Operative Techniques: Hand and Wrist Surgery [4 ed.] 0323794157, 9780323794152

Citation preview

Any screen. Any time. Anywhere. Activate the eBook version of this title at no additional charge.

Elsevier eBooks for Practicing Clinicians gives you the power to browse and search content, view enhanced images, highlight and take notes—both online and offline.

Unlock your eBook today. 1. Visit expertconsult.inkling.com/redeem 2. Scratch box below to reveal your code 3. Type code into “Enter Code” box 4. Click “Redeem” 5. Log in or Sign up 6. Go to “My Library”

It’s that easy!

Place Peel Off Sticker Here

For technical assistance: email [email protected] call 1-800-401-9962 (inside the US) call +1-314-447-8300 (outside the US) Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on expertconsult.inkling.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book, at expertconsult.inkling.com and may not be transferred to another party by resale, lending, or other means. 2020_PC

Operative Techniques In Hand and Wrist Surgery 4th Edition

Kevin C. Chung, MD, MS Charles B. G. de Nancrede Professor of Surgery Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Assistant Dean for Faculty Affairs Section of Plastic Surgery Department of Surgery University of Michigan Medical School Ann Arbor, Michigan

Elsevier 1600 John F. Kennedy Blvd. Ste 1600 Philadelphia, PA 19103-2899 OPERATIVE TECHNIQUES IN HAND AND WRIST SURGERY, FOURTH EDITION Copyright © 2022 by Elsevier, Inc. All rights reserved.

ISBN: 978-0-323-79415-2

Previous editions copyrighted 2008, 2012, 2018 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Control Number: 2021932735

Content Strategist: Belinda Kuhn Content Development Manager: Meghan Andress Content Development Specialist: Deborah Poulson Publishing Services Manager: Shereen Jameel Senior Project Manager: Kamatchi Madhavan Design Direction: Amy Buxton

Printed in India Last digit is the print number:  9  8  7  6  5  4  3  2  1

Contributors

Joshua M. Adkinson, MD Associate Professor of Surgery Adjunct Associate Professor of Orthopaedic Surgery Chief of Hand Surgery, Division of Plastic Surgery Chief of Plastic Surgery, Eskenazi Hospital Indiana University School of Medicine Indianapolis, Indiana Chun-Yu Chen, MD Assistant Professor Department of Orthopaedic Surgery Kaohsiung Veterans General Hospital Kaohsiung, Taiwan Kevin C. Chung, MD, MS Charles B. G. de Nancrede Professor of Surgery Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Assistant Dean for Faculty Affairs Section of Plastic Surgery Department of Surgery University of Michigan Medical School Ann Arbor, Michigan Elissa S. Davis, MD Staff Surgeon BJC Medical Group Orthopedics & Sports Medicine Belleville, Illinois Matthew Florczynski, MD, MSc Resident Physician Division of Orthopaedic Surgery University of Toronto Toronto, Ontario

Aviram M. Giladi, MD, MS Research Director The Curtis National Hand Center Baltimore, Maryland Assistant Professor Department of Plastic Surgery Georgetown University Washington, DC Assistant Professor Department of Plastic Surgery Johns Hopkins University Baltimore, Maryland

Phillip R. Ross, MD Assistant Professor Department of Orthopaedic Surgery University of Cincinnati College of Medicine Cincinnati, Ohio

David W. Grant, MD, MASc Hand Surgery Fellow Combined Hand Surgery Fellowship University of Michigan Ann Arbor, Michigan

Brian W. Starr, MD Hand Surgery Fellow Department of Surgery Section of Plastic Surgery Michigan Medicine Ann Arbor, Michigan

Benjamin K. Gundlach, MD Orthopaedic Surgery Resident Department of Orthopaedic Surgery Michigan Medicine Ann Arbor, Michigan Rachel C. Hooper, MD Staff Plastic Surgeon Department of Surgery Henry Ford Hospital Detroit, Michigan Shepard Peir Johnson, MD Hand Fellow Department of Surgery Section of Plastic Surgery Michigan Medicine Ann Arbor, Michigan

Sarah E. Sasor, MD Assistant Professor Department of Plastic Surgery Medical College of Wisconsin Wauwatosa, Wisconsin

Yu Zhou, MD, PhD Attending Surgeon Department of Gynecological Plastic Surgery Plastic Surgery Hospital Chinese Academy of Medical Sciences Beijing, China Robert L. Kane, BS Medical Student New York Medical College Valhalla, New York Natalie B. Baxter, BSE Medical Student University of Michigan Medical School Ann Arbor, Michigan

iii

Preface Operative Techniques in Hand and Wrist Surgery, 4th Edition After 2 years of capturing operative pictures and videos, I am proud to present you with a new edition of this classic textbook. Over 90% of the chapters were rewritten and updated with new photos, illustrative figures, and all-new videos. This textbook embodies the spirit of innovation and describes techniques that are safe and applicable to your practice. Rather than simply offering stylistic changes, each edition of this book has undergone fundamental revisions that enhance its content. We refined the description of procedures and highlighted key narratives to facilitate ease of learning for our readers. Tips and pearls are provided liberally, particularly in the videos that I have narrated. This textbook has served as an essential teaching forum in all corners of the world. During my travels in the United States and abroad, I have received enthusiastic endorsement of this series that guides the care of people with hand problems. I can confidently say that this new edition is one of the best textbooks in the field of hand surgery because of its artistic delivery and focused discussion of essential procedures. The content in this textbook is a collection of over 25 years of my experience, in collaboration with my past trainees, many of whom are in academic practices in charge of teaching hand surgery. Instead of presenting a multitude of procedures to the readers without endorsing a best approach, we strive to endorse techniques that we know will work. I am grateful to my coauthors who toiled tirelessly on this volume. We recognized the enormity of our responsibility as we wrote this 4th edition, for you are applying our philosophy in rendering the best treatments for your patients. A book of this depth and breadth can only be accomplished by a team of highly dedicated assistants whose devotion made this book a reality. Every word, every photo, and every video has undergone intense scrutiny by my team to assure a flawless delivery. I am grateful to two of my assistants, Natalie Baxter and Robert Kane, who supported each author by extracting images from my own archives and from Elsevier’s collection. They meticulously edited each chapter and worked with the production team at Elsevier to meet the strict timeline that we imposed on ourselves. We are also indebted to our international fellow, Yu Zhou, MD, from the Plastic Surgery Hospital in Beijing, for taking the heavy responsibility of editing over 100 new videos for this volume. Dr. Zhou’s meticulousness and creativity in capturing the images and videos imparts a compulsive spirit that resonates throughout this volume. I am also encouraged by the trust of the Elsevier team in supporting this 4th edition. My production team includes Belinda Kuhn, London, and Deborah Poulson, Philadelphia. Their devotion and contribution are immeasurable. Finally, I cherish the longstanding relationship with our readership, whose guidance and feedback drove me to complete this 4th edition. A number of my readers have approached me at national and international meetings to share how this series has transformed their practices. Earnestly sharing everything we have learned through our experiences has contributed to the far-reaching influence of this book. We have learned so much from our patients, and a key component of education is reflection. It is our culture to collect pictures and videos for all the operations I do so that I can refine my procedures in striving for excellence. Only through humility and self-enrichment can one emerge as a thoughtful, outstanding surgeon. I wish you great success in your practices. I am profoundly indebted to you for choosing to embark on a lifelong journey of learning with us through this 4th edition of Operative Techniques in Hand and Wrist Surgery.

v

vi

Preface

As the 75th president of the American Society for Surgery of the Hand (ASSH), I dedicate this book to members of the ASSH for their devotion to the art and science of hand surgery. Kevin C. Chung, MD, MS Charles B. G. de Nancrede Professor of Surgery Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Assistant Dean for Faculty Affairs Section of Plastic Surgery Department of Surgery University of Michigan Medical School Ann Arbor, Michigan

Foreword

I felt deeply honored when Dr. Chung asked me to write the foreword to the 4th edition of his now classic textbook Operative Techniques in Hand and Wrist Surgery. This multiauthored textbook was first published in 2008 and with each new edition, the individual chapters have been updated, refined, and structured for ease of readability. The 4th edition is no exception. Each chapter is stylistically consistent and methodically written by a seasoned senior surgeon and many of them are coauthored by an aspiring academician. Surgeons will appreciate the user-friendly format, particularly when preparing for a procedure for the first time. Each procedure is presented in a bulleted format that includes indications, a preoperative evaluation, relevant surgical anatomy, and a methodical guideline (including pearls, pitfalls, and complications) for carrying out the intended procedure. Each chapter not only outlines core treatment principles, but also consistently demonstrates that there are many ways to tackle a problem. Another highlight of Operative Techniques is the exemplary quality of Dr. Chung’s narrated videos, illustrations, and clinical photographs. His trademark green towel background, devoid of bloodstains and wrinkles, is a sure sign that the reader is getting the finest in clarity and precision. In contrast to many textbooks, it is not laden with countless and often irrelevant references. Each chapter concludes with a brief but highly germane annotated bibliography, a feature I found very useful. Dr. Chung’s text is a must for any hand surgeon’s library. It is encyclopedic, easy to navigate, and exceptionally well illustrated. With the combination of text and narrated videos, the preparation, performance, and rehabilitation of hand and wrist procedures will without a doubt enhance both the experienced and beginning surgeon’s opportunity to optimize outcomes. Peter J. Stern, MD Norman S. and Elizabeth C.A. Hill Professor of Orthopaedic Surgery Department of Orthopaedic Surgery University of Cincinnati College of Medicine

vii

Contents

Section I  Anesthesia and Emergency Procedures, 1 CHAPTER 1

Anesthesia of the Hand, 2 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 2

 asciotomy for Compartment Syndrome of the Hand F and Forearm, 4 Yu Zhou, Rachel Hooper, and Kevin C. Chung

CHAPTER 3

Digit Amputations, 5 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 4

Proximal Upper Extremity Amputations, 7 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 5

 inger Infections (Paronychia, Felons, Pyogenic Flexor F Tenosynovitis), 8 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 6

Splints and Orthoses, 16 Benjamin K. Gundlach and Kevin C. Chung

Section II  Hand Fractures and Dislocations, 17 CHAPTER 7

Principles of Bone Fixation and Healing, 18 Chun-Yu Chen and Kevin C. Chung

CHAPTER 8

Kirschner Wire Fixation of Mallet Fractures, 19 Chun-Yu Chen and Kevin C. Chung

CHAPTER 9

 echniques for Fixing Extraarticular Phalangeal T Fractures, 20 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 10

 ynamic External Fixation of Fracture-Dislocation D of the Proximal Interphalangeal Joint, 21 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 11

 pen Reduction and Internal Fixation of Intraarticular O Phalangeal Fractures, 22 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 12

 olar Plate Arthroplasty of the Proximal V Interphalangeal Joint, 23 Kevin C. Chung

CHAPTER 13

Hemi-Hamate Arthroplasty, 24 Shepard Peir Johnson and Kevin C. Chung

CHAPTER 14

Techniques and Fixation of Metacarpal Fractures, 33 Matthew Florczynski and Kevin C. Chung

ix

x

Contents

CHAPTER 15

 pen Reduction for Metacarpophalangeal Joint O Dislocation, 34 Shepard Peir Johnson and Kevin C. Chung

CHAPTER 16

 orrective Osteotomy of Metacarpal Fracture C Malunion, 40 Shepard Peir Johnson and Kevin C. Chung

CHAPTER 17

 econstruction of Acute and Chronic Ulnar Collateral R Ligament Injuries of the Thumb, 41 Elissa S. Davis and Kevin C. Chung

CHAPTER 18

 echniques for Fixing Bennett and Rolando T Fractures, 52 Benjamin K. Gundlach and Kevin C. Chung

Section III  Wrist Fractures and Carpal Instability, 53 CHAPTER 19

Wrist Arthroscopy, 54 Chun-Yu Chen and Kevin C. Chung

CHAPTER 20

 epairing Tears of the Triangular Fibrocartilage R Complex, 68 Aviram M. Giladi and Kevin C. Chung

CHAPTER 21

Scapholunate Ligament Repair, 80 David W. Grant and Kevin C. Chung

CHAPTER 22

Scapholunate Ligament Reconstruction, 93 Elissa S. Davis and Kevin C. Chung

CHAPTER 23

 unotriquetral Ligament Reconstruction Options L Using Tendon Grafts, 113 Aviram M. Giladi and Kevin C. Chung

CHAPTER 24

 capholunate and Lunotriquetral Ligament S Reconstruction with Internal Brace and Tendon Grafting, 125 Elissa S. Davis and Kevin C. Chung

CHAPTER 25

 pen Reduction and Internal Fixation of Acute O Scaphoid Fracture, 131 Matthew Florczynski and Kevin C. Chung

CHAPTER 26

Treatment of Scaphoid Nonunion, 142 Aviram M. Giladi and Kevin C. Chung

CHAPTER 27

Salvage Procedures for Scaphoid Nonunion, 161 Aviram M. Giladi and Kevin C. Chung

CHAPTER 28

 pen Reduction and Fixation of Acute Lunate O or Perilunate Dislocation, With or Without Fracture, 174 Aviram M. Giladi and Kevin C. Chung

CHAPTER 29

 lnar Shortening Osteotomy for Ulnar Impaction U Syndrome, 184 Aviram M. Giladi and Kevin C. Chung

CHAPTER 30

 istal Radioulnar Joint Reconstruction Using D Palmaris Longus Graft, 185 Aviram M. Giladi and Kevin C. Chung

Contents

CHAPTER 31

 rocedures for Avascular Necrosis of the Lunate P (Kienböck Disease), 194 David W. Grant and Kevin C. Chung

Section IV  Forearm Fractures, 211 CHAPTER 32

Operative Treatment of Distal Radius Fractures, 212 Chun-Yu Chen and Kevin C. Chung

CHAPTER 33

Corrective Osteotomy of Radius Malunion, 243 Elissa S. Davis and Kevin C. Chung

CHAPTER 34

 ssociated Ulnar Fixation (Ulnar Styloid and A Metadiaphyseal Fractures), 258 Shepard Peir Johnson and Kevin C. Chung

CHAPTER 35

 orearm Fracture-Dislocations (Galeazzi F and Monteggia), 266 Shepard Peir Johnson and Kevin C. Chung

Section V Rheumatoid Arthritis and Degenerative Disease, 277 CHAPTER 36

 etacarpophalangeal Joint Synovectomy, Crossed M Intrinsic Tendon Transfer, and Extensor Tendon Centralization, 278 Sarah E. Sasor and Kevin C. Chung

CHAPTER 37

 endon Transfers for Rheumatoid Tendon Attrition T Rupture, 285 Sarah E. Sasor and Kevin C. Chung

CHAPTER 38

 tabilization of Extensor Carpi Ulnaris Tendon S Subluxation with Extensor Retinaculum, 297 Sarah E. Sasor and Kevin C. Chung

CHAPTER 39

Correction of Swan-Neck Deformity, 304 Sarah E. Sasor and Kevin C. Chung

CHAPTER 40

Correction of Boutonniere Deformity, 312 Sarah E. Sasor and Kevin C. Chung

CHAPTER 41

Metacarpophalangeal Arthroplasty, 319 Sarah E. Sasor and Kevin C. Chung

CHAPTER 42

Proximal Interphalangeal Arthroplasty, 334 Sarah E. Sasor and Kevin C. Chung

CHAPTER 43

Distal Interphalangeal Joint Arthrodesis, 344 Sarah E. Sasor and Kevin C. Chung

CHAPTER 44

J oint Fusion for Thumb Metacarpophalangeal Instability, 345 Sarah E. Sasor and Kevin C. Chung

CHAPTER 45

Carpometacarpal Joint Fusion for Basilar Arthritis, 346 Sarah E. Sasor and Kevin C. Chung

CHAPTER 46

 econstruction for Thumb Carpometacarpal Joint R Instability Using Flexor Carpi Radialis (Littler Procedure), 353 Sarah E. Sasor and Kevin C. Chung

xi

xii

Contents

CHAPTER 47

 rapeziectomy and Abductor Pollicis Longus T Suspensionplasty, 360 Sarah E. Sasor and Kevin C. Chung

CHAPTER 48

Revision Carpometacarpal Joint Arthroplasty, 368 Sarah E. Sasor and Kevin C. Chung

CHAPTER 49

Distal Ulnar Resection (Darrach Procedure), 380 Sarah E. Sasor and Kevin C. Chung

CHAPTER 50

Sauvé-Kapandji Procedure, 386 Sarah E. Sasor and Kevin C. Chung

CHAPTER 51

Hemiresection Ulnar Arthroplasty, 393 Sarah E. Sasor and Kevin C. Chung

CHAPTER 52

Total Wrist Arthroplasty, 399 Sarah E. Sasor and Kevin C. Chung

CHAPTER 53

Total Wrist Fusion, 413 Sarah E. Sasor and Kevin C. Chung

CHAPTER 54

Wrist Denervation, 420 Sarah E. Sasor and Kevin C. Chung

Section VI  Nerve Conditions, 426 CHAPTER 55

Open Carpal Tunnel Release, 427 Rachel C. Hooper and Kevin C. Chung

CHAPTER 56

Endoscopic Carpal Tunnel Release, 433 Kevin C. Chung

CHAPTER 57

 evision Carpal Tunnel Release and Coverage Using R a Hypothenar Fat Pad Flap, 440 Rachel C. Hooper and Kevin C. Chung

CHAPTER 58

Procedures for Ulnar Compressive Neuropathy, 446 Rachel C. Hooper and Kevin C. Chung

CHAPTER 59

Radial Nerve Decompression, 459 David W. Grant and Kevin C. Chung

Section VII  Nerve Injuries and Palsy, 465 CHAPTER 60

Digital Nerve Repair, 466 Rachel C. Hooper and Kevin C. Chung

CHAPTER 61

Ulnar Nerve Group Fascicular Repair, 472 Rachel C. Hooper and Kevin C. Chung

CHAPTER 62

 edian Nerve Epineural and Group Fascicular Nerve M Repair, 476 Rachel C. Hooper and Kevin C. Chung

CHAPTER 63

 endon Transfers for Low Median Nerve Injury, 482 T David W. Grant and Kevin C. Chung

CHAPTER 64

Tendon Transfers for High Median Nerve injury, 494 David W. Grant and Kevin C. Chung

Contents

CHAPTER 65

 endon Transfers for Low and High Ulnar Nerve T Injury, 502 Phillip R. Ross and Kevin C. Chung

CHAPTER 66

 endon Transfers for High and Low Radial Nerve T Injury, 521 Phillip R. Ross and Kevin C. Chung

CHAPTER 67

Tendon Transfers for Combined Nerve Palsy, 530 Phillip R. Ross and Kevin C. Chung

CHAPTER 68

 istal Anterior Interosseous Nerve Transfer to Motor D Branch of Ulnar Nerve, 540 David W. Grant and Kevin C. Chung

Section VIII  Tetraplegic Conditions, 546 CHAPTER 69

 endon and Nerve Transfers for Spinal Cord Injury T Patients, 547 Rachel C. Hooper, Chun-Yu Chen, and Kevin C. Chung

CHAPTER 70

 estoration of Elbow Extension: Deltoid to Triceps R Transfer and Biceps to Triceps Transfer, 555 Rachel C. Hooper, Chun-Yu Chen, and Kevin C. Chung

CHAPTER 71

 estoration of Wrist Extension: Brachioradialis R to Extensor Carpi Radialis Tendon Transfer, 562 Rachel C. Hooper, Chun-Yu Chen, and Kevin C. Chung

CHAPTER 72

 estoration of Active Key Pinch: Brachioradialis and R Pronator Teres to Flexor Pollicis Longus Transfer, 566 Rachel C. Hooper, Chun-Yu Chen, and Kevin C. Chung

CHAPTER 73

Restoration of Passive Key Pinch, 572 Rachel C. Hooper, Chun-Yu Chen, and Kevin C. Chung

CHAPTER 74

 estoration of Active Pinch and Grasp: Extensor R Carpi Radialis Longus Transfer to Flexor Digitorum Profundus, 582 Rachel C. Hooper, Chun-Yu Chen, and Kevin C. Chung

CHAPTER 75

Intrinsic Tendon Reconstruction, 587 Chun-Yu Chen and Kevin C. Chung

CHAPTER 76

Nerve Transfer for Spinal Cord Injuries, 597 Rachel C. Hooper, Chun-Yu Chen, Kevin C. Chung

Section IX  Tendon Conditions, 601 CHAPTER 77

Wide-Awake Approach for Tendon Transfers, 602 Phillip R. Ross and Kevin C. Chung

CHAPTER 78

 cute Repair of Flexor Tendon Injuries in Zones A I to V, 610 Phillip R. Ross and Kevin C. Chung

CHAPTER 79

 wo-Stage Flexor Tendon Reconstruction with Silicone T Rod, 626 Phillip R. Ross and Kevin C. Chung

CHAPTER 80

 2 Flexor Tendon Pulley Reconstruction With Free A Tendon Graft, 635 Phillip R. Ross and Kevin C. Chung

xiii

xiv

Contents

CHAPTER 81

Tenolysis of Flexor Tendons, 637 Phillip R. Ross and Kevin C. Chung

CHAPTER 82

 cute Repair of Extensor Tendon Injuries: Zones I A To VII, 638 Phillip R. Ross and Kevin C. Chung

CHAPTER 83

Release of Trigger Finger, 640 Phillip R. Ross and Kevin C. Chung

CHAPTER 84

Release of De Quervain Tenosynovitis, 641 Phillip R. Ross and Kevin C. Chung

Section X  Flaps and Microsurgery, 642 CHAPTER 85

Management of Mangled Extremities, 643 Kevin C. Chung and Natalie B. Baxter

CHAPTER 86

 ocal Tissue Rearrangement for Treatment L of Scar Contractures, 653 Yu Zhou, Rachel Hooper, and Kevin C. Chung

CHAPTER 87

Flap Coverage of Fingertip Injuries, 663 Brian W. Starr and Kevin C. Chung

CHAPTER 88

Flap Coverage of Thumb Defects, 664 Rachel C. Hooper and Kevin C. Chung

CHAPTER 89

 orsal Metacarpal Artery Flap and Dorsal Metacarpal D Artery Perforator Flap, 666 Yu Zhou and Kevin C. Chung

CHAPTER 90

Pedicled Forearm Flaps, 673 David W. Grant and Kevin C. Chung

CHAPTER 91

Groin Flaps, 674 David W. Grant and Kevin C. Chung

CHAPTER 92

Lateral Arm Flap, 684 David W. Grant and Kevin C. Chung

CHAPTER 93

Venous Flap, 694 Yu Zhou, Chun-Yu Chen, and Kevin C. Chung

CHAPTER 94

 evascularization and Replantation of Digits R and Hand, 704 Kevin C. Chung

CHAPTER 95

Toe to Thumb Transfer, 715 Chun-Yu Chen and Kevin C. Chung

CHAPTER 96

 ympathectomy of Radial, Ulnar, and Common Digital S Arteries for Raynaud Phenomenon, 728 David W. Grant and Kevin C. Chung

CHAPTER 97

 lnar Artery to Superficial Arch Bypass with a Vein U Graft, 736 David W. Grant and Kevin C. Chung

Section XI  Contractures and Spastic Conditions, 744 CHAPTER 98

 urgical and Nonsurgical Treatment of Dupuytren S Contracture, 745 Shepard Peir Johnson and Kevin C. Chung

Contents

CHAPTER 99

Biceps and Brachialis Lengthening, 757 Phillip R. Ross and Kevin C. Chung

CHAPTER 100 S  tep-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor Digitorum Profundus Transfer, 764 Phillip R. Ross and Kevin C. Chung

CHAPTER 101

Flexor-Pronator Slide, 770 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 102

Thumb Adductor Release, 774 Shepard Peir Johnson and Kevin C. Chung

CHAPTER 103

 apsulotomy for Proximal Interphalangeal C Contracture, 779 Sarah E. Sasor and Kevin C. Chung

CHAPTER 104 C  apsulotomy for Metacarpophalangeal Contracture, 780 Sarah E. Sasor and Kevin C. Chung

Section XII  Congenital Hand Disorders, 785 CHAPTER 105 Pediatric Trigger Digits, 786 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 106 R  elease of Finger Syndactyly Using Dorsal Rectangular Flap, 794 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 107

Duplicated Thumb and Finger Treatment, 802 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 108 Index Pollicization for Hypoplastic Thumb, 814 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 109 Pediatric Opponensplasty, 825 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 110

Camptodactyly Correction, 833 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 111

Macrodactyly Correction, 842 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 112

Release of Constriction Ring Syndrome, 849 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 113

Centralization for Radial Longitudinal Deficiency, 857 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 114

Cleft Hand Reconstruction, 865 Joshua M. Adkinson and Kevin C. Chung

CHAPTER 115

Arthrogryposis Reconstruction, 873 Joshua M. Adkinson and Kevin C. Chung

Section XIII  Tumors, 882 CHAPTER 116

Hand Masses, 883 Shepard Peir Johnson and Kevin C. Chung

xv

xvi

Contents

CHAPTER 117

Excision of Vascular Lesions of the Hand, 892 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 118

Excision of Metacarpal Enchondroma, 893 Benjamin K. Gundlach and Kevin C. Chung

CHAPTER 119

Excision of Peripheral Nerve Schwannoma, 894 Brian W. Starr and Kevin C. Chung

CHAPTER 120 Excision of Malignant Skin Tumors, 900 Brian W. Starr and Kevin C. Chung





Index, 901

Video TOC

1.1

Anesthesia of the Hand

3.1

Digit Amputation

4.1

Mid-Forearm Amputation

4.2

Regenerative Peripheral Nerve Interface

9.1

Closed Reduction with Kirschner Wire Fixation of Extraarticular Phalangeal Fractures

11.1

Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures

12.1

Volar Plate Arthroplasty of the Proximal Interphalangeal Joint

14.1

Open Reduction and Internal Fixation of Metacarpal Shaft Fractures

17.1

Ulnar Collateral Ligament Repair Using the Mitek Mini Anchor

18.1

Bennett Fracture Treated with Metacarpal Corrective Osteotomy and Placement of AlloDerm in the Carpometacarpal Joint

19.1

Diagnostic Wrist Arthroscopy

20.1

Arthroscopic Repair of the Triangular Fibrocartilage Complex

20.2

Open Repair of TFCC

22.1

Scapholunate Ligament Reconstruction Using BoneLigament-Bone Construct

22.2

Scapholunate Ligament Reconstruction Using Extensor Carpi Radialis Brevis Tendon Graft and the Arthrex InternalBrace System

23.1

Lunotriquetral Ligament Reconstruction Using a Slip of Extensor Carpi Ulnaris Tendon

23.2

Lunotriquetral Ligament Reconstruction Using the Arthrex InternalBrace System

24.1

Scapholunotriquetral Ligament Reconstruction with the Arthrex InternalBrace System

25.1

Open Reduction and Internal Fixation of Acute Scaphoid Fracture Using a Dorsal Approach

26.1

Nonvascularized Bone Graft for Scaphoid Nonunion

26.2

Pronator Quadratus Vascularized Bone Graft for Scaphoid Nonunion

26.3

Medial Femoral Condyle Vascularized Bone Graft for Scaphoid Nonunion xvii

xviii

Video TOC

27.1

Scaphoidectomy and Four-Corner Fusion

27.2

Proximal Row Carpectomy

28.1

Open Reduction and Internal Fixation of Acute Perilunate Dislocation with Fracture

29.1

Transmetaphyseal Ulnar Shortening Osteotomy

30.1

Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft

31.1

Capitate Shortening Osteotomy With Vascularized Bone Graft for Avascular Necrosis of the Lunate

32.1

Percutaneous Kirschner Wire Fixation of Distal Radius Fracture

32.2

External Fixation of Distal Radius Fracture

32.3

Volar Plating for Distal Radius Fracture

32.4

Dorsal Plating for Distal Radius Fracture

34.1

Open Reduction and Internal Fixation of Distal Ulna and Radius

36.1

Cross Intrinsic Tendon Transfer

37.1

Distal Ulna Excision, Extensor Tenosynovectomy, and Extensor Indicis Proprius to Extensor Digitorum Communis Transfer

38.1

Extensor Carpi Ulnaris Subluxation Repair with Extensor Retinaculum

39.1

Proximal Interphalangeal Lateral Band Release for Swan-Neck Deformity

40.1

Correction of Boutonniere Deformity

41.1

Metacarpophalangeal Arthroplasty with Silicone Implant

41.2

Metacarpophalangeal Arthroplasty with Pyrocarbon Implant

42.1

Proximal Interphalangeal Silicone Arthroplasty

43.1

Distal Interphalangeal Joint Fusion

44.1

Thumb Metacarpophalangeal Fusion

45.1

Carpometacarpal Fusion with Synthes Locking Plate

46.1

Thumb Carpometacarpal Joint Stabilization with Flexor Carpi Radialis

47.1

Trapezium Excision and Abductor Pollicis Longus Tendon Stabilization to Extensor Carpi Radialis Longus

47.2

Carpometacarpal Arthroplasty with Trapeziectomy and Abductor Pollicis Longus Suspensionplasty with Suture to Flexor Carpi Radialis Tendon

49.1

Distal Ulna Resection

50.1

Distal Ulna Excision and Shelf Arthroplasty

51.1

Hemi-Resection Arthroplasty of the Distal Ulna

52.1

Total Wrist Arthroplasty

Video TOC

53.1

Total Wrist Fusion Using a Synthes Plate and Cadaveric Bone Grafting

54.1

Wrist Denervation: Anterior and Posterior Interosseous Nerve Neurectomy

55.1

Open Carpal Tunnel Release

57.1

Revision Carpal Tunnel Release with Flexor Tenosynovectomy and Hypothenar Fat Pad Flap

58.1

Ulnar Nerve Neurolysis at Guyon Canal

58.2

In-situ Ulnar Nerve Release at the Cubital Tunnel

58.3

Intramuscular Anterior Transposition of the Ulnar Nerve

59.1

Posterior Interosseous Nerve Release at the Level of the Supinator

60.1

Neuroma Excision and Digital Nerve Repair

62.1

Wrist Laceration with Median Nerve Repair

63.1

Palmaris Longus to Abductor Pollicis Brevis

63.2

Extensor Indicis Proprius to Abductor Pollicis Brevis

64.1

Superficialis to Profundus Transfer and Intrinsic Slide

64.2

Brachioradialis to Flexor Pollicis Longus, and Extensor Carpi Radialis Longus to Flexor Digitorum Profundus

65.1

Flexor Digitorum Superficialis Transfer to Correct Claw Deformity

65.2

Extensor Carpi Radialis Brevis with Palmaris Longus Tendon Graft for Adductorplasty

65.3

Partial Flexor Pollicis Longus to Extensor Pollicis Longus Tenodesis Stabilization

65.4

Abductor Pollicis Longus and Extensor Carpi Radialis Brevis Graft to First Dorsal Interosseous Tendon

65.5

Flexor Digitorum Superficialis - Lasso Procedure

65.6

Metacarpophalangeal Capsuloplasty/Volar Plate Advancement

66.1

Flexor Carpi Radialis to Extensor Digitorum Communis, Flexor Digitorum Superficialis to Extensor Pollicis Longus and Extensor Indicis Proprius

66.2

Palmaris Longus to Extensor Pollicis Longus

67.1

Flexor Carpi Radialis to Extensor Digitorum Communis, Palmaris Longus to Extensor Pollicis Longus, Brachioradialis to Flexor Pollicis Longus, Extensor Carpi Radialis Longus to Flexor Digitorum Profundus, Flexor Digitorum Superficialis to Abductor Pollicis Brevis

67.2

Tendon Transfers for High Median and Ulnar Nerve Injury: Brachioradialis to Flexor Pollicis Longus, Extensor Indicis Proprius to Abductor Pollicis Brevis, and Extensor Carpi Radialis Longus to Flexor Digitorum Profundus

68.1

Distal Anterior Interosseous Nerve Transfer to Motor Branch of Ulnar Nerve

xix

xx

Video TOC

69.1

Supinator to Posterior Interosseous Nerve Transfer

70.1

Deltoid to Triceps Transfer

71.1

Brachioradialis to Extensor Carpi Radialis Tendon Transfer

75.1

Intrinsic Tendon Reconstruction

76.1

Ulnar Digital Nerve and Radial Digital Nerve Transfers

78.1

Acute Repair of Flexor Tendon and Ulnar Digital Nerve (Zone I)

78.2

Tendon Rupture of the Thumb, Index Finger, and Small Finger (Zone V)

78.3

Flexor Pollicis Longus Tendon Repair (Zone TIV)

79.1

Stage I: Silicone Rod Placement for Flexor Tendon

79.2

Stage II: Tendon Reconstruction with Palmaris Tendon Grafting

81.1

Tenolysis of Flexor Tendons

82.1

Thumb Extensor Tendon Repair (Zone TIV)

84.1

Release of de Quervain Tendovaginitis

85.1

Arm Reconstruction with Neuromusculocutaneous Gracilis Free Flap

86.1

Webspace Contracture Release with 5-flap Z-plasty

87.1

Fingertip Reconstruction Using Thenar Flap

87.2

Homodigital Neurovascular Island Flap Coverage of Fingertip Injury

88.1

Moberg Flap Transfer to Repair Thumb Defect

88.2

First Dorsal Metacarpal Artery Flap Reconstruction for Skin Defect of the Thumb

89.1

Dorsal Metacarpal Artery Propeller Perforator Flap

90.1

Perforator Flap From Radial Artery

91.1

Groin Flap Transfer

93.1

Dermatofasciectomy for Dupuytren Contracture with Arterialized Venous Flow-Through Flap

95.1

Second Toe to Thumb Transfer at the Thumb Metacarpophalangeal Joint

96.1

Sympathectomy of Radial, Ulnar, and Common Digital Arteries

97.1

Ulnar Artery Repair with Vein Graft

98.1

Open Fasciectomy for Dupuytren Contracture

99.1

Biceps and Brachialis Lengthening

100.1

Superficialis to Profundus Transfer and Intrinsic Slide

100.2

Fractional Lengthening of Flexor Tendons

101.1

Flexor Pronator Slide

102.1

Thumb Adductor Release

Video TOC

103.1

Proximal Interphalangeal Volar Capsulotomy

104.1

Metacarpophalangeal Dorsal Capsulotomy

104.2

Metacarpophalangeal Dorsal Capsulotomy of Index, Middle, Ring, and Small Fingers

106.1

Release of Finger Syndactyly

107.1

Reconstruction of Type I Duplicated Thumb

107.2

Excision of Type IV Duplicated Thumb

108.1

Index Pollicization for Hypoplastic Thumb

109.1

Pediatric Opponensplasty

110.1

Proximal Interphalangeal Flexion Contracture Release

111.1

Finger Amputation for Macrodactyly

112.1

Release of Constriction Ring in Great Toe

114.1

Cleft Hand Reconstruction

116.1

Dorsal Wrist Ganglion Cyst Excision

116.2

Volar Wrist Ganglion Cyst Excision

116.3

Giant Cell Tumor Excision

117.1

Subungual Glomus Tumor Excision

118.1

Excision of Metacarpal Enchondroma

119.1

Excision of Peripheral Nerve Schwannoma

120.1

Nail Tumor Excision and Dermal Substitute Coverage

xxi

ddsf

SECTION I

Anesthesia and Emergency Procedures CHAPTER 1

Anesthesia of the Hand  2

CHAPTER 2

Fasciotomy for Compartment Syndrome of the Hand and Forearm  4

CHAPTER 3

Digit Amputations  5

CHAPTER 4

Proximal Upper Extremity Amputation  7

CHAPTER 5

Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)  8

CHAPTER 6

Splints and Orthoses  16

1

CHAPTER

1

Anesthesia of the Hand Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 1.1 – Anesthesia of the Hand.

KEY CONCEPTS • Local anesthesia has many practical uses and is straightforward to administer because of the superficial nature and consistent anatomic course of the sensory nerves surrounding the hand and wrist. It is increasingly used as the sole anesthetic in the outpatient setting for WALANT (wide awake, local anesthesia, no tourniquet) procedures. • Local anesthetics can be administered to individual digits (digital block); along named sensory nerves, such as the superficial radial and dorsal ulnar branches; or locally in random patterned areas to provide complete anesthesia. This technique facilitates detailed examination of important structures within the digits and hand in an emergency room setting, such as ensuring tendon continuity in a patient with an acute digit laceration. • Local anesthesia is also useful when evaluating a patient’s motion in real time in the operating room. For example, it may be used to ensure that a complete A1 pulley release has been performed with no residual triggering. This technique is also useful

Superficial radial nerve Dorsal cutaneous branch of ulnar nerve Median nerve Ulnar nerve

FIGURE 1.1  Sensory distribution of dorsal hand.

2

CHAPTER 1  Anesthesia of the Hand

for patients with critical cardiopulmonary illness because it can obviate the need for general anesthesia. • Lidocaine is the most widely used agent, with an onset of action of 3 to 5 minutes and duration of action of 60 to 120 minutes. • Blocks are most easily performed with the patient supine and the arm extended on a hand table. • All patients should be educated on the common phenomenon of rapid dissipation of the local anesthetic, leading to a rebound pain response. Procedures reviewed in this chapter: • Radial nerve block • Median nerve block • Ulnar nerve block • Intermetacarpal block • Subcutaneous digital block • Intrathecal block

3

CHAPTER

1

Anesthesia of the Hand Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Local anesthesia has many practical uses and is straightforward to administer because of the superficial nature and consistent anatomic course of the sensory nerves surrounding the hand and wrist. It is increasingly used as the sole anesthetic in the outpatient setting for WALANT (wide awake, local anesthesia, no tourniquet) procedures. • Local anesthetics can be administered to individual digits (digital block) along named sensory nerves, such as the superficial radial and dorsal ulnar branches, or locally in random patterned areas to provide complete anesthesia. • This technique facilitates detailed examinations of important structures within the digits and hand in an emergency room setting, such as ensuring tendon continuity in a patient with an acute digit laceration. • Local anesthesia is also useful when evaluating a patient’s motion in real time in the operating room. For example, it may be used to ensure that a complete A1 pulley release has been performed with no residual triggering. • This technique is also useful for patients with critical cardiopulmonary illness because it can obviate the need for general anesthesia.

Contraindications • WALANT is often not appropriate for children and adults who cannot follow instructions or remain still for prolonged periods of time.

CLINICAL EXAMINATION Anesthetic Agents • Lidocaine is the most widely used agent, with an onset of action of 3 to 5 minutes and duration of action of 60 to 120 minutes. It is most often found in either 1% or 2% concentrations. • Bupivacaine is also commonly used for longer duration of pain control (400–450 minutes). It has a much longer onset of action of 15 to 20 minutes. It often comes in either 0.25% or 0.5% concentrations. • Lidocaine and bupivacaine can be mixed in various ratios to provide the combined benefits of quick onset with lidocaine and long duration of action with bupivacaine. • The advantages of using epinephrine mixed with a local anesthetic (1:200,000 or even 1:100,000) are twofold; it causes vasoconstriction within the surrounding tissue, limiting blood loss during any open procedure, and it also increases the lidocaine/bupivacaine duration of action by preventing systemic absorption. We recommend using epinephrine for common surgical procedures, such as first dorsal compartment release or carpal tunnel release, to limit bleeding in these highly vascular areas. • A solution of 1% lidocaine in epinephrine is nearly 1000 times more acidic than subcutaneous tissue. It can be buffered with standard 8.4% sodium bicarbonate (NaCO3) in a 1 mL:10 mL (NaCO3:Lidocaine) ratio. The reduction in acidity is necessary to reduce the pain associated with injection.

SURGICAL ANATOMY • Fig. 1.1 shows the sensory distribution of the dorsal hand. • Fig. 1.2 shows the location of the radial, median, and ulnar nerves. The radial nerve crosses the wrist in the area of the radial styloid. The purely sensory nerve arborizes 3.e1

3.e2

CHAPTER 1  Anesthesia of the Hand

Superficial radial nerve Dorsal cutaneous branch of ulnar nerve Median nerve Ulnar nerve

FIGURE 1.1

Median nerve Ulnar nerve A

Radial sensory nerve

B FIGURE 1.2

proximal to the radial styloid and crosses the wrist divided into a few major branches that travel in subcutaneous tissues anywhere from just volar to the styloid and as far dorsal/ulnar as the area in line with the middle finger metacarpal (Fig. 1.3). • The median nerve crosses the wrist within the carpal tunnel, and the palmar cutaneous branch crosses in a similar region of the wrist but more superficially. The nerve runs between the palmaris longus (PL) and the flexor carpi radialis (FCR) tendons, and for patients with PL, this tendon can be used to help landmark for injections.

3.e3

CHAPTER 1  Anesthesia of the Hand

Extensor pollicis longus Superficial radial nerve

Styloid process of radius Scaphoid A

B

Abductor pollicis longus

FIGURE 1.3

Flexor carpi radialis

A

Median nerve Palmaris longus

B FIGURE 1.4

• To identify the PL, have the patient pinch their thumb to their ring/small finger and locate the tendon bulge in the wrist (Fig. 1.4). • If not present or identifiable, the ulnar border of the FCR tendon can be used as the landmark. • The ulnar nerve crosses the wrist in the area of the flexor carpi ulnaris (FCU) tendon, proximal to its insertion on the pisiform (before entering the Guyon canal). • The ulnar artery is radial to the nerve and to the FCU tendon. • The dorsal sensory branch also runs ulnar to FCU at the level of the wrist, more superficial to the major ulnar nerve trunk (Fig. 1.5). • Common digital nerves travel between the metacarpals. The injection site to perform a block of the common digital nerve to anesthetize multiple fingers at once is at the level of the distal palmar crease, approximately 1 cm proximal to the metacarpophalangeal joint. • Each finger has a volar and dorsal nerve on the ulnar and radial sides (for a total of four digital nerves). The volar branches are larger, and within the finger are volar to the corresponding digital artery. The volar branches pass from the common digital nerve proximal to each webspace and enter the finger (Fig. 1.6).

Ulnar nerve

POSITIONING Blocks are most easily performed with the patient supine and the arm extended out on a hand table. The great degree of motion through the shoulder, elbow, and wrist allow for these blocks to be performed in a variety of hand and arm positions.

FIGURE 1.5

3.e4

CHAPTER 1  Anesthesia of the Hand Dorsal sensory nerve

STEP 1 PEARLS

Dorsal branch of the volar digital nerve

• Aspirate the syringe before injecting to avoid intravascular administration of local anesthetic. STEP 1 PITFALLS

• The superficial radial nerve lies within the subcutaneous tissue. The needle tip should remain just beneath the dermis, and the injection should be met with almost no resistance. If it is difficult to administer fluid, the needle has likely advanced too deep into the periosteum or within the tendons of the brachioradialis/ first dorsal compartment.

Volar digital nerve FIGURE 1.6

RADIAL NERVE BLOCK STEP 2 PEARLS

• To maintain depth within the subcutaneous tissue, first create a small wheal beneath the dermis with the local anesthetic. With the subcutaneous layer identified, it is easier to advance the needle without exiting the correct tissue plane. • This technique often requires multiple needle insertion points to cover adequate territory around the curvature of the wrist without injecting too deeply. Additionally, it often requires more anesthetic than the other described techniques, with at least 10 mL needed for adequate infiltration of the entire area.

Step 1 • Begin by palpating for the radial artery, which lies immediately radial to the FCR tendon. • With the radial artery identified, inject directly radial to the artery (along the radial border of the forearm/wrist), proximal to the radial styloid. (Fig. 1.7).

Step 2 • Adjust position and move the needle along the radial border of the radius, then dorsally to the area of the radial styloid, and then further into the dorsal hand, injecting local anesthetic along the way (Fig. 1.8).

MEDIAN NERVE BLOCK

STEP 1 PEARLS

Step 1

• For most procedures around the median nerve, such as carpal tunnel release, local anesthetic can be administered superficial to the transverse carpal ligament (TCL) to permit diffusion into the surrounding tissue. This provides adequate anesthesia and reduces the risk for median nerve injury from a direct injection.

• Identify the interval between PL and FCR (or just ulnar to FCR). Enter approximately 0.5 cm deep and infiltrate with approximately 5 to 10 mL of local anesthetic (Fig. 1.9).

STEP 1 PITFALLS

• It is critically important to avoid injecting directly into the median nerve. Before injecting anesthetic, flex or extend the fingers to see if the needle “bobs.” If so, the needle has advanced too far and should be withdrawn. Additionally, any resistance to flow should raise concern of an intratendinous or, worse, intraneural needle placement.

ULNAR NERVE BLOCK Step 1 • Identify the FCU tendon and place the needle immediately ulnar to it. Administer 5 to 10 mL of local anesthetic to the surrounding area (Fig. 1.10).

Step 2 • At the level of the distal ulna, insert the needle and slide under the area of FCU (dorsal and ulnar to the tendon). • Inject approximately 5 mL of anesthetic solution in this plane.

Flexor carpi radialis Palmar cutaneous branch Range of infiltration

FIGURE 1.7

FIGURE 1.8

CHAPTER 1  Anesthesia of the Hand

Flexor carpi radialis Palmar cutaneous branch

Flexor carpi ulnaris

Palmaris longus

FIGURE 1.9

FIGURE 1.10 STEP 1 PEARLS

Step 3 • Withdraw slowly and inject again in the subcutaneous tissues to block the dorsal sensory branch as well.

• The ulnar nerve block can be administered radial or ulnar to FCU; however, we prefer the ulnar approach to minimize the risk for injection into the ulnar artery or nerve.

DIGITAL NERVE BLOCK Blocking digital nerves can be achieved with a variety of techniques.

INTERMETACARPAL BLOCK PEARLS

Intermetacarpal Block • If the goal is to block multiple adjacent fingers, an intermetacarpal block (also known as a transmetacarpal block) technique can be used (Figs. 1.11 and 1.12). • Inject alongside the metacarpal neck to block the common digital nerves to the fingers on either side of the corresponding webspaces (see Fig. 1.11A).

Flexor tendon

Common digital nerve Distal palmar crease

A

B

FIGURE 1.11A

• The injection site is at the distal palmar crease, proximal to the metacarpophalangeal joint. • The approach can be volar or dorsal, but many patients report less discomfort with a dorsal approach.

3.e5

3.e6

CHAPTER 1  Anesthesia of the Hand

Common digital nerve

A

B FIGURE 1.12

SUBCUTANEOUS DIGITAL BLOCK PEARLS

• If dorsal anesthesia is not required, a singleinjection volar technique is preferred by some. This is done with a single injection over the volar aspect, just proximal to the palmodigital crease. The needle can be moved to the radial border webspace and then withdrawn slowly and redirected to the ulnar side to allow for the injection of both sides with one needlestick. SUBCUTANEOUS DIGITAL BLOCK PITFALLS

• There is a debate on dorsal versus volar approach, with many preferring dorsal because it is reportedly less painful. • Volar-only techniques often still require a subcutaneous wheal injected on the dorsum of the finger to block the dorsal digital nerves.

STEP 1 PEARLS

• Intrathecal block offers anesthesia with one injection and reportedly has a faster onset.

Subcutaneous Digital Block • To block just one finger, the subcutaneous digital block technique can be used. • Infiltrate along the radial and ulnar border of the digit proximally, at the webspace (Fig. 1.13).

INTRATHECAL BLOCK Step 1 • Alternatively, a digital block can be performed using an intrathecal block technique that involves injecting into the flexor tendon sheath. • Injection is performed at the level of the palmodigital crease (Fig. 1.14).

Step 2 • Insert the needle until it contacts the bone. Then pull back slowly while injecting until a loss of resistance is felt—this is the plane between periosteum and tendon within the sheath (Fig. 1.15).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Most of these blocks can be expected to provide adequate reduction of pain and sharp sensation for the areas targeted. • All patients should be educated on the common phenomenon of rapid dissipation of the local anesthetic, leading to a rebound pain response. Because of the duration of action of most anesthetics and the fact that most elective outpatient procedures are

CHAPTER 1  Anesthesia of the Hand

A

B

C

Digital crease D

Flexor tendon

FIGURE 1.14

FIGURE 1.13

STEP 1 PITFALLS

• Because of the pressure within the flexor sheath during injection, some patients report increased and prolonged discomfort with the intrathecal block technique.

STEP 2 PITFALLS Flexor tendon sheath Flexor digitorum profundus

Volar digital nerve

Flexor digitorum superficialis

• Injection superficial to the tendon is often less accurate; in some cases, no intrathecal injection occurs because the injection is all performed in the subcutaneous space.

Volar digital artery POSTOPERATIVE PITFALLS Proximal phalangeal bone

FIGURE 1.15

done midday, this phenomenon frequently occurs in the middle of the night. We recommend patients begin transitioning to oral pain medications at the first sign of pain or a pins-and-needles feeling in the anesthetized area. See Video 1.1

• Neuropraxia is uncommon, especially with these distal nerve blocks. Should they occur, they will often resolve within 3 to 4 weeks. Patient support and reassurance is usually the only necessary treatment. In the rare event of complete or near-complete palsy, additional evaluation is warranted to rule out new sources of compression. • Toxicity from the local anesthetic, although incredibly uncommon with the small doses described here, should always be considered if a patient experiences central neurologic or cardiac changes in the perioperative period.

3.e7

3.e8

CHAPTER 1  Anesthesia of the Hand

EVIDENCE Hung VS, Bodavula VKR, Dubin NH. Digital anesthesia: comparison of the efficacy and pain associated with three digital nerve block techniques. J Hand Surg Br. 2005;30:581–584. This is a randomized, controlled, single-blind study of 50 healthy volunteers, comparing time of onset, pain from block, and method of preference of three different digital blocks. The metacarpal block took significantly longer to block the digital nerves than the other two methods. Forty percent of subjects felt discomfort for 24 to 72 hours after the transthecal digital block. Forty-three percent of subjects chose the subcutaneous block as the preferred method. (Level I evidence). Low CK, Vartany A, Engstrom JW, Poncelet A, Diao E. Comparison of transthecal and subcutaneous single-injection digital block techniques. J Hand Surg. 1997;22:901–905. Randomized double-blind study on 142 patients comparing transthecal digital block and subcutaneous digital block. No difference was found in effectiveness, distribution, onset, and duration of action. (Level I evidence). Sonmez A, Yaman M, Ersoy B, Numanodlu A. Digital blocks with and without adrenalin: a randomisedcontrolled study of capillary blood parameters. J Hand Surg Eur. 2008;33:515–518. Twenty patients were randomized to digital block with 2% lidocaine and 2% lidocaine with 1:80,000 adrenalin. Po2 and Sao2 in the digits were not significantly different between the groups. No concerning issues with digital perfusion were reported. Return of sensation in digits without adrenalin returned an average of 4.8 hours later, and with adrenaline occurred 8.1 hours later. (Level II evidence). Strazar RA, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg. 2013;132(3):675–684. This article published by Dr. Lalonde, a pioneer in WALANT hand surgery, discusses many different aspects of reducing the pain associated with local anesthesia injection. Included in the article is a repeatable and low-cost technique for buffering lidocaine/epinephrine solution to a physiologic pH.

CHAPTER

2

Fasciotomy for Compartment Syndrome of the Hand and Forearm Yu Zhou, Rachel Hooper, and Kevin C. Chung Full text of this chapter is available online at expertconsult.com.

KEY CONCEPTS • Compartment syndrome occurs when pressure within a fibro-osseous space increases beyond a level that is suitable for perfusion across tissues. The ischemia caused by compartment syndrome affects nerves and muscles; irreversible damage can occur within 6 hours for muscle and even less time for nerves. • The most common causes of forearm compartment syndrome are fracture, injection injury, extravasation injury, penetrating trauma, circumferential burns, and snake or insect bites. • Continuous pressure examination is the most reliable method for diagnosing acute compartment syndrome. Normal tissue pressures range from 0 to 8 mm Hg. A compartment pressure measurement over 30 mm Hg is typically an indication for urgent fasciotomy; readings of 20 or more warrant close monitoring and possibly surgical intervention. • The forearm has four major compartments: superficial and deep volar, dorsal, and lateral. The compartments of the hand with the most clinical significance and that most often require release include the thenar, hypothenar, adductor pollicis, dorsal interosseous, and volar interosseous. • If fasciotomy is performed within 4 to 6 hours of compartment syndrome onset, the patient may regain full function and sensation. If there is any concern for muscle viability, return to the operating room approximately 48 hours after initial surgery for examination and additional debridement. Procedures reviewed in this chapter: • Fasciotomy of the forearm • Fasciotomy of the hand

Arm incision

Dorsal ulnar

Volar radial Forearm incision

FIGURE 2.5  Incision markings for fasciotomy of the upper extremity.

4

CHAPTER

2

Fasciotomy for Compartment Syndrome of the Hand and Forearm Yu Zhou, Rachel Hooper, and Kevin C. Chung INDICATIONS • Compartment syndrome occurs when pressure within a fibroosseous space increases beyond a level that is suitable for perfusion across tissues. • The most common cause of forearm compartment syndrome is fracture, especially distal radius fracture. Other causes of compartment syndrome include an injection injury, an extravasation injury, a penetrating trauma, circumferential burns, and snake or insect bites. • Injection injuries involving air, water, or other hydrophilic liquids can potentially be observed depending on the volume and clinical presentation. • Injection of paint or other oil-based liquid requires early decompression and additional debridement as needed. Although seemingly benign, these injection injuries tend to develop ischemia and deep space infections if left untreated. • Ischemia-reperfusion occurs after prolonged tourniquet time and with the use of compressive wraps and casts. • Crush injury with resultant edema leads to increased pressure in the closed muscle space and can also progress to compartment syndrome. • Electrical injury, a type of burn injury, can also cause compartment syndrome when the hands and upper limbs are damaged by a high-voltage current. Unlike thermal damage caused by eschar compression, which requires escharotomy, the deep tissue necrosis and swelling caused by electrical burns leads to increased compartment pressure. This can only be treated with fasciotomy. • In most cases, the upper extremities are the points of contact with the power source and are likely to require amputation. Although the timing of debridement does not reduce amputation rates, the boundary between healthy and damaged tissue is often unclear initially. Early debridement is important to reduce secondary necrosis from infection. • Multiple debridement procedures are often required to determine the extent of damage and the need for amputation. It is necessary to return to the operating room every 24 to 48 hours to reassess the viability of the tissue and repeat the debridement. • Immediate surgery is necessary if the patient has progressive neurologic dysfunction, vascular compromise, compartment syndrome, or systemic clinical deterioration from suspected ongoing myonecrosis.

CLINICAL EXAMINATION • The ischemia caused by compartment syndrome affects the nerves and muscles; irreversible damage can occur within 6 hours for muscle and in even less time for nerves. • The diagnosis of compartment syndrome is generally a clinical one, based on findings of nerve or muscle injury. • Pain (out of proportion to injury, especially on passive stretch), paresthesia, paralysis, pallor, pulselessness, and inability to regulate limb temperature (poikilothermia) are common manifestations. • Pain out of proportion to injury and paresthesias are the two earliest findings, whereas pulselessness and pallor are often seen later or may not occur at all. • The compartments are often firm to palpation, and overlying skin may become shiny and even develop blisters (Figs. 2.1 and 2.2). 4.e1

4.e2

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

A

B

C

FIGURE 2.1  The thumb and index fingers are viable. There is a near circumferential eschar over the middle finger, which is alive. The ring finger and little finger are necrotic. There is compartment syndrome over the hand, forearm, and upper arm.

FIGURE 2.2  Blister.

• For patients with electrical injuries, it is important to put forth the caveat of life before limb because the heart and kidneys may be affected by electric shocks. The patient’s general condition should be evaluated first, and limb salvage surgery should be performed once the patient is stable from a trauma standpoint. • Do not be deceived by the superficial appearance of skin burns after electrical injury because deep tissue damage is often serious and harder to evaluate on examination (Fig. 2.3). • When an electric current passes through the body, the extent of damage to each tissue type depends on its inherent resistance. Bone is the most resistant to electric current, followed by fat, tendons, and skin. Muscles, blood vessels, and nerves are the least resistant.

IMAGING • Often, the diagnosis is clinically apparent, and therefore no additional imaging or other workup is needed. • Most commonly, the diagnosis in less clinically apparent cases is made by measuring the intramuscular pressure (IMP). Many techniques have been described, including arterial line transducer systems, slit catheters, and self-contained measuring systems.

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

B

A

FIGURE 2.3  Skin lesions are light.

• Single pressure measurement does not reflect pressure changes over time and has limited significance for clinical diagnosis. Continuous pressure examination is the current gold standard for the diagnosis of acute compartment syndrome. • Normal tissue pressures range from 0 to 8 mm Hg. A compartment pressure measurement over 30 mm Hg is typically an indication for urgent fasciectomy; readings of 20 or more warrant very close monitoring and possibly surgical intervention under the right clinical circumstances. Additionally, some consider a difference of 20 mm Hg between diastolic pressure and compartment pressure as an indication for fasciotomy as well (hypotensive/septic patients).

SURGICAL ANATOMY • The forearm has four major compartments—superficial volar, deep volar, dorsal, and lateral (mobile wad) (Fig. 2.4 and Table 2.1). • The interosseous membrane of the radius and ulna separates the forearm into volar and dorsal compartments. The deep volar compartment is most susceptible and most often affected by compartment syndrome, whereas the mobile wad (more superficial) is least commonly involved. Pronator quadratus belongs to the deep volar compartment, too. Some investigators consider it to be a separate subcompartment because it can be affected independently from other forearm muscles. • When compartment syndrome occurs in the volar compartment, it can be devastating to forearm function because the median nerve, anterior interosseous nerve (AIN), and the ulnar nerve run within it. The median nerve is the most common Median nerve Flexor carpi radialis muscle

Palmaris longus muscle

Brachioradialis muscle

Flexor digitorum superficialis muscle

Radial artery Superficial branch of radial nerve

Ulnar artery

Extensor carpi radialis muscle and tendon

Ulnar nerve Flexor carpi ulnaris muscle

Flexor pollicis longus muscle

Flexor digitorum profundus muscle

Anterior interosseous artery

Anterior interosseous nerve

Radius

Interosseous membrane

Extensor carpi radialis brevis muscle and tendon

Extensor pollicis longus muscle

Abductor pollicis longus muscle

Antebrachial fascia

Extensor digitorum muscle

Ulna

Posterior interosseus artery

Extensor carpi ulnaris muscle Extensor digiti minimi muscle Posterior interosseus nerve FIGURE 2.4

4.e3

4.e4

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

Table 2.1

Myofascial Compartments of the Upper Extremity and Their Contents Compartment

Muscle

Artery

Nerve

Arm

Anterior Posterior Deltoid

Biceps, brachialis, coracobrachialis; Triceps Deltoid

Brachial Profunda brachii —

Musculocutaneous Radial Axillary

Forearm

Volar Superficial Deep Dorsal Superficial Deep Mobile wad

Pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor carpi ulnaris; Flexor pollicis longus, flexor digitorum profundus, pronator quadratus; Extensor digitorum communis, extensor digiti minimi, extensor carpi ulnaris; Abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor indicis proprius, supinator; Brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis;

Radial and ulnar Pos. interosseous —

Median, ulnar, and anterior interosseous Pos. interosseous Radial

Hand

Thenar Hypothenar Adductor Interosseous Carpal tunnel Digit

Abductor pollicis brevis, opponens pollicis, flexor pollicis brevis; Abductor digiti minimi, opponens digiti minimi, flexor digiti minimi; Adductor pollicis; Four dorsal and three palmar interosseous muscles; Flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus.

Digital — — — — Digital

Recurrent motor Ulnar Ulnar Ulnar Median Digital

• •

•

•

damaged nerve. AIN runs on the superficial side of the deep fascia and innervates the deep flexor muscle. • The dorsal compartment is not as frequently injured compared with the volar compartment. The carpal tunnel is susceptible to compressive pressures and is often released when other upper extremity fasciectomies are performed. The compartments of the hand that have the most clinical significance and most often require release include the thenar, hypothenar, adductor pollicis, dorsal interosseous, and volar interosseous. Digital compartments are bound by Cleland and Grayson ligaments, although the clinical significance of these compartments in the setting of compartment syndrome is debated. For high-pressure injection injuries, the surgical approach may need to be adjusted to allow for adequate debridement of ischemic tissue in the area of injection.

Exposures • Forearm • Volar release is traditionally done via a curvilinear incision from the medial epicondyle to the proximal wrist crease. This, however, places the distal flexor tendons and median nerve at risk for exposure and desiccation. Therefore we advocate for an alternative approach. • We recommend two longitudinal incisions—one over the volar radial aspect (over the flexor muscles) and the other over the dorsal ulnar aspect of the extensor muscles. This approach decompresses the volar and dorsal compartments without exposing the median nerve or distal forearm tendons (Figs. 2.5 and 2.6A–B). • The more traditional dorsal release is performed via a single longitudinal incision along a line between Lister tubercle and an area 4 cm distal to the lateral epicondyle (incision is made in the space between extensor digitorum and extensor carpi radialis brevis; Fig. 2.7). This incision facilitates dorsal release; however, a more limited incision shown in Fig. 2.5 and Fig. 2.6A–B will provide adequate exposure and minimize wound morbidity.

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

Arm incision

Dorsal ulnar

Volar radial Forearm incision

FIGURE 2.5

A

B FIGURE 2.6  Incision design. (A) The curved incision in red across the forearm is incorrect, as it could expose either the median nerve or the distal forearm tendons. The two longitudinal incisions in green on the radial and ulnar side are correct.

4.e5

4.e6

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm EXPOSURES PEARLS

• Hypothenar compartment release should not be done directly on the ulnar border, but instead should be slightly radial to the border, so that the scar is not on a direct pressure area of the hand. • When decompressing the median nerve at the carpal tunnel, avoid incising across the wrist because this can increase the risk for wound dehiscence, with swelling and subsequent exposure of the median nerve and flexor tendons. EXPOSURES PITFALLS

It is not necessary to make release incisions distal in the midvolar forearm to expose the median nerve or distal flexor tendons because this could cause desiccation and necrosis of these vital structures. Avoid these exposure approaches whenever possible (Fig. 2.15A–B).

• Hand • The carpal tunnel is approached via a single incision between the thenar and hypothenar spaces, in line with the radial aspect of the ring finger (Fig. 2.8). • The thenar compartment is approached via an incision along the radial side of the thenar eminence between glabrous and nonglabrous skin (Fig. 2.9). • The hypothenar compartment is released via a longitudinal incision along the ulnar aspect of the palm (Fig. 2.10). • Dorsal hand compartments are released by two longitudinal incisions parallel and radial to the index and ring finger metacarpals (Fig. 2.11). This facilitates decompression of all four dorsal interosseus compartments (Fig. 2.12). • Finger • Decompression can be done with a midaxial incision along the noncontact (radial for index and thumb; ulnar for middle, ring, and small) side of the finger (Figs. 2.13 and 2.14).

Skin incision, dorsal forearm FIGURE 2.7

FIGURE 2.8  Carpal tunnel release.

FIGURE 2.9  Thenar decompression.

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

FIGURE 2.10  Hypothenar decompression. The incision should not be performed directly on the ulnar border but instead should be slightly radial to the border.

FIGURE 2.11  Two longitudinal incisions parallel and radial to the index finger and ring finger metacarpals on the dorsal side.

FIGURE 2.12  Dorsal decompression.

4.e7

4.e8

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

Skin incision, finger FIGURE 2.13

A

B

FIGURE 2.14  Incision design and finger release.

A

B

FIGURE 2.15  Avoid distal incisions in the volar forearm.

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm STEP 1 PEARLS

FASCIOTOMY OF THE FOREARM Step 1: Volar Forearm Release • The incision (see Fig. 2.6B) is made to the radial side of the volar forearm, between the brachioradialis (BR) and flexor carpi radialis (FCR). We prefer to check all the compartments through one incision. A longitudinal incision on the dorsal ulnar side can also be added if necessary (see Figs. 2.5 and 2.6A). • The incision is made through skin and subcutaneous tissues (Fig. 2.16A), and the deep fascia investing the muscles of the forearm is divided sharply. • Subcutaneous flaps can be elevated to permit mobilization of the incision site and improve exposure in all directions. • Check the superficial and deep volar compartment first. Dissect between FCR and palmaris longus to expose the deep flexors (flexor digitorum superficialis, pronator quadratus, flexor pollicis longus, and flexor digitorum profundus) and decompress as needed with fascial incisions (see Figs. 2.16B–C). • It is critical to visualize the deep compartment flexor muscles, particularly after electrical injury. • The dorsal compartment can be examined simultaneously through this incision or through a dorsal incision. • Via the same incision, approach the muscles of the mobile wad (BR, extensor carpi radialis longus, and extensor carpi radialis brevis) and divide fascia to release that compartment (see Fig. 2.16D).

Step 2 • Release the tourniquet (if one was used) and obtain hemostasis. If muscle is nonviable, stimulate it with electrocautery and look for fasciculations. If muscle has no response to electrocautery, consider debridement of nonviable soft tissues back to healthy, bleeding, fasciculating tissue.

• If the muscle still appears white after opening fascia, divide the epimysium as well. • Before approaching the deep flexor muscles, identify the median nerve and stay ulnar to it to avoid injury to the palmar cutaneous branch. • After electrical injury, even if the superficial volar forearm is soft, exposure and release of the deep compartment is often performed because this compartment can be injured from the electrical energy conducted through bone.

STEP 1 PITFALLS

• Avoid exposure of median nerve and distal flexor tendons (see Fig. 2.15A–B). • Traditional teaching of wide extensile exposure for forearm fasciotomy is shown in Fig. 2.15A. • Fig. 2.15B shows the risk of this approach for volar fasciotomy, a nonhealing wound with resulting exposure and desiccation of flexor tendons (black arrow pointing to flexor carpi radialis [FCR] tendon) and median nerve (white arrow); this patient required amputation.

Brachioradialis

FCR A

B

C

D

FIGURE 2.16  (A) The junction approach from the lateral and superficial volar compartment. (B) Muscles of superficialis volar compartment appeared to be alive. (C) Muscles of deep volar compartment appeared to be alive. (D) Muscles of lateral compartment appeared to be alive.

4.e9

4.e10

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm STEP 3 PEARLS

• If there is significant swelling, then leave most of the incision open and perform a partial closure over vital structures, such as the median nerve and flexor carpi radialis tendons. • Closure of the wounds immediately postrelease, when the tissues are significantly swollen, risks additional ischemia. It is also technically difficult because of the edema, which causes large gaps between wound edges. Retention systems can be used (e.g., staples and vessel loops; Fig. 2.17) to prevent wound gaps from spreading, which would make reconstruction more challenging.

Step 3: Post Release • Use mattress sutures to perform a partial or full (loose) skin closure if possible. • If skin closure is not possible, use a vessel loop to create a “Jacob’s ladder” or similar construct to prevent the skin from retracting. • Place a bulky moist dressing over any open wounds and fit a removable splint in a functional position. • Initiate regular dressing changes to prevent desiccation of exposed muscles and tendons.

FASCIOTOMY OF THE HAND Step 1: Carpal Tunnel Release • Make an incision between the thenar and hypothenar spaces, in line with the radial border of the ring finger. • Dissect down to and through the palmar fascia and identify the transverse fibers of the transverse carpal ligament. • Divide the transverse carpal ligament longitudinally across the full distal and proximal extent of the ligament, similar to a standard carpal tunnel release.

Step 2: Thenar Decompression • Deepen the incision until the abductor pollicis brevis is encountered. • Divide the fascia over the abductor pollicis brevis. FIGURE 2.17

STEP 1 PEARLS

• After releasing the carpal tunnel, close the skin with interrupted mattress sutures to prevent desiccation of the median nerve and flexor tendons.

Step 3: Hypothenar Decompression • Deepen the incision until the abductor digiti minimi is visualized. • Divide the fascia over the abductor digiti minimi.

Step 4: Finger Release • Decompression can be performed with a midaxial incision along the noncontact side of the finger (see Fig. 2.14).

Step 5: Amputation of Necrotic Fingers STEP 2 PITFALLS

Use caution with the distal extension of the incision so as not to expose the metacarpophalangeal joint. STEP 3 PITFALLS

Be careful not to divide the ulnar digital nerve to the small finger. STEP 4 PITFALLS

• In this case, the necrotic ring and little fingers were amputated at the head of the metacarpal (Fig. 2.18). A fillet dorsal skin flap was elevated for coverage of the head of the metacarpal.

Step 6: Dorsal Decompression • Incise along the index finger metacarpal to decompress the first dorsal interosseous, adductor pollicis, and second dorsal interosseous. • Incise along the ring finger metacarpal to decompress the third and fourth dorsal interossei.

Be careful not to damage the digital nerve. STEP 5 PEARLS

In the case of electrical injury, the amount of energy dissipated determines the severity of the injury and extent of tissue loss. Early decompression and debridement can prevent ongoing ischemia and tissue damage and, in some cases, prevent the need for amputation. STEP 6 PEARLS

To fully decompress the dorsal interossei, one must incise the overlying muscle fascia, which requires that the extensor tendons be mobilized and retracted to adequately access this fascia in each intermetacarpal space.

FIGURE 2.18  Amputation of ring and small fingers.

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

Step 7 • Release the tourniquet (if one was used) and obtain hemostasis. Proceed with debridement of nonviable soft tissues back to healthy bleeding tissue.

STEP 6 PITFALLS

Be cautious of the branches of the superficial radial nerve and dorsal branches of the ulnar nerve.

Step 8: Post Release • Place a few tacking sutures to secure soft tissue over the carpal tunnel and other exposed critical structures. • Place a bulky moist dressing over remaining open wounds and fit a removable splint with the wrist in slight extension, fingers flexed to 70 degrees at the metacarpalphalangeal (MCP) joint, and extended at the intrinsic plus (IP) joints. • Initiate regular dressing changes to prevent desiccation of exposed muscles and tendons.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Elevation of the extremity postoperatively is critical to reducing edema and improving pain control. • Reexamine the extremity within 12 to 24 hours to evaluate the need for additional debridement. • If there is any concern for muscle viability, return to the operating room (OR) approximately 48 hours after initial surgery for examination and additional debridement. • Wound care with regular moist gauze dressing changes (or petroleum-based dressings) is important to prevent desiccation of any open wounds. • Attempt closure of open wounds (whether primary wound closure or skin graft) within 3 to 5 days when tissues are still somewhat pliable to limit infection risk (Fig. 2.19A-C). • If fasciotomy was performed within 4 to 6 hours of compartment syndrome onset, the patient may regain full function and sensation; however, any delay beyond 3 to 4 hours may result in some degree of permanent nerve and/or muscle damage.

A

B

C

FIGURE 2.19  (A-C) Three days after surgery.

POSTOP PEARLS

If the patient can tolerate it, one may elevate the area by putting a stockinette on the arm and slinging the arm on an IV pole. If this is attempted, be sure to support the elbow with pillows.

4.e11

4.e12

CHAPTER 2  Fasciotomy for Compartment Syndrome of the Hand and Forearm

EVIDENCE Kistler JM, Ilyas AM, Thoder JJ. Forearm compartment syndrome: evaluation and management. Hand Clin. 2018;34(1):53–60. The authors introduced in detail the etiology, pathophysiology, anatomy, diagnosis, management, outcomes, and complications of forearm compartment syndrome. Lee DH, Desai MJ, Gauger EM. Electrical injuries of the hand and upper extremity. J Am Acad Orthop Surg. 2019;27(1):e1–e8. The authors described in detail how electric current can cause damage to the human body after the hand or upper limb is shocked. Clinical manifestations and principles of emergency surgical exploration of electrical injuries are also mentioned. Schmidt AH. Acute compartment syndrome. Injury. 2017;48(Suppl 1):S22–S25. The authors introduced the current diagnosis of acute compartment syndrome. The clinical findings and intramuscular pressure (IMP) measurement help determine the timing of the fasciotomy.

CHAPTER

3

Digit Amputations Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 3.1 – Digit Amputation.

KEY CONCEPTS • Amputation does not indicate failure of salvage; rather, it is part of the treatment algorithm for restoring optimal function after extensive traumatic injuries. • For injuries with a poor prognosis for return of function (e.g., joint destruction, need for extensive soft tissue reconstruction), patients may prefer amputation to prolonged therapy with only moderate return of function. Digit amputation should also be considered for any injury that damages a digit to the degree that vascularity, function, or soft tissue coverage cannot be restored. If possible, revascularization or replantation should be considered first. • For the thumb, it is important to preserve the carpometacarpal joint so that a toe transfer remains an available option. In multidigit injuries, it is important to consider using tissues from a digit requiring amputation to provide coverage for an adjacent digit or hand wound. • In general, revision finger amputations are done through the bony shaft distal to tendon attachment, rather than at joint level, to permit better contour of the amputation stump and flexion of the joint. For metacarpal amputations, one must decide between a transmetacarpal amputation and a ray amputation. Procedures reviewed in this chapter: • Revision digit amputation • Transmetacarpal or ray amputation

5

6

CHAPTER 3  Digit Amputations

Flexor tendon Palmar digital arteries and nerves

A1 pulley

Superficial palmar arch

FIGURE 3.2  Neurovascular structure of the hand and digits.

CHAPTER

3

Finger Amputations Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Digit amputation should be considered for any injury that damages a digit to the degree that vascularity, function, or soft tissue coverage cannot be restored. If at all possible, revascularization or replantation should be considered first. • Amputation should also be considered after finger injuries that substantially destroy structural and/or functional integrity beyond the ability to adequately reconstruct. Ring avulsions or other traction injuries may leave the digit largely intact; however, the underlying disruption of the digital vessels makes revascularization challenging unless the vessels are anastomosed as distally as possible. In severe cases, traction injuries can cause complete amputation with avulsion of the extensor/flexor tendons at the musculotendinous junction—these are very high energy injuries and salvage is unlikely. • Patient preference should also be considered after substantial trauma to digit(s). For injuries in which the prognosis for return of function is poor (joint destruction, need for extensive soft tissue reconstruction, etc.), patients may prefer amputation to prolonged therapy with only moderate return of function. Additionally, patients may elect for a digit amputation after a previous injury that has left them with a stiff, nonfunctioning digit. • Necrosis of the digit, either because of thermal or ischemic injury, requires amputation. Regardless of the mechanism, wait several weeks for digit necrosis to fully demarcate before finalizing an amputation to avoid incorporating developing necrotic tissue into the amputation site. • Neoplasm affecting either the structure or function of the digit may require amputation. Benign bone lesions, such an enchondromatosis, can substantially alter the physical function of the digit, but the digit can be reconstructed after tumor ablation, whereas malignant neoplasms such as melanoma or sarcoma require amputation to achieve wide resection with negative margins. The goal is to preserve functional length with durable soft tissue coverage. • For the thumb, it is important to preserve the carpometacarpal joint so that a toe transfer remains an available option. • In multidigit injuries, it is important to consider using tissues from a digit requiring amputation to provide coverage for an adjacent digit or hand wound. • Create soft tissue flaps for viable and potentially sensate coverage of other injured sites. • Use bone, tendon, vessel, or nerve for grafting in the reconstruction of other injured digits. • Amputation does not indicate failure of salvage; rather, it is part of the treatment algorithm for helping patients return to optimal function after extensive traumatic injuries.

Contraindications • Replantation or revascularization should be attempted over amputation in those with thumb amputations, multiple digit amputation, and/or loss of function in the contralateral upper extremity. • Replantation or revascularization should also be done in children because of their great capacity for recovery.

CLINICAL EXAMINATION • Check perfusion of the finger, looking at capillary refill, color, and turgor. Check that refill takes approximately 2 seconds. This is most easily done by compression and release at the nail bed if available (especially in patients with a darker skin tone). 6.e1

6.e2

CHAPTER 3  Finger Amputations

• If the finger feels soft and compressible, vascular inflow may have been lost, resulting in this loss of turgor. • Evaluate sensation. • Check the response to a sharp stimulus at the fingertip; the sharp end of a broken cotton swab or a sterile needle can be used. • Examine two-point discrimination (although this is often difficult in the recently injured patient). This can be done using a premade device, if available, or by opening up a paper clip to the desired prong width or gently using the tips of sharp Iris scissors opened to various widths. The objective is to test at what width the patient is able to distinguish two points from one point of pressure. On the volar fingertip, two-point discrimination is usually between 3 to 5 mm. • Examine the structural integrity of each involved finger. Test the flexion of the distal and proximal interphalangeal joints by blocking all adjacent joints. Finger extension is most easily tested by placing the hand on a flat surface and asking the patient to lift each finger off the surface.

IMAGING • X-ray is generally the only modality used to evaluate traumatized digits when determining structural integrity and potential for long-term function if salvaged.

SURGICAL ANATOMY

EXPOSURES PEARLS

• Put a clamp on the finger tourniquet as a reminder to remove the tourniquet after surgery. In the chaotic environment of the emergency room, the surgeon may forget that the tourniquet is still on without a reminder. • Ensure adequate time for the block to set in. It is often easiest to place the block early, even before thorough cleaning to ensure sufficient time.

EXPOSURES PITFALLS

As discussed in Chapter 1 “Anesthesia of the Hand”, long-acting local anesthetics can take 15 to 20 minutes to take full effect, especially for deep soft tissue and bone. Do not make the mistake of injecting local anesthesia immediately before beginning a procedure to avoid having to sit idly by until the noxious stimuli fade.

• In general, revision finger amputations are done through the bony shaft distal to tendon attachment, rather than at the joint level, to permit better contour of the amputation stump and flexion of the joint. • Knowledge of finger anatomy is important for maintaining attachments of flexor and extensor tendons if possible; within the digit, flexor tendons insert at the volar metaphysis, whereas extensor tendons insert onto the dorsal epiphysis. Avoiding the unnecessary violation of a proximal tendon insertion is essential (Fig. 3.1A–B). • Common digital vessels bifurcate just proximal to the webspace. It is important to take caution when performing revision amputation around the metacarpophalangeal (MCP) joints because one can inadvertently injure the proper digital artery to an adjacent digit if not careful (Fig. 3.2). • For metacarpal amputations, one must decide between a transmetacarpal amputation and a ray amputation. • For border digits, one often can do a transmetacarpal (neck or shaft) amputation, with the distal remaining bone cut at a 45-degree angle oriented toward the border surface to preserve hand curvature and shape. • For central digits, and for border digits in patients unhappy with hand function/ appearance after border amputation, a complete ray amputation with removal of the metacarpal is necessary. • For index and middle fingers, one must keep the metacarpal base to preserve the extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) attachments, respectively.

POSITIONING • With an adequate digital block, a revision finger amputation can often be performed in the emergency department or in a small procedure room rather than in the operating room. • Use of a finger tourniquet facilitates operating in a dry field. An extra glove can be used if no prefabricated finger tourniquet option is available (Fig. 3.3). • In an operating room setting with general anesthesia, a standard arm tourniquet can be used.

EXPOSURES • With the digit anesthetized, thoroughly clean the hand using peroxide and saline. This will aid in visualization of skin color, perfusion, and the extent of deformity and soft tissue injury.

CHAPTER 3  Finger Amputations

Terminal tendon

DIP joint

Lateral band

Middle phalanx

Central slip PIP joint

Proximal phalanx Sagittal bands MP joint

Juncturae tendinae

Extensor tendon

A

FDP

FDS

B FIGURE 3.1  A-B, Finger anatomy.

REVISION AMPUTATION Step 1 • In cases of traumatic amputation, there is often a zone of injury that extends beyond the immediate amputation site. Begin the operation by sharply removing devitalized skin from the periphery of the wound, as well any devascularized bone, tendon, or interosseous muscle within the wound (Fig. 3.4A–B).

6.e3

6.e4

CHAPTER 3  Finger Amputations

Flexor tendon Palmar digital arteries and nerves

A1 pulley

Superficial palmar arch

FIGURE 3.2  Vessel anatomy.

FIGURE 3.3  Finger tourniquet. STEP 1 PEARLS

The depth of the volar flap should be elevated directly off the flexor sheath. It is important to keep the flap at full thickness because a thin flap could lead to hypersensitivity and pain at the healed amputation site. STEP 1 PITFALLS

Be judicious with your initial resection and take care to not overresect in the beginning stages of the procedure. More bone and tissue can be removed later if necessary, but excessive resection leads to unnecessarily short finger stumps.

• In general, all skin and soft tissue proximal to laceration sites should be preserved, even if traumatized, unless it is clearly no longer viable. This extra soft tissue length will be needed to provide adequate durable coverage over the bony stump. • Bone will need to be resected proximal to the injury site to provide adequate soft tissue to close over the bone. Therefore this tissue must be dissected off of the bone with minimal injury to preserve viability. • With sharp scissors or an elevator directly on the phalanx, elevate the soft tissue envelope off of the bone. • If the flexor or extensor tendon remains attached to the distal bone segment that will be excised, pull on the tendon, divide as proximally as possible, and allow it to retract into the palm. This prevents the tendon from being tethered distally, which could restrict tendon excursion of the other fingers.

