the more severe contractures, removal of one of the slips of the flexor digitorum superficialis (FDS) tendon can help improve the contracture at the PIP joint.

Fig. 13.1 The ring finger is fixed in flexion due to stenosis at the A1 pulley. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

● ●

Distal release of the FDS tendon for tendon transfer Release of flexor tendon entrapment in cases of complex/ irreducible dorsal metacarpophalangeal (MP) joint dislocation

13.4 Indications

13.5 Contraindications

The most common indication for this procedure is the surgical correction of a triggering finger or thumb that is refractory to conservative treatment in the form of activity modification, anti-inflammatory medication, and corticosteroid injections (▶ Fig. 13.1). This exposure and technique can also be utilized for as part of other procedures that necessitate exposure of the proximal flexor sheath, such as: ● Decompression of the proximal flexor sheath in cases of flexor sheath infection ● Proximal pull-through testing of the flexor tendons in cases of flexor tenolysis or flexor tendon repair to confirm flexor tendon slide ● Debridement or biopsy of the flexor tenosynovium

A1 pulley release in the face of ulnar drifting of fingers secondary to rheumatoid arthritis may exacerbate and worsen the progression of the ulnar drift deformity and volar subluxation at the MP joint. In such cases, resection of the ulnar slip of the FDS flexor tendon while maintaining the A1 pulley integrity may be a better choice.

13.6 Special Considerations Digits that click and pop for reasons that are not related to catching of the flexor tendon at the A1 pulley will not be corrected with an A1 pulley trigger release. One must consider other

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Trigger Finger/Thumb Release common reasons for digital clicking and popping when selecting patients for this procedure. Other causes for digital clicking and popping can include instability of the extensor tendon over the dorsal MP joint due to rupture or instability of the sagittal bands. Additionally, instability or congenital laxity of the PIP joint volar plate can allow the PIP joint to assume a hyperextended position when the finger is extended and the PIP joint may then click as it initiates flexion from its hyperextended position. Treatment of the thumb requires special consideration to the radial digital nerve, as it is often found directly in the middle of the incision or centrally over the flexor tendon. Similarly, the index and small fingers require a bit more attention as the trajectory of the flexor tendons, nerves, and arteries is more angled to these fingers as compared to the central long and ring fingers. Additionally, the small finger, especially in a small patient, may have a small A1 pulley, necessitating careful attention to landmarks and to the anticipated A1 pulley size so as to avoid an inadvertent A2 pulley release.

13.7 Special Instructions, Positioning, and Anesthesia Patient participation can be helpful to confirm that there is no longer any flexor tendon catching or triggering with active digital motion. The procedure can be performed with local anesthesia alone or in combination with light sedation. Lidocaine can be combined with Marcaine in a single syringe for an anesthetic solution that provides a quick acting and a longer lasting anesthetic effect. Alternatively, drawing an additional milliliter of bicarbonate solution into a 10 milliliter Lidocaine syringe makes the infiltration of the local anesthesia more comfortable for the patient.

A lead hand is helpful for trigger release of the fingers, but has no role for the treatment of a trigger thumb. Surgery for the thumb requires special positioning with a rolled towel behind the patient’s hand and an assistant holding the wrist in flexion so as to rotate the palmar aspect of the thumb toward the surgeon. Considering the routine frequency of this short procedure, the efficiency of the surgery can be improved by eliminating the need for transfer of the patient to and from the standard operating room bed. The patient can be left on the transport gurney and the surgery performed with the patient’s upper extremity supported on a hand surgery table that can be rolled to the gurney edge or slid beneath the gurney pad.

13.8 Tips, Pearls, and Lessons Learned This procedure is a focused intervention with a small incision (▶ Fig. 13.2). The exact proximal to distal location of the A1 pulley can vary from patient to patient, and can be done via a transverse, oblique, or longitudinal incision. Considering that the A1 pulley correlates reasonably well with the capsular volar plate of the MP joint, palpation of the MP joint on the dorsal side of the hand can help gauge whether the A1 pulley will be biased a bit more proximally or distally in the interval between the distal palmar crease and MP flexion crease. Additionally, one can center the initial incision between the distal palmar crease and MP flexion crease and then extend the incision in either direction as needed once internal landmarks have been reviewed. Usually, there is a thickened quality of the A1 pulley in triggering fingers. If the thickened pulley is not noted, one should double check the anatomic landmarks to confirm that the

Fig. 13.2 Decompression of a trigger finger. (1) A1 pulley; (2) proper palmar digital artery and nerve; (3) tendon of the flexor digitorum superficialis (FDS); (4) inflamed swollen synovial tendon sheath. (a) Complete decompression is achieved by bisecting the entirety of the A1 pulley (dashed line) using microsurgical technique. The figure indicates a transverse incision along the palmar crease. The incision can also be made longitudinal or oblique. (b) In the presence of tenosynovitis of the flexor tendon, the pulley is incised and the swollen synovial membrane resected. (c, d) Normally, excision of a strip from the midline of the pulley with microscopic scissors will be sufficient, and a synovectomy of the flexor tendon is not performed. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

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Key Procedure Steps approach is not too proximal and fooled by the palmar pulley or too distal where the A2 pulley can be released inadvertently. Additionally, if the A1 pulley location is confirmed and it does not have the expected thickened quality as usually seen with triggering fingers, one should suspect that the “triggering” phenomena may be related to a different mechanism of digital clicking. Finally, the thickened sheath seen in trigger fingers may also involve the proximal few millimeters of the A2 pulley. While the objective of the procedure is the release of the A1 pulley, sometimes a careful release of these first few proximal millimeters of A2 may be necessary. Once the release is complete, one can double check that the remaining distal sheath allows the passage of the tip of a blunt instrument between the tendon and sheath and no longer has the thickened quality of the released segment. Withdrawing the flexor tendons through the surgical site after A1 pulley release helps confirm their independent excursion. When doing so, visually look at the tendon surfaces. Generally, the tendon may have some fusiform increased girth, and in these majority of cases, the tendon is left undisturbed. Although uncommon in an adult with a typical trigger finger, occasionally a dense and defined nodule can be noted on the tendon surface. Such nodules may be contributing to the trigger phenomena. These nodules can be carefully removed with a tangential excision that removes the protrusion of the nodule and restores the tendon to its normal girth. The thumb typically has two almost parallel MP flexion creases. The triggering thumb is released with a transverse incision between these creases. The digital nerve and artery are closest to the skin surface at the crease; therefore, making the skin incision just parallel to the crease, but not in the crease, gives one an increased margin of safety when incising across the location of these structures. Incise the skin alone and then develop the exposure with blunt dissection. As stated previously, the thumb digital nerve and artery can angle across the exposure; therefore, it is important to identify these structures on either side of the sheath (▶ Fig. 13.3).

13.9 Difficulties Encountered The A1/A2 pulley interval is the hardest landmark to identify. Aside from looking for a natural gap between these pulleys which is not always easy to identify, there are a number of tips that can be helpful, including: ● Spread open the last few millimeters of the distal edge of the A1 pulley with the blunt tip of the dissecting scissor. This maneuver can pop open the distal edge of the A1 pulley and spare the edge of the A2 pulley, thus defining the interval between these pulleys. ● The flexor tendons can be retracted aside and the transverse striations of the MP joint volar capsular plate can be seen deep to the tendons. These striations correlated reasonably well with the A1 pulley; thus, the distal end of these striations should also be the distal edge of the A1 pulley.

13.10 Key Procedure Steps For trigger finger release, the area between the distal palmar crease and the MP flexion crease in line with the operative finger is infiltrated with the local anesthetic solution using

Fig. 13.3 Impingement of the tendon of the flexor pollicis longus due to stenosis in the A1 pulley. (1) A1 pulley; (2) proper palmar digital nerve; (3) tendon of the flexor pollicis longus; (4) radial proper palmar digital artery of the thumb; (5) radial sesamoid. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

sterile technique. After formally prepping the extremity for surgery, exsanguination, and inflation of the tourniquet, a slightly oblique incision is made in this area centering the incision between these creases. Only the skin is incised with the knife blade. A small blunted tipped curved scissor is used to bluntly separate the subcutaneous fat as a superficial-to-deep single plane directed straight to the flexor sheath. A blunt spread is then directed to the radial side and then the ulnar side of the sheath so as to release the stout septae on either side of the sheath. Once the septae have been released, the placement of retractors on each side of the sheath is easier. Broad retractor like blunt Senn or eyelid retractors are very helpful to retract the fatty tissue. For the treatment of fingers, the neurovascular

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Trigger Finger/Thumb Release

Fig. 13.4 Ring trigger finger release. (a) Longitudinal incision. (b) Tendons visible after A1 pulley release. (c) Pull of tendons out of the wound to confirm pulley release. (Courtesy of Pedro Beredjiklian, MD.)

bundles on either side of the flexor sheath do not require formal exposure, but rather are protected on either side with these blunt retractors. The proximal edge of the A1 pulley is identified. Blunt dissection over the flexor tendons proximal to the A1 edge allows for a quick review of the palmar pulley and confirmation of one’s anatomic location and confirmation that there is no proximal stenosis around the flexor tendons. The A1 pulley is then incised in its mid-line and usually has a thick and dense quality. The A1 pulley is incised about 10 mm until the interval between the A1 and A2 pulley. Once the release of the A1 pulley has been completed, the proximal few millimeters of the A2 pulley are reviewed. It is common to find a thickened quality to the proximal edge of the A2 pulley and this edge is usually also carefully released. A blunt scissor tip can be spread transversely in the sheath just distal to the thickened A2 pulley edge so as to define the edge of the pulley for release and separate it from the remaining A2 pulley and prevent inadvertent release of too much of the A2 pulley. The flexor tendons are each pulled through the wound to confirm their independent excursion (▶ Fig. 13.4). If there is a thickened tenosynovial lining noted to the flexor tendons, a tenosynovectomy of this lining can be performed at this point. Full passive range of motion of the digit is reviewed and confirmed. Finally, the patient is asked to actively flex and extend the finger through a complete arc of motion and also try any specific maneuver that used to produce the triggering phenomena before surgery. Once active digital motion examination is complete, the tourniquet is deflated and the skin is closed. A dressing across the distal palm is applied and anchored at the wrist. Postoperatively, the patient is instructed to pursue regular active motion of all the digits. The dressing is soft and the patient is allowed to squeeze the dressing in order to achieve full flexion. While most patients will naturally focus on recovering finger flexion after surgery, they are reminded to focus attention on the restoration of complete finger extension especially at the PIP joint. The surgical dressing is kept dry until its removal along with the skin sutures at the first postoperative visit 10 days after surgery.

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For the treatment of a trigger thumb (▶ Fig. 13.5), the same local anesthetic solution is infiltrated with sterile technique across the thumb MP flexion creases. After prepping and draping of the extremity, the tourniquet is inflated after exsanguination. A transverse incision is made parallel to MP flexion creases through the skin only. With blunt dissection, the skin flaps are raised and the digital nerves and arteries are defined on each side of the tendon sheath. The proximal edge of the A1 pulley for the thumb is not always very evident and may be better defined after the A1 pulley is incised. Thus, one should err with a more proximal midline incision of the A1 pulley and carefully release the pulley to its distal end. The interval between the A1 pulley and the oblique pulley is usually easier to identify because of the significant difference between the thick quality of the A1 pulley and the thinner angled tissue of the oblique pulley. Similar to the finger trigger release, the flexor tendon is pulled through the site, the lack of a proximal point of stenosis is confirmed, and the thumb is checked for any triggering or restricted motion with a passive and active range of motion assessment. Additionally, the site is closed and dressed similar to the finger procedure and the patient is discharged with similar instructions as well.

13.11 Bailout, Rescue, and Salvage Procedures On uncommon occasions, all of the appropriate steps for a finger trigger release have been completed and the active testing of the digit still demonstrates triggering. At this point, the surgeon should verify that it is true flexor tendon triggering that is occurring and not some other cause for finger popping or clicking. If the flexor tendon is still implicated and pulley release has been maximized to its safest limit, a slip of the FDS flexor tendon can be resected to increase the space in the remaining sheath. The FDS flexor tendon is pulled proximally as much as possible and its ulnar slip is transversely cut as distally as possible by the A2 pulley edge. In cases where there is fraying of the FDS flexor tendon, one should resect the more frayed and damaged slip. The slip is then pulled out of the site and is resected obliquely at its proximal side leaving the other FDS slip in continuity.

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Bailout, Rescue, and Salvage Procedures

Fig. 13.5 Decompression of a trigger thumb. (a,b) A skin incision is made over the readily palpable ulnar sesamoid and the radial sesamoid, taking care to preserve the superficial radial sensory nerve of the thumb. (1) Proper palmar digital nerve; (2) radial sesamoid; (c) surgical site after the tendon sheath has been divided. The flexor pollicis longus tendon is inspected with a tendon retractor. Synovectomy of the flexor tendon is performed if necessary, as in the case of rheumatoid arthritis. (1) Tendon of the flexor pollicis longus. (2) Vinculum of the tendon. (3) A1 pulley. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

Suggested Readings Farnebo S, Chang J. Practical management of tendon disorders in the hand. Plast Reconstr Surg. 2013; 132(5):841e–853e Fiorini HJ, Tamaoki MJ, Lenza M, Gomes Dos Santos JB, Faloppa F, Belloti JC. Surgery for trigger finger. Cochrane Database Syst Rev. 2018; 2:CD009860

Giugale JM, Fowler JR. Trigger finger: Adult and pediatric treatment strategies. Orthop Clin North Am. 2015; 46(4):561–569 Lim MH, Lim KK, Rasheed MZ, Narayanan S, Beng-Hoi Tan A. Outcome of open trigger digit release. J Hand Surg Eur Vol. 2007; 32(4):457–459 Will R, Lubahn J. Complications of open trigger finger release. J Hand Surg Am. 2010; 35(4):594–596

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14 DeQuervain Tenosynovitis George L. Yeh Abstract DeQuervain tenosynovitis (DQT) is a common cause of pain along the radial wrist, which can be treated successfully with nonoperative and operative care. The structures affected are the first dorsal extensor compartment tendons (the extensor pollicis brevis [EPB] and the abductor pollicis longus [APL] tendons). It can be related to traumatic or overuse activities, but frequently the pain occurs gradually and without obvious cause. Patients present with pain over the radial styloid aggravated by thumb movement. Conservative management is usually helpful and can consist of rest and activity modification, immobilization in a thumb spica brace, nonsteroidal anti-inflammatory medications (NSAIDs), and cortisone injection. If conservative care is not adequate, then surgery to decompress the first extensor compartment tendons is effective, safe, and reliable. Special attention is needed to look for and release a separate tunnel for the EPB tendon, to prevent volar subluxation of the tendons after the release, and to avoid injury to the branches of the radial sensory nerve. Keywords: DeQuervain tenosynovitis, extensor compartment, extensor pollicis brevis, abductor pollicis longus, radial sensory nerve

14.1 Introduction DeQuervain tenosynovitis (DQT) or disease is a common cause of pain and disability affecting the wrist. The complaint is pain along the radial aspect of the wrist. DeQuervain disease can affect people of all ages, but it is more common in those in the forties and fifties. Women may be affected up to six to ten times more commonly than in men. It also frequently affects the parents and caretakers of the newborn baby after pregnancy. Although DeQuervain disease is more commonly called a tenosynovitis, the underlying pathophysiology is a stenosing tendovaginitis of the first dorsal extensor compartment of the wrist. Tendovaginitis describes the inflamed and thickened retinacular sheath. There typically is not significant proliferative inflammatory tissue. The first dorsal extensor compartment contains the EPB and APL (▶ Fig. 14.1). The average length of the compartment is 2 cm. The distal edge of the compartment starts within 2 mm of the tip of the radial styloid. Cadaveric studies show variations with the anatomy within the compartment. In more than 50% of wrists, there are multiple slips of the APL tendon, which insert into the trapezius and thenar muscles. The EPB is absent in 5 to 7% of cases. The most common arrangement is two slips of the APL and a single EPB (70%). Classically both tendons are found within a single tunnel, but two or more separate tunnels may be just as common. In one study a longitudinal septum was present in 47% of the specimens, and a separate EPB tunnel was found in 44%.

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Fig. 14.1 Anatomy of the radial wrist. Note that the branches of the radial sensory nerve (5) lie in close proximity to the APL and EPB tendons (3 and 4). Index metacarpal (1). Extensor pollicis longus tendon (EPL) (2). (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery, 1st edition. Thieme; 2000.)

14.2 Evaluation 14.2.1 Patient History The patient usually complains of pain in the radial aspect of the wrist. In addition there is often pain radiating proximally up the forearm, pain extending into the thumb, swelling, and occasionally feelings of crepitus or snapping with thumb motion. The pain is aggravated by activities that involve forceful and repetitive side-to-side motion with the wrist and by moving the thumb such as with pinching. Sometimes there is an

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Treatment Surgical acute specific cause such as a stressful activity. Lifting, carrying, and caring for a newborn baby are other common causes. But often the problem presents in a slow gradual fashion and is not related to any obvious history of traumatic or repetitive activities.

14.2.2 Physical Examination The most common finding on physical examination is local tenderness to palpation and swelling around the radial styloid. Sometimes there may be an associated painful cyst growing in the region of the radial styloid. Eichoff maneuver is a provocative maneuver that is the hallmark for the evaluation of DQT. This test involves placing the thumb in the palm with the other fingers wrapped around the thumb in a clenched fist. This is followed by ulnar deviating the wrist. Pain with this maneuver indicates and is pathognomonic of DQT. The Finkelstein test, also used for the diagnosis of DQT, is a similar maneuver that involves grasping of the thumb and quickly abducting the hand ulnarward. The Finkelstein maneuver is commonly confused with the Eichoff test. The EPB entrapment test helps to differentiate pain arising from a separate EPB tendon compartment that may have gone unreleased during surgery. The examiner first applies resistance to isolated thumb metacarpophalangeal (MP) joint extension, then resists thumb palmar abduction. The test is positive when the pain produced by resisted thumb MP joint extension is more than that of resisted thumb palmar abduction.

14.2.3 Imaging Routine radiographic imaging is not needed to diagnose DeQuervain disease. X-rays may be helpful if there is nearby pain in the carpus to evaluate for thumb carpometacarpal (CMC) arthritis, radiocarpal arthritis, calcific tendinitis, or occult traumatic injury.

14.2.4 Differential Diagnosis Another common cause of pain along the radial wrist and hand is thumb CMC arthritis. But the location of the pain is separate and distinct from the pain in DeQuervain disease. Intersection syndrome usually causes pain and swelling more proximally along the radial wrist, and is associated with palpable and sometimes audible crepitation with flexion and extension of the wrist. Superficial radial nerve neuritis (Wartenberg syndrome or cheiralgia paresthetica) is usually associated with numbness over the dorsoradial hand.

14.3 Nonoperative Treatment Conservative treatment options consist of rest and activity modification, immobilization in a thumb spica splint or brace, nonsteroidal anti-inflammatory medication (NSAIDs), and cortisone injection into the first dorsal compartment. Improvements with one or two cortisone injections have been reported in 60 to 80% of cases. In cases related to caring for a newborn, eventual improvement is usually expected with treatment and time. But repeated injections (more than two or three) may not be effective. In addition with the cortisone injections in this

subcutaneous area of the wrist, there is a small risk of local skin complications including depigmentation, subcutaneous atrophy, and fat necrosis, particularly in darker-skinned individuals, which usually resolve within 1 year.

14.4 Treatment Surgical 14.4.1 Indications Surgical treatment is indicated for patients who have failed various conservative modalities including cortisone injections. It is thought that steroid injections in patients with a separate EPB compartment may be less reliable and effective. There are no specific contraindications for surgical treatment. But the lack of at least temporary improvement from a corticosteroid/lidocaine injection may suggest the possibility of another cause for the problems.

14.4.2 Principles The goal of surgery is to decompress the tendons by incising and releasing the first dorsal compartment. In particular, special attention is directed to make sure that a separate EPB tunnel, if present, is also opened. Complete excision of the tendon sheath is not needed and is to be avoided. I explain to the patient that DeQuervain release is the same in principle as the more common and recognizable carpal tunnel release or trigger finger release. A dorsal bisection of the retinaculum is optimal to prevent volar tendon subluxation after the release.

14.4.3 Technique The surgery is generally performed under local anesthesia with or without sedation. The local anesthetic is used to infiltrate the subcutaneous tissues at the incision site, and a pneumatic tourniquet is inflated. A 2-cm transverse incision is made along the radial wrist centered over the first dorsal compartment about 1 cm proximal to the tip of the radial styloid (▶ Fig. 14.2). Alternatively a longitudinal or oblique incision can be used. Care is made to incise the skin only as the radial sensory nerve branches course over the compartment and can lie superficially in the subcutaneous fat. Using a tenotomy scissor or hemostat, dissect to the level of the first dorsal compartment. Identify and gently protect the branches of the radial sensory branches (typically one to three) as they pass through the field, either dorsal or volar to the first dorsal compartment. Expose the retinaculum of the first dorsal compartment. Along the dorsal margin incise longitudinally from the musculotendinous junction to the snuffbox (1 cm distal to the retinacular sheath) (▶ Fig. 14.3). Look for and incise the separate EPB tunnel if present. Also if there are any other subcompartments, release the septum if present. The septum can be excised if unusually thick. If there is a ganglion cyst arising from the tendon sheath, then excise the cyst with a portion of the tendon sheath. But avoid complete excision of the tendon sheath to avoid palmar subluxation of the tendons. In addition, any prominent synovial tissue within the tunnel can be excised.

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DeQuervain Tenosynovitis

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Fig. 14.2 Skin incision. The classic transverse incision is made about 1 cm proximal to the tip of the radial styloid (curved line) centered over the first extensor compartment (dotted lines).

Fig. 14.3 Tendon sheath incision. The tendon sheath is incised along the dorsal margin (purple dots). For reference the hand is on the left side.

Fig. 14.4 Tendon sheath flap. The palmarly based flap of the tendon sheath is retracted volarly, exposing the decompressed abductor pollicis longus (APL) (inferior broad tendon) and the extensor pollicis brevis (EPB) (superior small tendon).

Fig. 14.5 Confirmation of tendon sheath release. A retractor is used to pull the tendons out of the wound to help confirm complete release of the contents of the compartment.

Examine the compartment to confirm complete division of all intervening septa. Retracting the tendon sheath flap palmarly will reveal the APL and EPB tendons within the tunnel (▶ Fig. 14.4). Pull the tendons out of the tendon sheath to confirm complete decompression (▶ Fig. 14.5). In particular, identify both the APL and EPB to confirm complete release of both tendons. The EPB is always dorsal to the APL, smaller and rounder than the APL, and its muscle belly may be visible within the operative field. With gentle traction of the EPB, there is isolated extension of the thumb MP joint. With gentle traction of the APL there is abduction and extension of the thumb metacarpal. If the patient is awake, ask the patient to move the thumb and wrist to show complete release of the tendons. Flex the wrist to make sure that there is no tendon subluxation volarly. If there is significant tendon subluxation, the

tendons can be stabilized using a distally based slip of the brachioradialis or a strip of the extensor retinaculum. Routine lengthening or reconstruction of the tendon sheath is not needed. The tourniquet is released, and hemostasis is established. The skin is closed with a subcuticular suture. A bulky dressing with or without a volar splint is applied to limit too much wrist flexion.

14.4.4 Rehabilitation Gentle use of the thumb and wrist is allowed after a few days. Following the first dressing change, a simple wrist brace can be used for support. Avoid forceful or repetitive wrist flexion for the 2 or 3 weeks to help reduce the possibility of tendon

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Treatment Surgical

Fig. 14.6 (a) Volar instability of the first dorsal compartment tendons with wrist flexion. (b) Harvest of the volar half of the brachioradialis tendon at its point of attachment onto the distal radius (black arrow). (c) The slip is then sutured onto the dorsal margin of the compartment to stabilize the tendons by recreating the retinaculum (black arrow). (d) The tendons remain stable with passive flexion of the wrist. (These images are provided courtesy of Jonas Matzon, MD.)

subluxation as the tendons are most stressed with wrist flexion and thumb abduction. Full activities without restrictions are allowed at 6 weeks after surgery. A more restrictive splint with thumb immobilization is not needed unless there are special concerns such as tendon instability following the release. The patient can usually return to sedentary or light work within 2 weeks. Return to medium or heavy work requiring more physical activities may take 6 weeks. Formal rehabilitation or physical therapy is generally not needed following this procedure. However physical or hand therapy can be helpful if there is persistent pain related to the scar or persistent pain or weakness affecting ability to use the hand or work.

14.4.5 Complications Postoperative complications include infection, scar tenderness and adhesions, and radial sensory nerve–related numbness and sensitivity pain. These problems are usually transient and resolve gradually in a few weeks.

Transient injury to the superficial sensory branches of the radial nerve to some degree is relatively frequent. Retraction of the nerve can cause a neuroma-in-continuity injury, which can cause sensitivity pain at the zone of surgery and numbness over the dorsal radial aspect of the hand, which usually improves with time. Less commonly a sharp laceration of the nerve can cause a painful neuroma, which can be difficult to treat and may require further surgery. Another potential complication is volar subluxation of the tendons, which is more likely to occur with complete excision of the tendon sheath or with incision of the tendon sheath along the volar margin. Subluxation of the tendons can occur especially with activities requiring forceful wrist flexion and thumb pinching. With special care to preserve the tendon sheath flap to act as restraint against the tendon instability, painful volar subluxation of the tendon is rare. If the subluxation is painful, then treatment may consist of surgery to reconstruct the tendon sheath using a strip of the extensor retinaculum or the volar half of the brachioradialis tendon at its attachment onto the distal radius (▶ Fig. 14.6).

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DeQuervain Tenosynovitis

14.4.6 Outcome The long-term outcome after surgery is excellent. Long-term complications and dissatisfaction are not common. Complete relief of pain and return to regular activities are expected. Incomplete relief of the symptoms sometimes occurs, perhaps more in working women. A likely culprit is incomplete release of a separate EPB compartment. In addition, other causes of radial wrist pain such as thumb CMC arthritis, radial carpal arthritis, or intersection syndrome should be considered again. Repeat surgery to explore and look for incomplete release of a separate compartment is the last option.

14.4.7 Tips The classic incision is the transverse skin incision, which heals nicely along the natural skin creases. Oblique and longitudinal incisions have also been described. A longitudinal skin incision was felt to be more likely to develop a hypertrophic and contracted scar. However, a longitudinal skin incision also heals in a nice and cosmetically pleasing fashion. In addition, the longitudinal incision is more extensile, and injury to the radial sensory nerve may be less likely with the longitudinal incision. The sensory branches of the radial nerve lie superficially in the area of the surgery and are especially susceptible to injury. The superficial radial nerve usually bifurcates into a dorsal and volar branch around 5 cm proximal to the tip of the radial styloid, and there can be secondary branching, especially from the dorsal branch. The nerve branches (usually one to three) can lie in close proximity within a few millimeters from the central axis of the first extensor compartment. The nerves are usually easy to find and identify, even without loupe magnification. The key is to be aware that the nerves are vulnerable to injury and to make sure that the nerves are moved away from the zone of surgery with blunt exploration and gentle

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retraction. More aggressive dissection of the nerve branches is not needed and should be avoided, as even mild provocation to the nerve can cause temporary neuropraxia with numbness and pain. When examining the contents of the tendon sheath after the release, remember that there is variability of the anatomy. The most common pattern of the tendons is two slips of the APL and a single EPB. So if two tendon structures are identified, take extra care to make sure that the EPB is truly released. Incision of the tendon sheath along the dorsal margin will leave a palmarly based flap of the tendon sheath to act as a bumper to help restrain the tendons from subluxating volarly. If the flap flips volarly, flip it back over the tendons before the skin closure.

Suggested Readings Alexander RD, Catalano LW, Barron OA, Glickel SZ. The extensor pollicis brevis entrapment test in the treatment of de Quervain’s disease. J Hand Surg Am. 2002; 27(5):813–816 Bolger JT. DeQuervains release. In: Blair WF eds. Techniques in Hand Surgery. Baltimore, MD: Williams & Wilkins; 1996:574–578 Gonzalez MH, Sohlberg R, Brown A, Weinzweig N. The first dorsal extensor compartment: an anatomic study. J Hand Surg Am. 1995; 20(4):657–660 Gurses IA, Coskun O, Gayretli O, Kale A, Ozturk A. The relationship of the superficial radial nerve and its branch to the thumb to the first extensor compartment. J Hand Surg Am. 2014; 39(3):480–483 Lee HJ, Kim PT, Aminata IW, Hong HP, Yoon JP, Jeon IH. Surgical release of the first extensor compartment for refractory de Quervain’s tenosynovitis: surgical findings and functional evaluation using DASH scores. Clin Orthop Surg. 2014; 6(4): 405–409 Pechlaner S, Hussl H, Kerschbaumer F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000:508–509 Scheller A, Schuh R, Hönle W, Schuh A. Long-term results of surgical release of de Quervain’s stenosing tenosynovitis. Int Orthop. 2009; 33(5):1301–1303 Ta KT, Eidelman D, Thomson JG. Patient satisfaction and outcomes of surgery for de Quervain’s tenosynovitis. J Hand Surg Am. 1999; 24(5):1071–1077 Wolfe SW. Tenosynovitis. In: Green DP, Pederson WC, Hotchkiss RN, Wolfe SW, eds. Green’s Operative Hand Surgery. 5th ed. Philadelphia, PA: Elsevier Churchill Livingstone; 2005:2150–2154

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15 Extensor Carpi Ulnaris Tenosynovectomy/Instability Kevin F. Lutsky Abstract The extensor carpi ulnaris (ECU) is unique among the extensor tendons, in that it runs beneath both the retinaculum and its own subsheath. Disorders of the ECU commonly occur after twisting or overuse injuries and present with pain, tenderness, or instability of the tendon along the ulnar wrist. Conservative treatment is appropriate initially. Surgery for release or stabilization of the tendon can be performed when necessary. Keywords: extensor carpi ulnaris, tenosynovitis, tendon instability, ulnar wrist pain, sheath reconstruction

15.1 Anatomy The extensor carpi ulnaris (ECU) runs within the sixth dorsal compartment of the wrist. The sixth compartment is created by the extensor retinaculum and is unique, in that there is a separate subsheath beneath the retinaculum through which the ECU tendon runs. The tendon itself lies within a bony groove along the dorsal, distal ulna. The subsheath, along with the ECU groove, forms a fibro-osseous tunnel for the distal 1.5 to 2.0 cm of the sixth compartment. The ulnar aspect of the retinaculum inserts on the linea jugata, which is a stout band of tissue made up of both longitudinal and transverse fibers and acts to reinforce the sixth compartment. The linea jugata and subsheath function to prevent subluxation of the tendon during forearm rotation out of this groove. As the forearm rotates, the ECU tendon changes its direction and alignment. In pronation, the ECU tendon runs a straight course through the sixth compartment to its insertion at the base of the fifth metacarpal. However, as the forearm rotates into supination, the ECU exits the sixth compartment at an angle of approximately 30°1. Supination, particularly in conjunction with wrist flexion and ulnar deviation, puts substantial tension on the ECU tendon and stress on the sixth compartment and its supporting structures. Tennis and golf are common athletic activities that can result in ECU pathology. Inoue and Tamura2 noted two types of tears in the ECU sheath leading to instability. In type A tears, the sheath is disrupted along its ulnar aspect. This allows the tendon to re-enter the fibro-osseous sheath as it slips back and forth over the groove. In type B tears, the sheath is disrupted along its radial side. The remaining flap of tissue of the ulnar attachment blocks the tendon from re-entering the sheath. A third type of disruption (type C) has also been described, in which the periosteum and tendon sheath are stripped from the distal ulna resulting in a patulous, but intact, sheath within which the tendon subluxes.3 At the level of the wrist joint, and deep to the ECU tendon, the triangular fibrocartilage complex (TFCC) is closely associated with the undersurface of the sixth compartment, and ECU pathology and TFCC pathology are often coexistent.

15.2 Mechanism of Injury Pathologic conditions of the ECU can be broadly divided based upon the stability of the tendon within the sixth compartment. Tenosynovitis/tendinopathy of the ECU without instability can occur. When there is disruption of the sheath or when it becomes incompetent and no longer constrains the tendon, however, instability of the tendon can be symptomatic. Though these can coexist, differentiation between a stable and unstable condition is important as the treatment for each condition varies. Tenosynovitis without instability occurs when the tendon becomes inflamed or entrapped within the sixth compartment.3 While uncommon, this can occur in idiopathic fashion, after trauma, overuse, or in the setting of inflammatory arthritis. Traumatic instability of the tendon occurs when the wrist is loaded while the ECU is in a vulnerable position. This is often associated with golf and tennis, where stress may be applied with the wrist in a position of flexion, supination and ulnar deviation or when a strong force deviates the wrist while the ECU is isometrically contracted.4

15.3 Evaluation and Exam Diagnosing the source of ulnar-sided wrist pain can be difficult, as multiple anatomic structures in a relatively small and overlapping area can cause pain. Pathology of the TFCC, ECU tendon, lunotriquetral ligament, piso-triquetral joint, and distal radio-ulnar joint is among the other common causes of ulnar wrist pain. Standard evaluation of patients with ulnar wrist pain includes a detailed history and evaluation of mechanism of injury. Determining the acuity of the symptoms and whether there was a discrete traumatic event that precipitated them can be very helpful. Patients with traumatic pathology of the ECU often recall a forceful twisting or lifting motion, and may have been involved in one of the sports activities previously mentioned. Painful lifting, grip, or forearm rotation is commonly described. Patients may notice instability of the tendon, which can range in severity from mild visible subluxation to a painful or locking snapping. On exam, patients may have a discrete visible swelling over the dorso-ulnar wrist extending along the course of the tendon but this is less common in patients without inflammatory arthritis. Often the swelling is more subtle and not well defined, but is generally along the course of the tendon. In some patients, subluxation of the tendon can be easily visualized, and reproduced, with flexion, ulnar deviation, and supination of the forearm. The extent of tendon mobility should be compared to the contralateral, uninjured side. Palpation along the course of the tendon is performed. Although multiple ulnar wrist structures can cause tenderness, at the level of the ulnar groove proximal to the wrist joint itself the ECU is in a relatively isolated position and can be more discretely examined at that level. Wrist extension and ulnar deviation is painful, and the “ECU synergy test”5 has been shown to be sensitive and specific. This test is performed with the patient’s forearm in supination

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Extensor Carpi Ulnaris Tenosynovectomy/Instability and the digits and thumb abducted. The patient continues to radially deviate the thumb against the examiner’s resistance. Synergistic contraction of the ECU tendon causes reproduction of pain. Injection of local anesthetic along with a corticosteroid can be performed into the ECU sheath and the test repeated. Elimination of pain while the local anesthetic is active is confirmatory of ECU pathology. Imaging studies can be performed as needed. Standard radiographic assessment of the wrist is performed in all patients. Magnetic resonance imaging (MRI) can be obtained to rule out other confounding conditions. Since the MRI is a static imaging modality, it is less useful in establishing whether the tendon is stable. In particular, MRI images are often obtained with the forearm in a position of pronation, when the ECU would be expected to be in its reduced position. Dynamic ultrasound can be helpful in visualizing the real-time subluxation of the tendon as the forearm is rotated and useful in confirming or establishing the diagnosis of ECU instability.

Fig. 15.1 The surgical approach for treatment of extensor carpi ulnaris (ECU) pathology risks injury to the dorsal sensory branch of the ulnar nerve. This nerve is carefully protected as it crosses the field.

15.4 Treatment The initial management of ECU disorders is generally nonoperative. For patients with tenosynovitis, discontinuing the offending activity (when identifiable) is an obvious first step. Standard nonsurgical options include an immobilizing wrist splint, anti-inflammatory medication, and/or hand therapy. Duration of splint protection varies based on the severity of the symptoms, but typically 4 to 6 weeks is sufficient. Corticosteroid injections, in conjunction with the above, can be beneficial. As is the case for injections in other subcutaneous areas, patients should be counseled regarding the potential for steroid-related skin changes. Palpating the tendon both proximal and distal to the ulnar groove with fingers facilitates injection into the sixth compartment. The injection is placed between the fingers, and should not be met with significant resistance. The sheath can be felt distending as the fluid is injected. There is little data to guide physicians on the treatment of patients with acute ECU instability. A trial of immobilization is appropriate. This requires long arm splint or casting to control forearm rotation. The optimal position of immobilization is also not well established. Pronation is commonly suggested since the ECU is reduced in this position. Four to six weeks of immobilization is generally used, followed by gentle range-ofmotion exercises and a slow return to activity.

15.5 Surgical Approach Patients who have failed nonoperative treatment and remain symptomatic, or patients who present with subacute or chronic instability (in whom immobilization is unlikely to be successful) are appropriate candidates for surgical intervention. The surgical approach for management of the ECU tendon is similar regardless of pathology (▶ Fig. 15.1). A longitudinal incision is made directly overlying the sixth compartment. The dorsal ulnar sensory nerve runs obliquely across the surgical field and should be carefully identified and

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Fig. 15.2 The extensor retinaculum has been released over the sixth compartment, exposing the separate, thickened subsheath for the extensor carpi ulnaris (ECU).

protected throughout the procedure. The ECU tendon and sixth compartment are visualized. If needed, the forearm can be taken through a range of motion to confirm the stability of the tendon.

15.6 Tenosynovitis The extensor retinaculum is incised along the dorso-radial aspect of the sixth compartment. The relatively thin retinaculum can be separated from the thickened subsheath (▶ Fig. 15.2). The subsheath should be excised to free the ECU tendon from the area of compression. A tenosynovectomy can be performed if there is significant tenosynovitis. The ECU tendon is examined, frayed areas debrided, and longitudinal split tears repaired or debrided as required. The floor of the ECU groove should be examined for any irregularities or bony spicules that could be contributing and smoothed out with a rongeur, small curette, or a rasp. Once the subsheath has been excised, the radial septum dividing the fifth and sixth compartments is incised (▶ Fig. 15.3). The extensor retinaculum is then repaired over the combined

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References fifth and sixth compartments, creating a large space for the ECU to glide without fear of re-entrapment or subluxation. The extensor digitorum minimi can be transposed superficial to the retinaculum or left in situ.

15.7 Instability

Fig. 15.3 Excision of the subsheath, release of the sixth compartment and the septum between the fifth and sixth compartments, and subsequent repair of the retinaculum creates a large but contained space to avoid constriction of the extensor carpi ulnaris (ECU) tendon.

Commonly, patients with ECU instability are found to have a type C lesion. The patulous sheath keeps the tendon contained beneath the retinaculum but is too redundant/loose to prevent subluxation. Surgical repair of this condition requires tightening the sheath again to stabilize the tendon. The retinaculum is incised at its ulnarmost attachment, and reflected radially. The subsheath is excised and the groove examined for any incongruities. Suture anchors are placed adjacent to the groove in a medialized position so that repair of the retinaculum will stabilize the tendon. Prior to repair, the generally thin retinaculum is rolled up or folded so that the sutures can bite into several layers of tissue. This strengthens the repair and allows for a tighter closure with less risk of the sutures pulling through the tissue. Distally, the retinaculum is repaired with sutures to the labral tissue of the linea jugata. There is a fine line between a repair which is so loose that it does not adequately stabilize the tendon and one which is so tight that it results in constriction. To help ensure that the space is appropriate, a freer elevator should be placed beneath the retinaculum, between it and the tendon, as the sutures are tightened. Another option is to use a flap of retinaculum as a stabilizing sling (▶ Fig. 15.4). The wrist is taken through a range of motion with particular attention to flexion, supination, and ulnar deviation to ensure that the tendon remains located. Postoperatively, patients are immobilized in neutral forearm rotation for 6 weeks before starting therapy.

References [1] Campbell D, Campbell R, O’Connor P, Hawkes R. Sports-related extensor carpi ulnaris pathology: a review of functional anatomy, sports injury and management. Br J Sports Med. 2013; 47(17):1105–1111 [2] Inoue G, Tamura Y. Recurrent dislocation of the extensor carpi ulnaris tendon. Br J Sports Med. 1998; 32(2):172–174 [3] MacLennan AJ, Nemechek NM, Waitayawinyu T, Trumble TE. Diagnosis and anatomic reconstruction of extensor carpi ulnaris subluxation. J Hand Surg Am. 2008; 33(1):59–64 [4] Hajj AA, Wood MB. Stenosing tenosynovitis of the extensor carpi ulnaris. J Hand Surg Am. 1986; 11(4):519–520 [5] Ruland RT, Hogan CJ. The ECU synergy test: an aid to diagnose ECU tendonitis. J Hand Surg Am. 2008; 33(10):1777–1782

Fig. 15.4 Extensor carpi ulnaris (ECU) subsheath reconstruction with a slip of extensor retinaculum. The reconstructed compartment prevents volar instability of the ECU tendon.

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16 Intersection Syndrome Julia A. Kenniston Abstract Intersection syndrome (IS) is an overlooked cause of wrist pain. Pain in the wrist can be caused from many conditions including arthritis, tendonitis, ganglion cysts, and compressive neuropathies. IS is typically an overuse tendonitis of the wrist that is often confused with DeQuervain tendonitis as both pathologies affect the radial wrist and distal radial forearm. This chapter will review the history and potential causes of IS and explain the diagnosis and treatment options for this problem. Keywords: intersection syndrome, crossover syndrome, wrist tendonitis, overuse injury

16.1 History The symptoms of intersection syndrome (IS) were first discovered in 1841, however the phrase “intersection syndrome” was coined by Dobyns in 1978. This phrase refers to the condition caused at the area where the first dorsal extensor compartment crosses over or “intersects” the second dorsal extensor compartment. The intersection is at an angle of approximately 60 degrees.1 This disorder has been referred to by various names such as peritendinitis crepitans, crossover syndrome, oarsman wrist, and squeakers wrist.

16.2 Epidemiology IS is classically a sports overuse injury that is seen with repetitive wrist extension and flexion. It has been reported in rowers, skiers, weight lifters, and other similar type sports. This can also occur with occupational and other daily use activities. The overall incidence varies and has been reported as high as 11.9% in skiers during the first 2 days of the ski season.2 In the general population, ultrasound evaluation of the wrist in patients with wrist pain revealed an incidence of 1.9%.3

16.3 Pathoanatomy There are two main theories as to the cause of inflammation for IS. The original hypothesis suggests the cause of inflammation is due to friction of the muscle bellies of the first dorsal compartment (extensor pollicis brevis [EPB], abductor pollicis longus [APL]) as they cross over the contents of the second dorsal compartment (extensor carpi radialis brevis [ECRB], extensor carpi radialis longus [ECRL) (▶ Fig. 16.1).4 Another theory supports the idea of stenosing tenosynovitis of the second extensor compartment. Grundberg and Reagan intraoperatively discovered the pathologic abnormality as tenosynovitis in the second dorsal compartment. He found reliable improvement with decompression of this compartment.5

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Fig. 16.1 Extensor retinaculum and carpal tendon sheathes of the extensor tendons: dorsal compartments 1–6. (Reproduced with permission from Schmidt HM, Lanz U. Surgical Anatomy of the Hand. New York, NY: Thieme; 2004.)

16.4 Clinical Presentation Patients present with pain approximately 4 to 8 cm proximal to the radial styloid with swelling along the dorsal radial aspect of the mid to distal forearm. There may be localized inflammation and point tenderness. The clinical hallmark of IS is painful, palpable, and audible crepitation (“wet rubber feel”) with active wrist flexion and extension. Symptoms worsen with heavy lifting and gripping activities.

16.5 Differential Diagnosis The differential diagnosis of IS include DeQuervain tenosynovitis (DQT), thumb carpometacarpal arthritis, radial sensory nerve irritation (Wartenberg syndrome, cheiralgia paresthethica), and extensor pollicis longus (EPL) tendonitis. It is important to differentiate IS from DQT. DQT is an inflammatory tenosynovitis of the first dorsal compartment affecting the APL and EPB. In DQT, the pain is localized more distal at the radial styloid tip (▶ Fig. 16.2a) whereas tenderness to palpation from IS is localized approximately 4 cm proximal to the radial styloid tip (▶ Fig. 16.2b). Eichoff maneuver is a

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Surgery

Fig. 16.2 Differentiation of pain location from DeQuervain tendonitis and intersection syndrome. (a) Location of pain in DeQuervain tendonitis at radial styloid. (b) Location of pain in intersection syndrome 4 cm proximal to radial styloid.

provocative maneuver that can help to differentiate DQT from IS. This test involves placing the thumb in the palm with the other fingers wrapped around the thumb in a clenched fist. This is followed by ulnar deviating the wrist. Pain with this maneuver indicates and is pathognomonic of DQT. The Finkelstein test, also used for the diagnosis of DQT, is a similar maneuver that involves grasping of the thumb and quickly abducting the hand ulnarward.

16.6 Radiographic Features Further imaging studies are warranted if the diagnosis is difficult to ascertain with the history and clinical exam. Plain radiographs and computerized tomography scans are seldom helpful in supporting this diagnosis. If further imaging is being considered, ultrasound or magnetic resonance imaging (MRI) can be a diagnostic adjunct.

second extensor compartment tendons, extending proximally from the crossover point.7

16.7 Nonoperative Management Treatment for IS generally begins with rest, splinting, activity modification, oral nonsteroidal anti-inflammatory medications and cortisone injections. Immobilization is generally with the use of a thimb spica splint to limit the tendon use of both the first and second dorsal compartments. Surgical treatment may be warranted in cases where symptoms are refractory to conservative management.

16.8 Surgery 16.8.1 Positioning ●

16.6.1 Ultrasound Ultrasound imaging has been found to be reliable in the diagnosis of IS. The presence of peritendinous edema and fluid within the tendon sheaths at the crossing intersection point between the first and the second dorsal extensor tendon compartments, with loss of the hyperechoic cleavage plane between the two tendon groups, is confirmatory for IS.6

16.6.2 Magnetic Resonance Imaging MRI can also be used to support the diagnosis of IS if the diagnosis is difficult to confirm with clinical evaluation. In a retrospective review, Costa et al was able to diagnose IS based on peritendinous edema (peritendinitis) around the first and

●

Supine with hand table Anesthesia – Sedation with local anesthesia – Wide-awake, local anesthesia, no tourniquet (WALANT surgery) – General anesthesia

16.8.2 Surgical Technique ●

●

●

● ●

Longitudinal dorsal incision overlying second dorsal compartment Identify and protect the EPL and dorsal sensory branch of the radial nerve Complete release of the second dorsal compartment (▶ Fig. 16.3) Tenosynovectomy as needed Do not repair retinaculum

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Intersection Syndrome

Fig. 16.3 Second and third dorsal compartment. Dotted line represents incision to release second dorsal compartment. (Reproduced with permission and adapted from Hirt B, Seyhan H, Wagner M and Zumhasch R. Hand and Wrist Anatomy Biomechanics. New York, NY: Thieme; 2017; 89.)

16.8.3 Postoperative Care ● ● ●

Elevate and ice as needed Encourage digit range of motion Temporarily splint postoperatively with wrist in neutral to slight extension for approximately 10 days.

16.8.4 Pitfalls There are several pitfalls to avoid, including incomplete retinacular release, injury to the EPL tendon. Most importantly, injury to the sensory radial nerve or one of its branches can lead to the development of painful neuroma and dysfunction. Prior to releasing the retinaculum and tenosynovectomy, the nerve should be carefully identified and protected.

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References [1] Dobyns JH, Sim FH, Linscheid RL. Sports stress syndromes of the hand and wrist. Am J Sports Med. 1978; 6(5):236–254 [2] Palmer DH, Lane-Larsen CL. Helicopter skiing wrist injuries: a case report of “bugaboo forearm”. Am J Sports Med. 1994; 22(1):148–149 [3] Draghi F, Bortolotto C. Intersection syndrome: ultrasound imaging. Skeletal Radiol. 2014; 43(3):283–287 [4] Howard NJ. Peritendinitis crepitans. J Bone Joint Surg. 1937; 19:447–459 [5] Grundberg AB, Reagan DS. Pathologic anatomy of the forearm: intersection syndrome. J Hand Surg Am. 1985; 10(2):299–302 [6] Montechiarello S, Miozzi F, D’Ambrosio I, Giovagnorio F. The intersection syndrome: ultrasound findings and their diagnostic value. J Ultrasound. 2010; 13 (2):70–73 [7] Costa CR, Morrison WB, Carrino JA. MRI features of intersection syndrome of the forearm. AJR Am J Roentgenol. 2003; 181(5):1245–1249

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17 Lateral Epicondylar Debridement Frederic E. Liss Abstract This chapter on lateral epicondylar debridement will review some of the techniques available for surgical treatment of recalcitrant lateral epicondylitis (LE) and focus on the author’s preferred methods of treatment. There is general consensus in the literature that the vast majority of cases of lateral epicondylitis resolve within 6 to 12 months regardless of nonoperative treatment choices and that up to 10 per cent of cases will be treated with surgery.1 The author’s preferences will be discussed with detailed description of nonoperative care and surgical technique as well as immediate postoperative care and rehabilitation. Potential complications will be discussed. The goal of this chapter is to provide the reader with an understanding of the available choices, and discuss a safe, reproducible, effective and commonsense methodology and (when needed) surgical technique for treating intractable tennis elbow. Keywords: epicondylar debridement, lateral epicondylitis, intractable tennis elbow

17.1 Background It could be said that a lack of consensus is a consistent finding when one reviews the literature on lateral epicondylitis (LE) and its treatments. LE stands as an example of a diagnosis where many surgeons are convinced that their treatment protocol gets the best results, but the irony is that no one best evidence-based treatment has ever surfaced. There are, however, some features of this condition that have been accepted since the classic article by Nirschl and Pettrone in 1979. There has been a general consensus that the tissue found at the site of the extensor carpi radialis brevis (ECRB) origin at the lateral epicondyle and supracondylar ridge of the distal humerus is angio-proliferative in nature, and the histopathologic findings have been termed angiofibroblastic hyperplasia.2 The pathology can extend to the origins of extensor carpi radialis longus (ECRL), extensor digitorum communis (EDC), and even extensor carpi ulnaris (ECU). The pathology is not true “inflammation” as its suffix “-itis” would imply. LE preferentially affects the dominant extremity. It is also widely accepted that nonoperative treatment is the default approach for new onset “tennis elbow.”

17.2 Nonoperative Treatment Nonoperative treatment methodology runs the gamut from patient counseling alone, activity modification, corticosteroid injections, counterforce bracing during the waking hours/cockup wrist splinting during sleep to formal therapy. Therapeutic techniques include frictional massage, iontophoresis, lowintensity ultrasound, stretching of the extensor muscles, and alternating heat and ice application. Some practitioners promote the use of high-intensity ultrasonic shock wave treatment for LE, but there remains skepticism about its effectiveness and

high cost. The same concerns exist about plasma rich protein and autologous blood injections into the ECRB origin; these two modalities have not gained widespread appeal.

17.2.1 Author’s Preferred Method for Nonoperative Treatment The author’s preferred methodology for nonoperative treatment of LE is dependent on patient examination and the chronicity of the condition upon presentation. If the patient presents with a chronic and untreated LE, especially if they present with a flexion contracture of the elbow, or if passive extension of the elbow provokes lateral elbow pain, then formal therapy is initiated first, combined with patient education, activity modification, a home exercise program, and use of counterforce brace (CFB). We have anecdotally found “clasp” devices are more effective at controlling the pain with activities of daily living (ADLs) than the traditional single-ply TES. This may be because the clasps and padded TESs more accurately focus the counter force pressure on the extensor muscle group. In addition, the effectiveness of CFBs is dependent upon their proper positioning. Often, patients present to the office with straps that they have positioned directly over the lateral epicondyle. We recommend applying the CFB three finger breadths below the extensor tendon origin, centered on the midline of the extensor muscle group. Patients are instructed to tension the device compression, so that when they make a fist, they feel ample and comfortable compression of the extensor muscles, but when relaxed there is no constriction of the forearm. For patients with more acute localized LE and no elbow contracture, we provide education, offer a corticosteroid injection, and direct the patient on a home exercise program. The goal is to let them recover, on their own, for as long as they can endure, because the probability is overwhelmingly in favor of recovery with self-care and without surgery.

17.3 Differential Diagnosis Compression of the posterior interosseous nerve (PIN) at the arcade of Frohse at the distal end of the supinator, or radial tunnel syndrome (RTS), is reported to be present in approximately 5 percent of patients with LE.3 Electromyogram (EMG)/nerve conduction velocity (NCV) studies are often non-diagnostic. Clinical suspicion and careful examination are pivotal to not overlooking this diagnosis; examination for RTS (including palpation of the course of the PIN under the brachioradialis, resisted supination of the forearm, and resisted extension of the long finger at the metacarpophalangeal joint) should be performed at every examination of a patient with the working diagnosis of LE. Other more distinct diagnoses to be ruled out include primary osteoarthritis of the radio-capitellar joint, collateral ligament sprain or instability, fracture, osteochondritis dissecans, and even cervical nerve root compression.

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Lateral Epicondylar Debridement

17.4 Surgical Indications The primary indication for lateral epicondylar debridement is request for surgery by a patient who has demonstrated commitment but has failed to respond to 6 to 12 months of nonoperative treatment of LE.

17.5 Surgical Techniques Regardless of one’s surgical approach, the basic tenets of successful surgical treatment of LE are release and debridement of the ECRB origin and fascia. The two most widely used approaches, open and arthroscopic, are worthy of consideration and comparison, because they have similar high rates of success and better functional outcomes than percutaneous release.4 The percutaneous technique will not be discussed in this chapter.

17.5.1 Arthroscopic Debridement Proponents of the arthroscopic approach suggest the advantages as primarily being able to identify and treat intra-articular pathology, such as osteochondritis dissecans (OD) and capsular plicas. However, one would expect the diagnosis of OD to be borne out before surgery. With regard to posterior radiocapitellar capsular plicas, there is no clear evidence that resecting this tissue, alone or in combination with debridement of the ECRB origin, improves outcome satisfaction in patients treated with surgical arthroscopy.5 There are some claims in the literature that arthroscopic technique has a lower risk of complications and quicker return to work than open lateral epicondylar debridement.6

17.5.2 Author’s Preferred Technique: Open Release and Debridement The author’s preferred method is the open technique popularized by Nirschl with a few subtle modifications. A lateral incision is first planned by carefully marking out the surface anatomy of the lateral epicondyle of the distal humerus and the radial head, and defining the distal most extent of the approach, lateral ulnar collateral ligament (LUCL), and proximal extent of the approach at the top of the lateral epicondylar ridge (▶ Fig. 17.1). After intravenous sedation and local infiltration with 10 to 20 mL of 0.5% plain bupivacaine, an upper arm tourniquet is elevated to 250 mm pressure. The skin incision is made from the top of the epicondylar ridge to the distal margin of the capitellum, but not over the radio-capitellar joint. Using blunt dissection, first with gentle spreading with scissors in line with the incision down to the fascia and then using a gauze sweeping anteriorly and posteriorly from the epicondyle, the ECRL origin is easily exposed and visualized (▶ Fig. 17.2). Careful inspection of the ECRB sometimes identifies discolored attenuated fascia that can be resected during closure. Before proceeding with the fascial incision, it is advisable to confirm the location of the radio-capitellar interval in order to prevent unnecessary incision into the LUCL. Incision is then made down to bone proximally from the upper end of the lateral epicondylar ridge, distally to but not through the posterior margin of the LUCL. Using a periosteal elevator, the muscular origins of ECRB,

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ECRL (posteriorly and distally), and the EDC margin (anteriorly and proximally) are dissected off of the lateral epicondyle and lateral ridge of the humerus in single posterior and anterior musculofascial flaps (▶ Fig. 17.3a). Using a Rongeur, the lateral epicondyle and ridge are debrided of all soft tissue, carefully avoiding damaging the LUCL and violating the radio-capitellar joint capsule. Next, using wide skin hooks, the margins of the ECRB fascia are inverted and the undersurface of the muscle origin is sharply debrided with a knife and/or a Rongeur, down to healthy appearing muscular/fascial tissue (▶ Fig. 17.3b). Although the value of decortication with the Nirschl procedure has been argued in the literature,7 the author routinely performs drilling of the lateral epicondyle and the ridge with a .062 K-wire and light decortication with a coarse rasp prior to irrigation and closure, in order to facilitate the “re-anchoring” of the muscular origin back to the lateral epicondyle (▶ Fig. 17.4a,b). The fascial incision edges are then debrided of any attenuated fascia to a healthy tissue margin and closed with simple inverted stitches using 0.0 Vicryl suture (▶ Fig. 17.5). The dermis is closed with inverted 4.0 Monocryl simple stitches and the skin with a running 4.0 Nylon. After application of a sterile dressing, patient is placed in a well-padded long arm splint with the elbow at 90 degrees flexion, forearm in neutral rotation, and the wrist in slight flexion.

17.5.3 Postoperative Rehabilitation The patient is advised to leave the long arm splint and dressing in place until the first postoperative visit, when the sutures are removed and therapy is begun. At 10 days post op, the suture is removed and the patient sent directly to begin formal therapy two times per week. The patient is provided a choice (therapist assessment) of using a cock-up wrist splint or long arm orthosis (except during bathing and therapy/home exercises) for comfort and rest to the surgical site. In weeks one to three, the patient does exercises from shoulder to fingers as well as edema control. This includes passive range of motion with wrist and elbow flexed, progressing to stretching with the elbow more extended. At week four, the patient begins isometric strengthening, beginning with the elbow flexed 90 degrees and progressing to same with elbow extended. Beyond 6 weeks, there is progressive strengthening, including isotonic gripping and pinching, multi-angled weighted resistance, and commencing repetitive activities and work simulation. The goal is return to work using a CFB by 8 weeks post op. We recommend use of the CFB for exertional activities for up to 6 months post operatively.

17.6 Potential Complications and Pitfalls ●

●

● ● ●

Lateral collateral ligament complex injury and resultant elbow instability. Radial nerve injury (PIN, sensory radial nerve, and radial nerve proper). Capsular fistulas. Missed radial tunnel syndrome. Capitellar devascularization.

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Pearls, Tips, and Lessons Learned

Fig. 17.1 Surface anatomy and incisional planning.

Fig. 17.2 Exposure of the extensor muscle origins of the elbow.

17.7 Pearls, Tips, and Lessons Learned

radio-capitellar joint. The outline of the radial head and capitellum should be drawn out in every case to increase the accuracy of the approach and dissection.

17.7.1 Surface Anatomy

17.7.2 Positioning

The approach to the lateral epicondyle under normal circumstances is straightforward. In corpulent individuals, however, it can be more difficult to accurately identify the location of the

Supine position is logical. Placing a 4- to 5-inch-thick 12 × 12 square bump, at the posterior margin of the upper arm which sits at the edge of the bump, perfectly positions the elbow for

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Lateral Epicondylar Debridement

Fig. 17.3 (a) Dissection of extensor origin at the lateral epicondyle. (b) Debridement of extensor origin and the lateral epicondyle.

Fig. 17.4 (a, b) Drilling and rasping of the lateral epicondyle.

optimal surgical dissection. A folded sterile terrycloth towel works well.

17.7.5 Vascular Considerations for the Capitellum

17.7.3 Lateral Collateral Ligament and Joint Capsule

Although the vascular supply to the capitellum is robust, coming both from the radial recurrent and interosseous recurrent arteries, concern for avascular injury to the capitellum should not be overlooked. This can be prevented by avoiding both too distal a subperiosteal dissection and overly aggressive distal drilling into the epicondyle.

Sub-periosteal dissection should stop proximal and remain superficial to the lateral collateral ligament complex. Intraoperative confirmation of the radio-capitellar interval reduces risk of iatrogenic injury to the lateral ulnar collateral ligament and violation of the anterior capsule of the radio-capitellar joint. Breaches to the joint capsule can lead to a fistula.

17.7.4 Radial Nerve and Branches As long as the dissection remains subperiosteal, the risk to the radial nerve and its branches is minimal. This is a greater risk in over aggressive arthroscopic debridement where capsular resection is integral to the procedure itself.

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17.7.6 Rehabilitation When discussing postoperative care after surgery, the patient is advised to leave their long arm splint on until the first followup visit. However, they are given the option to remove the dressing and begin showering over the incision sooner. This gives them some control of the management, reduces phone calls and patient frustration, and also sets them up to be ready for structured therapy at the first postoperative visit.

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References ECRB (and sometimes ECRL, EDC, and ECU) muscular origins at the epicondyle and ridge of the distal lateral humerus in the 5 to 10 percent of patients who fail nonoperative treatment. It is the author’s opinion that Drs. Nirschl and Pettrone got it right in 1979. In the 39 years since, hand, shoulder and elbow, and sports medicine surgeons have tried to improve upon the results of the open procedure, and at best have equaled patient satisfaction using the arthroscopic debridement technique. Likely, the best recommendation in determining which technique to use comes down to the simple common sense of using the technique for which one has been best prepared.8

References

Fig. 17.5 Repair of the debrided extensor muscle origin.

17.8 Conclusion Both open and arthroscopic lateral epicondylar debridement(s) are safe and effective techniques to treat intractable tennis elbow. Each addresses the persistent painful and disabling existence of angioproliferative tissue that afflicts the

[1] Burn MB, Mitchell RJ, Liberman SR, Lintner DM, Harris JD, McCulloch PC. Open, arthroscopic, and percutaneous surgical treatment of lateral epicondylitis: a systematic review. Hand (N Y). 2017(March):1558944717701244 [2] Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979; 61 6A:832–839 [3] Moradi A, Ebrahimzadeh MH, Jupiter JB. Radial tunnel syndrome, diagnostic and treatment dilemma. Arch Bone Jt Surg. 2015; 3(3):156–162 [4] Pierce TP, Issa K, Gilbert BT, et al. A systematic review of tennis elbow surgery: open versus arthroscopic versus percutaneous release of the common extensor origin. Arthroscopy. 2017; 33(6):1260–1268 [5] Rhyou IH, Kim KW. Is posterior synovial plica excision necessary for refractory lateral epicondylitis of the elbow? Clin Orthop Relat Res. 2013; 471(1): 284–290 [6] Gowda A, Kennedy G, Gallacher S, Garver J, Blaine T. The three-portal technique in arthroscopic lateral epicondylitis release. Orthop Rev (Pavia). 2017; 8 (4):6081 [7] Dunn JH, Kim JJ, Davis L, Nirschl RP. Ten- to 14-year follow-up of the Nirschl surgical technique for lateral epicondylitis. Am J Sports Med. 2008; 36(2): 261–266 [8] Wang D, Degen RM, Camp CL, McGraw MH, Altchek DW, Dines JS. Trends in surgical practices for lateral epicondylitis among newly trained orthopaedic surgeons. Orthop J Sports Med. 2017; 5(10):2325967117730570

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18 Medial Epicondylar Debridement Lance M. Brunton Abstract Surgical intervention for chronic medial epicondylitis (or enthesopathy of the common flexor-pronator mass tendon origin) is an uncommon end point in the treatment of this largely selflimiting overuse condition. In the rare circumstance where surgery is indicated, several debridement options exist. Macroscopic identification of the pathologic tissue to be removed is not always obvious. “Controlled trauma” to the tendon origin combined with adequate postoperative rest may effectively stimulate or “reset” the dormant reparative pathways and lead to a satisfactory clinical outcome in recalcitrant cases. Addressing concomitant ulnar neuropathy is critical to achieving the best long-term results of upper extremity function. Keywords: medial epicondylitis, degenerative tendon origin debridement, flexor pronator mass

tendinosis,

18.1 Background Medial epicondylitis (or enthesopathy of the common flexorpronator mass tendon origin) is a common cause of medial elbow pain (▶ Fig. 18.1). Surgery to address chronic medial epicondylitis is an atypical treatment end point. Although many conservative strategies can be used for symptomatic patients, there is widespread consensus that the majority of these often middle-aged individuals are not cured by any particular active treatment but rather experience spontaneous symptom decline over a time frame of months to years. Education that emphasizes the avoidance of aggravating activities that correlate directly with symptom exacerbation may be the true cornerstone of treatment and a foundation for a more predictable trajectory of improvement and resolution. Superimposed on this antiinterventionalist thinking is the onslaught of behavioral research shedding light on the interplay between subjective symptom description and psychosocial factors. Periodically, however, there are scenarios where the severity of pain escalates and persists beyond a given individual’s ability to cope, prompting consideration of operative intervention, especially when the symptoms legitimately impact work productivity, jeopardize occupational safety or restrict specific recreational enjoyment. Still, only 26 patients with 2 years of follow-up could be found by investigators at the Mayo Clinic over a near quarter-century review of their operative cases for medial epicondylitis, highlighting the relative infrequency that surgery is indicated.1

18.2 Pathophysiology Understanding the pathophysiology of this overuse condition is paramount to crafting the type of surgery required to promote a satisfactory outcome. There has been a scientifically driven shift away from describing the pathologic common flexor

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Fig. 18.1 Muscular attachments of the medial epicondyle. (Reproduced with permission from Hirt B, Seyhan H, Wagner M, Zumhasch R. Hand and Wrist Anatomy and Biomechanics. 1st ed. © 2017 Thieme.)

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Ulnar Neuropathy pronator tendon origin as inflammatory to recognizing its purely degenerative nature. In fact, the hallmark histologic feature is angiofibroblastic hyperplasia, a term similarly acknowledged in the more commonly seen counterpart of lateral epicondylitis, or enthesopathy of the common extensor tendon origin. This denotes disorganization of collagen composition from a constellation of misplaced metabolic and cellular components. Consequently, the normal healing pathway is thwarted, and the degenerative tissue matrix can neither withstand repetitive forceful wrist flexion/forearm pronation nor the tensile strains on the affected area, thus leading to the subjective experience of pain and weakness. Routine actions such as swinging an axe, throwing a ball, or swinging a golf club become increasingly agonizing and resistant to simple behavioral modifications.

18.3 Evaluation The overarching reason that surgery may prove successful lies in the concept of “controlled trauma.” Patients often carry a misconception that their elbow tendons are torn or ruptured, often reinforced by the inaccurate language of radiologists interpreting abnormalities at the flexor pronator mass tendon origin on magnetic resonance images. At best, the tendon origin may sustain a cascade of microtears as the genesis of the condition and then functionally deteriorate from the faulty reparative process. Patients must often be convinced that the suggestion of “repairing” this injury is largely misguided. It would be more accurate to introduce and endorse the idea of “intentional collagen regeneration” by surgical means. Simply stated for the layman, this is effectively like hitting an imaginary reset button or creating order out of chaos. Contrasting this endeavor with the example of distal biceps tendon reattachment at its insertion for an acute eccentric rupture may suffice to illustrate the point. Additional reinforcement comes from the lack of noticeable external evidence of tendon disconnection in those afflicted with chronic elbow enthesopathy. This is not to suggest that a traumatic avulsion of the tendon origin isn’t possible, although the forces responsible in that instance would be arguably much larger and often produce simultaneous injury to the skeleton, ligamentous restraints and joint capsule.

18.4 Surgical Treatment Open debridement may be the most commonly employed method of intentional collagen regeneration. Following opening of the superficial fascia overlying the flexor pronator mass, tendinosis may manifest intraoperatively as distinct areas of discolored and dysmorphic tissue embedded within normal appearing tendon origin, most often involving the pronator teres and/or flexor carpi radialis. The distribution of this abnormal tissue is not typically patchy or sporadic but rather confluent in a surprisingly small region approximating less than a squared centimeter in most cases. Intraoperative findings can otherwise be perplexingly unimpressive. In the instances where areas of tendinosis are more obscure, the surgeon must estimate the offending location and sharply excise presumed inferior tissue while maximally respecting the normal environment. It is not entirely clear if this should be performed adjacent to the

interface with the epicondyle (enthesis) or at a finite distance “downstream.” The subsequent act of debriding bone as part of the surgical technique remains debatable. The possibly outdated notion that stimulating bleeding is necessary to unleash a barrage of locally confined healing factors must be weighed against the potential for more prolonged postoperative tenderness at the site of bony resection.2 Attempting to distinguish normal tissue from abnormal tissue in the open approach to debridement is obviated in the percutaneous method.3 A relatively blind tenotomy may, however, risk insufficient release if the true location of pathology is missed or the extent of the problem is underappreciated. In the era of producing less-invasive techniques to match a patient’s thirst for rapid recovery, inadequate or imprecise tenotomy represents a real concern akin to leaving a few fibers of transverse carpal ligament after endoscopic carpal tunnel release. Overzealous tenotomy may be equally counterproductive if the medial (ulnar) collateral ligament complex is compromised and transforms the painful elbow into a partially unstable one. Inadvertent transection of cutaneous nerves is similarly inexcusable, and direct injury to an aberrantly coursing ulnar nerve would be catastrophic. The feasibility of arthroscopic debridement has yet to be realized in the clinical arena.

18.5 Ulnar Neuropathy (▶ Fig. 18.2) A strong argument exists for more expedient surgical intervention in the context of well-established medial epicondylitis with ulnar neuropathy at the elbow.4 While the severity of peripheral compression neuropathy may dictate the timing of surgery, the presence of distinctly symptomatic medial epicondylitis may influence the type of surgery. Evidence supports a justification for and trend toward in situ decompression of the ulnar nerve at the elbow for cases of isolated cubital tunnel syndrome with or without nerve subluxation or instability. A notable exception may exist in this scenario of concurrent common flexor pronator enthesopathy, where deep submuscular anterior transposition of the ulnar nerve with musculofascial lengthening may productively address both conditions simultaneously.5 This efficient strategy may be sufficiently warranted if for no other reason than to avoid the pitfalls of reoperation if the neuropathy resolved from in situ decompression alone and the enthesopathy progressed to future operative indication separately. Navigating among the haphazard array of branches from the medial antebrachial cutaneous nerve distribution is challenging enough in native tissue such that avoiding a second surgery through a scar-infested environment could be the difference between a comfortable or hypersensitive incision site and the development of a pesky cutaneous neuroma. Now consider the trauma perpetrated to the flexor pronator mass during an intramuscular or submuscular transposition of the ulnar nerve. The degree to which the anatomy is surgically disrupted far exceeds what might have been altered in the diseased state preceding surgery for medial epicondylitis. How does a patient more predictably recover over a shorter time frame from this extent of musculotendinous trauma than a patient who suffered from a mere microscopic degenerative pathway from overuse tendinopathy? With that in mind, there may

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Medial Epicondylar Debridement

Fig. 18.2 (a,b) The relationship of the ulnar nerve and medial epicondyle. (1) Medial fascicle of the medical antebrachial cutaneous nerve. (2) Brachialis. (3) Medial epicondyle. (4) Common head of the flexors. (5) Canal of the ulnar nerve. (6) Triceps. (7) Medial intermuscular septum. (8) Ulnar nerve. (9) Arcade of Struthers. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

be perceived value for some surgeons to more aggressively detach or “take-down” the tendon origin and subsequently reattach it via drill holes or anchors at the medial epicondyle.6,7 Legitimate concern over inadequate debridement may drive this decision. Again, prospective studies are lacking to determine whether this more extensive approach is well founded. It is tempting to compare this approach to the relative success of detachment/reattachment for partial distal biceps tendon injuries or chronic insertional tendinosis, as the pertinence of anatomic differences between origin and insertion in this context is poorly understood. There is relative optimism for the various described methods of surgically altering the tendon origin environment, especially in the largest retrospective series available for medial epicondylitis.8,9 Whether by percutaneous tenotomy, open limited tendinosis debridement, or tendon origin detachment/reattachment, an act of “controlled trauma” followed by an interval of restricted arm use to promote a reparative process appears to be widely accepted. This particular condition may join a host of others in upper extremity orthopaedics where the lack of relevant prospective outcomes research stems from the relatively small percentage of cases that meet our current clinical criteria for surgical intervention. In the future, subjects could be disproportionately recruited for office-based therapies such as platelet-rich plasma (PRP) and other concoctions of growth-factor-rich injectable substances as we gravitate toward the exciting frontier of orthobiologic applications, potentially making surgical studies a lower priority in elbow enthesopathy research. If the pervasive sentiment among treating practitioners was that surgical intervention for this condition is unpredictable at

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best, adopting a paradigm-shifting technique would likely require multi-institutional collaboration. On the contrary, the overall positive results of various forms of operative debridement along with a perceived low rate of complications may call into question our reluctance to intervene earlier, as so many patients suffer the agonizingly slow process of spontaneous resolution with prolonged conservative management.

References [1] Vangsness CT, Jr, Jobe FW. Surgical treatment of medial epicondylitis: results in 35 elbows. J Bone Joint Surg Br. 1991; 73(3):409–411 [2] Schipper ON, Dunn JH, Ochiai DH, Donovan JS, Nirschl RP. Nirschl surgical technique for concomitant lateral and medial elbow tendinosis: a retrospective review of 53 elbows with a mean follow-up of 11.7 years. Am J Sport Med. 2011:[Epub ahead of print] [3] Baumgard SH, Schwartz DR. Percutaneous release of the epicondylar muscles for humeral epicondylitis. Am J Sports Med. 1982; 10(4):233–236 [4] Gabel GT, Morrey BF. Operative treatment of medical epicondylitis: influence of concomitant ulnar neuropathy at the elbow. J Bone Joint Surg Am. 1995; 77(7):1065–1069 [5] Gong HS, Chung MS, Kang ES, Oh JH, Lee YH, Baek GH. Musculofascial lengthening for the treatment of patients with medial epicondylitis and coexistent ulnar neuropathy. J Bone Joint Surg Br. 2010; 92(6):823–827 [6] Kwon BC, Kwon YS, Bae KJ. The fascial elevation and tendon origin resection technique for the treatment of chronic recalcitrant medial epicondylitis. Am J Sports Med. 2014; 42(7):1731–1737 [7] Vinod AV, Ross G. An effective approach to diagnosis and surgical repair of refractory medial epicondylitis. J Shoulder Elbow Surg. 2015; 24(8): 1172–1177 [8] Kurvers H, Verhaar J. The results of operative treatment of medial epicondylitis. J Bone Joint Surg Am. 1995; 77(9):1374–1379 [9] Han SH, Lee JK, Kim HJ, Lee SH, Kim JW, Kim TS. The result of surgical treatment of medial epicondylitis: analysis with more than a 5-year follow-up. J Shoulder Elbow Surg. 2016; 25(10):1704–1709

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Part IV Nerve Repair/Reconstruction

IV

19 Nerve Repair in the Hand

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20 Peripheral Nerve Injury and Repair using Autograft or Allograft

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21 Nerve Conduits for Nerve Repair/ Reconstruction

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22 Oberlin Transfer

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19 Nerve Repair in the Hand Patricia M. Kallemeier Abstract Functional recovery after nerve injury in the hand requires special attention to primary repair and reconstructive principles in order to optimize outcomes. The surgeon must have various reconstructive tools available to address all possible scenarios, with the goal being to achieve a tension-free repair site. There are myriad commercial reconstructive options available to bridge nerve gaps and defects, but nerve autograft currently remains the gold standard for nerve reconstruction. Despite optimal surgical technique, nerve function seldom returns to its preinjury status, with perhaps exception to the pediatric population. Keywords: primary nerve repair, direct coaptation, nerve connector, nerve conduit, processed nerve allograft, autograft, nerve reconstruction

19.1 Description Neglected nerve injuries in the hand frequently result in severe pain and disability. Nerve repair or reconstruction can improve functional recovery and outcome. Unfortunately, most patients fail to recover normal nerve function after trauma to a peripheral nerve. Consequently, the goal of nerve repair is to utilize the most appropriate technique to achieve a tension-free repair site and thereby optimize recovery. Often, nerve injury in the hand does not occur in isolation. Other injured structures should be repaired concomitantly if possible. The inflammatory response to trauma and the immobilization necessary to allow healing of injured bones, tendons, arteries, and skin can negatively affect the final outcome of nerve recovery.1

19.2 Key Principles Many independent factors affect recovery after nerve injury. Important factors that cannot be controlled for at the time of surgery include patient age, mechanism of injury, and delay in diagnosis. Younger patients have improved recovery of motor and sensory function after peripheral nerve repair.1,2 Also, recovery of sensory nerve function after sharp laceration is better than nerves injured by crush mechanisms.1 The timing of nerve repair is also an important factor. Primary repair or direct coaptation can usually be performed within a few days of the injury, and the nerve's landmark vasculature is more easily identifiable to guide alignment of the neurorrhaphy site. After a period of time, the nerve's elasticity decreases, which results in nerve gaps with attempts at primary repair. Nerve elasticity decreases as Wallerian degeneration occurs in the injured nerve.3 Nerve defects can also result when the zone of injury is larger, such as in a saw injury (▶ Fig. 19.1). The goal of any nerve repair or reconstruction is a tensionfree repair site. Nerve healing and axonal regeneration requires adequate blood flow, and excessive tension across the repair site decreases blood flow. An animal study by Clark et al4 evaluated nerve blood flow in an animal model. These researchers demonstrated that a 15% increase in tension across the repair site decreased the blood flow by 80%. Also, when a 16 to 17% increase in tension was applied to the repair site, it resulted in suture pullout and failure of the repair. These findings illustrate that lack of blood flow is likely the mechanism for nerve repair failure prior to disruption of the repair site.4 If a tension-free repair is not obtainable, the surgeon should consider any number of reconstructive techniques to bridge the gap and provide a tension-free repair.

Fig. 19.1 (a) Nerve defect as the result of tablesaw injury. Surgery was performed under local anesthetic with a digital tourniquet. (b) Processed nerve allograft reconstruction of the nerve defect. (Photo courtesy of Jeffrey Rodgers, MD.)

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Nerve Repair in the Hand Convenient nerve donors in the ipsilateral extremity include the terminal branch of the posterior interosseous nerve at the wrist’s 4th dorsal compartment, and the lateral and medial antebrachial cutaneous nerves in the forearm. These donor nerves can be used to reconstruct digital nerve defects.3

19.4 Contraindications The medical stability of the patient takes priority over the nerve injury. The patient must be medically stable to undergo the planned anesthetic, and the wound must not exhibit any signs of infection.

19.5 Special Considerations Fig. 19.2 Concomitant tendon repair with processed nerve allograft reconstruction of a digital nerve gap. (Photo courtesy of Jonas Matzon, MD.)

19.3 Indications Any nerve injury in the hand should be considered for repair or reconstruction. Painful neuromas may result from a neglected sensory nerve injury, and functional loss occurs from injuries to the motor branches of the median and ulnar nerves. Frequently, procedures such as fracture fixation, tendon and blood vessel repair, and soft tissue reconstruction can be performed at the same setting as nerve repair (▶ Fig. 19.2). If primary nerve repair or direct coaptation is not possible, then the surgeon needs to have a backup plan utilizing the reconstructive ladder of nerve conduits, autograft, and processed allograft. Nerve conduits are indicated for sensory nerve reconstruction with gaps up to 3 cm and function to give the sprouting axons a directional channel for regeneration.5 Commercially available artificial conduits are typically composed of collagen, caprolactone, or polyglycolic acid (PGA). In their study of 22 digital nerves reconstructed with collagen conduits, Taras et al5 demonstrated a moving and static 2-point discrimination of 5.0 and 5.2 mm, respectively, at a mean follow up of 20 months after surgery.5 Processed nerve allografts used to span digital nerve gaps of less than 3 cm resulted in an average static 2-point discrimination of 7.1 mm in 21 digital nerves.6 Commercially available processed nerve allografts were studied in the RANGER study, and are indicated for nerve gaps between 5 and 50 mm in digital sensory nerves and motor or mixed nerves. These researchers found meaningful recovery in 89% of digital sensory nerves, 75% of median nerves, and 67% of ulnar nerves.7 Nerve gaps greater than 5 cm are best reconstructed with vascularized nerve graft techniques. Nerve autograft, which is still considered the gold standard for nerve reconstructions, can be harvested from one of several donor sites depending on the diameter of the injured nerve. The sural nerve in the lateral leg can be used to graft defects between the wrist and the common digital nerves.

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Long-term studies of patients following nerve repair have demonstrated that the younger the patient, the better the outcome in terms of nerve recovery.2 While advanced patient age is not a contraindication to nerve repair surgery, age must be considered in the setting of severe proximal injuries that require reconstruction. The surgeon must also weigh the risks and benefits of surgery in the elderly population against the risk of painful neuroma development if surgical repair is not performed. Primary repair of motor nerve branches of the median and ulnar nerves in the hand require special attention to the alignment of nerve fascicles. At the level of the wrist, grouped fascicular repairs of the sensory and motor components can be performed, since these components can often be identified and separately repaired or reconstructed.

19.6 Special Instructions, Positioning, and Anesthesia The operating microscope can be used for repairs to assist with alignment of fascicles and perineural vasculature. Use of an operating microscope for motor nerve repairs has been shown to improve functional recovery in an animal model.8 However, human clinical studies on digital nerve repairs have not reflected improved outcomes of operating microscope over loupe-aided (3.5x) repair.9 The patient is positioned supine with an arm table and the arm prepped free. A nonsterile brachial tourniquet is utilized with the elbow exposed in case a nerve autograft from the ipsilateral upper extremity is necessary for reconstruction. A commercially available hand holder is helpful in positioning the limb, with the fingers extended and the wrist in neutral position on the hand table (▶ Fig. 19.3a). An overlying white sheet is used to drape around the hand to help with identifying the black microsutures during repair (▶ Fig. 19.3b). Surgical anesthesia type is chosen with consideration to the patient’s medical comorbities. These procedures can be performed under a general anesthetic, regional anesthetic, or with wide-awake local anesthetic no tourniquet (WALANT) in the cooperative patient. Isolated digital nerve injuries can be repaired or reconstructed under local anesthetic with a digit tourniquet (▶ Fig. 19.1b).

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Tips, Pearls, and Lessons Learned

Fig. 19.3 (a) Set-up for nerve repair surgery. The arm is surgically prepared with a nonsterile brachial tourniquet and commercially available hand holder. (b) An operating microscope is brought over the field. White sheets are placed around the prepared field to aid in visualizing the microsutures.

Fig. 19.4 A saline-moistened tongue blade and #15 scalpel blade are used to trim the nerve back to healthy fascicles.

Fig. 19.5 Epineurial repair is recommended for digital nerves. Matching fascicles is unnecessary, as digital nerves contain only sensory fibers. (Modified with permission from David J. Slutsky. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.)

19.7 Tips, Pearls, and Lessons Learned 19.7.1 Primary Nerve Repair Primary nerve repair or direct coaptation is performed aided by magnification with 3.5x loupes or an operating microscope. The nerve ends are resected back to healthy fascicles with a moistened tongue blade and a #15 scalpel blade (▶ Fig. 19.4). For digital nerves, 9-O or 10-O nylon suture is used to repair the nerve, with approximately 3 to 6 sutures required for coaptation of the epineurium (▶ Fig. 19.5). Fibrin glue can be used to augment the epineural repair and decrease the number of sutures needed to perform the nerve repair. However, the use of fibrin sealant for nerve repair is off-label.10 For median or ulnar nerve injuries in the hand, individual nerve branches can be identified proximally and distally and grouped fascicular repair performed. Larger

sutures such as 6-O or 8-O may be necessary for repairing larger peripheral nerves. Tension at the primary repair site can be judged initially by repairing the nerve with one stitch and with the digit and wrist in 0 degrees extension. After the first suture is tied, the finger is put through full passive range of motion. If the initial suture pulls out of the epineurium, with flexion and extension of the digit, then a reconstruction with nerve conduit or grafting may be required. Nerve connectors can be used to reduce tension at the repair site. These connectors are made of porcine submucosa extracellular matrix and are commercially available as AxoGen Nerve Connector (AxoGen, Inc, Alachua, FL). The nerve connector is slid over one of the nerve stumps prior to nerve repair with two sutures. The nerve connector is slid over the

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Nerve Repair in the Hand repair site and sutured to each side of the epineurium to ease tension off the coaptation site. The use of nerve connectors has been shown to improve sensory outcomes, reduce discomfort at the repair site, and decrease operating time.11

19.7.2 Nerve Reconstruction Nerve Conduits If a nerve conduit is used, the surgeon must have an array of sizes available. The conduit size reflects the diameter of the nerve to be repaired. Nerve conduits require an intraoperative saline soak hydration time and hemostasis is necessarily prior to suturing them in place. Once the size is determined and the conduit is soaked in saline, according to the manufacturer’s recommendations, the tourniquet is deflated and hemostasis is obtained. The nerve conduit is brought into the wound and sutured to one end of the injury with a horizontal mattress suture. The needle is passed from outside the conduit to the inside, at least 1 mm from the end of the conduit. The needle is then passed transversely through the epineurium approximately 1 to 2 mm from the edge of the lacerated nerve. The suture is then passed from deep to superficial through the lumen of the conduit and the knot is tied on the outside of the conduit. This technique draws the cut end of the nerve into the tube. The conduit is cut to fit the gap, with care taken to not cut it too short. The conduit tube is then filled with saline using an anterior chamber needle on a 1 ml syringe. A similar suture configuration is used on the other end of the cut nerve. The tube is refilled with saline after the second stitch is placed. Postoperatively, the rehabilitation involves splinting of the joint for up to 3 weeks. If the nerve conduit is performed with a concomitant tendon repair, a protected mobilization rehabilitation program can be initiated as per the tendon protocol.

Autograft For every nerve injury surgery, the possibility of reconstruction needs to be discussed with the patient preoperatively. Patients need to be aware of the potential donor site morbidity and the permanent site of numbness after surgery if an autograft sensory nerve is used. Other associated risks of nerve graft harvest include painful neuroma formation, scar tissue formation, and risks associated with increased operating time. In addition, the available nerve donor site needs to be prepped and draped for possible harvest. To minimize the possibility of the regenerating axons being lost in the graft at the autograft's branching points, the autograft nerve is typically sutured to the injured nerve in reversed orientation using 9-O or 10-O for digital nerves and larger caliber suture for median or ulnar nerves. The practice of reversing the autograft orientation has recently been called into question in a meta-analysis of animal model studies.12 Postoperative rehabilitation includes a short period of splint immobilization with protected range of motion starting at 1 to 2 weeks postoperatively.

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Fig. 19.6 A processed nerve allograft reconstruction with nerve connectors placed to reduce tension at the repair sites. (Photo courtesy of Jeffrey Rodgers, MD.)

cadaveric allografts had several drawbacks. These allograft nerves included all the nerve's cellular components and required an 18- to 24-month period of immunosuppression, while the graft became incorporated and nerve regeneration occurred. These nonprocessed allografts also carried the risk of disease transmission.13 Conversely, processed nerve allografts are treated with techniques to reduce the allograft's risk of disease transmission and immunogenicity. The process results in a nerve graft that provides a scaffold to guide nerve regrowth. The Food and Drug Administration (FDA)-approved processed nerve allograft available for off-the-shelf use is Avance (AxoGen, Inc, Alachua, FL). Avance is available in a variety of lengths (15–70 mm) and diameters (1–5 mm) that need to be ordered in advance of the surgery if they are not routinely kept at the facility where the procedure will be performed. In mixed nerves, cable grafts using processed allograft for separate reconstruction of motor and sensory components can be done to potentially improve the outcome of nerve recovery. The selected nerve allograft is thawed and rinsed in saline prior to suturing it in place. Nerve connectors can be placed at each end of the allograft to provide a tension-free repair site (▶ Fig. 19.6).

19.8 Difficulties Encountered For every repair or reconstruction, assure that it is free of tension. Trim the nerve back to healthy fascicles and perform conduit or grafting if any gap is present. The surgeon needs to have nerve conduits or processed allograft available. Size mismatch of conduits and allograft is difficult to remedy, so measure twice and open the correct size needed. If autograft is chosen, ensure that the harvest site has been prepped into the surgical field.

Processed Nerve Allograft

19.9 Key Procedural Steps

Prior to the introduction of processed nerve allografts for nerve reconstructions, the previously available nonprocessed

Under tourniquet control, extend the traumatic wounds proximally and distally. Any necessary wound debridement should

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References surgeries, it is ideal to start range of motion exercises early in order to prevent scar formation on or around the nerve graft.3 Scar formation can impair blood flow and subsequent nerve recovery. At 7 to 10 days, hand therapy is begun. Rehabilitation programs are typically dictated by the other injuries present, but in isolated nerve injury cases, the typical protected mobilization period with a dorsal block splint is 4 to 6 weeks.

19.10 Bailout, Rescue, and Salvage Procedures With every nerve repair surgery, ensure the patient’s consent is obtained for conduit, autograft, or allograft in addition to repair, and have potential donor sites surgically prepared. Discuss risks of infection and recovery time with clear expectations of outcome and prognosis prior to surgery.

References

Fig. 19.7 Primary nerve repair of the ulnar digital nerve to the thumb with microscope background in place. (Photo courtesy of Shane Cook, MD.)

be performed during this step and the wound thoroughly irrigated. If there are associated injuries, then these should be addressed including bone stabilization, tendon repair, and vascular repair. The nerve injury site is identified and the cut nerve ends are tagged with 10-O stitches under loupe magnification. The operating microscope is brought in and adjusted to the field. The scarred nerve ends are trimmed back to healthy fascicles with a scalpel blade and a saline-moistened tongue depressor. A microscope background is placed under the nerve ends (▶ Fig. 19.7). The nerve is repaired or reconstructed as indicated. The tourniquet is deflated and hemostasis is obtained prior to wound closure. A postoperative splint is placed, maintaining the joints in intrinsic plus position to protect the neurorrhaphy site from any tension. For nerve reconstruction

[1] Weinzweig N, Chin G, Mead M, et al. Recovery of sensibility after digital neurorrhaphy: a clinical investigation of prognostic factors. Ann Plast Surg. 2000; 44(6):610–617 [2] Chemnitz A, Björkman A, Dahlin LB, Rosén B. Functional outcome thirty years after median and ulnar nerve repair in childhood and adolescence. J Bone Joint Surg Am. 2013; 95(4):329–337 [3] Slutsky DJ. The management of digital nerve injuries. J Hand Surg Am. 2014; 39(6):1208–1215 [4] Clark WL, Trumble TE, Swiontkowski MF, Tencer AF. Nerve tension and blood flow in a rat model of immediate and delayed repairs. J Hand Surg Am. 1992; 17(4):677–687 [5] Taras JS, Jacoby SM, Lincoski CJ. Reconstruction of digital nerves with collagen conduits. J Hand Surg Am. 2011; 36(9):1441–1446 [6] Taras JS, Amin N, Patel N, McCabe LA. Allograft reconstruction for digital nerve loss. J Hand Surg Am. 2013; 38(10):1965–1971 [7] Cho MS, Rinker BD, Weber RV, et al. Functional outcome following nerve repair in the upper extremity using processed nerve allograft. J Hand Surg Am. 2012; 37(11):2340–2349 [8] Stancić MF, Mićović V, Potocnjak M, Draganić P, Sasso A, Mackinnon SE. The value of an operating microscope in peripheral nerve repair. An experimental study using a rat model of tibial nerve grafting. Int Orthop. 1998; 22(2): 107–110 [9] Thomas PR, Saunders RJ, Means KR. Comparison of digital nerve sensory recovery after repair using loupe or operating microscope magnification. J Hand Surg Eur Vol. 2015; 40(6):608–613 [10] Sameem M, Wood TJ, Bain JR. A systematic review on the use of fibrin glue for peripheral nerve repair. Plast Reconstr Surg. 2011; 127(6):2381–2390 [11] Ducic I, Safa B, DeVinney E. Refinements of nerve repair with connectorassisted coaptation. Microsurgery. 2017; 37(3):256–263 [12] Roberts SE, Thibaudeau S, Burrell JC, Zager EL, Cullen DK, Levin LS. To reverse or not to reverse? A systematic review of autograft polarity on functional outcomes following peripheral nerve repair surgery. Microsurgery. 2017; 37(2): 169–174 [13] Bassilios Habre S, Bond G, Jing XL, Kostopoulos E, Wallace RD, Konofaos P. The surgical management of nerve gaps: present and future. Ann Plast Surg. 2018; 80(3):252–261

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20 Peripheral Nerve Injury and Repair using Autograft or Allograft Santiago Rodriguez, Craig Rodner, and Anthony Parrino Abstract Peripheral nerve injuries can lead to significant motor and/or sensory disturbances in patients. These injuries can be difficult to treat and a thorough understanding of nerve anatomy, pathophysiology, and repair options are critical for optimizing patient outcomes. There are multiple options available for treatment including direct neurorrhaphy, as well as bridging a nerve defect with autograft, or allograft, and recent advances in the field of microsurgery have led to improvement in patient outcomes. Several key steps during nerve repair, no matter which method is used, are important to ensure that an optimal healing environment is created. Keywords: nerve, neurorrhaphy, autograft, allograft, epineurium, Wallerian degeneration, microsurgery

20.1 Background Nerve injuries can be a catastrophic event for patients and a major clinical challenge to treating surgeons. Although major advances have been made in the field of microsurgery leading to improvements in peripheral nerve repair results, the outcomes of such injuries continue to be unpredictable. With a thorough understanding of nerve anatomy and pathophysiology, attentive microsurgical technique, and adherence to important nerve repair principles, prognosis for satisfactory functional recovery is maximized.

20.2 Nerve Anatomy Peripheral nerves are organized into a network of nerve components and connective tissue. The endoneurium, perineurium, and epineurium comprise the framework of connective tissue that organize, nourish, and protect the nerve fibers and axons (▶ Fig. 20.1). The epineurium encircles the fascicles and acts as a cushion to protect the nerve, a consequence of its thick areolar tissue composition. In addition, the epineurium is highly vascularized, and feeder vessels from the epineurial blood vessels course throughout the inner aspects of the nerve, anastomosing with a vascular network within the perineurium and endoneurium.1 Within the epineurium lie the fascicles which are surrounded by a perineurium. This layer provides most of the nerve tensile strength. The innermost layer is the endoneurium, which runs within the fascicles, protecting and nourishing the individual axons.

20.3 Pathophysiology Trauma to a nerve results in a sequence of events affecting the proximal and distal ends of the transected or injured nerve. The proximal axonal segment undergoes degeneration extending to the nearest node of Ranvier, although depending on the type of injury and mechanism, the cell body may also die in the process. Distally, the axon undergoes Wallerian degeneration beginning 24 to 96 hours after injury, during which Schwann cells lose their myelin sheath, proliferate, and phagocytose myelin and axonal debris.1

Fig. 20.1 Cross-sectional anatomy of a nerve illustrating the epineurial, perineurial, and endoneurial layers. (Reproduced with permission from Baehr, Duus’ Topical Diagnosis in Neurology. Thieme; 2005.)

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Repair Methods Table 20.1 Sunderland nerve injury classification Seddon

Sunderland

Neurapraxia

Type 1

Conduction block; nerve in continuity

Axonotmesis

Type 2

Loss of axonal continuity; endoneurium, perineurium, epineurium intact

Type 3

Loss of axonal, endoneural continuity; perineurium and epineurium intact

Type 4

Loss of axonal, endoneural, perineural continuity; epineurium intact

Type 5

Physiologic disruption of entire nerve trunk

Neurotmesis

Description

20.4 Injury Classification Sir Herbert Seddon described and published the original widely used scheme for classifying nerve injuries, which was later expanded by Sunderland in order to account for the variability in prognosis encountered with axonotmetic injuries2 (▶ Table 20.1).

20.5 Repair Methods 20.5.1 Direct Repair Whenever possible, direct primary repair should be considered and is the preferred method of treatment when indications are met. Direct primary nerve repair is ideally performed as soon as possible.3 The wound should be clean and surrounding tissues well perfused to ensure healthy soft tissue coverage. Nerve repair should be achieved with no or minimal tension, minimizing postural positioning of the extremity to decrease tension. Tension across the repair site can cause a significant decrease in perfusion as well as an increase in scar formation and adhesions, compromising recovery.4

Fig. 20.2 (a) Harvesting the medial antebrachial cutaneous nerve (MABC). A key anatomical landmark for identifying this nerve is the basilica vein. The anterior branch is found anterior while the posterior branch is found posterior to the vein. (b) Adequate length of the MABC has been harvested with sharply transected ends.

20.5.2 Autograft

Key Procedural Steps

When the aforementioned indications or prerequisites for primary repair are absent, use of nerve grafting can provide a means to bridge a nerve gap that cannot be reconstructed by direct end-to-end suture. The gold standard for large nerve defects is the use of nerve autografts. This technique offers the ability to cover ample distance while providing neurotrophic factors to aid in recovery.5 The sural nerve, medial antebrachial cutaneous nerve, lateral femoral cutaneous nerve, and superficial radial sensory nerve are the most frequently harvested nerves used for autograft (▶ Fig. 20.2). The sural nerve graft has an appropriate diameter to fill in most defects, is easily obtainable, and is relatively expendable. For these reasons, the sural nerve is often referred to as the workhorse of nerve autografts.

When performing a nerve graft, the affected nerve should be sharply transected with microsurgical instruments in order to remove all necrotic tissues and obtain well-defined nerve ends with good exposure of fascicular architecture (▶ Fig. 20.3). The resulting defect is then measured and then the chosen graft is measured prior to making any cuts in order to ensure that a proper length is accessible, dissected, and adequately exposed. The length required should allow for the graft to be inserted without tension with the extremity in a neutral position. In addition, the graft should be harvested with extra length, in order to account for subsequent shortening secondary to connective tissue fibrosis. Donor nerve grafts are reversed in orientation in order to augment the density of axons distally, creating an environment that

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Peripheral Nerve Injury and Repair using Autograft or Allograft promotes distal regeneration by reducing the number of axons lost as side branches on the donor graft.1 The graft is then sutured in to fill the defect, using interrupted epineurial sutures of 8–0, 9–0, or 10–0 nylon depending upon the size of the nerve (▶ Fig. 20.3, ▶ Fig. 20.4, ▶ Fig. 20.5). If a diameter mismatch is present between the donor nerve and the injured nerve, multiple small caliber cable grafts can be used with attention to match corresponding fascicles to each other. The same epineurial suture technique should then be used to place these cable grafts in parallel fashion. Some surgeons prefer to use fibrin glue instead of sutures or use fibrin glue as an augment to the suture technique at the repair site. The glue can help to secure the nerve ends together as well as protect the repair site from the formation of scar tissue. 6

20.5.3 Allograft

Fig. 20.3 (a) Patient with a medial nerve defect after a laceration to volar forearm. The nerve and extent of injury have been identified and properly exposed. (b) The injured portion after adequate exposure. Note that necrotic and scar tissue have been removed and there is now good exposure of fascicular architecture.

Allografts can be used as a nonprocessed allograft with subsequent immunosuppression or decellular nerve allografts (DNAs). The potential advantages of using allografts include no donor site morbidity, readily available grafts, and shorter operative time. Historically, allografts have had worse outcomes than autografts mostly due to the host immunogenic response. DNAs may be useful as providing an optimal scaffold for nerve degeneration as they have already undergone Wallerian degeneration and the resulting architecture allows for migration of host Schwann cells. Thus, DNAs might theoretically be used in situations in which a bioabsorbable or vein conduit is indicated, such as in bridging defects under 3.0 cm.7 The surgical technique is similar to that described above for autografts, often using interrupted epineural nylon sutures. Bioabsorbable wraps and tubes are sometimes used to augment the repair, both in autografts and in allografts. Several studies exploring sensory nerve recovery after the use of allografts have shown favorable outcomes with bridging defects under 3.0 cm.7 Fig. 20.4 (a,b) Exposing the fascicle groups in a nerve defect larger than 4 cm. (1) Nerve graft. (c) A separate nerve graft is placed to reconstruct each fascicle group, which is then fixed with a tension-free suture. (1) Nerve graft. (d) The fascicle are reconstructed with nerve grafts placed in a well vascularized wound bed. (1) Nerve grafts. (e) Anatomic diagram of the course of sural nerve. (1) Lateral malleolus (2) Lateral dorsal cutaneous nerve (3) Point of exit of the sural nerve through the superficial layer of the fascia of the calf (4) Sural nerve (5) Small saphenous vein. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

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References [2] Sunderland S. Nerve Injuries and Their Repair: A Critical Appraisal. New York: Churchill Livingstone; 1991 [3] Dahlin LB. Techniques of peripheral nerve repair. Scand J Surg. 2008; 97(4): 310–316 [4] Mackinnon SE. New directions in peripheral nerve surgery. Ann Plast Surg. 1989; 22(3):257–273 [5] Houschyar KS, Momeni A, Pyles MN, et al. The role of current techniques and concepts in peripheral nerve repair. Plast Surg Int. 2016; 2016:4175293 [6] Sameen M, Wood TJ, Bain JR. A systematic review on the use of fibrin glue for peripheral nerve repair. Plastic and Reconstructive Surgery. 2011; 127(6): 2381–2390 [7] Tang P, Chauhan A. Decellular nerve allografts. J Am Acad Orthop Surg. 2015; 23(11):641–647

Suggested Readings Fig. 20.5 The autograft has been inserted using epineurial sutures and repair has been augmented with fibrin glue.

References [1] Lee SK, Wolfe SW. Peripheral nerve injury and repair. J Am Acad Orthop Surg. 2000; 8(4):243–252

Deal DN, Griffin JW, Hogan MV. Nerve conduits for nerve repair or reconstruction. J Am Acad Orthop Surg. 2012; 20(2):63–68 Isaacs J, McMurtry J. Different nerve grafting and wrapping options in upper extremity surgery. Curr Orthop Pract. 2014; 25(5):456–461 Pfister BJ, Gordon T, Loverde JR, Kochar AS, Mackinnon SE, Cullen DK. Biomedical engineering strategies for peripheral nerve repair: surgical applications, state of the art, and future challenges. Crit Rev Biomed Eng. 2011; 39(2): 81–124 Ray WZ, Mackinnon SE. Management of nerve gaps: autografts, allografts, nerve transfers, and end-to-side neurorrhaphy. Exp Neurol. 2010; 223(1):77–85 Siemionow M, Brzezicki G. Chapter 8: Current techniques and concepts in peripheral nerve repair. Int Rev Neurobiol. 2009; 87(C):141–172

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21 Nerve Conduits for Nerve Repair/Reconstruction Eon K. Shin Abstract A tension-free repair for sensory nerve injuries cannot always be achieved. Gaps in the neural tissue can often be bridged with a nerve conduit, usually made of polyglycolic acid or animalderived collagen. Results appear to be best for sensory nerve defects less than 20 mm in length, although studies have demonstrated limited success for mixed motor and sensory nerve injuries. Preparation of the nerve ends is an important first step in obtaining a successful outcome. The internal diameter of the nerve conduit should be slightly wider than the nerve being reconstructed to simplify its insertion and accommodate postoperative swelling. During suture fixation of the conduit, the lumen must be carefully filled with sterile saline or heparinized saline to discourage clot formation, which could compromise axonal ingrowth. Temporary splint immobilization and a therapy program must then be followed to optimize outcomes. Keywords: conduit, nerve repair, nerve injury, nerve gap, polyglycolic acid conduit, collagen conduit

21.1 Description The primary goal of nerve repair is to provide a framework to maximize the number and concentration of axonal fibers that regenerate across a nerve repair site. This requires precise apposition of two sides of a transected nerve using a minimum number of sutures. If a tension-free repair cannot be completed

primarily, then the use of a nerve conduit may be beneficial to span defects up to 30 mm in length.

21.2 Key Principles The assessment of nerve function requires a thorough preoperative motor and sensory physical examination. The surgical approach is facilitated by using loupes or a microscope for appropriate magnification of the operative field. The microsurgical technique typically utilizes 8–0 or 9–0 synthetic suture with suitable instruments. When repairing digital nerves, it is best to avoid positioning the adjacent joint into an extreme position simply to relieve tension at the nerve repair site. If necessary, excessive tension can be avoided by using a synthetic absorbable nerve conduit (▶ Fig. 21.1). Traditionally, nerve conduits are used for defects less than 30 mm in length, but results appear to be best for defects less than 20 mm.1

21.3 Nerve Conduit Characteristics 21.3.1 Advantages of Nerve Conduits Commercially available, absorbable nerve conduits provide a noncollapsible scaffold for nerve reconstruction that features excellent availability without the disadvantages of donor site morbidity. The use of nerve conduits also provides a simplified means of reconstruction which is arguably superior to autogenous nerve grafting. Multiple size options are available, and nerve conduit walls are semipermeable, which helps in maintaining the influx of nutrients and other factors required for optimal nerve regeneration (▶ Fig. 21.2).

21.3.2 Materials for Nerve Conduits

Fig. 21.1 Schematic of nerve conduit spanning a defect. (Permission granted by AxoGen, Inc, Alachua, FL, USA.)

Numerous materials for nerve conduits have been investigated. However, the optimal conduit material remains undetermined. In 1982, Lundborg et al published their results on bridging rat sciatic nerves using silicone tubes.2 Unfortunately, silicone conduits are nondegradable, causing inflammation of the

Fig. 21.2 (a,b) Electron microscopy of NeuraGen nerve guide, demonstrating the semipermeable inner membrane and the porous outer layer. The conduit walls allow nutrients into the lumen while keeping nerve growth factors inside. (Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ, USA.)

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Contraindications

Fig. 21.3 (a) Radial sensory nerve injury in the dorsal aspect of the first webspace. The resultant defect measured approximately 20 mm. (b) Radial sensory nerve reconstruction using the Nerbridge polyglycolic acid conduit filled with medical-grade collagen, which may improve nerve regeneration and vascularity. (Permission granted by Toyobo Corporation, Ltd, Osaka, Japan.)

surrounding tissues, secondary nerve constriction, and local discomfort. A secondary surgery is required for the removal of silicone conduits, which makes them less ideal for nerve reconstructions. Polyglycolic acid conduits are composed of a biodegradable thermos-polymer and absorb reliably in vitro via simple hydrolytic reactions. A randomized prospective study of digital nerve reconstructions using polyglycolic acid conduits demonstrated superior return of sensation when performed for nerve gaps of 4 mm or less.3 For nerve gaps up to 30 mm, Mackinnon and Dellon4 reported on 15 patients who underwent polyglycolic acid nerve conduit reconstructions. Clinical recovery was comparable to that of nerve autograft and end-to-end repair: Five patients (33%) demonstrated S4 sensory function, eight (53%) had S3 sensation, and two (14%) had S2 sensation or less. After implantation, polyglycolic acid conduits break down over a period of 90 days. Conduits made of caprolactone polyester have been shown to be a viable option for nerve reconstruction. This substance is degraded in vivo over the course of 2 years. Unfortunately, the prolonged degradation time may lead to problems with foreign body reaction, graft extrusion, and even fistulization.5 Bovine and porcine collagen conduits have become increasingly popular. Like other conduit materials, collagen is an attractive material as it is porous, biocompatible, and absorbable. In a retrospective review of collagen conduit reconstruction for average defects measuring 12.8 mm, 35% of patients demonstrated objective sensory improvement.6 A prospective study by Taras et al7 found that mean moving two-point discrimination and static two-point discrimination measured 5.0 and 5.2 mm, respectively, for those patients with measurable recovery following collagen conduit reconstruction for digital nerve injuries. Excellent results were achieved in 13 of 22 digits, good results in 3 of 22 digits, and fair results in 6 of 22 digits. There were no poor results.

21.4 Indications When tension-free, end-to-end repair of a sensory nerve is unachievable, reconstructive options include the use of nerve autograft, nerve allograft, and synthetic nerve conduits (▶ Fig. 21.3). Moderate to good recovery of two-point discrimination has been achieved with each of these approaches. Nerve conduits have become increasingly popular as they avoid potential donor site morbidity and result in shorter operative times. While some reports have recommended against the use of nerve conduits for mixed and motor nerve gap repair, Boeckstyns et al8 conducted a prospective randomized trial to compare the repair of acute lacerations of mixed sensory–motor nerves using collagen conduits versus conventional repair. The authors found that conduits produced recovery of sensory and motor functions that were equivalent to direct suture 24 months following repair when the nerve gap inside the tube was 6 mm or less. Thus, there may be a role for the use of nerve conduits for more complex mixed motor and sensory nerve injuries. Relative indications include nerve reconstruction after resection of a traumatic neuroma or a neoplasm. Nerve conduits are also occasionally used as a wraparound for a partially injured nerve or following neurolysis of a scarred nerve.

21.5 Contraindications Contraindications include uncertainty about the viability of the nerve ends, especially with avulsion injuries, gunshot wounds, or local infection. Inadequate soft tissue coverage may also preclude the use of nerve conduits. Finally, synthetic conduits are contraindicated in patients with known allergies to porcine- or bovine-derived materials or polyglycolic acid.

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Nerve Conduits for Nerve Repair/Reconstruction

21.6 Surgical Technique 21.6.1 Preparation of Nerve Ends The patient is positioned in the supine position, and the extremity is placed on an arm board under tourniquet control. Due to the duration of most nerve procedures, general anesthesia is usually employed. The proximal and distal nerve ends are identified, and meticulous hemostasis is obtained. Following mobilization and preparation of the severed nerve, the nerve gap is measured with the adjacent joints in full extension. The nerve stumps should be trimmed under magnification until healthy fascicles are identified. The maximum distance recommended for nerve conduit use is 30 mm. The diameter of the nerve is measured to determine appropriate sizing for the conduit. The nerve tube should have an internal diameter about 10 to 15% larger than the nerve itself to allow the ends to be easily inserted and to accommodate for postoperative swelling. Most conduits require saline immersion before implantation.

21.6.2 Suturing of Nerve Ends Following selection of a nerve conduit, one nerve end is pulled into the conduit, so that the nerve lies partially within the conduit by a distance equal to or greater than the nerve diameter. An 8–0 or 9–0 nylon suture is used to secure the nerve end to the conduit using a horizontal mattress stitch. This is performed by passing the stitch from outside to inside the conduit wall at least 1 mm from its edge. The suture is then passed transversely through the epineurium a distance of 2–3 mm from the stump and then passed back through the conduit from inside to out. The suture is then tied, pulling the nerve end into the conduit (▶ Fig. 21.4). The lumen of collagen conduits is then filled with sterile saline to prevent air bubbles or blood clot formation, which may impede axonal ingrowth. Heparinized saline is used to fill the intraluminal space of polyglycolic acid conduits. The opposite end of the conduit is then secured to the other nerve stump in similar fashion. Prior to suture fixation, the nerve conduit may be cut to an appropriate length as indicated. When a tourniquet is used, the tourniquet should be released and hemostasis achieved before the entubulation procedure commences.

21.6.3 Final Surgical Considerations Fibrin glue may be used as an additional sealant to separate the internal environment of the nerve conduit from the external milieu. However, a prospective study examining the effects of adjuvant fibrin sealant in conduit repairs did not find any meaningful differences in recovery.9 Loose soft tissue coverage is recommended to avoid placement of the repaired nerve within superficial layers of the subcutaneous tissues. Ideally, the nerve conduit is placed away

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Fig. 21.4 Major steps of conduit implantation: Step 1: Injured nerve ends are isolated and trimmed. Step 2: Nerve epineurium is sutured to the conduit using a nonabsorbable suture. Step 3: The lumen of the conduit is filled with saline to prevent clot formation. Step 4: The other end of the injured nerve is sutured in the same fashion as the first end. Step 5: Final filling of the conduit lumen with saline. Step 6: Final appearance after repair with a conduit. (Permission granted by Integra LifeSciences Corporation, Plainsboro, NJ, USA.)

from joints, tendons, and ligaments to avoid significant tension at the repair sites.

21.7 Postoperative Rehabilitation Postoperatively, a splint is used to protect the repair site for a period of 4 weeks. Physical therapy is initiated shortly thereafter to regain range of motion and strength of the affected area. The timing for therapy is often dependent on other associated injuries such as flexor tendon lacerations or open phalangeal fractures. Resisted motion is gradually applied at approximately 6 weeks, and full loading is permitted after 10 to 12 weeks. Clinically observable sensory recovery is dependent on the distance of the nerve injury from the target organ. Other factors that affect outcomes include patient age, mechanism of injury, and medical comorbidities that can affect nerve regeneration such as diabetes mellitus and renal disease.

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References

21.8 Special Considerations 21.8.1 Precautions ●

●

●

●

Surgical gloves should be rinsed prior to handling nerve conduits to remove glove powder. Hemostasis within the operative field should be achieved prior to final fixation of the conduit. A blood clot in the lumen of the conduit may impede axon growth. A tensionless repair technique should be used to prevent excessive strain along the length of the nerve. Nerve conduits should be used with caution for mixed nerves, motor nerves, or gaps longer than 30 mm.

21.8.2 Complications Possible device-related complications can occur with any surgical nerve repair procedure including pain, infection, wound dehiscence, decreased or increased nerve sensitivity, hypersensitivity that may be caused by polyglycolic acid and collagen, and complications associated with use of anesthesia. Possible device defects may include extrusion, rearrangement, kinking, or breakage of nerve conduits.

References [1] Bushnell BD, McWilliams AD, Whitener GB, Messer TM. Early clinical experience with collagen nerve tubes in digital nerve repair. J Hand Surg Am. 2008; 33(7):1081–1087 [2] Lundborg G, Rosén B, Dahlin L, Holmberg J, Rosén I. Tubular repair of the median or ulnar nerve in the human forearm: a 5-year follow-up. J Hand Surg [Br]. 2004; 29(2):100–107 [3] Weber RA, Breidenbach WC, Brown RE, Jabaley ME, Mass DP. A randomized prospective study of polyglycolic acid conduits for digital nerve reconstruction in humans. Plast Reconstr Surg. 2000; 106(5):1036–1045, discussion 1046–1048 [4] Mackinnon SE, Dellon AL. Clinical nerve reconstruction with a bioabsorbable polyglycolic acid tube. Plast Reconstr Surg. 1990; 85(3):419–424 [5] Griffin JW, Hogan MV, Chhabra AB, Deal DN. Peripheral nerve repair and reconstruction. J Bone Joint Surg Am. 2013; 95(23):2144–2151 [6] Wangensteen KJ, Kalliainen LK. Collagen tube conduits in peripheral nerve repair: a retrospective analysis. Hand (N Y). 2010; 5(3):273–277 [7] Taras JS, Jacoby SM, Lincoski CJ. Reconstruction of digital nerves with collagen conduits. J Hand Surg Am. 2011; 36(9):1441–1446 [8] Boeckstyns MEH, Sørensen AI, Viñeta JF, et al. Collagen conduit versus microsurgical neurorrhaphy: 2-year follow-up of a prospective, blinded clinical and electrophysiological multicenter randomized, controlled trial. J Hand Surg Am. 2013; 38(12):2405–2411 [9] Rafijah G, Bowen AJ, Dolores C, Vitali R, Mozaffar T, Gupta R. The effects of adjuvant fibrin sealant on the surgical repair of segmental nerve defects in an animal model. J Hand Surg Am. 2013; 38(5):847–855

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22 Oberlin Transfer Juan M. Giugale and John R. Fowler Abstract Restoration of elbow flexion is pivotal to improve function in patients with brachial plexus injuries. The Oberlin transfer was described in 1994 and involves transferring one or more motor fascicles of the ulnar nerve to the biceps branch of the musculocutaneous nerve. It has gained popularity as a more simple and reliable transfer than previously described procedures. Modifications to the Oberlin transfer has been proposed, such as the double fascicular transfer, but no procedure has proven to give better results than the Oberlin transfer. Keywords: brachial plexus injury, elbow flexion restoration, nerve transfer, Oberlin, double fascicular transfer

22.1 Description In 1994, Cristophe Oberlin et al described a nerve transfer using part of the ulnar nerve to the musculocutaneous branch of the biceps muscle in order to restore elbow flexion in C5–C6 nerve root avulsions.1

22.2 Key Principles Restoration of elbow flexion is the primary goal in the treatment of upper brachial plexus injuries (▶ Fig. 22.1). The Oberlin transfer is particularly successful because the ulnar nerve is usually not affected by upper brachial plexus injuries, and the ulnar nerve is in close proximity to the target musculocutaneous nerve branch of the biceps, allowing for direct repair and relatively quick reinnervation of the biceps muscle (▶ Fig. 22.2 and ▶ Fig. 22.3).

22.3 Expectations After this procedure, nearly all patients with C5–C6 plexus injuries are expected to regain elbow flexion with a motor grade level of greater than 3 (the ability to against gravity). Patients with involvement of C5–C6–C7 demonstrate less predictable results.2,3,4 Most patients will experience transient postoperative ulnar nerve paresthesias that resolve spontaneously. Grip

Fig. 22.1 Anatomy of the MCN in the medial arm. The relationships to the biceps and the brachialis muscles as well as the median and ulnar nerves are shown. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.) MCN, musculocutaneous nerve.

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Fig. 22.2 The branching patterns of the MCN and the percentage of various branching patterns to the biceps and brachialis muscles. Most common is the Type 1 pattern, with a single branch from the MCN that then ramifies. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.) MCN, musculocutaneous nerve.

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Key Procedural Steps

22.8 Tips, Pearls, and Lessons Learned

Fig. 22.3 One of the anatomic variations seen in the MCN, with the median nerve connecting to the MCN. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.) MCN, musculocutaneous nerve.

strength is expected to be equal to the contralateral unaffected extremity. Younger patients are expected to have more reliable results than older patients. The procedure has less successful outcomes if performed > 9 months after date of injury.

22.4 Indications ● ●

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Upper brachial plexus injuries. Pediatric peripartum Erb–Duchenne palsy without spontaneous resolution. Musculocutaneous nerve injury proximal to the biceps muscle branch.

22.5 Contraindications ● ● ●

Lower brachial plexus injuries (involvement of C8–T1). Ulnar nerve dysfunction. > 18 months from initial injury.

22.6 Special Considerations ● ●

●

●

A detail-oriented examination is imperative preoperatively. Ulnar nerve sensory and motor function should be carefully examined. Preoperative electromyography (EMG) is recommended to confirm examination findings and demonstrate a lack of spontaneous reinnervation of the biceps. Other deficits, which can be surgically addressed simultaneously, should be evaluated

22.7 Special Instructions, Positioning, and Anesthesia ● ●

●

General anesthesia is recommended. Patient is positioned supine with the arm abducted and externally rotated on a hand table. No tourniquet is used.

The nerve coaptation should have no tension. Repair should be with approximately three 10–0 nylon sutures, supplemented with fibrin glue. Nerve protector products can be considered to envelope around the repair. If several motor fascicles to flexor carpi ulnaris (FCU) are identified, two or three motor fascicles are coapted with the biceps brachii nerve. Mackinnon et al described a double fascicular transfer in which a redundant FCU motor fascicle is transferred to the musculocutaneous branch of the biceps, and a median nerve motor fascicle to flexor carpi radialis (FCR) is transferred to the musculocutaneous branch of the brachialis.5,6 This additional transfer can be considered; although, controversy persists as to whether there is clinically significant benefit when compared to a traditional Oberlin transfer. Postoperative care and rehabilitation consists of a 2-week immobilization in a sling (allowing for sling removal and passive range of motion exercises of elbow and shoulder twice a day to prevent stiffness) until the incision is healed. Therapy consists of range of motion exercises until the biceps show signs of reinnervation, followed by motor reeducation and strengthening.

22.9 Difficulties Encountered Anatomical variations can be encountered. Approximately 50% of patients may have two motor branches arising from the musculocutaneous nerve (one branch to the short head of the biceps and one branch to the long head of the biceps). In these cases, if more than one ulnar nerve fascicle can be harvested, each biceps motor branch should be repaired with an individual fascicle. If there are two branches to the biceps and only one motor ulnar nerve fascicle, the biceps branch that has the most similar cross-sectional area to the ulnar nerve fascicle should be selected for coaptation. One could consider transferring the median nerve motor branches of FCR to the additional biceps nerve branches. In a small percentage of people, the motor branch to the biceps can arise directly from the median nerve. Once this variation is identified and the branch to the biceps is delineated, it can be transected just distal to the branching point off the median nerve and coapted with the FCU motor branch of the ulnar nerve.

22.10 Key Procedural Steps A longitudinal 10 cm incision is made on the medial, proximal aspect of the arm anterior to the intermuscular septum (▶ Fig. 22.4). The biceps motor branch is located 10 to 15 cm distal to the acromion. The biceps fascia is incised and the muscle is retracted laterally. The musculocutaneous nerve is found between the biceps and coracobrachialis (▶ Fig. 22.5). The musculocutaneous nerve will trifurcate, giving a branch to the biceps muscle, a branch to the brachialis, and the continuation of the lateral antebrachial cutaneous nerve.

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Oberlin Transfer

Fig. 22.4 Surgical incision in bold solid line. Dotted line represents the anatomical location of the ulnar nerve.

Fig. 22.5 (a, b) Identification and dissection of the median and ulnar nerves in the medial arm. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstructio. 1st ed. © 2013 Thieme.)

Fig. 22.6 (a) Elevation of the medial biceps muscle fascia exposing the neurovascular structures. (b) Location and identification of the MCN on the deep surface of the medial edge of the biceps. The nerve is covered by the biceps fascia, which must be opened to identify and expose the nerve. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.) MCN, musculocutaneous nerve.

The musculocutaneous branch to the biceps is isolated and transected as close as possible to branch point from the musculocutaneous nerve (▶ Fig. 22.6 and ▶ Fig. 22.7).

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The ulnar nerve is identified posterior to the intermuscular septum. Under microscopic magnification, the epineurium is incised and the fascicles are meticulously and carefully separated (▶ Fig. 22.8). A microelectrical nerve stimulator is used to identify the motor fascicles to the flexor carpi ulnaris. The motor fascicles to the intrinsic musculature are preserved. Once the motor fascicles to the FCU are identified, one or two fascicles are selected and transected just proximal to distal interfasicular connections (▶ Fig. 22.9). The transected biceps branch of the musculocutaneous nerve is approximated to the selected ulnar nerve fascicles and coapted using 10–0 nylon suture and supplemented with fibrin glue (▶ Fig. 22.10).

22.11 Bailout, Rescue, and Salvage Procedures If incidental damage is done to the FCU motor branches of ulnar nerve, rendering them unfit for nerve transfer, the median nerve motor branches to FCR can be utilized and transferred to the biceps branch of the musculocutaneous nerve.

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Bailout, Rescue, and Salvage Procedures

Fig. 22.7 (a) The biceps branch of the musculocutaneous nerve is identified. (b) The musculocuntaneous nerve and its biceps branch are isolated. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.).

Fig. 22.9 The branch of the brachialis lies 4 to 5 cm distal to the branch to the biceps. The branch is slightly thinner than the LABCN and has a posteromedial take-off from the main trunk of the MCN. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.) LABCN, lateral antebrachial cutaneous nerve; MCN, musculocutaneous nerve.

Fig. 22.8 Diagram of the Berlin transfer and Donor fascicle of the ulnar nerve transferred to the biceps branch of the MCN. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.) MCN, musculocutaneous nerve.