CHAPTER 3  Finger Amputations

A

B FIGURE 3.4  (A-B) Amputation.

• With the damaged tissue excised, full-thickness flaps of volar skin and soft tissue are elevated proximally. These flaps will eventually be used to cover the amputation site.

Step 2

STEP 2 PEARLS

• The neurovascular bundles are identified along the volar region of radial and ulnar borders of the injured digit. • If soft tissue connections remain between the distal segment and the remaining digit, the neurovascular bundles may be in that soft tissue. Closely examine before transecting these soft tissue connections. • In the finger, the nerve is volar to the artery; in the palm, the artery is volar to the nerve. • Digital arteries may be under vasospasm during initial injury; however, once the smooth muscle of the endothelium relaxes, profuse bleeding can occur if the vessels are not properly ligated with electrocautery or permanent suture. • In amputated digits, the nerve should be placed on traction (Fig. 3.5) and then transected with sharp scissors so it can retract proximally away from the scar site. Nerves trapped in the sutured skin cause debilitating pain, whereas nerves retracted into the palm shield the neuroma from contact. • In metacarpal-level amputations, management of the primary neurovascular bundles is a more delicate matter because the common branches in the palm also feed the adjacent digits and therefore must be preserved. • First, identify the digital nerve distally in the finger and then follow it proximally to find it within in the intermetacarpal space. Putting traction on the digital nerve in the finger

If the nerve does not adequately retract after transection, attempt to tunnel the nerve end into soft tissue or into bone to prevent painful neuromas. All nerves will form a neuroma, but nerves trapped in contact areas and not buried may cause painful neuromas.

FIGURE 3.5  Nerve placed in traction.

6.e5

6.e6

CHAPTER 3  Finger Amputations STEP 3 PEARLS

Attempt to trim any bony spicules or radial/ulnar prominence to avoid leaving the stump with abnormally wide or prominent edges.

can help identify the branch-point in the webspace or the common nerve in the palm, showing a safe transection point for the nerve to the finger being amputated. • When approaching the metacarpal, approach directly over the bone and elevate soft tissue off to either side, protecting the neurovascular bundles.

Step 3 STEP 3 PITFALLS

If performing a metacarpal amputation, leave enough length/bone distally to preserve the intermetacarpal ligaments. Failure to do so will destabilize the remaining metacarpal.

FIGURE 3.6  X-ray demonstrating angled osteotomy.

• The level of amputation is determined by the available soft tissue and the level of bony injury. • After trauma to multiple digits, one may need to use soft tissue from one digit to cover wounds on neighboring digits or the hand. • Injuries like ring avulsions may require a more proximal amputation because of soft tissue loss, even if the majority of the bone structure is intact. • In the fingers, perform amputation through the phalangeal shaft if possible and avoid leaving the condyle prominent distally. • If possible, aim to preserve the attachments of flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP), and extensor digitorum communis (EDC) tendons. • If amputation takes place through the joint, the traditional teaching is to denude the cartilage along the distal aspect of the remaining phalanx and use a small rongeur to remove the articular condyles. This is done to prevent continued generation of synovial fluid. Experimental studies, however, have shown that articular removal is unnecessary so we do not routinely remove the articular surface. • Using a combination of rongeurs or, if available, a small oscillating saw, contour the distal bone. • For digits, do not leave sharp edges. • For metacarpals, angle distal osteotomy of border digits to be approximately 45 degrees angled toward the hand or nearest border, providing natural curved contour to match the rest of the hand (Fig. 3.6). • For ray amputations, leave the base of index and middle finger metacarpals to preserve the insertion of ECRL/ERCB.

Step 4: Closure • No buried sutures are needed. Place interrupted nylons in the skin (Figs. 3.7 and 3.8A–B). • Do not suture the flexor tendon to the extensor tendon or tack down the tendons because this can substantially limit function of the hand. • Because of the shared muscle belly of the digital flexor(s), a bound tendon can lead to quadrigia, in which the remaining fingers cannot fully flex. • Similarly, junctura are common among the extensor tendons, and an injured or adhered extensor tendon can prevent full extension of adjacent digits. • Consider loosely closing the skin flaps to permit drainage of any contaminated fluid as the wounds heal (rather than tight closure of all wound margins). • In children, only close with chromic suture or another rapidly dissolving suture that does not need removal because compliance with suture removal may be a challenge.

ELECTIVE AMPUTATION (TRANSMETACARPAL OR RAY AMPUTATION) If performing transmetacarpal or ray amputations to remove a nonfunctional digit after revision finger amputation or for ischemia/malignancy, consider these additional steps. FIGURE 3.7  Wounds closed. STEP 4 PEARLS

If there is a question of viability of remaining soft tissues, examine again in approximately 48 hours to determine whether additional debridement is required or if it can be treated with local wound care.

Step 1 • Plan your incision. At the level of the metacarpophalangeal join, draw a curvilinear teardrop incision along the volar aspect, and dorsally draw a narrow Y-shaped incision that extends further proximally (Fig. 3.9).

Step 2 • Start with a volar incision and identify the digital neurovascular bundles to the finger (Figs. 3.10 and 3.11).

CHAPTER 3  Finger Amputations STEP 4 PITFALLS

• Avoid volar-based wound closure if possible because this risks painful scars on the functional surface of remaining fingers. • Contour the digits by removing excess lateral skin so that the tip of the digit is round.

A

B

FIGURE 3.8  (A-B) Wounds healed/x-ray.

FIGURE 3.9  Incision design.

FIGURE 3.10  Identify neurovascular bundles.

FIGURE 3.11  Identify neurovascular bundles.

6.e7

6.e8

CHAPTER 3  Finger Amputations STEP 2 PEARLS

Be cautious with the dissection around the webspace. The common digital artery bifurcates more distally than the common digital nerve. Inadvertent damage to the common digital artery can harm blood flow to the adjacent digit.

• After identifying a nerve, place slight traction and see if it pulls in the webspace; if there is a tethering in the webspace, this is the proper digital nerve and it can be transected. If not, one may have the common digital nerve and need to explore further so as not to damage sensation of the adjacent digit. • Identify the A1 pulley, divide it, and transect the flexor tendons to the digit, permitting them to retract into the forearm.

Step 3 • Cut down to bone and elevate any volar soft tissues that are tethered to bone, protecting soft tissues on either side of the metacarpal (Figs. 3.12 and 3.13).

Step 4 • Turn to the dorsal side and make the Y incision overlying the bone. • Cut down, divide the extensor tendon to that digit, and continue down to bone before using a key elevator to lift interosseous muscles off the metacarpal. • Again, mobilize soft tissues to each side, protecting the neurovascular bundles, and avoid unnecessary trauma to the muscles and intermetacarpal ligaments.

Step 5 • Divide the transmetacarpal ligaments, preserving as much length as possible. • Use a saw to cut through metacarpal and remove the finger and metacarpal.

Step 6 • For third and fourth metacarpal amputations, use 2-0 Ethibond (or another braided suture of choice) to bring transmetacarpal ligaments together and close down the open space (Fig. 3.14). • Be cautious not to overtighten this suture because it can over-reduce the adjacent fingers, leading to a crossover deformity. • One can use buried absorbable suture to loosely bring soft tissues together, close down dead space, and cover the permanent suture. • Close overlying soft tissue with an interrupted nylon suture (Figs. 3.15A–B and 3.16).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients with finger amputations are often discharged with only a soft dressing unless other more proximal injuries are also identified. • After 48 hours, begin standard wound care with gentle cleansing and dressing changes (our preference is Xeroform daily or bacitracin twice a day). • With dressings in place, we encourage wrapping and elevation to control edema.

FIGURE 3.12  Cut down to bone.

FIGURE 3.13  Cut down to bone.

CHAPTER 3  Finger Amputations

FIGURE 3.14  Closure of the open space.

A

B

FIGURE 3.15  (A-B) Wound closure.

FIGURE 3.16  X-rays.

6.e9

6.e10

CHAPTER 3  Finger Amputations

• Once the wounds heal, patients are cleared to return to activities gradually. It is often a much more rapid recovery than if complex reconstruction were performed. • After metacarpal-level amputations, we often place the patient in an intrinsic-plus volar splint while healing to prevent collapse of border metacarpals and abnormal remaining finger cascade. See Video 3.1

EVIDENCE Wilkens SC, Claessen FMAP, Ogink PT, et al. Reoperation after combined injury of the index finger: repair versus immediate amputation. J Hand Surg Am. 2016;41(3):436–440. A retrospective study looking at the rate of reoperation of complex index finger injuries that underwent repair versus primary amputation; 114 patients underwent 75 repairs versus 39 immediate amputations. The rate of unplanned amputation was twice as high in the patients who underwent repair (44%) versus primary amputation (21%). Wang K, Sears ED, Shauver MJ, Chung KC. A systematic review of outcomes of revision amputation treatment for fingertip amputations. Hand (NY). 2013;8:139–145. This article is a review of outcomes after revision amputation for fingertip injuries. The authors reviewed 38 studies and concluded that near-normal sensation could be restored with satisfactory motion. Return to work took an average of 7 weeks. Whitaker LA, Graham WP III, Riser WH, Kilgore E. Retaining the articular cartilage in finger joint amputations. Plast Reconstr Surg. 1972;49:542–547. This article presents an experiment in cats that evaluated disarticulation amputation versus cartilage removal at a distal amputation site. Inflammation and remodeling occurred more quickly in the disarticulation model with longer recovery time in cases where the cartilage had been denuded. Yuan F, McGlinn EP, Giladi AM, Chung KC. A systematic review of outcomes after revision amputation for treatment of traumatic finger amputation. Plast Reconstr Surg. 2015;136:99–113. This is a systematic review of treatment for revision amputation injuries. The mean static two-point discrimination was 5 mm, with total active motion 93% of normal (slightly better after revision amputation compared with local flap coverage). Seventy-seven percent of patients reported cold intolerance. Ninety-one percent reported satisfactory or good/excellent overall function regardless of treatment.

CHAPTER

4

Proximal Upper Extremity Amputations Benjamin K. Gundlach and Kevin C. Chung

Full text of this chapter is available online at expertconsult.com. This chapter includes the following videos: Video 4.1 – Midforearm amputation; Video 4.2 – Regenerative peripheral nerve interface.

KEY CONCEPTS • The goal of upper extremity amputation is to provide a stable, functional limb with durable soft-tissue coverage that facilitates the use of a prosthesis. • Upper extremity amputation is most common after unsalvageable trauma, including crushed/mangled extremity, amputation with prolonged ischemic time, electrical burns, complex vascular injury, and cold injury/frostbite. Less common indications include unresectable sarcoma, necrotizing fasciitis, and elective amputation for chronic posttraumatic pain. • For acute injuries, determine whether replantation or limb salvage is possible. If not, determine what tissue remains viable. If there is extensive soft-tissue loss, skin grafting or a flap may be necessary to cover the stump site. • All transected nerves will form neuromas because the axons are seeking a target to innervate, whether through a nerve or into a muscle. Regenerative peripheral nerve interface (RPNI) is indicated at the time of primary amputation for management of peripheral nerves, with the goal of reducing the incidence of painful neuroma formation. RPNI should be delayed if infection or other gross contamination of the wound bed is present. • An interdisciplinary approach for upper extremity amputations is strongly recommended; patients should be referred to their physiatrist, prosthetist, and therapist early in the recovery process. Procedures reviewed in this chapter: • Trans-radial forearm amputation • Regenerative peripheral nerve interface

Brachioradialis m. Flexor carpi radialis tendon

Ulnar artery and nerve

Radial Superficial branch, artery radial nerve

Median nerve Pronator Flexor digitorum teres m. (cut) Flexor carpi superficialis m. radialis m.

Brachial artery

Biceps brachii m.

Palmaris Median longus m. nerve

Ulnar nerve

FIGURE 4.1  Key anatomic structures for trans-radial amputation.

7

CHAPTER

4

Proximal Upper Extremity Amputation Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • The goal of upper extremity amputation is to provide a stable, functional limb with durable soft-tissue coverage to facilitate the use of a prosthesis. • Upper extremity amputation is most common after unsalvageable trauma, such as a crushed/mangled extremity, amputation with prolonged ischemic time, electrical burns, complex vascular injury, or cold injury/frostbite. • Amputation is also used to remove unresectable sarcoma, such as tumors with extensive vascular involvement, osseous/articular destruction, or soft-tissue loss. • Infection, especially necrotizing fasciitis, in which soft-tissue reconstruction could not be accomplished after extensive debridement is another indication. • Rarely, an elective amputation may be chosen by a patient who has chronic posttraumatic pain and/or spasticity. • Regenerative peripheral nerve interface (RPNI) is indicated at the time of primary amputation for the management of peripheral nerves, with the goal of reducing the incidence of painful neuroma formation. All transected nerves will form neuromas because the axons are seeking a target to innervate, whether through a nerve or into a muscle. To avoid potential painful neuromas, we recommend performing RPNI after all primary upper extremity amputations. • Targeted muscle reinnervation (TMR) provides a similar function with identical indications, but instead of free muscle grafts to individual peripheral nerves as with RPNI, TMR uses nerve coaptations/transfers of nonfunctioning distal peripheral nerves (radial, ulnar, median) to functioning peripheral nerve branches of proximal muscle bodies (biceps, triceps, pectoralis, latissimus). We prefer RPNI to TMR because it is less complicated and does not sacrifice the function of proximal muscle bellies. • RPNI can also be used in a revision setting for the management of neuromas in a chronically painful amputated limb. • RPNI and TMR are currently being used experimentally for advanced control of myoelectric prosthetics.

Contraindications • Amputation should be avoided in patients who already have an amputation or disability of their contralateral upper extremity. • Preoperative evaluation with a physiatrist or amputation psychologist is strongly recommended in cases of elective amputation. If any concerns are raised about a patient’s ability to cope or adapt after an amputation, it should be avoided. • RPNI should be avoided when infection or other gross contamination of the wound bed is present. In this scenario, delaying the RPNI procedure is recommended.

TRANSRADIAL FOREARM AMPUTATION Clinical Examination • In cases of acute injury, it is important to first decide if replantation or limb-salvage is achievable. If not, one should assess the extremity and decide what is viable versus nonviable tissue. If there is extensive soft-tissue loss, then skin grafting or a flap may be necessary to cover the stump site. • In cases of malignancy, it is important to study the patient’s surface anatomy and advanced imaging because this will dictate the necessary level of amputation.

7.e1

7.e2

CHAPTER 4  Proximal Upper Extremity Amputation

Imaging • Standard anteroposterior (AP) and lateral radiographs should be obtained to identify any fractures or foreign bodies. • In cases of infection or malignancy, magnetic resonance imaging (MRI) with and without contrast can be invaluable in determining the proximal extent of pathology to avoid incorporating contaminated tissue into the amputation site.

Surgical Anatomy • There are five main nerves and four arteries that must be identified, divided, and ligated during a standard transradial amputation (Fig. 4.1): • The superficial radial nerve (SRN) is found within the radial, most subcutaneous tissue of the mid forearm. The smaller lateral and medial antebrachial cutaneous nerves can also be found in this area. • The radial artery is identified proximally under the brachioradialis. At the middleto-distal forearm, the radial artery runs between the flexor carpi radialis and brachioradialis tendons, with no superficial muscular covering. • The median nerve is found within the volar compartment. At the level of the mid forearm, the median nerve courses between the muscle bellies of the flexor digitorum superficialis and profundus, ulnar to the flexor carpi radialis. • The ulnar artery and nerve together comprise the ulnar neurovascular bundle. This structure courses deep into the flexor carpi ulnaris (FCU) muscle belly within the forearm, with the nerve traveling ulnar to the artery. • The anterior and posterior interosseous arteries run longitudinally along the anterior and posterior aspects of the interosseous membrane. Depending on the level of amputation, a proximal or distal anastomosis may be encountered. The terminal Ulnar artery

Level of bone division

Median nerve Radial artery

Ulnar nerve

Radial nerve

Radius

Ulna

Brachioradialis m. Flexor carpi radialis tendon

Ulnar artery and nerve

Median nerve

Radial Superficial branch, artery radial nerve

Brachial artery

Biceps brachii m.

Palmaris Median Pronator Flexor digitorum longus m. nerve teres m. (cut) superficialis m. Flexor carpi radialis m.

Ulnar nerve

FIGURE 4.1  Forearm anatomy. From Thal ER, Weigelt JA, Carrico CJ, eds. Operative Trauma Management: An Atlas. 2nd ed. New York: McGraw-Hill, 2002:449.

CHAPTER 4  Proximal Upper Extremity Amputation

branches of the anterior and posterior interosseous nerves are found just adjacent to their corresponding artery.

Positioning • A transradial forearm amputation is performed in standard supine position using a hand table. • An unsterile tourniquet will suffice for standard forearm amputations. In cases requiring more proximal amputation, however, a sterile tourniquet is necessary to avoid draping too close to the surgical field.

EXPOSURES PEARLS

In cases of infection or a mangled extremity, it is not always possible to determine the ideal level of amputation on initial presentation. Temporizing measures such as serial debridement may be performed to give the proximal tissue time to rest and demarcate. Distal guillotine amputation may be necessary in emergent situations, such as necrotizing fasciitis.

Exposures • Discuss the optimal location/level for the bone cuts with the prosthetic team to ensure that a compatible prosthesis is available. • If a tumor or infection is present, bone cuts are made at least 1 cm proximal to the contaminated area. In cases of trauma, bone cuts are made at a level proximal enough to ensure that the remaining, uninjured soft tissue can cover the amputation site without excessive tension. • Draw a fish-mouth incision with the proximal tail extensions along the radial and ulnar borders of the forearm. The skin flaps should extend at least 2 cm distal to the planned bone cuts (Fig. 4.2).

Procedure Step 1: Volar Dissection • Make the volar incision. Then, using electrocautery, start superficially and cut structure by structure until the flexor carpi radialis and palmaris longus are encountered. • Identify the superficial radial nerve along the radial border and tag it with an epineural suture for the RPNI procedure. • Next, identify the radial artery under the nerve and secure it with two opposing vessel clamps. Sharply divide the artery between the clamps. • Using nonabsorbable suture, stick tie the proximal artery stump to prevent postoperative bleeding. Stick tying is the preferred method because it incorporates the surrounding soft tissue to keep the suture in place around the artery (Fig. 4.3). • Find the median nerve in the midvolar forearm between the two digital flexor muscle bellies and divide it sharply; tag the nerve for subsequent RPNI (Fig. 4.4). • Use electrocautery to divide the FCU along its ulnar border. Identify the ulnar neurovascular bundle deep to the FCU. Perform artery ligation and nerve division as previously discussed (Fig. 4.5). • Isolate and secure the anterior interosseous artery with suture ligation. Sharply divide the anterior interosseous nerve, which is typically immediately ulnar to the artery.

Step 2: Osteotomy • Use a combination of electrocautery and a key elevator to subperiosteally expose both the radius and ulna.

FIGURE 4.2  Fish-mouth incision with skin flaps extending greater than or equal to 2 cm distal from the planned bone cuts. STEP 1 PEARLS

• When performing RPNIs, complete your initial nerve transections with enough working length remaining. • The basilic, cephalic, and other large dorsal veins will be encountered during superficial dissection; manage them with suture ligation as necessary. STEP 1 PITFALLS

• If the skin flaps are too small, then additional bone resection is necessary to facilitate wound closure. It is always better to create slightly larger skin flaps that can later be trimmed to size. • Only place suture through the epineurium of the peripheral nerves. Damaging the deeper nerve fascicles with needles or suture will act as a noxious stimulus.

Superficial radial nerve

FIGURE 4.3  Dissection of radial artery and superficial radial nerve.

Median nerve

FIGURE 4.4  Dissection of the median nerve.

7.e3

7.e4

CHAPTER 4  Proximal Upper Extremity Amputation

• Confirm the planned osteotomy level in relation to surface landmarks. Mark the planned osteotomy onto the radius and ulna using electrocautery. • Use a small or medium-sized oscillating saw to perform horizontal osteotomies through the radius and ulna. • Use a small rasp to lightly chamfer the bone edges.

Step 3: Dorsal Dissection • Identify the posterior interosseous artery immediately dorsal to the interosseous membrane and secure it with suture ligation. Then, sharply divide the posterior interosseous nerve. • Finish the remaining dorsal compartment dissection with electrocautery. Ulnar nerve and artery

FIGURE 4.5  Dissection of the ulnar nerve and artery. STEP 4 PEARLS

• A drain can be placed within the deep or superficial layers to prevent hematoma accumulation. • In distal forearm amputations, myodesis can be performed to stabilize the muscles. This theoretically maintains supination/pronation strength because the muscles are sutured directly to bone through interosseous drill holes. We prefer myoplasty because it provides more robust coverage of the terminal amputation stump (see Fig. 4.6A–B for a demonstration of each method in the lower leg; similar concepts apply to upper extremity reconstruction).

Step 4: Myoplasty and Closure • Use a 0 braided suture to bring the dorsal and volar muscular compartments together, covering the bone stumps of the radius and ulna. Be sure to grab the muscular fascia within this closure (Fig. 4.6B). • Use 3-0 absorbable braided suture to reapproximate the subcutaneous tissues. • Use 4-0 Nylon suture in an interrupted fashion for final skin closure. • Place a compressive wrap/bandage. Myodesis consists of suturing the transected muscle to the bone through drill holes.

STEP 4 PITFALLS

The forearm is highly vascular. Postoperative bleeding and hematoma can occur if small arteries and veins are not identified and ligated. We recommend relieving the tourniquet before closure to facilitate ligation/cauterization of any remaining vessels within the deep tissue.

The cut ends of antagonistic muscle groups and their fascias are sewn together for myoplasty.

FIGURE 4.6  (A–B) Myodesis versus myoplasty demonstrated in the lower leg. Similar concepts apply for upper extremity amputation. From Greisberg JK, Vosseller JT, eds. Core Knowledge in Orthopaedics: Foot and Ankle, 1st ed. Elsevier, 2014:213.

CHAPTER 4  Proximal Upper Extremity Amputation

REGENERATIVE PERIPHERAL NERVE INTERFACE

STEP 1 PITFALLS

Clinical Examination

Do not harvest muscle tissue from the area just proximal to the amputation; this muscle bulk is necessary to protect/pad the amputation stump and provides proper contour for the prosthetic socket.

• In patients who present for revision surgery of painful neuromas, evaluation of the amputation site is important. Note any hyperactive scar formation, prior skin grafting, or flap coverage that could make surgical dissection more difficult. • Tinel signs can indicate the location of neuromas, limiting the need for extensive surgical dissection. • If a primary amputation was performed by another surgeon, old operative reports are useful to determine how the peripheral nerves were managed at the time of surgery and if they were placed in a nonanatomic position.

Procedure Step 1: Muscle Harvest

STEP 2 PEARLS

• Regardless of amputation level (transradial, transelbow, transhumeral), RPNI requires a 1 cm ! 3 cm rectangle of free, nonvascularized muscle tissue, roughly 3 to 5 mm thick, for each nerve or fascicle. • For primary amputation, muscle tissue is harvested from the amputated distal extremity. In revision situations, other muscle autograft should be used. We prefer to harvest muscle tissue from the vastus lateralis as it has a large, easily accessible muscle belly. Donor site morbidity is limited because of the functional redundancy of the remaining quadriceps muscles (Fig. 4.7).

When a nerve carries both motor and sensory fascicles, an intraneural dissection should be performed to isolate the individual fascicles. Within the mid-to-distal forearm, both the ulnar and median nerves have separate motor and sensory fascicles.

Step 2: Nerve Preparation • When performing an amputation, identify, isolate, and sharply divide all major nerves, with ample length remaining for manipulation around the wound (Fig. 4.8). • In revision cases when amputation has previously been performed and neuroma has developed, start distally by identifying and dissecting out the neuroma. • Identify the neuroma and then dissect proximally, freeing 2 to 3 cm of the nerve. • Sharply divide the nerve, then use loupe magnification to ensure that there are healthy nerve fascicles that are free of scar tissue.

Step 3: Creating the Muscle–Nerve Interface • Take a piece of free muscle graft. Place the nerve ending on top of the muscle graft longitudinally.

Volar muscle donor site

Radial sensory N.

Median N.

Free muscle tissue

Ulnar N. (sensory and motor N.) FIGURE 4.7  Harvesting brachioradialis muscle graft from the volar forearm.

FIGURE 4.8  Radial sensory, median, and ulnar nerves, exposed and prepared for regenerative peripheral nerve interface (RPNI).

7.e5

7.e6

CHAPTER 4  Proximal Upper Extremity Amputation STEP 3 PEARLS

If there are plans for postoperative use of a myoelectric prosthesis, the individual RPNIs should be tunneled away from the direct weightbearing portion of the limb and placed within the subcutaneous tissues.

• Use two to three interrupted, 6-0 permanent monofilament sutures to secure the epineurium and muscle together as a unit. • Fold the adjacent muscle flaps over the nerve, creating circumferential muscle coverage around the nerve. Suture the two muscle flaps together with several 6-0 sutures (Fig. 4.9). • Repeat this process for each nerve/fascicle (Fig. 4.10). • The individual RPNIs should be buried within the wound, away from the direct weight-bearing portions of the stump. • Routine wound closure is then performed (Fig. 4.11).

Free muscle graft

Transected peripheral nerve placed in center of muscle graft

Placement of epineurial securing sutures

Muscle graft is rolled to cover nerve ending and secured with sutures

FIGURE 4.9  Suturing the peripheral nerve into the free muscle graft.

Superficial radial nerve

Median nerve

Ulnar nerve

FIGURE 4.10  Completed regenerative peripheral nerve interface (RPNI) to superficial radial, median, and ulnar (motor and sensory fascicles) nerves.

FIGURE 4.11  Completed transradial amputation with regenerative peripheral nerve interface (RPNI) and layered wound closure.

CHAPTER 4  Proximal Upper Extremity Amputation

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A gauze dressing with elastic compressive wrap should be applied to the wound and stump for the first week after surgery. • We strongly recommend an interdisciplinary approach for upper extremity amputations; patients should be referred to their physiatrist, prosthetist, and therapist early in the recovery process. • Once the wound starts to heal, the patient can begin to wear shrinker/compressive socks and initiate the process of prosthetic fitment. • Neuroma development is common after upper extremity amputation, regardless of the use of RPNI/TMR. In the event of neuroma development, a primary or revision RPNI should be performed. See Videos 4.1 and 4.2

EVIDENCE Kubiak CA, Kemp SWP, Cederna PS, Kung TA. Prophylactic regenerative peripheral nerve interfaces to prevent postamputation pain. Plast Reconstr Surg. 2019;144(3):421e–430e. In this study, 90 patients underwent amputation at various levels within the upper and lower extremities. RPNI was performed in 45 patients, whereas classic sharp ligation of peripheral nerves was performed in 45 patients, who served as the control group. 51% of RPNI patients reported phantom limb sensation compared with 91% in the control group. Painful neuromas developed in 6 out of 45 control patients, compared with 0 out of 45 RPNI patients (Level III Evidence). Chow JA, Van Beek AL, Bilos ZJ, et al. Anatomical basis for repair of ulnar and median nerves in the distal part of the forearm by group fascicular suture and nerve-grafting. J Bone Joint Surg Am. 1986;68(2):273–280. An anatomic study of the internal fascicular anatomy of the median and ulnar nerves. In total, 45 cadaveric specimens were dissected and the common patterns of intraneural topography were described. Initially intended to improve the accuracy of grouped fascicular nerve repair, this anatomy is vital to accomplishing fascicular RPNI or TMR. Resnik L, Ekerholm S, Borgia M, Clark MA. A national study of veterans with major upper limb amputation: Survey methods, participants, and summary findings. PLOS One. 2019;14(3):e0213578. The largest national survey of U.S. veterans highlighting outcomes and prosthetic usage in those who sustained either unilateral or bilateral upper extremity amputation. The rate of prosthetic use in unilateral amputees was only 60%; of those, 52% of unilateral and 76% of bilateral amputees used their prosthetic(s) for more than 8 hours every day. Phantom limb pain was reported in 83.4% of unilateral amputees (Level IV Evidence).

7.e7

CHAPTER

5

Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis) Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Paronychia, felons, and flexor tenosynovitis (FTS) are some of the most common infectious pathologies seen among hand surgeons. They are most often bacterial in origin—with Staphylococcus aureus as the most common pathogen—and can be pyogenic (pus-forming). • Paronychia is an infection of the lateral or proximal nail fold and soft tissue, which can also extend to the germinal and sterile matrix beneath the nail. • A felon is a purulent infection that develops within the volar septate pulp tissue of a finger or thumb. • Pyogenic FTS is a purulent infection that occurs within the sheath surrounding the flexor tendons. • Pyogenic infections should be dealt with promptly to prevent tendon scarring and necrosis, soft-tissue loss, proximal migration, and bacteremia. • Rapid progression of pyogenic infections is common in patients with diabetes or IV drug use and among those who are immunocompromised. • A recent history of puncture or injury to the soft tissue is common, but not required, for the development of pyogenic infections of the finger and hands. • Bites are a common mechanism of hand infection. Cats specifically have sharp, needle-like teeth, delivering bacteria (Pasteurella multocida)-laden saliva into wounds, which then quickly seal over. Human bites from physical altercations are also common, most frequently occurring on the dorsal ulnar hand at the level of the metacarpophalangeal joints.

Contraindications There are no contraindications to surgical management of pyogenic infections of the fingers and hand. The adage “the sun never sets on an abscess” remains relevant, regardless of the clinical setting. Even in critically ill patients, most finger infections can be temporized by lancing at the bedside under a digital block.

CLINICAL EXAMINATION • Clinical examination is the hallmark of diagnosis for felons, paronychia, and pyogenic FTS. Laboratory markers, such as white blood cell count (WBC) and erythrocyte sedimentation rate/C-reactive protein (ESR/CRP), are commonly within normal limits and of little clinical utility. • Patients with a finger infection will often report a recent history of swelling, erythema, and worsening pain within the finger or hand. • The common physical examination findings of pyogenic FTS are classically described by Kanavel (Fig. 5.1): • Fusiform swelling (also described as a “sausage digit”), with tense swelling along the entire length of the digit • Flexed posture • Tenderness to palpation along the flexor tendon sheath • Pain with passive digital extension • Felons are characterized by tense swelling of the volar pulp and a well-defined area of blanching overlying an obvious abscess (Fig. 5.2). As the infection worsens and pressure increases, a type of localized compartment syndrome can develop within the septa of the pulp tissue, leading to extreme pain. 8

CHAPTER 5  Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)

FIGURE 5.1  Flexor tenosynovitis, with the classic flexed posture and fusiform swelling of the affected index finger.

FIGURE 5.2  Obvious purulence within the pulp tissue, the hallmark sign of a felon.

• Paronychia are initially characterized by unilateral swelling, erythema, and pain of the lateral nail fold on one side. As the infection progresses, the swelling and erythema will affect both lateral nail folds and extend proximally into the dorsal skin of the digit (Fig. 5.3).

IMAGING • X-rays are necessary to rule out associated osteomyelitis or bony destruction, subcutaneous gas formation, or any retained foreign bodies. • Ultrasound is useful when there is concern for proximal spread into the deep spaces of the hand or forearm. Pain that spreads from the finger to the hand or forearm should raise concern. • Magnetic resonance imaging (MRI) is of little clinical utility for simple felons, paronychia, and FTS and will only serve to delay treatment.

SURGICAL ANATOMY • The flexor tendons of the fingers are contained by longitudinal sheaths, which are reinforced by the pulley systems within each individual finger. The A1, A3, and A5 pulleys originate around the distal necks and interphalangeal (IP) joints of the metacarpal, proximal phalanx, and middle phalanx, respectively. The A2 and A4 pulleys originate at the diaphysis of the proximal and middle phalanx, respectively, and function to prevent bow-stringing of the flexor tendons. • The flexor sheaths of multiple digits may be connected via radial and ulnar palmar bursa, although several anatomic variations have been described. The space of Parona, which is located proximally at a level between the carpal tunnel and pronator quadratus, often permits direct connections between bursa. The connections permit communication between the flexor tendons of the thumb and small finger and can facilitate seeding of the infection to the other digits. For example, a small finger pyogenic FTS can spread to include the thumb as well, forming a so-called “horseshoe abscess” (Fig. 5.4).

POSITIONING • Standard supine positioning with a hand table is used. • The inflammation associated with infections can cause increased surgical site bleeding, which makes it difficult to define normal anatomy. Use a digital or forearmbased tourniquet as necessary. Do not exsanguinate before inflation because this can force proximal extension of an underlying abscess. Instead, elevate the arm and let gravity assist with venous drainage before tourniquet inflation.

FIGURE 5.3  A patient with worsening thumb pain, proximal nail fold swelling, and obvious purulence beneath the nail.

9

10

CHAPTER 5  Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)

Tendon sheaths

Metacarpal heads

EXPOSURE PEARLS

Midaxial incisions should be placed on the radial border of the thumb and small finger and on the ulnar border of the index, long, and ring finger to avoid scar formation and denervation of the border/pinch surfaces.

Ulnar bursa Radial bursa

EXPOSURE PITFALLS

Avoid making a lateral incision directly over the neurovascular bundle, which runs parallel to the distal phalanx. A midaxial incision should be placed just dorsal to the bundle to permit access to the volar pulp tissue, while keeping the nerve and artery within the flap to preserve innervation. The midaxial incision is centered over the lateral joint crease when flexing the digits between the glabrous and nonglabrous skin. An incision dorsal to the bundle can provide complete access to the volar pulp tissue by dissection under the flap and over the tendon sheath.

STEP 1 PEARLS

Use a dental pick or freer elevator to palpate the underlying distal phalanx. If there is cortical erosion on x-rays, or the bone is soft on examination, then biopsies should be taken with a rongeur and sent for osteomyelitis analysis.

STEP 1 PITFALLS

FIGURE 5.4  The proximal extensions of the ulnar and radial bursa that communicate with the flexor sheaths. (From Fig. 16.8 in Chang J, Neligan PC, Liu DZ, eds. Plastic Surgery: Volume 6: Hand and Upper Limb. Elsevier; 2018.)

TREATMENT OF FELON INFECTIONS Exposures • The goal of surgical treatment of a felon is to completely release the internal septations within the volar pulp and debride any necrotic tissue. • This can be achieved with a midlateral incision, a volar midline incision, or an incision directly over the area of purulence (Figs. 5.5 and 5.6).

Step 1

Thorough debridement and irrigation is essential when treating a felon; however, do not remove excessive amounts of fat from the pulp tissue because this can lead to a thin, hypersensitive, and painful fingertip.

• After making the incision, use blunt dissection to release all underlying septa and express all underlying purulent material (Figs. 5.7 and 5.8). • Use small curettes or a synovial rongeur to lightly debride any necrotic fat. • Thoroughly irrigate the pulp tissue with sterile saline. The flexible tip of a standard angiocatheter on a large volume syringe can be used to precisely deliver fluid into the wound.

STEP 2 PITFALLS

Step 2

Do not reapproximate the wound with sutures because this will encourage the wound to close prematurely, risking reformation of the felon.

Place sterile packing gauze within the wound. Leave a small tail of gauze at the wound exit to keep the wound open. This prevents rapid closure of the septa and allows the wound to drain.

CHAPTER 5  Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)

Felon A Midlateral incision

B

Volar midline incision

FIGURE 5.6  Midaxial incision on the ulnar border of the right index finger.

C

FIGURE 5.5  Demonstration of the various septa that exist within the volar pulp tissue and of the various incisions used to drain a felon. (From Fig. 16.7 in Chang J, Neligan PC, Liu DZ, eds. Plastic Surgery: Volume 6: Hand and Upper Limb. Elsevier; 2018.) Incision posterior to digital artery and nerve

All septa divided

FIGURE 5.7  Pus draining from the wound immediately upon incision.

FIGURE 5.8  Complete decompression, release of all septa, and debridement of infectious material. (From Fig. 78.6 in Azar, FM, Canale ST, Beaty JH. Campbell’s Operative Orthopaedics. 13th ed. Elsevier; 2016.)

PYOGENIC FLEXOR TENOSYNOVITIS Exposures • There are two approaches to treating FTS. Traditionally, a long open midaxial approach has been used to expose a large area of the flexor sheath. This wide exposure permits direct visualization and clearance of any necrotic or thick purulent material. • Preferably, a more limited approach can be taken through small incisions proximally at the A1 pulley and distally at the A5 pulley. This approach necessitates flexible catheter irrigation of the sheath (Fig. 5.9) and has the advantage of not violating the tenuous inflamed volar tissue over the digit.

11

12

CHAPTER 5  Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)

A

B

C

FIGURE 5.9  (A) Extensile midaxial incision along the ulnar border of the middle finger. (B, C) Minimally invasive approach for catheter irrigation. (From Wolfe, SW, Pederson WC, Kozin SH, Cohen MS. Green’s Operative Hand Surgery. 7th ed. Elsevier: 2016.)

• We advocate use of the closed method in the majority of cases to preserve the soft tissue over the finger, decrease healing time, and reduce the development of postoperative stiffness and tendon adhesion. STEP 1 PEARLS

Place the incision along the nonborder/pinch surface of the digit, such as the radial border of the small finger, or ulnar border of the index, long, or ring finger.

STEP 2 PITFALLS

Take care to avoid disrupting the DIP joint capsule with the distal dissection because this may introduce infectious material into the DIP joint space.

Step 1: Incisions for Access to the Flexor Sheath • Design a diagonal or Bruner incision over the A1 pulley. The incision should roughly align with the distal palmar crease on the middle, ring, and small fingers or the proximal palmar crease on the index finger. • Distally, at the level of the distal IP joint (DIP), create a 1 cm longitudinal incision along the digital border of the finger, dorsal to the neurovascular bundle. This will place the exposure between the A4 and A5 pulley (Fig. 5.10).

Step 2: Exposing the Flexor Sheath • In the palm, use blunt dissection to spread down to the flexor sheath. Spread in a proximal/distal direction, parallel to the neurovascular (NV) bundles, to avoid injuring

FIGURE 5.10  Demonstration of all four Knavel signs and the planned proximal and distal incisions for a minimally invasive irrigation.

CHAPTER 5  Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)

the bundles that run on either side of the flexor sheath. If NV bundles are identified, retract them away from the sheath (Fig. 5.11). • Distally in the finger, spread in a plane parallel to the NV bundles. The NV bundles will be volar to the incision site.

Step 3: Entering the Sheath • In the palm, make a small longitudinal incision in the tendon sheath, just proximal to the A1 pulley. • In the finger, create a small window (around 0.5 cm) within the sheath distal to the A4 pulley and proximal to the A5 pulley.

Step 4: Irrigating the Sheath • Take the flexible end of a 14- or 16-gauge angiocatheter, which is readily available on most anesthesia carts, and insert it into the sheath through the proximal incision. • Connect the angiocatheter to a large volume (50cc) Luer lock syringe and irrigate thoroughly using sterile saline. Watch for continuous outflow from the distal incision site. A small self-retractor can be used proximally and distally to keep both incisions open. • Irrigate until the fluid is clear. Expect to use at least 500 cc for thorough irrigation even if drainage runs clear before that amount is used (Fig. 5.12).

FIGURE 5.11  The proximal palmar incision with blunt scissor dissection used to reach the entrance of the flexor sheath and A1 pulley.

Step 5: Finishing the Procedure

STEP 3 PEARLS

• Loosely close with 5-0 interrupted monofilament suture (Fig. 5.13). • Pack any open wounds with moist strip gauze to permit continued drainage of any remaining fluid and to prevent wound closure. • Wrap the hand in a bulky soft dressing and place it in a volar slab splint to rest the wounds.

Use needle aspiration before incising the sheath to obtain a sample for culture or be ready to acquire fluid for testing after making an incision in the sheath.

Although not as commonly available as angiocatheters, pediatric feeding tubes are another common tool used to irrigate the flexor sheath with minimal invasiveness.

PARONYCHIA Exposures • Superficial infections between the lateral fold and nail can be decompressed with a freer elevator or a 15-blade scalpel (Fig. 5.14). • Obvious purulence under the nail causing nail displacement or infections that extend proximally often needs to be treated with partial nail removal, irrigation, and debridement.

FIGURE 5.12  The incision of the A1 pulley is seen, with a 25Fr pediatric feeding tube entering the flexor sheath.

STEP 4 PEARLS

STEP 5 PITFALLS

If there is any concern about retained infectious material, or if signs and symptoms of infection worsen again postoperatively, then return to the operating room (OR) for re-exploration and additional irrigation and debridement, as necessary.

FIGURE 5.13  Wounds closed.

13

14

CHAPTER 5  Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)

Scapel blade Swollen nail fold

Collection of pus

FIGURE 5.14  Blunt dissection under the lateral nail fold, releasing the underlying purulence. (From Fig. 149.2 in Azar, FM, Canale ST, Beaty JH. Campbell’s Operative Orthopaedics. 13th ed. Elsevier; 2016.) STEP 1 PEARLS

• When the entire nail is affected, the whole nail should be removed. • Two longitudinal incisions can be created in the proximal nail fold, in line with the lateral nail folds, to decompress any proximal migration of the paronychia (Fig. 5.17).

FIGURE 5.15  A longitudinal cut is made down the length of the thumb nail, releasing the underlying purulence.

Step 1: Nail Removal • Slide the blunt end of a freer elevator between the affected lateral nail fold and fingernail to decompress the underlying abscess. • Use tenotomy scissors or a 15-blade scalpel to create a longitudinal cut in the nail, roughly one-third to one-half the width of the nail, on the affected side (Fig. 5.15). • Starting at the distal end of the nail, use the sharp end of a Freer elevator, with the curve pointing up toward the nail, to slowly release the nail fragment from the underlying sterile matrix (Fig. 5.16). • Finally, release the proximal nail from under the eponychium.

Step 2: Closure • Leave the wound open to drain and heal by secondary intention. • Splint the nail folds open with strip gauze to encourage continued drainage and prevent premature wound closure.

A

B

D

FIGURE 5.16  The nail is then dissected free of the underlying sterile matrix and proximal nail fold, fully decompressing the paronychia.

C

E

FIGURE 5.17  (A-E) Release of the proximal nail folds bilaterally, with the eponychium then held open with strip gauze to prevent premature wound closure. (From Fig. 16.2 in Chang J, Neligan PC, Liu DZ, eds. Plastic Surgery: Volume 6: Hand and Upper Limb. Elsevier; 2018.)

CHAPTER 5  Finger Infections (Paronychia, Felons, Pyogenic Flexor Tenosynovitis)

• Use a finger-based or stack splint to protect the vulnerable fingertip and prevent motion through the DIP joint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Postoperative management of felons, paronychia, and FTS are all similar. • On the first postoperative day, the patient can begin with soaks and dressing changes three times a day. Soaks can be performed in a 1:1 mix of peroxide and warm water, a warm soapy solution, or dilute betadine–saline solution. • Packing gauze should be removed after 36 to 48 hours. It is often too painful for this gauze to be replaced in the wound; thus we do not recommend it. • Stiffness often sets into the adjacent unaffected digits. We recommend starting hand therapy soon after surgery to prevent loss of motion. Active and passive range-ofmotion (ROM) exercises should be performed during soaks. • Felons, paronychia, and FTS are usually treated by an infectious disease specialist for 4 to 6 weeks with either IV or oral antibiotics. Repeat debridement is rarely required.

EVIDENCE Draeger RW, Bynum Jr DK. Flexor tendon sheath infections of the hand. J Am Acad Orthop Surg. 2012;20:373–382. This study highlights the importance of antibiotics, timing of surgical intervention, and available outcomes. It stresses the importance of earlier intervention for patients who present later and with advanced infection or with concerning comorbidities. Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol. 2015;40:720–728. Systematic review of the literature on treatment of pyogenic flexor tenosynovitis. It identifies the value of IV antibiotic treatment to avoid surgery in mild cases and highlights the benefits of closed irrigation rather than open washout and the use of antibiotics in addition to washout. Kanavel AB. An anatomical, experimental, and clinical study of acute phlegmons of the hand. Surg Gyneco Obstet. 1:221–259. These are the classic historical writings of Dr. Kanavel, where he first described the presentation of pyogenic FTS. He also used plaster of Paris injections of cadaveric hands and used radiographs to demonstrate many of the theoretical spaces within the hand where infection can accumulate. Many of his described treatments are still relevant today.

15

CHAPTER

6

Splints and Orthoses Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com.

KEY CONCEPTS • Think critically about the goals of the operation and consider whether immobilization is necessary. If immobilization is required, determine how far distal or proximal the orthosis should extend. For fractures or periarticular trauma, the first joints proximal and distal to the injury typically require immobilization. • Wrist motion can create substantial strain through the flexor and extensor tendons, even if individual fingers are immobilized. Therefore many tendon repair protocols advise immobilization of the wrist joint as well. • Unnecessary immobilization of adjacent joints can cause stiffness that slows the overall recovery process and may lead to permanent loss of motion. In particular, splints that cross the elbow should be avoided unless there is an absolute need to prevent forearm rotation, such as in forearm or distal radioulnar joint injuries. • Once motion is initiated in the recovery period, it is important to recognize how an orthosis can aid or inhibit passive and active motion. For example, a yoke splint is commonly used for sagittal band injuries. This prevents flexion of only the affected metacarpophalangeal (MCP) joint but enables free flexion and extension of all other joints. • Nonremovable splints are commonly applied to patients in the operating room. These splints are left in place for several weeks after the procedure until patients are no longer vulnerable to reinjury. By contrast, removable splints are commonly used in the later stages of postoperative recovery. Orthoses reviewed in this chapter: • Finger-based splint • Hand-based splint • Forearm-based splint • Gutter splint • Dynamic splint • Static progressive splint

FIGURE 6.11  Dynamic forearm-based orthosis.

16

CHAPTER

6

Splints and Orthoses Benjamin K. Gundlach and Kevin C. Chung INTRODUCTION This textbook describes over 120 surgical procedures of the finger, hand, wrist, and forearm. For many of these procedures, splints or orthoses are used to immobilize or support the operative sites. The goal of this chapter is to introduce the basic tenets of upper extremity splinting and to present the common orthoses that can be used during postoperative recovery.

BASIC PRINCIPLES OF ORTHOSES • Think critically about the goals of your operation. • First consider whether immobilization is necessary. Strict cast immobilization is often applied immediately after fracture fixation, joint stabilization, tendon repair, or free tissue transfer procedures to prevent displacement or reinjury of the repaired structures. Nevertheless, this is increasingly unnecessary because of advances in orthopedic implants and improved understanding of soft-tissue healing. For example, modern locked plating provides more than adequate stability and rigidity to permit early postoperative motion after extraarticular fracture fixation within the wrist or hand. Similarly, advancements in the scientific understanding of tendon healing and the publication of prospective trials evaluating postoperative rehabilitation indicate that early mobilization is beneficial after acute flexor tendon repairs. • If immobilization is required, consider how far distal or proximal the orthosis should extend. For fractures or periarticular trauma, the first joints proximal and distal to the injury typically require immobilization. For example, a sugar-tong splint that immobilizes the elbow and wrist is often indicated for a displaced distal radius fracture treated with closed reduction (Fig. 6.1). • Remember the tenodesis effect. Wrist motion can create substantial motion or strain through the flexor and extensor tendons, even if individual fingers are immobilized. Therefore many tendon repair protocols advise immobilization of the wrist joint as well. • Do not immobilize adjacent joints needlessly, because this causes unnecessary stiffness that slows the overall recovery process or causes permanent loss of motion. • Immobilization of the elbow is often unnecessary. Splints that cross the elbow should be avoided unless there is an absolute need to prevent forearm rotation, such as in forearm or distal radioulnar joint injuries. Elderly patients in particular can develop permanent elbow stiffness after only a few weeks of immobilization. • Historically, it was thought that forearm immobilization was required for carpal injuries such as scaphoid fractures. More recent biomechanical studies, however, suggest that forearm pronation/supination does not produce a significant displacement force. Therefore we recommend the elbow be left free in most patients with scaphoid injuries. • Pay close attention to the cascade of the metacarpal heads when fabricating plaster splints. It is a common mistake to extend the plaster or fiberglass too distally, past the small finger metacarpophalangeal (MCP) joint, when applying a forearm-based splint. This provides needless immobilization of the small finger. In combination with the swelling associated with a fracture or surgery, this can lead to long-term loss of motion in the digit. • Once motion is initiated in the recovery period, it is important to recognize how an orthosis can aid or inhibit passive and active motion. • For example, in many flexor tendon rehabilitation protocols, an orthosis is used to prevent finger extension beyond neutral but still permit active-assisted or passive flexion (Fig. 6.2).

FIGURE 6.1 From Dehn R, Asprey D. Essential Clinical Procedures. 4th ed. Philadelphia, PA: Elsevier; 2020.

FIGURE 6.2

16.e1

16.e2

CHAPTER 6  Splints and Orthoses

• Similarly, a yoke splint is commonly used for sagittal band injuries. This prevents flexion of only the affected MCP joint but enables free flexion and extension of all other joints (Fig. 6.3). • Determine when the patient can transition to a removable splint. • Nonremovable splints are commonly applied to patients in the operating room. These splints are left in place for several weeks after the procedure until patients are no longer vulnerable to reinjury. • In contrast, removable splints are commonly used in the later stages of postoperative recovery. Velcro removable splints are often preferred by patients because they are lighter and less bulky than nonremovable, circumferential casts or splints and because they permit hand hygiene.

CATEGORIES OF ORTHOSES Beyond the standard sugar-tong and forearm-based plaster splints, most upper extremity orthotic devices are created by hand therapists. Although it is outside the scope of this textbook to detail the steps of their fabrication, it is important that every hand surgeon understands the various types of orthoses available and when to use them. FIGURE 6.3

Finger/Digit Based A finger-based splint is used to immobilize the distal interphalangeal (DIP) or proximal interphalangeal (PIP) joints of one or multiple fingers. Fig. 6.4 demonstrates our preferred method for nonoperative treatment of mallet fingers using a splint. This method is advantageous over the traditional Stack/Stax splint because it causes less dorsal skin irritation and is easier for patients to place independently.

Hand Based • A hand-based splint immobilizes at least part of the hand and may extend distally to include the thumb or digits but does not extend proximal to the wrist joint. Handbased splints are typically used for acute injuries, such as metacarpal or phalangeal fractures, or in nonoperative management of patients who have chronic conditions, such as arthritis. • Fig. 6.5 portrays a hard, removable, hand-based thumb spica splint with the IP joint free, which is often prescribed to patients with thumb carpometacarpal (CMC) arthritis. A

Forearm Based

B

FIGURE 6.4

• Forearm-based orthoses encompass a broad range of immobilization devices that extend proximal to the wrist and include the forearm. Forearm-based immobilization can end at the level of the MCP joints, include a thumb spica extension, or extend to the fingertips. • A resting intrinsic plus position (Fig. 6.6) is necessary to prevent joint contractures, especially for acute injuries such as fractures of the second to fifth carpometacarpal joints or metacarpals. This places the wrist in 30 degrees of extension, the MCP joints in 70 to 90 degrees of flexion, and the PIP/DIP joints in 0 degrees extension. • Fig. 6.7 portrays a forearm-based thumb spica orthosis, which can be used after CMC arthroplasty, scaphoid open reduction and internal fixation (ORIF), or other procedures that affect the scaphoid or thumb. • Fig. 6.8 shows a standard volar forearm-based splint that terminates at the MCP joints and leaves the thumb free. This splint is provided to patients who undergo wrist surgery, such as distal radius ORIF. • Fig. 6.9 demonstrates a forearm-based orthosis that extends to the fingertips, which is often necessary for patients with inflammatory arthritis who have undergone MCP arthroplasty with centralization of the extensor tendons and cannot yet initiate active or passive motion.

Gutter • A gutter splint is an orthosis that immobilizes only part of the hand and digits on either the radial or ulnar border of the hand. Gutter splints can be hand-based or

CHAPTER 6  Splints and Orthoses

A

B

FIGURE 6.5

FIGURE 6.6 From Stender Z. Hand and wrist. In: Browner B, Fuller R, eds. Musculoskeletal Emergencies. Philadelphia, PA: Saunders. 2012;148–183.

A

B

C

FIGURE 6.7

16.e3

16.e4

CHAPTER 6  Splints and Orthoses

A

B

C FIGURE 6.8

A

B FIGURE 6.9

forearm-based and are commonly used to stabilize CMC joint, metacarpal bone, or MCP joint injuries. • Radial gutter splints immobilize the index and middle fingers, whereas ulnar gutter splints (Fig. 6.10) immobilize the small and ring fingers. Note that the thumb is usually free of immobilization in both ulnar and radial gutter splints.

Dynamic • Dynamic splints use the power of elastic bands and springs—in combination with pulleys and outriggers—to permit free movement in one direction while blocking or limiting movement in a different direction. • Fig. 6.11 shows a dynamic forearm-based orthosis that may be used by rheumatoid arthritis patients who have undergone MCP joint arthroplasties with a concomitant extensor tendon centralization procedure. This splint permits full digital flexion, provides

CHAPTER 6  Splints and Orthoses

A

B FIGURE 6.10

A

B FIGURE 6.11

dynamic assistance with extension to avoid stressing the sagittal band reconstruction, and prevents ulnar drift via the radially angled outriggers.

Static Progressive • Static progressive orthoses apply constant, low-level force to stiff joints over the span of days or weeks. They are used throughout the upper extremity to treat contractures after injury or surgery.

16.e5

16.e6

CHAPTER 6  Splints and Orthoses

• These splints typically consist of cords or straps and pulleys that provide a direct line of pull to the digits or wrist in the direction of terminal motion loss. Fig. 6.12 shows a forearm-based static progressive splint used for a stiff PIP joint with loss of flexion. The cord pulls the middle finger in a volar direction, whereas the extension on the middle finger to include the proximal phalanx ensures the force is directed only through the PIP joint.

EVIDENCE

FIGURE 6.12

McAdams TR, Spisak S, Beaulieu CF, Ladd AL. The effect of pronation and supination on the minimally displaced scaphoid fracture. Clin Orthop Relat Res. 2003;411:255–259. A biomechanical study of 10 upper extremities in which a waist fracture was created in the scaphoid. Metallic markers were placed at the margin of the fracture, and then the extremities were placed into a below-elbow cast. Computed tomography (CT) scanning was then performed in various forearm positions and compared with uncasted controls. There was no significant displacement of the scaphoid fracture with below-elbow casting throughout pronation-supination, whereas the uncasted control group had unacceptable displacement with identical movement. Clementsen SO, Hammer OL, Benth JS, et al. Early mobilization and physiotherapy vs late mobilization and home exercises after ORIF of distal radial fractures. JBJS Open Access. 2019;4(3):e0012.1–11. Level 1 evidence study in which 119 patients who underwent ORIF of an extraarticular distal radius fracture were randomized into early mobilization and therapy within 48 hours postoperatively or delayed mobilization with splinting for 2 weeks. At 24 months postoperatively, there were no changes in QuickDASH (Quick Disabilities of Arm, Shoulder, and Hand) scores, grip strength, or range of motion. These results suggest that early transition from plaster splints to a removable orthosis is well tolerated by patients with little to no long-term effects.

ddsf

SECTION II

Hand Fractures and Dislocations CHAPTER 7

Principles of Bone Fixation and Healing  18

CHAPTER 8

Kirschner Wire Fixation of Mallet Fractures  19

CHAPTER 9

Techniques for Fixing Extraarticular Phalangeal Fractures  20

CHAPTER 10

Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint  21

CHAPTER 11

Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures  22

CHAPTER 12

Volar Plate Arthroplasty of the Proximal Interphalangeal Joint  23

CHAPTER 13

Hemi-Hamate Arthroplasty  24

CHAPTER 14

Techniques and Fixation of Metacarpal Fractures  33

CHAPTER 15

Open Reduction for Metacarpophalangeal Joint Dislocation  34

CHAPTER 16

 orrective Osteotomy of Metacarpal Fracture C Malunion  40

CHAPTER 17

Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb  41

CHAPTER 18

Techniques for Fixing Bennett and Rolando Fractures  52

17

CHAPTER

7

Principles of Bone Fixation and Healing Chun-Yu Chen and Kevin C. Chung Full text of this chapter is available online at expertconsult.com.

KEY CONCEPTS • Fracture healing requires coordinated interactions among multiple cell types, cytokines, and growth factors. The healing process is influenced by the local mechanical and biologic environment, as well as the surgical fixation device and reduction method. To optimize fracture healing, the fracture must be reduced to a satisfactory position and stabilized. • Fractures heal via primary (intramembranous) and secondary (endochondral) types of healing. The degree of fracture stability will influence which type of healing predominates; more rigid fixation favors primary fracture healing. • Secondary bone healing progresses in the following stages: hematoma stage, inflammatory stage, soft callus stage, hard callus stage, remodeling stage. • Pins are used in percutaneous pinning of small bone fractures, commonly in hand and wrist fractures. They are also useful for temporarily maintaining the reduction of a fracture before implant placement. • Screws can be used on their own to hold two fragments together or used in combination with plates. • A variety of plates are available to provide absolute or relative fracture stability. Locking plates create angular stability between the implant and the bone. They are more resistant to mechanical disruption than a conventional plating system. Fixation techniques reviewed in this chapter: • Pins • Screws • Cortical screws • Cancellous screws • Cannulated screws • Self-tapping screws • Headless compression screws • Lag screws • Position screws • Plates • Conventional • Dynamic compression • Locking

18

A

B

C

D

FIGURE 7.8  The lag screw generates interfragmentary compression.

CHAPTER

7

Principles of Bone Fixation and Healing Chun-Yu Chen and Kevin C. Chung

THE ESSENTIAL COMPONENTS OF FRACTURE HEALING • Fracture healing is a complex and dynamic process that restores injured bones to prefracture conditions. • Fracture healing requires coordinated interactions among multiple cell types, cytokines, and growth factors. The healing process is influenced by the local mechanical and biologic environment, the surgical fixation device, and the reduction method. • Maintaining adequate blood flow to the affected site is the primary determinant of how well a fracture heals. To optimize fracture healing, the fracture must be reduced to a satisfactory position and stabilized.

TYPES OF HEALING Intramembranous Ossification (Primary Bone Healing) • Intramembranous ossification is the process of direct bone formation without a cartilage intermediate. This type of ossification is responsible for primary bone healing and normal bone remodeling. • Primary bone healing is favored when anatomic reduction minimizes the fracture gap and motion between two fracture surfaces is restricted through rigid internal fixation. • Intramembranous ossification begins with osteoprogenitor cells, a class of undifferentiated mesenchymal cells located in the deep layers of periosteum, endosteum, and marrow. These cells aggregate into membrane-like layers and proceed to differentiate directly to osteoblasts without the formation of cartilage. The process concludes with direct deposition of osteoid and subsequent mineralization. • Throughout this process, no clinically visible callus can be appreciated on radiographs.

Endochondral Ossification (Secondary Bone Healing) • Endochondral ossification is a sequential process that is responsible for secondary bone healing. • Secondary bone healing of a fracture is favored when the fracture site has some degree of mobility, unlike primary bone healing, which is favored by a rigid environment. Treatments that create favorable conditions for secondary bone healing include nonrigid fixation and casting immobilization. • The majority of fracture healing takes place via secondary bone healing. This process begins with mature chondrocytes undergoing senescence and calcification, leaving behind a scaffold of extracellular matrix. Blood vessels and osteoblasts then invade this cartilage matrix, resulting in the deposition of immature bone. • It is important to note that bone replaces cartilage in this process; cartilage is not converted to bone.

STAGES OF SECONDARY BONE HEALING

TYPES OF HEALING PEARLS

• Fractures heal via primary (intramembranous) and secondary (endochondral) types of healing. The degree of fracture stability will influence which type of healing predominates. • Both types of fracture healing require a similar amount of time to restore mechanical integrity. • Rigid fixation strives for primary bone healing that is more expedient in returning to function and induces less deformity at the fracture site.

The healing process begins at the time of the injury. Although secondary bone healing is conceptualized here in stages, these processes overlap with each other in reality (Fig. 7.1).

Hematoma Stage • A fracture causes local disruption of blood vessels, leading to the formation of a hematoma. 18.e1

CHAPTER 7  Principles of Bone Fixation and Healing

Inflammation stage Soft callus stage Hard callus stage Remodeling stage Biological activity (%)

18.e2

1 week

3 weeks

6 weeks

3 months

3 years

Hematoma stage FIGURE 7.1  Stages of secondary bone healing.

• The oxygen saturation inside a hematoma decreases significantly over the first 72 hours after a fracture. In response, hypoxia-inducible factor (HIF)-1 increases the production of vascular endothelial growth factor (VEGF), resulting in angiogenesis and revascularization of the affected area. • In addition, local hypoxic conditions alter the gene expression of osteoprogenitor cells, causing them to proliferate, secrete extracellular matrix, and differentiate into chondrocytes. • Several animal studies have shown that the removal of fracture hematoma during early healing (2–4 days) leads to inferior healing, highlighting the critical role of the hematoma in the healing process.

Inflammatory Stage • The inflammatory stage is characterized by a strong cellular response to fracture healing. • Cellular debris inside the hematoma incites an inflammatory response mediated by inflammatory cells including platelets, neutrophils, macrophages, and lymphocytes. These cells release various cytokines to modulate the healing process. Some cytokines elicit pain, encouraging the individual to immobilize the injured area. • Among these cytokines, tumor necrosis factor (TNF)-alpha plays a vital role in coordinating the inflammatory stage. A fracture-related hematoma contains a sevenfold higher concentration of TNF-alpha compared with peripheral blood. Low levels of TNF-alpha are associated with delayed fracture healing. SOFT CALLUS STAGE PEARLS

The local mechanical environment drives the differentiation of progenitor cells into either osteoblastic (stable environment) or chondroblastic (unstable environment) lineages of cells.

Soft Callus Stage • This stage begins a few days to 6 weeks after the injury. The process is analogous to the formation of cartilage through endochondral ossification. • Fibroblasts and chondroblasts build connective tissue and cartilage, respectively. The fibrocartilaginous callus fills the fracture gap, providing stability and supporting vascular ingrowth.

Hard Callus Stage • The conversion of cartilage into woven bone defines the hard callus stage. This occurs several weeks after a fracture and takes approximately 3 months. • Woven bone is a disorganized matrix of collagen fibers that further strengthens the callus and is visible on radiographs.

CHAPTER 7  Principles of Bone Fixation and Healing

• For patients receiving nonoperative treatment such as casting or traction, the hard callus stage is also accompanied by a clinically apparent reduction in pain and increased stability at the fracture site.

Remodeling Stage • In this stage, woven bone is converted into lamellar bone through organized osteoblast and osteoclast activity. This phase can continue for several years. • The histology of fully healed bone is almost identical to the unbroken bone. • During remodeling, bone responds to loading stress according to Wolff’s law.

FACTORS INFLUENCING FRACTURE HEALING For a summary of factors influencing fracture healing, see Table 7.1.

Local Factors • Viability of the fracture fragment depends on several factors: • Fracture location and pattern. For example, metaphyseal fractures are associated with faster healing. • Presence of soft tissue attachments, which is associated with enriched blood supply to the fracture site and better healing. • Bone loss and comminution, which are associated with delayed healing.

Systemic Factors • Smoking • Smoking reduces local blood supply and inhibits the growth of new blood vessels during the healing process. This increases the risk for nonunion and delayed union. • Smoking almost doubles the risk for infection in patients receiving surgery. • Smoking decreases fracture callus strength. • Alcohol • Alcohol inhibits osteoblast differentiation and has a dose-dependent adverse effect on the functions of osteoblasts. • Excessive intake is associated with osteomalacia and aseptic osteonecrosis of the hip. • Nutrition • Vitamin D and calcium supplementation should be encouraged because vitamin D deficiency is associated with nonunion.

TABLE Factors Influencing Bone Healing 7.1

Local factors

Systemic factors

Medications

Location

Age

NSAIDs

Fracture pattern

Traumatic brain injury

Corticosteroids

Comminution or bone loss

Diet and nutrition

Bisphosphonates

Fracture gap

Medical conditions (DM)

Quinolones

Soft-tissue coverage

Hormones

Antineoplastics

Method of fixation

HIV

Neurovascular injury

Alcohol

Open fracture

Smoking

Infection Radiation DM, Diabetes mellitus; NSAID, Nonsteroidal antiinflammatory drug.

REMODELING STAGE PEARLS

Wolff’s law states that the growth and remodeling of bone is influenced by mechanical forces that are applied to the bone. Placing moderate amounts of mechanical stress on bone during the remodeling phase can trigger an adaptive response that augments bone strength.

18.e3

18.e4

CHAPTER 7  Principles of Bone Fixation and Healing

• Protein malnutrition decreases callus strength. Amino acid supplementation can facilitate callus mineralization. • HIV • HIV infection can lead to a relative TNF-alpha deficiency, which is associated with poor fracture healing.

Medications • Nonsteroidal antiinflammatory drugs (NSAIDs) • Cyclooxygenase (COX)-2 activity is required for endochondral ossification during the healing process. • NSAIDs can prolong healing time by inhibiting COX-2. • Corticosteroids • Corticosteroids promote cell death of osteoblasts and osteocytes and inhibit osteogenesis. • They are associated with a higher nonunion rate. • Quinolones • Quinolones are associated with delayed fracture healing because of their harmful effects on chondrocytes.

FIXATION METHODS AND MECHANICAL STABILITY Stability and Fracture Healing

STABILITY AND FRACTURE HEALING PITFALLS

• Hypertrophic nonunion • Related to excessive fracture instability in the setting of adequate blood supply at the fracture site. • Atrophic nonunion • Caused by inadequate vascularity of fractured fragments or poor healing environment owing to infection, open fracture, compromised nutrition, or smoking.

The degree of fracture stability influences the type of fracture healing (Table 7.2). Absolute stability promotes primary bone healing, whereas relative stability facilitates secondary bone healing with callus formation.

Absolute Stability • Absolute stability is defined as rigid fixation with no motion between the fractured fragments under physiologic loading. • Under these conditions, bone heals through primary healing without a callus. • Examples of absolute stability include a simple oblique fracture treated with an interfragmentary screw and a simple transverse fracture treated with a dynamic compression plate.

Relative Stability • Relative stability is characterized by more elastic fixation, which permits micromotion at fracture site under physical loading. Nevertheless, excessive motion must be avoided because this increases the risk for hypertrophic nonunion. • Fractures with relative stability will preferentially heal via secondary bone healing with a callus. • Examples of relative stability include nonoperative management such as a cast or splint, external fixator, intramedullary nail, and bridge plate.

STRAIN THEORY

Strain =

L

ΔL L

ΔL

FIGURE 7.2  Conceptual diagram of fracture gap strain. L 5 Original length of fracture gap; ∆ L 5 change in length of fracture gap.

Strain is defined as the deformation of a material relative to its original form when a force is applied. In the context of a fracture, strain is quantified as a change in length of the fracture gap divided by the original length of the fracture gap (∆L/L) (Fig. 7.2).

Strain and Fracture Healing • A strain of less than 2% is associated with absolute stability and promotes primary fracture healing. • A strain of 2% to 10% is associated with relative stability and results in secondary fracture healing with callus. • A strain greater than 10% is associated with excessive instability at the fracture site and does not permit bone formation. • Multifragmentary fractures can tolerate more strain than simple fractures because the overall strain is distributed among many fracture gaps (Fig. 7.3A–B).

CHAPTER 7  Principles of Bone Fixation and Healing

TABLE Relationship Between Fixation Method and Fracture Stability 7.2

Suitable Fracture Type

Fixation Methods

Absolute stability (Primary healing)

Simple fracture

Rigid fixation Interfragmentary screw Dynamic compression plate Tension band wire

Relative stability (Secondary healing)

Comminuted fracture

Nonrigid fixation Casting External fixation Intramedullary nail Bridging plate

Simple fracture

L

Strain = 30%

A

1.3 L

Comminuted fracture

L

L

L

Strain = 10%

B

1.1 L

1.1 L

1.1 L

FIGURE 7.3  (A–B) Relationship between strain and fracture type. Comminuted fractures have a lower strain because the displacement can be distributed among multiple fracture gaps. L 5 Length of fracture gap.

Applying the Theory • A simple transverse or oblique fracture is best reduced anatomically and fixed by a compression screw or plate. This produces absolute stability and avoids high strain. • Optimal healing of multifragmentary fractures requires a callus to fill in all the fractures gaps, a process that is facilitated by relative stability. Nevertheless, multifragmentary fractures intrinsically have a low strain because of the distribution of mechanical stress over many fracture gaps. Therefore options with indirect reduction and less rigid fixation, such as a nail, bridge plate, or external fixator, are better choices because they provide slightly higher strain and promote relative stability.

FIXATORS FOR HAND AND WRIST SURGERY Pins • Pins can be threaded or smooth and are available in several sizes. The threaded pin minimizes sliding when engaging with the fragment and provides more stability than a smooth pin; however, this property also makes the threaded pin more challenging to remove.

PINS PEARLS

At least two pins should be used. To prevent sliding or rotation of the fragment, the pins should not be placed in parallel (Fig. 7.4A–C).

18.e5

18.e6

CHAPTER 7  Principles of Bone Fixation and Healing

A

B

C

FIGURE 7.4  (A–C) Pinning fixation for a distal radius fracture.

• Pins are useful for temporarily maintaining the reduction of a fracture before implant placement. They are also used in percutaneous pinning of small bone fractures, commonly in hand and wrist fractures. • Pins have less mechanical stability compared with plates and screws and therefore do not provide significant contributions to weight bearing or strength.

Screws • Screws are typically named according to their design, size, and choice of application. • The design can be cortical, cancellous, cannulated, self-tapping, headless, or compression. • Cortical screws are fully threaded, with shallower threads than those in cancellous screws. The distance between threads, known as the screw’s pitch, is shorter in cortical screws compared with cancellous screws. The blunt-ended tip of the cortical screw necessitates tapping before screwing. The cortical screw is used to secure both cortices during interfragmentary fixation or to fix plates to long bones. • Cancellous screws have a deeper thread and larger pitch than cortical screws. They are commonly used for fixation of the metaphyseal region, which contains a larger proportion of cancellous bone. Cancellous screws can be fully threaded or partially threaded; the latter can function as a lag screw to compress the fracture site (Fig. 7.5A–B). • The cannulated screw contains a hollow shaft. This feature enables the screw to insert over a guide pin or guide wire after a satisfactory position is confirmed. Cannulated screws are commonly used to fix fractures that require great precision and do not permit frequent change in position, such as femoral neck fractures and pediatric fractures. • Self-tapping screws have shallow threads with a sharp cutting flute that facilitates insertion. They can be inserted without tapping the screw track because of their ability to self-cut. The majority of locking plate systems use self-tapping screws. • Headless compression screws have a larger pitch at the distal threads than the proximal threads. This unequal pitch causes the screw to move forward at different rates in the proximal and distal fragments, resulting in compression of the fracture site. Because these screws must be buried in the bone to achieve maximal compression, they are suitable for fracture fixations where the screw head will not be exposed outside the bone, such as with femoral condyle fractures or scaphoid fractures (Fig. 7.6A–B).

CHAPTER 7  Principles of Bone Fixation and Healing

Deep and partially threaded

A

B

FIGURE 7.5  (A–B) Deep and partially threaded cancellous screws for fixation of a medial malleolar fracture.

Unequal pitch

A

B

FIGURE 7.6  (A–B) Headless compression screws for fixation of a scaphoid fracture.

• Dimension of outer thread diameter: The most common dimensions for screws are: 1.5, 2, 2.4, 2.7, 3.5, 4.5, and 6.5 mm. • Application includes cortex or cancellous bone, bicortical or monocortical, lag compression, position screw, or locking screw. • Screws can be used on their own to hold two fragments together (Fig. 7.7) or used in combination with plates.

Lag Screws • Lag screws generate interfragmentary compression and promote absolute stability of fracture fixation.

Course • First, drill a gliding hole with a drill bit slightly larger than the outer diameter of the cortex screw (Fig. 7.8A–B). Next, a drill sleeve is inserted into the gliding hole to

FIGURE 7.7  Screw fixation for a fourth metacarpal spiral fracture.

SCREWS PITFALLS

• The head of an isolated screw should be countersunk in the near cortex. This increases the contact area between the screw head and the bone, and reduces the risk of stress-related cracks. • Drilling with a dull drill bit may cause thermal necrosis, which is detrimental to fracture healing.

18.e7

18.e8

CHAPTER 7  Principles of Bone Fixation and Healing

A

B

C

D

FIGURE 7.8  Placing a lag screw. (A) An oblique fracture gap. (B) Drilling a gliding hole. (C) A drill sleeve is inserted into the gliding hole. A smaller drill bit is used to accurately center the opposite cortex. (D) A lag screw is used to pull the far cortex and compress the gap. LAG SCREWS PEARLS

• It is essential to first drill a gliding hole in the near cortex, then insert the drill guide into the hole to align the far cortex accurately. • If the surgeon drills through both cortices simultaneously and proceeds to make a big gliding hole in the near cortex, this may result in a misaligned screw direction.

LAG SCREWS PITFALLS

To generate optimal compression, a lag screw should be positioned perpendicular to the fracture plane. If the fixation direction is not perpendicular, interfragmentary compression can generate additional sliding forces that may compromise the anatomic reduction (Fig. 7.9).

POSITION SCREWS PEARLS

Unlike the lag screw, the position screw does not need to be placed perpendicular to the fracture plane. Nevertheless, completing an anatomic reduction before placing a position screw is recommended.

accurately center the threaded hole in the opposite cortex. The opposite cortex is drilled with a smaller drill bit corresponding to the inner diameter (core) of the screw (see Fig. 7.8C). • The thread only engages with the cortex opposite to the fracture line (far cortex), not with the cortex close to the screw head (near cortex). • When the screw head contacts the near cortex and can no longer move forward, the distal thread continues to engage the opposite cortex. This pulls the opposite cortex toward the proximal direction when driving, creating compression between the two fragments (see Fig. 7.8D).

Position Screws • A position screw is a fully threaded screw that engages in both cortices. Therefore when the screw is turned, the two fracture fragments are held at their current position. A defined gap between the fragments is maintained without generating compression. • Position screws can be used instead of lag screws when difficulties occur with exposure and drill direction. • The surgeon must compress the fracture gap with clamps to achieve anatomic reduction before drilling.

Course • First, drill a hole through both the far and near cortex with the same axis. Use a drill bit that corresponds to the inner diameter of the screw. • Tapping the screw may be advisable, but this depends on the bone quality. • A position screw advances to thread both cortices and maintains reduction, with or without a gap.

Conventional Plates • The conventional plate has screw holes that are countersunk by screw heads. This compresses the plate onto the bone and minimizes prominence. The preload and friction between the two surfaces promote stability. FIGURE 7.9  Incorrect positioning of a lag screw.

Functions of Various Plates • A variety of plates are available to serve different functions and are designed to provide absolute or relative stability.

CHAPTER 7  Principles of Bone Fixation and Healing

• A neutralization or protection plate protects a simple fracture that was reduced anatomically and fixed by lag screws. It is commonly used for smaller bones that are not primary weight bearing, such as the clavicle (Fig. 7.10). • A compression plate promotes axial compression through the eccentric placement of screws and is suitable for transverse fractures that require compression, such as radial (Fig. 7.11) or ulnar shaft fractures. • A buttress plate supports the large articular fragment to prevent gliding, such as the volar Barton or radial column fracture (Fig. 7.12) of the distal radius. • A tension band plate or tension band wire reduces tensile forces and augments compressive forces at fracture sites in eccentrically loaded bones. Tension band wires are often applied to fractures associated with joint motion, such as the olecranon (Fig. 7.13) or patellar fracture. • A bridging plate is a long plate inserted through small incisions at each end of the fracture site, obviating the need to expose the entire fracture site. Bridging plates are recommended for extensive and comminuted fractures (Fig. 7.14), for which other approaches may cause massive disruption of soft tissues.

FIGURE 7.10  Lag screw fixation of a clavicular fracture.The black arrow points to a lag screw.

FIGURE 7.11  Dynamic compression plate fixation of a transverse radial shaft fracture.

18.e9

18.e10

CHAPTER 7  Principles of Bone Fixation and Healing

FIGURE 7.12  Buttress plate fixation of a radial column fracture.

A

B

FIGURE 7.13  Tension band wire fixation of an olecranon fracture. The yellow arrows represent the force direction and location. (A) Without fixation, joint motion will create tensile forces that exacerbate fracture gap displacement. (B) After tension band wire fixation, tensile forces at the eccentric cortex are converted to compressive forces at the fracture site.

A

B

FIGURE 7.14  Long bridging plate fixation of a comminuted fracture of the radius. (A) Before fixation. (B) After fixation with long bridging plate. The yellow dotted lines represent the distal and proximal incisions.

CHAPTER 7  Principles of Bone Fixation and Healing

Compression distance

FIGURE 7.15  A dynamic compression plate contains holes with sloped edges on the side distal to the fracture site. In this image, the screw on the right was inserted away from the sloped edge, locking the plate without moving it. Next, the screw on the left is inserted on the other side of the fracture, with the screw head contacting the slope. When this screw is tightened, its movement down the slope will create a compressive force.

Dynamic Compression Plate • Dynamic compression plates (DCPs) contain oval-shaped screw holes with sloped edges on the side that is distal to the fracture site (Fig. 7.15). When a spherical screw head is placed eccentrically on the inclined aspect of the screw hole, tightening of the screw causes the screw head to slide down the slope of the hole toward the fracture site. This movement generates fracture compression. • Once the compression is deemed adequate, the remaining screws can be placed in a central fashion without contacting the sloped edge of the screw hole. • A new advancement in DCP technology is the limited contact DCP, which is designed to have less contact area on the bone. This reduces the harmful effects of pressure and friction in poorly vascularized bone (Fig. 7.16A–B).

Locking Plates • Locking plates are often applied through a minimally invasive approach that minimizes soft tissue disruption. Locking plates facilitate secondary fracture healing with callus formation.

A

B FIGURE 7.16  (A) Dynamic compression plate. (B) Limited contact dynamic compression plate.

18.e11

18.e12

CHAPTER 7  Principles of Bone Fixation and Healing BIOMECHANICS OF LOCKING PLATES PITFALLS

• A conventional screw should be inserted first. This closes the gap between the plate and the bone. Otherwise, the gap will persist and can lead to entrapment of tendons and soft tissue. • Locking screws should always be inserted after conventional screws. Once a locking screw has been inserted, additional conventional screws placed in the same segment would create undesirable tension forces within the plate and bone (Fig. 7.19A–B).

FIGURE 7.17  Conceptual diagram of a locking plate. COMMON INDICATIONS FOR LOCKING PLATES PITFALLS

• Reduction must be achieved before the placement of a locking plate. If not, the poorly reduced alignment and fracture gap will persist after plating. This may result in malunion or nonunion. • The intramedullary fixator is more appropriate than a locking plate for diaphyseal fractures of weight-bearing bones, such as femoral shaft fractures.

Biomechanics of Locking Plates • The locking screw head has a thread that engages with the reciprocal thread of the plate hole (Fig. 7.17). The system creates angular stability between the implant and the bone. • Unlike a conventional plate, tightening of the locking screw does not require the plate to be directly contacting the bony surface. The stability of the fixation is therefore not dependent on the preload and friction between bone and plate. • The load transfer occurs through the locking system, which is similar to an external fixator but underneath the soft tissue. • Because the plate is not required to directly contact the bony surface, periosteal blood flow in the underlying cortex is preserved. This feature appears to promote healing and lowers the risk for infection. • Locking plates are more resistant to mechanical disruption than a conventional plating system. To disrupt a locking plate, a bending or rotating force would have to be strong enough to pull out the entire screw-plate construct together. By contrast, a conventional plating system could be disrupted by a single loose screw that subsequently loosens the other screws downstream. (Fig. 7.18A–B).

Common Indications for Locking Plates Common indications for locking plates include: • Planning indirect fracture reduction • Dealing with osteoporotic fracture • Bridging severely comminuted fractures • Dealing with periprosthetic fractures that need to be managed with monocortical screws (Fig. 7.20)

B

A

FIGURE 7.18  (A) The angular stability in a locking plate prevents load concentration at a single screw-bone interface, resulting in a much greater force needed to pull out the whole construct. Blue arrows indicate direction of applied force. Black arrows indicate tensile forces. (B) In conventional plates, the load solely concentrates at the nearest screw, and continues to the next one if failure occurs.

A

B

FIGURE 7.19  (A) Locking plate secured by locking screws. (B) Inserting conventional screws after locking screws will press the plate onto the bone, causing plate deformities. Additionally, this could loosen the locking screws and lead to further trauma in fracture fragments. Black arrows represent tensile forces.

FIGURE 7.20  For periprosthetic fractures, an intramedullary prosthesis prevents screws from getting through both cortices. Monocortical screws in a locking plate can contribute angular stability.