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Oberlin Transfer Prior to the description of Oberlin’s transfer, other nerve transfers were employed to restore elbow flexion. The medial pectoral nerve, intercostal nerve, thoracodorsal nerve, and spinal accessory nerve have been described as nerve donors to the motor branch of the biceps brachii. The success of these transfers has not been as predictable or reliable as the Oberlin transfer, likely due to axonal mismatch between donor and recipient nerve and segmental gaps requiring interpositional nerve autografts (usually lateral antebrachial cutaneous nerve or medial antebrachial cutaneous nerve). However, in the event that an Oberlin transfer is contraindicated, other donor nerves can be considered.7,8,9,10 Steinder Flexorplasty is a tendon transfer that can be utilized in the event of unsuccessful nerve transfer. This procedure entails a proximal tenodesis of the flexor prontator mass from the medial epicondyle to a more proximal location on the humeral shaft. This allows for a better mechanical lever arm for these muscle contractions to produce elbow flexion.

References [1] Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am. 1994; 19(2):232–237 [2] Oberlin C, Ameur NE, Teboul F, Beaulieu JY, Vacher C. Restoration of elbow flexion in brachial plexus injury by transfer of ulnar nerve fascicles to the nerve to the biceps muscle. Tech Hand Up Extrem Surg. 2002; 6(2):86–90 [3] Leechavengvongs S, Witoonchart K, Uerpairojkit C, Thuvasethakul P, Ketmalasiri W. Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases. J Hand Surg Am. 1998; 23(4):711–716 [4] Teboul F, Kakkar R, Ameur N, Beaulieu JY, Oberlin C. Transfer of fascicles from the ulnar nerve to the nerve to the biceps in the treatment of upper brachial plexus palsy. J Bone Joint Surg Am. 2004; 86(7):1485–1490 [5] Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg. 2003; 98(2):313–318 [6] Mackinnon SE, Novak CB, Myckatyn TM, Tung TH. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am. 2005; 30(5):978–985 [7] Giuffre JL, Kakar S, Bishop AT, Spinner RJ, Shin AY. Current concepts of the treatment of adult brachial plexus injuries. J Hand Surg Am. 2010; 35(4): 678–688, quiz 688 [8] Tung TH, Mackinnon SE. Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am. 2010; 35(2):332–341 [9] Merrell GA, Barrie KA, Katz DL, Wolfe SW. Results of nerve transfer techniques for restoration of shoulder and elbow function in the context of a metaanalysis of the English literature. J Hand Surg Am. 2001; 26(2):303–314 [10] Bulstra LF, Shin AY. Nerve transfers to restore elbow flexion. Hand Clin. 2016; 32(2):165–174

Fig. 22.10 (a, b) Diagram of the double fascicular transfer and final transfer of FCU fascicle of the ulnar nerve to the biceps branch of the MCN and FCR fascicle of the median nerve to the brachialis branch of the MCN. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. © 2013 Thieme.) FCR, flexor carpi radialis; FCU, flexorcarpi ulnaris; MCN, musculocutaneous nerve.

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Part V Nerve Compression

V

23 Open Carpal Tunnel Release

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24 Endoscopic Carpal Tunnel Release

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25 Proximal Median Nerve Compression

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26 Open Ulnar Nerve Decompression at the Wrist

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27 Endoscopic Ulnar Nerve Decompression

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28 Open Ulnar Nerve Decompression/ Subcutaneous Transposition at the Elbow

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29 Submuscular Ulnar Nerve Transposition

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30 Partial Wrist Denervation for Chronic Wrist Pain

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23 Open Carpal Tunnel Release Violeta Gutierrez Sherman and Jennifer Moriatis Wolf Abstract Carpal tunnel syndrome (CTS) is a compressive neuropathy of the median nerve that can cause pain, numbness, and tingling in the hand. Carpal tunnel release is recommended after conservative treatment has failed to treat symptoms. Open carpal tunnel release has proven to be effective and safe, although knowledge of the anatomy of the median nerve and its branches is critical to success. Keywords: carpal tunnel syndrome, open carpal tunnel release, median nerve compression

23.1 Description

23.4 Indications Carpal tunnel release is recommended for patients who have failed conservative management including splints, analgesics, or corticosteroid injections. Surgery is also recommended in patients who present with evidence of thenar atrophy. In a patient with recurrent CTS, open revision release is recommended to ensure direct visualization and complete release of the transverse carpal ligament. If acute CTS develops in association with other pathologies (e.g., distal radius fracture, perilunate dislocation, or compartment syndrome), open carpal tunnel release is recommended for visualization of hematoma and other nerve compressive pathology.

23.5 Contraindications

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy affecting the general population, which is characterized by numbness, paresthesias, and pain in the distribution of the median nerve. A thorough history and complete physical examination are necessary to rule out other pathologies such as cervical spine issues, motor neuron problems, or polyneuropathy. Evidence has shown that while nonoperative modalities of splinting and corticosteroid injection are effective, surgical release has a superior outcome at 3 and 18 months compared to conservative modalities.1 Carpal tunnel release is performed over 400,000 times a year in the United States.2

CTS is primarily a clinical diagnosis, although electromyography and nerve conduction can provide adjunctive support. In a patient with equivocal symptoms or a confusing clinical picture, diagnostic steroid injection is recommended. If steroid injection does not temporarily resolve symptoms, carpal tunnel release is unlikely to address the problem3 and is relatively contraindicated. In addition, surgical intervention is generally not required in women who develop CTS during pregnancy. The majority of pregnant patients with CTS experience symptom resolution after parturition.

23.2 Key Principles

23.6 Instructions, Positioning, and Anesthesia

CTS is primarily a clinical diagnosis, based on symptom characteristics and physical findings. The degree of compression of the median nerve should be discussed with the patient preoperatively, as chronic compression can damage the nerve permanently, limiting the clinical impact of surgery. When carpal tunnel release is undertaken, complete release of the transverse carpal ligament is the most critical step of the procedure.

23.3 Expectations The outcomes of carpal tunnel surgery vary depending on the severity of nerve compression. It is important to explain to patients that the most reliable outcome from release of the transverse carpal ligament is prevention of disease progression. Patients generally experience resolution of their nocturnal neuropathic pain almost immediately, followed by improvement in paresthesias over the course of months. Patients afflicted with severe compression of the median nerve, resulting in weakness and thenar atrophy, should be warned that they may have minimal relief of numbness after carpal tunnel release, although neuropathic pain is predictably resolved after surgery.

●

●

●

Patient should be positioned supine on the operating table with the operative arm on a hand table. The procedure is performed under tourniquet control with choice of regional anesthesia, Bier block, or local anesthesia. Another option is the recently described technique of wideawake local anesthesia with no tourniquet (WALANT).4 – Lidocaine with epinephrine is used to decrease local site bleeding and obviates need for a tourniquet. – Use of WALANT is particularly beneficial to patients with medical comorbidities who have risks associated with sedation or regional anesthetics.

23.7 Tips, Pearls, and Pitfalls 23.7.1 Incision Marking To mark the incision for an open carpal tunnel release, use the ulnar border of the palmaris longus tendon as a guide, as well as the interthenar crease. The incision is placed in the palm, 1 cm distal to the wrist crease in order to avoid damage to the palmar cutaneous nerve. Kaplan’s cardinal line, extending from the ulnar side of the thumb across the palm, should mark the distal extent of the open release incision.

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23.7.2 Tissue Handling Sharp release of the transverse carpal ligament is both safe and tissue-friendly. The distal extent of the transverse carpal ligament should be visualized and divided, the fat surrounding the superficial palmar arch should be identified, and the vascular structures protected. The most common reason for revision carpal tunnel surgery is an incomplete release of the transverse carpal ligament.

23.7.3 Surgeon Positioning It is helpful to position the surgeon at the end of the hand table to obtain better visualization for the proximal release of the transverse carpal ligament.

23.8 Difficulties Encountered Although open carpal tunnel release is the most common procedure performed in hand surgery, a knowledge of nerve anatomy, including the described anatomic variations of the motor branch of the median nerve, is critical to avoid complications. In the majority of the population, the motor branch divides from the median nerve distal to the transverse carpal ligament in an extraligamentous and recurrent pattern to enter the thenar musculature. However, the nerve may also branch in a

Fig. 23.1 The incision is marked in line with the ulnar border of the palmaris longus tendon (if present) and within the interthenar crease.

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subligamentous pattern or emerge through the transverse carpal ligament (transligamentous branch), and is vulnerable to injury in persons with these anatomic variations. Knowledge of the variation is especially important during surgical decompression.5

23.9 Key Procedural Steps A 1.5 to 2 cm longitudinal incision is marked 1 cm distal to the distal wrist crease, in line with the ulnar border of the palmaris longus and, if possible, within the interthenar crease (▶ Fig. 23.1). If performing a revision carpal tunnel release, the incision may need to be extended proximally, crossing the wrist crease in a zigzag fashion to avoid scar contracture. After injection of 8 to 10 ml of local anesthetic in the subcutaneous plane at the base of the palm (▶ Fig. 23.2), exsanguination of the extremity is performed with elevation of forearm or upper extremity tourniquet. The subcutaneous fat is retracted, using dull Senn retractors, to expose the longitudinal fibers of the palmar fascia. This is incised sharply to expose the transverse fibers of the transverse carpal ligament (▶ Fig. 23.3). Under direct visualization, the ligament is incised sharply, entering the carpal tunnel at the proximal extent of the incision (▶ Fig. 23.4). The incision should be made on the ulnar border of the carpal canal to prevent injury to the motor branch. The transverse carpal ligament is released

Fig. 23.2 Site of injection of local anesthetic for carpal tunnel release.

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Key Procedural Steps

Fig. 23.3 The transverse carpal ligament is exposed after sharp release of the antebrachial fascia.

Fig. 23.4 The transverse carpal ligament is opened sharply with scalpel dissection.

Fig. 23.5 The fat surrounding the superficial palmar arch is visualized and marks the end of the transverse carpal ligament.

Fig. 23.6 The incision is closed using absorbable suture and 2-octylcyanoacrylate.

as far distally as the fat surrounding the superficial arch (▶ Fig. 23.5). Proximally, the ligament is visualized and divided sharply. Some surgeons prefer passage of tenotomy scissors proximally to facilitate release. The use of a Ragnell retractor at the proximal and distal ends of the incision will aid in visualization to ensure complete release.

After complete release and direct visualization of the median nerve, the wound is irrigated with normal saline. Skin closure is achieved either with buried, fast-absorbing subcuticular sutures and 2-octyl cyanoacrylate or interrupted nylon sutures placed with horizontal mattress pattern (▶ Fig. 23.6).

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23.10 Postoperative Management The wound is covered with a small gauze dressing and overwrapped with either soft cotton or cylindrical gauze and an elastic bandage. This allows range of motion while providing some soft tissue rest and support. Depending on the skin closure, the dressing can be removed in 2 to 3 days6 or should be kept dry and intact, as per surgeon preference. Evidence-based studies have shown no difference in outcomes based on duration of postoperative dressing. Patients are encouraged to move the fingers and are permitted to type, drive, write, and use the hand with limited lifting for 2 to 4 weeks.

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References [1] Gerritsen AA, de Vet HC, Scholten RJ, Bertelsmann FW, de Krom MC, Bouter LM. Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial. JAMA. 2002; 288(10):1245–1251 [2] Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory surgery data from hospitals and ambulatory surgery centers: United States, 2010. Natl Health Stat Rep. 2017(102):1–15 [3] Edgell SE, McCabe SJ, Breidenbach WC, LaJoie AS, Abell TD. Predicting the outcome of carpal tunnel release. J Hand Surg Am. 2003; 28(2):255–261 [4] Lalonde DH. Conceptual origins, current practice, and views of wide awake hand surgery. J Hand Surg Eur Vol. 2017; 42(9):886–895 [5] Seiler JG, III, Daruwalla JH, Payne SH, Faucher GK. Normal palmar anatomy and variations that impact median nerve decompression. J Am Acad Orthop Surg. 2017; 25(9):e194–e203 [6] Ritting AW, Leger R, O’Malley MP, Mogielnicki H, Tucker R, Rodner CM. Duration of postoperative dressing after mini-open carpal tunnel release: a prospective, randomized trial. J Hand Surg Am. 2012; 37(1):3–8

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24 Endoscopic Carpal Tunnel Release Jonas L. Matzon Abstract Endoscopic carpal tunnel release is a minimally invasive surgical technique developed as an alternative to open carpal tunnel release. Keywords: endoscopic carpal tunnel release, eCTR, carpal tunnel release, minimally invasive

24.1 Description Endoscopic carpal tunnel release (eCTR) is a minimally invasive surgical technique developed as an alternative to open carpal tunnel release (CTR).

24.2 Key Principles As with most procedures, excellent visualization is critical. The blade should only be elevated if and when there is acceptable visualization of the undersurface of the transverse carpal ligament (TCL) with no nerve interposition. Moreover, complete release must be achieved in order to ensure optimal outcomes.

24.3 Expectations Similar to open CTR, the benefit of eCTR lies in its ability to stop the progression of symptoms, with the hope that the symptoms will fully resolve. Night-time symptoms tend to resolve immediately. Patients with mild to moderate CTS, who experience intermittent symptoms, often have early resolution. In contrast, patient with severe CTS, who experience constant numbness and/or thenar weakness, have a more guarded prognosis with a more prolonged recovery. In comparison to open CTR, eCTR has the additional potential benefit of decreasing the severity of early palmar pain and shortening the time until return to work by 1 to 2 weeks.1,2 However, eCTR has an increased incidence of transient neuropraxia (1–2%).3,4 Overall, the long-term results seem to be equivalent between the two techniques.

24.4 Indications ●

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Symptomatic CTS that has failed nonoperative treatment with splinting and/or corticosteroid injections. Symptomatic CTS that has evidence of thenar denervation.

24.5 Contraindications There are no absolute contraindications for eCTR. Due to the concern over visualization secondary to scarring, some surgeons consider revision surgery a relative contraindication. Other surgeons have had good results with revision endoscopic CTR.5

24.6 Special Considerations Historically, eCTR was believed to result in an increased risk of neurovascular injury. However, more recent studies have refuted this belief.3,4 Overall, both open and endoscopic CTR have a similar, extremely low-rate of irreversible nerve injuries (< 0.5%).

24.7 Special Instructions, Positioning, and Anesthesia The patient is placed on a well-padded operating room table with the affected upper extremity on the hand table. While the procedure can be done with any method of anesthesia, it is typically performed under local anesthesia with or without sedation. Following induction of anesthesia, a pneumatic tourniquet is placed on the proximal arm and set at 250 mmHg. The procedure can be done off tourniquet, but a bloodless field does aid in visualization. Even when using local anesthesia alone, most patients tolerate the use of a tourniquet for a short period of time. If eCTR is performed under local anesthesia alone, the patient is prepared that they may feel pressure or electricity when the synovial elevator and/or endoscope are inserted. Equipment necessary: ● Endoscopic equipment including devise and blade (per various manufacturers). ● Endoscopy tower/monitor.

24.8 Tips, Pearls, and Lessons Learned As with most procedures, eCTR becomes easier with repetition, and the rate of conversion to an open CTR decreases with experience.6 There are several tips that may help to shorten the learning curve. ● The path of the endoscope should be slightly proximal radial to distal ulnar. This direction of insertion will minimize the risk of encountering the median nerve distally, as its branches take off. ● If the median nerve is sliding into the field of view, having an assistant extend the thumb will decrease this tendency. Furthermore, pronating the endoscope while supinating the wrist will block the median nerve from coming into view. ● The blade should only be elevated if and when there is acceptable visualization of the undersurface of the transverse carpal ligament (TCL) with no nerve interposition. If there is any doubt about visualization, the surgeon should attempt to improve it or should convert to an open CTR. ● Initially, only the distal half of the TCL is released. This allows confirmation that the distal half of the TCL has been released in its entirety prior to releasing the proximal half of the TCL. If the entire TCL is released in one pass, it becomes challenging to verify complete TCL release because the subcutaneous fat tends to obscure visualization.

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24.9 Difficulties Encountered In some patients, endoscopic CTR can be challenging. Often, this is secondary to the patient’s anatomy. In patients with small stature, the carpal tunnel can have a small volume, which makes introducing the endoscope more difficult. Furthermore, anatomic anomalies involving the motor recurrent branch of the median nerve, such as a transligamentous branch, makes endoscopic release more demanding.7 Finally, revision CTR can be tricky to perform endoscopically, depending on the time since the previous surgery and the amount of scar accumulation.

24.10 Key Procedural Steps A transverse incision is made proximal to the wrist flexion crease, lining up with the ring finger, and ulnar to the palmaris longus (▶ Fig. 24.1). Subcutaneous tissues are dissected sharply with a knife and then retracted with skin hooks. Next, the

antebrachial fascia is visualized. This fascia is lifted up, and a longitudinal fascial incision is made. The fascial flap is separated from the underlying synovium. Skin hooks are placed distally underneath the fascia, and the median nerve is readily identified. A dissecting scissors is then used proximally to release the distal extent of the antebrachial fascia. At this point, the synovial elevator is inserted underneath the TCL in line with the ring finger. It is used to remove any adhesions from the undersurface of the TCL. Once the tip of the elevator can be palpated at the distal edge of the carpal tunnel, it is replaced with a hamate finder, which created a path for the blade assembly. Next, the endoscope is introduced into the carpal tunnel while aiming at the ring finger, hugging the hook of the hamate, and pressing against the deep side of the ligament. After defining the distal aspect of the TCL and having a clear view of the transverse fibers of the TCL (▶ Fig. 24.2), the blade is elevated and the distal half of the TCL is released (▶ Fig. 24.3). The blade is then dropped and complete release of the distal half of the TCL is confirmed. Then, the proximal half of the TCL is released. Finally, the blade assembly is reinserted to verify complete TCL release (▶ Fig. 24.4).

24.11 Bailout, Rescue, and Salvage Procedures

Fig. 24.1 A transverse incision is made proximal to the wrist flexion crease, lining up with the ring finger, and ulnar to the palmaris longus.

Fig. 24.2 View of the transverse fibers of the TCL. TCL, transverse carpal ligament.

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If visualization of the TCL is inadequate and/or the entire TCL cannot be released, the procedure should be converted to an open CTR to ensure the safe and complete release of the entire TCL. If there is concern regarding nerve injury during the procedure, an extended open CTR should be performed to directly visualized the median nerve. If a nerve injury occurs, the nerve should be repaired using standard microsurgical technique.

Fig. 24.3 A blade is elevated and the distal half of the TCL is released. TCL, transverse carpal ligament.

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References

Fig. 24.4 The blade assembly is reinserted to verify complete TCL release. TCL, transverse carpal ligament.

References [1] Agee JM, McCarroll HR, Jr, Tortosa RD, Berry DA, Szabo RM, Peimer CA. Endoscopic release of the carpal tunnel: a randomized prospective multicenter study. J Hand Surg Am. 1992; 17(6):987–995 [2] Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-portal endoscopic carpal tunnel release compared with open release : a prospective, randomized trial. J Bone Joint Surg Am. 2002; 84(7):1107–1115 [3] Benson LS, Bare AA, Nagle DJ, Harder VS, Williams CS, Visotsky JL. Complications of endoscopic and open carpal tunnel release. Arthroscopy. 2006; 22(9): 919–24, 924.e1–2

[4] Boeckstyns ME, Sørensen AI. Does endoscopic carpal tunnel release have a higher rate of complications than open carpal tunnel release? An analysis of published series. J Hand Surg [Br]. 1999; 24(1):9–15 [5] Luria S, Waitayawinyu T, Trumble TE. Endoscopic revision of carpal tunnel release. Plast Reconstr Surg. 2008; 121(6):2029–2034, discussion 2035–2036 [6] Beck JD, Deegan JH, Rhoades D, Klena JC. Results of endoscopic carpal tunnel release relative to surgeon experience with the Agee technique. J Hand Surg Am. 2011; 36(1):61–64 [7] Lutsky KF, Jones CM, Kim N, Medina J, Matzon JL, Beredjiklian PK. Frequency of incidental median thenar motor nerve branch visualization during miniopen and endoscopic carpal tunnel release. Hand (N Y). 2017; 12(1):60–63

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25 Proximal Median Nerve Compression Michael Aversano, Mikhail Zusmanovich, Michael E. Rettig, and Nader Paksima Abstract Neuropathy can be defined generally as a disorder that results in impaired motor or sensory function of a peripheral nerve. The median nerve may become neuropathic from compression at multiple anatomic sites through its course along the upper extremity. This leads to various forms of dysfunction, including pain, motor weakness, and sensory changes. Median nerve compression at the elbow and the proximal forearm is much less common than its more distal entrapment at the carpal tunnel and represents only 7 to 10% of median nerve neuropathies.1 There are two distinct syndromes that make up proximal median nerve compression: pronator syndrome and anterior interosseous nerve (AIN) syndrome, each of which have distinct presentations and treatments that must be carefully delineated. Keywords: median nerve compression, pronator syndrome, anterior interosseous nerve

25.1 Anatomy The median nerve is composed of fibers from the fifth, sixth, seventh, and eighth cervical and the first thoracic nerve roots. It is a collection of fibers from the anterior divisions of the upper, middle, and lower trunks and the lateral and medial cords of the brachial plexus.2 It enters the upper arm behind the pectoralis minor and passes with relative freedom until around the elbow (▶ Fig. 25.1a,b). There are no branches of the median nerve in the upper arm, with the exception of a possible fascicular branch variant that innervates the pronator teres (PT). Distal to the elbow, the median nerve provides motor innervation to the PT, flexor digitorum superficialis (FDS), palmaris longus (PL), and flexor carpi radialis (FCR). The nerve gives off two main branches

in the forearm: anterior interosseous nerve (AIN) and the palmar cutaneous branch of the median nerve (PCBMN). The AIN supplies the flexor pollicis longus (FPL), flexor digitorum profundus (FDP) to the index and long fingers, and pronator quadratus (PQ). The nerve also provides sensory fibers to the radioulnar, radiocarpal, carpal, and carpometacarpal joints. Distal to the wrist, the median nerve provides innervation to some of the intrinsic hand muscles3 (▶ Box 25.1). Proximal median nerve compression occurs at several distinct anatomic locations near the antecubital fossa and forearm, as the nerve traverses particular areas of constriction and/or tethering (▶ Fig. 25.2a,b) 4: ● Ligament of Struthers and/or supracondylar process: The ligament of Struthers overlies the median nerve as it crosses the elbow. It is thought to be a vestigial tendon and most often arises from the supracondylar process; a bony

Box 25.1 Median nerve innervated muscles by location Forearm: Main branch ● Pronator teres ● Flexor carpi radialis ● Flexor digitorum superficialis ● Palmaris longus Forearm: Anterior interosseous nerve ● Flexor pollicis longus ● Pronator quadratus ● Flexor digitorum profundus (index and middle) Hand ● Abductor pollicis brevis ● Flexor pollicis brevis (only the superficial head) ● Opponens pollicis ● Lumbricals (index and middle)

Fig. 25.1 (a) Median nerve branches in the deep planes at the elbow. (1) Tendinous arch of the origin of the flexor digitorum superficialis (possible site of compression of the median nerve). (2) FDR. (3) FCR (4) Muscular branches of the median nerve (5) Bicipital aponeurosis (6) Ulnar head of the pronator teres (7) Humeral head of the pronator teres (8) Median nerve. (b) The tendinous arch of the origin of the flexor digitorum superficialis is incised to decompress the median nerve. (1) Lateral antebrachial cutaneous nerve (musculocutaneous nerve). (2) Tendinous arch of the origin of the flexor digitorum superficialis (divided). (3) Anterior interosseous nerve (4) Muscular branches of the median nerve (5) Ulnar head of the pronator teres (6) Humeral head of the pronator teres (7) Median nerve (8) Medial antebrachial cutaneous nerve. (Reproduced with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.). FCR, flexor carpi radialis; FDS, flexor digitorum superficialis.

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Pathophysiology

Fig. 25.2 (a) Sketch of the elbow demonstrates a characteristic supracondylar process which can be associated with a ligament of Struthers. (b) Anatomy of the median nerve and sites of compression (1) Pronator teres (2) Fibrous arcade of the FDS to the middle finger (3) Bicipital aponeurosis (4) Ligament of Struthers. FDS, flexor digitorum superficialis.

projection at the anteromedial aspect of the distal humerus approximately 5 cm proximal to the medial epicondyle. It is found in 1 to 3% of upper extremities.5 The supracondylar process can be differentiated from an osteochondroma as the supracondylar process grows toward the joint. ● Lacertus fibrosus (bicipital aponeurosis): The lacertus fibrosus originates from the distal short head of the biceps tendon and is a point of static and active compression of the median nerve with biceps contraction.6 ● Fascia of the PT: The median nerve passes beneath the deep/ humeral head of the PT; the median nerve can be irritated by repetitive contraction of this muscle.7 In Johnson and Spinner’s cadaveric dissection study, 20% of specimens had a fibrous arcade completely surrounding the median nerve at this location.1 ● Fibrous arch formed by fascia of the FDS: The median nerve then passes deep to the proximal fibrous arch of the two heads of the FDS. Johnson and Spinner noted that 30% of median nerve constrictions occurred at this site.1

25.1.1 Anomalous Anatomy Additional, even rarer, sites of compression of the median nerve in the forearm include anomalous muscles or arteries: Gantzer's muscle (an accessory head of the FPL), palmaris profundus, flexor carpi radialis brevis, or an aberrant radial artery have all been described as sites of compression.8

25.2 Pathophysiology The clinical findings in patients with chronic nerve compression reflect a broad spectrum of histopathologic changes. Most studies suggest a component of neural ischemia that

Table 25.1 Sunderland’s classification of nerve compression Grade

Description

1

Neurapraxia: Interruption of axial conduction at the site of injury

2

Axonotmesis: Loss of continuity of the axon and myelin covering. Preservation of the connective tissue framework of the nerve

3

Neurotmesis Lesion of the endoneurium, but the epineurium and perineurium remain intact

4

Only the epineurium remains intact, total internal architecture disruption

5

Complete loss of continuity of the nerve trunk

contributes to compression neuropathies. The continuum of neural changes depends on the degree of pressure and its duration. As has been elucidated through the use of animal models, the histopathology of chronic nerve compression begins with breakdown of the blood–nerve barrier, followed by edema of the endoneurium, ultimately resulting in perineurial thickening and constriction.9,10,11 A detailed classification of nerve injuries was first described by Seddon in 194312 and then expanded upon by Sunderland in 1951.13 Under their classifications, peripheral nerve injury is subdivided into varying degrees of damage based upon the nerve structures involved. This, in turn, determines prognosis and potential treatment strategies. Compression or entrapment is just one of the basic types of nerve injury (▶ Table 25.1). A nerve may be injured at multiple sites along its course and in varying gradations. It is important to recognize that one site of nerve compression may affect other sites of nerve compression. Therefore, all potential entrapment sites of nerve compression must be systematically evaluated. First introduced by

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Proximal Median Nerve Compression Upton and McComas,14 the double-crush phenomena states that compression of a nerve at one level will make the nerve more susceptible to damage at another level. In their clinical review of 115 patients with median or ulnar nerve compression, 81 showed evidence of a concomitant cervical root lesion. This concept of the double-crush mechanism is important in the assessment of patients with suspected proximal median nerve compression.15 Both more proximal cervical root lesions and more distal compression at the carpal tunnel can predispose to either pronator syndrome or anterior interosseous nerve (AIN) syndrome.

25.3 Diagnosis 25.3.1 Clinical Exam It is important for physicians who treat upper extremity disorders to be familiar with the constellation of symptoms associated with compression of the median about the elbow and forearm. A thorough differential must delve deeper than to assume that all median nerve injuries are related to carpal tunnel syndrome (CTS). To develop an effective treatment plan, it is necessary to identify and distinguish between sites of compression of the median nerve. The diagnosis begins with a complete history. This should include common etiologies of neuropathy such as trauma to the arm, fractures, work-related repetitive use and associated medical comorbidities. Use of a pain evaluation questionnaire and diagram in the office is often helpful in identifying all symptomatic areas and other factors that may contribute to a patient’s presentation: ● A patient who has AIN syndrome will often report poorly localizable pain or tenderness in the proximal forearm and antecubital fossa. This may present as an antecedent episode of pain that then resolves. This is often followed by weakness of pinch, which can manifest in difficulty with writing, buttoning, and picking up small objects. Patients may report that elbow flexion or forearm pronation worsen the symptoms. There is often no associated sensory loss with AIN syndrome. A history should differentiate this from brachial neuritis or Parsonage–Turner syndrome in which transient shoulder pain often following a viral illness precedes upper extremity weakness and paresthesia. In some cases, AIN syndrome may actually be a component of, or the end result of, Parsonage– Turner syndrome. ● The signs of pronator syndrome can overlap those of CTS. Both conditions are associated with pain and/or paresthesia in the hand to the radial three and one-half digits. Painful nocturnal symptoms that awaken individuals from sleep are much more common in association with CTS.16 The classic presentation for pronator syndrome is aching forearm pain. It can be differentiated from CTS by numbness in the palm in pronator syndrome and numbness in the fingertips in CTS. In patients with work-related symptoms, detailed consideration should be given to determine the involvement of associated activities such as those requiring repetitive, vigorous, or protracted use of the elbow or forearm. Examples of this include heavy manual labor with repetitive grasping or packaging or constant lifting and carrying or Jackhammer type activities.

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The next part of the diagnosis is a thorough clinical examination with particular attention to the sensory and motor evaluation of the median nerve. The concept of increasing tension or pressure on a nerve through provocative physical examination maneuvers, such as the tests commonly used in diagnosing CTS, may be extrapolated to other sites of nerve compression in the upper extremity. This can involve direct palpation of the nerve itself or stress on a particular tendon or muscle unit. Three main provocative tests have been described to help corroborate the site of compression (▶ Fig. 25.3a-c): ● The PT muscle: Symptoms are reproduced upon resisted pronation of the forearm in neutral position with the elbow extended. ● The lacertus fibrosus: Symptoms are reproduced upon resisted elbow flexion at approximately 120 flexion with the forearm in supination. ● The FDS: “Proximal Phalanx (Pinning) finger flexion test.” Pain may be elicited by resisted flexion of the flexor digitorum sublimis of the long finger. ● Direct compression over the median nerve at the level of the PT may reproduce some of the symptoms. Pronator syndrome and its findings on clinical examination were first described by Seyffarth in 1951.17 Tenderness is most localized to the origin of the PT. Weakness of the flexor pollicis longus muscle of the thumb is most pronounced. Dysesthesias are present but subtle and involve the skin overlying the thenar eminence and the palmar triangle, as this is innervated by the PCBMN. Since the PCBMN originates proximal to the transverse carpal ligament, this area is not affected in CTS and thus important in differentiating between the two pathologies. In addition, for pronator syndrome, there is no Tinel’s sign at the wrist like in CTS. The Tinel’s sign is most prominent at the main site of compression, around the proximal forearm/origin of the pronator. In CTS, several provocative tests should be performed during routine clinical examination. Phalen’s test results ranged in sensitivity from 0.46 to 0.80 and in specificity from 0.51 to 0.91; the median nerve compression test (Durkin’s) ranged in sensitivity from 0.04 to 0.79 and in specificity from 0.25 to 0.96.18,19 Combining the results of these tests will aid in accurate diagnoses. AIN syndrome was first described by Parsonage and Tumer20 in 1948 and later by Kiloh and Nevin21 in 1952. AIN syndrome can be partial or complete and results in paresis or paralysis of the FPL, FDP of the index, and sometimes the long finger and the PQ. This produces a characteristic pinch deformity that yields extension of the terminal joints of the thumb, index finger, and long fingers (▶ Fig. 25.4). Weakness or paralysis of the PQ can be demonstrated by resisted pronation of the forearm, with the elbow fully flexed to neutralize the unaffected pronator teres. With the exception of a few terminal sensory fibers, the AIN is essentially a motor nerve, and therefore, no sensory defects are found on physical examination.

25.3.2 Testing Proximal median nerve compression can be a challenging diagnosis, and clinical examination should therefore be combined with electrodiagnostic studies to make the diagnosis. Two

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Diagnosis

Fig. 25.3 (a) Pronation against resistance with arm extended. Pronator teres provocative maneuver. (b) Flexion of wrist against resistance. (c) Flexion of middle finger against resistance. FDS provocative maneuver to evaluate the median nerve at the fibrous arch of the FDS. By holding the index and ring finger DIP joints in full extension, we are isolating the FDS and eliminating the FDP contribution. DIP, distal interphalangeal joint; FDS, flexor digitorum superficialis.

Fig. 25.4 Hand posturing in AIN syndrome. AIN, anterior interosseous nerve.

aspects of electrodiagnostic testing are most often used to identify nerve entrapment syndromes: nerve conduction studies (NCS) and electromyography (EMG). These studies are not very

useful to diagnose proximal median nerve compression, but can help to rule out other forms of nerve compression or injury. ● NCV: Unlike distal median nerve compression within the carpal tunnel, NCV studies in proximal median nerve compression are often normal. ● EMG: May demonstrate membrane instability such as increased insertional activity, fibrillation potentials, or positive sharp waves of innervated muscles both proximal to and distal to the wrist. Whereas, in CTS, only intrinsic hand muscles demonstrate these findings.22 ● Radiographs/Ultrasound/MRI: A radiographic series of the elbow and forearm can be obtained to rule out bony pathology; the presence of a supracondylar process can suggest the presence of a ligament of Struthers.23 Although there are good indications for the use of ultrasound in CTS, the evidence to support the use of MRI or ultrasonography in the diagnosis of proximal median nerve compression is insufficient and not routinely recommended.24 Nevertheless, if neuritis is present, there may be secondary muscle changes, localized compression, hour-glass deformity of the nerve, and/or the presence of overlying fascial structures that may be able to be picked up by ultrasound. One scenario in which advanced imaging is recommended is when there is suggestion of a spaceoccupying lesion that can be further characterized.

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25.4 Treatment 25.4.1 Nonoperative Management Patients with either pronator syndrome or AIN syndrome should be managed with a trial of nonsurgical treatment. Nonoperative management should include avoidance of provocative activities such as those involving repetitive elbow flexion, forearm pronation, or gripping. A period of immobilization using a posterior elbow splint may reinforce the strategy of rest and aid in prohibiting these particular movements of the upper extremity. Use of nonsteroidal anti-inflammatories may aid in pain relief during this time. While controversy remains over the exact duration of nonoperative treatment and observation, most authors believe that a period of between 3 to 6 months is necessary before surgical treatment should be considered. ● It has been reported that 50 to 70% of patients with pronator syndrome may respond to conservative therapy.25 ● Neurology and hand surgery literature seem to differ in the surgical indications for treatment of AIN syndrome. In the neurology literature, numerous reports indicate that nearly all cases of AIN syndrome resolve spontaneously over time and surgery is not indicated. Spontaneous recovery has been shown to occur over 1 year following initial onset of symptoms.26 In one series by Miller-Breslow et al,27 all patients recovered without surgical intervention. In the hand literature, if no motor recovery is identified after a period of 3 to 6 months, most authors will argue for surgical release. Over this time, a denervated muscle will atrophy and the end-organs will become nonviable if the pathology is not corrected. After the 6-month window, there is a high level of uncertainty in functional motor recovery; even if surgical release occurs and a regenerating axon is able to reach the target, maturation and restoration of motor function is only possible if the end-organ and motor endplates are still viable.28

25.4.2 Surgical Decompression Patients who do not respond to conservative management, without recovery of nerve function, or those with a spaceoccupying lesion/mass, should be considered for surgical decompression. Long-term results of surgical treatment of pronator syndrome and AIN syndrome demonstrate excellent or good relief in approximately 80% of patients undergoing surgical decompression.1,29 Improvement can begin as soon as 4 weeks after surgical release but can take as long as 2 years in certain documented cases. Surgery should include exploration of the median nerve through its proximal course and release of all the potential sites of compression. In chronic cases with long-standing motor palsy, tendon transfers may be necessary. Side-to-side transfer of the FDP to the index and middle finger to the FDP of the ring and long fingers is an extremely useful tool. It can even be considered in acute and subacute cases of AIN syndrome, as there is no deficit produced by the transfer. Additional options include: (1) Transfer of the FDS of the ring finger to the FPL, (2) transfer of the brachioradialis to the FPL, and (3) thumb interphalangeal joint fusion. Tendon transfers for restoring pronation are not needed as the PT remains intact.

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Fig. 25.5 Incision to allow adequate exposure of median nerve. (Reproduced with permission from Kevin D. Plancher. MasterCases Hand and Wrist Surgery, 1st edition © 2004 Thieme.)

25.4.3 Surgical Technique Surgical exposure of the median nerve is through an Sshaped incision can be extended proximally (rather than start there) if a ligament of struthers or Supracondylar process is to be released (▶ Fig. 25.5). This allows for complete exposure of the median nerve and decompression from proximal to distal (▶ Fig. 25.6a-c). The dissection is carried down through the subcutaneous soft tissue and any cutaneous sensory branches are carefully preserved. Exploration begins proximal to the medial epicondyle at the potential origin of the ligament of Struthers. The nerve is then traced distally, passing beneath the lacertus fibrosus which is released (▶ Fig. 25.7a-b). Then, tracing the nerve along the tendinous proximal edge of the FDS, there is typically a fibrous arch that must be divided. Next, follow the nerve between the humeral and ulnar heads of the PT. The superficial insertion of the PT can be released with a step cut. Take note that nearly all branches of the median nerve arise on its ulnar side at this level, the most notable exception being the AIN branch, which originates on the radial side (▶ Fig. 25.8a-c). Make note of any anomalous structures, including muscle or arteries which could be potential sites of constriction. Internal neurolysis is typically not indicated, a focal epineurotomy can be performed if there is an hourglass deformity and scarring of the epineurium.2,30,31,32

25.4.4 Postop Protocol The arm is immobilized in a well-padded posterior splint with the elbow at 90 degrees and the forearm in neutral rotation. The splint is discontinued and motion is allowed approximately 1 week after surgery. Patients are allowed to return to full activity and work approximately 6 weeks after surgery.

25.4.5 Potential Pitfalls The critical pitfall in the treatment of pronator syndrome is arriving at the incorrect diagnosis. Given that objective testing for this condition (EMG/NCS) are unreliable, the diagnosis needs to be made on history and physical examination. For both

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Treatment

Fig. 25.6 (a) The median nerve passing under the fibrous sling of origin of the finger superficial flexor muscles in the proximal forearm. This is the common site for its compression, which occurs only very rarely at the pronator teres muscle. (b) Cutting the fibrous origin of the FDS crossing and compressing the median nerve. (c) Gross pathology (pointer) of the median nerve, which was hidden beneath the FDS sling of origin and thus visualized only after the decompression. FDS, flexor digitorum superficialis. (Reproduced with permission from Robert W. Beasley. Beasley’s Surgery of the Hand, 1st edition © 2003 Thieme.)

Fig. 25.7 (a) The arrow is pointing to the fibrous band of FDS muscle beneath which the median nerve is being compressed. To the right of the arrow is the median nerve of normal size distal to the pronator teres muscle. (b) The arrow is pointing to the grossly compressed median nerve which was beneath the severed FDS origin. Note the median nerve of normal size at the extreme right of the wound, exactly as seen in A. FDS, flexor digitorum superficialis. (Reproduced with permission from Robert W. Beasley. Beasley’s Surgery of the Hand, 1st edition © 2003 Thieme.)

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Fig. 25.8 (a) Photograph of the AIN illustrating arch of the FDS prior to release. (b) AIN with decompression in progress. (c) Complete release of the median nerve (AIN branch). AIN, anterior interosseous nerve; FDS, flexor digitorum superficialis.

pronator and AIN syndromes, incomplete nerve release is a potential complication. Injury to arterial structures, especially the brachial artery in the distal arm, should be considered. Incomplete recovery of muscle function is always possible in the setting of AIN syndrome, and patients should be counseled that tendon transfers may be necessary as a staged procedure.

References [1] Johnson RK, Spinner M, Shrewsbury MM. Median nerve entrapment syndrome in the proximal forearm. J Hand Surg Am. 1979; 4(1):48–51 [2] Mackinnon SE, Novak CB. Compression neuropathies. In: Wolfe SW, Pederson WC, Hotchkiss RN, Kozin SH, Cohen MS, Green DP, eds. Green's Operative Hand Surgery. 7th ed. Philadelphia: Elsevier/Churchill Livingstone; 2017 [3] Rodner CM, Tinsley BA, O’Malley MP. Pronator syndrome and anterior interosseous nerve syndrome. J Am Acad Orthop Surg. 2013; 21(5):268–275 [4] Hand ASfSot. Pronator Syndrome [5] Kessel L, Rang M. Supracondylar spur of the humerus. J Bone Joint Surg Br. 1966; 48(4):765–769 [6] Athwal GS, Steinmann SP, Rispoli DM, GS A. The distal biceps tendon: footprint and relevant clinical anatomy. J Hand Surg Am. 2007; 32(8):1225–1229 [7] Dellon AL, Mackinnon SE. Musculoaponeurotic variations along the course of the median nerve in the proximal forearm. Journal of hand surgery (Edinburgh, Scotland). 1987; 12(3):359–363 [8] Spinner M. Injuries to the Major Branches of Peripheral Nerves of the Forearm. 2nd ed. Philadelphia: WB Saunders; 1978 [9] Sunderland S. Nerve and Nerve Injuries. 2nd ed. Edinburgh: Churchill Livingstone; 1978

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[10] Mackinnon SE, Dellon AL, Hudson AR, Hunter DA, SE M. A primate model for chronic nerve compression. J Reconstr Microsurg. 1985; 1(3):185–195 [11] Tapadia M, Mozaffar T, Gupta R, M T. Compressive neuropathies of the upper extremity: update on pathophysiology, classification, and electrodiagnostic findings. J Hand Surg Am. 2010; 35(4):668–677 [12] Seddon HJ, Medawar PB, Smith H. Rate of regeneration of peripheral nerves in man. J Physiol. 1943; 102(2):191–215 [13] Sunderland S. A classification of peripheral nerve injuries producing loss of function. Brain. 1951; 74(4):491–516 [14] Upton AR, McComas AJ. The double crush in nerve entrapment syndromes. Lancet. 1973; 2(7825):359–362 [15] Kane PM, Daniels AH, Akelman E. Double Crush Syndrome. J Am Acad Orthop Surg. 2015; 23(9):558–562 [16] Tsai P, Steinberg DR. Median and radial nerve compression about the elbow. Instr Course Lect. 2008; 57:177–185 [17] Seyffarth H. Primary myoses in the M. pronator teres as cause of lesion of the N. medianus (the pronator syndrome). Acta Psychiatr Neurol Scand, Suppl. 1951; 74:251–254 [18] de Krom MC, Knipschild PG, Kester AD, Spaans F. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Lancet. 1990; 335(8686): 393–395 [19] Katz JN, Larson MG, Sabra A, et al. JN K. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med. 1990; 112(5):321–327 [20] Parsonage MJ, Turner JW. Neuralgic amyotrophy; the shoulder-girdle syndrome. Lancet. 1948; 1(6513):973–978 [21] Kiloh LG, Nevin S. Isolated neuritis of the anterior interosseous nerve. BMJ. 1952; 1(4763):850–851 [22] Gross PT, Jones HR, Jr, PT G. Proximal median neuropathies: electromyographic and clinical correlation. Muscle Nerve. 1992; 15(3):390–395

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References [23] Barnard LB, McCOY SM. The supra condyloid process of the humerus. J Bone Joint Surg Am. 1946; 28(4):845–850 [24] Andreisek G, Burg D, Studer A, Weishaupt D, G A. Upper extremity peripheral neuropathies: role and impact of MR imaging on patient management. Eur Radiol. 2008; 18(9):1953–1961 [25] Tsai TM, Syed SA, TM T. A transverse skin incision approach for decompression of pronator teres syndrome. J Hand Surg [Br]. 1994; 19(1):40–42 [26] Sood MK, Burke FD, MK S. Anterior interosseous nerve palsy. A review of 16 cases. J Hand Surg [Br]. 1997; 22(1):64–68 [27] Miller-Breslow A, Terrono A, Millender LH. Nonoperative treatment of anterior interosseous nerve paralysis. J Hand Surg Am. 1990; 15(3):493–496

[28] Menorca RM, Fussell TS, Elfar JC. Nerve physiology: mechanisms of injury and recovery. Hand Clin. 2013; 29(3):317–330 [29] Hartz CR, Linscheid RL, Gramse RR, Daube JR, CR H. The pronator teres syndrome: compressive neuropathy of the median nerve. J Bone Joint Surg Am. 1981; 63(6):885–890 [30] Olehnik WK, Manske PR, Szerzinski J. Median nerve compression in the proximal forearm. J Hand Surg Am. 1994; 19(1):121–126 [31] Knutsen EJ, Calfee RP, EJ K. Uncommon upper extremity compression neuropathies. Hand Clin. 2013; 29(3):443–453 [32] Median Nerve Release in the Forearm- Standard (Feat. Dr. Mackinnon). https://www.youtube.com/watch?v=fYFJQmRmRXg.

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26 Open Ulnar Nerve Decompression at the Wrist Daniel B. Polatsch, Steven Beldner, and Remy V. Rabinovich Abstract Open ulnar nerve decompression at the wrist is a safe and effective procedure for the treatment of ulnar tunnel syndrome. Knowledge of the unique anatomy of the ulnar nerve, as it courses from the wrist into the hand, is discussed in detail. Understanding of this complex anatomy helps in explaining the various clinical presentations, which can help locate the site of compression. Surgical pearls to help identify the ulnar nerve proper and the critical deep motor branch are explained. Useful surgical tips are discussed which help avoid unnecessary dissection and minimize postoperative complications. Finally, expected outcomes and postoperative protocols are discussed. Keywords: ulnar nerve compression, Guyon’s canal, ulnar tunnel syndrome, cyclist palsy

26.1 Description

sensory presentation is atypical. The ramus communicans has been described in the literature as being present in 4 to 100% of patients.4,6 The deep motor branch of the ulnar nerve, accompanied by the deep branch of the ulnar artery, then passes between the abductor digiti minimi (ADM) and the FDMB. This typically occurs just distal to the pisohamate ligament, which serves as an important landmark when isolating the motor branch. The motor branch then perforates the opponens digiti minimi (ODM) and courses radially and deep to curve around the hook of the hamate. It then follows the course of the deep palmar arch beneath the flexor tendons. At its origin, it innervates the hypothenar muscles. As it crosses the deep part of the hand, it innervates all the interosseous muscles and the third and fourth lumbricals. It ends by supplying the adductor pollicis (AP) and the medial head of the flexor pollicis brevis (FPB). It also sends articular branches to the adjacent carpal joints.

Ulnar tunnel syndrome is a common condition with a variable clinical presentation. A comprehensive understanding of the relevant anatomy is crucial to the successful diagnosis and ultimate treatment of this condition. When conservative measures are unsuccessful, open and methodical decompression of the ulnar nerve and its branches in a timely fashion often leads to resolution of symptoms and rapid return of function.

26.2 Key Principles The ulnar nerve at the proximal wrist lies subjacent to the flexor carpi ulnaris (FCU), is relatively superficial, and covered by fascia and skin. The ulnar nerve and artery enter Guyon’s canal, which is a fibro-osseous tunnel formed between the pisiform and hamate hook, as seen in ▶ Fig. 26.1. The pisohamate ligament forms the floor of the canal, while the roof comprises the volar carpal ligament. Within Guyon’s canal, the ulnar nerve bifurcates into superficial and deep branches. The ulnar artery lies radial and slightly volar to the ulnar nerve.1 The canal begins proximally at the level of the pisiform with a 6 mm oval opening termed the proximal hiatus. The majority of patients exhibit a distal hiatus at the level of the hamate hook, which can be seen as a sickle-shaped tendinous arcade that forms the origin of the flexor digiti minim brevis (FDMB).2 The branches of the ulnar nerve continue into the hand, with the superficial branch classically described as innervating the palmaris brevis muscle and continuing distally as a pure sensory nerve over the hypothenar muscles (▶ Fig. 26.2). It then divides into the fourth common digital nerve and the ulnar proper digital nerve to the small finger. Variations and overlap of this “typical” description exist and have been described in the literature.3,4,5 The inconsistencies might lead to confusion and delay in diagnosis of certain compressive neuropathies and traumatic injuries. The presence of communications between the ulnar fourth common digital nerve and the median third common digital nerve should be considered when the digital

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Fig. 26.1 Illustration demonstrating the opening and walls of Guyon’s Canal. The arrows indicate the proximal hiatus (bottom) and distal hiatus (top). FCU, flexor carpi ulnaris tendon; FDS, flexor digitorum superficialis; FR, flexor retinaculum; PL, palmaris longus; P, pisiform; PA, palmar aponeurosis; PB, Fibers of the palmaris brevis; PHL, pisohamate ligament; VCL, volar carpal ligament. (Reproduced with permission from Schmidt H-M, Lanz U. Surgical Anatomy Of The Hand. Stuttgart; New York: Thieme; 2004.)

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Key Principles

Fig. 26.2 (a) Schematic diagram of the musculature of the forearm and hand supplied by the ulnar nerve. (1) Proper palmar digital nerves. (2) Common palmar digital nerve. (3) Superficial branch of the ulnar nerve. (4) Deep branch of the ulnar nerve. (5) Dorsal branch of the ulnar nerve. (6) Ulnar nerve. (7) Muscular branches of the ulnar nerve. (8) Muscular branches of the ulnar nerve. (9) Palmar branch of the ulnar nerve. (b) Schematic diagram of the Guyon's canal. (1) Muscular branch (palmaris brevis). (2) Superficial branch of the ulnar nerve. (3) Deep branch of the ulnar nerve. (4) Ulnar nerve. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

Fig. 26.3 Ulnar nerve zones in the wrist.

Several clinical presentations of ulnar nerve dysfunction can occur due to compression at the level of the wrist and hand. The presentations might involve isolated sensory loss, isolated

motor weakness, or a combination of both.7,8,9 The clinical presentation is dictated by the anatomic site of compression (▶ Fig. 26.3). Guyon’s canal is often divided into three zones: zone 1, zone 2, and zone 3. Zone 1 is the area proximal to the bifurcation of the ulnar nerve, and compression at this level leads to a combined motor and sensory loss. Zone 2 includes the deep or motor branch after it has bifurcated. Compression in zone 2 leads to isolated loss of motor function of the ulnar innervated muscles. Zone 3 encompasses the superficial or sensory branch of the ulnar nerve, and injury at this level leads to sensory loss of the hypothenar eminence, small finger, and part of the ring finger. Zone 3 injury does not lead to motor weakness. We also propose a modification to this well-known classification system to include a newly described Zone 0. This new zone occurs proximal to the take-off of the dorsal sensory branch of the ulnar nerve (but well distal to the cubital tunnel and the innervation of the extrinsic flexor tendon). The clinical picture of a Zone 0 injury would be one of mixed motor and sensory loss, but would also include sensory loss on the dorsum of the little finger and ulnar aspect of the ring finger. Ulnar tunnel syndrome has been well-described in the literature and might be the result of various causes, including ganglia8,9,10,11 (as depicted in ▶ Fig. 26.4), fractures or dislocations of the ulnar side of the wrist,9,12,13 anomalous muscle bellies or fibrous bands,11,14,15 (as shown in ▶ Fig. 26.5), hemangiomas,16 bipartite hamate,17 giant cell tumors,18 thrombosis of the ulnar artery,9,11,19 osteoarthritis of the distal radioulnar joint and carpal joints,20,21 rheumatoid tenosynovitis,22 other benign soft tissue masses (shown in ▶ Fig. 26.6), bicycle racing, and other

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Fig. 26.4 Axial, proton density MRI of a 42-year-old patient with ulnar nerve intrinsic muscle paralysis and palpable mass at the base of the wrist in the region of Guyon’s Canal. The marker outside the skin designates the area of the mass. Adjacent to the hook of the hamate, a fluid structure is seen compressing the ulnar nerve and artery.

Fig. 26.5 Axial, fat-suppressed proton density image of a 36-year-old male with numbness in the small finger and ulnar aspect of the ring finger. The MRI demonstrates an anomalous flexor digiti minimi brevis muscle (white arrow) compressing the ulnar nerve in the Guyon’s Canal.

Fig. 26.6 (a-c) Coronal, axial, and sagittal, fat-suppressed, and T1-weighted postcontrast MRI of a 29-year-old female with an enlarging hypothenar mass and sensory loss in the small finger and ulnar half of the ring finger without motor weakness (Zone 3). Pathology was consistent with a fibroma of tendon sheath.

activities that require either prolonged wrist hyperextension or continuous pressure on the hypothenar eminence.16 More recently, with the extreme popularity of indoor cycling classes, we have seen an increased prevalence of this condition which is termed cyclers’ palsy.

26.3 Expectations Surgical outcomes following ulnar nerve decompression at the wrist depend on several variables. As seen with other nerve entrapments, intrinsic patient factors associated with worse prognosis include: older age, longer history of injury and/or compression, presence of muscle atrophy, severely delayed or absent sensory or motor responses, and metabolic or connective tissue diseases.23 Since both mechanical and ischemic factors contribute to nerve dysfunction, the severity of the injury often correlates with the degree and duration of

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nerve compression. It is therefore important to promptly diagnose and treat ulnar nerve compression in a timely fashion to maximize outcomes, particularly when there is motor weakness. Fortunately, the location of nerve compression is quite distal (unlike its cubital tunnel counterpart) and therefore much closer to its motor endplates. This frequently allows for early recovery of muscle function and high-patient satisfaction.

26.4 Indications and Contraindications Indications for open ulnar nerve decompression at the wrist include any physical examination and/or electrophysiologicproven distal ulnar nerve entrapment where there is associated muscle weakness and/or prolonged symptoms that have not

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Key Procedural Steps resulting in a markedly compromised median nerve, might have near normal thenar function both clinically and electrophysiologically.25 In the workup of ulnar nerve compression at the wrist, we typically order an MRI in preparation for surgical decompression. This helps with preoperative planning and is extremely beneficial for identifying and managing space-occupying lesions such as pisotriquetral ganglions, anomalous muscles, and benign tumors (shown in ▶ Fig. 26.4, ▶ Fig. 26.5, ▶ Fig. 26.6). Despite this, a negative MRI should not dissuade one from avoiding surgical decompression as MRIs can often be negative. This is particularly true when compression of the motor branch is secondary to a firm fibrous edge of the hypothenar musculature, as it courses dorsally around the hook of the hamate.

26.6 Special Instructions, Positioning, and Anesthesia Fig. 26.7 Schematic diagram of the potential connection between the motor branch of the ulnar nerve and th recurrent branch of the median nerve described by the Cannieu-Riche. (1) Deep branch of the ulnar nerve. (2) Muscular branch of the ulnar nerve. (3) Superficial branch of the ulnar nerve. (4) Ulnar nerve. (5) Anastomotic branch of the median nerve with the ulnar nerve. (6) Median nerve. (Reproduced with permission from Pechlaner S, Hussl H, Kerschbaumer. F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

responded to conservative management. In mild cases with only sensory deficits, conservative management consisting of splinting, nonsteroidal and even steroidal medication, occupational therapy, and careful observation should be performed initially. Once measurable motor weakness is present and certainly progressive, timely decompression should be performed without delay.

26.5 Special Considerations Two commonly mentioned nerve anastomoses should be considered because they are apt to confuse the diagnosis of ulnar nerve dysfunction, resulting in delayed or erroneous treatment. The first is the Martin–Gruber anastomosis in the forearm. With this anomaly, there is a communication between the ulnar nerve and the median nerve in the forearm. The point of connection can be anywhere from 3 to 10 cm distal to the medial epicondyle.24 With a Martin–Gruber anastomosis, the motor nerves that ultimately innervate the ulnar intrinsic muscles are carried in either the anterior interosseous nerve (AIN) or the median nerve proper. In the middle of the forearm, the motor fibers leave the AIN or the median nerve to join the ulnar nerve. Thus, with this condition, functioning intrinsics are present despite a complete ulnar nerve injury proximal to this connection which can be a confusing clinical picture. The second variation is the Riche–Cannieu anastomosis, by which the median and ulnar nerves cross-connect in the palm (▶ Fig. 26.7). In such cases, the motor fibers that typically are part of the median nerve might be carried in the ulnar nerve to the level of the hand and cross over in the palm. With this anomaly, a patient with advanced carpal tunnel syndrome,

We typically perform open ulnar nerve decompression at the wrist under a short acting brachial plexus block with supplemental intravenous sedation. Early in our careers, we would often perform these under general anesthesia as this would allow for immediate evaluation of ulnar nerve function postoperatively. As our experience has grown, we no longer feel this is necessary since regional anesthesia allows for improved pain control postoperatively. We perform the procedure supine and use a nonsterile upper arm tourniquet. Since we rarely dissect between the ulnar nerve and artery (see below), postoperative bleeding is minimal. We do routinely deflate the tourniquet and obtain meticulous hemostasis prior to closure. If there is any residual bleeding or drainage, we will use a small penrose drain for 24 hours to minimize the development of a postoperative hematoma.

26.7 Key Procedural Steps A longitudinal or slightly angling, ulnar-based 3 to 4 cm incision is drawn out in the palm when performing an isolated open ulnar nerve decompression at the wrist. It should parallel the hypothenar musculature. At the level of the distal wrist flexion crease, the incision is angled to minimize any scar contracture (depicted in ▶ Fig. 26.8). We have found that the skin is relatively poorly perfused over the distal and ulnar forearm. Keeping the angles somewhat obtuse allows for improved blood flow and therefore healing of the small skin flap. If the surgery is to be combined with a larger procedure such as fracture fixation and a standard carpal tunnel release, then the incision will be more centrally located in the palm but will be similarly angled in an ulnar direction at the level of the distal wrist crease. First, the palmar fascia and transverse carpal ligament (TCL) are sequentially divided in their entirety (▶ Fig. 26.9). This is done as ulnarly as possible and adjacent to the hook of the hamate. The TCL is released distally until prepalmar fat is seen, marking the proximity of the superficial palmar arch. Proximally, the distal forearm fascial is divided. At this point, deeper retractors are placed, gently retracting the digital flexor tendons and the median nerve in a radial direction. Next, deep dissection is always begun proximally, identifying the FCU ten-

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Fig. 26.8 This is a clinical photograph illustrating the incision for ulnar nerve decompression at the wrist.

Fig. 26.9 (a,b) Decompression of the ulnar nerve in Guyon's canal. (a) The ulnar nerve is exposed in the Guyon's canal. (1) Palmaris brevis. (2) Pisohamate ligament. (3) Pisiform. (4) Ulnar nerve. (5) Fascia of the forearm (6) Tendon of the flexor carpi ulnaris. (7) Ulnar margin of the palmar aponeurosis. (8) Flexor retinaculum. (9) Ulnar artery. (10) Proximal boundary. (b) The fascia of the forearm is divided to expose the entrapment site at the level of the proximal boundary. (1) Superficial branch of the ulnar nerve. (2) Deep branch of the ulnar nerve. (3) Forearm fascia (divided). (4) Ulnar nerve. (5) Ulnar artery. (c) Decompression of the ulnar nerve in Guyon's canal. The ulnar nerve is exposed to reveal a ganglion compressing the deep branch of the ulnar nerve at the level of the distal boundary. (1) Distal boundary. (2) Ganglion. (Reproduced with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

don and the ulnar neurovascular bundle. The ulnar nerve and artery are easily identified proximally, as this area is devoid of any substantial subcutaneous fat. This is in contrast to the hypothenar eminence, where identification of the ulnar nerve and artery can be more difficult, as it is obscured by the overlying and abundant hypothenar fat pad. Once the nerve and artery are identified, dissection is continued distally along the volar and radial aspect of the ulnar artery with care not to dissect between it and the ulnar nerve. Avoiding this common mistake minimizes surgical bleeding and only prolongs operative time.

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The pisohamate ligament is then encountered, incised, and reflected; thereby, opening Guyon’s Canal proximally. The two commonly found superficial sensory nerve branches stemming from the ulnar nerve proper should be dissected distally and further decompressed. Next, attention should be directed toward identifying and decompressing the deep motor branch. As stated earlier, this branch accompanied by the deep branch of the ulnar artery can be readily identified just distal to the pisohamate ligament, which serves as an important landmark. We recommend

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Tips, Pearls, and Lessons Learned

Fig. 26.10 This clinical photograph demonstrates the deep motor branch of ulnar nerve (black arrow). Note that the ulnar artery is being gently elevated in an ulnar direction with a Beasley forceps. This easily exposes the deep motor branching, coursing radially toward the distal and ulnar most corner of the hamate hook.

Fig. 26.11 This clinical photograph demonstrates complete and thorough decompression of the ulnar nerve and its branches at the wrist. The flexor tendons and median nerve are being retracted with a Langenbeck retractor. The deep motor branch is coursing around the hamate hook toward the dorsum of the hand and is free of compression.

identifying this critical nerve by gently elevating the ulnar artery along its radial side and isolating it deep to the artery coursing in a distal and radial direction, as it tracks toward the ulnar and distal aspect of the hamate hook (shown in ▶ Fig. 26.10). This method of identifying the nerve is in sharp distinction to others who may explore along the ulnar aspect of the ulnar nerve or even between the nerve and artery. The motor branch should then be meticulously dissected free, as it curves around the hook of the hamate and into the dorsum of the hand. When the deep motor branch is the site of compression, often a firm fibrous proximal edge of the hypothenar muscles can be seen compressing the motor branch with a visible indentation. We recommend sharply elevating the hypothenar musculature off of the hamate hook while protecting the deep motor branch underneath it. This is accomplished by incising the tissue subperiosteally from deep to superficial. This is typically done while the median nerve and flexor tendons are protected with a deep retractor such as a Langenbeck retractor. Finally, the distal nerve can be released as it courses to the dorsal aspect of the hand with a pair of tenotomy scissors (illustrated in ▶ Fig. 26.11). To ensure that there is no significant bleeding, the tourniquet is always deflated, and meticulous hemostasis is obtained with the use of a bipolar cautery. As stated earlier, by minimizing dissection between the ulnar nerve and artery as well as avoiding

dissection around the ulnar aspect of the nerve, there usually is minimal bleeding. The wound is closed with 5–0 Nylon suture and a penrose drain is placed exiting the wound proximally, if necessary. A volar plaster splint is placed allowing full and unrestricted metacarpophalangeal range of motion. Strict elevation is encouraged for 1 week. We typically leave sutures in place for 10 to 12 days as the proximal aspect of the incision has relatively poor skin perfusion and often requires additional time for healing. Occupational therapy is then prescribed which consists of active and passive range of motion, wound care, nerve gliding exercises, and strengthening as tolerated. Return to full unrestricted activity is typically 4 to 6 weeks postoperatively.

26.8 Tips, Pearls, and Lessons Learned The key pearls for this procedure are identifying the ulnar neurovascular bundle in the proximal wrist initially and then dissecting it distally through the hypothenar fat pad. This allows for prompt and easy identification without obscuring soft tissue planes. Second, avoiding dissection between the ulnar nerve and artery or along the ulnar side of the neurovascular bundle when attempting to identify the deep motor branch. The deep

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Open Ulnar Nerve Decompression at the Wrist motor branch can be reliably identified at the level of the pisohamate ligament as it courses in a predictable radial and distal direction. This can be facilitated by elevating the ulnar artery in this area and looking underneath it, avoiding any unnecessary dissection and possible iatrogenic injury (shown in ▶ Fig. 26.8). Finally, we recommend leaving the sutures in place for 10 to 12 days postoperatively. This allows the most proximal aspect of the wound to heal uneventfully.

26.9 Difficulties Encountered Various branching patterns of the ulnar nerve have been described and this can pose confusion during surgical dissection. Awareness of aberrant and anomalous anatomy are paramount when encountered. In these instances, careful dissection of all neurovascular structures is important from a proximal to distal direction, thereby minimizing iatrogenic injury. In addition, there are many small vessels and larger vinae comitans that run alongside the ulnar nerve and artery. Minimizing dissection of these vessels and coagulating them when necessary is important to avoid vascular insult and minimize postoperative bleeding. By dissecting along the volar and radial aspect of the ulnar artery (and not between it and the ulnar nerve), these vessels are minimally disrupted.

26.10 Bailout, Rescue, and Salvage Options The most significant complication following ulnar tunnel decompression at the wrist is injury to the neurovascular structures. In light of this, and even more importantly when a suspected nerve tumor or space occupying lesion is suspected, microsurgical instruments should be readily available to aid in mobilization of the nerve or its branches and thereby avoid fascicular injury. Finally, if exploring suspected ulnar nerve laceration, a tensionless primary epineural repair should always be performed to maximize recovery. If decompression and potential repair of the ulnar nerve at the wrist is performed in the setting of a more chronic nerve transection, a tensionless primary repair may not be possible due to abundant nerve retraction and scarring. Availability of a nerve conduit or nerve allograft should be confirmed.26 For anticipated larger gaps, or mixed motor and sensory deficits, harvesting of sural nerve autograft may be necessary and will depend on surgeon preference. Finally, if the deep motor branch has been transected, we have found that excision of the hamate hook and transposition of the nerve may be necessary. This not only increases the relative length but can often also facilitate a primary repair.

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References [1] Polatsch DB, Melone CP, Jr, Beldner S, Incorvaia A. Ulnar nerve anatomy. Hand Clin. 2007; 23(3):283–289 [2] Schmidt H-M, Lanz U. Surgical Anatomy Of The Hand. Stuttgart; New York: Thieme; 2004:viii, 259 pp [3] Stopford JS. The variation in distribution of the cutaneous nerves of the hand and digits. J Anat. 1918; 53(Pt 1):14–25 [4] Meals RA, Shaner M. Variations in digital sensory patterns: a study of the ulnar nerve-median nerve palmar communicating branch. J Hand Surg Am. 1983; 8(4):411–414 [5] Ferrari GP, Gilbert A. The superficial anastomosis on the palm of the hand between the ulnar and median nerves. J Hand Surg [Br]. 1991; 16(5): 511–514 [6] McCarthy RE, Nalebuff EA. Anomalous volar branch of the dorsal cutaneous ulnar nerve: a case report. J Hand Surg Am. 1980; 5(1):19–20 [7] Brooks DM. Nerve compression by simple ganglia. J Bone Joint Surg Br. 1952; 34-B(3):391–400 [8] Richmond DA. Carpal ganglion with ulnar nerve compression. J Bone Joint Surg Br. 1963; 45:513–515 [9] Dupont C, Cloutier GE, Prevost Y, Dion MA. Ulnar-tunnel syndrome at the wrist. a report of four cases ulnar-nerve compression at the wrist. J Bone Joint Surg Am. 1965; 47:757–761 [10] Seddon HJ. Carpal ganglion as a cause of paralysis of the deep branch of the ulnar nerve. J Bone Joint Surg Br. 1952; 34-B(3):386–390 [11] Kleinert HE, Hayes JE. The ulnar tunnel syndrome. Plast Reconstr Surg. 1971; 47(1):21–24 [12] Howard FM. Ulnar-nerve palsy in wrist fractures. J Bone Joint Surg Am. 1961; 43-A:1197–1201 [13] Nisenfield FG, Neviaser RJ. Fracture of the hook of the hamate: a diagnosis easily missed. J Trauma. 1974; 14(7):612–616 [14] Fahrer M, Millroy PJ. Ulnar compression neuropathy due to an anomalous abductor digiti minimi-clinical and anatomic study. J Hand Surg Am. 1981; 6(3): 266–268 [15] Failla JM. The hypothenar adductor muscle: an anomalous intrinsic muscle compressing the ulnar nerve. J Hand Surg Am. 1996; 21(3):366–368 [16] Ogino T, Minami A, Kato H, Takahata S. Ulnar nerve neuropathy at the wrist. Handchir Mikrochir Plast Chir. 1990; 22(6):304–308 [17] Greene MH, Hadied AM. Bipartite hamulus with ulnar tunnel syndrome–case report and literature review. J Hand Surg Am. 1981; 6(6):605–609 [18] Milberg P, Kleinert HE. Giant cell tumor compression of the deep branch of the ulnar nerve. Ann Plast Surg. 1980; 4(5):426–429 [19] Grundberg AB. Ulnar tunnel syndrome. J Hand Surg [Br]. 1984; 9(1):72–74 [20] Vanderpool DW, Chalmers J, Lamb DW, Whiston TB. Peripheral compression lesions of the ulnar nerve. J Bone Joint Surg Br. 1968; 50(4):792–803 [21] Belliappa PP, Burke FD. Excision of the pisiform in piso-triquetral osteoarthritis. J Hand Surg [Br]. 1992; 17(2):133–136 [22] Taylor AR. Ulnar nerve compression at the wrist in rheumatoid arthritis. Report of a case. J Bone Joint Surg Br. 1974; 56(1):142–143 [23] Mondelli M, Mandarini A, Stumpo M. Good recovery after surgery in an extreme case of Guyon’s canal syndrome. Surg Neurol. 2000; 53(2): 190–192 [24] Uchida Y, Sugioka Y. Electrodiagnosis of Martin-Gruber connection and its clinical importance in peripheral nerve surgery. J Hand Surg Am. 1992; 17(1): 54–59 [25] Refaeian M, King JC, Dumitru D, Cuetter AC. Carpal tunnel syndrome and the Riche-Cannieu anastomosis: electrophysiologic findings. Electromyogr Clin Neurophysiol. 2001; 41(6):377–382 [26] Melamed E, Polatsch D. Partial lacerations of peripheral nerves. J Hand Surg Am. 2014; 39(6):1201–1203

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27 Endoscopic Ulnar Nerve Decompression Claudia de Cristo, Ludovico Lucenti, and Pedro K. Beredjiklian Abstract Endoscopic cubital tunnel release is a minimally invasive procedure that relieves the compression on the ulnar nerve as it passes through the cubital tunnel. When conservative treatment fails, this procedure is used to relieve the pressure on the ulnar nerve. Keywords: cubital tunnel release, endoscopic release, ulnar nerve, cubital tunnel syndrome, ulnar nerve decompression

27.1 Introduction Cubital tunnel syndrome (CuTS) is a compressive neuropathy of the ulnar nerve at the elbow. It has an estimated incidence of 18 to 25 per 100,000 person-years1 and is the second most common form of nerve entrapment after carpal tunnel syndrome. Anterior transposition of the ulnar nerve (ATUN) was once the accepted gold standard surgical procedure for idiopathic CuTS; however, more recently, simple decompression has steadily gained support.2 The minimal differences in outcomes, higher-complication rates for ATUN,3 and cost effectiveness analyses4 suggest that simple decompression is a favorable surgical procedure for CuTS. Endoscopic cubital tunnel release (ECuTR), the newest surgical option for simple ulnar nerve decompression at the elbow, has been described using a variety of techniques.5

27.2 Description ECuTR, first described by Tsai et al in 1995, is a minimally invasive procedure that utilizes an endoscope for visualization through a small incision.6 It entails a reduced soft-tissue dissection compared with traditional approaches so it potentially allows for a more rapid recovery with minimal scarring.

27.3 Outcome Although ECuTR is minimally invasive and thus should allow faster return to work time, a great number of studies to support this hypothesis are not still available. However patients who underwent ECuTR seemed to have lower complication and higher satisfaction compared with the open ulnar decompression group.7

The first site is within the sulcus on the posterior surface of the medial humeral epicondyle (the sulci nervi ulnaris). The arcuate ligament of Osborne creates a fibro-osseous tunnel, spanning the sulcus between the medial epicondyle and the olecranon. The second site lies approximately 1 cm distal to the sulcus, where the nerve runs and between the two heads of the flexor carpi ulnaris muscle and the medial surface of the humerus.8

27.5 Indications and Contraindications 27.5.1 Indications ECuTR is indicated for patients with ulnar neuropathy at the elbow suspected by history of paresthesia or numbness in the ulnar nerve distribution, with positive physical findings (including Tinel’s sign over the ulnar nerve at the elbow) and elbow flexion-compression test with electrodiagnostical confirmation and unresponsive to conservative treatments.

27.5.2 Contraindications Ulnar nerve instability is considered a contraindication for simple decompression because of the risk of painful instability after decompression that could necessitate revision surgery with ATUN. In fact, for patients with preoperative evidence of ulnar nerve instability at the cubital tunnel or for those who develop ulnar nerve instability after endoscopic decompression, the procedure should be converted into an open subcutaneous or submuscular transposition.

27.5.3 Alternate Procedures Other main surgical methods are basically two: 1. Simple ulnar nerve decompression (with or without medial epicondylectomy).9 2. Subcutaneous, intermuscular, or submuscular anterior ulnar nerve transposition procedures.10 Both techniques were reported in literature in details with similar reported success rates.11

27.6 Operative Detail

27.4 Goals

27.6.1 Preparation—Planning/Special Equipment

The aim of the ECuTR procedure is to relieve the pressure on the ulnar nerve doing a complete release of the compressive structures in the cubital tunnel. Within the cubital tunnel, the ulnar nerve may be compressed at two different locations.

Patient is placed supine with the arm supported on a hand table. The procedure is typically performed under regional anesthesia but it is possible to supplement it with local anesthesia approximately 8 cm proximal to medial epicondyle. Preoperative IV antibiotics are administered 30 minutes before

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Fig. 27.1 Patient is placed supine with the arm supported on a hand table. The arthroscopic tower is placed toward the head of the table.

Fig. 27.2 The small skin incision is made directly posterior to the medial epicondyle. ME, medial epicondyle; OP, olecranon process.

Fig. 27.3 The dissection is taken down to the roof of the cubital tunnel which is incised. The nerve is identified and obturators are used to separate all soft tissue attachments from the nerve.

the incision. A pneumatic tourniquet can be used during the surgery. Standard arthroscopic equipment is used including a 4.0- and a 2.7-mm arthroscopes (▶ Fig. 27.1). Commercially, guides and endoscopic knives are available. Other commercially available spreaders can also be used to release the tunnel.

27.6.2 Technique/Key Steps The skin incision directly posterior to the medial epicondyle is made (▶ Fig. 27.2). Subcutaneous tissues are dissected with care to preserve branches of the medial antebrachial cutaneous nerve. The dissection is taken down to the roof of the cubital tunnel which is then incised along the line of the incision. The nerve is identified. The interval between the nerve and the overlying Osborne’s fascia is created with dissection and obturators, and all soft tissue attachments are freed (▶ Fig. 27.3). The endoscopic equipment is then introduced (▶ Fig. 27.4), and

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Fig. 27.4 The endoscopic equipment is introduced. The nerve is clearly visualized below the guide (black arrow) and separated from the overlying fascia (white asterisk) which will be bisected with a knife.

the overlying fascia is cut with the endoscopic knife while the nerve is visualized. The bisection is carried proximally and distally from the medial epicondyle (▶ Fig. 27.5). Distally, the fascia of the flexor carpi ulnaris muscle is bisected. Once the nerve is fully released, the elbow is taken through a full range of motion in flexion and extension to make sure there is no anterior instability of the nerve.

27.6.3 Risks/What to Avoid An appropriate preparation of the extremity is mandatory to allow for an open transposition if necessary.

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References ●

If there is “perching” (not true dislocation) of the nerve over the lateral epicondyle, the anterior slip of Osborne’s fascia can be sewn into the soft tissues to prevent nerve dislocation.

27.7 Postoperative 27.7.1 Postoperative Care ● ●

Standard wound care. Sling immobilization for a few days, encouraging elbow range of motion.

27.7.2 Complications

Fig. 27.5 The overlying fascia is cut with the endoscopic knife (white handle) while the nerve is visualized. The bisection is carried proximally and distally from the medial epicondyle. Distally, the fascia of the flexor carpi ulnaris muscle is bisected.

Main complications are: ● Hematoma ● Unrecognized nerve instability ● Nerve injury ● Failure of symptom resolution

References Major risks are injury to branches of the medial antebrachial cutaneous nerve and incomplete nerve release. Make sure the nerve is completely visualized while the fascia is being bisected to avoid iatrogenic nerve injury. Eventually, the elbow should be taken through a complete range of motion to make sure there is no nerve instability after the release.

27.6.4 Salvage Sometimes the surgeon may encounter an ulnar nerve instability or other difficulties that were not predicted preoperatively. The need to perform a different procedure like an open ulnar nerve decompression or a subcutaneous or submuscular ulnar nerve transposition should be discussed with the patient prior to surgery.

27.6.5 Tips and Pearls ● ●

●

●

Make the incision slightly proximal to identify the nerve. Placing the lateral aspect of the elbow on a bump can ease dissection. Attempt to bisect Osborne’s fascia on the posterior side to limit anterior nerve subluxation/dislocation. If a thick muscle belly is encountered (anconeus epitrochlearis muscle), an endoscopic release is not feasible, and a conversion to an open decompression or transposition should be performed.

[1] Latinovic R, Gulliford MC, Hughes RA. Incidence of common compressive neuropathies in primary care. J Neurol Neurosurg Psychiatry. 2006; 77(2): 263–265 [2] Malay S, Chung KC, Group SUNS, SUN Study Group. The minimal clinically important difference after simple decompression for ulnar neuropathy at the elbow. J Hand Surg Am. 2013; 38(4):652–659 [3] Caliandro P, La Torre G, Padua R, Giannini F, Padua L. Treatment for ulnar neuropathy at the elbow. Cochrane Database Syst Rev. 2012; 7(7):CD006839 [4] Song JW, Chung KC, Prosser LA. Treatment of ulnar neuropathy at the elbow: cost-utility analysis. J Hand Surg Am. 2012; 37(8):1617–1629.e3 [5] Yoshida A, Okutsu I, Hamanaka I. Endoscopic anatomical nerve observation and minimally invasive management of cubital tunnel syndrome. J Hand Surg Eur Vol. 2009; 34(1):115–120 [6] Tsai TM, Chen IC, Majd ME, Lim BH. Cubital tunnel release with endoscopic assistance: results of a new technique. J Hand Surg Am. 1999; 24(1):21–29 [7] Watts AC, Bain GI. Patient-rated outcome of ulnar nerve decompression: a comparison of endoscopic and open in situ decompression. J Hand Surg Am. 2009; 34(8):1492–1498 [8] Siemionow M, Agaoglu G, Hoffmann R. Anatomic characteristics of a fascia and its bands overlying the ulnar nerve in the proximal forearm: a cadaver study. J Hand Surg Eur Vol. 2007; 32(3):302–307 [9] Hahn SB, Choi YR, Kang HJ, Kang ES. Decompression of the ulnar nerve and minimal medial epicondylectomy with a small incision for cubital tunnel syndrome: comparison with anterior subcutaneous transposition of the nerve. J Plast Reconstr Aesthet Surg. 2010; 63(7):1150–1155 [10] Watchmaker G. Ulnar nerve compression. In: Allieu Y, Mackinnon SE, eds. Nerve Compression Syndromes of the Upper Limb. London: Martin Dunitz; 2002:97–115 [11] Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg Am. 2008; 33(8): 1314.e1–1314.e12

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28 Open Ulnar Nerve Decompression/Subcutaneous Transposition at the Elbow Na Cao and David E. Ruchelsman Abstract Ulnar nerve compression at the elbow is the second most common, compressive, peripheral neuropathy of the upper extremity. When symptoms are recalcitrant to nonoperative treatment, surgical interventions include in situ decompression, decompression with anterior nerve transposition, and medial epicondylectomy. Despite meta-analyses and randomized control trials that have attempted to elucidate the differences between various surgical approaches, the optimal surgical technique remains controversial. We describe our surgical technique for open ulnar nerve decompression at the elbow. Keywords: ulnar nerve, cubital tunnel syndrome, in situ decompression, open decompression, anterior transposition

28.1 Description Many different approaches and surgical techniques have been described to treat ulnar nerve compression at the elbow. Open in situ ulnar nerve decompression was first described in the 1920s.1 It involves step-wise decompression of the ulnar nerve at multiple anatomic sites of potential compression including the arcade of Struthers, medial intermuscular septum, cubital tunnel retinaculum, Osborne ligament, and along the superficial and deep investing fascia of the flexor carpi ulnaris. In select cases, recession of a hypertrophic or snapping medial triceps or division of an anconeus epitrochlearis may be required. Anterior transposition (both subcutaneous and submuscular) aims to prevent dynamic intraneural compression from repetitive elbow flexion. Proponents of transposition highlight that dynamic traction plays a significant role in symptom etiology in addition to static compression. Pearls and pitfalls of decompression and transposition are highlighted below.

28.2 Outcome A recent meta-analysis2 comparing open in situ decompression to subcutaneous or submuscular anterior transposition demonstrated no statistically significant differences in surgical outcomes between techniques; however, there was a strong trend across all included studies toward better results with either subcutaneous or submuscular transposition, with p-values approaching statistical significance. Anterior transposition may result in a higher rate of complications such as sensory loss around scar and superficial infection due to more extensive exposure frequently required for the procedure.3 Staples et al4 recently demonstrated that ulnar nerve transposition increases surgical morbidity due to persistent peri-olecranon paresthesia, greater narcotic consumption, and more patient-reported disability up to 8 weeks after surgery. However, in this series, most differences in surgical morbidity were transient and resolved after 8 weeks following surgery.

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28.3 Indications ● ● ● ● ●

Progressive neurological symptoms (sensory or motor) Persistent medial elbow pain Symptomatic ulnar nerve subluxation and snapping Failed conservative management Preoperative electrodiagnostic studies are helpful in confirming the diagnosis, and grading the severity of the electrophysiological disturbance. In the setting of negative electrodiagnostic studies yet consistent history and exam findings, ulnar nerve decompression is acceptable.

28.4 Positioning and Anesthesia Patients are positioned supine with the arm supported on a hand table. The procedure is typically performed under regional anesthesia. We supplement the regional anesthetic with local anesthesia approximately 8 cm proximal to medial epicondyle to ensure adequate anesthesia within the medial brachial and antebrachial cutaneous nerve territories. Preoperative IV antibiotics are administered according to surgeon preference. A sterile tourniquet is applied to ensure adequate proximal access. An Esmarch bandage is used for exsanguination. A sterile bump may be placed under the elbow and upper arm to allow better visualization of the medial elbow.

28.5 Operative Techniques 28.5.1 Open In Situ Ulnar Nerve Decompression The length of the incision varies based on surgeon preference, though more than 4 to 5 cm are rarely required, based on body habitus and soft tissue compliance. The incision is centered at the medial epicondyle and retrocondylar groove (▶ Fig. 28.1). Full-thickness subcutaneous flaps are elevated off the underlying investing fascia of the medial arm proximal to the medial epicondyle and off the investing fascia of the common flexor origin and flexor-pronator mass distal to the medial epicondyle. Cutaneous sensory nerve branches of the medial brachial (MBCN) and medial antebrachial cutaneous nerves (MABCN) are carefully identified and neurolysed. Osborne ligament is then identified and bisected along the line of the incision. The ulnar nerve typically lies just posterior to the medial epicondyle. Proximal and distal extension of the release can be achieved with deep retractors. Proximally, as much as the Arcade of Struthers is released, while distally the muscle fascia and heads of the flexor carpi ulnaris (FCU) muscle are bisected. Following complete decompression of the ulnar nerve, the elbow should be taken through full range of motion to observe ulnar nerve excursion and to assess

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Operative Techniques

Fig. 28.1 An 8- to 10-cm medial incision centered at the medial epicondyle is planned to facilitate ulnar nerve decompression and transposition.

instability, subluxation, or snapping. Hsu and colleagues5 demonstrated that anterior in situ release creates significantly more total subluxation of the ulnar nerve during ulnohumeral motion than posterior in situ release. When there is significant subluxation or snapping of the ulnar nerve, transposition is carried out as outlined below. Standard layered closure is performed. A sterile soft dressing and long-arm splint (depending on surgeon preference) is applied. Early motion and nerve gliding exercises are initiated during the first week.

Fig. 28.2 A medial brachial cutaneous nerve (MBCN) branch innervating the posterior skin flap proximal to medial epicondyle is neurolysed and protected. In some cases, it may pierce the medial intermuscular septum. Distally, the cubital tunnel retinaculum, Osborne ligament, and the superficial investing fascia between the humeral and ulnar heads of the flexor carpi ulnaris (FCU) are released. The natural raphe between the two heads of the FCU is mobilized and the thick deep investing fascia within the two heads of the FCU that encases the ulnar nerve is released several centimeters distal to the medial epicondyle. Compression of the ulnar nerve with demyelination changes are noted at the retroepicondylar groove (forceps).

28.5.2 Subcutaneous Ulnar Nerve Transposition and Z-Lengthening of the Flexor-Pronator Mass The subcutaneous transposition requires a larger incision than the in situ decompression, with about 8 to 10 cm proximal and 5 cm distal to the medial epicondyle. The ulnar nerve can be identified proximally in the arm posterior to the medial intermuscular septum. There is often an MBCN branch that innervates the posterior skin flap proximal to medial epicondyle and it may pierce the medial intermuscular septum (▶ Fig. 28.2). Three to five branches of the MABCN may be identified along the investing fascia of the flexor-pronator mass. The individual nerve branches can be protected with retractors or vessel loops. By keeping the incision slightly more posterior, the MABCN and its branches can sometimes be protected in the anterior skin flap. The medial epicondyle and medial intermuscular septum are identified (▶ Fig. 28.3). The ulnar nerve is identified along the posterior and inferior margin of the medial intermuscular septum. Retrograde neurolysis of the ulnar nerve can now be completed including generous release of the arcade of Struthers proximally. Distally, the nerve is dissected through its passage into the forearm by the two FCU heads. We attempt to leave as much of the longitudinal extrinsic blood supply and vasa vasorum with the nerve. The cubital tunnel retinaculum,

Fig. 28.3 The medial epicondyle and medial intermuscular septum (forceps) are identified. The ulnar nerve is identified along the posterior and inferior margin of the medial intermuscular septum.

Osborne ligament, and the superficial investing fascia between the humeral and ulnar heads of the FCU are released. The natural raphe between the two heads of the FCU is mobilized and the thick deep investing fascia within the two heads of the FCU that encases the ulnar nerve is released several centimeters distal to the medial epicondyle. Preservation of the anterior and posterior motor branches of the ulnar nerve at this level is paramount.

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Open Ulnar Nerve Decompression/Subcutaneous Transposition at the Elbow ●

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Generous release of the deep investing fascia within the two heads of the FCU minimizes the potential for ulnar nerve kinking at the distal extent of the decompression. Neurolysis of the motor branches to their takeoff assists in achieving tension-free anterior transposition.

28.6 Postoperative Rehabilitation The elbow is usually immobilized for 7 to 10 days in midflexion and with the forearm and wrist in neutral. Early motion and nerve gliding exercised are initiated, and the postoperative splint is weaned based on comfort. Progressive strengthening is initiated at 6 weeks postoperatively. Full unrestricted activities are achieved around 3 months postoperatively.

Fig. 28.4 A 360-degree neurolysis of the ulnar nerve is now completed. A Penrose drain is used to help mobilize the ulnar nerve from its native bed. Neurolysis of the motor branches to their takeoff assists in achieving tension-free anterior transposition.

Following “top-side” neurolysis as outlined above, the medial intermuscular septum is fully excised for several centimeters. The attachments of the soft tissues onto the flexor pronator fascia are elevated anteriorly to remove any potential sites of nerve kinking once the nerve is transposed. Meticulous hemostasis is maintained and the posterior venous plexus along the posterior-inferior margin of the septum should be protected. A 360-degree neurolysis of the ulnar nerve is now completed. A Penrose drain may be used to help mobilize the ulnar nerve from its native bed (▶ Fig. 28.4). The longitudinal extrinsic blood supply to the ulnar nerve can be maintained with the nerve usually up to the level of the medial epicondyle. Neurolysis of the motor branches to their takeoff assists in achieving tension-free anterior transposition. The anterior position of the nerve can then be maintained in a variety of ways, from creating a tunnel by suturing the deep subcutaneous tissues onto the medial epicondylar tissues or creating a generous fascialdermal sling from the flexor pronator fascia. Standard layered closure is performed. A sterile soft dressing and long-arm splint (depending on surgeon preference) is applied.

28.5.3 Key Procedural Steps: Pearls, Pitfalls, and Lessons Learned ●

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Neurolysis of the MBCN and MABCN branches in the fullthickness anterior subcutaneous flap facilitates mobilization of the skin flap anteriorly during exposure for transposition. Once the cutaneous branches are neurolysed and elevated within the full-thickness skin flap, the flap can be further elevated safely from the anterior surface of the medial intermuscular septum prior to exposure of the ulnar nerve in transposition procedures. Look for MBCN branches traversing or piercing the medial intermuscular septum proximal to medial epicondyle. The venous plexus along the posterior-inferior margin of the medial intermuscular septum should be preserved or meticulously cauterized during transposition.

28.7 Complications ●

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Neuroma formation of the medial antebrachial cutaneous nerve is a relatively common complication after ulnar nerve decompression at the elbow. Sarris et al6 reported up to 40% of patients with persistent elbow pain after ulnar nerve decompression at the elbow had intraoperative findings of MABCN neuroma during revision surgery. Initial treatment usually starts with nonoperative techniques such as systemic or topical anti-inflammatories, massage, nerve stimulation, and desensitization therapy. However, if pain persists longer than 6 months, operative exploration and subsequent nerve resection, relocation and burial in muscle, repair or reconstruction can be carried out. Ulnar nerve instability should be assessed during surgery and can be addressed with anterior transposition. UCL injury.

28.8 Failed Ulnar Nerve Decompression at the Elbow Outcomes following ulnar nerve decompression are generally favorable. In a study that examined 25,977 patients using Medicare data,7 the incidence of failed ulnar nerve decompression requiring revision surgery was 1.4%. The revision rate following in situ decompression ranges from 3.2 to 19%.8,9 Even though the rate of revision surgery after anterior transposition has not been specifically reported, subcutaneous transposition accounted for 60 to 80% of the failures in a published series of failed ulnar nerve decompression.10,11,12,13,14 Failure of ulnar nerve decompression at the elbow can be attributed to various preoperative, Intraoperative, and postoperative factors.15 Preoperative factors begin with inaccurate clinical diagnosis and incomplete evaluation of more proximal locations (i.e., cervical roots or brachial plexus), or more distal location (i.e., Guyon’s canal). It has been reported in a cross-sectional study that approximately 69% of people with ulnar nerve symptoms had concurrent medium nerve symptoms.16 Patient expectations must be managed regarding anticipated outcomes when the nerve is severely compressed based on clinical and electrophysiological criteria. Intraoperative factors include inadequate decompression, ulnar nerve instability and injury to medial antebrachial

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References cutaneous nerves, ulnar collateral ligament and motor branches of the ulnar nerve. Postoperative causes of failed surgery include perineural scarring and elbow stiffness. Perineural scarring can be a result from inadequate decompression or poor placement of the nerve after transposition. Intramuscular transposition may subject the ulnar nerve to repetitive traction during elbow range of motion that can result in perineural fibrosis.11,17 Risk factors for revision surgery include history of elbow fracture/dislocation, age younger than 50 at the time of index surgery, obesity, tobacco use, hyperlipidemia, diabetes, chronic liver disease, chronic anemia, and hypercoagulable state.7,8,9 Revision surgery has been shown in many retrospective studies to yield satisfactory outcomes, especially in younger patients and those with lower initial McGowan grades.12,13,17 However, patients who underwent revision surgery18 tend to experience incomplete relief of symptoms and changes in McGowan grading after surgery. Factors that might predispose patients to less favorable results include EMG findings of denervation, prior submuscular transposition, higher McGowan grades, and older age.12,13,17

References [1] Sargent P, Buzzard E. Some varieties of traumatic and toxic ulnar neuritis. Brain. 1922; 45(1):133 [2] Macadam SA, Gandhi R, Bezuhly M, Lefaivre KA. Simple decompression versus anterior subcutaneous and submuscular transposition of the ulnar nerve for cubital tunnel syndrome: a meta-analysis. J Hand Surg Am. 2008; 33(8): 1314.e1–1314.e12 [3] Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. 2005; 56 (3):522–530, discussion 522–530

[4] Staples R, London DA, Dardas AZ, Goldfarb CA, Calfee RP. Comparative morbidity of cubital tunnel surgeries: a prospective cohort study. J Hand Surg Am. 2018; 43(3):207–213 [5] Hsu PA, Hsu AR, Sutter EG, et al. Effect of anterior versus posterior in situ decompression on ulnar nerve subluxation. Am J Orthop. 2013; 42(6): 262–266 [6] Sarris I, Göbel F, Gainer M, Vardakas DG, Vogt MT, Sotereanos DG. Medial brachial and antebrachial cutaneous nerve injuries: effect on outcome in revision cubital tunnel surgery. J Reconstr Microsurg. 2002; 18(8):665–670 [7] Camp CL, Ryan CB, Degen RM, Dines JS, Altchek DW, Werner BC. Risk factors for revision surgery following isolated ulnar nerve release at the cubital tunnel: a study of 25,977 cases. J Shoulder Elbow Surg. 2017; 26(4):710–715 [8] Krogue JD, Aleem AW, Osei DA, Goldfarb CA, Calfee RP. Predictors of surgical revision after in situ decompression of the ulnar nerve. J Shoulder Elbow Surg. 2015; 24(4):634–639 [9] Gaspar MP, Kane PM, Putthiwara D, Jacoby SM, Osterman AL. Predicting revision following in situ ulnar nerve decompression for patients with idiopathic cubital tunnel syndrome. J Hand Surg Am. 2016; 41(3):427–435 [10] Vogel RB, Nossaman BC, Rayan GM. Revision anterior submuscular transposition of the ulnar nerve for failed subcutaneous transposition. Br J Plast Surg. 2004; 57(4):311–316 [11] Broudy AS, Leffert RD, Smith RJ. Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation. J Hand Surg Am. 1978; 3(1):85–89 [12] Gabel GT, Amadio PC. Reoperation for failed decompression of the ulnar nerve in the region of the elbow. J Bone Joint Surg Am. 1990; 72(2):213–219 [13] Caputo AE, Watson HK. Subcutaneous anterior transposition of the ulnar nerve for failed decompression of cubital tunnel syndrome. J Hand Surg Am. 2000; 25(3):544–551 [14] Mowlavi A, Andrews K, Lille S, Verhulst S, Zook EG, Milner S. The management of cubital tunnel syndrome: a meta-analysis of clinical studies. Plast Reconstr Surg. 2000; 106(2):327–334 [15] Ruchelsman DE, Lee SK, Posner MA. Failed surgery for ulnar nerve compression at the elbow. Hand Clin. 2007; 23(3):359–371, vi–vii [16] An TW, Evanoff BA, Boyer MI, Osei DA. The prevalence of cubital tunnel syndrome: a cross-sectional study in a U.S. Metropolitan Cohort. J Bone Joint Surg Am. 2017; 99(5):408–416 [17] Rogers MR, Bergfield TG, Aulicino PL. The failed ulnar nerve transposition: etiology and treatment. Clin Orthop Relat Res. 1991(269):193–200 [18] Aleem AW, Krogue JD, Calfee RP. Outcomes of revision surgery for cubital tunnel syndrome. J Hand Surg Am. 2014; 39(11):2141–2149

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29 Submuscular Ulnar Nerve Transposition Marc J. Richard and Patrick A. Holt Abstract Ulnar nerve compression at the elbow typically causes symptoms including numbness in the ring and small fingers, and potentially weakness in the hand with loss of grip strength. While patients with minimal symptoms may be treated nonoperatively, those patients with severe or progressive symptoms usually require surgical intervention. A number of treatment options exist for patients with cubital tunnel syndrome including ulnar nerve decompression with or without nerve transposition. This chapter describes ulnar nerve decompression and submuscular nerve transposition. Keywords: ulnar nerve, decompression, neurolysis, transposition, submuscular, cubital tunnel, elbow nerve compression

29.1 Key Principles A complete release of the ulnar nerve at all potential sites of compression is critical, including adequate release of the following: ● Arcade of struthers ● Osborne’s fascia ● Medial intermuscular septum ● Superficial and deep fascia overlying the two heads of flexor carpi ulnaris (FCU) Additional more rare sites of compression including cysts or an anconeus epitrochlearis must be identified and adequately addressed if present.1 After adequate decompression, if the ulnar nerve is unstable and subluxates over the medial epicondyle, an anterior transposition is performed. Close attention should be paid to ensure that after transposition, the nerve is free to glide smoothly and that the transposition itself does not act as an additional point of compression. Several techniques for placement of the nerve and securing the transposition have been described. The ulnar nerve can be positioned superficial, intramuscular, or submuscular depending upon the clinical scenario and surgeon preference. The remainder of this chapter will review the intramuscular and submuscular transposition options, which are reliable surgical techniques that provide symptomatic relief.2

29.3 Clinical Findings and Indications This procedure is indicated in patients with clinically identifiable ulnar nerve compression at the elbow. Most surgeons reserve submuscular transposition for severe compressive neuropathy or for revision cases. Clinical findings of ulnar nerve compression are variable but typically include diminished sensation in the ulnar nerve distribution of the hand including the small and ulnar half of the ring fingers. Compression of the ulnar nerve at the elbow also produces decreased sensation in the distribution of the dorsal cutaneous branch that innervates the dorsal ulnar skin of the hand. Other physical exam signs consistent with ulnar nerve compression at the elbow may include but are not limited to a positive Tinel’s sign at the elbow, a positive flexion-compression test, mechanical snapping of the nerve over the medial epicondyle, Froment’s sign, Wartenberg’s sign as well as intrinsic wasting. Nonoperative treatment may be attempted including night splinting with the elbow held in relative extension to relieve pressure on the nerve.3 In cases where the diagnosis is unclear, obtaining electrodiagnostic studies is reasonable to differentiate cubital tunnel syndrome from other pathologies.

29.4 Contraindications and Considerations It is critical to rule out other conditions that may mimic the symptoms of cubital tunnel syndrome, including: ● Cervical radiculopathy ● Peripheral neuropathy ● Ulnar tunnel syndrome ● Carpal tunnel syndrome ● Thoracic outlet syndrome Careful physical examination, electrodiagnostic studies, and appropriate imaging can assist the surgeon in eliminating other potential pathologies. Additionally, if patients present with ulnar nerve compression at the elbow, but no symptomatic nerve instability is noted, an ulnar nerve in situ decompression without nerve transposition may be an appropriate procedure.

29.2 Expectations Ulnar nerve decompression with submuscular nerve transposition provides a release of the ulnar nerve and a relocation of the nerve to prevent painful and symptomatic subluxation of the nerve over the medial epicondyle. The duration and severity of ulnar nerve compression at the elbow can influence the time course for ulnar nerve recovery. Typically, this procedure is well tolerated and provides decompression and stabilization of the nerve, leading to return of function and symptomatic relief.

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29.5 Special Instructions, Positioning, and Anesthesia ●

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This is typically an outpatient procedure and patients can plan for discharge after recovery in the postoperative area. Supine position. Hand Table. An upper arm tourniquet is used with care taken to avoid interference with the operative field. Depending upon the

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Key Procedural Steps

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patient’s body habitus, a sterile tourniquet may be preferred if there is any concern. Regional anesthesia with a brachial plexus nerve block is typically used to avoid the side effects associated with general anesthesia.

29.6 Tips, Pearls, and Lessons Learned ●

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Care should be taken to identify and protect the medial antebrachial cutaneous nerve as injury to these branches may result in a painful neuroma. The ulnar nerve is most easily identified proximal to the elbow. Because there are no major branches proximal to the elbow, it is also safest to dissect in this area. The medial intermuscular septum runs longitudinally through the brachium between the anterior and posterior compartments. It inserts on the medial epicondyle. The ulnar nerve lies just posterior to the medial intermuscular septum. Use of a vessel loop or Penrose drain around the nerve can aid in gentle retraction of the nerve during decompression. The superior ulnar collateral artery travels with the ulnar nerve proximal to the medial epicondyle. It is one of the major extrinsic pedicles to the ulnar nerve and should be preserved. The ulnar nerve proper has motor branches to the FCU that should be preserved. The FCU fascia commonly has both superficial and deep layers that both must be released in order to adequately decompress the ulnar nerve. Alternatively, only the superficial fascia should be incised and the nerve placed in an intramuscular fashion within the FCU muscle belly. After nerve transposition, the elbow should be evaluated over a complete range of flexion and extension to check for nerve stability.

29.7 Difficulties Encountered ●

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Care must be taken during the initial preparation of the surgical site to place the tourniquet as proximal as possible on the limb to avoid the tourniquet interfering with the surgical dissection. When excising the intermuscular septum, care must be taken to not deviate too far away from the septum as there are several large bleeding veins that can be easily injured and will complicate surgical visualization. Also, the median nerve courses just anterior to the medial intermuscular septum at the proximal end of the dissection and is at risk with blind dissection. The motor branch to FCU can sometimes be a tether that prevents anterior transposition of the ulnar nerve proper. If the motor branch is dissected distally as it enters into the FCU, this additional dissection typically should provide for enough length and excursion for the ulnar nerve to be adequately transposed.

29.8 Key Procedural Steps The procedure is divided into three parts: approach, decompression, and transposition.

29.8.1 Approach The initial incision involves making a curvilinear incision centered directly posterior to the medial epicondyle and curving anteriorly both proximally and distally. A #15 blade is used until subcutaneous fat is visible proximal to the medial epicondyle. Gelpi retractors are placed and tenotomy scissors are used to dissect through the subcutaneous fat until fascia is encountered. Hemostasis is achieved with bipolar cautery. The dissection is then carried distally, taking care to protect the medial antebrachial cutaneous nerve branches that are found at the level of the fascia.

29.8.2 Decompression After the ulnar nerve is carefully approached and identified, the decompression of the nerve is undertaken. It is typically easiest to first palpate the ulnar nerve for localization. The nerve can be reproducibly found just proximal to the medial epicondyle and posterior to the intermuscular septum. Using Adson forceps and tenotomy scissors, the nerve is traced and decompressed proximally with care taken to maintain an extra-neural plane. As the nerve is traced proximally and the Arcade of Struthers is identified, a handheld retractor is placed and the surgical assistant can lift up on the overlying soft tissue envelope. Debakey forceps can be placed deep to the Arcade of Struthers to gently depress the nerve, and with a combination of blunt finger dissection and tenotomy scissors, the fascia is released. With the nerve released proximally, attention is turned to the cubital tunnel and distal. On rare occasion, an anomalous anconeus epitrochlearis muscle is identified and can be removed. A Penrose drain or vessel loop is placed to allow gently manipulation of the ulnar nerve for soft tissue dissection purposes. Osborne’s fascia is released at the elbow and the nerve is traced distally. The motor branch of FCU is encountered and is dissected free to the FCU. This will assist in mobility of the ulnar nerve for anterior transposition. The ulnar nerve is followed until it enters the FCU and the nerve is decompressed between the two heads. Both the superficial and deep fascia are released. The medial intermuscular septum is identified just proximal to the medial epicondyle. Taking care not to injure the veins that are commonly found in close proximity to the septum, the medial intermuscular septum is traced proximally and resected.

29.8.3 Transposition The final part of the procedure involves submuscular transposition of the ulnar nerve. Care is taken to ensure that the nerve is adequately decompressed and mobilized prior to attempting to transpose the nerve. An Army-Navy retractor is used to retract the soft tissue over the flexor-pronator wad and a combination of blunt and sharp dissection is used to clear soft tissue away from the flexor-pronator wad. A z-plasty incision is made in the flexor-pronator wad approximately 1 cm distal to the origin. This is performed in the tendinous portion of the origin and allows for repair over the nerve with slight elongation to avoid compression. The flexor-pronator wad is then carefully elevated distally at the level of the FDS muscle. This is a natural plane with loose areolar tissue present. The median nerve and brachial

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Submuscular Ulnar Nerve Transposition

Fig. 29.1 Submuscular anterior transposition of the ulnar nerve.

Fig. 29.3 The superior flap is elevated from ulnar to radial until the vertical fibers of the brachialis are seen. The nerve is then transposed into the submuscular plane and should approximate a longitudinal course without proximal or distal kinking and run in parallel to the anticipated course of the median nerve. (This image is provided courtesy of Dr. David Ruchelsman.)

artery lie in this plane and care must be taken to avoid injury to these structures. The ulnar collateral ligament must also be protected during this dissection. Next, the ulnar nerve is translocated anteriorly to this position (▶ Fig. 29.1). The flexor-pronator mass is carefully reapproximated over the ulnar nerve using 3–0 nonabsorbable sutures in figure-of-eight format. The z-plasty allows for slight lengthening of the repair such that the nerve is not compressed. The elbow is then taken through range of motion in full flexion and extension to ensure that the ulnar nerve is not tethered and smooth gliding occurs without tension. Another alternative is to place the ulnar nerve in the intramuscular plane. For this variation, the flexor-pronator mass is identified and a Z-shaped myofascial incision is designed (▶ Fig. 29.2). The superior flap is elevated from ulnar to radial until the vertical fibers of the brachialis are seen (▶ Fig. 29.3). The distal flap is elevated from radial to ulnar.

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Fig. 29.2 The flexor-pronator mass is identified and a Z-shaped myofascial incision is designed. The superior flap is elevated from ulnar to radial, and the distal flap is elevated from radial to ulnar. (This image is provided courtesy of Dr. David Ruchelsman.)

The underlying flexor musculature is released proximal to distal to maintain innervation. The T-shaped vertical intermuscular septal plate is sharply excised. The ulnar collateral ligament at the most posterior aspect of the flexor pronator mass is preserved. The tourniquet is deflated and hemostasis is obtained with bipolar cautery. The surgical site is irrigated with normal saline. Subcutaneous tissue is closed with 3–0 absorbable suture and the skin is closed with either a running 4–0 absorbable suture or interrupted 4–0 nylon sutures. A drain is placed if there is concern for hematoma formation. The elbow is immobilized at 60 degrees of flexion for 2 weeks. The wrist is included in the initial postoperative splint to avoid tension of the flexorpronator repair. At 2 weeks, the sutures are removed and progressive mobilization of the elbow is initiated with a goal of complete extension by 6 weeks postoperatively.

29.8.4 Complications ●

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Medial antebrachial nerve injury with neuroma formation can be debilitating and a common reason for reoperation in these patients. UCL injury.

References [1] Eberlin KR, Marjoua Y, Jupiter JB. Compressive neuropathy of the ulnar nerve: a perspective on history and current controversies. J Hand Surg Am. 2017; 42 (6):464–469 [2] Zimmerman RM, Jupiter JB, González del Pino J. Minimum 6-year follow-up after ulnar nerve decompression and submuscular transposition for primary entrapment. J Hand Surg Am. 2013; 38(12):2398–2404 [3] Shah CM, Calfee RP, Gelberman RH, Goldfarb CA. Outcomes of rigid night splinting and activity modification in the treatment of cubital tunnel syndrome. J Hand Surg Am. 2013; 38(6):1125–1130.e1

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30 Partial Wrist Denervation For Chronic Wrist Pain Mikhail Zusmanovich, Michael Aversano, Nader Paksima, and Michael E. Rettig Abstract Diagnosis and treatment of chronic wrist pain is challenging. Treatment has traditionally been focused on elimination of the source of the chronic pain with wrist reconstruction. Partial wrist denervation is an alternative surgical procedure. Neurectomy of the posterior and anterior interosseous nerve can decrease chronic wrist pain without compromising wrist anatomy and function.

in 1965.5 Denervation has been utilized with increasing frequency as an alternative to salvage procedures and has been associated with good-to-excellent outcomes in patients with chronic wrist pain from various etiologies. A complete wrist denervation includes branches of the radial and ulnar nerves and the anterior and posterior interosseous nerves, while a partial denervation addresses the anterior and posterior interosseus nerves (▶ Fig. 30.1).

Keywords: chronic wrist pain, wrist denervation, anterior interosseous nerve, posterior interosseous nerve

30.2 Key Principles

30.1 Introduction Wrist pain remains a challenge in both diagnosis and treatment. The complex carpal kinematics, coupled with the anatomic intricacies, and variable injury patterns often present difficulty in evaluating and treating patients in a manner that minimizes disability and decreases or eliminates pain. Chronic wrist pain can result from multiple pathologies including scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), scaphoid trapezial trapezoid arthritis, Kienbock’s disease, posttraumatic arthritis after distal radius fracture, and inflammatory arthropathies such as rheumatoid arthritis.1 Traditional surgical management for these conditions is focused on elimination of the source of pain whether by means of resection, arthroplasty, or arthrodesis. These treatment methods have met with variable success2,3,4 because these surgical procedures alter the anatomy and biomechanics of the wrist, which can compromise ultimate recovery. Wrist denervation, which does not alter the gross anatomy or kinematics of the carpus, was first described by Wilhelm

Wrist denervation is an alternative for patients unwilling or unable to undergo reconstructive procedures with the potential for higher morbidity and uncertain relief of wrist pain. Furthermore, wrist denervation maintains carpal anatomy and wrist biomechanics while denervating carpal sensory branches and maintaining motor function.

30.3 Expectations Incomplete pain relief remains possible after partial wrist denervation procedures and should be discussed with patients. There can sometimes be minimal pain relief or increased pain after a wrist denervation procedure. However, if the wrist denervation procedure is unsuccessful, a more traditional wrist salvage procedure can still be completed in an effort to relieve wrist pain. Preoperative diagnostic anesthetic injections can give a rough approximation of how much pain relief the patient is likely to experience after surgical denervation. Wrist denervation has progressed from the extensive or complete wrist denervation offered in the 1960s to a more conservative and minimalistic approach. The results appear to be

Fig. 30.1 Technique of wrist denervation with five incisions seen from (a) palmar and (b) dorsal. Incision 1 is made on the radiopalmar side over the radius styloid between the brachioradialis and flexor carpi radialis to expose the anterior interosseous nerve (AIN) and the superficial branch of the radial nerve. Incision 2 is made over the Lister tubercle to expose the posterior interosseous nerve (PIN). Incision 3 is over the ulnar border of the ulnar head, exposing the dorsal branch of the ulnar nerve. Incision 4 is placed dorsally at the base of the first interosseous space, exposing the recurrent branch of the dorsoradial nerve of the index finger. Incision 5 is located over the base of the index–middle interosseous spaces to expose recurrent branches. (c) Performing a limited/partial wrist denervation, the anterior interosseous nerve may be resected from dorsally through the interosseous membrane. (Reproduced with permission from David J. Slutsky and Joseph F. Slade. The Scaphoid, 1st edition © 2010 Thieme.)

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Partial Wrist Denervation For Chronic Wrist Pain consistent with approximately 65 to 75% of patients experiencing good or excellent pain relief.6,7,8,9,10,11 Though only 45 to 50% of patients experience complete pain relief, most patients experience a level of pain relief that allows improved wrist function and improved ability to participate in activities of daily living. As many as 73% of patients are able to return to work.11 Only 8 to 10% of patients have increased pain after surgery and are then recommended to undergo a more extensive reconstructive surgical procedure.9 The outcomes data is based on studies that were for the most part completed in single institutions by one or two surgeons. There are no published prospective or randomized studies; therefore, results may be dependent on individual skill and experience of the surgeon. Long-term complications are rare. Some patients describe parenthesis and sensory disturbances, but they are usually transient and generally do not persist past 6 months postoperatively. Wrist denervation resulting in a neuropathic joint has not been reported.

30.4 Indications Wrist arthropathy and subsequent chronic pain can result from avascular necrosis as in Keinbock’s disease, inflammatory arthropathy, or it can be a consequence of trauma to the distal radius, carpus, or injury to the extrinsic or intrinsic wrist ligaments that can lead to SNAC or SLAC. When symptoms are severe, they can cause substantial loss of wrist and upper extremity function and diminish the ability of patients to perform activities of daily life and to be gainfully employed. Wrist denervation procedures are usually offered to skeletally mature patients with severe, chronic pain unresponsive to conservative management with at least a somewhat functional wrist range of motion.1,12

30.5 Contraindications In cases of severe range of motion deficits and wrist deformity, arthroplasty and/or resection may be more appropriate for long-term pain relief and restoration of wrist function. Absolute contraindications for denervation include active infection and more acute conditions that could be managed nonoperatively.1 Patient-specific concerns such as poor compliance, unrealistic expectation, or patient desire for a more definitive surgical procedure must also be addressed.

30.6 Anatomy The sensory innervations patterns of the wrist and carpal joints are complex and variable. Hilton’s law originally described in the 1800s states that the nerve supplying the muscles extending across and acting at a given joint also innervates that particular joint.13 While this remains true and multiple small peripheral nerves innervate virtually every carpal articulation, these small nerves can be cumbersome to

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identify and surgically challenging to directly target for localized pain relief. Hence the anterior interosseous nerve and the posterior interosseous nerve are the common targets of denervation at sites distal to their motor innervation.

30.6.1 Anterior Interosseous Nerve The anterior interosseous nerve (AIN) arises 5 to 8 cm distal to the lateral epicondyle from the median nerve. It initially passes between the two heads of the pronator teres and then runs along the volar surface the flexor pollicis longus and along the interosseous membrane on its way to the pronator quadratus (PQ) which is the terminal muscle innervated by the motor fibers of the AIN. Close to the wrist joint, the AIN passes deep to the PQ to supply the periosteum of the radius, ulna, and carpal bones, and sends a branch to the capsule of the wrist joint.14 The relationship to the PQ is extremely important due to the potential for denervating the motor function during sensory denervation procedures. The distal branch point of the AIN on the PQ is on average 5.5 cm from the radial styloid, 4.8 cm from the scaphoid facet, and 4.2 cm from the ulnar styloid.15 Distally, there are commonly two or three branches off the AIN that innervate the PQ. The most distal branch converges 2.4 cm from the articular edge of the distal radius.16 During wrist denervation procedures, this relationship is critical to maintain motor function of the PQ.

30.6.2 Posterior Interosseous Nerve The posterior interosseous nerve (PIN) originates from the radiohumeral joint line and initially courses through the arcade of Frosche at the radial head before diving under the supinator. It then winds around the radial neck to the posterior compartment of the arm until it reaches the posterior compartment of the forearm. There it sends muscular branches to the abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor pollicis longus (EPL), and extensor indicis, and finally sends terminal branches to the wrist joint and periosteal branches to the interosseous membrane, radius, and ulna.14 At the distal aspect of the forearm and wrist level, the PIN is much smaller than the AIN and typically courses dorsally along with the posterior interosseous artery in the floor of the fourth compartment. Grechenig evaluated the relationship of the PIN to three points 6, 8, and 10 cm proximal to the radial styloid and found the PIN to be 3.4, 5.8, and 3.75 mm from the ulnar edge of the radius, respectively.14 Distal to the radiocarpal joint, the PIN divides into three or four branches to supply the intermetacarpal joints and the second, third, and fourth carpometacarpal joints.17

30.7 Presurgical Diagnostic Testing Patients presenting with chronic wrist pain are initially thoroughly evaluated to determine the precise etiology of the wrist

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Surgical Procedure pain. A complete physical exam is necessary to discern the cause of pain as being distal and related to radiocarpal joint pathology, and not more proximal as in median or radial nerve compression neuropathy.

30.8 Surgical Procedure

Imaging to determine the degree of arthritis or collapse is imperative in surgical planning. Plain radiographs of the hand and wrist are recommended. MRI and CT scan may provide a useful adjunct in patients with normal appearing radiographs to demonstrate pathology.

If injections into the PIN and AIN provide the patient with pain relief, wrist denervation should be considered. Many authors have described various procedures and the associated outcomes of the procedure since Wilhelm’s first publication in 1965 which involved multiple incisions and the denervation of greater than eight articular nerve branches.5 However, due to the morbidity of this procedure, many surgeons have described less invasive exposures with excision of the posterior and anterior interosseous nerves only with good-to-excellent outcomes.

30.7.2 Injections

30.8.1 Dorsal Approach

Preoperative diagnostic injections can be somewhat helpful to determine if denervation of the distal branches of the AIN and PIN will provide pain relief to the patient and can be completed prior to any definitive surgical management.1 Though pain relief after injections as a means for indication for denervation procedures is controversial,7,11 most agree that injections provide a good negative predictive value. Several methods have been described in regard to wrist injections.18,19 Storey et al recommended five injection sites to denervate the palmar cutaneous branch of the median nerve, the articular branches of the radial nerve, the dorsal cutaneous nerve of the ulnar nerve, the PIN, and the AIN.19 Presently, many surgeons have focused on surgically denervating the AIN and PIN alone, so for indications purposes it is more relevant to determine outcomes after injecting these two nerves in isolation. In a cadaver study, Grutter et al evaluated methods to inject the AIN and PIN and found that a 100% accuracy for both nerves can be achieved based on anatomic landmarks.18 They recommended using a 25-gauge needle and advancing from dorsal to volar starting 1-cm ulnar and 3-cm proximal to Lister’s tubercle. The needle should be advanced until slight resistance is encountered at the level of the interosseous membrane. The needle should be slightly withdrawn and anesthetic injected to block the PIN. The needle should then be advanced past the interosseous membrane at which point a pop will be felt and the remainder of the anesthetic should be injected to block the AIN.

Berger has described a single incision dorsal approach which provided a means for denervating both the AIN and the PIN20 (▶ Fig. 30.2). A single 3- to 4-cm incision is centered between the radius and the ulna and extended proximal from approximately 1 fingerbreadth proximal to the ulnar head. The musculotendinous junctions of the extensor digitorum cominus and the extensor indicis proprius are identified. The tendons are gently separated exposing the interosseous membrane. The PIN is visualized on the dorsal surface of the membrane and a 2-cm segment of nerve is excised. A longitudinal incision is then made in the interosseous membrane. This exposes the dorsal surface of the PQ. The AIN branches to the wrist capsule lie within 1 mm of the dorsal PQ, which is then excised providing sensory denervation but maintaining motor function to the PQ.

30.7.1 Imaging

Ultrasound Guidance Many physicians also rely on ultrasound as an adjunct to visualize the interosseous membrane and aid in accuracy of the injection in both the dorsal and volar compartments. Anecdotally, this improves accuracy and patient satisfaction after the procedure. To our knowledge, there is no literature to compare the accuracy of ultrasound to anatomical landmarks when performing these injections.

30.8.2 Volar Henry Approach An incision is made on the radial border of flexor carpi radialis (FCR) until just proximal to the proximal wrist crease. The FCR tendon sheath is incised and the FCR is retracted ulnarly and subsequently the dorsal tendon sheath is incised. Underneath the dorsal sheath is the FPL, which should be retracted ulnarly. The PQ is then visualized and the distal capsular nerve fibers can be identified and excised. A longitudinal incision is then made in the interosseous membrane. An ideal incision zone is located 8-cm proximal to the radial styloid and 1-cm proximal to the proximal border of the PQ. This zone minimized risks of arterial damage and motor denervation of the PQ.14 The PIN may then be visualized and excised.

30.8.3 Volar Ulnar Approach This approach uses the plain between the ulnar artery and nerve and the tendons of the flexor digitorum superficialis (FDS) (▶ Fig. 30.3). The incision starts at the wrist crease and runs proximally parallel to the ulna. The interval between the

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Fig. 30.2 Dorsal approach for wrist denervation. AIN, anterior interosseous nerve; PIN, posterior interosseous nerve; EDC, extensor digitorum cominus; EIP, extensor indicis proprius; IM, interosseous membrane; PIA, posterior interosseous artery. (a) Incision for dorsal approach. (b) Superficial dissection demonstrates the interval between the EDC and EIP. (c) EDC and EIP are retracted demonstrating the PIN. (d) The PIN is demonstrated on the dorsal surface of the interosseous membrane with a fatty layer of tissue signifying the presence of the AIN on the volar surface of the interosseous membrane. (e) Longitudinal incision through the interosseous membrane demonstrates the AIN.

ulnar artery and FDS tendons is developed and the tendons are retracted ulnarly and radially, respectively. The PQ is then visualized and the terminal branches of the AIN can be excised. The pronator can be retracted radially and a small longitudinal incision can be made 5-mm radial to the ulnar artery along the fat encasing the PIN, which can be seen on the dorsal surface of the interosseous membrane. A segment of the PIN can then be excised.

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30.9 Pitfalls The most vexing problem with the wrist denervation procedures involves variable outcomes and the presence of persistent symptoms in spite of surgical intervention. Local bleeding from transection of the anterior and posterior interosseous arteries can occur and limit visualization. Careful hemostasis should be obtained at the time of nerve transection.

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References

Fig. 30.3 Volar ulnar approach for wrist denervation. AIN, anterior interosseous nerve; PIN, posterior interosseous nerve; C, capsular branches from AIN; F, flexor tendons; U, ulnar artery; IM, interosseous membrane; Q, pronator quadratus. (a) Incision for volar ulnar volar approach. (b) Superficial dissection demonstrates the interval between the flexor digitorum superficialis (FDS) and the ulnar artery and nerve. (c) FDS and ulnar vasculature retracted demonstrate the AIN intervention of the PQ. (d) Elevation of the PQ demonstrates the interosseous membrane, the AIN motor branches, as well as the distal capsular branch. (e) Longitudinal incision through the interosseous membrane demonstrates the PIN.

References [1] Kadiyala RK, Lombardi JM. Denervation of the wrist joint for the management of chronic pain. J Am Acad Orthop Surg. 2017; 25(6):439–447 [2] Laulan J, Bacle G, de Bodman C, et al. The arthritic wrist. II—The degenerative wrist: indications for different surgical treatments. Orthop Traumatol Surg Res. 2011; 97(4) Suppl:S37–S41 [3] Chedal-Bornu B, Corcella D, Forli A, Moutet F, Bouyer M. Long-term outcomes of proximal row carpectomy: a series of 62 cases. Hand Surg Rehabil. 2017; 36(5):355–362

[4] Dacho A, Grundel J, Holle G, Germann G, Sauerbier M. Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist). Ann Plast Surg. 2006; 56(2):139–144 [5] Wilhelm A. Denervation of the wrist. Hefte Unfallheilkd. 1965; 81:109–114 [6] Grechenig W, Mähring M, Clement HG. Denervation of the radiocarpal joint: a follow-up study in 22 patients. J Bone Joint Surg Br. 1998; 80(3):504–507 [7] Hofmeister EP, Moran SL, Shin AY. Anterior and posterior interosseous neurectomy for the treatment of chronic dynamic instability of the wrist. Hand (N Y). 2006; 1(2):63–70

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Partial Wrist Denervation For Chronic Wrist Pain [8] Ishida O, Tsai TM, Atasoy E. Long-term results of denervation of the wrist joint for chronic wrist pain. J Hand Surg [Br]. 1993; 18(1):76–80 [9] Schweizer A, von Känel O, Kammer E, Meuli-Simmen C. Long-term follow-up evaluation of denervation of the wrist. J Hand Surg Am. 2006; 31(4):559–564 [10] Simon E, Zemirline A, Richou J, Hu W, Le Nen D. Complete wrist denervation: a retrospective study of 27 cases with a mean follow-up period of 77 months. Chir Main. 2012; 31(6):306–310 [11] Weinstein LP, Berger RA. Analgesic benefit, functional outcome, and patient satisfaction after partial wrist denervation. J Hand Surg Am. 2002; 27(5): 833–839 [12] Braga-Silva J, Román JA, Padoin AV. Wrist denervation for painful conditions of the wrist. J Hand Surg Am. 2011; 36(6):961–966 [13] Hébert-Blouin MN, Tubbs RS, Carmichael SW, Spinner RJ. Hilton’s law revisited. Clin Anat. 2014; 27(4):548–555 [14] Grechenig S, Lidder S, Dreu M, Dolcet C, Cooper LM, Feigl G. Wrist denervation of the posterior interosseous nerve through a volar approach: a new technique with anatomical considerations. Surg Radiol Anat. 2017; 39(6): 593–599

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[15] Hinds RM, Gottschalk MB, Capo JT. The pronator quadratus and distal anterior interosseous nerve: a cadaveric study. J Wrist Surg. 2015; 4(3): 183–187 [16] Lin DL, Lenhart MK, Farber GL. Anatomy of the anterior interosseous innervation of the pronator quadratus: evaluation of structures at risk in the single dorsal incision wrist denervation technique. J Hand Surg Am. 2006; 31(6): 904–907 [17] Fukumoto K, Kojima T, Kinoshita Y, Koda M. An anatomic study of the innervation of the wrist joint and Wilhelm’s technique for denervation. J Hand Surg Am. 1993; 18(3):484–489 [18] Grutter PW, Desilva GL, Meehan RE, Desilva SP. The accuracy of distal posterior interosseous and anterior interosseous nerve injection. J Hand Surg Am. 2004; 29(5):865–870 [19] Storey PA, Lindau T, Jansen V, Woodbridge S, Bainbridge LC, Burke FD. Wrist denervation in isolation: a prospective outcome study with patient selection by wrist blockade. Hand Surg. 2011; 16(3):251–257 [20] Berger RA. Partial denervation of the wrist: a new approach. Tech Hand Up Extrem Surg. 1998; 2(1):25–35

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Part VI Hand Fractures

31 Distal Phalanx Fractures: Percutaneous Pinning and Open Reduction Internal Fixation

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32 Middle/Proximal Phalanx (Pinning)

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33 Proximal Phalanx (Pinning)/Proximal Phalanx (Open Reduction and Internal Fixation)

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34 Fixation of Uni and Bicondylar Phalangeal Fractures

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35 Bony Mallet Fixation

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36 Proximal Interphalangeal Joint Fracture-Dislocation

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37 Metacarpals (Pinning)

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38 Metacarpal Fracture Open Reduction and Internal Fixation (ORIF)

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39 Limited-Open Retrograde Intramedullary Headless Screw Fixation of Metacarpal Fractures

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40 First Metacarpal Base Fractures (Bennett and Rolando fractures) 199

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31 Distal Phalanx Fractures: Percutaneous Pinning and Open Reduction Internal Fixation Carl M. Harper Abstract The majority of distal phalangeal fractures can be successfully treated nonoperatively. However, there are several fracture subtypes that warrant surgical intervention. Surgical stabilization of mallet fractures, Seymour fractures, and open fractures may aid in early rehabilitation and prevent long-term sequelae. In the following text we will review operative indications and various techniques to confer skeletal stability to fractures of the distal phalanges. Keywords: distal phalanx fracture, Seymour, mallet, tuft fracture

31.1 Description To employ the appropriate treatment of fractures of the distal phalanx one must be familiar with its unique and complex anatomy. The digital arteries and nerves trifurcate distal to the distal interphalangeal joint (DIP) joint and converge centrally. The extensor tendon complex inserts dorsally proximal to the physis/epiphyseal scar (▶ Fig. 31.1). The flexor digitorum profundus (FDP) inserts volarly over a broad area in the metaphysis (▶ Fig. 31.2). The fibrous septae that comprise the volar pulp stabilize the distal phalanx volarly. Dorsally the nail plate confers significant stability to the distal phalanx.

Fig. 31.1 The terminal tendon inserts over a broad area about the central third of the distal phalanx immediately proximal to the eponychial fold. (1) Palmar digital artery. (16) Palmar digital nerve. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

Various fracture patterns are observed in the distal phalanx. Tuft and shaft fractures are often due to a high energy or crushing mechanism. Fractures of the articular base are usually due to an axial load with a torsional component. Two additional fracture patterns bare special mention: mallet fractures and Seymour fractures. Extensor tendon avulsion fractures (mallet fracture) are due to a hyperflexion or resisted extension moment. The dorsal corner of the base of the distal phalanx fractures is often retracted proximally with the extensor tendon complex. Seymour fractures occur in skeletally immature patients due to a hyperflexion moment on the distal phalanx. This results in failure of distal phalangeal physis. These are often confused with a mallet fracture. In these fractures the germinal matrix can become incarcerated in the physis causing growth disturbance and infection that may result in osteomyelitis.

31.2 Key Principles Most distal phalangeal fractures are inherently stable due to the support conferred by the fibrous septae and nail plate. Surgical fixation is reserved for specific indications (discussed below). Often fractures are due to a crush-type mechanism resulting in significant comminution and involvement of the tuft. In this setting, evaluation for associated nailbed injuries should

Fig. 31.2 The flexor digitorum profundus inserts over a broad area about the proximal half of the distal phalanx. (15) Fibrous sheath. (15.1) Annular part. (15.2) Cruciform part. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

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Distal Phalanx Fractures: Percutaneous Pinning and Open Reduction Internal Fixation be performed to prevent infection and/or chronic deformity. If possible, restriction of proximal interphalangeal joint (PIP) joint range of motion (ROM) following either operative or nonoperative treatment should be avoided.

31.3 Expectations The majority of patients with simple transverse fractures will recover well with no sequelae. Patients who experience crushing injuries, especially those associated with soft tissue injury such as nailbed lacerations will often demonstrate hypersensitivity about the fingertip for many months. In addition, these patients have a high incidence of nail deformities. Mallet fractures usually do well regardless of the quality of the joint reduction. It is not uncommon to observe a persistent extensor lag of 10° to 20°. This does not typically impact function. Seymour fractures are prone to growth arrest with resultant cosmetic deformity but minimal functional deficits.

31.4 Operative Indications 31.4.1 Seymour Fractures1 Surgical intervention is reserved for open injuries with associated nailfold/skin lacerations. If the fracture is open and/or the

Fig. 31.3 Note failure of the distal phalanx at the level of the physis. The distal metaphyseal fracture fragment can often lacerate the germinal/sterile matrix resulting in an open fracture. (Reproduced with permission from Nikkhah, Dariush. Hand Trauma: Illustrated Surgical Guide of Core Procedures, 1st edition © 2018 Thieme.)

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nail plate has been dislodged from the eponchial fold, surgical irrigation and debridement as well as fracture reduction is warranted. Any interposed germinal matrix has to be excised from the physis to limit the degree of nail deformity and minimize the likelihood of bone growth disturbance. The necessity of skeletal fixation is dependent upon the stability of the fracture following reduction but it is not mandatory (▶ Fig. 31.3 and ▶ Fig. 31.4).

31.4.2 Mallet Fractures2 Surgical treatment of mallet fractures remains controversial with equivalent outcomes seen in operative vs. nonoperative treatment. The generally accepted operative indications include > 30% involvement of the articular surface, volar subluxation of the distal phalanx, and patients unable to comply w/ splinting. However, several cases series comparing long-term follow-up in patients with subluxated DIP joints vs. congruent DIP joints have shown outcomes to be equivalent3,4 (▶ Fig. 31.5).

31.4.3 Open Fractures The standards of open fracture care in setting of unstable open fractures apply. In presence of contamination, wounds must be debrided. If stable, surgical stabilization may not be necessary.

Fig. 31.4 Reduction can be maintained with a single intramedullary K-wire that transfixes the DIP joint. (Reproduced with permission from Nikkhah, Dariush. Hand Trauma: Illustrated Surgical Guide of Core Procedures, 1st edition © 2018 Thieme.)

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Tips, Pearls, and Lessons Learned but hardware should not be placed in this setting. In patients with soft tissue injury causing loss of domain and exposed bone/tendon, attempt should be made to achieve a stable soft tissue envelope. This may take the form of revision amputation or local pedicled flap but skeletal stabilization is not indicated in this setting.

31.6 Special Considerations 31.6.1 Open Fractures While open fractures are an indication for irrigation and debridement, no indication exists for IV or PO antibiotics in the absence of gross contamination as outcomes are equivalent for open vs. closed fractures with or without antibiotics.6

31.6.2 Associated Nailbed Injury Careful attention should be paid to achieving an adequate nailbed repair. Once the fracture has been stabilized, repair of the nailbed should be performed under loupe magnification. While distal phalangeal fractures are tolerated well even in the setting of a malunion, deformity of the nailbed can result in significant disability.

31.7 Special Instructions, Positioning, and Anesthesia The patient is positioned supine with a radiolucent hand table. Skeletal stabilization and soft tissue repair can easily be performed with patient awake under a digital blockade. A tourniquet is not necessary if performing percutaneous fixation, but if performing open reduction internal fixation (ORIF) or more extensive fixation, digital tourniquet may be necessary. A standard local anesthetic consisting of 0.25% bupivacaine with 1% lidocaine in 1:1 ratio is used. Three to 4 mL are injected 1-cm proximal to MCP flexion crease. There is no indication for dorsal anesthetic (i.e., ring block) as dorsal sensory nerves do not travel beyond the PIP joint. Fig. 31.5 Note the tendency of the distal phalanx to translate volarly subluxing the DIP joint.

31.4.4 Unstable Fractures with Nail Plate Loss As discussed previously, the nail plate confers a great degree of stability to distal phalangeal fractures.5 If the nail plate has been avulsed and the soft tissue quality prevents splinting of the fracture, skeletal stabilization is indicated.

31.5 Contraindications The majority of distal phalangeal fractures may be treated conservatively with splints. No difference has been shown between orthoplast and aluminum splints regarding outcomes. Patients with active or chronic infections should be thoroughly irrigated

31.8 Tips, Pearls, and Lessons Learned 31.8.1 Mallet Fracture Extension block pinning: 0.035 wires or 0.045 K-wires are utilized depending upon the size of the finger and the bone fragment. Place the blocking wire in the head of the middle phalanx ensuring that the blocking wire is at 45° angle to dorsal cortex of the distal phalanx. Extend the DIP joint to compress the remainder of the articular surface against the avulsed fragment that is buttressed by the dorsal wire (▶ Fig. 31.6 and ▶ Fig. 31.7). A longitudinal wire is then inserted in an intramedullary fashion across the DIP joint to hold the fracture reduced. The surgeon must be careful to avoid overextension of the DIP or skin breakdown will occur at the pin site. The wires are left in place for 6 weeks and then removed in clinic.

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Fig. 31.6 The blocking wire may also be used to directly reduce the avulsed fragment to the distal phalanx.

31.8.2 Suture Anchor Fixation Suture anchors with nonabsorbable braided suture (3–0) are placed in the footprint of the bone fragment. Two limbs of suture are passed circumferentially over the bone fragment with its attached tendon and tied back down into footprint.

31.8.3 ORIF with a Compression Screw If the fragments are large enough to support 1.3-mm screws, screws are placed parallel to DIP joint surface to engage the far cortex. One or two screws are used and therapy can begin immediately postop to avoid DIP joint stiffness. Similarly, with a large fragment, a small headless compression screw can be used.

31.8.4 Seymour Fracture Due to the high risk of infection we recommend the use of IV antibiotics at the time of presentation. If a delay to treatment has occurred, continuation of PO antibiotics for 24 hours is recommended. In performing the reduction, retention of the nail if possible is recommended. We prefer to use K-wires only if the distal phalanx is unstable after reduction. If a large nail plate or nailbed injury is suspected, nail removal is helpful.

Fig. 31.7 To avoid migration a large 0.045 K-wire is inserted to the level of the subchondral bone of the middle phalanx.

a freer elevator to remove any interposed tissue caught within the physis. Reduce the physis and assess stability. If the fracture is unstable, place one or two longitudinal K-wires in a retrograde fashion to keep the epiphysis reduced to the distal phalangeal metaphysis.

31.9.2 Mallet Fracture Dorsal Blocking Pin Flex the DIP joint to disengage the avulsed bony fragment. Place a 0.035 wire at a 45° angle within the intracondylar groove of the middle phalanx. Extend the DIP joint to reduce the fragment using the blocking wire as a counterforce brace. Place a 0.035 or 0.045 K-wire down the longitudinal axis of the distal phalanx, advance it across the DIP joint and advance it in an intramedullary fashion down the middle phalanx, stopping at the subchondral bone.

Suture Anchor

31.8.5 Shaft Fracture Two intramedullary longitudinal 0.035 K-wires seated in subchondral bone prevent soft tissue irritation and allow immediate ROM. We recommend cutting the pins deep to the skin to avoid pin site care and interference w/ clothing.

31.9 Key Procedural Steps

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Expose the fracture fragment and the terminal tendon with a curvilinear-style incision. Avoid “H”-style incisions as the corner of the flaps are often compromised and can lead to poor wound healing. Expose the fracture site by folding the extensor apparatus back on itself. Place a suture anchor in the footprint of the avulsed fracture fragment. Bring each limb of the suture laterally around the avulsed fragment and tie the two ends over the top of the distal phalanx.

31.9.1 Seymour Fracture

Compression Screw

Make an incision at the lateral border of the eponychial fold extending proximally on each side of the nail to allow full exposure of the germinal matrix. Use a small instrument such as

Reduce the fracture fragment and pin it in place with two 0.045 K-wires. Penetrate the far cortex about the volar aspect of the distal phalanx. Leaving one K-wire in place and remove the

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References Table 31.1 Difficulties encountered

Box 31.2 Pitfalls

Seymour fracture

Nail deformity, osteomyelitis, growth arrest

●

Infection in setting of missed or delayed diagnosis of Seymour fractures

Mallet fracture

Infection, hardware complication, nail deformity, persistent extensor lag; 53% operative vs. 48% splinting

●

Nail deformity in setting of nailbed laceration

●

Swan neck deformity following Mallet fracture if tendon retracts proximally

Box 31.1 Bailout, rescue, and salvage procedures ●

Pin removal and conversion to splinting in setting of infection.

●

Cross the DIP joint if adequate fixation cannot be obtained to ensure longitudinal stability of the fingertip and provide a strut for bony healing.

●

If joint is incongruent and symptomatic, arthrodesis can provide pain relief and stable joint with minimal change in functionality of the finger.

●

DIP disarticulation in setting of osteomyelitis of the distal phalanx.

other. Use the tract created by the 0.045 K-wire to measure the depth of the hole created. Taking care not to apply excessive torque to the distal phalanx, select a 1.3-mm cortical screw and compress the fragment down to the distal phalanx.

31.10 Difficulties Encountered, Bailouts, and Pitfalls

References [1] Krusche-Mandl I, Köttstorfer J, Thalhammer G, Aldrian S, Erhart J, Platzer P. Seymour fractures: retrospective analysis and therapeutic considerations. J Hand Surg Am. 2013; 38(2):258–264 [2] Lamaris GA, Matthew MK. The diagnosis and management of Mallet finger injuries. Hand (N Y). 2017; 12(3):223–228 [3] King HJ, Shin SJ, Kang ES. Complications of operative treatment for mallet fractures of the distal phalanx. J Hand Surg [Br]. 2001; 26(1):28–31 [4] Stern PJ, Kastrup JJ. Complications and prognosis of treatment of mallet finger. J Hand Surg Am. 1988; 13(3):329–334 [5] Wang W, Yu J, Fan CY, Liu S, Zheng X. Stability of the distal phalanx fracture: a biomechanical study on the importance of the nail and the influence of fixation by crossing Kirschner wires. Clin Biomech (Bristol, Avon). 2016; 37:137–140 [6] Metcalfe D, Aquilina AL, Hedley HM. Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis. J Hand Surg Eur Vol. 2016; 41(4):423–430

See ▶ Table 31.1, ▶ Box 31.1, ▶ Box 31.2.

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32 Middle/Proximal Phalanx (Pinning) Salah Aldekhayel and MM. Al-Qattan Abstract Operative options for the phalanx fractures include many types of surgery including closed or open reduction and percutaneous pinning. Keywords: phalanx, phalangeal fracture, pinning, K-wire, fixation, percutaneous

32.1 Description

32.3 Expectations

Most phalangeal fractures are managed by splint immobilization, especially when the fracture is stable. Due to tendinous forces exerted on these fractures, certain fracture patterns require operative fixation for stability. Operative options include closed reduction and percutaneous pinning (CRPP), open reduction and pinning (ORP), open reduction and internal fixation (ORIF), and static or dynamic external fixation (Ex-fix). This chapter will discuss the percutaneous pinning of phalangeal fractures. In general, most pinnings are performed using Kirschner wires (K-wires).

Following the above principles can generally lead to good postoperative results and function. Management of fractured digits in children generally results in a better outcome when compared to adults due to quicker fracture healing, being less prone to stiffness, and the greater potential for remodeling. One exception in children is the phalangeal neck fractures that are known to have a high complication rate including stiffness, nonunion, malunion, and avascular necrosis of the phalangeal head. Open phalangeal fractures with comminution or concurrent tendon and soft tissue injury are considered as poor prognostic factors and therefore the prognosis is generally guarded. Chow et al1 studied 245 open digital fractures prospectively and demonstrated that the presence of concurrent extensor tendon injury or extensive skin loss had a major effect resulting in a poor outcome in 48% of patients. The worst effect was from concurrent flexor tendon injury resulting in a poor outcome in 86% of patients, defined as total active motion (TAM) of less than 180 degrees.

32.2 Key Principles The first key principle is achieving adequate reduction, which is best done under fluoroscopic guidance. Every effort should be made to obtain such a reduction by closed means because CRPP is generally preferred over ORP. The second principle is to provide “adequate” fracture stability. K-wire fixation is not rigid, but it can still provide enough stability to allow some early postoperative range of motion. The use of more than one K-wire provides better rotational stability, especially when transverse or oblique wires are utilized. Single axial and intramedullary K-wires are more stable when the size of the K-wire is large enough to “fill up” the medullary cavity. Another principle is to avoid placing the K-wire through the joint. Crossing the distal interphalangeal (DIP) joint of the fingers and the interphalangeal (IP) joint of the thumb is more tolerated than crossing the proximal interphalangeal (PIP) joint because the resulting stiffness of the former joints is usually mild and is less disabling from the functional point of view. Crossing of the DIP, IP, or PIP joints should be done with joint fully extended. However, crossing the metacarpophalangeal (MP) joint should be done with the joint flexed to avoid shortening of the collateral ligaments and intrinsic muscles. In the management of fractures, the early institution of postoperative mobilization is always preferred to prevent stiffness. Although this principle also applies for fractures of the middle and proximal phalanges, several factors should be taken into consideration such as age, concurrent tendon injuries, neurovascular injuries or soft tissue loss, the presence of ischemia or severe crush of the fractured digit, and the reliability of the patient. Young children with phalangeal fractures are typically immobilized in a cast after surgery. A common fracture pattern in industrial workers is transverse fractures of

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the middle phalanx with concurrent extensor tendon injury. An axial K-wire crossing the extended DIP joint is necessary because of concurrent extensor tendon injury. In fractured crushed digits with concurrent ischemia, early exercises are not advised. Finally, general principles of open fracture management should be applied such as early operative intervention, debridement, irrigation, and adequate antimicrobial coverage.

32.4 Indications Adequate reduction by closed or open methods is a prerequisite prior to fracture pinning. Phalangeal fractures can be broadly classified into extra-articular and intra-articular fractures. Extra-articular fractures include neck, shaft, and base fractures. Intra-articular fractures include condylar fractures and base intra-articular fractures with or without fracturedislocation. Intra-articular base fracture and/or fracture dislocation of PIP joint can be treated by dynamic external fixation, provided the ligamentotaxis effect allows adequate concentric reduction. Alternatively, other methods such as transarticular or dorsal block pinning, interfragmentary screw fixation, hemi-hamate arthroplasty, or volar plate arthroplasty may be utilized.

32.5 Contraindications ●

●

CRPP is contraindicated when closed fracture reduction is not achieved. Intra-articular fractures of the volar base of the middle phalanx with more than 40% involvement of the articular surface should not be treated by dynamic external fixation; rather alternative methods should be used.

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Individual Fractures Discussing Tips, Key Procedural Steps, and Expected Outcomes

32.6 Special Considerations Preoperative evaluation of the patient’s age, medical history, occupation, hand dominance, and compliance with postoperative rehabilitation is essential. Date and mechanism of injury as well as associated injuries will play an important role in the decision-making process. Associated flexor or extensor tendon injuries may require early mobilization and hence rigid fixation is preferred. Adequacy of reduction and fixation of intra-articular fractures should be confirmed intraoperatively under fluoroscopy to ensure stability of the fixation in order to allow early protected movement.

32.7 Special Instructions, Positioning, and Anesthesia ●

● ●

Majority of phalangeal fractures can be operated under local digital block anesthesia allowing for intra-operative testing of adequacy of reduction and fixation under fluoroscopy. Patient is placed supine with the hand on an arm board. Upper arm or digital tourniquet minimizes postreduction swelling and loss of digital landmarks, which would make the accurate placement of percutaneous pinning more difficult. Awake patients may not tolerate upper arm tourniquet of more than 20 minutes; intravenous sedation may be used as a supplement.

32.8 Individual Fractures Discussing Tips, Key Procedural Steps, and Expected Outcomes 32.8.1 Extra-Articular Fractures Neck Fractures Phalangeal neck fractures of the middle phalanx are more common than those of the proximal phalanx. They are usually seen in children but also occur in adults. Al-Qattan2 classified these fractures into three types: type I (undisplaced), type II (displaced but with some bone-to-bone contact), and type III (displaced with no bone-to-bone contact). Type II fractures are usually treated with closed reduction and axial K-wire fixation. Another technique of K-wire fixation is the K-wire “lever” technique. The displaced phalangeal head is usually dorsally displaced similar to the distal segment of a Colles’ fracture. Hence, a percutaneous K-wire may be placed dorsally into the fracture side and used as a “joystick” to reduce the fracture and then the wire is advanced into the medullary cavity of the proximal segment (i.e., diaphysis) to maintain the reduction. This method of K-wire fixation is similar to the Kapandji’s intrafocal technique of K-wire fixation of Colles’ fractures. Type III fractures are usually open injuries and the existing laceration may be used for reduction prior to K-wire fixation. These fractures have a high complication rate including delayed union, malunion, nonunion, avascular necrosis of the phalangeal head, and stiffness of the joint involved.

Middle Phalangeal Shaft Fractures Shaft fractures may have a transverse, oblique, spiral, or comminuted pattern. Closed reduction is performed under fluoroscopy and with the aid of digital traction and DIP joint flexion. Unstable fractures can be difficult to reduce using closed methods especially when soft tissue is interposed between fracture fragments, and in spiral and transverse fractures. Open techniques where small incision is made and an elevator is used to clean the fracture fragments can help achieve the reduction. If that fails, open reduction using dorsal incision with splitting of the extensor tendon should be done. Use of percutaneous bone clamp will help maintain the reduction in spiral and oblique fractures. Percutaneous pinning can be approached through the collateral recess of the phalangeal head in retrograde fashion or through the base of the middle phalanx in antegrade fashion. Crossing K-wires is the most commonly used fixation method using two pins of adequate size (0.035–0.045 inch). The crossing point of the K-wires should not be at the fracture site to avoid loss of rotational reduction. Another popular technique is longitudinal transarticular fixation of DIP joint with a single K-wire. Oblique and spiral fractures can be fixated by multiple (two to three) parallel pins (0.028–0.035 inch) perpendicular to the fracture line which provides adequate stability to start early active range of motion (ROM).3 Outcome of phalangeal fractures largely depends on the concurrent soft tissue injury as proposed by Chow et al.1 Expected poor outcomes (defined as TAM less than 180 degrees) is seen in 25% of type I fractures (defined as fractures with concurrent simple skin laceration and/or digital nerve injury). Fractures associated with significant soft tissue crush injury are expected to have poor outcomes compared with those without soft tissue crush.4 Type II fractures (defined as fractures associated with complete extensor tendon injury or extensive skin loss requiring reconstruction) have an expected poor outcome rate of 48%. Type III fractures (defined as fractures with concurrent flexor tendon injury or combined extensor tendon injury and skin loss requiring reconstruction) have an expected poor outcome rate of 86%.

Proximal Phalangeal Shaft Fractures Proximal phalangeal shaft fractures can be of different patterns depending on the force of injury. These fractures typically angulate volarly due to the pull of the intrinsic muscles proximally and the extensor mechanism distally at the PIP joint. Undisplaced transverse, oblique, and spiral fractures are managed in splint immobilization with close clinical and radiological follow-up to monitor any displacement. Displaced fractures require internal fixation with K-wires or plates and/or screws. CRPP helps to avoid additional surgical trauma, but prolonged immobilization may compound posttraumatic stiffness. Closed reduction must be attempted and the use of percutaneous bone clamps can help maintain the reduction until definitive fixation is applied (▶ Fig. 32.1b). Percutaneous pinning can be approached through the metacarpal head with the joint in 90 degrees of flexion (transarticular)5 or using periarticular approach where MP joint is avoided and the entry is at the ulnar and radial bases of the

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Fig. 32.1 Pinning and early motion in extra-articular shaft fractures of the proximal phalanx. (a) 35 year-old male fell on his left hand and sustained a spiral fracture of the proximal phalanx of index finger and comminuted extra-articular fracture of proximal phalanx of middle finger. (b) Use of percutaneous bone clamp in achieving closed reduction prior to K-wire fixation. (c) Three parallel K-wires (0.028 inch) used to fix the spiral fracture and one periarticular large K-wire (0.054 inch) supplemented with small interfragmentary K-wires (0.028 inch) are used for fixation of the comminuted fracture. (d) Early active range of motion exercises are started one week postoperatively. Protective splint is worn until fracture healing is confirmed clinically at 4 to 5 weeks.

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Individual Fractures Discussing Tips, Key Procedural Steps, and Expected Outcomes open reduction is required to achieve adequate reduction. During the open reduction, careful dissection should avoid detaching the collateral ligaments from the condylar segment that may devascularize the fragment and result in long-term consequences. Once reduction is achieved, two K-wires (0.028 to 0.035 inch) are needed to prevent loss of reduction and rotational displacement. Transverse subchondral pinning is adequate for unicondylar fractures (▶ Fig. 32.2). However, in bicondylar fractures, one transverse pin allows fixation of both condyles in coronal plane, and additional axial pins (one or two in crossed fashion) are required to maintain reduction in sagittal plane. Alternatively, percutaneous lag screws may be used.

Intra-Articular Base Fractures

Fig. 32.2 Pinning of unicondylar fracture of the proximal phalanx of the small finger in a 48-year-old male patient. After adequate reduction and restoration of joint congruency, three parallel K-wires (0.028 inch) are inserted transversely in the subchondral bone.

proximal phalanx (▶ Fig. 32.1c).6,7 Alternatively, K-wires can be introduced in retrograde fashion through the phalangeal head at the collateral recess, similar to middle phalanx fractures. Spiral or oblique fractures can be fixed with multiple parallel K-wires (two to three) perpendicular to the fracture line (▶ Fig. 32.1c). We prefer periarticular antegrade fixation technique (▶ Fig. 32.1c).6 Adequate closed reduction is confirmed under fluoroscopy and maintained with flexion of the MP joint and extension of the PIP joint. Large K-wire (0.054 inch) is introduced at the level of the distal third of the metacarpal between the extensor tendons and passed to the lateral base of the proximal phalanx underneath the sagittal band. Then, pin is introduced in antegrade fashion while the reduction is maintained. Another K-wire (0.035 inch) can be introduced from the other lateral base to prevent rotational deformity but often not required. Confirmation of adequacy of reduction and fixation should be done clinically by absence of malrotation and radiographically. Such fixation will allow early postoperative movement, as it does not interfere with the extensor apparatus (▶ Fig. 32.1d).

32.8.2 Intra-Articular Fractures Condylar Fractures Condylar fractures are classified into three types: type 1 includes undisplaced unicondylar fractures, type 2 includes displaced unicondylar fractures, and type 3 includes bicondylar or comminuted fractures. All condylar fractures are inherently unstable fractures and often require operative fixation. Percutaneous pinning provides adequate fixation if closed reduction can be achieved. However, these fractures can be difficult to reduce due to soft tissue interposition and an

Small lateral base fractures and small volar avulsion fractures can be managed by buddy taping and protected early active ROM to minimize joint stiffness. Dorsal avulsion fractures of the middle phalangeal base are associated with acute boutonnière deformity due to avulsion of the central slip and require transarticular pinning of the extended PIP joint to prevent postoperative extension lag. Volar base fractures of middle phalanx with dorsal subluxation or dislocation of PIP joint can be managed by dorsal blocking splinting or pinning and early active ROM if concentric reduction can be achieved and maintained. This reduction should be confirmed under fluoroscopy while the patient actively flexes and extends the PIP joint. Fracture fragment larger than 40 to 50% of the articular surface is associated with inherent instability due to detachment of the collateral ligaments and open reduction and internal fixation or joint reconstruction (hemi-hamate arthroplasty or volar plate arthroplasty) is often required. Comminuted base fractures (pilon fractures) are more difficult to reduce and dynamic skeletal traction can provide adequate reduction and fixation allowing early active ROM to minimize joint stiffness. Anatomic restoration of joint surface may not be achieved; however, articular remodeling happens over time and joint stiffness is reduced.8 Rubber and band dynamic distraction system9 is typically indicated for comminuted PIP fractures and/or dislocation where the attachments of the collateral ligaments are maintained to the distal fracture fragment allowing utilization of the ligamentotaxis effect of distraction to help reduce the fracture. Fracture fragments exceeding 40 to 50% of the articular surface cannot be fixed with this method, as the device will distract the fracture rather than realigning the fracture fragments. The procedure is best done under local anesthesia with digital or wrist block as it allows intraoperative testing of active ROM under direct fluoroscopy after fracture fixation. The first and most crucial step in deciding the suitability of this fixation method is to be able to achieve adequate reduction with manual digital distraction under fluoroscopy. If this reduction cannot be achieved, alternative methods should be used. Next, an axial traction pin (K1) using long K-wire (0.045 inch) is introduced transversely in the center of rotation of the proximal phalangeal head and confirmed in PA and lateral views (▶ Fig. 32.3b). K-wire is bent 90 degrees at 5 millimeters distance from the skin on either side. Next, a hook pin (K2, 0.035 inch) is inserted in the head of the middle phalanx and bent in a similar fashion. Careful attention

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Fig. 32.3 Dynamic external fixation (rubber and band system) for intra-articular base fractures. (a) Pilon fracture of the proximal phalangeal base of the thumb in a 40-year-old male. There is collapse and incongruency of the joint space. (b) Insertion of K1 and K2 transverse pins in the center of rotation of the heads of the metacarpal and proximal phalanx, respectively. (c) Fluoroscopic view of distraction with improvement in joint congruency. (d) Device assembly after applying the dental elastics. Tape is applied to prevent slippage of the elastics. Patient is instructed to start active range of motion on the first postoperative day.

should be paid to insert the pins in the center of rotation of the phalangeal heads, as incorrect placement will result in malrotation of the reduction. Next, hooks are fashioned at the ends of both pins leaving a distance of 1.5 cm between the ends of K1 and K2. Then, three to five dental elastics are placed on each hook and the amount of distraction and reduction of the fracture is monitored under fluoroscopy (▶ Fig. 32.3c). Once the device is assembled, reduction is tested by asking the patient to actively flex and extend the finger under direct fluoroscopy (▶ Fig. 32.3d). Additional reduction pin (K3) in the proximal shaft of the middle phalanx may need to be inserted to prevent dorsal subluxation of the device. The hooks and elastics are taped to prevent their displacement. Patient should be evaluated by a hand therapist on the first postoperative day to start active ROM. The device is removed at 4 to 5 weeks postoperatively once fracture healing is confirmed clinically.

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32.9 Bailout, Rescue, and Salvage Procedures The best chance to get a K-wire in the right axis is at the first attempt. Frequent attempts will create false intramedullary tunnels and can be difficult to change. Larger size wires or different entry points can be attempted to change the false tunnels. Mini-open techniques can be used if closed reduction cannot be achieved due to interposed soft tissue or fracture hematoma. If it fails, traditional open reduction and retrograde pinning or rigid fixation with plates and screws should be done. Comminuted fractures are best treated by closed techniques and percutaneous pinning. If open reduction is required, other adjuncts such as cerclage wires can help in controlling the reduction.

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References

32.10 Pitfalls ●

●

●

●

●

Condylar fractures should be approached using closed methods; however, if adequate reduction cannot be achieved, careful open reduction with minimal stripping of soft tissues should be done to minimize the risk of avascular necrosis. Transarticular pinning may result in joint stiffness; however, it might be the salvage option in difficult fractures such as comminuted dorsal base fractures of the middle phalanx with volar subluxation. Transarticular pinning should be done with the least number of trials to avoid late arthrosis. When the adequacy of fixation is less than optimal, supplementation with 3 to 4 weeks of splint immobilization should be done to avoid loss of reduction. Dynamic skeletal distraction should not be used in cases where manual distraction of the finger under direct fluoroscopy would cause distraction rather than reduction of the fracture.

References [1] Chow SP, Pun WK, So YC, et al. A prospective study of 245 open digital fractures of the hand. J Hand Surg [Br]. 1991; 16(2):137–140 [2] Al-Qattan MM. Phalangeal neck fractures in children: classification and outcome in 66 cases. J Hand Surg [Br]. 2001; 26(2):112–121 [3] Green DP, Anderson JR. Closed reduction and percutaneous pin fixation of fractured phalanges. J Bone Joint Surg Am. 1973; 55(8):1651–1654 [4] Al-Qattan MM. Extraarticular fractures of the middle phalanx with no associated tendon injury or extensive skin loss: the “soft-tissue crush” as a prognostic factor. Ann Plast Surg. 2013; 70(3):280–283 [5] Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalangeal fractures. J Hand Surg Am. 1984; 9(5):725–729 [6] Al-Qattan MM. Displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers in industrial workers: reduction and K-wire fixation leaving the metacarpophalangeal and proximal interphalangeal joints free. J Hand Surg Eur Vol. 2011; 36(7):577–583 [7] Eberlin KR, Babushkina A, Neira JR, Mudgal CS. Outcomes of closed reduction and periarticular pinning of base and shaft fractures of the proximal phalanx. J Hand Surg Am. 2014; 39(8):1524–1528 [8] Stern PJ, Roman RJ, Kiefhaber TR, McDonough JJ. Pilon fractures of the proximal interphalangeal joint. J Hand Surg Am. 1991; 16(5):844–850 [9] Suzuki Y, Matsunaga T, Sato S, Yokoi T. The pins and rubbers traction system for treatment of comminuted intraarticular fractures and fracture-dislocations in the hand. J Hand Surg [Br]. 1994; 19(1):98–107

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33 Middle/Proximal Phalanx (Open Reduction and Internal Fixation) Michael Rivlin Abstract Proximal and middle phalangeal fractures can usually be treated with nonsurgical methods. However, in cases when rotational or angular deformity is noted, or an unstable fracture pattern is seen, operative fixation is recommended. A dorsal or midlateral approach can be used. Plate fixation with locking or nonlocking screws can restore excellent stability and allow for early motion. Percutaneous or open-lag screw fixation can avoid the need for plate fixation in long oblique or spiral fracture patterns. Shortterm immobilization with early occupational therapist supervised motion protocol is started. Splinting is discontinued at 4 to 6 weeks or when fracture healing is confirmed radiographically.

33.2 Goals

Keywords: phalangeal fracture, hand fracture, ORIF hand fracture, open reduction internal fixation phalanx fracture

Open reduction and internal fixation should be considered in cases where nonsurgical management or percutaneous treatment would not allow adequate stability for bone healing. Proper evaluation of bony alignment is paramount in deciding to treat phalangeal injuries surgically. This requires adequate radiographic imaging with X-rays and scrutinizing the digital cascade through the full range of motion. Displaced condylar fractures, unstable spiral fractures, basilar fractures with joint incongruence and displacement or articular involvement, as well as appreciated angular deformity affecting the digital cascade should be operatively treated. More than 5–10 degrees of malrotation or coronal malalignment should be corrected. Sagittal plane deformities are much better tolerated and apex dorsal angle of up to 30 degrees and apex volar angle of 20 degrees may be acceptable if overall motion is preserved. Greater than 1 mm articular incongruence should be reduced to restore the joint line.1

33.1 Introduction Proximal and middle phalangeal fractures often cause rotational or angular deformity (▶ Fig. 33.1). Cascade preservation is important for appropriate restoration of hand function. As little as 5 degrees of rotational malalignment can lead to significant finger overlap. The proper tendon balance relies on anatomical length of the phalanx to avoid extensor lag or incomplete flexion. Multiple fixation options exist for middle and proximal phalangeal fractures.

As union and healing of osseous structures completes with high success in the hand, goals are focused on restoring anatomical alignment and allowing early motion. Injuries involving the fingers can lead to stiffness even with a brief period of immobilization; hence, motion that allows tendon gliding and joint range should be started as soon as bony stability allows.

33.3 Indications

33.4 Contraindications Contaminated wounds and inadequate tissue coverage are reasons to avoid fixation with permanent implants such as screws and plates. In the case of infected tissues, without the prior eradication of pathogenic materials implant use should be avoided. Although not an absolute contraindication, in the case of digital replantation and other complex procedures, open reduction and internal fixation with plates and screws is generally avoided dude to the length of time it takes to perform this procedure.

33.5 Alternate Procedures

Fig. 33.1 Rotational deformity from phalangeal fracture.

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Alternate fixation techniques are recommended in cases where implant fixation is not desired, such as in pediatric patients, grossly contaminated or infected fractures, and injuries with large soft tissue defects or lack of coverage. In these cases, pin or Kirschner wire (K-wire) fixation is generally preferred. In cases where the zone of fracture is to be avoided, external fixators can play a role.

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Operative Detail

33.6 Operative Detail 33.6.1 Preparation: Planning/Special Equipment Preoperative planning is essential in deciding the type of fixation, implant selection and approach. Mini C-arm availability is required. Instrumentation for K-wire fixation is needed as well. Even in the case of planned closed reduction pin fixation, implants for open reduction and internal fixation (ORIF) should be present if the fracture requires open treatment with internal fixation. Some implants allow for nonlocking constructs, whereas others allow for locked screw fixation that is helpful in periarticular fractures. Fixed or variable angle fixation options are available depending on the implant manufacturer. Furthermore, various size screw options exist. Based on the size of the bone, screw size ranging from 1.0 to 2.5 mm diameter may be used. Local anesthesia with sedation can be utilized for the ORIF of the finger. General or regional anesthesia may be needed if patient factors dictate.

33.6.2 Approach The phalanx can be approached from either dorsal or midaxial direction (▶ Fig. 33.2). Dorsal approach allows an extensile approach to most extensor structures on the hand and excellent visualization of the joints if needed. The extensor apparatus can be incised directly midline for full view of the dorsal side of the phalanx or retracted laterally to work through a window between the extensor and the bone. The midaxial approach provides direct access to the bone without violating the extensor apparatus and facilitate placement of the plate on the lateral aspect of the bone. This allows better clearance for the extensor apparatus. At the commencement of the fracture fixation if an extensor tendon was divided, it can be repaired in a side-to-side manner with a 4–0 nonabsorbable braided suture.

33.6.3 Reduction Reduction can be aided with small fracture reduction clamps and these can hold the fracture in reduced position until fixation is

achieved. Alternately K-wires can be used as joysticks to help in the restoration of the bony anatomy. Preliminary K-wire fixation is helpful to keep the reduced alignment until the plate is applied and secured.

33.6.4 Open Reduction and Lag Screw Fixation Lag screw fixation can secure long oblique or spiral fragments. It is important that no comminution is present for the reduction to be stable. Condylar fractures can be fixed with two, and other fractures with three lag screws (▶ Fig. 33.3). The screws can be inserted with an open incision or through small percutaneous windows from the midlateral approach. Avoid screw placement too close to the apex of the fracture to prevent fracture of the small part. Screws can be placed in a lag fashion (overdrill the proximal cortex). Prior to depth measurement and screw insertion, a countersink should be used so the head of the screw becomes flush with the bone to minimize prominence. This step also ensures that the screw head forces on the bone are equally distributed and decreases the chance of further comminuting the fracture. For a simple oblique fracture the screws can be oriented parallel to each other. However, when the fracture pattern is spiral, the screws need to gradually rotate trajectory to follow the fracture line and to keep the fixation perpendicular.

33.6.5 Open Reduction and Plate Fixation When the fracture is identified and prepared, decision has to be made if a plate is used in compression, such as with a simple transverse fracture, bridging of the comminution, or longitudinal instability. Periarticular plates can buttress the unstable fracture fragments (▶ Fig. 33.4). Depending on fracture characteristics and the implants available, the proper plate is selected once the preliminary reduction is achieved. The plate can be positioned dorsal or lateral depending on the fixation need and the approach chosen. Contouring and shortening the plate

Fig. 33.2 Dorsal and midaxial approaches to the phalanges.

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Middle/Proximal Phalanx (Open Reduction and Internal Fixation)

Fig. 33.3 (a–c) Proximal phalangeal fracture treated with lag screws.

Fig. 33.4 (a–c) Intra-articular proximal phalangeal fracture treated with a miniplate and screws.

may be necessary. Before implantation, fluoroscopic images are taken to confirm position and size. The plate is secured to the bone initially with one or two nonlocking screws. If the reduction and the cascade is as desired, further locking or nonlocking screws can be used to fix the plate to the bone. Variable locking screw options are available from multiple implant manufacturers and may be useful for complex periarticular fracture patterns.

33.6.6 Risks/What to Avoid Due to the small area of bony fixation careful placement of screws is needed to avoid articular penetration or blockade of flexion due to overly long screws in the palmar direction. Similarly, penetration of the drill bit through the flexor apparatus (flexor tendons, pulley, and volar plate) is likely to lead to adhesion formation, postoperative stiff finger, and suboptimal motion. The plate should not sit too distal or close to the interphalangeal joint so flexion is not affected. The neurovascular bundles need to be protected. These can easily be injured when lateral plate is placed on the phalanx as the contralateral bundle can be injured by overpenetrated pin, drill bit, or screw.

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33.7 Salvage 33.7.1 Corrective Osteotomy If the phalanx fuses in a malrotated position, digital overlap or scissoring can be function limiting. Corrective osteotomy may be performed at the fracture level by cutting the phalanx and rotating the distal portion to the desired position. Plate fixation in compression can lead to proper union. To avoid the zone of injury and the chance of scarring at the zone of injury, the corrective osteotomy may be performed at the metacarpal level. Eighteen degrees for the index, long, and ring fingers and up to 30 degrees of rotational correction can be achieved with this technique.2

33.7.2 Fusion Failed joint congruity can be salvaged by arthrodesis of the affected metacarpophalangeal or interphalangeal joint. A painful malaligned digit is often worse with a painless fused digit. However, since arthrodesis is an irreversible step, it is only advocated as last resort.

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References

33.8 Tips/Pearls ●

●

Always check rotation of the contralateral hand as finger anatomic variability is exceedingly common. Small fracture reduction clamps are very useful for finger injuries. Percutaneous distal application of a small tenaculum can help with rotation and traction to achieve anatomical reduction.

●

33.9 Postoperative Splint immobilization is recommended for most phalangeal fractures until seen for outpatient postoperative visit between 1 and 2 weeks. Reliable and motivated patients with good bony fixation may have their finger buddy strapped without the use of a splint. Routine use of postoperative antibiotics is not required in clean cases.

33.10 Postoperative Care With stable fixation, early postoperative motion is recommended. The patients should start dedicated occupational therapy at the time of suture removal (1–2 weeks). Range of motion with active assistance begins with protection of a removable custom-molded orthotic. At 3 weeks the patient can remove the protective splint when at rest. Strengthening begins at 6 weeks with therapist supervision. Unrestricted gripping is allowed at 8 weeks postoperatively. Impact and contact sports are avoided until 10 to 12 weeks after surgery.

33.11 Complications ●

●

Infection: Surgical site infections must be aggressively treated any time they are encountered. Instrumentation should be maintained if the infection can be eradicated early to prevent the formation of an infected nonunion site. Often, implant removal is required. Stiff finger: Post ORIF, stiffness is a common result of hand fractures. Aggressive occupational therapy and rehabilitative

●

modalities should be exhausted. In cases with plateaued motion that is inadequate, tenolysis and removal of implant is needed. This is common, and patients should be counseled regarding this prior to the initial procedure. Implant failure and malalignment: Loss of fixation can occur if stringent postoperative limitations are not followed. Occasionally, underappreciated fracture fragments and unrecognized comminution can lead to inadequate stability and early failure. Sometimes a short course of complete immobilization may allow for appropriate healing; however, in other case revision ORIF is necessary. Extensor lag: Shortening the proximal phalanx leads to 12 degrees of extensor lag per mm. Restoration of anatomical length is important and should be corrected.3

References [1] Jupiter JB, Axelrod TS, Belsky MR. Skeletal trauma. In: Browner BB, ed. Fractures and Dislocations of the Hand. 3rd ed. Philadelphia: WB Saunders; 2003:1153 [2] Gross MS, Gelberman RH. Metacarpal rotational osteotomy. J Hand Surg Am. 1985; 10(1):105–108 [3] Vahey JW, Wegner DA, Hastings H, III. Effect of proximal phalangeal fracture deformity on extensor tendon function. J Hand Surg Am. 1998; 23(4): 673–681

Suggested Readings Ataker Y, Uludag S, Ece SC, Gudemez E. Early active motion after rigid internal fixation of unstable extra-articular fractures of the proximal phalanx. J Hand Surg Eur Vol. 2017; 42(8):803–809 Henry MH. Fractures of the proximal phalanx and metacarpals in the hand: preferred methods of stabilization. J Am Acad Orthop Surg. 2008; 16(10): 586–595 Robinson LP, Gaspar MP, Strohl AB, et al. Dorsal versus lateral plate fixation of finger proximal phalangeal fractures: a retrospective study. Arch Orthop Trauma Surg. 2017; 137(4):567–572 Tan V, Beredjiklian PK, Weiland AJ. Intra-articular fractures of the hand: treatment by open reduction and internal fixation. J Orthop Trauma. 2005; 19(8): 518–523 von Kieseritzky J, Nordström J, Arner M. Reoperations and postoperative complications after osteosynthesis of phalangeal fractures: a retrospective cohort study. J Plast Surg Hand Surg. 2017; 51(6):458–462

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34 Fixation of Uni and Bicondylar Phalangeal Fractures J. Michael Hendry and Martin Dolan Abstract Phalangeal condyle fractures represent a complex spectrum of injury ranging from nondisplaced to inherently unstable fracture patterns. The challenge for the clinician is to decide which fractures require fixation and what fixation technique to use. An overview of surgical indications, techniques, and challenges is provided. Keywords: condyles, proximal interphalangeal joint, shear fracture, bicondylar fracture, unicondylar fracture

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Malunion Traumatic loss of condyle—osteochondral graft

34.5 Contraindications ●

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Nondisplaced unicondylar fractures in children (relative contraindication: thicker periosteum may be intact and confer stability)5 Unrealistic expectations Inability to engage hand therapy Low functional demands Concomitant severe injuries

34.1 Description Condyle fractures are intra-articular fractures involving the distal aspect of the proximal and middle phalanx. The majority of condyle fractures tend to be inherently unstable, even if nondisplaced initially.1 Management of these injuries must account for the unique architecture of this joint, as it is not a simple hinge. The condyles of the proximal and middle phalanx have smaller radii of curvature compared with the concave base of the middle phalanx, providing motion with 4 degrees of freedom.2,3 The structure of this joint provides mobility, stability, and circulation of synovial fluid. These relationships are lost with intra-articular and comminuted fractures, which must be repaired or reconstructed to restore normal function.

34.2 Key Principles Evaluation must take into account (1) angulation or malrotation at the fracture site; (2) fracture pattern to judge stability; (3) and status of the surrounding soft tissues. Operative management is focused on restoring articular congruity and fracture stability. The priorities in postoperative management for isolated condyle fractures are early range-of-motion and edema management, given the propensity for PIP joint stiffness.

34.3 Expectations Outcomes are patient-specific because of the multiple factors that influence recovery of motion. Diligent and aggressive rehabilitation is often required to maximize results; therefore, patient compliance with therapy is essential. An average result would typically be an arc of motion from 10° of extension to 80 to 90° of flexion. Among unicondylar fractures, volar shear fractures tend to have the greatest limitations in total active motion (57°) at an average 3-year follow-up.4 Postreduction limitations in motion are more often related to soft tissue contracture than fracture alignment.

34.4 Indications ● ●

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Unstable/Displaced intra-articular unicondylar fractures Bicondylar fractures

34.6 Special Considerations ●

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Small unicondylar fragments take their sole blood supply from the retained collateral ligament attachment. This attachment must not be stripped during exposure of the fracture to avoid osteonecrosis of the fracture fragment. No intra-articular displacement should be tolerated as this will likely lead to angulation of the digit.5 If managed nonoperatively, nondisplaced oblique fractures should be followed closely with weekly X-rays for a minimum of 3 weeks.

34.7 Special Instructions, Positioning, and Anesthesia ●

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Can be performed under general anesthesia, regional block, or a digital block Supine with hand outstretched on a hand table A tourniquet can be applied to the upper arm or digit Mini C-arm fluoroscopy available for intraoperative use Kirschner (K) wires (0.028–0.045 inch) Modular handset (1.0, 1.3-mm screws and 0.7- to 2-mm drill), depth gauge, screw driver If osteotomies are planned: Small osteotome, sagittal saw (0.4- to 1-cm blades)

34.8 Tips, Pearls, and Lessons Learned ●

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K-wire fixation with two small 0.028 wires can provide secure fixation with minimal soft tissue manipulation, but suboptimal intra-articular reduction should not be accepted. Reduction of bicondylar split fractures can be achieved by sequencing first the reduction of the two condyles to one another and provisional K-wire fixation. This distal construct is then mounted and secured onto the phalanx shaft by appropriate means. Debate exists about optimal number of wires/screws across the fragment: one5 vs two or more.4 Clinical judgment is required on an individual basis.

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Key Procedural Steps

34.9 Difficulties Encountered These fractures often involve small fragments that are challenging to manipulate and achieve secure fixation. These small fragments can split and crumble with too many passes with Kwires and screws. Excessive soft tissue stripping during open exposure of these fractures can predispose to osteonecrosis of the fracture fragment.

34.10 Key Procedural Steps 34.10.1 Closed Reduction and Percutaneous K-wire Fixation When managing unstable fracture patterns, closed reduction is sometimes possible followed by stabilization with percutaneous K-wires. Situations where this method is less favorable are when fracture fragments are significantly displaced, rotated, or there is question of soft tissue interposition. These circumstances would require open reduction.

The technique involves the use of intraoperative fluoroscopy. Ligamentotaxis alone through longitudinal traction of the digit can sometimes reduce the fragments. Precise percutaneous application of a pointed reduction clamp guided by fluoroscopy can be used to stabilize the reduction enough to advance small caliber K-wires across the condylar head of the phalanx. Reduction can also be facilitated by advancing a pin into the fracture fragment and using this as a joystick to achieve anatomic reduction. The number of K-wires required is dictated by the size of the fragment and rotational instability of the fracture pattern. ▶ Fig. 34.1 and ▶ Fig. 34.2 demonstrate K-wire fixation to stabilize both bicondylar and unicondylar fractures, respectively.

34.10.2 ORIF through Midlateral Approach A standard midlateral approach on the side of the fracture is used. Fibers of the transverse retinacular ligament coursing dorsal to volar are carefully divided, with plan for later repair. Subperiosteal exposure of the dorsal head of the phalanx is carried

Fig. 34.1 Unique crush injury involves simultaneous bicondylar fracture of the proximal and middle phalanx. Associated soft tissue injuries favored fixation with percutaneous K-wire technique. (a,b) Posteroanterior (PA) and lateral views show displacement of the middle phalanx fragments, whereas the proximal phalanx fragments are relatively nondisplaced. (c,d) K-wire fixation here begins with securing one of the condyles for each fracture with an oblique K-wire. The adjacent condyle is then reduced to the stabilized one and again secured with an oblique K-wire to complete the stable construct.

Fig. 34.2 (a,b) A unicondylar fracture with displacement best appreciated on the oblique views. (c,d) The displaced condyle fragment is rotated dorsally and secured in position with an obliquely placed, percutaneous K-wire. Fracture stability is confirmed intraoperatively and K-wires removed in 3 to 4 weeks’ time.

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Fixation of Uni and Bicondylar Phalangeal Fractures out, avoiding instrumentation of the plane under the extensor mechanism. The fractured condyle is hinged out of the wound on its collateral ligament pedicle and the fracture surfaces prepared with the flat edge of an elevator. The fracture is reduced and inspected. Judicious elevation of the collateral ligament from the fragment proceeds, just enough to allow screw placement. A 1.0, 1.2, or 1.4 self-tapping lag screw can be used for fixation. The transverse reticular ligament is repaired with a 5–0 absorbable suture.

34.10.3 Osteochondral Graft Reconstruction through Volar Approach (Shotgun) A volar shotgun approach is used if extensive exposure is required for reconstruction of the proximal phalanx head. Volar Bruner incisions are used with identification and protection of the radial and ulnar neurovascular bundles. A flap of flexor sheath centered over the A3 pulley, orientated in the opposite direction to the Bruner incision, is elevated to expose the flexor tendons over the PIP joint. Both flexor tendons are retracted to expose volar plate, which is then incised, leaving sufficient cuff for later repair. The volar fibers of the collateral ligament are released. The PIP joint is hyperextended. Take note to ensure dorsal subluxation of the neurovascular bundles to avoid traction injury to digital nerves. Prepare the condyle defect by squaring edges with osteotome, sagittal saw, or rongeur. Measure the dimensions of desired graft. Expose donor site at either the base of ipsilateral fifth metacarpal base6 or third toe middle phalanx.3 Procure grafts and trim to fit the condylar defects, matching the articular surface anatomically. Secure in place with two 1.0- or 1.3-mm self-tapping screws. Repair collateral ligament. Protect repair with dorsal blocking splint and begin supervised early range-of-motion therapy within 1 week.

34.10.4 Dorsal Approach If greater longitudinal exposure is required, for example if corrective osteotomies are required, a dorsal approach can be used. The advantages include broad dorsal exposure of the phalanx and condyles. The main disadvantages include disruption of the extensor mechanism, risk to the vascularity of the fracture fragments in and stiffness from intra-articular exposure.

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A midline dorsal incision is made, taking care to preserve dorsal veins. The interval between the central tendon and the lateral band can be entered to avoid incising the extensor tendon. Alternatively, a midline split of the extensor mechanism can be used. Avoid dis-insertion of the central slip from its dorsal insertion on the middle phalanx. Preserve soft tissue attachments to the fracture fragments, whether unicondylar or bicondylar, and secure provisional reduction with small gauge (0.028) K-wires. If stable, K-wires can be relied on as the sole fixation method (▶ Fig. 34.1 and ▶ Fig. 34.2). Alternatively, an appropriately sized, low-profile plate is selected and used to secure the reduction.

34.11 Bailout, Rescue, and Salvage Procedures Delayed presentations with malunion are less common. Reconstructive techniques to restore the articular surface can be used in these instances. These techniques include intra-articular osteotomy7 or extra-articular osteotomy.8 Obliterated condyles from saw injuries, for example, can be managed with osteochondral graft reconstruction of the missing articular elements.6 PIP joint arthroplasty or arthrodesis can be effective salvage procedures in the event of treatment failure or joint degeneration.

References [1] Day C, Stern PJ. Fractures of the metacarpals and phalanges. In: Wolffe SW, et al, eds. Green’s Operative Hand Surgery. Philadelphia, PA: Elsevier; 2016: 261–262 [2] Dumont C, Albus G, Kubein-Meesenburg D, Fanghänel J, Stürmer KM, Nägerl H. Morphology of the interphalangeal joint surface and its functional relevance. J Hand Surg Am. 2008; 33(1):9–18 [3] Hendry JM, Mainprize J, McMillan C, Binhammer P. Structural comparison of the finger proximal interphalangeal joint surfaces and those of the third toe: suitability for joint reconstruction. J Hand Surg Am. 2011; 36(6):1022–1027 [4] Weiss AP, Hastings H, II. Distal unicondylar fractures of the proximal phalanx. J Hand Surg Am. 1993; 18(4):594–599 [5] Shewring DJ, Miller AC, Ghandour A. Condylar fractures of the proximal and middle phalanges. J Hand Surg Eur Vol. 2015; 40(1):51–58 [6] Cavadas PC, Landin L, Thione A. Reconstruction of the condyles of the proximal phalanx with osteochondral grafts from the ulnar base of the little finger metacarpal. J Hand Surg Am. 2010; 35(8):1275–1281 [7] Teoh LC, Yong FC, Chong KC. Condylar advancement osteotomy for correcting condylar malunion of the finger. J Hand Surg [Br]. 2002; 27(1):31–35 [8] Harness NG, Chen A, Jupiter JB. Extra-articular osteotomy for malunited unicondylar fractures of the proximal phalanx. J Hand Surg Am. 2005; 30(3): 566–572

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35 Bony Mallet Fixation Genghis E. Niver Abstract Extensor tendon injuries at the level of the distal interphalangeal joint can lead to substantial deformity and functional disability, and are comprised of a spectrum of injuries. Extensor tendon disruptions that involve an avulsion fracture at the site of tendon attachment into the distal phalanx are termed bony mallet injuries. The treatment of these injuries remains controversial, and is in part dictated by the amount of articular surface involvement and articular stability. An overview of surgical indications and treatment challenges is provided in this chapter. Keywords: bony mallet, avulsion fracture, extensor tendon, distal phalanx, articular fracture, distal interphalangeal joint

superimposed upon one another for this radiograph to be exact. Although computed tomography (CT) can be performed, it is typically not necessary to determine volar subluxation or degree of articular involvement. In addition, stress radiographs with the distal phalanx in line with the middle phalanx may alter the amount of volar subluxation present, such as radiographs obtained while in a splint.

35.7 Special Instructions, Positioning, and Anesthesia ● ● ● ●

35.1 Description

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Local anesthesia with epinephrine Finger tourniquet can be considered Supine position with hand table Mini C-arm is optimal, although standard C-arm could be used. Availability of 0.035 inch and 0.045 inch Kirschner wires (K-wire)

A variety of fixation options exist for bony mallet fractures involving the distal phalanx (▶ Fig. 35.1), including percutaneous fixation and internal fixation.

35.2 Key Principles Multiple fixation strategies are possible for nondisplaced and displaced bony mallet fractures of the distal phalanx, which depend upon the amount of displacement, articular involvement, and presence of volar subluxation.

35.3 Expectations The goals of operative stabilization of bony mallet fractures would include improved mobility, better articular congruity, and decrease in the risk of future arthritis.

35.4 Indications Displaced avulsion fractures of the distal phalanx with articular involvement of greater than 30 to 50% of the articular surface or fractures with volar subluxation of the distal phalanx in relation to the middle phalanx.

35.5 Contraindications ● ● ●

Congruous distal phalanx with middle phalanx condyles No volar subluxation present Articular involvement of less than 30 to 50%

35.6 Special Considerations An exact true lateral image of the distal interphalangeal (DIP) joint is required to determine whether or not operative intervention is necessary. The middle phalanx condyles should be

Fig. 35.1 Lateral xray of a finger with an extensor tendon avulsion fracture at the level of the distal interphalangeal joint. The fracture involves about 50% of the articular surface of the distal phalanx.

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Bony Mallet Fixation

35.8 Tips, Pearls, and Lessons Learned

such as wire prominence, soft tissue irritation/infection, and nonunion.

35.8.1 Percutaneous Fixation

35.10 Key Procedural Steps

Using mini C-arm fluoroscopy, obtain a perfect lateral of the phalanx. With this view, a pointed reduction clamp can be utilized to obtain a reduction in the articular fragment prior to any percutaneous wire fixation (▶ Fig. 35.2). Typical extension block pinning can then proceed with the clamp in place (▶ Fig. 35.3). Finally, a third wire can be placed through this fragment further maintaining the reduction.

During placement of the pointed reduction forceps, further comminution can occur to the displaced articular fragment. Other difficulties can occur with wire placement, such as the wire being placed through the fracture as it spans the DIP joint or the extension block wire preventing reduction of the DIP joint. Wires can also be placed in such a configuration that they can prevent other wires from being placed, especially when the small finger is involved. During wire placement of various wires, occasionally the nail bed can get injured resulting in a subungual hematoma, or the eponychial fold may have pressure causing grooving in the nail plate. Finally, postoperative difficulties can be encountered,

To best secure the distal phalanx fragment using percutaneous pins, a small pointed reduction forceps should be placed to maintain the reduction. This should be placed slightly distal to the apex of the dorsal fragment so that a Kirschner wire can be placed to impale the fragment as added fixation if necessary. Once the pointed reduction forceps is placed, a 0.035inch K-wire should be placed from dorsal to volar at the most distal and dorsal portion of the middle phalanx head. This wire will be used as the extension block pin and should be placed with DIP joint in flexion. After verification of the appropriate placement, the DIP joint should be brought into extension to wedge the dorsal articular fragment of the distal phalanx against the initial K-wire. A second K-wire should be placed on the tip of the distal phalanx and inserted across the distal phalanx, DIP joint, and middle phalanx. Occasionally, to maintain the DIP reduction and prevent iatrogenic volar subluxation, slight flexion may be required for placement of this wire. Finally, a third K-wire can be placed from dorsal to volar into the distal phalanx to keep the dorsal fracture fragment further reduced. Similar reduction methods can be employed for placement of internal fixation using a 1.2-mm screw. However, a dorsal incision is required with exposure of the fracture fragment. This should not be used for very small fracture fragments as morselization can occur. In addition, placement of the screw should not significantly penetrate the volar cortex of the distal phalanx as soft tissue irritation and prominence can result. A 0.035-inch K-wire should still be placed from the distal phalanx across the DIP joint to maintain full extension as bony union occurs.

Fig. 35.2 Closed reduction of the fracture with a tenaculum demonstrating anatomic fracture reduction.

Fig. 35.3 Closed reduction and percutaneous pinning of the fracture with a transarticular and a dorsal blocking K-wire.

35.8.2 Internal Fixation Use of a modular handset with small screws can be used in conjunction with a wire spanning the DIP joint in extension (▶ Fig. 35.4). The screws can be 1.2-mm screws that can be placed adjacent to a pointed reduction clamp while maintaining the reduction.

35.9 Difficulties Encountered

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Bailout, Salvage, and Rescue Procedures

35.11 Bailout, Salvage, and Rescue Procedures For failed fixation, persistent extensor lag greater than 20 degrees, or postoperative arthritic changes, salvage procedures exist. Revision open reduction or percutaneous pinning can be quite difficult due to the small fragment size and soft tissue swelling. Arthrodesis is always a viable option, especially if utilized late, to alleviate a painful arthritic joint, or to add more stability if significant extensor lag is still present. This can be performed at any stage using K-wires or headless compression screws.

Suggested Readings Fig. 35.4 Open reduction and internal fixation of a bony mallet injury with a transarticular K-wire and a mini interfragmentary screw.

Nikkhah D. Hand Trauma: Illustrated Surgical Guide of Core Procedures. Stuttgart: Thieme; 2018 Plancher KD. Mastercases: Hand and Wrist Surgery. New York: Thieme; 2004

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36 Proximal Interphalangeal Joint Fracture-Dislocation William J. Knaus, J. Michael Hendry, and Joseph Upton Abstract Proximal interphalangeal joint injuries represent one of the more difficult problems in hand surgery. Fracture dislocations of the joint generally are complex problems involving intraarticular bony pathology in addition to surrounding soft tissue damage. A multitude of operative techniques, ranging from fracture fixation to partial arthroplasty grafts are available depending on the context and surgeon preference. Keywords: proximal interphalangeal joint, PIPJ, PIP joint, volar plate, volar plate arthroplasty, dynamic external fixation, hemihamate arthroplasty

injury patterns generally are less than 30% of the articular surface and unstable patterns are more than 50%. Between those values, examination and patient factors can help direct treatment. Fracture types can be simple or comminuted. Fractures that require greater than 30 degrees of flexion to reduce are considered unstable.

36.5 Contraindications ●

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36.1 Description

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Proximal interphalangeal joint (PIPJ) fracture-dislocation is one of the most difficult phalangeal injury patterns to manage. An array of options ranging in complexity are available. Simpler options include dorsal-block extension pinning and dynamic external fixation that can be performed closed. More invasive options include open reduction, internal fixation, volar plate arthroplasty, and hemi-hamate arthroplasty. Assessment of the involved joint surface and fracture pattern aid in treatment selection.

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36.2 Key Principles PIPJ fracture-dislocation involves damage to both the intraarticular aspect of the joint and the surrounding joint soft tissue structures (e.g., collateral ligaments, volar plate). The extent of injury varies and is generally best assessed by the amount of articular involvement and the pattern of fracture. The PIPJ is particularly predisposed to stiffness and, unfortunately, occurs in a functionally important area that accounts for the largest single-joint contribution to finger arc of motion. Injuries generally affect the grasping of objects. Management priorities include eliminating subluxation and early mobilization.

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36.6 Special Considerations Physical examination should include an assessment of PIPJ arc of motion and varus/valgus stability. Stability of volar lip fractures is confirmed clinically by maintained reduction in full extension and absent subluxation on lateral radiograph. Plain radiographs can underestimate the fracture component, particularly in the volar lip, and CT scans can add diagnostic information.

36.7 Special Instructions, Positioning, and Anesthesia ●

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36.3 Expectations Outcomes vary by extent of injury, time to presentation, and technique. Active range of motion (ROM) of around 90 degrees is possible for most injuries with appropriate treatment. Patients may underestimate the functional implications present as well as the considerable hand therapy rehabilitation involved to maximize motion. Patients will generally need to dedicate considerable time toward range-of-motion exercises over a 3-month period.

36.4 Indications Stability of fracture-dislocation depends on the amount of articular involvement and range of motion on examination. Stable

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Stable injuries amenable to progressive extension block splinting – Lesser intra-articular involvement (less than 30%) and ability to maintain reduction with 30 degrees or less of flexion Unrealistic expectations Inability to engage hand therapy Low functional demands Concomitant severe injuries Dorsal lip fractures with less than 2-mm displacement

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Can be performed under general anesthesia, regional block, or a digital block Supine with hand outstretched on a hand table A tourniquet can be applied to the upper arm or digit Mini C-arm fluoroscopy available for intraoperative use Kirschner (K-wires) (0.028–0.045 size) – Dynamic external fixation ○ Extended (9-inch) K-wires ○ Dental rubber bands Hand screw set (1.0, 1.3-mm screws and 0.7- to 2-mm drill), depth gauge, screw driver Hemi-hamate arthroplasty – Small osteotome, sagittal saw (0.4- to 1-cm blades), hand screw set

36.8 Tips, Pearls, and Lessons Learned The goals of restoration of the articular surface and early motion are important. With multiple approaches, there is no single best solution. The simplest operation that restores the joint

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Key Procedural Steps surface and will allow ROM up to 90 degrees should be pursued. Simpler injuries can be adequately addressed by extensionblock splinting alone and should be strongly considered, particularly for older patients (age 60 and older) with lesser complaints. For open approaches, broad exposure is important. Be prepared to perform a wide shotgun approach and carefully handle the surrounding tissues to allow for volar plate repair.

36.9 Difficulties Encountered Carefully planned and executed osteotomies are required. Jagged osteotomy cuts or creation of comminution during this step can complicate the plating and osteosynthesis.

36.10 Key Procedural Steps 36.10.1 Extension Block Pinning Useful for less involved articular fractures (30–40%) that are able to maintain an acceptable arc of motion (up to 90 degrees) and be closed reduced. This technique exclusively addresses the dislocation component of the injury. A 0.045-inch K-wire is placed obliquely into the proximal phalangeal head to prevent full extension of the PIPJ. The pin is passed between the central tendon and lateral bands. Generally, 30 degrees of joint flexion is maintained to the joint. If greater than 30 degrees flexion is required to achieve reduction of the fracture, a different technique should be selected. This technique prevents dorsal subluxation of the joint while allowing active flexion. The pin is removed at 2 to 3 weeks.

36.10.2 Dynamic External Fixation A construct of three K-wires are placed in a closed manner percutaneously to distract the joint surface, address the dorsal dislocation, and allow early active motion. Only two K-wires are used for a pilon-type fracture pattern. This technique can be used to address complex intra-articular fracture patterns with comminution or a pilon (extended dorsal) component by eliminating subluxation and allowing immediate range of motion. Anatomic restoration of the joint surface is not an absolute priority. The first 0.45 K-wire is placed transversely through the central axis of rotation of the proximal phalanx, at the level of the metaphyseal flare. Exact wire placement should be confirmed on true lateral X-rays and the transverse position perpendicular to the long axis of the phalanx confirmed on anteroposterior (AP) fluoroscopic views (▶ Fig. 36.1b,c). The second wire is then placed at the metadiaphyseal junction of the middle phalanx parallel to the joint surface and represents the most distal wire (▶ Fig. 36.1c). A third wire is placed through the diaphysis of the middle phalanx distal to the fracture component and serves as a fulcrum over which the proximal wire rests in order to provide a volarly or dorsally directed reduction force at the fracture. Note that in pilon fractures that have no stable dorsal or volar lip of the middle phalanx base, using the third wire as a fulcrum can cause fracture angulation and should therefore be avoided. Fluoroscopic

views confirm reduction of the fracture with longitudinal distraction. The completed construct will maintain this distracting force. The construct is formed by bending the wires and securing dental rubber bands to maintain joint distraction and reduction (▶ Fig. 36.1d,e). Distal hook formation: this begins by placing two bends in the distal end of the proximal wire to create an “S”-shaped hook. The first bend is placed at the level of the fingertip distal pulp. The second bend is set approximately 1-cm proximal to create a sufficiently deep hook. Proximal hook formation: two bends are placed in the distal-most wire in the middle phalanx. The first is a 90-degree bend so the wire tips point distally. The second bend brings the wire 180 degrees over itself to complete the formation of the hook. Ideally, 2.5 cm of distance between these two hooks is used to maintain distraction of the joint. Finally, the third wire is crimped over the proximal phalanx wire where they cross which helps to stabilize the construct. An arc of motion of 90 to 100 degrees is recommended intraoperatively. Generally, two to three elastic bands provide sufficient traction. If persistent subluxation is noted, more elastic bands can be added, but overdistraction must be avoided. Once the joint is reduced and gliding, no further attempts at reducing articular fragments are necessary. The patient is splinted and initiated on early motion after 2 to 3 days of immobilization under the guidance of hand therapist. Wires can be removed in about 4 weeks.

36.10.3 Open Reduction and Internal Fixation Best suited for a single, sizable volar fragment that can accommodate a 1- to 1.3-mm screw. A volar shotgun approach with Bruner incisions along the proximal and middle phalanges is performed. The A3 pulley is excised or raised in an ulnar or radially based flap, and the flexor tendons are retracted. The base of the flexor tendon sheath can be excised. The volar plate, if intact, can be transversely incised immediately proximal to the middle phalanx volar lip fragment, leaving a small cuff to facilitate later repair. Often, the volar portion of the collateral ligament proximal and distal attachments must be released sharply to allow the necessary hyperextension. The joint can then be hyperextended to visualize the intra-articular components of the proximal and middle phalangeal epiphyses. Ensure that the neurovascular bundles easily sublux dorsally during this maneuver. A dental pick is used to elevate the fragment and attempt open reduction. Fluoroscopic views are taken to ensure reduction of the articular surface. A 1.0- to 1.3-mm self-tapping lag screw can be placed with a 0.8-mm drill followed by a 1.0 to 1.3 mm for the volar fragment. If the fragments are too small to accept a screw, then a box plate can be used to effectively buttress the fragments in place. Care should be taken to avoid the screw from being proud due to its proximity to the flexor digitorum profundus. The A3 pulley does not need to be repaired. If uninjured, the volar plate can be secured to the radial and ulnar aspects of the A4 pulley with a 4–0 Nylon suture to stabilize the joint. The skin is closed and the patient is immobilized.

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Proximal Interphalangeal Joint Fracture-Dislocation

Fig. 36.1 Dynamic external fixation technique. (a) Unstable fracture dislocation of the PIP demonstrating persistent dorsal subluxation and comminuted small volar fragment; (b) precise placement in the center of the rotational axis of the proximal phalanx head is mandatory. True lateral views are required to confirm this; (c) intraoperative views of the final construct. The central pin acts as a fulcrum to aid in maintaining joint alignment. Ensure that the PIP joint is not overdistracted following placement of elastics; (d) in volar lip fractures of the middle phalanx that sublux dorsally, the long limbs of the axis pin travel dorsal to the middle “fulcrum” pin to apply a volar force on the middle phalanx. (e) Bending wires close to the skin limits irritation of adjacent digits. (f) Fracture remodeling occurs if joint congruity and early gliding range of motion are restored using this technique; (g, h) average result using dynamic external fixation.

36.10.4 Volar Plate Arthroplasty This technique requires preservation of at least 50% of the joint surface and can be considered in comminuted fracture patterns. It can be performed in chronic injuries. A volar shotgun approach is used. The volar plate is incised just off the collateral ligaments and transversely off the middle phalanx distally. The volar plate can be held with two 3–0 Ethibond sutures to the radial and ulnar distal corners of the tissue to assist in atraumatic handling. Comminuted fracture segments are debrided. At least 50% of the dorsal surface is needed for stability. A volar trough is developed with a rongeur and the volar plate is transposed into the defect. Two straight Keith needles are passed with a wire driver to the radial and ulnar aspect of the middle phalanx just dorsal to the trough and tensioned to the point of mild PIPJ flexion. The

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Keith needles can then be used to pass the Ethibond sutures through the dorsal bone and out the dorsal skin. The sutures are tied over a button to protect the soft tissues. An extension-block pin as described in an earlier section is performed. The K-wire is removed at 2 to 3 weeks and PIPJ motion is begun. Distal interphalangeal joint (DIPJ) motion can begin immediately. The suture is removed from the button at 6 weeks.

36.10.5 Hemi-Hamate Arthroplasty This technique can be used in chronic injuries and acute comminuted fractures. A volar shotgun approach is used to expose the PIPJ. The amount of volar fragment involvement is directly visualized and involved fracture fragments are excised. A sagittal saw can be used to define the distal and dorsal boundaries and allow

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Key Procedural Steps

Fig. 36.2 Hemi-hamate autograft technique. (a) PIP joint fracture dislocation with persistent dorsal subluxation; (b) typical donor site defect with segment of osteochondral graft centered on the distal articular crest of the hamate; (c) osteochondral graft inset into volar defect (top of image) through volar shotgun approach; (d,e) lateral and PA views of the reduced and fixated hemi-hamate osteochondral graft. Note the step in the level of subchondral bone on X-ray given thicker articular cartilage of the hamate, despite being continuous on direct inspection of the joint surface; (f) good result demonstrating restoration of PIP joint range of motion; (g) typical donor site scar.

clean osteotomy sites for more accurate measuring of the defect dimensions, ideally into a rectangular defect with same-size dimensions radially and ulnarly. Measurements of the defect from the middle phalanx epiphysis are taken in length, width, and depth and recorded on the drape. Depth of the defect at the fracture site can be estimated by measuring the excised fragments or by judging the amount needed to cover the proximal phalanx head. The hamate is exposed via a dorsal approach with a 3-cm longitudinal incision between the fourth and fifth carpometacarpal (CMC) joints (▶ Fig. 36.2b). The dorsal sensory branches are visualized during subcutaneous dissection and protected. The interval between the extensor digitorum communus and extensor digiti minimi is entered and a blunt Weitlander is used to expose the dorsal capsule of the hamate CMC joint. A longitudinal capsulotomy is made and subperiosteal elevation is performed over the body of the hamate. An autograft with

dimensions slightly larger than those measured at the defect is marked over the dorsal hamate, using the distal articular ridge as a reference point. A 4-mm sagittal saw can be used to perform the osteotomies radially, ulnarly, and proximally. The distal osteotomy should be performed with a palmar-directed force to the fourth and fifth metacarpals to expose the hamate/ CMC joint at an appropriate depth for the graft harvest. Alternatively, a trough in the hamate just proximal to the transverse osteotomy can be created to facilitate the coronal osteotomy with a curved osteotome advancing proximal to distal. The depth can be overestimated by 2 mm to accommodate for any loss of bone during the harvesting. Once raised, the autograft is rotated 180 degrees horizontally when inset into the middle phalanx base (▶ Fig. 36.2c). The joint should appear concentric and a small rongeur is used to make refinements to the position of the graft to improve the articular position. Concavity of the joint until it resembles a cup

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Proximal Interphalangeal Joint Fracture-Dislocation should be obtained. Depending on the size of the graft, two or three 1.0- to 1.3-mm lag screws is placed across the graft into the dorsal aspect of the middle phalanx as described in the open reduction and internal fixation section (▶ Fig. 36.2d,e). The joint is reduced and the screw lengths confirmed fluoroscopically. Note that the cartilage of the hamate graft is thicker than the native phalanx; therefore, it may appear as though there is a step off radiographically, whereas inspection of the joint surface confirms articular continuity. The volar plate is repaired and the skin closed. The patient is immobilized initially. After 1 week, range-ofmotion therapy begins within an extension block splint at 30 degrees, and continues for 4 weeks.

36.11 Bailout, Rescue, and Salvage Procedures In chronic injuries or failure of initial treatment, total joint arthroplasty (e.g., pyrocarbon or silicone prosthesis) can be performed in appropriately selected patients.

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A PIPJ fusion in a functional position of slight flexion can be performed to address chronic pain or previous treatment failure.

Suggested Readings Calfee RP, Kiefhaber TR, Sommerkamp TG, Stern PJ. Hemi-hamate arthroplasty provides functional reconstruction of acute and chronic proximal interphalangeal fracture-dislocations. J Hand Surg Am. 2009; 34(7):1232–1241 Kiefhaber TR, Stern PJ. Fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am. 1998; 23(3):368–380 Merrell G, Hastings H. Dislocations and ligament injuries of the digits. In: Wolffe SW, et al, eds. Green’s Operative Hand Surgery. Philadelphia, PA: Elsevier; 2016:494–498 Ruland RT, Hogan CJ, Cannon DL, Slade JF. Use of dynamic distraction external fixation for unstable fracture-dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2008; 33(1):19–25 Williams RMM, Kiefhaber TR, Sommerkamp TG, Stern PJ. Treatment of unstable dorsal proximal interphalangeal fracture/dislocations using a hemi-hamate autograft. J Hand Surg Am. 2003; 28(5):856–865

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37 Metacarpals (Pinning) Philip S. Brazio and Jacques A. Machol Abstract Pins, or Kirschner wires, are a versatile tool for fixation of metacarpal fractures. Closed approaches allowed by pinning can offer not only greater ease and lower morbidity than open approaches, but also achieve more reliable fixation in certain fracture patterns. Pinning options for common fracture patterns are reviewed, together with indications for pinning versus alternate approaches. Useful techniques for reduction and pinning are detailed and illustrated. Keywords: metacarpal fracture, Boxer fracture, Bennet fracture, Rolando fracture, Kirschner wire, K-wire, CRPP, percutaneous pinning, fracture pinning

37.1 Overview Metacarpal fractures represent one-fifth of all upper extremity fractures (264,000 every year) presenting to emergency departments in the United States.1 Most can be treated nonoperatively. For most operative metacarpal fractures, percutaneous pinning after closed or open reduction is a powerful and versatile technique that can be applied in a myriad of combinations to address individual fracture patterns.

37.2 Indications 37.2.1 For Operative Fixation Indications for closed reduction and pinning include instability of reduction, involvement of > 25% of the articular surface, > 1 mm of articular step-off, or rotation. Digit malposition should be determined clinically by comparing to the other hand, looking for “scissoring” of fingers, and observing the flexion cascade (all should converge toward the scaphoid tubercle). Fractures that are more proximal may translate to increased tip rotation versus more distal metacarpal injuries.

37.2.2 For Pinning over Internal Fixation Closed reduction and pinning has specific advantages over open approaches. It may decrease postoperative swelling and stiffness that follows open reduction. In many scenarios, plate and screw fixation may require extensive dissection and disruption of soft tissue attachments, even after difficult reduction requiring open treatment. In these cases, it is usually preferable to employ wire fixation. A comminuted intra-articular fracture may be managed with a closed pinning approach to take advantage of ligamentotaxis. Similarly, extra-articular comminuted fractures may reduce easier when the soft tissue envelope is preserved. Kirschner wires (K-wires) may also be preferable

in comminuted fractures, given the potential lower risk of fragment devitalization due to periosteal stripping.

37.2.3 Contraindications (Indications for Plating) K-wires may delay joint mobilization as they often require splinting for multiple weeks. Given this, they may be less desirable in those patients at risk for arthrosis presenting with simple fractures. True transverse fractures of the metacarpal shaft may be better stabilized using internal fixation.

37.3 Preparation 37.3.1 Diagnostic Studies Posterior-anterior, lateral, and oblique plain film radiographs should be obtained. Advanced imaging techniques are rarely employed for isolated metacarpal fractures

37.3.2 Equipment and Hardware 0.045-inch K-wires are generally adequate for metacarpal fractures in adults. In larger patients 0.062-inch wires may be preferred; in children, 0.035 inch may be adequate. A tourniquet is not overtly useful in closed reduction, but should be placed preoperatively, in case conversion to an open approach is needed. A mini C-arm is preferable over a full size C-arm fluoroscope to decrease radiation exposure.

37.3.3 Anesthesia Sedation with a local or brachial plexus block is generally adequate for hand fracture pinning. In pediatric patients or other healthy but uncooperative patients, general anesthetic may provide greater ease of reduction and fixation.

37.3.4 Assistants Because counter-traction may be necessary to obtain and hold reduction while positioning the C-arm or exchanging instruments for fixation, the surgeon should have a dedicated assistant who can focus on positioning, in addition to a scrub tech or nurse.

37.4 Approach to Specific Fracture Patterns 37.4.1 Bennett Fracture Dislocation Bennet fractures are intra-articular fractures of the first metacarpal head. The abductor pollicis longus exerts a strong pull on the distal fracture fragment, subluxing the first metacarpal proximally and radially.

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Indications for Operation Bennet fractures are considered inherently unstable. Stable internal fixation is encouraged.

Technique To aid reduction, the assistant applies axial traction while pronating the thumb. The surgeon abducts the distal metacarpal while pushing the metacarpal base into reduction with the Bennet fragment. The first point of fixation is easiest to achieve using a 0.045-inch K-wire-driven transversely from radial to ulnar through the distal fragment into the second metacarpal. This may not capture the proximal fragment, but it should stabilize sufficiently to allow a second wire to be driven retrograde through the proximal Bennet fragment. This wire may then be driven further into the carpus if additional fixation is desired but this is not usually necessary. The Bennet fragment is not always captured with a K-wire. A third wire may be utilized to improve stability of the construct. This final wire may be in parallel with the first or crisscross into the index finger metacarpal.

Variations Comminuted intra-articular fractures of the first metacarpal base (Rolando fractures) may be treated in a similar manner to Bennet fractures (▶ Fig. 37.1). The comminuted proximal fragments will generally reduce sufficiently via ligamentotaxis. As with other comminuted fractures, open treatment is discouraged. Extra-articular fractures of the first metacarpal base (not true Bennet fractures) are often stable and can be treated with closed reduction and splinting. If angulation > 30 degrees is present or the reduction is not stable, they may be pinned in the same manner as a true Bennet fracture.

37.4.2 Metacarpal Neck Fracture (Boxer Fracture) Indications for Operation Metacarpal neck fractures should be operated for shortening > 3 mm, extensor lag, rotation/scissoring, or significant angulation deformity. Angulation thresholds are 10 to 15 degrees for index and middle fingers, 30 to 40 degrees for ring and small fingers.

Technique The Jahss maneuver2 remains a reliable method to achieve reduction of the metacarpal neck. The metacarpophalangeal (MCP), then proximal interphalangeal (PIP), then distal interphalangeal (DIP) joints are flexed 90 degrees each, relaxing the intrinsic muscles and tightening the collateral ligaments (▶ Fig. 37.2). Pressure is then applied in a dorsal direction on the proximal phalanx, transmitting the force onto the metacarpal head. K-wires may be driven obliquely crossed, longitudinally, transversely, or in a combination (▶ Fig. 37.3). Purchase for retrograde, longitudinal pinning is gained by directing the wire through the skin in a direction perpendicular to the metacarpal epiphysis, resting on the collateral recess of the metacarpal head just distal to the epiphyseal plate and ulnar or radial to the extensor tendon (▶ Fig. 37.4a). The driver is then set onto the wire and used to create a small groove in the extra-articular bone surface—allowing the wire to pivot into a longitudinal orientation without slipping from the bone (▶ Fig. 37.4b). This technique will also leave the distal wire outside of the MCP joint to prevent joint impingement and to permit splinting in intrinsic plus (▶ Fig. 37.4c). Crossing the K-wires at the fracture line may decrease stability and should be avoided.

Fig. 37.1 Rolando fracture treated with two transverse K-wires to maintain length.

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Approach to Specific Fracture Patterns

Fig. 37.2 The Jahss maneuver. The metacarpophalangeal, then proximal interphalangeal, then distal interphalangeal joints are flexed 90 degrees each, relaxing the intrinsic muscles and tightening the collateral ligaments. Pressure is then applied in a dorsal direction on the proximal phalanx, transmitting the force onto the metacarpal head.

Fig. 37.3 Oblique crossed K-wire fixation for metacarpal neck fracture.

If the fracture reduction is laterally stable, transverse pinning may be used. At least two wires should be used to keep the fracture at length and prevent rotation: one in the distal and one in the proximal fragment. The wires should cross through the adjacent metacarpal. Additional stability may be gained by crossing into at least one cortex of yet another metacarpal, although this is not strictly necessary.

37.4.3 Comminuted Fractures Indications for Operation Nondisplaced comminuted fractures may require only cast immobilization without operative fixation. However, fixation is often necessary for associated soft tissue loss, open fracture,

multiple fractures, and shortening in addition to angulation and rotation deformities. Border metacarpals are more likely to require fixation because of the relative paucity of adjacent soft tissue stabilization.

Technique A closed approach is preferred due to the stabilizing effect of the soft tissue envelope. If an open technique is necessary, 0.024 or 0.026 dental cerclage wire may be added to K-wires to capture additional comminuted fragments. The specific technique used for comminuted fracture depends on the fracture patterns. The tenet of stabilizing larger, free fragments to an adjacent or proximal metacarpal/carpal should be followed to create a stable construct (▶ Fig. 37.5).

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37.5 Postoperative Care 37.5.1 Splinting Percutaneous pinning generally requires immobilization. The duration depends on the fracture’s requirements and the patient. Unless concomitant tendon or other injuries contraindicate it, the hand should be splinted in intrinsic plus position, with immobilization of the metacarpophalangeal and carpometacarpal joint of the affected and immediately adjacent finger. If the thumb metacarpal is involved a long thumb spica splint should be used to allow thumb IP motion. Patients are often referred to hand therapy to begin range-of-motion exercises, within the limits of the splint, and for long-term motion and strengthening after the fracture has healed.

37.5.2 Antibiotics In addition to perioperative antibiotics, antibiotics are indicated for open fractures and may be considered for longer term use when there are exposed K-wires, though routine prophylactic antibiotic postoperatively for closed fractures is discouraged, unless there is a pin track infection. Antibiosis should be tailored to the wound type.

37.5.3 Pin Removal Pin removal is often completed at 4 to 6 weeks, and should be preceded by radiographs to confirm adequate reduction and bony union. A post removal film may be completed to confirm complete removal of the hardware.

37.6 Complications 37.6.1 Infection Infection is the most common complication of metacarpal pinning, occurring in 7% in one large series,3 though recent series reveal the incidence to be larger. In most cases infection is superficial and is treated with a short course of oral antibiotics and pin care (hydrogen peroxide swabs and dressing changes). Deeper infection may require early pin removal and extended antibiotic therapy. Daily or twice daily pin site cares are recommended if able. There appears to be no difference in infection rate between buried or protruding pins.4

37.6.2 Pin Instability Wires are easily displaced. Inadequate immobilization or patient noncompliance may result in loosening or migration. Unlike internal plate fixation, early range of motion while pins are intact is not often completed as this may result in K-wire failure. K-wires may even distract fracture fragments if they are not properly inserted. Fig. 37.4 Technique for closed retrograde metacarpal pinning via the collateral recess, avoiding impingement on the metacarpophalangeal joint. (a) The wire is manually inserted perpendicular to the bone surface to gain purchase, (b) then pivoted proximally (c) to achieve longitudinal fixation.

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37.6.3 Stiffness Stiffness is a common complication of intra-articular metacarpal head fractures. Tendinous adhesions, contracture of the

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References

Fig. 37.5 Comminuted fracture secondary to gunshot wound, treated with transverse and oblique K-wires.

collateral ligaments or dorsal capsule, and articular surface irregularity may contribute to stiffness. It is crucial to mobilize each segment of the hand as early as possible to avoid this. Long-term therapy is often required.

References

[2] Jahss SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg Am. 1938; 20:178–186 [3] Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clin Orthop Relat Res. 1992 (276):194–201 [4] Stahl S, Schwartz O. Complications of K-wire fixation of fractures and dislocations in the hand and wrist. Arch Orthop Trauma Surg. 2001; 121(9): 527–530

[1] Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001; 26(5):908–915

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38 Metacarpal Fracture Open Reduction and Internal Fixation (ORIF) Edward S. Lee and Haripriya S. Ayyala Abstract Metacarpal fractures are among the most common hand injuries, often caused by a direct blow to the hand or by axial load. They are classified into fractures of the head, neck, and shaft and may be associated with soft tissue injury such as tendon lacerations and neurovascular injury. While some fractures can be treated conservatively with immobilization, many require operative treatment, varying from closed reduction and percutaneous pinning with immobilization to open reduction and internal fixation (ORIF). There are various indications for ORIF of metacarpal fractures as well as multiple approaches and techniques. Keywords: metacarpal fracture, principles of fixation, surgical approach, ORIF

38.1 Description

cerclage wires. Unstable reductions may require immobilization for 2 to 3 weeks before range-of-motion exercises are initiated. Skeletal traction or external fixation (▶ Fig. 38.1, ▶ Fig. 38.2, ▶ Fig. 38.3) may be needed if there are associated comminuted fractures of the adjacent base of the proximal phalanx. For open comminuted head fractures, especially fractures with bone loss, prosthetic arthroplasty is a reasonable alternative.

38.3.2 Metacarpal Neck Fractures Most closed metacarpal neck fractures can be treated nonoperatively. In the absence of pseudoclawing or rotational malalignment, they produce minimal to no functional problems. If pseudoclawing is not present, functional brace or dorsal-ulnar gutter splint can be used for 2 weeks. Reduction is indicated for pseudoclawing or rotational deformity using the Jahss maneuver and then subsequently immobilization for 2 weeks. The patient may return to sports and unrestricted activity at 4 to 6 weeks.

A number of different open reduction and internal fixation (ORIF) options for metacarpal fractures are available, including utilization of Kirschner wires (K-wires), lag screw, neutralization plate, dynamic compression plating (DCP), and headless screw use.

38.2 Key Principles There are various fixation options that exist for metacarpal fractures. Selection of the optimal treatment depends on several factors, including fracture location, severity of deformity, whether the fracture is open or closed, involvement of the articular surface, extent of osseous injury, degree of associated soft tissue injury, and intrinsic fracture stability. Anatomic reduction of these fractures is vital and a clinical evaluation for scissoring should be performed. Additional factors to consider include the patient’s age, occupation, presence of systemic illnesses, and patient compliance.

38.3 Expectations Tendons are less intimately associated with metacarpal bones compared to phalangeal fractures; therefore, outcomes in metacarpal fractures are typically better. Closed reduction may be attempted for displaced transverse metacarpal shaft fractures, but most displaced metacarpal fractures require fixation. Options include use of K-wires, interosseous wires, lag screws, and plates as per surgeon preference. In addition, isolated injuries tend to have significantly better outcomes than combined injuries.

38.3.1 Metacarpal Head Fractures Noncomminuted, displaced fractures that constitute more than 25% of the articular surface or exhibit more than 1 mm of articular step-off are treated operatively with K-wires and immobilization. Comminuted fractures require fixation with multiple K-wires or

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Fig. 38.1 Right-hand anteroposterior (AP) view second and third metacarpal comminuted shaft fractures with bony loss with external fixator.

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Contraindications

Fig. 38.3 Right-hand lateral view second and third metacarpal comminuted shaft fractures with bony loss with external fixator.

Fig. 38.2 Right-hand oblique view second and third metacarpal comminuted shaft fractures with bony loss with external fixator.

If an acceptable reduction cannot be maintained because of volar comminution and intrinsic muscle pull, percutaneous Kwires can be inserted crossed or transversely; intramedullary fixation under fluoroscopic guidance can be utilized. Care should be taken not to induce lateral translation of the fractured metacarpal head. If open reduction is necessary, crossed K-wires, dorsal tension band wire with a supplemental K-wire, or a laterally applied minicondylar plate can be utilized. Immobilization in an ulnar gutter splint is usually maintained for 2 to 3 weeks after percutaneous pin fixation.

● ● ●

Segmental bone loss Multiple fractures Associated soft tissue injury

38.4.2 Metacarpal Neck fractures ● ●

●

Open, articular displacement Angulation (index/middle 10–15 degrees; ring 40 degrees; small 60 degrees) Pseudoclaw formation, and the presence of a palpable head in the palm that can make grip painful

38.3.3 Metacarpal Shaft Fractures Most metacarpal shaft fractures are inherently stable and can be treated conservatively with acceptable functional outcomes. Open reduction and internal fixation (ORIF) can be accomplished using numerous techniques, including K-wire fixation, composite and cerclage wiring, intramedullary fixation, screw fixation, and plate fixation. Generally, the least invasive method that can reliably restore and maintain anatomic alignment of metacarpal shaft fractures is preferable for successful outcomes.

38.4 Indications 38.4.1 General Indications ● ● ● ●

Irreducible Malrotation (scissoring, spiral, and oblique) Articular Open

38.4.3 Metacarpal Shaft Fractures (▶ Fig. 38.4, ▶ Fig. 38.5, ▶ Fig. 38.6) ●

●

Any degree of rotation, multiple fractures, angulation (index/ middle 0–5 degrees; ring 20 degrees; small 30 degrees) Shortening more than 2 to 5 mm

38.5 Contraindications ● ●

●

●

Any factors that would prevent surgery for any patient For screw placement, extensive joint surface damage and nonreconstructable joints For metacarpal shaft fractures, extensive wound contamination and soft tissue injury are contraindications for plating with and without lag screw placement Composite (tension band wiring) is contraindicated when there is bone loss, comminution, or osteopenia

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Metacarpal Fracture Open Reduction and Internal Fixation (ORIF)

Fig. 38.4 Anteroposterior (AP) view right-hand second metacarpal transverse shaft fracture.

38.6 Special Considerations Detailed preoperative assessment of osseous, neurologic, and vascular anatomy is critical to success. Radiographs are typically sufficient and allow for an adequate understanding of the fracture morphology as well as the integrity and involvement of the articular surface. Image guidance with intraoperative fluoroscopy can provide significant information regarding fracture reduction, screw trajectory, and proper plate placement. Open fractures of a metacarpal head secondary to a clenched fist injury should be presumed to have oral contamination and are treated by formal irrigation and debridement. The wound is generally left open, and internal fixation, if necessary, is delayed until the wound shows no sign of infection. Patients who use their hands extensively for gripping (e.g., professional athletes, carpenters) may generate discomfort, however, from the flexed metacarpal head of the small finger in their palm. In these patients, we would typically not accept flexion greater than 40 degrees. For metacarpal neck fractures, manipulation is not usually worth attempting if the fracture is older than 7 to 10 days. For fractures that present late, it may not be possible to adequately reduce the fracture by closed means and thus ORIF may be necessary with use of osteotomies.

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Fig. 38.5 Oblique view right-hand second metacarpal transverse shaft fracture.

38.7 Special Instruments, Positioning, and Anesthesia 38.7.1 Patient Positioning ● ● ●

Patient placed in the supine position with hand on hand table Place tourniquet high on the affected extremity The use of fluoroscopy needs to be considered for room set-up

38.7.2 Anesthesia ●

Consider regional block with tourniquet vs general anesthesia

38.8 Tips, Pearls, and Lessons Learned ● ●

●

Many fractures do not require ORIF. When retracting, avoid complete muscle detachment and injury to the volar structures. Use short, blunt retractors (Langenbeck) rather than Hohmann levers. Many patients with these fractures may be unreliable, and this may compromise outcomes.

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Key Procedural Steps

Fig. 38.7 Lateral view right-hand third metacarpal plate/screws after comminuted shaft fracture.

Fig. 38.6 Lateral view right-hand second metacarpal transverse shaft fracture.

38.9 Difficulties Encountered Inadequate bone space for the accommodation of crossing K-wires, placement of screws, or inappropriate trajectory can lead to failure of wire and screw passage or intraoperative fractures. Awareness of the neurovascular bundle adjacent to the fracture is key when drilling and reducing fractures. Complications: ● Malunion ● Malrotation ● Nonunion ● Neurovascular damage ● Osteomyelitis ● Tendon adhesions ● Intrinsic muscle dysfunction

38.10 Key Procedural Steps ●

Exposure – Longitudinal or curvilinear incision over the metacarpal – Bluntly dissect to the extensor mechanism

Expose the fracture site and split the extensor mechanism Longitudinally incise the periosteum Reduction – Use a dental pick or small pointed reduction forceps to reduce the fracture Fixation – Metacarpal neck fractures: K-wires vs mini-condylar plate ○ Under fluoroscopic guidance, insert two 0.9-mm retrograde crossed K-wires from the lateral or dorsal (nonarticular) portion of the metacarpal head into the shaft; the pins may cross the joint surface if necessary; the pins should exit through the dorsal metacarpal shaft. ○ Other options include the use of two transverse pins from small to intact ring metacarpal head ○ “Bouquet” osteosynthesis: percutaneous antegrade insertion of pre-bent K-wires from small finger metacarpal base into head ○ ORIF with a lateral minicondylar plate: least desirable treatment option because stiffness may occur – Metacarpal shaft fractures: K-wires vs DCP plating/neutralization (▶ Fig. 38.7, ▶ Fig. 38.8, ▶ Fig. 38.9, ▶ Fig. 38.10, – –

●

●

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Metacarpal Fracture Open Reduction and Internal Fixation (ORIF)

Fig. 38.8 Oblique view right-hand third metacarpal plate/screws after comminuted shaft fracture.

Fig. 38.9 Anteroposterior (AP) view right-hand third metacarpal plate/ screws after comminuted shaft fracture.

●

●

▶ Fig. 38.11, ▶ Fig. 38.12; ▶ Fig. 38.13, ▶ Fig. 38.14, ▶ Fig. 38.15, ▶ Fig. 38.16, ▶ Fig. 38.17, ▶ Fig. 38.18) ○ K-wires can be crossed or transverse as mentioned above ○ For plating, measure the correct size and then provisionally fix the plate by clamping the plate to the bone proximally; the most commonly used plates are 2.0 to 2.5 mm ○ Add a subtle concave bend to the plate before its application to help compress the volar cortices ○ Check the sagittal and coronal plane alignment by direct inspection of the fracture site ○ Assess the rotation clinically with the aid of tenodesis Closure – Ensure at least four cortices of fixation in both the proximal and distal fragments – Close the periosteum and the interosseous muscle fascia over the plate; this provides a smooth gliding surface for the extensor mechanism Immobilization – Plate/lag screw: 1 week – K-wire: 3 weeks

38.11 Bailouts, Rescue, and Salvage Procedure Fig. 38.10 Anteroposterior (AP) view right-hand third and fourth oblique metacarpal shaft fractures fixated with K-wires.

● ●

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Corrective osteotomy for rotation Bone grafting for shortening

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Bailouts, Rescue, and Salvage Procedure

Fig. 38.11 Oblique view right hand third and fourth oblique metacarpal shaft fractures fixated with K-wires.

Fig. 38.12 Lateral view right-hand third and fourth oblique metacarpal shaft fractures fixated with K-wires.

Fig. 38.13 Anteroposterior (AP) view left-hand third and fourth metacarpal fractures, comminuted fixated with plates/screws.

Fig. 38.14 Oblique view left-hand third and fourth metacarpal fractures, comminuted fixated with plates/screws.

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Metacarpal Fracture Open Reduction and Internal Fixation (ORIF)

Fig. 38.15 Lateral view left-hand third and fourth metacarpal fractures, comminuted fixated with plates/screws.

Fig. 38.17 Oblique view left-hand second metacarpal shaft fracture with K-wire fixation.

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Fig. 38.16 Anteroposterior (AP) view left-hand second metacarpal shaft fracture with K-wire fixation.

Fig. 38.18 Lateral view left-hand second metacarpal shaft fracture with K-wire fixation.

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Bailouts, Rescue, and Salvage Procedure

Suggested Readings Al-Qattan MM. Outcome of conservative management of spiral/long oblique fractures of the metacarpal shaft of the fingers using a palmar wrist splint and immediate mobilisation of the fingers. J Hand Surg Eur Vol. 2008; 33(6):723–727 Kawamura K, Chung KC. Fixation choices for closed simple unstable oblique phalangeal and metacarpal fractures. Hand Clin. 2006; 22(3):287–295 Kollitz KM, Hammert WC, Vedder NB, Huang JI. Metacarpal fractures: treatment and complications. Hand (N Y). 2014; 9(1):16–23 Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg. 2000; 8(2):111–121

Saito T, Chung KC, Haase SC. Procedure 14—Open Reduction and Internal Fixation of Metacarpal Shaft Fractures. Operative Techniques: Hand and Wrist Surgery. 3rd ed. Elsevier; 2018:111–117 Souer JS, Mudgal CS. Plate fixation in closed ipsilateral multiple metacarpal fractures. J Hand Surg Eur Vol. 2008; 33(6):740–744 Trumble T, Rayan GM, Budoff JE, Baratz M, Slutsky DJ. Principles of Hand Surgery and Therapy. 3rd ed. Philadelphia, PA: Elsevier, Inc.; 2017 Wolfe SW, Hotchkiss RN, Pederson WC, et al. Green’s Operative Hand Surgery. 7th ed. Philadelphia, PA: Elsevier; 2017 Wong KP, Hay RAS, Tay SC. Surgical outcomes of fifth metacarpal neck fractures: a comparative analysis of dorsal plating versus tension band wiring. Hand Surg. 2015; 20(1):99–105

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39 Limited-Open Retrograde Intramedullary Headless Screw Fixation of Metacarpal Fractures David E. Ruchelsman and Chaitanya S. Mudgal Abstract Most metacarpal fractures can be treated conservatively with immobilization. Surgical intervention includes open reduction and internal fixation (ORIF). There are various indications for ORIF of metacarpal fractures as well as multiple approaches and techniques. Intramedullar fixation with screws has become an increasingly popular method of treatment. This method of fixation may offer clinical advantages over Kirschner wire fixation and other open techniques. Keywords: metacarpal fracture, principles of fixation, surgical approach, ORIF, intramedullary fixation

39.1 Description Fixation countersunk beneath the articular surface is wellaccepted for various upper extremity fractures. Multiple fixation techniques for displaced and significantly angulated metacarpal neck and subcapital fractures as well as axially stable shaft fractures have been described, 1,2,3,4,5 including percutaneous and limited open antegrade (i.e., bouquet pinning), retrograde (i.e., longitudinal intramedullary fixation), transmetacarpal Kirschner wire constructs, as well as plate fixation. Each technique is associated with its own advantages and disadvantages. There is no consensus on an optimal treatment modality. Selection of technique remains based upon fracture characteristics and surgeon preference. Optimal surgical fixation will limit surgical exposure of the fracture site, allow for early postoperative mobilization to regain full metacarpophalangeal (MCP) joint motion and extensor excursion, expedite return to activities of daily living and work/sport, and minimize the need for removal of hardware. Limited-open retrograde intramedullary headless screw fixation may offer clinical advantages over Kirschner wire fixation and other open techniques. Retrograde intramedullary fixation using a cannulated headless screw can be achieved using a limited-open, extensor-splitting approach and represents only one additional step beyond longitudinal, intramedullary, retrograde Kirschner wire fixation of these fractures through the metacarpal head articular surface. The headless design allows for fixation buried beneath the articular surface and early postoperative joint range of motion.

39.2 Key Principles Quantitative three-dimensional computed tomography (3DCT) data from our group supports the use of an articular

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starting point for these extra-articular fractures.6 Direct visualization of the starting point additionally and potentially eliminates multiple attempts at achieving the correct starting point during percutaneous Kirschner wire insertion for retrograde intramedullary fixation. In addition, in 3D models simulating this technique, metacarpal head surface area and subchondral head volume occupied was minimal. Articular surface area violation was least during clinically relevant sagittal plane arc of motion, because the dorsal articular starting point is in line with the medullary canal and avoids engagement of the center of the articular base through a majority of the sagittal plane arc. In metacarpal neck/subcapital fractures and axially stable shaft fractures that can be close reduced, countersunk, intramedullary headless screw fixation achieves relative stability by obtaining isthmal purchase. Reduction and rotational stability are maintained with distal fixation within the subchondral bone and proximal fixation against the endosteal isthmus of the medullary canal of the diaphysis. The buried location of the screw obviates the need for subsequent removal. The rotational stability and lack of requisite hardware removal are improvements over previously described intramedullary nail techniques for metacarpal fractures. In subcapital fractures with limited distal bone stock, this technique avoids low-profile locking plates at the level of the dorsal articular margin which may cause extensor adhesions and extension contractures, necessitating secondary removal of hardware, extensor tenolysis, and extension contracture release. Avery and colleagues found that, when compared to K-wires, headless compression screws for metacarpal neck fractures were biomechanically superior in load to failure, 3-point bending, and axial loading.7

39.3 Outcomes As this technique has gained popularity, medium-term clinical, functional, and radiographic outcome data have become available from several centers. In 48 metacarpal fractures treated with this technique by del Piñal et al,8 the mean total arc of motion was 249 degrees and all patients returned to full work duties or leisure activities. In a retrospective review of 18 metacarpal fractures who underwent intramedullary headless screw (IMHS) fixation, Tobert et al9 reported excellent functional outcomes in all patients with total active motion in excess of 240 degrees. Similarly, Ruchelsman et al10 published clinical data on 20 patients with metacarpal neck and shaft fractures treated with IMHS. At 3-month follow-up, all patients had osseous union, full composite flexion, and extension, and no secondary procedures were required. Recently, Ruchelsman et al have

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Key Procedural Steps presented longer term data in 91 patients treated with this technique. All 91 patients achieved full composite flexion, and all of them also achieved full active MCP extension or hyperextension. Postoperative mean MCP joint flexion–extension arc was 88° degrees.11 In addition, all 16 elite/professional athletes treated with IMHS fixation for acute displaced metacarpal neck/ subcapital and diaphyseal fractures achieved full composite MCP motion and mean return to full play in 5 weeks.12 A recent multicenter cohort comprising 160 metacarpal neck and shaft fractures treated by three fellowship-trained hand surgeons revealed a low overall complication rate (2.5%).13 Complications included three refractures due to recurrent blunt trauma (punching mechanism), following complete union and return to full activity, and only one case of early radiographic arthrosis.

39.4 Indications ●

● ● ●

Angulated metacarpal neck and distal diaphyseal metacarpal fractures. Displaced subcapital fractures. Axially stable, transverse metacarpal mid-diaphyseal fractures. Nascent malunions and nonunions.

39.5 Contraindications ● ● ● ●

●

Open metacarpal physis. Inadequate fracture alignment following closed reduction. Metacarpal intra-articular head-splitting fractures. Rotationally unstable metacarpal fractures (short oblique and spiral fractures). Proximal diaphyseal fractures precluding sufficient proximal intramedullary fixation.

39.6 Special Considerations Preoperative templating is paramount for this technique. Specifically, the ring finger isthmic diameter must be carefully

templated to allow intramedullary endosteal purchase. The ring finger isthmus is the narrowest and may require a smaller intramedullary screw diameter (i.e., 2.2–2.4 mm). In addition, one must be familiar with maximal screw lengths in the various commercially available systems to ensure that the leading threads extend past the proximal extent of axially stable diaphyseal fractures. In general, proximal 1/3 diaphyseal fractures are better treated with other intramedullary or plating techniques. Given the articular starting point, one must scrutinize imaging to confirm there is no intra-articular metacarpal “head-split” before proceeding with this technique.

39.7 Key Procedural Steps Patients are positioned supine with the arm supported on a radiolucent hand table. The procedure is typically performed under regional anesthesia and upper arm tourniquet control. Preoperative IV antibiotics are administered. An Esmarch bandage is used for exsanguination. Closed reduction is performed utilizing the Jahss maneuver under fluoroscopic guidance. A longitudinal or chevron incision is planned over the MCP joint. Following elevation of subcutaneous flaps, a small extensor split over the MCP joint followed by a limited dorsal arthrotomy is performed (▶ Fig. 39.1). Closed reduction is confirmed under fluoroscopic guidance and a 1.1 mm Kirschner wire is then inserted under direct visualization through the dorsal corridor of the metacarpal head in line with the medullary canal and then advanced to the subchondral bone of the metacarpal base (▶ Fig. 39.2). The dorsal–central starting point is well visualized following fracture reduction, dorsal capsulotomy, and passive MCP joint flexion. The K-wire is then overdrilled and replaced with a 2.2 to 3.0 mm cannulated headless compression screw based upon preoperative templating of the dimensions of the isthmus of the intramedullary canal. The extensor split is anatomically repaired with 3–0 nonabsorbable suture. The skin is then approximated with 5–0 nylon suture.

Fig. 39.1 Limited-open retrograde headless screw fixation is performed via a limited dorsal central extensor tendon split, followed by dorsal arthrotomy to visualize the starting point.

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Limited-Open Retrograde Intramedullary Headless Screw Fixation of Metacarpal Fractures

Fig. 39.2 (a, b) Following anatomic closed reduction, a 1.1 mm guide wire is advanced through the dorsal corridor of the metacarpal head in line with the medullary canal; (c, d) Cannulated headless compression screw fixation is completed. The diameter and length are determined by preoperative templating; (e, f) Clinical outcome at time of clinical union. Full MCP motion without extensor lag or contracture. MCP, metacarpophalangeal.

39.8 Postoperative Rehabilitation Intramedullary headless screw fixation allows early active and active-assisted motion within the first postoperative week. A removable, hand-based ulnar–gutter splint with the MCP joints in intrinsic plus position and the interphalangeal joints free is worn until suture removal and then is gradual weaned. With neck comminution, the screw is inserted without the compression sleeve. Hand strengthening is initiated at clinical union (i.e., resolution of fracture site tenderness). Strengthening is initiated at 4 weeks postoperatively.

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39.9 Tips, Pearls, and Lessons Learned Preoperative templating assists in screw size selection to optimize isthmal purchase. The initial extensor lag resolves quickly in the postoperative period. With increasing clinical experience with this technique for metacarpal neck fracture, we have expanded our indications in select cases to include axial-stable, transverse mid-diaphyseal fractures that are reducible with closed manipulation and symptomatic nascent malunions (▶ Fig. 39.3). In cases of nascent malunion of

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Tips, Pearls, and Lessons Learned

Fig. 39.3 (a) Nascent small finger metacarpal neck malunion. (b). Limited open osteoclasis to achieve anatomic reduction of the capital segment; (c) Retrograde, intramedullary 1.1 mm K-wire fixation via small limited open extensor split and dorsal arthrotomy; (d) Cannulated headless compression screw fixation; (e, f) 6-week clinical outcome demonstrates full motion without lag or contracture.

the metacarpal neck or shaft, a separate incision for local open osteoclasis is performed in order to facilitate anatomic reduction prior to retrograde fixation. Proximal diaphyseal fractures may be better treated with alternative fixation techniques, as use of IMHS fixation in these fractures requires significant countersinking of the trailing threads and may not allow the leading threads to fully cross the fracture site. Bending moments on proximal diaphyseal fractures upon recurrent blunt trauma may portend refracture and screw failure.

In instances of recurrent fracture and screw failure, the broken screw is removed via the fracture site, obviating the need to perform repeat arthrotomy and disturb the fibrocartilage at the prior articular insertion site. In cases of recurrent fracture, plate fixation is performed following screw removal and fracture reduction. In elite athletes, we allow early return to play when there is minimal clinical tenderness. A custom, hand-based splint with dorsal MCP padding and a hinge at the MCP joint that allows for unrestricted MCP motion is utilized inside sport-specific gloves and mitts for additional protection until full union (▶ Fig. 39.4).

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References

Fig. 39.4 A custom hand-based splint with dorsal MCP padding and a hinge at the MCP joint that allows for unrestricted MCP motion inside sport-specific gloves and mitts in the early postoperative period. MCP, metacarpophalangeal.

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[1] Boulton CL, Salzler M, Mudgal CS. Intramedullary cannulated headless screw fixation of a comminuted subcapital metacarpal fracture: case report. J Hand Surg Am. 2010 Aug; 35(8):1260–1263. doi: 10.1016/j.jhsa.2010.04.032. Epub 2010 Jul 8. [2] Foucher G. “Bouquet” osteosynthesis in metacarpal neck fractures: a series of 66 patients. J Hand Surg Am. 1995; 20(3 Pt 2) suppl 3:S86–S90 [3] Schädel-Höpfner M, Wild M, Windolf J, Linhart W. Antegrade intramedullary splinting or percutaneous retrograde crossed pinning for displaced neck fractures of the fifth metacarpal? Arch Orthop Trauma Surg. 2007; 127(6): 435–440 [4] Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and phalangeal shaft fractures. J Am Acad Orthop Surg. 2000; 8(2):111–121 [5] Friedrich JB, Vedder NB. An evidence-based approach to metacarpal fractures. Plast Reconstr Surg. 2010; 126(6):2205–2209 [6] ten Berg PW, Mudgal CS, Leibman MI, Belsky MR, Ruchelsman DE. Quantitative 3-dimensional CT analyses of intramedullary headless screw fixation for metacarpal neck fractures. J Hand Surg Am. 2013; 38(2): 322–330.e2 [7] Avery DM, III, Klinge S, Dyrna F, et al. Headless compression screw versus kirschner wire fixation for metacarpal neck fractures: a biomechanical study. J Hand Surg Am. 2017; 42(5):392.e1–392.e6 [8] del Piñal F, Moraleda E, Rúas JS, de Piero GH, Cerezal L. Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws. J Hand Surg Am. 2015; 40(4):692–700 [9] Tobert DG, Klausmeyer M, Mudgal CS. Intramedullary fixation of metacarpal fractures using headless compression screws. J Hand Microsurg. 2016; 8(3): 134–139 [10] Ruchelsman DE, Puri S, Feinberg-Zadek N, Leibman MI, Belsky MR. Clinical outcomes of limited-open retrograde intramedullary headless screw fixation of metacarpal fractures. J Hand Surg Am. 2014; 39(12):2390–2395 [11] Eisenberg G, Clain JB, Feinberg-Zadek N, Leibman M, Belsky M, Ruchelsman DE. Clinical outcome of limited intramedullary headless screw fixation of metacarpal fractures: 91 consecutive patients. Poster Presentation at the 2018 American Association of Hand Surgery, Phoenix, AZ January 2018 [12] Ruchelsman DE, Leibman M, Belsky M, Eisenberg G. Expedited return to play following intramedullary headless screw fixation of metacarpal fractures in elite athletes. Podium Presentation at the 2018 American Association for Hand Surgery Annual Meeting, Phoenix, AZ January 2018 [13] Warrender WJ, Ruchelsman DE, Livesey M, Mudgal CS, Rivlin M. Low rate of complications following intramedullary headless compression screw fixation for metacarpal fractures. Poster Presentation at the 2018 American Association for Hand Surgery Annual Meeting, Phoenix, AZ January 2018

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40 First Metacarpal Base Fractures (Bennett and Rolando Fractures) Brandon Rogalski and Richard Tosti Abstract Bennett and Rolando fractures are intra-articular fracture dislocations of the base of the first metacarpal that can be treated with several surgical techniques including fixation with Kirschner wires, interfragmentary screws, plate osteosynthesis, and arthroscopically assisted fixation. Keywords: Bennett, Rolando, first metacarpal base, fixation, K-wire, interfragmentary screw

40.1 Description A number of techniques for reduction and stabilization of first metacarpal base fractures exist including fixation with Kirschner wires, interfragmentary screws, plate osteosynthesis, and arthroscopically assisted fixation.

40.2 Key Principles Bennett and Rolando fractures are intra-articular fracture dislocations of the base of the first metacarpal which are displaced due to the pull of the abductor pollicis longus (APL) and adductor pollicis muscles. These fractures occur when an axial compressive load is directed through a partially flexed first metacarpal shaft. As a result, a fragment of the palmar articular lip of the metacarpal remains is reduced to the trapezium via its attachment to the volar beak ligament, while the remainder of the metacarpal subluxes in a proximal–dorsal–radial direction and adducts from the deforming forces of the APL and adductor pollicis muscles, respectively. Key principles include reestablishing alignment of the first metacarpal base on the trapezium and restoring articular congruity.

40.3 Expectations The fixation method in Bennett fractures depends upon the size of the marginal palmar fragment that remains attached to the intact volar beak ligament. In fractures where the palmar fragment is small and unable to accommodate screws, K-wire fixation is preferred. When the palmar fragment is larger (usually at least 1/3 of the articular surface), two interfragmentary screws can be placed across the fracture. Rolando fractures are three-part/comminuted, complete intra-articular fractures that usually require plate fixation.

40.4 Indications ●

●

Nondisplaced and stable fractures can be immobilized in a cast for 4 to 6 weeks. Surgery is indicated for fractures that are displaced, unstable, subluxed, or open.

40.5 Contraindications ● ●

Malunited fractures require a corrective osteotomy. Chronic injuries showing evidence of arthrosis in the carpometacarpal (CMC) joint require a fusion or an arthroplasty.

40.6 Special Considerations A computed tomography scan can help in determining the size of the palmar articular fragment, supplement preoperative planning in comminuted fractures, and identify associated injuries such as a fracture to the triquetrum. Arthroscopically assisted fixation can increase the accuracy of the reduction of the articular surface through direct visualization of the joint.

40.7 Special Instructions, Positioning, and Anesthesia ●

●

●

The patient is positioned supine with the arm on a hand table. Fluoroscopy should be available to judge the accuracy of reduction and placement of implants. Options for anesthesia include general anesthesia, sedation and local, regional block, or local injection depending on surgeon and patient preference.

40.8 Tips, Pearls, and Lessons Learned 40.8.1 Closed Reduction and Percutaneous Pinning Reduction of the fracture aims at counteracting the deforming forces on the metacarpal shaft. A combination of longitudinal traction, abduction/extension, and pronation will align the metacarpal base with palmar fragment. Fixation can be achieved by placing one or two wires across the base of the metacarpal to the trapezium and/or the index metacarpal. We prefer placing two wires: the first transfixing the base of the first metacarpal to the trapezium, and the second into the base of the index metacarpal (▶ Fig. 40.1).

40.8.2 Open Reduction Internal Fixation with Interfragmentary Screw After making a Wagner approach, the reduction maneuver of traction, abduction/extension, and pronation should reduce the fragments, which can be held with a reduction clamp. Usually the fracture can accommodate two small (1.5 mm) screws if the palmar fragment comprises at least 1/3rd of the total joint

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First Metacarpal Base Fractures (Bennett and Rolando Fractures) surface (▶ Fig. 40.2). Cannulated headless compression screws are another option (▶ Fig. 40.3). If the size of the palmar fragment is insufficient to accommodate a second screw, or if the first screw was not well-spaced, then a threaded K-wire across the fracture site, cut at the bone surface, can be placed as supplemental fixation.

Fig. 40.1 Bennett fracture with a small volar fragment was fixed with two K-wires.

40.8.3 Open Reduction Internal Fixation with A Plate Three-part Rolando fractures require plate fixation to reduce the proximal articular fragments to the distal metacarpal. A Wagner approach or a straight dorsal approach may be used depending

Fig. 40.3 Percutaneous headless compression screw placed in an arthroscopically assisted ORIF. ORIF, open reduction and internal fixation.

Fig. 40.2 (a) Preoperative and (b) postoperative images of a Bennett fracture fixed with interfragmentary screws. The arrow is showing an accurate and compressed articular surface.

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Bailout, Rescue, and Salvage Procedures

Fig. 40.4 (a) Preoperative and (b) postoperative images of a Rolando fracture fixed with a T plate.

on the orientation of the articular fragments. The articular block is first provisionally reduced with small K-wires and then secured with a 1.5 mm T plate or mesh plate (▶ Fig. 40.4). The articular block is then reduced to the shaft and held with at least two screws. An important consideration is the contour of the bone with respect to the proximal aspect of the plate, especially if not using a variable angle locking plate. The surgeon may have to bend the plate to facilitate a screw trajectory that has good bone purchase and does not penetrate the joint.

40.8.4 Arthroscopic Assisted Reduction Arthroscopy of the first CMC joint can be useful in assessing articular congruity and ensuring percutaneously placed screws do not pass through the joint surface. The patient is placed supine with the thumb suspended from a traction tower or an overhead boom with 5–10 pounds of traction. Three standard portals could be utilized with this method (1-R, 1-U, or a thenar portal). We prefer using the 1-R portal as a viewing portal, which is placed 1 cm radial to the APL tendon at the level of the CMC joint. The thenar portal is usually chosen as the working portal through which a hook can be used to assist the reduction (▶ Fig. 40.5). It is placed 90° to the viewing portal through the thenar muscle bulk at the level of the first CMC joint.

40.9 Difficulties Encountered Accurate placement of screws into small palmar fragments is usually the greatest source of technical difficulty. A strategy designed to reduce this difficulty involves placing inside-out glide holes (described below).

Fig. 40.5 Arthroscopic view of the intraarticular fracture line in a Bennett fracture.

developed, being mindful of radial branches of the radial sensory nerve. The thenar muscles are elevated off of the metacarpal volarly. The bone is exposed dorsally to the insertion of the APL. The fracture site is developed, capsulotomy is made in line with the fracture, and the joint is inspected and debrided. After making the Wagner approach, the fracture site is opened by supinating the metacarpal base fragment. If using inside-out glide holes, the glide holes for the lag screws are drilled from inside the fracture site to the outer cortex. The metacarpal base fragment is then reduced with pronation, held with a clamp, and thread holes are drilled with a smaller diameter drill bit through the preplaced glide holes. The screws are measured and inserted ensuring a perpendicular and evenly spaced orientation.