CHAPTER 7  Principles of Bone Fixation and Healing

EVIDENCE Arens S, Eijer H, Schlegel U, Printzen G, Perren SM, Hansis M. Influence of the design for fixation implants on local infection: Experimental study of dynamic compression plates versus point contact fixators in rabbits. J Orthop Trauma. 1999;13(7):470–476. The authors conducted a randomized, prospective study in experimental rabbits to compare infection resistance after local bacterial challenge in two different designs for fixation implants: the conventional dynamic compression plate (DCP) and the point contact fixator (PC-Fix). Under sterile conditions, specially manufactured titanium DCP or PC-Fix of identical dimensions were fixed to rabbit tibiae. After wound closure, different concentrations of Staphylococcus aureus, between 2  10(4) and 2  10(8) colony-forming units (CFU), were inoculated percutaneously at the implant site. The implants, underlying bone, and surrounding soft tissues were removed under sterile conditions and quantitatively evaluated for bacterial growth. Infection was defined as positive bacterial growth at the bone-implant interface. They found a higher infection resistance associated with the PC-Fix design, which seems to be related to the reduced contact area at the bone-implant interface (Level V evidence). Le AX, Miclau T, Hu D, Helms JA. Molecular aspects of healing in stabilized and non-stabilized fractures. J Orthop Res. 2001;19(1):78–84. In this study, the authors tested the hypothesis that alterations in the mechanical environment regulate mesenchymal cell differentiation and thus the formation of a cartilage or bony callus at the site of injury. They produced stabilized and nonstabilized tibial fractures in a mouse model, then used molecular and cellular methods to examine the stage of healing. Using the “molecular map” of the fracture callus, they divided the analysis into three phases of fracture healing: the inflammatory or initial phase of healing, the soft callus or intermediate stage, and the hard callus stage. Their results show that stabilizing the fracture, which circumvents or decreases the cartilaginous phase of bone repair, correlates with a decrease in IHH signaling in the fracture callus. These data support the hypothesis that mechanical influences affect mesenchymal cell differentiation to bone (Level V evidence). Claes LE, Augat P, Suger G, Wilke HJ. Influence of size and stability of the osteotomy gap on the success of fracture healing. J Orthop Res. 1997;15(4):577–584. The authors investigated the influence of the size of the fracture gap, interfragmentary movement, and interfragmentary strain on the quality of fracture healing. A simple diaphyseal long-bone fracture was modeled by means of a transverse osteotomy of the right metatarsus in sheep. In 42 sheep, the metatarsus was stabilized with a custom-made external ring fixator that was adjustable for gap size and axial interfragmentary movement. The sheep were randomly divided into six groups with different gap sizes (1, 2, or 6 mm) and strain (approximately 7% or 31%). After 9 weeks of healing, the explanted metatarsus was evaluated to determine bending stiffness and was radiographed to measure the callus formation. Increased size of the gap (from 1 to 6 mm) resulted in a significant reduction in the bending stiffness of the healed bones. Larger interfragmentary movements and strains (31% compared with 7%) stimulated larger callus formation for small gaps (1–2 mm) but not for larger gaps (approximately 6 mm) (Level V evidence).

18.e13

CHAPTER

8

Kirschner Wire Fixation of Mallet Fractures Chun-Yu Chen and Kevin C. Chung Full text of this chapter is available online at expertconsult.com.

KEY CONCEPTS • A mallet finger is caused by disruption of the terminal extensor tendon distal to the distal interphalangeal (DIP) joint and is categorized as either bony (mallet fracture) or nonbony (tendinous). • Although the majority of mallet fractures can be treated nonoperatively, there are several indications for managing these fractures with an extension block pinning technique: • Large displaced bone fragment • Loss of congruity of the DIP joint, articular gap greater than 2 mm • Palmar subluxation of the distal phalanx • If mallet fractures are left untreated, the extension force generated through the extensor mechanism is delivered entirely to the proximal interphalangeal (PIP) joint. Over time, this can lead to hyperextension of the PIP joint and a swan-neck deformity. • Seymour fractures are displaced physeal fractures of the distal phalanx with an associated nail bed injury. They are considered to be an open fracture because a nail bed laceration is present. Therefore early administration of antibiotics, irrigation/ debridement, nail bed repair, and fracture reduction are indicated to decrease the risk for infectious complications. • Nail bed disruption can lead to soft-tissue interposition, such as the torn portion of the nail bed in the fracture site. Interposed soft tissue should be removed because this can complicate fracture reduction and healing. • Failure to recognize and correct the nailbed laceration may result in nail plate deformity, physeal arrest, and chronic osteomyelitis. Removing the nail plate and carefully examining the nail bed is an essential step for managing this injury. Procedures reviewed in this chapter: • Extension block technique for mallet fracture • Kirschner wire fixation of Seymour fracture and nail bed repair

A

B FIGURE 8.12  (AB) Insertion of extension block pin for mallet fracture.

19

CHAPTER

8

Kirschner Wire Fixation of Mallet Fractures Chun-Yu Chen and Kevin C. Chung

Seymour Fractures and Nail Bed Repair INDICATIONS • Seymour fracture is defined as a displaced physeal fracture of the distal phalanx with an associated nail bed injury. This pediatric fracture pattern is typically caused by a crush injury and can be classified as a Salter-Harris I or II fracture. • The Seymour fracture is considered to be an open fracture because a nail bed laceration is present. Therefore early administration of antibiotics, irrigation/debridement, nail bed repair, and fracture reduction are indicated to decrease the risk for infectious complications.

Contraindications • Because soft tissue such as the germinal matrix may be trapped within the physeal fracture site, closed reduction is contraindicated because this approach impairs recognition and removal of interposed tissue.

CLINICAL EXAMINATION • A Seymour fracture should be suspected for distal phalangeal fractures with the following clinical presentations: (1) subungual hematoma or blood oozing from underneath the nail plate, (2) laceration over or proximal to the eponychial fold (Fig. 8.1), (3) a nail plate that is superficial to the eponychium, and (4) nail plate avulsion. • The flexor digitorum profundus tendon inserts into the metaphysis (distal to the Seymour fracture), which is distal to the extensor tendon’s insertion on the epiphysis of the distal phalanx (proximal to the Seymour fracture). This creates an imbalance between the flexor and the extensor tendons at the level of the fracture, resulting in a flexed distal phalanx (Fig. 8.2). • Although Seymour fracture may appear similar to a pediatric mallet finger, the injury patterns are distinct. Pediatric mallet finger is an avulsion fracture that enters the distal interphalangeal (DIP) joint, whereas the insertion of the extensor tendon remains intact in a Seymour fracture and the fracture line does not enter the DIP joint.

FIGURE 8.1  Laceration over the eponychial fold reflects the possibility of associated nail bed injury.

IMAGING PEARLS

• The lateral view is more reliable in identifying the displacement between the epiphysis and metaphysis and is necessary to confirm the diagnosis of Seymour fracture (Fig. 8.3). • Seymour fracture lines are present along the physis or travel away from the joint surface.

IMAGING Finger radiographs, including posteroanterior (PA) and lateral view, are recommended.

SURGICAL ANATOMY The flexor digitorum profundus tendon inserts into the metaphysis, which is relatively distal to the extensor tendon’s insertion on the epiphysis of the distal phalanx.

PROCEDURE Step 1: Remove the Nail Plate After digital anesthesia, the patient’s hand should be draped and prepped in the usual sterile fashion. Next, gently remove the nail plate and expose the nail bed (Fig. 8.4).

FIGURE 8.2  The imbalance between the flexor and the extensor tendons at the fracture level results in a flexed posture of the distal phalanx.

Step 2: Expose the Nail Bed Laceration and Fracture Site • Thoroughly inspect the entire nail bed for lacerations. The distal phalanx fracture site may be visible through the disrupted nail bed. • Debridement and saline irrigation can elevate the impacted soft tissue (Fig. 8.5). 19.e1

19.e2

CHAPTER 8  Kirschner Wire Fixation of Mallet Fractures

A

B

FIGURE 8.3  (AB) Displaced distal phalangeal physeal fractures are easier to recognize on lateral views compared with posteroanterior (PA) views.

FIGURE 8.4  The nail plate was then removed gently, and the nail bed was exposed for a thorough inspection. The white arrow shows a laceration of the nail bed.

Step 3: Fracture Fixation and Nail Bed Repair • Reduce the fracture under direct visualization. • Percutaneous insertion of an intramedullary 0.045-inch (1.1-mm) Kirschner wire (K-wire) can fixate the fracture through the DIP joint (Fig. 8.7). • Repair nail bed lacerations using interrupted absorbable sutures (5-0/6-0 chromic catgut; Fig. 8.8). • The removed nail plate (after aggressive cleaning) can be reinserted under the eponychium to cover the restored nail bed and stabilize the reduction, similar to a splint (Fig. 8.9).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES FIGURE 8.5  The fracture site can be seen through the disrupted nail bed. Saline irrigation and debridement are performed next.

STEP 2 PEARLS

• The eponychium can be incised and retracted proximally to permit clear visualization of the base of the nail bed (germinal matrix; see Fig. 8.4). • During exposure, take care to prevent iatrogenic injury to the insertion of the terminal extensor tendon at the distal phalanx epiphysis.

STEP 2 PITFALLS

• Nail bed disruption can lead to soft-tissue interposition, such as the torn portion of the nail bed in the fracture site (Fig. 8.6). Interposed soft tissue should be removed because this can complicate fracture reduction and healing. • Failure to recognize and correct the nail bed laceration may result in nail plate deformity, physeal arrest, and chronic osteomyelitis. Removing the nail plate and carefully examining the nail bed is an essential step for managing this injury. STEP 3 PEARLS

To avoid dislodging the nail plate during dressing changes, a 4-0 chromic suture can be used to stabilize the nail plate to its nail fold.

• Place the patient in a volar finger splint to stabilize the distal phalanx. • The patient should immediately initiate proximal interphalangeal (PIP) and metacarpophalangeal (MCP) range of motion exercises. Remove the pins after 4 weeks. The nail will fall off by itself.

Extension Block Technique INDICATIONS • A mallet finger is caused by disruption of the terminal extensor tendon distal to the distal interphalangeal (DIP) joint and is categorized as either bony (mallet fracture) or nonbony (tendinous). • The majority of mallet fractures are treated nonoperatively, with good success. • Indications for this technique are limited to specific situations in which reduction of the fracture is essential to avoid posttraumatic arthritis or instability: • A large displaced bone fragment (one-third or more of the articular surface of the distal phalanx) • Loss of congruity of the DIP joint and an articular gap greater than 2 mm • Palmar subluxation of the distal phalanx • If mallet fractures are left untreated, the extension force generated through the extensor mechanism is delivered entirely to the PIP joint, rather than distributed along the entire finger. Over time, this can lead to hyperextension of the PIP joint and a swan-neck deformity.

Contraindications • A comminuted or small avulsed fragment cannot be directly compressed with dorsal blocking pins. • Fractures that are older than 5 weeks are a relative contraindication because the presence of scar tissue impairs closed reduction. • Inexperience with performing this technique can lead to iatrogenic nail bed injury.

CHAPTER 8  Kirschner Wire Fixation of Mallet Fractures

FIGURE 8.6  Nail bed disruption can lead to soft-tissue interposition, such as the torn portion of nail bed in the fracture site, complicating fracture reduction and healing.

FIGURE 8.7  An intramedullary Kirschner wire was percutaneously inserted to fixate the fracture through the distal interphalangeal (DIP) joint.

FIGURE 8.8  The nail bed laceration was repaired.

FIGURE 8.9  The removed nail plate was reinserted under the eponychium to cover the nailbed. A chromic suture was used to stabilize the nail plate to its nail fold.

19.e3

19.e4

CHAPTER 8  Kirschner Wire Fixation of Mallet Fractures

A FIGURE 8.10  Flexed distal interphalangeal (DIP) joint on physical examination, with inability to actively extend the joint.

STEP 1 PEARLS

• Make sure the extension block wire is firmly anchored in cortical bone, so that it will not migrate inward or loosen. • If the fracture is subacute (partially healed), the fragments can be gently mobilized by manipulation with an additional percutaneous wire, being careful not to lacerate the extensor mechanism (Fig. 8.13). This will make reduction easier in Step 2. STEP 1 PITFALLS

If the extension block wire enters from a too volar position on the middle phalanx head, it will block extension of the DIP joint, which makes the correction of subluxation difficult.

B

FIGURE 8.11  (A) Lateral and (B) posteroanterior radiographs of mallet fracture in the fourth digit. (Courtesy Dr. Steven Haase, Michigan Medicine.)

CLINICAL EXAMINATION The patient will have a flexed DIP joint that is swollen and tender on examination. The patient will also be unable to actively extend the DIP joint (Fig. 8.10).

IMAGING • PA and lateral radiographs are necessary to evaluate the size of the avulsed fragment, joint congruity, and alignment (Fig. 8.11A–B). • Tendinous mallet finger will demonstrate normal bony anatomy on radiograph.

SURGICAL ANATOMY • Mallet fractures are an avulsion fracture at the dorsal base of the distal phalanx. • With larger dorsal avulsion fragments, the distal attachment sites of the collateral ligaments may become involved. This can lead to palmar subluxation of the distal phalanx.

PROCEDURE

STEP 2 PEARLS

Step 1: Insertion of Extension Block Pin

Be careful not to lacerate the extensor mechanism or cause comminution of the fragment.

• Hold the DIP joint in flexion to pull the avulsed fragment as distally as possible. • Guided by fluoroscopic imaging, a 0.045-inch (1.1-mm) K-wire is inserted percutaneously through the terminal extensor tendon just proximal to the avulsed fragment, holding it in place (Fig. 8.12A–B). In children (or smaller adults), a 0.035-inch (0.9-mm) K-wire may be more appropriate.

STEP 2 PITFALLS

• When the DIP joint is extended, the dorsal finger skin may become pinched beneath the extension block pin. A relaxing incision distal to the wire will release the pressure on the skin and avoid ulceration. • For subacute fractures, it may be difficult to achieve complete reduction because of scar tissue (fibrous nonunion) interposed between the fracture surfaces.

Step 2: Reduction • While applying longitudinal traction, the distal phalanx is translated in a volar- to-dorsal direction by compression at the base of the bone. • To complete the reduction, the DIP joint is then extended to a neutral position (Fig. 8.14A–B).

Step 3: Insertion of the DIP Joint Transfixation Pin • Another 0.045-inch (1.1-mm) K-wire is placed intramedullary from distal to proximal across the DIP joint while maintaining reduction (Fig. 8.15A–B). • If excellent reduction and joint congruency are achieved, it is not necessary to have the DIP in full extension.

CHAPTER 8  Kirschner Wire Fixation of Mallet Fractures

A

B

FIGURE 8.12  (A–B) Insertion of extension block pin.

FIGURE 8.13  Insertion of additional percutaneous wire can facilitate mobilization of the fracture fragment.

B

A

FIGURE 8.14  (A–B) Reduction of the mallet fracture. The thin arrow represents longitudinal traction; the thick arrow represents volar-to-dorsal force on the distal phalanx to reduce the fracture.

A

B FIGURE 8.15  (A–B) Insertion of the distal interphalangeal (DIP) transfixation pin.

• After confirming satisfactory reduction using fluoroscopy, the wires are cut and capped (Fig. 8.16). A protective finger-based splint is applied.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The pins are removed 4 to 6 weeks postoperatively, once the fracture is healed. Trabecular bridging on x-ray and a nontender fracture site are good indicators of fracture healing. • After pin removal, extension exercises can begin immediately. The finger is still protected with a removable volar DIP joint splint for another 2 to 3 weeks.

19.e5

19.e6

CHAPTER 8  Kirschner Wire Fixation of Mallet Fractures

• Progressive flexion exercises are introduced in the weeks after pin removal, advancing slowly to full active flexion. • Residual deformity and dorsal prominence occur in up to 80% of cases. Furthermore, a lack of terminal extension may persist.

EVIDENCE

FIGURE 8.16  Kirschner wires are cut and capped after reduction is confirmed.

STEP 3 PEARLS

Make sure that the longitudinal wire does not cross the PIP joint, so that the PIP can be mobilized quickly after surgery, avoiding development of significant stiffness. STEP 3 PITFALLS

Carefully monitor the advancement of the longitudinal wire at the fracture site. Take care that this wire does not disrupt an otherwise excellent reduction as it passes across the DIP joint.

Asano K, Inoue G, Shin M. Treatment of chronic mallet fractures using extension-block Kirschner wire. Hand Surg. 2014;19:399–403. This retrospective study reviewed the outcomes of 11 patients who presented with chronic (older than 4 weeks) mallet fractures. The average duration from injury to surgical treatment was 56 days. All were treated with extension block pinning using the Ishiguro technique; all patients went on to bony union. Patients were followed for a mean of 8 months. By Crawford criteria, outcome was excellent or good in 8 patients (73%). The authors conclude this technique may benefit younger patients with chronic mallet fractures. Reyes BA, Ho CA. The high risk of infection with delayed treatment of open Seymour fractures: SalterHarris I/II or juxta-epiphyseal fractures of the distal phalanx with associated nailbed laceration. J Pediatr Orthop. 2017;37(4):247–253. The authors divided all the patients into groups based on the timing and completeness of treatment. Appropriate treatment was defined as irrigation and debridement, fracture reduction, and antibiotic administration. Acute treatment was defined as management within 24 hours of the injury. A total of 35 Seymour fractures met the inclusion criteria. In total, 31% (11 of 35) received acute, appropriate treatment; 37% (13 of 35) received acute, partial treatment; and 31% (11 of 35) received delayed treatment. No infections occurred in the acutely, appropriately treated group (infection rate 0%, 0 of 11); two infections occurred in the acutely, partially treated group (15%, 2 of 13); and five infections occurred in the delayed treatment group (45%, 5 of 11). Han HH, Cho HJ, Kim SY, Oh DK. Extension block and direct pinning methods for mallet fracture: A comparative study. Arch Plast Surg. 2018;45(4):351–356. The authors treated patients with the extension block method (EBM) and the direct pinning method (DPM) and then compared the results. Twenty-one patients were treated with the EBM and 20 patients were treated with the DPM. The result showed the DPM proved to be superior to the EBM in that it produced more significant improvements in extensor lag and range of motion. Lin JS, Popp JE, Samora JB. Treatment of acute Seymour fractures. J Pediatr Orthop. 2019;39(1):e23–e27. The authors retrospectively investigated the treatments, outcomes, operative indications, and antibiotic choice for acute Seymour fractures to better define optimal management. Among the 65 Seymour fractures, 58 cases (89%) were initially managed in the emergency department. They concluded that most injuries would achieve good outcomes with management in the emergency department alone.

CHAPTER

9

Techniques for Fixing Extraarticular Phalangeal Fractures Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following videos: Video 9.1 – Closed Reduction With Kirschner Wire Fixation of Extraarticular Phalangeal Fractures; Video 9.2 – Open Reduction and Internal Fixation of Extraarticular Phalangeal Fractures.

KEY CONCEPTS • Extraarticular phalangeal fractures with angulation more than 10 degrees, shortening greater than 2 mm, or significantly comminuted fractures are best treated with reduction and fixation. • Percutaneous pinning enables quick fixation of simple fractures and avoids the need for the dissection and periosteal stripping required for internal fixation. • Rigid internal fixation is becoming increasingly common, given the possibility of early active range of motion postoperatively. Plates and screws are used when the phalangeal bones are so comminuted that percutaneous Kirschner wires (K-wires) will not be able to achieve adequate reduction. Because the extensor tendons are bound intimately around the phalanges, however, the exposure of the bone and hardware placement will cause tendon adhesions that limit digit motion. Tenolysis and/or proximal interphalangeal joint capsulotomy are required in a substantial number of patients who receive dorsal plating. • Providing stable fixation of extraarticular phalanx fractures with either percutaneous pinning or internal fixation should lead to a union rate of 90% or greater. Procedures reviewed in this chapter: • Closed reduction with K-wire fixation of extraarticular phalangeal fractures. • Open reduction and internal fixation of extraarticular phalangeal fractures.

FIGURE 9.7  Exposure of extraarticular fracture of the proximal phalanx.

20

CHAPTER

9

Treatment of Extraarticular Phalangeal Fractures Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Reduction and fixation should be performed for all fractures that cannot be reduced with closed methods or for those that remain unstable with loss of reduction after successful closed reduction. • Fractures with angulation more than 10 degrees or shortening greater than 2 mm and significantly comminuted fractures are best treated with reduction and fixation. Fractures with any rotational deformity or fingers that cross over each other with attempted finger flexion must be reduced and fixed to preserve normal hand function. • Rigid internal fixation is becoming an increasingly common option for fractures as opposed to percutaneous pinning, given the possibility of early active range of motion postoperatively. Nevertheless, because the extensor tendons are bound intimately around the phalanges, the exposure of the bone and hardware placement will cause tendon adhesions that limit digit motion. Plates and screws are used when the phalangeal bones are so comminuted that percutaneous Kirschner wires (K-wires) will not be able to achieve adequate reduction. • Percutaneous pinning enables quick fixation of simple fractures and avoids the need for the dissection and periosteal stripping required for internal fixation. • In complex traumatic injuries where multiple digits require fixation, such as multidigit amputation, pinning can provide quick stabilization, permitting time-sensitive microsurgery to proceed efficiently.

Rotation of injured finger

FIGURE 9.1  Note the rotational difference of the injured small finger compared with the remaining fingers.

Contraindications • Avoid rigid internal fixation in patients with soft-tissue defects that cannot be covered at the time of surgery because hardware infection is likely. Percutaneous fixation would be preferred in this scenario because pins can be removed readily if needed.

CLINICAL EXAMINATION • Note any rotational or angular deformity of the finger. This can be a subtle finding and will be more easily noticed when evaluating the fingertip posture by comparing the alignment of the fingernails (Fig. 9.1). • Depending on the location of the fracture, a complex balance between flexion and extension forces throughout the digit will determine the deforming force. • Fractures of the proximal phalanx will often have an apex volar displacement pattern because the interossei muscles pull the proximal fragment into flexion and the central slip pulls the distal fragment into extension. • Fractures of the middle phalanx will displace in an apex volar direction when the fracture is distal to the flexor digitorum superficialis (FDS) insertion or in an apex dorsal direction when the fracture is proximal to the FDS insertion (Fig. 9.2A–B). • Open fractures will require thorough debridement and careful assessment of the soft tissue injury, with repair of structures as indicated.

IMAGING • Standard radiographs are taken in three views (posteroanterior, oblique, and lateral; Figs. 9.3 and 9.4). • Computed tomography is usually not helpful or required for extraarticular phalanx fractures.

SURGICAL ANATOMY • The extensor mechanism incorporates both longitudinal and transverse components, covering most of the dorsal and lateral sides of the digit. 20.e1

20.e2

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

MCP joint

EDC (EIP, EDM)

PIP joint

Intrinsic muscle

DIP joint

FDS A

EDC (EIP, EDM)

MCP joint

PIP joint

DIP joint

Intrinsic muscle B

FDS

FIGURE 9.2  Key anatomic landmarks and tendon insertion sites. DIP, Distal interphalangeal; EDC, extensor digitorum communis; EDM, extensor digitorum minimi; EIP, extensor indicus proprius; FDS, flexor digitorum superficialis; MCP, metacarpophalangeal; PIP, proximal interphalangeal.

FIGURE 9.3  Preoperative x-rays.

FIGURE 9.4  Preoperative x-rays.

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

Terminal tendon

Terminal tendon Middle phalanx Triangular ligament

Conjoined lateral band

Conjoined lateral band Proximal phalanx Central slip

Central slip

Lateral slip

Lateral band

A

B

FIGURE 9.5  Surgical anatomy.

FIGURE 9.6  Incision design. EXPOSURES PEARLS

• The central slip inserts at the dorsal base of the middle phalanx and serves to extend the proximal interphalangeal (PIP) joint. • The lateral bands are formed at the sides of the finger, with extensions projecting off the common extensor tendon proximal to the central slip and additional contributions from the interosseous muscles and lumbricals (radial side only). They reconverge distally to form the terminal tendon, which inserts at the dorsal epiphysis of the distal phalanx (Fig. 9.5).

• Divisions of thin, transverse fibers of the extensor mechanism, such as the interval between lateral band and central slip, or the transverse retinacular ligament, do not require repair. • A small portion of the sagittal band may also be divided for exposure, but major disruptions should be repaired to prevent displacement of the extensor tendon with metacarpophalangeal flexion. • Extensive longitudinal splits in the extensor tendon should be repaired at closure.

EXPOSURES • When placing internal fixation, dorsal, dorsolateral, or midaxial incisions may be used for proximal and middle phalangeal fractures. • The interval between lateral band and central slip may be incised; this does not require repair at closure (Fig. 9.6). • The extensor tendon may be split longitudinally at the midline (middorsal) over the proximal phalanx; long splits should be repaired at time of closure. • With a lateral approach, the transverse retinacular ligament is divided to provide access; this does not require repair at closure. • Over the middle phalanx, the triangular ligament can be incised longitudinally to provide access between the two lateral bands. • Deep to the extensor mechanism, the periosteum is incised and stripped minimally to expose the fracture site (Fig. 9.7).

EXPOSURES PITFALLS

• At the base of the middle phalanx, be mindful of protecting the central slip insertion to the periosteum during tendon splitting. • Likewise, take care to protect the very thin, flat terminal tendon as it inserts onto the dorsal base of the distal phalanx.

CLOSED REDUCTION WITH KIRSCHNER WIRE FIXATION OF DISTAL PHALANGES Step 1 Reduction is performed with gentle manipulation. If the fracture is open, debridement and irrigation of the fracture site is required, along with nail bed repair.

FIGURE 9.7  Fracture site exposed.

20.e3

20.e4

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

FIGURE 9.8  Kirschner wires inserted.

STEP 2 PEARLS

The tuft of the distal phalanx is immediately beneath the nail matrix, and the tip of the distal phalanx is thin and narrow. A common error is to place the K-wire too volarly on the hyponychia, missing the distal phalanx entirely. The entry point should be just volar to the nail bed and hyponychia. STEP 2 PITFALLS

When placing a second K-wire across the fracture site, be sure not to accidentally distract the fracture and disturb the reduction.

Step 2 • Retrograde insertion of the K-wire is the most common method applied. • The wire is inserted in the tuft of the bone distally and advanced across the fracture site while the fracture is held in reduction manually. • In most cases, the wire should be advanced until it abuts the cortical bone at the base of the distal phalanx. For added stability, the wire can be advanced across the distal interphalangeal (DIP) joint with minimal additional morbidity (Fig. 9.8). • To prevent rotational displacement of the fracture around a single wire, a second wire can be placed across the fracture, ideally at a slightly divergent angle relative to the first wire.

Step 3 • The distal end of the K-wire can be cut and buried beneath the skin, or it can be left protruding for easier removal later. • Wires left buried present less risk for infection during the postoperative period but typically require a small incision under local anesthesia to remove the wire later.

CLOSED REDUCTION WITH KIRSCHNER WIRE FIXATION OF MIDDLE AND PROXIMAL PHALANGES STEP 1 PEARLS

The reduction often cannot be accomplished in a single effort. A second reduction clamp can be used to maintain a provisional reduction and the fracture can be further manipulated to perfect the reduction. STEP 1 PITFALLS

Residual apex-volar deformity in proximal phalangeal fractures is easily overlooked because the other digits may obscure the fracture in the lateral view. Confirm reduction of the fracture in multiple directions using intraoperative fluoroscopy.

Step 1 • Reduction is obtained by manipulation of the digit, incorporating traction or other maneuvers as indicated. Complex fractures may require a combination of these techniques. • Simple transverse fractures with apex-volar angulation are typically reduced by first applying traction with gentle manipulation to reduce any displacement and align the dorsal cortex. Then, the finger can be passively brought into flexion, reducing the angular displacement of the fracture. • Long oblique or spiral fractures may require traction to eliminate shortening plus the use of a reduction clamp for rotational control.

Step 2 • K-wires of 0.045 in (1.1 mm) diameter are used in most adult phalangeal fractures. • K-wires of 0.035 in (0.9 mm) or smaller diameter may be used in pediatric cases or in fractures with smaller, more delicate bone fragments. • Ideal entry points and trajectory for K-wires are identified under fluoroscopic control.

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

A

B

STEP 2 PEARLS

C

D FIGURE 9.9  Kirschner wires diverge proximal to fracture site.

• Insert K-wires antegrade (starting proximal and aiming distal) or retrograde (starting distal and aiming proximal) while holding the fracture reduced. • For stable fixation, a minimum of two K-wires is recommended. For maximum stability, K-wires should ideally be placed so that they cross and then diverge from each other proximal to the fracture. Avoid placing K-wires in parallel because this creates a biomechanically weak fixation (Fig. 9.9A–B). • For middle phalanx fractures, retrograde transarticular pinning across the DIP joint should be considered. Pinning the DIP joint for a short period of time results in minimal morbidity. Pins can enter from the tuft of the distal phalanx or from the side of the fingertip, depending on fracture characteristics (Fig. 9.10A–B). • For proximal phalanx fractures, two longitudinal or crossed K-wires are used to resist bending or rotation of the fracture during healing. These can often be placed with an extraarticular antegrade approach, entering from the radial and ulnar aspects of the proximal phalanx base, avoiding pins across the metacarpophalangeal (MCP) joint. Alternatively, these may be placed in a retrograde, extraarticular fashion (Fig. 9.11A–B). • When multiple fracture fragments exist, a stepwise approach should be taken. Systematically, each fragment should be reduced back to the unfractured diaphysis or metaphysis and held in place with orthogonal K-wire fixation (Fig. 9.12A–B). • The larger fragment or the easier-to-reduce fragment is stabilized first to establish a foundation for other fragments to fit in place.

• K-wires can be started on the near cortex perpendicular to the bone, with care taken not to completely penetrate the first cortex. Once a small divot is made in the cortical bone, the wire position can be changed to the more acute angle often required for phalangeal fixation. The wire is driven in place at high speed to core the proximal bone without bending the wire to establish a new pin trajectory. This technique prevents the K-wire from “skiving off” the bone and injuring adjacent structures. • The far tip of the K-wire should always be docked into cortical bone to prevent pin migration overtime. STEP 2 PITFALLS

• Whenever possible, the PIP and MCP joints should be left free to participate in gentle early motion, even with the K-wires in place. Although transarticular pinning of the DIP for short periods of time is relatively safe, pinning other joints may lead to joint contractures with significant morbidity. • Avoid making multiple passes back and forth with any given K-wire, because this will make the bone channel larger around the wire and decrease that wire’s effectiveness. • Similarly, avoid repeated transarticular drilling into adjacent phalanges, because this can create a large defect in the articular surface. Heat-induced necrosis of the bone is avoided by drilling the bone at low speed, with precision.

20.e5

20.e6

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

A

B FIGURE 9.10  Pins enter from tuft of distal phalanx.

A

B FIGURE 9.11  Retrograde, extraarticular Kirschner wire placement.

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

A

C

B

D

FIGURE 9.12  Orthogonal Kirschner wire fixation.

Step 3

STEP 3 PITFALLS

After checking the alignment of the finger with visual inspection and checking reduction of the fracture with fluoroscopy, K-wires are trimmed and/or bent, and protective pin caps are applied.

Do not cut or bend K-wires so that they lay immediately adjacent to the skin. Postoperative swelling will result, and pins can quickly erode into adjacent soft tissues if cut too short.

OPEN REDUCTION AND INTERNAL FIXATION Step 1: Reduction • The fracture site should be cleaned of clot, debris, and any foreign material to permit anatomic reduction of fracture fragments. • Open fractures should be debrided with meticulous care to prevent deep infection. Small cortical bone fragments that have been devitalized of any soft tissue can be removed if necessary. The bone is cleaned and used as bone graft to fill in the defect or to replace the original void. • Reduction is accomplished by gentle distraction and/or direct fracture manipulation. • Reduction can be maintained by use of various reduction clamps and/or temporary K-wires.

Step 2: Fixation • Phalangeal fixation is typically performed with 1.5- to 2.0-mm diameter screw sets. Smaller screws (1.0- to 1.3-mm diameter) may be indicated for smaller hands, small fracture fragments, or for lag screws, where larger screws might be too big.

STEP 1 PEARLS

• Preserving periosteal attachments can help maintain better blood supply to bone fragments. • Temporary K-wires should be placed outside the primary surgical field to prevent interference with plate and screw placement. • In petite fingers that can be difficult to grasp, longitudinal traction can be applied with the use of a bone tenaculum through the skin, grasping the affected phalanx.

20.e7

20.e8

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

• A screw can be placed in the track of the reduction K-wire when the K-wire is removed. Determine the size of the K-wire that will permit the replacement of a screw without additional drilling.

Lag Screws • Lag screws provide interfragmentary compression and are ideal for long oblique or spiral fractures. • The near cortex is drilled with a drill bit that has the same diameter as the external diameter of the screw, creating a gliding hole (e.g., for a 1.3-mm screw, use a 1.3-mm drill bit). • The far cortex is drilled with a drill bit that matches the core diameter of the screw, creating a threaded hole when the self-tapping screw is inserted (e.g., for a 1.3-mm screw, use a 1.0-mm drill bit). Some instrumentation sets include a special drill guide that fits into the gliding hole to assist with this step. • Some surgeons choose to reverse this process, drilling both cortices with the smaller drill bit first, then overdrilling the near cortex with the larger caliber drill bit. We do not advocate for this approach because the screw holes for both cortices may not align. It is preferable to overdrill the proximal cortex, then insert the drill guide into the gliding hole to drill the opposite cortex, which will ensure that the entire bone track is aligned with the screw. • Measure screw length and insert the screw. The screw will slide through the near cortex and engage the far cortex with the screw threads. Because most screws designed for this application are self-tapping, a separate tapping step is not required. • As the fully threaded screw is tightened in this lag configuration, the fracture site is compressed between the head of the screw and the distal threads • Three or more lag screws are ideal to obtain multidirectional stability. Short oblique fractures may only accommodate two screws (Fig. 9.13A–B).

Plate Fixation

STEP 2 PEARLS

For complicated fractures, plates with screws in more than one plane (three-dimensional [3D] plate, H-plate, or Z-plate) can aid in stability. These plates can fix several fragments from multiple directions. STEP 2 PITFALLS

• The phalangeal cortex is often too thin to accommodate screw head countersinking. • Screws placed dorsally cannot project beyond the volar cortex because the flexor tendons lie immediately adjacent to the volar surface of the phalanges. Multiple views should be taken using fluoroscopy to ensure that there is no screw prominence. This is especially important at the head of the proximal and middle phalanx, where the large articular condyles can hide a prominent screw.

• Given the small size of the phalanges, compression plating is not practical. • Plates conceptually fall into three other (noncompression) categories. • Bridging plates: Plates that span an area of comminution to prevent collapse during bony healing. • Tension band plates: Plates placed dorsally across a fracture with apex-dorsal deformity serve to redirect the deforming forces into compressive forces at the volar cortex. • Neutralization plates: Plates used to reinforce lag screws by providing additional stabilization against bending at the fracture site. Unlike fractures in larger longbones, phalangeal fractures often do not need neutralization plates if two or three lag screws can be placed with good purchase. • Phalangeal plates may incorporate holes in more than one plane or ovoid holes that can be adjusted for rotation and position. • Fracture reduction occurs as previously described, and preliminary reduction can be held in place with K-wires placed outside of the surgical field. • The plate should be fixed to bone with a single screw on either side of the fracture for provisional fixation, alignment should be checked, and then the remaining screws should be inserted (Fig. 9.14). • Fractures that occur near the articular surfaces provide a limited amount of bone to place screws. In this scenario, locking screws can be used to provide more rigid fixation (Fig. 9.15). • The thin plates used for phalangeal fractures should be bent carefully or twisted to improve finger alignment or, alternatively, plates with ovoid holes will allow for adjustments in alignment before final screw tightening.

Step 3: Closure and Splinting • Use the tenodesis effect to evaluate rotational alignment and finger cascade. With passive wrist flexion, the digits should extend because of extrinsic tendon attachments; with passive wrist extension, the digits should flex toward the scaphoid tubercle (Fig. 9.16).

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

A

B

C

FIGURE 9.13  Lag screw compression.

FIGURE 9.14  Screws inserted.

20.e9

20.e10

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

FIGURE 9.15  Fluoroscopy showing locking screws in place.

FIGURE 9.16  Tenodesis effect.

POSTOPERATIVE PEARLS

• When possible, the sutures to reapproximate the tendons should be passed from deep to superficial to bury knots. This is especially important when closing after a dorsal approach because unburied knots can remain prominent and cause irritation. • Once pins are removed, buddy-taping or strapping of the injured digit to an adjacent, uninjured digit can facilitate improvements in functional motion while maintaining alignment during final fracture healing.

• • • •

The extensor mechanism is repaired as indicated with nonabsorbable braided suture. Deflate the tourniquet and achieve good hemostasis before skin closure. The skin is closed using nonabsorbable sutures. A well-padded splint is applied to maintain the interphalangeal joints in extension, the MCP joints in 70 degrees of flexion, and the wrist in slight extension.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients should be seen in clinic within 1 to 2 weeks to have their splints removed and to transition to a custom orthosis. This permits removal of the orthosis for hand therapy exercises and pin care. • Uninjured fingers can begin therapy immediately to avoid unwanted stiffness. • Even with wires in place, the injured digit can typically participate in gentle active range of motion, so long as the fixation is relatively stable. Because K-wires do not

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures

FIGURE 9.17  Postoperative x-rays.

offer the same stability as plates and screws, an experienced hand therapist should supervise early motion activities, and exercises should be carefully individualized to the patient. • Pins are usually removed in 3 to 4 weeks. This is usually enough time for early bone healing to have stabilized the fracture. • Earlier pin removal can be considered in children because healing is typically faster. • After pin removal, the orthosis is still used for protection for an additional 3 to 4 weeks. • After 6 to 8 weeks, fractures are typically sufficiently healed to begin weaning out of the orthosis. Fracture healing is determined radiographically based on bone bridging across the fracture site and clinically when no motion or pain is felt at the fracture site with clinical examination (Fig. 9.17). • Providing stable fixation of extraarticular phalanx fractures with either percutaneous pinning or internal fixation should lead to a union rate of 90% or greater. See Video 9.1

EVIDENCE Bannasch H, Heermann AK, Iblher N, Momeni A, Schulte-Monting J, Stark GB. Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis show no increase of complications in the treatment of open compared with closed fractures. J Trauma. 2010;68:624–628. This study reviewed the radiographic and clinical outcomes and complications of internal fixation for 365 metacarpal and phalangeal fractures. Bony union was achieved in 91.2% of patients. In the functional analysis, 85.2% of patients had excellent to acceptable outcomes, and 14.8% had unsatisfactory results. The presence of multiple fractures and soft tissue injury were associated with worse functional outcomes. There was no significant difference in infection and nonunion rates between open and closed fractures (Level IV evidence). Curtin CM, Chung KC. Use of eight-hole titanium miniplates for unstable phalangeal fractures. Ann Plast Surg. 2002;49:580–586. This retrospective study reports on 13 patients with 16 unstable phalangeal fractures after a variety of traumatic injuries. Most were open fractures with complex soft-tissue injuries. The fractures were treated by open reduction and internal fixation with an eight-hole miniplate. For range of motion, six patients had good to excellent results with total active motion greater than 180 degrees, although

POSTOPERATIVE PITFALLS

• Despite early active motion, adhesions between plates and extensor tendons are quite common with dorsal plating. Tenolysis and/or PIP joint capsulotomy are required in a substantial number of patients. • Delaying pin removal until 5 or 6 weeks is not generally recommended, especially if pins are interfering with motion of the MCP and/or PIP joints. This will lead to joint contractures that may be impossible to overcome, even with appropriate hand therapy.

20.e11

20.e12

CHAPTER 9  Treatment of Extraarticular Phalangeal Fractures three of these six patients required hardware removal and tenolysis. The remainder of patients included two with poor results, two loss to follow-up, and three thumb fractures with acceptable range of motion. Immediate postoperative stability was obtained in all cases, but there were significant complication rates (Level IV evidence). 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;39:1524–1528. This retrospective study reviewed 43 patients with 50 fractures of the shaft or base of the proximal phalanx that were treated with periarticular pinning. This technique uses the radial and ulnar corners of the proximal phalanx base as entry points for two K-wires, which are driven antegrade across the fracture; the wires are not necessarily crossed. All patients were followed for an average of 17 weeks, and clinical union was achieved in an average of 35 days. Sixty-three percent of patients had an excellent result, 17% had a good result, and 17% had a fair result. Digital stiffness needing tenolysis was identified in three patients. Two patients had pin site infections. The author concluded that periarticular pinning is an acceptable treatment for extraarticular fractures of proximal phalanx (Level IV evidence). El-Saeed M, Sallam A, Radwan M, Metwally A. Kirschner wires versus titanium plates and screws in management of unstable phalangeal fractures: A randomized, controlled clinical trial. J Hand Surg Am. 2019;44(12):1091.e1–9. A randomized controlled trial comparing K-wire percutaneous pinning versus plate fixation for unstable extraarticular fractures of the proximal or middle phalanx in 40 adult patients. Quick Disabilities of Arm, Shoulder, and Hand (DASH) score, total active motion (TAM), grip strength, and visual analogue scale (VAS) were measured. Mean follow up was 6.8 months. There were no differences between the two groups with respect to grip strength, QuickDASH scores, pain, or rate of healing—which, on average, occurred in both groups by 3 months postoperatively. TAM was greater in the plating group (250 degrees) versus the K-wire group (218 degrees). The conclusion of the study is that for unstable phalanx fractures, rigid fixation with plating results in greater total active digit motion compared with percutaneous K-wire fixation (Level II evidence).

CHAPTER

10

Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com.

KEY CONCEPTS • Dynamic external fixation of the proximal interphalangeal (PIP) joint is primarily used to treat intraarticular fractures of the middle phalanx with significant comminution or joint surface impaction, fractures with disruption of the volar or dorsal articular lip, and metaphyseal fractures with limited bone stock for internal fixation. • A dynamic fixator can also be used for unstable dislocations or fracture-dislocations of the PIP that cannot maintain reduction with conservative treatments such as blocking splints. • The PIP joint develops posttraumatic stiffness rapidly. Dynamic external fixators are beneficial because they both permit continued flexion/extension of the PIP and maintain a reduction through ligamentotaxis. • Dynamic fixators must be cared for diligently by the patient, with pin care performed daily to prevent infection. Young children, patients with mental illness, or patients who are otherwise unable to participate in daily hygiene are not candidates for dynamic fixators. • The fixator device usually remains in place for 6 weeks. Reasons for earlier removal include pin site irritation or infection. Well-tolerated devices can remain in place for up to 8 weeks. • After healing is complete, the joint may still appear irregular on x-ray, but congruent joints tend to remodel over time.

Rubber bands

K3

K2

K1

FIGURE 10.9  Proximal and distal hooks of the dynamic external fixator are connected by rubber bands.

21

CHAPTER

10

Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Dynamic external fixation of the proximal interphalangeal (PIP) joint is primarily used to treat intraarticular fractures of the middle phalanx with significant comminution or joint surface impaction, fractures with disruption of the volar or dorsal articular lip, and metaphyseal fractures with limited bone stock for internal fixation. • Additionally, a dynamic fixator can be used for unstable dislocations or fracture dislocations of the PIP that cannot maintain reduction with conservative treatments such as blocking splints. • The PIP joint develops posttraumatic stiffness rapidly. Dynamic external fixators are beneficial because they permit continued flexion/extension of the PIP while maintaining a reduction through ligamentotaxis.

Contraindications • Dynamic fixators must be cared for diligently by the patient, with pin care performed daily to prevent infection. Young children, patients with mental illness, or patients who are otherwise unable to participate in daily hygiene are not candidates for dynamic fixators. • Patients with active infection or surrounding soft-tissue loss are not candidates for dynamic fixators. • Subacute fractures: After roughly 2 weeks, fracture callus begins to develop, and indirect reduction will be difficult or impossible to achieve through externally applied traction force alone. In these cases, open reduction is indicated.

CLINICAL EXAMINATION As with any injury of the phalanges, rotational and angular malalignment or shortening should be noted. Subtle rotational deformity can be identified by comparing the rotational alignment of the nail to the adjacent fingers.

IMAGING • Plain radiographs should be taken in posteroanterior (PA), oblique, and lateral views (Fig. 10.1A–C). • Fractures that disrupt the volar rim of the middle phalanx can create PIP instability, leading the middle phalanx to translate dorsally. This can create a subtle finding on a lateral radiograph, described as the “beak sign” or “V sign,” as detailed by the white lines in Fig. 10.1C. The formation of the beak sign signifies point loading between the articular surface of the proximal and middle phalanx, which can lead to rapid joint degeneration if not treated. • Computed tomography (CT) is rarely needed for phalanx fractures but can provide a more detailed assessment of articular comminution when plain radiographs are unclear.

SURGICAL ANATOMY • The PIP joint is a hinge joint that is stabilized by bony architecture and soft tissue restraints. • The proximal phalanx head consists of two concentric condyles. The concave surface of the base of the middle phalanx fits to the condyles. This bony structure provides stability during flexion and extension. 21.e1

21.e2

CHAPTER 10  Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint

A

B

C FIGURE 10.1

• Collateral ligaments restrict radial and ulnar deviation; each has two parts (proper and accessory ligaments). The proper collateral ligament originates from a sulcus on the lateral surface of the head of the proximal phalanx and inserts on the volar lateral aspect of the middle phalanx. The accessory collateral ligament originates from the proper collateral ligament and runs in a volar direction to attach to the volar plate (Fig. 10.2). • The volar plate and accessory collateral ligaments provide stability during extension. The proper collateral ligaments provide stability during flexion. • Fragmentation of more than 40% of the volar articular surface of the middle phalanx typically results in PIP instability and/or subluxation. (Fig. 10.3).

PROCEDURE • When using dynamic fixators, the reduction force is primarily applied through ligamentotaxis, meaning that the forces of the volar plate, PIP joint capsule, and collateral ligaments exert on the articular fragments when longitudinal traction is applied. (Fig. 10.4) • Many different techniques have been developed for dynamic external fixation of the PIP joint. The following technique describes the fixator commonly called the Suzuki frame.

Proper collateral ligament

Central tendon

Unstable

Middle phalanx

Proximal phalanx

Proximal phalanx

50% 30% Stable

Volar plate Accessory collateral ligament

FIGURE 10.2

FIGURE 10.3

Middle phalanx

CHAPTER 10  Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint

K3

K2 Middle phalanx

K1

Proximal phalanx

Volar plate Accessory collateral ligament

FIGURE 10.4

FIGURE 10.6

FIGURE 10.5

Step 1: Reduction • A true lateral view of the PIP joint is obtained with fluoroscopy. • The middle phalanx is most often affected in these injuries and, as such, is a poor reference for achieving a true lateral image. Instead, the two condyles of the proximal phalanx should be used. A true lateral image will have both condyles perfectly superimposed (Fig. 10.5). • Longitudinal traction is applied through the finger and a true lateral image is obtained. Dynamic/live fluoroscopy is then used, and the PIP is taken through flexion and extension to ensure that reduction can be maintained.

Step 2: Insertion of Proximal and Distal Kirschner Wires • While maintaining a true lateral x-ray of the PIP joint, the first Kirschner wire (K-wire; 0.045 in [1.1 mm], labeled “K1”) is inserted at the center of rotation (COR) of the proximal phalangeal head, perpendicular to the axis of the bone. • The next wire to be inserted is the distal K-wire (0.045 in [1.1 mm], labeled “K3”), which is placed in the distal part of the middle phalanx. • There is no center of rotation with which the K3 wire must be placed; however, perpendicular placement of the wire within the middle phalanx is still required. • These wires are advanced through the opposite side of the digit until the lengths of both sides are equal (Fig. 10.6).

Step 3: Bending of K-Wires

STEP 1 PEARLS

An in-office digital block with subsequent examination under fluoroscopy can be used to confirm fracture reducibility before committing to operative intervention with dynamic fixator placement.

STEP 2 PEARLS

Use of a longer K-wire or a smooth thin Steinmann pin for K1 is often useful to provide extra wire length on either side of the digit, which will be bent into position in later stages. Standard K-wires may not provide enough length to create these bends. STEP 2 PITFALLS

Correct placement of the K1 pin is the critical step of the operation. A K-wire placed outside of the COR will lead to uneven reduction force across the PIP joint and prevent PIP motion. STEP 3 PEARLS

• The proximal K-wire (K1) is bent on both sides of the digit 90 degrees and aimed distally. At the terminal end of the wires, further bends are made to create a hook for the rubber bands to seat into. • The distal K-wire (K3) is also bent on either side of the digit to form a similar recess for the other end of the rubber band (Figs. 10.7 and 10.8).

A needle driver is clamped in place where the intended bend is to be made, and a Frazier suction tip or additional needle driver is used to bend the wire. An additional needle driver should be used by an assistant to grasp and stabilize the wires proximally while the surgeon bends the wire into shape.

Step 4: Rubber Band Setting

STEP 3 PITFALLS

• The proximal and distal hooks are connected by rubber bands, and adequate traction is obtained by adjusting the number of bands or the size/strength of the bands (Fig. 10.9). • PIP congruency and stability is checked under physical examination and fluoroscopic control through a full range of motion (ROM), and traction is adjusted as necessary.

Pay close attention to the adjacent digits; the wires should not stick out so far laterally that they displace the surrounding digits. Similarly, avoid bending the wires so close to the affected finger that they impinge on the injured digit when there is postoperative swelling.

21.e3

21.e4

CHAPTER 10  Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint STEP 4 PEARLS

• Orthodontic elastic bands or other small rubber bands can be appropriately sterilized for this procedure. • If no sterile rubber bands are available, one may simply have to place nonsterile rubber bands on at the end of the case, once any incisions are closed and sterility is no longer a concern.

FIGURE 10.7

FIGURE 10.8 STEP 5 PEARLS

Step 5: Adding a Third K-Wire

This third wire should be thinner than the other wires (0.035 in [0.9 mm] or smaller), so it can be bent easily around the limbs of the proximal wire (K1) without undue torque on the fixator or the fracture.

• Many constructs will require a third K-wire, placed distal to the fracture but proximal to the distal K-wire (typically 0.035 in [0.9 mm], labeled “K2”). • The purpose of this wire is to control the tendency of the base of the middle phalanx to dorsally subluxate, which could lead to the “V sign” seen on lateral radiographs. • In the sagittal plane, the K2 wire should be placed slightly volar to the level of K1 to effectively resist against dorsal translation of the middle phalanx. The K2 wire can then be bent around the K1 wire.

POSTOPERATIVE PEARLS

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

Early motion will help maintain mobility, encourage joint surface remodeling, and enhance the health of the cartilage surfaces.

• After 48 to 72 hours of rest, the patient can begin active motion. • The patient should begin pin care at home starting on the first postoperative day. Sterile saline or a 50:50 mix of sterile saline and 3% hydrogen peroxide can be applied to a cotton swab to gently clean the pin sites.

CHAPTER 10  Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint

Rubber bands

K3

K2

K1

FIGURE 10.9

FIGURE 10.10

POSTOPERATIVE PITFALLS

• Dressing around the pin sites should be thin to avoid obstructing active motion. • Patients need to be careful that the fixator does not abrade or ulcerate adjacent digits, especially if sensation is altered because of nerve injury.

FIGURE 10.11

• Within the first 7 days, the patient’s alignment should be checked on physical examination and radiographs, and occupational therapy is started. • The fixator device usually remains in place for 6 weeks. Reasons for earlier removal include pin site irritation or infection. Well-tolerated devices can remain in place for up to 8 weeks. • After healing is complete, the joint may still appear irregular on x-ray, although congruent joints tend to remodel over time (Fig. 10.10). • With difficult intraarticular fractures, normal postoperative motion is not always expected, but select patients may obtain near-normal function, and average motion obtained approaches 90 degrees in published series (Fig. 10.11).

21.e5

21.e6

CHAPTER 10  Dynamic External Fixation of Fracture-Dislocation of the Proximal Interphalangeal Joint

EVIDENCE Ellis SJ, Cheng R, Prokopis P, et al. Treatment of proximal interphalangeal dorsal fracture-dislocation injuries with dynamic external fixation: A pins and rubber band system. J Hand Surg Am. 2007;32:1242–1250. This study reports the results of dynamic external fixator (Suzuki frame) treatment of unstable fracturedislocations of the PIP joint. Of 14 patients treated, 8 were available for follow-up at an average of 26 months. The average range of PIP joint motion at final follow-up was 88 degrees, and average grip strength was 92% of the uninjured hand. Five patients had a small step-off deformity or arthritis (Level IV evidence). 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;33:19–25. This retrospective study reviewed the outcome of Suzuki frame fixation for 34 unstable fracture-dislocations and pilon injuries of the PIP joint. All patients were followed for an average of 16 months. At the final follow-up, the average ROM was 88 degrees at the PIP joint and 60 degrees at the distal interphalangeal joint. Pin-track infections were identified in eight cases. There were no patients with septic arthritis, osteomyelitis, or loss of reduction. The preoperative level of activity was achieved in all cases (Level IV evidence). 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;19:98–107. This paper demonstrates operative technique of the dynamic traction system, postoperative care, and case reports. In the case reports, outcomes of seven severely injured joints were presented, and all patients were followed for an average of 13.1 months. At the final follow-up, the ROM averaged 80 degrees at the PIP joint (Level IV evidence).

CHAPTER

11

Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com.

KEY CONCEPTS • Open reduction and internal fixation is indicated for intraarticular phalangeal fractures that are displaced or those that shorten or angulate after successful reduction. • When there is significant soft-tissue loss over the phalanges or interphalangeal joints, treatment with Kirschner wire (K-wire) pinning is preferred. Pinning causes less soft tissue disruption, and pins are easier to remove in the case of a deep wound infection. • Intraarticular fractures of the middle phalangeal base should be scrutinized for joint subluxation. If greater than 50% of the volar articular rim is fractured, there is typically joint instability. Meanwhile, fracture of 30% to 50% of the articular surface can cause more subtle beaking or development of a V-sign, which also signifies joint instability. • The extensor mechanism covers most of the dorsal and lateral sides of the digit at the level of the proximal interphalangeal (PIP) joint. The central slip inserts onto the epiphysis of the middle phalanx, with lateral bands running adjacent as they go on to consolidate at the terminal tendon. Incisions and exposures must be performed with precision to avoid damaging these structures. Otherwise, extensor tendon scarring and adhesions will result. • Patients with multiple fractures or injuries to the same hand/extremity benefit from rigid internal fixation, even if their injury appears stable and reduced. Rigid internal fixation permits early active motion and faster recovery compared with nonoperative treatment. • Protective splinting of the digit is continued until fracture union, which takes about 6 weeks. After confirming union, the splint can be weaned and strengthening exercises started.

Unstable Proximal phalanx

50%

Middle phalanx

30% Stable

FIGURE 11.4  Instability of the volar middle phalanx PIP fracture begins with articular involvement of 30% or greater. PIP, Proximal interphalangeal.

22

CHAPTER

11

Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures Benjamin K. Gundlach and Kevin C. Chung

INDICATIONS There are a number of indications for this procedure, including: • Displaced fractures or fracture-dislocations, which are irreducible by closed reduction techniques. • Fractures that displace, shorten, or angulate after successful reduction. Because of the intraarticular extension of these fractures, any loss in reduction will likely lead to an articular step-off. Any articular step-off, or gap in the articular surface greater than 1 mm, should be treated surgically. • Intraarticular fractures of the middle phalangeal base should be scrutinized for joint subluxation. If greater than 50% of the volar articular rim is fractured, there is typically joint instability. Meanwhile, fracture of 30% to 50% of the articular surface can cause more subtle beaking, or development of a V-sign, which also signifies joint instability. • Patients with multiple fractures or injuries to the same hand/extremity benefit from rigid internal fixation, even if their injury appears stable and reduced. Rigid internal fixation permits early active motion, which helps accelerate recovery compared with nonoperative treatment and splinting.

A

Contraindications • When there is significant soft-tissue loss over the phalanges or interphalangeal joints, treatment with Kirschner wire (K-wire) pinning is ideal over plate and screw fixation. Pinning causes less soft-tissue disruption. In addition, pin removal is easier in the case of a deep wound infection.

CLINICAL EXAMINATION • Intraarticular fractures typically cause swelling, tenderness, and difficulty with range of motion (Fig. 11.1A–B). • Even in cases where range of motion is preserved, examine closely for angular or rotational deformity resulting from the fracture displacement.

B

IMAGING

FIGURE 11.1

• Standard posteroanterior and lateral radiographic views should be obtained to characterize the fracture (Fig. 11.2A–B). • One or more oblique views can provide additional information.

SURGICAL ANATOMY • The proximal interphalangeal (PIP) joint is a ginglymoid (hinge) joint. The concentric condyles of the proximal phalanx and the concave surface of the middle phalanx are congruent with each other and provide some innate stability, which is further reinforced by the strong collateral ligaments and the volar plate. • Fractures of the volar rim of the middle phalanx can create instability of the PIP. A sometimes-subtle finding of a so-called “beak sign” can be seen on lateral radiographs, as detailed by the dashed red lines in Fig. 11.3. In these injuries, there is loss of congruent articular contact between the proximal and middle phalanx, leading to point-loading of the volar articular surface. Failure to recognize and treat this will lead to rapid destruction of the PIP joint.

B

A

FIGURE 11.2

22.e1

22.e2

CHAPTER 11  Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures

Unstable Proximal phalanx

50%

Middle phalanx

30% Stable

FIGURE 11.4

FIGURE 11.3 EXPOSURES PEARLS

To avoid an increased risk of avascular necrosis, be sure to maintain the attachments of collateral ligament, volar plate, and other tissues to small fracture fragments. EXPOSURES PITFALLS

• When working on the dorsal aspect of the PIP joint, be careful to preserve the attachment of the central slip to the dorsal base of the middle phalanx. • When incising through joint capsule, it is of critical importance to remember that the articular surface is immediately deep to the capsule. Overaggressive dissection, or burying of the knife blade, will result in certain damage to the articular cartilage.

• Instability of volar middle phalanx PIP fractures can begin with articular involvement of 30% or greater (Fig. 11.4). • The extensor mechanism covers most of the dorsal and lateral sides of the digit at the level of the PIP joint. The central slip inserts onto the epiphysis of the middle phalanx, with lateral bands running adjacent as they go on to consolidate at the terminal tendon. Incisions and exposures must be performed with precision to avoid needless damage to these structures. Otherwise, extensor tendon scarring and adhesions will result.

EXPOSURES Dorsal or Dorsolateral Approach • This approach can be used to repair dorsal fracture fragments and provides access to one or both sides of the joint for condylar fractures. • A linear or curvilinear incision is made over the PIP joint. This can be designed as a middorsal line, a lazy “S,” or a zigzag incision. • Most condylar fractures can be visualized by incising the interval between the lateral band and the central slip; this can be done on one or both sides of the joint to help with visualization of the joint surface (Fig. 11.5).

Central slip

Lateral band

FIGURE 11.5

CHAPTER 11  Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures

• Immediately deep to the extensor mechanism is the joint capsule. If the capsule remains intact, attempt to define this layer because it will require separate closure. • With the capsule defined, create a capsulotomy along the vertical/long axis of the finger. • For better visualization of the proximal extension of condylar fractures, division of the transverse retinacular ligament may provide better visualization of the shaft of the proximal phalanx. • In rare cases, to visualize the center of the PIP joint, the central tendon can be split down its midline.

Volar Approach • The volar approach can be used for cases that have a volar fragment, such as a large avulsion fragment associated with the volar plate of the PIP joint. • A palmar Bruner-style incision is created over the center of the PIP joint (Fig. 11.6). • A flap of skin and subcutaneous tissue is elevated; the radial and ulnar neurovascular bundles should be identified and protected. • The flexor sheath is opened between the A2 and A4 pulleys, incising through the C1, A3, and C3 pulleys. It is important to leave a cuff of pulley remaining for later repair. • The flexor tendons are retracted and the volar plate is exposed (Fig. 11.7). • The volar plate may be detached at its distal or proximal aspects, depending on the configuration of the fracture and the exposure required. • To fully expose both joint surfaces, the collateral ligaments are released from the volar plate and from the base of the middle phalanx. This allows the joint to be hyperextended 180 degrees, exposing both joint surfaces. This is sometimes referred to as the “shotgun” exposure (Fig. 11.8).

PROCEDURE Step 1: Reduction • Anatomic reduction is required for all periarticular injuries. Failure to reduce the articular surface will lead to rapid joint degeneration. • Any clots and debris are removed from the fracture area for precise reduction. • A combination of pointed reduction clamps, dental picks, and longitudinal traction may be used to gain fracture reduction. • In some injuries, the middle phalanx articular surface can be impacted deep into the metaphyseal bone. In these scenarios, a small corticotomy can be created distal to the fracture and a dental pick can be used to tamp the articular surface back into place. • Use K-wires to hold the reduction in place (Fig. 11.9).

22.e3

EXPOSURES PEARLS

When releasing the collateral ligaments, it is best to work from within the joint and release outward toward the ligament insertion. This ensures that the immediately adjacent neurovascular bundle is safe from the knife blade and protects against accidental laceration of the ligament in its midsubstance. EXPOSURES PITFALLS

• If the volar plate is to be detached from the middle phalanx, leave a small remnant behind to reattach at the end of the procedure. Otherwise, it may be necessary to reattach with bone tunnels or anchors, which is technically challenging. • Be mindful of protecting the neurovascular bundles when the collateral ligaments are released; they are quite vulnerable during this step. • Additional mobilization of the neurovascular bundles is often needed to avoid a stretch injury to these structures when the shotgun exposure is used.

STEP 1 PEARLS

Minimize stripping of the periosteum and other soft tissue attachments from small fracture fragments to preserve the blood supply. If using a volar approach, take care to leave dorsal structures intact, and vice versa. STEP 1 PITFALLS

• The condylar (metaphyseal) bone is fragile, so be gentle when using clamps to avoid creating additional comminution. • Be cautious when placing K-wires for provisional fixation so that they do not interfere with the planned internal fixation. Avoid placing K-wires near the flat surfaces where a plate will lie.

Volar rim fragment FDP

FIGURE 11.6

FIGURE 11.7

FIGURE 11.8

22.e4

CHAPTER 11  Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures

Screw

Fracture site

FIGURE 11.10 FIGURE 11.9

STEP 2 PEARLS

Countersinking is not required for these screws and may lead to loss of screw purchase if the bone is too thin or too soft at the metaphysis. STEP 2 PITFALLS

• Do not place screws or a plate directly over or through the collateral ligament(s) because this will restrict the ligaments’ function, causing joint stiffness. If fixation is needed at the footprint of the collateral ligament, then it can be split in-line with its fibers, or its insertion can be partially released. • When using fluoroscopy, take a live shot and fully pronate/supinate the hand/finger to ensure that there is no screw prominence through the far-cortex. Evaluation of the static anteroposterior and lateral views alone can deceive the observer into believing there is no screw prominence—when in fact there is—as a result of the complex three-dimensional structure of the phalanges.

FIGURE 11.11

Step 2: Fixation • Small articular fragments are typically fixed with lag screws or bicortical screws. • Bicondylar fractures, or complex articular fractures with complete transverse disruption of the neck or shaft of the phalanx, may require plate fixation. Newer minifrag plating systems can be set with locking screws to create a fixed-angle construct which can better maintain a tenuous reduction. • Proximal phalangeal condyle fractures are typically fixed with 1.3- to 1.5-mm diameter screws. For smaller fragments, 1.0-mm screws may be used. • The screw is typically advanced from the mobile fracture fragment to the more stable (larger) fragment of bone (Fig. 11.10). • Fragments should be fixated with two screws to prevent loosening or rotation; however, tiny bone fragments may not have enough space to insert two screws. • The reduction, position, and length of the screws are confirmed under radiologic assistance (Fig. 11.11). • Range of motion of the finger is checked for smooth motion and stability. • Buttress plating of articular rim fragments can be used when fragments are too small or comminuted to permit screw fixation.

22.e5

CHAPTER 11  Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures

A

B FIGURE 11.12

Step 3: Closure • If the central slip was split for exposure, it should be repaired with a braided nonabsorbable suture. • If the extensor mechanism was split between the central slip and lateral bands, this does not require repair (nor does the transverse retinacular ligament if violated). • If the volar approach was used, reattach the volar plate back to its remaining stump, usually on the middle phalanx. If the collateral ligaments were released entirely, they should be loosely sutured back into place. Partial collateral ligament release does not require repair. • The skin is closed with nonabsorbable sutures. A forearm-based intrinsic plus gutter splint is applied to rest the soft tissues. Unless the fracture fixation is tenuous, the remaining fingers and thumb can be left free.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • In patients with rigid fixation, gentle active motion exercises can be started within a week. • Protective splinting of the digit is continued until fracture union, which takes about 6 weeks. The splint is removed for range-of-motion exercises. • After confirming union, the splint can be weaned and strengthening exercises started. • The restored joint usually recovers near-full range of motion and strength (Figs. 11.12A–B and 11.13A–B). See Video 11.1

EVIDENCE Hamilton SC, Stern PJ, Fassler PR, Kiefhaber TR. Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations. J Hand Surg Am. 2006;31:1349–1354. This study reports the outcomes of open reduction and internal fixation for nine patients with unstable fracture-dislocations of the PIP joint. The fractures were fixed with miniscrews using a volar approach. Average follow-up period was 42 months after surgery. The range of motion of the PIP joint at final follow-up averaged 70 degrees. Flexion contracture was an average of 14 degrees at the PIP joint. Two patients had pain during heavy activity, but the others reported no pain in the injured finger (Level IV evidence). Lee JY, Teoh LC. Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results. J Hand Surg Br. 2006;31:138–146.

A

B FIGURE 11.13

STEP 3 PITFALLS

• Overtightening or excessive repair of the extensor mechanism, volar plate, or collateral ligaments will lead to profound stiffness. Loose repair is preferred because stiffness—not instability—is the usual outcome after a PIP injury. • Check the finger position in the splint carefully. In particular, hyperextension needs to be avoided at the PIP joint, or instability may result because of improper healing of the volar plate after a volar approach.

22.e6

CHAPTER 11  Open Reduction and Internal Fixation of Intraarticular Phalangeal Fractures This study reports on a series of 10 patients with unstable fracture-dislocations of the PIP joint. Open reduction internal fixation was performed from a dorsal approach, using miniscrews. Patients were followed for an average of 8.7 months. All patients had good-to-excellent results, with an average PIP joint active range of motion of 85 degrees (Level IV evidence). Shewring DJ, Miller AC, Ghandour A. Condylar fractures of the proximal and middle phalanges. J Hand Surg Eur. 2015;40:51–58. This retrospective study reports the treatment of 74 patients with phalangeal condylar fractures. Although 12 patients were initially treated nonoperatively, five of these ultimately required fixation because of fracture displacement during follow-up. The remaining 62 patients were treated operatively with a single screw via a lateral approach. Fixation was easiest within the first week, but delays of up to 2 weeks had little effect on final results. Patients with unicondylar fractures that were fixed within a week had the best results, with very little loss of range of motion. Patients presenting late, and those with bicondylar fractures, fared less well (Level IV evidence). Federer AE, Guerrero EM, Dekker TJ, et al. Open reduction internal fixation with transverse volar plating for unstable proximal interphalangeal fracture-dislocation: The seatbelt procedure. Hand (N Y). 2020;15(2):201–207. Seventeen patients with PIP dorsal fracture-dislocations with large (>40%) articular volar rim fragments underwent open reductions and internal fixation with a horizontal plate through a volar approach. A 7-months mean follow-up demonstrated no recurrent instability, the average arc of motion was 70 degrees, and only two patients required hardware removal for irritation.

CHAPTER

12

Volar Plate Arthroplasty of the Proximal Interphalangeal Joint Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 12.1 – Volar Plate Arthroplasty of the PIP Joint.

KEY CONCEPTS • Volar plate arthroplasty of the proximal interphalangeal (PIP) joint is indicated for fracture dislocations of the PIP joint that are unstable and in which the volar lip (buttress) of the middle phalanx base cannot be salvaged or reconstructed by other means. • Volar plate arthroplasty can be used for acute or chronic cases, but ideally the articular surface of the head of the proximal phalanx is preserved. Acute injuries will present with tenderness and swelling of the digit. Range of motion (ROM) will be limited. Chronic injuries may present with stiffness and pain, often after what was believed to be a trivial “finger jam” injury. • In cases with subtle subluxation, the middle phalanx shifts relatively dorsal to normal joint alignment, and a “V sign” can be seen at the dorsal side of the joint on plain radiographs. • The volar plate is firmly attached at its distal edge to the volar lip of the middle phalanx. Its proximal attachments (checkrein ligaments) are ordinarily loose and flimsy in the nonpathologic state. These attachments allow the volar plate free excursion with flexion of the joint, but effectively prevent hyperextension. • When the comminution of the middle phalanx volar lip involves more than 40% of the articular surface, the PIP joint generally becomes unstable because of loss of the collateral ligament and the volar plate stabilizers. • Wide exposure of the joint is needed for this operation (“shotgun” exposure); by hyperextending almost 180 degrees, the whole joint surface can be exposed. • The damaged, volar portion of the middle phalanx base is shaped into a smooth, symmetric surface that is to be resurfaced by the volar plate.

Middle phalanx

Volar plate Checkrein ligaments

Collateral ligament

Proximal phalanx FIGURE 12.3  The volar plate attaches to the proximal phalanx via the checkrein ligaments.

23

CHAPTER

12

Volar Plate Arthroplasty of the Proximal Interphalangeal Joint Kevin C. Chung INDICATIONS • Indications for this procedure include fracture dislocations of the proximal interphalangeal (PIP) joint that are unstable and in which the volar lip (buttress) of the middle phalanx base cannot be salvaged or reconstructed with other means. • Volar plate arthroplasty can be used for acute or chronic cases. Ideally, the articular surface of the head of the proximal phalanx is preserved.

CLINICAL EXAMINATION • Acute injuries will present with tenderness and swelling of the digit. Range of motion (ROM) will be limited. • Chronic injuries may present with stiffness and pain, often after what was believed to be a trivial “finger jam” injury (Fig. 12.1).

IMAGING • Plain radiographs in three views (posteroanterior, oblique, and lateral) should be obtained. A properly aligned lateral view is especially important for identifying any subluxation (Fig. 12.2A). • In cases with subtle subluxation, the middle phalanx shifts relatively dorsal to normal joint alignment, and a “V sign” can be seen at the dorsal side of the joint, highlighting the incongruity of the joint surfaces (see Fig. 12.2B).

SURGICAL ANATOMY • The volar plate is firmly attached at its distal edge to the volar lip of the middle phalanx. Its proximal attachments (checkrein ligaments) are ordinarily loose and flimsy in the nonpathologic state. These attachments (volar plate and the accessory

FIGURE 12.1  Small finger presents with pain and stiffness.

23.e1

23.e2

CHAPTER 12  Volar Plate Arthroplasty of the Proximal Interphalangeal Joint

A

B FIGURE 12.2  (A–B) Plain radiographs demonstrate subtle subluxation of the middle phalanx.

collateral ligaments) permit free excursion of the volar plate with flexion of the joint, but effectively prevent hyperextension (Fig. 12.3). • When the comminution of the middle phalanx volar lip involves more than 40% of the articular surface, the PIP joint generally becomes unstable because of loss of the collateral ligament and the volar plate stabilizers (Fig. 12.4).

EXPOSURES • A V-shaped incision is made on the volar side of the PIP joint and the center of the incision is located on the PIP flexion crease. • The skin flap with subcutaneous tissue is elevated. The radial and ulnar neurovascular structures are identified and protected. • The sheath from the A2 to A4 pulley is exposed, incised, and reflected as a rectangular flap (Fig. 12.5A). • The volar plate is exposed by retracting the flexor tendons (see Fig. 12.5B).

CHAPTER 12  Volar Plate Arthroplasty of the Proximal Interphalangeal Joint

Middle phalanx

Volar plate Checkrein ligaments

Collateral ligament

Proximal phalanx FIGURE 12.3  Volar plate is attached at its distal edge to the volar lip of the middle phalanx.

Proximal phalanx Accessory collateral ligament Proper collateral ligament Volar plate

FIGURE 12.4  Comminuted middle phalanx volar lip creates instability of PIP joint. PIP, Proximal interphalangeal.

A3 VP

A

B

FIGURE 12.5  (A) The sheath from the A2 to A4 pulley is exposed, incised, and reflected as a rectangular flap. (B) The volar plate is exposed by retracting the flexor tendons. (Fig. 73.19A–B, from Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020.)

23.e3

23.e4

CHAPTER 12  Volar Plate Arthroplasty of the Proximal Interphalangeal Joint

PROCEDURE

STEP 1 PEARLS

The volar plate flap should be designed with adequate width to provide stability to the reconstruction. Also, it needs to be designed with symmetry between the radial and ulnar sides of the flap to avoid an angular deformity.

Step 1: Incision of the Volar Plate and Joint Exposure • Longitudinal incisions are made along the radial and ulnar edges of the volar plate, which is separated from the collateral ligaments, elevating it as a proximally-based flap. • Distally, the volar plate may already be avulsed with the fracture fragment(s). If not, a transverse incision is made at the most distal aspect of the volar plate, detaching it from the base of the middle phalanx (Fig. 12.6). • Wide exposure of the joint is needed for this operation (the “shotgun” exposure). The collateral ligaments are identified and the accessory collateral ligaments attaching to the volar plate are released (Fig. 12.7) distally from the middle phalanx in a stepwise fashion, checking periodically to see if enough has been released to open the joint fully. If possible, the proper collateral ligaments are kept in place. • By hyperextending almost 180 degrees, the whole joint surface can be exposed (Fig. 12.8A–B).

Step 2: Preparation of the Joint and the Volar Plate • Loose fracture fragments, including those attached to the distal volar plate, are excised. • The damaged, volar portion of the middle phalanx base is shaped into a smooth, symmetric surface that is to be “resurfaced” by the volar plate (Fig. 12.9). The depth

Middle phalanx

Incisions Collateral ligament Accessory collateral ligament

Volar plate

Proximal phalanx

FIGURE 12.6  Incision markings for volar plate.

A

FIGURE 12.7  Accessory collateral ligaments are identified and released. (Fig. 73.19C, from Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020.)

B

FIGURE 12.8  (A–B) Exposure of the whole joint surface by hyperextending almost 180 degrees.

CHAPTER 12  Volar Plate Arthroplasty of the Proximal Interphalangeal Joint Central tendon

Volar plate

Bone resection

Drill holes for sutures

Collateral ligament stump

Flexor digitorum superficialis tendon Drill hole Collateral ligament stump

FIGURE 12.9  The damaged, volar portion of the middle phalanx base is shaped into a smooth, symmetric surface that is to be “resurfaced” by the volar plate. (Fig. 67.52E, from Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020.)

Volar plate

FIGURE 12.10  Reshaped volar portion of the middle phalanx base.

of the step-off between the healthy dorsal articular surface and this reshaped volar portion of the middle phalanx base should be equal to the thickness of the volar plate (Fig. 12.10).

Step 3: Reduction • A 3-0 or 4-0 nonabsorbable suture is placed in the volar plate flap using a locking, grasping suture pattern such as a Bunnell stitch or Krackow stitch (see Fig. 12.10). • The sutures are passed through the base of the middle phalanx using Keith needles or a similar method (Fig. 12.11). • The needles should be inserted so that the volar plate is correctly brought into the resurfaced area, abutting the residual healthy articular surface, so that a smooth articular contour is achieved. • The needles should be directed toward the dorsum of the finger, where the suture can be tightened, pulling the volar plate into the articular defect (Fig. 12.12).

Keith needles

Proximal phalanx

Volar plate FIGURE 12.11  Sutures are passed through middle phalanx base using Keith needles.

Reshaped portion

23.e5

23.e6

CHAPTER 12  Volar Plate Arthroplasty of the Proximal Interphalangeal Joint Proximal phalanx

Middle phalanx

Volar plate FIGURE 12.12  Sutures are tightened to pull the volar plate into the articular defect.

STEP 3 PEARLS

• If the PIP joint cannot reach full extension after insertion of the volar plate, the volar plate should be mobilized further by partial, step wise release of the checkrein ligaments until full extension is possible. • If lateral instability is identified, the lateral sides of the volar plate may be sutured to the adjacent collateral ligaments to improve lateral stability (Fig. 12.14). STEP 3 PITFALLS

When the sutures are tied over the periosteum, be mindful to avoid entrapping any portion of the extensor mechanism.

FIGURE 12.13  Joint reduction and range of motion are assessed.

• The joint reduction and ROM are assessed under direct vision and radiographic guidance. The sutures can be tied over a button, or preferably the extensor tendons are dissected off the sutures and the sutures are tied over the periosteum to avoid skin troubles (Fig. 12.13).

Step 4: Fixation and Closure • Congruent reduction and stability through the entire ROM is confirmed under fluoroscopic imaging (Fig. 12.15). • The tourniquet is deflated, hemostasis is achieved, and skin is closed (Fig. 12.16). • Transarticular pinning of the PIP joint in slight flexion for 3 weeks may be performed to maintain accurate reduction during the early healing period. Preferably, the PIP joint is kept flexed at 30 degrees of flexion via a blocking splint for 3 weeks and active motion is initiated 1 week after surgery.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The PIP joint fixation is continued for 3 weeks after surgery. • For cases using extension block pinning, active flexion is begun within a week. • Full active flexion and extension is started when the block splint is removed at 3 weeks. • The pullout suture is removed after 6 weeks in cases when a button is used. • Dynamic splinting can be used after 6 weeks to help achieve full extension. • Gradual improvements in ROM may be seen even up to 1 year after surgery. See Video 12.1

Volar plate is split to reconstruct collateral ligaments

FIGURE 12.14  Volar plate is split to reconstruct collateral ligaments. (Fig. 73.19G, from Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020.)

FIGURE 12.15  Fluoroscopy confirms reduction and stability.

CHAPTER 12  Volar Plate Arthroplasty of the Proximal Interphalangeal Joint

FIGURE 12.16  Skin closure.

EVIDENCE Deitch MA, Kiefhaber TR, Comisar BR, Stern PJ. Dorsal fracture dislocations of the proximal interphalangeal joint: Surgical complications and long-term results. J Hand Surg Am. 1999;24:914–923. This is a retrospective study that compares the outcomes and complications of two treatments for acute dorsal fracture dislocations of the PIP joint: open reduction and internal fixation (ORIF) and volar plate arthroplasty. Twenty-three patients were treated with volar plate arthroplasty, and 33 were treated with ORIF. Redislocation occurred in 3 volar plate arthroplasty patients and 3 ORIF patients. Seventy-four percent of patients had little or no pain. There were no statistically significant differences in the grip strength and ROM between ORIF and volar plate arthroplasty (Level III evidence). Dionysian E, Eaton RG. The long-term outcome of volar plate arthroplasty of the proximal interphalangeal joint. J Hand Surg Am. 2000;25:429–437. This study shows the outcome of volar plate arthroplasty for 17 fracture dislocations of the PIP joint. The average follow-up period was 11.5 years. All patients had no pain with activity. Total active ROM averaged 85 degrees in patients having arthroplasty within 4 weeks of injury, and 61 degrees in patients having the procedure more than 4 weeks after injury. Joint narrowing was recognized in four patients. The authors concluded that volar plate arthroplasty supplies satisfactory function and pain-free motion (Level IV evidence). Tyser AR, Tsai MA, Parks BG, Means Jr KR. Biomechanical characteristics of hemi-hamate reconstruction versus volar plate arthroplasty in the treatment of dorsal fracture dislocations of the proximal interphalangeal joint. J Hand Surg Am. 2015;40:329–332. This biomechanical study compares stability and ROM after hemihamate reconstruction versus volar plate arthroplasty using 18 PIP joint fracture dislocation models of cadaver hands. Dorsal displacement of the middle phalanx averaged 0.01 mm in the hemi-hamate reconstructed joints and averaged 0.03 mm in the volar plate arthroplasty joints (Level III evidence).

23.e7

CHAPTER

13

Hemi-Hamate Arthroplasty Shepard Peir Johnson and Kevin C. Chung INDICATIONS

Loss of collinearity of the small finger

Indications include: • Unstable proximal interphalangeal (PIP) joint fracture–dislocations in which more than 50% of the palmar base of the middle phalanx is fractured or greater than 30 degrees of PIP joint flexion is required to maintain stability. • Fracture of the palmar base that results in loss of the cup-shaped geometry and buttressing effect of the volar lip. Hemi-hamate arthroplasty restores joint congruity and stability and permits early motion. • Comminuted lateral plateau fractures of the base of the middle phalanx. • Joint salvage after failed treatment of complex fracture–dislocations of the PIP joint.