40.10 Key Procedural Steps During Open Reduction and Internal 40.11 Bailout, Rescue, and Salvage Fixation (ORIF) Procedures The Wagner approach is a volar curvilinear incision along the glabrous border starting at the midmetacarpal and follows the thenar eminence to the wrist crease. Full thickness skin flaps are

If the screws have poor purchase in the palmar fragment or if there is residual instability, the screws can be replaced or

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First Metacarpal Base Fractures (Bennett and Rolando Fractures) supplemented with K-wires. If the base of the metacarpal or trapezium is too highly comminuted, one could acutely perform a CMC fusion. If a contaminated wound is present, an external fixator could be considered.

Suggested Readings Huang JI, Fernandez DL. Fractures of the base of the thumb metacarpal. Instr Course Lect. 2010; 59:343–356 Kadow TR, Fowler JR. Thumb injuries in athletes. Hand Clin. 2017; 33(1): 161–173

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Liverneaux PA, Ichihara S, Hendriks S, Facca S, Bodin F. Fractures and dislocation of the base of the thumb metacarpal. J Hand Surg Eur Vol. 2015; 40(1): 42–50 Mumtaz MU, Ahmad F, Kawoosa AA, Hussain I, Wani I. Treatment of Rolando fractures by open reduction and internal fixation using mini T-plate and screws. J Hand Microsurg. 2016; 8(2):80–85 Uludag S, Ataker Y, Seyahi A, Tetik O, Gudemez E. Early rehabilitation after stable osteosynthesis of intra-articular fractures of the metacarpal base of the thumb. J Hand Surg Eur Vol. 2015; 40(4):370–373

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Part VII Wrist Fractures

VII

41 Scaphoid Pinning/ORIF

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42 Percutaneous/Kapandji Pinning

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43 Distal Radius: Volar Approach

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44 Dorsal Approach to Distal Radius

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45 Bridge Plating of Distal Radius Fractures

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46 External Fixation of Distal Radius Fractures

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41 Scaphoid Pinning/ORIF Joseph D. Galloway and Irfan H. Ahmed Abstract Scaphoid pinning or open reduction internal fixation (ORIF) is utilized in the treatment of displaced scaphoid fractures. It is increasingly being used in minimally or nondisplaced fractures. The scaphoid is the most commonly fractured carpal bone with unique anatomy and qualities which complicate treatment. Nonunion of the scaphoid can have severe functional consequences, and therefore acute fractures warrant prompt treatment. Cast treatment can be very effective for nondisplaced fractures but requires prolonged immobilization. Surgical fixation, when indicated, can obtain high rates of union. Fixation may proceed from either volar or dorsal, each with its merits and pitfalls. Observance of fracture management principles, including anatomic reduction, compression, and soft tissue handling are of the utmost importance. In this chapter, we highlight several key considerations in scaphoid fracture fixation, and certain tips to aid in success. Keywords: scaphoid, waist, minimally displaced fracture, humpback, Herbert screw, percutaneous

41.1 Description

Union rates of nearly 100% have been obtained using percutaneous fixation of nondisplaced and minimally displaced scaphoid fractures.3 Operative fixation has also been shown to have faster time to union (7 vs. 12 weeks) and faster return to work (8 vs. 15 weeks) when compared to cast immobilization.4 However, this study was conducted in a controlled military setting and generalization to a broader population is limited. A recent meta-analysis showed heterogenous results in favor of surgical treatment regarding time to union and range of motion; however, there was also a trend toward increased complications.5

41.4 Indications Indications for operative management include: ● Displaced fractures– defined as having 1 mm of radiographic gapping or displacement, scapholunate angle > 65 degrees, or a radiolunate angle > 15 degrees.2,6 ● Open fractures. ● Complex fractures—associated with perilunate dislocations or distal radius fractures.6,7 ● Proximal pole fractures. ● Delayed diagnosis and delay in immobilization.2,6

There are several methods of operative fixation for scaphoid fractures. The bone can be approached dorsally or volarly via formal open reduction and internal fixation (ORIF) or miniopen percutaneous fixation. There have been multiple techniques and various screw designs described for internal fixation—most often, a cannulated, headless compression screw is used. The scaphoid’s unique anatomy and shape can present challenges to fixation.

Relative indications for fixation include a nondisplaced or minimally displaced waist fracture in an athlete, manual laborer, or patient who would otherwise not tolerate prolonged cast immobilization. While surgical treatment is a favorable option, there are limitations to the current literature and more rigorous studies are required. Ultimately, this should be a decision that is made with the patient after discussion of the risks and benefits.5

41.2 Key Principles

41.5 Contraindications

The goals of scaphoid fixation are to preserve vascularity, achieve anatomic articular reduction, generate compression and maximal biomechanical stability across the fracture site through a centrally placed implant, and restore intercarpal alignment to preserve wrist kinematics.

Scaphoid fixation is contraindicated in patients with radiocarpal degenerative arthritis in which a salvage procedure may be better indicated.

41.3 Expectations

The scaphoid’s unique anatomy needs to be considered carefully. It is a curved bone, with a volar–ulnar concavity and an axial twist with the distal tubercle being pronated relative to the proximal end. This can make screw positioning difficult, and fluoroscopic imaging deceptive and difficult to interpret. The body is predominantly covered in articular cartilage, and vascular inflow is limited to the dorsal surface at the waist, scaphoid ridge, and volar distal pole. Seventy to eighty percent of blood flow enters via the dorsal carpal branch of the radial artery. The proximal pole relies solely on retrograde blood flow, making healing more tenuous increasing the rates of delayed union, nonunion, and avascular necrosis of the fracture fragment.1

Nondisplaced or minimally-displaced scaphoid waist fractures can be treated by cast immobilization, usually with a thumb spica. Treatment usually requires 8 to 12 weeks of immobilization, and if initiated promptly, can result in union rates of 88 to 95%.1,2 The disadvantages of cast immobilization are frequent office visits to assess cast fit, recurrent X-rays to assess fracture alignment, prolonged immobilization with associated potential skin breakdown, and joint stiffness. Displaced fractures as well as proximal pole fractures carry a higher rate of nonunion with rates as high as 50%, and are therefore generally indicated for open reduction internal fixation (ORIF).2

41.6 Special Considerations

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Scaphoid Pinning/ORIF Fixation can be performed from either a dorsal or a volar approach. The volar approach works well for middle and distal third fractures as the fixation is retrograde. During open procedures, there is excellent exposure of the waist, allowing for reestablishment of length, alignment, and angulation. It offers the distinct advantage of preservation of the dorsal blood supply. Drawbacks of the volar approach are that it requires disruption of the important extrinsic radiocarpal ligaments, central implant placement is technically difficult and needs some degree of disruption of the scaphotrapezial joint, and proximal pole fractures cannot be captured reliably. Advantages of the dorsal approach are access to the proximal pole, preservation of the scaphotrapezial joint and extrinsic volar ligaments, and ease of central screw placement compared to the volar approach. Drawbacks include increased risk of insult to the dorsal vascular supply, and some degree of difficulty in correction of sagittal deformity.

41.7 Operative Treatment

●

●

●

●

41.7.1 Special Instructions, Positioning, and Anesthesia All procedures are performed supine with a hand table and tourniquet in place along with fluoroscopy. The authors like to have a wrist roll made to aid in either extension or flexion. The procedure may be performed under general anesthesia or under sedation with local or brachial plexus block.

41.7.2 Tips, Pearls, and Lessons Learned ●

●

Preservation of blood supply is paramount, especially as proximal pole fractures have a higher rate of avascular necrosis. This concept is particularly important when an open dorsal approach is utilized, as it places the main vascular inflow at risk.1,6 During a volar approach, it is essential that the extrinsic ligaments be repaired. Often, a zigzag- or s-shaped capsulotomy will facilitate a tension-free closure (▶ Fig. 41.1).

Fig. 41.1 A serpentine incision of the volar extrinsic ligaments marked.

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●

●

●

During a volar approach, the ideal guide wire starting point is within the scaphotrapezoid joint. As such, some of the trapezium may have to be removed with a Rongeur. In addition, a transtrapezial approach to screw placement can help improve positioning. Obvious concerns of these methods incudes disruption of the articular cartilage and eventual degenerative changes. Measure screw length with the K-wire in subchondral bone on the opposing side and the measuring guide sitting flush with scaphoid. This can be difficult from a volar approach, with the trapezium blocking access to the starting point. Select a screw at least 2.5 mm shorter (we prefer 4 mm shorter) than the measurement to avoid fracture distraction and screw prominence. During a dorsal approach, after measurement and prior to reaming, the K-wire may be driven into the trapezium to maintain reduction and prevent incidental pullout of the guide wire during reaming (▶ Fig. 41.2). Medullary compression screws should be placed within the central 1/3rd of the scaphoid in both AP and lateral radiographs. This has been shown to have 43% stiffer construct and improved alignment and range of motion compared to eccentric placement.8 Central placement has also been shown to have decreased time to union when compared with eccentric screw placement (▶ Fig. 41.3).9 Cannulated screw technique has been found to have a higher rate of central placement when compared to an external reference guide.9 Fluoroscopic guidance may be used to ream over the guide wire to reach subchondral bone without penetrating the joint. After appropriate alignment has been obtained and a central K-wire has been placed for a cannulated screw, it may be

Fig. 41.2 Note the guidewire has been driven into the trapezium to prevent accidental withdrawal during reaming and can be removed after screw insertion.

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Operative Treatment

Fig. 41.4 Demonstrates centrally placed guide wire as well as eccentric wire placed as an antirotation pin.

●

●

Fig. 41.3 Postop radiograph of a compression screw place in the central location for optimal compression and stiffness.

●

second K-wire centrally and the first will take on the function of an antirotation pin (▶ Fig. 41.4). The screw should be placed by hand, and the guide wire removed prior to the final turns to optimize compression.7 Screw heads should be countersunk to prevent chondrolysis, especially within the radioscaphoid joint.6 The most sensitive radiographic view to evaluate penetration into the radioscaphoid joint has been found to be 60 degrees of pronation from neutral, with the transducer beam parallel to the floor (▶ Fig. 41.5).10

41.7.3 Difficulties Encountered

Fig. 41.5 60-degree pronation view with transducer beam oriented parallel to the floor is the most sensitive view for visualization of screw protrusion into the radioscaphoid joint.

useful to place a second K-wire, eccentrically across the fracture site as an antirotation pin prior to screw insertion. Alternatively, if the first pass of a K-wire ends eccentrically, this should be left in place as an additional visual cue to place a

From either approach, it can be difficult to obtain a proper starting point. During the volar approach, the volar tubercle of the trapezium can block access to the ideal wire starting point, causing a starting point to be placed too volarly. This will subsequently cause the wire trajectory to be too dorsal, leading to failure to capture the center of the proximal fragment (▶ Fig. 41.6). Wrist hyperextension and a freer are useful in elevating the distal pole of the scaphoid. If more access is required, the volar tubercle of the trapezium may be Rongeured down or a trough made. Another method is to simply direct the K-wire through the trapezium and ream down to the scaphoid. With this last method, fluoroscopy may be needed during measurement for proper implant length, as the measuring guide may not sit flush on the scaphoid. Dorsally, the starting point is within the radioscaphoid joint. The proximal pole of the scaphoid is relatively fixed compared to the mobile distal pole. To obtain the optimal starting point, the carpus must be flexed, which can cause significant distraction through the fracture. Placing K-wires in each fragment to use as joysticks for fracture reduction can be particularly useful in this scenario (▶ Fig. 41.7). An eccentrically placed K-wire across the fracture site may also be required in this situation.

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Fig. 41.6 Illustration depicting the difficulty of obtaining start point in the scaphotrapezial joint. Note that extension translates the trapezium partially out of the way, allowing for a more central trajectory.

Fig. 41.7 Two dorsally placed K-wires used as joysticks to reduce the fracture prior to driving the guide wire across.

Fig. 41.8 Implant shown in (a) is too long; note the fracture gapping. After revision to a shorter screw, shown in (b), there is compression across the fracture.

41.7.4 Pitfalls ●

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A common error is the selection of a long implant which will cause distraction at the fracture site by pushing on subchondral bone, or it may protrude through the cartilage (▶ Fig. 41.8). When partially threaded implants are used, failure to fully cross the fracture site with the threads will block

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compression of the fracture. Utilize short threaded implant as needed. Small K-wires are prone to break during excessive flexion/ extension of the carpus after placement (e.g., trying to obtain proper fluoroscopic views). Beware of resistance when drilling over a guide wire. Always stop and evaluate for bending or breakage of the wire.

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Key Procedural Steps

Fig. 41.10 Superficial dissection exposing the FCR and incising the volar sheath to retract the tendon. FCR, flexor carpi radialis.

Fig. 41.9 Volar approach is marked over the FCR and curved toward the trapezium. FCR, flexor carpi radialis.

41.8 Key Procedural Steps 41.8.1 Volar Open Make a 3 cm curvilinear incision over the flexor carpi radialis (FCR) curved toward the trapezium (▶ Fig. 41.9). Identify the FCR, incise the sheath, and retract the tendon ulnarly (▶ Fig. 41.10). Identify the extrinsic volar carpal ligaments. Incise the extrinsic ligaments and wrist capsule in a serpentine fashion to facilitate closure at the completion (▶ Fig. 41.1). Obtain anatomic fracture reduction based on cortical visualization. Sagittal alignment should be restored if there is any humpback deformity. The starting point for the implant is within the scaphotrapezial joint. The surgeon should aim roughly at Lister’s tubercle. Fluoroscopy should be used to confirm center–center pin alignment prior to screw insertion. A 60-degree pronation oblique view should be obtained to ensure against penetration into the radioscaphoid joint. If there is concern, the wrist may be ranged under live fluoroscopy.10

Fig. 41.11 Dorsal skin incision overlying Lister’s tubercle, which is marked on the fascia with a circle

The capsule and radiocarpal ligaments must be carefully repaired. The skin is closed in tension-free fashion.

41.8.2 Dorsal Make a 2 to 3 cm longitudinal incision over the proximal pole in line with the second and third metacarpal interspace, or just ulnar to Lister’s tubercle (▶ Fig. 41.11). Open the extensor retinaculum, identify the EPL, and gently retract it radially (▶ Fig. 41.12 and ▶ Fig. 41.13).

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Fig. 41.12 Dorsal superficial layer; note the transversely oriented retinaculum fibers overlying the dorsal compartments.

Fig. 41.13 Deep layer after incision of the 3rd dorsal extensor tendon compartment. The EPL is retracted and protected radially, and the EDC tendons can just be visualized ulnarly in the 4th compartment. EDC, extensor digitorum communis; EPL, extensor pollicis longus.

Fig. 41.14 Dorsal capsule is incised carefully to protect the scapholunate ligaments. EPL is protected and retracted radially. EPL, extensor pollicis longus.

Fig. 41.15 Dorsal exposure of the fracture. Note that wrist flexion often displaces the fragments. The distal retractor is held gently to avoid stripping off the vascular supply.

Incise the capsule, taking care to protect the dorsal fibers of the scapholunate interosseous ligament (▶ Fig. 41.14). Pulling up on the capsule while incising helps protect the scapholunate ligament. Expose the fracture with meticulous dissection and avoid stripping to preserve the dorsal blood supply (▶ Fig. 41.15). After fracture reduction, the wrist is flexed to expose the proximal pole start point 1 to 2 mm radial to the scapholunate ligament attachment onto the scaphoid, and midheight in the sagittal plane of the scaphoid. While placing the guide wire, the surgeon should aim toward the thumb metacarpal base (▶ Fig. 41.16).7

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The screw is inserted by hand and the head of the screw is buried subchondral under direct visualization (▶ Fig. 41.17). The skin and subcutaneous tissue is closed in tension-free fashion.

41.9 Bailout, Rescue, and Salvage Procedures Rescue procedures include ORIF and bone grafting, with either cancellous or vascularized pedicle bone graft, as used in nonunion. Bailout or salvage procedures include limited carpal fusion, proximal row carpectomy, and wrist arthrodesis.

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References

Fig. 41.17 Screw is inserted over the guide wire by hand; note the screw has been buried into subchondral bone in the proximal pole.

Fig. 41.16 Starting point is at the midpoint of the AP diameter, and 1 to 2 mm radial to the scapholunate ligament. Trajectory should be roughly towards the base of the thumb.

References [1] Gelberman RH, Menon J. The vascularity of the scaphoid bone. J Hand Surg Am. 1980; 5(5):508–513 [2] Cooney WP, Dobyns JH, Linscheid RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res. 1980(149):90–97 [3] Haddad FS, Goddard NJ. Acute percutaneous scaphoid fixation. A pilot study. J Bone Joint Surg Br. 1998; 80(1):95–99

[4] Bond CD, Shin AY, McBride MT, Dao KD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001; 83(4):483–488 [5] Buijze GA, Doornberg JN, Ham JS, Ring D, Bhandari M, Poolman RW. Surgical compared with conservative treatment for acute nondisplaced or minimally displaced scaphoid fractures: a systematic review and meta-analysis of randomized controlled trials. J Bone Joint Surg Am. 2010; 92(6):1534–1544 [6] Ring D, Jupiter JB, Herndon JH. Acute fractures of the scaphoid. J Am Acad Orthop Surg. 2000; 8(4):225–231 [7] Lee SK. Fractures of the carpal bones. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds. Green's Operative Hand Surgery. Philadelphia, PA: Elsevier; 2017:588–652 [8] McCallister WV, Knight J, Kaliappan R, Trumble TE. Central placement of the screw in simulated fractures of the scaphoid waist: a biomechanical study. J Bone Joint Surg Am. 2003; 85(1):72–77 [9] Trumble TE, Clarke T, Kreder HJ. Non-union of the scaphoid. Treatment with cannulated screws compared with treatment with Herbert screws. J Bone Joint Surg Am. 1996; 78(12):1829–1837 [10] Kim RY, Lijten EC, Strauch RJ. Pronated oblique view in assessing proximal scaphoid articular cannulated screw penetration. J Hand Surg Am. 2008; 33 (8):1274–1277

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42 Percutaneous/Kapandji Pinning A. Samandar Dowlatshahi Abstract Closed reduction and percutaneous pinning of a distal radius fracture is a surgical option when closed manipulation and splinting have failed to provide adequate fracture reduction. Fractures best suited for this technique include extra-articular fractures without significant comminution in patients with adequate bone stock. Pinning can be performed in a standard fashion across the fracture site or using the intrafocal (Kapandji) method, where the pins are inserted into the fracture site, used to maneuver the fracture alignment, and then driven into the far (usually the volar) cortex to maintain the position of the fracture. The main bailout of this procedure is open reduction and internal fixation (ORIF) with plates and screws in cases where either reduction cannot be achieved by closed means or if the fixation construct is deemed to be unstable.

42.4 Contraindications

Keywords: distal radius fracture, pinning, Kapandji, intrafocal, percutaneous

42.6 Special Instructions, Positioning, and Anesthesia

Shear fractures, the presence of severe intra-articular or metaphyseal comminution, and poor bone stock usually preclude the use of the percutaneous technique. Bilateral fractures are a relative contraindication due to issues with hygiene and performance of activities of daily living.

42.5 Special Considerations A detailed preoperative radiographic assessment is necessary to identify the appropriate candidate for this procedure. The patient’s comorbidities, age, and the age of the fracture aid in decision making. A major advantage of this technique is its low cost and minimal instrumentation needs.

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42.1 Key Principles Careful analysis of the fracture pattern and a thorough understanding of fracture biomechanics are a prerequisite to successful utilization of this minimally invasive technique. Awareness of the limitations of this technique allows the surgeon to prevent failures and the need to resort to bailout procedures such as external fixation open reduction and internal fixation (ORIF) with plates and screws or bridge plating.

42.2 Expectations Articular congruency at the radiocarpal and distal radioulnar joint (DRUJ) must be established, and volar tilt, radial height, and inclination must be restored. Stability of DRUJ should be assessed once the distal radius is pinned. Instability may indicate the need for soft tissue repair and/or pinning of DRUJ.

42.3 Indications Percutaneous techniques are most successful in the acute period, within the first 2 to 3 weeks postinjury due to limited callus formation and relative mobility of the fracture fragments. This technique is indicated in fractures that can be reduced by traction, manipulation, and ligamentotaxis. This approach can be considered primarily in patients with dorsally displaced, extraarticular fractures with minimal comminution. Patients with intra-articular fractures that are minimally comminuted such as radial styloid fractures can also be treated with this technique. The ideal patients indicated for this technique are younger with good bone stock.

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Upper arm tourniquet Brachial plexus block usually adequate 10 to 15 lbs of traction can be helpful via finger traps on index and middle fingers Intraoperative fluoroscopy (mini C-arm) Instrumentation necessary if there is a need to convert to ORIF or external fixation and/or use of dorsal spanning plate

42.7 Tips, Pearls, and Lessons Learned 42.7.1 To Incise or Not to Incise Skin Injury to the superficial radial nerve or extensor tendons is possible. Some surgeons prefer to make 1- to 1.5-cm incisions and to use soft tissue guides for the safe placement of Kirschner wires (K-wires) about the distal radius (▶ Fig. 42.1).

42.7.2 Pinning Sequence If standard pins are used, the sequence should start with the radial styloid to reestablish radial height and inclination, followed by pins introduced dorsally to provide volar tilt and support a dorsal, ulnar fracture fragment, if present. If standard styloid pins are utilized, the placement of the styloid pin will lock the reduction in place and make it difficult to provide additional volar tilt with intrafocal pins. Therefore, if the Kapandji technique is going to be utilized, one must consider starting with the dorsal intrafocal pinning. The intrafocal radial styloid pin acts as buttress that the distal radius can hinge on. It does not have an interfragmentary trajectory, and hence does not impair further fracture reduction maneuvers.

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Key Procedural Steps

42.8 Postoperative Management Intrafocal pinning allows for early motion if the construct is deemed stable enough at the time of surgery. A minimum of three pins (one radial and two dorsal) are recommended for added stability of the construct. Kapandji’s original technique specifically mentioned the lack of postoperative splinting or casting. The pins are removed at 5 to 6 weeks. If desired, the patient can be casted for 5 to 6 weeks postoperatively. The pins are then removed and hand therapy is begun. An advantage of intrafocal pins over standard pinning is that the intrafocal pins are located away from the radiocarpal joint and don’t restrict wrist extension, should early active motion be desired.

42.9 Difficulties Encountered Inadequate brachial plexus block or sedation can make reduction challenging, in particular of the radial styloid component due to tightness of flexor and extensor muscle groups. A tourniquet placed low on the upper arm restricts arm motion since the drapes are in the way. Place the tourniquet as high as possible on the arm. Fractures in older patients with thin, friable skin must be manipulated with caution to prevent skin tears.

Fractures become more difficult to reduce closed two weeks and after following injury. The levering/manipulation of the fracture with the Kapandji technique can cause skin tenting and traction at the pin insertion site. This can lead to skin necrosis and pin tract infection if not addressed. Pins inserted via the radial styloid can injure the superficial branch of the radial nerve, and pins inserted via the dorsal lip of the distal radius can injure extensor pollicis longus tendon.

42.10 Key Procedural Steps Place the hand in 10 to 15 lbs of traction. Reduce the fracture with digital manipulation, ligamentotaxis, and deviation of the wrist, usually in a palmar and ulnar direction.

42.10.1 If Anatomic Reduction is Achieved by Closed Manipulation If the reduction appears to be anatomic, the radial styloid can be secured with one or two 0.062-inch pins: an incision is made, and blunt dissection carried out onto the radial styloid with careful visualization of the superficial radial nerve (▶ Fig. 42.1). Circumferential dissection of the nerve is not

Fig. 42.1 (a,b) Anatomy relevant to placement of a radial styloid pin. The asterisk (*) denotes the ideal pin entry point. (1) Extensor pollicis longus (EPL) (2) Abductor pollicis longus (APL) (3) Extensor pollicis brevis (EPB) (4) Lateral antebrachial cutaneous nerve (LABC) (5) Trapezium. (6) Scaphoid. (7) Radial styloid. (8) Extensor carpi radialis longus (ECRL) (9) Superficial radial nerve. (Reproduced with permission from Pechlaner S, Hussl H, Kerschbaumer, F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

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Percutaneous/Kapandji Pinning recommended. An additional pin is inserted via Lister’s tubercle from dorsal to volar across the fracture line, engaging the volar cortex proximal to the fracture. The point of insertion should be just distal and radial to Lister’s in order to prevent extensor pollicis longus (EPL) injury, and no further proximal since the metaphyseal bone is often thin and comminuted. Numerous pin constellations are possible (▶ Fig. 42.2).

42.10.2 If Anatomic Reduction Is Not Achieved by Closed Manipulation If the closed reduction is not adequate, intrafocal pinning is advised, starting with the radial styloid (▶ Fig. 42.3). A more proximal incision is made (longitudinal incision recommended) immediately over the fracture. Blunt dissection is carried out

Fig. 42.2 (a–e) Various pin configurations for different fracture types. Adding pins in a different plane, as demonstrated in (e) via the dorsal lip of the distal radius increases the stability of the construct. (Modified with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

Fig. 42.3 Demonstration of the Kapandji intrafocal pinning sequence. (a) Fracture before reduction. (b) Insertion of 0.062inch K-wire into fracture line from proximal to distal. (c) Once in the medullary canal, the angle is changed, so as to lever and reduce the fracture and drive the wire in a distal-to-proximal direction. (d) The wire engages the far cortex, proximal to the fracture line. (e) A dorsal pin is placed into the fracture in a proximal-to-distal direction. (f) The orientation of the wire is changed once in the medullary canal, levering the fracture into improved alignment. (g) The wire is advanced and engages the far, volar cortex. These steps are then repeated, inserting a second dorsal wire. (Modified with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

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Fig. 42.4 (a,b) The final osteosynthesis construct after intrafocal pinning is demonstrated, with correction of height, tilt, and inclination. (Modified with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

onto bone. One 0.062-inch K-wire is then inserted through the fracture in a proximal-to-distal orientation. Once within the fracture, the pin orientation is changed (intrafocally) distal to proximal. The wire is then driven into the far (volar) cortex, securing the reduction and correcting radial height and inclination. If the wire is introduced dorsal to the flexionextension axis of the wrist, it can also contribute to the correction of volar tilt. The next step is the correction of volar tilt. A short longitudinal incision is made in the interval between the second and third dorsal compartments at the level of the fracture line. A 0.062- or 0.045-inch K-wire is inserted through the fracture into the radius in a proximal-to-distal direction. Once in the medullary canal, the orientation is changed to a distal-to-proximal trajectory, and the pin is then advanced through the palmar cortex. Insertion of an additional wire through the floor of the fourth or fifth dorsal compartment is advisable (▶ Fig. 42.4). Pins can be left protruding through the skin, capped or bent. Alternatively, they can be cut just beneath the skin level and buried. It is critical to not cut the pins too short as they will fray the extensor tendons and lead to iatrogenic rupture.

The final step of the operation is to check the stability of the DRUJ. Alternatively, the DRUJ can be pinned, or one can proceed with open triangular fibrocartilage complex (TFCC) repair. If stable fixation is obtained, the patient can start with gentle active range of motion at the wrist 7 to 10 days postoperatively. Alternatively, the patient can be casted for 5 to 6 weeks. Pins are not left in place any longer than 6 weeks.

42.11 Bailout, Rescue, and Salvage Procedures Conversion to ORIF is the main bailout if either reduction cannot be achieved by closed means or the fixation construct is deemed to be unstable. This should be discussed with the patient beforehand. In fractures with metaphyseal bone loss, the use of an external fixator or dorsal spanning plate can be a helpful adjunct to percutaneous pinning. If critical loss of reduction occurs in the postoperative period, conversion to ORIF is advisable. This usually occurs in the first 2 weeks after reduction and pinning.

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43 Distal Radius: Volar Approach Juana Medina Abstract The volar approach for fixation of distal radius fractures has become more popular in the past years due to the introduction of locking metal plates and screws specifically designed to match the distal radius topography. In addition, other benefits include a decreased rate of tendon-related complications such as irritation and rupture. The traditional Henry approach is commonly used, but other approaches such as the trans–flexor carpi radialis approach and the volar extensile approach that includes the carpal tunnel release are also used. Keywords: volar approach, Henry, distal radius, trans-FCR

43.1 Description There are different intervals through which the radius can be approached from the volar aspect. The best known is the classical Henry approach, while others include the trans–flexor carpi radialis (FCR) approach and the volar extensile approach (including a carpal tunnel release). Other modifications have been added including the two-windows approach1 or the mini-open approach.2

43.2 Key Principles A thorough knowledge of the wrist and forearm anatomy is essential. The superficial anatomical landmarks are the FCR tendon, the radial artery, the palmaris longus (PL) tendon, and the flexor carpi ulnaris (FCU) tendon. The location of the median nerve (including the palmar cutaneous branch), the flexor pollicis longus (FPL) tendon, and the pronator quadratus (PQ) are also important.

43.5 Contraindications Contraindications include dorsal shear fractures that may be better treated from a dorsal approach, fractures that require double approach, and open fractures with inadequate soft tissue. In addition, fractures with severe comminution or complex articular surface disruption may better be treated with a bridge plate or an external fixator.

43.6 Considerations Previous identification of the fracture pattern by radiological images will allow a preoperative planning of the approach needed.

43.7 Requirements, Positioning, and Anesthesia ●

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A radiolucent hand surgery table, tourniquet, and fluoroscopy (mini C-arm) are needed Forearm in supine position Anesthesia can be general or via a regional nerve block

43.8 Approach 43.8.1 Henry Approach An incision is made between the radial artery and the FCR tendon, and the interval explored (▶ Fig. 43.1). The superficial forearm fascia is incised and the contents of the volar forearm retracted. The PQ is released from the distal and radial insertion to expose the fracture (▶ Fig. 43.2).4

43.8.2 The Trans-FCR

43.3 Advantages The volar approach has become more popular in the past years due to the introduction of locking metal plates and screws specifically designed to match the topography of the distal radius. In addition, other benefits include a decreased rate of tendonrelated complications such as irritation and rupture, and the biomechanical advantage of placing the plate on the tensile side.3

43.4 Indications Most of the distal radius fractures that require surgical treatment could be addressed from a volar approach, such as unstable intra- or extra-articular fractures with either a dorsal apex or a volar apex pattern, or partial articular fracture that requires fragment-specific fixation.

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An incision is made over the tendon and the tendon sheath is identified and incised. The tendon is then retracted ulnarly and the superficial forearm fascia is incised through the tendon floor. The deep dissection is the same as the Henry approach.

43.8.3 The Volar-Extensile Approach An incision is made between the PL and FCU, distally an oblique incision is made across the wrist into the palm for the carpal tunnel release. The ulnar neurovascular structures are retracted ulnarly and the finger flexors are swept radially, allowing a better visualization of the ulnar corner of the distal radius (▶ Fig. 43.3).

43.8.4 Modifications Some authors have described modifications of the volar approaches. Orbay described a braquioradiallis tendon release

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Approach

Fig. 43.1 Modified palmar Henry’s approach to the distal radius. Straight incision between radial artery and tendon of the flexor carpi radialis. Dissection between radial artery and flexor carpi radialis tendon. The forearm fascia is divided and pronator quadratus muscle is detached from radial bony insertion. Fracture is visualized. (a) Modified palmar Henry’s approach to the distal radius. (b) Straight incision between radial artery and tendon of the flexor carpi radialis. (c) Dissection between radial artery and flexor carpi radialis tendon. (d) The forearm fascia is divided and pronator quadratus muscle is detached from radial bony insertion. Fracture is visualized. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management. 1st ed. © 2018 Thieme.)

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Fig. 43.2 (a) The pronator quadratus is divided at the radial margin of the radius. (1) Radius. (2) Palmar branch of the median nerve. (3) Median nerve. (4) Flexor pollicis longus. (5) Tendon of the flexor carpi radialis. (6) Pronator quadratus. (b) The radius is exposed by retracting the pronator quadratus with the flexor tendons and the median nerve ulnarly and retracting the tendon of the flexor carpi radialis and the radial vessels of the forearm radially. (1) Pronator quadratus. (2) Radius. (Reproduced with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

Fig. 43.3 Extensile palmar exposure creating interval between ulnar artery and nerve and flexor tendons, extending to release carpal tunnel and proximally to decompress forearm flexor compartments. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management. 1st ed. © 2018 Thieme.)

that counteracts the deforming forces of this tendon.5 Controversy about losing function of this muscle as an elbow flexor has been raised.6 Mares described a two-window, “Mediolateral Windows Approach,” which includes a single superficial incision over the FCR tendon and two deep dissections. One between FCR and radial artery and another between FCU and PL.1 Zemirline described a mini-open approach composed of two short incisions of 2 cm each, proximal and distal using a Henry approach, allowing a minimal soft tissue damage and fast recovery.2

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The choice of one over another should depend on the fracture characteristics and the surgeon experience with each approach.

43.9 Pitfalls ●

The palmar cutaneous branch of the median nerve is typically located between the FCR and the PL distally in the wound but can have a variable course.7 Injury to this nerve can lead to painful neuroma and the development of complex regional pain syndrome. The nerve should be identified and protected.

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References ●

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The volar ulnar corner of the distal radius plays a critical role in radiocarpal stability. Failure to include this fragment in the fixation construct can lead to loss of fixation. Attritional tendon rupture can occur, especially if the distal aspect of the plate is prominent or placed too distally. The radial artery and its branches must be protected, especially during the Henry approach.

43.10 Bailout and Salvage Procedures Addition or conversion to an external fixator or a bridge plate is the main bailout if either reduction cannot be achieved or the fixation construct is deemed to be unstable. This should be discussed with the patient in cases with severe fracture comminution. If loss of reduction occurs in the postoperative period, conversion to a bridge plate is advisable. Fractures with a dorsal shear component can be stabilized with the addition of a dorsal plate. Very distal volar shear injuries are difficult to treat with the standard plating systems. Marginal plates are available for this purpose.

References [1] Mares O, Graves MA, Bosch C, Chammas M, Lazerges C. A new single volar approach for epiphyseal ulnar and radial-sided comminutive fracture of the distal radius: the mediolateral windows approach. Tech Hand Up Extrem Surg. 2012; 16(1):37–41 [2] Zemirline ATC. Minimally invasive surgery of distal radius fractures: a series of 20 cases using a 15 mm anterior approach and arthroscopy. Chir Main. 2014

[3] Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002; 27:205–2015 [4] Jupiter JB. AO Manual of Fracture Management: Hand and Wrist. Thieme, Ao Publishing; 2005 [5] Orbay JL, Badia A, Indriago IR, et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg. 2001; 5(4):204–211 [6] Kim JK, Park JS, Shin SJ, Bae H, Kim SY. The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function. J Hand Surg Am. 2014; 39(11):2246–2250 [7] Jones C, Beredjiklian P, Matzon JL, Kim N, Lutsky K. Incidence of an anomalous course of the palmar cutaneous branch of the median nerve during volar plate fixation of distal radius fractures. J Hand Surg Am. 2016; 41(8):841–844

Suggested Readings Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar extension of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg Am. 2006; 31(6):892–895 Emilie Pire JJ. Long volar plating for metadiaphyseal fractures of distal radius: study comparing minimally invasive plate osteosynthesis versus conventional approach. J Wrist Surg. 2016 Lattmann T, Dietrich M, Meier C, Kilgus M, Platz A. Comparison of 2 surgical approaches for volar locking plate osteosynthesis of the distal radius. J Hand Surg Am. 2008; 33(7):1135–1143 McCann PA, Amirfeyz R, Wakeley C, Bhatia R. The volar anatomy of the distal radius: an MRI study of the FCR approach. Injury. 2010; 41(10):1012–1014 Orbay JL, Gray R, Vernon LL, Sandilands SM, Martin AR, Vignolo SM. The EFCR approach and the radial septum-understanding the anatomy and improving volar exposure for distal radius fractures: imagine what you could do with an extra inch. Tech Hand Up Extrem Surg. 2016; 20(4):155–160 Pechlaner Sigurd KF. Atlas of Hand Surgery. Thieme; 2000 Protopsaltis TS, Ruch DS. Volar approach to distal radius fractures. J Hand Surg Am. 2008; 33:958–965 Raymond A, Pensy ML. Single-incision extensile volar approach to the distal radius and concurrent carpal tunnel release: cadaveric study. J Hand Surg Am. 2010; 35: 217–222

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44 Dorsal Approach to Distal Radius Rohit Garg and Jesse B. Jupiter Abstract Volar approach is commonly used for fixation of distal radius fractures. There are certain fracture patterns for which dorsal approach is recommended. This chapter outlines the indications for dorsal approach to distal radius fractures. Keywords: distal radius fracture, dorsal approach, fragmentspecific fixation

44.1 Introduction Distal radius fracture is one of the most common injuries to the musculoskeletal system. There are multiple treatment options ranging from nonoperative management, closed reduction and pinning, and closed reduction and external–fixator application to open reduction internal fixation. Open reduction and volar plate fixation has become the preferred treatment for most of these fractures.1 However, there are several fracture types for which dorsal approach is more suitable. This chapter outlines the indications for dorsal approach to distal radius fractures along with case examples.

44.2 Indications Dorsal approach to distal radius is indicated for the following: ● Radiocarpal fracture dislocation. ● Dorsal shearing fracture of the lunate facet. ● Displaced and irreducible dorsal–ulnar (die-punch) fragment. ● Irreducible dorsal articular impaction and articular surface reconstruction. ● Associated scaphoid fracture. ● Associated carpal ligament injury.

Fig. 44.1 Radiocarpal dislocation with dorsal dislocation of carpus relative to the radius, small cortical rim and radial styloid fractures.

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Radiocarpal fracture-dislocations are complex injuries characterized by dislocation of the radiocarpal joint (▶ Fig. 44.1). It is important to differentiate these from a Barton or reverse Barton (dorsal) fracture (▶ Fig. 44.2). Barton’s fracture involves a shear fracture of the articular surface of distal radius, with the fractured fragment attached to the carpus. In addition, the displaced fragment forms a substantial part of the distal radius articular surface. In contrast, radiocarpal fracture-dislocation is a high-energy injury with disruption of the radiocarpal ligaments. It is typically associated with a small cortical rim and/or radial styloid fracture (▶ Fig. 44.1). Dumontier et al2 proposed a classification system for radiocarpal dislocations. Type 1 is very rare and concerns primarily ligamentous injuries. Type 2 radiocarpal dislocations are associated with fractures of the radial styloid that involves more than 1/3rd of the width of scaphoid fossa and may continue to the dorsal margin of distal radius. The authors recommended repair of the volar ligamentous structures for type 1 injuries and a dorsal approach with fixation of the radial styloid fragment for type 2 injuries. Calderon et al3 described 20 patients with dorsal shear fractures associated with radiocarpal subluxation or dislocation. The authors found that these fractures involved dorsal shear fragments associated with (a) central impaction; (b) impaction of majority of distal radius articular surface; and (c) radiocarpal dislocations with rupture of the radiolunate ligaments or fracture of the volar portion of the lunate facet, where radiolunate ligaments originate. The authors recommended the dorsal approach to buttress the dorsal shear fractures and reconstruct the articular surface for associated central impaction. A combined volar approach was recommended for volar ligamentous repair or fixation of small volar avulsion fracture in radiocarpal dislocations with dorsal shear fractures

Fig. 44.2 Dorsal shear fracture of articular surface of distal radius (reverse Barton).

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Surgical Technique

Fig. 44.4 (a, b) Standard dorsal approach (hand to the right of the clinical image) with provisional fixation of the radial styloid fragment using 0.062 K-wire.

Fig. 44.3 (a–c) X-rays, two-dimensional CT sagittal views and threedimensional CT reconstruction showing dorsal radiocarpal dislocation with radial styloid and dorsal cortical rim fracture.

44.3 Surgical Technique 44.3.1 Case 1 A 30 y/o male sustained a fall from a height and presented with right distal radius fracture. PA and lateral radiographs revealed a complex radiocarpal fracture-dislocation of his right wrist (▶ Fig. 44.3). Sagittal, two-dimensional CT views demonstrate the very small shearing fracture of the dorsal aspect of the distal radius with dislocation of the carpus (▶ Fig. 44.3).

Three-dimensional CT reconstructions show the volar rim of the radius to be intact with the dorsal small shearing fracture fragments (▶ Fig. 44.3). Also seen in all the preoperative images is the radial styloid fracture. Notice the horizontal fracture line involving the entire scaphoid fossa and continuing to the dorsal cortical rim. Operative fixation was recommended. A standard dorsal approach to the wrist was used, with a longitudinal incision over distal radius and radiocarpal joint in line with the 3rd metacarpal. The extensor pollicis longus tendon was mobilized from the 3rd dorsal compartment and the tendons of the second and fourth dorsal compartment were retraced to gain exposure (▶ Fig. 44.4). The dorsal small rim and the radial styloid fractures are clearly visualized. Usually the capsule is torn (▶ Fig. 44.4), but if it is intact, a dorsal arthrotomy is made parallel to the dorsal rim to inspect the articular surface and look for any associated carpal injury. At this point, carpus is reduced and fixation is started with the less comminuted fracture fragment. In this case, a 0.062

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Dorsal Approach to Distal Radius smooth K-wire was used for provisional fixation of the radial styloid fracture, and articular reduction was also confirmed using intraoperative fluoroscopy (▶ Fig. 44.4). If dorsal rim fragments are adequately large, provisional fixation can be obtained with K-wires. If they are too small, they can be held with suture anchors or transosseous sutures. Low-profile dorsal–distal radius plates were then used for fragment-specific fixation (▶ Fig. 44.5). Radial column plate and 2.4 mm dorsal

plate were used. Capsule was repaired using resorbable suture (▶ Fig. 44.5). Follow-up at 8 months showed excellent function with some loss of wrist extension and flexion (▶ Fig. 44.6). Many plates are available for these fractures. The most recently designed plates have variable angle locking screws. The dorsal plate should be applied as distally as possible. These plates might need some contouring to fit the distal radius metaphysis and the radial styloid.

Fig. 44.5 (a–c) Fragment specific fixation achieved with low-profile plates. Capsule was closed using resorbable sutures.

Fig. 44.6 (a–d) Clinical result at 8-month follow-up for Case 1.

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Surgical Technique

44.3.2 Case 2 Another example of dorsal radiocarpal fracture-dislocation, with fractures of the radial styloid involving the entire scaphoid fossa, dorsal cortical rim, and distal ulna (▶ Fig. 44.7). A standard dorsal approach was used to achieve fragmentspecific fixation of the distal radius. A radial column buttress plate and a 2.4 mm L-shaped dorsal plate was used (▶ Fig. 44.8). A nonlocking, standard screw, which was long enough to engage the opposite cortex, was first placed through the oblong hole but not fully tightened. The reduction and plate position were confirmed using intraoperative fluoroscopy. If necessary, plate position can be adjusted until it is as distal and central as possible, and then the screw can be tightened. Once the plate position is satisfactory, it should be secured with a screw in the proximal screw hole. Screws are then inserted through the distal plate holes (L-part of the plate). A variable angle locking plate was applied to the radial column (▶ Fig. 44.8). Locking head screws were inserted into the distal locking hole of the plate. The position of these screws should be just under the subchondral bone (▶ Fig. 44.8). The tip of these screws should not penetrate the sigmoid notch. It is safer to leave these screws a little short and they should not be drilled into the opposite cortex (▶ Fig. 44.8). The screws were also placed in the proximal screw holes of this plate (▶ Fig. 44.8). A true joint view using intraoperative fluoroscopy should be obtained to confirm that there are no screws penetrating into the joint. Distal radioulnar joint (DRUJ) stability was checked at this point. A separate ulnar-side incision along the subcutaneous border of distal ulna was utilized to fix the distal ulna with a hook plate (▶ Fig. 44.8). Fig. 44.7 (a–d) Dorsal radiocarpal fracture dislocation with fractures of the radial styloid involving the entire scaphoid fossa, dorsal cortical rim, and distal ulna.

Fig. 44.8 (a–d) Fragment specific fixation of distal radius and a separate ulnar side incision along the subcutaneous border of distal ulna was utilized to fix the distal ulna with a hook plate.

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Dorsal Approach to Distal Radius

44.3.3 Case 3 A 42 y/o male involved in a bicycle accident sustained a dorsal shear fracture associated with central impaction and radial styloid fracture (▶ Fig. 44.9). A dorsal approach was utilized to dis-impact the central articular fragment and the void packed

with allograft bone chips. This helped to maintain the reduction as well as provide more mechanical stability to the construct. A dorsal plate was then used to buttress the dorsal shear component and raft screws were placed to support the articular fragment (▶ Fig. 44.10). A radial styloid plate was also placed to complete fragment-specific fixation (▶ Fig. 44.10).

Fig. 44.9 (a, b) Dorsal rim fracture associated with central impaction and radial styloid fracture.

Fig. 44.10 (a, b) Dorsal approach used to reconstruct the articular surface and achieve fragment specific fixation.

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Surgical Technique

44.3.4 Case 4 ▶ Fig. 44.11 shows PA radiograph, coronal, sagittal, and axial CT cuts, showing a radial styloid fracture with associated scapholunate (SL) dissociation and intact intermediate column. A dorsal approach, as described above, was used. The SL interval was reduced using joysticks in scaphoid and lunate and then held in

place with a 3.0 mm headless cannulated screw. The SL ligament was repaired. A 0.045-inch K-wire was also placed percutaneously from scaphoid to capitate (this was removed at 6 weeks). The same exposure can be utilized to reduce and fix radial styloid fracture. In this case, we used a combination of screws (3.5 mm fully threaded) and K-wires (0.045 inch; which were not removed unless problematic) (▶ Fig. 44.12).

Fig. 44.11 (a-e) PA radiograph, coronal, sagittal, and axial CT cuts showing a radial styloid fracture with associated SL dissociation and intact intermediate column. SL, scapholunate.

Fig. 44.12 (a, b) Dorsal approach used to repair the SL interval and fix radial styloid using a combination of screws and K-wires. SL, scapholunate.

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Dorsal Approach to Distal Radius

44.3.5 Case 5 ▶ Fig. 44.13 shows PA and lateral radiograph of a distal radius fracture with dorsal angulation and dorsal subluxation of carpus. On PA, there is a shadow seen in the intermediate column (arrow), suspicious for a die-punch fragment. Further evaluation with a CT shows an irreducible dorsal die-punch fragment (▶ Fig. 44.14). A dorsal approach was used to reduce the dorsal fragment (▶ Fig. 44.15). Combination of both volar and dorsal approaches was used for fragment-specific fixation of the intermediate column, radial column, and dorsal die-punch fragment (▶ Fig. 44.15).

44.4 Results Careful evaluation of X-rays and obtaining preoperative CT scans is essential to determining the fracture patterns that will benefit from a dorsal approach to restore anatomy. For radiocarpal fracture-dislocations, loss of about 30 to 40% of total wrist flexion/extension arc has been reported.2,4 Worse outcomes are associated with persistent articular incongruity, persistent neurological deficit, associated carpal

fractures, and residual ulnar translocation of the carpus.2,4–6 Good to excellent short-term outcomes have been reported in literature. Posttraumatic arthritis is commonly seen in these patients and is likely related to persistent articular incongruity or intercarpal instability. Posttraumatic arthritis does not necessarily result in a painful wrist at short-term follow-up.

44.5 Tips and Tricks ●

●

●

●

●

Preoperative CT scan including three-dimensional reconstruction is often helpful in determining fracture patterns and treatment planning. Dorsal approach is often combined with a volar approach if there is any median nerve compromise or to repair volar capsule and ligaments. Need to be facile with all common approaches to distal radius as they are often used together for fragment-specific fixation. Ulnar styloid and/or triangular fibrocartilage complex (TFCC) might need to be reattached for DRUJ instability. Intercarpal ligament injuries should be assessed and repaired as needed.

Fig. 44.13 (a, b) Shadow seen in intermediate column suspicious for die-punch fragment.

Fig. 44.14 (a–c) CT scan shows irreducible die punch fragment.

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References

Fig. 44.15 (a,b) Combination of volar and dorsal approach used for fragment specific fixation.

44.6 Conclusion Dorsal approach to the distal radius is preferred and allows for fixation of dorsal radiocarpal fracture-dislocations, dorsal shearing fractures, fractures with articular impaction, associated scaphoid fractures or other carpal injuries, carpal ligament injuries, and displaced dorsal–ulnar fragment of the distal radius.

References

[2] Dumontier C, Meyer zu Reckendorf G, Sautet A, Lenoble E, Saffar P, Allieu Y. Radiocarpal dislocations: classification and proposal for treatment. A review of twenty-seven cases. J Bone Joint Surg Am. 2001; 83(2): 212–218 [3] Lozano-Calderón SA, Doornberg J, Ring D. Fractures of the dorsal articular margin of the distal part of the radius with dorsal radiocarpal subluxation. J Bone Joint Surg Am. 2006; 88(7):1486–1493 [4] Mudgal CS, Psenica J, Jupiter JB. Radiocarpal fracture-dislocation. J Hand Surg [Br]. 1999; 24(1):92–98 [5] Ilyas AM, Mudgal CS. Radiocarpal fracture-dislocations. J Am Acad Orthop Surg. 2008; 16(11):647–655 [6] Penny WH, Green TL. Volar radiocarpal dislocation with ulnar translocation. J Orthop Trauma. 1988; 2(4):322–326

[1] Chen NC, Jupiter JB. Management of distal radial fractures. J Bone Joint Surg Am. 2007; 89(9):2051–2062

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45 Bridge Plating of Distal Radius Fractures Jonathan W. Shearin and Van Thuc Nguyen Abstract There exist a variety of methods to repair distal radius fractures. A challenging subset of these fractures includes those with substantial articular comminution or significant meta-diaphyseal extension. Historically, these fractures were treated with external fixators. Another recently described option is dorsal spanning or bridge plate fixation which consists of internal distraction plating. A plate is spanned dorsally from the index or long finger metacarpal to the shaft of the radius to provide stable fixation allowing for distraction across severely impacted and comminuted distal radius fractures. Keywords: bridge plating, spanning plate, internal distraction plating, comminution, distal radius fractures, metaphyseal– diaphyseal extension

45.1 Description The use of bridge plating for the treatment of distal radius fractures is one option in the armamentarium of surgeons for the management of a complex set of distal radius fractures with specific treatment challenges. It was first described by Burke and Singer as a stable construct and alternative to external fixators.1

across the intermediate column and a minor amount along the radial column. The ulnar column also withstands a significant load as it serves as the stabilizer of wrist pronation/supination, flexion/extension, and radial/ulnar deviation.2

45.2.3 Radiographic Parameters Melone described three standard radiographic parameters of the distal radius as follows (▶ Fig. 45.3)3: 1. Radial inclination: The angle formed between the line drawn from the tip of the radial styloid to the ulnar corner of the distal radius articular surface with respect to the line perpendicular to the radial shaft. Average measurement is 23°. 2. Volar tilt: The angle formed between the line drawn perpendicular to the long axis of the radius and the line between the dorsal and volar lips of the distal radial articular surface. Average measurement is 11°. 3. Radial height: The distance measured between the two parallel lines drawn perpendicular to the long axis of the radial shaft. One is drawn from the tip of the radial styloid and the other from the ulnar corner of the lunate fossa. Average measurement is 11 to 12 mm.

45.2 Anatomy A thorough understanding of the relevant anatomical structures is key for the management of distal radius fractures. Restoration of wrist anatomy in order to regain function is usually associated with satisfactory outcomes.

45.2.1 Bones The wrist is a complex joint that consists of two long bones and eight carpal bones. There are three main articulations (▶ Fig. 45.1): 1. Radiocarpal: Distal radius and triangular fibrocartilage complex (TFCC) to proximal row 2. Distal radioulnar joint (DRUJ) 3. Midcarpal: Between the proximal and distal carpal bone rows

45.2.2 Biomechanics Biomechanics of the wrist joint via the Column Concept: ● Radial column: Includes the radial styloid and scaphoid fossa ● Intermediate column: Includes the lunate fossa and sigmoid notch ● Ulnar column: Includes the distal ulna with the TFCC The column concept proposes a theory in which load is transmitted throughout the wrist (▶ Fig. 45.2). Under normal physiologic conditions, the majority of load is transmitted

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Fig. 45.1 Bones of the hand. (1) Hamate. (2) Capitate. (3) Pisiform. (4) Triquetrum. (5) Lunate. (6) Trapezium. (7) Trapezoid. (8) Scaphoid. (Reproduced with permission from Pechlaner S, Kerschbaumer F, Hussl H, Poisel S, eds. Atlas of Hand Surgery. 1st ed. Thieme; 2000.)

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Anatomy

Fig. 45.2 Column concept. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management. 1st ed. © 2018 Thieme.)

Fig. 45.4 Wrist extensor compartments. APL, abductor pollicis longus; BR, Brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM, extensor digiti minimi; EIP, extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FDP, flexor digitorium profundus; FDS, flexor digitorium superficialis; FPL, flexor pollicis longus; PL, palmaris longus; PQ, pronator quadratus. (Reproduced with permission from Beasley RW, ed. Beasley’s Surgery of the Hand. 1st ed. New York, NY: Thieme; 2003.)

45.2.4 Extensor Compartments

Fig. 45.3 Radial inclination and volar tilt. (Reproduced with permission from Hochschild J. Functional Anatomy for Physical Therapists. Stuttgart: Thieme; 2016.)

With bridge plating, an apparatus intimately involving the extensor compartments is utilized (▶ Fig. 45.4). These compartments are as follows: 1. Abductor pollicis longus (APL) and Extensor Pollicis brevis (EPB) 2. Extensor carpi radialis longus (ECRL) and Extensor carpi radialis brevis (ECRB) 3. Extensor pollicis longus (EPL)

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Bridge Plating of Distal Radius Fractures 4. Extensor indicis propius (EIP) and Extensor digitorum communis (EDC) 5. Extensor digiti minimi (EDM) 6. Extensor carpi ulnaris (ECU)

45.3 Definition Internal distraction (bridge or spanning) plating for distal radius fractures is utilizing a plate spanned from the index or long finger metacarpal down the shaft of the radius to provide stable fixation allowing for distraction across impacted and

comminuted distal radius fractures. The goal is to restore length and alignment.

45.4 Indications Hanel et al described the following indications for dorsal bridge plating4: ● Significant distal radial articular comminution and fragmentation (▶ Fig. 45.5a,b) ● Meta-diaphyseal comminution of the radius (▶ Fig. 45.6a,b) ● The need for augmented fixation in severely osteoporotic bone

Fig. 45.5 (a) Distal radius AP x-ray demonstrating a distal fracture with comminution. (b) Distal radius lateral X-ray with significant articular comminution.

Fig. 45.6 (a) Distal radius anteroposterior (AP) X-ray with meta-diaphyseal comminution. (b) Distal radius lateral X-ray with meta-diaphyseal comminution.

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Surgical Management ●

●

Polytrauma patients with the need for weight-bearing through the upper extremity due to lower extremity injuries Radiocarpal fracture dislocations involving a distal radius fracture and radiocarpal/carpal instability

the bone/fracture. Thus, a bridge plate provides the strongest possible fixator construct by its direct placement on the radius and metacarpals, compared to an external fixator device.5

45.5 Key Principles

45.9 Surgical Management

Various treatment options do exist for the management of distal radius fractures depending on a variety of factors. Before the advent of bridge plating techniques, these particular fractures would be managed with external fixation with or without Kirschner wire (K-wire) augmentation. Bridge plating has provided a new approach to these injuries.

45.9.1 Planning, Positioning, and Anesthesia

45.6 Contraindications ●

●

Metacarpal fractures of the index or middle fingers, which would interfere with distal fixation of the bridge plate Active infection

Either general anesthesia or regional anesthesia is utilized with the patient supine on the operating table with the involved extremity draped free and centered on a radiolucent hand table. Finger traps can be applied with approximately 5 to 10 lbs of traction. Either a mini C-arm or large C-arm can be used above or below the table. Hanel et al recommended a stainless steel implant specifically that can circumvent additional tendon ruptures because of the smooth edges and tapered tips of this type of implant.4

45.7 Special Considerations

45.9.2 Closed Reduction

Patients indicated for this treatment option include those with high-energy wrist injuries with significant articular comminution or meta-diaphyseal comminution, or as a means of augmented fixation. Polytrauma patients with multiple injuries who require load-bearing through the wrist for assistance with mobilization would also be candidates. Good-quality prereduction and postreduction radiographs should be obtained to assess the fracture pattern. CT scan or traction radiographs may be useful to assess for fracture pattern and degree of comminution.

A closed reduction maneuver can be employed involving longitudinal traction with palmar translation and ulnar deviation. Once completed, finger traps can be utilized with weighted traction or an assistant can hold traction (▶ Fig. 45.7a,b).

45.8 Biomechanical Stability Behrens et al demonstrated that rigidity of an external fixator is proportional to the distance between fixator bar and

45.9.3 Surgical Approach/Plate Placement The plate is positioned on the dorsal aspect of the wrist and fluoroscopy is utilized to confirm appropriate placement of the plate. The plate can extend from the index metacarpal to the distal radius or the long finger metacarpal to the radius. Surgeon’s preference will dictate this placement. A cadaveric study demonstrated that using the index metacarpal resulted in fewer cases of tendon entrapment under the plate. Plating

Fig. 45.7 (a) Intraoperative anteroposterior (AP) X-ray closed reduction. (b) Intraoperative lateral X-ray closed reduction.

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Bridge Plating of Distal Radius Fractures using the third metacarpal resulted in an increased frequency of tendon entrapment (▶ Fig. 45.8).6 Based on the fluoroscopic images, a 5-cm skin incision is marked distally at the chosen metacarpal and a 5-cm skin incision is marked proximally along the radius. Tourniquet is recommended (▶ Fig. 45.9). An incision is made distally where marked along the index metacarpal and a dorsal approach is performed. The extensor tendons are retracted ulnarly. If necessary, the dorsal interosseous muscles are elevated subperiosteally (▶ Fig. 45.10). The second incision is made proximally where marked and dissection is carried between the interval of the ERCL and ECRB to the diaphysis of the radius. Careful attention to protect the superficial branch of the radial nerve is necessary (▶ Fig. 45.11).

Distally, at the base of the second metacarpal, a hemostat or freer/key elevator is utilized to develop a path between ECRL and ECRB tendon insertions extending proximally. Similarly, a path is developed proximally between both tendons and extended distally with a key elevator or freer to mimic the path of the plate. The plate is then passed from distal to proximal. If resistance is encountered, gentle manipulation often will overcome the resistance. A suture retriever can also be used to aid in passage with the plate attached to the distal end of the wire and delivered into the hand. The goal is for the plate to pass on the floor of the second compartment. As a last resort, a third incision can be utilized ulnar to Lister tubercle to aid in passage of the plate while identifying and protecting EPL (▶ Fig. 45.12).

Fig. 45.8 Intraoperative anteroposterior (AP) X-ray with plate overlay on second metacarpal.

Fig. 45.9 Intraoperative plate overlay.

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Surgical Management

Fig. 45.10 Distal incision over second metacarpal.

Fig. 45.11 Proximal incision over distal radius.

45.9.4 Plate Fixation Distally the plate is secured to the index metacarpal with a cortical screw. The proximal aspect of the plate is identified in the forearm. At this point, fracture reduction, if not already restored, is established, with finger traps and weight, or manual traction from the assistant. Once reduction is achieved, a cortical screw is used to secure the proximal plate to the radius. As two non-locking screws have been placed, the plate is effectively fixed/lagged into intact bone. Confirm adequacy of restoration of radial length, radial inclination, and volar tilt via fluoroscopic imaging. The remaining screws are secured with fully threaded cortical and locking screws in alternating fashion. Final fluoroscopic images are taken to confirm adequacy of reduction and length of fixation (▶ Fig. 45.13a,b). If necessary to obtain an intra-articular reduction, limited periarticular incisions can be made and bridge plate fixation can be augmented with K-wires or fragment-specific periarticular plates.

45.9.5 Postoperative Care

Fig. 45.12 Bridge plate resting on second metacarpal.

The tourniquet is deflated and wound irrigated. Incisions are closed with a running subcuticular monocryl suture or nylon skin sutures. A volar splint can be placed for comfort. Digit range-of-motion exercises are started within 24 hours. Weight bearing can be initiated immediately through the forearm and elbow. The plate is removed between 2 and 4 months or when healing is evidenced on radiographs (▶ Fig. 45.14a,b).

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Bridge Plating of Distal Radius Fractures

Fig. 45.13 (a) Intraoperative anteroposterior (AP) X-ray of distal plate fixation. (b) Intraoperative lateral X-ray of distal plate fixation. (c) Intraoperative lateral X-ray of proximal plate fixation.

Fig. 45.14 (a) Postoperative anteroposterior (AP) X-ray. (b) Postoperative lateral X-ray.

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References

45.10 Pitfalls ●

●

● ●

Care must be taken to protect the radial sensory nerve in the proximal wound. The plate must be placed exactly on the index metacarpal. Placing the plate off center will not allow bicortical screw fixation. Care should be taken to not overdistract the radiocarpal joint. Care should be taken not to entrap the extensor tendons below the plate.

References [1] Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Up Extrem Surg. 1998; 2(4):248–252 [2] af Ekenstam FW, Palmer AK, Glisson RR. The load on the radius and ulna in different positions of the wrist and forearm: a cadaver study. Acta Orthop Scand. 1984; 55(3):363–365 [3] Melone CP, Jr. Articular fractures of the distal radius. Orthop Clin North Am. 1984; 15(2):217–236

[4] Hanel DP, Lu TS, Weil WM. Bridge plating of distal radius fractures: the Harborview method. Clin Orthop Relat Res. 2006; 445(445):91–99 [5] Behrens F, Johnson WD, Koch TW, Kovacevic N. Bending stiffness of unilateral and bilateral fixator frames. Clin Orthop Relat Res. 1983(178): 103–110 [6] Lewis S, Mostofi A, Stevanovic M, Ghiassi A. Risk of tendon entrapment under a dorsal bridge plate in a distal radius fracture model. J Hand Surg Am. 2015; 40(3):500–504

Suggested Readings Brogan DM, Richard MJ, Ruch D, Kakar S. Management of severely comminuted distal radius fractures. J Hand Surg Am. 2015; 40(9):1905–1914 Lauder A, Agnew S, Bakri K, Allan CH, Hanel DP, Huang JI. Functional outcomes following bridge plate fixation for distal radius fractures. J Hand Surg Am. 2015; 40 (8):1554–1562 Nourissat G, Mudgal CS, Ring D. Bridge plating of the wrist for temporary stabilization of concomitant radiocarpal, intercarpal, and carpometacarpal injuries: a report of two cases. J Orthop Trauma. 2008; 22(5):368–371 Richard MJ, Katolik LI, Hanel DP, Wartinbee DA, Ruch DS. Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients. J Hand Surg Am. 2012; 37(5):948–956

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46 External Fixation of Distal Radius Fractures William H. Kirkpatrick Abstract Distal radius fractures with significant articular comminution are difficult to manage. Historically, these fractures have been treated with external fixators. With the advent of bridge plate fixation, the use of external fixation appears to be diminishing.

46.5 Contraindications ●

●

●

Keywords: fractures

external

fixation,

comminution,

distal

radius ● ●

46.1 Description External fixation is a treatment option for distal radius fractures, which involves placement of threaded pins distal and proximal to the fracture with a connecting external frame.

46.2 Key Principles ●

●

●

●

External fixation can provide stabilization of distal radius fractures by ligamentotaxis,1 which is the principle of soft tissue tension across a joint to realign fracture components. External fixation may be applied with or without internal fixation, depending on fracture variables (open or closed, degree of comminution, and stability of fragment fixation) when ligamentotaxis alone does not restore fracture alignment. Optimal PA and lateral radiographic parameters to guide treatment include radial inclination of 22 degrees, volar tilt of 11 degrees, and ulnar variance similar to unaffected wrist. Central placement of pins, each through two cortices, into the index metacarpal and radial shaft provides secure fixation for the external fixator frame.

Stable fractures (minimally displaced or where internal fixation is preferred). Volar or dorsal marginal fractures requiring an internal buttress. Patient comorbidities (age and medical issues) not permitting surgical intervention. Noncompliant patients. Associated fractures of index, long metacarpals, or radial shaft, which may interfere with proper pin placement.

46.6 Special Considerations ●

●

CT scans can better define intra-articular fracture morphology and degree of comminution to assist in decision-making for use of external fixation. Intraoperative fluoroscopy can provide significant guidance regarding the adequacy of fracture reduction and pin placement.

With improved internal fixation techniques, including the option of internal bridge plating, the use of external fixation for distal radius fractures has become less common.2,3

46.7 Surgical Management 46.7.1 Planning, Positioning, and Anesthesia ●

A variety of external fixators are available and therefore the surgeon needs to be familiar with the specific components (▶ Fig. 46.1).

46.3 Expectations For unstable fractures following attempted closed reduction, external fixation with or without internal fixation can assist in the maintenance of acceptable fracture alignment, with the goal of preventing displacement and malunion and achieving painless and functional wrist range of motion.

46.4 Indications ●

●

● ●

236

Unstable fractures (extra and/or intraarticular) in which optimal radiographic parameters are not achieved with closed reduction and/or internal fixation. As a supplement to internal fixation in preventing fracture collapse due to significant comminution. Open/contaminated fractures. Patients who must bear weight on the wrist for ambulation.

Fig. 46.1 One example of an external fixator frame with attached threaded pins (Synthes– DePuy Synthes, Paoli, PA).

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Pitfalls ●

●

●

●

●

Supine with upper extremity on arm board; accessible to fluoroscopic unit. Avoid placement of radio-opaque components interfering with radiographic views, especially lateral. Postoperative hand therapy should be initiated soon after placement of external fixator. Pin sites can be inspected and cleaned daily by the patient with alcohol or hydrogen peroxide swabs. Alternatively, the pins can simply be monitored without specific pin care depending on surgeon preference. External fixators are removed between 4 to 8 weeks.

46.8 Tips and Pearls ●

●

●

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Determine preoperatively if index metacarpal is of sufficient diameter to accommodate a threaded pin; the adjacent long metacarpal may be used instead. Avoid pin placement into index carpometacarpal (CMC) joint. Minimal but sufficient mobilization of superficial radial nerve. Avoidance of overdistraction.4 Inspect passive digital range of motion after placement of external fixator. Low threshold for open reduction internal fixation (ORIF) if external fixation alone does not maintain a satisfactory reduction.

46.9 Key Procedural Steps A longitudinal 3 cm incision is placed dorsoradially over the proximal index metacarpal. Care should be taken to identify and protect sensory nerve branches and avoid penetration of the index CMC joint. A drill guide is used for the parallel placement of self-tapping threaded pins into the index metacarpal, providing four cortices of fixation (▶ Fig. 46.2). Alternatively, the proximal pin can also be placed through the index metacarpal base into the long metacarpal base for additional fixation. A second 3 cm incision is made over the radial forearm approximately 10 to 12 cm proximal to the tip of the radial styloid and within the distal third of the forearm. Avoiding branches of the superficial radial and lateral antebrachial cutaneous nerves, the interval between the brachioradialis and extensor carpi radialis longus (ECRL) is developed. The interval between ECRL and extensor carpi radialis brevis (ECRB) can also be used. The superficial radial nerve is identified under the brachioradialis and should be protected as the drill guide is placed onto the radial shaft. Self-tapping, threaded pins are inserted through a guide, generally parallel to the index metacarpal pins.5,6 (▶ Fig. 46.2). Intraoperative fluoroscopy confirms satisfactory bicortical pin placement. Loose closure of the two incisions prevents skin irritation at the pin sites. Closed reduction is achieved with gentle traction and fracture manipulation under fluoroscopy. The external fixator is assembled with preselected clamps and a rod and secured with tightening (▶ Fig. 46.3).

Fig. 46.2 Surgical exposure of index metacarpal shaft for bicortical placement of threaded half pins and of the radial shaft for pin placement between the brachioradialis and ECRL. The superficial radial nerve is seen under the brachioradialis and must be carefully identified and protected. ECRL, extensor carpi radialis longus.

46.10 Pitfalls ●

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If a fracture occurs in the index metacarpal shaft, as a result of pin placement, the adjacent long metacarpal shaft may be used as an alternate. Radial shaft pins should be placed away from the superficial radial nerve to avoid injury or painful neuroma. Overdistraction by the external fixator can lead to nonunion, limited digital range of motion, median nerve symptoms, and complex regional pain syndrome. Digital stiffness/swelling should be addressed in the early postoperative period with hand therapy.

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External Fixation of Distal Radius Fractures

Fig. 46.3 (a,b) PA and lateral radiographic views following external fixator placement for a distal radius metaphyseal fracture.

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Pin tract infections occur frequently and may require local care or repositioning of pins. Aggressive treatment with oral antibiotics is needed to prevent the development of a deep infection or osteomyelitis.

References [1] Agee JM. External fixation. Technical advances based upon multiplanar ligamentotaxis. Orthop Clin North Am. 1993; 24(2):265–274

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[2] Henry MH. Distal radius fractures: current concepts. J Hand Surg Am. 2008; 33(7):1215–1227 [3] Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am. 2005; 30(6):1185–1199 [4] Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius fractures. J Am Acad Orthop Surg. 2010; 18(3):180–189 [5] Seitz WH, Jr. External fixation of distal radius fractures. Indications and technical principles. Orthop Clin North Am. 1993; 24(2):255–264 [6] Seitz WH, Jr, Putnam MD, Dick HM. Limited open surgical approach for external fixation of distal radius fractures. J Hand Surg Am. 1990; 15(2):288–293

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Part VIII Bone Reconstruction

VIII

47 Phalangeal Osteotomies

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48 Corrective Osteotomy of Metacarpal Malunion

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49 Scaphoid Nonunion: Medial Femoral Condyle Vascularized Bone Graft

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50 Scaphoid Nonunion: ORIF and Bone Graft for Humpback Deformity

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51 Capitate Shortening Osteotomy

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52 Distal Radius Osteotomy for Malunion (Volar Approach)

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53 Distal Radius Osteotomy for Malunion: Dorsal Approach

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47 Phalangeal Osteotomies Mark Snoddy and Philip E. Blazar Abstract This chapter is a review of phalangeal malunion and the methods for correction including malunion evaluation, treatment options, and tips regarding phalangeal osteotomies. Given the variety of surgical options, surgeons must preoperatively plan in advance regarding the location, type, and fixation of osteotomies. While there are a variety of methods for surgical correction, operative procedures do not always achieve desired outcomes. Therefore, preoperative discussion must include current hand function difficulties and expected outcomes. Nonetheless, well-planned phalangeal osteotomies when indicated can achieve appropriate correction and improve overall hand function. Keywords: osteotomy, phalanx, malunion, deformity, stiffness, fixation

extensor lags, flexor and extensor imbalance, and adjacent joint contractures.1

47.4 Indications Malunion management is variable and is up to individual surgeon and patient preference, as patients will have different functional requirements and personal desires.1 While most malunions involve a combination of deformities, usually there is one major component causing functional change and causing surgical consideration.3 Phalangeal malunions greater than 15 degrees in the sagittal plane or 10 degrees of malrotation that are symptomatic or functionally obstructive may benefit from osteotomy.1,3 Other indications include pain or decreased grip strength.4

47.5 Contraindications 47.1 Description Malunion is the result of a fracture healed with deformity. The bone is stable, but the functional impact is determined by the location, type, and severity of the deformity. Osteotomy allows for deformity correction to achieve acceptable alignment with internal fixation.1

Acceptance of mild or sometimes greater deformity with a healed and asymptomatic malunion may be preferred when there is uncertain prospect for functional improvement. Physicians should have particular restraint in late presenting (> 10 weeks) patients and those with clinically stable malunions as near-perfect results are not typical and therapy focused on improved motion and strengthening may be an acceptable alternative to surgery. Furthermore, correction for cosmesis alone without functional restrictions should be discouraged.1

47.2 Key Principles In assessing a malunion, multiple factors must be evaluated. ● Malunion site, including extra-articular or intra-articular, combined, proximal, or distal metaphyseal, or diaphyseal ● Deformity type: radial or ulnar deviation, flexion or extension, pronation or supination, shortening, or combination ● Degree of healing, including immature versus mature callus ● Soft tissue involvement, including integrity/adhesions of the flexor and extensor tendons and condition/contracture of joint capsules2 Furthermore, it is important to assess the patient’s overall hand function, treatment goals and expectations, and specific functional limitations with daily activities. This information is vital in determining course of action to maximize that patient’s outcome.

47.3 Expectations Benefits of corrective osteotomy include and dexterity of the affected and adjacent as a functional unit. When phalangeal long-term complications include flexor

improved function digits and the hand malunions persist, tendon adhesions,

47.6 Special Considerations A detailed preoperative evaluation is important. This should include deformity and functional limitation assessment, including investigation of the bone and soft tissues. X-rays of the malunion site will help to determine potential correction sites and need for possible bone graft.5 Surgical timing is important as osteotomies performed earlier will allow for easier soft tissue rebalancing and deformity correction prior to the onset of tendon adhesions and joint contractures. If an osteotomy cannot be attempted prior to 10 weeks, consider starting a therapy program to maximize digital motion, and delay surgery until the 3-month mark.1 When surgery is necessary, the physician must choose among approaches, osteotomy site, operative techniques, fixation devices, and rehabilitation regimens.1 Preoperative discussion and patient selection are vital as both surgeon and patient should comprehend the potential benefits and realistic expected outcomes. Furthermore, both parties should be aware of the potential need to change surgical plans in the case of intraoperative complications such as intraarticular fragmentation or fixation failure requiring joint reconstruction or fusion. In this case, the surgeon may need other implants or methods of fixation available.

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Fig. 47.1 (a) A 44-year-old female with snowblower injury. (b) Malunion (c) correction with diaphyseal closing wedge osteotomy, fixed with 26 gauge wire and one 0.045-inch and one 0.035-inch K-wire.

47.7 Special Instructions, Positioning, and Anesthesia These procedures can be performed under general or regional anesthesia. However, there are some proponents of wide awake anesthesia that allows for intraoperative dynamic analysis of finger position.4 Patients should be positioned supine, with the arm on a hand table. Surgery can be performed under tourniquet. A fluoroscopy machine should be present. Besides basic hand surgical tools, additional instruments that may prove helpful include small osteotomes, various small Kirschner wires (K-wires) (0.035, 0.045, and 0.062 inch), dental pick, bone chip allograft, wires (26 gauge), and small (2 mm) burrs. Implants to have in the room may include locking and nonnonlocking hand plates (linear, T, and Y plates of sizes 2.0 mm and smaller). Also, implants that should be available in select cases include instrumentation to perform arthrodesis, and rarely metacarpophalangeal or proximal interphalangeal silicone or pyrocarbon arthroplasty implants.

47.8 Tips, Pearls, and Lessons Learned 47.8.1 Preoperative Planning Preoperative planning can save on intraoperative decision making. Using templated X-rays to assess length, osteotomy location, and osteotomy type can alleviate some of the difficulty in the correction.3 Other ideas include printing out X-rays and constructing osteotomies on the paper to determine appropriate cut locations and angles.6 Recent progress in computed tomography (CT) enables for CT-derived bone models to allow for preoperative planning. Ota et al developed a “linkage

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simulation” that uses a 3D CT model to determine current deformity and type of correction needed.7

47.8.2 Osteotomy Location and Type During preoperative planning, it should be determined where the osteotomy will take place and what type of osteotomy will be performed. Deformity correction at the site of malunion allows surgeons to address combined deformity and perform capsulodesis and tenolysis. Choosing an osteotomy in an adjacent bone can cause a zigzag deformity. Furthermore, metaphyseal osteotomies are more favorable to diaphyseal osteotomies due to faster healing. Also, if performing proximal phalanx corrections, osteotomies closer to the metacarpal phalangeal joint can tolerate stiffness better than proximal interphalangeal joints.1,3 Another point of discussion is opening versus closing wedge osteotomies. Benefits of closing wedge include faster healing, but can lead to tendon imbalance and/or extensor lag due to excessive shortening (▶ Fig. 47.1a–c). Opening wedge osteotomies maintain length but require bone grafting and can cause tendon over tightening.3 Another option for an apex malunion is a trapezoid osteotomy. This corrects bone length and deformity and prevents need for additional graft8 (▶ Fig. 47.2).

47.8.3 Approach While the midaxial or midlateral approach avoids extensor dissection, stable fixation becomes more difficult and placing a plate along the lateral border of a phalanx is more difficult than along the dorsal cortex. However, lateral plating decreases plate on tendon contact. Recently, some authors advocate for minimally invasive lateral incisions, which prevent soft tissue disruption. This small incision allows for small drill and osteotome work but does not allow for plate fixation.4 Most authors prefer the dorsal approach, allowing for better exposure and more reliable, stable fixation.3

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Tips, Pearls, and Lessons Learned

47.8.4 Tenolysis and Capsulectomy Prior to initiation of malunion takedown, ensure maximum joint and tendon excursion by preforming tenolysis and capsulolysis. Waiting until the end to perform this step can result in inadequate malunion correction and fixation disruption.1

47.8.5 Articular Malunions

Fig. 47.2 Trapezoid osteotomy.

If the bone is not fully united and callus is soft, correction should be performed at the malunion site. If the fracture is fully united, one can consider an osteotomy at a different location. However, if the malunion is intra-articular and the patient has arthrosis, consider arthroplasty or arthrodesis.3 Performing osteotomies of small fragments at the articular surface, such as unicondylar malunions, can be difficult to obtain adequate fixation after correction (▶ Fig. 47.3). Other techniques exist to prevent potential comminution and fragment necrosis. Teoh et al describes a “condylar advancement osteotomy” that incorporates an intercondylar osteotomy and advancement of the condylar block9 (▶ Fig. 47.4). Others still consider unicondylar advancement a risk for condylar necrosis and recommend extra-articular wedge osteotomies to correct unicondylar malunion. This osteotomy maintains the condylar block and is fixed with a tension band technique (▶ Fig. 47.5). Postoperatively, patients should be placed in a bulky dressing or splint, but should initiate range-of-motion exercises within the first week. Formal therapy can help with both range-of-motion protocols and edema control. When not performing exercises, the interphalangeal joints should be splinted in extension.5

Fig. 47.3 (a,b) A 30-year-old male with condylar malunion. Intra-articular osteotomy, fixed with 1.5-mm screws.

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Fig. 47.4 Condylar advancement osteotomy.

Fig. 47.5 Extra-articular wedge osteotomy for unicondylar malunion.

47.8.6 Types of Fixation While a variety of fixation options exist, the patient should not leave the operating room without ample stability at the osteotomy site. Since motion should be initiated within one week of surgery, fixation should be adequate to maintain a stable foundation prior to bony healing. For this reason,

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Fig. 47.6 A 60-year-old female with malunion of P1 ring finger. Dorsal opening wedge osteotomy with 1.5 locking plate fixation.

plates and screws or screws alone are preferred when possible over K-wire fixation alone. Plate options include 1.5-mm mini-locking or mini-locking condylar plates, with various plate shape options (▶ Fig. 47.6). Other options include combining two types of fixation such as 1 or more K-wires and 25 gauge wire loops.

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References

Fig. 47.7 K-wire-assisted malunion correction.

Risks of corrective osteotomy include persistent deformity, delayed bone healing, nonunion, implant failure, infection, stiffness, and chronic pain.3

For patients with known preoperative arthrosis or possible intraoperative complications, the most appropriate step in management may be joint arthroplasty or fusion. For this reason, surgeons must know the locations of these implants when performing corrective surgeries.

47.10 Key Procedural Steps

47.12 Pitfalls

Prior to initiating the deformity correction, K-wires can be placed perpendicular to the sagittal and coronal plates. Once the osteotomy is performed and positional correction attempted, these wire should eventually provide a marker for aggregate correction (▶ Fig. 47.7). Initiating the osteotomy may be difficult. Small K-wires can be used to puncture the cortex in multiple, precise locations prior to using an osteotome or saw to complete the osteotomy. This allows for better control and more precise osteotomy placement.4 When deformity correction allows, maintain the far cortex, which will act as a hinge and provide some stability during deformity correction and allow for fixation. When using plates, ensure four cortices of fixation on either side of the osteotomy.5 When drilling for screws, be precise as 1 mm of eccentricity can cause up to 10 degrees of malrotation.1

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47.9 Difficulties Encountered

47.11 Bailout, Rescue, and Salvage Procedures If a phalanx osteotomy is not possible, a metacarpal osteotomy can provide rotational correction up to 20 degrees in the index, long, and ring fingers and 30 degrees in the small finger. In many rotational deformities, the metacarpal location is the surgeon’s preference.

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Inadequate correction Poor fixation preventing early range of motion Excessive shortening Nonunion/malunion Stiffness

References [1] Freeland AE, Lindley SG. Malunions of the finger metacarpals and phalanges. Hand Clin. 2006; 22(3):341–355 [2] Büchler U, Gupta A, Ruf S. Corrective osteotomy for post-traumatic malunion of the phalanges in the hand. J Hand Surg [Br]. 1996; 21(1): 33–42 [3] Ring D. Malunion and nonunion of the metacarpals and phalanges. Instr Course Lect. 2006; 55:121–128 [4] Seo BF, Kim DJ, Lee JY, Kwon H, Jung SN. Minimally invasive correction of phalangeal malunion under local anaesthesia. Acta Orthop Belg. 2013; 79 (5):592–595 [5] Wolfe SW, et al. Green's Operative Hand. Philadelphia: Elsevier/Churchill Livingstone; 2011 [6] Harness NG, Chen A, Jupiter JB. Extra-articular osteotomy for malunited unicondylar fractures of the proximal phalanx. J Hand Surg Am. 2005; 30 (3):566–572 [7] Ota H, Iwatsuki K, Murakami Y, et al. Corrective osteotomy for malunited small finger proximal phalangeal fracture using linkage simulation: a case report. J Orthop Sci. 2017; 22(3):571–574 [8] Yong FC, Tan SH, Tow BP, Teoh LC. Trapezoid rotational bone graft osteotomy for metacarpal and phalangeal fracture malunion. J Hand Surg Eur Vol. 2007; 32(3):282–288 [9] Teoh LC, Yong FC, Chong KC. Condylar advancement osteotomy for correcting condylar malunion of the finger. J Hand Surg [Br]. 2002; 27(1):31–35

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48 Corrective Osteotomy of Metacarpal Malunion Pranay M. Parikh Abstract Corrective osteotomy of malunited fractures of the metacarpals is a valuable technique for the hand-and-wrist surgeon. In addition to correcting deformity, restoration of normal metacarpal anatomy can relieve pain, improve grasp, correct scissoring of digits, and restore intrinsic tendon balance to correct pseudoclawing of the digits. A variety of osteotomy techniques allow the surgeon to selectively address symptomatic angular, rotational, and length deformities following suboptimal initial fracture healing. With clearly articulated goals, thoughtful preoperative planning, and meticulous operative technique, the surgeon and patient should expect predictable improvement in hand function and correction of deformity. Keywords: metacarpal, corrective osteotomy, malunion, malrotation, angulation, scissoring, pseudo-clawing, derotation

48.1 Description Corrective osteotomy techniques allow the hand surgeon to address symptomatic rotational, angular, and length deformities that occur following malunion of metacarpal fractures. A number of techniques including closing wedge osteotomy, opening wedge osteotomy, and derotation osteotomy are available to address the specific three-dimensional pathoanatomy of the malunion.

Pathoanatomy of Malunion ●

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Identify the site and direction (rotational, angular, shortening) of the malunion Identify underlying deforming forces that contributed to metacarpal deformity, so that these may be corrected intraoperatively

48.2.3 Measure Twice, Cut Once ●

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Carefully plan the location, angle, and direction of osteotomy to achieve desired correction Achieve rigid stable fixation of osteosynthesis site, to prevent recurrence of deformity Anticipate need for bone graft to augment stability and/or cellularity of osteosynthesis site Perform frequent re-assessment of correction intraoperatively to ensure patient’s goals are achieved

48.3 Expectations Following corrective osteotomy of metacarpals, predictable and uneventful bony union should be expected. The surgeon should expect objective improvement in the patient’s functional deficit. The patient should expect resolution of the chief concern and subjective improvement of preoperative symptoms.

48.4 Indications 48.2 Key Principles 48.2.1 Treat the Patient, Not the Radiograph Identify the patient’s symptoms and concerns: ● Patients may complain of pain, weakness, lost range of motion, and deformity ● Articulate the functional deficit to be addressed ● Preoperative discussion of desired outcome is essential to a satisfactory result ● Typical functional goals for surgery include correction of digital overlap during grasp, or “scissoring,” eliminating pseudo-claw deformity to restore motion, and reduction of metacarpal head prominence in the palm

48.2.2 Diagnose Before Initiating Treatment Imaging ●

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Obtain high-quality radiographs of hand: three views (Postero-anterior, lateral, oblique) Obtain films of contralateral hand to serve as a template for baseline normal anatomy Obtain films of initial injury whenever possible

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Symptomatic angular deformities of the metacarpal Rotational deformity of the metacarpal1 – Less than 20 degrees—metacarpal base osteotomy – More than 20 degrees—osteotomy at malunion site, or step-cut derotation osteotomy Length discrepancy of the metacarpal Rotational deformity of the proximal phalanx (up to 20 degrees)

48.5 Contraindications ● ● ●

Active nicotine use Unresolved infection Insufficient soft tissue coverage

48.6 Special Considerations 48.6.1 Hardware Selection ●

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Rigid stable fixation of the osteotomy site is essential for predictable union, early postoperative mobilization, and optimal outcomes 2.0/2.4 mm metal plates and screws are typically used to achieve stable fixation of metacarpal osteotomy sites Many plating systems include purpose-made corrective osteotomy plates with oblong holes that facilitate angular

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Key Procedural Steps

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stability, while permitting rotational adjustment, which allows the surgeon to “dial in” the degree of correction desired The use of locking screws minimizes undesired deformation of osteosynthesis site during fixation

48.6.2 Bone Graft Selection ●

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For most cases with less than 1 cm of anticipated bone deficit, compressed cancellous autograft (from iliac crest, or distal radius) provides satisfactory material to fill the defect. For defects larger than 1 cm, structural corticocancellous iliac crest autograft may be useful, and additional lag screw fixation of the bone graft to the plate can enhance stability.

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Consider a radial approach for the index metacarpal to allow radial lateral plate position underneath the first dorsal interosseous muscle. Consider an ulnar approach for the small metacarpal to allow ulnar lateral plate position underneath the abductor digiti minimi. Identify, mark, and protect branches of radial sensory nerve and dorsal ulnar sensory nerve to minimize the risk of postoperative neuropathic pain. Consider raising a broadly based periosteal/intrinsic muscle fascia flap to facilitate plate coverage during closure, and minimize postoperative extensor tendon adhesions.

48.10.2 Deangulation Osteotomy

48.7 Positioning, Anesthesia Supine positioning with high brachial application of pneumatic tourniquet allows for access to hand, wrist, and forearm, and facilitates intraoperative fluoroscopy. Either general anesthesia or regional anesthesia with brachial plexus block can be used.

Opening and Closing Wedge Osteotomy ●

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48.8 Tips, Pearls, and Lessons Learned ●

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Periosteal flap elevation during exposure facilitates coverage of hardware at closure. Interposition of this layer minimizes postoperative extensor irritation and adhesion. Consider lateral plate positioning for border metacarpals to minimize tendon irritation and plate palpability. Adjacent uninjured metacarpals can be used as a template to facilitate rapid, accurate plate bending. The use of locking hardware minimizes deformation of osteosynthesis site during fixation. Throughout the operation, bring the digits into passive flexion and assess for rotational malalignment. Repeat this check frequently, especially during final fixation. Avoiding unnecessary periosteal stripping, preventing thermal injury during saw cuts, and ensuring vascularized soft tissue coverage will aid in predictable union.

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Closing wedge osteotomy is useful when angular correction alone is desired (▶ Fig. 48.1). Opening wedge osteotomy is useful when correction of metacarpal length deficiency is desired in addition angular correction (▶ Fig. 48.2). Prebend the selected plate using adjacent normal metacarpal as a template. Position the plate at the site of osteosynthesis, allowing for at least four (preferably six) cortices of fixation on either side of the osteotomy. Predrill proximal holes and select screws for fixation proximal to osteotomy site. At the site of each planned saw cut, insert a K-wire orthogonal to the long axis of the metacarpal. These will aid in precise measurement of wedge angles and also serve as cutting guides to position the saw blade. Chilled saline cooling of oscillating saw blade during operation helps to minimize thermal injury to bone.

48.9 Challenges/Pitfalls ●

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Poor preoperative planning, with incorrect location/direction of metacarpal correction Failure to identify complex malunions with combinations of angular and rotational components Unwanted deformation of the osteotomy site during fixation, due to screw distraction Development of stiffness in adjacent joints or digits due to delay in postoperative mobilization

48.10 Key Procedural Steps 48.10.1 Exposure ●

Dorsal longitudinal access incisions allow extensile exposure of most metacarpal malunions.

Fig. 48.1 Closing wedge osteotomy for deangulation of typical apex dorsal metacarpal malunion. K-wires are placed perpendicular to long axis of metacarpal at planned osteotomy sites (red line) and used as cutting guides to remove a wedge of bone (green). Dorsal cortices are approximated, and rigid fixation is secured. Bone grafting is typically not necessary.

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Fig. 48.2 Opening wedge osteotomy for deangulation and length restoration of apex dorsal metacarpal malunion with foreshortening. After the osteotomy is completed, the volar cortices are distracted, to restore metacarpal length and correction angulation. Bone graft (red) is packed into defect to fill the defect created.

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Replace plate proximally using predrilled holes and reduce distal fragment. Secure provisional fixation with K-wires or partial screw fixation. Verify clinical and radiographic alignment of the osteotomy site. Once satisfied with the position of the osteotomy site, the use of locking screws for distal fixation will help minimize undesired distraction and secondary deformity. If an opening wedge technique is used, cancellous bone graft can be packed into the osteosynthesis site following fixation.

Fig. 48.3 Metacarpal osteotomy for derotation with use of correction plate. The horizontal oblong hole allows for simplified, rapid correction of rotational deformity. The plate is placed, partial fixation is secured proximal to the osteotomy site, and eccentric placement of the screw in the oblong derotation hole allows for controlled motion of the screw along the hole, derotating the distal fragment.

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48.10.3 Derotation Osteotomy Metacarpal osteotomy with use of correction plate: ● Place the correction plate at the planned site of osteotomy. The oblong horizontal derotation hole is usually placed distal to the osteotomy site (▶ Fig. 48.3). ● Predrill proximal holes, and select appropriate screws. ● Eccentrically drill the oblong derotation hole, with care to ensure that screw motion along the hole will yield desired direction of rotational correction. ● Remove the plate, and complete the transverse osteotomy with cooled oscillating saw. ● Replace the plate and initial screws, leaving the derotation screw slightly loose to facilitate sliding. ● Derotate the mobile distal fragment to yield desired degree of correction. ● Achieve provisional fixation, verify satisfactory clinical and radiographic alignment, and place final fixation to secure the osteotomy. Metacarpal base osteotomy for rotation of metacarpal or proximal phalanx2:

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●

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Plan osteotomy site at the flare of metacarpal base (▶ Fig. 48.4). Use of periarticular T- or Y -shaped plates is ideal to maximize proximal fixation with limited bone length, and ensure minimum of four cortices of fixation. Predrill proximal holes and select screws for fixation proximal to osteotomy site. Place a vertical K-wire distal to the planned osteotomy site to serve as a joystick to control rotation. Chilled saline cooling of sagittal saw blade during operation to avoid thermal injury to bone. Place a K-wire as joystick to derotate the distal metacarpal, and provisionally secure fixation with a transverse K-wire to adjacent metacarpals. Verify satisfactory radiographic alignment of the osteotomy site, clinical correction of scissoring. Replace plate proximally using predrilled holes. Remove provisional K-wire and secure distal fixation, with eccentric screw placement to facilitate compression at osteotomy site.

Metacarpal step-cut osteotomy for rotation > 20 degrees3: Careful preoperative planning is mandatory—as this is a powerful, but technically demanding operation. ● Two hemitransverse osteotomies are planned 2 to 3 cm apart on the radial and ulnar aspect of metacarpal (▶ Fig. 48.5). ● Only the distal fragment will rotate, so the correct directionality of the step-cut is paramount. ●

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References

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Fig. 48.4 Metacarpal base osteotomy for derotation of metacarpal and phalangeal malunion. Following plate placement and predrilling of proximal holes, osteotomy (red) is completed, and K-wire is used as a joystick to derotate the distal fragment for final rigid fixation.

Fig. 48.5 Step-cut metacarpal osteotomy for derotation of malunion. Hemitransverse osteotomies are made 2.5 cm apart, with care to orient the distal cut toward the deformity. Dorsal cortical strip (green) is then excised, distal fragment is derotated, and lag screw fixation is secured.

The distal osteotomy should be planned on the same side as the deformity (e.g., if the long finger is rotated radially, overlapping the index finger during flexion, the distal osteotomy should be on the radial side of the long metacarpal). A strip of dorsal cortex is then excised with parallel saw cuts to achieve the desired degree of correction. Typically, 2 mm of dorsal excision yields 20 degrees of derotation. The volar cortex is scored with the saw, and dorsal cortices are then reduced with point-to point clamp, completing volar cortex release while maintaining the integrity of the volar periosteum. Provisional fixation is secured, and clinical rotation of digits is verified. Three or more interfragmentary lag screws (typically 1.7–2.0 mm) are used for definitive fixation.

fixation is less than ideal, then protected range of motion with hand therapist guidance may be beneficial. It is important to initiate early motion to minimize extensor adhesions and joint stiffness that can cause secondary dysfunction. The patient is followed until clinical correction of deformity and radiographic union have occurred.

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48.11 Pitfalls ● ● ● ●

Inadequate correction Poor fixation preventing early range of motion Nonunion/malunion Stiffness

References 48.10.4 Postoperative Care ●

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The operative hand is splinted for comfort and elevated for the first 48 hours. Beginning at day 2, active range of motion of metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints is encouraged when rigid fixation has been achieved. If

[1] Saito T, Chung KC, Haase SC. Corrective osteotomy of metacarpal fracture malunion. In: Chung KC, ed. Operative Techniques Hand and Wrist Surgery. Philadelphia, PA: Elsevier; 2018 [2] Bindra RR, Burke FD. Metacarpal osteotomy for correction of acquired phalangeal rotational deformity. J Hand Surg Am. 2009; 34(10):1895–1899 [3] Jawa A, Zucchini M, Lauri G, Jupiter J. Modified step-cut osteotomy for metacarpal and phalangeal rotational deformity. J Hand Surg Am. 2009; 34(2): 335–340

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49 Scaphoid Nonunion: Medial Femoral Condyle Vascularized Bone Graft Megan R. Miles and James P. Higgins Abstract This chapter provides a comprehensive overview of the use of medial femoral condyle flaps in the treatment of scaphoid nonunions. It covers the core essentials for managing patients, including specific indications for its use, special considerations during the preoperative assessment, a detailed description of the surgical technique, postoperative care, and the potential morbidity of the procedure. Keywords: medial femoral condyle flap, scaphoid nonunion, carpal collapse, vascularized bone graft, surgical technique, scaphoid waist nonunion

49.2 Key Principles The ideal donor site would have a long vascular pedicle that is a noncritical vessel, thin cortical bone, reliable anatomy, low morbidity, and a low incidence of chronic pain. The benefits of a MFC donor site include the ability to obtain large osseous segments of sufficient size to address significant bone loss and reshape it to fit the defect, a robust and consistent vascular supply, high-quality cancellous bone, and offers structural support capable of correcting dorsal intercalated segment instability (DISI) or scaphoid foreshortening.2

49.3 Indications 49.1 Description

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Medial femoral condyle (MFC) vascularized grafts have proven successful in the treatment of recalcitrant scaphoid waist nonunions. The MFC graft is a corticocancellous graft utilizing either the longitudinal branch of the descending geniculate artery (DGA) and vein or the superomedial genicular vessels. It is utilized as a structural interposition volar wedge graft allowing restoration of the scaphoid geometry in addition to restoring blood supply in the treatment of avascular necrosis (AVN) of the proximal pole. The use of MFC vascularized bone grafts has shown to have a significantly higher rate of union when compared to the widely used dorsal radius 1,2-intercompartmental supraretinacular artery pedicle graft in the setting of humpback deformity and AVN.1

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Recalcitrant scaphoid waist nonunion (▶ Fig. 49.1a,b) Significant bone loss Presence of humpback deformity (defined as lateral intrascaphoid angle ≥ 45 degrees) Absence of radiocarpal arthritic changes Salvageable proximal pole – Intact cartilage – Proximal fragment is of adequate size for fixation – Without fragmentation or comminution

49.4 Contraindications ●

Radiographic or intraoperative evidence of radioscaphoid arthritis

Fig. 49.1 Scaphoid waist nonunion with carpal collapse. (a) Posteroanterior radiograph. (b) Lateral radiograph.

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Key Procedural Steps ●

Nonviable proximal pole – Loss of cartilage – Small proximal fragment in which adequate screw fixation is unobtainable – Comminution

as it facilitates a two-team approach and allows the use of the contralateral hand for walking assistance or pushoff when rising from a bed or chair postoperatively. Pneumatic tourniquets should be placed on the ipsilateral upper and lower extremity.

49.5 Special Considerations

49.6.2 Volar Wrist Surgical Technique

49.5.1 Avascular Necrosis If avascular necrosis of the proximal pole is present, a vascularized graft should be utilized. A recent meta-analysis demonstrated union rates of only 47% with use of nonvascularized bone graft compared to 87% with use of vascularized bone graft.1 It is debatable if AVN is a requirement for the use of a vascularized bone graft. Studies have shown vascularized bone grafts have superior biological behavior, heal faster, and are stronger compared to conventional bone grafts.3 As such, at our institution, AVN is not considered a pre-requisite for the use of an MFC vascularized bone graft.

An extended volar Russe approach is utilized (▶ Fig. 49.2). The incision should be made in line with the flexor carpi radialis, beginning 8-cm proximal to the wrist crease and ending at the trapezium. Dissect down until exposing the radiocarpal joint at the level of the scaphoid. Make a volar capsulotomy in the scaphotrapezial joint to help obtain better visualization of the scaphoid. If present, remove any hardware from previous surgery. Generously debride fibrous tissue and necrotic bone from the nonunion site to expose healthy cancellous bone surfaces. Use an oscillating saw to flatten any irregular edges. Measure the dimensions of the defect to determine the amount of graft needed to restore scaphoid length.

49.5.2 Preoperative Imaging

49.6.3 Flap Harvest Surgical Technique

When considering a candidate for the use of an MFC vascularized bone graft, computed tomography (CT) scan is routinely used for preoperative planning to assess the degree of scaphoid collapse, bone loss, quality of the proximal pole, and direction and position of the scaphoid fracture plane. The most valuable CT studies are obtained using 1-mm cuts through the long axis of the scaphoid. Magnetic resonance imaging (MRI) is less helpful in defining the anatomy of the scaphoid. Some providers may obtain MRI to assess vascularity of the proximal pole. The presence or absence of AVN of the proximal pole does not affect the decision to use an MFC flap at our institution.

Make a longitudinal incision along the inner aspect of the distal thigh beginning at the adductor hiatus and extending to the MFC (▶ Fig. 49.3).4 Dissect down through the skin, subcutaneous tissue, and fascia of the vastus medialis. Continue the dissection in a subfacial plane down to the distal aspect of the femur. Retract the vastus medialis anteriorly exposing the osseous medial column of the femur. Suture-ligate the muscular arterial branch to the vastus medialis. Elevate the fibrofatty layer of the distal femur that lies immediately on top of the periosteum to better visualize the vasculature supplying the MFC. Dissect down to find the DGA lying parallel and anterior

49.6 Key Procedural Steps 49.6.1 Anesthesia and Positioning The procedure is performed under general anesthesia. The patient is placed in the supine position with the affected arm and ipsilateral leg draped free. The ipsilateral knee is utilized

Fig. 49.2 A closed extended volar Russe approach representing the typical scaphoid exposure.

Fig. 49.3 Approach to the medial femoral condyle (MFC) representing the typical size of an MFC exposure incision.

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Scaphoid Nonunion: Medial Femoral Condyle Vascularized Bone Graft vessels. Reapproximate the volar capsular incision and close the wound in layers.

49.7 Difficulties Encountered

Fig. 49.4 A rectangular area of medial femoral condyle (MFC) bone harvest marked out on a fully exposed DGA pedicle.

to the adductor tendon. The DGA branches from the superficial femoral artery approximately 12-cm proximal to the MFC. Approximately 10 to 15% of the time, no DGA can be identified.2 In this case, the flap is fed by the superomedial genicular artery that originates from the popliteal artery approximately 4-cm proximal to the MFC. Outline a rectangular shape of bone over the apex of the MFC (▶ Fig. 49.4). Select a flap of sufficient size to reconstruct the scaphoid defect, typically 10 to 12 mm in all three dimensions. When ready to harvest, ligate the pedicle vessels proximally at their origin from the superficial femoral vessels and reflect the pedicle distally. This will facilitate the safe and rapid creation of the bone cuts on all four sides of the bone segment, using a sagittal saw. Make an additional 45-degree cut just distal to the flap. This cut will assist in elevating the corticocancellous segment while reducing the risk of fracture and separation of the cortex and periosteum from the cancellous portion of the graft. Close the wound in layers over a subcutaneous closed suction drain.

49.6.4 Graft Fixation Shape the graft to fit the exact dimensions of the scaphoid defect. Insert the graft with the periosteum lying volarly. Fixation is obtained by placing a retrograde-directed cannulated scaphoid screw under fluoroscopic guidance. The screw should be placed within the central third of the longitudinal axis of the scaphoid. Such placement results in a significant decrease in time to union and increase in biomechanical stability.5

49.6.5 Microvascular Anastomosis An operative microscope is used to perform the microvascular anastomosis. An end-to-side approach is performed between the DGA or superomedial genicular artery and radial artery. Alternatively, an end-to-end approach can be used for an anastomotic connection to the palmar branch. The venous repair is performed end-to-end into the vena comitantes or cephalic vein. Use a 9–0 nylon suture for anastomotic repair. Release clamps and tourniquet to visually confirm patency and perfusion of the

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The MFC graft is an interposition graft, with the flap positioned between the native distal and proximal scaphoid poles. Accomplishing secure fixation of all three segments is the most challenging aspect of the procedure. The screw will achieve firm endosteal fixation in the proximal and distal segments, but will only purchase the cancellous portion of the MFC flap. After the screw is placed, the surgeon must assess the stability of the flap segment. If the flap segment fixation is not felt to be adequate, a second screw or additional Kirschner wire may be placed from the MFC flap to the proximal pole. If a second screw is used, this is typically a small caliber (i.e., 2.0 mm). Alternatively, if additional wire is utilized this is left buried beneath the skin to be removed volarly after scaphoid healing is confirmed. In cases where the nonunion proximal pole is considered too small or comminuted to achieve adequate fixation, an osteochondral medial femoral trochlea (MFT) flap is utilized. In this situation the proximal half of the scaphoid is resected and replaced using the convex cartilage-bearing bone flap utilizing the same vascular pedicle. Use of an MFT flap in these cases simplifies the fixation as there are only two bone segments (the MFT and the distal pole) that can easily achieve adequate stability with single screw fixation.6,7

49.8 Complications ●

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Persistent nonunion: if union is not achieved, a salvage operation including scaphoidectomy, four-corner fusion, or proximal row carpectomy can be performed once the patient develops symptomatic arthritis3 Saphenous nerve dysesthesia

49.9 Postoperative Care 49.9.1 Knee ●

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Remove subcutaneous closed suction drain on postoperative day 1 Weightbearing as tolerated, ice, elevate No imaging, splint, or brace needed Some may find use of physical therapy for quadriceps strengthening and ambulation helpful

49.9.2 Wrist ●

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Immediate short arm thumb spica splint with wrist in neutral position; change to short-arm thumb spica cast at 2 weeks postoperatively and changed every 3 weeks for a total of 12 weeks Aspirin 325 mg daily postoperatively for vascular anastomotic thrombosis prophylaxis Obtain radiographs at 3- to 6-week intervals and confirm healing with a CT at 12 weeks postoperatively (▶ Fig. 49.5a,b). Once union is confirmed on CT, hand therapy for 2 to 3 months

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References

Fig. 49.5 Two-year postoperative radiographs of a well-healed scaphoid waist nonunion with correction of a humpback deformity utilizing a retrograde directed cannulated scaphoid screw. (a) Posteroanterior radiograph. (b) Lateral radiograph.

49.10 Donor Site Postoperative Morbidity Three studies have provided insight into the safety and potential morbidity of harvesting large MFC bone segments from the distal femur. Rao et al set to determine the MFC donor site morbidity by performing a CT scan on patients who underwent MFC free flap procedures at a mean of 18 months postoperatively. No occult fracture or arthritic changes were identified; however, minimal reparative bone ingrowth was seen on imaging. The mean size of bone harvested per procedure was 16.1 cm3, significantly larger than the typical size of a scaphoid nonunion flap. These findings may suggest the need for bone graft or bone graft substitute at the donor site.8 Katz et al found that axial stability was maintained when composite femur models were subjected to axial loads twice that of physiologic force following removal of MFC segments as long as 24 cm.9 Endara et al found that a graft harvest of any size in a cadaveric model decreased the torsional torque at which ligamentous failure or iatrogenic fracture occurred. However, torsional stability was maintained at a torsional load exerted during typical activities of daily living.10 These studies suggest the flap harvest is of minimal morbidity,

particularly in cases of very small bone segment harvest, such as scaphoid nonunion reconstruction.

References [1] Jones DB, Jr, Bürger H, Bishop AT, Shin AY. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse: a comparison of two vascularized bone grafts. J Bone Joint Surg Am. 2008; 90(12):2616–2625 [2] Iorio ML, Masden DL, Higgins JP. The limits of medial femoral condyle corticoperiosteal flaps. J Hand Surg Am. 2011; 36(10):1592–1596 [3] Pokorny JJ, Davids H, Moneim MS. Vascularized bone graft for scaphoid nonunion. Tech Hand Up Extrem Surg. 2003; 7(1):32–36 [4] Wong VW, Higgins JP. Medial femoral condyle flap. Plast Reconstr Surg Glob Open. 2016; 4(8):e834 [5] Rhee PC, Jones DB, Jr, Shin AY, Bishop AT. Evaluation and treatment of scaphoid nonunions: a critical analysis review. JBJS Rev. 2014; 2(7):4 [6] Higgins JP, Bürger HK. Proximal scaphoid arthroplasty using the medial femoral trochlea flap. J Wrist Surg. 2013; 2(3):228–233 [7] Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg Am. 2013; 38(4):690–700 [8] Rao SS, Sexton CC, Higgins JP. Medial femoral condyle flap donor-site morbidity: a radiographic assessment. Plast Reconstr Surg. 2013; 131(3):357e–362e [9] Katz RD, Parks BG, Higgins JP. The axial stability of the femur after harvest of the medial femoral condyle corticocancellous flap: a biomechanical study of composite femur models. Microsurgery. 2012; 32(3):213–218 [10] Endara MR, Brown BJ, Shuck J, Bachabi M, Parks BG, Higgins JP. Torsional stability of the femur after harvest of the medial femoral condyle corticocancellous flap. J Reconstr Microsurg. 2015; 31(5):364–368

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50 Scaphoid Nonunion: ORIF and Bone Graft for Humpback Deformity Lee M. Reichel and David Ring Abstract Scaphoid nonunion with humpback deformity can be treated with open reduction and internal fixation (ORIF) using a nonvascularized, structural autogenous bone graft. If surgery gains union and improves wrist kinematics, it may be able to delay or lessen wrist arthritis.

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Keywords: scaphoid fracture nonunion, humpback deformity, nonvascularized structural bone graft, dorsal intercalated segment instability

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50.1 Key Principles Correction of both nonunion and deformity with a nonvascularized graft is considered to potentially delay or lessen wrist arthritis. If arthritic changes are already present, a salvage procedure should be considered.1

50.2 Expectations The goal of surgery is a healed and aligned scaphoid with improved wrist kinematics. The hope is that this will slow or arrest the development of scaphoid nonunion advanced collapse (SNAC) type arthritis. It may also limit daily symptoms. The surgery and immobilization are expected to reduce wrist motion. In addition, patients are exposed to risks such as infection, problems at the site the graft is obtained, errant internal fixation, and persistent nonunion.

50.3 Indications Nondisplaced scaphoid fractures can heal with adequate protection. However, about half of displaced fractures do not unite. Some scaphoid nonunions are fibrous, and there is no increase in deformity because they are not mobile.1 There is not a reliable and valid method to distinguish stable fibrous unions from unstable nonunions at risk of progressive bone loss and deformity. Mobile nonunions tend to lead to humpback (apex dorsal) deformity of the scaphoid and dorsal intercalated segment instability (dorsal tilt of the lunate seen on a lateral radiograph of the wrist.2 There is a gradual bone loss of the volar aspects of the fracture surfaces. Scaphoid nonunions with deformity are associated with abnormal wrist kinematics that may be associated with symptoms, as well as progressive radiocarpal and midcarpal arthrosis (often referred to as scaphoid nonunion advanced collapse; SNAC).3 Surgery intends to achieve more normal wrist kinematics and to slow or arrest the development of SNAC.

50.4 Contraindications ●

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Other than active infection, there are no absolute contraindications to corticocancellous bone grafting for scaphoid nonunion with advanced collapse.

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Osteonecrosis of the proximal pole may be a relative contraindication, but there is no reliable method of diagnosing osteonecrosis. Additionally, patients with magnetic resonance imaging (MRI) changes consistent with osteonecrosis do not have a higher risk of nonunion with avascular corticocancellous grafting compared to patients without avascular changes.4 It has been proposed that prior failed surgery for nonunion merits a different type of surgery such as a vascularized graft. However, if there are clear technical deficiencies in the prior surgeries, another corticocancellous graft is recommended. Prior failed screw fixation may cause loss of bone from loose implants, but Kirschner wires can often gain fixation of the scaphoid and the bone graft.5 Some surgeons state that a delay of more than 5 years between the initial fracture and treatment of the nonunion has a poor prognosis. However, the exact time of the initial injury is often unknown, and operative repair should still be considered in such cases.6 In the presence of any radioscaphoid arthritis, it is better to treat the SNAC nonoperatively or with a salvage procedure, because restoring kinematics will probably not slow and cannot reverse the arthritis.

50.5 Special Considerations The role of attempts to diagnose osteonecrosis of the proximal pole using MRI before operative treatment is debatable (see discussion above). Computed tomography (CT) of the planes defined by the long axis of the scaphoid can help quantify scaphoid malalignment, fragment positioning, bone loss, as well as incipient arthritis, which usually starts in the distal radioscaphoid joint. Prior surgery can lead to holes in the bone from prior screws, particularly if they are loose. These may make it difficult to use a screw again, and one might need to use Kirschner wires, which were successfully used in the original technique.

50.6 Special Instructions, Positioning, and Anesthesia ● ● ●

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Supine, with the involved arm on a hand table Tourniquet on the upper arm General anesthesia if the bone graft will be taken from the iliac crease Regional anesthesia with a brachial plexus block if the graft is taken from the radius The scaphoid is approached volarly (▶ Fig. 50.1), and the flexor carpi radialis tendon is retracted and a volar capsulotomy performed (▶ Fig. 50.2)

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Tips, Pearls, and Lessons Learned

50.7 Tips, Pearls, and Lessons Learned 50.7.1 Reduction of the Lunate Prior to Scaphoid Correction Before correcting the scaphoid deformity, one should reduce the lunate. This positions the proximal part of the scaphoid via its connection to the scapholunate ligament. Reduction is achieved via wrist hyperflexion. This can be temporarily fixed in position with a dorsal wire connecting the radius to the lunate. Some surgeons consider leaving this wire in place for 4 to 6 weeks for long-standing dorsal angulation of the lunate. Fig. 50.1 A palmar-radial (Henry or flexor carpi radialis) exposure is used. The skin incision crosses the transverse wrist creases obliquely to limit scar contracture. The palmar capsule is opened on line with the thick radioscaphocapitate ligament. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management. 1st ed. © 2018 Thieme.)

50.7.2 Graft Procurement and Placement The bone graft is commonly harvested from the iliac crest, but can also be obtained from the distal radius (▶ Fig. 50.3). The volar lip of the bony floor of the first dorsal compartment

Fig. 50.2 Palmar approach in scaphoid surgery. (a) The anatomic landmarks for the incision are the scaphoid tuberosity and the tendon of the flexor carpi radialis. (b) The tendon sheath and fibrous joint capsule are divided. (c) The radioscaphocapitate ligament is notched or divided. (d) Exposing of scaphoid: The tendon of the flexor carpi radialis muscle is retracted ulnarly in surgery in the middle and distal thirds of the bone, and radially in surgery on the proximal pole. (1) Scaphoid tuberosity. (2) Tendon of the flexor carpi radialis. (3) Radioscaphocapitate ligament. (4) Capitate. (5) Radioscaphoid ligament. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition © 2000 Thieme.)

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Scaphoid Nonunion: ORIF and Bone Graft for Humpback Deformity

Fig. 50.3 Russe bone graft: harvesting the chips and cancellous graft from the iliac crest. (1) Anterior superior iliac spine. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

makes a good graft in terms of size and structure (mix of cortical and cancellous bone).7 It is often recommended to plan and shape the graft according to preoperative imaging (radiographs —including radiographs of the other side—and CT). We use two principles for sizing the graft: (1) size based on the fully debrided nonunion; and (2) err toward a larger graft, since wedging in the graft adds inherent stability and it is unlikely that the scaphoid would be excessively lengthened. The graft is inserted with the cortical part of the graft oriented toward the palmar surface and then secured to the scaphoid with a screw or Kirschner wires (▶ Fig. 50.4). If there is any defect or mismatch, one can pack cancellous graft in before placing the corticocancellous graft. There is an inclination to contour the edges of the graft to match the cortical edges of the proximal and distal scaphoid for aesthetic reasons. However, having the graft sit underneath the cortices of proximal and distal fragments can help wedge the graft in place and increase stability. Bone-to-bone contact, stability (in part via compression), and rigid internal fixation are the primary goals. We think that more attention should be paid to surgical tactics that are important for union than to alignment.

50.7.3 Immobilization after Surgery The need for postoperative immobilization depends upon preoperative degree of instability, associated carpal malalignment,

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Fig. 50.4 A corticocancellous graft is placed in the nonunion defect with the cortex facing volar. Additional cancellous graft is placed in the gap as well. The scaphoid and graft are stabilized with a graft. (Modified with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

and the strength of internal fixation. Most surgeons prefer to immobilize patients for at least 4 to 6 weeks to protect the sometimes tenuous fixation of the scaphoid and the graft (▶ Fig. 50.5).

50.8 Difficulties Encountered Some authors recommend releasing the tourniquet to look for punctate bleeding of the proximal pole after debridement of the fracture surface to assess for presence and/or degree of osteonecrosis. It’s not clear that one can distinguish bleeding from fracture surfaces deep in the wrist from blood coming from other sources. Moreover, it is possible that an avascular proximal pole will heal just as well with a nonvascular graft. This is still an area of debate. It can be challenging to keep the graft from extruding volar or radial. A few tips for limiting this: be generous in the resection of fracture surfaces, particularly on the less worn (dorsal) fracture surfaces, and put in a large, even oversized graft. A Kirschner wire placed through the volar part of the distal and proximal scaphoid and over (external to) the graft can be used temporarily intraoperatively, or even for a few weeks to limit extrusion. It may be difficult to get good fixation of the graft with a screw. It is reasonable to use Kirschner wires as with the original technique.

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Bailout, Rescue, and Salvage Procedures

Fig. 50.5 (a,b) Presence of carpal collapse from long-standing scaphoid nonunion with an increased scapholunate angle. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management. 1st ed. © 2018 Thieme.)

50.9 Key Procedural Steps (▶ Fig. 50.6) ● ● ●

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●

●

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Exposure through the FCR sheath. Zigzag across the volar flexion creases. Mobilize or cauterize the superficial radial artery, or prepare it for implantation into the fracture site (Hori). Cut the radiocarpal wrist capsule over the fracture. Try to preserve capsule over the proximal pole where access is less critical. Preserving the radiolunate ligaments will prevent ulnar translation of the carpus. Plan to try to repair the capsule. Identify the fracture site, mark it with a needle, and confirm under the image intensifier. You do not want to start resecting and then discover you were in the scaphotrapezial joint. Resect the fracture surfaces sharply with an osteotomy or a burr. Drill the sclerotic fracture surfaces to encourage bleeding and healing. Use 0.062-inch Kirschner wires as joy sticks to help realign the proximal and distal fragments. Measure the defect you have created. If you have made a preoperative plan, compare your measurements as a way to double check. Obtain and shape the graft. After debriding the nonunion, measure the defect size. Sometimes a small lamina spreader can be used to distract the fracture to help size the defect. If working space is small using a small bent Kirschner wire and clamping at the defect size to bring to a ruler can be helpful if the ruler doesn’t fit in wound. If taking the graft from the iliac crest adds approximately 5 mm to the size of the graft, allow for contouring. Also, some cancellous graft can be taken from the graft to pack in the proximal and distal poles prior to inserting the corticocancellous graft. Oversize the contouring.

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Holding the graft with a Kocher clamp and using a small sagittal saw to contour. The shape is usually a wedge. Using broad blunt tip instruments can help to shove the oversized graft into place without breaking it when you push against the cortical side. Getting the cortex of the graft underneath the cortices of the proximal and distal pole can greatly improve stability, the tendency for the graft to extrude volarly in particular. Insert the graft and check for size, fit, and alignment. Fix it provisionally with a Kirschner wire. Place a cannulated screw. An additional small derotational wire may help stabilize the construct during insertion (▶ Fig. 50.7). Confirm screw and wire placement in the wound and on the image intensifier. Close the capsule. Suture the wound. Apply a splint.

50.10 Bailout, Rescue, and Salvage Procedures If the graft is broken or misshapen, a second graft can be obtained from another aspect of the radius or the iliac crest. If the patient is not aware of this possibility, there is no harm in staging the procedure so you can have that discussion with them. If you are not sure about the degree of arthritis, discuss the option of excision of the distal pole of the scaphoid with the patient, in case more distal radioscaphoid arthritis is encountered than expected.

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Scaphoid Nonunion: ORIF and Bone Graft for Humpback Deformity

Fig. 50.6 (a) The nonunion is debrided to bleeding cancellous surfaces and the distal pole of the scaphoid extended to correct the scaphoid deformity. Intraoperative radiographs are used to monitor the position of the lunate. (b) A corticocancellous bone graft from the iliac crest or distal radius is placed in the defect to help with stability and healing. (c) A headless screw is inserted from the distal pole across the positioned bone graft and into the center of the proximal pole. (d) The opening in the palmar radiocarpal ligaments is repaired with nonabsorbable suture. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management. 1st ed. © 2018 Thieme.)

Fig. 50.7 (a,b) A thumb-spica below-elbow cast is recommended for 3 to 6 weeks followed by active motion. Resisted activities started when union was radiographically visible. Follow-up at one year. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management. 1st ed. © 2018 Thieme.)

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References

References [1] Pao VS, Chang J. Scaphoid nonunion: diagnosis and treatment. Plast Reconstr Surg. 2003; 112(6):1666–1676; quiz 1677; discussion 1678–1669 [2] Oka K, Moritomo H, Murase T, Goto A, Sugamoto K, Yoshikawa H. Patterns of carpal deformity in scaphoid nonunion: a 3-dimensional and quantitative analysis. J Hand Surg Am. 2005; 30(6):1136–1144 [3] Berdia S, Wolfe SW. Effects of scaphoid fractures on the biomechanics of the wrist. Hand Clin. 2001; 17(4):533–540, vii–viii [4] Singh AK, Davis TR, Dawson JS, Oni JA, Downing ND. Gadolinium enhanced MR assessment of proximal fragment vascularity in nonunions after scaphoid

fracture: does it predict the outcome of reconstructive surgery? J Hand Surg [Br]. 2004; 29(5):444–448 [5] Merrell GA, Wolfe SW, Slade JF, III. Treatment of scaphoid nonunions: quantitative meta-analysis of the literature. J Hand Surg Am. 2002; 27(4): 685–691 [6] Tambe AD, Cutler L, Stilwell J, Murali SR, Trail IA, Stanley JK. Scaphoid nonunion: the role of vascularized grafting in recalcitrant non-unions of the scaphoid. J Hand Surg [Br]. 2006; 31(2):185–190 [7] Aguilella L, Garcia-Elias M. The anterolateral corner of the radial metaphysis as a source of bone graft for the treatment of scaphoid nonunion. J Hand Surg Am. 2012; 37(6):1258–1262

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51 Capitate Shortening Osteotomy Matthew B. Cantlon Abstract Capitate shortening osteotomy is a procedure used to mechanically unload the lunate in patients with early stage Kienbock disease. This procedure has traditionally been utilized for patients with neutral or positive ulnar variance where radial shortening osteotomy is contraindicated. The goal of the procedure is to decrease the load on the lunate, allowing revascularization and preventing articular collapse. Capitate shortening osteotomy is a technically straightforward procedure that entails excising a 2-mm wafer of bone from the capitate waist. Reported outcomes are in-line with other unloading procedures for early stage Kienbock disease. Keywords: capitate shortening osteotomy, Kienbock disease, lunate unloading

51.1 Introduction Capitate shortening osteotomy was introduced by Almquist1 in 1986 as a procedure to mechanically unload the lunate in early stage Kienbock disease. It was originally described as a treatment option for those patients with ulnar neutral or positive variance when joint leveling procedures, such as radial shortening osteotomy or ulnar lengthening, are contraindicated. However, capitate shortening osteotomy can be utilized independent of the length relationship between the radius and the ulna and does not affect the kinematics of the distal radioulnar joint. The goals of capitate shortening osteotomy are decreasing the mechanical load on the lunate, promoting revascularization, and halting the progression of disease. Various adjunct procedures have been described with capitate shortening osteotomy including capitohamate arthrodesis1 and vascularized bone grafting of the lunate.2

51.2 Indications Capitate shortening osteotomy can be used as a lunate unloading procedure in Kienbock disease in patients that have failed conservative treatment as well as primary treatment in Lichtman stages II (X-ray positive but without articular surface collapse) and IIIa (articular surface collapse but without carpal collapse). Traditionally, it has been used in ulnar neutral and ulnar positive variance, when joint leveling procedures are contraindicated; however, it can be utilized regardless of variance.

51.3 Contraindications ● ●

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Lunate fragmentation Advanced arthritic changes of the radiolunate articular surface Advanced arthritic changes of the midcarpal articular surfaces

51.4 Operative Technique A dorsal longitudinal incision is utilized in-line with the middle finger ray, beginning at the base of the middle finger metacarpal and extending proximally to the radiocarpal articulation. The distal aspect of the extensor retinaculum may need to be incised to allow for appropriate retraction of the fourth extensor compartment. A posterior interosseous neurectomy may be performed at this time as a wrist capsule denervation procedure. A longitudinal dorsal capsulotomy is performed exposing the capitate and lunate. Direct observation of the lunate is undertaken with specific attention toward any fragmentation. Gentle traction is applied along the middle finger and the proximal and distal lunate articular surfaces are inspected. The surgery proceeds if no contraindications are met. Parallel cuts are then created at the capitate waist with a fine oscillating saw so as to remove a 2-mm wafer of bone. The kerf of the blade should be taken into account when planning the cuts in order to remove the appropriate thickness of bone. The cut surfaces are manually compressed using a blunt instrument inserted into the capitolunate articulation. Fixation of the osteotomy can occur using various methods including K-wires, headless compression screw, or staple. It is the author’s preference to use a headless compression screw placed antegrade (▶ Fig. 51.1). Wrist flexion aids in presenting the capitate head for placement of the screw, taking care not to distract the osteotomy site with the maneuver. The wound is closed in layers and a short-arm splint is applied which is maintained until the first postoperative visit. At that time, a short-arm cast is applied and is continued until union is confirmed on radiographs, typically in 6 to 8 weeks. Gentle range-of-motion exercises are initiated at that time; however, the wrist remains protected by a removable splint until there is evidence of revascularization of the lunate.

51.5 Operative Technique Alternatives Almquist’s original description of capitate shortening osteotomy included a simultaneous capitohamate arthrodesis. Subsequent clinical and biomechanical studies have shown no significant advantage over capitate shortening osteotomy performed in isolation.3,4 Due to concern for distal carpal row collapse and subsequent scaphoid flexion after capitate shortening osteotomy, partial capitate shortening has been described in an attempt to preserve midcarpal kinematics.5 A “reverse L” osteotomy is performed of the lunate facet of the capitate leaving the scaphocapitate articulation intact. Early clinical and biomechanical data has demonstrated decreased radiolunate pressures and similar outcomes to capitate shortening osteotomy.5,6

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References

Fig. 51.1 (a) Postoperative anteroposterior (AP) and (b) lateral radiographs of a capitate shortening osteotomy fixed with headless compression screw in a wrist with Lichtman stage 3A Kienbock disease and neutral ulnar variance.

51.6 Outcomes Biomechanical evaluation of isolated capitate shortening osteotomy has shown load reduction on the lunate of 49% under a 9.8-N load and 56% under a 19.6-N load.3 ● In small clinical series, preoperative pain was completely relieved in 64%,4 mobility was not significantly improved over preoperative levels,2,4 and grip strength improved to approximately 75% of the unaffected side.2,4 ● Some series show no progression of Kienbock disease at final follow-up,2 while one showed an 18% re-operation rate due to progression of disease.4

51.7 Complications ● ●

Nonunion of the capitate osteotomy Avascular necrosis of the proximal pole of the capitate

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Abnormal midcarpal mechanics Progression of Kienbock disease

References [1] Almquist EE. Kienbock’s disease. Clin Orthop Relat Res. 1986(202):68–78 [2] Waitayawinyu T, Chin SH, Luria S, Trumble TE. Capitate shortening osteotomy with vascularized bone grafting for the treatment of Kienböck’s disease in the ulnar positive wrist. J Hand Surg Am. 2008; 33(8):1267–1273 [3] Werner FW, Palmer AK. Biomechanical evaluation of operative procedures to treat Kienböck’s disease. Hand Clin. 1993; 9(3):431–443 [4] Gay AM, Parratte S, Glard Y, Mutaftschiev N, Legre R. Isolated capitate shortening osteotomy for the early stage of Kienböck disease with neutral ulnar variance. Plast Reconstr Surg. 2009; 124(2):560–566 [5] Citlak A, Akgun U, Bulut T, Tahta M, Dirim Mete B, Sener M. Partial capitate shortening for Kienböck’s disease. J Hand Surg Eur Vol. 2015; 40(9):957–960 [6] Kataoka T, Moritomo H, Omokawa S, Iida A, Wada T, Aoki M. Decompression effect of partial capitate shortening for Kienbock’s disease: a biomechanical study. Hand Surg. 2012; 17(3):299–305

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52 Distal Radius Osteotomy for Malunion (Volar Approach) Kevin D. Han and Peter S. Kim Abstract Malunion of distal radius fracture is a common but clinically important entity. Distal radius osteotomy can help restore the anatomic parameters of the distal radius. Preoperative planning and templating are critical to reduce operative time and intraoperative complications. Patients should have near-normal digital function prior to considering corrective osteotomy. Patients with significant posttraumatic arthrosis are better candidates for salvage procedures. The distal radioulnar joint (DRUJ) should be reevaluated after the corrective osteotomy to ensure adequate stability and congruence. Proper patient selection is the most important factor leading to meaningful improvement. Radiographic parameters alone do not warrant operative intervention. Keywords: malunion, malalignment, distal radius fracture, osteotomy, corrective osteotomy, volar approach

52.1 Overview Malunion of the distal radius is a common sequelae following distal radius fracture. Not all nonanatomically aligned fractures of distal radius fracture result in poor outcomes but patients with a malunion often experience wrist pain, limited wrist motion, strength, and deformity.

52.2 Basic Anatomy The osseous anatomy of the distal radius is commonly understood. The average radiographic values radial volar tilt of 11° to 12°, a radial inclination of 23°, and a radial length of 11 to 12 mm are only useful as a guide though significant variability exists among patients (▶ Fig. 52.1). Bony anatomy is best evaluated by comparison with the uninjured contralateral wrist.

Fig. 52.1 (a, b) Normal radiographic parameters of the distal radius.

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52.3 Key Principles Healed distal radius fracture with incorrect alignment alter the force transmitted across the radiocarpal, distal radioulnar joint (DRUJ), and midcarpal joints. A shortening of radius or a relative increase in ulnar positive variance can cause ulnocarpal impaction and pain. A disruption of DRUJ kinematics occurs with shortened radius and a loss of volar tilt causing loss in forearm rotation. A change in radial inclination is not benign and can create a loss of ulnar deviation and grip strength. Finally, cosmetic deformities from malaligned wrist may create significant distress and disabilities to patients.

52.4 Indications and Contraindications The goal of corrective osteotomy is restoration of preinjury anatomy in several planes. Radial height, volar tilt, and finally radial inclination should be re-established. Radiographic parameters for healed distal radius fractures are only one factor in patient selection for osteotomy. The patient’s physiologic age, functional demands, overall health, limitations, and severity of pain are equally important factors in the decision-making process.

52.4.1 Indications Common indications for corrective osteotomy include an active patient with a symptomatic malunion demonstrating ≥ 15° dorsal tilt, and/or 5 mm of radial shortening, DRUJ incongruity, radiocarpal step-off > 2 mm, dynamic midcarpal instability, or ulnocarpal abutment. Operative correction must be tailored to the specific site of deformity and take into account all potential sites of malalignment.

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52.4.2 Contraindications

52.6.3 Physical Examination

Relative contraindications to reconstruction include patients who have poor general health, uncontrolled complex regional pain syndrome, fixed carpal malalignment, and asymptomatic radiographic malunion in low demand patients, or advanced posttraumatic arthrosis.

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52.4.3 Timing

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Both early interventions for nascent malunions or late treatment for mature malunions are acceptable. We find that operative intervention on nascent malunions is technically easier to perform in the setting of early callus with less soft tissue and DRUJ contractures. It is our preference to proceed with early reconstruction (2 months) once the patient has met the appropriate surgical indications, and a full disclosure of risks and benefits has been discussed. In older, low-demand patients, delay of corrective osteotomy (10 months) may be justified in anticipation of possible acceptable functional results without surgical intervention.

52.5 Anesthesia We prefer regional anesthesia for our distal radius malunion surgeries. It increases operating room efficiency as nerve blocks (infraclavicular or axillary blocks) are done prior entering the operating room. It is useful for postoperative pain control, as patients require less narcotic medication, and also experience less postoperative nausea and vomiting. Regional blocks are typically performed in conjunction with monitored anesthesia control, per the discretion of the anesthesiologist.

52.6 Caveats, Pearls, and Lessons Learned 52.6.1 Preoperative Assessment Patients with a malunited distal radius fracture may seek medical attention for a gamut of complaints including wrist pain, weakness, limited wrist/forearm motion, deformity, instability, and/or numbness of the hand. This can be challenging even for the most experienced surgeons. A systematic and thorough clinical evaluation is of paramount importance in determining the etiology of symptoms.

52.6.2 History ●

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Time and mechanism of injury as well as the treatment rendered. Location of the pain, specifically isolating it to the radiocarpal, ulnocarpal, midcarpal, or DRUJs (ask patient to point with one finger). The history should also detail the quality, duration, and severity of symptoms in addition to any ameliorating or exacerbating factors. A patient’s comorbidities, activity level, functional demands, and pre-existing upper extremity injuries are vital to completing the clinical health assessment.

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Begin at the level of the skin with documentation of previous surgical incisions, neurological status, and the presence of possible complex regional pain syndrome. Finger sensibility is objectively measured and recorded. We prefer monofilament measurement and two-point discrimination. The patient’s finger/wrist/forearm motion, and grip strength should be recorded and compared to the uninjured contralateral extremity. Dorsally angulated distal radius malunions commonly have limited wrist flexion, while volar angulated malunions present with loss of wrist extension. Provocative elicitation of pain on palpation can help define the pathology contributing to the patient’s symptoms. Stress examination can elucidate concomitant soft tissue pathology in the intercarpal, radiocarpal, midcarpal, or distal radial ulnar joints.

52.6.4 Imaging Standard posteroanterior, lateral, and oblique radiographs of both wrists are typically adequate for evaluation of a distal radius malunion. Comparison images to the uninjured wrist allow for direct measurements of relative change in the key radiographic parameters. This is time when we personally communicate with the radiology technician that 90° to 90° posteroanterior with the forearm in neutral position and lateral radiographs must be obtained in the exact same fashion for both wrists. Computed tomography with threedimensional reconstructions has provided added understanding of malunion morphology. We recommend advanced imaging only for complex deformities in more than one dimension.

52.6.5 Volar Approach The advent of volar fixed-angle plating technology has expanded the surgeon’s ability to correct distal radius malunions from a volar approach. The volar fixed-angle plate construct is rigid enough to permit the use of nonstructural cancellous bone graft and substitute and allow for early motion. Reconstruction of both volarly and dorsally displaced malunions has been successfully treated using a volar-based approach. The use of the volar fixed-angle plate can itself aid in facilitating reduction by initially securing the plate distally and then levering it proximally to obtain adequate correction in the sagittal plane.

52.6.6 Key Operative Steps Instrumentation ● ● ● ● ● ● ●

Standard hand tray with bone holding instruments An oscillating saw Osteotomes Image intensifier Laminar spreaders Multiple sized Kirschner wires A volar fixed-angle plate

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Extra-Articular Malunions The patient is positioned supine on a standard radiolucent hand table. A nonsterile tourniquet is applied to the arm. Preoperative templating against the contralateral uninjured wrist serves to permit accurate calculation of the necessary correction in all planes. The distal radius is exposed through a standard but often longer volar approach, exploiting the interval between the radial artery and the flexor carpi radialis tendon. The pronator quadratus is elevated from its radial border with care taken to preserve the volar radiocarpal ligaments. A subperiosteal brachioradialis release is almost always performed to reduce the deforming force and allow for adequate lengthening and rotation. Kirschner wires are used as reference guides inserted from volar to dorsal cortex, parallel to the articular surface, in the metaphysis at the proposed level of the osteotomy. A volar fixed-angle plate is then provisionally fixed to the distal radius by predrilling and filling the distal locking screws, which in turn allows the distal end of the plate to be firmly affixed to the bone. This distal screw is then loosened and the plate is rotated 180° away from the exposed radius. Based on the positioning of the plate and the sigmoid notch, the osteotomy is performed parallel to the joint surface using an oscillating saw. Laminar spreaders are then used to distract the osteotomy site and allow

for release of the dorsal periosteum and adhesions under direct visualization. This maneuver is critical in mobilizing the distal fragment and overcoming the dorsal sagittal soft tissue forces. The fixed-angle plate is then realigned with the distal radius and secured to the distal fragment by tightening the previously placed screw. With the proximal portion of the plate lifted off the cortex, the angle between the plate and proximal radial fragment should subtend the correction in the sagittal plane. With the proximal limb of the plate loosely affixed to the radius using a cortical screw in the distal limb of the oval hole, the necessary lengthening is achieved using a laminar spreader. Once adequate length, tilt, and radial inclination are obtained, the proximal screw is tightly secured. Correction of rotation is achieved simultaneously with plate application. Once adequate correction is restored, the remaining proximal screw holes are filled and cancellous bone allograft or autograft can be used to fill the osteotomy defect (▶ Fig. 52.2). A volar opening wedge osteotomy is performed for the less frequently encountered volarly displaced distal radius malunion. The osteotomy is performed in a similar technique as described for the dorsally displaced malunion. However, in this scenario the plate application is performed with the proximal screws inserted first to provide a buttress function and restore both length and excessive volar tilt.

Fig. 52.2 An extra-articular malunion corrected using a volar fixed-angle plate. (a) Preoperative films demonstrate loss of inclination and radial height. (b) Intraoperative imaging demonstrating correction and (c) follow-up radiographs demonstrating incorporation of bone cement and maintenance of correction.

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Intra-Articular Malunion

Bone Graft and Substitute

The precise location of an intra-articular distal radius malunion will largely dictate the surgical approach employed for corrective osteotomy. The dorsal 4 to 5 interval can help gain access to dorsal ulnar and sigmoid notch malunited fragments. The extended carpal tunnel incision will provide better access to the isolated volar ulnar fragment than the standard volar approach. The intra-articular osteotomy is performed using an osteotome to carefully recreate the initial fracture line. Once the appropriate articular correction is obtained and provisionally secured, bone graft may be required to support the previously impacted subchondral bone and definitive fixation with fixed-angle plating or fragment-specific plate is performed.

Historically, the gold standard treatment of distal radius malunions included the use of structural corticocancellous bone graft, but with the advances in technology and technique the necessity of structural bone graft has come into question. For majority of corrective osteotomy, we use a combination of calcium phosphate bone cement and cancellous chips.

52.6.7 Special Considerations Distal Radioulnar Joint (DRUJ)

52.6.8 Difficulties and Complications

If correction of the distal radius malunion does not adequately address DRUJ congruence, stability, or posttraumatic arthrosis, an additional ulnar-sided procedure may be indicated. With the restoration of the DRUJ following a distal radius corrective osteotomy, residual loss of forearm rotation may be the result of a long-standing DRUJ contracture that can be managed with dorsal DRUJ capsulectomy to restore pronation and volar DRUJ capsulectomy to restore supination.

Potential complications associated with corrective distal radius malunion include persistent pain, infection, loss of correction, persistent deformity, symptomatic hardware, nonunion, hardware failure, extensor tendon rupture, flexor tendon rupture with volar plating, Complex regional pain syndrome (CRPS), carpal tunnel syndrome, DRUJ instability, radioulnar synostosis, and potential donor site complications of bone graft harvesting. Edema and stiffness of the hand and wrist are minimized by early mobilization.

Ulnar Shortening Osteotomy It may be tempting to offer an ulnar shortening osteotomy to level the radioulnar joint if malunion primarily involves loss of radial height. We find this more often acts as a “band aid” that is not as effective as addressing the underlying biomechanical problem caused by the malunited radius.

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53 Distal Radius Osteotomy for Malunion: Dorsal Approach Ludovico Lucenti, Claudia de Cristo, and Pedro K. Beredjiklian Abstract Distal radius osteotomy can help restore the anatomic parameters of the distal radius when fractures heal in an incorrect position. Various surgical techniques have been described to perform a corrective osteotomy of a distal radius malunion. We describe herein a dorsal approach to correct bony deformity.

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The most common deformities are: Loss of the normal volar tilt of the articular surface in the sagittal plane Loss of ulnar inclination in the frontal plane Loss of radial length Rotational deformity (rare)1

Keywords: distal radius fracture, corrective osteotomy, malunion, dorsal approach

53.3 Outcomes

53.1 Introduction

Several clinical studies have shown a significant correlation between anatomic reduction and wrist function.8 Corrective osteotomy of a malunion can offer many advantages including reduction in pain, increase in grip strength, increase in range of motion (ROM), and overall functional status.9

Fractures of the distal radius are one of the most common skeletal injuries of the upper extremity. Fracture malunion is a common complication, occurring in approximately 5% of cases of all the distal radius fractures (▶ Fig. 53.1).1 In some cases, malunions can be asymptomatic and do not require treatment. In some cases, however, the bony position can lead to pain, loss of motion, and reduction of the grip strength, leading to poor functional outcomes.2,3,4 Loss of radial length and disruption of the articular surface are radiographic parameters leading to symptomatic malunion.5 In symptomatic cases refractory to conservative treatment, corrective osteotomy of the fracture can often provide pain relief, improved kinematics, and functional outcomes.6 Various techniques including opening or closing wedge osteotomies with or without bone grafting have been described.7

53.4 Special Considerations Especially when multiplanar and intra-articular deformities are present, corrective osteotomies are technically challenging procedures. Preoperative planning with comparison of the bony anatomy with the normal, contralateral side can be helpful (▶ Fig. 53.2). Computerized tomographic (CT) scanning can add useful information in the preoperative stage, especially in fractures with an articular component.10

53.5 Indications and Contraindications

53.2 Key Principles

53.5.1 Indications

Distal radius fracture malunion can be extra-articular, intraarticular, or a combination of both.

Patients with malunion of the distal radius can experience symptoms, such as wrist pain, crepitus in the radiocarpal joint,

Fig. 53.1 (a,b) 45-year-old woman. Malunion of the distal radius after cast application. There was substantial shortening and dorsal angulation of the distal radius. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

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Fig. 53.2 Preoperative planning for an osteotomy to correct a deformity of the distal radius. (a) Right wrist, dorsal aspect. Dorsal impaction of the radial metaphysis. (b) Left wrist, dorsal aspect. Comparison with contralateral side reveals normal anatomy. (c) Right wrist, radial aspect. Dorsal impaction of the radial metaphysis and negative dorsopalmar articular angle of the radius. (d) Left wrist, radial aspect. Comparison with contralateral side reveals normal anatomy. (1) Lister tubercle. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

decreased ROM, lower grip strength, instability of the distal radioulnar joint, cosmetic deformity, and median neuropathy. It is important to understand the needs of the patient before to decide to go through surgery. The indication for performing an osteotomy of a distal radius malunion is a patient symptomatic with pain and functional limitations. Asymptomatic patients with a severe cosmetic deformity that desires correction can also be considered for surgery in very carefully selected patients.11 The most common deformities observed with a distal radius malunion include: ● Reversal of the palmar tilt ● Shortening of the length of the radius ● Radial displacement of the distal fragment (and carpus) ● Loss of the normal radial inclination

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Compensatory midcarpal instability pattern Distal radioulnar joint instability Rotational deformity12,13

From a radiological perspective, there are no fixed parameters to determine the indication for corrective osteotomy.

53.5.2 Contraindications Contraindications for radial osteotomy are: ● Marked degenerative changes of the radiocarpal or distal radioulnar joint ● Medical comorbidities ● Fixed carpal malalignment ● Complex regional pain syndrome14,15

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53.6 Special Instructions, Positioning, and Anesthesia

53.6.2 Anesthesia Consider regional brachial plexus block with tourniquet versus general anesthesia

53.6.1 Patient Positioning ●

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Patient should be positioned supine on the operating table with the operative arm on a hand table (▶ Fig. 53.3). Place tourniquet high on the affected extremity A fluoroscopy machine should be available.

53.7 Preoperative Planning Preoperative planning is essential for intraoperative decision making. Desired angles for correction are determined corresponding to the opposite side (▶ Fig. 53.4). Using templated X-rays to assess length, osteotomy location, and osteotomy or either printing out X-rays and constructing osteotomies on the paper to determine appropriate cut locations, angles, and center of rotation can be very helpful (▶ Fig. 53.5). CT-derived threedimensional bone models can allow for preoperative planning. Two methods for preoperative planning have been described by Nagy and Fernandez on the basis of plain X-ray (▶ Fig. 53.6). Intra-articular and rotational deformities are difficult to assess on radiographs; the use of three-dimensional imaging and patient-specific guides can help the challenge.16,17

53.8 Operative Details 53.8.1 Preparation—Planning/Special Equipment

Fig. 53.3 Patient preparation and positioning. Pronate forearm on hand table. Nonsterile pneumatic tourniquet. Prophylaptic antibiotics optional. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

Standard equipment: power equipment; wires or pins, oscillating saw and blades, osteotomes. ● Power equipment ● Oscillating saw and blades ● Osteotomes ● Small distractor ● Plate and screw system of choice ● Screws: cortical, cancellous, or locking screws ● Cancellous bone graft

Fig. 53.4 Thirty-five-year-old man. (a,b) Deformity following a dorsal extra-articular fracture. The patient complained of limited forearm rotation and weak grip. (c,d) The normal side X-ray is also used. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

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Fig. 53.5 (a-d) Determining the angle of correction for an osteotomy to correct a deformity of the distal radius. The contours of the affected radius and the mirror image of the contralateral radius from standardized radiographs are traced on acetate sheets. The trading of the affected radius is divided, drawing at the level of the planned osteotomy. The size of the correction required is determined by aligning the contours of two distal radius tradings. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

Fig. 53.6 (a-e) The technique described by Ladislav Nagy will determine the type of defect and bone graft required. Tracing is made of deformity and placed over the normal side X-ray. A line is drawn from the end of the dorsal and also volar cortices with a perpendicular line created midway between the two points. Where the two perpendicular lines intersect will define what type of correction will be required in the sagittal and frontal planes. The orientation of the plane of the true deformity will be the vector determined through trigonometric equation based upon the deformity angle in the sagittal plane. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

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53.8.2 Procedures

53.8.3 Approaches

The surgical procedures consist of: ● Opening wedge osteotomy (▶ Fig. 53.7) ● Closing wedge osteotomy ● Bone grafting if required in opening wedge osteotomies

The two main approaches are: 1. Dorsal approach (▶ Fig. 53.8): for dorsally angulated malunions. 2. Palmar approach (according to Henry or modified Henry approach) (▶ Fig. 53.9): this approach can give more predictable control over rotational malalignment and less soft tissue problems with the implant.

(▶ Fig. 53.7a–c), usually from iliac crest A fixed-angle plate or a standard T-plate (▶ Fig. 53.7d–e) are the most preferred implants, using head locking screws. Cases of severe radial shortening need ulnar side procedures.

The literature shows few differences between the approaches: an extensor tendon irritation can appear after dorsal approach, and a better final wrist flexion is seen after palmar approach; therefore, the palmar approach is preferred.17,18,19

Fig. 53.7 Osteotomy to correct dorsal shortening of the distal radius. (a) An oblique osteotomy is made with an oscillating saw. The plane of the cut is angled distally from dorsal to palmar. The palmar cortex is only partially divided. (b) Radial aspect. The osteotomy gap is spread open until the desired degree of correction is achieved. (c) Correcting the radial angle from a radioulnar approach. A prefabricated corticocancellous wedge is inserted. (d,e) The correction is stabilized with a dorsal plate. One screw engages the wedge graft. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

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Fig. 53.8 (a,b) Dorsal approach. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

Fig. 53.9 Distal limb of Henry incision is versatile. (a) Longitudinal incision. (b) Incision between flexor carpi radialis and radial artery. (c) Exposure of the pronator quadratus. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

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53.8.4 Technique/Key Steps Exposure The dorsal approach can be chosen between the different extensor compartments (I–VI), as dictated by the specific deformity pattern. The most used is the approach through the third extensor compartment. The intermediate and the radial columns may be approached separately using a single dorsal skin incision. The third compartment is opened in line with the EPL tendon in the extensor retinaculum. When opening the tendon sheath, be careful not to cut the tendon. The incision is extended proximally in line with the EPL tendon. Distally, open the extensor retinaculum as far as needed. On the other hand, it is recommended to preserve the distal part, so the tendon still glides toward the thumb. Alternatively, the sheath may be opened distally, and the tendon elevated and retracted radially. The extensor pollicis longus is identified and elevated from the extensor retinaculum with a vessel loop (▶ Fig. 53.10 and ▶ Fig. 53.11). To expose the intermediate column, elevate subperiosteally the fourth compartment, leaving

the compartment itself intact. If an exposure of the distal articular surface is required, incise the capsule in the line of the distal radial articular surface as much as needed to identify and deal with the articular injury. To expose the radial column, one option is a separate retinacular incision between the first and second compartment; the alternative is using the same retinacular incision and advance under the second extensor compartment. If a palmar approach is performed, make the skin incision along the radial border of the flexor carpi radialis tendon. The classical Henry approach goes between brachioradialis and the radial artery, i.e., radial to the radial artery. The modified approach is ulnar to the radial artery.

Osteotomy Mark the site of the planned osteotomy. Place two K-wires or two Schanz screws proximal and distal to the planned site of osteotomy to control the correction. Make the osteotomy with an oscillating saw and osteotomes (▶ Fig. 53.12).

Fig. 53.10 (a,b) A dorsal approach is used. The extensor pollicis longus (EPL) is identified and elevated from the extensor retinaculum. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

Fig. 53.11 (a–c) A dorsal approach with dorsal wrist capsulotomy. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

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Operative Details

Fig. 53.12 (a) After the insertion of two K-wires the osteotomy is performed with the saw. (b) Small laminar spreaders are used to reach the correction. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

Fig. 53.14 The plate is placed to fix the correction. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

Fixation The distal plate, dorsal or volar, is applied to fix the correction (▶ Fig. 53.14). The distal part of the plate is fixed to the distal fragment at its anatomically correct position allowing for additional indirect Fig. 53.13 Realignment is facilitated with a skeletal distractor. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

Reduction Perform the correction with the help of laminar spreader. Apply a distractor to help the realignment (▶ Fig. 53.13) or use K-wires as joysticks. Fix the new position temporarily with a large smooth K-wire, then verify the correction with the fluoroscopy. When needed, perform carefully an elevation of the articular surface with one or two elevators or osteotomes.

reduction. The angle formed by the plate shaft with the radial diaphysis corresponds to the malalignment of the articular surface of the radius.

Harvest If needed, to fill the residual gap, a small amount of cancellous bone graft can be taken from the iliac crest with a trephine biopsy needle through a small incision. The harvest can also be performed as bicortical bone. A trapezoid shape is the ideal (▶ Fig. 53.15). The graft can be fixed with wires, screws, or a plate.

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Fig. 53.15 A trapezoidal bicortical graft from iliac crest is wedged into the defect created by of the osteotomy. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

Closure Close the periosteum and the interosseous muscle fascia over the plate; this provides a smooth gliding surface for the tendons. After a volar approach, every attempt should be made to reattach the pronator quadratus. After a dorsal approach, the second and fourth compartments are sutured back underneath the EPL tendon without any tension. The distal part of the tendon sheath is left intact, so the tendon still lies in its anatomical position. The first and second compartments are not closed. If the brachioradialis tendon has been released, it does not need to be reattached.

Immobilization Up to 4 weeks of casting if osteoporotic bones.

53.8.5 Risks/What to avoid Major risks are: injury of the radial artery and the palmar cutaneous branch of the median nerve during volar approach; the sensory branch of the radial nerve during dorsal approach. Inadequate exposure of the articular surface can lead to poor anatomical realignment. Instability of the distal fragment after the osteotomy can lead to significant difficulties during correction. The subchondral bone can fragment during careless elevation.

Fig. 53.16 Fixed-angle plate with locking head screws. (Reproduced with permission from Jupiter JB, Ring DC. AO Manual of Fracture Management—Hand and Wrist. 1st ed. © 2005 Thieme.)

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53.8.6 Salvage Fragmentation of the articular side can occur. Use LCP locking screws to give stability to the articular components. Severe cases may have a great soft tissue contracture. Perform a release or lengthening of the brachioradialis.

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53.8.7 Tips/Pearls ●

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During a dorsal approach, make an extensile exposure because a small one will not allow the release of brachioradialis. The osteotomy can be performed either at the prior fracture site or at a different site. It is technically easier to perform the

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osteotomy proximal to the original fracture site, as close to the original fracture site as possible. For an easier reduction, make a release of the brachioradialis with a Z-lengthening. This is essential for lengthening greater than 10 mm. Fixed-angle plates with locking head screws give an excellent fixation and stability, avoiding the use of bone grafting (▶ Fig. 53.16). If a plate has been applied with the EPL lying over it, the V-shaped retinacular flap should be drawn underneath the EPL tendon to prevent contact with the plate. Leaving the EPL tendon in a subcutaneous position is also acceptable. Make a longitudinal marker vertically to osteotomy in order to verify the rotation. Severe cases can require two incisions for ulnar resection.

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References

53.9 Considerations An external fixator can be used to stabilize the site of the corrective osteotomy. Pins must be placed in the distal fragment. This allows postoperative adjustment of length or alignment if they are unsatisfactory.17,18,19

53.10 Postoperative Care The postoperative management depends on the type of deformity, on the correction, on the bone quality, and above all the fixation method. A splint can be provided for the first 2 weeks, followed by a brace for 4 weeks. Then, patients can start active and passive ROM recoveries. Clinical and radiographic follow-up should be arranged every 4 weeks until complete bony union and maximal return of function is obtained.

53.11 Complications Main complications are: ● Hematoma ● Nerve injury ● Failure of symptom resolution

References [1] Prommersberger KJ, Froehner SC, Schmitt RR, Lanz UB. Rotational deformity in malunited fractures of the distal radius. J Hand Surg Am. 2004; 29(1): 110–115 [2] Hirahara H, Neale PG, Lin YT, Cooney WP, An KN. Kinematic and torquerelated effects of dorsally angulated distal radius fractures and the distal radial ulnar joint. J Hand Surg Am. 2003; 28(4):614–621 [3] Taleisnik J, Watson HK. Midcarpal instability caused by malunited fractures of the distal radius. J Hand Surg Am. 1984; 9(3):350–357

[4] Jenkins NH, Mintowt-Czyz WJ. Mal-union and dysfunction in Colles’ fracture. J Hand Surg [Br]. 1988; 13(3):291–293 [5] Aro HT, Koivunen T. Minor axial shortening of the radius affects outcome of Colles’ fracture treatment. J Hand Surg Am. 1991; 16(3):392–398 [6] Fernandez DL. Correction of post-traumatic wrist deformity in adults by osteotomy, bone-grafting, and internal fixation. J Bone Joint Surg Am. 1982; 64(8):1164–1178 [7] Bushnell BD, Bynum DK. Malunion of the distal radius. J Am Acad Orthop Surg. 2007; 15(1):27–40 [8] Villar RN, Marsh D, Rushton N, Greatorex RA. Three years after Colles’ fracture: a prospective review. J Bone Joint Surg Br. 1987; 69(4):635–638 [9] Prommersberger KJ, Van Schoonhoven J, Lanz UB. Outcome after corrective osteotomy for malunited fractures of the distal end of the radius. J Hand Surg [Br]. 2002; 27(1):55–60 [10] de Muinck Keizer RJO, Lechner KM, Mulders MAM, Schep NWL, Eygendaal D, Goslings JC. Three-dimensional virtual planning of corrective osteotomies of distal radius malunions: a systematic review and meta-analysis. Strateg Trauma Limb Reconstr. 2017; 12(2):77–89 [11] Buijze GA, Prommersberger KJ, González Del Pino J, Fernandez DL, Jupiter JB. Corrective osteotomy for combined intra- and extra-articular distal radius malunion. J Hand Surg Am. 2012; 37(10):2041–2049 [12] Dunn J, Martin K, Pirela-Cruz MA. Correction of extra-articular distal radius malunions using an anatomic radial plate. Tech Hand Surg. 2013; 17: 162–168 [13] Hollevoet N. Effect of patient age on malunion of operatively treated distal radius fractures. Acta Orthop Belg. 2010; 76(6):743–750 [14] Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am. 2002; 27(2):243–251 [15] Jupiter JB, Ring D. A comparison of early and late reconstruction of malunited fractures of the distal end of the radius. J Bone Joint Surg Am. 1996; 78(5): 739–748 [16] Michielsen M, Van Haver A, Bertrand V, Vanhees M, Verstreken F. Corrective osteotomy of distal radius malunions using three-dimensional computer simulation and patient-specific guides to achieve anatomic reduction. Eur J Orthop Surg Traumatol. 2018; 28(8):1531–1535 [17] Jupiter JB, Ring DC. AO Manual of Fracture Management: Hand and Wrist [18] Rothenfluh E, Schweizer A, Nagy L. Opening wedge osteotomy for distal radius malunion: dorsal or palmar approach? Journal of Wrist Surgery. 2013; 2(1):49 [19] Prommersberger K-J, Pillukat T, Mühldorfer M, van Schoonhoven J. Malunion of the distal radius. Arch Orthop Trauma Surg. 2012; 132(5):693–702

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Part IX Arthritis

54 Distal Interphalangeal Joint Arthrodesis

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55 Thumb Basal Joint Arthroplasty– Trapeziectomy

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56 Ligament Reconstruction Tendon Interposition (LRTI)

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57 Total Wrist Arthrodesis

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58 Proximal Row Carpectomy

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59 Scaphoidectomy and Four-Corner Fusion 304

IX

60 Partial Distal Ulna Resection (Wafer, Hemiresection)

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61 Complete Distal Ulna Excision (Darrach)

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54 Distal Interphalangeal Joint Arthrodesis Ryan D. Katz Abstract This chapter on distal interphalangeal joint (DIPJ) arthrodesis describes the techniques, indications, contraindications, and procedural pearls and pitfalls. Keywords: distal interphalangeal joint arthrodesis, arthrodesis, distal interphalangeal joint arthritis, finger fusion, finger arthritis, DIP fusion, DIP arthritis

54.2 Key Principles ●

●

●

54.1 Description

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The distal interphalangeal joint (DIPJ) is a ginglymus (hinge) joint with an average arc of motion approximating 70 degrees. When diseased either as a result of trauma, rheumatologic conditions, or progressive deterioration of cartilaginous surfaces over time, the joint can become stiff, painful, and deformed. In these instances, eliminating the joint and repositioning the posture of the distal phalanx relative to the middle phalanx can provide pain relief and correction of deformity. This can be accomplished with a formal arthrodesis. There are numerous methods of achieving a successful DIP fusion, all of which involve preparing the proximal and distal bone surfaces by removing remaining cartilage and cortical bone, positioning the fusion site to achieve optimal cancellous bone-to-bone contact, and utilizing a construct (pins, wires, screw, or combination thereof), to achieve skeletal stability.

Various methods of achieving skeletal stability exist. The selection of fixation device should take into consideration the bone stock, size of the medullary canal, and adequacy of the soft tissue envelope. (▶ Table 54.1) Meticulous preparation of the bone is of paramount importance. The bone must be taken back to healthy appearing cancellous bone prior to fixation. The germinal matrix must be protected during the fusion to avoid postoperative nail plate deformity. The fusion is often positioned in neutral extension unless there exists a specific patient request or vocational need to have the digit flexed at this level.

54.3 Expectations DIP fusions are well-tolerated, not technically demanding, have a favorable risk/benefit profile, and predictably provide patients with pain relief and satisfaction. The fusion construct requires a period of postoperative splinting until stability is either suspected clinically or confirmed radiographically. Postoperative imaging is not always necessary if the fusion site is clinically stable and patient free from pain. Postoperative therapy is rarely required unless the patient develops proximal interphalangeal joint stiffness or stiffness of adjacent digits. This fusion has a relatively low nonunion rate.

Table 54.1 Methods of fixation Advantages Headless compression screw

● ● ● ●

Technically easy Rapid Compression Buried

Disadvantages ● ● ● ● ● ●

90 × 90 Wires

● ● ●

Technically easy Cost-effective Buried

● ●

● ●

Wire and Pin

● ● ● ●

●

Kirschner wire(s)

● ● ● ●

Technically easy Cost-effective Buried Avoids the need to pass wires in orthogonal planes Allows compression

●

Technically easy Cost-effective Can be buried or left external Excellent bailout option if other methods fail intraoperatively

●

●

● ●

Cost Availability Distal phalanx size/diameter allowance Soft bone will make it difficult to compress bone without fracture Displacing intramedullary bone volume limits bone surface area contact at fusion site May not provide adequate purchase in digits such as the thumb with a wide middle phalanx medullary canal Potential prominent hardware Soft bone will make it difficult to compress bone without fracture or wire pull through Limited bone stock could make it difficult to pass wires in the coronal plane Wires passed through the sagittal plane could injure germinal matrix Prominent hardware Soft bone will make it difficult to compress bone without fracture or wire pull through

Not rigid No compression One wire alone cannot control rotation

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Fig. 54.1 (a,b) A transversely oriented “H” incision is designed over the DIPJ. Release of all capsular attachments and collateral ligaments allows exposure of the underlying distal interphalangeal joint.

Fig. 54.2 (a,b) The distal aspect of the middle phalanx head and the proximal aspect of the distal phalanx base are prepared by taking down any remaining cartilage and subchondral bone back to bleeding cancellous bone.

54.4 Indications

54.6 Special Considerations

Disruption of a joint’s integrity brings with it the risk of limited motion, painful motion, or both. Deterioration of the distal interphalangeal joint can also be associated with clinical deformity (Heberden’s Nodes, angulation deformities, or mallet posture) and periarticular ganglion cysts (mucous cysts). Ganglion cysts at this level can cause attenuation of the overlying skin, become intermittently infected, and often result in nail plate deformity. For the patients with limited motion and pain, or for those with gross clinical deformity, functional disturbance, or recurrent bothersome ganglion cysts, the physician should consider a motion eliminating treatment (arthrodesis). For most DIPJ derangements, a motion-eliminating treatment is predictable, well-tolerated, and carries a favorable risk-tobenefit profile.

54.6.1 Special Instructions, Positioning, and Anesthesia

54.5 Contraindications Since a successful fusion requires a healthy and adequate bone stock as well as a suitable soft tissue envelope, contraindications to this procedure include active local skin infection, inadequate, scarred or noncompliant skin envelope, active bone infection, or inadequate bone stock. Further contraindications include unrealistic patient expectations (e.g., unwillingness to trade motion loss for pain relief) or a patient’s inability to comply with a postoperative splinting regimen. For the patient with limited motion/deformity but no pain, no treatment is necessary unless the limited motion or deformity places the hand at a functional disadvantage.

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The procedure can be performed with any method of anesthesia preferred (local, MAC, or general). Equipment should include: ● Mini C-arm for intraoperative multiplanar radiographic evaluation. ● Power. ● Method of fixation (K-wires, headless compression screw, or steel wires). The patient is placed supine on a well-padded table with the extremity positioned on a well-padded hand table. A finger tourniquet may be used to facilitate visualization but is not necessary. A dorsal incision is designed over the DIPJ. This is designed either as an “H” or “T,” with the transverse component of the incision situated at level of the condyles of the middle phalanx (▶ Fig. 54.1). The skin is incised and skin flaps are elevated off of the terminal tendon. Care should be taken to avoid injury to the germinal matrix of the nail. The terminal tendon is then incised, reflecting the cut ends proximally and distally. The collateral ligaments are released, sharply allowing for maximal flexion of the DIPJ which fully exposes the articular surface. A rongeur is used to take down the condyles of the middle phalanx, preparing the bone as a “cone” back to healthy appearing cancellous bone (▶ Fig. 54.2). The base of the distal phalanx is then prepared back to healthy-appearing cancellous bone with a curette and rongeur in a “cup” configuration. The distal phalanx “cup” is then placed over the middle phalanx “cone” in the position desired (▶ Fig. 54.3). For nearly all DIP

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Tips, Pearls, and Lessons Learned fusions, unless flexion is needed or a specific vocation or avocation, the author prefers positioning the arthrodesis in neutral extension. The fusion is then completed using any method of skeletal fixation (retrograde headless compression screw, Kwire, and K-wire and steel wire).

54.7 Tips, Pearls, and Lessons Learned ●

●

A “cup and cone” preparation of bone is recommended as it not only preserves bone stock but also allows the surgeon maximum flexibility in positioning the distal part. Positioning of longitudinal wires (guidewire for compression screw or Kirschner wire for definitive fixation) through the central portion of the distal and middle phalanges can be facilitated with an “anterograde–retrograde” technique (▶ Fig. 54.4). In this technique, the surgeon first drives the wire through the base of the prepared distal phalanx “cup”,

Fig. 54.3 The fusion site has been prepared back to healthy-appearing cancellous bone. A “cup” and “cone” configuration was selected to allow optimal bone-to-bone contact.

under direct visualization, in a proximal to distal direction. Once exiting the skin distally, the wire is withdrawn distally until its proximal aspect is just protruding from the distal phalanx base. The slightly protruding wire can then be impaled into the prepared middle phalanx “cone.” This will ensure passage of the wire into the medullary canal of the middle phalanx. The bone is then manually reduced and compressed, and the wire advanced in a distal to proximal direction into the middle phalanx.

54.7.1 Headless Compression Screw This method of fixation utilizes an intramedullary screw to provide rigid stability and compression across the fusion site. A guide wire is passed through the distal phalanx, across the fusion site, and into the middle phalanx. After confirming the adequate positioning of the guide wire, a small stab incision is made in the distal aspect of the digit and the appropriate screw length is measured (▶ Fig. 54.5). The length of the screw should ideally be selected to allow the leading threads to land in the narrow (“isthmus”) portion of the middle phalanx diaphysis. This will ensure excellent screw purchase and minimize rotation that could occur around this construct. ● The diameter of the trailing threads should be selected to allow the screw to fit within the distal phalanx while minimizing disruption or perforation of the dorsal cortex. This, as well as screw length, can be approximated intraoperatively by holding the screw in position next to the finger and using intraoperative fluoroscopy (▶ Fig. 54.6). ● While advancing the screw, the distal phalanx must be held by the surgeon to minimize rotation with each turn of the screw driver (▶ Fig. 54.7). ● Ensure the screw is, at least, flush with the bone distally to avoid hardware prominence (▶ Fig. 54.8). ● For digits with a wide middle phalanx diaphysis such as the thumb, screw purchase may be poor or inadequate. If this is the case, consider a supplemental Kirschner wire, longer period of immobilization, or alternative means of osteosynthesis.

Fig. 54.4 (a-c) Placing a guide wire in an “anterograde” followed by “retrograde” fashion facilitates positioning the wire through the central aspect of the distal phalanx.

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Fig. 54.5 The appropriate length of screw is confirmed using a depth gauge.

Fig. 54.7 The headless compression screw is inserted over the guide wire.

Fig. 54.6 The size and suitability of the screw can be evaluated radiographically prior to insertion.

Fig. 54.8 (a, b) Final radiographs demonstrating appropriate screw placement and length. Good bone-to-bone apposition is visualized.

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Bailout, Rescue, and Salvage Procedures

54.7.2 Kirschner Wires After bone preparation, stability can be achieved with one or two longitudinal Kirschner wires. These can be left buried under the skin or left exposed. Even if buried, pin prominence is often an issue and pin removal should be considered once union has been achieved. This method of fixation is not rigid and does not provide compression across the fusion site. It is, however, technically easy, quick, and cost-effective.

54.7.3 90 × 90 Wires/Wires and Pins If compression is desired and a compression screw is unavailable or not preferred, stainless steel wire can be employed in either a “90 × 90” or “tension band” wire-and-pin construct. ● 24 Gauge wire is preferred as it is less elastic than a smaller gauge wire and therefore does not require “pre-stretching.” It is also less likely to loosen after twisting ● Twisted wire left dorsal can be prominent; care should be taken to tuck the twists toward the nonthumb-contact side of the digit and as close to the bone as possible. ● As the footprint of these constructs is quite small, the wire only or wire-and-pin construct is an excellent “bailout” if other methods of fixation fail intraoperatively. ● Passage of the wire through bone can be facilitated by drilling the bone tunnel with an 18G angiocatheter needle and then placing the wire through the exposed lumen of the needle.

54.7.4 Bone Loss In patients who have experienced trauma, there may be bone loss or poor-quality bone. If a DIP fusion is desired in these patients, consideration should be given to bone graft at the time of fusion. ● If compression is employed, a corticocancellous bone graft from the distal radius will allow compression while resisting deformation. ● If the fusion construct does not employ compression (e.g., Kirschner wires), cancellous autograft is preferred.

54.7.5 Failure of Fixation If failure of fixation occurs intraoperatively, corrective action should be taken. If a screw fails, it can be removed and upsized only if the distal phalanx can accommodate the larger trailing thread diameter. All other methods of fixation can be either redone, used interchangeably, or augmented with another wire or pin as needed.

amount of bone available for fusion is less favorable in revision surgery than primary surgery.

54.8 Difficulties Encountered In advanced arthritis, there is often significant erosive changes and cavitation of the base of the distal phalanx. This makes it difficult to prepare the bone with a rongeur. Bone preparation can be facilitated with a small, sharp curette or a small (3 mm) burr. In such an instance, preservation of the proximal dorsal lip of the distal phalanx base will protect the dorsal cortex and germinal matrix from unintended injury as the bone is prepared. Sometimes, the gentle curve of the middle phalanx precludes passing longitudinal pins without slight flexion of the distal phalanx. If this is not desired, a different construct (90 × 90 wires) should be selected. In the thumb, which usually has a capacious middle phalanx medullary canal, purchase from a headless compression screw is sometimes less than desired. In this circumstance, the screw can either be upsized or removed in exchange for a different method of fixation. Occasionally, the size of the distal phalanx cannot accommodate a headless compression screw. If this is suspected or encountered, an alternative means of achieving fixation should be selected. If arthritis and deformity exist at the proximal interphalangeal joint (PIPJ), the DIPJ construct selected should take into account the possible future needs of this more proximal joint. Specifically, a longitudinal screw positioned within the medullary canal of the middle phalanx could make a proximal PIPJ fusion or arthroplasty quite difficult.

54.9 Key Procedural Steps ●

●

●

●

The soft tissues around the base of the distal phalanx and distal aspect of the proximal phalanx should be liberally released. This includes the terminal tendon, collateral ligaments, and pericapsular tissues. The bone is prepared by removing any residual cartilage and cortical bone and preparing the bone, in a proximal “cone” and distal “cup” configuration, back to healthy-appearing cancellous bone. Care should be taken to ensure no soft tissue is interposed between the prepared bone surfaces. Multiplanar intraoperative fluoroscopy is utilized to ensure bone coaptation and appropriate hardware positioning and length.

54.7.6 Failure of Union

54.10 Bailout, Rescue, and Salvage Procedures

A stable fibrous nonunion requires no action more than serial clinical and radiographic examinations to ensure no hardware associated problems (e.g., loosening or damage to bone via “windshield wipering”). An unstable nonunion requires revision surgery. This may need to be augmented with bone autograft, as the quality and

Intraoperative failure of fixation should be either revised or exchanged for a different method of fixation. Poor-quality bone can fracture with techniques that utilize cerclage-type wires or those that attempt to achieve compression. If this occurs, a noncompression technique should be utilized instead (e.g., longitudinal Kirschner wire[s]).

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Suggested Readings Dickson DR, Mehta SS, Nuttall D, Ng CY. A systematic review of distal interphalangeal joint arthrodesis. J Hand Microsurg. 2014; 6(2):74–84 Fowler JR, Baratz ME. Distal interphalangeal joint arthrodesis. J Hand Surg Am. 2014; 39(1):126–128 Katzman SS, Gibeault JD, Dickson K, Thompson JD. Use of a Herbert screw for interphalangeal joint arthrodesis. Clin Orthop Relat Res. 1993(296):127–132 Leibovic SJ. Instructional Course Lecture. Arthrodesis of the interphalangeal joints with headless compression screws. J Hand Surg Am. 2007; 32(7):1113–1119

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Owusu A, Isaacs J. Revision of failed distal interphalangeal arthrodesis complicated by retained headless screw. J Hand Surg Am. 2013; 38(7): 1408–1413 Pickering GT, Barnes JR, Bhatia R. Accurate screw arthrodesis of the distal interphalangeal joint. Ann R Coll Surg Engl. 2014; 96(3):245–246 Rigot SK, Diaz-Garcia R, Debski RE, Fowler J. Biomechanical analysis of internal fixation methods for distal interphalangeal joint arthrodesis. Hand (N Y). 2016; 11 (2):221–226 Villani F, Uribe-Echevarria B, Vaienti L. Distal interphalangeal joint arthrodesis for degenerative osteoarthritis with compression screw: results in 102 digits. J Hand Surg Am. 2012; 37(7):1330–1334

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55 Thumb Basal Joint Arthroplasty: Trapeziectomy Jessica Hawken and Kenneth R. Means Abstract Trapeziectomy has emerged as the most likely standard-of-care procedure for recalcitrant symptomatic thumb carpometacarpal arthritis. Whether performed alone or with adjunct techniques, knowing how, and being able, to successfully accomplish this procedure is a critical basic skill for all hand surgeons to master. In this chapter, we describe our preferred method for trapeziectomy along with relevant important considerations and lessons learned relative to the technique. Keywords: trapeziectomy, thumb carpometacarpal, basilar joint, arthritis

55.1 Description There are a variety of distinct surgical procedures that have been described for treating various stages of thumb basilar, or carpometacarpal (CMC), joint arthritis. These procedures include but are not limited to trapeziometacarpal capsuloligamentous reconstruction, metacarpal osteotomy, CMC arthrodesis, joint replacement, denervation, and partial or complete trapeziectomy. Trapeziectomy can be performed independently or augmented with other procedures, with the most common ones being tendon interposition (TI), ligament reconstruction (LR), or ligament reconstruction combined with tendon interposition (LRTI). In this chapter, we focus on simple trapeziectomy.

55.2 Key Principles The primary pain generator in basilar thumb degeneration is thought to be the CMC joint, involving the base of the thumb metacarpal, trapezium, and supporting capsuloligamentous and nerve structures. In addition to addressing the thumb CMC arthritis, it is important to assess and address other potential pain and disability generators in the region, such as scaphotrapezoidal degeneration, distal flexor carpi radialis (FCR) tendinosis, thumb metacarpophalangeal (MCP) hyperextension or degeneration, first extensor compartment tenosynovitis (deQuervain’s disease), and carpal tunnel syndrome.

55.5 Relative Contraindications ●

●

55.6 Special Considerations We recommend routine preoperative radiographic assessment of the patient’s anatomy, which helps with identifying osteophytes, loose bodies, and any other joints in the area with degenerative changes. However, advanced imaging is not required or recommended for standard preoperative planning.

55.7 Special Instructions, Positioning, and Anesthesia ●

●

55.4 Indications Symptomatic, radiographic-proven osteoarthritis of the thumb CMC joint which has failed nonoperative measures.

Place patient supine on operating table and the upper extremity on an operating arm board. Apply pneumatic tourniquet for adequate visualization and hemostasis; using local anesthetics with epinephrine and no tourniquet or regional anesthesia is an option to diminish or eliminate the need for sedation or general anesthesia as well.

55.8 Tips, Pearls, and Lessons Learned ●

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55.3 Expectations Trapeziectomy alone has comparable outcomes to trapeziectomy with LRTI or other thumb CMC arthritis procedures, is more cost effective, is less technically demanding requiring less operative time on average, and in some studies has fewer complications such as reoperation, complex regional pain syndrome, and infection.

Eaton stage I (inflammatory stage without degenerative changes on X-ray) osteoarthritis. Recent thumb CMC intra-articular corticosteroid injection: in keeping with other orthopedic surgery evidence and recommendations, we typically recommend waiting 3 months after an injection before proceeding with surgery, although we are not aware of any studies which have corroborated this for trapeziectomy specifically.

●

Remove trapezium in one piece if possible. We have found that removing the trapezium as a whole saves operative time. We also evaluate with inspection and palpation of the entire area, after trapeziectomy, to identify any residual loose bodies or metacarpal base osteophytes. Assess scaphotrapeziotrapezoidal (STT) joint preoperatively, and the scaphotrapezoidal joint after trapeziectomy, to determine if this could be another pain source in the area. Intraoperative assessment of the articulation between the trapezoid and distal scaphoid directs decision-making as to whether to proceed with partial or complete trapezoidectomy or limited fusions as required. Unlocking a degenerative STT joint may inadvertently lead to the development or worsening of radiographic dorsal intercalated segment instability of the carpus, although this may not correlate with a development or increase in symptoms. Evaluate the distal FCR tendon in the base of the joint after trapeziectomy and debride or excise if you visualize significant degeneration. We think this could also be a postoperative residual pain source similar to the long head biceps tendon in the shoulder joint, which is often tenotomized, although we are aware of no investigative studies to corroborate this as of yet.

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55.9 Key Procedural Steps ●

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●

Some surgeons like to use a sterile finger trap on the thumb with weights hung off of the end of the arm board to provide traction for the procedure, but we do not routinely do so. Our preferred skin incision is dorsal, curvilinear, and centered over the trapezium. We place two incision-marking dots with one at the tip of the radial styloid and one just distal to the thumb CMC joint at the central dorsal base of the metacarpal. The incision is then drawn in an S-shape between these dots, curving from proximal palmar to distal dorsal (▶ Fig. 55.1). After the skin incision is made, any superficial branches of the radial nerve and lateral antebrachial cutaneous nerve are protected, and the interval between the extensor pollicis brevis and longus is opened longitudinally (▶ Fig. 55.2). Next, we identify, mobilize, and protect the dorsal branch of the radial artery. The orientation of this vessel is variable, sometimes traveling longitudinally or transversely through the surgical field but most often at about a 45 degree angle off of the longitudinal axis of the thumb ray and in line with the central portion of the skin incision (▶ Fig. 55.3). We carefully mobilize the vessel proximally until it can be retracted proximal to the STT joint without undue tension. When mobilizing the vessel, we use bipolar cautery for the branches to the thumb CMC joint. An inverted “T” capsulotomy is then performed with the longitudinal portion starting at the thumb metacarpal base distally, and extending over the trapezium proximally and the transverse portion at the STT joint (▶ Fig. 55.4). Capsular flaps are then elevated radially and ulnarly off the

Fig. 55.1 Our preferred skin incision for trapeziectomy extends in a curvilinear fashion from the radial styloid tip to the base of the thumb metacarpal.

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trapezium, being careful to maintain the capsular attachments at the thumb metacarpal base. We use a scalpel to release circumferentially about the trapezium to a depth of about half of the trapezium. Next, we use a small, approximately one-fourth inch, osteotome to push away the capsule at the base of the trapezium circumferentially. We do not use a mallet for this; instead, we just use the osteotome as a dissecting tool. We push through this capsular base carefully around the trapezium, so as to not damage the FCR, flexor pollicis longus, and median nerve below. When pushing through the deep capsule, a slight “pop” is felt or heard. If the trapezium is not freely mobile at this point, the osteotome can be used to elevate under the deep side of the trapezium as well. Once the trapezium can be toggled easily with forceps, it is typically ready to be removed in its entirety with a Rongeur. We prefer the Leur Rongeur for this, which is the Rongeur with short, stout, and slightly curved ends. It straddles the proximal-distal sides of the trapezium all the way to the crux of the jaws. Next, the trapezium is gripped with the Rongeur and gently rotated in one direction without pulling up on the trapezium. Once the trapezium can be turned several times, it is ready to be pulled out of the joint (▶ Fig. 55.5). If there were significant osteophytes/degeneration about the base of the trapezium, the FCR may show signs of significant degeneration as well, but otherwise the distal FCR should remain pristine with this technique (▶ Fig. 55.6). Next we inspect and palpate for loose bodies and capsular bone fragment remnants in the space, especially between the thumb and index metacarpal bases. We pull the FCR out of the wound with a Ragnell or similar retractor, with the wrist flexed in order to inspect as much of it as possible. If there is significant

Fig. 55.2 Superficial cutaneous nerve branch in the EPB–EPL interval. EPB–EPL, extensor pollicis brevis–extensor pollicis longus.

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Key Procedural Steps

●

degeneration to the point where we think this could be a continued pain generator for the patient postoperatively, then we will transect it in the base of the wound as proximal as possible and allow it to retract proximally. We then dissect out the remaining FCR as distally as possible toward the index metacarpal insertion, transect, and remove it (▶ Fig. 55.7). We then explore the scaphotrapezoid joint for any significant degeneration. This is best accomplished with manual traction of the index finger ray and gentle probing with a Freer elevator. If there is significant wear at the proximal trapezoid or distal scaphoid, we will use a sharp osteotome and mallet to remove however much of the proximal base of

the trapezoid is involved. Once this is removed, we put the joint through a range of motion to insure there are no residual areas of potential pain generation or impingement. We continue this process until confirming no residual issues, and then load the index ray longitudinally to confirm no instability (▶ Fig. 55.8).

Fig. 55.3 The dorsal branch of the radial artery traversing the operative field; this is its most common course at approximately 45 degrees off the longitudinal axis of the thumb ray.

Fig. 55.4 Our preferred capsulotomy is an inverted-T shape (black lines) with the longitudinal portion starting at the thumb metacarpal base and the transverse portion at the (STT) joint. STT, scaphotrapeziotrapezoidal.

Fig. 55.5 (a, b) After the trapezium is released circumferentially, including pushing away its deep capsule circumferentially, it is ready to be removed as a whole.

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Fig. 55.6 The distal FCR tendon is inspected after trapeziectomy. FCR, flexor carpi radialis.

Fig. 55.7 If the FCR is in poor condition, it is retracted distally with the wrist flexed, transected in the proximal base of the wound to allow it to retract proximally into the forearm, and then the distal stump is excised as distally as possible in the distal wound. FCR, flexor carpi radialis.

Fig. 55.8 (a-c) The scaphotrapezoidal joint (blue arrow) is inspected; if the joint is significantly diseased, the proximal portion of the trapezoid is removed with an osteotome until no further pathologic articulation with the scaphoid is present; afterward, the index finger ray is axially loaded to confirm no significant instability or impingement.

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The wound and joints are copiously irrigated until clear. The previously made inverted “T” dorsal capsulotomy is closed longitudinally first, with absorbable figure-8 sutures, for which we favor 4–0 Monocryl. Then, the proximal

transverse portion of the capsule is closed while holding the thumb metacarpal base in extension. After this capsular closure, the thumb should rest with the metacarpal base in slight extension (▶ Fig. 55.9). This counteracts its prior

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Salvage Procedures dorsal radial artery and its venae comitantes. We prefer 4–0 Monocryl subcutaneous buried interrupted sutures and adhesive strips for skin closure. A sterile dressing is applied, followed by a wrist thumb spica plaster splint, with the thumb metacarpal base in slight extension and the MCP joint in slight flexion.

55.10 Salvage Procedures ●

In cases where trapeziectomy fails, it is most important to try to confirm the reason for failure and rule out other potential causes of residual or recurrent symptoms or disability. This will direct any potential salvage options. However, we discuss with all patients and give them written information that, although most patients will have most of their pain relieved and their strength improved, there are a certain percentage of patients who will have residual pain or disability no matter which thumb CMC procedure they undergo. The reasons for this are poorly understood and likely multifactorial. Compensatory thumb MCP hyperextension should be treated initially with hand therapy and splinting and, failing that, one can consider volar capsulodesis or arthrodesis, depending on the degree of hyperextension, residual functional flexion, and arthrosis present.

Suggested Readings

Fig. 55.9 Closure of the transverse portion of the inverted-T capsulotomy should bring the thumb metacarpal base into a slightly extended position at rest, which also allows the MCP joint to rest in slight flexion. MCP, metacarpophalangeal.

tendency for flexion and MCP hyperextension, the socalled Z-collapse deformity. If thumb MCP hyperextension needs to be addressed with volar capsulodesis or fusion, we perform that after trapeziectomy but before capsular closure. If a tourniquet was used, it is released at this point and hemostasis is obtained with special attention to the

Elvebakk K, Johnsen IE, Wold CB, Finsen T, Russwurm H, Finsen V. Simple trapeziectomy for arthrosis of the basal joint of the thumb: 49 thumbs reviewed after two years. Hand Surg. 2015; 20(3):435–439 Gangopadhyay S, McKenna H, Burke FD, Davis TR. Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition. J Hand Surg Am. 2012; 37(3):411–417 Li YK, White C, Ignacy TA, Thoma A. Comparison of trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition: a systematic literature review. Plast Reconstr Surg. 2011; 128(1):199–207 Mckee D, Lalonde D. Wide awake trapeziectomy for thumb basal joint arthritis. Plast Reconstr Surg Glob Open. 2017; 5(8):e1435 Mohan A, Shenouda M, Ismail H, Desai A, Jacob J, Sarkhel T. Patient functional outcomes with trapeziectomy alone versus trapeziectomy with TightRope. J Orthop. 2015; 12 Suppl 2:S161–S165–. eCollection 2015 Dec Naram A, Lyons K, Rothkopf DM, et al. Increased complications in trapeziectomy with ligament reconstruction and tendon interposition compared with trapeziectomy alone. Hand (N Y). 2016; 11(1):78–82 Vermeulen GM, Slijper H, Feitz R, Hovius SE, Moojen TM, Selles RW. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J Hand Surg Am. 2011; 36(1):157–169 Wajon A, Carr E, Edmunds I, Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst Rev. 2009(4):CD004631

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56 Ligament Reconstruction Tendon Interposition (LRTI) Charles A. Daly and Christopher L. Forthman Abstract Trapeziectomy and ligament reconstruction tendon interposition (LRTI) is an excellent form of treatment for thumb basal joint arthritis in the carefully selected patient. A complete trapeziectomy appears to be the critical portion of the procedure. Suspension of the metacarpal with flexor carpi radialis (FCR) is a commonly performed portion of the procedure, although it has not been demonstrated to improve outcomes. En block resection of the trapezium can be easily performed with the help of the techniques described. Reproducible and efficient complete trapeziectomy decreases operative time and likely results in less soft tissue trauma. Suspension of the base of the thumb metacarpal can similarly be performed simply with precision in order to create the bone tunnel and pass the FCR tendon. Pitfalls including tunnel fracture and transection of the FCR tendon can be mitigated by employing the techniques described.

56.4 Indications

Keywords: trapeziectomy, ligament reconstruction and tendon interposition (LRTI), basal thumb arthritis, CMC arthritis, base of thumb pain

Metacarpophalangeal (MP) joint hyperextension must be evaluated concomitantly during the planning stages for treatment of thumb carpometacarpal (CMC) joint arthritis. During pinch, MP joint hypertension can direct the first metacarpal base into a subluxated position, potentially stressing any ligament reconstruction. Preoperative examination should pay particular attention to dynamic joint collapse during pinch rather than static laxity. Treatment can include percutaneous pinning of the MP joint in slight flexion + / – extensor pollicis brevis tendon transfer, volar capsulodesis/sesamoidesis, or MP joint fusion based on severity.

56.1 Description Gervis described trapeziectomy for the management of basal joint arthritis in 1949. While relieving pain in most cases, trapeziectomy alone allowed gradual subsidence of the thumb ray and some degree of ongoing pain and weakness. A number of options for basal joint arthroplasty of the thumb have been described with the hope of improving outcomes to include ligament reconstruction tendon interposition (LRTI) using flexor carpi radialis (FCR) (Burton and Pellegrini), suspensionplasty with abductor pollicis brevis (Thompson), hematoma distraction arthroplasty (Meals), and numerous variations using implants such as anchors, buttons, screws, and artificial joints. Of these procedures, LRTI is, by far, the most common.

56.2 Key Principles Surgical options are largely based on a common theme of complete trapeziectomy with and without suspension of the thumb metacarpal.

56.3 Expectations No benefit has been definitively demonstrated when comparing trapeziectomy alone to one of the more complex procedures including LRTI. Pain relief and patient satisfaction are generally good to excellent. Grip strength and pinch strength seem to improve, with grip strength improving more dramatically.1 Proximal migration does occur with LRTI but less so than without suspension of the metacarpal.2 No significant correlation has been found between maintenance of arthroplasty space and clinical outcomes.3

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Advanced radiographic disease that has failed conservative management. May consider fusion of the thumb carpopmetacarpal joint for young, active, and high-demand individuals. May consider arthroscopy, dorsal extension osteotomy, or Eaton–Littler ligament reconstruction for younger patients or those without significant amount of degenerative changes on X-ray.

56.5 Contraindications ● ●

Young age. High-demand activities.

56.6 Special considerations

56.7 Special Instructions, Positioning, Anesthesia Supine, hand table, typically performed under general anesthesia or regional anesthesia with monitored anesthesia care and an upper arm tourniquet. Typically, fluoroscopy is not required. Traction with a finger trap and 5 to 7 lbs of weight hung off of the end of the hand table may be beneficial. This along with a small bump made from a single, rolled blue towel may provide good positioning without the use of an assistant for most patients (▶ Fig. 56.1).

56.8 Tips, Pearls, and Lessons Learned 56.8.1 Approach Volar/Dorsal The thumb basilar joint may be approached dorsally with an incision between the first and third extensor compartments or palmarly with an incision along the glabrous skin line. A dorsal approach is more widely used as the trapezium is directly subcutaneous and the incision avoids the palmar branch of the median nerve as well as the potentially irritable skin region of the wrist flexion crease. The dorsal approach requires meticulous attention to prevent injury to the superficial branches of the radial nerve.

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Tips, Pearls, and Lessons Learned

Fig. 56.1 Surgical setup. Traction placed on thumb with a finger trap over a rolled towel.

Fig. 56.2 Authors’ preferred surgical incisions.

Fig. 56.3 Superficial surgical dissection demonstrating branches of radial artery to be cauterized to allow mobilization and protection.

The dorsal incision utilized by the authors is demonstrated in ▶ Fig. 56.2. Nerve branches should be maintained in the areolar tissue with the dorsal skin flap and not skeletonized or divided, which would risk neuroma formation and/or complex regional pain syndrome. The thin fascia between the first and third extensor compartments is incised longitudinally and a 2, 3 Weitlaner retractor placed.

Branches of Radial Artery The radial artery courses from under the first extensor compartment to just superficial to the joint capsule of the scaphotrapezial joint, as it traverses the anatomic snuffbox. There are multiple small branches to the joint capsule and surrounding tissues which should be cauterized with bipolar electrocautery in order to mobilize and protect the radial artery (▶ Fig. 56.3). The Weitlaner can be adjusted to protect the radially artery dorsally.

Meticulous Capsulotomy Longitudinal and transverse capsulotomy is performed to obtain subperiosteal exposure of the trapezium. The capsule should not be elevated off the scaphoid or the proximal

Fig. 56.4 Deep surgical dissection demonstrating longitudinal and transverse capsulotomy performed capsule with capsule left attached to the scaphoid and proximal metacarpal to allow stout capsular repair.

metacarpal, so as to allow later capsular repair (▶ Fig. 56.4). The Weitlaner retractor can again be adjusted to protect the capsular layer. As much soft tissue as visible should be sharply divided at its attachment on the trapezium.

56.8.2 Trapeziectomy There are two main approaches for trapeziectomy. Dividing the trapezium and removing in parts or removing the trapezium en block.

Dividing Trapezium The surrounding structures are protected by the Weitlaner retractor or small Hohman retractors. An oscillating saw is used to make 2 or 3 longitudinal cuts through most of the trapezium. The cuts are completed with an osteotome using a twisting motion. The trisected trapezium is removed with a Rongeur by elevating off the soft tissues. Care is taken to avoid perforation of the deep capsule and laceration of the FCR.

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Ligament Reconstruction Tendon Interposition (LRTI)

Fig. 56.5 Deep surgical dissection demonstrating capsular attachments released by sliding the osteotome down the trapezium, working from ulnar to radial.

Fig. 56.6 Inspection of STT joint. STT, scaphotrapeziotrapezoid.

56.8.3 Inspection of Scaphotrapeziotrapezoid (STT) Joint and Partial Trapeziectomy The STT joint should be inspected, and if arthrosis is present, a small portion of the articular surface of the trapezoid removed (▶ Fig. 56.6).

56.8.4 Tunnel Placement

Fig. 56.7 3 mm motorized burr is used to create a channel through the first metacarpal base entering in the plane of the nail.

A motorized 3 mm burr is used to create a channel through the first metacarpal for transfer of the FCR tendon and suspension of metacarpal. The hole should be in the plane of the nail on the dorsal aspect of the metacarpal and also be directed out the volar ulnar aspect of the metacarpal in the vicinity of the anterior oblique and ulnar collateral ligaments (▶ Fig. 56.7).

Anatomy of Tethering Structures The trapezium can be removed en block with a systematic division of the capsular attachments. First, the ulnar-most aspect of the trapezium (including the articular face for the index metacarpal) is grasped with a Brown forcep and freed from the capsular tissues between the first and second CMC joint and from the capsule at the articulation with the trapezoid. A standard 15 blade can be used along with a sharp 1/8 osteotome. The FCR is at risk of injury at its insertion on the 2nd metacarpal base. Next, the deep distal capsular attachments to the trapezium are released by sliding the osteotome down the “saddle” face of the trapezium, working from ulnar to radial. Then, the knife can be used to elevate the capsule and thenar muscle lying on the radial side of the trapezium. At this stage, a single action Rongeur can be used to grasp the trapezium as the bone should be mobile. The surgeon will then release the deep volar capsular attachments to the trapezium, taking care to avoid FCR injury when dissecting around the tendon groove. With a gentle twist, the trapezium is lifted from the wound (▶ Fig. 56.5).

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56.8.5 Harvesting FCR FCR tendon is palpated to a point approximately 8 to 10 cm from the wrist flexion crease. A 1.5 cm, an oblique incision is made, centered on the palpable FCR tendon. The tendon sheath is incised and the tendon delivered into the wound. Once it is confirmed that the tendon isolated is FCR, and only FCR by traction on the tendon and careful inspection, the tendon is transected. A Ragnell retractor or curved clamp is then placed around the FCR tendon in the arthroplasty space to deliver the tendon into that wound. Some adhesions may need to be freed from the tendon to have a direct line of pull between the index metacarpal base and the tunnel within the metacarpal base of thumb.

56.8.6 Passing FCR The end of FCR is tapered with scissors. A 26 Gauge wire is folded over itself and placed through the bone tunnel from dorsal to volar. About 1 cm of FCR tendon is placed through

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Tips, Pearls, and Lessons Learned the wire, and the wire is carefully pulled through the base of the metacarpal (▶ Fig. 56.8). If resistance is met, the FCR tendon may need to be tapered further, or the tunnels expanded with care to provide enough bony stability to prevent tunnel fracture. The tendon is pulled out the dorsum of the metacarpal.

56.8.7 Securing MC Suspension A nonabsorbable 4–0 brained suture (Ethibond or equivalent) is secured to the deep capsule adjacent to the FCR insertion site on the index metacarpal base. The weighted traction is then

with the previously placed nonabsorbable suture (▶ Fig. 56.9). The FCR is also sutured to periosteum as it exits the metacarpal dorsally, so as to strengthen the suspension. The remainder of the FCR tendon can be sutured into a ball or “anchovy” with an absorbable suture (4–0 Vicryl or equivalent) and then placed into the CMC joint to act as interposition. The remainder of the tendon can be folded and sutured to itself; then, subsequently the deep capsular tissue of the CMC joint to act as interpositional material if desired (▶ Fig. 56.10). We do not routinely place a K-wire across the CMC joint, as the risks of infection and piercing the FCR tendon within the tunnel appear to outweigh the potential benefits.

released, allowing the arthroplasty space to collapse. Next, tension is applied to the FCR tendon, such that the thumb metacarpal is suspended at the level of the index metacarpal. The FCR is pulled to the depths of the wound under tension and secured

Fig. 56.8 Passing FCR tendon utilizing 26 Gauge wire. FCR, flexor carpi radialis.

Fig. 56.9 FCR is pulled to the depths of the wound under tension to slightly elevate the thumb metacarpal which is then secured with nonabsorbable suture. FCR, flexor carpi radialis.

Fig. 56.10 (a) The remainder of the tendon can be folded and sutured to itself to act as interpositional material. (b) A schematic demonstrating the anchovy occupying the space left for the trapezium. (Reproduced with permission from Plancher KD. MasterCases Hand and Wrist Surgery. 1st ed. © 2004 Thieme.)

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Ligament Reconstruction Tendon Interposition (LRTI)

Full Transection If the FCR is fully transected, a hemislip of extensor carpi radialis longus (ECRL) tendon can be utilized. The ECRL hemislip is passed posterior to anterior through a drill hole and the index metacarpal about 1 cm distal to its base. The same thumb metacarpal base tunnels may be used as noted above and the tendon secured similarly. Suture button fixation between the index and thumb metacarpal bases can be utilized in isolation or in addition to the before-mentioned procedures as well.

56.9.2 Tunnel Fracture Fig. 56.11 The capsule is tightly repaired with a nonabsorbable suture with careful attention to the protection of radial sensory nerve branches and the radial artery.

56.8.8 Capsular Closure The capsule is tightly repaired with a nonabsorbable suture with careful attention to the protection of radial sensory nerve branches and the radial artery (▶ Fig. 56.11). The thin fascia between the first and third extensor compartments may be closed with an absorbable suture.

56.9 Bailout, Rescue, and Salvage Procedures 56.9.1 FCR Transection Hemitransection If the FCR is only partially transected, then utilize the intact portion of the FCR in an LRTI type of reconstruction.

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Tunnel fracture may occur; in such cases, the tendon can be passed through the abductor pollicis longus (APL) tendon and sutured back to itself to provide suspension of the base of the thumb metacarpal without the use of a bone tunnel.

References [1] Tomaino MM, Pellegrini VD, Jr, Burton RI. Arthroplasty of the basal joint of the thumb. Long-term follow-up after ligament reconstruction with tendon interposition. J Bone Joint Surg Am. 1995; 77(3):346–355 [2] De Smet L, Sioen W, Spaepen D, van Ransbeeck H. Treatment of basal joint arthritis of the thumb: trapeziectomy with or without tendon interposition/ ligament reconstruction. Hand Surg. 2004; 9(1):5–9 [3] Kriegs-Au G, Petje G, Fojtl E, Ganger R, Zachs I. Ligament reconstruction with or without tendon interposition to treat primary thumb carpometacarpal osteoarthritis. A prospective randomized study. J Bone Joint Surg Am. 2004; 86 (2):209–218

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57 Total Wrist Arthrodesis John C. Dunn, Curt Hanenbaum, and Keith A. Segalman Abstract Total wrist arthrodesis is the gold standard treatment for the end-stage arthritic wrist. The procedure involves the fusion of radiocarpal, intracarpal, and sometimes the carpometacarpal joints. High rates of union (98%), satisfaction (96%), grip strength, and physical function underscore the value of the procedure. Total wrist arthrodesis is classically indicated in the higher demand patient with posttraumatic arthritis to include scapholunate advanced collapse and scaphoid nonunion advanced collapse. The procedure is also indicated for inflammatory arthropathy, salvage cases, segmental bone loss, and cerebral palsy. Fusion is most often commonly achieved with an anatomic spanning dorsal plate. The most common complication is tendon irritation. Despite this, the total wrist fusion provides a stable and functional wrist in the setting of advanced arthritis.

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57.5 Contraindications ●

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57.1 Description ●

57.2 Key Principles Total wrist arthrodesis involves the preparation and fusion of radiocarpal, intracarpal, and sometimes the carpometacarpal joints. Most surgeons prefer plate fixation but intramedullary devices are another option.

57.3 Expectations Following total wrist arthrodesis using a compression plate in the setting of posttraumatic arthritis, 98% will go on to union at an average of 10 weeks. Postoperatively, the vast majority are satisfied (91%), would undergo the procedure again (96%), and would have the procedure sooner (91%).1 Grip strength is 77 to 83% of the contralateral hand.2 However, most patients will have some degree of pain and experience some limitations with work.3 These points are critical in preoperative counseling.

57.4 Indications ●

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Posttraumatic arthritis of midcarpal and/or radiocarpal joints to include degenerative carpal collapse, following a scaphoid fracture non-union, scapholunate dissociation, or Kienbock disease. Inflammatory arthropathy of the wrist with instability to include rheumatoid arthritis. Segmental bone loss from trauma, infection, or malignancy.

Cases in which wrist motion is required, either for highdemand activity or to augment digital motion. Some authors would consider a bilateral wrist arthrodesis a relative contraindication. Active infection.

57.6 Special Considerations

Keywords: total wrist arthrodesis, total wrist fusion, posttraumatic, inflammatory arthritis

Total wrist arthrodesis offers stability and pain relief, most commonly in the setting of a posttraumatic arthritis.

Salvage following failed total wrist fusion, limited intracarpal fusion, proximal row carpectomy, distal radius fixation, or total wrist arthroplasty. Paralytic disorders such as cerebral palsy.

Carpal tunnel syndrome may be concurrently present preoperatively; however, the examination may be veiled by trauma or the pain of an arthritic wrist. In addition, carpal tunnel syndrome may be present in up to 10% of patients following total wrist fusion.1 Symptoms could be made worse following total wrist fusion secondary to postoperative edema. A complete preoperative physical examination should include testing for carpal tunnel syndrome and, if necessary, a carpal tunnel release should be completed intraoperatively. Postoperative ulnocarpal abutment should be considered, particularly in the setting of inflammatory arthritis or preoperative ulnar positive wrists. Resecting the distal ulna in patients with rheumatoid arthritis should be preoperative considerations.

57.7 Special Instructions, Positioning, and Anesthesia ●

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The patient is placed supine with the arm extended on a hand table. In addition to general anesthesia, 20 ml of 0.5% marcaine without epinephrine is used at the onset of the case. Regional anesthesia is always an option, but it is often difficult to obtain adequate intraoperative pain relief. A posterior interosseous neurectomy may provide a small degree of postoperative pain relief.

57.8 Tips, Pearls, and Lessons Learned ●

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A step cut in the extensor retinaculum may facilitate closure at the conclusion of the case. Although rarely necessary, the triquetrum may be excised to reduce the likelihood of ulnar impaction and can be subsequently used as bone graft. Reconstruction plates are not advised because these do not provide adequate stiffness.

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Total Wrist Arthrodesis

Fig. 57.1 Skin incision for wrist arthrodesis.

Fig. 57.2 Extensor compartments 2, 3, 4, and 5 have been retracted to expose the dorsal wrist capsule. Exposure of the distal branch of the posterior interosseous nerve before resection.

57.9 Difficulties Encountered ●

Fig. 57.3 Dorsal wrist capsule has been incised and the carpal bones are exposed.

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First removing the scaphoid, lunate, and triquetrum (PRC) before fusion has a few advantages4: – The removed bones are a source of bone graft for the fusion mass. – There is a theoretically decreased risk of nonunion by decreasing the number of moving articular fragments which need to fuse. – There is a theoretically decreased risk of ulnar carpal abutment. – This is a technically simple procedure and is particularly indicated after a previous PRC or spastic pathology. – After a previous PRC, autologous bone grafting is recommended. – Decortication of the radiocarpal and intercarpal joints. – Proximal tibia bone graft is recommended if autogenous bone graft is required. Some authors prefer not to remove the proximal carpal row in a younger patient to avoid the theoretical shortening of the wrist with a “PRC” wrist fusion. In this situation, bone graft is suggested but not essential. Additional pearls: – Apply the plate distally over the third metacarpal with fixation of the capitate. – Use the short bend, precontoured wrist fusion plates. – Create a small trough in the distal radius to accommodate the plate. Ensure the plate is centered over the distal radius to properly align the wrist.

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It is imperative to center the plate on the metacarpal in the anteroposterior and lateral projections. In addition, the plate should be long enough to allow for three screws into the metacarpal. Secure the plate to the metacarpal before placing screws, in compression mode, in the radius. This will reduce the likelihood of poor metacarpal fixation and a rotational deformity when securing the plate proximally. The plate may not sit on the carpus and distal radius in an anatomic manner. If this is the case, a trough in the dorsal radius may be performed to allow for better plate-to-bone contour. The plate may not allow an anatomic screw into the capitate. If this is the case, one can forgo fixation into the carpus. If one elects to place a screw into the carpus, a unicortical locking screw may be advisable, because a bicortical screw may protrude into the carpal canal. If neither a PRC nor a distal ulnar resection is performed, the lunate must be centered within its fossa on the distal radius during the fusion. If this is not accounted for, ulnocarpal abutment is possible.

57.10 Key Procedural Steps ●

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A nonsterile brachial tourniquet is inflated 100 Torr above the systolic pressure A 15-cm incision is made (large enough to accommodate the plate selected) and centered over Lister’s tubercle. The extensor retinaculum is incised in line with the extensor pollicus longus (EPL). The EPL is transposed radially and can be held in place with a large self-retaining retractor. At the conclusion of the case, the EPL should be left transposed above the retinaculum (▶ Fig. 57.1). The 4th and 5th extensor compartment are sharply elevated off of the distal radius for ease of accessing the ulnar carpus. The wrist capsule is incised in line and carried to the third metacarpal (▶ Fig. 57.2). The radiocarpal (radioscaphoid and radiolunate) and intracarpal (scaphocapitate, capitolunate, capitohamate, and lunohamate) are decorticated (▶ Fig. 57.3 and ▶ Fig. 57.4).

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Key Procedural Steps

Fig. 57.5 The location of the most distal screw is marked on the third metacarpal. Fig. 57.4 The carpal bones have been decorticated with a Rongeur. An oscillating saw is used to resect the articular surface of the radius.

Fig. 57.6 The distal metacarpal screw hole is drilled without the plate in place to ensure it is centrally located on the metacarpal.

Fig. 57.7 Plate fixation is completed in the metacarpal and a locking screw is placed in the capitate. A trough in the distal radius is created with an oscillating saw to accommodate the bend in the precontoured plate.

Although not absolutely necessary, the second and third carpometacarpal joints may be exposed and decorticated with a small burr and Rongeur down to cancellous bone. This is typically done if there are arthritic changes. An osteotomy of the dorsal surface of Lister’s, radial metaphysis, or dorsal carpus may allow the plate to sit more appropriately. This bone may be saved and packed into the fusion construct. Cancellous bone graft may be harvested from the radial metaphysic at this step as well, although it is likely that another source of bone graft will be necessary. Plate selection. Plates can be straight or may be made for a 5 to 15° dorsiflexion moment. The mild dorsiflexion will aid in power grip. A 3.5 mm limited contact dynamic compression plate (LC-DCP) can be countered to the appropriate dorsiflexion with plate bending instruments. A plate accepting 3.5 mm screws in the shaft and 2.7 mm screws in the metacarpal is ideal (▶ Fig. 57.5). Most precontoured wrist fusion-specific plates will be stainless steel and will offer locking options. We prefer these plates. Locking screws are typically not necessary

in the metacarpal and radial shafts, but may prove useful in two options: – Providing unicortical fixation into the carpus. – Securing intercalary bone graft (iliac crest autograft or femoral head allograft) in revision cases (revision of a total wrist arthroplasty) or during scenarios of significant bone loss. The plate is first compressed to bone with a self-tapping 2.7 mm screw after first drilling using a 2.0 mm drill into the metacarpal. A second metacarpal screw is placed. Once the plate is perfectly centered over the metacarpal, the remaining metacarpal screw and capitate screw is placed. The trough is made in the radius and a 3.5 mm screw is used to compress the plate to the radial shaft by first drilling eccentrically with a 2.5 mm drill. Typically, three screws are placed in the metacarpal and three in the radial shaft (▶ Fig. 57.5–▶ Fig. 57.11). If a PRC is required, the proximal aspect of the scaphoid, as well as the lunate and triquetrum are removed and the remaining surfaces are decorticated (▶ Fig. 57.12 and ▶ Fig. 57.13).

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Fig. 57.8 Eccentric drilling of the radius screw hole allows compression of the plate.

Fig. 57.9 Completed fixation of the wrist arthrodesis.

Fig. 57.10 AP X-ray of a completed wrist fusion.

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At the conclusion of the case, the capsule is closed if possible. The 4th compartment is placed back on top of the radius and the retinaculum will be closed with a few absorbable stitches. The EPL should remain transposed. The tourniquet is released and hemostasis is achieved. The skin is closed with 4–0 nylon suture. A drain is typically used. A volar slab plaster of Paris splint is used. Postoperative care: The patient is discharged on the first postoperative day. The patient is encouraged to perform active finger movements while in the splint. Sutures are removed at 10 to 14 days and the splint is changed to a short arm cast. At 6 weeks, the cast may generally be discontinued and the patient may progress to strengthening. At 12 weeks, unrestricted use is permitted as long as there are no signs of radiographic loosening.

Fig. 57.11 Lateral X-ray of a completed wrist fusion.

57.11 Bailout, Rescue, and Salvage Procedures ●

Inadequate bone quality or fracture: Locking screws may be used in these scenarios. In addition, the second metacarpal may be used if the third has poor bone quality either from fracture or previous dorsal spanning distal radius plate secured into the third metacarpal. A longer 3.5 mm LC-DCP may be used if there is an intraoperative fracture of the distal radius. Fusion construct may be augmented with autologous bone from the distal radius, iliac crest, proximal ulna, or proximal tibia. The proximal tibia is our preferred site of bone graft harvest. In the setting of large bone loss (trauma or a failed total wrist fusion), femoral head allograft may also be used.

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References

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Fig. 57.12 Line of resection has been marked for a PRC wrist fusion. The scaphoid is resected at the waist, the head of the capitate is removed, and the lunate and triquetrum are removed. PRC, proximal row carpectomy.

Fig. 57.13 The PRC wrist fusion prior to manual decortication of the remaining carpal bones. PRC, proximal row carpectomy.

In the setting of advanced inflammatory disease, a single Steinmann pin may be driven from the third metacarpal in a retrograde fashion into the distal radius, correcting ulnar drift of the carpus. The ulnar head may be excised and used as bone graft. In addition, there are intramedullary devices which serve to fuse the wrist as well; however, the authors prefer traditional dorsal compression plating.

Denervation of the posterior interosseous nerve intraoperatively is a reasonable consideration. Arthritis of an adjacent joint may be painful and could potentiate loosening of the plate, particularly at the carpometacarpal joint. For these reasons, one may consider incorporating the second and third carpometacarpal (CMC) joints into the fusion mass if symptomatic preoperatively. Plate removal is rarely required with the precountered plates but should be delayed for at least 12 months if removal is desired.

57.12 Pitfalls ●

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Tendon irritation may be problematic volarly if the bicortical screws are excessively long or dorsally (19% of cases1) near the plate-metacarpal interface. Early active motion of the fingers and careful dissection of the fourth dorsal compartment may reduce the likelihood of a tendon irritation or laceration. Formal therapy is prescribed while the wrist is casted if digital range of motion has not returned by the first postoperative visit. Persistent postoperative pain may be related to reflex sympathetic dystrophy, nonunion, or unknown etiology. Although the incision and plate avoid the radial nerve, fully recessing the screws may limit radial and cutaneous nerve irritation.

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References [1] Hastings H, II, Weiss AP, Quenzer D, Wiedeman GP, Hanington KR, Strickland JW. Arthrodesis of the wrist for post-traumatic disorders. J Bone Joint Surg Am. 1996; 78(6):897–902 [2] Bolano LE, Green DP. Wrist arthrodesis in post-traumatic arthritis: a comparison of two methods. J Hand Surg Am. 1993; 18(5):786–791 [3] Adey L, Ring D, Jupiter JB. Health status after total wrist arthrodesis for posttraumatic arthritis. J Hand Surg Am. 2005; 30(5):932–936 [4] Louis DS, Hankin FM, Bowers WH. Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis. J Hand Surg Am. 1984; 9(3):365–369

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58 Proximal Row Carpectomy Laura Lewallen and Dawn M. LaPorte Abstract Proximal row carpectomy (PRC) is one of several surgical options for patients with advanced wrist arthritis. It is a reliable, motion-preserving procedure. The surgical technique and technical pearls are outlined here. PRC is not recommended for patients with midcarpal arthritis, specifically involving the capitate, or degenerative changes within the lunate fossa. Keywords: proximal row carpectomy, scaphoid nonunion advanced collapse, scapholunate advanced collapse, wrist arthritis, Kienbock’s disease

motion-preserving procedure, and is therefore often recommended in younger patients (minimum, 35–40 years old).1,2,3

58.3 Indications ●

● ●

Advanced scapholunate advanced collapse (SLAC) (stage II) (▶ Fig. 58.1) or scaphoid nonunion advanced collapse (SNAC) (stage II or stage III if lunate and capitate preserved). Kienböck’s disease (stages III and IV). Rheumatoid arthritis.

58.4 Contraindications 58.1 Description A number of surgical options exist for the treatment of endstage/advanced wrist arthritis, including wrist denervation, proximal row carpectomy, scaphoid excision and four-corner fusion, total wrist arthroplasty, and wrist arthrodesis.

Proximal row carpectomy (PRC) is not recommended for patients with midcarpal arthritis, specifically involving the capitate, or for those with degenerative changes within the lunate fossa. Patients with an incompetent radioscaphocapitate ligament are also not candidates for this procedure.

58.2 Key Principles

58.5 Special Considerations

Treatment choice is based on patient age, functional demands, pattern/location of arthritis, and expected durability. Proximal row carpectomy has been shown to be a reliable,

Preoperative radiographs of the wrist (posteroanterior, lateral, and oblique views) are necessary to assess the location and severity of arthritic changes. Computed tomography may be

Fig. 58.1 (a,b) Preoperative radiographs (PA, lateral views) demonstrating scapholunate advanced collapse pattern arthritis.

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Key Procedural Steps

Fig. 58.2 Longitudinal incision ulnar to Lister’s tubercle.

Fig. 58.3 EPL tendon identified and incised along its sheath. EPL, extensor pollicis longus.

Alternating between an osteotome or freer to elevate the bone, and a Rongeur to remove the bone, often piecemeal for the lunate and/or scaphoid is helpful. A freer elevator can be used to protect the cartilage of the proximal capitate. Distal traction or a rolled towel placed volarly can improve visualization and access to the carpus. It is important to take care to preserve the integrity of the radioscaphocapitate ligament. Consider the possible need for radial styloidectomy to avoid radial impingement.

58.8 Key Procedural Steps

Fig. 58.4 Dorsal ligament-sparing capsular incision.

used for further evaluation and can be particularly helpful for visualizing the midcarpal joint. These findings are correlated with the patient’s history and physical examination findings.

58.6 Special Instructions, Positioning, Anesthesia Patients are positioned supine, with the operative extremity on a hand table. General anesthesia or intravenous sedation is required. Regional anesthesia is used as an adjunct at some institutions.

58.7 Tips, Pearls, and Lessons Learned Various instruments may be helpful in performing the carpectomy successfully. A threaded pin can be used as a “joystick.”

A dorsal longitudinal incision is centered over the radiocarpal joint, just ulnar to Lister’s tubercle (▶ Fig. 58.2). This is preferred over a transverse incision because it allows for extensile exposure and would be used if additional surgery is needed in the future (such as revision to wrist arthrodesis). Any dorsal sensory branches of the radial and ulnar nerves are protected. Skin flaps are raised to expose the extensor retinaculum. The retinaculum is incised just ulnar to Lister’s tubercle, over the extensor pollicis longus (EPL) tendon. The EPL tendon is followed distally, continuing the incision along its sheath (▶ Fig. 58.3). The floor of the fourth dorsal compartment is elevated, raising a flap ulnarly. The posterior interosseous nerve is identified along the floor of the fourth dorsal compartment radially. A portion is excised to aid in pain relief. The second dorsal compartment is then elevated, raising a flap radially off Lister’s tubercle. It is important to visualize the fibers of the wrist joint capsule at this point because it can be difficult to distinguish from the overlying retinacular layer. Various types of capsular incisions are acceptable; the options include the following: ● Dorsal ligament-sparing approach4 (▶ Fig. 58.4). ● Longitudinal. ● H- or T-shaped flap. ● Distally based, U-shaped flap. Our preferred technique is a T-shaped incision. Regardless of the capsular incision performed, it is critical to avoid damaging the deep dorsal branch of the radial artery.

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Proximal Row Carpectomy At this point, the articular surfaces of the capitate and lunate fossa are visualized and assessed. If arthritic changes are present in either location, PRC is not the recommended procedure. If there are arthritic changes at the proximal capitate, scaphoid excision and four-corner fusion would be a better choice. If there are degenerative changes at the lunate fossa, wrist arthrodesis (or possibly arthroplasty) is recommended. The goal is to remove the triquetrum, lunate, and scaphoid each as a unit, if possible. This is often quite challenging and piecemeal removal may be required. Distal traction or a rolled towel placed volarly may help improve visualization and access. A threaded Steinmann pin or Kirschner wire (0.062-inch diameter) may be used as a joystick to help mobilize the bones

during the removal process (▶ Fig. 58.5). It is necessary to protect the volar ligaments, specifically the radioscaphocapitate ligament, which serves as a tether upon completion of the carpectomy. Radiographs are taken to confirm removal of all bony fragments and assess the position of the capitate within the lunate fossa (▶ Fig. 58.6a). The wrist is deviated ulnarly to confirm there is no subluxation (▶ Fig. 58.6b), demonstrating that the radiocarpal ligaments are intact. Radial styloidectomy may be indicated at this point if there is concern for impingement of the trapezium on the radial styloid (▶ Fig. 58.6c). If so, an osteotome is used to remove approximately 5 mm of the styloid, taking care to preserve the radioscaphocapitate ligament. Capsular closure is then performed. One may consider closing the extensor retinaculum deep to the extensor tendons. This provides additional protection of the tendons, which is particularly important in patients with rheumatoid arthritis.

58.9 Bailout, Rescue, and Salvage Procedures ●

●

●

Fig. 58.5 Kirschner wire used as a joystick during carpectomy.

●

Pinning the distal radius to the capitate is necessary if ulnar translation is present after performing the carpectomy, because this suggests disruption of the radioscaphocapitate ligament. Capsular interposition is an option for patients with intraoperative findings of mild proximal capitate wear. Scaphoid excision and four-corner fusion are recommended if there is evidence of midcarpal arthritis. Wrist arthrodesis is recommended if degenerative changes are present within the lunate fossa.

Fig. 58.6 (a) Intraoperative fluoroscopic assessment after carpectomy. Posteroanterior view to assess position of the capitate within the lunate fossa. (b) Ulnar deviation view to confirm no carpal translation/subluxation. (c) Radial deviation view to assess for impingement of the trapezium on the radial styloid.

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References

References [1] Brinkhorst ME, Singh HP, Dias JJ, Feitz R, Hovius SER. Comparison of activities of daily living after proximal row carpectomy or wrist four-corner fusion. J Hand Surg Eur Vol. 2017; 42(1):57–62 [2] Chim H, Moran SL. Long-term outcomes of proximal row carpectomy: a systematic review of the literature. J Wrist Surg. 2012; 1(2):141–148

[3] Wall LB, Didonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am. 2013; 38(8):1498–1504 [4] Berger RA. A method of defining palpable landmarks for the ligamentsplitting dorsal wrist capsulotomy. J Hand Surg Am. 2007; 32(8): 1291–1295

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59 Scaphoidectomy and Four-Corner Fusion David R. Steinberg and Oded Ben-Amotz Abstract When a patient desires motion-preserving salvage surgery for treating certain forms of posttraumatic wrist arthritis, scaphoid excision combined with intercarpal arthrodesis is a popular procedure that provides good subjective and objective outcomes. This chapter reviews the indications and contraindications for this procedure. The reader is provided a detailed description of surgical steps, including the three most popular fixation techniques. Keywords: wrist arthritis, SLAC, SNAC, intercarpal arthrodesis, four-corner fusion, scaphoid excision

59.1 Description When a patient desires motion-preserving salvage surgery for treating certain forms of posttraumatic wrist arthritis, scaphoid excision combined with four-corner fusion is a popular procedure that provides good subjective and objective outcomes.

to 80% of the uninjured side. Complete recovery may be prolonged, taking 6 to 12 months.2,3,4,5

59.4 Indications Stage 2 or 3 scapholunate advanced collapse (SLAC) wrist and scaphoid nonunion advanced collapse (SNAC) wrist. Less common indications include radiocarpal arthrosis, certain carpal instability patterns, and failed soft tissue reconstructions, as long as there is preservation of the radiolunate articulation.

59.5 Contraindications Radiolunate arthritis, Kienbock’s disease, patient’s desire for one-stage definitive treatment, and advanced pan arthritic changes accompanied by severely restricted range of motion and pain.

59.6 Special Considerations

Four-corner fusion with scaphoidectomy is preferred over proximal row carpectomy (PRC) when capitolunate arthritis is present or when the patient is younger than 40 years of age. Fixation options for four-corner fusion include K-wires, staples, headless compression screws, or intercarpal fusion plates.1

Plain radiographs: PA, lateral, ulnar deviation, and clenched fist views are usually sufficient for diagnosis and may reveal excessive flexion of scaphoid, scapholunate widening, and radiocarpal and/or midcarpal arthritis (▶ Fig. 59.1). We often obtain views of the contralateral wrist for comparison. When the condition of the radiolunate joint is unclear, magnetic resonance imaging (MRI), computed tomography (CT), or diagnostic wrist arthroscopy can be helpful.

59.3 Expectations

59.7 Positioning and Anesthesia

Patients should expect to maintain approximately 50 to 60% normal wrist range of motion. Grip strength usually improves

Regional anesthesia with sedation is preferred. The patient is placed supine, with extremity on a hand table and proximally

59.2 Key Principles

Fig. 59.1 SLAC pattern of wrist arthritis. (a) PA radiograph demonstrates large scapholunate diastasis, with narrowing and subchondral sclerosis of radioscaphoid and capitolunate joints. (b) Pronounced DISI deformity seen on lateral, with 90 degree scapholunate angle and dorsal subluxation of capitate. DISI, dorsal intercalated segment instability; SLAC, scapholunate advanced collapse.

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Key Procedural Steps applied tourniquet. It is easier to perform the procedure when the surgeon sits on the side of the extremity that allows them to operate in a proximal to distal direction on the dorsal wrist and forearm.

59.8 Tips, Pearls, and Lessons Learned

59.9.2 Scaphoidectomy A thin cortical shell of the scaphoid tubercle may remain in the volar capsule; it may be left alone as long as it does not articulate with or impinge on the other wrist bones during passive motion. Attempts to remove every last fragment of bone could result in damage to the radioscaphocapitate (RSC) or long radiolunate (LRL) ligaments, resulting in instability.4

59.8.1 Approach

59.9.3 Ensuring Fusion

The superficial approach is usually through the third extensor compartment; preserving retinaculum over the fourth compartment minimizes postoperative finger stiffness. Transection of the posterior interosseous nerve (PIN) at this stage may decrease postoperative pain.

In advanced cases, sclerotic degenerative bone must be addressed to improve chances of intercarpal fusion, especially between lunate and capitate. If all diseased bone cannot be removed, the surgeon should perform a “microfracture” technique, making multiple fenestrations in the bone with drill or K-wire.

59.8.2 Arthrotomy The dorsal wrist capsule consists of the dorsal radiocarpal ligament (DRC) and the dorsal inter-carpal ligament (DIC) with conjoint insertion on triquetrum. Arthrotomy is achieved with a proximally based “T” or a ligament-sparing approach.6 Longitudinal traction by an assistant opens up the carpus and allows maximum exposure of the lunate and triquetrum.

59.8.3 Scaphoidectomy

59.10 Key Procedural Steps Initial exposure is performed through a dorsal midline incision over radiocarpal joint, just ulnar to Lister’s tubercle. Raising thick soft tissue flaps ensures preservation of cutaneous radial sensory branches, which should nevertheless be visualized during dissection. Open extensor retinaculum over the 3rd dorsal compartment and transpose extensor pollicis longus (EPL) radially (▶ Fig. 59.2). Raise retinaculum radially and ulnarly

One may attempt to excise the scaphoid in one piece. This is facilitated by using a threaded K-wire or carpal corkscrew as a joystick in the scaphoid. When excising this bone, ensure that the volar radiocarpal ligaments are protected. This may necessitate piecemeal excision of the scaphoid.

59.8.4 Styloidectomy A radial styloidectomy should be performed if there are significant degenerative changes, or if it impinges on the trapezium during radial deviation.

59.8.5 Graft Bone graft for intercarpal fusion may be taken from excised scaphoid (if healthy), radial styloidectomy, or cancellous bone of distal radius accessed through Lister’s tubercle.

59.8.6 Alignment Failure to align the lunate with the capitate, or dorsal prominence of intercarpal fusion plate, will lead to limited wrist extension. Dorsal radiocapitate impingement may present up to one year postoperatively.7 This may be corrected with plate removal or excision of the dorsal lip of the radius.

59.9 Difficulties Encountered 59.9.1 Approach One may need to extend arthrotomy under the fourth compartment to access the triquetrum and hamate.

Fig. 59.2 Dorsal approach to wrist through third extensor compartment, with preservation of retinaculum over second and fourth compartments (curved Jake retracting unroofed EPL tendon).

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Fig. 59.3 PIN travels along floor of fourth compartment and innervates dorsal capsule. PIN neurectomy may decrease postoperative pain. PIN, posterior interosseous nerve.

Fig. 59.4 Ligament-sparing wrist arthrotomy with radially based capsular flap. Distal incision bisects dorsal intercarpal ligament, ulnar oblique incision bisects dorsal radiocarpal ligament, and third limb follows the radioscaphoid joint.

with preservation of the 2nd, 4th, and 5th compartments. Retract the extensors, identify the PIN in the floor of the 4th compartment, and resect a distal 1 to 2 cm segment (▶ Fig. 59.3). After the surgeon makes their preferred arthrotomy (▶ Fig. 59.4), they should inspect the radiolunate joint and ensure that it is free of degenerative changes. During scaphoidectomy, remember to preserve the volar capsule and radiocarpal ligaments. If indicated, perform radial styloidectomy. Place a 0.062-inch Kirschner wire in the dorsal lunate as a joystick. Expose the midcarpal joint and remove the cartilage of distal lunate and proximal capitate (▶ Fig. 59.5). The lunotriquetral (LT) and triquetral-hamate (TH) joints must be prepared and cartilage should be removed. Inadequate articular preparation can lead to delay or nonunion. Joints are copiously irrigated prior to grafting. Autologous bone graft or allograft should be placed in those intervals prior to fixation. Capitohamate (CH) interval is relatively immobile; some surgeons elect not to graft this joint. After joint preparation is complete, lunate joystick is used to correct dorsal intercalated segment instability (DISI) deformity; lunate should be flexed to align its longitudinal axis with that of the capitate (the lunate usually covers approximately two thirds of the capitate) and confirmed with fluoroscopy. At this point, if K-wires will be definitive fixation, multiple 0.045-inch Kirschner

wires should be placed across all joints to be fused (either percutaneously or through the dorsal incision) (▶ Fig. 59.6a). These are usually cut to sit just beneath the skin. If the surgeon plans to use screw or plate fixation, then K-wires are used for provisional stabilization of the lunate, capitate, and triquetrum. Some surgeons place an additional oblique K-wire from distal radius to lunate in order to maintain its reduced position. When using headless cannulated compression screws, one is placed across the capitolunate joint, and another across the lunotriquetral or triquetrocapitate intervals (▶ Fig. 59.6b). Some surgeons may place an additional screw across the capitohamate joint. If an intercarpal fusion plate is the fixation of choice (▶ Fig. 59.7), the surgeon must make sure to ream/prepare the carpal bones, so that the plate sits flush with their dorsal cortices; otherwise, wrist extension will be limited when the plate impinges on the dorsal radius. Once stable fixation is confirmed clinically and fluoroscopically, the provisional K-wires are removed (▶ Fig. 59.8). Dorsal capsule and retinaculum (if needed) are closed with nonabsorbable sutures, EPL is left in a subcutaneous transposed position, followed by closure of subcutaneous tissues and skin. Volar forearm-based wrist splint is applied. Recommended postoperative management is outlined in ( Box 59.1).

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Key Procedural Steps

Fig. 59.5 Elevation of capsular flap reveals carpal bones with almost complete loss of articular cartilage over proximal pole of capitate (forceps).

Fig. 59.7 Intraoperative view of intercarpal fusion plate stabilizing four-corner fusion with a combination of locking and nonlocking screws.

Fig. 59.6 Alternative fixation techniques. (a) multiple 0.045-inch Kirschner wires transfixing lunate, capitate, triquetrum, and tip of hamate. (b) Cannulated headless screws stabilizing lunate, capitate and triquetrum as main fusion mass. (The senior author, DRS, no longer augments this fixation with K-wires, as seen in this radiograph).

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Scaphoidectomy and Four-Corner Fusion

Fig. 59.8 Six-month postoperative PA (a) and lateral (b) radiographs of scaphoid excision and four-corner fusion with plate. (a) Congruent articulation between lunate fossa and fusion mass through lunate. (b) Plate is recessed to prevent dorsal impingement. Although DISI deformity was not completely corrected in this case, patient was able to achieve functional and pain-free extension. DISI, dorsal intercalated segment instability.

Box 59.1 Postoperative recommendations ●

●

●

●

● ●

Splint is maintained until 7–10 days postsurgery and replaced with short arm cast for an additional 3–8 weeks, depending on fixation technique. While in the cast, fingers and MCP joints are free and encouraged to move. Premature wrist ROM can lead to hardware failure; plate or screw fixation are most stable, allowing early motion, while K-wires require complete immobilization until they are removed. Serial X-rays allow the surgeon to follow the progress of intercarpal fusion. When K-wires are sole fixation, they may be removed once there is evidence of radiographic fusion, usually around 8 weeks. Strengthening is usually initiated 12 weeks postop. Maximal recovery may take up to one year and should be discussed with patient preoperatively.

Abbreviations: MCP, metacarpophalangeal; ROM, range of motion.

59.11 Bailout, Rescue, and Salvage Procedures Rarely, the surgeon may encounter radiolunate arthritis that was not predicted by preoperative imaging studies. They should

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have a discussion with the patient prior to surgery about the need to perform a total wrist arthrodesis, if more advanced arthritis exists, and have the appropriate implants available. Alternatively, if the patient is insistent on a motion-sparing procedure, the surgeon could consider a capsular interposition between the radius and lunate, or a total wrist arthroplasty, although the long-term success of these procedures is unknown.

References [1] Vance MC, Hernandez JD, Didonna ML, Stern PJ. Complications and outcome of four-corner arthrodesis: circular plate fixation versus traditional techniques. J Hand Surg Am. 2005; 30(6):1122–1127 [2] Cohen MS, Kozin SH. Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. J Hand Surg Am. 2001; 26(1):94–104 [3] Dacho AK, Baumeister S, Germann G, Sauerbier M. Comparison of proximal row carpectomy and midcarpal arthrodesis for the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist) in stage II. J Plast Reconstr Aesthet Surg. 2008; 61(10): 1210–1218 [4] El-Mowafi H, El-Hadidi M, Boghdady GW, Hasanein EY. Functional outcome of four-corner arthrodesis for treatment of grade IV scaphoid non-union. Acta Orthop Belg. 2007; 73(5):604–611 [5] Ben Amotz O, Sammer DM. Salvage operations for wrist ligament injuries with secondary arthrosis. Hand Clin. 2015; 31(3):495–504 [6] Berger RA, Bishop AT, Bettinger PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg. 1995; 35(1):54–59 [7] Ashmead D, IV, Watson HK, Damon C, Herber S, Paly W. Scapholunate advanced collapse wrist salvage. J Hand Surg Am. 1994; 19(5):741–750

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60 Partial Distal Ulna Resection (Wafer, Hemiresection) Jason D. Wink and Ines C. Lin Abstract Partial distal ulnar resection can be used to manage symptoms related to ulnar impaction syndrome and distal radioulnar joint (DRUJ) arthritis. The wafer procedure involves removal of a small portion of the distal ulna in order to offload the ulnocarpal joint in cases of ulnar impaction syndrome. The ulna hemiresection arthroplasty involves removal of the ulnar portion of the DRUJ while maintaining the ulnar styloid and triangular fibrocartilage complex (TFCC), and is performed for management of DRUJ arthritis or incongruity. Neither procedure requires healing of an osteotomy and both maintain the stabilizing structures of the DRUJ and ulnocarpal joints. Each procedure has been shown to decrease pain and improve motion for management of their specific indications. Keywords: wafer procedure, ulna hemiresection, ulnar impaction syndrome, distal radioulnar joint (DRUJ) arthritis

60.1 Wafer Procedure 60.1.1 Description The wafer resection of the distal ulna is one means of treating ulnar impaction, or ulnar abutment syndrome. This diagnosis is made clinically when excessive load on the ulnocarpal joint is identified. This most often occurs due to ulnar positive variance, although it has also been described in the ulnar neutral or negative wrist.1 Patients can present with ulnar-sided wrist pain, decreased motion, and grip weakness. Ulnar positive variance can occur as a normal variant, after a trauma resulting in shortening of the radius such as malunion of a distal radius fracture, or due to a congenital deformity such as Madelung’s deformity or multiple enchondromatoses. This procedure involves resection of the very distal ulna while preserving the triangular fibrocartilage complex (TFCC) foveal attachment. It can be done through an open incision, arthroscopically, or a combined approach.

60.1.2 Key Principles The wafer procedure can offload the ulnocarpal joint without healing of an osteotomy or implantation of hardware.2 It has been shown in an ulnar neutral wrist that 18% of force across the wrist joint is centered on the ulnocarpal joint, and when ulnar length increases by 2.5 mm, the force across the ulnocarpal joint increases to 41.9%.3 Injury to the TFCC is commonly associated with ulnar abutment due to constant loading between the ulna and lunate and triquetrum, and can be addressed during the same surgical procedure. Distal radioulnar joint (DRUJ) pathology, such as arthritis, is not addressed with an ulnar wafer resection.

60.1.3 Expectations The results of the wafer procedure have shown diminished pain, with return of wrist motion and grip strength4 in patients

with mild ulnar impaction syndrome. When comparing the wafer procedure to ulnar shortening osteotomy, both groups of patients achieved a return to functional wrist motion and pain relief, although hardware removal in patients who undergo ulnar shortening osteotomy is a relatively common occurrence.5 Return to normal activity after the wafer procedure may take up to 6 months, and there is no guarantee of return to heavy manual labor postoperatively.

60.1.4 Indications The wafer procedure is considered for patients who present with ulnar-sided wrist pain from ulnar impaction syndrome. Their pain is typically aggravated by forceful grip, forearm pronation, and ulnar deviation. Clinical examination may reveal swelling over the dorsal wrist with tenderness to palpation over the ulnocarpal joint and triquetrum and decreased range of motion. Other causes of ulnar-sided wrist pain must be ruled out, including lunotriquetral (LT) pathology, DRUJ arthritis, DRUJ instability, hook of the hamate injury, extensor carpi ulnaris (ECU) subluxation, and pisotriquetral joint injury or arthritis. Imaging studies begin with three view X-ray of the wrist which can reveal ulnar positive variance (▶ Fig. 60.1) and possible cystic changes of the lunate and/or triquetrum. Ulnar impaction is frequently associated with tears of the TFCC,6 which can be evaluated by magnetic resonance imaging (MRI), magnetic resonance arthrogram, and/or arthroscopy. For a successful wafer procedure, no more than 4 mm of the distal ulna is resected, or the procedure will result in removal of the majority of the ulnar head articular surface in contact with the sigmoid notch, potentially compromising the DRUJ articular surface.

60.1.5 Contraindications The wafer procedure is contraindicated in the setting of DRUJ or LT instability or DRUJ arthritis, as the procedure does not address these pathologies. A distal ulnar wafer resection should not be done if more than 4 mm resection is required to neutralize ulnar variance.

60.1.6 Special Considerations With a three view X-ray of the wrist, ulnar variance is measured on the A/P X-ray with the wrist in neutral rotation. This is achieved with the shoulder abducted at 90 degrees, elbow flexed at 90 degrees, and the forearm and palm flat on the X-ray cassette. A true A/P X-ray can be confirmed by identifying the location of the ECU groove radial to the long axis of the ulnar styloid. The measurement is performed by drawing a line through the volar sclerotic line of the distal radius and perpendicular to its long axis. The distance between this line and the cortical margin of the ulnar dome is then measured as ulnar variance. Ulnar positive variance can be further exacerbated by X-ray performed with the patient in power grip or with the forearm pronated. Ulnar height increases on average

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60.1.7 Special Instructions, Positioning, and Anesthesia The wafer procedure can be performed under general anesthesia or upper extremity regional nerve block with monitored anesthesia care. The patient should be positioned on the operating room table with the arm abducted to 90 degrees and forearm pronated for dorsal open approach to the wrist. Upper arm tourniquet is inflated prior to incision for hemostasis and visualization. Mini-C arm fluoroscopy may be used for confirming the location of the incision and extent of the wafer osteotomy. A fine oscillating saw, fine burr or hand-held osteotome can be used for the bony resection. Wrist arthroscopy instruments with traction tower can also be utilized for diagnostic arthroscopy of the wrist and distal ulnar resection with a burr through the central defect in the TFCC which typically occurs with impaction syndrome. It is controversial whether the arthroscopic wafer procedure should be performed in patients who have an intact TFCC.

60.1.8 Tips, Pearls, and Lessons Learned Identification of the dorsal sensory branch of the ulnar nerve is critical for the approach to the distal ulna. The nerve should be found in the subcutaneous tissues, just deep to the basilic veins and gently retracted away from the surgical site. Fluoroscopy is helpful to identify the width of bony resection, in order to ensure that the DRUJ is not violated, and verify that sufficient bony resection is performed. It is critical that the foveal attachment of the TFCC and ECU subsheath be kept intact to maintain the stability of the DRUJ and ulnar carpal bones.

60.1.9 Difficulties Encountered Fig. 60.1 Example of AP view of a wrist X-ray with ulnar positive variance in the setting of ulnar sided wrist pain with a distal radius fracture malunion.

0.4 mm with forearm pronation versus neutral, and this difference may not be clinically significant,7 but ulnar height can increase an average of 2 mm with a power grip in pronated position.8 An X-ray of the contralateral wrist is performed for anatomic comparison. Cystic changes and osteophytes of the lunate, triquetrum, and distal ulna usually best seen on PA view are sequelae of long-term ulnar impaction. The DRUJ and LT intervals must also be visualized. Widening or incongruity of either joint or volar intercalated segmental instability (VISI) deformity is consistent with instability and would raise other causes of wrist pain and concern that ulnar wafer resection would be inadequate treatment for the patient. MRI is useful to diagnose pathology of the TFCC prior to attempting surgical intervention. Increased T2 signal in the ulna and carpal bones is consistent with edema related to increased load and stress across the joint. If TFCC injury is suspected, but not identified on routine MRI, an MR arthrogram can be performed with greater sensitivity in diagnosing injury sustained to the TFCC.9

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The wafer procedure is performed through an open or arthroscopic approach to the distal ulna. The dorsal branch of the ulnar nerve must be identified and carefully retracted out of the surgical field to prevent laceration or traction injury to the nerve. In exposing the distal ulna for an open resection, preservation of the TFCC foveal attachment and DRUJ ligaments is critical for maintaining DRUJ stability. Injury to these structures must be repaired, upon recognition, or the wafer procedure will be unsuccessful. The TFCC should also be tensioned appropriately when closing the wrist capsule. Once all important structures are exposed, the wafer resection can be verified with fluoroscopy. This is essential to ensure that an adequate amount of bone is resected without compromising the DRUJ itself. If the ulnar styloid is fractured during the osteotomy and DRUJ instability occurs, a pin, or other hardware, must be placed for fixation, and the postoperative regimen must be altered to protect healing of this fracture.

60.1.10 Key Procedural Steps A longitudinal or ulnar-based, V-shaped incision is made centered over the DRUJ at the level of the ulnocarpal joint. Dissection is carried down to the level of the extensor retinaculum, taking care to identify and protect the dorsal sensory branch of the ulnar nerve which lies distal to the ulnar styloid. The

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Wafer Procedure

Fig. 60.2 This schematic drawing illustrates the surgical exposure to the TFCC and DRUJ (a), position of the osteotomy (b) and bone wafer excision (c). (Reproduced with permission from Baratz M et al. Wrist Surgery Tricks of the Trade. 1st ed. New York, NY: Thieme 2016.) DRUJ, distal radioulnar joint; TFCC, triangular fibrocartilage complex.

Fig. 60.3 Intraoperative photograph of the wafer procedure showing the exposure of the distal ulna (a) and resection of approximately 4 mm of ulna (b). The TFCC (>) has been retracted away from the distal ulna so that the resection (*) can be performed. Photos used with permission from Benjamin Chang, MD. TFCC, triangular fibrocartilage complex.

ligation of superficial veins is necessary for adequate surgical exposure. The fifth extensor compartment is then opened in a longitudinal fashion and the extensor digiti minimi is retracted in a radial direction. An ulnar or radially based flap is then made in the capsule of the DRUJ to expose the joint and the head of the distal ulna. It is important to preserve the ECU subsheath as it is a secondary stabilizer of the DRUJ. At this point, fluoroscopy can confirm the planned osteotomy. A sagittal saw, side-cutting burr, or osteotome can be used to perform the resection. It is recommended to start with an initial cut on the distal ulna closest to and parallel to the ulnar styloid to mark the ulnar-most edge of the osteotomy in an attempt to prevent a fracture of the styloid. If a fracture occurs, it must be secured with Kirschner wires or interosseous wiring. Once initiated, the osteotomy can then be continued as a flat cut of the distal ulna toward the radial border while carefully preserving the TFCC attachment. The resection thickness is 2 to 4 mm, aiming to give the patient a slightly ulnar negative variance (▶ Fig. 60.2, ▶ Fig. 60.3, ▶ Fig. 60.4). Once the resection is completed, the DRUJ capsule and skin are sequentially closed. Appropriate tensioning of the closure is important. Fluoroscopy will confirm adequate resection, and the forearm should be ranged between full pronation and supination to assess ulnar height and DRUJ stability. This procedure can also be performed arthroscopically at the time of TFCC debridement with the resection being performed through an existing hole in the TFCC.10

Fig. 60.4 Postoperative AP radiograph after wafer resection for treatment of ulnar impaction. Note the restored ulnar neutral variance.

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Partial Distal Ulna Resection (Wafer, Hemiresection) The patient is placed in a sugar tong splint for 2 weeks postoperatively and then transitioned to a removable orthosis. The patient is weaned to a volar wrist splint once 45 degrees of pronation and supination is achieved. Splinting for a longer period of time may be required if fixation of the ulnar styloid is performed to allow for bony healing. There are no formal activity restrictions after 6 weeks, but patients should be counseled that full recovery may not occur until 3 to 6 months after surgery.

60.1.11 Bailout, Rescue, and Salvage Procedures Salvage of the wafer procedure is determined by the wrist pathology and symptoms that may still remain. In the case of continued ulnar impaction, an ulnar shortening osteotomy can be used in place of the wafer procedure, and this decision should ideally be weighed preoperatively when assessing the patient’s ulnar variance and other factors that may affect bony healing. The benefit of the ulnar shortening osteotomy is that it is an extra-articular procedure in which the ulnar dome cartilage remains untouched and it can be used to address greater than 4 mm of ulnar positive variance. The disadvantages of this approach are the placement of hardware, requirement of bony union, and inability to address any TFCC pathology through the same surgical site, all of which are benefits of performing the wafer procedure. The wafer resection will fail in the setting of DRUJ arthritis and/or instability, which are better addressed with other procedures. An open wafer procedure can also be performed after an arthroscopic procedure if it is felt that an inadequate bony resection was performed and better visualization is needed.

60.2 Ulnar Hemiresection Arthroplasty 60.2.1 Description Chronic changes at the DRUJ can result from posttraumatic arthritis, inflammatory arthritis, or osteoarthritis.11 A number of surgical options are available for the management of these patients, if DRUJ incongruity or arthropathy is identified as the primary cause of pain. Ulnar hemiresection arthroplasty refers to a subset of surgical procedures that involve resection of the radial portion of the ulna at the carpus while preserving the ulnar styloid and foveal attachment to maintain DRUJ stability. This resection with augmentation of tendon interposition is often referred to ulnar hemiresection interposition (HIT) arthroplasty in the literature.

60.2.2 Key Principles Ulnar hemiresection, arthroplasty was designed as a procedure to address DRUJ arthritis while maintaining the stabilizing attachments of the TFCC.12 Impinging debris and bone are removed from the ulnar side of the DRUJ to allow for unimpeded motion of the radius around the ulna. Joint capsule or tendon graft can be interposed to maintain the anatomic relationship of the radius and ulna.

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60.2.3 Expectations The expectation is that, by removing abnormal pathology of the DRUJ while maintaining the supporting structures of the TFCC, pain associated with forearm rotation can be reduced. Pain can continue if other causes of ulnar-sided wrist pain remain, such as existing injury to the TFCC, LT ligaments and abutment of the ulnar styloid on the carpal bones. It is expected that patients will lose some strength but hopefully, in exchange for pain relief, will return to full activity after approximately 3 to 6 months. Postoperative immobilization is necessary after surgery, and supervised hand therapy is prescribed to carefully regain motion of the hand, wrist, and forearm.

60.2.4 Indications The ulnar hemiresection arthroplasty treats DRUJ arthropathy, arising from posttraumatic, degenerative, or rheumatoid/ inflammatory etiology.11 In the latter situations, it is most effective in early stage rheumatic disease where ligamentous attenuation has not occurred. It can also be performed in settings of distal radius fracture malunion, resulting in distortion of the sigmoid notch which, in turn, affects forearm rotation. In this instance, it is possible for a corrective distal radius osteotomy to be performed as well, but this will lengthen the postoperative course as bony union will be required, and thus hemiresection of the ulna would be a reasonable alternative to address the DRUJ without needing bony healing. A thorough physical examination of the wrist, as described in the previous section, must be performed to localize pain and confirm that no other pathology exists. Palpation over the TFCC and DRUJ is performed to assess for tenderness with DRUJ tenderness consistent with arthropathy. Full active and passive range of pronation and supination should be assessed. The examiner must be aware of a palpable “click” or mechanical block that inhibits forearm rotation that could be attributed to the DRUJ. The integrity of the TFCC can be confirmed clinically by the TFCC compression test performed with the wrist in ulnar deviation and forearm in neutral, assessing for reproduction of pain or ulnar fovea tenderness. The piano key sign is performed to assess the stability of the DRUJ by dorsal pressure on the distal ulna in the volar direction, like pushing down on a piano key. DRUJ laxity is evaluated as the distal ulna is stressed volarly and dorsally with the forearm in neutral, pronation, and supination.

60.2.5 Contraindications The hemiresection arthroplasty should not be performed in patients with instability of the DRUJ. For example, later stage rheumatoid patients are poor candidates for this procedure due to ligamentous instability. Patients with significant ulnar positive variance must also be treated with an osteotomy or tendon graft interposition to limit impaction of the remaining ulnar styloid on the carpus.