Contraindications

A Small finger missing from natural finger cascade

• Concentric PIP joint reduction can be maintained with open reduction and internal fixation (ORIF) of a large, noncomminuted volar lip fracture. • Loss of integrity of the dorsal cortex of the middle phalanx to permit fixation of the graft. • Damage to the cartilage surface and head of the proximal phalanx that prohibits a smooth articulation with a reconstructed middle phalanx. • If a patient has preexisting arthritis, they may be a better candidate for arthrodesis or arthroplasty. • Injured or arthritic hamate carpometacarpal articulation.

CLINICAL EXAMINATION • The PIP joint is inspected for stability in both an extended and flexed position. • If greater than 30 degrees of flexion is required to maintain stability, then reconstitution of the middle phalanx articular surface is indicated. • Examine the sagittal alignment with the finger extended, looking for collinearity of the proximal phalanx and middle phalanx. • Evaluate coronal plane alignment, assessing for lateral deviation that suggests asymmetric compression of the articular surface (Fig. 13.1). • Record active and passive range of motion of the affected finger.

IMAGING

B FIGURE 13.1  Right small finger proximal interphalangeal (PIP) joint fracture–dislocation resulting in (A) loss of collinearity in the coronal plane. The red arrow shows that the axis of the middle phalanx does not align with axis of proximal phalanx. (B) There is also disruption of the natural finger cascade where the small finger is not seen because of loss of PIP joint flexion (white arrow indicates where small finger should be visualized).

24

• Standard radiographs (anterior-posterior, oblique, and later) are obtained to evaluate the cortical and articular surfaces. The base of the middle phalanx and the proximal phalanx head should be evaluated (Fig. 13.2). • A computed tomography (CT) scan can be helpful in determining more detailed anatomy. In noncomminuted circumstances, ORIF may be favored over arthroplasty in acute or subacute cases (Fig. 13.3).

SURGICAL ANATOMY • The PIP is composed of the bicondylar articular head of the proximal phalanx and the concave base of the middle phalanx. A box of ligamentous structures aids the stability of the joint. The volar plate forms the floor, the radial and ulnar collateral ligaments serve as the sides, and the extensor mechanism is the lid. • The PIP joint is a hinge joint, where the middle phalanx actually glides more than rotates on a fixed point. Stability during initiation of flexion relies on an intact articular surface and the volar lip of the middle phalanx. Fracture or loss of this volar stability can lead to dorsal subluxation. Additionally, a dorsally subluxated middle

CHAPTER 13  Hemi-Hamate Arthroplasty

A

B

C

FIGURE 13.2  Anteroposterior (AP), oblique, and lateral views of this left middle phalanx fracture-dislocation show loss of proximal interphalangeal (PIP) joint articular surface continuity. (A) The AP view shows a comminuted fracture of the radial plateau of the middle phalanx with loss of height (red arrow). (B) The oblique view demonstrates the loss of joint congruity and loss of the buttressing effect of the volar lip (blue arrow). (C) The lateral view demonstrates the dorsal subluxation or “V sign” (green angle) and approximately 50% destruction of the volar lip (yellow bracket).

A

B

FIGURE 13.3  A Severe impaction of the middle phalanx articular surface can be clearly seen (blue arrow) as well as comminution of the volar cortex and articular surface (red arrow).

phalanx will lose its gliding motion and lever at the fracture site, leading to a hinge motion and loss of flexion (Fig. 13.4). • The rationale of this procedure is based on the anatomy of the hamate and the base of the middle phalanx. The distal dorsal surface of the hamate has a central ridge between its articulations with the bases of the ring and small metacarpals. This

25

26

CHAPTER 13  Hemi-Hamate Arthroplasty

Proximal phalanx Accessory collateral ligament Proper collateral ligament Volar plate

FIGURE 13.4  Dorsal subluxation occurs with avulsion fractures when the insertions of the collateral ligaments are retained on the volar fragment.

Middle phalanx

Metacarpal V

Metacarpal IV A B

C

B B

A PIP joint

Lateral view

Hamate

Volar view

Dorsal view

FIGURE 13.5  The hemi-hamate donor graft is harvested such that the hamate ridge (depicted by line B) is centered on the recipient middle phalanx so that it articulates with the bicondylar shape of the head of the proximal phalanx. Therefore, the line marked by B is not always centered on the width of the graft (line A). The depth of the hemi-hamate donor graft (line C) is critically important because it must be large enough to reestablish the volar lip to prevent subluxation.

FIGURE 13.6  The Bruner incision is designed from the metacarpophalangeal (MCP) joint to the distal interphalangeal (DIP) joint to provide adequate exposure.

bicondylar articular surface of the distal hamate has a contour similar to the base of the middle phalanx. The dorsal lip has a cup-shaped architecture that has matched anatomy for replacement of the volar lip of the middle phalanx (Fig. 13.5).

POSITIONING • The patient is placed supine with the arm extended on a hand table. • A tourniquet is placed on the upper arm.

EXPOSURES PEARLS

The A3 pulley may already be damaged from the injury and can be excised.

EXPOSURES • To expose the injured PIP joint, a volar Bruner incision is designed from the distal interphalangeal (DIP) to the metacarpophalangeal (MCP) joint (Fig. 13.6).

CHAPTER 13  Hemi-Hamate Arthroplasty

• The skin and subcutaneous tissue are incised, and a flap is raised on the flexor sheath protecting the neurovascular bundles. • The A3 pulley is divided on its lateral edge to expose the flexor tendons. The A2 and A4 pulleys are preserved. • The tendons are retracted away, exposing the volar plate (Fig. 13.7).

Preserved joint surface

PROCEDURE Step 1: Shotgun Exposure of the PIP Joint • Detach the volar plate distally from the base of the middle phalanx. • Sharply release the lateral portions of the volar plate by separating it from the accessory collateral ligaments. • Retract the volar plate proximally to expose the joint. • While protecting the neurovascular bundles, divide the collateral ligaments to permit the joint to be hyperextended and “shot-gunned,” exposing the articular surfaces of the proximal and middle phalanges (see Fig. 13.7). • The proximal phalanx is inspected for any major articular wear that would prohibit hemi-hamate arthroplasty reconstruction.

Step 2: Preparation of Fracture Site • Irrigate and debride all comminuted fracture fragments. The residual articular damage is often irregular. • A volar box resection that includes all the damaged articular surface is designed. A box design is easier to both resect and fill with a contoured graft piece. Resecting only the damaged area will make graft fitting difficult. • Ideally, leave the radial and ulnar margins (if uninjured) around the box to create a notch for future inset. • A power saw or osteotome is used to make parallel cuts, resecting the damaged articular surface (Fig. 13.8). • Measure the dimensions of the defect (length, width, and depth; see Fig. 13.5). • Make note of the location of the proximal articular ridge with respect to the defect. • If the articular ridge does not equally bisect the box defect, cut a plastic ruler template to match the length and width dimensions and mark the location of the ridge along the width.

Step 3: Hemi-Hamate Graft Harvest • Locate the fourth and fifth metacarpal interval with fluoroscopy (Fig. 13.9). • Make a 3-cm transverse incision over the interval.

Damaged articular surface

FIGURE 13.7  The proximal interphalangeal (PIP) joint has been shot-gunned to expose both joint surfaces. The purple triangle indicates the damaged portion of the middle phalanx articular surface (red arrow). The proximal articular surface is well preserved, and the blue arrow shows the small valley of the bicondylar head that will articulate with the ridge of the hemi-hamate donor graft. STEP 1 PEARLS

Mobilization of the volar plate in a distal to proximal manner allows it be draped over the hamate graft at the end of surgery. STEP 1 PITFALLS

• Avoid excessive manipulation of the tendons because this can create postoperative adhesions leading to poor mobility outcomes. • Always be cognizant of the location of the neurovascular bundles. STEP 2 PEARLS

• Making parallel and symmetric cuts aids in measurement and contouring of the graft. • The depth (or horizontal cut) can be slightly tapered distally (i.e., become more shallow). This ensures that when the hemi-hamate graft is inset, the graft recreates the volar lip and follows the natural contour of the articular surface. • If using a saw, irrigate to prevent thermal osteonecrosis. STEP 2 PITFALLS

During preparation of the fracture site, it is important not to fracture the dorsal cortex of the middle phalanx. The dorsal cortex is used for fixation of the replacement piece. STEP 3 PEARLS

A small trough is made proximal to the horizontal cut. This trough aids in the placement of a curved osteotome to make a volar osteotomy parallel to the dorsal cortical surface. FIGURE 13.8  A box-shaped defect has been created (red arrow) in the middle phalanx. The condyle on the radial side has been preserved to allow ease of graft inset (blue arrow). The ulnar condyle was too heavily injured to preserve. The green dotted line shows the location of the ridge on the proximal phalanx. This line does not equally bisect the box defect, and this must be considered when harvesting the hemi-hamate graft.

STEP 3 PITFALLS

The cuts should be designed 1 mm larger in all dimensions to ensure that a large graft is harvested. The piece can then be trimmed to provide perfect inset.

27

28

CHAPTER 13  Hemi-Hamate Arthroplasty

4th MC 5th MC Hamate

A

B

FIGURE 13.9  Identifying the fourth and fifth metacarpal (MC) interval guides placement of the dorsal hand incision.

• Retract and protect the longitudinal sensory nerves and veins. • Retract the extensor digiti minimi ulnarly and extensor digitorum communis radially and expose the joint interval and hamate (Fig. 13.10A). • Use the template previously created to mark the dimensions of the graft (and to match the location of the hamate ridge that will articulate with the central groove of the proximal phalanx; see Fig. 13.10B–C). The dorsal aspect of the hamate will serve as the volar lip of the middle phalanx. • Close the capsule over the joint and close the wound.

Metacarpal

A

B

Hamate

C

FIGURE 13.10  (A) Retract the extensor digiti minimi ulnarly (blue arrow) and extensor digitorum communis (red arrow) radially and expose the joint interval. The dimensions are marked as described, and a small trough is made proximal to the graft (green arrow). (B–C) The two lateral cuts are made first, followed by the volar cut. The trough made proximal to the graft facilitates placement of a curved osteotome to make this volar cut parallel to the dorsal cortex.

CHAPTER 13  Hemi-Hamate Arthroplasty

A

C

B FIGURE 13.11  The hemi-hamate graft is inset flush into the box recess previously created. The red arrow highlights the hamate ridge that will articulate with proximal phalanx recess (blue arrow).

FIGURE 13.12  Three bicortical screws are securing this graft to the dorsal cortex. The lateral view shows a well-contoured articular surface and recreation of the volar lip (red arrow). Additionally, there is no “V sign” dorsally, which indicates resolution of dorsal subluxation.

Step 4: Hemi-Hamate Graft Inset

STEP 4 PEARLS

• The hamate graft is fashioned to fit the predesigned, previously made box recess (Fig. 13.11). • Contour the graft as needed so that it is well seated. • The graft must be inset so that it recreates the volar lip, which prevents dorsal subluxation. • Using fluoroscopy, the hamate is secured with multiple 1-mm screws to the dorsal cortex (Figs. 13.12 and 13.13).

STEP 5 PEARLS

Step 5: Closure • The tourniquet is released, and hemostasis is obtained with bipolar cautery. • The finger is reduced from the shotgun position to its anatomic position. The released volar plate is laid distally over the newly secured hamate graft as the flexor tendons naturally resume their anatomic position.

A properly placed hemi-hamate graft is angulated to reconstitute the volar lip (Fig. 13.14).

• The tendon sheath (A3 pulley) can be interposed between the tendons and volar plate as an added layer of soft tissue if the volar plate is thin or damaged. • The graft is fitted visually to fill the defect. Because the hemi-hamate has more bone substance, it will often appear larger on the xrays, when in actuality it is a good fit with the cartilaginous construct of the volar cortex of the middle phalanx.

29

30

CHAPTER 13  Hemi-Hamate Arthroplasty

• Movement and stability of the finger is manually tested in the operating room. • The Bruner incision is closed with interrupted 4-0 nylon. • The patient is placed in a dorsal splint with the wrist neutral and finger immobilized in 20 degrees of flexion.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The splint is removed at 1 week. • Active PIP joint flexion is started with an extension block splint that prevents full PIP joint extension. Active and passive motion is started for the MCP and DIP joints. • Radiographs are obtained at 2 weeks and 6 weeks to evaluate the graft position and bone healing (Fig. 13.15). • Unrestricted use of the hand is allowed at 12 weeks.

FIGURE 13.13  Three-month follow-up shows excellent bony healing and reconstitution of joint congruity.

Incorrect

Correct

FIGURE 13.14  The graft should be inset such that it recreates the volar lip (black arrow) and the contour follows the natural curve of the articulation.

CHAPTER 13  Hemi-Hamate Arthroplasty

D A

B

E

F

C FIGURE 13.15  Post-operative radiographs after right small finger PIP joint hemi-arthroplasty demonstrates near full extension and approximately 90 degrees of flexion.

EVIDENCE 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;34:1232–1241. The authors retrospectively evaluated 33 patients at an average of 4.5 years after hemi-hamate arthroplasty for both acute and chronic PIP joint fracture–dislocations. Patients had an average PIP range of motion of 70 degrees and DIP motion of 54 degrees. The average visual analogue (VAS) functional score was 1.4 and Disabilities of the Arm, Shoulder, and Hand (DASH) score was 5. Ten patients complained of increased pain with cold temperatures. Only one patient required revision surgery. The authors concluded that hemi-hamate arthroplasty restores PIP function after both acute and chronic PIP joint fracture–dislocations (Level V evidence). Frueh FS, Calcagni M, Lindenblatt N. The hemi-hamate autograft arthroplasty in proximal interphalangeal joint reconstruction: a systematic review. J Hand Surg Eur Vol. 2015;40:24–32. This article is a systematic review of hemi-hamate arthroplasty. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and initial selection was performed by two independent reviewers. Thirteen articles on hemi-hamate autograft were included in full-text analysis. Results of 71 cases were summarized: (1) Number of patients treated; (2) degree of joint involvement; (3) delay to surgery; (4) follow-up time; (5) functional outcome (range of motion, grip strength); and (6) complications and donor site morbidity. Mean follow-up was 36 months and mean proximal interphalangeal joint range of motion was 77 degrees. Overall complication rate was around 35%. Up to 50% of patients showed radiographic signs of osteoarthritis. Nevertheless, few of those patients complained about pain or impaired finger motion. The authors conclude that hemi-hamate arthroplasty is reliable for the reconstruction of acute and chronic proximal interphalangeal joint fracture–dislocation with joint involvement greater than 50%. Longer-term follow-up studies are required to evaluate its outcome, especially regarding the rate of osteoarthritis (Level III evidence).

31

32

CHAPTER 13  Hemi-Hamate Arthroplasty Burnier M, Awada T, Braun FM, et al. Treatment of unstable proximal interphalangeal joint fractures with hemi-hamate osteochondral autografts. J Hand Surg Eur Vol. 2017;42(2):188–193. This retrospective study included 19 patients (average age of 39 years) with an isolated fracture of the base of the middle phalanx (10 chronic, 9 acute) that involved more than 40% of the articular surface who underwent hemi-hamate arthroplasty. Outcomes were measured at a mean follow-up of 24 months. The mean active flexion at the PIP joint was 83 degrees with a mean fixed flexion of 17 degrees. The mean active DIP joint motion was 41 degrees, mean QuickDASH was 11, and mean grip strength was 82% of the contralateral side (Level III evidence).

CHAPTER

14

Techniques and Fixation of Metacarpal Fractures Matthew Florczynski and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 14.1 – Open Reduction and Internal Fixation of Metacarpal Shaft Fractures.

KEY CONCEPTS • Most metacarpal fractures do not require operative treatment. Nondisplaced fractures or minimally displaced fractures without clinical deformity that meet acceptable radiographic parameters can be treated with a brief period of immobilization and early motion. Surgery may be indicated for metacarpal fractures that have recurrent or residual displacement after an attempt at reduction, especially if the fracture displacement results in disturbance in form or function of the hand. • Posteroanterior radiographs provide the best evaluation of shortening, whereas lateral views are best for identifying angulation. • Provisional reduction can be obtained with a variety of methods, including reduction clamps, bone forceps, or temporary Kirschner wires. • Operative fixation with an intramedullary device may be preferred to permit early rehabilitation and return to sport. Treatment with lag screws and/or a plate construct can also be used. Lag screw fixation should ideally include screws with two different orientations: screws perpendicular to the fracture line provide better compression, whereas screws perpendicular to the long axis of the bone resist axial shear better. • Bridging plates are useful for maintaining bone length in situations where collapse might otherwise occur. • Most patients should recover near-normal motion and strength, with excellent union rates and radiographic outcomes. Procedures reviewed in this chapter: • Percutaneous intramedullary fixation of metacarpal head and neck fractures • Open reduction and internal fixation of metacarpal shaft fractures: • Lag screws • Compression plates • Bridging plates • Tension-band wiring • Neutralization plates

FIGURE 14.27  Compression plate fixation of metacarpal fractures.

33

CHAPTER

14

Techniques and Fixation of Metacarpal Fractures Matthew Florczynski and Kevin C. Chung Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures INDICATIONS • Surgery may be indicated for fractures that have recurrent or residual displacement after an attempt at reduction, especially if the fracture displacement results in disturbance in form or function of the hand. • Specific indications for surgery include rotational deformities, angular deformities, shortening, multiple fractures, and open fractures.

Rotational Deformity Even small amounts of rotational deformity (10 degrees; Fig. 14.1) can cause overlap (“scissoring”) of the digits; therefore this deformity must be corrected to preserve proper hand function.

Rotational deformity

Angular Deformity Angular deformity is typically apex-dorsal (Fig. 14.2). Because of compensatory motion at the carpometacarpal (CMC) joints, residual angulation of metacarpal fractures is tolerated better in the thumb, ring, and small fingers than in the index and middle fingers. In particular, the small finger metacarpal neck fracture (often called a “boxer’s fracture”) is a common fracture that typically heals with negligible morbidity, despite significant residual angulation, as long as there is no rotational deformity. Surgical correction should be considered for shaft angulation of: • Index and middle: More than 5 to 10 degrees • Ring: More than 20 degrees • Small: More than 30 degrees • Thumb: More than 30 degrees Surgical correction should be considered for neck angulation of: • Index and middle: More than 10 to 15 degrees • Ring: More than 20 to 30 degrees • Small: More than 40 to 70 degrees (wide variation in recommendations)

FIGURE 14.1  Clinical assessment of rotational deformity of a fourth metacarpal fracture demonstrating “scissoring.”

Angular deformity

Dorsal

Volar

FIGURE 14.2  Apex-dorsal angular deformity.

Shortening Shortening is better tolerated than angular and rotational deformity, but loss of more than 5 mm of length may cause symptoms of pain, weakness, and a noticeable extension lag.

Multiple Fractures If adjacent metacarpals are injured, fracture instability is dramatically increased beyond what is seen for a single fracture, owing to loss of additional supporting structures.

Open Fractures Percutaneous Kirschner wire (K-wire) fixation may be preferable for open fractures with contamination or soft tissue defects requiring supplementary coverage to avoid exposure of hardware in an open wound. • Metacarpal neck fractures can also be treated with intramedullary fixation (see “Percutaneous Intramedullary Fixation of Metacarpal Head and Neck Fractures”). • Long oblique or spiral metacarpal shaft fractures may be more easily treated with lag screws (see “Open Reduction and Internal Fixation of Metacarpal Shaft Fractures”). 33.e1

33.e2

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

Contraindications • Note that most metacarpal fractures do not require operative treatment. Nondisplaced fractures or minimally displaced fractures without clinical deformity that meet acceptable radiographic parameters can be treated with a brief period of immobilization and early motion. Stable displaced fractures with satisfactory alignment after closed reduction can also be treated nonoperatively. • General contraindications for surgery: • Medically unfit: Highly comorbid patients or patients with active hemodynamic compromise or systemic infections should have medical issues addressed before considering operative treatment. • Patient preference: Low-demand patients can have satisfactory functional results even with substantial deformity and may prefer to be treated nonoperatively. • Specific contraindications for closed reduction and K-wire fixation include: • Comminution: K-wire fixation may not adequately maintain length and rotational stability in fractures with long comminuted segments, which can be better treated with bridge plating constructs (see Open Reduction and Internal Fixation of Metacarpal Shaft Fractures). • Bone loss: Fractures with segmental bone loss also require a lengthy and rotationally stable construct and can be better treated with bridge plating. • Early return to athletic activity: Exposed pins can migrate or cause infection and are not ideal for athletes seeking to return to early vigorous activity. • Noncompliance: Because of concerns for pin site infection, patients who will not reliably return for follow-up should be treated with other means.

A

CLINICAL EXAMINATION

B FIGURE 14.3  Swelling of the (A) dorsal and (B) volar hand.

• Swelling and wounds on the dorsal surface should be noted. Swelling may obscure fracture displacement, and wounds may indicate the presence of an open fracture or associated soft tissue injury that may be prone to osteomyelitis if the bone is not debrided of contaminants (Fig. 14.3A–B). • Malrotation can be assessed by simultaneously flexing the digits. Digits normally converge slightly and point toward the scaphoid tuberosity. Fig. 14.4 shows a ring finger that is not pointing toward the scaphoid tuberosity, labeled “S.” • Subtle malrotation may be identified by close examination of the fingertips in mild flexion. Fig. 14.5 shows a ring finger that is pronated relative to the other digits. • Limitations in range of motion should be identified, including any weakness, mechanical blocks, or extension lag. A mechanical block to motion may be present in juxta-articular fractures or be indicative of intra-articular extension. The presence of mild-to-moderate extension lag (20–30 degrees) at the metacarpophalangeal (MCP) joint is common but often improves over time.

IMAGING • Plain radiographs should be obtained in three views (posteroanterior [PA], oblique, and lateral; Fig. 14.6A–C).

S

FIGURE 14.4  Assessment of fourth metacarpal rotational deformity. S, scaphoid tuberosity. .

FIGURE 14.5  Subtle rotational deformity in ring finger.

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

STEP 1 PEARLS

A

B

C

• Subacute (partially healed) fractures may benefit from percutaneous manipulation with the tip of a K-wire or dental pick to loosen any early bony callus. • Rotational alignment needs to be assessed, corrected, and maintained during reduction and fixation. Holding the injured digit and neighboring digits in a composite fist can help maintain rotational alignment during this process.

FIGURE 14.6  (A) Posteroanterior [PA], (B) oblique, and (C) lateral radiograph of a second metacarpal fracture.

STEP 2 PEARLS

• PA view gives the best evaluation of shortening. Metacarpal heads of middle, ring, and small fingers are usually arranged in a line. • The lateral view provides the best evaluation of angulation. • Computed tomography (CT) may be useful in the evaluation of subtle or complex fracture patterns, or if intra-articular extension is suspected. CT is typically unnecessary for diaphyseal fractures.

• Longitudinal K-wires: • Wires can be placed extra-articular to the metacarpophalangeal (MCP) joint if the entry point is at the collateral ligament recess (metacarpal head/neck). • Consider mini-open techniques with limited dissection in some cases to avoid damage to cutaneous nerves and/or extensor tendons.

SURGICAL ANATOMY • Dorsal cutaneous nerves are at risk of injury or irritation, especially with wires placed near larger, more proximal nerve branches. • The metacarpal shaft is comprised of heavy cortical bone with a narrow medullary canal. In contrast, the cortical bone is thinner at the neck (metaphysis) of the metacarpal. • Of all the metacarpals, the ring finger is the narrowest, making it a challenging target for percutaneous fixation techniques.

PROCEDURE Step 1 • Longitudinal traction, plus external pressure at the fracture site, can reduce most metacarpal shaft fractures, which typically have an apex-dorsal configuration. • The Jahss maneuver (Fig. 14.7) can help with reduction of metacarpal neck fractures intraoperatively. This maneuver uses dorsally-directed force applied to the flexed proximal interphalangeal (PIP) joint to reduce an apex-dorsal metacarpal neck fracture. Alternatively, this maneuver can be performed with the PIP joint extended to relax the intrinsic muscles and further facilitate reduction.

STEP 2 PITFALLS

• Longitudinal K-wires • Wires placed through the head of the metacarpal will transfix the extensor mechanism and often lead to extensor tendon adhesions. These tendon adhesions can typically be managed with postoperative therapy but may occasionally require reoperation. • Transverse K-wires • At least two K-wires are needed in the distal fragment to avoid palmar rotation of the distal fragment. • Fractures reduced indirectly can shorten over time. This K-wire configuration is best suited for length-stable fracture patterns (i.e., transverse or short oblique patterns with minimal translation at the fracture site).

Step 2 • Fixation is usually performed with 0.045-inch (1.1-mm) K-wires. Two configurations of wires can be used: longitudinal or transverse. • Longitudinal K-wires: • They are typically placed from distal to proximal (Fig. 14.8A–D). • Wires may be left exposed distally or advanced to exit the skin proximally. • At least two wires are required for rotational stability. • Alternatively, a single longitudinal wire can be used to prevent angular displacement, and postoperative buddy-straps can be used to control rotational displacement in stable fracture patterns. • Transverse K-wires: • They are typically placed from index-to-middle or small-to-ring metacarpals (Fig. 14.9). • Uses a healthy neighboring metacarpal as a stable foundation to immobilize the adjacent fracture indirectly.

FIGURE 14.7  Jahss maneuver.

33.e3

33.e4

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

A

B

C

D

FIGURE 14.8  Postoperative (A) posteroanterior [PA], (B) oblique, (C) lateral radiographs, and (D) intraoperative fluoroscopic image demonstrating K-wire fixation of a fourth metacarpal fracture.

Step 3 • K-wires are cut to an appropriate length to accommodate a pin cap (a protective covering for the end of the wire). • Alternatively, K-wires can be cut beneath the surface of the skin and removed with a minor procedure at a later date (not common). • A protective splint is applied, with ample padding around the K-wire exit sites. This initial splint is typically a forearm-based intrinsic-plus splint for the operative digit and at least one neighboring digit.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

FIGURE 14.9  Transverse K-wire technique.

STEP 3 PEARLS

• Strategies to prevent inadvertent K-wire migration into the hand: • Place a bend in the wire a few millimeters above the level of the skin. The wire should be far enough from the skin surface so that postoperative swelling will not cause impingement. • During insertion, position the K-wires so that the distal tip is abutted against cortical bone—either the cortex of the metacarpal base or the shaft on the opposite side of the fracture line. This will prevent inward migration of K-wires. • Padding and dressings should be designed to minimize skin tension and motion at pin sites. The repetitive pistoning of skin around pin entry points contributes to the introduction of bacteria at these sites.

• Patients are typically seen in 7 to 10 days to initiate mobilization exercises for all uninvolved digits and joints. • Even joints adjacent to the fracture should be able to be gently mobilized with the K-wires in place. • Long-term immobilization (over 4 weeks) is to be avoided because it will lead to unwanted stiffness. • A removable orthosis is used to protect the pin sites and permits the hand to rest in a safe position (intrinsic-plus) between therapy sessions. • Alternatively, for very young patients or others with poor compliance, casting for the first few weeks can provide protection during the early stages of healing. • Remove K-wires in the clinic once fracture healing is underway. Typically, this can occur around 4 weeks postoperatively or when the fracture site is nontender or minimally tender to palpation. • Excellent union rates, range of motion, and grip strength are generally expected. Biomechanical strength and radiographic outcomes for complex fractures may be slightly inferior to the other techniques described in this chapter.

Percutaneous Intramedullary Fixation of Metacarpal Head and Neck Fractures INDICATIONS • See “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures” for a detailed discussion of the following indications: • Rotational deformity • Angular deformity • Shortening • Multiple fractures • For athletes, operative fixation with an intramedullary device may be preferred to permit early rehabilitation and return to sport. Treatment with lag screws and/or a

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

plate construct can also be used (see “Open Reduction and Internal Fixation of Metacarpal Shaft Fractures”). • Long oblique or spiral metacarpal shaft fractures may be more easily treated with lag screws (see “Open Reduction and Internal Fixation of Metacarpal Shaft Fractures”).

Contraindications • For general contraindications to surgery, see “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures.” • There are a few specific contraindications for percutaneous intramedullary fixation: • Comminution/bone loss: Intramedullary fixation is unlikely to adequately maintain metacarpal length in fractures with comminution or segmental bone loss, which can be better addressed with bridge plating constructs (see “Open Reduction and Internal Fixation of Metacarpal Shaft Fractures”). • Malrotation: Intramedullary devices generally confer limited rotational stability. Fractures with substantial rotational deformity are better treated with the other fixation techniques in this chapter. • Skin defects over the dorsal metacarpal head can provide direct access to the fracture and should be treated with internal fixation and flap closure.

POSTOPERATIVE PEARLS

Radiographic signs of consolidation at the fracture site may not be visible for several months, so decisions about pin removal should not be dependent only on radiographic findings. When fracture site palpation is minimally painful, there is typically enough healing present to remove pins and begin gentle mobilization.

POSTOPERATIVE PITFALLS

Wires exiting percutaneously near the MCP joint need to be protected by limiting MCP extension postoperatively. Excess tension on these wires can lead to bending of the wires and/or pin site infections.

CLINICAL EXAMINATION • Rotational alignment should be carefully assessed. • For details of the clinical examination, see “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures.”

IMAGING • For details of the imaging, see “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures.”

SURGICAL ANATOMY • The dorsal sensory branch of the ulnar nerve passes directly over the base of the small finger metacarpal and is at risk for exposures or punctures in this area. • The terminal branches of the superficial radial nerve are vulnerable to injury at the base of the thumb and/or index metacarpals. • The finger extensor tendons cross over the bases of the middle, ring, and small finger metacarpals on their way to the digits (Fig. 14.10). • The metacarpal bases serve as insertion points for the wrist extensors: • Extensor carpi radialis longus (ECRL) on the dorsal base of the index finger metacarpal • Extensor carpi radialis brevis (ECRB) on the dorsal base of the middle finger metacarpal • Extensor carpi ulnaris (ECU) on the dorsal-ulnar base of the small finger metacarpal

EXPOSURES Intramedullary fixation techniques make use of small incisions at the base of the fractured metacarpal (Fig. 14.11). Using small retractors and blunt dissection, the overlying extensor tendons and sensory nerve branches can be swept aside and protected, enabling safe access to the metacarpal base (Fig. 14.12).

PROCEDURE Step 1 • Closed reduction is used to correct any fracture displacement. The Jahss maneuver (Fig. 14.13) is ideal for this. See “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures” for additional details. • Fluoroscopic images are taken to verify reduction of the metacarpal and determine the diameter of implant needed to match the size of the intramedullary canal. The implant can be placed directly over the metacarpal while taking a PA fluoroscopic image. Its diameter should fill the diaphysis of the metacarpal.

EXPOSURES PEARLS

For the small finger, this approach can be made at the ulnar border of the metacarpal base, making it easier to avoid the finger extensors. EXPOSURES PITFALLS

Percutaneous techniques (without open dissection) risk damage to sensory nerves and extensor tendons with the introduction of K-wires at the metacarpal bases.

STEP 1 PEARLS

It may be desirable to measure the diameter of the intramedullary canal on a preoperative x-ray, particularly if the implant size must be determined in advance. STEP 1 PITFALLS

Poor size-matching of the implant to the intramedullary canal will result in inadequate fracture stability if the implant is too small or fracture distraction/comminution if the implant is too large.

33.e5

33.e6

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

EDC

EIP

EDM

ECRL

ECU

ECRB

FIGURE 14.10  Extensor tendon anatomy.

FIGURE 14.11  Percutaneous skin incisions from intramedullary fixation of fourth and fifth metacarpal fractures.

FIGURE 14.12  Fluoroscopic image of canal entry device for intramedullary metacarpal stabilization.

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

FIGURE 14.13  Closed reduction of metacarpal fracture under fluoroscopic visualization.

Step 2 • Once the base of the metacarpal is exposed, the fixation device is inserted into the medullary canal, headed distally toward the fracture. • Options for fixation include multiple K-wires as well as commercially available devices. If using K-wires, thin wires are preferred (e.g., 0.035 inch [0.9 mm]) because they are more flexible for navigating the medullary canal. • Commercial devices may contain a starter awl to make this initial hole in the cortical bone. Often, this awl incorporates a channel or cannula for introducing the intramedullary fixation device (Fig. 14.14A–B).

Step 3 • Once the fracture is reduced, the intramedullary fixation device is advanced across the fracture site and into the metacarpal head. Ideally, the device should stop at the level of the subchondral bone without penetrating the cortex (see Fig. 14.13). • Most commercially available devices are designed to advance with manual pressure. A handle is often provided to drive in the intramedullary device (Fig. 14.15). Cannulated screw systems may include a thin guidewire that can be advanced into the metacarpal and across the fracture site to facilitate screw insertion. • Some devices rely on a locking peg at the base to control rotation around a single large intramedullary rod. This peg is covered with a silicone cap to protect the extensor tendons during the healing period; these devices are designed to be removed after fracture healing is complete (Fig. 14.16). • When using smaller devices without locking pegs, at least two divergent rods or wires are required to control rotation. Round-tipped K-wires can be pre-bent into a gentle curve and used for this purpose (Fig. 14.17A–B).

Step 4 • Once fully advanced, the intramedullary device is truncated at the metacarpal base. Locking pegs are applied if indicated; other devices or K-wires may simply be bent and cut. Some commercial devices may supply specialized bending and/or cutting tools for this purpose. • If hardware removal is planned at a later date, the device should be left protruding slightly from the bone to make removal easier. • Some surgeons elect to leave K-wires in permanently, in which case the wires can be cut flush with the cortex of the metacarpal base.

STEP 2 PEARLS

• If no starter awl is available, the sharp end of a large K-wire (0.062 inch [1.6 mm] or larger) can be used for this purpose. Gentle manual twisting of this wire can be used to make a controlled, small cortical opening in the bone. • Creating the initial cortical opening with an oblique trajectory (proximal-to-distal) helps to introduce the fixation device into the medullary canal. STEP 2 PITFALLS

Be sure not to penetrate the opposite cortex when making the starter hole. If using a power drill, be very cautious because the metaphyseal region at the dorsal metacarpal base has a thin cortex. STEP 3 PEARLS

• Advance the device carefully under fluoroscopic guidance to avoid penetration of the distal cortex at the metacarpal head or neck. Accidental perforation of the joint can lead to intra-articular damage and postoperative stiffness. • Either fully threaded or partially threaded screws can be used for most fractures. Partially threaded screws should be used if there is comminution at the fracture site because fully threaded screws or those with variable pitch can cause overcompression and shortening. STEP 3 PITFALLS

It is possible to malrotate the fracture while advancing an intramedullary screw with a tight fit. The digit should be held in the desired rotation while advancing the screw, particularly as the final few turns are applied.

33.e7

33.e8

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

A

B

FIGURE 14.14  Fluoroscopic images of (A) canal entry device for intramedullary stabilization of fifth metacarpal and (B) passage of guidewire into canal.

FIGURE 14.15  Commercially available handle for intramedullary device insertion.

A

B

FIGURE 14.16  Postoperative (A) posteroanterior [PA] and (B) lateral radiographs of intramedullary wires with locking pegs.

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

A

B

FIGURE 14.17  (A) Preoperative and (B) postoperative radiographs of a fifth metacarpal fracture stabilized with multiple intramedullary K-wires.

• Motion of the fingers should be checked with passive and/or active maneuvers to verify that the extensor tendons are gliding freely without interference.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The hand is protected with an intrinsic-plus splint for the first several weeks, but early motion out of the splint is important, starting 4 to 7 days after surgery. • Buddy-taping can help with maintaining rotational stability and improving motion during the healing period. • In about 6 weeks, most patients have very little fracture pain and have restored their preoperative motion. At that point, they can wean from their splint and begin strengthening. • Uncomplicated union with restoration of full range of motion and grip strength and excellent subjective outcomes are expected for most fractures. • If hardware removal is planned, it should be performed after fracture healing is complete.

Open Reduction and Internal Fixation of Metacarpal Shaft Fractures INDICATIONS • See “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures” for a detailed discussion of the following indications: • Rotational deformity • Angular deformity • Shortening • Multiple fractures • Fractures irreducible by closed means are another indication. • Other indications are unstable fracture patterns: • Spiral or long oblique fractures • Multiple metacarpal fractures • Comminuted fractures • Fractures with segmental bone defects • Open fractures with adequate soft tissue coverage • A polytrauma patient may require the procedure. • An athlete requiring early rehabilitation may require the procedure.

POSTOPERATIVE PEARLS

Removal of hardware can be difficult because the bone has often healed around the curved intramedullary device. A secure grasp of the end of the rod/wire with heavy pliers works best; small needle-drivers or hemostats do not have enough mechanical advantage to be successful. POSTOPERATIVE PITFALLS

Removal of hardware needs to be performed gently without excessive torque to avoid fracture of the metacarpal base.

33.e9

33.e10

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

Contraindications • See “Closed Reduction with Kirschner Wire Fixation of Metacarpal Neck and Shaft Fractures” for general contraindications for surgery. • Specific contraindications for open reduction and internal fixation include: • Inadequate soft tissue envelope: Open fractures with wound contamination or large skin defects requiring supplementary soft tissue coverage should be treated with alternate means, such as closed reduction with K-wire fixation or external fixation, to minimize hardware exposure and infection risk. • Open reduction, particularly with plate and screw fixation, should be avoided in patients with poor skin integrity at risk for wound healing complications. • Closed reduction and percutaneous K-wire or intramedullary fixation should be strongly considered in patients with systemic risk factors for wound healing complications (e.g., systemic inflammatory disease, diabetes, smoking).

CLINICAL EXAMINATION Refer to “Closed Reduction with K-Wire Fixation of Metacarpal Neck and Shaft Fractures” for a discussion of the clinical examination.

IMAGING FIGURE 14.18  Radiograph of third metacarpal fracture.

EXPOSURES PEARLS

• Be alert for small subcutaneous veins; they are often paired anatomically with nerves. • Nerves tend to lie a little deeper than the veins, in the deep subcutaneous tissue, but superficial to the fascia. • Offset or “stagger” the incisions in each layer (skin, subcutaneous tissue, and fascia) to avoid a continuum of scar extending from skin to deeper structures. In other words, do not make the skin incision directly over your incision in the fascia/paratenon and do not incise paratenon directly over your periosteal incision. This permits uninjured tissue to be interposed between the layers of scar (Fig. 14.23). • Elevate the periosteum and interosseous fascia as a single unit, preserving this layer for closure over the hardware after fixation is complete.

EXPOSURES PITFALLS

• Avoid making an incision directly over an extensor tendon to decrease the chance of postoperative tendon adhesions. • Do not completely strip the extensor tendons of their surrounding fatty areolar tissue (paratenon) because this can also result in tendon adhesions. • Do not strip away more periosteum or muscle than is necessary to achieve good reduction/ fixation because this can reduce the blood supply for fracture healing. STEP 1 PEARLS

For most fracture configurations, the Auerbach bone reduction instrument (Fig. 14.24; Stryker Corp., Kalamazoo, MI) works nicely.

• Refer to “Closed Reduction with K-Wire Fixation of Metacarpal Neck and Shaft Fractures” for a discussion of the radiographic evaluation of metacarpal fractures (Fig. 14.18). • Fracture configuration will directly influence the type of fixation considered. • Transverse fractures are typically fixed with compression plating. • Long oblique (spiral) fractures are typically fixed with interfragmentary compression screws (lag screws). • Short oblique fractures, where there is limited space for interfragmentary screws, may benefit from a combination of lag screws and compression/neutralization plating techniques. • Comminuted fractures generally require a bridging plate to span the fracture, in addition to other techniques such as lag screws or cerclage wires.

SURGICAL ANATOMY • Distal branches of the superficial radial nerve and the dorsal sensory branch of the ulnar nerve are at risk for injury on the dorsum of the hand (Fig. 14.19). • Juncturae tendinum interlink the extensor tendons at the level of the metacarpal necks and may need to be divided during fracture exposure. Repair may be considered but is probably not necessary in most cases (Fig. 14.20). • Interosseous muscles originate from the metacarpal shafts; the fascia covering these muscles is contiguous with the periosteum on the dorsum of the bones.

EXPOSURES • The dorsal approach is essentially universal. • A skin incision is made longitudinally and slightly off-center along the dorsum of the metacarpal (Fig. 14.21). • For fixation of adjacent metacarpal fractures, a single incision can be made between the metacarpals so that both fractures can be exposed. • Subcutaneous tissue is gently dissected to avoid damage to cutaneous nerves. • Extensor tendons are retracted, and periosteum is incised to expose the fracture (Fig. 14.22).

PROCEDURE Step 1: Reduction • Fracture edges need to be cleaned of debris and fracture hematoma to accurately assess the reduction. • Provisional reduction can be obtained with a variety of methods, including reduction clamps, bone forceps, or temporary K-wires.

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

Superficial branch of the radial nerve

Dorsal cutaneous branch of the ulnar nerve

FIGURE 14.19  Nerve anatomy in the dorsal hand.

Juncturae tendinum

FIGURE 14.20  Juncturae tendinum.

33.e11

33.e12

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

FIGURE 14.21  Dorsal hand skin incision.

FIGURE 14.22  Dorsal exposure of second metacarpal.

Incision line Skin Subcutaneous tissue Fascia

Bone FIGURE 14.23  Staggering of layers in exposure of metacarpal.

FIGURE 14.24  Auerbach bone reduction instrument.

STEP 1 PITFALLS

Step 2: Fixation

• Care must be taken not to strip more periosteum than necessary to achieve adequate visualization of the fracture edges. Excessive periosteal stripping will compromise the blood supply and healing potential of the bone. • Even if reduction appears anatomic, check the posture and alignment of the finger carefully before performing fixation. Once the bone has been fixed with a plate and/or screws, it is very difficult to revise the reduction.

Metacarpal fixation is typically performed with 2.0- to 2.4-mm diameter screw sets, although smaller screws (1.5- to 1.7-mm) may be preferred for smaller hands or for lag screws, where 2.0-mm screws may be too large.

Lag Screws • Lag screws provide interfragmentary compression and are ideal for long oblique fractures. • The near cortex is drilled with a drill bit that has the same diameter as the external diameter of the screw, creating a gliding hole (e.g., for a 1.5-mm screw, use a 1.5-mm drill bit). • The far cortex is drilled with a drill bit that matches the core diameter of the screw, creating a threaded hole when the screw is advanced (e.g., for a 1.5-mm screw, use a 1.1-mm drill bit). Some instrumentation sets include a special drill guide that fits into the gliding hole to assist with this step. • Some surgeons choose to reverse this process, drilling both cortices with the smaller drill bit first, then overdrilling the near cortex as needed. • A countersink can be used on the proximal screw hole to minimize the prominence of the screw head, particularly if it is to be buried under a neutralization plate. • Measure screw length and insert the screw. A fully threaded screw should be used. The screw will slide through the near cortex and engage the far cortex with the screw threads. Because most screws designed for this application are self-tapping, a separate tapping step is not required.

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

• As the screw is tightened in this lag configuration, the fracture site is compressed between the head of the screw and the distal threads (Fig. 14.25). • Three or more lag screws are ideal (Fig. 14.26A–D). • Lag screws may not be appropriate if the fracture length is less than twice the bone diameter, and short oblique fractures may only accommodate two screws.

Compression Plates • Compression plates have ovoid holes so that compression can be generated at the fracture site (Figs. 14.27 and 14.28). • A screw hole adjacent to the fracture should be drilled first. The plate should be pulled toward the fracture as a screw is inserted and tightened so that the screw is positioned eccentrically in the hole. • The ovoid hole on the opposite side of the fracture should be drilled next. This hole is drilled eccentrically on the side of the hole distant from the fracture. Many instrumentation sets have specialized drill guides to facilitate this step. By tightening the second screw, axial compression is generated at the fracture site (Fig. 14.29). • Screws are then placed in the remaining holes. These screws serve to reinforce the fixation but do not generate additional compression.

A

B

C

D

FIGURE 14.26  (A) Preoperative and postoperative (B) posteroanterior [PA] and (C) lateral photograph and (D) clinical photograph showing lag screw fixation of a third metacarpal fracture.

FIGURE 14.25  Lag screw technique.

33.e13

33.e14

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

FIGURE 14.27  Compression plating clinical photograph.

FIGURE 14.28  Compression plating radiograph.

FIGURE 14.29  Compression plating technique.

Bridging Plates • This plate construct spans an area of comminution or bone loss and provides relative stability. Bridging plates are useful for maintaining bone length in situations where collapse might otherwise occur (Fig. 14.30). • At least three screw holes should be filled on each side of the fracture, spanning as much of the metacarpal as possible to confer maximal stability. • If bone loss is present, intercalary bone graft can be placed in the defect.

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

STEP 2 PEARLS

FIGURE 14.30  Bridge plating.

Tension-Band Wiring This construct counteracts the forces that typically cause an apex-dorsal deformity in metacarpal fractures. The deformity results from eccentric forces on the fracture site, causing distraction of the dorsal side of the fracture (tension side) and compression of the volar side. Tension-band wiring converts tension forces on the dorsal side of the fracture into compression forces, preventing angular displacement (Fig. 14.31).

Neutralization Plates This plate construct is used to reinforce lag screws or another compressive fixation. The plate is applied after the lag screws have been placed and provides stability instead of additional compression.

Step 3: Closure and Splinting

• Lag screw fixation should ideally include screws with two different orientations: screws perpendicular to the fracture line provide better compression, whereas screws perpendicular to the long axis of the bone resist axial shear better. • Lag screw fixation alone may not confer sufficient stability in fragile or osteoporotic bone or when fewer than three screws are used. The construct should be supplemented with a neutralization plate in such scenarios. • Plates with staggered holes permit more points of fixation over a smaller exposure and may be desirable for fractures located proximally or distally in the metacarpal with limited bone available for fixation on one side of the fracture (Fig. 14.32). STEP 2 PITFALLS

• Lag screws should not be placed within two screw diameters of the edge of a fracture. Doing so may lead to additional comminution of the bone. • Volar gapping at the fracture site can occur with improperly contoured compression plating. Compression plates must be bent into a gentle curve, slightly more than the natural dorsal curve of the metacarpal, to compress the volar cortex (Fig. 14.33).

• Carefully check for residual malalignment or rotational deformity. • Passive motion (tenodesis effect): With passive wrist flexion, the digits should extend because of the extrinsic tendon attachments, and with passive wrist extension, the digits should flex toward the scaphoid tubercle. This permits the surgeon to evaluate for any residual rotational malalignment. • Active motion: An awake patient can demonstrate flexion actively, but this can be simulated in an anesthetized patient by applying pressure to the volar forearm at the musculotendinous junction, which causes the fingers to flex and enables judgment of alignment (Fig. 14.34). • Repair periosteum and fascia to cover the plate and/or screws. • Repair juncturae tendinum if possible. • Deflate tourniquet and achieve hemostasis before skin closure. • Close skin in layers. • Apply a well-padded volar splint to immobilize the wrist and MCP joints. Including the interphalangeal (IP) joints is not necessary but may improve comfort for the patient.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Reliable patients with rigid fixation can start early active finger motion of all joints within 1 week to improve tendon gliding and tissue edema. • Even in suboptimal conditions, the IP joints should be mobilized within 1 week to avoid joint contractures. • A removable forearm-based orthosis that maintains MCP joint flexion and IP joint extension can be used for protection during the first several weeks.

FIGURE 14.31  Tension band wiring. (Fig. 6, from Weinstein LP, Hanel DP. Metacarpal fractures. Journal of the American Society for Surgery of the Hand. 2002;2(4):168–180.)

33.e15

33.e16

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures

• Once fracture healing is evident around 6 weeks, the splint can be weaned and strengthening exercises initiated. • Most patients should recover near-normal motion and strength, with excellent union rates and radiographic outcomes. See Video 14.1

EVIDENCE

Plate with staggered holes

FIGURE 14.32  Staggered hole plate applied to third metacarpal fracture.

FIGURE 14.33  Effect of plate contouring.

FIGURE 14.34  Intra-operative assessment of wrist motion cascade. POSTOPERATIVE PITFALLS

Low-demand or elderly patients may have very little pain at the fracture site despite minimal bone healing. Clinical examination of the fracture site, which would normally serve to limit activity in younger patients, cannot be used as reliably in these patient groups and delayed fixation failure may occur. Consider delaying weight-bearing and strength training until radiographic evidence of healing becomes apparent.

Avery DM, 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. This biomechanical study compared two fixation techniques for metacarpal neck fractures. Fifteen fingers stabilized with two crossed 1.1-mm K-wires were compared with 16 matched fingers that underwent intramedullary stabilization with a 3.5-mm headless compression screw. In axial loading, the intramedullary screw construct demonstrated greater stiffness (178.0 N/mm vs 111.6 N/mm for K-wires) and load to failure (467.5 N/mm vs 198.3 N/mm). The intramedullary screw also demonstrated greater load to failure in 3-point bending (401.2 N/mm vs 205.3 N/mm). These findings suggest that intramedullary screw fixation of metacarpal neck fractures provides superior stability to fixation with two crossed K-wires. Beck CM, Horesh E, Taub PJ. Intramedullary screw fixation of metacarpal fractures results in excellent functional outcomes: A literature review. Plast Reconstr Surg. 2019;143(4):1111–1118. This meta-analysis evaluated clinical outcomes across 9 studies including 169 metacarpal fractures treated with intramedullary screw fixation. On average, patients achieved MCP joint flexion of 86 degrees and grip strength of 96% compared with the contralateral side by final follow-up (average 11 months). On average, return to daily activities occurred at 8.1 weeks and a 100% radiographic union rate was reported, taking on average 5.2 weeks. There were no major complications and few minor complications (5.3%), mostly consisting of hardware removal. The authors concluded that excellent outcomes can be expected after intramedullary screw fixation of metacarpal neck and shaft fractures. Dreyfuss D, Allon R, Izacson N, Hutt D. A comparison of locking plates and intramedullary pinning for fixation of metacarpal shaft fractures. Hand (N Y). 2019;14(1):27–33. This single-center retrospective cohort study compared outcomes of 39 metacarpal fractures treated with one or two K-wires from 2013 to 2015 with 35 fractures treated with a locking plate and screws from 2016 to 2017. After follow-up of at least 12 months, fingers treated with the locking plate construct demonstrated significantly less total active motion loss (14 degrees vs. 29 degrees for K-wires) and improved grip strength (93% of contralateral hand vs. 83%). Patients treated with K-wires had significantly shorter operative time (41 minutes vs. 58 minutes for locking plate and screws) and time to radiographic healing (50 days vs. 59 days). Fixation with locking plates and screws was favored by the authors because it enabled earlier mobilization with improved clinical outcomes compared with K-wire techniques. Eisenschenk A, Spitzmüller R, Güthoff C, et al. Single versus dual Kirschner wires for closed reduction and intramedullary nailing of displaced fractures of the fifth metacarpal neck (1-2 KiWi): A randomized controlled trial. Bone Joint J. 2019;101-B(10):1263–1271. This multicenter randomized controlled noninferiority trail compared two fixation techniques in patients with acute displaced fifth metacarpal neck fractures. Patients were treated with either a single 1.6-mm intramedullary K-wire (n 5 146) or two 1.2-mm intramedullary wires (n 5 144). There were no significant differences in Disabilities of the Arm, Shoulder and Hand (DASH) scores, pain, functional range of motion, radiologic measurements, or complications. The authors concluded that either approach can be used, but the single wire approach is less technically demanding. Hoang D, Vu CL, Jackson M, Huang JI. An anatomical study of metacarpal morphology utilizing CT scans: Evaluating parameters for antegrade intramedullary compression screw fixation of metacarpal fractures. J Hand Surg Am. 2020. Online ahead of print. This anatomic study investigated metacarpal morphology based on measurements from 100 CT scans of the hand. Cortical thickness, intramedullary canal size and length, and optimal entry points for intramedullary constructs in each of the metacarpals were characterized. The ring finger was found to have the narrowest intramedullary canal, measuring 2.8 mm in the coronal plane and 3.5 mm in the sagittal plane at the diaphyseal isthmus. At the metacarpal head, the optimal entry point for intramedullary headless compression devices was found to be 3.5 to 3.8 mm volar to the dorsal cortex. This entry point could be most safely achieved in the thumb, middle, and little finger without violating the carpometacarpal joints. Hooper RC, Chen JS, Kuo CF, Chung KC. Closed metacarpal neck fractures: A review of resource use in operative and nonoperative management. Plast Reconstr Surg. 2020;146(3):572–579. This database study compared resource use and cost of operative and nonoperative treatments for closed metacarpal neck fractures. Four treatment groups were compared: closed reduction and percutaneous pinning (CRPP; n 5 1094), open reduction and internal fixation (ORIF; n 5 684), closed treatment with or without reduction (n 5 11,215) and no intervention (n 5 33,852). Operative treatment resulted in higher overall costs ($2406/patient in the CRPP group, $3092/patient in the ORIF group) compared with nonoperative treatment ($546/ patient in the closed treatment group, $261/patient in the no intervention group). Nevertheless, nonoperatively treated patients required significantly more clinic visits (1.7 visits/patient compared with 1.2 in the operative groups) and incurred a substantial proportion of overall healthcare costs because of the high volume of these injuries.

CHAPTER 14  Techniques and Fixation of Metacarpal Fractures Vasilakis V, Sinnott CJ, Hamade M, Hamade H, Pinsky BA. Extra-articular metacarpal fractures: Closed reduction and percutaneous pinning versus open reduction and internal fixation. Plast Reconstr Surg Glob Open. 2019;7(5):e2261. This retrospective cohort study compared outcomes of two techniques in the treatment of single-finger closed extraarticular metacarpal fractures. Forty-four patients underwent closed reduction and percutaneous pinning (CRPP) with K-wires, whereas 26 patients underwent open reduction and internal fixation (ORIF) with a plate and screws or lag screws. Patients treated with ORIF were immobilized for a shorter duration (19.7 days vs. 30.7 days for CRPP patients), but there were no differences in total clinic visits or hand therapy referral rates. The two groups did not differ in terms of total active motion, QuickDASH scores, or stiffness rates. Both techniques were found to have excellent clinical outcomes and few complications, with ORIF permitting earlier postoperative mobilization. Yalizis MA, Ek ETH, Anderson H, Couzens G, Hoy GA. Early unprotected return to contact sport after metacarpal fixation in professional athletes. Bone Joint J. 2017;99-B(10):1343–1347. This retrospective case series investigated outcomes of 16 professional athletes with nonthumb metacarpal fractures who underwent open reduction and internal fixation with a plate and screws. Average time to return to unrestricted professional play was 2 weeks, and 46 of 48 athletic performance metrics measured were unaffected after return to play.

33.e17

CHAPTER

15

Open Reduction for Metacarpophalangeal Joint Dislocation Shepard Peir Johnson and Kevin C. Chung

INDICATIONS Indications for this procedure include: • Complex (or irreducible) metacarpophalangeal (MCP) joint dislocation. • Concomitant fractures that require open reduction internal fixation.

CLINICAL EXAMINATION • The index finger is the most common site of this injury. • Most dislocations are dorsal and occur during forced hypertension of the MCP joint. • The involved joint will be painful and swollen; range of motion (ROM) will be decreased (Fig. 15.1A–C). • There may be sensory changes because of traction on the neurovascular bundle. • Simple dislocations typically have a hyperextended appearance, with the proximal phalanx base and metacarpal head remaining in close contact (Fig. 15.2A). • Complex dislocations often appear less displaced than simple dislocations. • Complex dislocations usually have more separation between the joint surfaces, and the proximal phalanx base may be displaced dorsal and proximal to the metacarpal head (“bayonet” deformity; see Fig. 15.2B). In these cases, the finger does not appear grossly hyperextended (see Fig. 15.1) but may be shortened, with an easily identifiable bump in the palm corresponding to the metacarpal head (Fig. 15.3).

IMAGING • Plain radiographs of the hand should be obtained in three views (Fig. 15.4A–C). • The affected joint may appear hyperextended or it may be in a so-called “bayonet” position; the joint space will be widened if there is soft tissue interposed in the joint. • Identify the position of the sesamoids, if present. If they are within the joint, it shows that the volar plate is entrapped in the intraarticular space. • Additional views, such as a reverse oblique or Brewerton view, may be useful for detecting additional details, including subtle fractures of the metacarpal head.

SURGICAL ANATOMY • With dorsal dislocations, the volar plate remains attached to the proximal phalanx.

Simple MCP Joint Dislocation • Volar plate remains draped over the metacarpal head (not interposed in the joint space; see Fig. 15.2A). • Excessive hyperextension or traction during reduction may draw the volar plate into the joint and convert the injury into a complex, irreducible dislocation. • Proper reduction includes flexing the wrist (relaxes the flexors) and applying pressure to the dorsal base of the proximal phalanx in distal and volar directions. This will slide the proximal phalanx over the metacarpal head.

Complex (Irreducible) MCP Joint Dislocation • The volar plate is either transposed between the joint surfaces or trapped dorsal to the metacarpal head (see Fig. 15.2B). • The metacarpal head becomes locked volarly as it “button-holes” between ligamentous and tendinous structures. 34

CHAPTER 15  Open Reduction for Metacarpophalangeal Joint Dislocation

A

B

C

FIGURE 15.1  Complex dislocation of the index finger results in a swollen digit held in extension. Notice that there is no substantial metacarpophalangeal (MCP) joint hyperextension in complex dislocations (red arrow).

Metacarpal head

Proximal phalanx Reducible (simple)

FIGURE 15.3  The head of the metacarpal can be seen and palpated just beneath the skin.

Metacarpal Volar plate

A

Volar plate Proximal phalanx

Irreducible (complex)

B

Metacarpal

FIGURE 15.2  (A) With simple dislocations, the volar plate remains draped over the metacarpal head and the metacarpophalangeal (MCP) joint is held in substantial hyperextension. (B) In complex dislocations, the volar plate can be drawn entirely dorsally.

A

B

C

FIGURE 15.4  (A) Anteroposterior, (B) oblique, and (C) lateral views show the metacarpophalangeal (MCP) joint dislocation of the index finger (white arrows). The radiographs demonstrate increased joint space, loss of congruity, and subtle softtissue swelling.

35

36

CHAPTER 15  Open Reduction for Metacarpophalangeal Joint Dislocation Palmar view of MCP joint of index finger

Ulnar side of proximal phalanx

Natatory ligament displaced distally

Radial side of proximal phalanx

Metacarpal head “button-holing”

Superficial transverse metacarpal ligament displaced proximally Flexor tendon displaced to ulnar side

A

Palmar view of MCP joint of 5th digit Ulnar side of proximal phalanx

Natatory ligament displaced distally

Radial side of proximal phalanx

Metacarpal head “button-holing”

Superficial transverse metacarpal ligament displaced proximally Lumbrical Abductor digiti displaced to minimi muscle radial side displaced to ulnar side

Flexor tendon displaced to radial side

B

FIGURE 15.5  Artistic representation of an (A) index finger and (B) small finger metacarpophalangeal (MCP) joint dislocation with displacement of surrounding ligamentous and tendinous structures that form a so-called “noose” around the metacarpal head.

• In the case of index finger dislocation, the metacarpal head is typically pinched between the lumbrical radially and the flexor tendons ulnarly (Fig. 15.5A). With small finger MCP dislocations, the head is trapped between the flexor tendons radially and the abductor digiti minimi tendon ulnarly (see Fig. 15.5B). • In both cases, there is additional entrapment of the head between the displaced natatory ligament and the superficial transverse metacarpal ligament. • Together, these structures act as a “noose” around the neck of the metacarpal, preventing closed reduction. EXPOSURES PEARLS

• Dislocations that are not acutely treated may be difficult to reduce. Both dorsal and volar exposures may be required for these cases. • Care must be taken when making the skin incision, as the radial neurovascular bundle will be tented over the metacarpal head of the index finger (or ulnar neurovascular bundle of the small finger; Fig. 15.8).

EXPOSURES • A dorsal, volar, or combined approach may be used to treat MCP joint dislocations. • The location of an associated fracture may guide whether a dorsal or volar approach is more suitable for fixation. • The volar approach provides better visualization of the neurovascular structures if needed, but the dorsal approach has a lower risk for neurovascular injury.

Dorsal Approach • A curvilinear incision is made on the dorsal aspect of the MCP joint (Fig. 15.6). • To expose the joint capsule, the extensor mechanism is split. • For the thumb, index, and small fingers, split between the two extensor tendons. • Thumb: between extensor pollicis brevis and extensor pollicis longus. • Index: between extensor digitorum communis and extensor indicis proprius. • Small: between extensor digitorum communis and extensor digiti minimi. • For middle and ring fingers, split the tendon in the midline. • Beneath the torn dorsal capsule, the base of the proximal phalanx with attached volar plate can be identified dorsal to the metacarpal head.

Volar Approach • An oblique palmar incision is used from the proximal to the distal palmar crease. This may be extended onto the digit with a Bruner incision (Fig. 15.7).

CHAPTER 15  Open Reduction for Metacarpophalangeal Joint Dislocation

Extensor digiti minimi

Extensor digitorum communis FIGURE 15.6  For a dorsal approach, the joint is exposed via a lazy-S skin incision and incising longitudinally between extensor tendons (or splitting a single extensor tendon over the middle or ring finger).

Metacarpal head

FIGURE 15.7  For a volar approach, the joint is exposed via an oblique palmar incision directly over the palpable metacarpal head.

• Identify and protect the neurovascular bundles, which may be displaced centrally from their usual position(s). • The prominent metacarpal head is easily recognized and found just deep to the skin within the subcutaneous tissue. • The proximal phalanx and attached volar plate are often obscured by the metacarpal head.

DORSAL APPROACH Step 1: Expose Joint

STEP 1 PEARLS

• The dorsal joint capsule is thin and typically torn. Incise any remaining joint capsule to expose the dislocation. • With careful dissection and gentle distraction, identify the dorsally displaced proximal phalanx, the volar plate, and the metacarpal neck. The metacarpal head may be entirely hidden from view.

• It is critical to distinguish the articular surface of the metacarpal head from the volar plate, which may be stretched tightly over the surface of the metacarpal head. Both surfaces may look shiny and white. • Inspect for osteochondral lesions that were not identified on preoperative imaging.

Step 2: Perform Reduction • While flexing the wrist to loosen tension on the extrinsic flexors, the proximal phalanx is gently pushed distally and volarly. • If the volar plate is interfering with reduction, it can be leveraged over the metacarpal head using a blunt periosteal elevator, such as a Freer. • If necessary, gently place narrow Hohmann retractors around the neck of the metacarpal to hold back the lumbrical and flexor tendons, allowing the metacarpal head to become unstuck from its noose and reduce properly.

Step 3: Evaluate Joint Congruity • Confirm a stable joint through full ROM under both direct vision and fluoroscopic guidance.

STEP 2 PEARLS

• In cases where the metacarpal head is firmly trapped underneath a tight volar plate, the volar plate may be split longitudinally, allowing the radial and ulnar halves to pass to either side of the head as it reduces. • When incising the volar plate, the underlying articular surface of the metacarpal head must be protected from the scalpel blade—a Freer elevator interposed between these two structures is helpful.

37

38

CHAPTER 15  Open Reduction for Metacarpophalangeal Joint Dislocation

Metacarpal head

Neurovascular bundle

A FIGURE 15.9  Repair the longitudinal incision to prevent subluxation of the extensor tendons (red arrow).

B

FIGURE 15.8  During the volar approach, care must be taken to protect the neurovascular bundles (red arrow), which are often displaced centrally and superficially from their native position by the metacarpal head (blue arrow).

STEP 4 PEARLS

The dorsal capsule can be left unrepaired if obliterated from the injury.

• After reduction, use fluoroscopy to check for any subtle shear fractures of the metacarpal head. If present, these will require fixation, often with small wires or screws.

STEP 2 PEARLS

Step 4: Close

Inspect for osteochondral lesions that were not identified on preoperative imaging.

STEP 3 PEARLS

• The dorsal capsule of the MCP joint is repaired with 4-0 absorbable suture. • The longitudinal incision in the dorsal extensor hood is repaired with nonabsorbable 4-0 suture (Fig. 15.9). • The skin is closed. • Immobilize the MCP joint in 10 to 30 degrees of flexion with a dorsal blocking splint.

Alternatively, a blunt elevator can be used as a lever between the metacarpal head and tendons (that are creating the noose) to guide the metacarpal head dorsally.

Step 1: Release the A1 Pulley

STEP 3 PITFALLS

If not completely torn by the traumatic injury, release the A1 pulley for complete visualization.

Dividing the volar plate may still be necessary, but this is more difficult to do from the volar approach; proceed cautiously.

Step 2: Identify Tendons and Volar Plate in Relation to Metacarpal Head

VOLAR APPROACH

• Identify the structures that are entrapping the metacarpal head. Fig. 15.10 shows an index finger metacarpal dislocation entrapped between lumbrical (radial) and flexor tendons (ulnar). • The volar plate may be visible behind the metacarpal head, or it may be completely hidden in complex dislocations (Fig. 15.11).

Step 3: Perform Reduction

FIGURE 15.10  The metacarpal head (white arrow) is entrapped by the lumbrical on the radial side (red arrow) and flexor tendons on the ulnar side (blue arrow – not visualized in this image)

• Have an assistant gently retract the constricting tendinous structures. • Flex the wrist. • Grasp the affected digit while simultaneously placing the thumb on the volar aspect of the metacarpal head. • Apply pressure to the volar aspect of the metacarpal head to reduce it dorsally, while simultaneously pushing the proximal phalanx distally and volarly. Feel the proximal phalanx roll over the metacarpal head as it returns to a reduced position. • If needed, a Freer elevator can be used to gently coax the proximal phalanx and the attached volar plate into reduction.

CHAPTER 15  Open Reduction for Metacarpophalangeal Joint Dislocation

A FIGURE 15.11  In complex metacarpophalangeal (MCP) joint dislocations, the volar plate (red arrow) is visualized dorsal to the metacarpal (white arrow) and reflected into the field with a blunt elevator.

B

FIGURE 15.12  Fluoroscopically obtained images showing (A) anteroposterior, (B) oblique, and (C) lateral views of a well reduced index finger metacarpophalangeal (MCP) joint dislocation (black arrows).

Step 4: Evaluate Joint Congruity and Close • Check the reduction of the MCP joint under fluoroscopic guidance (Fig. 15.12A–C). • The volar plate does not need to be repaired because the reduced joint is often stable and the volar plate will scar down during recovery. • Close the skin. • Immobilize the MCP joint in 10 to 30 degrees of flexion with a dorsal blocking splint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • • • •

C

After a few days of rest but within the first week, active ROM is started. The splint is weaned around 6 weeks, and light independent activity is permitted. Heavy activity, including sports, is allowed at 12 weeks. Posttraumatic arthritis may result in cases with intraarticular fracture. Chronic dislocations have poorer functional results despite successful open reduction.

EVIDENCE Afifi AM, Medoro A, Salas C, Taha MR, Cheema T. A cadaver model that investigates irreducible metacarpophalangeal joint dislocation. J Hand Surg Am. 2009;34:1506–1511. Using a cadaver model of dorsal MCP dislocation, this study demonstrated how the anatomy around the MCP joint may contribute to irreducibility of these injuries. For successful reduction, they found that a split of the volar plate was required in all cases. Division of the deep transverse metacarpal ligament did not aid in reduction (Level V evidence). Barry K, McGee H, Curtin J. Complex dislocation of the metacarpo-phalangeal joint of the index finger: a comparison of the surgical approaches. J Hand Surg Br. 1988;13:466–468. This cadaver study compared the volar and dorsal approaches to reduction of MCP joint dislocation. Reduction could be achieved by either approach, and no difference in joint stability between approaches was found. Using the volar approach, there was some vulnerability of the radial neurovascular bundle. The dorsal approach was felt to be safer; however, the volar plate had to be longitudinally divided to achieve reduction (Level III evidence). Rubin G, Orbach H, Rinott M, Rozen N. Complex dorsal metacarpophalangeal dislocation: Long-term follow-up. J Hand Surg Am. 2016;41(8):e229–e233. This retrospective case series of five patients (mean of 13 year follow-up) and literature review evaluated long-term outcomes of complex dorsal MCP joint dislocations. The authors found that the literature indicates that complications after dorsal MCP joint dislocations are related to multiple failed closed reduction attempts, associated fractures, and prolonged immobilization. Their small series suggested that patients do well with open reduction on the day of injury (via volar or dorsal approach) and long-term outcomes are satisfactory.

39

CHAPTER

16

Corrective Osteotomy of Metacarpal Fracture Malunion Shepard Peir Johnson and Kevin C. Chung

Full text of this chapter is available online at expertconsult.com.

KEY CONCEPTS • Corrective osteotomy is indicated for metacarpal malunion with angular, rotational, or shortening deformity that results in functional results. Inquire about functional limitations, including weakness, pain, muscle cramping, or muscle fatigue. • The involved digit will usually have decreased prominence of the metacarpal head (loss of “knuckle”). The metacarpal head may be palpable in the palm as a tender nodule. • The osteotomy should be planned out carefully, using measurements from accurate, well-positioned radiographs. • Angular deformities are corrected with either a closing wedge or opening wedge osteotomy. Rotational deformities are addressed with a derotational osteotomy. A combination of a wedge osteotomy and a derotational ostomy are sometimes required to correct complex malunions. • The correction of angular and/or rotational deformity can be confirmed with intraoperative fluoroscopy, as well as active and passive maneuvers, such as tenodesis effect. Final fixation should consist of lag screws or plate fixation. • An opening wedge osteotomy will require bone grafting. Dorsal plating can be configured to provide some compression of the interposition bone graft or can serve as a tension band. Larger bone grafts may even accommodate a screw to be lagged to the plate. • Rest and elevation are advised for the first 3 days postoperatively. Thereafter, patients with stable fixation can start early active finger motion to avoid extensor tendon adhesions and joint stiffness.

Bone graft FIGURE 16.6  A bone graft is needed to fill the void created by opening wedge osteotomy.

40

CHAPTER

16

Corrective Osteotomy of Metacarpal Fracture Malunion Shepard P. Johnson and Kevin C. Chung INDICATIONS • One indication is metacarpal malunion with angular, rotational, or shortening deformity, which results in functional deficits. • Acceptable limits of each deformity are debatable (suggested indications for primary surgery are reviewed in Chapter 14 Techniques and Fixation of Metacarpal Fractures), but indication for surgery is dictated by functional deficits that may be improved by corrective osteotomy.

Angular Deformity • Angulation typically occurs in the sagittal plane (dorsal angulation); angulations up to 15 to 30 degrees generally are well tolerated. • Angulation in the coronal plane (radial/ulnar) is less well tolerated because small degrees of malunion may lead to angulation of the digit, which interferes with the function of the adjoining fingers.

Malrotation Deformity • Rotational deformity is not tolerated as well as angular deformity. • Malrotation deformity commonly leads to overlap of the digits (so-called “scissoring”). • Five degrees of malrotation at the metacarpal level can cause 1.5 cm of digit overlap distally.

Shortening • Greater than 6 mm of shortening can lead to an unacceptable extensor lag. • Extensors can accommodate for some shortening because of their range of excursion. • Every 2 mm of metacarpal shortening results in a 7-degree extensor lag.

Contraindications Contraindications include metacarpal malunions on radiographic examination that have no functional deficit. Patients often adapt to minor deformities even when they are greater than the standards, indicating the need for primary operative intervention.

CLINICAL EXAMINATION • Assess hand function in the context of a patient’s occupation, activities of daily living, and recreational interests. Many patients can adapt to minor deformities without difficulty. • Inquire about functional limitations, including weakness, pain, muscle cramping, or muscle fatigue. • Examine the hand for pseudoclawing (hyperextension of the metacarpophalangeal [MCP] joint with flexion of the proximal interphalangeal [PIP] joint), which is often related to apex-dorsal deformity of the metacarpal neck or shaft. Because of the flexed posture of the metacarpal, patients will attempt to hyperextend at the MCP joint, which causes reciprocal flexion of the PIP joint. • The involved digit will usually have decreased prominence of the metacarpal head (loss of “knuckle”). The metacarpal head may be palpable in the palm as a tender nodule. • Check for a decrease in grip strength and pain with grip.

40.e1

40.e2

CHAPTER 16  Corrective Osteotomy of Metacarpal Fracture Malunion

A

B

C

FIGURE 16.1  (A) Anteroposterior, (B) oblique, and (C) lateral views demonstrate an apex dorsal malunion of the small finger metacarpal (red arrow). In the oblique view, the compensatory small finger metacarpophalangeal joint hyperextension can be appreciated (blue arrow).

• Check range of motion, noting any extension lag, flexion lag, or overlapping (scissoring) of the digits during motion. • Compare length and arc of motion to the contralateral hand for guidance on operative goals.

IMAGING • Radiographs of hands should be obtained in three views (posteroanterior [PA], oblique, and lateral; Fig. 16.1A–C). • Shortening is best evaluated on the PA view by examination of the relationship of the metacarpal heads. The middle, ring, and small metacarpal heads are typically colinear. • Angular deformity is best assessed on the lateral view.

SURGICAL ANATOMY FIGURE 16.2  Before performing a closing wedge osteotomy, Kirschner wires (K-wires) are placed perpendicular (red angles) to the dorsal cortical surface in the metacarpal proximal and distal to the malunion. The saw cuts are then performed with precision by aligning the angle of the saw parallel with the K-wires.

• Distal branches of the superficial radial nerve and the dorsal sensory branch of the ulnar nerve have a possibility of injury on the dorsal side of the hand (see Fig. 14.19). • Juncturae tendinum may need to be divided for exposure (see Fig. 14.20). • Interosseous muscles originate from the metacarpal shafts and are covered with fascia that is continuous with the metacarpal’s dorsal periosteum.

EXPOSURES The metacarpal is usually exposed with a dorsal approach, which is presented in detail in the Chapter 14 Techniques and Fixation of Metacarpal Fractures section on “Open Reduction and Internal Fixation.”

PROCEDURE FIGURE 16.3  The Kirschner wires are used as joysticks to reduce and hold the fracture. Leaving periosteum on the volar side of the metacarpal also aids in stabilizing the reduction.

Step 1: Perform an Osteotomy to Correct Malunion Deformity • The osteotomy should be planned out carefully, using measurements from accurate, well-positioned radiographs. • Angular deformities are corrected with either a closing wedge or opening wedge osteotomy.

Closing Wedge Osteotomy

FIGURE 16.4  Fixation is obtained with a 2.0 to 2.4 mm plating system.

• To aid in resecting a precise wedge, use fluoroscopy and preplace Kirschner wires (K-wires) as guides on either side of the malunion. The K-wires should be perpendicular to the dorsal cortical surface of the metacarpal (Figs. 16.2–16.4). • Measure the angle between the two K-wires. This angle serves as a guide to the osteotomy cuts.

CHAPTER 16  Corrective Osteotomy of Metacarpal Fracture Malunion

• Perform osteotomy cuts with an oscillating saw immediately adjacent to the malunion. Minimize the amount of bone removed by designing the proximal and distal saw cuts so that they converge at the far cortex. • The saw cuts can be executed with precision by maintaining a parallel trajectory with the preplaced K-wire guides.

Opening Wedge Osteotomy • Using fluoroscopy, make a single osteotomy saw cut in the center of the malunion that symmetrically bisects the angle of the malunion (Figs. 16.5 and 16.6). • Obtain and place bone graft in the defect created by osteotomy.

Rotational Deformities • These are addressed with a derotational osteotomy. Use a step-cut osteotomy with excision of a small cortical strip of bone along the longitudinal limb to derotate the malunion (Fig. 16.7). • An oscillating saw is used to make a hemi-transverse cut in the proximal and distal diaphysis (on opposite sides of the shaft), approximately 2.5 cm apart. • The distal cut is made on the side that the finger will be rotating toward (i.e., derotating back to normal position; see Fig. 16.7). • Two parallel, dorsal longitudinal cuts (connecting the proximal and distal transverse cuts) are made to remove a small strip of bone. Leave the volar cortex intact. • Manually derotate the digit into normal alignment by closing the longitudinal defect with reduction forceps. This will often crack the volar cortex. • Assess tenodesis of the digit to evaluate cascade (remove additional longitudinal bone if needed). • Use two 2.0 mm interfragmentary lag screws to fixate.

STEP 1 PEARLS

• Despite the removal of bone, closing wedge osteotomies do actually lengthen the metacarpal as the angulation is corrected. • When possible, leave the volar periosteum intact while making the osteotomy cuts. This will allow it to remain as a “hinge” on the volar surface, providing some stability during the case and some assistance to early bone healing postoperatively. • For derotational osteotomies, estimate the amount of rotational deformity at the midpoint of finger flexion (this is when the deformity is the largest). As a guide, approximately 2 mm of longitudinal bone resection will result in 20 degrees of rotational correction at the tip of the finger. • A combination of a wedge osteotomy and a derotational ostomy are sometimes required to correct complex malunions.

STEP 1 PITFALLS

The oscillating saw should be cooled with saline while cutting to avoid overheating the bone surfaces, which can damage the bone and slow healing.

FIGURE 16.5  The opening wedge osteotomy is performed at the apex of the malunion (blue arrow) to equally bisect the angle of the deformity (marked by two equivalent red angles).

Bone graft

FIGURE 16.6  Fixation is obtained with a 2.0 to 2.4 mm plating system. A bone graft is needed to fill the void created by the opening wedge osteotomy. If large enough, the graft can be fixated to the plate with an orthogonally placed screw.

FIGURE 16.7  Derotational step-cut osteotomies are performed to address digital rotatory deformities. The distal hemi-transverse cut (red arrow) is made on the side that the affected digit will derotate toward (blue arrows). The proximal cut is made on the contralateral side (green arrow) approximately 2.5 cm proximal to the distal cut. The longitudinal cuts (purple arrow) are made to remove a bone strip. For every 2 mm in width removed, approximately 20 degrees of correctional rotation is achieved. The closing osteotomy is fixated with two 2.0 mm lag screws.

40.e3

40.e4

CHAPTER 16  Corrective Osteotomy of Metacarpal Fracture Malunion STEP 3 PEARLS

• Use of locking screws may have some benefit in patients with osteoporosis, where purchase of nonlocking bicortical screws may be compromised. • An opening wedge osteotomy will require bone grafting. Dorsal plating can be configured to provide some compression of the interposition bone graft or can serve as a tension band. Larger bone grafts may even accommodate a screw to be lagged to the plate (see Fig. 16.6). STEP 3 PITFALLS

Be careful that the plate fixation does not distract at the osteotomy site. Prebending the plate can assist with providing some compression; dynamic compression miniplates can also be used (see Fig. 14.33).

Step 2: Reduce Deformity to Achieve a Normal Alignment and Arc of Digit Motion • After completing the osteotomy cuts, the deformity is corrected. Use the preplaced K-wires as “joysticks” to assist reduction (see Fig. 16.3). • Temporary or partial fixation should be employed to hold the osteotomy reduced while alignment is checked. K-wires may be used for this step, so long as their position does not interfere with final hardware placement. • If available, specialty miniplates with oblong, horizontally oriented holes can be used. These plates facilitate temporary fixation while still permitting minor adjustments in rotation of the distal segment. • The correction of angular and/or rotational deformity can be confirmed with intraoperative fluoroscopy or with active and passive maneuvers, such as tenodesis effect. Multiple techniques for checking alignment are described in Chapter 14 Techniques for Fixation of Metacarpal Fractures, ORIF Step 3 (see Fig. 14.34).

Step 3: Fixation and Closure • Final fixation should consist of lag screws (1.7–2.0 mm) or plate fixation (2.0–2.4 mm; see Fig. 16.4). • In a malunion of the metacarpal neck or base, a T- or Y-shaped plate will provide additional points of fixation close to the joint. At least two screws (four cortices) of fixation are required on either side of the osteotomy. • Rigidity of the plate/screw construct can be improved with locking screws, but these are not routinely required. • After completing the internal fixation, verify that any rotational and/or angular deformity has been corrected by clinical and radiographic assessment (Fig. 16.8A–C).

A

B

C FIGURE 16.8  After completing the osteotomies, evaluate the arc of motion with tenodesis from (A) wrist flexion and (B) wrist extension, and (C) use intraoperative fluoroscopy to check bony alignment and contact, as well as hardware placement.

CHAPTER 16  Corrective Osteotomy of Metacarpal Fracture Malunion

A

B

C

D

FIGURE 16.9  Postoperative examination demonstrates excellent digit range of motion and alignment.

A

B

C

FIGURE 16.10  Postoperative radiographs demonstrate healing osteotomy and maintenance of hardware position.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Rest and elevation are advised for the first 3 days. • Thereafter, patients with stable fixation can start early active finger motion to avoid extensor tendon adhesions and joint stiffness. • The correction of deformity is evaluated by radiographic and physical examination at follow-up (Figs. 16.9A–D and 16.10A–C).

EVIDENCE Karthik K, Tahmassebi R, Khakha RS, Compson J. Corrective osteotomy for malunited metacarpal fractures: Long-term results of a novel technique. J Hand Surg Eur Vol. 2015;40:840–845. This retrospective study reviewed the outcomes of 12 patients with 14 malunited metacarpal fractures. The average follow-up period was 46 months. The mean dorsal angulation of the metacarpal was 43 degrees. Rotational deformity was recognized in all but three cases. All were treated with their reported technique of closing wedge osteotomy. There was significant improvement in the Disabilities of the Arms, Shoulders, and Hands (DASH) scores after surgery. By the Büchler criteria, the outcome was excellent in all patients. The authors conclude that their technique is an easy and safe method to correct malunited metacarpal fractures (Level IV evidence). Jawa A, Zucchini M, Lauri G, Jupiter J. Modified step-cut osteotomy for metacarpal and phalangeal rotational deformity. J Hand Surg Am. 2009;34A:335–340. This retrospective case series of 12 patients evaluated the outcomes of rotational step-cut osteotomies to correct digital rotatory deformities associated with metacarpal and phalangeal malunions. All patients had successful resolution of deformities with bony union and maintained or improved digit motion. The authors concluded that this technique allowed precise correction of rotational deformities and the rigid fixation permitted early postoperative motion therapy. Van der Lei B, de Jonge J, Robinson PH, Klasen HJ. Correction osteotomies of phalanges and meta- carpals for rotational and angular malunion: A long-term follow-up and a review of the literature. J Trauma. 1993;35:902–908. This retrospective case series reported on nine phalanges and six metacarpals that underwent corrective osteotomy for rotational and angular malunions. The 15 patients were followed for a mean of 4.5 years. All patients achieved bony union, and the preoperative range of motion was maintained in all except one patient. Adequate correction of the deformity and high satisfaction was seen in 13 patients (87%; Level IV evidence).

40.e5

CHAPTER

17

Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb Elissa S. Davis and Kevin C. Chung INDICATIONS • A complete tear of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MCP) joint of the thumb necessitates this procedure. • An avulsion fracture at the attachment site of the UCL with displacement greater than 5 mm may also require repair/reconstruction. • Acute injuries are best treated with repair; chronic injuries (more than 3–6 weeks old) will likely require reconstruction. • Studies on the long-term outcome of ligamentous repair, rather than reconstruction, for chronic UCL injuries demonstrate durable outcomes; however, the majority of patients eventually develop osteoarthritis. • Other techniques for UCL repair, such as those using an internal brace and the BioTenodesis Screw System, are also options for surgical reconstruction.

Contraindications • If significant metacarpophalangeal (MCP) arthrosis or arthritis is present, MCP joint fusion should be done because ligament reconstruction is not a durable option and will not provide pain relief.

CLINICAL EXAMINATION • Acutely injured patients typically have tenderness and swelling on the ulnar side of the MCP joint (Fig. 17.1). • The integrity of the UCL is tested by applying valgus (radially directed) stress to the MCP joint and comparing the injured thumb to the uninjured contralateral thumb. The degree of laxity is measured, and the endpoint of the deviation is assessed. • A complete UCL tear is present if there is more than 35 degrees of laxity, with the MCP in either flexion or extension, or if there is more than 15 degrees of additional laxity compared with the uninjured side. Typically, a soft endpoint is present when a complete tear exists (see Fig. 17.1). • Less than 10 to 15 degrees of increased laxity, combined with a firm endpoint, probably indicates only a partial tear, and open repair is not typically indicated. • Crepitus or pain with joint loading may be a sign of arthritis with loss of healthy joint cartilage.

IMAGING • Standard radiographs should be obtained in posteroanterior, lateral, and oblique views to assess if there is an associated avulsion fracture (Fig. 17.2). Stress testing should not be done in the setting of displaced fractures. Fractures made up of greater than 30% of the joint surface and with significant displacement/malrotation should be treated surgically. • In the lateral view, volar subluxation of the proximal phalanx may indicate an accompanying dorsal capsular tear of the MCP joint. Some subluxation may be physiologic, so comparing it with radiographs of the uninjured side is important. Pathologic subluxation may require additional capsular repair or imbrication at the time of UCL repair. • In chronic injuries, radiographs should be carefully scrutinized for the presence of osteoarthritis of the thumb MCP joint.

41

42

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb

FIGURE 17.1  Clinical examination.

FIGURE 17.2  Imaging.

• Ultrasonography can differentiate between partial and complete injury in most cases, especially in the hands of an experienced ultrasonographer. Furthermore, the position and orientation of the torn ligament can be ascertained in most cases. • Magnetic resonance imaging (MRI) may also be a useful adjunct, but these tests are unnecessary if the clinical examination is conclusive.

SURGICAL ANATOMY • Distal branches of the superficial radial nerve often lie in the operative field and are at risk for injury. • The thumb MCP joint is a diarthrodial ginglymoid joint that is movable in all planes but primarily moves in a flexion-extension arc. • The joint is stabilized by both static (volar plate, collateral ligaments) and dynamic (intrinsic and extrinsic muscles) structures.

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb Proper collateral ligament

Metacarpal bone

Proximal phalanx

Volar plate Accessory collateral ligament FIGURE 17.3  Ulnar collateral ligament (UCL) anatomy.

Proximal phalanx Dorsoulnar digital nerve Adductor aponeurosis

UCL: torn and displaced Thumb metacarpal Adductor pollicis

FIGURE 17.4  Ulnar collateral ligament (UCL) tear.

• The UCL is composed of two distinct structures: the proper UCL and the accessory UCL. The proper UCL arises from the lateral condyles of the thumb metacarpal head and travels distally and volarly to insert on the lateral tubercle of the proximal phalanx. The accessory UCL courses superficially from a more volar site on the metacarpal head to the volar plate and sesamoids (Fig. 17.3). • When excessive valgus stress is applied, the UCL usually tears (or avulses) at its distal attachment. If the radial deviation of the proximal phalanx continues, the avulsed UCL displaces further, and the leading edge of the adductor aponeurosis passes over and beyond the torn ligament. As the injured MCP joint reduces, the torn UCL folds back upon itself, and the adductor aponeurosis becomes interposed between the torn inverted ligament and its attachment site on the proximal phalanx. This anatomic occurrence is termed a Stener lesion (Fig. 17.4). • Stener lesions are reported to occur in the majority of complete UCL tears (64%– 88%). Because the ligament is displaced from its point of attachment, normal healing cannot occur, even with prolonged immobilization. This is why operative repair is indicated for most, if not all, complete UCL ruptures.

EXPOSURES • A lazy-S incision is marked on the dorsal-ulnar aspect of the thumb MCP joint (Fig. 17.5A). Alternatively, the incision can be hidden within the skin fold when the thumb adducts (see Fig. 17.5B) The incision curves from volar distally to dorsal proximally, remaining ulnar to the extensor pollicis longus (EPL) tendon.

EXPOSURES PEARLS

• Mark the adductor aponeurosis with a surgical marker before incising it and leave an edge to sew to radially. This makes it easier to identify and repair this structure at the end of the case. • If a tiny avulsion fragment is present, it should be excised to avoid impingement in the joint. EXPOSURES PITFALLS

Take time to carefully evaluate this anatomy; one must avoid accidentally detaching the proximal portion of the collateral ligament as the adductor aponeurosis is incised and the joint capsule opened.

43

44

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb

A

B

FIGURE 17.5  (A) Lazy-S incision design. (B) Incision hidden within the crease of the thumb.

• Identify and protect branches of the superficial radial nerve within the subcutaneous layer. • The proximal border of the adductor aponeurosis is exposed. • If there is a Stener lesion, a rounded mass of tissue will appear at the proximal edge of the aponeurosis. • The adductor aponeurosis must be incised longitudinally, ulnar to the EPL, to expose the joint capsule. The joint capsule is then opened longitudinally at the dorsal edge of the collateral ligament, and the soft tissue and bone injury can be exposed and evaluated (Fig. 17.6). • Radially deviate the proximal phalanx and irrigate the joint to gain maximal visualization.

Ulnar collateral ligament

FIGURE 17.6  Joint capsule exposed.

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb

REPAIR OF ACUTE ULNAR COLLATERAL LIGAMENT INJURY Step 1: Preparation of the UCL and the Insertion Site • The UCL may be foreshortened, folded back on itself, or otherwise malpositioned. It should be gently dissected free from surrounding debris and scar and unfolded to its full length. • The site for UCL reattachment on the proximal phalanx is exposed, any distal ligament remnants are excised, and the surface of the bone is abraded with a curette or rongeur. This will provide a cut edge of ligament to heal directly to the bone without intervening tissue.

STEP 1 PITFALLS

Be very careful when dissecting out the UCL, which may appear distorted when it is first encountered. Avoid accidentally damaging the ligament or detaching it from the metacarpal.

Step 2: Reattaching the Ligament • This step may be accomplished with a suture anchor or transosseous sutures. • Suture anchor method: • Anchors preloaded with a 2-0 or 3-0 nonabsorbable suture are preferred. • A drill guide is used to place the pilot hole for the anchor at the reattachment site. • The anchor is deployed, making sure that it is fully countersunk into the bone (Fig. 17.7). The position can be checked fluoroscopically. • The attached suture is used to secure the UCL down to the bone, using a grasping suture technique (Kessler- or Bunnell-style stitch; Fig. 17.8). • Bone tunnel method when suture anchor is not available: • A pair of parallel drill holes is created, beginning from the intended site of ligament attachment, heading across the phalanx to the radial side, angled from proximal to distal. • This drilling can be accomplished with 0.045-in (1.14-mm) Kirschner wires (K-wires) or a small drill bit. • A 3-0 nonabsorbable grasping suture is placed into the ligament stump. • The free ends of the suture are passed through the bone tunnels using Keith needles, specialty K-wires, or other suture passing devices (Fig. 17.9). • The sutures are tied on the radial side of the proximal phalanx (Fig. 17.10). • Alternatively, sutures can be tied over the skin using a button. If pull-out sutures are tied over the button, use Prolene suture because it can glide over structures and be removed readily, unlike braided suture, which will not glide. • Alternatively, using a small counterincision for exposure, sutures can be directly tied over the periosteum. This prevents any potential skin compromise from pressure injury from the button. • Regardless of the method used for ligament repair, the MCP joint is temporarily pinned by a percutaneous, transarticular K-wire to protect the repair.

Suture attached to anchor

STEP 2 PEARLS

The repair can be supplemented by suturing the distal end of the ligament to local tissue or to periosteum around the attachment site. STEP 2 PITFALLS

One must be sure that the distal attachment point of the ligament is correct. It should be attached to the volar aspect of the ulnar side of the base of the proximal phalanx (see Fig. 17.3). Reattaching the ligament at the wrong point may cause stiffness or instability of the MCP joint.

Ulnar collateral ligament repaired

Ulnar collateral ligament

FIGURE 17.7  Suture anchor deployed.

FIGURE 17.8  Suture in place to repair the ulnar collateral ligament.

45

46

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb

Keith needles

K-wire

Ulnar collateral ligament FIGURE 17.9  Free ends of sutures passed through bone tunnels.

FIGURE 17.10  Sutures tied on the radial side of the proximal phalanx.

Step 3: Closure • Before closing, any large dorsal capsular tears should be repaired to reduce the chance of joint subluxation later. • The adductor aponeurosis is repaired with a 4-0 absorbable suture. • Deflate the tourniquet and achieve good hemostasis before skin closure. • Close skin in layers. • A thumb spica splint is applied with the interphalangeal (IP) joint of the thumb left free. STEP 1 PEARLS

If the PL is absent, a slip of the abductor pollicis longus, flexor carpi radialis, ECRL, or the proximal aspect of the extensor pollicis brevis (EPB) can be used as a tendon graft.

RECONSTRUCTION OF CHRONIC ULNAR COLLATERAL LIGAMENT INJURY Step 1: Preparation of the Attachment Sites and Graft • In chronic cases, the joint must be carefully inspected for arthritis before proceeding with ligament reconstruction. • Both the proximal and distal ligament attachment sites need to be exposed and prepared. • In the chronic situation, residual ligament tissue will be insufficient for repair, though the remaining ligament stumps can be used to identify the correct attachment points for the graft and may be sutured to the tendon graft to reinforce the reconstruction. • The palmaris longus (PL) graft is harvested through a transverse incision at the volar wrist crease and a second proximal incision over the musculotendinous junction, where the tendon is mobilized and divided. The tendon is withdrawn through the wrist incision with traction on the distal cut end of the tendon. If the PL tendon is not present, one can obtain a split segment of tendon graft from the extensor carpi radialis longus (ECRL) or extensor carpi radialis brevis tendon.

Step 2: Reattachment

FIGURE 17.11  Pilot holes are made at the proximal and distal attachment sites.

• As with acute repair, chronic ligament reconstruction can be accomplished with either suture anchors or bone tunnels. • Suture anchor method: • Temporary K-wire fixation of the MCP joint is performed in slight flexion, with the joint in neutral or slight ulnar deviation. • After preparing the sites, pilot holes are made at the proximal and distal attachment sites (Fig. 17.11). • Suture anchors preloaded with 2-0 or 3-0 suture are deployed at each location (Fig. 17.12A–B).

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb

A

The suture attached to the anchor

B

FIGURE 17.12  (A) Sutures deployed.

• The PL is folded on itself, sutured together, and fashioned to the appropriate length to span the two attachment sites (Fig. 17.13). • The graft is secured in place proximally and distally with the sutures attached to the suture anchors to firmly approximate the tendon graft down to bone at both sites (Figs. 17.14 and 17.15). • Bone tunnel method: • This method requires passing the tendon graft through bone tunnels to reconstruct the ligament between the anatomic attachment points of the native UCL. The bone tunnel provides much more support for secure tendon-bone healing (Fig. 17.16A–B). • Holes may be created with K-wires, small drills, or burs. • The tendon graft can be passed through the bone tunnels with the aid of a custom tendon- or suture-passer or loops of stainless steel wire fashioned into narrow snares to grab the tendon and pull it through the bone. If these bone tunnels are used, the tendon graft may need to be trimmed to fit into the tunnel.

PL tendon graft

FIGURE 17.13  Palmaris longus (PL) tendon graft.

Step 3: Closure

STEP 2 PEARLS

• • • •

The graft may be secured to residual ligament, periosteum, and joint capsule to augment the repair.

The adductor aponeurosis is repaired with a 4-0 absorbable suture. Deflate the tourniquet and achieve good hemostasis before skin closure. Close the skin in layers. A thumb spica splint is applied with the IP joint of the thumb left free.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Immobilization in a full-time splint or cast is continued for the first 6 weeks. The Kwire is removed at 4 weeks. • After 6 weeks of immobilization, range of motion exercises are begun, though radially directed stress is avoided. • Strengthening exercises are started at 8 weeks under the guidance of a hand therapist. • Activities that directly stress the reconstruction, including lateral side pinch, are permitted after 12 weeks. • Patients can typically return to full activities, including contact sports, 4 months after surgery. • The reconstruction of the UCL is evaluated by radiographic and physical examination at follow-up (Fig. 17.17A–E).

STEP 2 PITFALLS

• Set the tension of the graft appropriately. If the graft is made too tight, motion of the MCP joint is limited and may cause pain postoperatively. • When creating multiple bone tunnels, be careful to avoid comminution or fracture of the small bone bridges between the tunnels/holes. Holes that are big enough to accommodate passage of a tendon graft also put the bone at some risk for fracture.

47

48

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb

B A

PL tendon graft

FIGURE 17.15  Graft secured. PL, Palmaris longus

FIGURE 17.14  Graft secured.

B

A

FIGURE 17.16  Bone tunnel method.

• Although mild loss of pinch strength and mild loss of motion are typically reported, most patients are satisfied after UCL reconstruction (see Fig. 17.17D–E). POSTOPERATIVE PEARLS

Sensory disturbances after surgery may be because of stretching of the cutaneous nerves during surgery, irritation from pin(s), or thumb spica splints that apply pressure to the digital nerves. Most of these disturbances are temporary and require only reassurance to the patient. STEP 1 PEARLS

• Careful assessment of the quality and quantity of the UCL should be done to see if the ligament may be repairable. • A suture anchor should be on hand if a UCL suitable for repair is identified, even in a chronic situation.

RECONSTRUCTION OF CHRONIC ULNAR COLLATERAL LIGAMENT INJURY WITH MINI MITEK ANCHOR Step 1: Identification of the UCL • In chronic cases, the joint must be carefully inspected for arthritis before proceeding with ligament reconstruction or repair. • The UCL should be identified and inspected. Occasionally, the ligament may be repaired with the use of suture anchors if the ligament itself is stout. In this case, the UCL was torn from its proximal attachment off the metacarpal and thus the ligament itself was not frayed or degenerated (Fig. 17.18)

Step 2: Reattachment Suture anchor method: • The MCP joint is held in slight flexion, with the joint in neutral or slight ulnar deviation to take tension off the repair.

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb

A

D

B

C

E FIGURE 17.17  Postoperative result.

FIGURE 17.18  Ligament torn off metacarpal, distal attachment to proximal phalanx intact; stout ligament without degeneration present.

FIGURE 17.19  Mini-mitek suture anchor placed at the proximal insertion.

• After preparing the site, a pilot hole is made at the proximal attachment site. • Suture anchors preloaded with 2-0 or 3-0 suture are deployed to secure the UCL repair (Fig. 17.19). Additional ethibond suture is placed to repair the UCL (Fig. 17.20).

Step 3: Closure • The joint capsule is repaired with a 4-0 Vicryl suture. • Deflate the tourniquet and achieve good hemostasis before skin closure.

STEP 2 PEARLS

• Ensure that the suture anchor is buried within the bone to the laser line. • Test the strength of the suture anchor by gently pulling on the sutures. A well-deployed suture anchor will not pull out of the bone.

49

50

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb STEP 2 PITFALLS

Set the tension of the repair appropriately. If the ligament is repaired with the MCP joint in too much ulnar deviation, the repair will be overly tight and limit MCP motion.

FIGURE 17.20  Ethibond suture used with ligament repaired.

POSTOPERATIVE PEARLS

Sensory disturbances after surgery may be because of stretching of the cutaneous nerves during surgery or thumb spica splints that apply pressure to the digital nerves. Most of these disturbances are temporary and require only reassurance to the patient.

• Close the skin in layers. • A thumb spica splint is applied with the IP joint of the thumb left free.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Immobilization in a full-time splint or cast is continued for the first 4 weeks. • After 4 weeks of immobilization, range of motion exercises are begun, though radially directed stress is avoided. • Strengthening exercises are started at 8 weeks under the guidance of a hand therapist. • Activities that directly stress the reconstruction, including lateral side pinch, are permitted after 12 weeks. • Patients can typically return to full activities, including contact sports, 4 months after surgery. See Video 17.1

EVIDENCE Katolik LI, Friedrich J, Trumble TE. Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint: A retrospective comparison of pullout sutures and bone anchor techniques. Plast Reconstr Surg. 2008;122:1451–1456. This retrospective study compared the outcome between pullout sutures and bone anchor techniques in 30 patients with complete rupture of the ulnar collateral ligament of the thumb. All were assessed at a mean follow-up of 29 months. Average range of motion at the MCP joints was 97% of the contralateral side in the anchor group and 86% in the button group. Pinch strength was average 101% of the contralateral side in the anchor group and 95% in the button group. Tourniquet time for the anchor group averaged 28 minutes compared with 43 minutes for the button group. Complications were identified in 27% of patients in the button group and 7% in the anchor group (Evidence level III). Samora JB, Harris JD, Griesser MJ, Ruff ME, Awan HM. Outcomes after injury to the thumb ulnar collateral ligament—A systematic review. Clin J Sport Med. 2013;23:247–254. This review compared nonoperative treatment with surgical repair and reconstruction of UCL injuries of the thumb in a systematic review, which included 14 articles. Thirty-two nonoperative cases were compared with 261 operative cases; 200 acute injuries and 93 chronic injuries were included. Patients were followed for a mean of 42.8 months. Nonoperative treatment often met with failure. Both acute UCL repair and UCL reconstruction for chronic injury achieved excellent clinical outcomes. In fact, there was no significant difference between the outcomes in the acute and chronic groups (Evidence level III). Weiland AJ, Berner SH, Hotchkiss RN, McCormack Jr RR, Gerwin M. Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor. J Hand Surg Am. 1997;22:585–591. This study reported the outcomes of 36 patients with 37 complete tears of the UCL treated with suture anchor repair. Postoperative range of motion in both the IP and MCP joints was decreased by an average of 15 degrees and 10 degrees, respectively. Stress testing for radial deviation showed no significant difference between the repaired thumb and contralateral thumb. No obvious complications arose. The authors feel that a suture anchor is a secure method for treatment of the UCL tear of the thumb MCP joint (Evidence level IV). Christensen T, Sarfani S, Shin AY, Kakar S. Long-term outcomes of primary repair of chronic thumb ulnar collateral ligament injuries. Hand. 2016;11(3):303–309.

CHAPTER 17  Reconstruction of Acute and Chronic Ulnar Collateral Ligament Injuries of the Thumb A retrospective review of long-term follow-up of patients undergoing ligamentous repair of chronic UCL injuries. Assessed radiographs, postoperative outcome questionnaire DASH, and VAS sores. Confirmed local tissue repair with durable outcomes but majority progress to osteoarthritis (Evidence Level III). Baskies MA, Tuckman D, Paksima N, Posner MA. A new technique for reconstruction of the ulnar collateral ligament of the thumb. Am J Sports Med. 2007:35(8):1321–1325. A cadaveric study looking at biomechanical outcomes on cadaveric systems. Compared tendon free graft versus Bio-Tenodesis Screw System and found no difference between peak load failures of the two reconstructions (Evidence Level III)

51

CHAPTER

18

Techniques for Fixing Bennett and Rolando Fractures Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 18.1 – Bennett Fracture Treated With Metacarpal Corrective Osteotomy and Placement of Alloderm in the Carpometacarpal Joint.

KEY CONCEPTS • Bennett fractures are intraarticular fractures of the base of the thumb metacarpal that classically have two main fracture fragments: a constant “Bennett” fragment of the volar-ulnar thumb metacarpal, and the remaining thumb metacarpal, which displaces radially and proximally because of unopposed pull from the abductor pollicis longus (APL) and into flexion and adduction because of pull from the adductor pollicis. • In modern practice, any complex periarticular fracture of the thumb metacarpal is referred to as a Rolando fracture. Classically, a Rolando fracture is a Bennett fracture with an additional intraarticular fracture through the dorsal-radial base of the thumb metacarpal, creating a Y- or T-shaped intraarticular fracture pattern. • There are three aspects to reduction of Bennett and Rolando fractures, which are performed in the following order: longitudinal traction of the thumb, pronation of the thumb, and abduction applied at the level of the thumb carpometacarpal (CMC). • Closed reduction and percutaneous pinning is indicated for any Bennett or Rolando fracture with articular step-off greater than 1 mm, fracture-dislocation of the thumb CMC joint, or angulation/rotation greater than 10 degrees. • Open reduction with internal fixation is indicated for open fractures of the thumb CMC or fractures that cannot be reduced via closed methods. Internal fixation should be avoided in open injuries with soft tissue loss, unless coverage can be provided acutely.

Adductor pollicis muscle

Palmar oblique ligament Abductor pollicis longus muscle

B FIGURE 18.3  (B) In a Bennett fracture, the remaining thumb metacarpal is displaced by the unopposed pull from the abductor pollicis longus and the adductor pollicis.

52

CHAPTER

18

Techniques for Fixation of Bennett and Rolando Fractures Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Closed reduction and percutaneous pinning is indicated for any Bennett or Rolando fracture with articular step-off greater than 1 mm, fracture-dislocation of the thumb carpometacarpal (CMC) joint, or angulation/rotation greater than 10 degrees. • Open reduction with internal fixation is indicated for open fractures of the thumb CMC or fractures that cannot be reduced via closed methods.

Contraindications • The integrity of the thumb CMC joint is vital for normal thumb/hand function. Therefore there are few contraindications to reduction and fixation of displaced Bennett and Rolando fractures. • Internal fixation should be avoided in open injuries with soft-tissue loss, unless coverage can be provided acutely. In this scenario, percutaneous pinning is chosen for ease of hardware removal should a wound healing issue or infection arise.

CLINICAL EXAMINATION • Swelling and tenderness are present on the proximal part of the thumb metacarpal (Fig. 18.1). • The thumb may appear shortened because of subluxation or dislocation of the CMC joint or because of fracture comminution.

IMAGING • A true thumb posteroanterior (PA) view (Robert’s view) and lateral view (Bett’s view) are needed (Fig. 18.2). • For a true PA view of the thumb CMC, the shoulder, forearm, and hand must be internally rotated and hypersupinated so that the thumb lays flat against the cassette/image sensor. • Computed tomography is rarely needed but can help with the assessment of fracture comminution and joint congruity in complex cases.

SURGICAL ANATOMY Bennett Fracture • Bennett fractures are intraarticular fractures of the base of the thumb metacarpal that classically have two main fracture fragments: • A constant “Bennett” fragment of the volar-ulnar thumb metacarpal • The remaining thumb metacarpal, which displaces radially and proximally because of unopposed pull from the abductor pollicis longus (APL) and into flexion and adduction because of pull from the adductor pollicis (Fig. 18.3). • Classically, the anterior oblique “beak” ligament (AOL) has been thought to be the primary ligamentous stabilizer of the constant fragment, keeping it reduced in position. More recent research has demonstrated that the AOL is more of a capsular thickening than a true ligament and that the ulnar collateral ligament of the thumb CMC is the true ligamentous stabilizer of the constant fragment.

Rolando Fracture • Classically, a Rolando fracture is a Bennett fracture with an additional intraarticular fracture through the dorsal-radial base of the thumb metacarpal, creating a Y- or 52.e1

52.e2

CHAPTER 18  Techniques for Fixation of Bennett and Rolando Fractures

A

B FIGURE 18.1  Arrow indicates swelling at thumb metacarpal.

A

B

FIGURE 18.2  (A) Left thumb posteroanterior (PA) and lateral imaging demonstrate an impacted Rolando fracture of the left thumb.

Intermetacarpal ligament

Adductor pollicis muscle

Anterior oblique ligament Capsule

Palmar oblique ligament

Abductor pollicis longus

Abductor pollicis longus muscle Flexor carpi radialis B

A FIGURE 18.3 

CHAPTER 18  Techniques for Fixation of Bennett and Rolando Fractures

T-shaped intraarticular fracture pattern. Because of this, a volar-ulnar “constant” fragment is still seen in Rolando fractures and can act as a stable base for the reduction of additional fragments. • In modern practice, any complex periarticular fracture of the thumb metacarpal is referred to as a Rolando fracture. • Similar deforming forces are seen in Rolando fractures, but the APL is often attached to the dorsal-radial fragment and can act as a strong deforming force of this small fragment.

Abduction

CLOSED REDUCTION Traction

Step 1: Reduction • There are three aspects to reduction of Bennett and Rolando fractures, which are performed in the following order (Fig. 18.4): • Longitudinal traction of the thumb • Pronation of the thumb • Abduction applied at the level of the thumb CMC • This maneuver works because of ligamentotaxis of the CMC joint capsule and dorsal ligamentous complex on the fracture fragments, which often remain intact in these injuries. • The reduction is confirmed with fluoroscopy. If there is residual articular step-off greater than 1 mm or persistent metacarpal subluxation, open reduction should be performed (Fig. 18.5A–B).

Pronation

FIGURE 18.4

Step 2: Kirschner Wire Fixation • Often, an assistant can perform the initial fixation while the reduction is maintained or can hold the reduction while the surgeon places the Kirschner wire (K-wire). • A 0.045-inch (1.1-mm) K-wire is placed in retrograde fashion, from the metacarpal into the trapezium, holding the reduction. • The starting point for the K-wire is on the dorsal-radial aspect of the thumb metacarpal, at the level roughly between the proximal and middle third of the metacarpal. • The so-called “constant” fragment, if large enough, may then be captured by an additional wire placed across the fracture line (Fig. 18.7). • Rolando fractures are innately unstable because of increased comminution; therefore multiple K-wires are usually required (Fig. 18.8A–B). • In cases where the fragments are very small or numerous, direct capture with a K-wire will be impossible. In these cases, maintaining solid joint reduction with an additional K-wire either into the trapezium or second metacarpal can provide increased resistance against redisplacement (Fig. 18.9A–C).

STEP 1 PEARLS

The tip/pulp of the thumb should be roughly parallel with the adjacent fingers when positioned to directly oppose each other. This can act as a quick verification of alignment/reduction before fluoroscopic images are taken (Fig. 18.6). STEP 2 PITFALLS

• Branches of the superficial radial nerve may run directly through the area of K-wire placement, and iatrogenic injury to these nerve branches may lead to chronic pain. If placing several Kwires, consider a so-called “mini-open” approach with a small (less than 1 cm) incision, enabling the subcutaneous tissues to be retracted away. • The scaphotrapeziotrapezoid joint has a complex three-dimensional shape and can easily obscure a prominent K-wire. Several fluoroscopy images should be taken and scrutinized to ensure the transarticular thumb CMC K-wire has not advanced too far proximally. The pulp of the thumb is parallel to the other digits.

Pronation of the thumb

A

B FIGURE 18.5

FIGURE 18.6

52.e3

52.e4

CHAPTER 18  Techniques for Fixation of Bennett and Rolando Fractures

FIGURE 18.7 B

A

FIGURE 18.8

A

B

C FIGURE 18.9

OPEN REDUCTION Step 1: Incision and Dissection • An incision is created along the radial border of the thumb metacarpal and thumb CMC joint. Typically, the transition between the glabrous (non-hair-bearing) and nonglabrous (hair-bearing) skin defines the interval (Fig. 18.10). • Superficial dissection is taken down to the level of the metacarpal, and the thenar musculature is gently elevated off the volar surface, exposing the joint capsule of the thumb CMC joint. • The joint capsule is further defined volarly and dorsally (Fig. 18.11A) and then opened longitudinally in line with the incision, exposing the fracture site (see Fig. 18.11B). Excessive dissection and stripping of fracture fragments should be avoided.

Step 2: Reduction FIGURE 18.10

• As with all periarticular trauma, the goal is to reestablish a congruent articular surface with less than 1 mm of articular step-off.

CHAPTER 18  Techniques for Fixation of Bennett and Rolando Fractures

A

B

FIGURE 18.12

FIGURE 18.11

• The fracture site is manually opened, and a combination of irrigation, curettes, and small-tipped rongeurs are used to remove any fracture hematoma that prevents an exact reduction. • A dental pick or small elevator can then be used to mobilize the fracture fragments into position, which can then be temporarily maintained with a pointed reduction clamp (Fig. 18.12). • A 0.045-inch (1.1-mm) or 0.035-inch (0.9-mm) K-wire can be used to temporarily hold reduction of the individual fragments. • In cases of a Rolando fracture with three or more articular fragments, reduction should be systematic. • Articular fragments are reduced back to each other first and held with temporary K-wire fixation (Fig. 18.13A–B). • With the articular surfaces reduced together, the consolidated articular surface can then be reduced back to the metacarpal shaft. • Confirm reduction with fluoroscopy.

A

B FIGURE 18.13

STEP 2 PITFALLS

With a Rolando fracture, attempting to reduce articular fragments to the metacarpal shaft before reestablishing the articular surface will often make anatomic reduction more difficult. The reduced working area will inhibit reduction of the remaining fragments and reduce visualization of the articular surface.

52.e5

52.e6

CHAPTER 18  Techniques for Fixation of Bennett and Rolando Fractures STEP 3 PEARLS

K-wires can be used for definitive fixation of Rolando fractures if enough metaphyseal bone is attached to the articular fragments. The primary benefit of K-wire fixation is that the pins can be removed easily in an outpatient setting, avoiding the need for more permanent internal fixation and the potential for extensor tendon irritation.

Step 3: Fixation • Depending on the size of the fracture fragments, fixation can be performed with K-wires, 1.3-mm or 1.5-mm lag-screws, or mini fragment locking plates designed for the thumb metacarpal. • Even if a plate construct or interfragmentary screws are used, a retrograde K-wire entering the metacarpal and crossing the thumb CMC joint into the trapezium remains a valuable tool for stabilizing the CMC joint and maintaining reduction.

Step 4: Closure STEP 3 PITFALLS

The metacarpal base articular surface is concave, which can obscure identification of the intraarticular screw penetration. Multiple views on fluoroscopy and direct inspection of the joint surface should be performed to confirm accurate screw placement.

• If open reduction was performed, the thumb CMC joint is thoroughly irrigated to ensure no fracture fragments remain within the joint (Fig. 18.14A–B). • The joint capsule should be repaired with 4-0 braided suture. • The subcutaneous tissues and skin are closed per surgeon preference. • Exiting K-wires are bent using a needle driver and Frazier suction tip and cut, then a protective cap is placed over the sharp end. • Xeroform or other petroleum-impregnated gauze is placed around the pin sites. • A forearm-based thumb spica splint or cast is placed to the thumb tip to ensure complete immobilization of the thumb metacarpal and CMC joint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Radiographic examination is performed 2 weeks after surgery to confirm that the reduction is maintained. • Patients are maintained in a full-time splint or thumb spica cast for 4 to 6 weeks. • If rigid internal fixation was placed, transition to a thumb spica cast with the interphalangeal (IP) joint free may be initiated at 2 weeks postoperatively to encourage motion and lessen the risk for tendon adhesion. • If K-wires were placed, they are removed roughly 6 weeks after the operation depending on radiographic healing. • After pin removal, gentle mobilization of the CMC joint is started under the supervision of a hand therapist. • Reduction with residual displacement of less than 1 mm leads to good radiographic and clinical outcomes in Bennett fractures (Fig. 18.15A–E). See Video 18.1

A

A

B

D

FIGURE 18.14

B

C

E

FIGURE 18.15

CHAPTER 18  Techniques for Fixation of Bennett and Rolando Fractures

EVIDENCE Kang JR, Behn AW, Messana J, Ladd AL. Bennett fractures: A biomechanical model and relevant ligamentous anatomy. J Hand Surg Am. 2019;44(2):154.e1–154.e5. An anatomical study that aimed to clarify the ligamentous stability of Bennett fractures. Six cadaver upper extremities were dissected to expose to the thumb CMC joint. A Bennett fracture was simulated by employing axially applied loading in a grip position. The proper ulnar collateral ligament of the thumb CMC joint was found to be intact and fully attached to the Bennett constant fragment in all six specimens, whereas the anterior-oblique ligament was found to be diminutive in comparison and more often attached to the remaining metacarpal. Livesley PJ. The conservative management of Bennett’s fracture-dislocation: A 26-year follow-up. J Hand Surg Br. 1990;15:291–294. This is a study with 17 patients to demonstrate the long-term outcome of conservative treatment for Bennett fracture. The average follow-up period was 26 years. All patients had decreased range of motion and grip strength. A characteristic deformity of the hand was shown in 12 patients. Subluxation of the CMC joint and degenerative changes were revealed in radiographs (Level IV evidence). Lutz M, Sailer R, Zimmermann R, Gabl M, Ulmer H, Pechlaner S. Closed reduction transarticular Kirschner wire fixation versus open reduction internal fixation in the treatment of Bennett’s fracture dislocation. J Hand Surg Br. 2003;28:142–147. In this study, 32 patients with Bennett fractures were treated with either closed reduction and percutaneous pinning or open reduction and internal fixation. The patients were followed for an average of 7 years. The type of operation performed had no statistical impact on the clinical outcome or on the prevalence of radiologic posttraumatic arthritis. Adduction deformity of the thumb metacarpal was significantly more common in the percutaneous pinning group (Level III evidence). Middleton SD, McNiven N, Griffin EJ, Anakwe RE, Oliver CW. Long-term patient-reported outcomes following Bennett’s fractures. Bone Joint J. 2015;97:1004–1006. This study reviewed the long-term outcomes of 143 patients after displaced Bennett fractures treated with K-wire fixation. The average follow-up period was 11.5 years. The average satisfaction and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were 94% and 3.0, respectively. There were no patients who required salvage procedures or a change in occupation or sports activities (Level IV evidence).

52.e7

ddsf

SECTION III

Wrist Fractures and Carpal Instability CHAPTER 19

Wrist Arthroscopy  54

CHAPTER 20

TFCC Repair  68

CHAPTER 21

Scapholunate Ligament Repair  80

CHAPTER 22

Scapholunate Ligament Reconstruction  93

CHAPTER 23

Lunotriquetral Ligament Reconstruction Options using Tendon Grafts  113

CHAPTER 24

Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting  125

CHAPTER 25

Open Reduction and Internal Fixation of Acute Scaphoid Fracture  131

CHAPTER 26

Treatment of Scaphoid Nonunion  142

CHAPTER 27

Salvage Procedures for Scaphoid Nonunion  161

CHAPTER 28

Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation With or Without Fracture  175

CHAPTER 29

Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome  184

CHAPTER 30

Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft  185

CHAPTER 31

Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)  194

53

CHAPTER

19

Wrist Arthroscopy Chun-Yu Chen and Kevin C. Chung

INDICATIONS Diagnostic The diagnostic indications include the following: • To identify or confirm pathology that is suggested by physical examination or noninvasive radiographic imaging, such as x-ray or magnetic resonance imaging (MRI). • To investigate the source of chronic pain that is thought to originate in the wrist and has persisted despite conservative measures, such as corticosteroid injections or occupational therapy (including splinting). • To characterize partial and complete ligamentous and cartilaginous injury, and to determine whether the patient will benefit from either arthroscopic or open operative intervention.

Therapeutic A therapeutic indication is to aid in the treatment of (1) distal radius and scaphoid fractures, (2) debridement and shrinkage or repair of the scapholunate (SL) or lunotriquetral (LT) interosseous (IO) ligaments and dorsal wrist capsule, (3) triangular fibrocartilage complex (TFCC) repairs, (4) removal of foreign bodies, or (5) wrist irrigation in the case of infection or debridement of synovitis in inflammatory conditions such as rheumatoid arthritis (Table 19.1).

Contraindications • Contraindications include any cause of visible swelling that distorts the normal anatomy and/or significant capsular tears that might lead to extravasation of irrigation fluid, neurovascular compromise, coagulopathy, or severe infection. • Being unfamiliar with regional anatomy is a relative contraindication.

TABLE Therapeutic Indications for Wrist Arthroscopy 19.1

Common Arthroscopic Procedures Loose body removal Synovectomy Intraarticular adhesion release Lavage of septic wrist joint Debridement of chondral lesion; hypertrophic or torn ligament Ganglion excision; volar and dorsal Assisted reduction of distal radius and scaphoid fractures Bone resection (radial styloidectomy; distal ulnar; proximal hamate) Carpal bone excision (scaphoid; lunate; proximal row) and arthrodesis TFCC repair Treatment of carpal instability TFCC, Triangular fibrocartilage complex.

54

CHAPTER 19  Wrist Arthroscopy

CLINICAL EXAMINATION • History and physical examination should cue the surgeon to the specific anatomic structures that may have been injured. • Anatomic snuff box tenderness suggests a scaphoid fracture. • Pain distal to the Lister tubercle, between the third and fourth extensor compartments, prompts suspicion of an SL ligament injury. LT ligamentous injury may be suspected with pain over the 4-5 interval or with radial-ulnar compression of the wrist. • Ulnar-sided wrist pain and tenderness over the ulnar head or prestyloid recess suggests a possible TFCC injury. • Diffuse wrist swelling and tenderness over the distal radius suggests a distal radius fracture.

IMAGING • Noninvasive imaging may be enough to identify an injury that would benefit from either nonoperative or operative intervention. • Plain x-rays can help identify dynamic or static wrist ligamentous injury, displaced carpal bone fractures, fractures of the distal radius and ulna, and ulnar variance. • MRI or magnetic resonance arthrography can be used to locate ligamentous pathology with reasonable sensitivity and may demonstrate changes within the lunate or triquetrum associated with an ulnar abutment.

SURGICAL ANATOMY • Before beginning the procedure, several anatomic structures should be marked, including the bony landmarks: the Lister tubercle, the articular margins of the carpal bones, and the radius and ulna (Fig. 19.1). • Tendons should be identified as they cross the wrist, including the extensor pollicis longus (EPL), extensor digitorum communis (EDC), extensor digiti minimi (EDM), and extensor carpi ulnaris (ECU; Fig. 19.2). • Portal sites 3-4, 4-5, radial and ulnar midcarpal, 6R, and 6U are marked before incision. The name of the portal is defined by the interval in which it is located. • The 3-4 portal refers to the wrist entry site between the third and fourth extensor compartments just distal to the dorsal lip of the radius. The 4-5 portal is located between the fourth and fifth extensor compartments, slightly more proximal than the

Ulna midcarpal portal (MCU) 6U portal

Radial midcarpal portal (MCR) 3-4 portal

6R portal 4-5 portal

FIGURE 19.1  Markings for each portal are based on anatomic landmarks.

55

56

CHAPTER 19  Wrist Arthroscopy

EDM

MCR portal

MCU portal 6U portal

3-4 portal Lister tubercle EDC

6R portal 4-5 portal ECU

ECRL/ECRB

POSITIONING PEARLS

• Isotonic and crystalloid solutions such as normal saline (0.9% NaCl solution) or lactated Ringer solution are preferable because they can be rapidly absorbed into the tissues. • Irrigation can be introduced through the sheath of arthroscope or another separate inflow portal. Inflow by gravity is adequate for clearing the visual field and distending the joint space and can also decrease the risk for fluid extravasation into subcutaneous tissue.

FIGURE 19.3  A traction device is used to suspend the hand and enlarge the wrist joint space.

EXPOSURES PEARLS

Some surgeons prefer not to use extremity exsanguination with a tourniquet, except when bleeding tendency is expected. Because the patient’s hand is held high during the operation, fluid continuously distends the joint space with sufficient pressure to minimize bleeding. Others prefer a dry arthroscopy without infusion of fluid. All are suitable techniques based on the surgeon’s experience and preference.

FIGURE 19.2  Portals are named according to the anatomic compartments in which they are located. ECRB, Extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM, extensor digitorum minimi; MCR, radial midcarpal; MCU, ulnar midcarpal.

3-4 portal, following the inclination of the radius. The 6R and 6U portals permit entry into the wrist on the radial and ulnar side of the ECU tendon, respectively. The radial and ulnar midcarpal portals are located approximately 1 cm distal to the 3-4 and 4-5 portals, respectively. These portals permit entry into the midcarpal joint.

POSITIONING • A sterile traction device is used to suspend the hand with the elbow flexed at 90 degrees (Fig. 19.3). • Finger traps suspend the index and long finger. Approximately 5 to 10 lbs of weight is applied through the traction tower to distract the wrist. • For better visualization of ulnar-sided pathology, the finger traps can suspend the index and ring finger. For patients with fragile skin, additional finger traps can reduce the force on the skin. • A 1.9- to 2.7-mm angled arthroscope, along with a camera attachment, is essential to permit adequate mobilization without injury to surrounding structures and articular cartilage. The 1.9-mm scope is remarkably advantageous for the evaluation of small joints such as the distal radioulnar joint, basal joint, and metacarpophalangeal joint. Besides the standard 30-degree arthroscope, a 70-degree arthroscope is occasionally useful.

EXPOSURES • Extremity exsanguination with subsequent tourniquet control should be performed for all arthroscopic cases, except where infection or malignancy is expected. • The traditional portal is the 3-4 portal, located in the radiocarpal joint in the interval between the third and fourth extensor compartments. The marking for the 3-4 portal is performed by locating the Lister tubercle and traveling distally 1 cm beyond the dorsal articular surface of the distal radius. This portal is generally in line with the radial border of the long finger metacarpal, just distal to the EPL tendon. • The 4-5 portal is located by identifying the EDC tendons of the fourth compartment and marking a position slightly more proximal than the 3-4 portal, in the interval

CHAPTER 19  Wrist Arthroscopy

•

• •

•

•

between the fourth and fifth compartment. This portal is typically in line with the mid axis of the ring metacarpal. 6R and 6U are named according to their positions in relation to the ECU tendon, with 6R located radial and 6U located ulnar. 6R is typically a working portal, and 6U is often used for inflow or outflow of fluid into and out of the wrist. The 1-2 portal is identified along the dorsal aspect of the anatomic snuff box. Take care to avoid injury to the radial artery. The radial and ulnar midcarpal portals are made 1 cm distal to the 3-4 and 4-5 portals, respectively. The radial midcarpal (MCR) portal is bounded radially by the ECRB and ulnarly by the EDC. The EDC and EDM bound the ulnar midcarpal (MCU) portal which is often more accessible than the radial midcarpal portal. If a scaphotrapezial-trapezoid (STT) portal is desired, the incision is made ulnar to the EPL tendon. The exact location of this portal can be confirmed with an arthroscope in the radial midcarpal portal by passing a spinal needle into the STT space. A typical arthroscopic examination includes variable combinations of the 3-4 portal, 4-5 portal, MCR portal, MCU portal, and 6R/U portals (see Fig. 19.1).

Arthroscopic Evaluation of Wrist Step 1: Injection of Radiocarpal Joint and Preparation of the 3-4 Portal • Axial traction is applied to the wrist via finger trap suspension through the index and long finger. Approximately 10 lbs (4.5 kg) of traction is used, although 15 lbs (6.8 kg) can be used in a more muscular patient or when arthritis has significantly narrowed the joint space. • An 18-gauge needle attached to a 10-cc syringe filled with saline should be used to enter the radiocarpal joint via the 3-4 portal, remembering to enter at approximately 10 degrees of downward inclination toward the hand to match the dorsal-volar inclination of the distal radius. The bevel of the needle should be parallel with the extensor tendons to avoid inadvertent injury (Fig. 19.4). If not positioned correctly, one may have difficulty with entry into the joint, impeded by either the scaphoid or the radius. If the portal is not positioned perpendicular to the joint capsule, in the center of the joint, movement of the scope and visualization of all anatomic structures of the radiocarpal joint will be difficult.

FIGURE 19.4  The needle enters at approximately 10 degrees of inclination toward the wrist joint.

EXPOSURES PITFALLS

• Understanding the normal anatomy of the wrist is essential to avoiding injury to structures. • The portal placement must be precise to within 1 to 2 mm of the desired location to avoid damage to articular surfaces. • When the wrist is swollen after acute trauma, one should palpate bony landmarks to confirm portal location.

57

58

CHAPTER 19  Wrist Arthroscopy STEP 1 PEARLS

• The skin incision should be shallow to avoid injury to important subcutaneous structures such as tendons and nerves. • After a shallow skin incision, blunt dissection should be carried out to the level of the joint capsule, followed by arthroscope introduction with blunt trocar to avoid injury to the extensor tendons or the articular cartilage. • Remember that the distal radius volar tilt will require the radiocarpal instruments to be inserted at approximately 10 degrees toward the hand. STEP 2 PEARLS

• The inflow through the arthroscope can push debris away instead of pulling it towards the camera. • When creating a new portal, an 18- to 22-gauge needle can be inserted under direct arthroscopic visualization. • The 4-5 and 6R portals are positioned slightly proximal to the 3-4 portal because of the inclination of the radius. • Dry arthroscopy can be performed to confirm a diagnosis when an open operation is planned. In this way, the structures will not be distorted by arthroscopy fluid.

• Entry into the joint can be determined by feeling a distinct “pop” through the dorsal capsule. Further confirmation can be ascertained by injecting approximately 5 cc of saline to distend the radiocarpal joint. • An 11-blade scalpel, inserted parallel to the extensor tendons, is used to increase the size of the skin incision. • Remembering the angle in which the needle entered the joint, a mosquito is used to bluntly dissect and increase the opening in the dorsal joint capsule (Fig. 19.5). • A blunt cannula is used to place the 2.7-mm arthroscope within the radiocarpal joint.

Step 2: Preparation of the 4-5 and 6R/U Portals • The gravity-driven inflow of arthroscopy fluid can be provided by the 6U portal or through the arthroscopic cannula. An 18-gauge needle is placed in the 6U portal for outflow. The outflow of fluid should be collected in a basin to avoid the pooling of saline in the operative field. • Traditional working portals are the 4-5 portal or 6R portal (Fig. 19.6). • The interval between the fourth and fifth extensor tendons is palpated, and the radiocarpal joint is entered with an 18-gauge needle. The portal is dilated using a mosquito as previously described. The 6R/U portals are on the radial and ulnar side of the ECU tendon; entry can be similarly accessed.

Step 3: Evaluation of Radiocarpal Joint • With the arthroscope in the 3-4 portal, the radiocarpal space is evaluated systematically from radial to ulnar in the order of articular surface, extrinsic ligament, and intrinsic ligament. • The articular surfaces are examined first: radius, scaphoid, lunate, and triquetrum (R, radius; S, scaphoid; L, lunate; Figs. 19.7 and 19.8). • The extrinsic ligamentous structures are evaluated next: radioscaphocapitate ligament (RSC), long radiolunate ligament (LRL), ligament of Testut (radioscapholunate ligament), short radiolunate ligament (SRL), prestyloid recess, and TFCC (Figs. 19.9–19.11).

FIGURE 19.5  A mosquito is used to bluntly dissect and increase the opening in the dorsal joint capsule.

FIGURE 19.6  The traditional viewing portal is the 3-4 portal. Working portals are the 4-5 or 6R portal.

59

CHAPTER 19  Wrist Arthroscopy

A

B

FIGURE 19.7  (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed (radiocarpal joint). R, Radius; S, scaphoid.

A

B

FIGURE 19.8  (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed (radiocarpal joint). L, Lunate; R, radius.

S S

L

Long radiolunate ligament (LRL)

Radioscaphocapitate ligament

R

FIGURE 19.9  R, Radius; S, scaphoid.

Ligament of Testut R

FIGURE 19.10  L, Lunate; R, radius; S, scaphoid.

60

CHAPTER 19  Wrist Arthroscopy Prestyloid recess

S TFCC

L

FIGURE 19.11  TFCC, Triangular fibrocartilage complex. R

FIGURE 19.12  The dotted line indicates the scapholunate interosseous ligament. L, Lunate; R, radius; S, scaphoid.

STEP 3 PEARLS

• Gently resting your middle and ring fingers on the patient’s dorsal hand is essential for stabilizing the arthroscope (Fig. 19.13). • Do not confuse the normal prestyloid recess with a peripheral TFCC tear. Most peripheral tears are observed dorsal to the fovea.

• The RSC ligament is the radial-most structure, originating from the radial styloid. The slightly wider LRL can be seen ulnar to the RSC ligament. • The ligament of Testut is seen ulnar to the LRL and is primarily a neurovascular structure. It marks the SL interval and sagittal ridge, which should be redundant on probing. The SRL is next to the ulnar side. • The integrity of the TFCC can be assessed using a probe via the 6R/U portal. • The intrinsic ligaments can also be evaluated from the 3–4 portal: the SL IO ligament and the LT IO ligament (Fig. 19.12). • The extrinsic ulnar ligaments, including the ulnar lunate (UL) and ulnar triquetral (UT) ligaments, are best visualized with the arthroscope in the 6R portal.

FIGURE 19.13  Gently rest your middle and ring fingers on the patient’s dorsal hand to stabilize the arthroscope.

CHAPTER 19  Wrist Arthroscopy

Step 4: Preparation of Midcarpal Portals and Evaluation • Midcarpal evaluation should be performed after a thorough evaluation of the radiocarpal joint. • A needle can be placed in the radial midcarpal portal approximately 1 cm distal to the 3-4 portal. Upon entering the joint, if there is arthroscopy fluid flowing out, one should suspect an IO ligament injury because of fluid communicating through the ruptured proximal intercarpal ligaments. • The ulnar midcarpal portal, approximately 1 cm distal to the 4-5 portal, can be confirmed under direct visualization with an arthroscope in the radial midcarpal portal. • The proximal articular surfaces, including trapezium (Tzm), trapezoid (Tzd), capitate (C), and hamate (H), are best appreciated through the midcarpal joints. Furthermore, the distal articular surfaces of the scaphoid (S), lunate (L), and triquetrum (T) are also seen (Figs. 19.14–19.17). • Widening of the SL and LT IO interval is best seen through the midcarpal portals.

Systematic Evaluation and Common Pathologies Step 1: Radiocarpal Joint See Table 19.2 and Figs. 19.19–19.27 for an overview of the procedure and pictures. • Begin with the 3-4 portal, which is the primary viewing portal. • Move from radial to central to ulnar.

Tzd

Tzm S A

B

FIGURE 19.14  (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed (scaphotrapezial-trapezoid joint). S, Scaphoid; Tzd, trapezoid; Tzm, trapezium.

C

S

A

L

B

FIGURE 19.15  (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed. C, Capitate; L, lunate; S, scaphoid.

STEP 4 PITFALLS

• Remember the location of cutaneous nerves when creating portals or placing percutaneous Kirschner wires (K-wires) for provisional fixation (Fig. 19.18). • If thermal shrinkage is performed for soft tissue debridement, it is crucial to monitor the temperature of the fluid exiting the wrist to avoid high-temperature injury.

61

62

CHAPTER 19  Wrist Arthroscopy

C

T

L

B

A

FIGURE 19.16  (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed. C, Capitate; L, lunate; T, triquetrum.

C

A

H

B

FIGURE 19.17  (A–B) The circle in the x-ray indicates the position in the joint where the scope is placed. C, Capitate; H, hamate.

• 4-5 and 6R portals can be used as the working portal. • Change to the 4-5 or 6R portal as the viewing portal to easily access the ulnocarpal joint.

Step 2: Midcarpal Joint See Table 19.2 and Figs. 19.28–19.32 for an overview of the procedure and pictures. • Begin with the MCR portal, which is the primary viewing portal. • Move from central to ulnar to radial. • The MCU or STT portal can be used as the working portal.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • After routine arthroscopic evaluation and soft tissue debridement/thermal shrinkage, the patient is instructed to remain in a soft dressing for 72 hours, after which the patient may shower and keep the incisions clean. • Range-of-motion and strengthening exercises are dictated by the treatment of the specific pathology and will be described in separate chapters. See Video 19.1

CHAPTER 19  Wrist Arthroscopy

TABLE Systematic Evaluation of Wrist Arthroscopy 19.2

Radiocarpal Joint Field of View 1.

2.

3.

Anatomic Structures

Checkpoint

Common Pathologies

Proximal scaphoid, radial styloid, and radial facet

Arthritic change

Fig. 19.19–20

Volar extrinsic ligaments

RSC, LRL, RSL (Testut)

SL ligament

Normal concave appearance Tear or diastasis Drive-through sign

Fig. 19.21

Proximal lunate and lunate facet

Arthritic change

Fig. 19.22–23

Radial to 3-4 portal

Central to 3-4 portal

Ulnar to 3-4 portal

Fig. 19.24–25

LT ligament Triquetrum Radial attachment of the TFCC TFCC and prestyloid recess

4.

Easily evaluated from the 4-5 or 6-R portal

Trampoline test Hook test (fovea tear) Palmer classification

Fig. 19.26–27

Ulnolunate and ulnotriquetral ligaments

Midcarpal joint Field of View 1

2

Common Pathologies

Anatomic Structures

Checkpoint

Convexity of the capitate

Arthritic change

SL joint

SL instability by Watson’s test Widening interval (Geissler grade)

Fig. 19.28–30

Lunate, hamate, triquetrum surface

Arthritic change

Fig. 19.31

LT joint

LT instability by ballottement test Widening interval (Geissler grade)

Fig. 19.32

Central to MCR portal

Ulnar to MCR portal

Triquetrohamate joint space is normally quite tight 3

Radial to MCR portal STT portal as working portal

STT joint (Bubbles frequently collect here)

Arthritic change

LRL, Long radiolunate ligament; LT, lunotriquetral; MCR, radial midcarpal; RSC, radioscaphocapitate ligament; RSL, radioscapholunate ligament; SL, scapholunate; STT, scaphotrapezial-trapezoid; TFCC, triangular fibrocartilage complex.

63

64

CHAPTER 19  Wrist Arthroscopy

S

Superficial branch of the radial nerve

Radioscaphocapitate ligament (RSC)

Dorsal cutaneous branch of the ulnar nerve

R

FIGURE 19.18  Remember the location of cutaneous nerves when creating portals or placing percutaneous Kirschner wires for provisional fixation.

FIGURE 19.19  Synovitis around radial styloid. R, Radius; S, scaphoid.

S

L L S

R FIGURE 19.20  Synovitis and scaphoid articular wear.

FIGURE 19.21  Arrow indicates attenuated scapholunate ligament. L, Lunate; S, scaphoid.

FIGURE 19.22  Arrow indicates lunate articular wear.

CHAPTER 19  Wrist Arthroscopy

S

L T

Lunate facet TFCC

FIGURE 19.23  Arthritic change of lunate facet on the radius. L, Lunate; S, scaphoid.

FIGURE 19.24  Demonstrates arthritis change of triquetrum. T, Triquetrum; TFCC, triangular fibrocartilage complex.

L

L

TFCC

TFCC Ulna head

FIGURE 19.25  Arrow indicates TFCC tear from the radial attachment. L, Lunate; TFCC, triangular fibrocartilage complex.

FIGURE 19.26  Demonstrates TFCC central tear with ulna head exposure. TFCC, Triangular fibrocartilage complex.

L

S

< 2 mm

FIGURE 19.27  Arrow indicates TFCC peripheral tear. TFCC, Triangular fibrocartilage complex.

FIGURE 19.28  Shows Geissler grade 2 gapping (, 2 mm) of the scaphoid and lunate. L, Lunate; S, scaphoid.

65

66

CHAPTER 19  Wrist Arthroscopy

S

L

> 2 mm

S

FIGURE 19.29  Shows Geissler grade 3 gapping (. 2 mm) of the scaphoid and lunate. L, Lunate; S, scaphoid.

L

FIGURE 19.30  Illustrates Geissler grade 4 gapping of the scaphoid and lunate, drive-through sign. L, Lunate; S, scaphoid.

C

H

H

C

T

Step off

L

FIGURE 19.31  Arrow indicates hamate articular wear. C, Capitate; H, hamate.

FIGURE 19.32  Geissler grade 3 gapping (. 2 mm) of the lunate and triquetrum, with step off. C, Capitate; H, hamate; L, lunate; T, triquetrum.

EVIDENCE Chung KC, Zimmerman NB, Travis MT. Wrist arthrography versus arthroscopy: A comparative study of 150 cases. J Hand Surg Am. 1996;21:591–594. The authors used triple-injection wrist arthrography and arthroscopy to evaluate 150 patients with suspected wrist ligamentous injuries. The diagnoses obtained by these two techniques were compared to determine the differences between the two modalities. All of the patients in this study had both a clinical diagnosis of ligamentous injuries of the wrist and normal findings on x-ray films. Intercarpal abnormalities were found in 106 patients (71%) at wrist arthrography and in 136 patients (91%) at arthroscopy. There was only 42% agreement (63 patients) between the arthrographic and arthroscopic diagnoses. Eightyseven patients (58%) had alterations of their arthrographic diagnoses after arthroscopy. For patients with normal arthrographic findings (44 patients), 88% underwent arthroscopy because there was insufficient correlation between the physical examination findings and the arthroscopic findings. Of the 44 patients with normal arthrographic findings, 35 patients (80% of the subgroup) had injuries found at arthroscopy. More than half of the patients had alterations in their arthrographic diagnoses after arthroscopy. The authors concluded that in a patient with suspected ligamentous injury of the wrist, wrist arthroscopy may be the most effective method for arriving at a definitive diagnosis (Level IV evidence). Johnstone DJ, Thorogood S, Smith WH, Scott TD. A comparison of magnetic resonance imaging and arthroscopy in the investigation of chronic wrist pain. J Hand Surg Br. 1997;22:714–718. The authors conducted a prospective study wherein they evaluated 43 patients with chronic wrist pain MRI and arthroscopy. Pathology within the wrist joint was detected in 30 cases with MRI and in 32 cases with arthroscopy. The sensitivity and specificity of MRI compared with arthroscopy were 0.8

CHAPTER 19  Wrist Arthroscopy and 0.7 for TFCC pathology, 0.37 and 1.0 for SL ligament, and 0 and 0.97 for LT ligament. They concluded that MRI is not helpful in the investigation of suspected carpal instability and that the results of MRI for TFCC injuries should be interpreted with caution (Level IV evidence). Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg Am. 1997;22:344–349. This study examined the role of arthroscopic debridement alone for complete and incomplete intercarpal ligament tears in 43 wrists. At an average of 27 months follow-up, 29 (66%) wrists with a complete SL ligament tear and 36 (85%) wrists with a limited SL ligament tear had either complete symptom resolution or improved symptomatology. Thirty-three (78%) wrists with a complete LT ligament tear and 43 (100%) wrists with a limited LT ligament tear had complete symptom resolution or improvement. There were no static intercarpal instability pattern changes on follow-up radiographs and grip strength improved 23% postoperatively. These findings suggest that in a majority of patients, partial and complete intercarpal ligament tears may be treated from a symptomatic standpoint by debridement alone. Long-term data are not available (Level IV evidence).

67

CHAPTER

20

Repairing Tears of the Triangular Fibrocartilage Complex Aviram M. Giladi and Kevin C. Chung INDICATIONS • Indications for repair include tears of the triangular fibrocartilage complex (TFCC) that cause persistent pain and/or distal radioulnar joint (DRUJ) instability. • Another indication for repair involves symptomatic TFCC injuries that are refractory to conservative treatments (usually at least 6 weeks of immobilization). • Peripheral tears of the TFCC are amenable to repair owing to better blood supply, whereas tears of the relatively avascular central zone of the TFCC are not (Fig. 20.1). • The Palmer classification system categorizes TFCC injuries as traumatic or degenerative. This chapter will focus on the treatment of Type 1 (traumatic) TFCC lesions

Radioscapholunate ligament Radioscaphocapitate ligament Radial collateral ligament

Long radiolunate ligament Articular disc (fibrocartilage)

Disk-carpal ligaments (D-L) (D-T)

Ulnar collateral ligament

Extensor carpi ulnaris

Deep and superficial radioulnar ligaments

Dorsal branch of anterior interosseous artery

Dorsal radioulnar capsule

FIGURE 20.1  Anatomy and vascular supply of the triangular fibrocartilage complex and surrounding structures. (Fig. 50.18, from Standring S, ed. Gray’s Anatomy, 42nd ed, 2020:930–954.e3)

68

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

TABLE Palmer Classification of Traumatic TFCC Injuries 20.1

Name

Location/Pathology

Treatment

1A

Tear or perforation of central aspect of disk (fovea)

Rest/activity modification/immobilization Arthroscopic or open repair

1B

Tear within the peripheral TFCC

Arthroscopic or open repair

1C

Distal detachment of TFCC from carpus

Conservative

1D

Proximal detachment of TFCC from carpus

Conservative

TFCC, Triangular fibrocartilage complex.

Dorsal

A

D

B

Palmar

C

Common TFC Tears FIGURE 20.2  Palmer classification of traumatic triangular fibrocartilage complex tear. (Fig. 3, from Carlsen B, Rizzo M, Noran S. Soft-tissue injuries associated with distal radius fractures. Operat Teach Orthop 2009;19(2):107–18)

(Table 20.1). Type 1A (Fig. 20.2) lesions are treated with debridement but not with repair because the central disk does not tend to heal. Types 1B, 1C, and 1D are all candidates for arthroscopic or open repair. Type 1B lesions are the most common and are the subject of this chapter.

Contraindications • Chronic/degenerative lesions with associated changes of carpal chondromalacia or other signs of arthritic wear are not good candidates for TFCC repair. • Evaluate for ulnar positive status because a prominent ulna can contribute to TFCC injury and stress a repair. • Concomitant extensor carpi ulnaris (ECU) tendon subluxation or instability must be identified before TFCC repair. • Evaluate for ulnar styloid injury that can also be associated with TFCC injury and resultant DRUJ instability. • Many TFCC injuries can be repaired with arthroscopic techniques if proper equipment is available; however, if ECU subluxation, ulnocarpal impaction, other carpal ligament injury (e.g., lunotriquetral ligament injury), and/or large ulnar styloid fracture segment is identified, an arthroscopic approach is likely contraindicated.

CLINICAL EXAMINATION • TFCC injuries often present as ulnar-sided wrist pain. • Acute injuries are associated with a fall, especially on an outstretched and pronated hand, or with an aggressive traction or torque event. • Patients may complain of clicking, popping, or locking during pronosupination. • To look for a positive fovea sign, palpate the soft spot of the ulnar wrist, just distal to the ulnar styloid and proximal to the pisiform, between the ECU and flexor carpi ulnaris tendons. Substantial pain with deep palpation here is a positive fovea sign (supporting the diagnosis of a peripheral TFCC tear).

69

70

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

• To complete an ulnocarpal stress test, with the patient’s elbow bent at 90 degrees, the examiner puts their nondominant hand under the elbow and grips the palm/ carpus of the affected hand with a handshake-style grip. The examiner then maximally ulnarly deviates the patient’s hand, and, while holding this axial ulnar load, the examiner puts the joint through passive pronation and supination. Reproduction of symptoms is a positive test indicating likely TFCC pathology (a nonpainful click is not considered positive). • The ballottement test evaluates DRUJ stability (Fig. 20.3). Grasp the radius in the examiner’s nondominant hand and the distal ulna with the dominant index finger and thumb, then move the distal ulna volar and dorsal relative to the radius. Soft endpoints, pain, and/or notable instability compared with contralateral all indicate DRUJ instability. • To look for a piano key sign, with the wrist in pronation, note the position of the ulnar head. A notably prominent ulnar head that shifts down with volarly directed pressure and then recoils to the dorsally displaced position indicates DRUJ instability (positive piano key sign).

IMAGING FIGURE 20.3  Ballottement test. (Fig. 3, from Atzei, A, Luchetti, R. Foveal. TFCC tear classification and treatment. Hand Clin. 2011;27(3): 263–272.)

• Although the TFCC cannot be seen on x-rays, it is important to evaluate standard posteroanterior (PA), lateral, and oblique images. To properly assess ulnar variance, the PA x-ray should be taken with the forearm in neutral rotation, elbow flexed to 90 degrees, and shoulder abducted to 90 degrees. Obtain similar x-rays of the contralateral side for comparison. • Indicators of possible TFCC injury (especially acute) include ulnar styloid fracture and/or DRUJ incongruity. • Other sources of ulnar-sided wrist pain or contributors to TFCC pathology include ulnar positive variance, ulnar styloid nonunion, widened lunotriquetral interval indicative of LT ligament injury, cystic changes in the lunate indicative of impaction, and DRUJ arthritis. • Triple injection arthrogram can be used in evaluation but has a moderately high false negative rate. It has generally fallen out of favor as magnetic resonance imaging (MRI) has improved. • Modern MRI machines have sensitivity and specificity around 90% or better for identifying TFCC injury; however, peripheral injuries have the lowest diagnostic accuracy and findings may depend on the experience of the radiologist. • The standard diagnostic modality is arthroscopy.

SURGICAL ANATOMY • Identifying the area of the TFCC that is injured guides the surgical approach. • The TFCC is composed of the triangular fibrocartilage (TFC, otherwise known as the articular disk), meniscus homologue, radioulnar ligament (RUL), ulnotriquetral ligament, ulnolunate ligament, ECU subsheath (not included in the figure image), and ulnar joint capsule (Fig. 20.4). • Injuries to the TFC are the most commonly discussed (and treated) component of TFCC injuries. • Nevertheless, evaluating the other components of the TFCC that contribute to DRUJ stability is critical, especially when DRUJ instability is part of the presenting problem. • The TFCC attaches radially along the sigmoid notch of the radius and ulnarly along the ulnar fovea (Fig. 20.5). Injuries that result in tearing of the TFCC in either of these two attachment zones are appropriate for repair. • The TFC attachment to the ulna has superficial and deep components (see Fig. 20.5) that must be considered during the evaluation and repair of TFCC injuries. • The superficial component attaches to the styloid. • The deep component attaches to the ulnar fovea. • Ulnar styloid nonunion in the setting of TFCC peripheral tear often warrants excision of the styloid segment before the TFCC repair/reanchoring procedure.

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex Ulnolunate ligament* Ulnotriquetral ligament*

Scaphoid fossa Lunate fossa

Articular disk*

Ulnar capsule* Meniscus homologue* Prestyloid recess

Ulnar styloid

Ligamentum subcruentum (runs deep, inserts into ulnar fovea) Radius

Dorsal DRUL superficial portion*

*Indicates a component of the TFC complex

Ulna

Dorsal DRUL deep portion*

(ECU subsheath not shown)

FIGURE 20.4  Anatomy of the foveal attachment of the triangular fibrocartilage complex (TFCC). Red asterisk indicates the structure is a component of the TFCC. (Fig. 72.2, from Adams JE. Disorders of the distal radioulnar joint. In: Miller, MD, Thomas, SR, eds. DeLee, Drez & Miller’s Orthopaedic Sports Medicine, 5th ed. Elsevier:865–872)

Sigmoid notch Ulna styloid

A TFC superficial limb Lister’s tubercle TFC deep limb Fovea

R

U

B FIGURE 20.5  Anatomy of the triangular fibrocartilage complex and associated structures. (Fig. 6.4, from Adams BD, Mitchell SA. The distal radioulnar joint and triangular fibrocartilage complex. In: Trumble TE, Ghazi MR, Baratz ME, Budoff JE, Slutsky DJ, eds. Principles of Hand Surgery and Therapy. 3rd ed. Philadelphia, PA: Elsevier; 2017:117–143.)

71

72

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

Ulnar midcarpal portal (MCU)

Radial midcarpal portal (MCR) 3–4 portal

6U portal 6R portal 4–5 portal

FIGURE 20.6  Markings for each arthroscopy portal are based on anatomic landmarks.

FIGURE 20.7  Skin markings. Courtesy W. Hugh Baugher, MD

POSITIONING AND EQUIPMENT PEARLS

Before beginning arthroscopy, consider where an open incision would be needed to perform an open repair, and confirm that easy access is available even with the arm still in the arthroscopy tower. EXPOSURES PEARLS

It is far easier to see, feel, and mark landmarks before beginning arthroscopy.

• For arthroscopic approaches to TFCC evaluation and repair, combinations of the dorsal 3 to 4, dorsal 4 to 5, and 6-R or 6-U portals are often used. Additionally, many surgeons will also use radial and ulnar DRUJ arthroscopy portals (Fig. 20.6) • Before repair (either during arthroscopy or after the open exposure), evaluate the lunate, triquetrum, and ulnar head for signs of impaction and associated chondromalacia.

POSITIONING AND EQUIPMENT EXPOSURES PITFALLS

Avoid positioning the hand/arm in the arthroscopy tower in any way that obstructs access to the 6U/6R portal or to the open approach of choice.

• The patient is placed supine on the operating room table. • A standard arthroscopy setup is used, with elbow at 90 degrees and upper arm secured to the hand table.

EXPOSURES • For arthroscopic repair, it is common to use a 1.5- to 2.5-cm longitudinal incision volar to the ulnar styloid to properly expose the ulna/ulnar capsule before tying down the sutures. • When using this approach, protection of the ulnar sensory branches is critical. • For open repair, two common approaches are either dorsal in the area of the fifth extensor compartment (Fig. 20.7) or along the ulnar border of the wrist via a longitudinal incision (Fig. 20.8). • For both approaches, ulnar sensory nerve branches are at risk and must be protected. • For the dorsal approach, designing proper capsular flaps is necessary to permit durable repair/closure (Fig. 20.9A–B). • For the ulnar border approach, a longitudinal incision through the capsule can be repaired primarily. When using this approach, it is also important to avoid injury to the ECU/ECU sheath.

INSIDE-OUT ARTHROSCOPIC REPAIR – TYPE 1B TEAR FIGURE 20.8  Longitudinal incision along the ulnar border of the wrist is an alternative approach for open repair.

Before any TFCC repair, perform a diagnostic arthroscopy. • The location of the injury and surgical approach for repair are based on findings from arthroscopy. There are several critical components for evaluating the TFCC injury: • Visualize the central disk and the radial attachment.

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

A

B

FIGURE 20.9  (A) Extensor retinaculum markings. (B) Extensor retinaculum incisions to create flaps for repair. Courtesy W. Hugh Baugher, MD.

A

B

FIGURE 20.10  (A) Trampoline test. (B) Hook test. (Fig. 4, from Atzei, A, Luchetti, R. Foveal. TFCC tear classification and treatment. Hand Clin. 2011;27(3):263–272.)

• Examine for lunate chondral injury. • Perform the hook test and trampoline test to identify a peripheral TFCC injury (Fig. 20.10A–B). There are many techniques described for TFCC repair. One of the many arthroscopic techniques (inside-out with meniscal repair kit; Fig. 20.11A–F) passes the needle from radial to ulnar to capture the TFCC with the suture. We present clinical photos of an ulnar-based inside-out technique and an open repair from a dorsal approach that requires minimal additional equipment/expense and is usually performed on a hand table, with no need for an arthroscopy tower or traction.

Step 1

STEP 1 PEARLS

• With the arthroscope in the 3-4 or 4-5 portal to facilitate direct visualization, use the two cannulated needles to capture the TFCC. • Needles are both placed from ulnar to radial, entering along the ulnar border of the wrist. • Both are aligned to enter from the fovea/deep to the ulnar styloid and are passed superoradially to capture the frayed ulnar margin of the torn TFCC. • The needles must enter the TFCC along the ulnar side of the disc but stay separated from each other.

Leave adequate TFCC substance between the two cannulated needles so that the suture has durable purchase of the TFCC.

73

74

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

Articular surface Joint capsule of lunate bone Tear in rim of TFC

Tuohy needle

2–0 PDS suture

Tuohy needle penetrates ulnar TFC Radius Ulna

A

B

Triangular fibrocartilage (TFC) over ulna

Tear in rim of TFC

Tear in rim of TFC

Second point of penetration

Second point of penetration 2–0 PDS suture

C

2–0 PDS suture

D Dorsal sensory branch of ulnar n.

Ulna Knot tied over joint capsule

Arthroscopic view 2–0 PDS suture

Protected dorsal sensory branch of ulnar n.

TFC tear

2–0 PDS suture

E

F

FIGURE 20.11  (A–F) Arthroscopic inside-out repair. (Fig. 6, from McAdams TR, Swan J, Yao J. Arthroscopic treatment of triangular fibrocartilage wrist injuries in the athlete. Am J Sports Med 2009;37:291–297.)

Step 2 • 2-0 or 0 PDS is passed in through one of the needles (Fig. 20.12A–B). • A looped grasper is used via the second needle to pull the suture out and through the second needle, capturing a segment of TFCC with the suture (Fig. 20.13A–B).

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

A

B

FIGURE 20.12  (A) Suture passer inserted through trocar. (B) 0-PDS inserted through opposite trocar and suture passer loop.

A

B

FIGURE 20.13  (A) Polydioxanone suture secured with passer against trocar. (B) Passer and trocar withdrawn as a single unit.

Step 3

STEP 3 PEARLS

• The suture is tied down over the capsule to secure the TFCC along the ulnar fovea/ ulnar margin of the capsule. • Use the scope to visualize/confirm the repair is well seated and durable to stress (Fig. 20.14A–B).

Dissect adequately to avoid trapping other tissue along the capsule or in the suture knot, particularly the dorsal ulnar sensory nerve.

OPEN REPAIR – TYPE 1B TEAR Step 1 Complete exposure. • After elevating the retinacular flaps (see Fig. 20.9A–B), the dorsal capsule will be exposed (Fig. 20.15). • Make a transverse incision through the dorsal capsule just distal to the ulnar head (Fig. 20.16). • Retract the dorsal capsule and elevate if off of the ulna to expose the ulnar head. The ulna will be notably dorsally displaced once freed.

STEP 3 PITFALLS

Inadequate dissection and visualization of the suture site puts the sensory nerve branches (and other soft tissues) at risk for injury or entrapment.

75

76

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

A

B

FIGURE 20.14  (A) Prerepair. (B) Postrepair.

Extensor digiti minimi

Dorsal capsule Extensor carpi ulnaris FIGURE 20.15  Dorsal capsule exposed. Courtesy W. Hugh Baugher, MD

Extensor digiti minimi

FIGURE 20.16  Dorsal capsule incision. Courtesy W. Hugh Baugher, MD

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

Fovea

TFCC

FIGURE 20.17  Fovea. Courtesy W. Hugh Baugher, MD

FIGURE 20.18  Placing the suture in the triangular fibrocartilage complex (TFCC). The TFCC is being held within the pickups with the suture being passed from proximal/underside of TFCC to distal. It will then be passed back distal to proximal to complete the horizontal mattress. Courtesy W. Hugh Baugher, MD

Step 2 Suture in the TFCC. • Identify and mobilize the TFCC, taking care to preserve all radial and volar/dorsal attachments that remain. • Once the injured TFCC is mobilized, clear out any fibrinous debris and identify and mark the fovea (Fig. 20.17). • Make a distal transverse incision in the capsule, parallel and distal to the initial transverse incision, to permit visualization of the carpus-facing side of the TFCC. • Now with direct visualization of the proximal and distal aspects of the TFCC, place a #2 or #0 fiber-wire suture through the ulnar margin of the TFCC in a horizontal mattress (Fig. 20.18).

Step 3 Create bone tunnels. • Use two 0.045-mm Kirschner wires (K-wires) to create two separate bone tunnels through the fovea and out the head of the ulna (Fig. 20.19).

Step 4 Pass the suture. • Use a bent 26-gauge wire as a suture retriever. • Remove the K-wire, make a loop in the 26-gauge wire, pass the wire through the bone tunnel, and pull the suture through (Fig. 20.20). Do the same for the other tunnel/other arm of the suture in the TFCC.

Step 5 Secure the TFCC. • Manually mobilize the TFCC to confirm that it can reach and seat in the fovea. • With each suture through its respective bone tunnel, tie down the sutures and secure them over the ulnar head. • Confirm that the TFCC is now secured back to the ulnar fovea (Fig. 20.21A–B).

Step 6 Finish the repair. • Repair the capsule using 3-0 Vicryl suture (Fig. 20.22). After the capsule is repaired, test wrist range of motion to confirm that the repair is stable and motion is preserved. • Repair the retinacular flaps using 3-0 Vicryl suture (Fig. 20.23). After the retinaculum is repaired, test wrist range of motion to confirm that the repair is stable and motion is preserved.

STEP 1 PEARLS

When making the transverse capsule incision, use a hook to provide distal traction. STEP 1 PITFALLS

Be sure to leave a small cuff of capsule on the ulna so that the repair can be performed; leaving inadequate capsule on the ulna risks a weak closure. STEP 2 PEARLS

Confirm that the TFCC is adequately freed/ mobilized before placing any sutures. STEP 2 PITFALLS

Inadequate freeing of the TFCC along both proximal and distal aspects will make repair more difficult and likely restrict ability to achieve a tight repair. STEP 3 PEARLS

Leave an adequate bone bridge between the two drill sites to avoid pull-through of the suture when securing. STEP 5 PEARLS

Have an available assistant place traction on the TFCC and volar pressure on the ulna to aid in facilitating maximal ulnar translation of TFCC and proper ulnar reduction when securing the repair. STEP 5 PITFALLS

If the TFCC is secured but the ulna has not been properly reduced, this risks persistent instability or repair failure.

77

78

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

Ulnar head Wire loop

FIGURE 20.19  Bone tunnels. Courtesy W. Hugh Baugher, MD

FIGURE 20.20  The suture has been pulled through one bone tunnel (and is being retracted in the top-center of the image), with the wire loop now through the second tunnel preparing to pull the other side of the suture through. Courtesy W. Hugh Baugher, MD

Extensor digiti minimi

Extensor digiti minimi

Extensor carpi ulnaris A

B

FIGURE 20.21  (A–B) Securing the triangular fibrocartilage complex. Courtesy W. Hugh Baugher, MD

FIGURE 20.22  Capsule repair. Courtesy W. Hugh Baugher, MD

FIGURE 20.23  Extensor retinaculum repair. Courtesy W. Hugh Baugher, MD

CHAPTER 20  Repairing Tears of the Triangular Fibrocartilage Complex

• Repair the skin per surgeon preference (we use 4-0 Monocryl in the deep dermis followed by 4-0 Monocryl running subcuticular).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES The patient is placed in a long-arm splint in the operating room. They return to clinic in approximately 2 weeks to begin active range of motion therapy and otherwise are in a Muenster splint. After 6 weeks, start to wean them out of the splint. If the patient is still very stiff at 2 to 3 months postoperation, add passive range of motion to the therapy protocol. See Videos 20.1 and 20.2

EVIDENCE Luchetti R, Atzei A, Cozzolino R, Fairplay T, Badur N. Comparison between open and arthroscopic- assisted foveal triangular fibrocartilage complex repair for posttraumatic distal radio-ulnar joint instability. J Hand Surg Eur Vol. 2014;39(8):845–855. Prospective study of 25 arthroscopic and 24 open TFCC repairs. All cases had a positive arthroscopy hook test before repair. At 6 months, 44 of 49 patients had a stable TFCC. Both groups had significant improvement in wrist pain, Mayo wrist score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Patient-Rated Wrist Evaluation (PRWE). The DASH score was significantly better (lower) in the arthroscopic group at 6 months; otherwise, there were no significant differences between groups. 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. Retrospective review of 36 arthroscopic and 39 open TFCC repairs with an average follow-up of nearly 4 years. Across all patients, 57% improved in pain and 17% underwent subsequent surgery for DRUJ instability. Comparing groups, there were no significant differences in pain improvement or postoperative complications, although there was a higher incidence of ulnar sensory nerve temporary irritation in the open group.