60.2.6 Special Considerations Three view X-ray of the wrist is used to evaluate alignment and degenerative changes of the ulnocarpal joint and DRUJ. X-ray of

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Ulnar Hemiresection Arthroplasty the contralateral arm should be performed for comparison. The A/P view of the wrist may show joint space narrowing and/or osteophytes in cases of arthritis. DRUJ instability can be seen with widening of the joint space on A/P view or malposition of the ulnar head relative to the distal radius on a true lateral. However, it is important to note that the ulnar head may appear subluxated due to imprecise lateral views, and the diagnosis needs to be confirmed with clinical examination. Stress or clenched fist view A/P X-ray of the wrist in pronation can be used to accentuate ulnar height for potential impaction.8 After hemiresection, maximum migration of the ulna toward the radius is about 0.75 cm. Thus, ulnar height must be carefully studied preoperatively, so that at least 2 mm of space remains between the remaining ulnar styloid and carpus to avoid impaction. MRI is indicated when physical examination reveals injury sustained to the TFCC or ulnocarpal ligaments to better characterize and confirm the examination findings. This is helpful in creating a plan prior to surgery.

60.2.7 Special Instructions, Positioning, and Anesthesia This procedure can be performed under general anesthesia or monitored anesthesia care with upper extremity regional nerve block. The extremity is positioned on a hand table with an upper arm tourniquet, shoulder abducted to 90 degrees, and forearm pronated for the dorsal approach to the wrist. A mini C-arm is used to plan the correct position of the osteotomy which can then be performed with a saw or osteotome. A bone rasp can smooth out the remaining ulna after osteotomy is performed.

The TFCC including the foveal attachment and ECU subsheath need to be carefully protected during dissection and resection to minimize risk of injury. Attention should also be paid to the ulnocarpal joint during this procedure. The wrist should be loaded in ulnar deviation and pronation under fluoroscopy to ensure there is no contact between the ulnar styloid and carpus. If so, a shortening of the ulnar styloid can be performed, or a tendon graft can be interposed.

60.2.10 Key Procedural Steps A longitudinal incision is made centered over the DRUJ at the level of the ulnocarpal joint. Dissection is carried down to the level of the extensor retinaculum, taking care to identify and protect the dorsal sensory branch of the ulnar nerve. The fifth extensor compartment is then opened in a longitudinal fashion and the extensor digiti minimi is retracted in a radial direction. The DRUJ joint capsule is then opened with an L-shaped incision for an ulnarly based flap. A small flat osteotome, saw, or Rongeur is used to remove the ulnar head (▶ Fig. 60.5). Care must be taken not to disrupt the foveal attachments of the TFCC. A small laminar spreader can be placed between the ulna and radius to ensure adequate exposure and facilitate resection. The flap of the DRUJ capsule is then used for soft-tissue interposition by suturing it to the volar capsule, or placing tendon interposition at this time. Retinaculum and skin are then closed. Patients are placed in a long-arm or sugar tong splint for 2 weeks postop and then transitioned to an orthosis. Active forearm rotation is begun at 4 weeks postoperatively, and the patient is transitioned to a volar wrist splint once 45 degrees of pain-free pronation and supination is regained. Strengthening

60.2.8 Tips, Pearls, and Lessons Learned During the surgical approach, it is critical to identify and protect the dorsal branch of the ulnar sensory nerve at the level of the subcutaneous tissue. After resection of the radial aspect of the ulnar head, the width of the ulna should be smooth along the length of the bone and dowel-shaped in the A/P view. It is crucial to ensure full smooth supination and pronation of the arm prior to closing. This with intraoperative fluoroscopy ensures adequate bony resection. An osteotomy of the ulnar styloid or an ulna shortening procedure may be required if ulnar impaction is anticipated. Joint capsule or tendon graft such as palmaris longus or allograft can be used to interpose between the remaining ulna and radius.

60.2.9 Difficulties Encountered The resection of the ulna should be performed under direct visualization with the assistance of fluoroscopy, so that the proper amount of bone is resected. A laminar spreader is helpful. The ulna should be tapered carefully to ensure smooth pronation and supination which should be ranged intraoperatively. It is common for the dorsal corner of the ulna to rub against the sigmoid notch during full supination, and this must be checked prior to closure.

Fig. 60.5 This schematic drawing illustrates the surgical exposure and location of the osteotomy performed during the ulnar hemiresection arthroplasty. (Reproduced with permission from Baratz M et al. Wrist Surgery Tricks of the Trade. 1st ed. New York, NY: Thieme 2016.)

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Partial Distal Ulna Resection (Wafer, Hemiresection) and weight bearing begins at 8 weeks with no formal restrictions at 12 to 16 weeks. Most patients return to full activity between 3 to 6 months.

60.2.11 Bailout, Rescue, and Salvage Procedures If the hemiresection fails because of ulnar impingement, an interposition tendon graft sutured into place between the radius and ulna can limit radial migration of the remaining ulna.12 In the case of ulnar abutment or impaction of the ulnar styloid against the carpus, an ulnar diaphyseal osteotomy and shortening could be used to correct ulnar positive variance. If ulnarsided wrist pain continues, DRUJ salvage procedures for arthritis include the Darrach or Sauve-Kapandji procedures. These ablate the DRUJ but also are associated with ulnar convergence, as the ulna migrates toward the radius. This results in pain with loading of the forearm. Another salvage option is total DRUJ arthroplasty with an unconstrained or a semiconstrained device, depending on the integrity of the ligamentous support of the DRUJ.13 For patients who present with DRUJ instability or concern for ulnar translocation of the carpus, a Sauve-Kapandji procedure is considered.

60.3 Acknowledgments Special thanks to David Bozentka, MD, and Benjamin Chang, MD, for their assistance in writing this chapter.

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References [1] Tomaino MM. Ulnar impaction syndrome in the ulnar negative and neutral wrist. Diagnosis and pathoanatomy. J Hand Surg [Br]. 1998; 23(6):754–757 [2] Griska A, Feldon P. Wafer resection of the distal ulna. J Hand Surg Am. 2015; 40(11):2283–2288 [3] Palmer AK, Werner FW. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1984(187):26–35 [4] Feldon P, Terrono AL, Belsky MR. Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome. J Hand Surg Am. 1992; 17(4):731–737 [5] Constantine KJ, Tomaino MM, Herndon JH, Sotereanos DG. Comparison of ulnar shortening osteotomy and the wafer resection procedure as treatment for ulnar impaction syndrome. J Hand Surg Am. 2000; 25(1):55–60 [6] Feldon P, Terrono AL, Belsky MR. The “wafer” procedure. Partial distal ulnar resection. Clin Orthop Relat Res. 1992(275):124–129 [7] Yeh GL, Beredjiklian PK, Katz MA, Steinberg DR, Bozentka DJ. Effects of forearm rotation on the clinical evaluation of ulnar variance. J Hand Surg Am. 2001; 26(6):1042–1046 [8] Tomaino MM. The importance of the pronated grip x-ray view in evaluating ulnar variance. J Hand Surg Am. 2000; 25(2):352–357 [9] Pahwa S, Srivastava DN, Sharma R, Gamanagatti S, Kotwal PP, Sharma V. Comparison of conventional MRI and MR arthrography in the evaluation wrist ligament tears: A preliminary experience. Indian J Radiol Imaging. 2014; 24(3):259–267 [10] Colantoni J, Chadderdon C, Gaston RG. Arthroscopic wafer procedure for ulnar impaction syndrome. Arthrosc Tech. 2014; 3(1):e123–e125 [11] Ahmed SK, Cheung JP, Fung BK, Ip WY. Long term results of matched hemiresection interposition arthroplasty for DRUJ arthritis in rheumatoid patients. Hand Surg. 2011; 16(2):119–125 [12] Bowers WH. Distal radioulnar joint arthroplasty: the hemiresectioninterposition technique. J Hand Surg Am. 1985; 10(2):169–178 [13] Bizimungu RS, Dodds SD. Objective outcomes following semi-constrained total distal radioulnar joint arthroplasty. J Wrist Surg. 2013; 2(4):319–323

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61 Complete Distal Ulna Excision (Darrach) Dominic J. Mintalucci Abstract Darrach resection of the distal ulna has been performed for over 150 years to treat arthritis and instability of the distal radioulnar joint (DRUJ). The procedure is performed on low-demand, elderly and sedentary patients, but provides reliable pain relief with good long-term functional results. Radioulnar convergence and symptomatic stump instability with impingement have been described, but with proper technique, these negative effects can be minimized. The Darrach procedure remains a reliable and viable treatment option in the correctly selected patient. Keywords: Darrach, distal ulna resection, ulnar head, distal radial ulnar joint, posttraumatic arthritis, rheumatoid arthritis, osteoarthritis, DRUJ instability, radioulnar convergence

extensor carpi ulnaris (ECU) tendon, its subsheath, as well as the dorsal and volar radioulnar ligaments also play critical roles in stabilizing the DRUJ. A considerable percentage (70%) of DRUJ stability is provided by the soft tissue stabilizers with only 30% related to the bony articulation itself.3 However, presence of the ulnar head serves to tension the soft tissues, and keeps them at a correct length in order to provide that stability. The pronator quadratus also originates from the distal radius and attaches to the distal ulna, serving as a dynamic stabilizer of the distal ulna. The dorsal sensory branch of the ulnar nerve lies within the subcutaneous tissue, and is potentially at risk during exposure and the surgical procedure. This nerve travels from volar to dorsal, and bifurcates distally typically 1 to 2 cm distal to the ulnar head.

61.1 Description Many procedures have been described for the treatment of the symptomatic distal radioulnar joint (DRUJ). Complete resection of the distal ulna was first described in the 1850s by Bernard and Huette,1 and Malgaigne,2 and several others in the decades to follow, typically indicated for acute trauma. Darrach described the technique in 1912 for management of DRUJ instability, which became the eponym of choice to describe the procedure. Classically, the procedure involves a limited resection of the distal ulna (typically 1.5–3 cm) (▶ Fig. 61.1).

61.2 Indications ● ● ●

● ●

Older and lower demand patient’s with DRUJ arthritis. Rheumatoid arthritis of the DRUJ with symptomatic synovitis. Radial or ulnar malunions with posttraumatic incongruency of the DRUJ. Chronic DRUJ instability. Ulnar impaction, caput ulna syndrome.

61.3 Contraindications ● ●

Young, active, and higher demand patients. Ulnar translocation of the carpus.

61.4 Pertinent Anatomy The DRUJ is the distal articulation head of the ulna and the sigmoid notch of the distal radius. This loosely constrained joint allows for forearm rotation, some proximal and distal migration, and palmar and dorsal translation during forearm rotation. The ulnar head not only serves as a fulcrum through which pronation and supination occur but also allows for support of the ulnar carpus. The fovea contains the critical deep attachment layer of triangular fibrocartilage complex (TFCC),

Fig. 61.1 Depiction of resected distal ulna with some preservation of the soft tissue attachment of the triangular ligament. (Reproduced with permission from Beasley RW. Beasley’s Surgery of the Hand. 1st ed. © 2003 Thieme.)

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61.5 Clinical History and Physical Examination Degeneration of the DRUJ can be due to inflammatory arthritis, osteoarthritis, or posttraumatic conditions. Pain with activated grip, activities which require torque, lifting and turning doorknobs, or opening jars, can reproduce pain over the DRUJ. Patients with inflammatory arthritis typically have prominence of the distal ulna and fullness over the DRUJ relating to the synovitic response. Concomitant extensor tendon rupture may occur and should be evaluated preoperatively. ECU subluxation is distinguished from DRUJ arthritis by noting any ECU subluxation with supination and ulnar deviation of the wrist. Patients present with limited and painful forearm rotation, and with tenderness at the DRUJ. Pain or instability with shuck of the DRUJ can be encountered. The shuck test should be performed in neutral, pronation, and supination, and compared to the contralateral side. The compression squeeze test where the examiner applies manual pressure across the DRUJ can also elicit pain with forearm rotation.

61.6 Imaging Standard radiographs are the mainstay for diagnosis of arthritis and instability of the DRUJ. A grip view with weight can elucidate convergence. In posttraumatic cases, CT scan may help elucidate incongruity of the DRUJ if X-rays are inconclusive. MRI is typically unnecessary, but can be used to differentiate pathology related to ulnar abutment, and competency of the TFCC. In patients with inflammatory arthritis, evaluation of the radiocarpal joint and ulnar translation of the carpus is paramount, as resection of the distal ulna will further destabilize the wrist.

61.8 Positioning and Anesthesia The patient is positioned supine, with the extremity abducted on the hand table under tourniquet control. The procedure may be performed under regional block or general anesthetic.

61.9 Surgical Procedure 61.9.1 Approach The incision used for the procedure may vary, and can depend on whether any associated procedures were performed in conjunction with distal ulnar resection (▶ Fig. 61.2). An apex volar chevron incision can be used if approaching the distal ulna in isolation, and typically utilizes the interval between the flexor carpi ulnaris (FCU) and ECU. I prefer the more versatile dorsal approach. Take care to avoid the dorsal sensory branch of the ulnar nerve; however, this is generally relatively volar at the level of the planned osteotomy. The gateway to the ulnar wrist is through the fifth extensor compartment, and release of this compartment along its more lateral half allows for use of a ulnarly based fifth extensor retinaculum flap, as an augmentation for soft tissue stabilization and repair to the volar radial capsule at the completion of the procedure. Perform a dorsal capsulotomy, starting just proximal to the dorsal radial ulnar ligament, and complete it proximally.

61.9.2 Osteotomy Use subperiosteal dissection to maintain a periosteal sleeve for later closure. Locate the proximal edge of the sigmoid notch, and plan this as the location for the proximal extent of the osteotomy. An oscillating saw is then utilized to osteotomize the distal ulnar metaphysis (▶ Fig. 61.3). The osteotomy

61.7 Nonoperative Management Immobilization in a Muenster-type cast or sugartong splint, and activity modifications which limit torque and forearm rotation, can diminish symptoms. Anti-inflammatory medications can be helpful, and intra-articular cortisone injection can provide relief.

Fig. 61.2 Dorso ulnar approach to the distal ulna.

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Fig. 61.3 An oscillating saw is used to perform the osteotomy.

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Radioulnar Convergence/Stump Instability and Salvage can be transverse or angled slightly from distal medial to proximal lateral, but should stop just proximal to the sigmoid notch. The ulnar head is excised sharply from the surrounding tissue, with no advantage to preserving the ulnar styloid. By keeping the osteotomy as distal as possible helps preserve as much of the soft tissue support as possible, including the interosseous membrane and pronator quadratus to minimize instability.

61.10 Postoperative Management

61.9.3 Closure and Stabilization

61.11 Functional Outcomes

Ulnar Stump Stabilization A major concern after removal of the distal ulna is related to stump instability and radioulnar convergence. My preferred technique to augment the stability of the ulnar stump is to perform an ECU tenodesis (▶ Fig. 61.4). The ECU tendon is split longitudinally, and the radial half of the tendon is released proximally at the myotendinous junction, leaving a distally based tendon slip. A 3.5 mm drill bit is utilized to drill a hole in the dorsal cortex of the ulna, and the tendon passed through the drill hole and out the intramedullary canal, sewn to itself and weaved interlacing fashion. Another option is to use the dorsal capsule to stabilize both the DRUJ and the ECU tendon (▶ Fig. 61.5).

The patient is immobilized in a sugar tong splint or Muenstertype cast for 6 weeks postoperative. Isolated flexion and extension of the radiocarpal and ulnohumeral joint is encouraged early. Forearm rotation and slow progressive weightbearing can begin at 6 weeks, with return to unrestricted activities between 8 to 10 weeks.

The procedure typically provides reliable relief of pain, but does leave the patient with significant limitations, typically in grip strength. Hernekamp4 reviewed 27 wrists and found reduction of pain in visual analog scale (VAS) from 8.8 to 2.3, rotation was 89.7% of the contralateral side, and grip strength was 57% the contralateral side. Stein5 also reviewed 27 wrists with 13-year follow-up, and showed patients had 0.1 VAS pain (scale 1–4), 0.6 VAS pain with activity (scale 1–4), and high-overall satisfaction score 3.7 (scale 1–4). They noted excellent range of motion with 85° pronation, 70° supination, 41° flexion, and 45° extension. Half (50%) of the patients exhibited radiographic evidence of radioulnar impingement based on dynamic radiography;6 however, ulnar impingement was not associated with clinical reports of pain or functional difficulty.

Wound Closure Special care must be taken during closure. Closure of the periosteal layer is accomplished first. 3–0 nonabsorbable suture is placed along the volar radial capsule, ulnar stump is then depressed, and the medially based flap of the fifth extensor compartment retinaculum along with the capsule is sewn to the volar radial capsule as an anterior to posterior soft tissue constraint. The extensor digiti minimi is left transposed dorsal to the retinaculum. The incision is closed with nylon.

61.12 Radioulnar Convergence/ Stump Instability and Salvage The nature of the Darrach procedure inherently leads to radioulnar convergence (▶ Fig. 61.6). The weight and gravity of the radius and carpus “descends” on the ulna after removal of the ulnar seat, and is exacerbated with grip and torqueing of the wrist. Zimmerman7 reviewed a variety of resection

Fig. 61.4 ECU stabilization of the distal ulna. (a) Drill hole through metaphysis; (b) passing of half of ECU through drill hole; (c) ECU half tied to itself distally.

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Fig. 61.5 The distal ulna resection/with stabilization: (a) distal ulna excision. (b) dorsal capsule closure. (c) extensor retinaculum closure with stabilization of the ECU. ECU, extensor carpi ulnaris.

procedure. Bell et al retrospectively reviewed 10 cases of painful, disabling pseudoarthrosis secondary to radioulnar convergence after resection of the distal ulna. Several procedures have been described to stabilize the ulnar stump after “failed Darrach” resection, including tendon stabilization procedures and even wider resection of the distal ulna.9,10,11 There have been more encouraging results with attempts to restore the distance between the ulna and radius with biologic interposition and implant arthroplasty. Sotereanos12 popularized a large biologic interpositional Achilles allograft, and showed 72% improvement in grip strength, with mean patient pain scores improved from 8.1 to 1.3. Luis Scheker has shown improvement in VAS, pronosupination, DASH and PRWE scores, and highpatient satisfaction;13 more recently, in patients under the age of 4014 with his constrained bipolar total DRUJ replacement. Radiolulnar synostosis, or creation of a one bone forearm, should remain a salvage option of last resort.15

61.13 Pearls and Pitfalls Fig. 61.6 Radioulnar convergence.

procedures, and found 74% had radiographic convergence with the Darrach having the greatest degree of instability. Minami et al8 reported 12 of 20 wrists had pain and instability after Darrach resection, although none of the patients in the series underwent a tenodesis or stabilization at the time of the index

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Patient selection is key to success and should be performed on low-demand, elderly patients. Resect as little of the distal ulna as possible, stopping at the proximal aspect of the sigmoid notch. Soft tissue reconstruction and stabilization is paramount; capsular imbrication with retinacular augmentation can provide added stability. ECU tenodesis is a simple adjunctive procedure which adds minimal operative time, and may prevent symptomatic radioulnar impingement.

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References

References [1] Bernard CH, Huette CH. In: Buren WHV, Isaacs CE, eds. Illustrated Manual Of Operative Surgery And Surgical Anatomy. New York: H. Bailliere; 1857 [2] Malgaigne JF, Baillière JB. Traité des fractures et des luxations. Paris: chez J.-B. Baillière; 1855 [3] Stuart PR, Berger RA, Linscheid RL, An KN. The dorsopalmar stability of the distal radioulnar joint. J Hand Surg Am. 2000; 25(4):689–699 [4] Hernekamp JF, Yary P, Bigdeli AK, et al. Corrigendum to “long-term functional outcome and patient satisfaction after ulnar head resection” [J Plast Reconstr Aesthet Surg 69 (2016), 1417–1423]. J Plast Reconstr Aesthet Surg. 2016; 69 (12):1719 [5] Grawe B, Heincelman C, Stern P. Functional results of the Darrach procedure: a long-term outcome study. J Hand Surg Am. 2012; 37(12):2475– 80.e1, 2 [6] Lees VC, Scheker LR. The radiological demonstration of dynamic ulnar impingement. J Hand Surg. 1997; 22:448–450 [7] Zimmermann R, Gschwentner M, Arora R, Harpf C, Gabl M, Pechlaner S. Treatment of distal radioulnar joint disorders with a modified Sauvé-Kapandji procedure: long-term outcome with special attention to the DASH Questionnaire. Arch Orthop Trauma Surg. 2003; 123(6):293–298

[8] Minami A, Iwasaki N, Ishikawa J, Suenaga N, Yasuda K, Kato H. Treatments of osteoarthritis of the distal radioulnar joint: long-term results of three procedures. Hand Surg. 2005; 10(2–3):243–248 [9] Breen TF, Jupiter JB. Extensor carpi ulnaris and flexor carpi ulnaris tenodesis of the unstable distal ulna. J Hand Surg Am. 1989; 14(4):612–617 [10] Allende C. Allograft tendon interposition and brachioradialis tendon stability augmentation in revision surgery for failed Darrach distal ulna resections. Tech Hand Up Extrem Surg. 2010; 14(4):237–240 [11] Wolfe SW, Mih AD, Hotchkiss RN, Culp RW, Keifhaber TR, Nagle DJ. Wide excision of the distal ulna: a multicenter case study. J Hand Surg Am. 1998; 23 (2):222–228 [12] Sotereanos DG, Göbel F, Vardakas DG, Sarris I. An allograft salvage technique for failure of the Darrach procedure: a report of four cases. J Hand Surg [Br]. 2002; 27(4):317–321 [13] Laurentin-Pérez LA, Goodwin AN, Babb BA, Scheker LR. A study of functional outcomes following implantation of a total distal radioulnar joint prosthesis. J Hand Surg Eur Vol. 2008; 33(1):18–28 [14] Rampazzo A, Gharb BB, Brock G, Scheker LR. Functional outcomes of the aptis-scheker distal radioulnar joint replacement in patients under 40 years old. J Hand Surg Am. 2015; 40(7):1397–1403.e3 [15] Peterson CA, II, Maki S, Wood MB. Clinical results of the one-bone forearm. J Hand Surg Am. 1995; 20(4):609–618

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Part X Instability

X

62 Finger (PIP/DIP) Collateral Ligament Repair

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63 Finger Metacarpophalangeal Joint Collateral Ligament Repair

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64 Thumb Metacarpophalangeal Joint Collateral Ligament Repair

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65 Thumb Metacarpophalangeal Joint Collateral Ligament Reconstruction

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66 Scapholunate Ligament Repair

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67 Scapholunate Capsulodesis

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68 Scapholunate Ligament Reconstruction (Brunelli Types)

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69 Distal Radioulnar Ligament Repair/ Reconstruction

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62 Finger (PIP/DIP) Collateral Ligament Repair Meredith N. Osterman Abstract Finger collateral ligament injuries are frequently treated by hand surgeons. Collateral ligament injuries to the fingers are common but most can be treated nonoperatively. Joint instability and joint incongruency, which have failed conservative treatment, are indications for surgical intervention. Keywords: collateral ligament, joint instability, joint congruency, PIP joint, protected range of motion

62.1 Description The collateral ligaments of the finger joints are one of the most commonly injured structures in the hand and are often associated with joint dislocations. Stability of the joint should always be tested, both actively and passively, and radiographic evaluation of joint congruency is essential. The most commonly injured joint in the finger is the proximal interphalangeal (PIP) joint, with the incidence being 37.3 per 100,000 a year in the United States.1 Ligamentous injury to the distal interphalangeal (DIP) joint is rare due to increased stability from the flexor digitorum profundus (FDP) tendon and terminal extensor tendon. Sequelae of a missed joint disruption includes joint stiffness, joint pain, swelling, early degenerative changes, and ultimately loss of function.

62.2 Anatomy PIP joint stability is afforded through bony constraints, capsule, tendons, and collateral ligaments which allow for a 110-degree arc of motion. The lateral stability of the joint is provided by the radial and ulnar collateral ligaments. Collateral ligaments comprise “proper” and “accessory” fibers, confluent with one another but differentiated by their insertion point. The proper ligament inserts volarly on the lateral tubercle of the middle phalynx and has a

dorsal and volar edge. The dorsal part runs parallel to the middle phalanx, while the volar aspect fans out obliquely to its insertion point.2 The accessory ligament is flimsy, travels obliquely, and inserts directly into the volar plate, adding to the stability of this volar structure. The proper ligaments are taut in flexion and slack as the joint comes into extension, due to its more dorsal attachment. In contrast, the accessory component tightens in extension and becomes loose in flexion. Hyperextension of the joint is prevented by the volar plate, with the check-rein ligaments being the major component imparting this stability (▶ Fig. 62.1).

62.3 Evaluation The joint needs to be tested in isolation to evaluate all the soft tissue stabilizers, including the collateral ligaments, volar plate, and central slip. Active and passive range of motion should be tested, and the soft tissue structures need to be stressed to evaluate their integrity. Examination of the uninjured side is helpful in assessing the patient’s “normal” degree of laxity and range of motion. If the joint cannot be reduced concentrically, there is likely soft tissue interposed in the joint. This is commonly the lateral band, collateral ligament, or volar plate. The lateral stress test isolates the collateral ligament. It should be performed in full extension and 30 to 40 degrees of flexion, with the latter isolating the collateral ligaments and removing stability from the secondary stabilizers. Using the tip of a pen or eraser can help isolate the exact location of pain, as the ligaments lie in close proximity to the other soft tissue joint structures. Isolating the exact location of pain can help isolate the exact injured structure. A digital block can help to assess the joint when pain is limiting the examination. Radiographs assess joint congruency and it is essential to obtain a dedicated true lateral of the joint. A hand X-ray does not suffice. An MRI or ultrasound can be helpful in assessing the ligament but are often unnecessary with good clinical examination. Arthroscopic evaluation of the PIP joint using 1.5mm or smaller arthroscopes is an evolving technique to fully asses the joint and evaluate for chondral injuries. The most common injury pattern is an avulsion off the origin site proximally, with the radial side more commonly injured.3,4 Ligament injuries are graded as I, II, or III. Grade I injuries are sprains with stable active and passive range of motion. Grade II injuries are complete disruption of one collateral ligament with stable active range of motion and passive range of motion illustrating instability greater than 20 degrees of angular deviation.3 Grade III injures involve complete disruption of one collateral ligament and another stabilizing structure (volar plate, central slip, etc), with unstable active and passive range of motion.

62.4 Key Principles Fig. 62.1 Anatomy of the PIP joint and collateral ligaments. PIP, proximal interphalangeal.

Key principles of treating collateral injuries of the PIP and DIP joint are based on the joint stability. Stable joints can be treated nonoperatively with a short period of immobilization followed

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Fig. 62.2 (a-c) Oval-8 splint for conservative treatment of PIP collateral ligament injuries. The splint allows for protective motion and collateral ligament stability. PIP, proximal interphalangeal.

Fig. 62.3 Bone anchor fixation of a ligament tear with primary repair.

by protective range of motion (▶ Fig. 62.2). If an unstable or noncongruent joint can be stabilized with reduction and orthosis, an attempt at conservative treatment should be the first line. Unstable or noncongruent joints that fail closed reduction and immobilization require surgical intervention, with the goal being to reconstitute normal anatomy and restore motion. At the time of surgery, the integrity of the ligament is assessed. In acute injuries, the ligament fibers have maintained good tissue quality for a primary repair. The repair can be performed in a variety of ways, including bone tunnels and pull-out stitch or bone anchors. Bone anchors provide a quick and strong repair without the potential for knot irritation on the opposite side of the phalynx (▶ Fig. 62.3 and ▶ Fig. 62.4). In chronic cases, the integrity of the ligament is often compromised and a ligament reconstruction is required. Donor grafts include a slip of abductor pollicis longus (APL), partial slip

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Fig. 62.4 Suture fixation of a ligament tear.

of extensor carpi radialis brevis (ECRB), palmaris longus, or an allograph. The flexor digitorum sublimis (FDS) has also been described as a donor for reconstruction.5,6 The reconstruction can be fixated to bone with bone tunnels and pull-out stitch or bone anchors.7 Arthroscopic evaluation of the PIP joint is another tool to fully assess the joint and ligament integrity. Grade I injuries can be debrided and undergo thermal shrinkage if necessary. At the time of surgery, arthroscopic evaluation of the joint can also be carried out to assess for cartilaginous injury, which is helpful in setting patient expectations and any future surgical intervention. Platelet-rich-plasma (PRP) is well-documented as a treatment for collateral ligaments in larger joints by increasing growth factors and cytokines that aid in regenerative properties of the soft tissue.8 There may be a role for injections of PRP into the digits for similar effects, but the data at this time is sparse.

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References Surgical approaches to collateral ligaments of the PIP joint include midlateral or dorsal. The dorsal incision can be midline or curvilinear; the latter is recommended to avoid scar over the extensor mechanism. It is imperative to preserve the central slip insertion on P2 and expose the joint between the central slip and lateral bands. Another option is a midline opening of the extensor tendon, preserving the central slip insertion.

62.5 Expectations Injuries to the PIP joint often result in some degree of stiffness. Even after repair of acute collateral ligament, joint stiffness and contracture is common. The healing ligament and the scar tissue from surgery increase the overall size of the joint, leading to limited range of motion in both extension and flexion. Patients are often informed that their joints will increase in ring size, even when complete healing has occurred. It is important to discuss this with patients as they often question the increased size of their joints, despite returning to pain-free functionality. If the FDS is used for ligament reconstruction, weakness in grasp or swan neck deformity are potential sequelae.

62.6 Indications for Surgery Indications for ligament repair is instability of the joint that has failed conservative treatment. The radial collateral ligament to the index and the long are most imperative for chuck pinch. With conservative treatment, the ligaments can heal with some laxity or insufficiency, which may require surgical reconstruction if chuck pinch is affected. Indications for ligament reconstruction include chronic, symptomatic instability of the joint with a ligament that is not repairable, and no arthritic changes. The patient should have near-full passive range of motion and have failed conservative treatment.

62.6.1 Contraindications Contraindications for ligament repair or reconstruction include fixed joint contracture, degenerative changes of the articular surface, inflammatory conditions, or patient inability to comply with postoperative protocols.

62.6.2 Postoperative Care Patients are placed in a plaster splint during surgery, which is removed at their first postoperative visit, 12 to 14 days after the procedure. The sutures are removed and patients are fitted with a custom digital gutter orthosis by the hand therapist. Protected range of motion starts at 2 weeks, with splint wear between exercises. Coban is helpful in controlling edema. At 6 weeks postoperatively, the splint is transitioned to nighttime wear and advanced range of motion occurs during the day. An oval-8 splint can be helpful during the transition. Strengthening starts at 6 weeks. Patients are cleared for full activity as tolerated at 3 months.

62.7 Pearls I prefer to treat these “wide-awake.” This allows for the patient to perform active range of motion after the repair and assess joint stability. The patient is met in the preoperative holding area, where a digital block is administered using lidocaine with epinephrine and bicarbonate. In arthroscopic evaluation of the joint, the patient must have regional or general anesthesia. The real pearls of PIP collateral ligament injuries are recognizing them and treating them quickly, often with nonoperative measures. Surgical indications are rare.

References [1] Ootes D, Lambers KT, Ring DC. The epidemiology of upper extremity injuries presenting to the emergency department in the United States. Hand (N Y). 2012; 7(1):18–22 [2] Allison DM. Anatomy of the collateral ligaments of the proximal interphalangeal joint. J Hand Surg Am. 2005; 30(5):1026–1031 [3] Kiefhaber TR, Stern PJ, Grood ES. Lateral stability of the proximal interphalangeal joint. J Hand Surg Am. 1986; 11(5):661–669 [4] Wray RC, Young VL, Holtman B. Proximal interphalangeal joint sprains. Plast Reconstr Surg. 1984; 74(1):101–107 [5] Lane CS. Reconstruction of the unstable proximal interphalangeal joint: The double superficialis tenodesis. J Hand Surg Am. 1978; 3(4):368–369 [6] Carlo J, Dell PC, Matthias R, Wright TW. Collateral Ligament Reconstruction of the Proximal Interphalangeal Joint. J Hand Surg Am. 2016; 41(1):129–132 [7] Lee JI, Jeon WJ, Suh DH, Park JH, Lee JM, Park JW. Anatomical collateral ligament reconstruction in the hand using intraosseous suture anchors and a free tendon graft. J Hand Surg Eur Vol. 2012; 37(9):832–838 [8] Saucedo JM, Yaffe MA, Berschback JC, Hsu WK, Kalainov DM. Platelet-rich plasma. J Hand Surg Am. 2012; 37(3):587–589, quiz 590

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63 Finger Metacarpophalangeal Joint Collateral Ligament Repair Gregory G. Gallant Abstract Injuries to the collateral ligaments of the fingers are less common than those sustained in the thumb. This injury can be functionally disabling if not properly diagnosed and treated appropriately. X-rays can be helpful in the workup of this injury and MRI can be a valuable diagnostic tool as well. Partial (Grade 1 and 2) injuries and nondisplaced fractures are treated conservatively. Complete (Grade 3) injuries and displaced fractures are treated surgically. For chronic injuries, direct repair is recommended if satisfactory ligament quality is present. When ligament quality is not satisfactory, tendon graft reconstruction is preferred. Clinical results of acute repair are usually better than chronic repair or reconstruction which emphasizes the importance of early diagnosis and treatment.

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Keywords: collateral, ligament, metacarpophalangeal, fingers, proper, accessory, grades, repair

63.1 Description ●

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Injuries to the collateral ligaments of the metacarpophalangeal (MP) joints of the index, long, ring, and small digits are less common than sustained in the thumb. 1 in 1,000 hand injuries are injuries to collateral ligaments, with 39% involving the fingers and 61% involving the thumb.1 These injuries can be functionally disabling and are frequently neglected by the patient or underdiagnosed.

63.2 Anatomy/Physiology ●

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Finger MP joint radial and ulnar collateral ligaments consist of both the proper ligament and the accessory ligament (▶ Fig. 63.1). The proper collateral ligament is the most important and strongest stabilizer of the MP joint, but in severe injuries, the accessory collateral ligament can be torn as well.

The proper collateral ligament is a thick cord which originates from the posterior tubercle on the lateral surface of the metacarpal head, which is in a slightly dorsal position, and courses obliquely to insert on the palmar portion of the lateral surface of the base of the proximal phalanx. The proper collateral ligaments are the main static restraints, with the MP joints in maximum flexion. The accessory collateral ligament is a fan-shaped structure that originates from the apex of the anterior tubercles of the lateral surface of the metacarpal head and spreads toward the palm to insert along the lateral margin of the volar plate. The accessory collateral ligaments along with the volar plate are the main static restraints with the MP joints in full extension. Fingers MP joints are most lax in extension and become progressively tighter with flexion, mainly due to the cam shape of the metacarpal head causing an overall lengthening and therefore tightening of the proper collateral ligament with increasing joint flexion.2

63.3 Examination ●

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Stability of the collateral ligament is best assessed with the MP joint in full flexion. Baseline examination of the opposite side noninjured similar digit is very important in providing a normal for comparison.3

63.4 Clinical Aspects ●

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Injuries to the finger collateral ligaments are most common in the 4th decade and occur slightly more commonly in men than women. This injury occurs due to an abduction or adduction force with the MP joint in some degree of flexion. The middle finger is most commonly injured with both radial and ulnar collateral ligaments equally affected. The radial collateral ligament is more commonly injured than the ulnar collateral ligament in the ring and small digits. The ulnar collateral ligament is more commonly injured in the index finger, although injury of the radial collateral ligament of the index finger may be a very functionally disabling injury due to the importance of this ligament with thumb to index pinch. Collateral ligaments may be avulsed from bone with either a large or small attached fracture fragment.

63.5 Ligament Injury Grades/Classification 63.5.1 Grade 1 Fig. 63.1 Lateral view of finger MP joints shows the normal anatomy of the proper and accessory collateral ligaments and volar plate.

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Ligament becomes stretched with a few torn fibers. No laxity is present on physical examination.

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Positioning and Anesthesia

63.5.2 Grade 2 ● ● ●

There is a greater number of torn ligament fibers. More pain and swelling noted clinically. Increased laxity on clinical examination with a definite endpoint.

63.7 Radiographic Studies ●

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63.5.3 Grade 3 ● ●

All ligament fibers are torn. Marked laxity on exam with no definite endpoint

63.5.4 Fractures ● ●

Small avulsion fragment. Larger bone fragment.

63.6 Location of Ligament Injury ● ● ● ●

Avulsion from the proximal phalanx (most common). Midsubstance ligament tear. Avulsed from the metacarpal (least common). Disruption of the sagittal band may also be seen in these injuries and can become entrapped at the site of the ligament tear, which is similar to a Stener’s lesion of the thumb4 (▶ Fig. 63.2).

Plain X-rays are necessary to assess for fracture or subluxation. Brewerton X-ray views can be helpful in diagnosing possible avulsion fracture of the metacarpal head. If this injury is difficult to assess clinically, and X-rays are negative, then an MRI can be done for further assessment.

63.8 Conservative Treatment ● ● ●

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Recommended for Grade 1 and most Grade 2 injuries. Also recommended for nondisplaced fractures. Buddy taping to an adjacent digit and allowing flexion/ extension arc of motion for approximately 3 weeks can be used for Grade 1 injuries. Formal splinting, either radial (for index and long digits) or ulnar gutter type (for ring and small digits), is recommended for most Grade 2 injuries. Formal casting for approximately 3 to 4 weeks is recommended for nondisplaced fractures.

63.9 Indications for Surgical Treatment ● ● ● ●

All grade 3 injuries.1 Grade 2 injuries which have failed conservative treatment. Fractures displaced greater than 2 mm. Chronic injuries (usually greater than 6 weeks postinjury) causing significant pain and/or dysfunction.

63.10 Contraindications to Surgery ●

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General underlying medical conditions making surgery too high-risk in nature. Presence of active infection either systemic or local. Presence of underlying arthritis at the MP joint where arthroplasty surgeries would be more appropriate.

63.11 Positioning and Anesthesia ●

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Fig. 63.2 A more severe force can cause a sagittal band tear, in addition to a collateral ligament tear. In this example, the collateral ligament is torn in its midsubstance.

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Standard OR table or stretcher, which is convertible to an OR table, are normally used. Anesthesia is usually local injection with 1 to 2% lidocaine along with IV sedation. The lidocaine should be injected proximal to the planned surgical area to anesthetize the nerve distribution to the affected digit. This allows less fluid at the actual operative site as excess fluid can lead to soft tissue distortion, making visualization a bit more difficult. More proximal block anesthesia and, rarely, general anesthesia can be used as well. A standard arm tourniquet is also used. IV antibiotics are administered prior to tourniquet inflation.

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63.12 Surgical Techniques 63.12.1 Acute Injuries ●

A standard dorsal incision is made approximately 2 to 3 cm in length. The sagittal band on the side of the injured ligament is incised longitudinally which allows exposure of the injured area. If the sagittal band is torn as a result of the injury, exposure of the collateral ligament can be done through this torn section with later sagittal band repair. Also, if the sagittal band is torn and entrapped at the ligament tear site (similar to a

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Stener’s lesion of the thumb), it can be extracted from the tear site at this time.4 Location of the ligament tear is then identified. If the ligament is torn from the proximal phalanx (most common), repair with a suture anchor is then performed (▶ Fig. 63.3a, b). I prefer the Mini-Mitek (Depuy Synthes, USA) metallic or bioabsorbable suture anchor for this. If the ligament is torn from the metacarpal, it is repaired in a similar fashion (▶ Fig. 63.4a, b). If the ligament is torn at its midsubstance, direct repair with a 2–0 nonabsorbable suture is recommended. I prefer 2–0 FiberWire suture (Arthrex, USA) in this situation (▶ Fig. 63.5a, b).

Fig. 63.3 (a) Shows rupture of an ulnar collateral ligament from its insertion onto the proximal phalanx; (b) shows repair of the ligament directly to bone using a suture anchor. The collateral ligament is exposed by making a longitudinal incision in the sagittal band.

Fig. 63.4 (a) Shows rupture of an ulnar collateral ligament from its origin on the metacarpal; (b) shows repair of the ligament directly to bone using a suture anchor.

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Outcomes

Fig. 63.5 (a) Shows tear of the ligament in its midsubstance; (b) shows direct repair with suture.

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Ligaments are repaired holding the thumb MP joint in approximately 30 degrees of flexion. Layered closure is then performed using 3–0 vicryl for repair of the sagittal band and 4–0 nylon for skin closure. A sterile dressing is then applied, and the operative digit and one adjacent digit are immobilized using a forearm-based splint which extends to the tips of the digits.

63.12.2 Chronic Injuries ● ●

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Standard approach is performed the same as for acute injuries. The injured ligament is then inspected, and the quality of the ligament and the ability to directly repair the ligament are assessed. If the injured ligament is of good quality and able to be repaired, direct repair is then performed as it is for an acute injury. If the injured ligament is of poor quality and/or cannot be primarily repaired, then reconstruction is recommended. A tendon graft, most often the ipsilateral palmaris longus, is used to reconstruct the ligament. The tendon graft can be anchored using either drilled tunnels (▶ Fig. 63.6) or interference screw fixation (▶ Fig. 63.7). I prefer to use Arthrex 3 mm x 8 mm tenodesis screw fixation (Arthrex, USA), as it allows a less technically demanding procedure with outcomes similar to using drilled tunnels.5 The graft is tensioned holding the MP joint in approximately 30 degrees of flexion. The same postoperative dressing used for acute repair is used for reconstruction of chronic injuries.

63.12.3 Small Displaced Avulsion Fractures ● ●

Fragment excision with direct ligament repair is recommended. Surgical repair techniques is the same as for acute injuries.

63.12.4 Larger Displaced Fractures ●

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This type of fracture usually occurs at the base of the proximal phalanx. Fractures displaced greater than 2 mm and involving 10% or more of the joint surface are treated with open reduction internal fixation6 (▶ Fig. 63.8).

63.13 Postoperative Treatment ● ●

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All surgeries are performed on an outpatient basis. The patient is seen approximately 1-week postop and sutures are removed and a short arm cast is applied incorporating the operative digit and an adjacent digit. The cast is removed at 4 weeks and a formal hand therapy program is initiated. From week 4 to 10, an active and passive range of motion program is performed with no lifting, pushing, or pulling greater than 2 pounds to protect the repair. At week 10, a gradual progressive strengthening program is initiated. Return to sports or vigorous activity is allowed at the 3-month mark with taping to an adjacent digit until the 6-month mark. At the 6-month mark, no further protection is needed and unrestricted activity is allowed.

63.14 Outcomes ●

Delaere and colleagues reported on 10 patients with a total of 12 collateral ligament repairs. Most fingers undergoing surgery regained full mobility at 10.7 weeks had no residual instability or pain, and remained asymptomatic at the 2-year follow-up evaluation.1

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Fig. 63.7 Shows ligament reconstruction technique using interference screw fixation for tendon fixation.

Fig. 63.6 Shows ligament reconstruction technique using drilled bone tunnels through which the tendon graft is passed.

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Riederer and colleagues reported 16 good or excellent results and four poor results with regard to pain relief following radial collateral ligament reconstruction of finger MP joints with tendon grafts. Fourteen patients had stable joints, four had minimal residual instability, and two had marked instability.8 However, Lutsky and associates noted overall suboptimal results with primary repair of subacute-to-chronic grade 3 collateral ligament injuries in 23 patients. They therefore recommended surgical repair of complete tears in the acute setting.9

63.15 Pitfalls ●

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Stiffness in the MP joint is encountered frequently. Appropriate splint positioning after surgery is critical to avoid this problem. The position of the pilot drill hole should be checked prior to insertion of the anchor to avoid malpositioning.

References Fig. 63.8 Shows screw fixation of larger fracture fragment.

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Schubiner and Mass reported satisfactory results following repair of complete collateral ligament tears at the MP joint of the fingers in 10 patients.7 Repair of chronic injuries shows a much more guarded prognosis.

[1] Delaere OP, Suttor PM, Degolla R, Leach R, Pieret PJ. Early surgical treatment for collateral ligament rupture of metacarpophalangeal joints of the fingers. J Hand Surg Am. 2003; 28(2):309–315 [2] Rozmaryn LM. The collateral ligament of the digits of the hand: anatomy, physiology, biomechanics, injury, and treatment. J Hand Surg Am. 2017; 42 (11):904–915 [3] Lutsky K, Matzon J, Walinchus L, Ross DA, Beredjiklian P. Collateral ligament laxity of the finger metacarpophalangeal joints: an in vivo study. J Hand Surg Am. 2014; 39(6):1088–1093 [4] Lourie GM, Gaston RG, Freeland AE. Collateral ligament injuries of the metacarpophalangeal joints of the fingers. Hand Clin. 2006; 22(3):357–364, viii

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References [5] Dy CJ, Tucker SM, Hearns KA, Carlson MG. Comparison of in vitro motion and stability between techniques for index metacarpophalangeal joint radial collateral ligament reconstruction. J Hand Surg Am. 2013; 38(7):1324–1330 [6] Green DP. Dislocations and ligamentous injuries of the hand. In: Evarts CM, ed. Surgery of the Musculoskeletal System, Vol. 1. New York: Churchill Livingston; 1983:119–183 [7] Schubiner JM, Mass DP. Operation for collateral ligament ruptures of the metacarpophalangeal joints of the fingers. J Bone Joint Surg Br. 1989; 71(3):388–389

[8] Riederer S, Nagy L, Büchler U. Chronic post-traumatic radial instability of the metacarpophalangeal joint of the finger. Long-term results of ligament reconstruction. J Hand Surg [Br]. 1998; 23(4):503–506 [9] Wong JC, Lutsky KF, Beredjiklian PK. Outcomes after repair of subacute-tochronic grade III metacarpophalangeal joint collateral ligament injuries in the lesser digits are poor. J Hand Surg [Am]. 2013; 38(10):supplement, e23–4

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64 Thumb Metacarpophalangeal Joint Collateral Ligament Repair Megan L. Jimenez and Bruce A. Monaghan Abstract Thumb metacarpophalangeal joint (MCPJ) collateral ligament repair is a treatment option in acute complete ligament tears and those associated with Stener lesions or MCPJ subluxation. Ulnar collateral ligament tears are more common than radial collateral ligament tears. While physical examination is typically sufficient for the diagnosis of complete tears, advanced imaging can be useful to fully delineate collateral ligament injuries in cases of clinical uncertainty. Repair of the collateral ligaments of the thumb can be performed with suture anchors. The key to the procedure is precise reattachment to the bony footprint. Keywords: thumb metacarpophalangeal joint, ulnar collateral ligament tear, acute ulnar collateral ligament tear, thumb ulnar collateral ligament repair, radial collateral ligament tear, radial collateral ligament repair

64.1 Description Treatment of thumb metacarpophalangeal joint (MCPJ) ulnar collateral ligament (UCL) injuries depends on acuity of the injury, location, partial versus complete rupture, and the presence

of a Stener lesion. Acute (< 4 weeks old) injuries are often referred to as a Skier’s thumb and are amenable to primary repair, whereas chronic injuries are referred to as Gamekeeper's thumb and frequently require ligament reconstruction.1,2 Radial collateral ligament (RCL) injuries are far less common. Although a Stener type lesion (abductor aponeurosis rather than the adductor) can occur, it occurs less frequently with RCL tears. Physical examination may show a prominent dorsal prominence of the metacarpal head because of the rotational deformity caused by a torn RCL. Phalangeal subluxation may also suggest dorsal capsule injury in addition to a RCL tear.1,2

64.1.1 Anatomy/Physiology Thumb MPCJs, RCLs, and UCLs consist of both the proper ligament and the accessory ligament (▶ Fig. 64.1). The proper collateral ligament is mechanically important and functions as primary stabilizer of the MCPJ, originating from the lateral aspect of the metacarpal and inserting on the palmar portion of the lateral surface of the base of the proximal phalanx. It is lax in extension and taut in flexion due to the cam shape of the metacarpal head. The accessory collateral ligament originates from the metacarpal head and attaches on the volar plate. A Stener lesion occurs when the avulsed ligament becomes

Fig. 64.1 MCP joint of the thumb. (Reproduced with permission from Hirt B, Seyhan H, Wagner M, Zumhasch R. Hand and Wrist Anatomy and Biomechanics. 1st ed. © 2017 Thieme.) MCP, metacarpophalangeal.

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Indications

Fig. 64.2 A Stener lesion occurs when the avulsed ligament becomes caught and proximally reflected on the proximal edge of the adductor aponeurosis, precluding healing. 1 – sensory nerve; 2 – ulnar collateral ligament; 4 – adductor aponeurosis. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

Fig. 64.3 Hand Based Orthoplast Splint. (Reproduced with permission from Plancher KD. Master Cases Hand and Wrist Surgery. New York, NY. Thieme; 2004.)

64.3 Expectations

Fig. 64.4 Greater than 30 degrees laxity with radial stress.

caught on the proximal edge of the adductor aponeurosis, precluding healing as the ligament stump is removed from its point of insertion (▶ Fig. 64.2).

64.2 Key Principles Specific treatment of acute thumb UCL tears depends on location. Midsubstance tears are treated with direct suture repair, whereas distal avulsions are treated with suture anchor fixation back to bone.1,2 The most important element of repair for both UCL and RCL tears is the precise anatomic realignment of the ligament to its bony footprint.

Following surgery, the thumb is immobilized with the interphalangeal joint left free for 3 to 4 weeks. Hand therapy is begun 3 to 4 weeks postoperatively and the patient is switched to a hand-based thermoplastic splint which should be worn an additional 2 to 4 weeks after removal of the postoperative splint or cast (▶ Fig. 64.3). Stiffness should be expected for several weeks to months following surgery. Unrestricted activity may be restarted approximately 3 to 4 months after surgery; some minor discomfort may continue up to 1 year following surgery.2

64.4 Indications Partial UCL ruptures can be treated nonoperatively within 3 to 4 weeks of continuous immobilization. Operative fixation is performed when any of the following criteria are met, although it is recommended that several tests be performed and considered together. ● Greater than 30 degrees of laxity with radial stress (▶ Fig. 64.4). ● Greater than 15 degrees of laxity with radial stress compared to the contralateral thumb. ● Lack of a solid end point when stressing the MCPJ at 30 degrees of flexion.3

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Thumb Metacarpophalangeal Joint Collateral Ligament Repair Table 64.1 MRI classification of UCL injuries4 Group

UCL appearance on MRI

Treatment

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Partial/undisplaced tear

Immobilization

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Immobilization

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Complete tear greater than 3 mm

Surgical repair

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Stener lesion

Surgical repair

Displacement of the UCL greater than or equal to 3 mm visualized on MRI.4 ● Interposition of the adductor aponeurosis (Stener lesion), which can be found on MRI or ultrasound. This can occasionally be palpated on physical examination.5,6 ● Complete RCL tear where progressive volar and ulnar subluxation of the MCPJ can occur due to the unopposed pull of the adductor aponeurosis. Partial RCL tears can be treated like partial UCL tears. Complete RCL tears are diagnosed similar to tears of the UCL, although a Stener equivalent is usually not observed. A unique finding to RCL tears is volar subluxation on standard radiographs, which occurs more commonly than with complete UCL tears. Complete, acute tears should be treated with early surgical repair.2,7,8 ●

Fig. 64.5 Coronal MRI PD Fat Sat showing a complete tear of the UCL (white arrow) and an intact RCL. The ligament is reflected proximally indicating a Stener lesion. PD Fat Sat, proton density fat saturation; RCL, radial collateral ligament; UCL, ulnar collateral ligament.

64.5 Contraindications General contraindications for surgical patients can be applied to collateral ligament treatment. Local infections and patients who are medically unfit for surgery should either delay surgery or attempt nonoperative management. Chronic tears, 3 to 6 weeks, are challenging to treat with repair secondary to fibrosis and experience difficulty with identifying the torn remnant of the ligament. These injuries are classically treated with reconstruction. Ligament repair or reconstruction should not be undertaken when there are arthritic changes present at the MCPJ. When arthritis is present, arthrodesis is often indicated.1,2,9

64.6 Special Considerations Although advanced imaging is not required when physical examination clearly indicates a complete tear, the decision to operate on UCL tears is often made after evaluating the combination of physical examination, X-rays, and advanced imaging. Ultrasound allows for the evaluation of dynamic examination, whereas MRI has shown to provide 100% sensitivity and specificity in the diagnosis of a Stener lesion (▶ Table 64.1).4,5,6 UCL tears can be classified by type depending on the MRI findings. Type 3 and 4 tears should be treated operatively (▶ Fig. 64.5).4

64.7 Special Instructions, Positioning, and Anesthesia ● ●

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Surgery is performed as an outpatient. The options for anesthesia include general anesthesia, regional anesthetic block, wide-awake local anesthesia and no

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tourniquet (WALANT), or under local anesthesia with monitored anesthesia care. – For wide-awake anesthesia, the recommended dosage is 15 mL of 1% lidocaine with 1:100,000 epinephrine and 8.4% bicarbonate (mixed in a 10:1 ratio). The injection technique includes 2 mL on each of the volar and dorsal aspects of the proximal phalanx, with the remainder around the metacarpal head. This technique allows the surgeon to assess the gliding of the adductor aponeurosis over the repaired ulnar collateral anesthetic.10 Position the patient supine with a removable hand table placed on the operative side. If using a tourniquet, a nonsterile tourniquet can be placed proximal on the arm. Otherwise, a sterile tourniquet for placement on the forearm should be available if a proximal tourniquet is contraindicated (e.g., arteriovenous [AV] shunt or concomitant proximal limb injury). Prep and drape according to surgeon preference for hand/ wrist procedures.

64.8 Tips, Pearls, and Lessons Learned Patients should be counseled regarding the possibility of dorso– ulnar numbness and paresthesias following surgery secondary to manipulation of the dorsal sensory branches of the radial nerve in the operative approach. Stress radiographs (with comparative views, if needed) can aid in making a diagnosis of

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Key Procedural Steps (UCL Repair)

Fig. 64.6 Comparison stress radiograph, where the left is positive for UCL tear and the right thumb is normal. (Reproduced with permission from Boyer MI, Chang J. 100 Hand Cases. New York, NY. Thieme; 2016.) UCL, ulnar collateral ligament.

Fig. 64.7 Dorsal incision.

Fig. 64.8 Superficial branch of the radial nerve. (Reproduced with permission from Nikkhah D. Hand Trauma: Illustrated Surgical Guide of Core Procedures. New York, NY. Thieme; 2018.)

collateral ligament tear (▶ Fig. 64.6). In addition, critical assessment of the radiographs is necessary to rule out subtle or frank volar joint subluxation that should be addressed with dorsal capsular ligament repair and/or temporary pinning of the MCPJ. Stiffness can also occur if the ligament is not at the isometric insertion point of the volar aspect of the proximal phalanx base. This can be avoided by placing the anchor at the appropriate anatomic insertion site which is 25% dorsal to the volar margin of the proximal phalanx.1 Visualization of the articular surface is essential to assure that no degenerative changes are present, which would prevent a successful outcome after ligament repair or reconstruction. In those cases, the symptomatic patient is best served by an arthrodesis of the MCPJ.11

64.9 Difficulties Encountered In cases where the collateral ligament may be difficult to visualize, it is useful to find its origin at the metacarpophalangeal head and dissect it gently distally. The expectation is

that the ligament may be adherent and folded on itself, making it appear too short for reattachment. If, after adequate dissection, the quality or length of the ligament precludes anatomic realignment, then augmentation or replacement with a tendon graft will be required. While palmaris longus is the most commonly cited autograft, the extensor pollicis brevis is also expendable and can be harvested without an additional incision. This graft can be utilized for augmentation of a repair, but its length may not be amenable for formal ligament reconstruction.1

64.10 Key Procedural Steps (UCL Repair) A straight or curvilinear (extending proximal–dorsal to distal– volar) 3 cm incision is made over the ulnar metacarpal head extending distally over the metacarpophalangeal joint, and ending over the middle of the proximal phalanx (▶ Fig. 64.7). Care is taken to identify, protect the branches of the superficial radial nerve (▶ Fig. 64.8). These may be tagged with a vessel loop and protected during the entire procedure. The next structure that comes into view is the adductor aponeurosis, which must be identified, separated from the capsule, longitudinally split, and the underlying capsule and ligament stump identified (▶ Fig. 64.9a, b). The joint surface should be inspected at this point. If necessary, a transosseous 0.0062 K-wire is placed from the ulnar base of the proximal phalanx to engage the metacarpal head. Placement of a K-wire is not routine and should only be done to help with alignment of the MCPJ, in cases of persistent following. The distal insertion site on the ulnar base of the proximal phalanx is curetted to prepare the bony bed which can be found at the footprint where the remnants of the UCL are

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Fig. 64.9 (a) The adductor aponeurosis is divided along the line of the incision to reveal the ruptured ligament. 1 – adductor aponeurosis; 2 – proper ulnar collateral ligament; 3 – accessory ulnar collateral ligament. (Modified with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.) (b) The ulnar collateral ligament is visualized (black arrow) after the adductor aponeurosis (black asterisk) is sectioned.

Fig. 64.10 (a) Microanchor placed in the proximal phalanx. (b) Schemtic of a microanchor placed in the proximal phalanx. (c) Sutures from anchor used to repair the ligament back to the point of insertion into the proximal phalanx.

often present. A small suture anchor is placed in the proximal phalanx footprint (▶ Fig. 64.10). Use the suture from the anchor to secure the ligament to its point of insertion (▶ Fig. 64.11c). Fix the distal UCL in 30 degrees of MCPJ flexion, then perform a tension-free repair of the adductor aponeurosis (▶ Fig. 64.11). In addition, tears in the volar plate and

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capsule must be identified and repaired. Skin closure is performed with 4–0 nonabsorbable monofilament suture. The K-wire, if placed, is cut and bent just outside the skin, and the thumb is placed in a bulky dressing and thumb spica splint. Postoperatively, the splint is maintained and the patient is seen for follow-up in 10 days.1,12

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References

Fig. 64.11 (a) Adductor aponeurosis closure over the UCL repair. Note: a K-wire is used when further stabilization of the joint is needed. (b) Schematic demonstrating aponeurosis repair. (Modified with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.) Repair of adductor aponeurosis.UCL, ulnar collateral ligament.

64.11 Bailout, Rescue, and Salvage Procedures In cases of chronic tears or insufficient tissue for repair, the surgeon must be prepared to augment the repair with local tissue or perform a reconstruction procedure.11,13 Reconstruction, with a free tendon graft, must always be discussed preoperatively with the patient as an alternative procedure, should repair be insurmountable. In the setting of advanced arthritis or instability, arthrodesis of the MCPJ may also be considered.

64.12 Pitfalls ●

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Injury/neuropraxia of the terminal branches of the radial sensory nerve. Nonanatomic alignment of the collateral ligament. Poor quality of tissue leading to insufficiency of repaired collateral ligament. Residual joint subluxation of the MCPJ. Failure to recognize arthritic change of the joint.

References [1] Merrell G, Hastings H. Dislocations and Ligament Injuries of the Digits. Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS. Green’s Operative Hand Surgery. Philadelphia: Elsevier; 2016: 302–310

[2] Calandruccio, JH. Fractures, Dislocations, and Ligamentous Injuries. Azar FM, Beaty JH, Canale ST. Campbell’s Operative Orthopedics. Philadelphia: Elsevier; 2017: 3417–3422 [3] Malik AK, Morris T, Chou D, Sorene E, Taylor E. Clinical testing of ulnar collateral ligament injuries of the thumb. J Hand Surg Eur Vol. 2009; 34(3): 363–366 [4] Milner CS, Manon-Matos Y, Thirkannad SM. Gamekeeper’s thumb–a treatment-oriented magnetic resonance imaging classification. J Hand Surg Am. 2015; 40(1):90–95 [5] Papandrea RF, Fowler T. Injury at the thumb UCL: is there a Stener lesion? J Hand Surg Am. 2008; 33(10):1882–1884 [6] Resonance M, Tresley J, Singer AD, Ouellette EA, Blaichman J, Clifford PD. Multimodality approach to a Stener lesion: radiographic, ultrasound, magnetic resonance imaging, and surgical correlation. Am J Orthop. 2017; 46(3):195–199 [7] Coyle MP, Jr. Grade III radial collateral ligament injuries of the thumb metacarpophalangeal joint: treatment by soft tissue advancement and bony reattachment. J Hand Surg Am. 2003; 28(1):14–20 [8] Edelstein DM, Kardashian G, Lee SK. Radial collateral ligament injuries of the thumb. J Hand Surg Am. 2008; 33(5):760–770 [9] Gluck JS, Balutis EC, Glickel SZ. Thumb ligament injuries. J Hand Surg Am. 2015; 40(4):835–842 [10] Lalonde D, Eaton C, Amadio P, Jupiter J. Wide-awake Hand and Wrist Surgery: A New Horizon in Outpatient Surgery. Instr Course Lect. 2015; 64: 249–259 [11] Carlson MG, Warner KK, Meyers KN, Hearns KA, Kok PL. Mechanics of an anatomical reconstruction for the thumb metacarpophalangeal collateral ligaments. J Hand Surg Am. 2013; 38(1):117–123 [12] Moharram AN. Repair of thumb metacarpophalangeal joint ulnar collateral ligament injuries with microanchors. Ann Plast Surg. 2013; 71(5):500–502 [13] Glickel SZ. Thumb metacarpophalangeal joint ulnar collateral ligament reconstruction using a tendon graft. Tech Hand Up Extrem Surg. 2002; 6(3): 133–139

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65 Thumb Metacarpophalangeal Joint Collateral Ligament Reconstruction Armin Badre and Ruby Grewal Abstract Thumb metacarpophalangeal joint (MCPJ) ulnar collateral ligament (UCL) reconstruction is indicated in patients with symptomatic chronic instability without degenerative changes or subluxation. The native origin and insertion site of the UCL may be less clear during the operative intervention for chronic instability. Recent anatomical studies provide valuable details that can be used for anatomic reconstruction of the thumb UCL. We believe that anatomic reconstruction is essential to restore MCPJ stability, as previous biomechanical studies have shown that even a small deviation from the native origin and insertion sites significantly increase the MCPJ laxity. Keywords: gamekeeper’s thumb; skier’s thumb, thumb ulnar collateral ligament instability, thumb UCL instability, thumb ulnar collateral ligament reconstruction, thumb UCL reconstruction, chronic

2.8 mm (± 0.7 mm) or 24% (± 7%) from the volar surface of the proximal phalanx and 3.4 mm from the articular surface.3 A Stener lesion is when the proximal stump of ruptured UCL is displaced proximal and superficial to the adductor aponeurosis. The interposed adductor aponeurosis prevents reapproximation and thus healing of the avulsed UCL to its anatomic insertion site.

65.3 Clinical Presentation 65.3.1 History Patients with chronic UCL instability usually present with pain, weakness, and functional disability. The pain is localized to the MCPJ and they experience difficulty performing activities requiring forceful pinch or grasp, for example, pencil grip, turning keys, and unscrewing a jar lid.

65.3.2 Physical Examination

65.1 Description Acute injuries to the ulnar collateral ligament (UCL) of the metacarpophalangeal joint (MCPJ) of the thumb are common among skiers and frequently referred to as “skier’s thumb.” “Gamekeeper’s thumb” refers to chronic attritional attenuation of the UCL due to the repetitive trauma to the ulnar side of the thumb. Scottish gamekeepers fractured the necks of rabbits between their thumbs and index fingers. The repetitive radial deviation of the thumb proximal phalanx at the MCPJ resulted in progressive stretching and attenuation of the UCL. In addition to attritional attenuation, chronic instability may be due to an untreated acute tear.

65.2 Relevant Anatomy A combination of static and dynamic structures provide stability to the thumb MCPJ. The static stabilizers of thumb MCPJ include bony congruity, dorsal capsule, volar plate, proper, and accessory UCLs and radial collateral ligaments (RCLs).1 There are intrinsic and extrinsic muscles that act as dynamic stabilizers of the thumb MCPJ. The extrinsic muscles include the extensor pollicis longus (EPL), extensor pollicis brevis (EPB), and flexor pollicis longus (FPL). The intrinsic muscular stabilizers include the abductor pollicis brevis (APB), flexor pollicis brevis (FPB), and adductor pollicis.2 Although the origin and insertion sites of the collateral ligaments can usually be identified without much difficulty in the acute setting, these attachment sites may be less clear during operative interventions for chronic instability. Thus, understanding the anatomy of the UCL is crucial for its reconstruction. Carlson et al showed that the mean center of the metacarpal origin of UCL was 4.2 mm (± 0.8 mm) or 38% (± 8%) from the dorsal edge of the metacarpal head and 5.3 mm from the articular surface.3 They also showed that the mean center of the phalangeal insertion was

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Clinical evaluation of patients with chronic UCL instability begins with inspection. The resting posture of the thumb should be assessed for the presence of any radial deviation or volar subluxation at the MCPJ. The MCPJ should then be palpated for tenderness. A palpable thickening on the ulnar aspect of the metacarpal neck may suggest a Stener lesion. Finally, the stability of the MCPJ should be assessed with stress testing of the ligaments in extension and in 30° of flexion. The proper collateral ligaments are taut in flexion; whereas, the accessory collateral ligaments are taut in extension. A complete rupture of both the proper and accessory collateral ligaments result in laxity in both positions. Patients with chronic instability generally present with gross instability with no endpoint on MCPJ stress testing. As with acute injuries, however, there is no consensus in the literature regarding the criteria to define an abnormal stress test. Most publications have considered the test abnormal if there is more than 30 to 45° of radial deviation of the MCPJ or more than 10 to 20° of radial laxity compared to the contralateral side.4 Malik and colleagues showed, however, that there is a large variation in comparative MCPJ laxity between the thumbs even in normal individuals with 34% having at least 10° of variation and 12% having at least 15° of variation.4

65.3.3 Radiographic Evaluation Thumb radiographs should be obtained and assessed for radial and/or volar subluxation of the MCPJ as well as any evidence of degenerative changes.

65.4 Indications Thumb MCPJ UCL reconstruction is indicated in patients with chronic UCL instability who experience significant pain or functional limitations.

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Surgical Technique of UCL Reconstruction: Key Procedural Steps Various techniques of UCL reconstruction have been described. The authors prefer an anatomic reconstruction of UCL based on a modification of the Glickel procedure for thumb UCL reconstruction.5,6 In an in vitro cadaveric study, Bean and colleagues showed that even a 2 mm palmar displacement of UCL metacarpal origin or a 2 mm dorsal displacement of UCL phalangeal insertion significantly increases the radial deviation of the MCPJ.7 Thus, the authors advocate a more anatomic reconstruction of the thumb UCL based on the native origin and insertion sites.

65.5 Contraindications Thumb MCPJ UCL reconstruction is contraindicated in the setting of MCPJ degenerative changes or severe chondromalacia, multidirectional instability, or a chronically fixed subluxation of the MCPJ.6 In these cases, MCPJ arthrodesis may be considered.

65.6 Surgical Technique of UCL Reconstruction: Key Procedural Steps 65.6.1 Setup The patient is placed supine on the operating table and the arm is supported on a hand table. A tourniquet is used for this procedure. A local anesthetic with intravenous sedation or a regional anesthetic should suffice.

65.6.2 Exposure A lazy S-shape incision is used along the ulnar aspect, centered over the thumb MCPJ. Dissection is carried out through the subcutaneous tissue, and dorsal and volar flaps are elevated. The adductor aponeurosis is exposed (▶ Fig. 65.1a). If present, a

Fig. 65.1 (a) The adductor aponeurosis is shown along the ulnar side of the thumb MPCJ; (b) the adductor aponeurosis is incised longitudinally to expose the joint capsule; (c) remnant of UCL is shown and followed to the phalangeal insertion site; (d) proximal stump of UCL is followed to the metacarpal origin. MCPJ, metacarpophalangeal joint; UCL, ulnar collateral ligament.

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Thumb Metacarpophalangeal Joint Collateral Ligament Reconstruction Stener lesion is identified with the proximal stump of the ruptured UCL lying superficial to the adductor aponeurosis. In the chronic setting, the ligament is usually scarred down and difficult to separate from adjacent structures. The adductor aponeurosis is longitudinally incised parallel to and approximately 2 to 3 mm volar to the EPL tendon in order to expose the joint capsule (▶ Fig. 65.1b). The joint capsule is then opened. Radial deviation of the proximal phalanx allows better visualization for the assessment of the articular cartilage of the metacarpal head and the base of the proximal phalanx. If significant degenerative changes or chondromalacia is present, the reconstruction is abandoned and MCPJ arthrodesis is considered. Any remnant of the UCL is identified and used as a landmark for identification of the anatomic origin and insertion sites of the thumb UCL (▶ Fig. 65.1c, ▶ Fig. 65.1d).

65.6.3 Bone Tunnel Preparation Using a small burr, two small cortical windows are made at the base of the proximal phalanx. In order to recreate the anatomic

insertion site, these holes are made in a fashion that the midpoint of the bone bridge between them is near the native phalangeal insertion of the UCL, as described by Carlson and colleagues.3 Therefore, the first window is made along the volar surface of the proximal phalanx approximately 5 mm from the articular surface to avoid inadvertent articular penetration/ fracture (▶ Fig. 65.2a). The second window is made approximately 50% of phalangeal height dorsal to the first window and again approximately 5 mm distal to the articular surface (▶ Fig. 65.2a). These cortical windows should converge within the medullary canal and are sequentially enlarged using handheld gouges, so that the tendon graft can be easily passed through. At this stage, a 28-gauge wire is looped and passed between these two windows to be used later as a shuttle for passage of the tendon graft (▶ Fig. 65.2b). Care must be taken at all stages of this portion of the procedure to ensure the bone bridge between the tunnels does not break. A bone tunnel is then created in the metacarpal neck using a small burr. This tunnel starts on the ulnar side approximately 4 mm (or 40% of the metacarpal height) from the dorsal edge of

Fig. 65.2 (a) The phalangeal and metacarpal bone tunnels are marked based on the anatomic metacarpal origin and phalangeal insertion sites; (b) a 28-gauge wire is looped and passed between the two phalangeal bone tunnels; (c) a free tendon graft is passed through the phalangeal bone tunnels using the previously placed shuttle wire.

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Surgical Technique of UCL Reconstruction: Key Procedural Steps the metacarpal head and 5 mm from the articular surface (▶ Fig. 65.2a). As the tunnel is drilled to the radial side, it is aimed slightly more proximal.

65.6.4 Tendon Harvest The palmaris longus tendon or a slip of the flexor carpi radialis may be used as a free tendon graft for the reconstruction. Approximately 10 to 15 cm of tendon graft is generally required.

65.6.5 Tendon Graft Passage and Tensioning The two ends of the free tendon graft are tubularized with a nonabsorbable, braided suture for shuttling through the bone tunnels. The shuttle suture at one end of the tendon graft is passed through the phalangeal bone tunnel using the previously placed 28-gauge shuttle wire. The tendon graft is then brought through the phalangeal bone tunnel by gently pulling on the shuttle suture (▶ Fig. 65.2c). Once the tendon graft is

brought through this tunnel, the two limbs of the tendon are equalized. The two ends of the graft are then brought to the metacarpal bone tunnel. A small incision is made on the radial side of the metacarpal neck at the level of the previously made metacarpal tunnel. Careful dissection is carried out and the radial side of the metacarpal tunnel is exposed. While protecting the soft tissues, a Keith needle is used to bring the shuttle sutures at the ends of the tendon graft through the metacarpal bone tunnel from ulnar to radial. Both limbs of the tendon graft are then brought through this tunnel by gently pulling on the shuttle sutures (▶ Fig. 65.3a). While holding the MCPJ congruently reduced, the two limbs of the tendon graft are tensioned and tied in a knot (▶ Fig. 65.3b). Tying the two limbs of the tendon together prevents subsidence of the tendon graft back into the metacarpal tunnel and subsequent loosening of the reconstruction. (▶ Fig. 65.3c) shows the reconstructed ligament through the ulnar incision. At this stage, the tension of the reconstruction is tested by applying a gentle, radially directed force to the thumb MCPJ to ensure it has been adequately stabilized. Passive

Fig. 65.3 (a) An incision is made along the radial border of the metacarpal tunnel. Both limbs of the free tendon graft are passed through the metacarpal tunnel to the radial side; (b) the two limbs of the tendon graft are appropriately tensioned and tied in a knot; (c) the ulnar side of the MPJ is shown with the reconstructed UCL. MCPJ, metacarpophalangeal joint; UCL, ulnar collateral ligament.

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65.7 Pitfalls During the exposure, dorsal sensory branches of the radial nerve may cross the operative field and care should be taken to protect these branches throughout the procedure. While passing the tendon graft through the phalangeal bone tunnel, avoid pulling on the graft forcefully, so as not to fracture the bone bridge. It is imperative that the graft is tensioned appropriately so that it is not too loose or too tight. If the reconstruction is tensioned loosely, it does not adequately stabilize the MCPJ. If the reconstruction is too tight, the range of motion of the thumb MCPJ will be restricted, resulting in persistent stiffness. The K-wire transfixing the MCPJ should be placed only after the tension of the reconstruction and the range of motion of the MPJ is checked and appropriate tensioning is achieved.

65.8 Rehabilitation 65.8.1 Phase I: 0–6 weeks Postoperatively, the patient is placed in a well-padded thumb spica splint. The splint is changed to a forearm-based thumb spica cast at the first postoperative visit. The thumb interphalangeal (IP) joint is left free to allow for the range of motion of the IP joint. Fig. 65.4 Intraoperative fluoroscopy demonstrating the direction of the metacarpal tunnel, K-wire transfixing the MPCJ, as well as placement of a suture anchor to further secure the graft knot. MCPJ, metacarpophalangeal joint.

motion of the MCPJ should be checked to avoid overtightening. If needed, the two limbs of the tendon graft are untied and retensioned. Once appropriate tension of the reconstruction is achieved, the extra length of the tendon graft is cut. The tendon knot is sutured to the surrounding periosteum using a 3–0 Ethibond suture (Ethicon, USA). A suture anchor may also be used to secure the tendon knot to the bone adjacent to the metacarpal tunnel without compromising the tunnel (▶ Fig. 65.4). At this point, a 0.062-inch Kirschner wire (K-wire) is driven across the MCPJ to hold the joint in a reduced position while the reconstruction heals (▶ Fig. 65.4).

At 6 weeks, the cast and K-wire are removed and the patient is referred to a hand therapist. A removable, hand-based thermoplastic splint immobilizing the thumb MCPJ while leaving the IP joint free is used until 8 to 10 weeks postoperatively. The splint is removed for the range-of-motion exercises as per the direction of the hand therapist. In this phase, modalities for control of pain and swelling are continued. The patient begins active and active-assisted range of motion of the MPJ approximately three times per day. Any radially directed force to the MCPJ must be avoided.

65.8.3 Phase III: > 12 weeks

Suture anchors may be used instead of the bone tunnel technique. In this technique, two suture anchors are placed at the metacarpal and phalangeal insertion sites of the native UCL as described previously. The tendon graft is tied to the ulnar side of the MCPJ using the sutures attached to these suture anchors.

In this phase, the splint is weaned off; although, the patient may continue to wear a splint for at-risk activities. In addition to the range-of-motion exercises, the patient may begin strengthening exercises. The patient gradually returns to full activities. Return to sporting activities depends on the assessment of healing, swelling, range-of-motion, strength, and the ability to perform sport-specific exercises. Patients should be informed that the swelling and pain may last a few months before complete resolution.

65.6.7 Closure

References

65.6.6 Other Fixation Techniques

The capsule is closed with a 3–0 Ethibond suture. The adductor aponeurosis is closed using a 3–0 Ethibond suture. The tourniquet is deflated and hemostasis is obtained. The skin is then closed.

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65.8.2 Phase II: 6–12 weeks

[1] Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med. 2010; 20(2): 106–112 [2] Tang P. Collateral ligament injuries of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg. 2011; 19(5):287–296

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References [3] Carlson MG, Warner KK, Meyers KN, Hearns KA, Kok PL. Anatomy of the thumb metacarpophalangeal ulnar and radial collateral ligaments. J Hand Surg Am. 2012; 37(10):2021–2026 [4] Malik AK, Morris T, Chou D, Sorene E, Taylor E. Clinical testing of ulnar collateral ligament injuries of the thumb. J Hand Surg Eur Vol. 2009; 34(3):363–366 [5] Glickel SZ, Malerich M, Pearce SM, Littler JW. Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Am. 1993; 18(5):930–941

[6] Glickel SZ. Thumb metacarpophalangeal joint ulnar collateral ligament reconstruction using a tendon graft. Tech Hand Up Extrem Surg. 2002; 6(3): 133–139 [7] Bean CH, Tencer AF, Trumble TE. The effect of thumb metacarpophalangeal ulnar collateral ligament attachment site on joint range of motion: an in vitro study. J Hand Surg Am. 1999; 24(2):283–287

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66 Scapholunate Ligament Repair Daniel A. Seigerman and Michael J. Pensak Abstract Complete rupture of the scapholunate (SL) ligament causes diastasis between the scaphoid and lunate, and subsequent instability that can lead to arthritic changes (scapholunate advanced collapse [SLAC] wrist). Surgical repair is warranted in acute ruptures and should be performed expeditiously. Various nuances with respect to the surgical procedure are described, but most importantly, an anatomic reduction of the SL interval is necessary. Suture anchors are used to repair the ligament, and often, a capsulodesis procedure will be performed to augment the repair. The SL interval is pinned in place with Kirschner (K) wires to maintain reduction while the soft tissue structures heal. The wrist is immobilized for 6 to 10 weeks postoperatively, at which point the pins are removed and the patient starts guided hand therapy. Diminished wrist motion, and subsequent widening of the scapholunate articulation is often observed during long term follow-up. Keywords: scapholunate ligament rupture, scapholunate ligament repair, SL widening, SL repair, carpal instability

66.1 Description and Diagnosis The scapholunate (SL) ligament is one of the mechanical cornerstones of the wrist joint (▶ Fig. 66.1) A rupture of this ligament has deleterious effects on wrist biomechanics, which can

eventually lead to arthrosis. Pain after trauma located at the SL interval, often times associated with swelling, may represent a SL ligament tear.1 There are many clinical and radiographic signs which may help to make the diagnosis. On physical examination, pain over the SL ligament and the presence of a positive Watson’s scaphoid shift test2 may be indicative of a scapholunate interosseous ligament (SLIL) rupture. There are many radiographic indicators, including diastasis between the scaphoid and lunate on the PA radiograph greater than 3 mm (▶ Fig. 66.2a). Moreover, a clenched fist/pencil grip view (▶ Fig. 66.2b) drives open the SL interval and can accentuate the deformity. A cortical ring sign (▶ Fig. 66.2c) and an increased scapholunate angle (▶ Fig. 66.2d) are other indicators of this pathology. MRI studies are often performed (▶ Fig. 66.3), but have variable rates of sensitivity and specificity.3 The gold standard for diagnosis of a SL ligament rupture remains diagnostic arthroscopy. The Geissler classification is used to characterize a tear.4

66.2 Indications Direct surgical repair is indicated for patients with acute wrist pain and a diagnosis of an acute SL ligament tear (< 6 weeks). Treatment for chronic injuries (> 6 weeks) is controversial, and options include direct repair with capsulodesis, tendon reconstruction, open reduction with screw fixation, and other techniques.

Fig. 66.1 (a) Deep ligaments of the wrist joint. (Reproduced with permission from Hirt B, Seyhan H, Wagner M, Zumhasch R. Hand and Wrist Anatomy and Biomechanics. 1st ed. © 2017 Thieme). (b,c) Interosseous ligaments on the proximal carpal bones. (Reproduced with permission from Schmidt HM, Lanz U. Surgical Anatomy of the Hand. New York, Thieme 2004).

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Surgical Technique for Scapholunate Ligament Repair with Capsulodesis Augmentation

Fig. 66.3 Coronal MRI image revealing a complete acute tear of the scapholunate interosseous ligament (white arrow).

Fig. 66.2 (a) PA radiograph of the wrist demonstrating diastasis > 3 mm at the scapholunate interval. (Reproduced with permission from Martin I. Boyer and James Chang. 100 Hand Cases, 1st edition © 2016 Thieme.) (b) Pencil grip view demonstrating widening of the SL interval. (c) Cortical ring sign. (d) Increased scapholunate angle. SL, scapholunate.

66.3 Outcomes 66.3.1 Expectations SL ligament tears are particularly difficult injuries for all hand surgeons. Expectations should be clearly delineated for the patient. The purpose of surgical repair is to slow or halt the progression of arthritic changes, that is, (scapholunate advanced collapse) SLAC wrist, although this has been recently debated.5 It is not uncommon for recurrent diastasis to be noted in the late postoperative period. The procedure is nonetheless worthwhile and recommended in the setting of an acute scapholunate ligament rupture. Motion loss is common after this procedure and the patient should be counseled accordingly.

66.3.2 Special Considerations There is a high rate of recurrent instability after repair; therefore, the repair is often augmented with various capsulodesis procedures. Many have been described including the Blatt (proximally based) capsulodesis6 and the Mayo capsulodesis7

which utilize the dorsal intercarpal ligament to reinforce and tether the scaphoid. There are advantages and disadvantages to each type of capsulodesis.

66.4 Surgical Technique for Scapholunate Ligament Repair with Capsulodesis Augmentation 66.4.1 Special Instructions and Positioning The procedure often begins with a diagnostic arthroscopy which requires a traction setup. Utilization of a traction tower that can be easily disassembled after the arthroscopy portion when transitioning to the open portion of the procedure is critical. The traction tower is set up on the hand table with the patient in the supine position. General anesthesia with a regional block is recommended.

66.4.2 Diagnostic Arthroscopy Unless otherwise contraindicated, a diagnostic arthroscopy should be utilized to first assess and evaluate the SL interval. Its utility involves characterizing the tear and help determine treatment. The radiocarpal and midcarpal joints should be exploited to aid in visualization. To begin, the wrist is injected with 10 mL of sterile saline via the standard 3–4 portal. The 3–4 viewing portal is then established and the 2.3 mm arthroscope is inserted. An 18G needle is then inserted into the 6 U portal

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Scapholunate Ligament Repair Kirschner (K) wires are used as joysticks to reduce the articulation. Care should be taken to use 0.062 K-wires and ensure that they are sufficiently advanced into the bones to avoid pullout upon reduction. Since the scaphoid is flexed, the scaphoid joystick should be placed obliquely from dorsal distal to volar proximal. Since the lunate is extended, the lunate joystick should be placed from proximal dorsal to volar distal (▶ Fig. 66.5a). The joysticks are now brought together, which will subsequently reduce the scaphoid and lunate. The joysticks are now clamped. To reduce the diastasis, the joysticks are squeezed together with the help of an assistant or a second clamp (▶ Fig. 66.5b). After multiplanar fluoroscopy confirms reduction, an incision is made just distal to the radial styloid. Care should be taken to protect the sensory braches of the radial nerve by performing blunt dissection down to the level of the scaphoid. Two parallel 0.062 wires are placed across the SL interval and a third wire is placed from the scaphoid into the capitate (▶ Fig. 66.5c).

66.4.5 Repair of the Ligament Fig. 66.4 Elevation of a proximally based slip of capsule in preparation for a Blatt capsulodesis.

for outflow. The midcarpal portals are also established. The scaphoid and lunate are evaluated, and the SL interval is assessed and classified based on the Geissler classification.4 Additional pathology found can be addressed at this juncture, such as triangular fibrocartilage complex (TFCC) tears, which can be repaired or debrided based upon its type.

66.4.3 Exposure A dorsal approach to the wrist is performed. A longitudinal incision just ulnar to Lister’s tubercle is made. Blunt dissection is taken down to the extensor retinaculum, which is carefully incised to expose the extensor pollicis longus (EPL). The EPL is identified, removed from its groove, and retracted radially. The fourth dorsal compartment is identified and protected in an ulnar direction. The posterior interosseous nerve (PIN) lies on the floor of the fourth dorsal compartment. A PIN neurectomy can be performed at this juncture to decrease longstanding wrist pain. A portion of the nerve can be excised with bipolar cautery to ensure a complete neurectomy is performed. The dorsal wrist capsule is next identified and a proximally based flap of capsule is elevated (Blatt type capsulodesis) (▶ Fig. 66.4). The scaphoid and lunate bones are now identified and the torn ligament is identified.

66.4.4 Reducing the SL Interval The critical step involves performing a reduction of the SL interval. When the ligament has torn, the scaphoid takes on a flexed position, and the lunate will sit in an extended position.

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Once the SL interval is reduced, the ligament is primarily repaired. A small suture anchor is placed at the site of avulsion and a mattress suture is placed through the torn ligament (▶ Fig. 66.6). Typically, the ligament tears from the scaphoid attachment but this can be variable.

66.4.6 Capsulodesis Once the ligament is repaired, capsulodesis is performed. The previously elevated proximally based capsular tissue is advanced to the distal pole of the scaphoid and secured with a suture anchor (Blatt capsulodesis). The wound is then closed and a splint is applied.

66.5 Postoperative Care The patient is immobilized in a short arm splint after surgery and rigid immobilization is continued for a total of 8 to 10 weeks. The patient is encouraged to maintain motion at the metacarpophalangeal and interphalangeal joints. At the 8- to 10-week time point, the pins are removed in an operative setting and therapy is recommended.

66.6 Pitfalls Placement of the K-wires across the reduced scapholunate interval can be difficult. It is our recommendation that the wires are placed prior to placement of the suture anchor to avoid fracture of the anchor. Care should be made to ensure that the reduction of the scapholunate articulation is restored prior to application of fixation. Once the wires are placed, reduction should be checked on both the PA and lateral intraoperative fluoroscopic images to ensure an acceptable SL angle and correction of the diastasis. If the reduction is unacceptable, improvement should be attempted.

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References

Fig. 66.5 (a) Application of appropriate K-wires to be used as joysticks. (b) Utilization of the joysticks to reduce the scapholunate interval. (c) Reduced and stabilized scapholunate interval with K-wires. (d) Schematic representation of repaired and stabilized scapholunate interval.

References

Fig. 66.6 Repair of the SL interval after K-wire stabilization. The white arrow points to the anchor on the scaphoid while the forceps hold the ligament. SL, scapholunate.

[1] Buijze GA, Lozano-Calderon SA, Strackee SD, Blankevoort L, Jupiter JB. Osseous and ligamentous scaphoid anatomy: part I. A systematic literature review highlighting controversies. J Hand Surg Am. 2011; 36(12):1926–1935 [2] Watson HK, Ashmead D, IV, Makhlouf MV. Examination of the scaphoid. J Hand Surg Am. 1988; 13(5):657–660 [3] Zanetti M, Saupe N, Nagy L. Role of MR imaging in chronic wrist pain. Eur Radiol. 2007; 17(4):927–938 [4] Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996; 78(3):357–365 [5] O’Meeghan CJ, Stuart W, Mamo V, Stanley JK, Trail IA. The natural history of an untreated isolated scapholunate interosseus ligament injury. J Hand Surg [Br]. 2003; 28(4):307–310 [6] Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clin. 1987; 3(1):81–102 [7] Slater RR, Jr, Szabo RM, Bay BK, Laubach J. Dorsal intercarpal ligament capsulodesis for scapholunate dissociation: biomechanical analysis in a cadaver model. J Hand Surg Am. 1999; 24(2):232–239

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67 Scapholunate Capsulodesis Moody Kwok Abstract The scapholunate interosseous ligament (SLIOL) has a stabilizing function which is critical in wrist joint biomechanics. Failure of this ligament can lead to instability and eventual degenerative changes. In cases where the ligament is not repairable, reconstruction can restore stability and diminish the likelihood of degeneration. Scapholunate (SL) capsulodesis is a surgical attempt to reconstruct the ligamentous relationship between the scaphoid and lunate using extrinsic ligamentous structures to restore stability. Keywords: scapholunate capsulodesis, scapholunate capsulorraphy, Scapholunate injuries, SLIOL

67.1 Introduction Isolated scapholunate interosseous ligament (SLIOL) disruptions can occur in isolation or as a group of more complex carpal ligamentous structures. Most of these injuries are traumatic in nature. Scapholunate (SL) capsulodesis (and capsulorraphy) is a surgical attempt to recreate the ligamentous relationship between the scaphoid and lunate. Although it can be utilized for more complex and comprehensive injuries, for simplicity of illustration, it will be discussed within this chapter and be limited to isolated SLIOL ligament injuries.

67.2 Anatomy The carpus comprises of eight bones attached by a complex system of intrinsic ligaments. Its relationship to the remainder of the upper extremity is facilitated by an attachment of extrinsic ligaments as well. However, no tendinous insertion exists on the proximal row of the carpus, which is formed by the scaphoid, lunate, and triquetrum. The forces across this intercalary system is therefore dictated by external forces such as tendinous insertions proximal and distal to the proximal carpal row. Disruption of the stabilizing components of the proximal carpal row such as a SLIOL tear leads to derangement of the anatomic

relationships between bones, with alteration of kinematics and eventual degenerative changes.

67.3 Pathophysiology, Nonoperative Treatment, and Natural History Force transmission from the digits enter the carpus mainly though the capitate and are then transmitted across the scapholunate junction. This force, by virtue of the local anatomy, will place a flexion force within the body of the scaphoid, an extension force across the lunate, and diastasis between these two bones; these deforming forces are resisted by the intact SLIOL (▶ Fig. 67.1). The natural history of a SLIOL tear is “scapholunate advanced collapse” (SLAC) wrist. The dissociated carpus no longer functions as a solitary unit, resulting in abnormal carpal motions, and subsequent increases in develop pressures across the radiocarpal and midcarpal joints. Erosions of articular surfaces ensue, with the eventual development of posttraumatic osteoarthritis.1

67.4 Clinical and Imaging Evaluation A thorough history and physical can often elucidate and differentiate the diagnosis of scapholunate (SL) incompetence. Tenderness at the scapholunate junction and a positive Watson maneuver can especially pinpoint the pathology to this location. Plain radiographs in the PA, lateral, and oblique views can reveal a diastasis between the scaphoid and lunate. Greater than 3 to 4 mm gapping may offer the appearance of a “Terry Thomas sign.” On the lateral view, the SL angle is a line drawn between the long axis of the scaphoid and lunate on the lateral X-ray view. Normally, this angle measures between 30 to 60 degrees. Given the propensity of the scaphoid to flex in the

Fig. 67.1 (a) Normal relationship between the scaphoid (S) and lunate (L) in the AP plane; (b) rupture of the SL ligament leads to diastasis or separation between the bones (black arrow). SL, scapholunate.

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Contraindications

Fig. 67.2 (a) Normal relationship between the scaphoid (S) and lunate (L) in the lateral plane; (b) rupture of the scapholunate ligament leads to flexion of the scaphoid (black arrow) and extension of the lunate, leading to an increased scapholunate angle and DISI deformity. DISI, dorsal intercalated segment instability.

Fig. 67.3 Blatt capsulodesis. Anteroposterior (a) and lateral (b) schematics of a proximally based capsular flap of extrinsic dorsal capsular tissue onto the dorsal distal pole of the scaphoid through a bone tunnel. The scaphoid is extended from its flexed position via the pull of the capsular tissue (black arrow).

absence of a competent SLIOL, the SL angle on the lateral film will be increased > 60 degrees. This is termed dorsal intercalated segmental instability (DISI) (▶ Fig. 67.2). Provocative radiographs such as PA clench or scaphoid X-rays can also accentuate the radiographic malalignment. CT offers three-dimensional insight into the osseous carpal relationships; this is often helpful in complex carpal dissociations and fractures. However, MRI is more useful in showing the SLIOL ligament, intrinsic and extrinsic ligaments, and associated soft tissue injuries.

67.5 Operative Treatment 67.5.1 General Concepts The intent of operative treatment such as capsulodesis is to maintain, as best as possible, the normal architecture of the carpus. In the setting of SLIOL dissociation, the main focus involves restoring the flexed scaphoid and the extended lunate into their normal neutral position to minimize aberrant contact pressures within the wrist joint. A secondary focus is to reestablish the coronal coaptation of the SL interval in order to further solidify the carpal mechanics. The term capsulorraphy describes this direct repair of the ligament.

67.5.2 Blatt Capsulodesis (Historical Perspective) In 1987, Blatt described a surgical attempt to tether scaphoid in its native position by attaching a proximally based capsular flap of extrinsic dorsal capsular tissue onto the dorsal distal pole through a bone tunnel (▶ Fig. 67.3). The results were complicated by wrist stiffness (especially reducing flexion) because of the origin of the capsule on the distal radius. In addition, it also failed to address the diastasis from the lunate.2 The Blatt capsulodesis, however, did inspire a litany of other soft tissue

procedures that would shape the evolution of the concepts of SL dissociation.

67.5.3 Alternatives SLIOL Capsulorraphy, Capsulodesis Primary repair alone should be performed in the acute setting where there is quality ligament to repair. After the 6- to 8-week time point postinjury, a primary may not be feasible due to ligament scarring and shortening. It is performed by reduction of the SLIOL interval in the coronal and sagittal planes (with “joystick Kirschner [K] wires”), and subsequent placement of supportive K-wires between the scaphoid and lunate. An additional pin between the scaphoid and the capitate is often used to secure the scaphoid in its ideal position (▶ Fig. 67.4). Bone anchors are often helpful for ligament reattachment. Either alone, or in conjunction with SLIOL direct repair, capsulodesis with local capsular and ligamentous structures have been described to provide and/or augment the SLIOL association (▶ Fig. 67.5). The dorsal intercarpal ligament (DIC) and the dorsal radiocarpal ligament (DRC) have both been utilized as donor adjuncts to SLIOL capsulodesis. Invariably, the donor capsule or ligament is redirected to the SLIOL interval. Again, anchors facilitate this reattachment.

67.6 Indications Patients are indicated for a capsulodesis if there is subacute or chronic scapholunate disruption without development of SLAC changes.

67.7 Contraindications ● ●

SLAC arthritic changes of the wrist. Inflammatory arthritis of the wrist.

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Fig. 67.4 Primary SLIOL repair. Anteroposterior and lateral schematics of a primary SLIOL repair. (a) The SLIOL is typically torn off the scaphoid insertion. (b) The repair is typically performed with suture anchors into the scaphoid, and the repair augmented by K-wires across the scapholunate and scaphocapitate intervals. SLIOL, scapholunate interosseous ligament.

first modification involves the harvest of the proximal half of the DIC from its point of insertion onto the radial dorsal wrist, and attaching it to the dorsal distal scaphoid with the recipient bone reduced in extension (▶ Fig. 67.6a). This allows tethering of the scaphoid in extension without crossing the radiocarpal joint. A second modification involves the harvest of the proximal half of the DIC from its point of origin on the triquetrum on the ulnar dorsal wrist, and attaching it to the dorsal lunate. After the scaphoid is reduced, the slip of the DIC is then rotated proximally and attached to the dorsal aspect of the lunate (▶ Fig. 67.6b). This allows tethering of the scaphoid in extension without crossing the radiocarpal joint. Fig. 67.5 Normal anatomy of the dorsal capsular tissues of the wrist joint. (Courtesy of Moody Kwok, MD)

67.8 Special Considerations Arthroscopic examination can be performed to evaluate the extent of any arthritis, if present.

67.9 Special Instructions, Positioning, and Anesthesia The patient should be positioned supine with an upper arm tourniquet. Either general or regional anesthesia can be utilized. For fixation, either suture anchors or 3.0 or 4.0 tenodesis screws will be required.

67.10 Tips, Pearls, and Lessons Learned As mentioned previously, the capsulodesis, as originally described by Blatt, involved tethering of the scaphoid onto the radius using capsular tissues. This tethering, by necessity, would involve limitation of wrist motion. An understanding of the anatomy dorsal capsular tissues of the wrist, specifically the dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments, provides the possibility of motion-sparing modifications of Blatt’s original description (▶ Fig. 67.5). The

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67.11 Key Procedural Steps A standard dorsal approach between the third (EPL) and fourth (EDC) compartments is developed. A ligament-sparing arthrotomy is performed to enter the joint in order to allow for visualization of the articular surfaces. Both the DRC and DIC should be well-defined and well-visualized. Using either modification of the Blatt procedure, the proximal half of the DIC is harvested and dissected sharply to the point of origin or insertion. After the scaphoid is reduced, the ligament is attached to the bone using suture anchors. Pinning with K-wires is at the discretion of the treating surgeon.

67.11.1 Postoperative Course The K-wires, if present, can either be left proud or buried under the skin. The wrist is immobilized for 6 weeks, followed by removal of the K-wires and initiation of supervised therapy.

67.12 Bailout, Rescue, and Salvage Procedures Instead of the use of K-wires, some have advocated the reduction and association of the scaphoid and lunate (RASL) procedure. Described as a reconstructive procedure, it involves repair of the SLIOL interval, and augmented by a screw across the scapholunate interval to control the SLIOL diastasis3

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References

Fig. 67.6 (a, b) Motion preserving modifications of the Blatt procedure using the DIC ligament. DIC, dorsal intercarpal.

(▶ Fig. 67.7). Some studies indicate promising success, but others have found screw fixation between the scaphoid and lunate (especially in isolation of concomitant reconstructive efforts) to be wrought with osseous and carpal collapse and other complications. If the reconstruction fails, then standard SLAC salvage procedures can be entertained, including proximal row carpectomy, intercarpal arthrodesis, or total wrist arthrodesis, depending on the stage of degenerative changes.

References [1] Linscheid RL. Scapholunate ligamentous instabilities (dissociations, subdislocations, dislocations). Ann Chir Main. 1984; 3(4):323–330 [2] Blatt G. Capsulodesis in reconstructive hand surgery. Dorsal capsulodesis for the unstable scaphoid and volar capsulodesis following excision of the distal ulna. Hand Clin. 1987; 3(1):81–102 [3] Rosenwasser MP, Miyasajsa KC, Strauch RJ. The RASL procedure: reduction and association of the scaphoid and lunate using the Herbert screw. Tech Hand Up Extrem Surg. 1997; 1(4):263–272

Suggested Reading Fig. 67.7 RASL procedure. RASL, reduction and association of the scaphoid and lunate.

Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995; 20(3 Pt 2):S82–S85

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68 Scapholunate Ligament Reconstruction (Brunelli Types) Bryan A. Hozack and Asif M. Ilyas Abstract The scapholunate (SL) ligament is a critical component of the architecture of the wrist, and its stabilizing function a cornerstone of joint mechanics. Failure of this ligament can lead to instability and eventual degenerative changes. In cases where the ligament is not repairable, reconstruction can restore stability and theoretically diminish the likelihood of degeneration. Several options for ligament reconstruction are available. We describe one type using a tendon graft. Keywords: scapholunate ligament, chronic, reconstruction, Brunelli, tendon graft

68.1 Description Brunelli initially described a technique to stabilize the unstable and flexed scaphoid in the setting of a scapholunate ligament (SLL) tear by passing half of a flexor carpi radialis (FCR) tendon —released proximally but anchored distally—through the axis of the scaphoid and securing it to the posterior distal radius to prevent scaphoid flexion and progression of scapholunate advanced collapse (SLAC)1 (▶ Fig. 68.1). Several modifications of Brunelli’s reconstruction have been described subsequently to reconstruct the SLL in order to provide scaphoid stability while also preserving physiologic movement of the scaphoid (▶ Fig. 68.2).

68.2 Key Principles There are several strategies for restoring scapholunate (SL) instability due to SLL disruption. A tendon slip of the FCR is utilized as a tendon graft. The graft stabilizes the scaphoid from distal (volar) to proximal (dorsal). Rotatory stability is achieved by securing the graft to either the dorsal distal radius (the original Brunelli technique), lunate bone, or other carpal structures (various modified Brunelli techniques).

68.3 Expectations Patients may avoid progression to a SLAC wrist if scapholunate instability is addressed in a timely manner.2,3 This technique restores anatomy and stability by reconstructing the SLL in an anatomic manner, while maintaining wrist range of motion which may be diminished with other reconstructive procedures such as a capsulodesis.

68.4 Indications Patients are indicated for a Brunelli-type reconstruction if there is acute SL instability or subacute but reducible SL instability without development of SLAC changes. SL insufficiency or diastasis can be diagnosed by increased space between the scaphoid and lunate (▶ Fig. 68.3), flexed scaphoid, or extended lunate on lateral radiographs.4

68.5 Contraindications ● ● ●

Chronic and/or unreducible scapholunate diastasis. SLAC arthritic changes of the wrist. Inflammatory arthritis of the wrist.

68.6 Special Considerations Arthroscopic examination can be performed prior to embarking on the reconstruction to better assess and classify the scapholunate ligament tear, and evaluate the extent of any arthritis if present.5

68.7 Special Instructions, Positioning, and Anesthesia The patient should be positioned supine with an upper arm tourniquet. Either general or regional anesthesia can be utilized. A radiolucent hand table with mini C-arm will be

Fig. 68.1 Schematic of the Brunelli procedure using half of FCR passed through a scaphoid bone tunnel across the radiocarpal joint (Provided courtesy of Moody Kwok, MD). FCR, flexor carpi radialis.

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Fig. 68.2 Schematic of the Brunelli procedure using half of FCR passed thought the scaphoid sparing the radiocarpal joint to preserve motion (Provided courtesy of Moody Kwok, MD).

required. Cannulated drill bits, measuring 2.5 or 3.0, are recommended. For final fixation, either suture anchors or 3.0 or 4.0 tenodesis screws will be needed.

Fig. 68.3 Clenched fist view of the hand showing the presence of diastasis between the scaphoid and lunate in the left wrist (yellow arrow).

68.8 Tips, Pearls, and Lessons Learned A variety of SLL reconstructions utilizing a half-FCR tendon has been described since Brunelli’s initial technique was presented. The most popular is likely the modification presented by Garcia-Elias, dubbed the “3 Ligament Tenodesis,” where the FCR graft is run across the axis of the scaphoid and then repaired to the dorsal radiocarpal ligaments to not only correct scaphoid flexion but also minimize scapholunate diastasis.4 The technique to be described here is the Ross-modified Brunelli technique that not only builds upon these two techniques but also provides a more anatomic and biologic reconstruction of the SLL and stronger fixation of the graft with a tenodesis screw. This technique involves passing the FCR through the scaphoid dorsal to volar, passing the tendon across the scapholunate and lunotriquetral ligments, and securing the graft on the triquetrum with an interference screw (▶ Fig. 68.4).6 Postreconstruction, pinning of the scaphocapitate joint and prolonged immobilization (8–12 weeks) of the wrist is recommended. Some residual diastasis is common following reconstruction as a result of creep within the tendon graft.

68.9 Difficulties Encountered Aggressive mobilization of the scaphoid by excising scar tissue in the SL and scaphotrapeziotrapezoid joints may be necessary to obtain proper reduction of the scaphoid.

68.10 Key Procedural Steps 68.10.1 Volar Approach and Graft Harvest The distal pole of the scaphoid and distal extent of the FCR tendon is exposed distally through an oblique wrist incision

Fig. 68.4 Depiction of bone tunnel placement for the Ross modification of the Brunelli technique.6

centered over the distal pole of the scaphoid. The FCR tendon is harvested through a single longitudinal or individual small transverse incision. At least 10 cm of a half-FCR tendon measuring no more than 2 to 3 mm in diameter is required. It should be kept attached distally but released proximally.

68.10.2 Dorsal Approach A standard dorsal approach between the third (extensor pollicis longus [EPL]) and fourth (extensor digitorum communis [EDC]) compartments is developed. Either a longitudinal or ligamentsparing arthrotomy is performed to enter and expose the carpal bones.

68.10.3 Tunnel Placement A guide wire is placed just horizontal to the center axis of the scaphoid, thereby avoiding both the scaphotrapezial and radioscaphoid articular surfaces (▶ Fig. 68.5a,b). A 3.0 mm

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Fig. 68.5 (a) AP and (b) lateral view of guide wire placed just horizontal to the center axis of the scaphoid, thereby avoiding both the scaphotrapezial and radioscaphoid articular surfaces. (c) AP and (d) lateral view of second guide wire placed across the axis of the lunate and triquetrum, exiting into the scapholunate joint.

Fig. 68.6 (a) Image showing the FCR graft being drawn through the scaphoid dorsally with a suture passer. (b) The graft is then drawn through the scaphoid and triquetrum exiting ulnarly. FCR, flexor carpi radialis.

cannulated drill is placed over the guide wire. A second guide wire is next placed across the axis of the lunate and triquetrum, exiting into the scapholunate joint (▶ Fig. 68.5c,d). Again, a 3.0 mm cannulated drill is placed over the guide wire.

68.10.4 Graft Placement Using a tendon or suture passer, the FCR graft is drawn through the scaphoid dorsally (▶ Fig. 68.6a). Next, again using a passer,

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the FCR graft is drawn through the scaphoid and triquetrum, exiting ulnarly (▶ Fig. 68.6b).

68.10.5 Reduction and Fixation The graft is cycled and tensioned, which will not only result in reduction of the scaphoid and lunate but also correction of scaphoid flexion. With the graft held under tension and the carpal alignment restored, two K-wires are placed across the

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References

Fig. 68.7 (a) AP view showing two K-wires placed across the scaphocapitate joint in order to secure carpal alignment. (b) Image showing the graft held under tension before tenodesis screw placement across the triquetrum to secure the graft in place, as shown in this radiograph (c).

scaphocapitate joint in order to secure carpal alignment (▶ Fig. 68.7a). Finally, again with the graft held under tension, a 3.5 or 4.0 tenodesis screw is placed across the triquetrum, securing the graft in place (▶ Fig. 68.7b,c).

68.10.6 Postoperative Course The K-wires can either be left proud or buried under the skin. The wrist is immobilized for 12 weeks, followed by removal of the K-wires and initiation of supervised therapy.

68.11 Bailout, Rescue, and Salvage Procedures Intraoperatively, if unable to secure or pass the graft through the lunate and triquetrum, it can be secured dorsally to the radiocarpal ligament, as described in the 3-ligament tenodesis technique. If the reconstruction fails, then standard

SLAC salvage procedures can be entertained, including proximal row carpectomy, intercarpal arthrodesis, and total wrist arthrodesis.

References [1] Brunelli GA, Brunelli GR. A new technique to correct carpal instability with scaphoid rotary subluxation: a preliminary report. J Hand Surg Am. 1995; 20 (3 Pt 2):S82–S85 [2] Watson HK, Weinzweig J, Zeppieri J. The natural progression of scaphoid instability. Hand Clin. 1997; 13(1):39–49 [3] Berdia S, Wolfe SW. Effects of scaphoid fractures on the biomechanics of the wrist. Hand Clin. 2001; 17(4):533–540, vii–viii [4] Garcia-Elias M, Lluch AL, Stanley JK. Three-ligament tenodesis for the treatment of scapholunate dissociation: indications and surgical technique. J Hand Surg Am. 2006; 31(1):125–134 [5] Messina JC, Van Overstraeten L, Luchetti R, Fairplay T, Mathoulin CL. The EWAS classification of scapholunate tears: an anatomical arthroscopic study. J Wrist Surg. 2013; 2(2):105–109 [6] Ross M, Loveridge J, Cutbush K, Couzens G. Scapholunate ligament reconstruction. J Wrist Surg. 2013; 2(2):110–115

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69 Distal Radioulnar Ligament Repair/Reconstruction A. Samandar Dowlatshahi and Tamara D. Rozental Abstract Distal radioulnar joint (DRUJ) instability can be acute, subacute or chronic, and the decision to proceed with repair versus reconstruction is multifactorial. The radioulnar ligaments (palmar and dorsal) are the primary stabilizers of the DRUJ. Ligament repair can be performed in the acute or subacute setting, while reconstruction is indicated in patients with subacute or chronic instability in the setting of congruous articular surfaces. Ligament reconstruction is typically achieved with tendon slips or free grafts. Keywords: distal radioulnar joint, instability, reconstruction, tendon graft

69.1 Description Distal radioulnar joint (DRUJ) instability can be acute, subacute or chronic and the decision to proceed with repair versus reconstruction is multifactorial. Knowledge of the complex anatomy of the DRUJ is of key importance. The radial and ulnar articular surfaces have a different radius of curvature and the soft tissues surrounding the DRUJ are thus required to stabilize the joint. The triangular fibrocartilage complex (TFCC) is the name given to these soft tissues that span and support the distal radioulnar and ulnocarpal articulations. The radioulnar ligaments (palmar and dorsal) are the primary stabilizers of the DRUJ.

69.2 Key Principles DRUJ instability may be associated with soft tissue injuries such as TFCC tears or with alterations in bony anatomy, particularly ulnar variance. The pathomechanism of instability is essential in determining the optimal treatment method, particularly in choosing between soft tissue repairs, reconstruction, osteotomies, and fusions.

69.3 Expectations Articular congruency at the DRUJ must be established. Integrity of the volar and dorsal radioulnar ligaments is essential. The goal is thus to restore stability and a painless arc of motion. Gross instability should only be expected if the TFCC and interosseous ligaments are disrupted. Discontinuity of only a portion of the TFCC is less likely to lead to instability. Furthermore, in the acute setting such as with a distal radial fracture with DRUJ instability, direct repair is not always necessary. The DRUJ can be reduced and pinned in the most stable position, allowing the soft tissues to heal.

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DRUJ ligament reconstruction is indicated in patients with instability and irreparable TFCC tears in the setting of congruous articular surfaces.

69.5 Contraindications ● ● ●

DRUJ arthritis. DRUJ incongruity. Connective tissue disorders.

69.6 Special Considerations As part of a detailed preoperative assessment plain films are obtained to assess ulnar variance. CT is helpful in defining the anatomy of the DRUJ and its instability. Using a “dynamic” scan, both wrists are evaluated in full forearm pronation, supination, and the neutral position. MRI is also useful in assessing the ligamentous structures, including all components of the TFCC, and looking for degenerative changes at the DRUJ. The assessment of static instability on advanced images is inadequate, and comparison with the uninvolved extremity is essential for diagnosis. Soft tissue reconstruction is likely to fail and should be avoided if significant articular incongruity is present. Also, beware of patients with bilateral DRUJ hypermobility and a flat sigmoid notch, as the results are not predictable in cases of systemic hyperlaxity disorders.

69.7 Special Instructions, Positioning, and Anesthesia ●

●

One should assess the contralateral DRUJ preoperatively for comparison. Surgery is routinely performed with a brachial plexus block. – An upper arm tourniquet advised. – A mini C-arm is helpful for orientation. – If planning reconstructive options, the surgeon should verify the availability of autologous tendon graft material before surgery.

69.8 Tips, Pearls, and Lessons Learned Chronically unstable DRUJs can cause a reproducible clunk with forearm rotation. Laxity may be more pronounced in a neutral position rather than pronation and supination. Extensor carpi ulnaris (ECU) subluxation as well as lunotriquetral and midcarpal instability can present with similar findings and these need to be differentiated.

69.4 Indications

69.8.1 TFCC Repair

DRUJ ligament repair can be performed in the acute or subacute setting. It is also indicated in cases where a TFCC tear can be repaired.

Peripheral TFCC tears can be repaired using open or arthroscopic techniques or a combination of both. When the DRUJ is grossly unstable, an open repair may prove beneficial.

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Key Procedural Steps

69.8.2 Ligament Reconstruction Ligament reconstruction can be performed by forming an ulnocarpal sling with a strip of FCU tendon, as described by Boyes and Bunnell (▶ Fig. 69.1) or Hui and Linscheid (▶ Fig. 69.2). These techniques primarily address ulnocarpal instability and not DRUJ instability. Reconstructing the radioulnar ligaments with a tendon graft has also been described. The Adams technique involves reconstruction of both the dorsal and palmar radioulnar ligaments, with a palmaris longus graft passed through bone tunnels in the radius and ulna. It reconstructs the anatomic origin and insertion of the respective ligaments. Correct tensioning of the construct can be challenging and has a steep learning curve. Be cautious not to disrupt or unnecessarily dissect the ECU sheath and subsheath.

69.10 Key Procedural Steps ●

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69.9 Difficulties Encountered

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Soft tissue reconstructions will fail if malunions of the radius and/or ulna are not addressed. A flat sigmoid notch should also be addressed with a deepening procedure. Underlying DRUJ arthritis will likely result in worsening of symptoms if the joint is further tightened.

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Fig. 69.1 Boyes–Bunnell method of ulnocarpal ligament reconstruction.

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Exposure is performed through the 5th dorsal compartment (▶ Fig. 69.3). An L-shaped DRUJ capsulotomy is made. If the TFCC can be repaired, proceed with an open or arthroscopic repair (▶ Fig. 69.4). In there is chronic instability with significant DRUJ laxity and attenuated soft tissues, proceed with reconstruction. For DRUJ tendon reconstruction, a palmar incision is made between the ulnar neurovascular bundle and the flexor group. A first bone tunnel is made with a cannulated 3.5 mm drill bit several millimeters proximal to the lunate fossa and radial to the lunate fossa. The position of the wires should be confirmed fluoroscopically before overdrilling (▶ Fig. 69.5). A second bone tunnel is made in the distal ulna between the ulnar fovea and the ulnar neck with the same 3.5 mm drill bit. A suture retriever is utilized to pass the tendon graft through the radius tunnel. The two free limbs of the tendon graft are passed through the tunnel made at the fovea. The graft is tensioned with the forearm in neutral rotation and both ends are tied together around the ulnar neck.

Fig. 69.2 Hui–Linscheid method of ulnocarpal ligament reconstruction.

Fig. 69.3 Exposure through an L-shaped capsular incision via the 5th extensor compartment.

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Distal Radioulnar Ligament Repair/Reconstruction

Fig. 69.4 Possibilities of direct repair. Open TFCC repair on the left, and open repair of the dorsal distal radioulnar ligament on the right. TFCC, triangular fibrocartilage complex.

Fig. 69.5 Distal radioulnar ligament reconstruction using the Adams–Berger procedure.

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Tensioning is accomplished by compressing ulna and radius in neutral forearm rotation and tying the ends of the graft together. The arm is immobilized in a long arm cast for 4 weeks with the forearm in neutral position, followed by short arm cast for 2 weeks. Full activity is permitted after 3 to 4 months.

69.11 Bailout, Rescue, and Salvage Procedures In the case of an arthroscopic repair, convert to an open repair if adequate stability is not achieved. Salvage procedures typically involve bony reconstruction of the DRUJ. This can be accomplished with a Sauve Kapandji DRUJ fusion, Darrach resection in lower demand patients, or DRUJ arthroplasty.

69.12 Outcomes A series of patients with chronic instability treated with capsular imbrication or reefing reported improvement in outcome scores and restoration of stability up to 7 years after

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surgery. Several series have documented outcomes following DRUJ ligament reconstruction. Adams et al reported symptom relief and restoration of stability in 12/14 patients using their technique.

69.13 Pitfalls ●

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A thorough clinical examination in neutral forearm rotation, pronation, and supination is required to detect instability. Instability most often occurs in pronation or neutral position. Supination is most difficult to achieve after repair or reconstruction. Supination is also the most stable position for the DRUJ. If possible, immobilize the forearm in supination postoperatively. Ensure that closed reduction of the DRUJ is possible before committing to reconstruction or repair.

Suggested Readings Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am. 2002; 27(2): 243–251

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Pitfalls Bain GI, McGuire D. lee YC, Eng K, Zumstein M. Anatomic foveal reconstruction of the TFCC with a tendon graft. Tech Hand Up Extrem Surg. 2014; 18: 92–97 Kouwenhoven ST, de Jong T, Koch AR. Dorsal capsuloplasty for dorsal instability of the distal ulna. J Wrist Surg. 2013; 2(2):168–175

Lawler E, Adams BD. Reconstruction for DRUJ instability. Hand (N Y). 2007; 2(3): 123–126 Manz S, Wolf MB, Leclère FM, Hahn P, Bruckner T, Unglaub F. Capsular imbrication for posttraumatic instability of the distal radioulnar joint. J Hand Surg Am. 2011; 36(7):1170–1175

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Part XI Skin

XI

70 Split Thickness Skin Graft

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71 Full Thickness Skin Graft

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72 V–Y Advancement Flap

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73 Volar Advancement Flaps—Moberg

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74 Cross Finger (and Reverse) Flap

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75 Thenar Flap

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76 Axial Flag Flap and First Dorsal Metacarpal Artery Flap (Kite Flap)

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77 Z-plasty

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78 Radial Forearm Flap

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70 Split Thickness Skin Graft Rosemary Yi and Virak Tan Abstract Split-thickness skin grafts (STSGs) are indicated for wounds that cannot close primarily and are at risk of secondary skin contracture. A healthy wound bed is required for STSG. Healing occurs by plasmatic imbibition, which provides the necessary nutrients for capillary ingrowth (inosculation) and fibroblastic maturation. Vacuum-assisted closure (VAC) device dressings can aid in take of the skin graft. The technique for successful STSG harvest and application is described, and so are techniques for salvage and dealing with complications. Keywords: split thickness skin graft, skin replacement, wound coverage, skin loss.

70.1 Introduction 70.1.1 Indications Split-thickness skin grafts (STSGs) are indicated when primary wound closure is not an option and closure by secondary intention is a poor choice. In order for a STSG to heal, a suitable wound bed is required. The wound should be debrided of necrotic tissue and bacterial load should be minimized in order to prevent graft loss from infection.1 In addition, the graft bed must be well-vascularized to allow for plasmatic imbibition, the diffusion process by which skin grafts receive their nutrition. The wound bed should not contain any areas of denuded bone, or exposed tendon or joint, as these tissues will not support inosculation, which is the process whereby the skin graft undergoes capillary ingrowth from the underlying tissue. A simple rule of thumb is to avoid skin grafting on top of any white structures: bone, tendon, joint, ligament, or nerve. Healthy fat, muscle, paratenon, or periosteum is suitable for successful incorporation of skin graft. Skin grafting can be performed using either STSGs or fullthickness skin grafts. A STSG harvests the epithelium and a varying portion of the dermal layer. A full-thickness skin graft harvests the epithelium and the entire dermal layer. STSGs undergo secondary contraction and, as such, are not suitable for wounds over joints. In addition, STSGs have poor elasticity and durability and this should be considered when grafting wounds over areas that are subject to frequent shear. An advantage of STSGs is that they adhere more readily to wound beds and therefore are more likely to take in less ideal wound beds. Fullthickness skin grafts are preferred in wounds around joints or in the palm of the hand due to a lower degree of secondary contracture. However, full-thickness skin grafts experience greater levels of a hypermetabolic state after harvest due to the increased thickness of dermal tissue requiring nutritional support. Therefore, full thickness skin grafts are more likely to fail than STSGs in difficult wounds.

70.1.2 Alternatives Skin graft substitutes offer an alternative to skin grafting. There are several classes of skin substitutes. Two commonly used skin substitutes are: (1) AlloDerm (LifeCell Corp., Branchburg, NJ), a cadaveric human acellular dermal matrix and (2) Integra Dermal Regeneration Template (Integra LifeSciences Corp., Plainsborough, NJ), a dual layer of bovine collagen dermal matrix with a silicone membrane. Skin graft substitutes provide a scaffold for cellular invasion and capillary growth, which can be beneficial for soft tissue coverage of large wounds2,3 as well as for staging prior to skin grafting in order to enhance the wound bed or thickness of the underlying dermal layer.4 Another treatment alternative is allowing for secondary wound closure. However, large wounds often are better managed surgically to minimize wound healing time and prevent secondary wound or joint contractures.

70.2 Surgical Technique 70.2.1 Preparation—Planning and Special Equipment Skin grafting can be performed once the wound has been appropriately debrided to a healthy, vascularized wound bed with minimal bacterial contamination. The vacuum-assisted closure (VAC; KCI, Inc., San Antonio, TX) device is a useful tool to help promote healthy granulation tissue prior to skin grafting.5 (▶ Fig. 70.1) In addition, it can also be used as a dressing over the skin graft which can enhance take of the graft by limiting fluid collection under the skin graft and promoting epithelial mitosis and vascular ingrowth through the negative pressure effect.6 The surgeon should discuss the planned donor site with the patient during informed consent, as well as the possibility of failed take of the skin graft. For STSG, the most preferred site for harvest is the anterior or lateral thigh, due to the ease of harvest and postoperative care. The medial and posterior thigh should be avoided, if possible, to minimize postoperative pain from the donor site resting on the bed or rubbing the contralateral thigh. A dermatome is required as well as a mesher. Meshing of the STSG is not required, but does help prevent fluid from collecting between the graft and the wound bed and allows for a greater area of coverage than the area of donor skin. Various ratios of meshing are available: 1:1.5 is recommended for improved cosmesis and quicker time to reepithelialization.7 An alternative to meshing is “pie-crusting,” whereby serial small (1–2 mm) holes are perforated in the skin graft to allow for egress of fluid.

70.2.2 Technique The patient should be positioned supine if the donor site is the anterior or lateral thigh, with the operative arm outstretched

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Split Thickness Skin Graft

Fig. 70.2 The wound is measured and the donor site is marked. The subcutaneous tissue is infiltrated with 0.25% marcaine and epinephrine and the skin is lubricated. An assistant places tension on the skin, while the surgeon maintains the dermatome at 45 degrees and advances with steady pressure.

Fig. 70.1 This patient had a crush injury to his left volar forearm with a traumatic wound near the antecubital crease. After debridement and VAC treatment, the wound is ready for skin grafting. VAC, vacuumassisted closure.

on a hand table. Using the ipsilateral leg typically allows for easier room setup. The wound is measured and the donor graft site is marked on the thigh (▶ Fig. 70.2). The donor site should be preinjected with local anesthetic containing epinephrine for hemostasis and postoperative pain control. The dermatome should be set to appropriate thickness, typically 0.0012 to 0.0015” for upper extremity wounds. Mineral oil, or alternatively chlorhexidine soap, is applied to the donor site as a lubricant. An assistant holds tongue depressors against the skin proximal and distal to the donor site in order to apply tension to the skin. The dermatome is started off the skin and held near a 45-degree angle to the surface of the skin throughout the harvest. The dermatome is advanced with steady, even pressure against well-lubricated skin to prevent skipping of the blade. When the end of the harvest area is reached, the dermatome is lifted off the skin, and any remaining skin graft attached to the donor site is divided sharply. After harvest, the skin graft is placed on the appropriate carrier for the mesher, with the epithelium against the carrier. A few drops of saline will not only keep the skin moist but also aid in flattening the graft against the carrier. The carrier is loaded onto the mesher and the skin

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Fig. 70.3 The harvested skin graft is loaded onto a carrier with the epidermis against the carrier. The assistant watches, as the skin graft exits the mesher to ensure the skin graft does not wrap around the mesher.

graft is advanced into the mesher by a crank mechanism (▶ Fig. 70.3). If meshing is not used, the graft is perforated with a scalpel (pie-crusted) to allow for exudate to escape. The skin graft is then applied by laying it onto the wound bed. By keeping the epithelium against the carrier, the skin graft can be transferred to the wound without having to be lifted off the carrier (▶ Fig. 70.4). The skin graft is tailored to the wound if the borders are irregular and extra skin graft can be applied to any remaining small defects. The border of the skin graft can be secured to the wound edges with 5–0 chromic sutures, which do not require removal, or with surgical staples

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Complication

Fig. 70.5 The edges of the skin graft are sutured to the periphery of the wound bed with 5–0 chromic sutures.

can be meshed to a larger ratio to be expanded for more coverage. Finally, a skin substitute can be placed instead of a STSG. Fig. 70.4 By keeping the dermis up and the epidermis against the carrier, the skin graft can easily be applied by pressing the graft against the wound, where it will stick to the moist wound bed. Forceps are used to place the skin graft in its proper location.

(▶ Fig. 70.5). Quilting sutures can help secure skin graft to any irregularities in the surface of the wound by passing a chromic suture through adjacent meshed holes, with an intervening pass through the underlying wound bed. Tying the suture will secure the intervening skin graft to the underlying wound bed. The goal is to have good apposition of the dermal side of the STSG to the wound bed. A nonadherent dressing such as xeroform (Kendall, Mansfield, MA) or adaptic (Systagenix, London, UK) should be placed over the graft. An absorbant, loosely-applied circumferential dressing, bolster, or VAC dressing should be placed to apply compression on the skin graft.8 The donor site can be dressed in a number of ways, but the author’s preferred method is a nonadherent layer with occlusive tape.9

70.2.3 Salvage If the graft is disrupted or perforated during harvest, the graft can still be used. Place the graft on the carrier, so the cut edges are adjacent to each other, and mesh with care to ensure the graft does not wrap around the mesher as it passes through. The grafts can be placed on the wound, and secured at the periphery with 5–0 chromic sutures, as well as between the cut edges of graft. If there is not adequate graft, the available graft

70.3 Postoperative Care A splint should be applied to the extremity if the skin graft is placed on a wound bed that will be experiencing shear forces, that is, underlying muscle or tendon or near a joint. The dressing should be kept in place for at least 5 days to allow adequate time for inosculation and adherence of the graft. The dressing should be removed very carefully to prevent lift off of the graft from the wound bed. The graft has taken if inosculation has occurred, which is observed as a pink hue to the graft with adherence to the wound bed (▶ Fig. 70.6 and ▶ Fig. 70.7). After removal of the initial operative dressing, the wound can be redressed with a nonadherent gauze and absorbant gauze on top, with a loose circumferential wrap until the wound no longer weeps. The donor site operative dressing can stay in place as long it remains intact and until the underlying skin has reepithelialized.

70.4 Complication If the graft has not taken at all or there is a large area of failure, then the wound must be inspected for infection or other causes of failure such as hematoma formation or unsuitable wound bed. Once the wound bed is healthy and vascularized with low bacterial load, the site can be considered for regrafting, if adequate donor tissue is available for a STSG. If the patient no longer has an available donor site, consideration should be given to skin substitute. Finally, if there are no options for coverage or if the area of failed take is small, the wound may have to heal by secondary intention, taking care to minimize contractures.

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Fig. 70.6 After removal of the initial VAC dressing, the skin graft has near 100% take with a light pink hue to the skin graft and adherence to the wound bed. VAC, vacuum-assisted closure.

References [1] Perry AW, Sutkin HS, Gottlieb LJ, Stadelmann WK, Krizek TJ. Skin graft survival–the bacterial answer. Ann Plast Surg. 1989; 22(6):479–483 [2] Askari M, Cohen MJ, Grossman PH, Kulber DA. The use of acellular dermal matrix in release of burn contracture scars in the hand. Plast Reconstr Surg. 2011; 127(4):1593–1599 [3] Frame JD, Still J, Lakhel-LeCoadou A, et al. Use of dermal regeneration template in contracture release procedures: a multicenter evaluation. Plast Reconstr Surg. 2004; 113(5):1330–1338 [4] Held M, Medved F, Stahl S, Bösch C, Rahmanian-Schwarz A, Schaller HE. Improvement of split skin graft quality using a newly developed collagen scaffold as an underlayment in full thickness wounds in a rat model. Ann Plast Surg. 2015; 75(5):508–512 [5] Scherer SS, Pietramaggiori G, Mathews JC, Prsa MJ, Huang S, Orgill DP. The mechanism of action of the vacuum-assisted closure device. Plast Reconstr Surg. 2008; 122(3):786–797

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Fig. 70.7 Several weeks after skin grafting, the interstices have fully healed through reepithelialization and the split thickness skin graft has matured.

[6] Azzopardi EA, Boyce DE, Dickson WA, et al. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg. 2013; 70(1):23–29 [7] Davison PM, Batchelor AG, Lewis-Smith PA. The properties and uses of non-expanded machine-meshed skin grafts. Br J Plast Surg. 1986; 39(4): 462–468 [8] Kim EK, Hong JP. Efficacy of negative pressure therapy to enhance take of 1-stage allodermis and a split-thickness graft. Ann Plast Surg. 2007; 58(5): 536–540 [9] Voineskos SH, Ayeni OA, McKnight L, Thoma A. Systematic review of skin graft donor-site dressings. Plast Reconstr Surg. 2009; 124(1):298–306

Suggested Reading Hallock GG, Morris SF. Skin grafts and local flaps. Plast Reconstr Surg. 2011; 127(1): 5e–22e

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71 Full Thickness Skin Graft Aaron Rubinstein and Jonathan Keith Abstract Full-thickness skin grafts are a commonly performed surgical procedure for the management of a certain subclass of soft tissue defects. The unique role of the human hand requires durable and sensate skin surfaces to accommodate for a variety of positions and fine motor tasks essential for the purposes of daily living. Most commonly, full-thickness skin grafts are utilized on the volar surface of the hand, as they have been shown to limit contracture and preserve motion. Given their lack of intrinsic blood supply, full-thickness skin grafts are limited to surfaces that have adequate vascular beds, and cannot be used on bone or tendon without intact paratenon. Unique challenges faced during full-thickness skin grafting include adequate selection of donor tissue, preparation of a viable wound bed, and avoidance of hematoma and limiting of shear forces in the postoperative period. Keywords: full thickness skin graft, techniques, wound management, hand injuries

71.1 Description Skin grafting is a commonly performed surgical procedure that comprises a step on the reconstructive ladder, which is designed to address wounds that cannot be left to heal by secondary intention or closed primarily. The skin is an organ with a multitude of diverse functions, serving as a means of homeostasis, sensory input, and selectively permeable barrier. In general, the overall structure of the skin is conserved, with a thinner layer of epidermis covering the underlying thicker dermis, but specific subcomposition varies depending on anatomic region and intended function. Skin grafts are predominately divided into two major types: split and full-thickness. Split-thickness skin grafts (STSGs) comprise the epidermis and a part of the dermis. These grafts are traditionally harvested with a dermatome; thus, allowing the donor site to heal secondarily and experience a greater degree of secondary graft contracture. Full-thickness skin grafts comprise the epidermis and the entire dermis, are traditionally harvested with a scalpel, require primary closure, and experience less secondary graft contracture. The role of the human hand in carrying out vital life functions cannot be understated. With regard to the skin, there are several unique functions of the hand that must be accommodated, and it is useful to divide the hand into palmar and dorsal surfaces to recognize these diverse roles. The palmar skin comprises a thicker epidermis, and is devoid of hair and sebaceous glands, features designed to enhance grip and accommodate for pinching. Deeper dermal papillae and enhanced keratinization of the epidermis helps in accomplishing these roles. In addition, the palmar skin must be uniquely sensate, allowing for interaction with the environment and tactile feedback during fine motor tasks. This is accomplished by a high-density of specialized sensory appendages, such as Pacinian and Meissner’s

corpuscles, that line the dermal papillae and provide valuable sensory feedback. The skin on the dorsum of the hand is less specialized than that of the palmar surface, but must still be able to accommodate the multitude of positions and actions that the human hand performs on a daily basis. As such, it is more elastic than the palmar skin, and contains hair follicles, but is still adequately durable to protect the underlying tendons and muscles in movement, particularly during flexion.

71.2 Key Principles There are several unique principles that should be followed when evaluating the need for a full-thickness skin graft. As a guideline, full-thickness skin grafts are used only when durable, sensate skin with limited contracture is a requirement. In general, adequate skin for full-thickness skin grafting is less readily available than for STSGs. Technically, full-thickness skin grafts require a more robust vascular bed, making graft take more difficult. Moreover, they are more prone to infection than splitthickness grafts. With regard to the hand, full-thickness skin grafts are traditionally reserved for the volar surface of the hand. Glabrous donor sites contain a high-density of mechanoreceptors, and are devoid of hair, offering the best chance for a durable, sensate, and functional volar surface. Hair follicle transfer is an unwanted consequence of transferring nonglabrous skin and can result in a less aesthetic outcome. Selection and preparation of an adequate wound bed is paramount in determining the success of full-thickness skin grafts. As skin grafts do not have their own blood supply, they are dependent upon the recipient site for survival. Initially, the graft is nourished by a transudate from the wound bed in a process called plasmacytic circulation. Within several days, capillary ingrowth will begin to nourish the graft, as vascularization begins to develop. This process is dependent on the maintenance of a healthy wound base, as hematoma or any barrier between the graft and bed will result in failure to take. For similar reasons, full-thickness skin grafts directly onto bone or tendon, without intact paratenon, are contraindicated.1 The management of wound contracture is of particular importance with regard to managing soft tissue defects of the hand. In general, any violation of the dermis has the ability to undergo wound contracture in a process mediated by myofibroblast infiltration. The subsequent production of collagen fibrils results in wound edge contracture, which can result in potentially devastating losses of function with regard to volar surface injuries. A study by Rudolph evaluated myofibroblasts and wound contracture in an animal model. Microscopic and histologic findings suggest that full-thickness skin grafts function by speeding up the myofibroblast life cycle and therefore result in less wound contracture than STSG or granulation.2 Overall, this translates into a more functional outcome with less need for subsequent reconstructive procedures.

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Full Thickness Skin Graft Timing for skin grafting is a delicate balance between establishing a healthy, viable wound bed to maximize the potential for graft success and prompt timing to limit contracture. Traditionally, early debridement of the wound bed is performed and grafting is carried out within 2 to 3 days to maximize outcomes.

71.3 Expectations When performing a full-thickness skin graft, the expected result at the recipient site is a durable skin graft with normal texture, minimal secondary contracture, and maintenance of some degree of sensation. Occasionally, pigment mismatches between donor and recipient site occur and this is more prominent in darker-skinned individuals. In order to maximize graft viability, a 7 to 10 day period of immobilization accompanied by a bulky dressing or bolster is recommended prior to unveiling. In addition, sheer forces will disrupt the graft–recipient interface and need to be limited in the postoperative period for approximately 2 weeks. A unique advantage of full-thickness skin grafts over STSGs is the cosmesis of the donor site. The donor site is closed primarily with suture, leaving a linear, cosmetically favorable scar with less care and morbidity than the partial thickness wounds left by the harvest of a STSG.

71.4 Indications Indications for a full-thickness skin graft are largely the requirement for durable, sensate coverage with limited contracture. With regard to the hand, this is typically limited to palmar skin, which must be able to withstand everyday stresses through a variety of specialized tasks and movements such as grasp and pinch. Minimizing contracture is vital to preserving function and limiting the need for future procedures.

71.5 Contraindications Inadequate recipient vascular bed is the major contraindication to performing a full-thickness skin graft. Tissues without adequate blood supply, such as tendon, bone and nerve, or those that have not been thoroughly debrided to a healthy base, will harm the graft’s chances of survival and need to be addressed. In addition, grossly contaminated or potentially infected recipient beds should likewise undergo further debridement until deemed safe for grafting.

71.6 Technique, Positioning, and Anesthesia In general, the patient should be positioned, prepped, and draped to accommodate easy access to both donor and recipient sites. General anesthesia is standard for full-thickness skin grafts. Preoperatively, the appropriate donor site should be selected with particular consideration for satisfactory pigmentation, thickness, and hairlessness. With regard to the hand, often utilized sites include the hypothenar eminence, medial upper arm, cubital creased, and groin crease.

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Fig. 71.1 A 10-year-old boy suffered electrical burns to his hands with resulting full-thickness skin loss over his left long finger measuring 3 × 1.2 cm.

The surgeon should then mark out an appropriately sized ellipse of skin, as this shape will facilitate linear closure later. The donor site is then infiltrated with an admixture of local anesthetic and 1:100,000 epinephrine solution to elevate the skin and facilitate a more technically easy graft harvest. The skin is excised and subsequently defatted with scalpel or curved iris scissors to improve graft take. Often, pie-crusting is performed by perforating the graft with several small slits to prevent underlying fluid accumulation. The donor site is then closed primarily by undermining the adjacent skin and closing in layers in a linear fashion, thereby avoiding excess tension. The recipient site is prepared with gentle debridement and irrigation to obtain a healthy bleeding base (▶ Fig. 71.1 and ▶ Fig. 71.2). A thrombin solution may be utilized to minimize hematoma formation. The graft is tailored to fit the defect and applied dermis side down. It is secured in place with absorbable suture such as chromic gut (▶ Fig. 71.3). It is important to express as much underlying blood and fluid as possible to optimize contact between the graft and wound bed. Convex surfaces typically maintain graft positioning; however, concave surfaces may result in graft tenting over the defect, and require compression in the form of a bolster and possibly a tethering suture to the underlying tissue bed. After a nonadherent dressing is applied, a bolster is created using moist cotton or soft foam and tied over the dressing; Often, a splint is applied for protection and to limit contracture.3

71.7 Postoperative Care Postoperatively, the splint and dressing are left in place for approximately 7 days unless there is high-suspicion of hematoma or complication. As the graft is most likely to fail under tension, shear forces must be strictly limited. The dressing and bolster should be removed by 7 days and graft take evaluated. The patient should then be counseled to continue in order to limit sheer forces, keep the graft hydrated with petroleum-based ointment, and maintain a compressive dressing for several more weeks.

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Tips, Pearls, and Lessons Learned

Fig. 71.2 (a) A 4 × 1.5 cm ellipse of skin was marked in the ipsilateral groin crease; (b) After infiltration of local anesthetic with epinephrine, the graft was harvested at the junction of dermis and subcutaneous fat with a #15 scalpel; (c) Next, the hemostat clamps were attached to the dermis on each end to create tension; (d) Finally, the graft was defatted and thinned with curved iris scissors by holding the clamps under traction in the surgeon’s nondominant hand.

Fig. 71.3 (a)The wound underwent gentle debridement in preparation for the full-thickness skin graft; (b) The skin graft was then inset with absorbable suture; (c) Next, the groin donor site was closed primarily with absorbable suture and skin glue; (d) Finally, a bolster was sutured into place over the graft and he was immobilized in a splint.

71.8 Tips, Pearls, and Lessons Learned When harvesting a full-thickness skin graft, utilization of loupe magnification and scalpel in order to specifically harvest the graft at the junction of the dermis and subcutaneous

fat will serve to limit the need for extensive defatting of the graft. When thinning the graft, apply a hemostat or other clamp to each end of the dermis such that the weighted graft drapes over the surgeon's nondominant index and long fingers. This will allow the surgeon to better grasp a smaller graft and exert adequate tension to deflate and thin the graft with curved iris scissors

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Full Thickness Skin Graft The healing phase of full-thickness grafts can look quite different than that of STSGs and may involve some degree of desquamation of the epidermal layer of skin. Continue with graft hydration and allow time for healing which is often longer than with STSGs. It is important to counsel patients about the possibility of hyper or hypopigmentation of the full-thickness graft. After an initial period of hypopigmentation, the graft may return to its original pigmentation or become darker over time. This is especially true in darker-skinned individuals.

71.9 Complications Postoperative graft failure is the most commonly encountered complication of a full-thickness skin graft. Careful prevention of hematoma formation between the graft and underlying

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vascular bed through intraoperative pie-crusting of the graft, and postoperative use of a bolster, as well as minimization of sheer forces through relative immobilization can serve to address the main underlying causes of graft failure. Additionally, infection can significantly impair graft take by as much as 80%, and adequate preoperative wound bed debridement can help minimize such issues.1

References [1] Pederson WC. Nonmicrosurgical coverage of the upper extremity. In: Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed [2] Rudolph R. Inhibition of myofibroblasts by skin grafts. Plast Reconstr Surg. 1979; 63(4):473–480 [3] Golpanian S, Kassira W. Full-thickness skin graft. In: Anh Tran T, Panthaki Z, Hoballah J, Thaller S, eds. Operative Dictations in Plastic and Reconstructive Surgery. Cham: Springer; 2017

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72 V–Y Advancement Flap Michael J. Pensak and Daniel A. Seigerman Abstract Fingertip amputations causing a soft tissue void with retained volar skin, are amenable to a V–Y advancement flap. The flap is readily available, allows for 1 cm of tissue advancement, and can be performed under general or local anesthesia. Care is taken to preserve the vascularity to the flap while dissecting the subcutaneous attachments to the periosteum and flexor sheath in order to advance the flap. When done correctly, a sensate, soft tissue graft is achieved in one setting to provide adequate coverage for dorsal and distal soft tissue loss at the fingertip. Keywords: V–Y flap, V–Y advancement flap, fingertip amputation, completion amputation

72.1 Expectations The V–Y flap is able to provide sensate full thickness skin to fingertips including partial distal phalanx amputation. Patients may experience sensitivity at the tip of their digit, hypoesthesia, cold intolerance, nail deformity and pain, as a result of both the underlying injury and/or surgery.

72.2 Indications The flap is best suited to address finger tip injuries where there is an equal amount of dorsal and volar soft tissue loss or more loss dorsally than volar (▶ Fig. 72.1). An eponymous variant of this flap is the Kutler flap which describes advancement of ulnar and radial flaps into defects located on the sides of digits.1 The tissue to be advanced should be undamaged and be of full thickness.

joint flexion crease. The transverse distal edge of the flap should be as wide as the width of the nail plate.2 From a technical perspective it is essential that the flap be easily advanced to its recipient site. Any tethers hindering flap mobility are likely to lead to problems with inset and viability. Subcutaneous tissue and fat within the pulp space should be adequately dissected down to the volar aspect of the phalanx.2 In the midline of the digit, fibrous attachments to the volar surface of the flexor tendon sheath need to be released2 Along the margins of the flexor tendon, fibrous periosteal attachments also need division (▶ Fig. 72.3). Sharp scalpels or fine tenotomy scissors can accomplish this easily so long as adequate traction is kept on the distal flap. Fine single or double-pronged skin hooks facilitate dissection of the flap by keeping the skin on tension. The only structures that need to be preserved are the thin and mobile nerves and vessels. Since these structures are elastic, they will not tether the flap nor prevent its advancement into the recipient site. Individual neurovascular elements should never be identified or isolated in their course through the subcutaneous tissue to the flap.2 Attempts to skeletonize these fine structures will only cause damage to the fine and friable veins, causing vascular congestion, poor outflow, and possible flap failure. If resistance is encountered when trying to advance the flap, the surgeon should reassess for any tight fibrous septae that may have been missed. If the flap is freely mobile, it should inset easily into the recipient site and abut

72.3 Contraindications Extensive palmar soft tissue loss or damage precludes this flap from being harvested. Defects larger than 1.0 × 1.5 cm cannot be adequately covered with this flap. Advancements of more than 1.0 cm in line with the flap are poorly tolerated.

72.4 Special Instructions, Positioning, and Anesthesia Patient is positioned supine on the operating room table with a hand table attachment. Anesthesia can be general, regional, or local anesthesia. A variety of tourniquets can be used including pneumatic arm and forearm varieties or their nonpneumatic counterparts. A digital tourniquet can be used as well.

72.5 Tips, Pearls, and Lessons The vertical oblique limbs of the “V” should be curvilinear rather than straight when drawn out on the patients’ skin (▶ Fig. 72.2). For the volar single midline V–Y advancement, the apex of the V should lie at the distal interphalangeal (DIP)

Fig. 72.1 Dorsal oblique amputation of fingertip with exposed bone. (Reproduced with permission from Dariush Nikkhah. Hand Trauma: Illustrated Surgical Guide of Core Procedures, 1st edition © 2017 Thieme.)

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Fig. 72.2 (a) Incision of the skin under digital tourniquet. (b) Curvilinear markings, the flap width should be the width of the nailbed. (Reproduced with permission from Dariush Nikkhah. Hand Trauma: Illustrated Surgical Guide of Core Procedures, 1st edition © 2017 Thieme.)

Fig. 72.3 (a) Detachment from flexor sheath. (b) Division of fibrous septa facilitates advancement. The vessels are more elastic in contrast to the fibrous septae. (Reproduced with permission from Dariush Nikkhah. Hand Trauma: Illustrated Surgical Guide of Core Procedures, 1st edition © 2017 Thieme.)

Fig. 72.4 (a,b) Sufficient advancement achieved to provide a well-padded tip. (Reproduced with permission from Dariush Nikkhah. Hand Trauma: Illustrated Surgical Guide of Core Procedures, 1st edition © 2017 Thieme.)

Fig. 72.5 (a,b) The flap is advanced and sutured in place. (Reproduced with permission from Dariush Nikkhah. Hand Trauma: Illustrated Surgical Guide of Core Procedures, 1st edition © 2017 Thieme.)

the tip of the nail plate (▶ Fig. 72.4). If the defect is too large to allow for easy inset of the flap flush against the nail plate, it is advisable to leave a gap and allow the resultant defect to heal by secondary intention.2 Alternatively, one can use a small split thickness skin graft.2 If the flap is advanced too far distal, perfusion may be compromised, leading to graft failure.

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The actual advancement of the flap begins when skin closure commences. The apex of flap is closed first, which creates the vertical portion of the “Y.” Closure continues to progress distally until the flap is inset. The tourniquet should be let down to ensure that the flap is pink and has good capillary refill (▶ Fig. 72.5). If the flap appears white after the tourniquet is let

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References removing some of the sutures from the vertical portion of “Y.”2 A schematic of the procedure is shown in (▶ Fig. 72.6). The lateral advancement flap is supplied by only neurovascular bundle and can occasionally be based on a random vessel pattern contained within the subcutaneous tissues. It is elevated just like its midline counterpart and can be used to cover more laterally based fingertip defects.2

72.6 Difficulties Encountered

Fig. 72.6 Stump of amputated finger. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F. Atlas of Hand Surgery, 1st edition ©2000 Thieme.)

down, warm saline-soaked gauze should be applied over the tip of digit while the surgeon waits for perfusion to return. After 20 minutes of waiting and no return of perfusion, one can try

Failure to release adequate fibrous septae and periosteal attachments to the tendon sheath will limit excursion of the flap into the defect. In such cases, the flap may be inset under tension, which will manifest as poor perfusion to the flap when the tourniquet is let down. The surgeon can address this scenario by releasing any tethering fibrous connections and/or removing tight sutures.

References [1] Kutler W. A new method for finger tip amputation. J Am Med Assoc. 1947; 133(1):29 [2] Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green’s Operative Hand Surgery. 6th ed. Philadelphia, PA: Elsevier; 2011

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73 Volar Advancement Flaps—Moberg John E. Nolan III, Nathan T. Morrell, and Adam B. Shafritz Abstract Volar advancement flaps are useful in managing fingertip amputations. The indications, contraindications, and outcomes of both Moberg and V–Y advancement flaps are presented. Key technical considerations for success are highlighted. Keywords: volar advancement flaps, Moberg flap, V–Y advancement flap

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73.4.2 V–Y Advancement Flap Indications ●

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73.1 Description Volar advancement flaps allow for full-thickness soft tissue coverage for fingertip amputations. Two main types of volar advancement flaps exist: (1) the Moberg flap and (2) the V–Y volar advancement flap devised by Atasoy.1,2 The Moberg flap addresses volar oblique soft tissue loss at the thumb.3 It was historically performed on other digits; however, suboptimal outcomes can occur when performed on digits 2–5, leading most surgeons to restrict its use to soft tissue loss at the distal thumb. The V–Y advancement flap addresses transverse and dorsal oblique soft tissue loss on all digits.3

73.2 Key Principles Both the Moberg and V–Y volar advancement flaps allow for soft tissue coverage at areas of distal fingertip loss. Flap choice is based on the pattern of soft tissue loss, as the V–Y flap is best suited for transverse and dorsal–oblique-oriented defects, and the Moberg flap lends itself to volar oblique tissue defects. As flap success is predicated on full-thickness coverage, patterns that restrict full coverage, or large defects which may require the selection of another flap type (e.g., homodigital island flap) versus heterodigital reconstruction. Further, the neurovascular supply must be preserved to maintain flap viability.

73.3 Expectations When indicated, volar advancement flaps provide full-thickness soft tissue coverage to distal fingertip amputations. Preservation of the flap’s neurovascular supply may allow for maintenance of two-point discrimination in the transposed tissue, although altered sensation is often an outcome. Cold intolerance has also been described.

73.4 Indications 73.4.1 Moberg Advancement Flap Indications ●

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Volar oblique soft tissue loss at the thumb.

Tissue loss of a maximum of 1 to 1.5 cm (although modifications may improve mobilization up to 3 cm).

Dorsal–oblique or transversely oriented soft tissue loss at any digit. Tissue loss distal to the lunula.

73.5 Contraindications 73.5.1 Moberg Advancement Flap Contraindications ● ●

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Soft tissue loss at digits 2 to 5. Transversely oriented or dorsal–oblique soft tissue loss at the thumb. Thumb soft tissue defects requiring greater than 1.5 cm of distal tissue advancement

73.5.2 V–Y Advancement Flap Contraindications ● ● ●

Volar–oblique soft tissue defects. Extension of the soft tissue loss proximal to the lunula. Need for the proximal extent of the flap to originate proximal to the distal interphalangeal joint (digits 2–5) or the interphalangeal joint of the thumb.

73.6 Vascular Considerations Understanding the vascular anatomy of the Moberg and V–Y advancement flaps affords informed flap selection. The thumb has significant contributions to its blood supply both volarly and dorsally. The dorsal contribution of the thumb emerges from the paired dorsalis pollicis arteries emanating from the first dorsal metacarpal artery off the dorsal carpal arch. These paired arteries supply the thumb’s distal phalanx, whereas the dorsal blood supply does not extend as far distally in digits 2 to 5.4 Furthermore, the primary volar blood supply to the thumb emerges from paired arteries emanating from the princeps pollicis artery (a branch from the radial artery), which is located dorsally. For the other digits, the digital arteries serve as the main vascular supply to the digit volarly and the dorsum of the distal phalanx. As the Moberg flap may jeopardize the digital neurovascular bundles, digits 2 to 5 are at increased risk of flap and tip necrosis following the procedure. The thumb’s robust dorsal vasculature along with the dorsal location of its volar blood supply (from the princeps pollicis artery) protect it from this complication.4

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Procedural Modifications

73.7 Special Instructions, Positioning, and Anesthesia ● ●

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May be performed under local, regional, or general anesthesia Visualization may be aided by the use of a forearm tourniquet for the Moberg or V–Y advancement flap; a digital tourniquet may be placed for V–Y advancement flap procedures. The patient should be positioned supine with the use of a hand table. Loupe magnification may assist with dissection about the neurovascular bundles.

73.8 Key Procedural Steps 73.8.1 Moberg Advancement Flap Technique Incisions should be made midlateral along the radial and ulnar borders of the thumb, dorsal to the neurovascular bundle. Remaining dorsal will allow for advancement of the entire pedicle within the tissue. The flap is then dissected free of the flexor tendon sheath and subsequently advanced along its long axis in a proximal to distal direction. Advancement greater than 1.5 to 2 cm may require flexion at the thumb interphalangeal joint for distal coverage. The incisions are then closed primarily (▶ Fig. 73.1).

73.8.2 V–Y Advancement Flap Technique The volar V–Y advancement flap creates a triangular-shaped flap that is moved both distally and dorsally for soft tissue coverage.2 The distal edge is transverse in nature and abuts the soft tissue defect. The two oblique limbs of the triangular flap are formed by skin incisions that converge to a common point located at or distal to the distal interphalangeal joint crease. Underlying subcutaneous tissue is not incised to ensure preservation of the flap’s vascular supply. Working through the distal transverse edge, the septae are released deep into the subcutaneous tissue to allow for superficial soft-tissue advancement without vascular compromise. The proximal portion is primarily closed side-to-side to form the vertical limb of the “Y.” The oblique limbs are then closed primarily to surrounding tissue, and the distal transverse limb is sutured to the remaining nailbed (▶ Fig. 73.2).

73.9 Technical Difficulties Technical difficulties associated with volar advancement flaps include mobilization of tissue, providing bulk to the digital pad, and maintaining fingertip contour. Surgeons are limited in their ability to advance the flap without causing necrosis by imparting undue tension on the blood supply. Therefore, having tissue for both near normal appearance and function can be difficult.

Fig. 73.1 (a) Volar oblique tissue loss at the right thumb with marked midlateral incision for Moberg flap reconstruction. (b) Incision and volar advancement of Moberg flap. (c) Final suturing and closure of Moberg flap with slight thumb interphalangeal joint flexion.

73.10 Procedural Modifications 73.10.1 Moberg Modifications The Moberg flap is a viable option for thumb reconstruction of volar oblique soft tissue defects up to 1.5 to 2 cm. Defects exceeding this range may require interphalangeal joint flexion during the procedure. This may result in a postoperative flexion contracture (▶ Fig. 73.3d). Modifications to the procedure have been proposed to allow for flap mobilization distally, without the need for joint flexion, thereby aiming to prevent the aforementioned deformity. Described techniques include: (1) the O’Brien modification (▶ Fig. 73.4), (2) creation of a V–Y flap at the Moberg’s base (▶ Fig. 73.5), and (3) Z-plasties at the Moberg’s base (▶ Fig. 73.6).5,6,7 A cadaveric study conducted by Jindal et al found that the O’Brien modification allows 104% more advancement than the standard Moberg flap, and Zplasties afforded 55 percent more advancement.6 The O’Brien modification involves a transverse incision at the base of the flap which creates a soft tissue defect there. This can either be covered with a full-thickness skin graft or be left to

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Volar Advancement Flaps—Moberg

Fig. 73.2 The Atasoy volar V–Y advancement flap. (a) V-shaped incision is made and the subcutaneous tissue is elevated from the bone. (b) A full-thickness flap is developed and advanced. (c) The skin is then closed. (Modified with permission from Wolters Kluwer Health, Inc.: Atasoy E, Ioakimidis E, Kasdan M, Kutz JE et al,. Reconstruction of the amputated finger tip with a triangular volar flap: a new surgical procedure. Journal of Bone & Joint Surgery, 1970; 52:5: 922.)

heal by secondary intent (▶ Fig. 73.3 and ▶ Fig. 73.4).5 With skin grafting, there can be additional scarring, contracture of the graft, and donor site morbidity. Other studies have found that V–Y advancement at the base of the Moberg as well as Z-plasty transposition flaps can increase the flap’s distal advancement by up to 2 cm without the need for additional grafting (▶ Fig. 73.5 and ▶ Fig. 73.6). However, additional flaps at the base of the Moberg flap increase the risk for extension of the flap into the thenar eminence, which can lead to symptomatic scarring and contracture.

73.10.2 V–Y Modifications Contemporary modifications to the V–Y advancement flap have two main purposes: further advancement of soft-tissue as well as improved contouring of the digit. Diaz et al described a technique of dual V–Y flaps which increased mobilization of tissue up to 0.5 cm (▶ Fig. 73.7).8 This technique not only provides for greater soft tissue coverage to the tip but also helps prevent a volar-based pull on the dorsal tissue. The result may help to prevent a hook nail by providing slack on the nailbed-associated tissue. Further, by decreasing tension

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on the flap, the risk for necrosis is decreased. Another technique to decrease tension on the tissue and improve pad thickness and contouring of the digit’s tip includes suturing the proximal ends of the triangular flap together, as opposed to trimming the edges.9 A final focus includes nailbed and nail matrix grafting for dorsal–oblique and transverse defects. One recent study reports that bone and nail bed grafting at the time of V–Y flap resulted in favorable nail growth and take in 78.6% of 14 patients, with preservation of 7.5 mm two-point discrimination, grip strength less than 10 percent different than the contralateral side, and less than 10 degrees of metacarpophalangeal and interphalangeal joint extension losses.10

73.11 Expected Outcomes Both advancement flaps provide full-thickness, volarly based soft tissue coverage to the distal aspect of the affected digit. Assuming a tension free repair, the patient may expect to have two-point discrimination that is within 5 mm.6 However, decreased sensation and cold temperature intolerance are commonly reported. Although the literature states that up to

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Expected Outcomes

Fig. 73.3 (a) Preoperative image demonstrating volar oblique tissue loss at the thumb. (b) Perioperative photos denoting a Moberg flap with an O’Brien’s modification without grafting at the flap’s base. (c) Postoperative image denoting healing of the Moberg flap and proximal donor site. (d) Postoperative flexion contracture

Fig. 73.4 (a) Volar oblique tissue loss at right thumb, with marked out Moberg incision with O’Brien modification. (b) Volar advancement of flap with skeletonization of neurovascular bundles. (c) Final suturing of flap with residual volar soft-tissue defect at modification site which will require skin graft coverage

Fig. 73.5 (a) Volar oblique tissue loss at right thumb, with marked Moberg inicison with proximal V–Y modification. (b) Volar advancement of flap. (c) Final suturing of Moberg flap with proximal V–Y modification connecting the midlateral incisions obviating the need for coverage proximally.

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Volar Advancement Flaps—Moberg

Fig. 73.6 (a) Volar oblique tissue loss at right thumb, with marked Moberg incision with proximal Z-plasty at base of midlateral incision. (b) Volar advancement with transposition of two triangular flaps at the base of the Z-plasty to allow for lengthening of the Moberg flap. (c) Final suturing of the combined Moberg and Z-plasty flap

45 degrees of interphalangeal joint flexion can be tolerated at the time of Moberg advancement without residual deformity, a slight flexion contracture commonly occurs, and patients should be counseled about this expected outcome.

73.12 Complications The major complications associated with volar advancement flaps include infection, sensory changes and flap death/ necrosis. While infections commonly lead to decreased flap survival, overtensioning the neurovascular bundles during advancement reduces inflow and outflow and can result in flap death. Other common patient complaints include inadequate pulp tissue that may result in pain with pinching/squeezing and poor appearance.4 Should the flap fail, few bailout procedures exist. A volar– oblique thumb defect that has failed a Moberg flap will likely require a heterodigital island flap or a free flap. A transverse or dorsal oblique defect with a failed V–Y advancement flap would likely lack adequate soft tissue to subsequently undergo a homodigital neurovascular island flap and would instead require revision amputation with digital shortening.

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Fig. 73.7 (a) Transverse fingertip amputation with full-thickness tissue loss with dual V–Y flap incisions–initial flap at standard position with second flap occurring more distal. (b) Incision and advancement of flap. (c) Final suturing of flap allowing for further advancement than the standard V-Y flap.

References [1] Moberg E. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg Am. 1964; 46(4):817–825 [2] Atasoy E, Ioakimidis E, Kasdan ML, Kutz JE, Kleinert HE. Reconstruction of the amputated finger tip with a triangular volar flap. a new surgical procedure. J Bone Joint Surg Am. 1970; 52(5):921–926 [3] Lemmon JA, Janis JE, Rohrich RJ. Soft-tissue injuries of the fingertip: methods of evaluation and treatment. An algorithmic approach. Plast Reconstr Surg. 2008; 122(3):105e–117e [4] Macht SD, Watson HK. The Moberg volar advancement flap for digital reconstruction. J Hand Surg Am. 1980; 5(4):372–376 [5] O’Brien B. Neurovascular island pedicle flaps for terminal amputations and digital scars. Br J Plast Surg. 1968; 21(3):258–261 [6] Jindal R, Schultz BE, Ruane EJ, Spiess AM. Cadaveric study of a Z-plasty modification to the Moberg flap for increased advancement and decreased morbidity. Plast Reconstr Surg. 2016; 137(3):897–904 [7] Kojima T, Kinoshita Y, Hirase Y, Endo T, Hayashi H. Extended palmar advancement flap with V-Y closure for finger injuries. Br J Plast Surg. 1994; 47(4): 275–279 [8] Díaz LC, Vergara-Amador E, Fuentes Losada LM. Double V-Y flap to cover the fingertip injury: new technique and cases. Tech Hand Up Extrem Surg. 2016; 20(4):133–136 [9] Tezel E, Numanoğlu A. A new swing of the atasoy volar V-Y flap. Ann Plast Surg. 2001; 47(4):470–471 [10] Zhou X, Wang L, Mi J, et al. Thumb fingertip reconstruction with palmar V-Y flaps combined with bone and nail bed grafts following amputation. Arch Orthop Trauma Surg. 2015; 135(4):589–594

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74 Cross Finger (and Reverse) Flap Justin M. Miller, John M. Yingling, and John T. Capo Abstract The cross-finger flap and reversed cross-finger flaps are utilitarian techniques for obtaining soft tissue coverage of phalangeal defects. Both have specific indications and limitations but with proven outcomes. The key procedural steps, special considerations, and technique pearls are covered in the following chapter. Keywords: cross, reverse, flap, palmar, volar, dorsal, phalanx, coverage, defect

74.1 Description The cross-finger flap and reversed cross-finger flaps are utilitarian techniques for obtaining soft tissue coverage of phalangeal defects. Both have specific indications and limitations but with proven effective outcomes.

74.2 Key Principles After sustaining a traumatic injury to a digit, suitable soft-tissue coverage is required to properly return adequate hand function and activities of daily living. Resurfacing of the wound defect anatomy and meticulous surgical technique are paramount to obtaining acceptable outcomes.

74.3 Expectations The cross-finger flap is a reliable and simple method of finger tissue coverage that results in good clinical outcomes with regard to pulp reconstruction, pain relief, return of sensation, and patient satisfaction.1 One can anticipate a relatively quick operative time, no need for in-patient admission or anticoagulation, and a high rate of flap survival.

74.4 Indications 74.4.1 Cross-Finger Flap Loss of volar, phalangeal skin and subcutaneous tissue that comprises more than 75% of the entire finger pulp from the distal interphalangeal (DIP) joint crease and distal; or defect over the volar aspect of the middle phalanx. These flaps are particularly effective when the bed of the defect has exposed bone, tendon, tendon sheath, and/or neurovascular bundle. If only subcutaneous fat is exposed, then a full-thickness skin graft alone could be sufficient2

74.4.2 Reverse Cross-Finger Flap Reconstruction of dorsal digital defects that may include the eponychial skin fold, large sterile matrix nailbed defects, as well as exposed and injured extensor tendon defects over the middle phalanx and proximal interphalangeal (PIP) joint.3

According to Martin and colleagues, soft tissue destruction of less than 1 cm2 on either the volar or dorsal surfaces of the digits can be managed conservatively.4

74.5 Contraindications 74.5.1 Both Cross-Finger and Reverse Flaps Extensive soft tissue damage or amputation of adjacent fingers where donor sites would be lacking in adequate and mobile healthy tissue. In addition, the size of the defect must not be excessively large (> 5 cm2) to be covered by the potential donor site.2,3

74.6 Special Considerations The skin of the fingertips contains one of the human body’s most densely aggregated areas of sensory end organs. Thus, recreating proper tactile function with adequate full thickness flaps is integral to adequate outcomes. This is especially crucial if the patients’ occupation and daily activities call for precise manual tasks such as those required of a surgeon. On the contrary, the recovery time and loss of work may hinder a manual laborer’s ability to maintain gainful employment, making proximal amputation more advantageous. Although, many heavy labor occupations demand complete fingertip capabilities capable of strong grasp and dexterity.2 Furthermore, donor site choice for the full-thickness skin graft is an important consideration, whether it be from the ipsilateral forearm, lateral thigh, or hypothenar area. These decisions are based on surgeon preference, and the particular skin color and needs of the patient.

74.7 Special Instructions, Positioning, and Anesthesia ● ● ● ●

Supine with a hand table. Prep out the appropriate donor site. Tourniquet. Regional block if preferred.

74.8 Tips, Pearls, and Lessons Learned The advantage of the cross-finger flap lies in its versatility. The flap hinge can be based more proximally, laterally, or distally, with potential length-to-width ratios as great as 2:1. For instance, the hinge can be created distally in order to gain coverage for more distal amputations. The flap may also be angled opposite to its intended direction of transfer. For example, if the flap is angled more proximally, the resulting transposed

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Cross Finger (and Reverse) Flap coverage can be more distal. In addition, the cross-finger flap can also be utilized as a pseudo “flag flap,” creating a narrow pedicle flap that follows the dorsal branches of the digital vessels and allowing increased flexibility.5 In order to maximize the length-to-width ratio capabilities and unique defect coverage, one can manipulate the proximal or distal transverse incisions. For example, one can extend the distal incision more volarly than the proximal incision, creating a flap that faces more distally. This strategy can also be applied if the flap becomes kinked on one side when stretching it to cover the defect.6 In instances where the flap is lacking in mobility, Cleland’s ligament may be the structure preventing mobilization of the flap. These should be incised adjacent to the bone in order to protect the vascularity feeding the flap deep to the ligament.6 The dissection plane is not only critical for flap viability but also the resulting donor site’s suitability for skin grafting. The wispy layer of paratenon, with its small arterioles and veins, must be maintained to allow a good incorporation of a pliable full-thickness skin graft. Maintaining vascularity to the flap is paramount to its survival. Extension of the recipient finger can create stress on the flap’s pedicle, cutting off its circulation. The finger should be gently flexed to assure adequate blood flow. The tourniquet should be released to check the vascularity and the finger position can be adjusted accordingly. In unusual situations, such as in combative or noncomplaint patients, the fingers may be held more securely with a transfixing Kirschner (K) wire or multiple sutures.6 Finally, Vidal designed a technique to estimate the crossfinger flap’s actual required size. It involves using a finger cut from a sterile glove and initially creating a template of the intended flap on the glove in order to check its shape against the defect for a precise fit. This avoids cutting a flap of inadequate size or shape.7

If a reversed cross-finger flap is required in a slender patient, the subcutaneous tissue required for the onlay flap may be inadequate for coverage. In this case, the flap should be abandoned and an alternative method used.

74.10 Key Procedural Steps 74.10.1 Cross-Finger Flap A standard cross-finger flap is intended to cover volar finger loss at the pulp or the volar aspect of the finger and is designed from the dorsal surface of the adjacent middle phalanx (▶ Fig. 74.1). The adjacent digit with the closest length match, and least amount of injury, should be chosen. This may be the radial or ulnar border digit. On the dorsal surface, a three-sided rectangular flap is created, which when elevated will create a door whose hinge is adjacent to the injured finger (▶ Fig. 74.2a–d). This flap pattern should be designed in order to fully cover the defect site, being of similar size and shape. The most radial and ulnar borders of the donor flap should not

74.9 Difficulties and Complications Encountered While allowing for volar soft tissue coverage, the cross-finger flap creates a dorsal donor defect that can be problematic. This defect is typically covered with a full-thickness skin graft. However, the appearance of the dorsal finger can be regarded as unsightly for some patients. Furthermore, the dorsal skin has much less subcutaneous fat compared to a finger pulp and may contain hair follicles. Resulting hair growth at the finger tip can be an annoyance for the patient. Another common complication is cold intolerance, although this is postulated to be secondary to the injury pattern as well as the type of coverage achieved.8 Finally, patients often will complain of decreased sensation in the recipient area. This has not been shown to be very debilitating, but does create issues with fine motor function. Lee and colleagues explored an innervated cross-finger flap which showed promising results with increased sensation and decreased overall complaints in fine motor function.9

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Fig. 74.1 Deep volar defect on the middle phalanx of a finger. The reconstructed deep flexor tendon is exposed. (1) Proper palmar digital artery and nerve. (2) Reconstructed tendon of the flexor digitorum profundus muscle. (3) Fibrous sheath with defect. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

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Key Procedural Steps

Fig. 74.2 (a, b) Demonstrates two views of the injury with (c, d) showing the designed graft site, ensuring the planned resection covers the defect, and radial/ulnar borders do not pass volar to neurovascular bundles.

Fig. 74.3 Ipsilateral forearm full thickness graft harvest site.

pass volar to the neurovascular bundles at the corresponding midlateral lines. The incisions can be marked as far distally and proximally as the DIP and PIP joints, respectively. In order to reach a more distally located defect, the flap should be angled at the proximal and distal limbs to allow the flap to reach as far as possible distally. First, the three skin edges of the flap are incised. As the skin is carefully raised, longitudinal veins are seen which should be preserved if possible. The ideal dissection plane is deep to these veins and just superficial to the extensor tendon. Loose areolar tissue is within the dissection plan, and this tissue needs to be preserved on the tendon as it represents the paratenon. This well-vascularized tissue is crucial to ensure that

skin graft has good ingrowth at the donor site. The flap is then flipped 180 degrees over its hinge and it is mobilized distally to cover the defect. Next, a full-thickness skin graft is acquired from a suitable donor site. The exact site is discussed with the patient preoperatively and may be: the medial ipsilateral forearm (▶ Fig. 74.3), hypothenar area, volar wrist, or groin. This should be measured appropriately before harvesting according to the corresponding donor defect. The donor flap as well as the full-thickness skin graft is then stitched into place with small nylon suture. It is easier to inset and suture the vascularized flap and then assess the resulting donor defect before harvesting and affixing the skin graft. A final check is preformed to ensure a proper tensionfree fit; any redundant edges are trimmed, and adequate vascularity to the flap is confirmed. A nonadherent dressing is utilized with a well-padded splint to protect the reconstruction. The patient is seen at follow-up within a week, and then scheduled for division of the flap at 2 to 3 weeks from flap creation (▶ Fig. 74.4a–e). At division, the flap may be somewhat dry and congested, but typically has good healing and full incorporation at 6 weeks postoperatively 2,6,10 (▶ Fig. 74.5a–d). A schematic of the procedure is shown in (▶ Fig. 74.6).

74.10.2 Reverse Cross-Finger Flap The reverse cross-finger flap is indicated for defects on the dorsum of the finger and must be treated with a different

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Cross Finger (and Reverse) Flap

Fig. 74.4 Dorsal (a) and volar (b) aspects prior to separation at the 2-week interval. (c–e) demonstrates the coverage after separation and closure of the cross-finger flap.

Fig. 74.5 (a-d) Multiple views of 6 weeks postop which demonstrates complete healing with a good cosmetic result.

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Bailout, Rescue, and Salvage Procedures

Fig. 74.6 (a–d) Cross-finger flap. (a) A pedicled flap is mobilized on the dorsal aspect of the adjacent finger. (1) Skin flap. (2) Branch from the proper palmar digital artery. (3) Dorsal aponeurosis with peritenon. (b) The flap with its lateral pedicle is placed over the volar defect in the adjacent finger. (1) Skin flap. (2) Branch from the proper palmar digital artery. (3) Reconstructed tendon of the flexor digitorum profundus. (c) The cross-finger flap covers the volar skin defect. The flap is fixed with retention sutures. (d) The donor site on the dorsal aspect of the finger is covered with a full-thickness skin graft. The suture tails of the retention sutures are left long for the foam rubber pressure bandage. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

the flap still being created on the dorsum of the adjacent middle phalanx. The skin hinge of this flap with be on the opposite side, away from the injured finger. First, the skin should be raised away from the injured finger, as a fullthickness skin flap above the subcutaneous venous plexus and fat using a scalpel. What remains is a layer of vascularized subcutaneous tissue that can then itself be used as a flap in the same manner as the standard cross-finger flap. This tissue can then be sharply incised, coagulating any small veins or arterioles, elevated off the tendon with a hinge toward the injured defect, and flipped over 180 degrees for coverage. What was the superficial surface is now lying down directly over the defect. Finally, the skin graft elevated from the donor finger to unroof the flap can be sutured back down to its original position over the extensor tendon and its paratenon. The postoperative plan, dressing, and timeline for flap separation is treated similarly as the standard cross-finger flap.3,6

Fig. 74.7 Deep dorsal defect extending to the bone in the middle phalanx. (1) Dorsal aponeurosis. (2) Bony defect. (3) Margin of skin defect. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

technique (▶ Fig. 74.7). The flap entails taking an alternate type of graft from the dorsum that can be mobilized to a dorsal defect on an adjacent finger (▶ Fig. 74.8). The base of the flap is opposite to the standard cross-finger flap, with

74.11 Bailout, Rescue, and Salvage Procedures Alternatives to the cross-finger flap include the thenar flap, homodigital or heterodigital island flap, or a local V–Y advancement flap. A thenar flap is reliable for coverage of the index, middle, and ring fingers, but should be reserved for only young patients (< 30 years) and those with supple joints. A problematic flexion contracture in the PIP joint can result if this flap is used in older patients. If the adjacent digits are damaged, then a homodigital island flap may be appropriate. This flap involves taking a proximal midlateral

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Cross Finger (and Reverse) Flap

Fig. 74.8 (a–f) Reversed cross-finger flap. (a) The planned finger flap is deepithelialized and reflected to cover the defect in the adjacent finger. The split-thickness skin graft created is later used to cover the defect created at the donor site. This procedure requires extremely careful dissection with the aid of magnifying loupes. (1) Margin of the skin defect. (2) Dorsal aponeurosis. (3) Split-thickness skin graft. (4) Bony defect. (5) Subcutaneous tissue. (b) Dissecting the deepithelialized flap consisting of portions of the dermis and subcutaneous tissue. (2) Dorsal aponeurosis with peritenon. (3) Split-thickness skin graft. (c) The deepithelialized flap is reflected to cover the defect in the adjacent finger. (1) Deepithelialized flap. (2) Dorsal aponeurosis with peritenon. (3) Split-thickness skin graft. (d) The reflected flap and donor site are covered with the split-thickness skin graft removed earlier. (1) Split-thickness skin graft. (e) The flap is divided three weeks later. (f) The wounds are closed with retention sutures. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

tissue paddle, based on the digital artery perfused in a retrograde manner. The advantage is that the surgery is limited to the affected digit, but the disadvantage is that the

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digital artery is sacrificed. If the finger defect is smaller (< 50% of the pulp area), then a local V–Y advancement flap is ideal.

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References

References [1] Rabarin F, Saint Cast Y, Jeudy J, et al. Cross-finger flap for reconstruction of fingertip amputations: Long-term results. Orthop Traumatol Surg Res. 2016; 102(4) Suppl:S225–S228 [2] Tempest MN. Cross-finger flaps in the treatment of injuries to the finger tip. Plast Reconstr Surg. 1952; 9(3):205–222 [3] Atasoy E. The reverse cross finger flap. J Hand Surg Am. 2016; 41(1): 122–128 [4] Martin C, González del Pino J. Controversies in the treatment of fingertip amputations. Conservative versus surgical reconstruction. Clin Orthop Relat Res. 1998(353):63–73

[5] Beasley RW. Soft tissue replacements. In: Beasley's Surgery of the Hand. Thieme; 2011:95–100 [6] Pederson WC, Lister G. Local and regional flap coverage of the hand. In: Wolfe SW, ed. Green's Operative Hand Surgery. Churchill Livingstone; 2011 [7] Vidal P. Cross-finger flap: how to design its shape accurately. Ann Plast Surg. 1994; 33(1):100–101 [8] van den Berg WB, Vergeer RA, van der Sluis CK, Ten Duis HJ, Werker PM. Comparison of three types of treatment modalities on the outcome of fingertip injuries. J Trauma Acute Care Surg. 2012; 72(6):1681–1687 [9] Lee NH, Pae WS, Roh SG, Oh KJ, Bae CS, Yang KM. Innervated cross-finger pulp flap for reconstruction of the fingertip. Arch Plast Surg. 2012; 39(6):637–642 [10] Curtis RM. Cross-finger pedicle flap in hand surgery. Ann Surg. 1957; 145(5): 650–655

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75 Thenar Flap Stephen Ros and James Monica Abstract The thenar flap is a random-pattern flap which is best suited to repair volar oblique distal fingertip amputations, with subtotal or total pulp loss but no major bony or nail involvement. The flap provides excellent reconstitution of three-dimensional bulk, contour of finger pulp, and fingertip projection due to the significant amount of subcutaneous tissue available, reducing the risk of claw deformity. This two-stage technique is simple to perform with excellent tissue color and texture match, excellent recovery of functional sensibility, and low-donor site morbidity due to its inconspicuous flap design. The thenar flap is superior to the cross-finger flap as it provides more appropriate soft tissue bulk and obviates the need for adjacent finger involvement and subsequent disfiguring donor defect. The thenar flap has no strict age limitations and can be easily performed for injury to index, long, and ring fingers. Long-term outcomes show no significant proximal interphalangeal (PIP) joint contractures or finger stiffness in those without joint damage, infrequent donor site tenderness, and no cold intolerance or hypersensitivity. In spite of this, thenar flaps are generally considered to lead to PIP joint flexion contracture in adults, and as such this procedure is generally favored in the pediatric patient population. Appropriate patient selection is critical as the procedure requires meticulous postoperative care and splint immobilization until flap division. Keywords: thenar flap, volar oblique fingertip amputation, pedicle graft

Fig. 75.1 (a–c) Schematic of a thenar flap.

386

75.1 Description The thenar flap was first described by Gatewood6 in 1926 and modified by Flatt in 1957 as a two-stage, proximally based transfer flap from the medial aspect of the thenar eminence.5 (▶ Fig. 75.1). Depending on the clinical situation, several modifications exist including pedicle source of flap, location on thenar eminence, and flap base positioning all with excellent outcomes.5,7,8,9 The thenar flap is ideally suited for volar skin and pulp avulsions of the terminal phalanx of the index, long, and ring fingers, with a majority of nail and bone intact.1 For volar oblique soft tissue injuries too extensive for healing by secondary intention, primary closure, or V–Y advancement, the thenar flap provides restoration of pulp contour and bulk, soft tissue color and texture match, and recovery of functional sensibility.7

75.2 Key Principles The thenar flap provides excellent recovery of bulk, contour, and fingertip projection, thereby enabling improved nail support (▶ Table 75.1). The glabrous skin over the thenar eminence provides a perfect tissue match and an abundance of subcutaneous tissue from an inconspicuous donor site. This is in stark contrast to the cross-finger flap which has inadequate soft tissue for pulp reconstruction and is associated with donor-site morbidity, joint stiffness, and cold intolerance.

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Key Procedural Steps

75.6 Special Considerations

Table 75.1 Thenar flap Flap Tissue

Volar skin

Course of vessels

Dermal circulation without a named artery

Dimensions

1.5 cm wide × 2–3 cm long

Anatomy

Relies on inosculation of pedicle flap to wound bed

Surgical technique

Flap is elevated at subcutaneous plane with pedicle no more than twice the length of the flap base. Oriented to inset into the digital pulp defect of the injured finger

Patient position

Supine with hand table and tourniquet control

Dissection

In subcutaneous plane with preservation of perforating vessels

Advantages

Excellent color and texture match, and rapid dissection

Disadvantages

Pedicle flap requires digital flexion and attachment of the digit to the thenar eminence for 2 weeks

Pearls and pitfalls

Risk of PIP joint flexion contracture in elderly patients

Patient selection is critical to success. The staged nature of the procedure and need for postoperative care of skin bridge and splint requires a reliable patient.

75.7 Special Instructions, Positioning, and Anesthesia ●

●

● ●

75.8 Tips, Pearls, and Lessons Learned ●

75.3 Expectations In cases of volar oblique fingertip amputations with intact bone and nail, the thenar flap is expected to obtain an aesthetically pleasing result, with preservation of functional length, reconstitution of pulp bulk and contour, and recovery of functional sensibility. Anticipated outcomes include acceptable donor site morbidity, minimal joint range of motion deficits, no cold intolerance, and quick return to occupational function. Resolution of soreness and improvement of dexterity usually occurs by 2 to 3 months postoperatively. Thenar flaps have historically been thought to lead to PIP joint flexion contracture in the elderly, and as such this procedure is ideally suited to the pediatric and young adult patient population.

●

●

●

75.4 Indications ●

●

●

●

Volar oblique fingertip amputations with skin and pulp loss of the terminal phalanx of index, long, and ring fingers, with a majority of nail and bone intact. Index7 and small fingers may find it more difficult to achieve an acceptable flap design with minimal tension. Injuries too extensive for healing by secondary intention, primary closure, or V–Y advancement flaps. Pediatric fingertip amputations requiring soft tissue reconstruction.2,4

75.5 Contraindications ●

● ●

●

Significant bone loss, tendon involvement, or neurovascular compromise. Prior trauma to thenar eminence. Preoperative PIP and distal interphalangeal (DIP) joints’ range of motion (ROM) deficits. No strict age limitation; however, adults are more likely to have joint stiffness.7

Patient is positioned supine on the operative table with hand table extension. Regional anesthesia is ideally utilized for the first stage of the procedure. Flap division may be performed under local anesthesia. Consider general anesthesia for children for both stages.

●

●

Avoid PIP joint flexion contractures by keeping in mind the following points3: – Design proximally based flap proximal to thumb metacarpophalangeal (MCP) joint, avoiding the midpalmar area. – Radial border should fall in the MCP joint flexion crease. – Obtain full flexion of MCP and DIP joints, allowing PIP joint flexion to be less than 40 to 50 degrees. – Sever flap at 12 to 14 days after first stage and begin active ROM, extension, and intrinsic muscle exercises to obtain full IP joint extension. Sensory reeducation should begin once ROM and touch perceptions are recovered. – Hand therapy and extension splinting may be necessary if joint contracture occurs. Avoid excessive finger flexion as it results in too proximal of a donor site, causing excessive flap tension. Place flaps high on the thenar eminence to avoid the midpalmar aspect of the hand and radial digital nerve of the thumb.4 Design flap with distal redundancy in the event that flap vascularization is not excellent. Distal flap should be loosely approximated beyond the fingertip margin to avoid an abnormally bulbous contour. Selective defatting of the pedicle graft is required are approximately 1.5 cm to obtain a cosmetic volar contour.

75.9 Difficulties Encountered ●

Maintaining finger flexion to minimize tension at the flap site with a dorsal block splint is challenging. Augmentation with a 2–0 nylon suture is recommended from the involved finger to palm.

75.10 Key Procedural Steps 75.10.1 Stage 1 ●

●

Local, regional, or general anesthesia, along with antibiotic prophylaxis are provided. Tourniquet applied and extremity prepped and draped in the usual sterile fashion.

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Thenar Flap ●

●

●

●

●

Injured finger (▶ Fig. 75.2a) irrigated and debrided, and skin edges cleaned and trimmed. Donor site identified by flexing injured finger to thenar eminence, with maximal MCP and minimal PIP joint flexion. The flap should be designed around the imprint of blood remaining. The flap should lie high on the thenar eminence proximal to the MCP joint. – Design flap as rectangle with triangular tip distally to avoid contractures. – Flap dimensions are approximately 1.5 cm wide by 2 to 3 cm long. Since the rounded end of the fingertip is a half circle, the width of the flap must be 1.5 to 2 times the defect width.7 Raise full-thickness flaps of subcutaneous tissue and fascia to preserve flap vascularity. Dissection occurs in a distal to proximal fashion, being careful to identify the radial digital nerve to the thumb. The triangular tip of the donor site is closed with 5–0 nylon simple sutures. The donor site may be either left open, primarily closed, or covered by full-thickness skin graft. Donor flap is sutured to the defect by attaching the distal end to the nailbed edge using 5–0 nylon simple sutures. The nail plate may need to be removed to facilitate this. If necessary, suture may be passed through the nail.

Sides of the defect should not be closed to prevent tissue ischemia. The flap should be completely tensionless. This may be facilitated by applying a 3–0 nylon retention suture on each side of the palm. Release tourniquet, check flap viability, and obtain hemostasis. Xeroform and fluffed gauze dressings are applied. A wellpadded dorsal blocking splint and thumb spica are applied to maintain the designed finger flexion and tension-free flap. Dressings may need to be changed twice weekly. ○

●

● ●

75.10.2 Stage 2 ● ● ● ●

● ●

The second stage ideally occurs at 12 to 14 days postoperatively. Local, regional, or general anesthesia is provided. Extremity prepped and draped in the usual sterile fashion. The flap is divided and blood flow assessed. The flap is then loosely inset using 5–0 nylon simple suture. The donor site is irrigated and debrided and may be primarily closed using 3–0 nylon simple suture (▶ Fig. 75.2b). Xeroform and fluffed gauze dressing are applied. Sutures are removed at 10 to 14 days postoperatively (▶ Fig. 75.3a-c).

Fig. 75.2 Volar oblique fingertip amputation of middle finger preoperatively (a) and after thenar flap division, (b) showing loose inset of flap into defect and primary closure of donor site.

Fig. 75.3 (a–c) Follow-up images post thenar flap division showing excellent cosmesis of defect and donor site without flexion contracture.

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References

75.11 Bailout, Rescue, and Salvage Procedures ●

●

Capillary refill is assessed regularly, as swelling may impair circulation, thereby requiring suture removal. Growing fingernail may not adhere over flap. A nail-bed reconstruction using great toe nail-bed graft may be necessary.

75.12 Pitfalls ● ●

●

●

Significant fingertip sculpting may lead to tip necrosis. Donor site tenderness is uncommon; however, home massage is useful. Avoid injury to the radial digital nerve to the thumb, which is found superficial to the midaxial line of the thumb. The motor branch of the median nerve is deep and ulnar to the donor site and is rarely exposed.

References [1] Barbato BD, Guelmi K, Romano SJ, Mitz V, Lemerle JP. Thenar flap rehabilitated: a review of 20 cases. Ann Plast Surg. 1996; 37(2):135–139 [2] Barr JS, Chu MW, Thanik V, Sharma S. Pediatric thenar flaps: a modified design, case series and review of the literature. J Pediatr Surg. 2014; 49(9): 1433–1438 [3] Beasley RW. Reconstruction of amputated fingertips. Plast Reconstr Surg. 1969; 44(4):349–352 [4] Fitoussi F, Ghorbani A, Jehanno P, Frajman JM, Penneçot GF. Thenar flap for severe finger tip injuries in children. J Hand Surg [Br]. 2004; 29(2): 108–112 [5] Flatt AE. The thenar flap. J Bone Joint Surg Br. 1957; 39-B(1):80–85 [6] Gatewood MD. A plastic repair of finger defects without hospitalization. JAMA. 1926; 87(18):1479 [7] Melone CP, Jr, Beasley RW, Carstens JH, Jr. The thenar flap–An analysis of its use in 150 cases. J Hand Surg Am. 1982; 7(3):291–297 [8] Polatsch DB, Rabinovich RV, Beldner S. The double thenar flap: a technique to reconstruct 2 fingertip amputations simultaneously. J Hand Surg Am. 2017; 42(5):396.e1–396.e5 [9] Rinker B. Fingertip reconstruction with the laterally based thenar flap: indications and long-term functional results. Hand (N Y). 2006; 1(1): 2–8

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76 Axial Flag Flap and First Dorsal Metacarpal Artery Flap (Kite Flap) Roger B. Gaskins III and Zhongyu Li Abstract The axial and kite flaps are rotational flaps available for coverage of proximal phalangeal defects. The axial flag flap is a simple cutaneous rotational flap from the dorsum of the proximal phalanx rotated to cover the volar or dorsal aspect of the proximal phalanx or metacarpophalangeal (MCP) joint. The kite flap is a similar fasciocutaneous flap harvested from the radial aspect of the proximal phalanx and can be used to cover adjacent digits or thumb. Both flaps utilize the dorsal metacarpal artery of the donor digit, and have minimal donor site morbidity Keywords: axial flap, kite flap, rotational, proximal phalanx, dorsal metacarpal artery

76.1 Description Several local tissue flaps are available for coverage of the proximal phalanx. The axial flag flap is a simple cutaneous rotational flap from the dorsum of the proximal phalanx rotated to cover the volar or dorsal aspect of the proximal phalanx or metacarpophalangeal joint. The kite flap is a similar fasciocutaneous flap harvested from the radial aspect of the proximal phalanx and can be used to cover adjacent digits or thumb.

recommend leaving approximately 5 to 10 mm of fatty tissue around the artery. The axial flag flap only needs an intact tissue bridge at the corner about which the flap will be rotated. The small size of the tissue bridge allows for significant mobility of this flap. The kite flap may be mobilized along the length of the artery, usually 30 mm.

76.3 Expectations These flaps reliably provide adequate coverage for the traumatized proximal phalanx with minimal donor-site morbidity. This technique requires a Doppler, basic microsurgical principles, and healthy tissue at the recipient site.

76.4 Indications Volar or dorsal soft tissue loss of the proximal phalanx or the metacarpophalangeal (MCP) joint requiring coverage. The flap must have a Doppler signal along the dorsal metacarpal artery to allow adequate perfusion of the flap. The recipient site must be a healthy bed with all devitalized tissue removed (▶ Fig. 76.1).

76.5 Contraindications ●

76.2 Key Principles

●

Both flaps utilize the dorsal metacarpal artery of the donor digit. They do not require vascular pedicle dissection; we

●

●

Active infection. Defect too large for coverage with local flap. No Doppler signal of dorsal metacarpal artery. History of trauma to the dorsal radial artery, vaso-occlusive or spastic disorder affecting the radial artery.

Fig. 76.1 (a) Defect at the palmar aspect of the index finger over the metacarpal head. (b) Design of a reverse first DMCA flap (“reverse kite flap”). (c) Flap rotated into the defect. (d) Primary closure of the donor site (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. ©2013 Thieme.) DMCA, dorsal metacarpal artery.

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Bailout, Rescue, and Salvage Procedures

76.6 Special Considerations A preoperative discussion with the patient regarding the options for coverage is important to inform as well as manage the expectations of the patient prior to undergoing flap coverage. The patient should be aware that the donor site must be grafted following the mobilization of the flap. Loupe magnification and a Doppler are required for this procedure.

76.7 Special Instructions, Positioning, and Anesthesia ● ● ● ●

Ensure a healthy tissue bed at recipient site. Supine on a stretcher or standard OR bed with a hand table. Regional block. Tourniquet is recommended after dorsal metacarpal artery is identified.

76.8 Tips, Pearls, and Lessons Learned The flap often takes several minutes to perfuse after the release of the tourniquet. Warm, sterile saline washed over the flap may help expedite reperfusion. If the flap is tunneled, evaluate venous congestion at any areas of compression. If the angle of rotation of the flap is too acute, it can lead to vessel kinking and flap congestion. Including venae comitantes and dorsal subcutaneous veins aid in venous outflow. The flap will shrink as it incorporates.

76.8.1 Pedicle Dissection Leaving a cuff of tissue (5–10 mm) surrounding the vascular pedicle will avoid unnecessary trauma to the vessels and decrease the chances of pedicle loss. The kite flap pedicle can be traced back to the princeps pollicis artery, or the radial artery, to maximize pedicle length.

76.8.2 Flap Sizing Carefully measure the size of the defect for planned flap coverage. The flap extends from the base of the proximal phalanx to the dorsal–proximal interphalangeal crease and can be up to 4 × 2.5 cm. Be aware of an additional 2 to 3 mm from each side of the donor flap to allow for flap to be placed in recipient site, without any tension and allow for future flap shrinkage.

76.8.3 Closure We commonly use 5.0 nylon suture in simple interrupted fashion (spaced approximately 5–6 mm apart) to allow for a tensionfree closure.

76.9 Difficulties Encountered After pedicle dissection, Doppler signals should remain similar as compared to prior dissection. If a decreased signal is noted,

the pedicle likely has undergone trauma or is under excessive tension. Patients with small vessel disease are poor candidates for this type of flap coverage.

76.10 Key Procedural Steps (▶ Fig. 76.2) The dimensions of the flap are determined by the size of the digital defect. The dorsal metacarpal artery is confirmed with Doppler prior to dissection. It is frequently on the dorsal–radial aspect of the phalanx (▶ Fig. 76.3). The width of the pedicle is commonly the radial 1/3 of the width of the phalanx. The terminal aspect of the flap is sized to meet the need of the recipient site (taking an additional 2–3 mm from each side of the donor flap). The maximum size of the donor flap is the dorsal aspect of the donor phalanx and can be up to 4 × 2.5 cm. The flap is drawn with a sterile surgical marker to confirm size and adequate coverage. An arm tourniquet is then inflated without exsanguinating the limb. A full-thickness skin flap is then made with a #15 scalpel. Care is taken to dissect, but not through, the level of the extensor paratenon. Damage to the paratenon can lead to postoperative extensor adhesion, requiring extensive therapy or surgical lysis. If a sensate flap is required, terminal branches of the superficial radial nerve may be included. We recommend leaving 5 to 10 mm of fatty tissue around the vascular pedicle to avoid trauma. After the flap has been fully elevated, an incision may be needed to allow the pedicle to inlay without tension along the course of the flap. It is important to ensure no pressure is on the pedicle. Then, release tourniquet to evaluate perfusion of the flap visually and with Doppler (▶ Fig. 76.4). When adequate perfusion is established, the flap is then sutured to the donor site with 5.0 interrupted nylon suture. A full-thickness skin graft is taken from the antecubital fossa. Again, adequate size of the graft is required to allow tension-free closure of the donor site. Any areas of excessive bleeding are controlled with bipolar electrocautery. A nonadherent dressing is placed over the flap and the skin graft site. The donor site is covered with saline-soaked gauze, cast padding, and a loose elastic bandage.

76.11 Bailout, Rescue, and Salvage Procedures Local tissue rearrangement can be helpful in cases of inadequate coverage from the flap alone. Finger flexion at the recipient phalanx may be used if pedicle has insufficient length to reach the donor site. If possible, the hand should be maintained in intrinsic plus position to avoid postoperative contractures. If the flap is not salvageable, the defect may be covered with a forearm, arm, abdominal, or groin flap. However, these options are not ideal due to the bulk of the donor flap and frequent need for multiple operations.

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Axial Flag Flap and First Dorsal Metacarpal Artery Flap (Kite Flap)

Fig. 76.2 FDMAu flap. (a) Be aware that the vessels tend to run more radially than expected. (b) The pedicle can be traced back to the princeps pollicis or radial artery to maximize pedicle length. (c) Flap mobilization. Include a branch of the superficial radial nerve for a sensate flap. (d) Tension-free closure (Reproduced with permission from Günter Germann, L Levin S, Sherman R. Reconstructive Surgery of the Hand and Upper Extremity. ©2017 Thieme.) FDMAu, first dorsal metacarpal artery.

Fig. 76.3 Cadaver demonstration of (a) the ulnar branch of the FDMAu arising from the radial artery (asterisk); (b) FDMAu in the dorsal fascia of the index finger with preserved paratenon (Reproduced with permission from Slutsky, D. The Art of Microsurgical Hand Reconstruction. ©2013 Thieme.) FDMAu, first dorsal metacarpal artery.

Fig. 76.4 (a) Clinical picture of an insensate thumb with soft tissue deficiency; (b) First dorsal metacarpal artery was exposed within the interosseous muscle fascia; (c) Elevated flap demonstrating perfusion after tourniquet released; (d) Healed flap and skin graft site (Reproduced with permission from Günter Germann, L, Levin S, Sherman R. Reconstructive Surgery of the Hand and Upper Extremity. ©2017 Thieme.)

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Suggested Readings Adani R, Busa R, Bathia A, Caroli A. The “kite flap” for dorsal thumb reconstruction. Acta Chir Plast. 1995; 37(3):63–66 Foucher G, Braun JB. A new island flap transfer from the dorsum of the index to the thumb. Plast Reconstr Surg. 1979; 63(3):344–349

Germann G, Hornung RW, Raff T. [Possibilities for using the first dorsal metacarpal artery in acute management of severe hand injuries]. Handchir Mikrochir Plast Chir. 1994; 26(6):325–329

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77 Z-plasty Rosemary Yi Abstract Z-plasty is a useful technique in hand surgery for the release of scar or webspace contracture. Triangular flaps are raised along the central element, which is oriented along the line of greatest tension. The rearrangement of the local flaps allows elongation along the central element through the transposition of the transverse tissue. This chapter describes the techniques for 60° z-plasty and multiple z-plasties in series. In addition, specific modifications, such as the four-flap z-plasty or the “jumping man” z-plasty are described to achieve greater lengthening, which is useful for webspace contractures. Keywords: z-plasty, local flaps, longitudinal scars, four-flap z-plasty, jumping man z-plasty, five-flap z-pasty

77.1 Introduction 77.1.1 History Z-plasty is often utilized to improve the function and cosmetic appearance of scars. The first description was provided by

Denonvilliers1 in 1856 for surgical correction of lower lid ectropion. Limberg and Davis further popularized the technique for lengthening scars.2,3 Currently, there are numerous modifications of the technique which are available for various applications.

77.1.2 Classification In hand surgery, z-plasty is most suitable to breakup longitudinal skin contracture, such as in volar hand scars, Dupuytren’s contracture, first webspace contractures, or amniotic band syndrome (▶ Fig. 77.1). Z-plasty is a random-pattern transposition flap. Random-pattern flaps receive their blood supply from the subdermal or subcutaneous plexus, as opposed to axial-pattern flaps that receive their blood supply from a single, named vessel. Therefore, careful attention to maintaining dissection in the correct plane is prudent in order to preserve the small vessels that supply the triangular z-plasty flaps from the base. Transposition flaps are a type of local flap which utilize local tissue; they are advantageous because they possess similar appearance and function. Transposition flaps mobilize the flap lateral to the pedicle or base of the flap; therefore, they require pliability of the skin lateral to the line of contracture.

Fig. 77.1 (a) First web space contracture. (b-d) Simple z-plasty. (b) The scar is conservatively excised and a Z is created. (c) The skin flap is advanced and the rest of the scar tissue is excised. (1) Skin flap. (2) Saddle artery (variant occurring in 25% of all patients). (3) Deep portions of the scar. (d) Z-shaped skin closure. (e–f) Schematic diagram of simple z-plasty. (e) Z-plasty before advancement. (f) Z-plasty after advancement. (1) Length increase (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

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Technique

Fig. 77.2 60° z-plasty. After transposition of the flaps, the central limb (dashed line) is seen to increase in length by 75%.

Table 77.1 Types of z-plasties and their theoretical lengthening. Data from Hudson DA. Some thoughts on choosing a z-plasty: The z-plasty made simple Type of z-plasty

Theoretical increase in length of central element

Simple 45° z-plasty

50%

Simple 60° z-plasty

75%

Simple 90° z-plasty

100%

Four-flap z-plasty with 45° angles

100%

Four-flap z-plasty with 60° angles

150%

Five-flap z-plasty

125%

Fig. 77.3 A male patient with Dupuytren’s contracture of his right ring and small fingers involving both metacarpophalangeal and proximal interphalangeal joints. Open fasciectomy with longitudinal incisions and multiple z-plasties in series marked on skin.

77.2 Technique Z-plasty elongates a contracted scar by creating triangular flaps along both sides of the central element and transposing the lateral skin to convert transverse pliability into lengthening along the central element. The most commonly used 60° angle z-plasty will give a theoretical increase of 75% in length of the central limb (▶ Fig. 77.2). Although larger-angled flaps provide greater lengthening (▶ Table 77.1), they are not useful due to the excessive tension in transposing the flaps, which can lead to wound dehiscence, flap tip necrosis, scar hypertrophy, or secondary contracture. If a single, large z-plasty cannot be accommodated by the available skin, multiple z-plasties in series can be designed; in theory, the transverse loss remains constant but the longitudinal gain is cumulative. Multiple z-plasties in series are useful for longitudinal scars or Dupuytren’s contracture in the volar finger or hand (▶ Fig. 77.3, ▶ Fig. 77.4, ▶ Fig. 77.5). The transverse pliability should be tested as part of the planning for the z-plasty. This is performed by pinching the skin adjacent to the central element. If the skin is pliable, a single, large z-plasty may be suitable. If the available transverse skin is limited, multiple z-plasties in series should be designed. It is important to ensure there is no significant scarring lateral to the central limb, especially at the base of the flap, as this will limit the distance the flaps can be transposed. The central element is oriented along the axis of maximal contraction. The scar constricture should be excised if it is significantly constrictive, such as in amniotic band syndrome (▶ Fig. 77.6, ▶ Fig. 77.7). The length of the limbs in the flap should be equal

Fig. 77.4 Results of surgery demonstrate improved contractures, as well as well-apposed skin closure with multiple z-plasties in series to avoid skin tension.

so as to avoid problems with transposition. In addition, the angles also should be as accurate as possible. A ruler can help ensure accurate angles, as a 60° flap is formed by two sides of an equilateral triangle, and the length at the base of the flap is equal to the length of both sides of the flap. If the mobility of the flap is in question, the incisions should be made and tested in sequence. The flap should be raised with care to preserve the subdermal and subcutaneous plexuses by maintaining the thickness of the flap as dissection is carried toward the base. The flap can be thinned at the tip if needed, but should not be thinned at the base. Once the first flap is made, a skin hook is used to transpose the flap across the central element, with care taken to avoid crushing the tip of the flap. If the flap can be transposed halfway across the central element, there is adequate transverse pliability to continue (▶ Fig. 77.8). Difficulty transposing the limb can be addressed by shortening the limbs and adding more transverse limbs. Suturing the

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Z-plasty

Fig. 77.5 (a, b) Schematic demonstration of multiple z-plasties. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

Fig. 77.6 A 13-month-old girl born with amniotic band syndrome affecting bilateral hands. She has no functional middle or ring finger and constriction bands around her thumb and index finger. Inset: Skin markings demonstrated for band excision to address the distal lympedema. In addition, multiple z-plasties in series were designed for recontouring the digits.

transposed limbs begins with corner stitches which are halfburied horizontal mattresses with a subcutaneous pass through the apex of the flap. Attention should be paid toward handling the apices with care as they are fragile and most likely to necrose. The intervening limbs are then sutured with either running or interrupted sutures.

77.3 Modifications

Fig. 77.7 6 weeks postoperatively, the incisions are healed and the digit contours are improved. The distal lymphedema is subsiding.

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Greater gains can be made with greater angles; however, transposition also becomes more difficult. This is the reason as to why the 60° z-plasty is most commonly used. Specific modifications, including the four-flap z-plasty and the five-flap z-plasty, are useful in hand surgery and are also called the “jumping man” flaps. These modifications are particularly useful for first web space contractures. To gain greater length, the four-flap z-plasty converts either a 90° flap into two 45° flaps for a theoretical gain in length of 125% (▶ Fig. 77.9). Alternatively, the four-flap z-plasty can utilize two 60° flaps for a theoretical gain of 264% in length; for a 120° flap, however, transposition can result in increased tension compared to the 45° flaps. For first webspace contractures, the central limb is oriented over the distal webspace ridge (▶ Fig. 77.10). The flaps are designed as 45° flaps. The flaps are developed just superficial to the fascia of the thenar musculature. If additional depth of the webspace is required, the fascia

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References

Fig. 77.8 A 60-degree z-plasty is designed. After elevating one flap, the ability to transpose the flap is determined based on the ability to bring the flap across the central element by 50%. The remaining flap is then elevated and transposed.

Fig. 77.9 Four-flap z-plasty utilizing 45° flaps for a theoretical gain in length of 120%.

Fig. 77.10 Jumping man z-plasty for first webspace contracture.

and musculature of the first interosseous can be recessed or the insertion of the adductor pollicus divided. The five-flap z-plasty or “jumping man” flap is also of great utility in first webspace contractures. The flap incorporates a V– Y advancement between the opposing z-plasties to allow for greater lengthening as well as ease of transposition (▶ Fig. 77.10). The theoretical gain in length is 75% for the double opposing z-plasty plus 50% for the V–Y advancement flap, totaling 125%.4 The actual lengthening was shown to be less in the five-flap z-plasty when compared to the four-flap z-plasty.5 However, the four-flap Z-plasty requires more laxity of the surrounding tissues, so the five-flap z-plasty may be a better choice when there is more scarring surround the webspace ridge.

References

77.4 Postoperative Care

Citron ND, Nunez V. Recurrence after surgery for Dupuytren’s disease: a randomized

The hand is placed in a soft dressing if the flaps transposed easily without undue tension. The dressing comprises a nonadherent gauze and dry sterile gauze over the surgical site, followed by a compressive wrap. The wound is evaluated at 10 to 14 days. In the case of joint contracture/stiffness, a custom-molded splint is applied to maintain finger extension or to keep the thumb abducted. Occupational therapy is initiated once the wound is stable. Scar massage and range-of-motion exercises will help maintain the gain in length.

[1] Denonvilliers CP. Blepharoplastie. Bull Soc Chir Paris. 1856; 7:243 [2] Limberg AA. Skin Plastic with Shifting Triangle Flaps. Leningrad Traumatological Institute; Russia; 1929:862 [3] Davis JS, Kitlowski EA. The theory and practical use of the Z-incision for the relief of scar contractures. Ann Surg. 1939; 109(6):1001–1015 [4] Hudson DA. Some thoughts on choosing a Z-plasty: the Z made simple. Plast Reconstr Surg. 2000; 106(3):665–671 [5] Fraulin FOG, Thomson HG. First webspace deepening: comparing the fourflap and five-flap z-plasty. Which gives the most gain? Plast Reconstr Surg. 1999; 104(1):120–128

Suggested Readings trial of two skin incisions. J Hand Surg [Br]. 2005; 30(6):563–566 Crow ML, McCoy FJ. Volume increase by Z-plasty to the finger skin: its application in electrical ring burns. J Hand Surg Am. 1977; 2(5):402–403 Miura T. Congenital constriction band syndrome. J Hand Surg Am. 1984; 9A(1): 82–88 Moody L, Galvez MG, Chang J. Reconstruction of first web space contractures. J Hand Surg Am. 2015; 40(9):1892–1895, quiz 1896 Rohrich RJ, Zbar RIS. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg. 1999; 103(5):1513–1517, quiz 1518 Roush TF, Stern PJ. Results following surgery for recurrent Dupuytren’s disease. J Hand Surg Am. 2000; 25(2):291–296 Upton J, Tan C. Correction of constriction rings. J Hand Surg Am. 1991; 16(5):947–953

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78 Radial Forearm Flap Takintope Akinbiyi and Benjamin Chang Abstract The radial forearm flap is perfused by the reliable and consistent radial arterial system and provides well-vascularized tissue that can include skin, subcutaneous tissue, fascia, tendon, nerve, and bone. Perfusion to the hand is preserved via the ulnar artery and an intact palmar arch. Skin paddles of up to 35 cm by 15 cm have been described. It can be raised as an antegrade, retrograde, or free flap further increasing its versatility. Recent reports have demonstrated its use as a perforator-based rotational flap, thus preserving the radial artery. Care must be taking during the dissection to preserve the radial artery perforators to the overlying soft tissue and, if harvesting bone, the periosteum of the radius. The resulting donor defect can be closed primarily for smaller flaps, or skin grafted for larger ones. Keywords: fasciocutaneous flap, adipofascial flap, osteocutaneous flap, radial forearm flap, perforator flap, radioulnar synostosis, recurrent carpal tunnel syndrome, and neurostynalgia of the median nerve

tendons while allowing gliding and is especially useful in treating radioulnar synostosis, recurrent carpal tunnel syndrome, and neurostynalgia of the median nerve. It can be harvested as a proximally based pedicled flap for defects around the elbow, a reversed (distally based) pedicled flap for defects as distal as the proximal phalanges, and as a free flap for remote defects.

78.5 Contraindications ●

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Incomplete palmar arch with inability to reconstruct the radial artery after harvest Prior damage to the radial artery History of surgery on the extremity or scarring along course of the radial artery Smokers or diabetics (relative contraindication) Osteopenia/osteoporosis (relative contraindication for osteocutaneous flap)

78.6 Special Considerations 78.1 Description First described in 1981, and initially termed the “Chinese flap”, the radial forearm flap (RFF) provides well-vascularized tissue that can include skin, subcutaneous tissue, fascia, tendon, nerve, and bone.

78.2 Key Principles The RFF is raised on the radial artery or one of its perforators. Distal perfusion to the ipsilateral hand is preserved via the ulnar artery and an intact palmar arch. Sensibility can be preserved by including the medial or lateral antebrachial cutaneous nerves.

A detailed examination of the hand is required to observe for both radial and ulnar pulses, intact superficial and deep palmer arches (assessed via an Allen’s test), and any indications of prior surgery, trauma, or arterial catheterization at the wrist. Suboptimal arterial inflow that cannot be reconstructed with a vein graft will lead to hand ischemia, especially of the thumb, and may limit flap viability. Attention should be paid to the quality and quantity of the hair, if any, if the flap is to be used for mucosal resurfacing. If venous outflow is suboptimal, the cephalic vein can easily be harvested to provide additional drainage for antegrade flaps.

78.7 Special Instructions, Positioning, and Anesthesia ●

78.3 Expectations The RFF can be raised as a fasciocutaneous, adipofascial, osteocutaneous, or fascial flap. If taken with a skin paddle, dimensions of up to 35 cm by 15 cm have been described.1 If pedicled, it has an arc of rotation from the dorsum of the hand to the elbow. If raised as a free flap, its pedicle can be dissected to the point of origin at the brachial artery providing generous length. It can be raised as a sensate flap but provides only protective sensation.

78.4 Indications The RFF can be used to reconstruct small-to-moderate size defects involving skin, subcutaneous tissue, fascia, bone, and tendon requiring well-vascularized coverage with thin and pliable tissue. It can be used anywhere but is ideally suited for use in oropharynx, facial, and neck reconstruction or for distal upper extremity coverage. The fascia can provide cover for exposed

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Supine patient positioning with the arm abducted and placed on a hand table. Ideally the non-dominant hand is selected. The entirety of the upper extremity is prepped into the field. The recipient site, if distant, should be separately prepped to allow for wide exposure of recipient vessels. A portion of a leg should also be prepped providing access to the saphenous vein in case reconstruction of the radial artery is necessary. A tourniquet is helpful but is not mandatory. If used, the arm should only be partially exsanguinated to allow better visualization of the vessels. The flap can be raised under region block or general anesthesia.

78.8 Tips, Pearls, and Lessons Learned 78.8.1 Radial Artery Perforator Location The radial artery perforators are primarily located within the distal half to third of the forearm (▶ Fig. 78.1).2,3 In addition,

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Difficulties Encountered

Fig. 78.1 Radial forearm flap. (a) The forearm flap is dissected to expose the radial artery and its adjacent veins and the well-vascularized fascia of the forearm that supplies the skin above it. (1) Radial artery and adjacent veins. (2) Flexor carpi radialis. (3) Forearm fascia. (4) Brachioradialis. (5) Pronator teres. (b) The forearm flap is mobilized on its vascular pedicle (radial artery and adjacent veins) and placed in the defect on the dorsum of the hand. The direction of blood flow through the flap is reversed, which is now supplied by the ulnar artery via the palmar arches. (1) Flexor carpi radialis. (2) Radial artery and adjacent veins. (3) Superficial branch of the radial nerve. (4) Brachioradialis. (5) Pronator teres. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer, F. 1st ed. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

78.8.2 Composite Flap A composite flap can be created utilizing multiple tissue types depending on the nature of the defect being reconstructed. The RFF is capable of supplying a small segment of rigid bone by raising the lateral cortex of the distal radius. The palmaris longus tendon can be included if tendon is required.

78.8.3 Tunneling a Pedicled Flap Under a Skin Bridge

Fig. 78.2 Example of a septocutaneous radial artery perforator within the intermuscular fascia. RA, radial artery. (Reproduced with permission from Slutsky DJ. Pedicled radial forearm flap. In: Slutsky DJ, eds. The Art of Microsurgical Hand Reconstruction. © Thieme; 2013.)

they tend to run in an axial fashion once they reach the fascia. Free flaps, whether perforator-based or incorporating the radial artery, or pedicled flaps with skin paddles must be designed with this consideration in mind. Reverse pedicled flaps based on a very proximal skin paddle for maximal pedicle length are possible if the distal fascia is also incorporated while leaving the overlying skin behind or taking a larger paddle to capture more perforators. Two or more separate islanded skin paddles can be designed if based distally or perforators are identified within each island (▶ Fig. 78.2).

Passing a flap through a tunnel under a skin bridge can be challenging. Squeezing the flap through a tight space can shear the perforators between the radial artery and skin paddle and cause partial or full loss of the paddle. To avoid this problem, the flap can be wrapped with a sterile plastic drape with the end of the flap sutured to the drape while the pedicle is left free. This will protect the skin paddle as it is transposed while maintaining its orientation so the pedicle does not get twisted (▶ Fig. 78.3).

78.9 Difficulties Encountered For pedicled flaps, adequate pedicle length for the arc of rotation is crucial to avoid kinking or mechanical compression. Suture or other similar material can be used to create a template to help plan the final rotation/tunneling. It is advantageous to dissect out an extra 1 to 2 cm of pedicle. Because the majority of perforators are in the distal half of the radial artery, proximally positioned skin paddles may fail to incorporate adequate perforators, and can lead to flap ischemia and necrosis. If the palmar arch is not intact, the hand may be ischemic once the flap is harvested.

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Radial Forearm Flap

78.10 Key Procedural Steps 78.10.1 Anatomy The brachial artery bifurcates to form the radial and ulnar arteries in the antecubital fossa. The radial artery then travels directly under the brachioradialis but above the pronator teres, pronator quadratus, and flexor pollicis longus. The radial artery gives off perforators along its length in the fascia between the brachioradialis and flexor carpi radialis (FCR). These septocutaneous perforators to the overlying fascia and skin are generally 1 to 2 cm apart but concentrated more distally along the length of the radial artery. On average, they are 0.3 to 0.5 mm in diameter. In addition to the septocutaneous perforators, the radial

Fig. 78.3 To protect the skin paddle and maintain the orientation of the pedicle while it is transposed, the flap can be wrapped with a sterile plastic drape with the end of the flap sutured to the drape while the pedicle is left free.

artery also supplies musculoperiosteal vessels along the lateral aspect of the radius distal to the insertion of the pronator teres. These must be captured in the design if a portion of the radial bone is to be harvested. After the takeoff of the radial recurrent artery proximally along the course of the radial artery, there are no named branches until the wrist. The flap is drained via both the superficial (cephalic, basilic, or median forearm) and deep venous systems (venae comitantes) (▶ Fig. 78.4).

78.10.2 Antegrade Fasciocutaneous Pedicled Flap and Free Flap For small- to medium-sized defects of the proximal forearm and elbow, a pedicled antegrade fasciocutaneous RFF can be very useful (▶ Fig. 78.5a). Raising the flap consists of five key steps: 1. Skin paddle design: Using a handheld Doppler probe, the course of the radial artery is mapped out along with the superficial veins. If raising an RFF with a skin paddle, the dimensions are marked on the volar forearm (▶ Fig. 78.5b). The design can be shifted slightly in an ulnar direction to capture skin with less hair growth. Generally, the proximal margin is defined by the length of pedicle required. The distal margin is defined by the size of the flap required and must be proximal to the wrist crease. The ulnar border lies over the flexor carpi ulnaris and the radial border is over the brachioradialis. The arm is exsanguinated by elevating it and the tourniquet is inflated. The Esmarch bandage is not used to allow better visualization of the smaller vessels. 2. Ulnar-side dissection: Starting along the ulnar border, the incision is carried down to the level of the deep fascia. The flap is then elevated from ulnar to radial until the tendon of the FCR is encountered. Care should be taken to preserve the exposed paratenon. The deep fascia is incised radial to

Fig. 78.4 (a) The flap axis is shown by a straight line down the midline of the forearm that is slightly medial to the radial artery (RA). The flap may be outlined anywhere along the flap axis. (b) The flap (in blue) is raised subfascially to the lateral border of the flexor carpi radialis (FCR). The deep dissection includes the intermuscular septum. PL, palmaris longus; FDS, flexor digitorum sublimus; FCU, flexor carpi ulnaris. (c) Cross-section through the forearm distal to the pronator teres showing the position of the radial artery (RA) and plane of dissection for elevation of a fasciocutaneous flap. FCR, flexor carpi radialis; FPL, flexor pollicis longus; FDS, flexor digitorum sublimus; FDP, flexor digitorum profundus; FCU, flexor carpi ulnaris; BR, brachioradialis; UA, ulnar artery. (Reproduced with permission from Slutsky DJ. The Art of Microsurgical Hand Reconstruction. 1st ed. Thieme.)

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Fig. 78.5 Antegrade (forward) radial forearm flap. (a) Defect with exposed hardware on the lateral aspect of the elbow. (b) Plan flap with radial artery and incision marked. (c) Paddle and pedicle after dissection. (d) The flap was then tunneled into the defect. (e) Donor site closed with split-thickness skin graft.

Fig. 78.6 Retrograde (reverse) radial forearm flap. (a) The flap was designed with a small tail directly over the pedicle. The tail can be extended along the pedicle to allow complete release of the skin bridge while still covering the pedicle. (b) The flap was then tunneled into the dorsal defect. The tail was not needed in this case and the extra skin was excised prior to inset.

the FCR, and the septum between the brachioradialis and FCR is identified and preserved. 3. Radial-side dissection: The radial border of the flap is incised approximately 1 to 2 cm radial to the radial artery and the flap is raised off of the brachioradialis from radial to ulnar. The superficial branch of the radial nerve is protected as it emerges from the brachioradialis muscle. Retraction of brachioradialis tendon will aid in dissecting out the radial artery but care must be taken to not injure the perforating vessels. If additional venous drainage is required, the radial border is shifted more radially to capture the cephalic vein. 4. Isolation and division of distal pedicle: The distal radial artery is isolated and provisionally occluded with a microvascular clamp. The tourniquet is deflated and the hand and flap are checked for perfusion. If both are well perfused, the radial artery and vena comitantes are ligated distal to the flap (▶ Fig. 78.5c). 5. Flap elevation and transfer: The flap and pedicle are elevated carefully from distal to proximal. Small branches are clipped or cauterized to prevent bleeding and hematoma formation. Again, care must be taken to leave paratenon intact when elevating the paddle off of underlying tendons. The flap should be transferred to the recipient site without

twisting or kinking the pedicle. The flap can be wrapped in a sterile plastic drape, as discussed in 1.8.3, if it will be passed through a tunnel. If the flap is being used as a free flap, the radial artery is divided proximally once sufficient pedicle length has been dissected out (▶ Fig. 78.5d,e).

78.10.3 Retrograde (Reverse) Fasciocutaneous Pedicled Flap A retrograde or reverse radial artery fasciocutaneous flap can be used to reconstruct defects on the distal forearm or dorsum of the hand. The fasciocutaneous portion is raised similarly as described above (steps 1–3) with the paddle placed proximally on the forearm (▶ Fig. 78.6). As the majority of the radial artery perforators are located along the distal half of the radial artery, it is imperative that a sterile Doppler probe is used to confirm inclusion of adequate perforators. Alternatively, a small skin paddle is possible if the volar adipofascial layer is also incorporated to capture sufficient perforators over the distal pedicle. For distal defects on the hand, the flap and pedicle may be tunneled under the intervening skin bridge. The skin bridge may be divided as long as the pedicle has been harvested with a

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Radial Forearm Flap strip of overlying skin. The proximal radial artery is then dissected out and an atraumatic vascular clamp is placed at the proposed ligation site to test the vascular integrity of the flap after the tourniquet has been released. Once perfusion is confirmed with a sterile Doppler and dermal bleeding, the proximal radial artery is ligated.4

antebrachial cutaneous nerves can be incorporated. The donor site can sometimes be closed primarily based on the patient’s habitus if the flap is less than 6 cm wide. A split-thickness skin graft can be used to cover the donor site, provided the paratenon of any exposed tendon is intact (▶ Fig. 78.5e). A volar forearm splint should be placed after skin grafting the donor site.

78.10.4 Radial Artery Sparing Perforator-based Pedicled Flap

78.11 Bailout, Rescue, and Salvage Procedures

A radial artery forearm flap can be taken as a perforator-based rotation flap. This is ideal for coverage of smaller adjacent defects without sacrificing the radial artery. A flap of up to 18 cm × 8 cm can be successfully harvested.5 An ideal perforator is first identified with a handheld Doppler probe to mark out the skin paddle. The tourniquet is not used so that the perforator can be continuously identified and checked intraoperatively. The skin and fascial dissection are the same as described earlier (steps 1–3); however, the nondominant perforators are ligated at the level of the fascia in the intermuscular septum so the longitudinal vascular plexus remains intact. The dominant perforator is dissected down to the level of the radial artery and preserved. The flap can then be pivoted to cover an adjacent defect.

78.10.5 Adipofascial Flap The RFF can be raised as an adipofascial flap. This leaves the overlying skin intact and obviates the need to skin graft the donor site, especially useful for ensuring tendon coverage. However, a skin graft is needed to cover the flap at the recipient site. Full descriptions of raising an adiofascial RFF can be found in the literature.6

78.10.6 Osteocutaneous Flap For reconstruction requirements involving bony deficits, an osteocutaneous RFF can be useful. The fasciocutaneous portion of the flap is raised as described above (steps 1–3) with some notable additions. For proper visualization of the radius, the brachioradialis tendon and radial aspect of the flexor digitorum superficialis must both be fully mobilized to allow their complete retraction. The flexor pollicis longus, lying directly over the radius, can then be split and retracted. If an osteocutaneous flap is being raised, the skin paddle may be shifted in an ulnar direction to provide soft tissue coverage if the radius will be plated. This shift may preclude incorporation of the cephalic vein in the flap. Up to 10 cm and 50% of the cross-sectional area of lateral, mostly cortical bone may be harvested. Enough distal radius, approximately 3 cm proximal to styloid process, should be left for stability and for anchoring the plate. The osteotomy should be tapered at both ends to minimize stress points in the residual radius. It is essential to preserve the radial artery perforators to the radial periosteum in the lateral intermuscular septum.1,7

78.10.7 Other Flap Considerations Palmaris longus tendon can be taken with the skin paddle if tendon is required. If a sensate flap will be raised, the lateral

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If the arterial inflow is insufficient in a retrograde flap, hand and/or flap ischemia can result. A sterile pulse oximeter can be placed on the thumb to aid in diagnosing hand ischemia. If hand ischemia is present, the radial artery will need to be reconstructed with a saphenous vein graft. Flap ischemia can occur secondary to mechanical compression, inadequate arterial inflow, or damage to the perforators. Mechanical compression can result from closing the recipient site under excessive tension or by kinking of the pedicle. The flap should be elevated from the recipient site and the pedicle evaluated. Overlying skin bridge may need to be released. Insufficient arterial inflow may preclude the use of the flap or require conversion to a free flap. In the event of damage to the perforators feeding the paddle, the skin of the paddle can be harvested as a full thickness and used to cover the donor site. An alternate flap will need to be used. Injury to the radial artery during dissection may require conversion to a free flap with an interposition vein graft when necessary.

78.12 Pitfalls Harvest of a hair bearing skin paddle to reconstruct intraoral defects is undesirable. Harvest of too much bone for a vascularized bone flap predisposes radial shaft fractures. Skin grafts used to reconstruct donor site can be very noticeable. Severe flap edema may occur depending on extent of venous drainage. Failure to preserve paratenon will result in failure of a skin graft to take over the tendon or adhesion formation with restriction of tendon gliding. Hand ischemia after harvest of an RFF can result from ulnar arterial disease or an incomplete palmar arch. Flap ischemia, especially in retrograde flaps, can develop if an insufficient number of perforators are included. Fasciocutaneous flaps that are thicker than the recipient defect will result in a step-off when inset. To avoid excessive tension when a flap is inset into a shallower defect, the paddle should be made larger than the defect to allow the flap edge to be brought down to the defect edge.

References [1] Slutsky DJ. Pedicled radial forearm flap. In: Slutsky DJ, eds. The Art of Microsurgical Hand Reconstruction. New York, NY: Thieme; 2013:24–32 [2] Kimura T, Ebisudani S, Osugi I, Inagawa K. Anatomical analysis of cutaneous perforator distribution in the forearm. Plast Reconstr Surg Glob Open. 2017; 5(10):e1550 [3] Onode E, Takamatsu K, Shintani K, et al. Anatomical origins of the radial artery perforators evaluated using color Doppler ultrasonography. J Reconstr Microsurg. 2016; 32(8):594–598 [4] Kaufman MR, Jones NF. The reverse radial forearm flap for soft tissue reconstruction of the wrist and hand. Tech Hand Up Extrem Surg. 2005; 9(1):47–51

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References [5] Ho AM, Chang J. Radial artery perforator flap. J Hand Surg Am. 2010; 35(2): 308–311 [6] Samson D, Power DM. The adipofascial radial artery perforator flap: a versatile reconstructive option in upper limb surgery. Hand Surg. 2015; 20 (2):266–272 [7] Shnayder Y, Tsue TT, Toby EB, Werle AH, Girod DA. Safe osteocutaneous radial forearm flap harvest with prophylactic internal fixation. Craniomaxillofac Trauma Reconstr. 2011; 4(3):129–136

Suggested Readings Chang SM, Hou CL, Zhang F, Lineaweaver WC, Chen ZW, Gu YD. Distally based radial forearm flap with preservation of the radial artery: anatomic, experimental, and clinical studies. Microsurgery. 2003; 23(4):328–337 Chim H, Bakri K, Moran SL. Complications related to radial artery occlusion, radial artery harvest, and arterial lines. Hand Clin. 2015; 31(1):93–100

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Part XII Dupuytren’s Disease

XII

79 Needle Aponeurotomy for Dupuytren's Disease

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80 Subtotal Fasciectomy for Dupuytren's Disease

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79 Needle Aponeurotomy for Dupuytren's Disease Charles F. Leinberry Abstract There are several techniques used to treat Dupuytren's disease surgically. Needle aponeurotomy (NA) has become more popular after its introduction into United States in 2003 and has gained popularity over the past decade. Its advantage is that it is a simple procedure with a fairly quick return to function, while its disadvantages are that it has a quicker recurrence rate and the potential for nerve or tendon injuries. It is ideally suited for metacarpophalangeal (MP) or mild proximal interphalangeal (PIP) contractures in individuals who want a quicker return to function and are not as concerned with the potential for a sooner recurrence. Keywords: Dupuytren's disease, needle aponeurotomy, contractures

79.1 Key Principles Dupuytren's disease is prevalent and estimated to affect about 3% to 6% among adult Caucasians or approximately 13.5 to 27 million people in the United States or Europe. It is present in people of all races and peaks in their 40 s and 50 s, with men at 50 years of age and women slightly older at 60 to 70 years of age. The incidence rises with increasing age. The most common fingers affected in Dupuytren's tend to be the ring finger followed by the small, middle, and thumb, with the index finger being least affected. There also can be seen web involvement as the proliferative phase develops with the random accumulation of myofibroblast which form palmar nodules. Fibroblast can align along tension lines and form ropelike structures named cords. These collagen cords are relatively acellular and avascular. Often times, there is an early phase skin pitting and/or dimpling. This can be due to the pretendinous bands that connect the dermis to the palmar fascia. Metacarpophalangeal (MPJ) and proximal interphalangeal (PIPJ) contractures can occur together. The metacarpophalangeal (MP) contractures also can produce natatory bands, which involve the web space between adjacent fingers. Needle aponeurotomy (NA) was reintroduced in the modern era by Lermusiaux in the 1980s, who used a needle instead of a knife and brought to the United States by Dr. Eaton in the early 2000s. NA has gained popularity significantly in the past several years as an alternative to an open fasciectomy. NA is based on the principles of using a needle to cut the cord versus an open surgical procedure. It is designed to provide a quicker return to function yet also provide a reasonable degree of contracture correction. It requires an understanding of the anatomy and the location to place and cut the cord to provide the maximum correction with minimal complications.

79.2 Indications NA can be used for either MPJ or PIPJ joint contractures or a combination of both. It, however, has its best and longer lasting results when MPJ contractures are the ones that are corrected,

whereas PIPJ contractures have less reliable results. It does require a skill set of having done this previously and usually the patient is kept awake to avoid significant complications. It is ideally suited for a large cord producing an MPJ or PIPJ contracture with minimally large nodularity. A positive tabletop test is required or an MPJ contracture of at least 30 degree or similar PIP contracture. Recurrence is usually defined as a greater than 20 degrees contracture after treatment. Across all treatment techniques, the estimated rates of recurrence are almost 65% at 10 years, 30% usually seen in the first and second postoperative years with the additional 15% during the third to fifth, and 10% between the 5th and 10th year. NA is considered for any patient who has a large palpable cord. The larger the cord and the larger the contracture especially at the MPJ, the easier it is to treat.

79.3 Contraindications ●

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NA is contraindicated in patients where a previous surgical procedure causing the presence of significant scarring producing a contracture. NA is not indicated in patients with the disease at the nodular phase without a contracture. When there is an isolated PIPJ contracture produced by an ulnar-based cord, care should be taken to protect the digital nerve, which can be located on the palmar surface and centrally on top of the cord. NA can also be performed in patients who require the maintenance of blood thinners such as Plavix, aspirin, or Coumadin.

79.4 Procedure NA can be performed in either an office or an outpatient surgical setting. It does not usually require anesthesia, although breaking of the cord can be very painful. In cases where pain is expected, the procedure can be performed in an outpatient setting with slight sedation after the cord has been cut, using a wrist or digital block. The procedure is usually performed with the patient lying on a stretcher or table, with the hand out on a hand table. The hand can be then sterilely prepped and draped if in a surgical facility or sterilely prepped with alcohol prior to performing the procedure. If the surgeon is right handed and the cord is involving the right hand, the surgeon should sit in the armpit, and the opposite, for the left-hand procedure. This will allow the use of a syringe in the dominant hand and the nondominant hand to perform traction on the cord/tensioning it while the procedure is being performed. Typically, a 5-mL syringe containing 3 mL of lidocaine and 1 mL of Depo-Medrol loaded with 25-gauge 5/8 needle is used. A small amount of anesthetic is injected above the cord. To cut the cord, place the needle in the cord, and use a combination of up and down and sweeping techniques (▶ Fig. 79.1a). Avoid

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Fig. 79.1 (a) Diagrammatic representation of entering the cord, placing a small amount of anesthetic, clearing the tissue, perforating and cutting the cord with a sweeping technique. (b) Placing the needle into the cord starting from superficial volar and not too deep otherwise it will not cut the cord. (Reproduced with permission from Eaton C. MD Chapter 4 Dupuytren’s Disease 2017.)

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Technical Tip/Pearl penetrating through the cord. When performing the sweeping technique, make sure to start from superficial volar and go deeper as the cord. Do not place the needle too deep into the cord or the needle will not cut (▶ Fig. 79.1b). Keep the patient awake during the procedure when possible to give feedback regarding paresthesias if the needle tip comes in proximity to the neurovascular bundle. Start from proximal to distal above the flexion crease, then through the flexion creases, and then down into the finger (▶ Fig. 79.2a,b).

79.5 Technical Tip/Pearl The cord should not be attempted to be cut in the area of maximum nodular formation but rather in the area where the cord is most prominent (▶ Fig. 79.3a–d). Also having and selecting the thinner areas of the cord makes it easier to cut. During the procedure, the needles can bend as the sweeping motion is performed. Multiple needles are required for the procedure.

79.5.1 Breaking the Cord Fig. 79.2 (a,b) Needle placement for a finger proximal interphalangeal (PIPJ) contracture. (Reproduced with permission from Eaton C. MD from C. Eaton et al, eds. Dupuytren’s Disease and Related Hyperproliferative Disorders, 267. DOI 10.1007/978–3-642–22697–7_34, © Springer-Verlag Berlin Heidelberg 2012.)

Occasionally, the cord will break during the cutting procedure. If not, once all the areas have been cut, the patient is given some light sedation or a wrist or digital block, and pressure gently applied to rupture the cord by extending both the MP and PIP joints.

Fig. 79.3 (a–d) Pre- and postfigures and diagrams of correction possible after needle aponeurotomy. (Reproduced with permission from Eaton C. MD from J Hand Surg 2011;36A:910–915.)

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Needle Aponeurotomy for Dupuytren's Disease Once the finger is straightened, skin tears can develop. Tears can be avoided by not placing the cutting areas within dimples, or in areas in which the skin is attached to the cord, but rather adjacent to these areas. Fortunately, most skin tears will heal with conservative wound care. Immediately after the procedure is performed, the patient is placed in a temporary fiberglass splint involving the affected finger and joints, keeping them in as much extension at the MPJ and PIPJ as possible. The splint is removed and replaced with a splint usually made by a hand therapist, which is worn at night for the next 3 months. Simple wound care is provided to any open areas. Postoperatively, the patient is told to avoid any heavy gripping or lifting for the first 2 weeks. These include golf or other racquet sports in the event that there was any tendon injury during the procedure.

79.5.2 Complications Recurrence Recurrence is usually defined as a greater than 20 degrees recurrent contracture after treatment. Across all treatment techniques, the estimated rates of recurrence are almost 65% at 10 years and 30% are usually seen in the first and second postoperative years, with the additional 15% during the third to fifth

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and 10% between the 5th and 10th years. NA recurrence rate has been reported to be 30% to 85%. Approximately 50% of the NA patients will have some sort of recurrence within the first 2 years.

Other In addition to recurrence, other complications include skin tears and incomplete correction of the contracture. Neurovascular injury can occur in less than 1% of patients.

Suggested Readings Badois FJ, Lermusiaux JL, Massé C, Kuntz D. Non-surgical treatment of Dupuytren's disease using needle fasciotomy. Rev Rhum. 1993; 60(11):808–813 Chen NC, Shauver MJ, Chung KC. Cost-effectiveness of open partial fasciectomy, needle aponeurotomy, and collagenase injection for Dupuytren's contracture. J Hand Surg Am. 2011; 36(11):1826–1834.e32 Cheng HS, Hung LK, Tse WL, Ho PC. Needle aponeurotomy for Dupuytren’s contracture. J Orthop Surg (Hong Kong). 2008; 16(1):88–90 (Hong Kong) Eaton C. Percutaneous fasciotomy for Dupuytren’s contracture. J Hand Surg Am. 2011; 36(5):910–915 Eaton C. ASSH presentation, 2006. http://www.eatonhand.com/tlk/na_web.htm Pess GM, Pess RM, Pess RA. Results of needle aponeurotomy for Dupuytren's contracture in over 1,000 fingers. J Hand Surg Am. 2012; 37(4):651–656 van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fasciectomy. Plast Reconstr Surg. 2012; 129(2):469–477

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80 Subtotal Fasciectomy for Dupuytren's Disease Craig S. Phillips and Grigory E. Gershkovich Abstract Subtotal fasciectomy is one of the most common surgical techniques for the treatment of Dupuytren's disease. As this benign fibroproliferative disease progresses, hand function deteriorates secondary to digit contracture. Once surgery is indicated, subtotal fasciectomy involves excision of the involved pathologic tissue with preservation of the palmar skin whenever possible. Successful outcomes can be obtained with restoration of digit extension and protection of the neurovascular structures. Keywords: Dupuytren's disease, Fasciectomy, subtotal fasciectomy, contracture, Dupuytren's diathesis

80.1 Key Principles Dupuytren's disease is a proliferative condition of the palmar fascia on the palm of the hand (▶ Fig. 80.1). It initially manifests itself as palmar nodules, which can then progress to cord formation and eventual digital contracture. Performing subtotal fasciectomy

is based on four principles: (1) design and preservation of skin flaps; (2) identification and preservation of neurovascular units to each digit; (3) removal of diseased tissue when implicated in contracture; and (4) contracture release.

80.2 Indications Once contracture of the metacarpal phalangeal joint (MCPJ) and/or proximal interphalangeal joint (PIPJ) becomes severe enough to interfere with the patient’s daily function, surgery becomes a viable option. As the disease progresses, opening the hand becomes difficult and grasping objects becomes awkward. The social stigma may also become aggravating to the patient. The “table top test” may be a good test for the patient to monitor his or her own disease progression. The test is positive when the patient can no longer place their palm flat on a flat surface. Flexion contracture of the MCPJ > 30 degrees and PIPJ > 5 to 10 degrees has been used previously as indicators for surgical intervention.1 However, the degree of contracture and how it interferes with function differs from patient to patient (▶ Fig. 80.2a,b).

Fig. 80.1 Topographic anatomy of the palmar aponeurosis (a) Subcutaneous layer of the palm. (1) Superficial transverse metacarpal ligament. (2) Proper palmar digital arteries. (3) Common palmar digital artery. (4) Proper palmar digital nerves. (5) Transverse bands. (6) Cutaneous branches of the proper palmar digital nerves. (7) Palmaris brevis. (8) Medial antebrachial cutaneous nerve. (9) Palmar branch of the ulnar nerve. (10) Palmar monticuli. (11) Longitudinal bands. (12) Thenar fascia. (13) Palmar aponeurosis. (14) Superficial palmar branch of the radial artery. (15) Superficial branch of the radial nerve. (16) Palmar branch of the median nerve. (17) Tendon of the palmaris longus muscle and palmar aponeurosis. (18) Palmar branch of the lateral antebrachial cutaneous nerve. (b) Palmar aponeurosis in relation to the cutaneous ligaments of the fingers. (1) Cleland ligament. (2) A4 pulley. (3) Grayson ligament. (4) A3 pulley. (5) Proper palmar digital nerve. (6) C1 pulley. (7) A2 pulley. (8) Proper palmar digital arteries. (9) Tendinous fibers. (10) Common palmar digital arteries. (11) A1 pulley. (12) A5 pulley. (13) Longitudinal band of the finger. (14) Superficial transverse metacarpal ligament. (15) Mediolateral ligament. (16) Longitudinal band. (17) Transverse band. (c) Continuation of the palmar aponeurosis in the longitudinal band system of the finger. (1) Longitudinal bands of the finger. (2) Grayson ligament (reflected). (3) Superficial transverse metacarpal ligament (reflected). (Reproduced with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery, 1st ed. ©2000 Thieme.)

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Fig. 80.2 (a,b) Palmar view and lateral view of the right hand demonstrating Dupuytren's disease with involvement of the ring finger. A cord is seen within the palm extending across the metacarpophalangeal (MCP) joint and just distal to the proximal interphalangeal (PIP) joint. Skin puckering is seen within the palm denoting intimate involvement of the diseased fascia with the overlying skin. Contracture of the MCP joint and PIP joint significantly impairs hand function and is the indication for subtotal fasciectomy.

80.3 Contraindications Surgery is contraindicated in patients who are debilitated or where the general medical condition prohibits elective surgery. Furthermore, surgery is not a good option in patients with poorly controlled mental illness, or any patient that is unwilling or unable to participate in the postoperative rehabilitation protocol. Active infection in the ipsilateral extremity is also a contraindication to this elective procedure.

80.3.1 Relative Contraindication A known injury to the affected digit with only one residual digital nerve or artery is a relative contraindication to this procedure. Injury to the remaining artery or nerve may render the digit dysvascular or insensate with a poor outcome. Additionally, a relative contraindication exists in patients with Dupuytren's diathesis's or with recurrent disease and severe contracture. These patients may require more extensive fasciectomy and full-thickness skin grafting.2,3

80.4 Procedure In contrast to dermofasciectomy, skin incision and flap design is paramount. Preservation of skin coverage after excision of the Dupuytren's fascia allows for more rapid wound healing, less postoperative wound management by the patient and surgeon, and an accelerated rehabilitation. Psychologically, the patient does not need to prepare for an open wound and is better able to participate in the postoperative course. Preservation of the palmar skin overlying the diseased tissue can be challenging as cords and nodules lie in close proximity to the dermis. As a result, separation of these layers can be difficult. Identifying the plane of dissection proximal and distal to the diseased tissue will aid in identifying the correct tissue plane so as

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not to compromise the skin flap or leave excess diseased tissue in the hand/palm. The procedure is best performed under loupe magnification.

80.4.1 Skin Incision The design of skin flaps is surgeon dependent, but often is a variation of the classic volar Brunner incision (▶ Fig. 80.3a). Other options include longitudinal midline incisions with subsequent z-plasty flaps, curvilinear incisions, V-Y advancements, or combinations of all the above.4 The risk of perforating the skin may occur during dissection, but so long as not excessive is usually of little consequence. These areas, when small, allow for hematoma drainage and heal without additional intervention.

Special Consideration Care must be taken during skin flap design in anticipation of the neurovascular bundles. Extensive identification and protection is paramount. High-risk areas are at the radial and ulnar skin creases of each digit and surrounding the cords and nodules (▶ Fig. 80.3b).

Technical Tips/Pearls Skin Flap Handling Atraumatic manipulation of the skin flaps is important and performed with great care. Preserving the skin flaps will prevent tip necrosis with subsequent delayed healing or hypertrophic scar. A 4–0 nylon suture can be placed in a subcutaneous fashion in each flap and the two limbs secured with a hemostat or sutured to the adjacent skin (▶ Fig. 80.4). However, if the suture is placed full thickness through the corner of the flap, it may easily tear out and compromise the skin.

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Procedure

Fig. 80.3 (a) Palmar view demonstrating the planned skin incision. Skin flaps are drawn in a Brunner fashion. The proximal extent of the planned incision is designed to terminate in line with the distal aspect of the transverse carpal ligament in the event a future carpal tunnel incision is needed for the patient. (b) A second Dupuytren's case with identified neurovascular units: high-risk areas for injury to the neurovascular unit include the interphalangeal creases and when in close proximity to the Dupuytren's cord. Seen here are the ulnar and radial digital nerves to the small finger. The nerves and their respective arteries are superficial in the dissection at these areas.

fascial anatomy and pathology; (2) to identify and protect the neurovascular structures during fascial excision.

Anatomy

Fig. 80.4 Palmar view of the right hand demonstrating elevated skin flaps. The flap corners are held with a 4–0 nylon suture in a subcutaneous fashion to prevent full-thickness skin tearing in the event of suture tension. In this case, the sutures are tied down to the adjacent skin throughout the case.

Skin Closure Prior to closure, the tourniquet is deflated and meticulous hemostasis is achieved to prevent a postoperative hematoma and wound complication. Additionally, the finger is monitored to ensure adequate perfusion in full extension before and after skin closure (▶ Fig. 80.5a). The skin is typically repaired with a simple suture configuration in a non-watertight fashion to allow hematoma drainage and to minimize potential for skin loss (▶ Fig. 80.5b).

80.4.2 Subtotal Fasciectomy Regardless of the technique, the principles of fasciectomy remain the same: (1) to gain a fundamental understanding of the

The anatomy is distorted and the task becomes daunting if not familiar with the normal fascial framework. The course of the neurovascular structures becomes aberrant as the normal fascial bands become diseased (▶ Fig. 80.6). These diseased bands become known as cords. Of particular importance is the predictable nature of the spiral cord in relationship to the neurovascular bundle of the digit. With increasing interphalangeal joint contracture, the spiral cord displaces the neurovascular bundle superficial and toward the midline within the finger. The previously linear pathway of the neurovascular bundle becomes displaced and wrapped around the spiral cord as it contracts5 (▶ Fig. 80.7).

Technical Tip/Pearl It is easy to identify cords and nodules, but not as easy to identify the neurovascular structures. In fact, as the neurovascular bundle travels from proximal to distal in the digit, it can traverse deep and adjacent to the cord, giving the illusion that it abruptly ends. With meticulous dissection and identification of the neurovascular bundle both proximal and distal to the Dupuytren's fascia, one can carefully separate these important structures from the affected tissue (▶ Fig. 80.8a,b). Always identify both neurovascular bundles supplying the digit prior to excision of the fascia.

80.4.3 Contracture Release Once a clear delineation has been established between the Dupuytren's fascia and the adjacent neurovascular bundle, the fascial tissue is excised (▶ Fig. 80.9). Care is taken to not violate the flexor tendon sheath deep to the dissection, as this can lead to adhesions, subsequent bowstringing, and digital stiffness.

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Fig. 80.5 Palmar view of the hand after completion of subtotal fasciectomy. (a) The tourniquet is released, meticulous hemostasis is achieved, and perfusion is assessed. (b) Skin closure is performed with a 4–0 nylon suture in an interrupted fashion.

Fig. 80.6 Forms of fibromatous changes in the fingers. (a) Thickening of the longitudinal bands with associated displacement of the neurovascular bundle. (1) Cleland ligament. (2) Longitudinal bands of the finger. (3) Grayson ligament. (4) Proper palmar digital nerve. (5) Proper palmar digital artery. (6) Superficial transverse metacarpal ligament (reflected). (7) Mediolateral ligament. (b) Formation of a fibromatous band over the tendon sheath. (1) Grayson ligament. (2) Median band. (c) Combined disorder with formation of fibromatous median and lateral bands and topographic displacement of the neurovascular bundle. (1) Lateral band. (2) Grayson ligament. (3) Proper palmar digital nerve. (4) Proper palmar digital artery. (5) Superficial transverse metacarpal ligament. (6) Mediolateral ligament. (7) Median band. (Reproduced with permission from Pechlaner S, Hussl H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

Special Considerations The amount of correction achieved at the conclusion of the procedure is remarkable, and the patient’s function can be improved significantly (▶ Fig. 80.10). Preoperatively, contracture of the MCPJ is more easily tolerated by patients than

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contracture of the PIPJ. Contractures of the PIPJ are more difficult to deal with than similar degrees of contractures of the MCPJ. When severe contracture exists, full correction of a PIPJ contracture is less likely achieved than full correction of MCPJ contracture. Improvements in hand function are also more

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Procedure correlated with corrections in PIPJ contracture. For this reason, many surgeons may be more aggressive when initial PIPJ deformity occurs. Additionally, the volar periarticular structures can be tight from chronic digit contracture. Open release of the volar periarticular structures (volar plate, accessory collateral ligaments) is no longer encouraged as subsequent scarring around these structures is common. Additionally, contracture correction is not maintained when compared to just fasciectomy.6 Simple manipulation of these structures to achieve full PIP extension is advised.

Fig. 80.7 Palmar view of the hand demonstrating the relationship between the ulnar digital nerve to the ring finger as it is displaced to the midline and superficial by the spiral cord deep to it. The nerve is at the tip of the freer elevator. The base of the Dupuytren’s cord is held proximally by the Kocher and can be traced distally as it becomes intimately associated with the digital nerve.

80.4.4 Recurrence and Complications Recurrence of disease can be defined as the appearance of Dupuytren's fascia at a previously excised site. Recurrence is more likely for the PIPJ than the MCPJ, especially in the first 6 months after surgical intervention. More severe initial contractures are associated with higher likelihood of recurrence. Recurrence is also higher in patients who are noncompliant with postoperative therapy and bracing.7 One theory regarding Dupuytren's recurrence stems from the belief that key cells involved in the pathology of the disease are not just in the fascia of the hand, but also superficially at the dermis.8 A subtotal fasciectomy leaves the skin intact over the diseased fascia and risks leaving these cells behind. The risk of disease recurrence is higher with the subtotal fasciectomy technique due to the remaining native skin at the surgical site. Studies have demonstrated lower recurrence rates with dermatofasciectomy and full-thickness skin grafting. Moreover, disease recurrence has been seen in patients at areas adjacent to the surgical site; however, it does not recur at the site of full-thickness skin grafting.2,3 Skin grafting requires a donor site and immobilization for 3 to 4 weeks postoperatively to protect the graft from shear forces. This can slow postoperative rehabilitation. If disease does recur, a dermatofasciectomy is likely to be the preferred next surgery instead of repeat subtotal fasciectomy. Complications such as injury to the neurovascular unit, hematoma, wound infection, skin slough, and scar contractures can occur. The more serious complications of nerve or vessel injury is higher with more severe digit contracture.9

Special Considerations Patients with Dupuytren's diathesis, a particularly severe form of early onset and widespread disease, have a higher risk of recurrence after surgery.10

Fig. 80.8 Palmar view of the hand with the neurovascular unit being protected with a white vessel loop. (a) The Dupuytren's cord is held with a Kocher and used to aid in manipulation of the pathologic tissue. (b) The cord is slowly freed from the rest of the tissue, carefully separated away from the neurovascular unit with dissecting scissors, and brought distal with the Kocher until all of the cord is excised.