STEP 6 PEARLS

The ulnar head will remain somewhat proud dorsally until the capsule is repaired. POSTOPERATIVE PEARLS

Because stability of the repair and range of motion are tested in the operating room, patients can begin active range of motion in the first 2 weeks after surgery with low risk.

79

CHAPTER

21

Scapholunate Ligament Repair David W. Grant and Kevin C. Chung INTRODUCTION • The scapholunate (SL) ligament is a commonly injured wrist ligament. A complete SL ligament injury that is not treated can progress to pancarpal arthritis, as described later, making the diagnosis and repair of SL ligament injuries important. • The SL ligament is the primary stabilizer of the scapholunate joint. As a stabilizer, the SL ligament prevents the scaphoid and lunate from moving independently at the SL joint. If disrupted, the scaphoid tends to flex (volarly), whereas the lunate tends to extend (dorsally) when viewed from a lateral radiograph. • The secondary stabilizers of the SL joint are the scaphotrapeziotrapezoid (STT), scaphocapitate (SC), and radioscaphocapitate (RSC; Fig. 21.1A–B). These are volar structures and resist the scaphoid’s tendency to flex; in this way, they are secondary stabilizers. The STT and SC are volar intrinsic ligaments, whereas the RSC is a volar extrinsic ligament.

TT

Td

C

CT

Tm S

CH

H

H

HT

DIC SL

CH TH

T

T

SC TC

P

LT L DRC

Td C TC TT

L UT UL UC SRL PRU U

U

Tm

S

RSC LRL

R

R A

B

AIA

RA

= secondary stabilizer of SL joint FIGURE 21.1  (A) Dorsal. (B) Volar. Primary and secondary stabilizers of the scaphoid and lunate. Red asterisks indicate secondary stabilizers of SL joint. AIA, Anterior interosseous artery; C, capitate; CH, capitohamate ligament; CT, capitotriquetral ligament; DIC, dorsal intercarpal ligament, H, hamate; HT, hamate-triquetral ligament; L, lunate; LRL, lunotriquetral ligament; P, pisiform; PRU, palmar radioulnar ligament; R, radius; RA, radial artery; RSC, radioscaphocapitate; S, scaphoid; SC, scaphocapitate; SL, scapholunate; SRL, short radiolunate ligament; T, triquetrum; TC, triquetral capitate ligament; Td, trapezoid; TH, triquetral hamate ligament; Tm, trapezium; TT, trapeziotrapezoid ligament; U, ulna; UC, ulnocapitate ligament; UL, ulnolunate ligament; UT, ulnotriquetral ligament.

80

CHAPTER 21  Scapholunate Ligament Repair

• If an SL ligament injury is severe enough and does not spontaneously heal, the primary stabilizer is lost and the secondary stabilizers become stressed. • Over time, loss of the secondary stabilizers permits scaphoid flexion and changes in wrist biomechanics, leading to a spectrum of dysfunction known as scapholunate advanced collapse (SLAC). • The endpoint of SLAC is pancarpal arthritis; therefore timely identification and repair of an SL ligament injury can prevent the development of pancarpal arthritis.

STAGING • SL ligament injuries exist along a continuum, and different treatments exist for different stages along this continuum. • Table 21.1 presents a staging system that shows the progression from partial injury (stage I) to arthritis (stage VI). • The dorsal SL ligament is strongest and most important. Stage I indicates an incomplete SL ligament tear involving only the volar and proximal portions (Fig. 21.2) with an intact dorsal aspect of the SL ligament. This is also known as predynamic because the scaphoid does not move with provocative testing or imaging. • Stages II and III both have complete SL ligament disruptions and normal carpal alignment; however, the distinction is whether the SL ligament is reparable. Progression from stage II to III is influenced by both time and the location of the tear. Complete SL ligament injuries older than 6 weeks are usually irreparable and are generally described as chronic injuries. Meanwhile, midsubstance tears are often harder to repair over time than avulsion-type injuries. • For complete SL ligament tears in both stages II and III, there may be widening of the SL interval with stress views such as a clenched fist view, so these stages are known as dynamic. • The progression from stages II and III to IV and V reflects a loss of the secondary stabilizers. With disruption of the primary stabilizer (SL ligament) and secondary stabilizers (STT, SC, RSC), the scaphoid flexes and the lunate extends. Early on, the scaphoid can be reduced to its normal alignment. With time, fibrosis can make reduction impossible, thereby distinguishing stages IV and V. (Of note, scaphoid flexion is only considered “reducible” and therefore stage IV, if only mild force is needed to reduce the scaphoid. If tremendous force is required, current reconstruction techniques will not maintain reduction, and therefore it is classified as not reducible, stage V). • Eventually, abnormal wrist biomechanics leads to wrist arthritis through a predictable pattern known as SLAC wrist (stage VI). TABLE Staging System for Scapholunate Dissociation 21.1

Stage

Definition

I

Partial SL ligament injury (“predynamic”)

II

Complete disruption that is reparable, with normal static scapholunate alignment (“dynamic”)

III

Complete disruption that is not reparable but has normal static scapholunate alignment (“dynamic”)

IV

Complete disruption that is not reparable, with static volar flexion of the scaphoid that can be reduced to normal (“static”)

V

Complete disruption that is not reparable, with volar flexion of the scaphoid that cannot be reduced to normal, but the cartilage surfaces are intact (“static”)

VI

Complete disruption that is not reparable, with volar flexion of the scaphoid that cannot be reduced to normal, with cartilage degeneration (scapholunate advanced collapse [SLAC])

SL, Scapholunate. Adapted from: 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.)

81

82

CHAPTER 21  Scapholunate Ligament Repair

Scapholunate ligament Scaphoid

(1) Dorsal portion

(2) Palmar portion

(3) Proximal portion

Lunate Long radiolunate ligament

Scaphoid tuberosity

Radioscaphoid ligament Short radiolunate ligament

Triquetrum Radius

FIGURE 21.2  Key anatomic structures related to the scapholunate ligament.

The authors’ preferred operative technique will be presented for stages I and II. Chapter 22 will review treatment for stages III to VI. The Geissler arthroscopic classification is another system used to grade the severity of SL ligament injuries (Table 21.2); however, it is not as complete as the aforementioned system.

INDICATIONS AND CONTRAINDICATIONS • Patients with diagnosed SL ligament injuries who present with wrist pain should generally receive treatment that is appropriate for the stage of their injury. • The only exception is if a patient presents without pain and no obvious injury within 6 weeks; these patients are typically left untreated. • This is guided by clinical experience because no randomized trials can offer guidance on this recommendation. TABLE Geissler System for Arthroscopic Grading of Scapholunate Ligament 21.2 Injury Appearance of Ligament

Appearance of Joint

Radiocarpal Scope

Midcarpal Scope

Attenuated (Normal concave ligament appears convex)

No gap

No step-off

II

Attenuated, partial tear

No gap

Step-off 1 (Probe [~2 mm] cannot be passed through joint)

III

Complete tear

Gap 1

Step-off 1 (Probe [~2 mm] can be passed through joint)

IV

Complete tear

Gap 1

Step-off 1 (2.7-mm arthroscope can be passed through joint)

Grade

Radiocarpal Scope

I

CHAPTER 21  Scapholunate Ligament Repair

CLINICAL EXAMINATION • Patients present with radial-sided wrist pain, particularly with axial loading, power grip, and with extremes of wrist extension and radial deviation. • An SL ligament tear results in tenderness over the scaphoid in the anatomic snuff box and distal to the Lister tubercle over the scapholunate interval. • Many provocative tests exist to aid in diagnosis: • The carpal shake test involves passively shaking the wrist into extension and flexion by grasping the forearm. If this does not elicit pain or resistance to movement, then carpal pathology is unlikely. • The sitting hand test involves weight-bearing/loading the wrist as the patient rises from the seated position to standing. If this elicits pain, then it is suspicious for wrist pathology. • The scaphoid shift test (Fig. 21.3A–B) is the bimanual examination of the scaphoid in relation to the radius. One hand is used to apply pressure dorsally over the distal radius while the thumb presses on the distal pole of the scaphoid. The examiner’s opposite hand is then used to passively move the hand from ulnar to radial deviation. With SL ligament laxity or tear, the proximal pole of the scaphoid subluxes dorsally out of its fossa, which can result in pain along the SL interval. With release of pressure on the distal scaphoid, an audible and palpable clunk can be appreciated with reduction of the scaphoid back into its fossa. • Resisted long finger extension is when the patient extends the long finger with resisted extension and partial flexion of the wrist. This may elicit pain over the SL interval, which lies directly under the long finger extensor tendon. • To complete the SL ballottement test, after firmly stabilizing the lunate with one hand, the opposite hand is used to translate the scaphoid dorsally and volarly. Pain, crepitus, or mobility suggests disruption of the SL interval.

Distal pole of scaphoid

Distal pole of scaphoid

A

B

FIGURE 21.3  (A) Photos of scaphoid shift test. (B) Illustration of scaphoid shift test. (Fig. 8.10, from Haase SC, Chung KC. Fractures and dislocations of the wrist and distal radius. Chang J, ed. Plastic Surgery: Hand and Upper Extremity. 2018. Elsevier: 170–187.)

83

84

CHAPTER 21  Scapholunate Ligament Repair

A

B

C

FIGURE 21.4  (A–C) Standard wrist x-rays will only identify static scapholunate instability, showing a widened SL interval (arrow) or flexed scaphoid.

IMAGING • Standard wrist x-rays will only identify static SL instability, showing a widened SL interval (Fig. 21.4A–C) or flexed scaphoid. • Additional views are known as stress views and include clenched fist, posteroanterior (PA) maximal radial deviation, and PA maximal ulnar deviation (scaphoid view). • Arthroscopic evaluation is the reference standard for diagnosis of SL injuries, particularly predynamic and dynamic injuries. • The Geissler arthroscopic classification of SL ligament injuries can both diagnose an SL tear and examine the articular surface for signs of degeneration (see Table 21.2).

SURGICAL ANATOMY • The SL ligament can be found distal to the Lister tubercle and deep to the dorsal wrist capsule between the second and fourth dorsal extensor compartments. • The SL ligament is a U-shaped ligament consisting of palmar, proximal, and dorsal fibers. The dorsal ligament is the strongest of the ligamentous complex (see Fig. 21.2). • Wrist kinematics are governed by the primary (intrinsic) and secondary (extrinsic) ligamentous stabilizers of the wrist. The primary stabilizer of the scaphoid and lunate is the SL ligament. The secondary stabilizers of importance in scapholunate injury include the volar STT, SC, and RSC ligaments (see Fig. 21.1). • Predynamic scapholunate instability represents a partial ligament injury that results in pain but cannot be appreciated on plain x-ray. Diagnosis can be confirmed by arthroscopy, which may reveal attenuation, hemorrhage, or a partial tear of the scapholunate ligament (see Table 21.1). • With complete disruption of the scapholunate ligament and preservation of the secondary stabilizing ligaments, dynamic instability can be appreciated. This refers to an injury pattern in which the scapholunate interval widens with activation of extrinsic muscular forces across the wrist. With axial loading, such as clenching the fist, radiographs will demonstrate an increase in the scapholunate interval (Fig. 21.5). • After complete scapholunate injury and attenuation or rupture of the secondary stabilizing ligaments, static carpal malalignment results. This refers to fixed gapping of

CHAPTER 21  Scapholunate Ligament Repair

Clenched fist radiograph demonstrates widening of scapholunate interval FIGURE 21.5  Clenched fist radiograph shows scapholunate widening.

Scaphoid Lunate

A

B Fixed scaphoid (Signet ring)

Wide scapholunate (Terry Thomas sign)

FIGURE 21.6  (A) Fixed scaphoid and wide scapholunate.

the scapholunate interval (4 mm; Terry Thomas sign) and flexion of the scaphoid (Signet ring sign) with or without extension of the lunate (Fig. 21.6).

ARTHROSCOPIC DEBRIDEMENT AND PINNING OF THE SL INTERVAL Indications • If an SL ligament injury is suspected based on clinical examination and imaging studies, wrist arthroscopy can be performed to fully characterize the extent of the

85

86

CHAPTER 21  Scapholunate Ligament Repair

S

L

Healthy scapholunate ligament FIGURE 21.7  The circle denotes arthroscopy field. L, Lunate; S, scaphoid.

wrist pathology. If plain x-rays, computed tomography (CT), and/or magnetic resonance imaging (MRI) demonstrate static SL widening, scaphoid flexion, or extensive wrist arthritis, a different procedure should be considered. • For Geissler grade I and II injuries, debridement and pinning of the SL interval should be performed. Geissler grade I and II injuries (see Table 21.1) both correspond to stage I injuries (see Table 21.2). • Comprehensive evaluation of the wrist ligamentous structures and articular surfaces will guide treatment. STEP 1 PEARLS

Step 1: Arthroscopic Evaluation of the Wrist

• It is important to perform a systematic evaluation of the wrist to identify and treat concomitant ligamentous and/or bony pathology. • The 6U portal has a higher risk for injuring the dorsal cutaneous ulnar nerve than the 6R portal. A longer incision and blunt dissection down to the wrist capsule can avoid injuring this structure.

• Systematic wrist arthroscopic evaluation is performed, as described in Chapter 19. • The 3–4 portal is located in the interval between the third and fourth extensor compartments. Upon introducing the arthroscope, this portal can be used to view the SL ligament from the radiocarpal joint (Fig. 21.7). • The 6R or 6U portal can be used for outflow of arthroscopy fluid, if needed. • The radial midcarpal portal, located 1 cm distal to the 3–4 portal, should be used to identify gapping of the SL ligament. • Fig. 21.8 shows a Geissler grade I SL injury where there is fraying or hemorrhage within the ligament. A grade I SL injury can be diagnosed from the 3–4 radiocarpal portal. All others are confirmed using the radial midcarpal portal. • Fig. 21.9 shows the gap of a Geissler grade II SL injury as seen from the midcarpal portal. There is gapping or motion between the scaphoid and lunate that is less than a probe width. • Fig. 21.10 shows the gap of a Geissler grade III SL injury. The gap is more than a probe width. • Fig. 21.11 shows the gap of a Geissler grade IV SL injury. The gap is more than the scope diameter. • Attenuation and gapping of the SL interval should be documented. • For Geissler grade I or II injuries, debridement and pinning of the scapholunate interval should be performed. • If a Geissler grade III to IV injury is identified, this corresponds to stage II1 injury (see Table 21.2) and other treatment options should be considered. These options are described later in this chapter or in Chapter 22.

CHAPTER 21  Scapholunate Ligament Repair

S

L

Type I S

L

FIGURE 21.8  Geissler grade I scapholunate injury can be diagnosed from the 3 to 4 radiocarpal portal. All others are confirmed using the radial midcarpal portal. L, Lunate; S, scaphoid.

S

L

< 1 mm (less than probe width) Type II S

L

FIGURE 21.9  Geissler grade II scapholunate injury. L, Lunate; S, scaphoid.

87

88

CHAPTER 21  Scapholunate Ligament Repair

L S

> 1 mm (more than probe width) Type III S

L

FIGURE 21.10  Geissler grade III scapholunate injury. L, Lunate; S, scaphoid.

> 2.7 mm (scope)

S

C

Type IV S

L

FIGURE 21.11  Geissler grade IV scapholunate injury. L, lunate; S, scaphoid; C, capitate.

L

CHAPTER 21  Scapholunate Ligament Repair

Scaphoid Lunate A

B FIGURE 21.12  (A) Illustration of scapholunate pinning. (B) Fluoroscopy confirms scapholunate pinning.

Step 2: Debridement of the SL Ligament and Pinning of the SL Interval • If a Geissler grade I or II is confirmed (see Table 21.1), this represents a stage I SL injury (see Table 21.2). In the absence of other pathology, the SL ligament should be debrided to healthy appearing tissue. • After debridement, the SL interval can be pinned using a single 0.062-in (1.1-mm) Kirschner wire (K-wire). • The entry site of the K-wire should be positioned just distal to the radial styloid, along the scaphoid waist. • The wire should be passed from the scaphoid into the lunate, perpendicular to the long axis of the forearm (Fig. 21.12A–B). • The K-wire should be buried under the skin for future removal at 8 weeks.

OPEN SL REPAIR AND DORSAL CAPSULODESIS Indications • With complete SL ligamentous disruption, dynamic instability will be present. Clenched fist radiographs will demonstrate gapping between the scaphoid and lunate. • If dynamic SL injury is suspected, wrist arthroscopy should be performed to characterize the injury, identify concomitant injuries, and rule out articular wear. • If complete SL ligament injury is confirmed by arthroscopy, the wrist should be opened in preparation for SL ligament repair and dorsal capsulodesis. • With identification of significant radioscaphoid arthritis, one should consider aborting the soft-tissue repair/reconstruction in favor of performing a salvage operation, such as a scaphoidectomy and partial wrist fusion.

Step 1: Markings A standard dorsal exposure of the wrist is marked (Fig. 21.13).

Step 2: Exposure • Sharp dissection is carried out through the skin and subcutaneous tissue to the extensor retinaculum (Fig. 21.14). The third compartment is identified and the extensor pollicis longus (EPL) is protected. • The extensor retinaculum is open longitudinally, and the fourth extensor compartment is entered. Tendons are retracted ulnarly. • The dorsal wrist capsule is entered on the radial side of the fourth extensor compartment. The dorsal SL ligament lies deep to the floor of the extensor compartments.

STEP 2 PEARLS

Fluoroscopy can confirm the correct place for dorsal wrist capsulotomy.

89

90

CHAPTER 21  Scapholunate Ligament Repair

Extensor retinaculum FIGURE 21.14  Exposure of extensor retinaculum.

FIGURE 21.13  Dorsal wrist marking for incision.

Step 3: Debridement of the Scapholunate Interval • Scar tissue between the scaphoid and lunate is debrided to healthy-appearing ligament. • At this point, one needs to determine whether the ligament is amenable to repair. STEP 4 PITFALLS

Step 4: Repair of the Scapholunate Ligament

If the ligament is not tightly secured into the cancellous trough, there will be no bone-ligament healing. Raw cancellous bone will help the ligament heal.

• If there is a midsubstance rupture, the ligament can be repaired using several interrupted 4-0 Ethibond sutures (Fig. 21.15). • If the ligament has been avulsed from either the scaphoid or lunate, it should be reattached using two Mitek mini suture anchors. • Starting from the bone from which the SL ligament has avulsed, a 3-mm trough on the dorsal surface of the bone is created using a rongeur or small bur. • This should reveal healthy cancellous bone. The trough should be created at the site of prior ligamentous attachment. If this is not readily apparent, the debrided ligament should be placed on top of the bone to which it will be reattached. Its contact with the bone should be marked for creation of the trough. • The Mitek mini suture anchors are placed within the cancellous trough. • The ligament should be sutured down to the cancellous trough with direct ligamentto-bone apposition.

Step 5: Dorsal Capsulodesis • The distal scaphoid is identified. • The Mitek mini suture anchor entry point, in the center of the distal pole, is confirmed visually and radiographically.

L Repaired ligament

S

FIGURE 21.15  Scapholunate ligament repaired. L, Lunate; S, scaphoid.

CHAPTER 21  Scapholunate Ligament Repair

L S

FIGURE 21.16  Dorsal capsulodesis. Dorsal capsule

S

Radius

A

Bone anchor

S

Radius

B

FIGURE 21.17  (A) Illustration of bone anchor tethering scaphoid to dorsal capsule. S, Scaphoid. (B) Close-up photo of bone anchor tethering scaphoid to dorsal capsule.

• A curette can be used to remove the dorsal cortex, revealing a 3-mm area of cancellous bone. • Using the drill bit within the Mitek mini suture anchor kit, a hole is drilled in the distal scaphoid (Fig. 21.16). • The two-tailed suture from the suture anchor is passed through the radial-sided dorsal capsule, directly overlying the distal scaphoid. • The dorsal capsule is tied down to the cancellous bone of the distal scaphoid (Fig. 21.17A–B).

Step 6: Closure • The dorsal wrist capsule should be closed using 3-0 Vicryl suture. • Hemostasis is obtained after releasing the tourniquet. • The skin can be closed using 4-0 monocryl or 4-0 PDS suture.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is placed into a forearm-based, volar wrist splint at the conclusion of the procedure. • Sutures are removed at 2 weeks postoperatively and the incision is inspected. • A custom, thermoplastic splint is designed and the patient is instructed to wear it at all times, except when showering, during which the wrist should be protected.

91

92

CHAPTER 21  Scapholunate Ligament Repair

• No strenuous activity or heavy lifting is permitted for 8 weeks. • K-wires are removed 6 to 8 weeks after surgery. The pins should be buried to reduce the risk for pin-tract infection. • After removal of the splint at 8 weeks, active range of motion exercises are initiated. There is no need for formal hand therapy. The goal of the procedure is to reduce wrist motion and to promote healing of the reconstruction. Early active motion or strenuous activity could lead to reconstructive failure. The patient should be counseled preoperatively to expect a postoperative loss of flexion compared with the contralateral side. The goal of the operation is to reduce wrist pain and prevent or delay the progression of arthritis at the expense of some wrist motion.

EVIDENCE 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. The authors present a concise review of SL ligament injuries and outline their thoughtful algorithm for managing SL injuries along the entire spectrum. Park IJ, Maniglio M, Shin SS, Lim D, McGarry MH, Lee TQ. Internal bracing augmentation for scapholunate interosseous ligament repair: A cadaveric biomechanical study. J Hand Surg Am. 2020;45(10): 985.e1–985.e9. The authors performed a biomechanical study to determine whether nonabsorbable suture tape can augment SL ligament repair. They used 21 fresh frozen cadavers and compared native SL ligaments with repaired SL ligaments and repaired ligaments with costabilizing suture tape along various biomechanical metrics. Although the suture tape did not recreate native SL ligament strength, it was significantly stronger than repair alone, suggesting that suture tape could enhance SL ligament repair. Long-term results and clinical outcomes were not examined. Bleuler P, Shafighi M, Donati OF, Gurunluoglu R, Constantinescu MA. Dynamic repair of scapholunate dissociation with dorsal extensor carpi radialis longus tenodesis. J Hand Surg Am. 2008;33:281–284. This study described the outcomes after extensor carpi radialis longus (ECRL) tenodesis for symptomatic scapholunate instability in 20 wrists of 19 patients with static scapholunate instability. Preoperative evaluation, in all patients, consisted of clinical and radiologic evaluation and arthroscopy for confirming the diagnosis of static scapholunate instability. The aforementioned technique involves the fixation of the ECRL tendon on the dorsal aspect of the scaphoid by means of a cancellous screw and a special washer. Eighteen of 19 patients were satisfied with the operation and all patients returned to work between 1.5 and 4 months after the surgery. Pain was reduced postoperatively based on a reduction in visual a nalog score (VAS). This study is limited by short follow-up and the small sample size (Level IV evidence). Nienstedt F. Treatment of static scapholunate instability with modified Brunelli tenodesis: results over 10 years. J Hand Surg Am. 2013;38:887–892. Ten patients who underwent the modified Brunelli, three-ligament tenodesis, with a mean follow-up of 13.8 years were evaluated. Subjective outcomes including the Green and O’Brien scale were excellent or good in seven of eight patients. DASH and modified Mayo scores averaged 9 and 83, respectively. Mean total wrist motion and grip strength were 85% of the opposite normal side, at the final postoperative visit. Six of eight patients were pain free; one patient had slight and occasional pain, and another had chronic pain. The mean scapholunate gap was 5.1 mm preoperatively, corrected to 2.4 mm at surgery and was 2.8 mm at final follow-up. Scapholunate angle was maintained at 63 degrees at final follow-up. Progressive degenerative arthritis was present in only one patient at final follow up (Level IV evidence). Soong M, Merrell GA, Ortmann F IV, Weiss AP. Long-term results of bone-retinaculum-bone autograft for scapholunate instability. J Hand Surg Am. 2013;38:504–508. The authors report long-term outcomes of scapholunate interosseous ligament reconstruction with boneretinaculum-bone (BRB) autograft in patients with dynamic scapholunate instability. Of the 14 patients initially treated with BRB reconstruction, only 6 returned for clinical examination and radiographs at an average of 11.9 years of follow up (range, 10.7–14.1 y). Three were reached by telephone, and two were lost to follow-up. Three of 14 patients underwent salvage procedures (two total wrist arthrodeses and one proximal row carpectomy). On average, clinical and radiographic outcomes deteriorated moderately from the interim report. Mayo wrist score averaged 83. Findings at repeat surgery in the failed group included an intact graft without any apparent abnormalities, a partially ruptured graft (after a subsequent reinjury), and a completely resorbed graft. The authors conclude that bone-retinaculum-bone autograft reconstruction is a viable treatment option for reducible, dynamic scapholunate instability, but some patients will develop arthritis requiring a salvage procedure (Level IV evidence). Weiss AP, Sachar K, Glowacki KA. Arthroscopic debridement alone for intercarpal ligament tears. J Hand Surg Am. 1997;22:344–349. This was a retrospective review in which authors performed arthroscopic debridement alone for isolated scapholunate and lunotriquetral ligament tears. At an average follow-up of 27 months, 29 wrists (66%) having a complete scapholunate ligament tear and 36 (85%) wrists having a limited scapholunate ligament tear had either complete symptom resolution or improved symptomatology. Of the wrists with complete lunotriquetral (LT) ligament tear or partial LT ligament tear, 78% and 100% had complete symptom resolution, respectively. Static intercarpal instability was not apparent in any of the wrists at final follow-up. Grip strength improved on average 23% (Level IV evidence).

CHAPTER

22

Scapholunate Ligament Reconstruction Elissa S. Davis and Kevin C. Chung INDICATIONS • See Chapter 21 Scapholunate Ligament Repair. • This chapter reviews reconstruction options for stage III and IV scapholunate ligament injuries. Unlike stage I and II injuries, the ligament is not repairable because of poor tissue quality, and thus reconstruction should be attempted.

Contraindications • As discussed in Chapter 21, stage I and II injuries still have good ligament quality after partial or complete injury. Therefore repair should be attempted. • For stage V and VI injuries, where either irreducible malalignment of the carpus (stage V) or cartilage loss with arthritis is present (stage VI), salvage procedures should be pursued (Chapter 27 Salvage Procedures for Scaphoid Nonunion). Options include proximal row carpectomy, four-corner fusion, or wrist arthrodesis (Chapter 53 Total Wrist Fusion).

CLINICAL EXAMINATION See Chapter 21.

IMAGING See Chapter 21.

SURGICAL ANATOMY See Chapter 21.

EXPOSURES See Chapter 21.

Stage III: Complete Disruption With Irreparable Ligament but Normal Alignment: Bone-Tissue-Bone Reconstruction INDICATIONS • One indication is dynamic scapholunate dissociation in which the ligament cannot be repaired primarily. • Bone-tissue-bone (BTB) reconstruction can be performed for static, reducible instability through a ligament reconstruction; a three or four ligament tenodesis should be considered. • BTB reconstruction is contraindicated where there is evidence of radiocarpal or midcarpal arthritis. • Standard posteroanterior (PA), oblique, and lateral wrist radiographs will not show scapholunate (SL) widening with dynamic SL instability. • Clenched-fist views, when the wrist is loaded, will reveal gapping between the scaphoid and lunate if the ligamentous injury is significant. • Arthroscopy can be performed to confirm the diagnosis and to rule out articular wear that would preclude reconstruction in favor of a salvage operation, such as wrist fusion. • The dorsal SL ligament is the strongest portion of the U-shaped ligament that also has a proximal and volar component. • Repair or reconstruction of the dorsal portion of the ligament is desired. 93

94

CHAPTER 22  Scapholunate Ligament Reconstruction

• Scaphoid stabilization with extensor carpi radialis longus (ECRL) tenodesis is also an option for this stage of injury and may be more predictable. STEP 1 PEARLS

PROCEDURE

A ligament-sparing approach to the wrist can be performed. The design of this radially based triangular flap splits the fibers of the dorsal radiocarpal and dorsal intercarpal ligaments (Fig. 22.4A–C).

Step 1: Debride the Scar Tissue Within the Scapholunate Interval

STEP 2 PEARLS

Step 2: Reduce the Scaphoid and Lunate

• Because the scaphoid has assumed a flexed position and the lunate is extended, the wires should be placed from distal to proximal in the scaphoid and proximal to distal in the lunate. This will facilitate reduction. • Stouter 0.062-in (1.57-mm) K-wires are used instead of 0.045-in (1.14-mm) wires.

• If static, reducible instability is present, the scaphoid will need to be anatomically reduced to correct any dorsal intercalated segment instability (DISI) deformity. • Two 0.062-in (1.57-mm) Kirschner wires (K-wires) can be used to reduce the scaphoid and lunate into preinjury anatomic alignment (Fig. 22.5). • Because the scaphoid is flexed and the lunate is extended with a DISI deformity, the K-wires should be placed from distal to proximal in the scaphoid and proximal to distal in the lunate.

• A 6-cm longitudinal incision is designed on the dorsal wrist, ulnar to the Lister tubercle (Fig. 22.1). • After incising the extensor retinaculum between the third and fourth compartments, the extensor pollicis longus (EPL) is identified and retracted radially (Fig. 22.2). • The wrist capsule is opened longitudinally to expose the SL interval. • After exposing the SL interval, scar tissue should be debrided back to healthy bleeding tissue (Fig. 22.3).

FIGURE 22.1  Incision design.

Detached ECRL Tendon

EPL

Lunate

FIGURE 22.2  EPL identified. EPL, Extensor pollicis longus.

FIGURE 22.3  SL interval debrided. SL, Scapholunate.

CHAPTER 22  Scapholunate Ligament Reconstruction

DIC DRC

A

B

C

FIGURE 22.4  (A–C) DIC, Dorsal intercarpal ligament; DRC, dorsal radiocarpal ligament.

• Using the K-wire, the lunate should be flexed maximally toward the fingers to ensure that it is neutral with respect to the long axis of the radius. • The scaphoid can be extended to ensure that the flexed, pronated posture is corrected (Fig. 22.6). • To close the gap between the two bones, the wires are compressed.

95

96

CHAPTER 22  Scapholunate Ligament Reconstruction

Scaphoid

Lunate

FIGURE 22.5  Kirschner wires (K-wires) in the scaphoid and lunate to aid reduction.

FIGURE 22.6  Correction of the DISI deformity by extending the scaphoid and flexing the lunate. DISI, Dorsal intercalated segment instability.

STEP 3 PEARLS

• The SL angle should be corrected and confirmed radiographically: normal scapholunate angle is 30–60 degrees and normal radiolunate angle is 0–15 degrees. • Gapping between the scaphoid and lunate should be eliminated. STEP 5 PEARLS

• When harvesting the graft, it is important to center your template over the capitohamate ligament and preserve this attachment to both the capitate and hamate. • Alternatively, you can harvest BTB from the distal radius over the Lister tubercle (Fig. 22.11); however, the capitohamate ligament is more accessible because it is at the same operative field, just distal to the SL interval. It is important to remove a segment of bone from this BTB graft (Fig. 22.12). The goal is to reconstruct the dorsal ligament and avoid bony fusion between the scaphoid and lunate.

Step 3: Use a Kirschner Wire to Temporarily Maintain Scapholunate Reduction • Reduction is maintained by pinning the scapholunate interval. This can be achieved with one 0.062-in (1.57-mm) K-wire. The entry point for the K-wire is just distal to the radial styloid. The wire should be directed perpendicular to the long axis of the forearm to capture the scaphoid and lunate. Reduction of the scapholunate gap and restoration of the normal scapholunate angle (30–60 degrees) should be confirmed fluoroscopically. • A second 0.062-in (1.57-mm) K-wire can be driven across the scaphocapitate (SC) interval to prevent midcarpal motion (Fig. 22.7).

Step 4: Create a Trough in the Scaphoid and Lunate • Using a 5-mm osteotome, create a trough on the dorsal surface of the scaphoid and lunate to accept the BTB graft. • The dimensions of this trough measured 12 mm long, 6 mm wide, and 6 mm deep (Fig. 22.8).

Step 5: Harvest Bone-Ligament-Bone Graft From Capitohamate • After measuring the defect created in the dorsum of the scaphoid and lunate, transpose this template onto the capitohamate (Fig. 22.9A–B). • Using the 5-mm osteotome, harvest the BTB graft (Fig. 22.10).

CHAPTER 22  Scapholunate Ligament Reconstruction

Scaphoid Lunate

FIGURE 22.7  Reduction of DISI deformity pinned in place with Kirschner wires (K-wires) and confirmed on x-ray. DISI, Dorsal intercalated segment instability.

FIGURE 22.8  Create a trough in the scaphoid and lunate dorsal surface.

Capitate Hamate

A

B

FIGURE 22.9  (A) Transposing the template. (B) Removed trough of scaphoid and lunate.

Capitate

Hamate

FIGURE 22.10  BTB harvested from capitate and hamate. BTB, Bone-tissue-bone.

97

98

CHAPTER 22  Scapholunate Ligament Reconstruction

BTB graft

Harvest site

SL trough

A B

BTB construct

FIGURE 22.11  (A–B) BTB, Bone-tissue-bone; SL, scapholunate.

FIGURE 22.12  BTB graft. BTB, Bone-tissue-bone.

FIGURE 22.13  Screws inserted into the harvested graft.

Step 6: Securing the Graft • After contouring and placing the graft in the trough on the dorsum of the scaphoid and lunate, 1.3-mm or 1.5-mm screws can be placed through each side of the graft into the corresponding carpal bone (Fig. 22.13). Alternatively, if precise measurements are obtained, then the graft can be press fit into the trough by gently tapping the bone grafts into the slot with a bone tamp. • The K-wire should be buried and left in place to maintain reduction of the SL interval (Fig. 22.14).

Step 7: Closure • After the tourniquet is deflated and hemostasis is ensured, the dorsal capsule and extensor retinaculum can be closed using 3-0 or 4-0 Vicryl suture. • The skin can be closed using 4-0 Monocryl or 4-0 PDS.

CHAPTER 22  Scapholunate Ligament Reconstruction

FIGURE 22.14  Final x-ray with Kirschner wires (K-wires) in place in the SL and SC to maintain reduction of the SL interval. SC, Scaphocapitate; SL, scapholunate.

Stage III: Complete Disruption With Irreparable Ligament but Normal Alignment: Scaphoid Stabilization With ECRL Tenodesis INDICATIONS • Indications include scaphoid dissociation, complete disruption of the SL ligament, and intact secondary stabilizing ligaments. • SL ligament is not amenable to direct repair. • Dynamic instability is present as confirmed by clenched fist radiographs and diagnostic arthroscopy. • There is no evidence of articular wear. • BTB dorsal scapholunate reconstruction is also an option but may not lead to a predictable result.

PROCEDURE Step 1: Debridement of the Scapholunate Interval • The SL ligament is exposed using a 6-cm longitudinal incision, ulnar to the Lister tubercle, as previously described. • After the SL interval is identified, any scar tissue is debrided to healthy-appearing tissue.

Step 2: Pinning of the Scapholunate Interval • After reduction of the SL interval is ensured, one 0.062-in (1.57-mm) K-wire can be used to maintain reduction. The entry point for the K-wire is just distal to the radial styloid. The wire should be directed perpendicular to the long axis of the forearm to capture the scaphoid and lunate. • A second 0.062-in (1.57-mm) K-wire can be driven across the SC interval to prevent midcarpal motion (Fig. 22.15).

Step 3: Dissection and Separation of Extensor Carpi Radialis Longus Tendon • The ECRL should be identified at its insertion into the base of the index metacarpal. • An ulnar-sided slip (50%) of the ECRL or the entire ECRL may be disinserted from the metacarpal. Our preference is to use the entire ECRL tendon (Fig. 22.16).

Step 4: Insertion of Mitek Mini Suture Anchor • The distal pole of the scaphoid is identified and confirmed fluoroscopically. • A Mitek mini suture anchor is placed into the distal pole of the scaphoid after removing a 3-mm rim of cartilage for insertion of the tendon into the cancellous bone.

STEP 3 PEARLS

The ECRL insertion, on the base of the index metacarpal, can be confirmed by fluoroscopy. STEP 4 PEARLS

• This reconstruction attempts to counteract the flexion of the scaphoid and the strain on the secondary stabilizers, which are too weak and cause instability in the SL interval. • Repositioning of the ECRL tendon insertion acts as a dynamic tenodesis, theoretically providing more wrist flexion than a traditional static capsulodesis procedure. • Maintenance of normal scaphoid alignment prevents the articular wear associated with a flexed, pronated scaphoid.

99

100

CHAPTER 22  Scapholunate Ligament Reconstruction

Scaphocapitate pin

ECRL Tendon

FIGURE 22.15  Kirschner wire (K-wire) driven across SC interval. SC, Scaphocapitate.

FIGURE 22.16  ECRL tendon detached distally. ECRL, Extensor carpi radialis longus. STEP 4 PITFALLS

• Care is taken to avoid injury to the vascular pedicle of the scaphoid along its dorsal ridge (Fig. 22.20). • A common problem is that the tendon does not contact the cancellous bone, and healing at the tendon/bone interface does not occur. It is critical that the tendon is cinched down to the bone trough. Because FiberWire is used for the mini anchor, breakage of the suture is uncommon.

The suture must be tied tightly to be sure that the tendon contacts the bone. The wrist can be extended to ensure that there is no tension when tying down the suture (Fig. 22.17). • The ECRL is attached to the distal pole of the scaphoid via the suture anchor (Fig. 22.18). • Fluoroscopic confirmation of SL alignment is obtained (Fig. 22.19).

Step 5 • The dorsal wrist capsule should be closed using 3-0 Vicryl suture. • Hemostasis is obtained after releasing the tourniquet. • The skin can be closed using 4-0 Monocryl or 4-0 PDS suture.

Scapholunate Ligament Reconstruction Using the Internal Brace (If the Suture Anchor Is Available) INDICATIONS • The indications are the same as for scaphoid stabilization with ECRL tenodesis. • If the internal brace is available, we prefer this technique for SL and lunotriquetral (LT) ligament reconstruction because of the ease of exposure, reduced trauma to the

Detached ECRL Tendon

Distal pole of the scaphoid

FIGURE 22.17  Drilling for mini Mitek suture anchor placement in distal pole of the scaphoid.

CHAPTER 22  Scapholunate Ligament Reconstruction

Dorsal FIGURE 22.18  Mini Mitek placed (black arrow) to stabilize ECRL tendon to distal pole of scaphoid. ECRL, Extensor carpi radialis longus.

Drill hole

Scaphoid

Radius

FIGURE 22.19  X-ray showing confirmation of scapholunate alignment.

FIGURE 22.20  Avoid injury to the vascular pedicle of the scaphoid along its dorsal ridge.

bone via bone tunnels, and stout tendon/suture tape construct that stabilizes the intercarpal ligaments.

PROCEDURE Step 1: Debridement of the Scapholunate Interval • The scapholunate ligament is exposed using a 6-cm longitudinal incision, ulnar to the Lister tubercle, as previously described (Fig. 22.21). • After the SL interval is identified, any scar tissue is debrided to healthy-appearing tissue.

Step 2: Dissection and Separation of ECRB Tendon • The ECRB should be identified at its insertion into the base of the index metacarpal. • Harvest a 2-mm width of ECRB that measures 10 cm in length (Fig. 22.22). A thicker tendon graft will not fit within the bone trough.

Step 3: Insertion of Kirschner Wires • Place 0.054-in K-wires from the internal brace kit into the proximal and distal poles of the scaphoid and lunate (Fig. 22.24A–B). Verify the position of the K-wire insertion sites under fluoroscopy. • Overdrill your K-wires using the drill bit and guides in your internal brace kit.

STEP 2 PEARLS

• The ECRB insertion, on the base of the middle metacarpal, can be confirmed by fluoroscopy. • The harvested ECRB should span 10 cm, from the proximal pole of the scaphoid to the lunate to the distal pole of the scaphoid (Fig. 22.23). It should be whip-stitched at both ends with fiberloop for insertion into the forked eyelet of the anchor. • The limb of tendon extending from the lunate to the distal pole of the scaphoid helps correct scaphoid flexion. • A harvested tendon graft more than 2 mm in width will be difficult to place inside the suture anchor with suture tape.

101

102

CHAPTER 22  Scapholunate Ligament Reconstruction

FIGURE 22.21  Incision design ulnar to Lister tubercle.

FIGURE 22.22  ECRB identified and 2-mm-thick portion harvested. ECRB, Extensor carpi radialis brevis.

FIGURE 22.23  ECRB measuring 10 cm in length. ECRB, Extensor carpi radialis brevis.

Distal pole of the scaphoid Distal pole of the scaphoid

Proximal pole of the scaphoid

Lunate

Proximal pole of the scaphoid

Lunate A

B

FIGURE 22.24  (A) Insertion of Kirschner wires (K-wires) into the scaphoid and lunate. (B) Fluoroscopy confirmation of K-wire placement in the scaphoid and lunate.

CHAPTER 22  Scapholunate Ligament Reconstruction

FIGURE 22.25  Loaded forked eyelet with suture tape and tendon graft.

Residual hole from K-wire reduction

STEP 3 PEARLS

FIGURE 22.26  Final anchors placed.

Step 4 • Insert the tendon graft and then suture tape into the forked eyelet of the suture anchor. In the proximal pole of the scaphoid anchor, one end of the tendon graft and suture tape should be placed in the forked eyelet to maximize the length of graft, and the suture tape should span from proximal scaphoid to lunate to distal scaphoid (Fig. 22.25). • Next, place your lunate anchor, including the suture tape and tendon graft. The final anchor should be placed in the distal pole of the scaphoid and include both graft and suture tape (Fig. 22.26).

• Ensure that the K-wires have been buried up to the laser line. • If tendon graft is used in addition to suture or suture tape for 3.5-mm anchors, drill with the 3.5-mm drill bit. • Drill each suture anchor hole as each is placed because the tendon graft may not be long enough to reach all anchors. In this case, the distal pole of the scaphoid anchor may need to be drilled with the smaller drill bit to accommodate just the suture tape. This will bring the scaphoid into extension to avoid stressing the SL internal. STEP 3 PITFALLS

Care should be taken to avoid the vascular pedicle to the scaphoid along the dorsal ridge (see Fig. 22.20).

Step 5 • The dorsal wrist capsule should be closed using 3-0 Vicryl suture. • Hemostasis is obtained after releasing the tourniquet. • The skin can be closed using 4-0 Monocryl or 4-0 PDS suture.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES The patient will remain splinted for 6 weeks to encourage healing before initiation of range-of-motion (ROM) exercises.

STEP 4 PEARLS

• Apply firm pressure to insert the suture anchors and ensure that the laser line is at or below the surface of the bone. • Between each suture anchor placement, twist the suture tape and graft to aid in loading of the subsequent anchor eyelet.

103

104

CHAPTER 22  Scapholunate Ligament Reconstruction

Stage IV: Complete Disruption With Irreparable Ligament and Reducible Rotary Subluxation of the Scaphoid— Ligament Reconstruction With Flexor Carpi Radialis Tenodesis INDICATIONS Indications include chronic SL instability with static malalignment, evidence of DISI, and no evidence of degenerative change (Fig. 22.27A–B).

EXPOSURES Dorsal • An 8-cm longitudinal incision is centered over the Lister tubercle (Fig. 22.28). • The extensor retinaculum is sharply incised, and then the EPL is identified and retracted radially to expose the dorsal wrist capsule. • The wrist capsule is opened to examine the SL interval (Fig. 22.29).

Volar Three 1- to 2-cm incisions are made over the course of the flexor carpi radialis (FCR). An oblique incision can be designed over the distal pole of the scaphoid (Fig. 22.30).

SL angle 30-60°

56°

A

Normal

SL angle >70°

92°

B FIGURE 22.27  (A–B) SL, Scapholunate.

CHAPTER 22  Scapholunate Ligament Reconstruction

FIGURE 22.28  Dorsal incision design.

FIGURE 22.29  Examining the SL interval. SL, Scapholunate.

FIGURE 22.30  Volar incision design.

PROCEDURE Step 1: Debridement of the Scapholunate Interval • The SL ligament is exposed using a longitudinal incision, ulnar to the Lister tubercle, as previously described. • After the SL interval is identified, any scar tissue is debrided to healthy-appearing tissue.

Step 2: Harvest a Slip of Distally Based Flexor Carpi Radialis Tendon Using the distal-most 1-cm incision over the FCR, a 3-mm radial-sided slip of FCR is split from the remaining tendon. This is then sharply dissected, using proximal discontinuous incisions, up to its musculotendinous junction (Fig. 22.31).

STEP 2 PEARLS

Remember that the FCR tendon rotates 90 degrees within its sheath. It is important to carefully dissect the fibers proximally to avoid inadvertent complete transection of the tendon.

105

106

CHAPTER 22  Scapholunate Ligament Reconstruction

FIGURE 22.31  FCR harvest. FCR, Flexor carpi radialis.

Step 3: Create a Bone Tunnel Within the Scaphoid • A 0.045-in (1.14-mm) K-wire is directed from the dorsal proximal scaphoid toward the volar, radial corner of the scaphoid. The correct position of the wire should be confirmed visually and fluoroscopically (Fig. 22.32). • Using the K-wire as a guide, a 2.7-mm cannulated drill is directed dorsal to volar to create the bone tunnel. STEP 4 PITFALLS

Forcing a strip of FCR larger than 3 mm through the bone tunnel could fracture the scaphoid.

Step 4: Pass the Flexor Carpi Radialis Through the Scaphoid Tunnel Using a Hewson suture passer inserted from dorsal to volar, the distally based slip of FCR can be passed from volar to dorsal back through the bone tunnel (Fig. 22.33).

FIGURE 22.32  Preparation of scaphoid bone tunnel from the dorsal rim to the distal pole.

FIGURE 22.33  Passage of the FCR from volar to dorsal using a Hewson suture passer. FCR, Flexor carpi radialis.

CHAPTER 22  Scapholunate Ligament Reconstruction

Step 5: Reduce the Scaphoid and Lunate • If static, reducible instability is present, the scaphoid will need to be anatomically reduced to correct any DISI deformity. • Two 0.062-in (1.57-mm) K-wires can be used to reduce the scaphoid and lunate into preinjury anatomic alignment. • Because the scaphoid is flexed and the lunate is extended with a DISI deformity, the K-wires should be placed from distal to proximal in the scaphoid and proximal to distal in the lunate (Fig. 22.34). • Using the K-wire, the lunate should be flexed maximally toward the fingers to ensure that it is neutral with respect to the long axis of the radius. • The scaphoid can be extended to ensure that the flexed, pronated posture is corrected. • To close the gap between the two bones, the wires are compressed. Reduction is confirmed on fluoroscopy (Fig. 22.35).

STEP 5 PEARLS

Because the scaphoid has assumed a flexed position and the lunate is extended, the wires should be placed from distal to proximal in the scaphoid and proximal to distal in the lunate. This will facilitate reduction.

Step 6: Use a K-Wire to Temporarily Maintain Scapholunate Reduction • Reduction is maintained by pinning the SL interval. This can be achieved with one 0.062-in (1.57-mm) K-wire. The entry point for the K-wire is just distal to the radial styloid. The wire should be directed perpendicular to the long axis of the forearm to capture the scaphoid and lunate. Reduction of the SL gap and restoration of the normal SL angle (30–60 degrees) should be confirmed fluoroscopically. • A second 0.062-in (1.57-mm) K-wire can be driven across the SC interval to prevent midcarpal motion.

FIGURE 22.34  Appropriate placement of the Kirschner wires (K-wires) to aid in scaphoid and lunate reduction.

FIGURE 22.35  Fluoroscopic imaging of SL reduction and DISI correction. DISI, Dorsal intercalated segment instability; SL, scapholunate.

STEP 6 PEARLS

• The SL angle should be corrected and confirmed radiographically: normal SL angle is 30–60 degrees and normal radiolunate angle is 0–15 degrees. • Gapping between the scaphoid and lunate should be eliminated.

107

108

CHAPTER 22  Scapholunate Ligament Reconstruction

Step 7: Secure the FCR to the Lunate • Using a bur, an approximately 2-mm-wide trough is made on the dorsum of the lunate. A 1.8-mm suture anchor (Mitek mini quick anchor or similar) is used to secure the FCR to the midportion of the lunate bone trough (Fig. 22.36A–B). Rather than drilling a hole into the lunate, which may fracture the lunate, the bone trough helps to seat the tendon into the lunate groove. • The remaining tendon beyond the suture anchor is passed through the dorsal radiocarpal ligament and sutured to itself over the lunate using 3-0 Ethibond (Fig. 22.37A–B and Fig. 22.38).

Step 8: Closure • The dorsal wrist capsule is closed using 3-0 Ethibond suture (Fig. 22.39A–B). • After closure of the capsule, the tourniquet is deflated and hemostasis is ensured. To avoid ischemic rupture, the EPL tendon is transposed over the extensor retinaculum,

Scaphoid

Bone anchor suture

Lunate

Joystick K-wires

Radiotriquetral ligament

Radius Distally based FCR A

Bone reduction clamp

B

FIGURE 22.36  (A–B) Suture anchor is used to secure the FCR to the midportion of the lunate bone trough. FCR, Flexor carpi radialis.

A

B FIGURE 22.37  (A–B) Anchor inserted into the dorsal gutter of the lunate (yellow arrow).

CHAPTER 22  Scapholunate Ligament Reconstruction

FIGURE 22.38  Completed tenodesis with wrist capsule closed.

Joystick K-wires Bone anchor suture

Radiotriquetral ligament

Distally based FCR B

A

FIGURE 22.39  (A–B) FCR fixed through the dorsal capsule under the fourth compartment. FCR, Flexor carpi radialis.

within the subcutaneous tissue. The extensor retinaculum is then closed using 3-0 Ethibond suture (Fig. 22.39A–B). • The skin can be closed using 4-0 Monocryl or 4-0 PDS. • Fig. 22.40 demonstrates correction of SL gapping and prior DISI deformity.

Stage V: Complete Disruption With Irreducible Malalignment and Intact Cartilage—Salvage Procedure, Soft Tissue Reconstruction Not Indicated INDICATIONS This stage is uncommon because static irreducible carpal bone is associated with cartilage wear. Attempts at reconstruction are futile, with high failure probability if the malalignment of the carpus cannot be corrected; thus salvage procedures such as proximal row carpectomy (PRC) or four-bone fusion are pursued.

109

110

CHAPTER 22  Scapholunate Ligament Reconstruction

Correction of SL angle, no DISI present

SL interval restored

FIGURE 22.40  One-year postoperative x-rays.

POSTOPERATIVE PEARLS

Although ROM will decrease, the majority of patients report a decrease in wrist pain after this procedure.

POSTOPERATIVE PITFALLS

• Despite reconstruction, some patients will progress to arthrosis and/or arthritis requiring a salvage operation such as a scaphoidectomy and partial wrist fusion. • Using the Garcia-Elias staging system as a guide to SLL injuries, treatment options tailored to the injury can be identified.

Stage VI: Chronic Scapholunate Interosseous Ligament Disruption With Cartilage Loss—Salvage Procedure, Soft Tissue Reconstruction Not Indicated INDICATIONS • When static, irreducible instability or SL advanced collapse is present, soft tissue reconstruction is unlikely to provide a durable reconstruction and long-term pain relief. • The patient should be counseled about the risks and benefits of a salvage operation. • Treatment options differ based on the location of articular wear.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is placed into a forearm-based, volar wrist splint at the conclusion of the procedure. • The incision is inspected 2 weeks postoperatively and the sutures are removed. • A custom thermoplastic splint is designed and the patient is instructed to wear it at all times, except when showering, during which time the wrist should be protected. • No strenuous activity or heavy lifting is permitted for 8 weeks. • K-wires are removed 6 to 8 weeks after surgery. The pins should be buried to reduce the risk of pin tract infection. • After removal of the splint at 8 weeks, active ROM exercises are initiated. There is no need for formal hand therapy. The goal of the procedure is to reduce wrist motion and promote healing of the reconstruction. Early active motion or strenuous activity could lead to reconstructive failure. The patient should be counseled preoperatively to expect a postoperative loss of flexion compared with the contralateral side. The goal of the operation is to reduce wrist pain and prevent or delay the progression of arthritis at the expense of some wrist motion. Our goal is painless wrist motion for any wrist procedures. • Fig. 22.41A–D demonstrates ROM at 13 months after reconstruction of left SL dissociation with dorsal ECRL tenodesis. • Notice a reduction in flexion arc, though all other wrist motions are similar to the contralateral side. • Fig. 22.42 demonstrates the 13-month radiographic appearance of the wrist after ECRL tenodesis. • Fig. 22.43A–D demonstrates wrist motion at 4 months’ follow-up after BTB reconstruction. • Fig. 22.44 demonstrates preservation of the SL interval and no evidence of DISI deformity at 4 months after BTB reconstruction. See Videos 22.1 and 22.2

CHAPTER 22  Scapholunate Ligament Reconstruction

A

B

C

D

FIGURE 22.41  (A–D) Four-month follow-up.

FIGURE 22.42  Preservation of the scapholunate interval and no evidence of DISI deformity at 4 months after BTB reconstruction. BTB, Bone-tissue-bone; DISI, dorsal intercalated segment instability.

A

B

C

D

FIGURE 22.43  (A-D) Demonstrates wrist motion at 4 months’ follow-up after BTB reconstruction. BTB, Bonetissue-bone.

111

112

CHAPTER 22  Scapholunate Ligament Reconstruction

FIGURE 22.44  Demonstrates preservation of the scapholunate interval and no evidence of DISI deformity at 4 months after BTB reconstruction. BTB, Bone-tissue-bone; DISI, dorsal intercalated segment instability.

EVIDENCE Konopka G, Chim H. Optimal management of scapholunate ligament injuries. Orthop Res Rev. 2018;10:41–54. The authors provide a review of the anatomy and biomechanics of the wrist with surgical options based on the Garcia-Elias staging system (Level IV evidence). Pappou IP, Basel J, Deal DN. Scapholunate ligament injuries: A review of current concepts. Hand (NY). 2013;8(2):146–156. This review provides a description of SL ligament injuries and an overview of treatment options.

CHAPTER

23

Lunotriquetral Ligament Reconstruction Options Using Tendon Grafts Aviram M. Giladi and Kevin C. Chung Isolated lunotriquetral (LT) ligament tears are rarely treated acutely. Therefore, the traditional treatment approaches have been to attempt ligament repair, ligament reconstruction, or LT fusion. • Ligament repair is often not an available option for chronic injuries because the remaining ligamentous substance is inadequately substantive to repair. • LT fusion has a relatively high complication and nonunion rate (up to 50%). • LT reconstruction has traditionally been performed with a distally based extensor carpi ulnaris (ECU) weave. Nevertheless, other techniques have been published, including a weave using palmaris longus, dorsal capsulodesis using the dorsal radiocarpal ligament, or our preferred technique, using an Arthrex InternalBrace. • When opting for ligament reconstruction, we have come to favor the InternalBrace method because it provides an exceedingly strong construct without the need for the cumbersome creation of bone tunnels. • The disadvantage of this technique is the cost of the equipment that some facilities may not be able to absorb. Some surgeons have advocated for the use of ulnar shortening osteotomy to treat symptomatic LT ligament injury as long as imaging and arthroscopy confirm no joint degeneration and no triangular fibrocartilage complex (TFCC) or scapholunate (SL) ligament injury. We have used this approach as well.

INDICATIONS Indications for this procedure include: • Symptomatic LT dissociation without evidence of wrist arthritis • If volar intercalated segment instability (VISI) is seen on x-ray (see section on “Imaging”), it should be passively correctable and confirmed with fluoroscopy before pursuing reconstruction. • Continued wrist pain with associated LT injury despite conservative management • Ruled out concomitant or other reasons for ulnar-sided wrist pain

Contraindications • Evidence of arthritic changes in the radiocarpal or midcarpal joints is a contraindication for the procedure. • Another contraindication is VISI that cannot be manually reduced with traction and/ or manipulation. • Notable ulnar positive variance is a relative contraindication to performing LT reconstruction alone.

CLINICAL EXAMINATION • The patient complains of ulnar-sided wrist pain that may have been preceded by trauma. • Common causes of ulnar-sided wrist pain include ulnar abutment syndrome, ECU subluxation, distal radial ulnar joint (DRUJ) instability, TFCC pathology, pisotriquetral arthritis, and hook of hamate fractures. • Provocative maneuvers can help differentiate LT pathology from other causes of ulnar-sided wrist pain. • Palpate the LT interval; with the wrist in 30 degrees of flexion, the interval is found dorsally between the fourth and fifth compartments, one fingerbreadth distal to the DRUJ. 113

114

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

• When conducting an LT compression test, radially directed pressure over the triquetrum may elicit pain with LT instability (Fig. 23.1). • The LT ballottement test is similar to the LT compression test, but here one hand controls/stabilizes the wrist and lunate while the other applies radially directed force on the triquetrum, driving it into the lunate. • With the LT shear test, stabilizing the lunate centrally and directing the triquetrum volarly and dorsally elicits pain, crepitus, and excessive mobility compared with the contralateral side when LT instability is present (Fig. 23.2).

IMAGING • Plain radiographs are often normal with LT dissociation. One may see a slight widening of the LT interval (Fig. 23.3) or a step-off or disruption of Gilula’s proximal arc between the lunate and triquetrum. • VISI may be present. This can be appreciated on lateral x-ray. The lunate flexes with the scaphoid, making the SL angle too acute (,30 degrees, normal is 30 to 60 degrees; Fig. 23.4). • Arthroscopy can be used to diagnose LT dissociation. Normally, the lunate (L) and triquetrum (T) are tightly articulated, but with dissociation, a gap or step-off can be seen on arthroscopy. A probe can be used to separate the lunate from the triquetrum via the midcarpal portal (Fig. 23.5). This image demonstrates Geisler grade III instability, where a probe can be passed easily between the two bones. • We advocate performing wrist arthroscopy to survey the entire wrist joint before entertaining reconstruction. • Concomitant injuries can be identified and the amount of gapping can help decide on the reconstructive options, including assessing the articular wear that may preclude ligament reconstruction.

SURGICAL ANATOMY FIGURE 23.1  The LT compression test is performed by using a radially directed force against the ulnar border of the triquetrum. LT, Lunotriquetral.

• The LT ligament is a C-shaped ligament, but unlike the scapholunate ligament in which the dorsal fibers confer the most support, the volar fibers of the LT ligament are strongest.

Slightly widened LT SL angle < 30°

FIGURE 23.2  An LT shear test allows the examiner to stress the LT interval by manually manipulating the lunate and triquetrum to test for pain, crepitus, or laxity compared with the contralateral side. LT, Lunotriquetral.

VISI FIGURE 23.3  X-ray demonstrating slight LT interval widening (arrow points to widened LT interval). LT, Lunotriquetral.

FIGURE 23.4  Illustration of the carpal relationship that develops in a volar intercalated segment instability (VISI) deformity, with the scapholunate (SL) angle more acute than normal.

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

L

T

Triquetrocapitate ligament

Triquetrohamate ligament Ulnocapitate ligament Ulnotriquetal ligament Ulnolunate ligament

LT interval FIGURE 23.5  Arthroscopic image from a midcarpal view showing an LT step-off associated with Grade III instability. Arrow points to the incongruous LT interval. L, Lunate; LT, lunotriquetral; T, triquetrum. FIGURE 23.6  Illustration of the main volar secondary stabilizers of the LT interval. LT, Lunotriquetral.

Dorsal intercarpal (DIC)

Dorsal radiocarpal (DRC)

FIGURE 23.7  Illustration of the main dorsal secondary stabilizers of the LT interval. LT, Lunotriquetral.

• Secondary stabilizers of the LT ligament include the ulnocarpal (ulnolunate, ulnocapitate, and ulnotriquetral ligaments), midcarpal (triquetrohamate and triquetrocapitate ligaments), and dorsal carpal (dorsal intercarpal and dorsal radiotriquetral/ radiocarpal) ligaments (Figs. 23.6 and 23.7).

115

116

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

Central wrist incision Triquetrum

Freer in LT Space

Lunate

FIGURE 23.8  Incision used to approach the LT interval. LT, Lunotriquetral.

FIGURE 23.9  Dorsal exposure of the LT region of the wrist. The freer is easily able to pass between the lunate and triquetrum, indicating a torn LT ligament. LT, Lunotriquetral.

• With injury to the LT ligament and failure of the secondary stabilizers, the lunate and triquetrum dissociate, permitting the scaphoid and lunate to flex together, resulting in VISI. EXPOSURES PITFALLS

Branches of the dorsal ulnar sensory nerve should be identified and protected. This nerve branches off from the main ulnar nerve about 8 cm proximal to the pisiform. It then passes dorsal to the flexor carpi ulnaris (FCU) and pierces the deep fascia about 5 cm from the pisiform. It reaches the dorsum of the hand after coursing in close relation to the ulnar styloid process (Fig. 23.10).

POSITIONING • The patient is positioned supine, with arm extended on an arm board. • A sterile tourniquet is used on the upper arm.

EXPOSURES • A 6- to 8-cm longitudinal incision is designed over the dorsal wrist between the fourth and fifth compartments (Fig. 23.8). • After protecting the fourth and fifth compartment tendons, sharply enter the wrist and expose the LT interval (Fig. 23.9).

Dorsal branch of ulnar nerve

Pisiform

8 cm

FCU

A

B

FIGURE 23.10  Illustration of the course of the dorsal sensory branch of the ulnar nerve. FCU, Flexor carpi ulnaris

117

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

K-wire joysticks ECU slip tendon graft ECU tendon

ECU EDM

T

L

Ulna

FIGURE 23.11  Harvest of the distally based ECU tendon for weave technique. ECU, Extensor carpi ulnaris.

S

Radius

FIGURE 23.12  Harvest of ECRB graft for the InternalBrace technique. ECRB, Extensor carpi radialis brevis brevis; ECU, Extensor carpi ulnari; L, lunate; S, scaphoid; T, triquetrum.

PROCEDURE Step 1: Excise the Scar Tissue Between the Lunate and Triquetrum After exposure of the LT interval, debride the scar tissue (see Fig. 23.9).

Step 2: Harvest Tendon for Reconstruction ECU Weave Technique Identify a 3-mm slip of ECU tendon along the radial aspect of its insertion on the base of the small finger metacarpal and separate it from the remaining tendon. This can be dissected proximally to its musculotendinous junction (Figs. 23.11 and 23.12).

Arthrex InternalBrace Technique • Identify the extensor carpi radialis brevis (ECRB) exiting the second extensor compartment heading toward the base of the third metacarpal. • Harvest a 2-mm wide segment of ECRB (Fig. 23.13). • The ECRB tendon is chosen for harvest because of its wide caliber, which should not weaken the remaining tendon. Nevertheless, the ECU tendon can be harvested similar to the weave procedure.

ECRB tendon graft

FIGURE 23.13  Illustration of ECU tendon for weave and K-wire joysticks for LT reduction. ECU, Extensor carpi ulnaris; K-wire, Kirschner wire; L, lunate; LT, lunotriquetral; S, scaphoid; T, triquetrum.

STEP 2 PEARLS

The ECU tendon strip width should not exceed 3 mm to smoothly pass the tendon through the bone tunnels.

118

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

C

T

L

S

FIGURE 23.14  Illustration of K-wire manipulation to facilitate LT reduction. C, Capitate; K-wire, Kirschner wire; L, lunate; LT, lunotriquetral; S, scaphoid; T, triquetrum.

Step 3: Reduction of the Lunate and Triquetrum ECU Weave Technique and Arthrex InternalBrace Technique

STEP 3 PEARLS

• Evaluate the position of the lunate and triquetrum and confirm that a reduction can be easily performed and maintained. • To help with reduction (as needed), insert two 0.062-inch (1.6-mm) Kirschner wires (K-wires), one into the lunate and one into the triquetrum, to act as joysticks to reduce the carpal bones (Fig. 23.14; see also Fig. 23.12). • Place these wires out of the future bone tunnel path. For the InternalBrace, these wires can also function as the procedure guidewires (see Step 4) rather than placing joysticks and guidewires. • Because the lunate has flexed with the scaphoid, the lunate K-wire should be directed from distal to proximal, with the wire somewhat flat (near the plane of the hand) and distal so that the joystick can extend the lunate without obstruction from the radius. • The K-wire inserted within the triquetrum should be placed from proximal to distal. • Manipulate the wires toward being more perpendicular to the plane of the hand to reduce any malalignment or dissociation (Fig. 23.15). • Confirm reduction.

With a VISI deformity, the lunate follows the scaphoid into a flexed position and the triquetrum is extended. Placement of the K-wires from distal to proximal in the lunate and proximal to distal in the triquetrum facilitates reduction.

FIGURE 23.15  Joystick in the lunate and triquetrum being manipulated to perform the LT reduction. LT, Lunotriquetral.

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

• Place a 0.062-inch (1.6-mm) K-wire across the LT interval to maintain reduction. • Direct the K-wire from the midportion of the triquetrum through the central axis of the lunate. The starting point and trajectory can be confirmed fluoroscopically. • Remove the joystick K-wires.

Step 4: Create Bone Tunnels ECU Weave Technique • There are two versions of this technique, one with a tunnel in the lunate and triquetrum and another with only a tunnel in the triquetrum and a trough in the dorsal lunate, with a bone anchor to secure the graft. Both are viable options, based on available equipment. We prefer the trough approach, because drilling the tendon path in the lunate risks fracturing the cortex of the lunate when traction is placed on the tendon. • The entry point for a 0.045-inch (1.1-mm) K-wire guide should be at the proximal, volar, and radial aspect of the triquetrum. This K-wire should then be directed toward its distal, dorsal, and ulnar corner. • Once the position of the K-wire is confirmed radiographically, a 2.7-mm cannulated drill can be used to create the bone tunnel within the triquetrum (Fig. 23.16). • If making a lunate tunnel, it is best directed from proximal ulnar lunate (aligned with the tunnel in the triquetrum) to distal dorsal radial (Fig. 23.17C).

H

T L C

FIGURE 23.16  Drilling from proximal to distal f or the triquetrum bone tunnel. C, Capitate; H, hamate; L, lunate; T, triquetrum.

T

ECU H

L C

T H

L C

A

B

ECU

S ECU

T

LT interval C

L

FIGURE 23.17  Clinical photo of ECU graft before (A) and after (B) being passed through the triquetrum bone tunnel, as represented in the illustration (C). C, Capitate; ECU, extensor carpi ulnaris; H, hamate; L, lunate; S, scaphoid; T, triquetrum.

119

120

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

H C L

T

ECU

Lunate trough

A

T

L

B ECU

FIGURE 23.18  Clinical photo (A) and illustration (B) of the lunate tunnel and bone anchor to secure the graft. C, 5capitate; L, 5lunate; T, 5triquetrum; H, 5hamate; ECU, 5extensor carpi ulnaris. Dotted outline indicates the lunate trough in the clinical photo. STEP 4 ECU WEAVE PEARLS

• Alternatively, the triquetrum K-wire can be placed distal to proximal, from the distal ulnar corner toward the volar, radial corner of the bone. • A small curette can be used as an alternative to the drill to avoid fracturing the triquetrum.

• If a suture anchor is available, make a trough in the dorsal lunate rather than a tunnel through the bone. • Use a bur to create a 3-mm-wide, shallow trough on the dorsal aspect of the lunate to secure the tendon graft. • The trough should have healthy-appearing cancellous bone to promote bone– tendon healing (Fig. 23.18A–B).

Arthrex InternalBrace Technique • Place a guidewire in the triquetrum and in the lunate, setting the location for the tenodesis screw that will hold the tendon graft and suture tape. • Aim to have guidewires in the midsubstance of the respective bones in the reduced position (Fig. 23.19). • Plan that the position of the guidewires will set the location of the drill hole for the interference screws.

Step 5: Prepare and Place the Tendon Graft ECU Weave Technique: Passing the Slip of ECU Through the Bone Tunnel • Pass a fine 25-gauge wire from proximal to distal, through the triquetrum bone tunnel. The tendon is then sutured to the wire and pulled through the tunnel from distal to proximal (see Fig. 23.17A–C). • The same method is used to pull the tendon from proximal ulnar in the lunate through the tunnel to the distal radial exit site.

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

L

T L

T

FIGURE 23.19  X-ray of the InternalBrace guidewires in place in the lunate (L) and triquetrum (T).

Tendon graft whip-stitched with Fiberwire FIGURE 23.20  Preparing the tendon graft for use with InternalBrace.

Arthrex InternalBrace Technique: Preparing the Tendon

STEP 5 ECU WEAVE PITFALLS

• Use a fiber-wire suture to whip-stitch the graft, adding stability and creating a lower profile tendon that can fit into the screw (Fig. 23.20).

Do not force the tendon graft through the bone tunnel because this could fracture the carpal bone. Instead, trim the tendon graft to fit.

Step 6: Secure the Tendon Graft/Weave ECU Weave Technique • If using the lunate trough technique, secure the graft to the base of the trough with a suture anchor. • Within the trough, over the center of the lunate, place a 1.8-mm mini Mitek suture anchor (or similar). • Put the ECU under tension from radial to ulnar and suture the ECU slip to the lunate (Fig. 23.21). • Pull the graft over the lunate from radial to ulnar (either from the bone tunnel or from the secured anchor in the trough) to create tension. • Pass the remaining graft through the ulnar-sided dorsal capsule and suture it to itself over the lunate using 3-0 nonabsorbable suture (Fig. 23.22).

Arthrex InternalBrace Technique • Prepare tenodesis screw placement by passing the weaved tendon graft and suture tape through the screw. • Place tenodesis screw with the graft and tape into the lunate and triquetrum to secure the graft and tape as a replacement for the LT ligament (Fig. 23.23A–B).

STEP 6 PEARLS

Fluoroscopy should be used at this point to confirm that the lunate is in neutral position and has not fallen back into VISI deformity. There should be no gapping between the lunate and triquetrum; this should be confirmed visually and radiographically.

121

122

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

ECU

C

S T L

T

L

ECU FIGURE 23.21  Illustration of tensioning and securing the ECU graft in the lunate trough with the bone anchor. ECU, Extensor carpi ulnaris; L, lunate; T, triquetrum.

Triquetrum tenodesis screw placed

FIGURE 23.22  Illustration of the final steps in securing the ECU weave. C, Capitate; ECU, extensor carpi ulnaris; L, lunate; S, scaphoid; T, triquetrum.

Tendon graft + suture tape ligament reconstruction

Lunate tenodesis screw placed

A Triquetrum tenodesis screw placed

Tendon graft + suture tape ligament reconstruction

Lunate tenodesis screw B

Lunate tenodesis screw placed

Triquetrum tenodesis screw

C

FIGURE 23.23  Clinical photos of (A) the InternalBrace and ECRB graft being placed into the lunate and triquetrum with interference screws and (B) the final appearance with the graft trimmed after proper tensioning with x-ray (C) of the construct in place with tenodesis screw in the lunate and in the triquetrum. ECRB, Extensor carpi radialis brevis.

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

• The suture tape provides added strength to the repair until the tendon graft has stiffened to provide permanent stability.

Step 7: Close the Capsule, Extensor Retinaculum, and Skin • If a K-wire was used to pin across the LT interval, decide whether to leave it in place for 8 weeks before extracting the pins in the operating room. Leaving K-wires outside the skin for more than 3 weeks risks pin track infection that may progress to osteomyelitis of the carpal bone, a devastating complication. • For the ECU weave technique, we almost always leave the pin for future extraction; therefore, we cut the pin to bury it under the skin. • For InternalBrace, we often do not use an LT pin because of the stability of the construct. If the pin is to be kept in place, we would recommend burying it. • The wrist capsule should be closed with interrupted 3-0 Vicryl or Ethibond sutures. • The skin can be closed with 4-0 Monocryl or 4-0 Polydioxanone (PDS).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is kept in a volar wrist splint for 8 weeks. • Postoperative x-rays are performed. • With the InternalBrace technique, if no LT pin was left in place, we will begin gentle motion at 4 weeks. • If a pin is in place (either technique), the LT K-wire is removed after 8 weeks and the patient starts gentle range-of-motion exercises. • The patient should expect wrist stiffness and loss of range of motion compared with the contralateral side, especially in flexion; however, nearly all patients report a reduction or absence of pain after this procedure (Fig. 23.24A–B). • Despite this ligamentous reconstruction, some patients will need to undergo a salvage operation, such as a partial wrist fusion, because of the progression of wrist arthritis. See Video 23.1 and 23.2

A

B FIGURE 23.24  Postoperative range of motion showing extension (A) and flexion (B) of the operative right wrist compared with the uninjured left.

123

124

CHAPTER 23  Lunotriquetral Ligament Reconstruction Options using Tendon Grafts

EVIDENCE Shin AY, Weinstein LP, Berger RA, Bishop AT. Treatment of isolated injuries of the lunotriquetral ligament in comparison of arthrodesis, ligament reconstruction, and ligament repair. J Bone Joint Surg Br. 2001;83:1023–1028. In this retrospective review, the authors compared outcomes in 57 patients at a mean follow-up of 9.5 years with LT ligament injury treated with arthrodesis, direct ligament repair, or ligament reconstruction using a slip of the ECU tendon. The following outcomes were compared: written questionnaires; the Disabilities of the Arm, Shoulder, and Hand (DASH) score; range of movement; strength; morbidity; and rates of reoperation. Before surgery, all patients were confirmed to have isolated LT injury by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years, and the injuries were subacute or chronic in 98.2%. Eight patients underwent LT reconstruction using a distally based strip of the tendon of ECU, 27 had LT repair, and 22 had LT arthrodesis. The probability of remaining free from complications at 5 years was 68.6% for reconstruction, 13.5% for repair, and less than 1% for arthrodesis. Of the LT arthrodeses, 40.9% developed nonunion, and 22.7% developed ulnocarpal impaction. The probabilities of not requiring further surgery at 5 years were 68.6% for reconstruction, 23.3% for repair, and 21.8% for arthrodesis. The DASH scores for each group were not significantly different. Objective improvements in strength and movement and subjective indicators of pain relief and satisfaction were significantly higher in the LT repair and reconstruction groups than in those undergoing arthrodesis (Level III evidence). van de Grift TC, Ritt MJ. Management of lunotriquetral instability: A review of the literature. J Hand Surg Eur Vol. 2016;41(1):72–85. doi:10.1177/1753193415595167. In this literature review, the available data supporting conservative treatment, progression to arthroscopy, arthroscopic guidance of surgical treatment, and ligament reconstruction for isolated LT ligament injury are all reviewed. The authors highlight areas where decision-making and treatment clarity is lacking and describe the methodologic issues that limit broad usability of available data on this condition. Thompson RG, Dustin JA, Roper DK, Kane SM, Lourie GM. Suture tape augmentation for scapholunate ligament repair: A biomechanical study. J Hand Surg Am. 2020;S0363–5023(20)30376. This cadaveric study reported on the strength of the suture tape/InternalBrace construct across the SL interval. The SL ligament was sharply transected, immediately repaired, and then directly stressed/ tested to failure. The suture tape technique had significantly higher load to failure than the direct repair using two suture anchors (mean 135N vs. 68N).

CHAPTER

24

Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting Elissa S. Davis and Kevin C. Chung

INDICATIONS • In young individuals without arthritis, attempts at reconstruction rather than salvage should be pursued to recreate the scapholunate and lunotriquetral ligaments. • Internal brace and tendon grafting is an option to reconstruct various stages of scapholunate (SL) ligament injury without articular wear, in particular in association with lunotriquetral (LT) ligament dissociation. In cases with both SL and LT ligament tears, proximal row carpectomy is a suitable option, but if the articular surfaces are intact, it is preferable to stabilize the ligaments to preserve carpal mechanics. • Ulna shortening should be performed at the time of surgery if the LT tear and instability are secondary to ulnar positive variance to prevent retear of the reconstructed ligament. • Additionally, the triangular fibrocartilage complex (TFCC) should be examined carefully because LT tears are often associated with degenerative tears of the TFCC.

Contraindications If SL injury has already led to scapholunate advanced collapse (SLAC) arthritis, or articular wear is present at the LT joint, then salvage options, including proximal row carpectomy, scaphoid excision, and four-corner fusion or wrist arthrodesis, should be explored. Otherwise, these patients will likely experience pain and dysfunction as a result of their arthritis.

CLINICAL EXAMINATION See Chapter 21 (Scapholunate Ligament Repair) and Chapter 23 (Lunotriquetral Ligament Reconstruction using Tendon Grafts)

IMAGING See Chapter 21 and 23.

SURGICAL ANATOMY See Chapter 21 and 23.

POSITIONING AND EQUIPMENT • The patient is positioned supine on a stretcher with a tourniquet on the operative extremity. • The operative extremity is pronated on a hand table.

EXPOSURES See Chapter 21.

EXPOSURES PEARLS

Posterior interosseous nerve (PIN) neurectomy can be performed at the time of surgical exposure by identifying and resecting the nerve in the floor of the fourth extensor compartment.

PROCEDURE Step 1 • A 6-cm longitudinal incision is designed on the dorsal wrist, ulnar to the Lister tubercle (Fig. 24.1). 125

126

CHAPTER 24  Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting

FIGURE 24.2  Posterior interosseous nerve (PIN) identified.

FIGURE 24.1  Incision design.

S/L interval

L/T interval FIGURE 24.3  Wrist capsule opened.

STEP 1 PEARLS

A ligament-sparing approach to the wrist can be performed. The design of this radially based triangular flap splits the fibers of the dorsal radiocarpal and dorsal intercarpal ligaments (Fig. 24.4). STEP 2 PEARLS

• An adequate amount of tendon must be harvested to span from the proximal pole of the scaphoid to the lunate and the triquetrum. • Harvesting more than a 2-mm width of tendon graft will make it difficult to place inside your suture anchor with suture tape. STEP 3 PEARLS

• If the wrist is in DISI, the scaphoid is in a flexed position, and the lunate is extended, then the wires should be placed from distal to proximal in the scaphoid and proximal to distal in the lunate. This will facilitate reduction. • If volar intercalated segment instability (VISI) is present, the wires should be placed from distal to proximal in the lunate and proximal to distal in the triquetrum. • Stouter 0.062-in (1.57-mm) K-wires are used instead of 0.045-in (1.14-mm) to aid in reduction. • The SL angle should be corrected and confirmed radiographically. A normal scapholunate angle is 30–60 degrees and a normal radiolunate angle is 0–15 degrees. • Gapping between the scaphoid and lunate, and lunate and triquetrum should be eliminated.

• After incising the extensor retinaculum between the third and fourth compartments, the extensor pollicis longus (EPL) is identified and retracted radially. • A PIN neurectomy is performed to excise 3 cm of nerve (Fig. 24.2). • The wrist capsule is opened longitudinally to expose the SL and LT intervals (Fig. 24.3). • After exposing the SL and LT intervals, scar tissue is debrided back to healthy bleeding tissue.

Step 2 • The extensor carpi radialis brevis (ECRB) is identified at its insertion into the base of the middle metacarpal. • Harvest a 2-mm width of ECRB that measures 10 cm in length. The tendon graft must be thin enough to fit within the drill hole of the screw (Fig. 24.5). • Whip-stitch both ends of the graft with fiberwire loop (Fig. 24.6).

Step 3 • If static, reducible instability is present between the scaphoid and the lunate, then the scaphoid needs to be anatomically reduced to correct any dorsal intercalated segment instability (DISI) deformity. • Three 0.062-in (1.57-mm) Kirschner wires (K-wires) can be used to reduce the scaphoid, lunate, and triquetrum into preinjury anatomic alignment. • Care should be taken not to place the K-wires in the path of the suture anchors at the proximal and distal poles of the scaphoid and the lunate and triquetrum. • To close the gap between the three bones, the wires are compressed. • Assess the carpal alignment on intraoperative fluoroscopy.

Step 4 • Place 0.054-in K-wires from the internal brace kit into the proximal and distal poles of the scaphoid, lunate, and triquetrum. • Overdrill your K-wires using the drill bit and guides in your internal brace kit (Fig. 24.7A–B).