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Fig. 80.9 The Dupuytren's cord is excised and passed off to pathology.

References [1] Rayan GM. Dupuytren’s disease: anatomy, pathology, presentation, and treatment. Instr Course Lect. 2007; 56:101–111 [2] Hueston JT. ‘Firebreak’ grafts in Dupuytren’s contracture. Aust N Z J Surg. 1984; 54(3):277–281 [3] Tonkin MA, Burke FD, Varian JP. Dupuytren’s contracture: a comparative study of fasciectomy and dermofasciectomy in one hundred patients. J Hand Surg [Br]. 1984; 9(2):156–162 [4] McFarlane RM, McGrouther DA, Flint MH. Dupuytren's Disease: Biology and Treatment. Edinburgh, New York: Churchill Livingstone; 1990 [5] McFarlane RM. Patterns of the diseased fascia in the fingers in Dupuytren’s contracture: displacement of the neurovascular bundle. Plast Reconstr Surg. 1974; 54(1):31–44

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Fig. 80.10 Lateral view of the hand demonstrating the extent of proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joint final extension to an acceptable degree.

[6] Beyermann K, Prommersberger KJ, Jacobs C, Lanz UB. Severe contracture of the proximal interphalangeal joint in Dupuytren’s disease: does capsuloligamentous release improve outcome? J Hand Surg [Br]. 2004; 29(3):240–243 [7] Rives K, Gelberman R, Smith B, Carney K. Severe contractures of the proximal interphalangeal joint in Dupuytren’s disease: results of a prospective trial of operative correction and dynamic extension splinting. J Hand Surg Am. 1992; 17(6):1153–1159 [8] McCann BG, Logan A, Belcher H, Warn A, Warn RM. The presence of myofibroblasts in the dermis of patients with Dupuytren’s contracture: a possible source for recurrence. J Hand Surg [Br]. 1993; 18(5):656–661 [9] Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren’s contracture surgery. J Hand Surg Am. 2005; 30(5):1021–1025 [10] Degreef I, De Smet L. Risk factors in Dupuytren’s diathesis: is recurrence after surgery predictable? Acta Orthop Belg. 2011; 77(1):27–32

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Part XIII Arthroscopy

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81 Thumb CMC and MCP Joint Arthroscopy

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82 Diagnostic Wrist Arthroscopy

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83 Arthroscopic TFCC/Ligament Debridement

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84 TFCC Outside-In Repair

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81 Thumb CMC and MCP Joint Arthroscopy Mark L. Wang and Pedro K. Beredjiklian Abstract Indications for thumb carpometacarpal (CMC) and metacarpophalangeal (MCP) joint arthroscopic-assisted procedures are evolving, and the application of these minimally invasive and tissue-sparing techniques continues to expand. The most common indications of these techniques include diagnostic evaluation of small joint disorders, synovectomy and joint capsular shrinkage, joint surface resection, and the arthroscopic management of reducible intra-articular fractures. Contraindications for these techniques include active soft tissue disruption or infection, comminuted fractures of the metacarpal base, or intra-articular fractures not amenable to closed reduction. While these evolving techniques represent technically achievable tools in the surgeon’s armamentarium, the use of such techniques should be weighed against the respective risks and benefits of their open procedure alternatives. Keywords: carpometacarpal arthroscopy, thumb base arthritis, trapeziometacarpal arthritis, small joint arthroscopy, arthroscopic Bennett fracture management

81.1 Indications The most commonly described applications include the diagnostic evaluation of small joint arthrosis and ligamentous injuries, synovectomy, joint capsular shrinkage, joint surface resection, intra-articular fracture reduction assistance, the reapproximation of collateral ligament avulsion injuries, septic arthritis, and the retrieval of small foreign bodies.1,2,3,5,6,7,8

81.2 Contraindications Contraindications for these techniques include active infection, disrupted surrounding soft tissue, comminuted fractures (e.g., Rolando-type fractures), or intra-articular fractures not amenable to closed reduction.1,2,3,4

81.3 Procedural Setup In the supine position, with the patient under general or regional anesthesia, the operative arm is fully prepped and draped in standard fashion. A sterile tourniquet is applied over the extremity and can be insufflated to improve arthroscopic visualization as necessary. The arm is positioned and secured to the wrist arthroscopy traction tower and all bony prominences are protected and padded with sterile towels (▶ Fig. 81.1). A finger trap is placed over the thumb and approximately 8 pounds of traction is spanned across the wrist and adjusted intraoperatively to optimize arthroscopic visualization of the joint. A ¼-inch Coban strip wrapped around the finger trap mechanism can be helpful to improve finger trap security.

81.3.1 Establishing Portals The 1-R Portal is located at the level of the thumb carpometacarpal (CMC) joint line and radial to the abductor pollicis longus (APL) tendon. The 1-U Portal is located at the same level and ulnar to the extensor pollicis brevis (EPB) tendon (▶ Fig. 81.2). Outlining the course of first dorsal compartment tendons traversing the CMC joint is helpful prior to establishing portals. A 22-gauge hypodermic needle is placed through the 1-R Portal, with a radial to ulnar trajectory and an approximately 25-degree distal angulation to accommodate the saddle-shaped surface of the CMC joint.1,4 Similarly, the 1-U Portal may be established in an analogous manner based on surgeon preference. If difficulty is encountered during this step, mini-C-arm fluoroscopy may be utilized to verify the proper working level and needle position. The joint can be insufflated with approximately 1.0 mL of saline prior to establishing both portals. Using a #11 blade, small 3-mm skin incisions are made. We prefer longitudinal incisions parallel to the course of the extensor tendons, thus minimizing the possibility of iatrogenic injury. A small mosquito hemostat is useful to bluntly spread and dissect down to the capsular layer, prior to entering the joint with the scope sheath and blunt trocar. A 1.9-mm 30-degree scope and 3-mm hook portal are inserted into the chosen portals, saline inflow is opened via gravity or a small joint pump, and diagnostic arthroscopy may now ensue, with the pneumatic tourniquet insufflated to 250 mm Hg as needed. A 2.7-mm 30-degree scope can also be utilized to increase the visual field after working portals are established.

81.4 Diagnostic Arthroscopy

Fig. 81.1 Set up with the thumb in the distraction tower.

Typical camera orientation places the base of the metacarpal surface at the 12 o’clock position.1,4,5,6,7 The quality of the metacarpal and trapezial articular surfaces and location and grade of chondromalacia is documented. Via the 1-R Portal, images of the intra-articular portions of the dorsoradial, posterior oblique ligament and ulnar collateral ligament can be digitally captured. Utilizing the hook probe through the 1-U Portal, the integrity

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Thumb CMC and MCP Joint Arthroscopy extensor tendons, superficial branches of the radial nerve, and surrounding dermal tissue.

81.7 Joint Surface Resection Following thorough debridement and synovectomy of the CMC joint, arthroscopic resection of the arthritic metacarpal and trapezial joint surfaces can be performed utilizing a 2.9-mm round via both working portals. Intraoperative mini-C-arm fluoroscopy may be useful to locate marginal osteophytes and gauge the amount of resected osseous tissue. To facilitate access to large medial trapezial osteophytes, Slutsky2 has described a distal/dorsal (D2) accessory portal, located ulnar to the extensor pollicis longus (EPL) and approximately 1 cm distal to the Vshaped cleft at the interval of the index and thumb metacarpal bases, slightly distal and dorsal to the dorsal intermetacarpal ligament. The D2 portal trajectory follows a proximal, radial, and palmar angle, and the dorsal course of the radial artery at this level should be noted when utilizing shaver and bur devices.2 With the utilization of the 1-R, 1-U, and D2 portals, experienced small joint arthroscopists have expanded this technique to include partial or complete trapeziectomy, with or without graft interposition and suspension plasty.1,2,5,6,7 At present, while these various techniques report good clinical outcomes in small series, the clinical superiority of any one particular technique for the treatment of CMC arthrosis remains unclear.

81.8 First Metacarpal Intra-Articular Fracture Reduction Fig. 81.2 CMC joint portals. CMC, carpometacarpal.

of each structure can also be dynamically tested. Via the 1-U Portal, the anterior oblique ligament, posterior oblique ligament, and ulnar collateral ligament can be visualized.

81.5 Arthroscopic-Assisted Synovectomy Utilizing both 1-R and 1-U Portals, arthroscopic-assisted partial synovectomy may be performed using a 2-mm shaver.1,4,5,6,7 Additionally, a 1.3-mm 30-degree micro-ablation wand permits maneuvering around the small joint and can be applied for synovial resection, ablation, and coagulation of synovial soft tissue. Tourniquet insufflation during synovectomy may be helpful in improving arthroscopic visualization.

81.6 Joint Capsular Shrinkage Capsular shrinkage for the treatment of CMC joint laxity with early arthrosis has been previously described. A small thermocouple probe can be used to shrink and stiffen the collagenous tissue of the joint capsule and adjacent intra-articular portions of the CMC ligaments.4,5,6 With the judicious use of this device, care should be taken to prevent the possibility of iatrogenic thermal injury to adjacent overlying structures, including the

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Arthroscopic-assisted reduction of an intra-articular fracture of the base of the thumb metacarpal (e.g., Bennett fracture) has been described.3 Prior to proceeding with the arthroscopy, the affected digit should be examined under anesthesia with fluoroscopy to confirm that the fragment is mobile and can be reduced in a closed manner. If the fracture is not amenable to this technique, conversion to an open procedure should be considered. Such possible alternatives should be discussed with the patient preoperatively. Once the decision for arthroscopy is made, a 0.045-inch K-wire is placed at the base of the first metacarpal joint, with the Bennett fragment in the path of the pin trajectory. Under standard technique, debridement and synovectomy of the CMC joint is performed, allowing the intra-articular visualization of the fracture fault line. Adjusting traction and manipulating the thumb metacarpal permits arthroscopic confirmation of the anatomic reduction, and stabilization is achieved by advancing the 0.045-inch K-wire. Patient is placed in a well-padded thumb spica splint. This technique is not amenable, and thus contraindicated, for comminuted fractures (including Rolando-type fractures), extra-articular fractures, and injuries with soft tissue disruption.3

81.9 Septic Arthritis Irrigation and drainage of a septic CMC joint has been described utilizing saline inflow, which may be treated with antibiotics based on surgeon discretion, and a 2.0-mm synovial resector.

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References body retrieval, diagnosis of collateral ligament injuries, and re-approximation of the Stener lesion. 8 Similar to thumb CMC arthroscopy, the affected digit is secured with a finger trap and approximately 8 pounds of traction is spanned across the joint. 1-R and 1-U portals located radial and ulnar to the EDC tendon of the affected digit, at the level of the MCP, are established with standard atraumatic technique (▶ Fig. 81.3). At present, indications for MCP joint arthroscopy remain limited and unclear. While technically achievable, the use of such techniques should be weighed against the risks and benefits of their respective open procedure alternative.

References Fig. 81.3 The 1-R and 1-U portals for MCP joint arthroscopy. Dotted line represents the extensor pollicis longus (EPL) tendon. MCP, metacarpophalangeal.

The utility of this technique should be weighed against the potential advantages of open incision and drainage, in the case of diffuse extra-articular abscess collections.

81.10 MCP Joint Arthroscopy The use of metacarpophalangeal (MCP) arthroscopy has been described for the treatment of septic arthritis, foreign

[1] Berger RA. A technique for arthroscopic evaluation of the first carpometacarpal joint. J Hand Surg Am. 1997; 22(6):1077–1080 [2] Slutsky DJ. The use of a dorsal-distal portal in trapeziometacarpal arthroscopy. Arthroscopy. 2007; 23(11):1244.e1–1244.e4 [3] Solomon J, Culp RW. Arthroscopic management of Bennett fracture. Hand Clin. 2017; 33(4):787–794 [4] Slutsky DJ. The role of arthroscopy in trapeziometacarpal arthritis. Clin Orthop Relat Res. 2014; 472(4):1173–1183 [5] Badia A. Trapeziometacarpal arthroscopy: a classification and treatment algorithm. Hand Clin. 2006; 22(2):153–163 [6] Culp RW, Rekant MS. The role of arthroscopy in evaluating and treating trapeziometacarpal disease. Hand Clin. 2001; 17(2):315–319, x–xi [7] Menon J. Arthroscopic management of trapeziometacarpal joint arthritis of the thumb. Arthroscopy. 1996; 12(5):581–587 [8] Ryu J, Fagan R. Arthroscopic treatment of acute complete thumb metacarpophalangeal ulnar collateral ligament tears. J Hand Surg Am. 1995; 20(6): 1037–1042

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82 Diagnostic Wrist Arthroscopy Joseph Said III and Donald Mazur Abstract Wrist arthroscopy is the reference standard in diagnosing and evaluating suspected intra-articular wrist disorders after a comprehensive history and physical examination. Its role continues to expand as an adjunct procedure to treat several disorders.

82.4 Contraindications

Keywords: wrist arthroscopy, diagnostic arthroscopy, arthroscopic debridement, scapholunate ligament, lunotriquetral ligament, triangular fibrocartilage complex, portals

Most arthroscopic procedures are performed through dorsal portals in relation to the extensor compartments. Because of their remoteness from the radial artery and radial nerve branches, the 3–4 and 4–5 portals are considered the safest.1,2 The superficial branch of the radial nerve and radial artery are found to be on average 16 mm and 26 mm, respectively, from the 3–4 portal. As such, these portals are established first. The greatest risk of neurovascular injury is in creation of the 1–2 portal. Here, the superficial radial nerve and radial artery both pass within 3 mm of the portal. The dorsal sensory branch of the ulnar nerve is found 4.5 mm from the 6 U portal and 8.3 mm from the 6 R portal.1 Volar portals are less commonly used because of greater dissection and neurovascular risks but they provide visualization of the dorsal capsule and volar interosseous ligaments as needed. Finally, avoid thermal injury by using short pulses of the radiofrequency cautery rather than prolonged use. A small joint arthroscope (1.9 or 2.7 mm) is typically used.

82.1 Key Principles A comprehensive evaluation and documentation of the radiocarpal and midcarpal joints is essential. Arthroscopy should proceed in a systematic and uniform approach to avoid missing pathology and to review captured images in a predictable sequence. Preoperative evaluation, including the specific location of pain and mechanism of injury, if any, will help differentiate symptomatic pathology from asymptomatic, degenerative conditions. Particular attention should be made in preserving articular cartilage by avoiding abrasion and thermal injury.

Radiographic evidence of significant radiocarpal arthritis

82.5 Special Considerations

82.2 Expectations Patients should be informed of the unique risks of this procedure including structural injury, failure to identify pathology, and any possible interventions including the need for immobilization. In cases of an uncertain diagnosis, the patient and the surgeon should be prepared for open surgery. An option for a staged procedure should be offered to and discussed with the patient preoperatively in the event that the findings indicate a subsequent procedure should be performed.

82.6 Special Instructions, Positioning, and Anesthesia ● ●

● ●

Supine, with the involved arm on a hand table (▶ Fig. 82.1) Tourniquet on the upper arm although inflation is often not required Fingers in traction tower with the elbow and forearm padded General anesthesia or regional block with sedation

82.3 Indications Wrist arthroscopy may be performed to diagnose and evaluate suspected intra-articular wrist disorders after a comprehensive history and physical exam. In general, the following procedures may be performed arthroscopically: ● Synovectomy ● Loose body excision ● Ganglion cyst resection ● Triangular fibrocartilage complex (TFCC) tear debridement or repair ● Scapholunate interosseous ligament (SLIL) assessment and debridement ● Lunotriquetral interosseous ligament (LTIL) assessment and debridement ● Evaluation and treatment of midcarpal joint disorders ● Capsular shrinkage/contracture release ● Arthroscopic resection of distal ulna, radial styloid, and carpal bones ● Arthroscopic-assisted reduction and fixation of fractures

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Fig. 82.1 Patient positioning and setup.

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Special Instructions, Positioning, and Anesthesia Table 82.1 Arthroscopic portals Portal

Description

Uses

Structures at risk

1–2

Between EPB and ECRL

Thumb trapeziometacarpal joint instrumentation

Superficial branch of radial nerve, radial artery

3–4

Between EPL and EDC. 1-cm distal to Lister tubercle, in line with the second webspace

Primary viewing portal

Superficial branch of radial nerve, radial artery

4–5

Between EDC and EDM. In line with the ring finger metacarpal

Primary instrumentation portal

Superficial branch of radial nerve, radial artery

6R

Radial to ECU

Outflow portal, instrumentation for ulnar-sided disorders

Dorsal cutaneous branch of ulnar nerve

6U

Ulnar to ECU

Instrumentation for ulnar-sided disorders

Dorsal cutaneous branch of ulnar nerve

Midcarpal radial

1-cm distal to the 3–4 portal, distal to SLIL

Viewing and instrumentation portal for midcarpal joint

Superficial branch of radial nerve

Midcarpal ulnar

1-cm distal to the 4–5 portal, distal to LTIL

Viewing and instrumentation portal for midcarpal joint

Dorsal cutaneous branch of ulnar nerve

VR

Directly posterior to FCR with FCR retracted ulnarly

Visualization of volar LTIL, SLIL, dorsal wrist ligaments

Median nerve, palmer cutaneous nerve, radial artery

VU

Posterior to flexor tendons with tendons retracted radially

Visualization of volar LTIL, SLIL, dorsal wrist ligaments

Median nerve, palmer cutaneous nerve, ulnar artery

Abbreviations: ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; LTIL, lunotriquetral interosseous ligament; SLIL, scapholunate interosseous ligament.

82.6.1 Tips, Pearls, and Lessons Learned Positioning and Wrist Distraction Avoid exsanguination of the limb to better visualize dorsal veins during portal placement. Finger traps should be applied with consideration to the effects of radial and ulnar deviation. In general, application of large-sized finger traps to the index and ring fingers provides uniform distraction across the radiocarpal joint. Ten to fifteen lb of traction is required to introduce the camera and instruments. If the traction tower is unstable on the hand table, place sterile towels or a metal tray cover under the tower base to stabilize it. Slight wrist flexion distracts the dorsal wrist permitting easier instrumentation.

82.6.2 Portal Placement The standard portals are detailed in ▶ Table 82.1 and ▶ Fig. 82.2. The radiocarpal joint is insufflated with normal saline using a 22G needle through the 3–4 portal, bearing in mind the normal radial volar tilt of 11°. Shallow vertical incisions through the skin and blunt capsulotomy with a mosquito clamp decrease the risk of tendon injury. The EPL tendon is particularly at risk at the 3–4 portal. A blunt trocar is inserted, the obturator is removed, and a 2.7-mm 30°-angled arthroscope is inserted. An outflow portal is created using an 18G needle placed into the 6 U portal under arthroscopic visualization. To avoid high-pressure ejection of fluid from the portal, attach an IV extension tube to the outflow needle to guide fluid directly into a kidney basin. The 4–5 portal may be created at this time under arthroscopic visualization to introduce a probe.

Fig. 82.2 Clinical photograph of the typical portals used for diagnostic wrist arthroscopy. (A) Radial midcarpal portal, (B) ulnar midcarpal portal, (C) 3–4 portal, (D) 4–5 portal, (E) 6 R portal, (F) 6 U portal, (G) Lister tubercle.

82.6.3 Radiocarpal Joint With the arthroscope in the 3–4 portal, diagnostic arthroscopy begins with proper orientation of the radioscaphoid articulation and the radioscaphocapitate ligament volarly (▶ Fig. 82.3). With orientation established, evaluation proceeds radial to ulnar. Attention is first turned to the radial gutter looking for loose bodies and synovitis around the radial styloid. Returning to the radiocarpal joint, the articular cartilage of the radiosca-

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Fig. 82.3 Radioscaphoid articulation. Note the proper orientation of the scaphoid (S) and lunate (L) superiorly, scaphoid fossa of the distal radius (DR) below, and radioscaphocapitate ligament (RSL) in the background in a left wrist.

Fig. 82.4 Scapholunate ligament—scaphoid (S); lunate (L); ligament (star).

Table 82.2 Arthroscopic classification of interosseous ligament injuries Grade

Radiocarpal joint description

Midcarpal joint description

I

Attenuation or hemorrhage of the ligament

No Attenuation or hemorrhage seen No Step-off

II

Attenuation or hemorrhage of the ligament

Attenuation or hemorrhage of the ligament Incongruity or step-off Unable to pass probe between carpal bones

III

Incongruity or step-off

Incongruity or step-off Probe can be passed between carpal bones

IV

Incongruity or step-off

Incongruity or step-off 2.7-mm arthroscope can be passed between carpal bones

Source: Data from Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intraarticular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78(3):357–365. Fig. 82.5 Radiolunate articular surfaces—Lunate fossa (LF); lunate (L).

phoid joint is inspected and documented. The volar capsular ligaments from radial to ulnar are as follows: radioscaphocapitate, long radiolunate ligament, short radiolunate ligament, radioscapholunate ligament (ligament of Testut). The radioscapholunate ligament is a wispy neurovascular structure without any biomechanic significance and can be debrided. The SLIL is inspected (▶ Fig. 82.4) and assessed using the Geissler system (▶ Table 82.2).3 The camera can be angled upward to view the

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proximal membranous portion of the SLIL. Here, dorsal ganglion cysts can be decompressed and resected. Next, the radiolunate cartilage is assessed and documented (▶ Fig. 82.5). The LTIL can be inspected by advancing the camera further ulnar but often it is difficult to distinguish. The radial insertion, central disk, ulnar attachments of the TFCC are assessed using a

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Difficulties Encountered Table 82.3 Palmer classification Class 1: Traumatic

Class 2: Degenerative (ulnar abutment syndrome)

(a) Central tear

(a) TFCC wear

(b) Ulnar avulsion with or without ulnar fracture

(b) TFCC wear + lunate and/or ulnar chondromalacia

(c) Distal avulsion

(c) TFCC tear + lunate and/or ulnar chondromalacia + LTIL tear

(d) Radial avulsion

(d) TFCC tear + lunate and/or ulnar chondromalacia + LTIL tear + ulnocarpal arthrosis

Abbreviations: LTIL, lunotriquetral interosseous ligament; SLIL, scapholunate interosseous ligament; TFCC, triangular fibrocartilage complex. Source: Data from Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg 1989;14(4):594–606.

3-mm hook probe.4,5 The Palmer classification is useful in characterizing TFCC tears (▶ Table 82.3 and ▶ Fig. 82.6).6 The trampoline test involves assessing tautness of the TFCC by pushing down on the central portion with the probe (▶ Fig. 82.7 and ▶ Fig. 82.8). Laxity indicates a peripheral tear. The hook test involves lifting the peripheral insertion of the TFCC to note any peripheral detachment. Central tears are evident by central fraying and exposed ulnar head. The prestyloid recess is often the location of ulnar-sided wrist pain in which case synovitis may be encountered and debrided (▶ Fig. 82.9). Finally, extensor carpi ulnaris (ECU) subsheath tenosynovitis can be debrided by turning the camera dorsally to view the dorsal capsule. For evaluation of the dorsal structions and volar SLIL and LTIL, the volar portals may be established. Using a 1-cm incision over the flexor carpi radialis, the volar sheath of the tendon is incised and retracted ulnarly. An 18G needle is used to localize the radiocarpal joint and a blunt capsulotomy is performed with a mosquito clamp. The VU portal is created using a 1-cm incision just ulnar to the flexor tendons, which are then retracted radially. The radiocarpal joint is localized with a needle and a blunt capsulotomy is performed.

Fig. 82.6 Central triangular fibrocartilage complex (TFCC) tear.

82.6.4 Midcarpal Joint A complete diagnostic wrist arthroscopy includes the midcarpal joint. Enter the joint using an 18G needle perpendicular to the wrist, 1 cm distal to the 3–4 portal. A significant return of fluid indicates disruption of the SLIL or LTIL. With proper positioning, the capitate head should be seen at the top of the image and the SLIL below. The 6 U portal is created 1-cm distal to the 4–5 portal. The midcarpal joint is searched for loose bodies and synovitis is debrided. The SLIL and LTIL are again assessed using Geissler arthroscopic grading.3 The proximal pole of the hamate is assessed for arthrosis.7 In the presence of arthrosis and LTIL injury, the HALT (hamate arthrosis and lunotriquetral tear) procedure may be performed in which the LTIL is debrided and about 2.4-mm of the proximal pole of the hamate is resected. Finally, midcarpal instability may be assessed and treated with thermal shrinkage of the volar capsule and ligaments.8,9

Fig. 82.7 Trampoline test with a probe engaging the triangular fibrocartilage complex (TFCC).

82.7 Difficulties Encountered ●

●

Small movements are required more so in wrist arthroscopy than other joints. To prevent withdrawing the camera out of the joint, place your index finger on the dorsal wrist while grasping the arthroscope to improve fine movement. It may be difficult reaching the TFCC from the 3–4 and 4–5 portals. Tips for increasing visualization include: using the

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●

Fig. 82.8 Trampoline test with a probe disengaged from the triangular fibrocartilage complex (TFCC). Note the rebound effect indicating intact peripheral margins.

Fig. 82.9 A probe inserted into the ulnar recess.

finger traps on the small and ring fingers, ulnar deviating and flexing the wrist slightly, moving the arthroscope behind the scaphoid and lunate along the dorsal capsule from the 3–4 portal, or utilizing the 6 R and 6 U portals for the camera and instrumentation. Confirming TFCC peripheral tears that are repairable may be difficult. In one study, the intraobserver and interobserver agreements on the presence or absence of a tear were 67.4 and 66.7%, respectively.10

with less distraction weight removed for easier access to the ulna. Suture the wounds. Splint the wrist depending on the intervention.

82.8 Key Procedural Steps ●

●

●

●

●

●

● ●

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Apply a tourniquet to the arm exsanguination and inflation may be avoided to better visualize the dorsal wrist veins during portal creation. Create the working 3–4 and 4–5 working portals first using shallow, vertical skin incisions followed by blunt capsulotomy with a mosquito clamp. Diagnostic arthroscopy is performed from radial to ulnar, documenting findings and interventions with image captures. Preserve articular cartilage by avoiding abrasion and thermal injury. Particular attention is made to assess common pathology including the SLIL, LTIL, articular cartilage, and TFCC. Debride the typical areas of synovitis near radial styloid, radioscaphocapitate ligament, prestyloid recess, and ECU. Evaluate the midcarpal joint. If an ulnar shortening osteotomy or outside-in TFCC repair is to be performed, maintain the wrist in the traction tower

● ●

82.9 Bailout, Rescue, and Salvage Procedures Several options exist if visualization is inadequate including increasing traction up to 15 lb, elevating the tourniquet, temporarily increasing pump pressure, and converting to an open procedure using the appropriate approach. The possibility of an open procedure including possible immobilization should be discussed with the patient preoperatively. The option for staged, separate procedures should be offered in the setting of suspected arthrodesis or reconstructive procedures. In general, a universal dorsal approach may be utilized for carpal instability disorders and dorsal ganglion cysts. The DRUJ can be approached through the fifth extensor compartment. The TFCC can be approached through the sixth extensor compartment or extending the direct ulnar approach. Volar pathology can be approached through an extended carpal tunnel approach with retraction of the carpal tunnel contents.

References [1] Abrams RA, Petersen M, Botte MJ. Arthroscopic portals of the wrist: an anatomic study. J Hand Surg Am. 1994; 19(6):940–944 [2] Slutsky DJ. Principles and Practice of Wrist Surgery. Saunders; 2010

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References [3] Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996; 78(3):357–365 [4] Atzei A, Rizzo A, Luchetti R, Fairplay T. Arthroscopic foveal repair of triangular fibrocartilage complex peripheral lesion with distal radioulnar joint instability. Tech Hand Up Extrem Surg. 2008; 12(4):226–235 [5] Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am. 1991; 16(2):340–346 [6] Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am. 1989; 14(4):594–606

[7] Harley BJ, Werner FW, Boles SD, Palmer AK. Arthroscopic resection of arthrosis of the proximal hamate: a clinical and biomechanical study. J Hand Surg Am. 2004; 29(4):661–667 [8] Hargreaves DG. Arthroscopic thermal capsular shrinkage for palmar midcarpal instability. J Wrist Surg. 2014; 3(3):162–165 [9] Michelotti BF, Chung KC. Diagnostic Wrist Arthroscopy. Hand Clin. 2017; 33 (4):571–583 [10] Park A, Lutsky K, Matzon J, Leinberry C, Chapman T, Beredjiklian PK. An evaluation of the reliability of wrist arthroscopy in the assessment of tears of the triangular fibrocartilage complex. J Hand Surg Am. 2018; 43(6):545–549

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83 Arthroscopic TFCC/Ligament Debridement Matthew L. Drake Abstract Tears of the scapholunate and lunotriquetral ligaments and the triangular fibrocartilage complex (TFCC) can be treatable pain generators in patients presenting with wrist pain. Simple arthroscopic debridement of these lesions has been suggested to yield successful outcomes with minimal surgical risk in patients without instability. Assessment with advanced imaging such as MRI or diagnostic arthroscopy can provide valuable information regarding articular pathology. Keywords: triangular fibrocartilage complex, scapholunate ligament, lunotriquetral ligament, wrist arthroscopy, debridement

83.1 Description The painful wrist without carpal instability or arthritis can be a diagnostic and treatment challenge. Partial tears of the scapholunate and lunotriquetral interosseous (intercarpal, IC) ligaments and triangular fibrocartilage complex (TFCC) tears can be treatable pain generators (▶ Fig. 83.1). Simple arthroscopic debridement of these lesions has been suggested to yield successful outcomes with minimal surgical risk.

83.2 Key Principles A thorough understanding of wrist anatomy is essential to enable arthroscopic evaluation of the joint for proper diagnosis and treatment decision making. Careful preoperative decision making and patient selection is critical to a successful result. For the TFCC tears that occur in the vascularized periphery are amenable to repair, whereas those in the avascular center should be debrided (▶ Fig. 83.2).

83.3 Expectations The painful wrist without carpal or distal radial ulnar joint (DRUJ) instability may benefit from debridement of structures found to be degenerative on magnetic resonance imaging (MRI) or arthroscopic visualization. The surgeon must recognize when instability is present and potentially the source of pain, as debridement may not be the procedure of choice.

83.4 Indications Commonly suggested wrist pain generators are the scapholunate (SL) and luntotriquetral (LT) ligaments as well as the TFCC. These structures can become partially disrupted after a fall or become degenerative over time. When the structures are functioning appropriately (no intercarpal or DRUJ instability present), arthroscopic debridement alone may be appropriate, although high-quality literature supporting these procedures is sparse.

83.5 Contraindications When evidence of instability exists, debridement alone is unlikely to be beneficial. Carpal instability is demonstrated by static changes on imaging, positive provocative maneuvers on exam, or high-grade IC ligament tears seen arthroscopically. DRUJ instability is best demonstrated on physical exam. Additionally, if arthritic changes are present, simple debridement of the TFCC or IC ligaments is unproven to be beneficial.

83.6 Special Considerations Preoperative decision making is of utmost importance. The surgeon must be aware that IC ligament and TFCC tears seen on MRI are extremely common and increase with age, and therefore should be presumed to be incidental findings.1,2 The patient with a stable, but painful wrist should be managed conservatively to the maximal extent to include bracing, therapy, anti-inflammatory medications, steroid injections, and most importantly activity modification. Most patients seeking care will report dorsal wrist pain when loading the joint in extension. If that particular activity can be avoided, this may solve the problem altogether. Patients should be informed that pain relief after debridement of these structures can be unpredictable.

83.7 Special Instructions, Positioning, and Anesthesia General anesthesia or a regional block is typically used. Supine position is preferred. A traction tower is applied with 10 to 15

Fig. 83.1 (a,b) Partial scapholunate (SL) tear and triangular fibrocartilage complex (TFCC) perforation. (Reproduced with permission from Schmitt R, Lanz U. Diagnostic Imaging of the Hand. 1st ed. © 2007 Thieme.)

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Key Procedural Steps

Fig. 83.2 Triangular fibrocartilage complex (TFCC) zones of repair or debridement.

lb of distraction force needed to achieve visualization of the joint (▶ Fig. 83.3). There are multiple commercial traction devices which can be utilized. Simple longitudinal traction is sufficient for this procedure, although some devices allow for easy rotating and repositioning of the limb which is helpful in cases requiring fluoroscopy. A small joint arthroscope (1.9 or 2.7 mm) is used, along with a small probe, 3.5 mm mechanical shaver, and a cautery/radiofrequency probe.

83.8 Tips, Pearls, and Lessons Learned ●

●

●

●

Finger traps are applied to the index and middle fingers; additional fingers are unnecessary. Applying a liquid adhesive to the digits helps keep the finger traps in place. Radial deviation and slight flexion of the wrist helps visualization. Injecting 5 to 10 mL of normal saline into the radiocarpal joint before incision helps minimize iatrogenic chondral injury when establishing the portals. Typically, only the 3–4, 4–5, and 6 R portals are needed to achieve successful debridement (▶ Fig. 83.4). Midcarpal portals are helpful adjuvants to accomplish the surgical goal. Portals are created using a scalpel at the level of the skin only. Use a small hemostat to penetrate the joint and open/spread

Fig. 83.3 Surgical setup utilizing traction for distal radius fracture (arthroscopic technique). (Reproduced with permission from Plancher KD. Master Cases Hand and Wrist Surgery. 1st ed. © 2004 Thieme.)

●

●

the instrument to enlarge the portals. If the portals are too small, passing instruments becomes difficult. Gravity inflow of fluid through the arthroscope is sufficient. Outflow is achieved by placing an 18-gauge needle ulnarly attached to IV tubing. Minimize use of radiofrequency probes, as elevating the temperature inside the joint may have deleterious effect on tissues.3

83.9 Key Procedural Steps After the traction device has been employed to provide 5 to 10 lbs of traction, establish the 3–4 portal and insert the arthroscope. Turning the camera ulnarly allows a needle to be percutaneously used to help determine the best location for the 4–5 portal prior to committing with a skin incision. After the 4–5 portal is established, a diagnostic arthroscopy is carried out. The primary structures of interest are the SL and LT ligaments, and the TFCC (▶ Fig. 83.5). The status of the visible volar extrinsic ligaments and articular cartilage should be noted. The arthroscope can be alternately moved between portals depending on visualization needed. The shaver is used to debride dorsal capsule to enhance visualization. A

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Arthroscopic TFCC/Ligament Debridement small probe is used to evaluate the status of the SL and LT ligaments. Low-grade tears without gross instability or diastasis are appropriate for simple debridement. If a higher degree of instability is encountered such as with a complete ligament tear, a repair or reconstructive procedure should be considered (▶ Fig. 83.6). The 6 R portal is often needed for good visualization and debridement of the LT ligament and

Fig. 83.4 Arthroscopic accesses. The accesses to the radiocarpal joint on the extensor side (3–4, 4–5, 6 R, and 6U) and the accesses to the midcarpal joint (MCR and MCU) are marked in red. MCR, midcarpal radial; MCU, midcarpal ulnar. (Reproduced with permission from Schmitt R, Lanz U. Diagnostic Imaging of the Hand. 1st ed. © 2007 Thieme.)

Fig. 83.6 Complete rupture of the scapholunate ligament. Radiocarpal arthroscopy with a midcarpal view of the head of the capitate. (Reproduced with permission from Schmitt R, Lanz U. Diagnostic Imaging of the Hand. 1st ed. © 2007 Thieme.)

Fig. 83.5 (a) Diagram of the arthroscopic anatomy of the radiocarpal joint. (b–d) Normal arthroscopic findings in the radiocarpal joint. (b) Radioscapholunate (RSL) ligament. (c) Scapholunate (SL) ligament. (d) Test of the triangular fibrocartilage complex (TFCC) with the examining probe. In the upper part of the picture, one sees the lower surface of the triquetral cartilage. (Reproduced with permission from Schmitt R, Lanz U. Diagnostic Imaging of the Hand. 1st ed. © 2007 Thieme.)

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References

Fig. 83.7 (a, b) Arthroscopic findings in lesions of the triangular fibrocartilage (TFC). (Reproduced with permission from Schmitt R, Lanz U. Diagnostic Imaging of the Hand. 1st ed. © 2007 Thieme.)

Fig. 83.8 (a) A central tear of the triangular fibrocartilage complex (TFCC). The ulnar head can be seen through the defect. (b) An arthroscopic cautery probe is used to debride the tear edges. (This image is provided courtesy of Dr. Pedro Beredjiklian, MD.)

TFCC. For the IC ligaments, the free edges are debrided using a shaver to stable borders. Take care to not debride the dorsal aspect of the SL or volar aspect of the LT ligaments as these portions are thought to be of the most structural importance. During evaluation of the TFCC, it should be determined whether the tear is repairable (peripheral) or whether a debridement should be performed (central) (▶ Fig. 83.7). For the TFCC, the central portion can be debrided to a stable peripheral rim, with minimal impact DRUJ stability (▶ Fig. 83.8). Flush out all loose debris created from the debridement. At the conclusion of the debridement, the skin is closed with a single-layer simple suture and a splint is applied at the surgeon’s discretion. The debridement can be performed with an arthroscopic shaver or a cautery probe.

83.10 Bailout, Rescue, and Salvage Procedures Despite these procedures being commonly performed, the literature support for their effectiveness is mostly small, retrospective case series. The clinical significance of imaging findings showing partial tears remains unclear, and the physical exam may not predict imaging findings.4 Given that surgical treatment is largely unproven, conservative measures should be the mainstay in the setting of normal radiographs and an objectively normal physical examination.

If one encounters a higher degree of intercarpal instability than expected, alternative options in the form of ligament repair or reconstruction may be necessary. During evaluation of the TFCC tear, the ulnar head may be found to be prominent, protruding past the tear. Often the cartilage surfaces may be degenerative. One option in this scenario would be to add an arthroscopic partial ulnar head (wafer) resection using a burr through the debrided TFCC.5 If adequate visualization is not achieved with the primary portals, the surgeon should be prepared to add a 6 U, or potentially an FCR portal. Patients should be fully counseled and consented should there be any preoperative suspicion that additional procedures beyond simple debridement may be needed.

References [1] Wright TW, Del Charco M, Wheeler D. Incidence of ligament lesions and associated degenerative changes in the elderly wrist. J Hand Surg Am. 1994; 19 (2):313–318 [2] Iordache SD, Rowan R, Garvin GJ, Osman S, Grewal R, Faber KJ. Prevalence of triangular fibrocartilage complex abnormalities on MRI scans of asymptomatic wrists. J Hand Surg Am. 2012; 37(1):98–103 [3] Huber M, Loibl M, Eder C, Kujat R, Nerlich M, Gehmert S. Effects on the distal radioulnar joint of ablation of triangular fibrocartilage complex tears with radiofrequency energy. J Hand Surg Am. 2016; 41(11):1080–1086 [4] Cantor RM, Stern PJ, Wyrick JD, Michaels SE. The relevance of ligament tears or perforations in the diagnosis of wrist pain: an arthrographic study. J Hand Surg Am. 1994; 19(6):945–953 [5] Tomaino MM, Weiser RW. Combined arthroscopic TFCC debridement and wafer resection of the distal ulna in wrists with triangular fibrocartilage complex tears and positive ulnar variance. J Hand Surg Am. 2001; 26(6):1047–1052

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84 TFCC Outside-In Repair Sara Low and Christopher Williamson Abstract Triangular fibrocartilage complex (TFCC) is an intra-articular wrist structure with a significant role in stabilization, rotation, translation, and load transmission of the wrist. TFCC tears are traumatic but it can be degenerative. The initial treatment for these tears is always conservative and involves wrist immobilization for 6 to 12 weeks. Those patients that fail conservative treatment can be treated with arthroscopic repair or debridement, depending on whether the tear is central or peripheral. Keywords: TFCC, triangular fibrocartilage complex, outside-in

84.1 Introduction The triangular fibrocartilage complex (TFCC) is an intra-articular wrist structure that has a significant role in stabilization, rotation, translation, and load transmission of the wrist.1 The TFCC was traditionally described by Palmer and Werner in 1981 to consist of five structures; an articular disk, volar and dorsal radioulnar ligaments, a meniscus homologue, the ulnar collateral ligament (UCL), and the subsheath of the extensor carpi ulnaris (ECU)2 (▶ Fig. 84.1). The articular disk is bordered by the superficial and deep radioulnar ligaments, which insert on the ulnar styloid horizontally and vertically on the fovea ulnaris and base of the ulnar styloid, respectively1,2 (▶ Fig. 84.2). The TFCC also inserts onto the lunate and triquetrum as the ulnolunate

Fig. 84.1 Anatomy and relation of the triangular fibrocartilage complex (TFCC) to the radiocarpal joint. (1) Scaphoid. (2) Interosseous ligament. (3) Radioscapholunate ligament. (4) Radius. (5) Lunate. (6) Lunotriquetral interosseous ligament. (7) Triquetrum. (8) Ulnolunate and ulnotriquetral branches of the ulnolunatotriquetral ligament. (9) Ulnar collateral ligament of the wrist. (10) Triangular fibrocartilage. (11) Ulna. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer F. Atlas of Hand Surgery. 1st ed. ©2000 Thieme.)

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and ulnotriquetral ligaments.2 Ahn et al also described a constant perforation of the meniscus homologue, termed the “prestyloid recess,” which is a normal anatomical structure.2 In addition, Atzei et al described three distinct components of the ulnar aspect of the TFCC, consisting of the proximal triangular ligament, distal hammock structure, and UCL. They proposed a treatment-oriented classification system based on these components, which has been endorsed by the European Wrist Arthroscopy Society (EWAS). The proximal triangular ligament represents the proximal component of the ulnar TFCC (pc-TFCC) and is synonymous with the ligamentum subcruentum or deep radioulnar ligaments. The distal component of the ulnar TFCC (dc-TFCC) is composed of the UCL and distal hammock structure (▶ Fig. 84.3).3 The integrity of these structures dictate treatment options, as will be described below.

84.2 Key Principles The TFCC receives its blood supply from the dorsal and palmar radiocarpal branches of the ulnar artery and also from the anterior interosseous artery.1 It should be noted that the microvasculature of the TFCC is similar to the meniscus of the knee. It has been established that 10 to 40% of peripheral TFCC has a rich vascular supply, and the central region is relatively avascular.1,4

84.3 Description The mechanism of injury of TFCC tears can be classified as traumatic or degenerative. The majority of TFCC tears are traumatic, and commonly involve a fall onto an outstretched hand with the wrist in an extended, supinated position or a violent traction, twisting injury.1,3,4,5 TFCC injuries also commonly occur in association with distal radius fractures, with studies reporting an incidence of 60% in intra-articular distal radius fractures.6,7 In contrast, degenerative TFCC tears are the result of ulnar impaction syndrome with or without a component of ulnar positive variance. TFCC tears commonly cause decreased grip strength and impaired wrist function, especially during powerful rotatory wrist movements.1,8 Patients often have pain with palpation in the ulnar snuffbox, which is ulnopalmar to the ECU tendon at the wrist.1 If distal radioulnar joint (DRUJ) instability is present in association with TFCC tears, patients often report spontaneous “giving way” of the wrist during resisted rotatory forearm movements.3 Physical examination of TFCC injuries should include DRUJ ballottement test both in the clinic and under anesthesia to evaluate DRUJ stability. Ahn et al described a provocative ulnar grind test by dorsiflexing, axial loading, and ulnar deviating or rotating the wrist. Pain with this maneuver suggests a TFCC tear.2 A positive ulnar foveal sign, which is point tenderness just palmar to the ECU tendon is also indicative of a TFCC tear.3 Radiographs and MRI may be able to identify bony abnormalities and TFCC tears but are not able to accurately predict the size or location of the tear.2,3 Wrist arthroscopy remains the gold standard for diagnosis of TFCC tears.3

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Special Considerations

Fig. 84.2 (a,b) Volar and dorsal views of the triangular fibrocartilage complex (TFCC). The different components of the TFCC are clearly illustrated. (Reproduced with permission from Hirt B, Seyhan H, Wagner M, Zumhasch R. Hand and Wrist Anatomy and Biomechanics. 1st ed. © 2017 Thieme.)

Fig. 84.3 Coronal cut of ulnar side of wrist with proximal and distal components of the triangular fibrocartilage complex (TFCC) outlined. (Modified with permission from Atzei, A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur) Vol 2009;34(5):582–591.)

84.4 Special Considerations Palmer et al described the classification of TFCC tears in 1989, and divided them into traumatic type 1 and atraumatic or degenerative type II tears.2 Type 1a tears are located at the avascular central region and are the most common. If management with immobilization fails, arthroscopic debridement can

provide symptomatic relief. Type 1b involves tears at the base of the ulnar styloid, type 1c involve the ulnotriquetral or ulnolunate ligaments, and type 1d tears are tears of the radial attachment. Type 1b–1d tears are initially managed conservatively, with good results with arthroscopic or open repair of type 1b and 1c tears which fail nonoperative management. Type 1d tears involve the avascular region; however, some authors report successful repair as well.2 When conservative management or arthroscopic debridement is unsuccessful, degenerative tears of the TFCC are generally treated with variations of ulnar shortening or salvage procedures, depending on ulnar variance.2 In 2009, Atzei et al subclassified type 1b tears into five classes, and proposed management options for each subtype.3 This classification was endorsed by EWAS, and is based on distal or proximal ulnar TFCC lesions as well as reparable or irreparable lesions.3 Atzei et al also incorporated the previously described trampoline test9 and the hook test into their classification, which are described in detail below. The trampoline test assesses the peripheral TFCC by using a probe to apply a compressive force across it (▶ Fig. 84.4). A positive test is seen when the TFCC loses its normal rebound tautness and is soft and compliant, indicating a peripheral TFCC tear.2,3 However, the trampoline test is not always sensitive nor specific as some patients may have a more lax TFCC causing a slower rebound of the trampoline test which would lead to false positives. We recommend using the trampoline test as an adjunct to surgical decision-making. If the patient has failed nonoperative treatment and has a TFCC tear on MRI, an equivocal or positive trampoline test would be an indication for surgical repair or reconstruction. The hook test assesses the pc-TFCC and is performed by applying radial traction to the ulnarmost border of the TFCC. If the TFCC displaces upwards and radially, this indicates a tear of foveal insertion of the TFCC or pc-TFCC tear.1,3 The Atzei classification of type 1b TFCC tears is described in ▶ Table 84.1. Briefly, Class 1 lesions have a reparable isolated dc-TFCC tear, a normal hook test and respond well to capsular

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TFCC Outside-In Repair

84.7 Special Instructions, Positioning, and Anesthesia Place the patient in the supine position, with a standard hand table. Sedation with regional anesthesia is recommended. Place a sterile or unsterile arm tourniquet on the operative extremity and prep and drape in standard sterile fashion. Attach the padded hand and wrist to the traction tower, with ~10 to 15 lb of traction, ensuring that the wrist is slightly volarly flexed to facilitate dorsal portal placement.

84.8 Key Steps

Fig. 84.4 The trampoline test. Insert the probe through the 6 R portal and apply pressure on the center of the triangular fibrocartilage complex (TFCC). (This image is provided courtesy of Dr. Pedro Beredjiklian.)

suture repair. Class 3 lesions are reparable isolated pc-TFCC tears with a positive hook test and should be treated with foveal reinsertion. Class 2 and Class 4 tears are complete tears, but are either reparable and treated with foveal fixation or irreparable and need tendon graft reconstruction, respectively. Class 5 is any ulnar styloid base tear associated with DRUJ arthritis and requires salvage procedures.1,3

84.5 Indications and Contraindications The majority of TFCC injuries with intact DRUJ stability can be treated nonoperatively with immobilization and heal in 6 to 9 months.9 However, if the patient experiences persistent symptoms or has gross DRUJ instability, an MRI, wrist arthroscopy, and surgical management should be considered.5,9 Absolute contraindications to primary repair of TFCC tears include suturing under tension due to large tears, chronic tears with degenerated or necrotic edges, presence of DRUJ chondromalacia or arthritis, chronic Essex-Lopresti injury, previous infection, and severe ulnar head osteoporosis.3 Relative contraindications are carpal chondromalacia and dysplasia of the sigmoid notch.3

84.6 Procedures Surgical options for the repair of TFCC tears include open exploration and repair, arthroscopic-assisted, and all-arthroscopic repair using suture tunnels, suture anchors, or sutures only.4,9 The all suture outside-in arthroscopic-assisted repair is ideal for reparable Palmer type 1b TFCC tears. The recommended surgical technique using the Smith and Nephew Meniscus Mender II set is described below.

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1. Establish the 3–4 portal just distal to Lister tubercle using standard technique and insert a 1.9- or 2.7-mm arthroscope. 2. Using direct visualization, establish the 6 R or 6 U portal just radial or ulnar to the ECU tendon for outflow. 3. Perform diagnostic arthroscopy, using a shaver or electrocautery to debride redundant tissue to allow better visualization of the TFCC. 4. Establish the remaining 6 R or 6 U portal and perform the hook test by using a probe to tug on the ulnar margin of the TFCC, attempting to pull it radially. 5. Use a shaver or curette to debride the foveal footprint, to facilitate anatomical healing of the TFCC. 6. Address the most volar portion of the tear first. Insert the curved (or straight) needle with its stylet 1-cm proximal to the ulnocarpal joint. If using the curved needle, position the concavity of the needle facing distally. 7. Pierce the dorsal ulnar capsule then pierce the articular disk 2 to 3 mm radial from the edge of the tear. 8. Insert a second needle with its stylet through the skin at the level of the ulnocarpal joint, just distal to the entry point of the first needle. This second needle can pierce the TFCC distal or dorsal to the first needle, creating either a vertical or horizontal mattress, respectively. For appropriate trajectory, it may be necessary to place this second needle dorsal to, or even through the ECU tendon. If so, this will be addressed when tying the suture. 9. Remove the second needle stylet, and advance a tension lasso into the joint. 10. Manipulate the first needle tip so that it passes through the wire loop of the lasso (▶ Fig. 84.5). 11. Remove the first needle stylet and thread a 2-0 PDS suture through it and through the lasso. 12. Pull the first needle back slightly so that the needle is outside of the wire loop. 13. Tighten the lasso around the suture without cutting the suture on the needle. 14. Withdraw the first needle just outside the capsule to avoid the risk of cutting the suture on the needle during suture passage. 15. Withdraw the second needle and tension lasso in a smooth, quick movement so that the distal end of the PDS suture comes with it and is outside the skin. 16. Then fully withdraw the curved needle so the proximal end of the suture is also outside of the skin. This creates the first horizontal mattress suture.

None/slight Torn

Intact

Good Good

Repair: Suture Ligament-tocapsule)

Clinical DRUJ instability

Appearance of TFCC distal component (RC arthroscopy)

Status of TFCC proximal component (Hook test/ DRUJ arthroscopy)

Healing potential of TFCC tear´s margins

Status of DRUJ cartilage (DRUJ arthroscopy)

Treatment

Class 1: reparable distal tear

Repair: Foveal refixation

Good

Good

Torn

Torn

Mild/severe

Class 2: reparable complete tear

Good

Good

Torn

Intact

Class 3: reparable proximal tear

Table 84.1 The Atzei Classification of Type 1b TFCC tears listing characteristics and treatment recommendations

Reconstruction: Tendon graft

Good

Poor

Torn

Torn

Severe

Class 4: nonreparable tear

Salvage: Arthroplasty or joint replacement

Poor

Variable

Mild/severe

Class 5: arthritic DRUJ

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Key Steps

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84.10 Tips/Pearls

Fig. 84.5 Schematic of a peripheral triangular fibrocartilage complex (TFCC) tear repair using an outside-in technique to perform a horizontal mattress, as described in our technique. The only difference is that with in the Meniscal Mender set, the suture can be fed through a cannulated needle.

17. Repeat steps 6 to 16 as needed, moving from volar to dorsal, until there is an adequate number of sutures spanning the repair site. 18. Pull gentle tension on the sutures to evaluate the stability and tension of the repair. If the sutures were placed appropriately, the articular disk should be pulled down toward its foveal footprint. 19. Make a 2 to 3 cm longitudinal incision centered in between the suture strands. 20. If indicated for ECU tenosynovitis, the ECU sheath can be opened and tendon debrided. 21. Dissect down to the retinaculum, taking care to preserve branches of the dorsal sensory branch of the ulnar nerve. 22. Use a hemostat to retrieve the suture strands, bringing them into the longitudinal incision. If a suture was passed through the ECU tendon, it should be retrieved so that it passes under, and not through the ECU tendon. 23. Tie down the paired sutures, ensuring that the knots lay directly on the retinaculum without soft tissue interposition, and that the correct pairs of suture ends are tied together. Again, ensure that no branches of the dorsal ulnar sensory nerve are entrapped. 24. Irrigate wounds thoroughly, and perform standard closure.

This all suture technique is recommended because it avoids the need for bone tunnels in a small ulna head or costly suture anchors while providing satisfactory long-term results.5 We recommend using an absorbable suture to reduce the risk of suture irritation of the thin ulnar subcutaneous skin as well as nearby ECU and sensory nerves.10 PDS suture is preferred to Monocryl suture, as PDS has a longer reabsorption rate in vivo of ~6 months compared with 3 months and maintains ~60% of its strength at 6 weeks, while Monocryl strength nears 30% at the 2 week mark; therefore, it will provide increased support for the healing TFCC.11 Persistent DRUJ instability is the most common cause of unsatisfactory results and reoperations.3 This is usually due to failure to identify DRUJ instability or an inadequate repair.3 Failure to identify concomitant issues such as ligamentous injury or ulnar positive variance can also cause persistent symptoms and unsatisfactory results.4 Incidence of injury to the dorsal ulnar sensory nerve has been reported to be 0.08 to 50% in small case series.4,12 The majority of patients experience transient paresthesias, but several patients required reoperation for nerve injury.12 This is best avoided by minimizing work through the 6 U portal, and meticulous dissection when locating and tying sutures and using absorbable suture. Cyst formation, stiffness, tendon injury, and infection are other complications that can occur from wrist arthroscopy; however, these are not specific to outside-in TFCC repairs.4

84.11 Pearls and Pitfalls ●

●

●

●

84.9 Postoperative Care Postoperative rehabilitation should consist of wrist immobilization with consideration for sugar tong splinting in full supination and 20 degrees of wrist extension for 3 to 4 weeks. At that point, the patient is placed in a long-arm splint in neutral rotation. At 6 weeks, all splinting is discontinued and active and passive wrist range of motion is allowed. Strengthening exercises and return to sport as tolerated may be begun at 10 weeks. However, high demand sports that require axial loading on the wrist joint are restricted until at least postoperative week 12.10

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●

●

●

●

Ensure that DRUJ laxity is examined under anesthesia, as muscle tension and guarding in the clinic may cause a falsenegative exam.10 After identifying the pattern of the tear, the arthroscope can be switched to the 6 R portal and rotated to look down onto the fovea to evaluate the deep fibers of the TFCC inserting on to the fovea. At this point, the hook test may be performed. When debriding the foveal footprint, a direct foveal portal can be used if access to the footprint is difficult. This portal is made 1-cm proximal to the 6 U portal, with the forearm in maxima; supination, which presents the volar aspect of the distal ulna.3 Always address the volar needle passage first to allow better visualization of the second needle. When inserting the first needle to address more dorsal tears, the needle entry point upon skin entry should be more distal, to avoid the ulnar styloid.4 When creating the ulnar incision, meticulous dissection down to the retinaculum will avoid iatrogenic injury to the superficial branches of the dorsal ulnar sensory nerve.4,10 Use a right-angle clamp to ensure there is no soft tissue interposition within the suture knots.4 Check DRUJ stability after the repair is completed, as DRUJ instability is a cause for persistent symptoms.

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References

References [1] Kirchberger MC, Unglaub F, Mühldorfer-Fodor M, et al. Update TFCC: histology and pathology, classification, examination and diagnostics. Arch Orthop Trauma Surg. 2015; 135(3):427–437 [2] Ahn AK, Chang D, Plate A-M. Triangular fibrocartilage complex tears: a review. Bull NYU Hosp Jt Dis. 2006; 64(3–4):114–118 [3] Atzei A. New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability. J Hand Surg Eur Vol. 2009; 34(5):582–591 [4] Frank RM, Slikker W, Al-Shihabi L, Wysocki RW. Arthroscopic-assisted outside-in repair of triangular fibrocartilage complex tears. Arthrosc Tech. 2015; 4(5):e577–e581 [5] Soreide E, Husby T, Haugstvedt JR. A long-term (20 years’) follow-up after arthroscopically assisted repair of the TFCC. J Plast Surg Hand Surg. 2017; 51 (5):296–300 [6] Ogawa T, Tanaka T, Yanai T, Kumagai H, Ochiai N. Analysis of soft tissue injuries associated with distal radius fractures. BMC Sports Sci Med Rehabil. 2013; 5(1):19

[7] Klempka A, Wagner M, Fodor S, Prommersberger KJ, Uder M, Schmitt R. Injuries of the scapholunate and lunotriquetral ligaments as well as the TFCC in intra-articular distal radius fractures: prevalence assessed with MDCT arthrography. Eur Radiol. 2016; 26(3):722–732 [8] Atzei A, Luchetti R, Braidotti F. Arthroscopic foveal repair of the triangular fibrocartilage complex. J Wrist Surg. 2015; 4(1):22–30 [9] Hermansdorfer JD, Kleinman WB. Management of chronic peripheral tears of the triangular fibrocartilage complex. J Hand Surg Am. 1991 Mar; 16(2): 340–6 [10] Chen WJ. Arthroscopically assisted transosseous foveal repair of triangular fibrocartilage complex. Arthrosc Tech. 2017; 6(1):e57–e64 [11] Ethicon, Inc. or Ethicon Endo-Surgery, Inc., Data on file [12] Anderson ML, Larson AN, Moran SL, Cooney WP, Amrami KK, Berger RA. Clinical comparison of arthroscopic versus open repair of triangular fibrocartilage complex tears. J Hand Surg Am. 2008; 33(5):675–682

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Part XIV Infection

XIV

85 Paronychia

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86 Felon

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87 Flexor Tenosynovitis

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88 Septic Joint

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85 Paronychia T. Robert Takei Abstract Acute and chronic paronychia continues to be a commonly encountered problem by many clinicians. Most acute infections with associated abscess formation will require surgical drainage. Further research will be required to determine the optimal treatment related to the use of antibiotics in conjunction with drainage procedures. The increasing prevalence of community-acquired methicillin-resistant staph aureus (CA-MRSA) has changed prescribing patterns for the initial empiric treatment of acute infections. Recent studies have added to the understanding of chronic paronychia implying an inflammatory process rather than a true mycotic infection. As a result, this may further alter the primary medical management of these conditions focusing on the anti-inflammatory concept of treatment together with preventive measures. Keywords: paronychia, infection, CA-MRSA, steroids

85.1 Description Paronychia is an infection or inflammatory process involving the soft tissues surrounding the nail of a digit.

85.2 Anatomy The digital nail complex comprises the nail plate and perionychium. The perionychium comprises the nail bed and paronychium. The paronychium (lateral nail fold) is the soft tissue lateral to the nail bed. The proximal nail plate sits beneath the nail fold. The eponychium represents the distal portion of the proximal nail fold where it attaches to the nail plate surface (▶ Fig. 85.1).

eczematous reaction rather than a true mycotic infection.1 This has been supported by data reporting better results with topical and systemic steroids when compared to antifungal therapy.2 These findings also suggest the concept of secondary fungal colonization that further exacerbates the ongoing inflammatory process rather than the traditional thinking of a primary infection.3

85.4 Pathogens Most common bacteria implicated in acute infections remain Staphylococcus aureus and streptococcal species representing normal skin flora. Bacteria such as Eikenella corrodens or Pasteurella multocida may be causative organisms in cases with exposure to oral mucosa. Other commonly reported pathogens include Klebsiella pneumoniae, Bacteroides species, Enterococcus faecalis, and Pseudomonas aeruginosa. Over the past several decades, the incidence of community-acquired methicillin-resistant staphylococcal aureus (CA-MRSA) infections has been steadily rising.4 Candida albicans is the most common pathogen associated to chronic paronychial infections. Other dermatophytes seen in chronic cases can include trichophyton, microsporum, and epidermophyton.

85.5 Risk Factors Conditions such as diabetes and an immunocompromised state are associated with a higher risk for chronic infections. The significance of comorbidities in relationship to acute paronychia has not been clearly evaluated in the literature.3

85.3 Pathophysiology The majority of acute cases are associated with a history of minor trauma. Epithelium lysis or direct inoculation caused typically by normal skin flora can result in secondary infection. Most infections are limited to the soft tissue but can at times extend beneath the nail plate or even deeper beneath the nail bed to involve the distal phalanx resulting in osteomyelitis. Infections can extend around the eponychium to the opposite side and are referred to as a “runaround infection.” In chronic paronychia, causation appears to be related to multifactorial inflammatory changes affecting the nail fold. Such changes thereby result in an increased susceptibility to retention of moisture, irritants, and infecting organisms resulting in a vicious cycle of serial flare-ups and consequently limiting proper healing of the nail fold. Recent understanding now suggests that chronic paronychia is more representative of an

Fig. 85.1 Digital anatomy.

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Paronychia

85.6 Differential Diagnosis Conditions that mimic acute infection include gout, acute calcification (hydroxyapatite), pyogenic granuloma, and herpetic whitlow. The latter is more commonly seen in those individuals with exposure to the oral and respiratory systems and in children. Surgery is contraindicated in the management of herpetic whitlow, a condition that is typically seen as a somewhat protracted but self-resolving process (▶ Fig. 85.2). In acute and chronic cases, differential diagnosis includes the possibility of squamous cell carcinoma, melanoma, adenocarcinoma, and other neoplastic conditions.1,5 A chronic inflammatory condition unresponsive to conventional treatment should increase the suspicion for malignancy. Other less common causes of inflammatory changes may include secondary reactions related to drug toxicity to include retinoids (indinavir), epidermal growth factor–receptor inhibitors (cetuximab, gefitinib, lapatinib), and protease inhibitors.3

can be contributory factors. Examination often demonstrates an area of swelling and erythema along the nail fold that is tender upon palpation. In earlier cases, there may be no evidence of abscess formation. Purulent collection may develop within the paronychium but may also extend beneath the nail plate affecting the adherence of the nail (▶ Fig. 85.3).

85.7 Diagnosis 85.7.1 Acute Paronychia A careful history will often elicit a prior history of limited trauma that may precede the onset of symptoms by several days. Manicure treatments, hangnail, ingrown nail, and nail biting

Fig. 85.2 Herpetic Whitlow. (Reproduced with permission from Boyer MI, Chang J. 100 Hand Cases. 1st ed. © 2016 Thieme.)

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Fig. 85.3 (a) Paronychia with abscess formation – Schematic. (b) Clinical figure of an acute paronychia affecting the thumb. (Reproduced with permission from Boyer MI, Chang J. 100 Hand Cases. 1st ed. © 2016 Thieme.)

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Treatment

85.7.2 Chronic Paronychia Chronic infections are often associated with a history of exposure to moisture, irritants, and alkali, resulting in a more prolonged course of problems extending beyond 6 weeks. History is often characterized by recurring bouts of inflammation and drainage as well as symptoms of itching and burning. Examination often reveals an area of induration and rounding of the eponychium with varying degrees of skin maceration (▶ Fig. 85.4). Thickening and grooving of the nail plate may be seen. Drainage from the nail fold has often been intermittent associated with recurring episodes of inflammation.

85.7.3 Studies In uncomplicated cases, routine imaging is not required. More complex problems may require further studies to include radiographs and possibly MRI to rule out osteomyelitis, a complication normally not seen in acute and chronic paronychia. In cases where the differential diagnosis needs further consideration, additional testing may be required.

85.8 Treatment

or chlorhexidine and topical treatments with antibiotics and corticosteroids have been reported with varying degrees of effectiveness. Unfortunately, none of these treatments have been clearly supported by any high level of evidence data.6 In the presence of an abscess, drainage takes precedence over antibiotics. There is no consensus regarding drainage methods. Techniques ranging from simple needle drainage, hypodermic needle elevation of the nail fold, incisional reflection of the nail fold, incision of the paryonychium, to partial vs. complete nail plate removal have all been described (▶ Fig. 85.5). Resection of the nail plate may be more commonly performed in cases of an ingrown nail or situations where the infection tracks beneath the nail. When performing incisional drainage, avoidance of directly incising the eponychial fold is recommended when possible. The level of evidence supporting one technique against another in terms of outcomes is limited in the literature.6 A recent study did report good outcomes with very low recurrence in both acute paronychia and felon cases treated by simple abscess drainage without antibiotic coverage in healthy individuals without comorbidities.7 Benefits of such an approach has been postulated to help lower the cost of treatment as well as potentially reducing the increasing problem of monotherapy and drug resistance.

85.8.1 Acute Infection

85.8.2 Antibiotics

In early stages, infections can be treated with local care to include warm soaks and empiric oral antibiotics. The use of warm soaks with or without additive dilution with povidone-iodine

The mainstay of antibiotic treatment in the management of acute hand infections has been first-generation cephalosporins or penicillinase-resistant penicillin. However, with the increasing

Fig. 85.4 Chronic paronychia.

Fig. 85.5 (a) Drainage of acute paronychia incising the epithelium adjacent to the nail plate. (b) Some epithelium can be removed to allow for continuous drainage. (Reproduced with permission from Beasley RW. Beasley's Surgery of the Hand. 1st ed. © 2003 Thieme.)

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Paronychia 0.1% cream and betamethasone 17-valerate 0.1% ointment have shown clinical effectiveness in treatment.2 A recent study has also shown promising results with tacrolimus ointment 0.1%, a nonsteroidal preparation initially indicated for the treatment of atopic and allergic contact dermatitis.9 The results of recent treatment trials support the concept of an inflammatory process and further suggest that the clinical benefits related to antifungals may be equally attributed to their anti-inflammatory properties. Surgical management is recommended only in refractory cases that do not respond to medical management and other diagnoses are ruled out. While various surgical techniques have been described in the past, eponychial marsupialization with or without nail plate removal has been the most commonly reported surgical technique (▶ Fig. 85.6). Re-epithelialization typically requires 2 to 4 weeks of gradual healing supported by local wound care and hydrogen peroxide soaks. Other techniques reported include en bloc excision of the nail fold together combined with wound care and topical antibiotics. In all techniques, favorable results have been reported. There are no comparative studies indicating the superiority of one technique with respect to another supported by outcomes data.3

Fig. 85.6 Marsupialization technique for surgical management of chronic paronychia.

85.9 Pitfalls ● ●

prevalence of CA-MRSA, there is a changing approach to empiric coverage. In cases where the local MRSA penetration is greater than 10% for all hand infections, oral trimethoprim/sulfamethoxazole (TMP-SMX) or clindamycin represents a better first-line treatment.4 However, there is also increasing incidences of reported clindamycin-resistant CA-MRSA.8 In individuals who are exposed to oral flora, i.e., nail biting, the use of broader spectrum antibiotics such as clindamycin or amoxicillin/clavulanic acid is favored over first-generation cephalosporins. While literature is more limited, the use of doxycycline and minocycline together has been reported to be effective in the treatment of MRSA soft tissue infections.4

85.8.3 Chronic Infection The majority of chronic paronychia is secondary to frequent exposure to moisture and/or irritants in day-to-day activities. The problem can often be controlled by limiting exposure as well as by maintaining dryness of the nails through even the simple use of a hair dryer. In the past, the use of topical agents to include clotrimazole or tolnaftate was commonly employed as a first-line treatment. More refractory cases were treated with systemic therapy such as oral itraconazole or terbinafine. More recent data suggests that both topical and oral steroid therapy may have a more important role in the management of chronic paronychia. Both methylprednisolone aceponate

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Incomplete drainage of the abscess Inadequate drainage with extension of infection into the finger pulp causing a felon, into the flexor tendon sheath causing an infectious tenosynovitis, and into bone leading to osteomyelitis Inadequate antibiotic coverage

References [1] Relhan V, Goel K, Bansal S, Garg VK. Management of chronic paronychia. Indian J Dermatol. 2014; 59(1):15–20 [2] Tosti A, Piraccini BM, Ghetti E, Colombo MD. Topical steroids versus systemic antifungals in the treatment of chronic paronychia: an open, randomized double-blind and double dummy study. J Am Acad Dermatol. 2002; 47(1):73–76 [3] Shafritz AB, Coppage JM. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014; 22(3):165–174 [4] Harrison B, Ben-Amotz O, Sammer DM. Methicillin-resistant Staphylococcus aureus infection in the hand. Plast Reconstr Surg. 2015; 135(3): 826–830 [5] Meesiri S. Subungual squamous cell carcinoma masquerading as chronic common infection. J Med Assoc Thai. 2010; 93(2):248–251 [6] Ritting AW, O’Malley MP, Rodner CM. Acute paronychia. J Hand Surg Am. 2012; 37(5):1068–1070, quiz 1070 [7] Pierrart J, Delgrande D, Mamane W, Tordjman D, Masmejean EH. Acute felon and paronychia: antibiotics not necessary after surgical treatment. Prospective study of 46 patients. Hand Surg Rehabil. 2016; 35(1):40–43 [8] Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014; 39(8):1628–1635, quiz 1635 [9] Rigopoulos D, Gregoriou S, Belyayeva E, Larios G, Kontochristopoulos G, Katsambas A. Efficacy and safety of tacrolimus ointment 0.1% vs. betamethasone 17-valerate 0.1% in the treatment of chronic paronychia: an unblinded randomized study. Br J Dermatol. 2009; 160(4):858–860

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86 Felon Brian Katt, Daren Aita, and Daniel Fletcher Abstract A felon is a subcutaneous abscess of the tip of the finger involving the palmar pad. A felon left untreated can cause compartment syndrome of the distal phalangeal pulp. Staphylococcus aureus is the most common causative organism for a felon. Prompt incision and drainage is indicated to prevent pulp loss and neurologic damage at the tip of the finger. Prompt drainage can also prevent spread into the distal phalanx, distal interphalangeal joint, and flexor tendon sheath. Incisions that lower the chance of skin necrosis or neurological damage should be used. Keywords: felon, infection, MRSA, I&D

86.1 Description A felon is an abscess of the deep tissues of the palmar surface of the fingertip or thumb that is typically caused by a bacterial infection.

86.2 Anatomy The anatomy of the distal pulp is different from the rest of the finger. Multiple vertical trabeculations divide the pulp space into distinct separate septal compartments. The trabeculae give the fingertip strength by running from the periosteum of the terminal phalanx to the skin. These septal compartments are filled with adipose tissue and eccrine sweat glands which exit into the glabrous skin. The digital arteries run along the volar radial and ulnar sides of the distal phalanx. Just volar to the arteries are the digital nerves. The nerves have extensive terminal branches on the volar aspect of the fingertip which provide for excellent tactile discrimination.

86.3 Pathophysiology Bacteria can enter the distal pulp via a variety of ways. This can occur by direct inoculation with a needle stick or with a penetrating foreign body. Skin bacteria can also enter via the eccrine sweat glands which lead directly to the distal pulp and are contained in septal compartments. These compartments are unyielding to any increased pressure. The resultant inflammation and abscess formation leads to ischemic pain and continued vascular comprise. If not decompressed, the felon can progress to digital ischemia and skin slough. Additionally, due to the strength of the skin in this location, the infection continues deeper to cause damage to the bone and joint capsule as opposed to decompressing itself through the skin.1

86.4 Pathogens The most common causative organisms are Staphylococcus aureus followed by streptococcal species. Community-acquired methicillin-resistant Staphylococcal aureus (CA-MRSA) is so

common that first-line antibiotic regimen should now include coverage for such. The incidence of MRSA ranges from 34 to 73% of all hand infections.2 A felon infection is more likely to be MRSA when looking at all hand infections.3 In this paper looking at all hand infections, felon was 1.9% of the total but 6.3% of the CA-MRSA infections. Intravenous drug use and a prior hand infection were additional risk factors for CA-MRSA infection. Cases of felons due to gram-negative bacteria have been reported.4 Eikenella corrodens or Pasteurella multocida may be causative when the penetrating injury was a human or animal bite. Patients with diabetes or who are immunocompromised are more likely to have polymicrobial infections.

86.5 Risk Factors Patients who are required to do fingerstick measurements for blood glucose are at risk for direct inoculation. Individuals in occupations where their hands are around dirty, sharp objects and those who are exposed to animals and potential animal bites are theoretically at risk. Immunocompromised individuals are also at risk.

86.6 Differential Diagnosis Gout, pyogenic granuloma, and herpetic whitlow can mimic infection. Local trauma can present with pain, redness, and swelling. Localized cellulitis without abscess can have similar subjective complaints. Determining when a superficial infection becomes deep is difficult, and additional imaging may be needed.

86.7 Diagnosis Obtaining the patient’s history will assist in making the diagnosis. Oftentimes, a felon will result from a puncture wound or direct inoculation. Examination often demonstrates an area of swelling, warmth, and tenderness to the volar aspect of the finger distal to the distal interphalangeal joint flexion crease. Patients complain of severe pain, swelling, throbbing, and tension in the finger pulp. Ten to fifteen percent of hand infections are due to felons.5 In early cases, there may be no evidence of abscess formation. As the disease progresses, a purulent collection may develop within the pulp of the finger. Progression of the felon can cause swelling, tension, compromised venous return, microvascular injury, and soft tissue necrosis (▶ Fig. 86.1). Severe cases can progress to osteitis, osteomyelitis, septic arthritis, and suppurative flexor tenosynovitis (▶ Fig. 86.2).1 When a felon is suspected, imaging is not necessary to make the diagnosis. An ultrasound evaluation may be used to identify an abscess if the diagnosis cannot be made clinically. With a delayed presentation, radiographs may be of value to assess for osteitis or osteomyelitis. Additionally, an MRI may be of value to assess the degree of deep structure involvement.

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Felon

Fig. 86.1 Skin necrosis due to felon.

Fig. 86.2 Severe felon extending into the flexor sheath of the thumb. (This image is provided courtesy of Dr. Pedro Beredjiklian, MD.)

86.8 Treatment 86.8.1 Overview Treatment of a felon involves surgical drainage. Cases of finger cellulitis without abscess may be treated with warm compresses, elevation, and antibiotics. These treatments are widely used yet not supported or refuted by current data.6 Most often the surgical procedure is coupled with antibiotic therapy. However, based on a recent paper, antibiotics may not be necessary after surgical decompression in healthy patients.7

86.8.2 Antibiotics Traditionally, hand infections were managed empirically with first-generation cephalosporins. This class of antibiotics was effective against the most common organisms, both Staphylococcus and Streptococcus species. Now with the growth in percentage of infections due to CA-MRSA, management has changed. Trimethoprim/sulfamethoxazole (TMP-SMX) or doxycycline both seem to be effective against MRSA.2 Linezolid, a broad-spectrum oral antibiotic, can also be given for severe infections. Clindamycin has been used as a first-line agent but now there is increasing clindamycin-resistant CA-MRSA and its use is less indicated.8

86.8.3 Felon Surgery Several approaches to drainage of a felon have been described with the mainstay of intervention through a midaxial (▶ Fig. 86.3) or longitudinal palmar incision (▶ Fig. 86.4). Additional approaches historically described include a fish-mouth incision (▶ Fig. 86.5), hockey stick or “J” incision, palmar transverse and bilateral midaxial incisions with through and through dissection. Those additional approaches have been documented to have a higher risk of residual pulp instability, scar sensitivity, digital nerve injury, digital pulp necrosis, and are currently not recommended.9,10 Tourniquet use is recommended with arm elevation rather than Eshmark compression used to exsanguinate the limb.

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Fig. 86.3 Midaxial incision location.

Anesthesia may include a digital or regional block with or without sedation. Most commonly used is the midaxial incision preferably placed on the ulnar borders of the index, long, and ring fingers, and the radial borders of the small finger and thumb, although the side of the approach may be adjusted dependent on the location of the abscess.9,11 The incision should be placed ~2 mm palmar to the lateral nail plate and distal to the interphalangeal crease. Care should be taken not to dissect proximal to the midportion of the distal phalanx to minimize

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References

Fig. 86.4 Longitudinal palmar incision.

the risk of penetrating the flexor sheath and iatrogenically causing a suppurative flexor tenosynovitis. The incision should be carried through skin and continued with a scalpel separating the fibrous vertical septae until the abscess cavity is entered. Further dissection may be completed with a hemostat or blunt probe. The digital nerve and vessel arborize palmar to the incision line and should be protected by avoiding dissection in a palmar direction. Alternatively, a midline longitudinal palmar approach may be used and is particularly useful in cases where a sinus tract is present or is forming.10 Some authors advocate this approach as having a lower risk of digital nerve injury while others believe this may lead to a higher chance of scar sensitivity through the digital pad.9,10 Upon entrance into the abscess cavity appropriate cultures should be obtained and the wound irrigated. The wound is gently packed open and dressing changes started within the first 24 to 48 hours and can be replaced multiple times per day. The time frame to discontinue packing, time to healing, and residual deformity from pulp atrophy varies dependent on the severity of the initial infection.

Fig. 86.5 Fishmouth incision. (This should be avoided.)

References [1] Watson PA, Jebson PJ. The natural history of the neglected felon. Iowa Orthop J. 1996; 16:164–166 [2] Koshy JC, Bell B. Hand infections. J Hand Surg Am. 2019 Jan; 44(1):46–54 [3] Imahara SD, Friedrich JB. Community-acquired methicillin-resistant Staphylococcus aureus in surgically treated hand infections. J Hand Surg Am. 2010; 35(1):97–103 [4] Perry AW, Gottlieb LJ, Zachary LS, Krizek TJ. Fingerstick felons. Ann Plast Surg. 1988; 20(3):249–251 [5] Green DP. Green’s Operative Hand Surgery. 5th ed. Philadelphia: Elsevier, Churchill, Livingstone; 2005:61 [6] Ritting AW, O’Malley MP, Rodner CM. Acute paronychia. J Hand Surg Am. 2012; 37(5):1068–1070, quiz 1070 [7] Pierrart J, Delgrande D, Mamane W, Tordjman D, Masmejean EH. Acute felon and paronychia: antibiotics not necessary after surgical treatment. Prospective study of 46 patients. Hand Surg Rehabil. 2016; 35(1):40–43 [8] Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014; 39(8):1628–1635, quiz 1635 [9] Canales FL, Newmeyer WL, III, Kilgore ES, Jr. The treatment of felons and paronychias. Hand Clin. 1989; 5(4):515–523 [10] Kanavel AB. Infections of the Hand. 6th ed. Philadelphia: Lea and Febiger; 1933:157–166 [11] Linscheid RL, Dobyns JH. Common and uncommon infections of the hand. Orthop Clin North Am. 1975; 6(4):1063–1104

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87 Flexor Tenosynovitis Jason M. Rovak Abstract Purulent flexor tenosynovitis is an acute infection affecting the flexor sheaths in the hand. Patients present with pain, swelling, and decreased motion. Treatment requires prompt surgical drainage and antibiotics specific to the causative organism. Keywords: hand infection, flexor tenosynovitis, flexor sheath infection, purulent tenosynovitis

87.1 Description Purulent flexor tenosynovitis is an acute infection that extends proximally and distally within the flexor sheath. Treatment should be expeditious to prevent complications such as tendon sheath scarring or tendon rupture. The most common causative organism is Staphylococcus aureus.

radial bursa which extends into the carpal tunnel. Attritional communication between the radial and ulnar bursae can occur through Parona space, and lead to the formation of a “horseshoe abscess” (▶ Fig. 87.1).

87.4.2 Laboratory Findings The diagnosis of purulent flexor tenosynovitis is primarily based on history and physical exam. While an elevated white blood count (WBC) with a left shift may aid in the diagnosis, healthy patients with a localized hand infection may not have notable lab abnormalities. A normal WBC should not be used to rule out the diagnosis. Erythrocyte sedimentation rate and Creactive protein are nonspecific inflammatory markers and may be elevated in noninfectious conditions as well. That said, elevations in WBC, especially with a left shift, as well as inflammatory markers may be good data points to evaluate efficacy of treatment as the patient recovers.

87.2 History

87.4.3 Radiology

The route for infection is generally penetrating trauma to the volar aspect of the digit. Patients present complaining of pain, especially with motion, and erythema.

Imaging studies do not play a significant role in diagnosing purulent flexor tenosynovitis and may delay treatment. Depending on the history, a plain film may be beneficial to

87.3 Differential The common differential includes superficial abscess, septic joint, and crystalline disease such as gout or pseudogout.

87.4 Work-up 87.4.1 Physical Exam The classic physical exam findings associated with purulent flexor tenosynovitis were described by Kanaval in 1921. (1) Fusiform swelling (sausage digit), (2) the affected digit rests in a flexed posture, (3) pain with passive extension, and (4) tenderness along the flexor sheath. The first three are generally sensitive but not specific. Conditions such as septic joints as well as localized abscesses can lead to notable digital swelling and pain with motion. Since a flexed posture is the normal resting cascade of the digit, it is certainly not specific to flexor tenosynovitis. Flexor sheath tenderness is present in all cases and is fairly specific to flexor tenosynovitis. Again, the entire clinical picture should be used; however, this is the finding that I have found most useful in practice. With a localized abscess, the patient may have pain with motion, swelling, and a flexed posture, but will generally not be tender outside of the confines of the fluid collection. Tenderness over the A1 pulley in the palm is a good differentiating finding; however, an extensive superficial abscess can certainly have similar findings. The anatomy of the tendon sheaths of the finger includes an isolated sheath for the index, long, and ring fingers. The small finger sheath extends proximally into the carpal tunnel and represents the ulnar bursa. The thumb sheath represents a

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Fig. 87.1 Anatomy of the flexor sheaths in the hand: RB, radial bursa; UB, Ulnar bursa; PS, Parona space. Deep Spaces: T, thenar; M, midpalmar; H, hypothenar.

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Treatment ensure that there is not an occult foreign body. Soft tissue gas on plain films may be indicative of a more nefarious process, such as a necrotizing infection. In cases that are questionable, magnetic resonance imaging (MRI) is the study of choice for the assessment of these patients (▶ Fig. 87.2).

87.5 Treatment Treatment for purulent flexor tenosynovitis is surgical drainage with appropriate antibiotic coverage. Infectious disease consultation is appropriate. While antibiotics alone can be used in very early cases, the consequences of failure are high and include scarring within the flexor sheath and flexor tendon rupture. For practical reasons, such as operating room (OR) availability or surgeon availability, some practitioners will admit the patient, treat with IV antibiotics, and then proceed with surgical drainage when appropriate staff and equipment are available. If surgery can be accomplished expeditiously, obtaining surgical cultures prior to antibiotic treatment is preferable, as aggressive antibiotic treatment may complicate the culture results and it may be more difficult to determine an appropriate outpatient antibiotic regimen.

87.5.1 Anesthesia Surgical drainage may be safely accomplished with either a local anesthesia or general anesthesia. Bier blocks and brachial plexus blocks are typically avoided in the setting of infection. Use of local anesthesia requires appropriate patient selection. If the distal palm is erythematous, it may be difficult to achieve adequate anesthesia. Infected soft tissue is an acidic environment and local anesthetics, such as Marcaine or lidocaine, may not be effective. Local anesthetics themselves are weak bases, and will not cross cell membranes in their protonated, charged, form. If the erythema does not extend to the A1 pulley level,

I have found local anesthesia to be both an effective and costconscious way to treat this problem. It may be appropriate to attempt a local anesthetic block and determine the appropriate course based on whether adequate anesthesia is achieved. Wrist blocks are also useful if the area of erythema is more extensive and does not allow adequate anesthesia with palm-level injections. A tourniquet is used for hemostasis, which may be the limiting factor in determining whether a local anesthesia is appropriate. If there is an extensive superficial abscess as well and a large surgical approach is planned, the patient may not tolerate the additional tourniquet time. I have not attempted this procedure using local anesthesia with epinephrine, but that may provide adequate hemostasis without the use of a tourniquet. If local anesthesia is not appropriate, I will proceed with a general anesthesia.

87.5.2 Surgical Technique A Brunner incision just proximal to the A1 pulley level is used to access the flexor sheath system if the infection appears to be isolated to the flexor sheath without a significant superficial abscess (▶ Fig. 87.3). There is usually bulging synovitis with a purulent appearance. A counterincision is then made distally. A transverse incision in the distal interphalangeal flexion crease allows access to the flexor sheath without disrupting the pulley system. A small window is made in the distal aspect of the flexor sheath and milking the hand/digit from proximal to distal will cause an egress of abnormal appearing fluid. This should be sent for appropriate cultures. If there is an obvious site of localized swelling along the digit, an additional incision may be necessary to rule out superficial infection. This is commonly at the initial site of inoculation. A small IV catheter is then placed from proximal to distal into the flexor sheath through the proximal incision and the sheath is copiously irrigated with normal saline. An 18-gauge catheter is usually appropriate. The saline

Fig. 87.2 Abscess in the flexor tendon sheaths of the index finger. (a) The axial T2*-weighted GRE sequence shows massive fluid retention in the tendon sheath and separation of the superficial from the deep flexor tendons. (b) Inflammatory edema of the paratendinous soft tissues and the bone marrow of the middle phalanx, from which the flexor tendons are displaced. T2-weighted FSE sequence with fat saturation. (c,d) Inflammatory contrast enhancement in the periphery of the tendon sheath abscess. The inflammation has spread to the metacarpal space. T1-weighted SE sequences plain and fat saturated after administration of gadolinium. (Reproduced with permission from Schmitt R, Lanz U. Diagnostic Imaging of the Hand. 1st ed. © 2007 Thieme.)

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Flexor Tenosynovitis

87.6 Antibiotic Management Empiric treatment should address Staphylococcus and presume MRSA until cultures and sensitivities are obtained. As cultures and sensitivities become available, antibiotics can be tailored to specific organisms as well aid in choosing appropriate IV or oral outpatient regimens.

87.7 Inpatient versus Outpatient Treatment

Fig. 87.3 Small finger—standard Brunner incisions. Ring and long fingers—Brunner incisions with midlateral extensions. Index finger—standard surgical approach for flexor tenosynovitis.

If the patient is generally healthy and reliable, flexor tenosynovitis can be treated as an outpatient rather than have the patient bear the expense of inpatient treatment when they are not receiving any care other than a once or twice a day antibiotic administration and a dressing change. I prefer to have the patient receive appropriate empiric antibiotics at the time of initial treatment, see the patient in the office the next day where the dressing is changed and they begin OT for soaks, dressing/packing changes, and range-of-motion exercises as discomfort and swelling allow. I will have them see the infectious disease physician that day as well. Both oral and IV antibiotics can be administered on an outpatient basis. Treating as an outpatient is predicated if the patient is generally healthy without signs of systemic illness, reliable, and has insurance that will cover outpatient treatment that may include a PICC line. If it is a weekend and postoperative day one, follow up is not practical, if the patient is unreliable, or if the patient’s insurance does not cover outpatient IV antibiotic treatment, I do not hesitate to treat as an inpatient.

87.8 Expectations should flow easily and flow out of the distal incision. If the fluid does not flow freely, the catheter may be kinked. Repositioning the digit usually helps. Associated superficial abscesses may require a more extensile surgical approach. This can be accomplished with Brunner incisions or a Brunner incision over the proximal and distal phalanges, connected by a midlateral incision at the middle phalanx level. This provides a nice flap of tissue to cover exposed structures (▶ Fig. 87.3). After appropriate washout, the wounds should be stented open with either standard packing material or a Penrose drain. Tacking stitches may be used to loosely approximate the soft tissue and cover exposed critical structures. A soft bulky dressing is applied with or without a splint for comfort.

87.5.3 Postoperative Care On postoperative day 1, the dressing is removed, and the hand is soaked in a mix of ½ saline and ½ hydrogen peroxide for 5 to 10 minutes, then redressed. A packing change may be performed at the time of dressing changes. Penrose drains are pulled on day 2 and may be repacked if necessary. If there is not appropriate clinical improvement, repeat drainage should be considered. Early postoperative physical/occupational therapy can aid in more rapid recovery of motion.

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Flexor tenosynovitis can lead to scarring within the flexor sheath. Recovery can take quite a while and may require a fair amount of outpatient therapy. I recommend counseling patients that their digit may not completely return to normal, and that they may have prolonged swelling, discomfort, or stiffness.

87.9 Pitfalls ● ●

● ●

Incomplete drainage Inadequate drainage with extension of infection into bone leading to osteomyelitis Inadequate antibiotic coverage In severe cases, staged surgical debridements or continuous saline drainage through a catheter may be necessary

Suggested Readings Bruner JM. The zig-zag volar-digital incision for flexor-tendon surgery. Plast Reconstr Surg. 1967; 40(6):571–574 Hall RF, Jr, Vliegenthart DH. A modified midlateral incision for volar approach to the digit. J Hand Surg [Br]. 1986; 11(2):195–197 Kanavel A. Infections of the Hand. 4th ed. Philadelphia: Lea & Febiger; 1921 Stevens, D.L. et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15;59(2):e10–52

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88 Septic Joint Samir Sodha Abstract Septic arthritis of the hand warrants urgent surgical attention. Delay in surgical treatment can result in rapid articular cartilage degradation from the bacterial toxins, with the inflammatory response and volume overload causing pressure necrosis. Infections of the hand joint can be caused by adjacent spread of an existing infection and less commonly by a hematogenous route. However, the most common mechanism for joint contamination in the hand is penetrating trauma. Direct inoculation through a laceration or puncture is of particular concern when metacarpophalangeal (MCP) joints are involved in clenched fist injuries. Not only is the history of infection source important to the treatment and selection of antibiotics, but also the location of the septic joint in the hand. The distal interphalangeal (DIP) joint, proximal interphalangeal (PIP) joint, MCP joint, and wrist joint all have special considerations when managing pyogenic infections in these spaces.

pain with motion.7 While important with any infection, a thorough review of the medical history with particular attention to inflammatory and immunological comorbidities is essential when evaluating the likelihood of a septic wrist.8

Keywords: hand infection, septic wrist, fight bite, septic finger joint

A patient with a septic finger joint usually presents with a readily recognizable fusiform swelling of the involved joint along with erythema, warmth, and pain with any kind of motion. In this setting, the finger is fluctuant and motion may not be possible due to the volume overload in the joint capsule. The site of injury along the involved digit also gives clues as to mechanism of inoculation and will help determine the operative plan. During the examination, the clinician should appreciate even the smallest of wounds over joints as a source of the contamination. However, exam findings of the septic wrist can also be found in painful wrists in many of the inflammatory and other immune system conditions. These signs include warmth, pain with active and passive range of motion, redness, and edema.7

88.1 Introduction The management of joint infections in the hand and wrist shares the same principles with treating infections in larger joints. In the closed confines of the relatively smaller space, the bacterial toxins along with immunogenic response both begin to erode the surface within hours after inoculation.1 Therefore, prompt surgical irrigation of the joint and debridement of necrotic tissue are of paramount importance. Intraoperative cultures should be taken both for aerobic and anaerobic organisms. In clinical settings, where the patient is immunocompromised or has a history of marine water exposure, it is recommended to also include fungal and mycobacterial cultures. Recent studies have had some impact on the antibiotic choice and duration when dealing with small joint infections and will be discussed further in this chapter.2,3,4,5

88.2 Clinical Presentation Penetrating injury with a foreign object or a bite is the more common history preceding a joint infection in the finger. An untreated paronychia or felon prior to presentation is also relevant as it can seed the DIP joint.6 Another source of infection can be a flexor sheath infection, which is known to contaminate the PIP joint if this is left unchecked or undertreated. Systemic signs are less reliable in the diagnosis of the isolated septic finger joint; however, the presence of such signs, such as fever, chills, and abnormal vital signs, should warrant specific attention to a distant source of infection via hematogenous spread. The septic wrist joint has a different presentation from that of the infections of the small finger joints. Usually, it presents as an atraumatic painful wrist that is accompanied by warmth and

88.3 Diagnosis The diagnosis of septic finger joints has more obvious clinical signs with many times an antecedent trauma involving a human or animal bite, puncture from a thorn or needle, cut with a knife, and many other mechanisms of traumatic seeding of the joint. The septic wrist joint presents differently and warrants more attention to medical history and relies more on diagnostic testing to rule out other causes such as inflammatory arthropathies that may represent an infection.

88.3.1 Physical Examination

88.3.2 Differential Diagnosis The more common conditions in the differential diagnosis for septic arthritis are listed in ▶ Table 88.1. In the setting of direct trauma, prior surgery, and recent infection, the diagnosis of joint infection can be made readily with correlating exam. Without such predisposing factors and when the exam alone is not enough to establish a diagnosis, a more complete clinical evaluation can be made with proper radiographic and laboratory testing.

88.3.3 Laboratory and Diagnostic Testing Laboratory testing in any instance where septic joint is in the differential should entail a white cell count (WBC), C-reactive protein (CRP) level, and an erythrocyte sedimentation rate (ESR). When clinically appropriate, uric acid level, Lyme disease titer, and serum inflammatory disease markers should also be obtained. Elevated acute phase inflammatory markers, along with physical exam findings of a painful warm

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Septic Joint Table 88.1 Diagnostic testing summary for septic arthritis differential Joint aspiration

X-rays

Pertinent lab values

+ Gram stain + Cultures

Possible joint Widening, foreign bodies

Very high CRP

CPPD

Weakly positive nonbirefringent crystals

Chondrocalcinosis

Gout

Negatively birefringent needle shaped crystals

Periarticular erosions “rat bitten” shaped

Elevated uric acid level

Inflammatory disease

Juxta-articular and periarticular erosions

Positive RF, ANA

Calcific periarthritis

Periarticular calcium deposits

Septic arthritis

joint, typically put a septic joint diagnosis high on the differential.9 Despite this, the presence of elevated serum inflammatory markers is nonspecific as examined in many previous studies and can be found in many noninfectious conditions.10,11,12 Radiographs can add further evidence in helping to rule or rule out joint infections. In one study looking at wrist inflammation, findings of chondrocalcinosis on radiographs suggest in most cases a noninfectious process.13 Other radiograph findings particular to different inflammatory arthropathies in the differential are listed in ▶ Table 88.1. Given the lack of key pathognomonic imaging or laboratory criteria to establish joint infection, joint fluid analysis remains the best option for a definitive diagnosis.8 Joint aspiration of small joints in itself can be difficult to perform and attempts that yield no fluid doesn’t necessarily rule out joint infection.10 When a successful arthrocentesis is performed, preference of the synovial fluid analysis should go to gram stain, cultures, and crystalline analysis.14 A variety of conditions can be identified with synovial fluid testing as detailed in ▶ Table 88.1. Joint fluid WBC can be obtained if enough volume is available; however, the unpredictability in using this to diagnose septic joint makes this a second-tier option.14,15,16 Systematic work-up of suspected joint infections in the hand and wrist involves several elements of clinical evaluation, imaging, and serum analysis. The arrival to a final diagnosis is made with a combination of these findings, rather than any one in particular.

88.4 Surgical Treatment Septic arthritis of the hand and wrist warrants urgent surgical drainage. Once the arthrotomy is made, it is recommended to place longitudinal traction on the joint as to aid in the lavage of the entire joint. While many surgical principles remain the same concerning infected tissue debridement, foreign body removal, and articular cartilage evaluation, each particular joint in the hand and wrist have unique considerations, given their respective anatomy and location.

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88.4.1 Septic Distal Interphalangeal Joint Surgical Approach The distal interphalangeal (DIP) joint is approached typically via a dorsal “H” or “Y” incision. Full-thickness flaps are raised and careful attention made to protect the terminal extensor tendon. The joint is entered on either side of the terminal tendon. In the setting of penetrating trauma, the wound should be extended to expose the joint. At times, when this is not possible, a separate incision is made to open the DIP joint, and the wound itself can be used as a portal to allow drainage from the lavage. Using a small gauge angiocatheter is a useful trick when irrigating small joints through small wounds (▶ Fig. 88.1). A midaxial incision can also be used allowing better protection of the terminal tendon. Deeper dissection is directed anteriorly opening the joint capsule between the collateral ligament and the terminal extensor tendon. This approach also has the benefit of dealing with a concomitant flexor tendon sheath infection.

Special Considerations Unique to DIP joint infections is the attenuation of the terminal extensor tendon. If the terminal extensor tendon is compromised at the time of initial surgery, a helpful hint is to place one or two dermotenodesis stitches through the extensor mechanism while leaving the rest of the wound open. As the infection resolves, this at least has a chance of supporting some structure of the tendon in conjunction with DIP joint splinting. Development of a late mallet deformity can be salvaged either by secondary reconstruction after infection has cleared or arthrodesis of the joint.

88.4.2 Septic Proximal Interphalangeal Joint Surgical Approach The proximal interphalangeal (PIP) joint can be accessed either by a dorsal or a midaxial approach. In the dorsal approach, the capsule is exposed on either side of the central slip with careful handling of the extensor mechanism. When using the midaxial incision, the joint is opened between the volar plate and accessory collateral ligament after the transverse retinacular ligament is divided.17 Once again, it is helpful to use an angiocatheter to irrigate the joint with this approach as the portal is relatively small.

Special Considerations When the extensor mechanism is either degraded by infection or directly traumatized, this can result in a boutonnière deformity. The partially or completely disrupted central slip is encountered within a dorsal traumatic wound. While this adds to the complexity to the overall condition, attention is first given to resolution of the septic PIP joint. One helpful hint is to place a dermotenodesis stitch to bring the lateral bands more dorsal if the central slip is compromised. The rest of the wound can be left open to all drainage and the finger PIP joint

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Postsurgical Care visualization of the articular surfaces for damage and any other retained foreign bodies or debris. Standard protocol for irrigation and debridement is then carried out.

Special Considerations One particular cause of a septic MCP joint deserves special mention, given how frequent this injury is overlooked by healthcare providers. The clenched-fist or fight bite injury is caused when the tightly flexed MCP joint resulting in stretched overlying skin and extensor tendon makes contact with the mouth of another individual (▶ Fig. 88.2). The presenting wound may appear benign sometimes, prompting treating clinicians to dismiss the injury as minor. Insufficient irrigation and wound management can result in a septic MCP joint.18,19 Delayed presentation can also have dire consequences necessitating amputation.19,20 Hence it is recommended that fight bite injuries should be adequately explored, debrided, and thoroughly decontaminated in an operating room setting.20,21 Concomitant extensor mechanism lacerations can be repaired at the time of initial surgical washout if satisfactory debridement can be achieved.22,23 In most settings, however, tendon injuries are better addressed at a later stage.

88.4.4 Septic Wrist Joint Surgical Approach

Fig. 88.1 Clinical photograph illustrates a dorsolateral approach to the DIP joint with using an angiocatheter to assist in the irrigation of the joint.

should be kept splinted in extension. Late reconstruction of the boutonnière deformity is also an option assuming the joint infection can be cleared and articular cartilage is maintained. However, if the joint surface is compromised superimposed on extensor mechanism insufficiency, arthrodesis is favored.

88.4.3 Septic Metacarpophalangeal Joint Surgical Approach The metacarpophalangeal (MCP) joint is exposed through a dorsal approach. The deeper capsulotomy can be performed through a longitudinal split in the extensor mechanism or through the proximal part of the sagittal band. Either method requires careful handling of the sagittal bands as to avoid extensor tendon subluxation. Manual traction of the joint aids in

Arthroscopic and open surgical treatments have both been advocated in the management of the septic wrist.7,24 While either method is acceptable, arthroscopic surgery has been shown to reduce hospital stays and number of procedures.15,24,25 If the arthroscopic approach is utilized, then the standard 3– 4 portal is established with a small joint arthroscope. The irrigation fluid then enters through the arthroscope and exits via the 6 R or 6 U portal (▶ Fig. 88.3). The outflow portal can also be used for instrumentation and synovectomy as needed.26 The portals are left open once the lavage has been completed, or drains can be left behind to keep the portals patent. If, however, arthroscopic equipment is unavailable, or one elects to perform an open arthrotomy, a dorsal incision is made just ulnar to Lister tubercle. The dissection is then carried down to the joint capsule between the third and fourth extensor compartments.7 Once the irrigation and debridement is begun, it is important to flex and extend the wrist to reach all of the recesses of the joint. The wound is left open or can be loosely closed over drains.

88.5 Postsurgical Care 88.5.1 Surgical Wound Management Once adequate surgical irrigation and debridement of the septic joint has been performed, the surgical wounds are typically left open and kept patent with any of the several available options of packing material, drains, or gauze wicks. If a second washout is planned, delayed closure can be considered. Barring significant tendon injury, early joint mobilization is recommended.

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Septic Joint

Fig. 88.2 (a) Clinical photograph of a patient 5 days following a “fight-bite” injury with increasing pain and swelling in the MP joint; (b) upon incising the skin, a large amount of purulent drainage is observed; (c) a fragment of articular cartilage is identified in the wound; (d) the wound is found to communicate with the metacarpophalangeal joint, and the articular cartilage of the metacarpal head is visible (white arrow); (e) a partial extensor tendon injury is noted.

88.5.2 Antibiotic Therapy

Fig. 88.3 Clinical photograph illustrating a standard arthroscopic setup for the wrist. Note the 6 R portal is localized with a needle, and can be substituted for a larger caliber cannula for fluid egress.

454

In this era of increasing bacterial resistance to antibiotics, a thoughtful selection of an appropriate antimicrobial regimen is all the more important. Escalation of antibiotic treatment is certainly warranted when dealing with a septic joint, given the grave consequences of undertreatment or delayed treatment due to emerging organism resistances. The increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus infections necessitates initial empiric broad-spectrum coverage. 2,3 Intravenous empiric treatment with vancomycin and piperacillin/ tazobactam is recommended. 27 Other options, in addition to administering vancomycin, are ceftriaxone or ampicillinsulbactam. 14 Alternates to vancomycin are clindamycin, trimethoprim-sulfamethoxazole, or daptomycin.2,3 These first-line empiric antibiotics can be tailored to a more specific regimen targeting the organisms once identified by cultures and Gram stain. The duration of the course of antibiotics in treatment of small joint infections has also evolved. Combined with proper surgical treatment, shorter courses of intravenous and oral antimicrobial courses can be considered.4,5 Current recommendation for parenteral treatment is 1 week or less, supplemented with oral treatment for an additional 1 to 3 weeks. 4,5 It is important to consider that modifications of the above recommendations may be needed depending on the length and severity of the infection, host factors, and clinical setting.

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References

88.6 Septic Joint Sequelae Good outcomes can be expected with prompt surgical intervention and appropriate antibiotic management.7,12,15,20 Joint stiffness even after successful and timely eradication of the septic joint is not uncommon.28 Delayed diagnosis or presentation portends a more ominous prognosis resulting in joint degradation, tendon compromise, and osteomyelitis.

References [1] Josefsson E, Tarkowski A. Staphylococcus aureus-induced inflammation and bone destruction in experimental models of septic arthritis. J Periodontal Res. 1999; 34(7):387–392 [2] Harrison B, Ben-Amotz O, Sammer DM. Methicillin-resistant Staphylococcus aureus infection in the hand. Plast Reconstr Surg. 2015; 135(3): 826–830 [3] Tosti R, Samuelsen BT, Bender S, et al. Emerging multidrug resistance of methicillin-resistant Staphylococcus aureus in hand infections. J Bone Joint Surg Am. 2014; 96(18):1535–1540 [4] Kowalski TJ, Thompson LA, Gundrum JD. Antimicrobial management of septic arthritis of the hand and wrist. Infection. 2014; 42(2):379–384 [5] Meier R, Wirth T, Hahn F, Vögelin E, Sendi P. Pyogenic arthritis of the fingers and the wrist: can we shorten antimicrobial treatment duration? Open Forum Infect Dis. 2017; 4(2):ofx058 [6] Rangarathnam CS, Linscheid RL. Infected mucous cyst of the finger. J Hand Surg Am. 1984; 9(2):245–247 [7] Rashkoff ES, Burkhalter WE, Mann RJ. Septic arthritis of the wrist. J Bone Joint Surg Am. 1983; 65(6):824–828 [8] Umberhandt R, Isaacs J. Diagnostic considerations for monoarticular arthritis of the hand and wrist. J Hand Surg Am. 2012; 37(7):1480–1485 [9] Boustred AM, Singer M, Hudson DA, Bolitho GE. Septic arthritis of the metacarpophalangeal and interphalangeal joints of the hand. Ann Plast Surg. 1999; 42(6):623–628, discussion 628–629 [10] Skeete K, Hess EP, Clark T, Moran S, Kakar S, Rizzo M. Epidemiology of suspected wrist joint infection versus inflammation. J Hand Surg Am. 2011; 36(3):469–474

[11] Mehta P, Schnall SB, Zalavras CG. Septic arthritis of the shoulder, elbow, and wrist. Clin Orthop Relat Res. 2006; 451(451):42–45 [12] Yap RT, Tay SC. Wrist septic arthritis: an 11 year review. Hand Surg. 2015; 20 (3):391–395 [13] Kang G, Leow MQH, Tay SC. Wrist inflammation: a retrospective comparison between septic and non-septic arthritis. J Hand Surg Eur Vol. 2017; 1: 1753193417738166 [14] Jennings JD, Ilyas AM. Septic arthritis of the wrist. J Am Acad Orthop Surg. 2018; 26(4):109–115 [15] Sammer DM, Shin AY. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg Am. 2009; 91(6):1387–1393 [16] Schulz BM, Watling JP, Vosseller JT, Strauch RJ. Markedly elevated intraarticular white cell count caused by gout alone. Orthopedics. 2014; 37(8): e739–e742 [17] Abrams RA, Botte MJ. Hand infections: treatment recommendations for specific types. J Am Acad Orthop Surg. 1996; 4(4):219–230 [18] Gonzalez MH, Papierski P, Hall RF, Jr. Osteomyelitis of the hand after a human bite. J Hand Surg Am. 1993; 18(3):520–522 [19] Shoji K, Cavanaugh Z, Rodner CM. Acute fight bite. J Hand Surg Am. 2013; 38 (8):1612–1614 [20] Mennen U, Howells CJ. Human fight-bite injuries of the hand. A study of 100 cases within 18 months. J Hand Surg [Br]. 1991; 16(4):431–435 [21] Kelly IP, Cunney RJ, Smyth EG, Colville J. The management of human bite injuries of the hand. Injury. 1996; 27(7):481–484 [22] Nygaard M, Dahlin LB. Dog bite injuries to the hand. J Plast Surg Hand Surg. 2011; 45(2):96–101 [23] Briden AJ, Povlsen B. Primary repair of a flexor tendon after a human bite. Scand J Plast Reconstr Surg Hand Surg. 2004; 38(1):62–63 [24] Sammer DM, Shin AY. Arthroscopic management of septic arthritis of the wrist. Hand Clin. 2011; 27(3):331–334 [25] Hariri A, Lebailly F, Zemirline A, Hendriks S, Facca S, Liverneaux P. Contribution of arthroscopy in case of septic appearance arthritis of the wrist: a nine cases series. Chir Main. 2013; 32(4):240–244 [26] Sammer DM, Shin AY. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. Surgical technique. J Bone Joint Surg Am. 2010; 92 Suppl 1 Pt 1:107–113 [27] Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014; 39(8):1628–1635, quiz 1635 [28] Wittels NP, Donley JM, Burkhalter WE. A functional treatment method for interphalangeal pyogenic arthritis. J Hand Surg Am. 1984; 9(6):894–898

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Index Note: Page numbers set bold or italic indicate headings or figures, respectively.

3 3 ligament tenodesis 353

8 8-strand Gelberman-Winters technique 14

2 24 Gauge wire 283

A abductor pollicis longus (APL) 87 35 absorbable suture material 3 acute injuries 328 acute paronychia 442 Adams technique 357 adequate excursion of tendon 40 adequate strength of tendon 40 adipofascial flap 402 AIN, see anterior interosseous nerve (AIN) Allen's test 21 anesthesia 4 angiofibroblastic hyperplasia 85 antegrade fasciocutaneous pedicled flap and free flap 400 anterior interosseous nerve (AIN) 148 anterograde-retrograde technique 281 APL, see abductor pollicis longus (APL) arthroscopic assisted reduction 201 arthroscopic debridement 86 arthroscopic TFCC 428 arthroscopic-assisted synovectomy 420 arthrotomy 305 articular malunions 243 atraumatic technique 17 Atzei classification of type 1b TFCC tears 433 autograft 98 avascular necrosis 251 axial flag flap 390

B bailout procedures 15 Becker technique 8 Bennett fracture, dislocation 181 Bennett fracture 199 Blatt capsulodesis 349 bone graft, for humpback deformity 254 bone reconstruction phalangeal osteotomies 241 bone to bone 14 bone tunnel preparation 340 bone tunnel technique 342 bony mallet repair 5 Bouquet osteosynthesis 189 Boutonniere finger 5 Boutonnihre deformity 6 boxer fracture 182 branches of radial artery 291

bridge plating of distal radius fractures 228 Brunelli technique 352, 353 Bruner approach 13 Brunner zigzag technique 32 Bunnell suture technique 8

C Camper's chiasm 27 cannulated screw technique 206 capitate shortening osteotomy 260 capsular closure 294 capsulectomy 243 carpal tunnel syndrome 42 carpus injuries 10 central slip 5 central slip injuries 5 central slip repair 6 cheiralgia paresthetica 75 chronic central slip deficiency 6 chronic injuries 329 chronic paronychia 443 classic suture techniques 16 claw deformity 50 closed reduction and percutaneous pinning 199 comminuted fracture 183 complete distal ulna excision (Darrach) 315 compression screw 158 condylar advancement osteotomy 243 condylar fractures 165 controlled trauma 90 core suture techniques 16 corrective osteotomy of metacarpal malunion 246 corrective osteotomy techniques 246 cross finger (and reverse) flap 379 cross-stitch technique 18 crossover syndrome 82 cyclers' palsy 131

D deangulation osteotomy 247 Dequervain tenosynovitis (DQT) 74 derotation osteotomy 248 diagnostic wrist arthroscopy 422 distal forearm injuries 10 distal interphalangeal joint arthrodesis 279 distal phalanx fractures 13 distal radioulnar joint (DRUJ) 265 distal radioulnar ligament repair/ reconstruction 356 distal radius, dorsal approach to 220 distal radius 216 distal radius osteotomy for malunion 266 distal radius osteotomy for malunion (volar approach) 262 distal stump 13 dividing trapezium 291 donor site postoperative morbidity 253 dorsal approach, to distal radius 220 dorsal approach 149, 266, 290

dorsal blocking pin 158 double grasp technique 20 double loop technique 9 double-crush mechanism 123 DQT, see Dequervain tenosynovitis (DQT) DRUJ, see distal radioulnar joint (DRUJ) Dupuytren's disease – needle aponeurotomy for 407 – subtotal fasciectomy for 411 dynamic external fixation technique 177

E ECRB recipient 35 ECU synergy test 79–80 ECuTR, see endoscopic ulnar nerve decompression (ECuTR) EDC recipient 35 EDC tendon repair 7 end to side transfers 22 endoscopic carpal tunnel release 119 endoscopic ulnar nerve decompression (ECuTR) 137 epineural technique 21 epineurial suture technique 101 EPL recipient 35 expendable donor 40 extensor carpi ulnaris tenosynovectomy/instability 79 extensor compartments 229 extensor indicis proprius tendon transfer, for rupture of extensor pollicis longus tendon 56 extensor indicis proprius to extensor digitorum comminus 60 extensor mechanism 3 extensor tendon repair – zone 1, 3, 5 –– anesthesia 4 –– bony mallet repair 5 –– central slip injuries 5 –– central slip repair 6 –– EDC tendon repair 7 –– MCP joint injuries 7 –– soft tissue mallet repair 4 –– terminal tendon injuries (mallet finger) 4 – zone 2, 4, 6-9 –– carpus injuries 10 –– distal forearm injuries 10 –– metacarpal injuries 10 –– middle phalanx injuries 9 –– proximal forearm injuries 10 –– proximal phalanx injuries 9 –– rehabilitation 11 –– repair techniques 9 external fixation of distal radius fractures 236 extra-articular fractures – middle phalangeal shaft fractures 161 – neck fractures 161 – proximal phalangeal shaft fractures 161 extra-articular malunions 264

F failed Darrach resection 317 failed ulnar nerve decompression at elbow 142 FCR donor 35 FCU donor 35 FDS donor 35 felon 445 fight bite injuries 3 finger (PIP/DIP) collateral ligament repair 323 finger MP joint collateral ligament repair 326 first dorsal metacarpal artery flap (kite flap) 390 first metacarpal base fractures 199 first metacarpal intra-articular fracture reduction 420 flap harvest surgical technique 251 flexor mechanism 27 flexor sheath infection 451 flexor tendon injuries, zone 3-5 – classification 20 – primary repair with intercalary defects, interposition grafts 22 – rehabilitation 22 – wide-awake flexor tendon repair –– end to side transfers 22 –– side-to-side transfers 22 flexor tendon repair – zone 1 –– bailout procedures 15 –– bone to bone 14 –– distal phalanx fractures 13 –– distal stump 13 –– rescue procedures 15 –– salvage procedures 15 –– tendon to bone 14 –– tendon-to-tendon repair 14 – zone 2 16 flexor tenolysis 32 flexor tenosynovitis 448 four-corner fusion 304 free tendon graft 15 Froment sign 50 full thickness skin graft 367 full transection 294

G Gamekeeper's thumb 338 graft fixation 252

H hamate hook 130 hand fractures distal phalanx fractures 155 headless compression screw 281 hemi-hamate arthroplasty technique 178 hemitransection 294 henry approach 216 horizontal mattress stitch 106 horseshoe abscess 448 humpback deformity, bone graft for 254 Hunter-Salisbury method 29

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Index

I ICAM protocol, see immediate controlled active motion (ICAM) protocol immediate controlled active motion (ICAM) protocol 11 incompetent pulley mechanism 28 intentional collagen regeneration 91 interposition grafts 22 intersection syndrome 75, 82, 82 intra-articular fractures – condylar fractures 163 – intra-articular base fractures 163 intra-articular malunions 265 intrasynovial grafts 28

J joint capsular shrinkage 420 joint surface resection 420 jumping man flaps 396

K Kapandji's intrafocal technique 161 Kirchmayer/Kessler 20 Kirschner wires, lever technique 161 Kirschner wires 283

L lacertus fibrosus 124 larger displaced fractures 329 lasso fixation 54 lateral epicondylar debridement 85 ligament debridement 428 ligament reconstruction tendon interposition (LRTI) 290 limited-open retrograde intramedullary headless screw fixation of metacarpal fractures 194 linkage simulation 242 longitudinal transarticular fixation of DIP joint 161 low median nerve palsy tendon transfers – ADM (Huber) transfer 44, 47 – EIP transfer 43, 45 – FDS transfer 43, 47 – PL (Camitz) transfer 43, 45 low ulnar nerve palsy, tendon transfers for 50 LRTI, see ligament reconstruction tendon interposition (LRTI)

M mallet finger 4 Mallet fractures 156–157 marsupialization technique 444 MCP joint arthroscopy 419, 421 MCP joint injuries 7 medial epicondylar debridement 90 medial femoral condyle vascularized bone graft 250 median nerve innervated muscles 122 mediolateral windows approach 218 medullary compression screws 206 metacarpal fracture open reduction and internal fixation 186 metacarpal head fractures 186

458

metacarpal injuries 10 metacarpal neck fracture 182, 186–187 metacarpal shaft fractures 187 metacarpals (pinning) 181 meticulous atraumatic surgical technique 16 meticulous capsulotomy 291 microfracture technique 305 microvascular anastomosis 252 middle finger flexion test 124 middle phalangeal shaft fractures 161 middle phalanx injuries 9 middle/proximal phalanx (pinning) 160 mini-open techniques 164 Moberg advancement flap technique 375

N neck fractures 161 needle aponeurotomy, for Dupuytren's disease 407 nerve compression open carpal tunnel release 115 nerve conduits 98 nerve conduits for nerve repair/ reconstruction 104 nerve repair/reconstruction nerve repair in hand 95 neuropathy, define 122 Nirschl procedure 86 nonoperative techniques 142

O oberlin transfer 108 one tendon, one function 40 one-stage grafting procedure 15 open fractures 156 open in situ ulnar nerve decompression 140 open reduction and internal fixation (ORIF) 186, 254 open reduction internal fixation (ORIF) – with A plate 200 – with interfragmentary screw 199 open ulnar nerve decompression at wrist 130 open ulnar nerve decompression/ subcutaneous transposition at the elbow 140 opening and closing wedge osteotomy 247 optimal repair technique 8 ORIF, see open reduction and internal fixation (ORIF) osteocutaneous flap 402 osteosynthesis techniques 3 osteotomy 316

P palm zigzag approach 13 Paneva-Holevich method 29 Paneva-Holevich technique 29 paradigm-shifting technique 92 paronychia 441 partial distal ulna resection (wafer, hemiresection) 309 partial trapeziectomy 292

partial wrist denervation for chronic wrist pain 147 pediatric transepiphyseal fractures 5 percutaneous pinning and open reduction internal fixation 155 percutaneous techniques 5 percutaneous/Kapandji (pinning) 212 periarticular antegrade fixation technique 163 peripheral nerve injury and repair using autograft or allograft 100 phalangeal neck fractures 160 pie-crusting 363 pig sticker 56 PIN, see posterior interosseous nerve (PIN) PL donor 35 plasmacytic circulation 367 posterior interosseous nerve (PIN) 148 PRC, see proximal row carpectomy (PRC) prestyloid recess 432 primary nerve repair 97 processed nerve allograft 98 pronator syndrome 42, 124 proximal forearm injuries 10 proximal hiatus 130 proximal median nerve compression 122 proximal phalangeal shaft fractures 161 proximal phalanx injuries 9 proximal row carpectomy (PRC) 300 PT donor 35 Pulvertaft technique 20 Pulvertaft weave 64 Pulvertaft weave technique 22 punching mechanism 195

R radial artery sparing perforator-based pedicled flap 402 radial forearm flap 398 radial nerve palsy tendon transfers – ECRB recipient 35 – EDC recipient 35 – EPL recipient 35 – FCR donor 35 – FCU donor 35 – FDS donor 35 – PL donor 35 – PT donor 35 radial nerve palsy tendon transfers 34 reconstructive techniques 172 repair technique 9 repair techniques 9 rescue procedures 15 retrograde (reverse) fasciocutaneous pedicled flap 401 reverse cross-finger flap 379 reverse kite flap 390 reverse L osteotomy 260 RITM (running, interlocking, horizontal mattress) technique 8 Rolando fracture 199 Royle-Thompson variation of FDS transfer 44 running lock technique 18 Russe approach 251

S S-shaped hook 177 salvage procedures 15 scaphoid nonunion 250, 254 scaphoid pinning 205 scaphoidectomy 304 scapholunate advanced collapse (SLAC) 348 scapholunate capsulodesis 348 scapholunate ligament reconstruction (Brunelli types) 352 scapholunate ligament repair 344 septic arthritis 420 septic joint, sequelae 455 septic joint 451 septic wrist joint 453 Seymour fractures 5, 156, 158 shaft fractures 158 shotgun approach 172 side-to-side transfers 22 skier's thumb 338 skin closure sutures 4 skin flap handling 412 SLAC, see scapholunate advanced collapse (SLAC) SLIOL capsulorraphy 349 small displaced avulsion fractures 329 soft tissue equilibrium 40 soft tissue mallet repair 4 split thickness skin graft 363 standard layered closure 140 standard microsurgical technique 120 stenosing tenosynovitis 69 sterile technique 71 straight line of pull 40 STT joint, see scaphotrapeziotrapezoid (STT) joint styloidectomy 305 subcutaneous ulnar nerve transposition 141 submuscular ulnar nerve transposition 144 subtotal fasciectomy 413 subtotal fasciectomy technique 415 subtotal fasciectomy, for Dupuytren's disease 411 superficialis finger 29 superficialis transfer for rupture of flexor pollicis longus tendon 63 supple joints 40 suture anchor 158 suture anchors 342 suture button technique 15 sweeping technique 409 synergistic tendon 40

T table top test 411 tendinopathies trigger finger/thumb release 69 tendon disruptions 7 tendon graft passage and tensioning 341 tendon graft reconstruction 15 tendon reconstruction flexor tendon reconstruction in zone 2 – single-stage flexor tendon reconstruction 28 – two-stage flexor tendon reconstruction 28 tendon to bone 14

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Index tendon transfers, for low ulnar nerve palsy 50 tendon-to-tendon repair 14 tennis elbow straps (TESs) 85 tenolysis 243 tenosynovitis 74, 80 terminal tendon injuries (mallet finger) 4 Terry Thomas sign 348 TESs, see tennis elbow straps (TESs) TFCC outside-in repair 432 thenar flap 386 therapeutic techniques 85 thumb basal joint arthroplastytrapeziectomy 285 thumb CMC 419 thumb metacarpophalangeal joint collateral ligament repair 332 thumb mpj collateral ligament reconstruction 338

Tinel's sign 124 tissue-sparing techniques 419 top-side neurolysis 142 totalwrist arthrodesis 295 trans-FCR 216 transarticular pinning 165 trapeziectomy 291 Tsuge's loop technique 20 Tuft fractures 155 tunnel fracture 294 tunnel placement 292

U ulnar hemiresection arthroplasty 312 ulnar neuropathy 91 ulnar shortening osteotomy 265 ulnar stump stabilization 317

unstable fractures with nail plate loss 157

V V-Y advancement flap 371 vascularized nerve graft techniques 96 volar advancement flaps-Moberg 374 volar approach 216, 262–263, 290 volar henry approach 149 volar plate arthroplasty technique 178 volar ulnar approach 149 volar wrist surgical technique 251 volar-extensile approach 216

W wafer procedure 309 Wagner approach 201

WALANT technique 57 Wartenberg sign 50 Wartenberg syndrome 75 Watson's scaphoid shift test 344 wet rubber feel 82 wide-awake flexor tendon repair – end to side transfers 22 – side-to-side transfers 22 widea-wake tendon surgery 22 wound closure 317 Wyndell Merritt protocol 8

Z z-collapse deformity 288 z-lengthening of the flexor-pronator mass 141 z-plasty 394 Zancolli lasso procedure 52

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