CHAPTER 24  Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting

DIC DRC

FIGURE 24.5  Extensor carpi radialis brevis (ECRB) harvested. A

FIGURE 24.6  Whip-stitched fiberwire loop. STEP 4 PEARLS

B

C

FIGURE 24.4  (A-C) Ligament-sparing approach. DIC, Dorsal intercarpal; DRC, dorsal radiocarpal.

Step 5 • Insert the tendon graft and then suture tape into the forked eyelet of the suture anchor. In the proximal pole of the scaphoid anchor, one end of the tendon graft is placed into the forked eyelet to maximize the length of graft to span from proximal scaphoid to lunate to triquetrum. The suture tape is loaded in the center to create two limbs, which will span from scaphoid to lunate (Fig. 24.9A–B). • Next, place your lunate anchor, including both limbs of the suture tape and tendon graft. When placing the triquetrum anchor next, only load one limb of suture tape

• Ensure that the K-wires have been buried up to the laser line. If tendon graft is used in addition to suture tape, then drill with the 3.5-mm drill bit for a 3.5-mm anchor. If suture or suture tape is used without tendon graft, then drill with a 2.5-mm drill bit for a 2.0-mm anchor. • Drill each suture anchor hole as the anchors are placed because the graft may not be long enough to reach all anchors. The goal is to have the tendon and suture tape span from scaphoid to lunate and triquetrum. • The distal pole of the scaphoid anchor should be drilled with the 2.0-mm drill because this anchor will only have suture tape spanning from the lunate. This is also necessary because the anchor is 2.5 mm, not 3.5 mm. This helps to prevent flexion of the scaphoid, similar to the dorsal capsulodesis technique, to keep the scaphoid extended and prevent shearing stress over the SL ligament repair. STEP 4 PITFALLS

Care should be taken to avoid injuring the vascular pedicle to the scaphoid along the dorsal ridge (Fig. 24.8).

127

128

CHAPTER 24  Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting

A

B FIGURE 24.7  (A–B) Kirschner wires inserted.

Dorsal

Drill hole

Scaphoid

A

Radius

FIGURE 24.8  Drill hole location.

B

FIGURE 24.9  (A–B) Suture tape loaded.

CHAPTER 24  Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting Tendon graft Suture tape

4

3

2

A

1

B FIGURE 24.10  (A–B) Suture tape inserted.

FIGURE 24.11  Final anchor placed.

along with the tendon graft. The other limb of suture tape from the lunate anchor will be used without tendon graft in the distal pole of the scaphoid (Fig. 24.10A–B). • The final anchor is placed in the distal pole of the scaphoid and includes only one limb of suture tape from the lunate anchor (Fig. 24.11).

Step 6 • The dorsal wrist capsule is closed using 3-0 Vicryl suture and the EPL is placed over the extensor retinaculum to prevent entrapment (Fig. 24.12). • Hemostasis is obtained after releasing the tourniquet. • Skin is closed using 4-0 Monocryl or 4-0 nylon sutures (Fig. 24.13). • Patient is placed in a short arm splint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES The patient remains splinted for 6 weeks to permit healing of the reconstructed ligament. Then range of motion exercises can be initiated. See Video 24.1

STEP 5 PEARLS

• Apply firm pressure to insert the suture anchors, and ensure that the laser line is at or below the surface of the bone. • Between each suture anchor placement, twist the suture tape and graft to aid in loading of the subsequent anchor eyelet. • Remember, only suture tape should extend from the lunate to the distal pole of the scaphoid, and so you should drill this anchor last. This aids in preventing flexion of the scaphoid. • 3.5-mm by 8.5-mm anchors are placed in the proximal pole of the scaphoid, lunate, and triquetrum. A 2.5-mm by 7-mm anchor is placed in the distal pole of the scaphoid.

129

130

CHAPTER 24  Scapholunate and Lunotriquetral Ligament Reconstruction with Internal Brace and Tendon Grafting

FIGURE 24.12  Extensor pollicis longus (EPL) placed over extensor retinaculum to prevent entrapment.

FIGURE 24.13  Wounds closed.

EVIDENCE Schwartzenberger JJ, Clark C, Santoni BG, Garcia M, Stone JD, Nydick J. Poster 146: Scapholunate ligament reconstruction using tendon autograft and 3.5 mm fork-tip interference anchors. Presented at: 72nd Annual Meeting of the American Society for Surgery of the Hand; September 7-9, 2017; San Francisco, CA. The authors compare early clinical and radiographic outcomes of all-dorsal scapholunate reconstruction with internal brace versus three-ligament tenodesis. The all-dorsal reconstruction group had significant correction of scapholunate and radioscaphoid angle (76.2 degrees and 65.5 degrees) preoperatively to postoperatively (52.5 degrees and 47.8 degrees). Lee SJ, Coyle R, Porter DA, Kremenic I. Poster No. P0218: Biomechanical testing of scapholunate reconstruction with internal brace versus scapholunate repair. Presented at: AAOS 2018 Annual Meeting; March 6-10, 2018; New Orleans, LA. The authors compare the biomechanical properties of all-dorsal scapholunate reconstruction with internal brace versus scapholunate repair with two suture anchors in a cadaveric model. The ultimate strength of the internal brace averaged 82.0 N versus ligament repair averaged 41.7 N.

CHAPTER

25

Open Reduction and Internal Fixation of Acute Scaphoid Fracture Matthew Florczynski and Kevin C. Chung

INDICATIONS • A scaphoid fracture is considered acute when presenting within 6 weeks of injury. Fractures in which presentation is delayed have poorer healing potential and a higher likelihood of progressing to nonunion with or without surgical intervention. • The decision to pursue operative or nonoperative intervention depends on a number of factors, including fracture location and pattern within the scaphoid, displacement or deformity, associated ligamentous injury, and patient preferences. • The duration of immobilization and union rates with nonoperative treatment differ based on the location of the fracture. • Distal pole fractures heal more quickly than waist or proximal pole fractures. • Union rates for nonoperative treatment of nondisplaced distal pole fractures approach 100%, compared with 95% for waist fractures and only 70% for proximal pole fractures. Therefore operative treatment should be considered for any fracture displaced more than 2 mm or any proximal pole fracture, regardless of displacement. • Operative treatment of nondisplaced fractures will enable accelerated rehabilitation and earlier return to work or athletic activity and may be preferred in laborers, athletes, or highly active patients. • Specific indications for operative treatment are reviewed in Table 25.1. TABLE Indications for Operative Treatment of Acute Scaphoid Fracture 25.1

Injury Characteristic

Operative Indication

Fracture location (Fig. 25.1)

• The volar approach is preferred for distal pole fractures. • Scaphoid waist fractures can be stabilized through either a dorsal or volar approach. • The dorsal approach is preferred for proximal pole fractures.

Angular deformity

Certain radiographic parameters are associated with carpal instability and warrant operative treatment: • Scapholunate angle . 60 degrees (Fig. 25.2) • Humpback deformity, or lateral intrascaphoid angle (LISA) . 35 degrees (Fig. 25.3) • Dorsal intercalated segment instability (DISI) in the subacute or chronic fracture setting

Comminution/bone loss

These fractures will lead to shortening and predispose to degenerative wrist disease. They warrant operative treatment, potentially with bone grafting of the fracture gap.

Perilunate injury

Any scaphoid fracture occurring in the setting of a perilunate fracture dislocation should be treated operatively because these injuries are highly unstable.

Open fracture/ polytrauma

Surgical stabilization is warranted in settings requiring irrigation and debridement for open fracture and/or operative treatment of other fractures.

Ipsilateral distal radius fracture

Fixation of the scaphoid and distal radius fracture can be performed concurrently through an extended volar approach.

131

132

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

Scaphoid tubercle fracture

Scaphoid waist fracture

Proximal pole fracture

FIGURE 25.1  Common locations of scaphoid fractures. (Fig. 5.2, from Trumble TE, Omori D. Scaphoid fractures. In: Trumble TE, Rayan GM, Budoff JE, Baratz ME, Slutsky DJ, eds. Principles of Hand Surgery and Therapy. 3rd ed. Philadelphia, PA: Elsevier; 2017:100–116.)

Scapholunate normal ∝ = 46° (30° to 60°)

DISI ∝ > 60°

LISA

VISI ∝ > 30°

FIGURE 25.2  Scapholunate angle. (Fig. 4.5, from Rosewasser MP, Zeltser DW. Carpal instability. In: Trumble TE, Rayan GM, Budoff JE, Baratz ME, Slutsky DJ, eds. Principles of Hand Surgery and Therapy. 3rd ed. Philadelphia, PA: Elsevier; 2017:70–99.)

FIGURE 25.3  Lateral intrascaphoid angle (LISA). Yellow: outline of scaphoid. Red: perpendicular lines to each pole of the scaphoid.

Contraindications • There are few true contraindications for surgery in displaced scaphoid fractures. • Highly comorbid patients or patients with active hemodynamic compromise or systemic infections should have medical issues managed before considering operative treatment. • A strong patient preference for nonoperative treatment, particularly for nondisplaced fractures, warrants an appropriate period of immobilization and close observation.

CLINICAL EXAMINATION • History usually includes a fall onto an outstretched hand in a patient younger than 40 years of age (Fig. 25.4). • The injury may also occur in the context of a high energy trauma with perilunate dislocation.

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

FIGURE 25.4  Mechanism of scaphoid fracture. (Fig. 69.47, from Azar FM, Beaty JH, Canale ST, eds. Campbell’s Operative Orthopaedics. 2017:3478–3575.e10.)

Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Anatomic snuff box

FIGURE 25.5  Anatomic “snuff box.” (Fig. 7.99, from Magee DJ. Orthopedic Physical Assessment. 6th ed. Saunders: 2014: 429–507.)

• The classic mechanism is an axial load onto an extended and ulnarly deviated wrist. • The combination of snuff-box tenderness, scaphoid tubercle tenderness, and pain with axial compression of the wrist is highly characteristic of a scaphoid fracture (Figs. 25.5 and 25.6).

IMAGING • The initial x-ray series should include standard posteroanterior (PA), oblique, and lateral wrist x-rays (Fig. 25.7A–C) and a scaphoid view (see Fig. 25.7D). • The scaphoid view brings the plane of the scaphoid from a flexed to a neutral position through ulnar deviation at the wrist to better visualize the entire bone. • Additional views that can be considered include a clenched fist PA, which increases the axial load across the wrist and may make the fracture more apparent, and a pronated oblique view. • The incidence of false-negative plain x-ray diagnosis of acute scaphoid fracture is 10% to 30%. When initial x-rays are negative and there is a strong clinical suspicion for scaphoid fracture, several diagnostic strategies can be used: • The traditional approach has been to immobilize the patient in a thumb spica splint and repeat x-rays in 2 weeks when the fracture line is more radiolucent.

FIGURE 25.6  Palpation of the scaphoid tubercle for tenderness.

133

134

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

A

B

C

D

FIGURE 25.7  Radiographs demonstrating a fracture of the scaphoid waist: (A) posteroanterior [PA], (B) pronated oblique, (C) lateral, and (D) scaphoid view.

This strategy has been found to be less cost-effective than immediate magnetic resonance imaging (MRI) or computed tomography (CT), but it is still preferred in many centers. • MRI is the most cost-effective, sensitive, and specific imaging modality for identifying acute scaphoid fractures. Cortical disruption in the presence of bone marrow edema is diagnostic (Fig. 25.8). MRI is also useful for determining vascularity when the timing of the injury is unknown and avascular necrosis is suspected. • CT can diagnose occult scaphoid fractures when MRI is not available. CT demonstrates excellent bony detail for preoperative planning but is less sensitive and specific than MRI and exposes the patient to radiation.

SURGICAL ANATOMY

FIGURE 25.8  Magnetic resonance imaging (MRI) demonstrating an occult fracture of the scaphoid.

• Eighty percent of the scaphoid is covered by articular cartilage, leaving limited space for the entrance of an arterial supply. • The axis of the scaphoid lies 45 degrees radial to the axis of the wrist. • Because it is the largest bone in the proximal carpal row, the scaphoid articulates with the trapezium, trapezoid, capitate, lunate, and radius and serves as a mechanical link between the proximal and distal carpal rows. • Although there are multiple intrinsic and extrinsic ligaments that attach to the scaphoid, the scapholunate ligament is the most important intrinsic ligament, providing stability and linking the bones of the proximal row. The most important extrinsic ligament is the radioscaphocapitate (RSC) ligament, which acts as a fulcrum for rotation along the midaxis of the scaphoid (Fig. 25.9). • Dorsally, the proximal pole of the scaphoid is relatively immobile because it is surrounded by the dorsal rim of the radius, RSC ligament, long radiolunate ligament (LRL) and scapholunate interosseous ligament (SLIL). On the other hand, the distal pole of the scaphoid, located volarly, is mobile and susceptible to fracture at the waist when subjected to an axial load. • The dorsal groove courses the length of the scaphoid and provides attachment surfaces for ligaments and blood vessels. The dorsal blood supply (branch of the radial artery), which delivers 70% to 80% of the blood supply, courses from distal to proximal through the bone. Occasionally, there is a partial volar contribution to this blood supply. • A palmar branch of the radial artery supplies the scaphoid tubercle, accounting for 20% to 30% of the scaphoid blood supply. • Because of the distal-to-proximal course of the blood supply, proximal fractures take longer to heal than distal fractures. • This also explains why the scaphoid is at higher risk for avascular necrosis in proximal fractures (Fig. 25.10). Once avascular necrosis has developed, there is a high likelihood of nonunion.

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

Trapezium

Capitate

Scaphoid Scapholunate ligament

Radioscaphocapitate ligament

Long radiolunate ligament Radiolunate ligament

Radius

FIGURE 25.9  Ligamentous anatomy of the scaphoid.

Dorsal carpal branch

Superficial palmar branch

Radial artery

EXPOSURES PEARLS Dorsal

Volar

FIGURE 25.10  Vascular anatomy of the scaphoid.

POSITIONING AND EQUIPMENT • A rolled towel can aid in flexion or extension of the wrist to achieve a central screw trajectory perpendicular to the fracture site. • The wrist should be flexed as much as possible when performing fixation through a dorsal approach and extended when using a volar approach.

DORSAL APPROACH Exposure • A percutaneous approach can be used to stabilize nondisplaced scaphoid fractures. It carries an increased risk of tendon or nerve injury and should not be used unless the surgeon is particularly familiar with this approach. Percutaneous techniques are not recommended for displaced fractures, which require an anatomic reduction.

• Using the dorsal approach, the starting point is relatively easy to find and there are no other carpal bones obstructing the long axis of the scaphoid. With the volar approach, one must navigate the trapezium to obtain the perfect trajectory. • For proximal pole fractures, the dorsal approach is preferred to facilitate capture of the proximal fragment with the threads of the headless compression screw. EXPOSURES PITFALLS

• The dense fibers of the SLIL should be clearly identified and dissected from the dorsal wrist capsule to avoid inadvertent injury. • Preservation of the soft tissue attachments along the dorsal ridge at the scaphoid waist will ensure that the blood supply remains intact.

135

136

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

FIGURE 25.11  Dorsal skin incision.

FIGURE 25.12  Identification of the fracture site.

STEP 1 PEARLS

• With scaphoid waist fractures, the distal fragment often needs to be extended and supinated to obtain anatomic reduction. • A temporary 0.045-in (1.14-mm) K-wire can be used for provisional fixation. It should be placed dorsoradially to avoid interfering with placement of the definitive fixation construct. STEP 1 PITFALLS

• Carefully examine all fluoroscopic views to ensure anatomic reduction. • If placing a joystick K-wire radially, be aware of the position of the radial artery as it courses dorsally through the anatomic snuff box.

• Under tourniquet control, a 6-cm dorsal incision is made ulnar to Lister tubercle (Fig. 25.11). A no. 15 blade is used to incise skin and subcutaneous tissue, exposing the extensor retinaculum. • Dissection is continued in the interval between the third and fourth extensor compartments, and the dorsal wrist capsule is identified deep to the interval. • The plane between the dorsal wrist capsule and the SLIL is developed. • The dorsal surface of the scaphoid is sharply dissected, separating the bone from the loose capsular attachments. • The fracture can be identified by the presence of hematoma or early callus formation, depending on its chronicity. A Freer elevator is passed into the fracture gap. • Debridement of fracture site is performed as necessary using a dental pick, rongeur, or small bone curette if callus is present (Fig. 25.12).

Step 1: Reduction and Provisional Stabilization of the Scaphoid • If the fracture is displaced, a 0.062-in (1.57-mm) joystick Kirschner wire (K-wire) can be inserted into each fragment to facilitate reduction (Fig. 25.13). • Fracture reduction is confirmed visually and radiographically.

Step 2: Guidewire Placement • After confirming anatomic reduction and trajectory of the guidewire, advance the guidewire along the long axis of the scaphoid. • The entry point of the guidewire should be confirmed by fluoroscopy. Once confirmed, the guidewire is advanced by a few millimeters and the trajectory is verified by fluoroscopy again. This avoids multiple passes of the guidewire into the scaphoid. • Ensure that the tip is in the distal subchondral bone. The manufacturer’s depth gauge is placed over the wire to measure screw length (Fig. 25.14). To ensure that the entire screw is buried within the bone, 4 mm should be subtracted from the depth gauge measurement.

FIGURE 25.13  Intraoperative fluoroscopic image of fracture reduction with Kirschner wires (K-wires).

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

Step 3: Drilling the Scaphoid • The provisional K-wire will help counteract rotational forces during drilling that could result in lost reduction. • Drilling should be performed using a hand reamer. A power drill is not recommended because it is difficult to control the trajectory of the drill over the guidewire and this may lead to breaking the guidewire. • Assessment under fluoroscopy will ensure that drilling is carried down to the subchondral bone of the distal fragment and that the path of the guidewire is maintained (Fig. 25.15).

STEP 2 PEARLS

• An imperfect guidewire can be left in place and used as a reference for placement of a new wire. • Multiple attempts at passing the wire will create several pathways through the bone, making it challenging to direct the wire correctly along the long axis of the scaphoid.

Step 4: Compression Screw Placement • The guidewire is advanced to capture the trapezium so that the wire does not come loose after drilling. An appropriately sized headless compression screw is placed under direct visual and fluoroscopic guidance (Fig. 25.16A–B). • The provisional K-wire is removed or, rarely, cut at the cartilage surface to provide additional stability during bony healing.

VOLAR APPROACH Exposure • The scaphoid is exposed via a curvilinear or chevron wrist incision. This incision extends from the radial aspect of the thenar eminence, across the wrist, and parallel and radial to the flexor carpi radialis (FCR) tendon (Fig. 25.17A–B).

FIGURE 25.14  Intraoperative depth gauge measurement. STEP 3 PEARLS

Holding the reduction during drilling is essential and can be aided using the joystick K-wires. This is particularly important in young patients with dense bone.

FIGURE 25.15  Intraoperative fluoroscopic image of drilling over a guidewire.

STEP 3 PITFALLS

Headless screws with guidewires of less than 0.045-in (1.14-mm) are particularly susceptible to shearing if drilling is not performed collinear with the guidewire. Verify constantly with fluoroscopy. STEP 4 PITFALLS

Advancing the screw can cause distraction at the fracture site if the reduction is not stabilized or the drill holes are not aligned as the screw is driven across the fracture site. EXPOSURE PEARLS

B FIGURE 25.16  (A–B) Intraoperative fluoroscopic images of antegrade compression screw.

• Care is taken to identify and avoid the FCR tendon. • The LRL and a portion of the RSC ligament should be preserved to stabilize the proximal pole of the scaphoid and maintain reduction.

137

138

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

Flexor carpi radialis

Flexor carpi radialis

A

B

FIGURE 25.17  (A) Volar incision and (B) interval adjacent to flexor carpi radialis for exposure of the scaphoid.

FIGURE 25.18  Identification of scaphoid fracture through the volar approach.

• A no. 15 blade is used to dissect sharply to the level of the wrist capsule. • The FCR sheath is opened longitudinally and the FCR is retracted ulnarly. • The RSC ligament and LRL are incised, and the joint capsule is entered, exposing the scaphoid. • The fracture site can be identified by passing a periosteal elevator between the proximal and distal fragments (Fig. 25.18). • Fluoroscopy is used to confirm the fracture site. • In the acute setting, minimal debridement is needed. A curette or rongeur can be used to debride any callus or hematoma. STEP 1 PEARLS

Step 1: Reduction and Provisional Stabilization of the Scaphoid

A second 0.045-in (1.14-mm) K-wire can be placed into the proximal fracture fragment and used as a joystick to aid in reduction (Fig. 25.20).

• Once the fracture site is debrided and the distal scaphoid pole can be mobilized, manual reduction is performed. The reduction is verified under fluoroscopy. • While maintaining the reduction, a 0.045-in (1.14-mm) K-wire is inserted from distal to proximal for provisional stabilization. • It is important to start this wire slightly radial to the long axis of the scaphoid to avoid interference with final screw placement (Fig. 25.19).

Joystick K-wire Provisional K-wire

FIGURE 25.19  Stabilization of the scaphoid fracture with a provisional Kirschner wire (K-wire).

S

FIGURE 25.20  Intraoperative photograph of Kirschner wire (K-wire) assisted reduction.

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture STEP 2 PEARLS

• The trapezium often obscures the ideal entry point into the scaphoid when using the volar approach. Wrist extension and ulnar deviation helps to move the trapezium out of the way when inserting the guidewire. • It may be necessary to trim a portion of the trapezium to direct the K-wire along the desired trajectory. This can be performed with a rongeur. • An alternative technique is to direct the guidewire through the trapezium and into the scaphoid along its desired trajectory. We typically do not disturb the trapezium in the volar approach but attempt to place the screw as central to the scaphoid as possible.

A

B FIGURE 25.21  (A–B) Intraoperative fluoroscopic image of retrograde guidewire.

Step 2: Guidewire Placement • With the provisional K-wire in place, the guidewire for the definitive screw is directed from the distal scaphoid tubercle to the proximal ulnar corner of the scaphoid. • The desired trajectory for the definitive screw is typically central and in line with the long axis of the scaphoid to maximize length of the screw construct and to minimize trauma to the scaphoid blood supply. Ideally, the screw trajectory should be as perpendicular as possible to the fracture line, which may not be possible in some fracture patterns. Placement of the guidewire should be confirmed under fluoroscopy.

Step 3: Drilling the Scaphoid • Before drilling, the manufacturer’s depth gauge is placed over the wire to measure screw length. To ensure that the entire screw is buried within the bone, 4 mm should be subtracted from the depth gauge measurement. • After radiographic confirmation of trajectory, the guidewire is advanced into the distal radius to prevent the guidewire from pulling out and maintain the path of the drill when the scaphoid is drilled from distal to proximal (Fig. 25.21A–B).

STEP 3 PEARLS

• The K-wire must be in perfect position before estimating the screw length. To ensure an accurate estimate of length, there should not be any tissue between the guide and the distal pole of the scaphoid. • Fluoroscopy is used to confirm that the scaphoid has been drilled up to the proximal subchondral bone. STEP 3 PITFALLS

• If the guidewire has been inserted through the trapezium to obtain the desired trajectory within the scaphoid, screw length must be estimated using indirect means and may be inaccurate. • If the guidewire has been inserted through the trapezium, it is crucial that the drill used is of the same diameter as the screw head of the final implant. If the screw head is larger than the drill, it will not advance through the trapezium. STEP 4 PEARLS

Step 4: Compression Screw Placement • An appropriately sized screw is placed over the guidewire (Fig. 25.22A–B). • Screw placement, entirely within the bone, is confirmed radiographically and the guidewire is removed. The provisional K-wire is removed (Fig. 25.23A–B).

The patient’s wrist should be taken through a full range of motion to confirm that the screw is extraarticular.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

Particularly for patients with risk factors for nonunion, it may be desirable to obtain a CT scan to confirm fracture healing. Osseous bridging of at least 50% of the fracture site is typically considered sufficient to wean immobilization.

• The patient is placed into a thumb spica splint. At 2 weeks postoperatively, the splint is removed for wound check and suture removal.

A

POSTOPERATIVE PEARLS

B

FIGURE 25.22  (A) Intraoperative and (B) fluoroscopic images of retrograde drilling of the scaphoid.

139

140

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture

A

B

FIGURE 25.23  (A–B) Postoperative radiographs of a retrograde compression screw.

A

B

POSTOPERATIVE PITFALLS

• A potential pitfall of the dorsal approach is scarring on the dorsal wrist, and patients may experience a decrease in wrist flexion compared with the contralateral side. • Proximal pole fractures may take up to 3 months to heal. Patients should be instructed to protect the wrist until that time. • Scaphoid malunion is associated with increased radioscaphoid contact area and early arthritis, but the long-term clinical consequences are unknown.

C

D FIGURE 25.24  (A–D) Postoperative photos of dorsal and lateral hand.

• The patient is subsequently placed into a thumb spica cast and seen at 2- to 4-week intervals until healing is confirmed radiographically. • At 24 months’ follow-up (Fig. 25.24A–D), the patient demonstrates range of motion and radiographic evidence of healing after dorsal screw placement. See Video 25.1: Open Reduction and Internal Fixation of Acute Scaphoid Fracture Using a Dorsal Approach, on Expertconsult.Com.

EVIDENCE Chambers SB, Padmore CE, Grewak R, et al. The impact of scaphoid malunion on radioscaphoid joint contact: A computational analysis. J Hand Surg Am. 2020;45(7):610–618. This anatomic study investigated the biomechanical effects of scaphoid malunion with a computational analysis of 6 cadaveric scaphoid specimens. Scaphoid waist fractures with 2 mm of bone loss and

CHAPTER 25  Open Reduction and Internal Fixation of Acute Scaphoid Fracture various increments of angular deformity were simulated in the specimens. Angular deformities of 15 degrees or greater correlated significantly with increases in radioscaphoid joint contact area and ulnar translation of the center of the contact area. Daly CA, Boden AL, Hutton WC, et al. Biomechanical strength of retrograde fixation in proximal third scaphoid fractures. Hand (N.Y.). 2019;14(6):760–764. This biomechanical study compared fracture fixation strength between antegrade and retrograde compression screw techniques in scaphoid proximal pole fractures. Twenty-two matched cadaveric scaphoid specimens with proximal pole fractures were stabilized with variable pitch compression screws. There were no significant differences in screw length needed, load to failure, cycles to failure, or number of catastrophic failures between the antegrade and retrograde constructs. Dias JJ, Brealey SD, Fairhurst C, et al. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): A pragmatic, multicentre, open-label, randomised superiority trial. Lancet. 2020;396(10248):390–401. This randomized controlled trial involving 439 patients and 31 hospitals is the largest to date to compare operative and nonoperative management of scaphoid waist fractures. Patients with fractures displaced by equal to or greater than 2 mm were assigned to early operative management with a compression screw or nonoperative management in a below-elbow cast. Patients managed nonoperatively who showed evidence of nonunion between 6 to 12 weeks of follow-up promptly underwent surgical fixation. By 12 weeks after injury, there were no significant differences between the groups in terms of patient-reported outcomes, pain, range of motion, or grip strength. By final follow-up at 1 year, the number of nonunions and days of lost productivity did not differ significantly between groups. The number of potentially serious complications was significantly higher in the operative group (14%) compared with the nonoperative group (1%). This practice-changing study provides strong evidence for nonoperative management of scaphoid waist fractures displaced by less than or equal to 2 mm. Karl JW, Swart E, Strauch RJ. Diagnosis of occult scaphoid fractures: A cost-effectiveness analysis. J Bone Joint Surg Am. 2015;97(22):1860–1868. This cost-effectiveness study used decision analysis to compare three management strategies for suspected scaphoid fractures in the setting of initially negative radiographs. The three strategies simulated were (1) casting with repeat radiographs in 2 weeks, (2) immediate CT, and (3) immediate MRI. The prevalence of occult scaphoid fractures and costs of investigations, lost productivity and surgery were extrapolated from the literature. When factoring in the costs of lost productivity owing to immobilization, and long-term costs of missed fractures, symptomatic nonunion and additional surgeries, both advanced imaging strategies were found to be substantially less costly with better long-term outcomes than empiric immobilization. MRI was slightly more cost-effective than CT because of its superior diagnostic sensitivity and specificity. Morsy M, Sabbagh MD, van Alphen NA, et al. The vascular anatomy of the scaphoid: New discoveries using micro-computed tomography imaging. J Hand Surg Am. 2019;44(11):928–938. This anatomic study investigated the vascular anatomy of the scaphoid in 13 cadaveric specimens using micro-CT. Retrograde blood flow entering the scaphoid at the dorsal ridge was the dominant vascular network, accounting for 83% of the blood supply, whereas a secondary network of vessels entering the scaphoid volarly at the tubercle supplied the remainder of the bone in most specimens. Using 3D-printed renderings of each bone, it was extrapolated that a screw placed along the central axis of the scaphoid was least disruptive to the internal blood supply (14.5% disruption), followed by a dorsal/antegrade axis screw (16.3%), long axis screw (17.0%), and volar/retrograde axis screw (24.3%). Two distinct scaphoid phenotypes were found, with slender scaphoids being more vulnerable to disruption of the vasculature by screw fixation.

141

CHAPTER

26

Treatment of Scaphoid Nonunion Aviram M. Giladi and Kevin C. Chung Treatment of Scaphoid Nonunion INDICATIONS • Operative treatment of scaphoid nonunion varies based on the timing of the injury, bone loss at the fracture site, location of the fracture, presence of humpback deformity or an increased intrascaphoid angle, and the vascularity of the proximal pole. • Humpback deformity results from collapse of the distal pole of the scaphoid. Normal intrascaphoid angle is 30 degrees plus or minus 5 degrees. Humpback deformity is present when the intrascaphoid angle measured on lateral x-ray or computed tomography (CT) scan is greater than 35 degrees (Fig. 26.1). • Table 26.1 highlights our treatment algorithm for scaphoid nonunion based on specific fracture characteristics.

Contraindications Signs of radiocarpal or intercarpal arthritis, especially patterns indicative of scaphoid nonunion advanced collapse (SNAC; Fig. 26.2 and Table 26.2), often confirm that repair/reconstruction are no longer options and salvage should be considered.

CLINICAL EXAMINATION • The distal pole of the scaphoid may be tender to palpation, and axial compression of the thumb may reproduce the pain. • Nagging wrist pain or tenderness in the snuff box months after an injury may indicate a scaphoid fracture that has progressed to a nonunion. • Decreased wrist motion and grip strength are common findings in patients with a scaphoid nonunion. • If a patient continues to have radial-sided wrist pain with tenderness over the scaphoid in the anatomic snuff box despite prior treatment, this may reveal progression to nonunion.

> 35° 30° +/– 5

FIGURE 26.1  Intrascaphoid angle.

142

CHAPTER 26  Treatment of Scaphoid Nonunion

TABLE Treatment Algorithm for Scaphoid Nonunion Based on Specific 26.1 Fracture

Type of Fracture

Treatment

Delayed union (, 6 months)

Open reduction and internal fixation with headless compression screw

Established nonunion without humpback deformity

Open reduction and internal fixation with headless compression screw 1 bone graft (distal radius, iliac crest cancellous bone graft)

Nonunion with humpback deformity but no evidence of avascular necrosis

Open reduction via volar approach, corticocancellous bone graft

Avascular nonunion without humpback deformity

Vascularized bone graft, dorsal or volar approach

Avascular nonunion with humpback deformity

Vascularized medial femoral condyle bone graft via volar approach

Stage I

Stage II

Stage III

Stage IV

C Nonunion

S

SNAC

L Radius Radial styloid OA

Stage I+Scaphocapitate OA Stage II+Lunocapitate OA

Stage III+Radiolunate OA

Increased SL gap

SLAC

Radial styloid OA

Stage I+Proximal radioscaphoid OA

Stage II+ Stage III+Radiolunate OA Scaphocapitate/Lunocapitate OA

FIGURE 26.2  Scaphoid nonunion advanced collapse (SNAC).

IMAGING • A standard three-view wrist x-ray should be obtained. If present, the nonunion is often apparent (Fig. 26.3). • Bone loss, cyst formation, and degree of displacement should be noted. • Use the lateral view to approximate the lateral intrascaphoid angle to assess for collapse (Fig. 26.4; see also Fig. 26.1). • Evaluate for signs of SNAC wrist (posteroanterior [PA] view) and abnormal scapholunate angle (lateral view; see Table 26.2). • X-rays may show previously placed hardware. • CT and magnetic resonance imaging (MRI) can be useful adjuncts to clinical examination and standard x-ray. Humpback deformity, joint incongruity, and structure of the proximal pole are best appreciated on CT scan. MRI may be used to assess the vascularity of the proximal pole, although there remains no diagnostic gold standard for avascular necrosis (Fig. 26.5).

TABLE Stages of Scaphoid Nonunion 26.2 Advanced Collapse

Stage

Sites of Osteoarthritis

1

Radial styloid

2

Stage 1 & Scaphocapitate

3

Stage 2 & Lunocapitate

4

Stage 3 & Radiolunate

143

144

CHAPTER 26  Treatment of Scaphoid Nonunion

LISA

FIGURE 26.3  Three-view wrist x-ray. Arrow indicates site of scaphoid nonunion.

FIGURE 26.4  Lateral intrascaphoid angle (LISA).

FIGURE 26.5  Magnetic resonance imaging (MRI) assessment of proximal pole vascularity.

Ulna (Corticocancellous or Cancellous) Bone Graft INDICATIONS • Indications for ulna bone grafting: • Established nonunion with or without humpback deformity • No evidence of avascular necrosis of the proximal scaphoid pole • Minimal cystic change, displacement, or carpal malalignment

Contraindications Active smoking is a notable risk factor. We do not operate on patients who are current smokers because of the high risk for nonunion. Urine cotinine testing is obtained to clear a patient for surgery.

POSITIONING Both the ulna donor site and scaphoid recipient site are prepped and draped into the same operative field.

EXPOSURES • The decision to use a volar or dorsal approach to the scaphoid is guided by the location of the nonunion, the presence of humpback deformity, and the planned procedure. • A proximal nonunion is treated via a dorsal approach for better exposure and for the trailing screw head to purchase the proximal pole. • The volar approach improves visualization of more distal fracture/nonunion locations. • A notable humpback deformity is generally corrected via a volar approach.

CHAPTER 26  Treatment of Scaphoid Nonunion

FIGURE 26.6  Incision marking for volar approach.

A

B FIGURE 26.7  (A–B) Incision marking and exposure for dorsal approach.

• Recipient site: • For the volar approach, the scaphoid is exposed via a curvilinear wrist incision. This incision extends from the radial aspect of the thenar eminence, across the wrist, parallel and radial to the flexor carpi radialis (FCR) tendon (Fig. 26.6). • For a dorsal approach, a longitudinal or curved incision over the interval between the third and fourth extensor compartments (use Lister tubercle as a landmark) is used. Branches of the superficial radial nerve and the extensor pollicis longus tendon must be protected during this approach. • If using a corticocancellous graft, this incision can be somewhat limited (Fig. 26.7A–B). • If planning for vascularized bone options (see the section on “Pedicled Vascularized Bone Graft From Dorsal Distal Radius [1,2 Intercompartmental Supraretinacular Artery]”), a wider approach is used. • Donor site: A 5-cm longitudinal incision over the ulna, starting 1 cm distal to the olecranon, is used to expose the flat portion of the proximal ulna in preparation for bone graft harvest. The advantage of the proximal bone graft is that the exposure is relatively avascular and the bone is easily accessible. • Other graft sites (i.e., iliac crest) can also be used, but we prefer the ulna to keep the procedure to one surgical limb.

SURGICAL ANATOMY • The dominant blood supply to the scaphoid is via a branch from the radial artery that enters through the dorsal ridge and supplies 70% to 80% of the intraosseous vascularity to the proximal pole. This vessel and its branches enter distally and dorsally and travel retrograde through the scaphoid (Fig. 26.8). • The scaphoid proximal pole is uniquely susceptible to avascular necrosis after fracture because of the high dependence on a dominant retrograde-traveling intraosseous vessel. • A volar branch of the radial artery supplies 20% to 30% of the scaphoid in the region of the distal tuberosity.

145

146

CHAPTER 26  Treatment of Scaphoid Nonunion

Dorsal carpal branch

Superficial palmar branch

Radial artery

Dorsal

Volar FIGURE 26.8  Blood supply to the scaphoid.

• Corticocancellous bone is harvested from the ulna, just proximal to the tip of the olecranon. A 5-mm-wide by 10-mm-long by 5-mm-deep bone graft is usually all that is needed for the scaphoid, but up to 20 mm by 30 mm by 10 mm can be harvested as long as both cortices of the ulna are not violated. STEP 1 PEARLS

The LRL and a portion of the RSC ligament should be preserved to stabilize the proximal pole of the scaphoid and maintain reduction.

PROCEDURE Step 1: Debridement of the Scaphoid • The volar wrist incision is carried out through the skin and subcutaneous tissue. The FCR is identified and protected. • The FCR sheath is opened longitudinally and the FCR is retracted ulnarly. • The radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments are incised, and the joint capsule is entered, exposing the scaphoid. • The nonunion site is identified by passing a periosteal elevator between the proximal and distal fragments (Fig. 26.9). Fluoroscopy is used to confirm the nonunion site (Fig. 26.10A–B). • A curette or rongeur can be used to debride the scaphoid to healthy-appearing bone. Look for punctate bleeding as one potential indicator of healthy bone. Necrotic bone is typically whitish and hard, whereas the healthier bone has more of a porous, cancellous consistency.

Step 2: Ulna Bone Graft Harvest • A 5-cm longitudinal incision, centered over the proximal ulna, is performed 1 cm distal to the tip of the olecranon (Fig. 26.11).

FIGURE 26.9  Periosteal elevator identifies nonunion site.

CHAPTER 26  Treatment of Scaphoid Nonunion

A Ulna periosteum marked for bone graft harvest

FIGURE 26.12  Marking the periosteum to plan harvest.

FIGURE 26.11  Incision marking for ulnar graft harvest.

• The incision is continued to the level of the periosteum. • The amount of bone necessary to bridge the gap in the scaphoid after debridement should be estimated. This often is approximately 5 mm wide by 10 mm long by 5 mm deep. • The flat portion of the ulna, near the tip of the olecranon, should be used for the bone graft harvest. • The template is measured and marked on the ulna (Fig. 26.12). The periosteum overlying the graft is incised longitudinally and dissected carefully to facilitate reapproximation after graft removal. • A 5-mm osteotome can be used to harvest the bone graft. • To extricate the graft, a 45-degree osteotomy is performed, approximately 1 cm distal to the distal end of the graft. This will permit an osteotome to be introduced at approximately 5 mm deep within the cancellous bone of the ulna. The graft can be separated from the remaining cancellous bone by using a straight or curved osteotome (Fig. 26.13).

Step 3: Fixation of the Graft • If necessary, the graft is trimmed to fit within the gap in the scaphoid. • The cortical portion of the graft is positioned along the volar cortex of the scaphoid to resist compression.

FIGURE 26.13  Harvested bone graft.

B FIGURE 26.10  (A–B) Fluoroscopy confirms nonunion site.

STEP 2 PEARLS

Preserving periosteal flaps during the approach to the bone graft harvest site will permit reapproximation during closure.

147

148

CHAPTER 26  Treatment of Scaphoid Nonunion

A

B

C

FIGURE 26.14  (A) K-wire placed in scaphoid. (B–C) Fluoroscopy confirms Kirschner wire (K-wire) position.

STEP 3 PEARLS

• The wrist should be taken through range of motion (ROM) after placement of the K-wires/ screw to ensure that the graft is secure.

STEP 4 PEARLS

Because the skin overlying the olecranon is thin, permanent suture material to close the periosteum should be avoided because the knots will be palpable.

• With the graft in position, two 0.045-in (1.14-mm) Kirschner wires (K-wires) are used to secure the graft. • The K-wire enters the scaphoid along its distal tubercle and is directed through the graft toward the proximal ulnar corner of the scaphoid (Fig. 26.14A). • A second K-wire is directed collinearly to prevent rotation. • The position of the K-wires should be confirmed fluoroscopically (see Fig. 26.14B–C). • The K-wires are cut and buried under the skin for later removal. • If a cannulated screw is available, the screw can also be used for fixation. The initial K-wire should be the guidewire for the screw, and the screw, rather than K-wires, can then be used for internal fixation (Fig. 26.15).

Step 4: Closure • The wrist capsule is closed using 3-0 Ethibond sutures. • The periosteum of the elbow donor site is closed using 3-0 Vicryl suture. • The skin is closed with either 4-0 Monocryl or 4-0 polydioxanone (PDS).

FIGURE 26.15  Kirschner wire (K-wire) serving as a guidewire for cannulated screw fixation.

CHAPTER 26  Treatment of Scaphoid Nonunion

Pedicled Vascularized Bone Graft From Dorsal Distal Radius (1,2 Intercompartmental Supraretinacular Artery) INDICATIONS • Indications for pedicled vascularized bone graft: • Established nonunion without humpback deformity • If a humpback deformity is identified, a volar pedicled bone graft can be considered versus medial femoral condyle (MFC; see later section). • Evidence of avascular necrosis of the proximal scaphoid pole

POSITIONING • Both the distal radius donor site and scaphoid recipient site are prepped and draped into the same operative field.

EXPOSURES

EXPOSURES PEARLS

• A 6-cm curvilinear incision is designed over the dorsoradial wrist in preparation for scaphoid debridement and bone graft harvest (Fig. 26.16).

Branches of the superficial radial nerve should be identified and protected.

SURGICAL ANATOMY • Donor site: The vessels on the dorsal surface of the distal radius are described based on their relationship to the dorsal extensor compartments. The 1,2 intercompartmental, supraretinacular artery (1,2 ICSRA) lies between the first and second dorsal compartments, superficial to the extensor retinaculum, where it is closely adherent to the radius (Fig. 26.17A–B). • The 1,2 ICSRA branches from the radial artery approximately 5 mm proximal to the radiocarpal joint.

PROCEDURE

STEP 1 PEARLS

Step 1: Debridement of the Scaphoid • The dorsal curvilinear incision is made. Dissect down to the extensor tendons/retinaculum. • An incision between the second and fourth dorsal compartment tendons is used to expose the wrist capsule directly overlying the scaphoid. Identify the extensor pollicis longus tendon as it comes around the Lister tubercle and heads radially. Mobilize it radially to keep it out of the surgical field. • The tendons of the second and fourth compartments are identified and retracted, radially and ulnarly. • The dorsal wrist capsule is incised longitudinally, and the scaphoid nonunion site is identified (Fig. 26.18). A periosteal elevator is passed into the nonunion site. • Fluoroscopy can be used to confirm the position of the nonunion site (Fig. 26.19). • A curette or rongeur is used to debride the scaphoid to healthy-appearing bone.

A

FIGURE 26.16  Curvilinear incision marking for dorsal approach.

B

1,2 ICSRA

FIGURE 26.17  (A–B) Exposure and identification of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA).

Joystick 0.045-in (1.14-mm) K-wires can be placed within the proximal and distal scaphoid to distract the nonunion site and aid in debridement (Fig. 26.20).

149

150

CHAPTER 26  Treatment of Scaphoid Nonunion

Nonunion site

FIGURE 26.18  Identification of the scaphoid nonunion site.

FIGURE 26.19  Fluoroscopy confirms position of nonunion site.

Step 2: Bone Graft Harvest

FIGURE 26.20  Kirschner wires (K-wires) used to distract the nonunion site.

• The 1,2 ICSRA is identified and protected. Its periosteal attachments are seen approximately 10 to 15 mm proximal to the radiocarpal joint. • A template from the scaphoid bone gap is transposed to the distal radius, centered around the 1,2 ICSRA. • A #15 blade is used to incise the periosteum in preparation for osteotomy. • A 5-mm osteotome is used to harvest the bone from the distal radius. A curved osteotome can be used to complete the harvest at a depth of approximately 5 mm. • The pedicle and flap are dissected from proximal to distal, to the level of the radiocarpal joint, where the pedicle bifurcates from the radial artery. This permits adequate rotation into the scaphoid defect (Fig. 26.21).

Step 3: Tunneling the Graft • While avoiding tension on the pedicle or disruption of the periosteum, the bone flap is tunneled under the extensor tendons and placed into the scaphoid bony defect. • It is often necessary to trim the bone graft to permit correct placement (Fig. 26.22). • The cortical portion of the graft is positioned dorsally or radially to resist compression.

Step 4: Fixation of the Graft 1,2 ICSRA Graft

FIGURE 26.21  Dissection of the flap and pedicle.

STEP 2 PEARLS

• Care is taken to ensure that the periosteum remains adherent to the underlying bone graft. Disruption of the periosteum will limit or eliminate blood flow. • Flow to the bone graft can be confirmed by deflating the tourniquet. Nevertheless, we generally do not deflate the tourniquet to visualize bleeding of the bone graft, given that this procedure is not reversible after harvest. Therefore great care must be taken to not disrupt the pedicle and the periosteum on the bone, particularly during inset.

• After confirming the position of the graft visually and fluoroscopically, the bone is secured using two 0.045-in (1.14-mm) K-wires (Fig. 26.23A–B). • Before insetting the bone, cancellous bone is harvested from the radius to pack into the void in the excavated distal and proximal poles of the scaphoid. • The first K-wire can be driven from the proximal ulnar corner of the scaphoid and directly along its long axis toward the distal pole. • If a cannulated screw is available, this K-wire should be the guidewire for the screw.

STEP 4 PEARLS

The wrist should be taken through ROM after placement of the K-wires, with direct visualization of the inset flap to ensure that it is secure.

EPL FIGURE 26.22  Graft is tunneled under extensor tendons and placed into bony defect. EPL, Extensor pollicis longus.

CHAPTER 26  Treatment of Scaphoid Nonunion

A

B

FIGURE 26.23  (A–B) Kirschner wire (K-wire) fixation of the graft under fluoroscopy.

• A second K-wire is used to prevent rotation of the graft. This can be placed collinear to the first K-wire. • If being used as the primary modality for fixation (no screw available), the K-wires are cut and buried under the skin for later removal.

Step 5: Closure • The wrist capsule is closed using 3-0 Ethibond sutures. • The skin is closed with either 4-0 Monocryl or 4-0 PDS.

Pedicled Vascularized Bone Graft From Volar Distal Radius INDICATIONS • Indications for volar pedicled vascularized bone graft (flap): • Established nonunion with humpback deformity benefiting from volar approach to correct the deformity. • The volar approach is used to add structural bone to the volar cortex that has collapsed and foreshortened. • The bone graft harvest from the volar cortex of the radius has its structure and vascularity supported by the pronator quadratus muscle. • Evidence of avascular necrosis of the proximal scaphoid pole.

POSITIONING Both the distal radius donor site and scaphoid recipient site are in the same operative field.

EXPOSURES

EXPOSURES PEARLS

Step-cut of the RSC ligament (rather than longitudinal split) may facilitate repair/closure after the flap is mobilized into the wrist.

A 6-cm L-shaped incision is designed over the volar wrist/FCR in preparation for scaphoid debridement and bone graft harvest (Fig. 26.24).

SURGICAL ANATOMY • Donor site: The volar carpal artery runs along the volar aspect of the carpus from radial artery to ulnar artery. • Around 98% of the time, the connection from the radial artery is dominant. • Harvest site for flaps using the volar carpal artery are adjusted based on which side is dominant (Fig. 26.25). • Another option is to use a segment of the pronator quadratus as the vascular supply; for this procedure, the bone is harvested from the radial styloid base (Fig. 26.26).

PROCEDURE Step 1: Debridement of the Scaphoid • The volar incision is carried out over the scaphoid distally and radius proximally. • The FCR is identified and protected.

FIGURE 26.24  Incision marking for volar approach.

151

152

CHAPTER 26  Treatment of Scaphoid Nonunion

Ulnar artery

Radial artery

Volar carpal artery

A

B

FIGURE 26.25  (A-B) Volar carpal artery can receive dominant blood supply from radial or ulnar artery. From Elzinga K, Chung KC. Volar radius vascularized bone flaps for the treatment of scaphoid nonunion. Hand Clin. 2019;35(3):353–363.

Distal pronator quadratus contributes vascular supply to flap

FIGURE 26.26  Pronator quadratus can provide vascular supply for volar approach. From Elzinga K, Chung KC. Volar radius vascularized bone flaps for the treatment of scaphoid nonunion. Hand Clin. 2019;35(3):353–363. STEP 1 PEARLS

Joystick 0.045-in (1.14-mm) K-wires can be placed within the proximal and distal scaphoid to distract the nonunion site and aid in debridement.

• The FCR sheath is opened longitudinally and the FCR is retracted ulnarly. • The RSC and LRL ligaments are incised, and the joint capsule is entered, exposing the scaphoid. • Consider step-cut for the RSC to facilitate closure. • The nonunion site is identified by passing a periosteal elevator between the proximal and distal fragments. • If there is a notable humpback deformity, this must be corrected and confirmed with fluoroscopy.

Step 2: Bone Harvest • Decide on which volar flap to use; the leash on the pronator quadratus flap tends to be more limited than the volar carpal artery flap, but both are usually viable options. • If using a volar carpal artery flap, the artery is identified just distal to the margin of the pronator quadratus. • Mobilizing the most distal edge of the muscle proximally will help with exposure. • Identify which side of the artery appears dominant to decide which segment of bone to harvest.

CHAPTER 26  Treatment of Scaphoid Nonunion

FIGURE 26.27  Marking the bone harvest site and segment of the pronator quadratus.

• •

•

•

• If using the pronator quadratus flap, identify alignment of the oblique fibers to guide the muscle split. • Mark the bone harvest site and associated muscle (Fig. 26.27). • Bone harvest site is radial, proximal to the styloid tip, and volar to the abductor pollicis longus tendon. A template from the scaphoid bone gap is transposed to the distal radius at the desired bone flap harvest site. A #15 blade is used to incise the periosteum in preparation for osteotomy. • If using the volar carpal artery, a vascular clip may be needed for proper hemostasis of the segment not being used for the flap. A 5-mm osteotome is used to harvest the bone flap/graft from the distal radius. A curved osteotome can be used to complete the harvest at a depth of approximately 5 mm. The pedicle and flap are dissected as needed to allow for proper rotation. Cuts in the periosteum, especially around the branching site of the volar carpal artery, may be needed to optimize mobilization.

Step 3: Mobilize and Transpose the Bone • While avoiding tension on the pedicle or disruption of the periosteum, the bone flap is mobilized distally and placed into the scaphoid bony defect (Fig. 26.28). • It is often necessary to trim the bone to permit correct placement. • The cortical portion of the graft is positioned volarly to resist compression and add structure to the scaphoid.

Step 4: Fixation of the Graft This step was explained previously.

FIGURE 26.28  Mobilizing the bone graft distally into the scaphoid nonunion site.

153

154

CHAPTER 26  Treatment of Scaphoid Nonunion

Free Vascularized Medial Femoral Condyle INDICATIONS • Indications for free MFC vascularized bone graft/flap: • Established nonunion with humpback deformity • Evidence of avascular necrosis of the proximal scaphoid pole • Presence of scaphoid nonunion with a history of a failed nonvascularized bone graft • If no intrascaphoid collapse is present (humpback deformity), vascularized bone grafting can be attempted through a dorsal approach via a vascularized distal radius bone graft. • A volar approach is necessary when humpback deformity is present. If the proximal pole appears relatively well preserved and carpal alignment is not abnormal, a volar pedicled vascularized graft from the distal radius (see previous section) is an alternative to the MFC.

SURGICAL ANATOMY • Donor site: • Proximal to the adductor hiatus, the superficial femoral artery gives off the descending genicular artery. The descending genicular artery travels distally and gives off saphenous and muscular branches. The superior medial genicular artery arises from the superficial femoral artery more distally. • The descending genicular artery and superior medial genicular artery continue distally, penetrate the bone, and provide the blood supply to the medial femoral condyle as intraosseous nutrient vessels. • Blood supply to the medial femoral condyle skin flap is provided by the saphenous branch of the descending genicular artery (Fig. 26.29).

POSITIONING • The recipient site is prepared under tourniquet control of the upper extremity. • The ipsilateral knee is maintained in slight flexion and abduction to access the medial femoral condyle. A sterile tourniquet is placed on the thigh, near the groin crease, in preparation for graft harvest.

EXPOSURES • The scaphoid and radial arteries are exposed via a curvilinear volar wrist incision extending from the radial aspect of the thenar eminence, across the wrist, parallel and radial to the FCR tendon (Fig. 26.30).

Descending genicular artery

Femur Superficial femoral artery Saphenous branch of descending genicular artery

Tibia

Medial collateral Superficial medial ligament genicular artery

FIGURE 26.29  Vascular supply to the femoral condyle.

CHAPTER 26  Treatment of Scaphoid Nonunion

FIGURE 26.30  Volar wrist incision marking. FIGURE 26.31  Incision marking for medial femoral condyle exposure.

• Exposure of the medial femoral condyle and its pedicle is achieved using an approximately 20-cm incision on the distal medial thigh, along the midaxis of the femur, up to the joint line of the knee (Fig. 26.31).

TEAM 1: DONOR SITE (BONE GRAFT HARVEST)

EXPOSURES PEARLS

This procedure can be performed with two teams simultaneously.

STEP 3 PEARLS

Step 1: Identification of the Medial Thigh Structures The femur, patella, and femoral-tibial joint line of the ipsilateral lower medial thigh are marked. The incision should be approximately 20 cm, centered on the midaxis of the femur starting from the femoral-tibial joint line. Wide exposure helps facilitate clean dissection of the pedicle.

There is a bloodless, loose areolar plane between the VM and the descending genicular vascular pedicle.

Step 2: Expose the Vastus Medialis

The radial artery travels in close proximity to the volar scaphoid; therefore a long pedicle is often unnecessary. Using a shorter pedicle can limit dissection time.

Skin, subcutaneous tissue, and the fascia of the vastus medialis (VM) are incised, exposing the underlying muscle (Fig. 26.32).

STEP 4 PEARLS

Step 3: Anterior Elevation of the Vastus Medialis The posterior border of the VM muscle is identified and elevation is carried out from posterior to anterior, exposing the descending genicular vessels (Fig. 26.33).

Step 4: Mobilize the Pedicle Identify the descending genicular artery and its periosteal extensions. After determining the area on the medial femoral condyle that will be used for bone grafting, dissect the pedicle proximally to obtain approximately 5 cm of length (Fig. 26.34).

Vastus medialis

Descending genicular artery

FIGURE 26.32  Exposure of vastus medialis.

FIGURE 26.33  Exposure of descending genicular artery.

155

156

CHAPTER 26  Treatment of Scaphoid Nonunion Descending genicular artery

Harvest site

FIGURE 26.35  Harvested bone flap.

FIGURE 26.34  Descending genicular artery and harvest site.

STEP 5 PEARLS

• The medial collateral ligament of the knee should be identified and protected. • Because the avascular scaphoid often does not have sufficient cortical bone strength to buttress the bony defect, the bone graft must have an adequate amount of cortical bone. The MFC bone graft provides structure, not constrained by the pedicle length (unlike the radius pedicle graft) and an abundance of vascularity, provided that the vascular anastomosis is patent, which requires fine microsurgical expertise. STEP 5 PITFALLS

Excessive harvest of cancellous bone from the femur risks weakening the bone to torsional forces; avoid excess harvest of additional cancellous bone after MFC flap harvest.

Step 5: Design the Bone Flap Harvest Based on the amount of scaphoid bone loss, a rectangular corticocancellous flap is designed around the nutrient branches and periosteal extensions of the descending genicular artery. An approximately 5-mm-wide by 10-mm-long by 5-mm-deep corticocancellous segment is needed after debridement of the scaphoid (Fig. 26.35). Additional cancellous bone graft can be harvested from the femur to pack around the vascularized graft.

Step 6: Harvesting the Bone • The markings on the periosteum are incised. • A 5-mm osteotome is used to harvest the bone graft. To assist with final extrication and to minimize the risk for fracture, a separate 45-degree osteotomy is performed just distal to the marked flap. This facilitates precise osteotomy of the deep margin (Fig. 26.36).

STEP 6 PEARLS

Meticulous dissection of the pedicle and of the periosteum, proximal to the flap, will aid harvest.

FIGURE 26.36  Illustration of harvesting vascularized bone graft.

CHAPTER 26  Treatment of Scaphoid Nonunion

FIGURE 26.37  Closure of leg donor site.

Step 7: Ligation of the Vascular Pedicle • When adequate length has been confirmed, the proximal vascular pedicle is ligated, and the graft is prepared for anastomosis at the wrist. • Hemostasis is achieved, and the leg donor site is closed in layers over a closed suction drain (Fig. 26.37).

TEAM 2: PREPARATION OF THE RECIPIENT SITE Step 1: Exposure of the Scaphoid

STEP 1 PEARLS

• Preserving much of the LRL and a portion of the RSC ligament will help stabilize the proximal pole and maintain reduction. • Volar capsulotomy of the scaphotrapezial joint will improve visualization of the scaphoid (Fig. 26.38). • Fluoroscopy is used to confirm the nonunion site.

• The incision is carried out along the radial border of the thenar eminence, across the wrist and parallel to the FCR tendon. • If the patient has had prior surgery, that scar may dictate the location of the incision. • The FCR sheath is opened longitudinally and the FCR is retracted ulnarly. • The RSC and LRL are incised and the joint capsule is entered, exposing the scaphoid.

Step 2: Debridement of the Scaphoid Nonunion • After careful exposure of the scaphoid, the nonunion is debrided back to healthy bleeding bone of the distal pole. A small curette or rongeur is used for debridement of fibrous tissue. • The scaphoid articulations must be examined for the presence of arthritis. Careful attention must be paid to the radioscaphoid and midcarpal joints. Care is taken to not perforate the cortical shell of the proximal pole of the scaphoid during the debridement.

FIGURE 26.38  Volar capsulotomy of the scaphotrapezial joint to facilitate visualizing the scaphoid.

Step 3: Measurement of the Bony Defect

STEP 2 PEARLS

After careful debridement, the size of the bony defect is measured and used as a template for bone flap harvest (Fig. 26.39).

• Joystick 0.045-in (1.14-mm) K-wires can be placed within the proximal and distal scaphoid to distract the nonunion site and aid in debridement. • A slow-speed bur can be used to aid in debridement; however, the scaphoid must be continuously irrigated to prevent further necrosis.

Bony defect

FIGURE 26.39  Size of bony defect determines size of bone flap harvest.

STEP 3 PEARLS

• Err on harvesting a slightly smaller bone flap rather than one that is too large. This will permit easier placement within the scaphoid recipient site and reduce time spent on contouring (and the risk for injury to the blood supply). • Cancellous bone can be harvested from the donor site to pack into the crevices of the scaphoid defect. Time is often wasted on contouring a large bone graft when a slightly smaller bone graft will fit more easily into the scaphoid defect.

157

158

CHAPTER 26  Treatment of Scaphoid Nonunion

Step 4: Correction of the Dorsal Intercalated Segment Instability Deformity • Under fluoroscopic guidance, the dorsal intercalated segment instability (DISI) deformity is corrected by flexing the wrist until the radiolunate angle is neutral (Fig. 26.40). • A K-wire can be placed from the radius to the lunate to maintain the lunate in neutral posture.

Step 5: Preparation of Recipient Vessels to Accept the Graft Radiolunate angle (0–15°)

• The radial artery is dissected radial to the FCR during initial exposure. Meticulous dissection and identification of its venae comitantes should be performed. • One end-to-end venous anastomosis will be performed to an associated vena comitante. The most suitable recipient vessel is chosen based on size match. • End-to-side anastomosis is performed to the radial artery.

Step 6: Fixation of the MFC

FIGURE 26.40  Dorsal intercalated segment instability (DISI) deformity correction. STEP 6 PEARLS

The cortical surface of the graft is directed volarly to resist compression and to correct the humpback deformity.

• The bone flap is contoured to fit into the scaphoid defect (Fig. 26.41A) and secured using either buried K-wires (see Fig. 26.41B) or a headless compression screw. • The benefit of K-wires is ease of placement. One K-wire should be directed along the long axis of the scaphoid. The K-wire enters the scaphoid, centered on the distal pole, and is directed toward the proximal ulnar corner. An additional K-wire can be placed collinearly to prevent rotation. Alternatively, K-wires can be directed obliquely to secure the graft. • If available and the surgeon has familiarity with the hardware, a cannulated screw can provide excellent fixation. This has become the preferred option for many surgeons who perform this procedure. • Reduction of the scaphoid and correction of the DISI deformity must be confirmed during and after fixation.

Step 7: Microsurgical Anastomosis STEP 7 PEARLS

Although one venous anastomosis is sufficient, a second anastomosis may be performed to improve venous outflow.

• The descending genicular artery is anastomosed to the radial artery in end-to-side fashion using 9-0 nylon sutures. • The venae comitantes of the donor and recipient pedicles can be anastomosed in end-to-end fashion with 9-0 or 10-0 nylon.

Step 8: Closure • Because of the microvascular anastomosis, the joint capsule cannot be closed. • The skin is closed over the vessels using 4-0 nylon suture.

A

B FIGURE 26.41  (A) Bone flap placed into scaphoid bony defect. (B) Reduction of scaphoid confirmed with fluoroscopy.

CHAPTER 26  Treatment of Scaphoid Nonunion

• Because no postoperative monitoring is used with the anastomoses under the skin closure, perfect anastomoses and robust flow in the pedicle must be assured before skin closure.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

POSTOPERATIVE PEARLS

• The patient is placed in a thumb spica splint with the thumb palmarly abducted and the wrist neutral to slightly flexed for 2 weeks until the wound is examined and sutures are removed. A monitoring window can be fashioned to allow for nursing assessment of Doppler tones and early detection of vessel thrombosis. • After examining the wound, a short-arm thumb spica cast is placed and left on for 8 to 12 weeks until union is confirmed radiographically. • If an ulna bone graft has been performed, a bulky, soft dressing is placed, and the patient is encouraged to move the elbow to prevent stiffness. Weight restriction, through the elbow, is limited to 1 to 2 pounds until union of the scaphoid is confirmed. • If an MFC flap has been performed, the knee and medial thigh are protected with a soft, bulky dressing. The knee may be immobilized in the immediate postoperative period for patient comfort, but we encourage gentle early use whenever possible. • The patient is allowed to ambulate immediately after the procedure but should be informed that pain may persist for several weeks. • Fig. 26.42A–B shows 5-month postoperative x-rays after an MFC flap. See Video 26.1, 26.2 and 26.3.

Many surgeons use CT scans to confirm union before allowing the patient to begin active motion therapy. Generally, this scan is obtained 3 months after surgery as long as the x-ray shows encouraging progress.

A

B FIGURE 26.42  (A–B) 5-month postoperative x-rays.

159

160

CHAPTER 26  Treatment of Scaphoid Nonunion

EVIDENCE Al-Jabri T, Mannan A, Giannoudis P. The use of the free vascularized bone graft for nonunion of the scaphoid: A systematic review. J Orthop Surg Res. 2014;1:9–21. Twelve articles met inclusion criteria, which detailed 245 cases of scaphoid nonunion. Fifty-six patients underwent vascularized bone grafts from the medial femoral condyle with reported union rate and correction of humpback deformity in all patients. One hundred eighty-eight patients underwent vascularized bone grafting from the iliac crest with a reported union rate of 87.7%. The authors concluded that the rate of union was significantly different (P = 0.006) in favor of the medial femoral condyle donor site. Chang MA, Bishop AT, Moran SL, Shin AY. The outcomes and complications of 1,2 intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am. 2006;31:387–396. In this retrospective review, the authors treated 50 scaphoid nonunions with 1,2 ICSRA vascularized bone grafts. Thirty-four of 50 patients (68%) went on to radiographic union at an average of 15.6 weeks. Complications occurred in 8 patients (16%). Univariate analysis demonstrated that older age, proximal pole avascular necrosis, humpback deformity, nonscrew fixation, tobacco use, and female gender were all associated with a higher rate of complications. Jones Jr. DB, Burger 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;90:2616–2625. The authors retrospectively reviewed consecutive cases of scaphoid nonunion and carpal collapse in which patients were treated with either vascularized bone from the distal radius or MFC flap. Twentytwo patients were identified. Four of the twelve patients treated by distal radius pedicled flap went on to union at a median of 19 weeks. All 12 nonunions treated with MFC flap went on to union at a median of 13 weeks. They determined that rate of union was significantly higher (P = 0.005) and the time to union was significantly shorter (P < 0.001) in favor of the MFC group.

CHAPTER

27

Salvage Procedures for Scaphoid Nonunion Aviram M. Giladi and Kevin C. Chung Scaphoidectomy and Four-Corner Fusion INDICATIONS • Proximal row carpectomy (PRC) and scaphoidectomy with four-corner fusion (4CF) are motion-preserving salvage operations for patients with proximal wrist degeneration or advanced ligamentous injury. • There are variations on the 4CF involving different intercarpal (two bone, three bone) fusions; however, the only “partial wrist fusion” technique we will discuss in this chapter is the traditional 4CF. • Examples of pathology or surgical diagnoses include: • Static scapholunate instability • Scaphoid nonunion advanced collapse (SNAC), stage 1 or mild stage 2 • Scapholunate advanced collapse (SLAC), stage 1 or 2 • Kienbock, stage 3b or 4 • Indications for PRC and 4CF are similar, but the midcarpal joint must be preserved (most notably the capitate articular surface) for PRC. • Compared with 4CF, PRC does not require hardware or osseous union. • The option for total wrist arthrodesis is preserved with either procedure. • In elderly, low-demand patients, nonoperative management with splinting and nonsteroidal antiinflammatory drugs (NSAIDs) should be attempted even for advanced degenerative changes. Surgery is reserved for failure of nonsurgical management and intractable pain. • For the younger, higher-demand patient, some believe that surgery may prevent further progression of arthritis.

Contraindications • Notable arthritic degeneration of the proximal capitate is a contraindication for PRC. • Notable arthritic degeneration of the lunate facet of the radius is a contraindication for PRC and 4CF. • Ulnar translation of the carpus seen on posteroanterior (PA) x-ray may indicate ligamentous laxity and instability of PRC. • Traditionally, surgeons have avoided PRC in younger patients or patients who perform heavy manual labor; however, a growing body of evidence supports use of PRC in these patients as well.

CLINICAL EXAMINATION • A thorough wrist examination is necessary, including range of motion, locations of point tenderness, and any soft-tissue abnormalities. • The wrist should be examined dorsally and volarly with direct palpation over bone intervals to identify pain and inflammation. • Check for tendon excursion because the overall kinematics at the wrist can change with shortening. • A predictable pattern of wrist arthritis develops with untreated scaphoid nonunion or static scapholunate instability, termed scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC), respectively (Fig. 27.1). • Degenerative changes of the radioscaphoid articulation are common because of the incongruent shape of the scaphoid fossa on the scaphoid with positional change and uneven loading. The lunate fossa is resistant to degenerative change because of the spherical shape that remains congruent with loading in all positions of the wrist. 161

162

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion Stage I

Stage II

Stage III

Stage IV

C Nonunion

S

SNAC

L Radius Radial styloid OA

Stage I+Scaphocapitate OA Stage II+Lunocapitate OA

Stage III+Radiolunate OA

Increased SL gap

SLAC

Radial styloid OA

Stage I+Proximal radioscaphoid OA

Stage II+ Stage III+Radiolunate OA Scaphocapitate/Lunocapitate OA

FIGURE 27.1  Scaphoid nonunion advanced collapse (SNAC) and scapholunate advanced collapse (SLAC).

• Patients are often seen for persistent wrist pain, and the diagnosis is confirmed radiographically or arthroscopically. • With stage III SNAC or SLAC arthritis, partial wrist fusion/4CF is preferred over a proximal row carpectomy (PRC) because the capitolunate articulation has been affected. Removal of the proximal row will result in contact of the arthritic capitate on the lunate fossa of the radius and will lead to continued pain.

IMAGING • Standard PA, oblique, and lateral x-rays of the wrist should be obtained (Fig. 27.2A–C). These views are often sufficient for diagnosing wrist arthritis and confirming whether or not the capitolunate or radiolunate articulations are affected. • Ulnar translation of the carpus suggests that the palmar extrinsic wrist ligaments are stretched and may not reliably support PRC.

A

B

C

FIGURE 27.2  (A–C) Posteroanterior, oblique, and lateral x-rays of the wrist.

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

• Advanced imaging such as computed tomography (CT) can be used to determine the status of the midcarpal joint; however, most surgeons do not find this necessary. • Arthroscopy is the reference standard for diagnosing and characterizing the degree of wrist articular wear and can be used to guide the treatment algorithm if x-rays are unclear; however, patients are made aware preoperatively that an intra-operative decision to convert to a limited wrist fusion can be made if there is excessive, unrecognized midcarpal joint degenerative change.

SURGICAL ANATOMY • The volar extrinsic ligaments (radioscaphocapitate, short and long radiolunate) originate from the volar radius and extend obliquely to the carpus. These should be left intact. Attenuation, insufficiency, or iatrogenic injury may lead to ulnar translation and instability, especially after PRC (Fig. 27.3). • The dorsal ligaments of the wrist—dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) have a conjoined insertion on the triquetrum. They provide the capsulotomy landmarks for ligament-sparing wrist exposure (Fig. 27.4). • The posterior interosseous nerve can be found on the floor of the fourth dorsal compartment. Distal neurectomy at the wrist can be performed to aid in postoperative pain control.

EXPOSURES • A longitudinal, 6-cm incision is centered over the third metacarpal, just ulnar to the Lister tubercle (Figs. 27.5 and 27.6). Flaps are elevated sharply at the level of the extensor retinaculum, with care taken to not injure the dorsal sensory nerves. • Dissection is carried out to the extensor retinaculum and the extensor pollicis longus (EPL) is identified within its third dorsal compartment. • An incision is made between the second and fourth dorsal compartments and the EPL is transposed radially. • If wider exposure is needed, especially for 4CF, elevate retinacular flaps radially and ulnarly, through the intercompartmental septae for the second through fifth dorsal compartments. This exposes the contents of these compartments but keeps the dorsal retinaculum intact as a “roof” that can be repaired later.

Td CH C TC TT Tm H T TH SC S TC P RSC L LRL UT UC UL SRL PRU R

U AIA

DIC DRC

RA

FIGURE 27.3  Volar extrinsic ligaments. AIA, Anterior interosseous artery; C, capitate; CH, capitohamate; H, hamate; L, lunate; LRL, long radiolunate; P, pisiform; PRU, palmar radioulnar; R, radius; RA, radial artery; RSC, radioscaphocapitate; S, scaphoid; SC, scaphocapitate; SRL, short radiolunate; T, triquetrum; TC, trapeziocapitate; Td, trapezoid; TH, triquetrohamate; Tm, trapezium; TT, trapezium-trapezoid; U, ulna; UC, ulnocapitate; UL, ulnolunate; UT, ulnotriquetral.

FIGURE 27.4  Dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments.

163

164

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion Lister tubercle Dorsal ulnar sensory n.

FIGURE 27.5  Longitudinal incision marking.

Dorsal radial sensory n. FIGURE 27.6  Incision lies ulnar to the Lister tubercle.

EXPOSURES PEARLS

• Identify and avoid branches of the superficial radial nerve. • The dorsal capsular ligaments are more prominent with the wrist in flexion. Placing a green towel bump under the wrist can help with visualization. Additionally, separation of fibrofatty tissue off the surface with a sponge can be useful to better visualize the ligament fibers. • For the ligament-sparing approach, leave a cuff of ligament along the radius rim for capsular repair. This cuff should be small enough, however, so that there is adequate exposure of the proximal carpal row.

S L

FIGURE 27.7  Exposure of the proximal carpal row. L, Lunate; S, scaphoid.

STEP 1 PEARLS

• A 0.062-inch (1.57-mm) joystick Kirschner wire (K-wire) can be used to aid in manipulating the scaphoid. • If the scaphoid is unhealthy (scaphoid nonunion), distal radius, iliac crest, or cancellous bone allograft can be used to aid in fusion of the remaining carpal bones. STEP 1 PITFALLS

• Careful dissection of the volar capsule should be performed to preserve the radioscaphocapitate and long radiolunate ligaments. • The radiolunate articulation must not be injured during removal of the scaphoid. • The radial artery is in relatively close proximity during this dissection, so caution must be taken to not injure the artery, especially during the volar dissection.

• The wrist can be entered in two different ways: • Continuing the longitudinal incision through the dorsal wrist capsule exposes the proximal carpal row (Fig. 27.7). • For a “ligament-sparing approach,” a radially based dorsal capsular flap is designed over the proximal carpal row. This is then incised along the DIC and DRC ligaments (Fig. 27.8A–B). • Once the wrist is exposed, inspect the capitolunate and radiolunate articulations to confirm which procedure is appropriate.

FOUR-CORNER FUSION WITH CIRCULAR PLATE Step 1: Removal of the Scaphoid • The dorsal scapholunate ligament is sharply incised and the scaphoid is separated from the lunate. A scalpel or a periosteal elevator can be used to free the scaphoid from its attachments to the volar wrist capsule (Fig. 27.9). • Ideally, the scaphoid is removed in one piece (Fig. 27.10). Alternatively, a rongeur can be used to remove the scaphoid segmentally. • The scaphoid can be morselized and used for bone graft if the bone quality is good.

Step 2: Reduction of the Lunate • A 0.062-inch (1.57-mm) joystick K-wire can be used to reduce the lunate into neutral position from its extended posture. • Because the lunate is extended in a dorsal intercalated segment instability (DISI) deformity, the K-wire should be placed from proximal to distal on the lunate.

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

A

B

FIGURE 27.8  (A–B) Dorsal capsular flap for a ligament-sparing approach.

Scaphoid excised

FIGURE 27.9  Freeing the scaphoid from attachments to the volar wrist capsule.

FIGURE 27.10  Removal of the scaphoid.

• The K-wire can then be flexed maximally toward the fingers, bringing the lunate to neutral with respect to the long axis of the radius. • After confirming the position of the lunate radiographically (Fig. 27.11A), another K-wire can be passed from the radius into the lunate to maintain reduction (see Fig. 27.11B).

Step 3: Stabilize the Remaining Carpal Bones After confirming neutral reduction of the lunate, the remaining carpal bones can be held in alignment using additional 0.045-inch (1.45-mm) K-wires (Fig. 27.12).

STEP 2 PEARLS

• Reducing the lunate to neutral position is critical. If the lunate is fixed in dorsal posture, wrist flexion will be reduced after the fusion. • Wrist flexion can help present the lunate properly for guidewire placement. STEP 3 PEARLS

The K-wires should be positioned volarly within the carpal bones to avoid interfering with the reamer.

165

166

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

Joystick

S Radiolunate K-wire used to stabilize the lunate in neutral position

T L

B

A

FIGURE 27.11  (A) Fluoroscopy confirms reduction of lunate. (B) Second Kirschner wire passes from radius to lunate, stabilizing the lunate.

T

H L

FIGURE 27.12  Stabilizing the remaining carpal bones.

STEP 4 PITFALLS

Reaming must be deep enough to permit placement of the entire circular plate beneath the dorsal cortices of the carpal bones. Failure to do so may result in impingement of the plate on the distal radius. STEP 5 PEARLS

• Continuous irrigation of the bones while burring will limit heat-induced necrosis at the fusion site. • Meticulous removal of cartilage is necessary to optimize fusion rate.

C

FIGURE 27.13  Carpal bones to be reamed. C, Capitate; H, hamate; L, lunate; T, triquetrum.

Step 4: Ream the Carpal Bones in Preparation for Plate Placement The reamer is centered over the four carpal bones, and the dorsal surface is reamed until the dorsal surfaces of the carpal bones lie within the two lines on the reamer (Figs. 27.13 and 27.14).

Step 5: Remove the Cartilage Between the Four Carpal Bones Using a side-cutting bur, remove the cartilage from the four adjacent carpal bones between which fusion is desired (Fig. 27.15).

Step 6: Packing of Bone Graft Cancellous bone or bone allograft should be placed between the bones before application of the plate.

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

Reamed bone

Placement of reamer

Two lines on the reamer head FIGURE 27.15  After dorsal central reaming, the cartilage between reamed carpal bones has now also been removed.

FIGURE 27.14  Placement of reamer.

Step 7: Placement of the Circular Plate • The correctly sized plate is placed within the reamed dorsal surface. According to the manufacturer’s guidelines, screws are placed into the four carpal bones. The Acumed Hub Plate recommends fixation of the hamate first, followed by the lunate, capitate, and triquetrum. After placing one screw into each bone, additional screws may be placed into the remaining holes. • The Acumed system uses a 2.0-mm drill bit and 2.7-mm self-tapping screws. The holes should be drilled to the subchondral bone of the far cortex but avoid bicortical drilling.

STEP 7 PEARLS

Do not overtighten the hamate screw until the lunate screw has been positioned. After these two screws have been placed, they should be tightened sequentially to flatten the plate and ensure that it does not remain prominent.

Step 8: Placement of the Plate Cover The central hole of the plate can be packed with additional bone graft, after which the screw cover is placed (Fig. 27.16).

Step 9: Final Fluoroscopic Confirmation Final fluoroscopic assessment should confirm proper placement of screws, and range of motion should be free of impingement on the distal radius (Fig. 27.17A–B).

FIGURE 27.16  Placement of circular plate.

A

B

FIGURE 27.17  (A–B) Fluoroscopy confirms placements of circular plate.

167

168

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

FIGURE 27.18  Dorsal wrist capsule is closed.

Step 10: Closure

STEP 3 PEARLS

• Continuous irrigation while burring will limit heat-induced necrosis of bone at the fusion site. • Meticulous removal of the articular cartilage will increase predictability of union.

• The dorsal wrist capsule is closed using 3-0 Ethibond suture (Fig. 27.18), after which the tourniquet is deflated to ensure hemostasis. • The extensor retinaculum is closed using 3-0 Ethibond. The skin can be closed with 4-0 Monocryl or 4-0 polydioxanone (PDS). • A well-padded dressing and plaster splint are applied. A volar resting splint to the level of the metacarpophalangeal (MCP) joints is adequate. • The wrist should be splinted for at least 6 weeks to permit the carpal bones to fuse.

FOUR-CORNER FUSION WITH KIRSCHNER WIRES Step 1 See previous section.

Step 2 See previous section.

Step 3 Using a rongeur or a small bur, the cartilage surfaces of the capitate, lunate, hamate, and triquetrum are removed in preparation for fusion.

Step 4: K-Wire Fixation of Fusion Mass

STEP 4 PEARLS

• Cancellous autograft or allograft is packed between the bones, after pinning, to promote union. • Bury K-wires to reduce the risk for pin tract infection.

• 0.062-inch (1.57-mm) K-wires are used to immobilize the carpal bone mass to promote fusion. • K-wires should be driven across the lunotriquetral and capitolunate intervals (Fig. 27.19A–B). A third K-wire can be passed from the triquetrum to the capitate. • The starting point for the capitolunate wire can be directly visualized within the surgical field. Start at the capitate waist and drive toward the proximal ulnar corner of the lunate. • The triquetrolunate wire is started percutaneously at the midportion of the triquetrum. Direct this wire toward the proximal radial corner of the lunate. • Choose a similar starting point for the triquetrocapitate wire. Drive this wire perpendicular to the long axis of the forearm to capture the proximal capitate.

Step 5: Closure See Step 10 in the previous section.

FOUR-CORNER FUSION WITH CANNULATED HEADLESS COMPRESSION SCREWS Step 1 See previous section.

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

A

B

FIGURE 27.19  (A–B) Kirschner wire fixation of fusion mass.

Step 2

STEP 3 PEARLS

See previous section.

• Continuous irrigation of the bones while burring will limit heat-induced necrosis of bone at the fusion site. • Meticulous removal of the articular cartilage will increase predictability of union.

Step 3 Using a rongeur or a small bur, the cartilage surfaces of the capitate, lunate, hamate, and triquetrum are removed in preparation for fusion.

Step 4: K-Wire Placement to Guide Screws for Fusion • 0.062-inch (1.57-mm) K-wires are used to immobilize the carpal bone mass and guide screw placement. • At the end of wire placement, confirm that the lunate is properly positioned on the radius and the capitate is well reduced/positioned on the lunate. • We prefer to place all wires before any screws are drilled/placed. • Many different screw combinations have been reported: • All techniques use a capitolunate screw (Fig. 27.20). • This screw can be placed distal to proximal, or proximal to distal. • One or two screws can be used for this fusion site.

Scaphoid removed

FIGURE 27.20  Cannulated headless compression screws fuse the capitate and lunate. (Fig. 12.29 from Rizzo M. Wrist arthrodesis and arthroplasty. In: Wolfe S, Pederson W, Hotchkiss R, Kozin S, Cohen, M, eds. Green’s Operative Hand Surgery. 7th ed. 2016; Elsevier: 373–417).

169

170

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

STEP 1 PEARLS

• If minor arthrosis is present on the proximal capitate or within the lunate fossa, a capsular interposition arthroplasty can be considered. This does require a different approach to the carpus than previously described so that a dorsal capsular flap that is attached to the radius (proximally based) can be created. • Osteochondral resurfacing has also been described as an adjunctive procedure with PRC for capitate chondrosis. An osteochondral graft is obtained from the excised carpus, usually the lunate, and inserted into the defect created after excising the area of cartilage loss (limited to a single area ,10 mm in diameter). STEP 2 PEARLS

• Preserve the volar ligaments and avoid injury during lunate excision. • It is generally easier to completely remove the lunate en bloc with careful circumferential dissection rather than using a piecemeal technique with a rongeur.

STEP 2 PITFALLS

Injuring the volar extrinsic ligaments can lead to postoperative wrist instability and carpal ulnar translation.

• Most advocate for a triquetrohamate screw. • Some position this screw to also include the capitate. • Some will also add a lunotriquetral screw, but others have reported that this screw is not needed if there is good capitolunate and triquetrohamate compression screw placement. • Capitolunate screw: • If driving the capitolunate screw from distal to proximal, start at the distal dorsal capitate and drive toward the proximal ulnar corner of the lunate. • If going from proximal to distal, start relatively centrally on the lunate. • Some authors advocate placing a second smaller screw across this interval if needed. • Triquetrohamate screw is generally placed proximal to distal. • If a lunotriquetral screw is desired, consider volar/dorsal positioning when placing the capitolunate and triquetrohamate screws (ideally aim both volar or both dorsal in the proximal row bones so there is adequate space for the third screw).

Step 5: Place the Screws • Before screw placement, pack the intercarpal intervals with autologous or allograft cancellous bone graft. • Place the headless compression screws. • We prefer to start with the capitolunate screw. • Depending on the hardware system chosen, follow the appropriate instructions for the screw of choice. We prefer using a fully threaded headless compression screw system. • Confirm visually and radiographically that the construct is secure, and screws are not proud at any of the remaining articular surfaces. • Pack additional bone graft as needed in the fusion sites.

Step 6: Closure See Step 10 under “Procedure: Four-Corner Fusion With Circular Plate.”

PROXIMAL ROW CARPECTOMY Step 1: Inspect the Joint Surface The lunate fossa and the proximal capitate should be intact before proceeding with PRC.

Step 2: Excision of the Lunate STEP 3 PITFALLS

• Care should be taken in areas that are difficult to visualize. Avoiding injuries to the volar extrinsic ligaments, radial artery, and the proximal head of the capitate are the keys to the procedure. • During triquetrum excision, the ulnar nerve, artery, and ulnar dorsal sensory branch lie in close proximity. • En bloc resection assures no bone fragments are left in the wrist. A sharp-edged freer is helpful to detach the volar capsule from the carpal bones. STEP 4 PITFALLS

• Radial stylocarpal impingement may persist if the radiocarpal joint is not decompressed by styloidectomy. • When performing the styloidectomy, a short oblique osteotomy of 3 to 4 mm or less is ideal to avoid injury to the radioscaphocapitate ligament that inserts around 4 mm from the tip of the styloid (Fig. 27.24).

• The lunate and the scaphoid are identified (Fig. 27.21). • K-wire joysticks can be placed into the scaphoid and the lunate to help maneuver the bones while performing soft tissue dissection. • Attention is first turned to the lunate. The lunotriquetral and scapholunate ligaments, or scarring from a previous injury, are divided. • The K-wire in the lunate can then be turned to enable direct dissection of the volar ligaments off of the lunate. • The lunate is then excised entirely (Fig. 27.22).

Step 3: Excision of the Triquetrum and Scaphoid • After removal of the lunate, the lunate articular surfaces of the triquetrum and scaphoid are identified. • The triquetrum is excised en bloc with circumferential dissection. Avoid damaging the proximal capitate. • The scaphoid is controlled using the previously placed joystick wire. Avoid injuring the volar extrinsic ligaments or the radial artery during dissection of the scaphoid. The scaphoid is removed en bloc rather than piecemeal when possible (Fig. 27.23).

Step 4: Seating the Capitate • The capitate is positioned within the lunate fossa to complete the PRC (see Fig. 27.23).

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

Lunate

FIGURE 27.22  Lunate removed. FIGURE 27.21  Preparing to excise the lunate.

C

Radioscaphocapitate ligament

T

L

S

Styloidectomy

Lunate fossa

FIGURE 27.23  Excision of the triquetrum, lunate, and scaphoid. C, Capitate; L, lunate; S, scaphoid; T, triquetrum.

FIGURE 27.24  Avoid injury to the radioscaphocapitate ligament when performing a radial styloidectomy (Fig. 31, from Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg. 2007;32(5):724–746).

• Impingement from the radial styloid should be assessed with motion and, if present, a radial styloidectomy performed.

Step 5: Closure and Repair of the Wrist Capsule • The dorsal wrist capsule is repaired in interrupted fashion using nonabsorbable suture (Fig. 27.25A). • After capsular repair, the tourniquet is released, the wound is irrigated with normal saline solution, and hemostasis is obtained with bipolar electrocautery. • The extensor retinaculum is repaired, leaving the EPL transposed to prevent friction at the Lister tubercle. • Skin can be closed with either absorbable subcuticular or permanent running suture (see Fig. 27.25B). • A well-padded dressing and plaster splint are applied. A volar resting splint to the level of the MCP joints is adequate as the patient can move their fingers postoperatively. • Position of the capitate in the lunate fossa is confirmed with fluoroscopy and x-rays at the first postoperative clinic appointment. (Fig. 27.26).

171

172

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

Dorsal wrist capsule

A

B FIGURE 27.25  (A–B) Closure of the dorsal wrist capsule and skin.

FIGURE 27.26  Postoperative wrist x-rays confirm that the capitate remains seated in the lunate fossa.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients should be immobilized in a short-arm volar splint for 2 weeks, at which point a custom thermoplastic splint should be worn for an additional 6 weeks. • Gentle finger range of motion and strengthening are started at 2 weeks. • Wrist range of motion exercises are formally started at 6 weeks. • For PRC, some toggling motion before 6 weeks is permissible, as long as it does not cause notable pain. • For 4CF, initiation of wrist motion depends on fusion. The timeline may need to be prolonged until radiographic evidence of healing is confirmed. Fusion can be difficult because all of the carpal bones may not be compressed; therefore wrist motion should not commence until radiographic union is seen.

CHAPTER 27  Salvage Procedures for Scaphoid Nonunion

• If used for 4CF, K-wires should be removed in the operating room when there is clinical and radiographic evidence of healing. • Light strengthening can begin usually 10 to 12 weeks after surgery. Slowly progress as tolerated. • Long-term patients should expect a 50% loss in wrist range of motion compared with the contralateral side. Grip strength can return to about 80% of the unaffected side. See Video 27.1 and 27.2

EVIDENCE Chung KC, Watt AJ, Kotsis SV. A prospective outcomes study of four-corner wrist arthrodesis using a circular limited wrist fusion plate for stage II scapholunate advanced collapse wrist deformity. Plast Reconstr Surg. 2006;118:433–442. Eleven patients were prospectively enrolled in a study that detailed outcomes of scaphoidectomy and four-corner arthrodesis using a circular plate for internal fixation. Ten of 11 patients completed their 1-year follow-up. Grip strength, lateral pinch strength, and Jebsen-Taylor test scores at 1 year were not significantly different from preoperative values. Mean active range of motion was 87 degrees preoperatively and 74 degrees at 1-year follow-up (p  0.19). The Michigan Hand Outcomes Questionnaire showed no significant improvement in function, activities of daily living, work, pain, or patient satisfaction. The mean pain scores decreased from 54 preoperatively to 42 1-year postoperatively (p  0.30), indicating persistent wrist discomfort. Three patients had broken screws: one was asymptomatic, one required 3 months of strict wrist immobilization, and one was reoperated for symptomatic nonunion. Authors concluded that using the first-generation circular plate as a means to achieve four-corner arthrodesis resulted in continued pain, functional limitation, impairment at work, and poor patient satisfaction. There was also a high rate of implant failure (3 of 11 patients). 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;30:1122–1127. The authors retrospectively reviewed 58 patients who underwent four-corner arthrodesis. Twenty-seven patients underwent fusion using a circular plate, and 31 patients underwent fusion using traditional techniques (wires, staples, or screws). Major complication rate (nonunion or impingement) was significantly higher in the circular plate group (48% vs. 6%) compared with the group in which traditional fixation was performed. Grip strength, range of motion, and patient satisfaction were also worse in the circular plate group. Erne HC, Broer PN, Weiss F, et al. Four-corner fusion: Comparing outcomes of conventional K-wire, locking plate, and retrograde headless compression screw fixations. J Plast Reconstr Aesthet Surg. 2019;72(6):909–917. Retrospective review of 4CF patients with 21 K-wire, 26 plate, and 17 screw techniques used. All groups had pain reduction and reduced Disabilities of the Arms, Shoulders, and Hands (DASH) scores compared with preoperative. The screw group, however, had significantly lower pain scores and DASH scores. There were no significant differences in nonunion rates; however, this study was likely underpowered for that outcome (Level IV evidence). DiDonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: Study with a minimum of ten years of follow-up. J Bone Joint Surg Am. 2004;86:2359–2365. Twenty-two PRCs in 21 patients were reviewed with an average follow-up time of 14 years. Eighteen of the 22 patients demonstrated satisfactory pain relief, 72 degrees of flexion-extension arc, and recovery of 91% of grip strength of the opposite side. Pain relief was graded as complete in 9, mild in 4, and moderate residual in 5. There were 4 failures, all in patients younger than 35 years old (Level IV evidence). Lumsden BC, Stone A, Engber WD. Treatment of advanced-stage Kienböck’s disease with proximal row carpectomy: An average 15-year follow-up. J Hand Surg Am. 2008;33:493–502. Proximal row carpectomy was used to treat 17 patients with advanced-stage (Lichtman IIIA and IIIB) Kienböck disease. Thirteen of the 17 patients with an average follow-up of 15 years were evaluated. Twelve of 13 patients demonstrated excellent or good results. They achieved a total arc of motion of 73% of the uninvolved side and grip strength that averaged 92% of the uninvolved side. All patients demonstrated some degree of degenerative changes. Despite radiographic evidence of radiocapitate degenerative change in nearly all patients, clinical results did not correlate with radiographic degeneration (Level IV evidence). Fowler JR, Tang PC, Imbriglia JE. Osteochondral resurfacing with proximal row carpectomy: 8-year follow-up. Orthopedics. 2014;37(10):e856–e859. This paper presents average 101-month follow-up in 5 patients that had osteochondral resurfacing of the capitate in addition to PRC. Grip strength improved at every postoperative time point, but motion did decrease over time. Mayo wrist score and DASH score both remained stable or improved from 18-month to final follow-up (Level IV evidence).

POSTOPERATIVE PEARLS

• Patients receiving wrist salvage operations should be counseled that pain often returns over time, carpal degeneration is progressive, and future arthrodesis may be necessary for symptomatic relief. • According to some reports, full recovery can take as long as 12 to 18 months for this operation.

173

CHAPTER

28

Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture Aviram M. Giladi and Kevin C. Chung INDICATIONS • Acute and subacute perilunate dislocation or fracture-dislocation (,6 weeks). • Patients who present more than 6 weeks after the injury may be better served by a salvage procedure, such as a proximal row carpectomy or partial wrist fusion. • Although urgent reduction of a perilunate dislocation can often be accomplished by closed means, operative fixation and consideration of open ligamentous repair are generally indicated. • Perilunate injury can be purely ligamentous (lesser arc injury) or associated with fracture of the scaphoid, capitate, or triquetrum (greater arc injury). • A unique subset, termed scaphocapitate syndrome, is characterized by a transscaphoid transcapitate fracture with the head of the capitate rotated 90 or 180 degrees out of position. • Mayfield and colleagues described the progressive spectrum of pathology, moving from radial to ulnar across the carpus, associated with perilunate/lunate injury (Table 28.1). • In lunate dislocation, the lunate is displaced volarly and the remaining carpal bones maintain alignment in relation to the distal radius. • In perilunate dislocation, the lunate remains within its fossa on the distal radius, and the remaining carpus dislocates dorsally (Fig. 28.1).

Contraindications These injuries often occur in high-energy trauma. If surgery on the wrist is not safe for the patient (or not the acute priority), reduction and splinting is acceptable even for a few weeks until the patient is stabilized.

TABLE Spectrum of Pathology Associated With Perilunate Injury 28.1

174

Stage I

Stage II

Stage III

Stage IV

Radiographic findings

Scaphoid rotation

Capitate dislocation

Malrotation of scaphoid and triquetrum Triquetrolunate diastasis Volar triquetral fracture

Lunate dislocation

Joint disruption

Scapholunate

Scapholunate Capitolunate

Scapholunate Capitolunate Triquetrolunate

Scapholunate Capitolunate Triquetrolunate Radiolunate

Ligament affected

Radioscaphoid Scapholunate Radiocapitate

Radioscaphoid Scapholunate Radiocapitate

Radioscaphoid Scapholunate Radiocapitate Radial collateral Palmar radiotriquetral 1/2 Ulnotriquetral

Radioscaphoid Scapholunate Radiocapitate Radial collateral Palmar radiotriquetral 1/2 Lunotriquetral 1/2 Dorsal radiocarpal

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

Dorsally dislocated carpus in relation to lunate Lunate

FIGURE 28.1  Lateral radiograph depicting a dorsally dislocated carpus in relation to lunate.

CLINICAL EXAMINATION • Clinical examination may reveal extreme pain, wrist edema, tenderness, and ecchymosis with diminished active and passive wrist motion. • It may be accompanied by acute carpal tunnel syndrome (∼25% of patients), resulting in severe and progressive pain and paresthesia in the median nerve distribution. • If severity of pain progresses despite radiographically confirmed closed reduction, urgent carpal tunnel release and open reduction and fixation should be performed. • If closed reduction results in a decrease in pain severity and improvement in numbness, open reduction and fixation can be performed semielectively as soon as possible.

IMAGING • The standard radiographic assessment of the wrist should be conducted, including a careful evaluation of Gilula’s arcs (Fig. 28.2) to identify carpal dislocation. • The radial shaft, lunate, capitate, and metacarpal shafts should be colinear on lateral x-ray. • Despite the severity of the injury, perilunate or lunate dislocation can be missed; therefore it is important to carefully examine all radiographic views. • Plain radiographs can also reveal associated fractures of the radial styloid, scaphoid, capitate, or triquetrum—demonstrating a greater arc pattern of injury (Fig. 28.3).

SURGICAL ANATOMY • In severe injuries, the dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments are often injured (Fig. 28.4). • In a volar dislocation, the lunate is forced through the space of Poirier, a weak region in the volar capsule that is devoid of extrinsic ligaments. The arc of the

175

176

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

FIGURE 28.2  Gilula’s arcs: First arc (red) is the proximal convexity of the scaphoid, lunate, and triquetrum; the second arc (blue) represents the distal concavities of the scaphoid, lunate, and triquetrum; the third arc (black) represents the proximal curvatures of capitate and hamate.

Carpus overlapping lunate

Scaphoid waist fracture

DIC DRC

FIGURE 28.3  Greater arc pattern of injury visible on plain radiograph.

• • • •

FIGURE 28.4  DIC, Dorsal intercarpal ligament; DRC, dorsal radiocarpal ligament.

radioscaphocapitate (RSC) and the ulnocapitate (UC) ligaments form the distal anatomic border of the space of Poirier (Fig. 28.5). In a dorsal perilunate dislocation, the lunate remains in normal position on the distal radius and the remaining carpus dislocates dorsally. Perilunate dislocation requires interosseous—scapholunate (SL) and lunotriquetral (LT)— ligament injury. The dorsal SL ligament and volar LT ligament are repaired if possible. In a Mayfield IV lunate dislocation, the blood supply to the lunate is maintained by the short radiolunate ligament volarly (Fig. 28.6). Reduction is performed through a series of specific steps: • Encourage muscle relaxation via a limb block or sedation/anesthesia. • Place around 10 lbs of longitudinal traction in finger traps for 10 to 15 minutes. • Initiate with dorsally directed pressure on the volar aspect of the lunate and remove the traction weight once in this position.

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

CH

H

Td C TC TT

TH

T P

SC TC

Tm

S

RSC

L UT UC UL SRL PRU U

Space of Poirier

LRL

R

AIA

RA

FIGURE 28.5  AIA, Anterior interosseous artery; C, capitate; CH, capitohamate ligament; H, hamate; L, lunate; LRL, long radiolunate ligament; P, pisiform; PRU, palmar radioulnar ligament; R, radius; RA, radial artery; RSC, radioscaphocapitate ligament; S, scaphoid; SC, scaphocapitate ligament; SRL, short radiolunate ligament; T, triquetrum; TC, triquetrocapitate ligament; Td, trapezoid; TH, triquetrohamate ligament; Tm, trapezium; TT, trapeziotrapezoid ligament; U, ulna; UC, ulnocapitate ligament; UL, ulnolunate ligament; UT, ulnotriquetral ligament.

Long radiolunate ligament

Scapholunar ligament

Dorsal

Palmar

Neurovascular bundle Lunate Short radiolunate ligament FIGURE 28.6  Vascular supply to the lunate.

177

178

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

• With the weight off, maximally extend the wrist; then, with manual longitudinal traction, flex the wrist. This should bring the capitate into flexion and onto the lunate, reducing the injury.

POSITIONING AND EQUIPMENT • A standard radiolucent hand table and mini c-arm are used for intraoperative confirmation of reduction. • Also, 5 to 10 pounds (2.3–4.5 kg) of a longitudinal traction applied via finger traps may be used to facilitate reduction. EXPOSURES PEARLS

Hematoma and edema may displace the median nerve or its palmar cutaneous branch. Identify and avoid injury to these structures.

STEP 1 PEARLS

• The short radiolunate ligament should be preserved to protect the blood supply to the lunate. • The SL ligament is generally preserved in a greater arc injury involving a scaphoid fracture (as opposed to the lesser arc injury where the SL ligament is disrupted). Be sure not to injure the ligament during exposure and fracture management. • It can be easier to place the reduction K-wires into the triquetrum and scaphoid before performing the reduction (inside-out pin placement) so they are properly positioned for eventual pinning into the lunate once the lunate is reduced into its anatomic position.

EXPOSURES • In volar exposure, an extended carpal tunnel incision is designed across the wrist crease (Fig. 28.7). • After completely releasing the transverse carpal ligament, the carpal tunnel contents are retracted to reveal the volar wrist capsule. • In dorsal exposure, a 6- to 8-cm longitudinal incision is designed between the third and fourth extensor compartments (Fig. 28.8). • The dorsal wrist capsule is exposed by entering the interval between the second and fourth compartments. • A longitudinal incision can be made over the scapholunate interval to expose the proximal carpal row. • Alternatively, a radially based capsular flap can be designed in line with the fibers of the DRC and DIC ligaments (see “Ligament Sparing Approach” in Chapter 22).

OPEN REDUCTION, INTERNAL FIXATION TRANSSCAPHOID PERILUNATE FRACTURE/DISLOCATION Step 1: Dorsal Exposure and Reduction of the Scaphoid Fracture • An incision between the second and fourth dorsal compartments is used to expose the scaphoid. Tendons are retracted out of the operative field with a self-retaining retractor (Fig. 28.9). • The scaphoid fracture is identified and any hematoma or early callous formation is debrided. • Reduction of the scaphoid fracture is confirmed both visually and radiographically.

Step 2: Placement of Guidewire for Headless Compression Screw Fixation • A provisional 0.045-inch (1.14-mm) Kirschner wire (K-wire) is placed away from the anticipated screw placement site to maintain scaphoid fracture reduction. This will also prevent rotation of the fracture fragments upon screw advancement.

FIGURE 28.7  Volar exposure markings.

FIGURE 28.8  Dorsal exposure markings.

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

FIGURE 28.9  Dorsal exposure approach.

Scaphoid A

B

S

C

S

FIGURE 28.10  (A–C) Placement of guidewire into scaphoid for headless compression screw fixation. (B) The wire is only in the proximal segment of the scaphoid as it is being passed across the fracture line. White arrow in B and C points to scaphoid wire.

• The cannulated screw guidewire should be started at the proximal ulnar corner of the scaphoid (Fig. 28.10A). The wire is directed along the long axis of the scaphoid. The K-wire should be driven into the subchondral bone of the distal scaphoid tubercle (see Fig. 28.10B–C).

179

180

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture STEP 2 PEARLS

• Use the long axis of the thumb as a visual aid to help align the positioning and trajectory of the scaphoid guidewire. • To ensure that the screw is entirely within the bone, 4 mm should be subtracted from the length estimated by the manufacturer’s guide. STEP 3 PEARLS

Guided by fluoroscopy, drilling is complete after reaching the subchondral bone of the distal pole of the scaphoid. STEP 4 PEARLS

• Fig. 28.11A–B demonstrates a correctly placed screw positioned along the long axis of the scaphoid (the screw is deep within the cartilaginous component of the proximal scaphoid, confirmed with direct visualization). • Live fluoroscopy is used to confirm that the screw is not prominent. • Wrist circumduction should be performed intra-operatively. If concern exists that the screw may be prominent within the joint, it should be exchanged or repositioned.

• Confirm proper reduction of the scaphoid, including alignment of the scaphocapitate articulation. • After confirming the appropriate trajectory and position of the guidewires, the manufacturer’s guide is used to estimate screw length.

Step 3: Drilling the Scaphoid After confirming that the guidewire has been advanced to the subchondral bone of the distal scaphoid, the bone is drilled in preparation for screw placement.

Step 4: Screw Placement After confirming a screw length that will be entirely within the bone, the screw is advanced under fluoroscopy (Fig. 28.11A–B).

Step 5: Pinning the Scapholunate, Lunotriquetral, and Midcarpal Joints • Several K-wires should be used to immobilize the scapholunate, lunotriquetral, and midcarpal joints. • The lunate should be neutral, defined by a radiolunate angle of 0 to 15 degrees on lateral x-ray. If the lunate has assumed an extended or flexed posture because of remaining attachments, it must be properly reduced before fixation. • With extension or dorsal intercalated segment instability (DISI) deformity, the wrist is flexed maximally, bringing the lunate into neutral position. A 0.062-inch K-wire can be driven from the dorsal, distal radius into the lunate to maintain reduction. • If the lunate is abnormally flexed (volar intercalated segment instability [VISI]), the wrist should be maximally extended to bring the lunate into neutral position. A K-wire is passed from the dorsal, distal radius into the lunate to maintain reduction. • After confirming that the radius and lunate are colinear, a 0.062-inch (1.57-mm) K-wire can be placed from the triquetrum to the lunate (Fig. 28.12). • The entry point on the midportion of the triquetrum can be confirmed radiographically. The K-wire should be driven into the subchondral bone of the lunate. • Immobilization of the scapholunate interval can be achieved with one 0.062-inch (1.57-mm) K-wire. The entry point for the K-wire is just distal to the radial styloid. The wire should be directed perpendicular to the long axis of the forearm to capture the scaphoid and lunate. Confirm reduction of the scapholunate gap and restoration of the normal scapholunate angle (30–60°) fluoroscopically. • Place a 0.062-inch K-wire from the distal scaphoid to the capitate (see Fig. 28.12). • A second 0.062-inch (1.57-mm) K-wire can be driven across the scaphocapitate interval to aid in preventing midcarpal motion.

LT SC SL

A

B

FIGURE 28.11  (A–B) Screw has been placed.

FIGURE 28.12  Pinning the scapholunate, lunotriquetral, and scaphocapitate joints.

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

• Adjust the entry point as needed to avoid obstruction by the intrascaphoid screw. • As previously mentioned, pre-placement of the wires into the scaphoid and triquetrum (inside-out placement) when treating a lesser arc injury can simplify this step.

Step 6: Repairing the Scapholunate and Lunotriquetral Ligaments • When present, a midsubstance tear of the dorsal SL and/or LT ligaments should be repaired using 3-0 Ethibond sutures. • If the ligament has been avulsed from its bony attachment, a suture anchor can be used to facilitate reattachment.

Step 7: Carpal Tunnel Release and Repair of the Volar Capsule • An extended carpal tunnel release is performed, in which the structures of the carpal tunnel are identified and protected. • If the lunate is volarly dislocated and cannot be properly reduced with a closed technique, this volar approach is performed first. • Once open, use the same reduction maneuver as previously described but now with pressure directly on the exposed lunate bone. • The capsule can obstruct reduction, so it may need to be mobilized off the lunate. • Even with appropriate closed lunate reduction, beginning with the volar approach is acceptable based on surgeon preference. • Many surgeons advocate for always including the volar approach for Stage III and IV injuries to facilitate repair of the capsule and deeper volar structures. • Inspection of the floor of the carpal tunnel may reveal a rent or tear in the volar capsule. The synovial lining is the most easily visualized component of the capsule, whereas the more important deeper structures are harder to visualize. • Capsular tears are repaired using 3-0 Ethibond suture (Fig. 28.13A–B).

A

Tear in volar wrist capsule

B

FIGURE 28.13  (A–B) Carpal tunnel release and repair of the volar capsule.

STEP 5 PEARLS

• K-wires are usually buried deep to the skin to reduce the risk for pin tract infection. • Multiple fluoroscopic views are necessary to confirm that the K-wires have been positioned correctly.

181

182

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

• Inspect deep to the tear and visualize injuries to deeper (more important) structures. • Closely evaluate the radial and ulnar corners of the tear where the radial radioscaphocapitate ligament and ulnar LT ligament are often found. • Include these deeper structures in the repair if possible.

Step 8: Closure • The dorsal wrist capsule is closed with 3-0 Ethibond suture, after which the tourniquet is deflated and hemostasis is ensured. • The dorsal skin is closed with 4-0 Monocryl or 4-0 PDS.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

POSTOPERATIVE PEARLS

• It is important to manage expectations preoperatively by educating the patient about substantial postoperative wrist stiffness, even with a perfect repair/reconstruction. • Despite anatomic reduction, the majority of patients will develop wrist arthritis.

• A forearm-based splint is applied at the conclusion of the procedure; if a scaphoid fracture was also repaired as part of the injury, we prefer using a thumb spica splint. The patient is instructed to keep the splint clean and dry for 10 to 14 days, at which point the splint is removed, the wound is inspected, and sutures are removed. • The patient is placed in a cast for 8 to 12 weeks. • Follow-up should be scheduled every 3 to 4 weeks to ensure that the reduction is maintained and to monitor fracture healing radiographically. • The cast and K-wires are removed at 8 to 12 weeks under local anesthesia or sedation. • Occupational therapy is initiated once wires have been removed, beginning with gentle range of motion and progressing to strengthening. • Fig. 28.14A–B shows 1-year postoperative x-rays that demonstrate fracture union and maintenance of the scapholunate and lunotriquetral intervals. See Video 28.1

FIGURE 28.14  (A–B) One-year postoperative x-rays.

CHAPTER 28  Open Reduction and Fixation of Acute Lunate or Perilunate Dislocation, With or Without Fracture

EVIDENCE Israel D, Delclaux S, André A, et al. Peri-lunate dislocation and fracture-dislocation of the wrist: Retrospective evaluation of 65 cases. Orthop Traumatol Surg Res. 2016;102(3):351–355. The authors retrospectively reviewed 18 dislocations and 47 fracture-dislocations, all treated surgically. The average follow-up was 8 years (ranged 2–16). Average quick Disabilities of the Arm, Shoulder, and Hand score was 21 and average Patient-Rated Wrist Evaluation score was 28. Pain averaged 1.3 out of 10 at rest but up to 4.3 out of 10 with effort/use. Average flexion/extension arc was 96 degrees and strength averaged 70% of contralateral. Radiographic evaluation showed arthritic changes in nearly 60% of cases, and 26% needed secondary surgery at the time of the most recent evaluation. Findings and outcomes between the dislocation and fracture-dislocation were not significantly different in this small study. Notably, an observed osteochondral defect at the time of initial surgery, and altered scapholunate angle, were both correlated with subsequent osteoarthritis during follow-up evaluations (Level IV evidence). Krief E, Appy-Fedida B, Rotari V, et al. Results of perilunate dislocations and perilunate fracture dislocations with a minimum 15-year follow-up. J Hand Surg Am. 2015;40:2191–2197. The authors retrospectively reviewed 30 patients at a mean follow-up of 18 years who were treated for perilunate dislocation or perilunate fracture-dislocation. The mean flexion-extension arc, radial-ulnar abduction arc, and pronation-supination arc were, respectively, 68%, 67%, and 80%, compared with the contralateral side. The mean grip strength was 70%, relative to the contralateral side. The mean Mayo wrist score was 70, and the mean Quick Disabilities of the Arm Shoulder and Hand and Patient-Rated Wrist Evaluation scores were 20 and 21, respectively. Five patients underwent a secondary procedure. Six patients were diagnosed with complex regional pain syndrome. Arthritis was evident in 70% of wrists.

183

CHAPTER

29

Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome Aviram M. Giladi and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 29.1 – Transmetaphyseal Ulnar Shortening Osteotomy.

KEY CONCEPTS • Ulnar shortening osteotomy is indicated for ulnocarpal abutment (ulnar impaction syndrome), posttraumatic incongruency of the distal radioulnar joint (DRUJ), loss of radial height associated with distal radius fracture malunion, and Madelung deformity. • Ulnar variance is measured on a neutral rotation posteroanterior (PA) view with shoulder and elbow at 90 degrees. Ulnar positive variance may be associated with ulnocarpal abutment. Other radiographic features of this disorder include sclerosis of the ulnar corner of the lunate, the triquetrum, or the radial portion of the ulnar head. Wrist arthroscopy can facilitate the diagnosis of ulnocarpal abutment and rule out other wrist pathologies. • The ulnocarpal joint transmits around 20% of the load across the neutral ulnar wrist, whereas the radiocarpal joint transmits around 80% of the load. Load transmission across the ulna in patients with 2.5-mm positive ulnar variance increases to 42%. This considerable increase in load with ulnar-positive variance puts the wrist at a high risk for articular degeneration and ligamentous injury. Increased dorsal tilt of the radius can further exacerbate loading onto the ulnar side of the wrist. With 2.5-mm negative ulnar variance, the load transmission decreases to 4.3%. This is the basis for the ulnar shortening osteotomy. • Ulnar shortening with the metaphyseal technique achieves similar results compared with the diaphyseal shortening approach and may have a lower risk of malunion. The more distal and dorsal approach, however, may carry a greater risk for injury to the dorsal sensory branches of the ulnar nerve.

FIGURE 29.13  Limited subperiosteal dissection provides adequate exposure of the ulna and avoids unnecessary injury to the surrounding structures and blood supply.

184

CHAPTER

29

Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome Aviram M. Giladi and Kevin C. Chung INDICATIONS Indications for the procedure include: • Inherited or acquired ulnocarpal abutment (ulnar impaction syndrome) • Posttraumatic incongruency of the distal radioulnar joint (DRUJ) • Loss of radial height associated with distal radius fracture malunion • Madelung deformity or premature physeal closure of the distal radius

Contraindications There are also several contraindications: • DRUJ arthritis • Dorsal DRUJ dislocation or other notable DRUJ instability • Caution use (relative contraindication) in patients with DRUJ malalignment. • Specifically, reverse oblique DRUJ configuration is considered by some to be a notable relative contraindication (Fig. 29.1) because the ulnar shortening may adversely affect DRUJ loading and accelerate arthritic wear of the DRUJ. • If DRUJ alignment is a concern, consider a distal wafer procedure—either open or arthroscopic—to reduce the height of the ulnar head without altering DRUJ or ulnar styloid position.

CLINICAL EXAMINATION • Patients present with ulnar-sided wrist pain with swelling and decreased range of motion of the wrist. Ulnar-sided wrist pain is a symptom of various conditions, and these must be investigated with physical examination and radiographic or arthroscopic techniques. • Other common causes of ulnar-sided wrist pain include triangular fibrocartilage complex (TFCC) injuries, DRUJ instability or arthritis, extensor carpi ulnaris (ECU)/ flexor carpi ulnaris (FCU) tendinopathy, carpal fracture or instability, vascular (hypothenar hammer syndrome), or neurogenic pathology (ulnar dorsal sensory neuritis, compression in the Guyon canal). • The ulnocarpal stress test and ulnar foveal signs may be positive with ulnocarpal abutment, but neither is specific.

I Parallel

II Oblique

III Reverse oblique

FIGURE 29.1  Tolat classification of DRUJ. (Fig. 1, reprinted with permission from Heiss-Dunlop W, Couzens GB, Peters SE, Gadd K, Di Mascio L, Ross M. Comparison of plain x-rays and computed tomography for assessing distal radioulnar joint inclination. J Hand Am Surg. 2014;39(12):2417–2423).

184.e1

184e2

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

FIGURE 29.2  Ulnocarpal stress test (TFCC grind test). The lightning bolt indicates pain.

FIGURE 29.3  Eliciting the ulnar foveal sign.

• The ulnocarpal stress test (TFCC grind test) attempts to recreate ulnar-sided wrist pain when the wrist is maximally ulnarly deviated and axial-loaded. The maneuver is tested while the wrist is passively put through the arc of pronation and supination. A positive ulnocarpal stress test may be caused by ulnocarpal abutment or isolated TFCC injury. Extreme pronation brings the carpus in line with the ulnar head and will likely exacerbate pain with ulnar loading if ulnar abutment is present (Fig. 29.2). • The ulnar foveal sign is a provocative maneuver that is useful in diagnosing foveal detachment of the TFCC or ulnotriquetral ligamentous injury. The examiner identifies the interval along the ulnar side of the wrist between the pisiform and the ulnar styloid and applies direct pressure with the wrist and forearm in neutral position (Fig. 29.3). • To perform a pisiform boost, while simultaneously depressing the ulnar head with volar-directed force and applying dorsally directed pressure on the volar aspect of the pisiform, the patient is asked to both actively and passively ulnarly deviate the wrist. This provocative maneuver loads the central portions of the ulnar dome, TFCC disk, lunate, and triquetrum. A painful positive test suggests TFCC pathology, ulnar abutment, or DRUJ arthritis.

IMAGING • Standard posteroanterior (PA), oblique, and lateral x-rays of the wrist are obtained with a particular interest in the relationship between the articular surfaces of the distal ulna and the radius. Ulnar variance is measured on a neutral rotation PA view with the shoulder and elbow at 90 degrees. When the lunate facet of the distal radius and dome of the ulna are measured at the same level, this is termed neutral variance and is seen in 12% of the general population (Fig. 29.4). If the ulnar articular surface is distal to the lunate facet of the radius, this is called positive variance (55%). Negative ulnar variance exists when the ulna is proximal to the radius (33%). Normal variance is considered to be 22 mm to 12 mm. Pronation (up to 11 mm) and power grip (up to 12.5 mm) may change the articular relationship (Fig. 29.5). Considering the wide range of so-called “normal” variance, always check a contralateral x-ray before deciding on the diagnosis/treatment for ulnar abutment. • Ulnar-positive variance may be associated with ulnocarpal abutment. Other radiographically apparent features of this disorder include cystic changes or sclerosis of the ulnar corner of the lunate, the triquetrum, or the radial portion of the ulnar head (Fig. 29.6).

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

R

U

A

R

B

U

R

184.e3

U

C

FIGURE 29.4  Ulnar variance. (A) Neutral. (B) Negative. (C) Positive. (Fig. 3A–C, reprinted with permission from Mag Res Imag Clin of Nor Am. 2010;18(4):643–662.)

Ulnar variance

Ulnar variance

FIGURE 29.5  Ulnar positive variance may be associated with ulnocarpal abutment.

• Magnetic resonance imaging (MRI) may be useful in identifying changes associated with ulnocarpal abutment. Short T1-weighted inversion recovery images and fatsuppressed T2-weighted images may reveal subchondral bone marrow edema and early chondromalacia (Fig. 29.7). Focal proximoulnar cystic changes in the lunate (see Fig. 29.7) are a pathognomonic radiographic finding of ulnar abutment. • Wrist arthroscopy can be used to accurately diagnose ulnocarpal abutment and to rule out other associated pathology of the wrist. A large central TFCC perforation with associated articular wear of the ulnar head or proximal articular cartilage of the lunate or triquetrum suggests that the bones are contacting. • The distal radioulnar joint must be examined radiographically for signs of arthritis because this could contribute to wrist pain and may be exacerbated by shortening the ulna.

SURGICAL ANATOMY The ulnocarpal joint transmits around 20% of the load across the neutral ulnar wrist, whereas the radiocarpal joint transmits around 80% of the load. Load transmission across the ulna in patients with 2.5-mm positive ulnar variance increases to 42%. This

FIGURE 29.6  Sclerosis of the ulnar corner of the lunate (right arrow) and radial corner of the triquetrum (left arrow).

184e4

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

C A

B

A

B

C

EXPOSURES PEARLS

• Dissect over the ulnar diaphysis in the supraperiosteal plane. This preserves blood supply at the osteotomy site and may promote union. • Only perform subperiosteal circumferential dissection around the osteotomy site to preserve the blood supply. One of the major causes of nonunion may be injudicious stripping of periosteum circumferentially for the full extent of the ulna along the incision, which devascularizes the osteotomy site. EXPOSURES PITFALLS

• Take care in identifying and protecting the dorsal sensory branch of the ulnar nerve. It arises 8 cm proximal to the ulnar styloid, passes deep to the FCU, and courses obliquely toward the ulnar styloid, crossing from volar to dorsal around 1.5 cm proximal to the ulnar styloid (Fig. 29.12). • The metaphyseal technique may have a lower risk for malunion. Nevertheless, the more distal and dorsal approach may carry a greater risk for injury to the dorsal sensory branches of the ulnar nerve.

FIGURE 29.7  Subchondral bone marrow edema and early chondromalacia seen on magnetic resonance imaging. (A) Early chondromalacia. (B) Focal proximoulnar cystic changes in the lunate. (C) Subchondral bone marrow edema.

considerable increase in load with ulnar-positive variance puts the wrist at a high risk for articular degeneration and ligamentous injury. Increased dorsal tilt of the radius can further exacerbate loading onto the ulnar side of the wrist. With 2.5-mm negative ulnar variance, the load transmission decreases to 4.3%. This is the basis for the ulnar shortening osteotomy.

EXPOSURES • For shortening the diaphysis, an approximately 10-cm longitudinal incision is designed over the ulna along its subcutaneous border. The incision stops 2 to 3 cm proximal to the ulnar styloid to avoid injuring the dorsal sensory nerve that crosses the incision distally. After incising the skin and subcutaneous tissue, the ECU and FCU are identified and the interval between them is developed to expose the ulna (Figs. 29.8 and 29.9). • Alternatively, a metaphyseal shortening technique has been described. This technique uses a more dorsal approach (Fig. 29.10) to expose the ulnar head. The approach is between the fifth and sixth extensor compartments (Fig. 29.11).

FIGURE 29.8  Design for longitudinal incision over the ulna along its subcutaneous border. The incision stops 2 to 3 cm proximal to the ulnar styloid.

FIGURE 29.9  ECU and FCU are identified and the interval between them is developed to expose the ulna. ECU, Extensor carpi ulnaris; FCU, flexor carpi ulnaris.

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

FIGURE 29.10  Dorsal incision used to approach the ulnar head for the metaphyseal shortening technique.

184.e5

FIGURE 29.11  Exposing the interval between the fifth and sixth extensor compartments to approach the ulnar head/metaphysis. Black arrow points to the planned longitudinal incision over the neck/metaphyseal region of the ulna.

DBUN

STEP 1 PEARLS

US

ECU

Proximal

FIGURE 29.12  Identify and protect the dorsal sensory branch of the ulnar nerve. DBUN, Dorsal branch of ulnar nerve; ECU, extensor carpi ulnaris; US, ulnar styloid.

PROCEDURE Step 1: Exposure of the Ulna in Preparation for the Osteotomy After incising the skin and subcutaneous tissue, the interval between the FCU and ECU is developed, and tendons are retracted volarly and dorsally. The osteotomy site should be marked on the ulna, followed by limited subperiosteal dissection, approximately 2 cm (Fig. 29.13). The ideal osteotomy location is approximately 5 to 7 cm proximal to the ulnar styloid and 2 to 3 cm proximal to the sigmoid notch.

Step 2: Placement of the Guide • The plate is selected and placed within the wound at the level of the desired osteotomy. The distal end of the plate should be approximately 3 to 4 cm from the ulnar styloid, ensuring that all screws will avoid the DRUJ. • The second hole (from proximal) is marked on the bone and then the plate is moved away and replaced by the Rayhack cutting guide where the second hole (from proximal) is lined up with the marking.

• Various cutting guide systems are available, or the osteotomy can be done freehand if needed. We most frequently use a Rayhack device (Generation I or II) to create the oblique osteotomy (Fig. 29.14), and demonstrate that device in this section. A six-hole, low-profile locking plate or a six-hole limited contact dynamic compression plate can be used. The use of newer, lower-profile locking plates may reduce plate-related complications and need for removal. • When a compression device is not available and the plan is for freehand osteotomy, the surgeon can apply a compression plate over the ulna by drilling and placing screws proximal to the osteotomy site. Then, the bone wafer is cut out of the ulna, and shortening is achieved by using the compression mode of the plate to bring the two cut ends of the ulna together. Alternatively, if no cutting/compression system is available, a step-cut shortening can be performed and is easier to do freehand (Figs. 29.15 and 29.16). • The freehand technique is especially useful when a large amount of shortening (5 mm or greater) is required. • The limbs of the step cuts (see Fig. 29.15B) can be made long and then sequentially shortened as needed to provide an adequate amount of ulnar excision. • The metaphyseal shortening technique uses one K-wire to confirm that the osteotomy is proximal to the DRUJ, and a second K-wire to mark the proximal margin of the wedge excision (Fig. 29.17). • Before any screw placement, evaluate the proposed osteotomy site radiographically to ensure that the distal-most screw will not be placed near the DRUJ. • It is essential to avoid subperiosteal dissection beyond the proposed osteotomy site. Preserving periosteum will improve vascularity and promote union.

184e6

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

Distal

Proximal 3 21

Blade slots

Hypotenuse 7.4 mm

4.9 mm

3.5 mm 2.5 mm

90

3.5 mm

o

5.2 mm FIGURE 29.13  Limited subperiosteal dissection provides adequate exposure of the ulna and avoids unnecessary injury to surrounding structures or blood supply.

1

2

3

4

5

A

6

7

3

2

1

FIGURE 29.14  Cutting guide systems can facilitate various sizes of oblique osteotomy. Dorsal

Volar

X

B

C

X

X

FIGURE 29.15  Freehand step-cut osteotomy is an acceptable alternative to using a cutting guide system. (A) An AO plate is used as a template to facilitate design of the step cut between the third and fifth holes. (B) The desired distanced for shortening is marked and cut. (C) After reduction, a lag screw is placed at the dorsal surface to compress the arms of the osteotomy. A 3.5-mm AO neutralization plate is then applied to the volar surface. (Fig. 1, reprinted with permission from Darlis NA, Ferraz IC, Kaufmann RW, Sotereanos DG. Step-cut distal ulnar-shortening osteotomy. J Hand Am Surg . 2005;30(5):943–948).

FIGURE 29.16  Final fixation for diaphyseal step-cut shortening osteotomy.

• The cutting guide is held manually. Using a straight drill guide, a 2.5-mm drill is used to make a hole through the second hole on the guide. The depth of the hole is measured, the hole is tapped with a 3.5-mm tap, and a 3.5-mm cortical screw is placed. This procedure is repeated for the fourth and then the third holes on the saw guide.

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome STEP 1 PITFALLS

• The plate may be positioned on the volar or dorsal/subcutaneous border of the ulna. The volar approach requires more soft tissue dissection and periosteal stripping and may result in a higher incidence of delayed or nonunion. Although the dorsal approach may result in palpable hardware because of the paucity of soft tissue, we prefer this method because of the ease of placement, reduction in soft tissue stripping, and possible increase in overall union rate. A devastating complication is injuring the ulnar neurovascular bundle, which lies adjacent to the FCU tendon. Use retractors to protect these structures during dissection and osteotomy. • Place the plate in the wound as a guide to determine the amount of soft tissue dissection needed to accommodate and to help localize the osteotomy site before any periosteal stripping. FIGURE 29.17  K-wires guide the osteotomy for the metaphyseal shortening technique. The distal wire (left arrow) marks proximal to the distal radioulnar joint, and the proximal wire (right arrow) measures the osteotomy width.

Step 3: Performing the Oblique Osteotomy • The amount of bone to be removed can be measured on the 90 to 90 neutral PA view and should equal the amount of positive ulnar variance plus the amount of negative ulnar variance desired. • Generally, 2 to 2.5 mm of negative ulnar variance is desired. The slots (numbered from proximal to distal) that are used to make the parallel oblique osteotomy cuts will determine the amount of resultant ulnar shortening (slots 1 and 2 5 3.5 mm; slots 2 and 3 5 4.9 mm; and slots 1 and 3 5 7.4 mm; Fig. 29.18; see also Fig. 29.14). • The distal and proximal osteotomies can be performed in sequence. Limited circumferential subperiosteal dissection is used to expose the osteotomy site. • Homan retractors are placed behind the ulna to prevent injury to deeper structures, including the ulnar nerve. Contact with the retractor by the saw blade will cue the surgeon that the osteotomy is complete. The blade’s trajectory must be seen as it traverses the bone to ensure the blade does not plunge deeply past the bone.

FIGURE 29.18  Rayhack device in place, guiding the osteotomy cuts.

STEP 2 PEARLS

Although not always necessary, prebending the ulnar plate before screw placement ensures that the volar cortex will not open with tightening of the compression screws.

STEP 3 PEARLS

• Careful retraction of tendons and dorsal sensory branches of the ulnar nerve must be performed to avoid inadvertent injury from the saw blade. • A smaller saw blade (~5 mm) may be used instead of the proposed 10-mm blade to more precisely control the osteotomy. • It may be necessary to remove the guide to complete the osteotomy. • If correctly performed, removal of the wafer should reveal smooth, parallel surfaces. If there is a step off, or change in contour, the remaining ulna should be inspected for an incomplete osteotomy. • If necessary, a rongeur can be used to smooth the osteotomy cuts and ensure direct apposition of the proximal and distal segments. • Saline irrigation during osteotomy can prevent heat-induced thermal necrosis of the bone. • The screws used to hold the guide in place will be reused to apply the plate. Be sure to keep track of which holes the screws came from if the lengths are variable.

184.e7

184e8

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

• After completion of the osteotomy, the guide can be removed, revealing the wafer of bone to be discarded. • For the metaphyseal technique, the K-wires frame the osteotomy site and provide the wafer width for amount of shortening. STEP 4 PEARLS

• The osteotomy must be aligned perfectly before tightening the compression device. It may be necessary to pre-align the proximal and distal ulna before tightening the device. • Balanced compression can be confirmed radiographically. • Avoid overcompression with the external device because further compression will be achieved by the interfragmentary lag screw.

STEP 4 PITFALLS

• Alternate tightening turns of both compression arms. Using only one side for tightening can create poorly balanced forces that damage the device. • For the metaphyseal technique, a point-topoint clamp can be used to hold the reduction and prevent distraction while using the screw across the osteotomy site.

Step 4: Application of the Plate and Compression of the Osteotomy • The pre-bent six-hole plate is positioned according to the previously identified screw holes and a 3.5-mm screw is passed into the second hole of the plate (from proximal). The Rayhack compression device is secured using the third hole (through the plate and into the ulna) with a screw that is 4 mm longer than the previously selected screw (Fig. 29.19). • Another screw is passed between the compression arms of the device and into the elliptical hole on the plate and third hole in the bone. Do not fully tighten the screw. Instead, leave some laxity to permit movement within the elliptical hole during compression. • Alternate between tightening each of the longitudinally directed screws on the compression device until the osteotomy surfaces appear to be compressed. • For the metaphyseal technique, a cannulated screw is used to provide fixation and compression of the osteotomy (Figs. 29.20 and 29.21).

FIGURE 29.19  Application of the plate and compression of the osteotomy.

A

B

FIGURE 29.20  Guidewire for the cannulated screw (A) and derotational wire (B) in place for the metaphyseal shortening osteotomy.

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

B

A FIGURE 29.21  With the derotational wire removed and cannulated screw in place (B), the metaphyseal osteotomy site is now compressed (A).

Step 5: Placement of the Interfragmentary Lag Screw • The 22-degree angled drill guide is placed into the round hole of the compression block. • A 2.7-mm drill bit is used to drill the near cortex. The far cortex is drilled with a 2.0-mm drill bit. • After measuring the depth, the drill guide is reapplied, and the far cortex is tapped with a 2.7-mm tap. Remove the drill guide and then insert a 2.7-mm cortical lag screw to aid in compression.

Step 6: Final Plate Fixation • A 2.5-mm drill bit and handheld drill guide are used to drill through the fifth hole of the plate. The depth is measured, and the hole is tapped. A 3.5-mm cortical screw is placed. • A locking screw drill guide is inserted into the sixth hole, and a 2.3-mm drill bit is used to make a hole. This depth is measured, and a 2.7-mm locking screw is placed. • The longitudinally oriented compression screws of the compression block should be loosened before removing the screws that are holding it onto the plate. • After removing the compression device, the original screws for holes 3 and 4 are re-inserted (Fig. 29.22).

FIGURE 29.22  Final plate fixation for diaphyseal wedge osteotomy shortening.

STEP 5 PITFALLS

Do not drill the far cortex with the 2.7-mm drill bit because this will prevent proper lag compression.

184.e9

184e10

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

FIGURE 29.23  Fluoroscopy can facilitate detection of screws that are incorrectly sized.

• The position of the plate and screws is confirmed fluoroscopically (Fig. 29.23). Replace any incorrectly sized screws.

Step 7: Closure After release of the tourniquet, ensure hemostasis. The wound should be closed in layers using interrupted 4-0 Monocryl or 4-0 PDS. An ulnar gutter splint is placed over the forearm and wrist. POSTOPERATIVE PITFALLS

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

Complications after ulnar shortening osteotomy include delayed union or nonunion (5%), chronic pain, DRUJ stiffness, prominence of hardware requiring removal (up to 20%), and injury to the dorsal sensory branch of the ulnar nerve.

• The wrist is maintained in an ulnar-sided splint for 4 weeks. At that time, early rangeof-motion exercises can be initiated. Once bony union is evident radiographically (Figs. 29.24 and 29.25), splinting can be discontinued and progressive strengthening exercises initiated. In the absence of complications, the patient will have no restrictions by 3 months postoperatively. • The majority of patients will achieve good-to-excellent results in terms of pain control and recovery of function. • Ulnar shortening with the metaphyseal technique achieves similar results compared with the diaphyseal shortening approach (Fig. 29.26). See Video 29.1

Preoperative

Postoperative

FIGURE 29.24  Three-month postoperative imaging.

Preoperative

Postoperative

FIGURE 29.25  Three-month postoperative imaging.

CHAPTER 29  Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

B A

FIGURE 29.26  Two weeks after metaphyseal shortening for a patient with mild Madelung deformity and prominent ulna. Note the correction from ulnar positive (A) before surgery to near neutral (B) after.

EVIDENCE Baek GH, Chung MS, Lee YH, Gong HS, Lee S, Kim HH. Ulnar shortening osteotomy in idiopathic ulnar impaction syndrome. J Bone Joint Surg Am. 2005;87:2649–2654. The authors retrospectively reviewed 31 patients who underwent ulnar shortening osteotomy for ulnar impaction syndrome. An average preoperative ulnar variance of +4.6 mm (range, 2–7.5 mm) was reduced to an average of −0.7 mm (range, −4 to +1 mm) postoperatively. Preoperatively, the modified Gartland and Werley score was an average (and standard deviation) of 69.5 ± 7.6, with 24 wrists rated poor and 7 rated fair. Postoperatively, the score improved to an average of 92.5 ± 8.0, with 24 wrists rated excellent; 5, good; 1, fair; and 1, poor. Dorsal subluxation of the distal aspect of the ulna was found concomitantly in nine wrists, and it was found to be reduced by the shortening osteotomy. Seven patients had cystic changes in the carpal bones preoperatively, but these were not evident 1 to 2 years after the operation. Baek GH, Lee HJ, Gong HS, et al. Long-term outcomes of ulnar shortening osteotomy for idiopathic ulnar impaction syndrome: At least 5-years follow-up. Clin Orthop Surg. 2011;3:295–301. The authors retrospectively reviewed 36 patients who underwent ulnar shortening osteotomy for ulnar impaction syndrome. At a mean follow-up of 79.1 months, the average modified Gartland and Werley wrist score improved from 65.5 ± 8.1 preoperatively to 93.4 ± 5.8 at the last follow-up visit. The average preoperative ulnar variance of 4.7 ± 2.0 mm was reduced to an average of −0.6 ± 1.4 mm postoperatively. Osteoarthritic changes of the DRUJ were first seen at 34.8 ± 11.1 months follow-up in 6 of 36 wrists (16.7%). Those who had osteoarthritic changes in the DRUJ had significantly wider preoperative ulnar variance, a longer distal radioulnar distance, and a greater length of ulnar shortening, but the wrist scores of the patients who had osteoarthritic changes in the DRUJ were comparable to those who did not have osteoarthritic changes in the DRUJ. Fufa DT, Carlson MG, Calfee RP, Sriram N, Gelberman RH, Weiland AJ. Mid-term results following ulna shortening osteotomy. HSS J. 2014;10:13-17. At a minimum of 5-year follow-up, the authors reviewed the results of ulnar shortening osteotomy in a cohort of 33 patients. Mean follow-up was 10 years. Eighty-eight percent of patients reported they were either satisfied or very satisfied with the procedure and 91% reported they would have the same procedure again. At final follow-up, average pain rating was 2 out of 10. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 11 (range, 0–39). Removal of hardware was performed in 10 patients (30%). The overall rate of reoperation was 45%. Papatheodorou LK, Sotereanos DG. Step-cut ulnar shortening osteotomy for ulnar impaction syndrome. JBJS Essent Surg Tech. 2017;7(1):e3. doi:10.2106/jbjs.st.16.00062. Article available free on PMC, presenting the technique for step-cut ulnar shortening osteotomy. This is an excellent technique, especially for situations where added hardware and cutting guides are not available. Hammer WC, Williams RB, Greenberg JA. Distal metaphyseal ulnar-shortening osteotomy: Surgical technique. JHS. 2012;37A:1071–1077. Article describing the metaphyseal shortening technique, another excellent alternative to diaphyseal shortening when additional hardware and cutting guides may not be readily available.

184.e11

CHAPTER

30

Distal Radioulnar Joint Reconstruction Using Palmaris Longus Graft Aviram M. Giladi and Kevin C. Chung INDICATIONS Indications for this procedure include: • Chronic, symptomatic distal radioulnar joint (DRUJ) instability that is generally associated with irreparable triangular fibrocartilage complex (TFCC) injury/degeneration. • No evidence of distal radioulnar joint arthritis. • No evidence of a malunited distal radius fracture with resulting DRUJ dysfunction.

Contraindications Although not a true contraindication, a relatively flat DRUJ may risk failure of the reconstruction because of inadequate added support and stability from DRUJ anatomy.

CLINICAL EXAMINATION • It is important to consider and properly diagnose other conditions that may result in ulnar-sided wrist pain before performing a DRUJ reconstruction. Ulnar-sided pain may be caused by extensor carpi ulnaris (ECU) or flexor carpi ulnaris (FCU) tendinitis, ECU subluxation, lunotriquetral instability, TFCC injury that does not create DRUJ instability (e.g., a central TFCC tear), or ulnar impaction syndrome. • Several clinical examination maneuvers can be useful in confirming instability of the DRUJ: the piano key sign, the radioulnar ballottement test, the press test, the ulnar compression test, and the Schaeffer test.

The Piano Key Sign With the forearm pronated and resting on the table, the ulnar head tends to be prominent when the DRUJ is unstable. If the ulnar head can be depressed easily and springs back dorsally into the proud position, that is a positive piano key sign.

The Radioulnar Ballottement Test The examiner stabilizes the distal radius as the distal ulna is moved volar to dorsal with the other hand (Fig. 30.1). Comparison to the contralateral, unaffected side may reveal excessive motion or pain. The wrist should be stressed in pronation, neutral, and supination. More laxity typically occurs in neutral because the radioulnar ligaments of the DRUJ are tightened in extremes of pronation and supination.

The Press Test The patient is asked to rise from a chair by pushing off with his or her hands. If instability of the DRUJ is present, the affected ulna head will depress in relation to the radius and compared with the contralateral side. This will result in pain.

Ulnar Compression Test With the elbow in 90 degrees of flexion and the forearm neutral, manually compress the radius and ulna at the DRUJ (Fig. 30.2). Pain indicates likelihood of DRUJ arthritis or synovitis.

Schaeffer Test Use the Schaeffer test to evaluate for the presence or absence of a palmaris longus (PL) tendon: The patient is asked to oppose the thumb to the small finger and flex the wrist. If present, the PL tendon will be identifiable and prominent immediately ulnar to the flexor carpi radialis tendon. 185

186

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft

FIGURE 30.1  Radioulnar ballottement test. (From Atzei A, Luchetti R. Foveal. TFCC tear classification and treatment. Hand Clin. 2011;27(3):263–272.)

IMAGING PEARLS

Ensure that the lateral radiograph is positioned correctly: The index, long, and ring metacarpals, the proximal pole of the scaphoid on the lunate, and the radial styloid in the center of the lunate should all be aligned. Additionally, the palmar surface of the pisiform should be visible midway between the palmar convexities of the distal pole of the scaphoid and the capitate (Fig. 30.6).

FIGURE 30.2  Ulnar/distal radioulnar joint (DRUJ) compression test.

IMAGING • Standard posteroanterior (PA), oblique, and lateral x-rays should be obtained with a PA and lateral in 90-90 positioning: shoulder abducted to 90 degrees and elbow flexed to 90 degrees with wrist neutral. The PA view may reveal widening of the DRUJ (Fig. 30.3). The lateral view may demonstrate dorsal or volar translation of the ulnar head. • The PA view may also demonstrate a fracture through the base of the ulnar styloid (Fig. 30.4) or a bony avulsion within the ulnar fovea. • Confirm no notable positive ulnar variance or DRUJ arthritis on PA view. • A stress view, with wrist loading of 5 to 8 pounds (2.3–3.6 kg), may demonstrate instability by accentuating a subtle deformity (Fig. 30.5).

DRUJ widening FIGURE 30.3  Distal radioulnar joint (DRUJ) widening visible on x-ray.

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft

L

Ulnar styloid fracture

FIGURE 30.4  Ulnar styloid fracture.

Stress view

FIGURE 30.5  Dorsal displacement of ulnar head after loading an unstable distal radioulnar joint (DRUJ).

Palmar surface of pisiform

Proximal pole of scaphoid

FIGURE 30.6  Properly aligned lateral x-ray.

• A computed tomography (CT) scan can confirm subtle degrees of joint instability, better characterize sigmoid notch alignment, and identify arthritic changes. • Magnetic resonance imaging (MRI) or arthroscopy can evaluate the TFCC and DRUJ and rule out or treat other causes of ulnar-sided pain.

SURGICAL ANATOMY • The DRUJ is an articulation between the sigmoid notch of the radius and the ulnar head. The DRUJ is stabilized predominantly by ligaments, fibrocartilage of the volar and dorsal rims of the sigmoid notch, and the shape of the sigmoid notch in the coronal plane that can be quite variable. • The extrinsic stabilizers of the DRUJ include the TFCC, pronator quadratus (PQ), ECU, and interosseous membrane (Fig. 30.7). • The TFCC refers to all of the soft tissues and support structures that span the DRUJ and ulnocarpal joints. The TFCC includes the triangular fibrocartilage (TFC, also known as the articular disk), meniscus homologue, palmar and dorsal radioulnar

187

188

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft

ECU tendon ECU subsheath

PQ

Interosseous membrane

FIGURE 30.7  Extrinsic stabilizers of the distal radioulnar joint (DRUJ). ECU, Extensor carpi ulnaris; PQ, pronator quadratus.

ligaments, ulnar collateral ligament, ulnotriquetral ligament, ulnolunate ligament, ECU subsheath, and prestyloid recess. • The main stabilizers of the DRUJ are the palmar and dorsal radioulnar ligaments. These ligaments extend from the palmar and dorsal distal margins of the sigmoid notch and converge in a triangular configuration to attach to the ulna. Each radioulnar ligament divides in the coronal plane into a deep limb that inserts into the ulnar fovea and a superficial limb that inserts into the midportion of the ulnar styloid (Fig. 30.8A–B). EXPOSURES PEARLS

Avoid incising the uninjured portions of the TFCC, including any intact radioulnar ligament. If present, a tear in the articular disk can be debrided. EXPOSURES PITFALLS

Identify and protect the dorsal sensory branches of the ulnar nerve. STEP 1 PEARLS

Avoid injury to normal TFCC structures, including the ECU subsheath that reflects over the ulnar styloid.

POSITIONING AND EQUIPMENT Axial traction is applied to the wrist similar to what is used in preparation for arthroscopy. Finger traps should be placed on the index and long fingers, and up to 10 pounds (4.5 kg) of traction is used to distract the wrist (Fig. 30.9).

EXPOSURES • A Y-shaped dorsal, longitudinal incision is designed over the interval between the fifth and sixth extensor compartments. The longitudinal limb is positioned over the ulnar styloid. The volar limb extends toward the pisiform and the dorsal limb is directed toward the Lister tubercle (Fig. 30.10). • The fifth extensor compartment is opened over the DRUJ and the extensor digiti minimi tendon is retracted radially. • An L-shaped capsular flap is created to expose the DRUJ and TFCC. The longitudinal limb is designed through the ulnar aspect of the floor of the fifth extensor compartment and the transverse limb is positioned over the articular cap of the ulna (Fig. 30.11).

PROCEDURE Step 1: Inspection of the TFCC and Debridement of Existing Injury After exposing the TFCC by the aforementioned approach, integrity should be assessed and potential for repair should be determined. If it is not amenable to repair, debridement of any granulation tissue or scar should be performed (Fig. 30.12).

189

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft Lunate fossa

Scaphoid fossa

PRUL

A DRUL

TFCC

Ulna styloid

Volar

FIGURE 30.9  Finger traps provide axial traction.

Dorsal TFC deep limit (ligamentum subcruetum)

TFC superficial limb Fovea

R

U

B

FIGURE 30.8  (A) Cadaver dissection depicting key anatomic structures of the triangular fibrocartilage complex (TFCC). (B) Illustration of key anatomic structures of TFCC. (From Carr LW, Adams B. Chronic distal radioulnar joint instability. Hand Clin. 2020;36(4):443–453.)

Dorsal branch of ulnar nerve

FIGURE 30.10  Y-shaped dorsal, longitudinal incision.

Ulnar head

DRUJ

FIGURE 30.11  Creation of L-shaped capsular flap.

190

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft

Step 2: Exposuring the Radius A subperiosteal dissection is performed beneath the fourth dorsal compartment, radial to the sigmoid notch.

Step 3: Creating a Bone Tunnel Within the Radius 3 4 1

• Use live fluoroscopy to confirm that the entry point on the radius is far enough away from the sigmoid notch and lunate fossa to avoid inadvertently entering the joint (Fig. 30.13A–B). • A guidewire for a 3.5-mm cannulated drill is driven through the radius parallel to the articular surface of the sigmoid notch. After confirming proper guidewire placement, the tunnel is formed using a 3.5-mm cannulated drill.

2

Step 4: Creating a Bone Tunnel Within the Ulna

FIGURE 30.12  Inspection of the triangular fibrocartilage complex (TFCC). 1, Ulna head. 2, Extensor carpi ulnaris tendon. 3, Ulnar corner of distal radius. 4, Dorsal radioulnar ligament of TFCC. STEP 2 PEARLS

Dissection should be carried out approximately 5 mm radial to the sigmoid notch and 5 mm proximal to the lunate fossa articular surface in preparation for drill hole placement. If the drill hole is created too close to these articular surfaces, inadvertent entry into the joint and fracture of the cortex could occur. STEP 3 PEARLS

The sigmoid notch is a curved structure; be sure that the drill hole is 5 mm or more from the deepest part of the notch, not the rim of the notch that is often easier to see on fluoroscopy. The same consideration must also be made for the lunate fossa.

• Subperiosteal dissection is performed around the ulnar neck. • A guidewire is passed from the ulnar fovea to the subcutaneous border of the ulna, at the level of the ulnar neck. • Using a 3.5-mm cannulated drill, create an anterograde tunnel from the ulnar neck to the fovea (Fig. 30.14A–C).

Step 5: Harvesting the Palmaris Longus Tendon After identifying the PL tendon, several discontinuous incisions can be made to harvest the full length of the tendon from the wrist to its musculotendinous junction.

Step 6: Passing the Tendon Graft Through the Radius • The volar limb of the Y-shaped incision is used to expose the volar wrist. • The finger flexor tendons and ulnar neurovascular bundle are retracted to reveal the volar wrist capsule. • Fluoroscopy is used to confirm the position of the bone tunnel within the radius. • A suture retriever or fine wire is passed through the bone tunnel from dorsal to volar to pull the tendon through the radius bone tunnel from volar to dorsal (Fig. 30.15A–B).

Step 7: Passing the Tendon Through the Ulna • A straight hemostat is used to create a tunnel through the volar wrist capsule and to pass the tendon graft from volar (extracapsular) to dorsal back within the capsule. • This grasps some of the volar capsule with the tendon graft, theoretically providing added volar stability to the reconstruction

STEP 5 PEARLS

• Alternatively, a single, transverse incision can be made over the distal wrist crease where the palmaris longus (PL) tendon is transected. A tendon stripper can be passed over the PL up to the musculotendinous junction while applying gentle, longitudinal countertraction on the PL tendon. This returns the full length of the tendon without the morbidity of several incisions. • A strip of flexor carpi radialis tendon can be used if the PL tendon is absent. STEP 6 PEARLS

Many surgeons prefer to pass the tendon from dorsal to volar through the radius to improve visualization; either approach is acceptable.

A

B FIGURE 30.13  (A–B) Creation of bone tunnels in radius.

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft

Ulna

A

B

C

FIGURE 30.14  (A–B) Creation of bone tunnels in ulna. (C) Illustration of bone tunnels. (From Carr LW, Adams B. Chronic distal radioulnar joint instability. Hand Clin. 2020;36(4):443–453.)

Suture passer

Radius

Ulna

PL tendon graft A

B FIGURE 30.15  (A–B) Tendon graft is passed through the radius.

• Through the dorsal exposure, a hemostat is used to grasp the tendon and bring it through the capsule. Both ends of the tendon graft are then passed through the ulna bone tunnel, directed from the fovea to exit the ulna neck, using a suture retriever or fine wire (Fig. 30.16A–B).

Step 8: Securing the Tendon Graft • Both limbs of the tendon are wrapped around the neck of the ulna and tension on the repair is confirmed with the wrist in neutral position.

STEP 7 PEARLS

The ulna bone tunnel may need to be enlarged to accommodate both ends of the tendon graft.

191

192

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft 7 6 5

4

ECU Wire loop 1

2

3

Ulna

Wire loop pulled through bone tunnel

Tendon graft

B

A

FIGURE 30.16  (A) Tendon graft is passed through the ulna. (B) Illustration of tendon graft through ulna bone tunnel.

A

FIGURE 30.17  Fluoroscopy confirms appropriate distal radioulnar joint (DRUJ) alignment.

B

FIGURE 30.18  (A–B) Closure of distal radioulnar joint (DRUJ) capsule and extensor retinaculum.

STEP 8 PEARLS

If the tendon graft length is not sufficient to wrap around the ulna, the graft may be secured in other ways: • Bone anchors can be used to secure the ends of the tendon graft either within the ulnar fovea or proximal to the exit hole on the subcutaneous border of the ulna. • An interference screw can be placed within the bone tunnel, started at the ulna neck and driven toward the fovea. • Place a second bone tunnel from the fovea to the ulnar neck parallel to the initial tunnel and pass each limb of the graft through a separate tunnel, then secure the graft over the ulnar neck. This approach may risk fracturing the ulna so a smaller drill hole such as 2.0 mm may be considered.

• The limbs of the tendon are sutured together using 2-0 Ethibond. • Confirm appropriate DRUJ alignment and positioning (Fig. 30.17).

Step 9: Closure • The DRUJ capsule and extensor retinaculum are closed in a single combined layer using 3-0 Ethibond suture (Fig. 30.18A–B). The extensor digiti minimi can be left out of the sheath in the subcutaneous plane. • The skin of the dorsal and volar wrist is closed in layers with 4-0 Monocryl. • The DRUJ is pinned using a stout pin to stabilize the DRUJ in the neutral posture. The pin is removed at 4 weeks before initiating wrist motion.

Step 10: Immobilization A long-arm splint is applied with the forearm in neutral posture.

CHAPTER 30  Distal Radioulnar Joint Reconstruction Using the Palmaris Longus Graft

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The long-arm splint is removed after 10 to 14 days and the wounds are examined. The splint is replaced with another long-arm splint for a total duration of 4 weeks of above the elbow splinting after surgery. The DRUJ pin is removed 4 weeks after surgery. • The long-arm splint is replaced with a short-arm splint for an additional 4 weeks, at which point no further splinting is needed. • Physical therapy is initiated at 8 to 10 weeks postoperatively, beginning with gentle range of motion and transitioning to strengthening at 12 weeks. • The goal should be to recover approximately 85% of forearm motion by 6 months, compared with the contralateral side. See Video 30.1

EVIDENCE Adams BD, Berger RA. An anatomic reconstruction of the distal radioulnar ligaments for posttraumatic distal radioulnar joint instability. J Hand Surg Am. 2002;27:243–251. This article describes a commonly used technique of distal radioulnar ligament reconstruction for posttraumatic DRUJ instability in 14 patients with 4 years’ follow-up. This technique restored stability and range of motion with pronation and supination for all patients except for those with associated ulnocarpal ligament injury and sigmoid notch deficiency (Level V evidence). Lawler E, Adams BD. Reconstruction for DRUJ instability. Hand (NY). 2007;2:123–126. This article introduces an update of the procedure developed by the senior author that anatomically reconstructs the palmar and dorsal radioulnar ligaments at their anatomic origins and insertions. It includes an update on indications/contraindications, surgical technique, rehabilitation, and complications. Gillis JA, Soreide E, Khouri JS, Kadar A, Berger RA, Moran SL. Outcomes of the Adams-Berger ligament reconstruction for the distal radioulnar joint instability in 95 consecutive cases. J Wrist Surg. 2019;8(4):268–275. Retrospective review of 95 consecutive wrists in 93 patients treated with a tendon weave DRUJ reconstruction procedure. The average follow-up time was 65 months. A stable DRUJ was achieved in over 90% of patients, and 76% reported mild or no pain. Twelve patients (14%) underwent revision at an average of 13 months after the initial reconstruction, with 86% being considered successful reconstructions. In this series, using an interference screw to secure the tendon was the most notable factor associated with failure. Type of graft and notch anatomy were not significant contributors to failure in this cohort (Level IV evidence). Teoh LC, Yam AKT. Anatomic reconstruction of the distal radioulnar ligaments: Long-term results. J Hand Surg Br. 2005;30:185–193. The authors describe outcomes after open ligamentous repair for chronic DRUJ instability in nine patients with an average of 9 years of follow-up. Patient outcomes were assessed using the Mayo Wrist Score. The authors reported significant improvement in wrist scores after the repair that extended throughout the postoperative period. At follow-up, arthritis did not develop in any patients, but two patients developed recurrent instability (Level IV evidence).

193

CHAPTER

31

Procedures for Avascular Necrosis of the Lunate (Kienböck Disease) David W. Grant and Kevin C. Chung

INTRODUCTION • Kienböck disease describes the avascular necrosis of the lunate. Although its cause and natural history are uncertain, it is thought to progress through four stages: necrosis and subsequent collapse of the lunate, leading to changes in biomechanics of the other carpal bones and finally to the development of arthritis. • Nonoperative management of Kienböck disease is controversial and is usually indicated only in stage I disease. • Operative treatments fall into 3 categories: (1) strategies to off-load the lunate (see “Capitate Shortening” or “Radius Shortening”), (2) strategies to revascularize the lunate (see “Pedicled Vascularized Bone Grafts From the Middle Finger Metacarpal or Distal Radius” and “Free Osteochondral Flaps”), and (3) salvage arthrodesis procedures (see Chapter 53 Total Wrist Fusion and proximal row carpectomy [PRC] in Chapter 27 Salvage Procedures for Scaphoid Nonunion).

INDICATIONS • The treatment of Kienböck disease is guided by its stage. The most common staging system is the Lichtman classification (Fig. 31.1). • Stage I: Plain x-ray negative or single linear fracture; decreased signal in lunate on T1-weighted magnetic resonance imaging (MRI). • Stage II: Multiple fractures and/or sclerosis seen within the lunate but no evidence of lunate collapse. • Stage IIIA: Lunate collapse but the carpal alignment has been maintained. • Stage IIIB: Lunate collapse with fixed scaphoid flexion. • Stage IV: Arthritis around the lunate. • If the patient has stage IV disease, salvage procedures are performed (wrist denervation, PRC, or limited arthrodesis, depending on the arthritic surfaces). • If a patient has stage I, II, or IIIA disease, a combination of lunate off-loading and revascularization is performed during a single surgical session. We prefer to perform a capitate shortening osteotomy and pedicled bone flap from the middle finger metacarpal in most situations because it is relatively simple, requires a limited exposure, and avoids donor site morbidity. Osteochondral flaps may also be considered. • If a patient has stage IIIB disease, then the biomechanical changes may progress to arthritis even with off-loading or revascularization procedures. Treatment at this stage is controversial. Though some surgeons perform off-loading and revascularization procedures, others recommend salvage procedures when symptoms are intolerable.

Contraindications • Performing a radial shortening osteotomy in patients with ulnar negative variance can lead to ulnocarpal abutment syndrome. Capitate shortening osteotomy should be performed in these patients instead. • One contraindication is evidence of wrist arthritis. • Another is flexion of the scaphoid with radioscaphoid angle greater than 60 degrees because this indicates stage IIIB disease. This is controversial, however, because some surgeons achieve good results with off-loading and revascularizing procedures in patients with stage IIIB disease. 194

195

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

I

II

A

B

Lunate collapse, normal carpal alignment

Flexion of the scaphoid

IIIA C

IIIB D

FIGURE 31.1  (A–D) The Lichtman classification for Kienböck disease.

CLINICAL EXAMINATION

CLINICAL EXAMINATION PEARLS

• Kienböck disease is difficult to diagnosis early because patients typically present with vague dorsal wrist pain and limited range of motion (ROM), with or without antecedent trauma. • A thorough wrist examination is necessary to assess ROM, locations of point tenderness, and any soft tissue defects. • The wrist should be examined dorsally and volarly with direct palpation over bone intervals and the carpus to identify pain and inflammation. The pain may be localized to the radiolunate joint. It often increases with activity and is relieved with rest and immobilization. • Test for pain with axial loading or inherent joint instability because these are relative contraindications to PRC. • Check for tendon excursion because the overall kinematics at the wrist will change with shortening. • Tenderness is common over the dorsal lunate, which can be palpated just distal and ulnar to the Lister tubercle.

Kienböck disease should be suspected in any young person with vague wrist pain.

196

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

IMAGING Radiographs • Standard radiographs are always obtained to (1) rule out other pathology, (2) diagnose stage II or later Kienböck disease, and (3) determine ulnar variance. The lunate may appear normal on x-rays despite the presence of stage I disease. • Radiographs can show lunate sclerosis in stage II or lunate collapse in stage III and beyond (Fig. 31.2). Stage IIIA has normal overall carpal alignment, whereas stage IIIB has carpal collapse with scaphoid flexion. • Two measurements are used to distinguish stage IIIA from stage IIIB (Fig. 31.3): (1) The radioscaphoid angle reflects scaphoid flexion. It is measured between the long axis of the radius and the axis of the scaphoid and should be between 30 and 60 degrees. (2) Carpal height ratio reflects collapse of the carpus onto a collapsed lunate and flexed scaphoid; it is the ratio of carpal height to middle finger metacarpal height. The range is 0.52 plus or minus 0.02; less than 0.45 generally indicates carpal collapse. • Stage IV disease demonstrates arthritis and is treated with observation, rest, and splinting, or salvage operations such as wrist denervation, PRC, or limited wrist fusion.

Sclerotic lunate

A

Coronal fracture through lunate

B

FIGURE 31.2  Radiographs of a patient with stage IIIA disease, PA (A) and lateral (B). Note lunate sclerosis and collapse on the PA and coronal split on lateral. PA, Posteroanterior.

Axis of radius 3rd metacarpal height: 64 mm Axis of scaphoid

Carpal height, measured at capitate-lunate: 33 mm

A

Radioscaphoid angle: 58°

B

FIGURE 31.3  Same patient from Fig. 31.2. (A) Carpal height ratio is 33/64, or 0.52 (normal). (B) Radioscaphoid angle is 58 degrees (normal).

197

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

• Ulnar variance is measured on a neutral rotation posteroanterior (PA) view. When the distal radius and ulna are measured at the same level, this is termed neutral variance. If the ulnar articular surface is distal to the articular surface of the radius, this is called positive variance. Negative ulnar variance exists when the ulna is proximal to the radius. Normal variance is considered 22 mm to 12 mm. Pronation (up to 11 mm) and power grip (up to 12.5 mm) may change the articular relationship. • Shortening the radius can decrease the lunate strain by up to 70%, and 90% of this can be accomplished with 2 mm of radial shortening. • If x-rays demonstrate ulnar neutral or ulnar positive variance, shortening of the radius could lead to ulnocarpal abutment and subsequent wrist pain. In these patients, a capitate shortening should be considered.

Magnetic Resonance Imaging Stage I disease is only reliably detected with MRI imaging that demonstrates decreased T1 signal diffusely throughout the lunate (Fig. 31.4). The decrease in signal intensity must be seen uniformly throughout the lunate to diagnose avascular necrosis of the lunate. Ulnar impaction syndrome, fractures, interosseous ganglions, or enchondromas may cause focal decrease in signal on T1 or hyperintense signal on T2.

SURGICAL ANATOMY • There is a rich anastomotic network of arteries at the dorsal wrist that provides several pedicled bone flap options (Fig. 31.5). • Pedicled bone flaps either travel above or below the extensor retinaculum. We use the fourth extensor compartment artery (ECA) bone flap, which travels below the extensor retinaculum. Other surgeons use bone flaps that travel above the extensor retinaculum, or “supraretinacular” SRA flaps: the 1,2- and 2,3-intercompartmental supraretinacular artery (ICSRA). • For the revascularization procedures presented in this chapter, it is necessary to bur out the necrotic lunate to receive the pedicled bone flap. It is challenging to fit the flap within the lunate because the lunate is curved and the bone flap is a cube (Fig. 31.6).

RA Collapsed lunate with T1 hypointensity on MRI

dRCa

1, 2 ICSRA

dICa

UA dSRa

2, 3 ICSRA

4th ECA 5th ECA

FIGURE 31.4  T1-weighted MRI showing avascular necrosis of the lunate with collapse, indicating stage IIIA disease. Stage I disease is indicated by a normal x-ray and the same MRI appearance of the lunate but no collapse. MRI, Magnetic resonance imaging.

PIA aAIA

pAIA

AIA

FIGURE 31.5  There is a rich anastomotic network of vessels around the dorsal wrist that can supply multiple pedicled bone flaps for lunate revascularization.

198

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

FIGURE 31.6  The lunate’s curved three-dimensional shape makes it difficult to remove the central necrotic bone. Care must be taken to avoid damaging the cortical articular bone.

Capitate Shortening Osteotomy POSITIONING • All procedures in this chapter require the same positioning: general anesthetic or a block and monitored anesthesia care, supine on the operating room table with a tourniquet. • Prophylactic antibiotics are administered. STEP 1 PEARLS

• Use long incisions to achieve better visualization. • Confirm markings are over the capitate with fluoroscopy before incision. STEP 2 PEARLS

• Elevate thick subcutaneous flaps that contain all structures superficial to the extensor retinaculum. This will ensure that the radial sensory and dorsal cutaneous ulnar nerves are raised in the skin flaps. • Cauterize any crossing veins. There is no benefit to preserving them, and they can often bleed when the tourniquet is taken down. STEP 2 PITFALLS

The EPL tendon is more easily transected than the fourth extensor tendons because it crosses the dorsal wrist at an angle and is more superficial, whereas the other extensor tendons are longitudinal and deeper.

Step 1: Markings The incision is designed over the fourth extensor compartment, from the distal radius to the mid-third metacarpal (Fig. 31.7).

Step 2: Expose the Dorsal Wrist Capsule • The tourniquet is inflated with minimal exsanguination to help identify vessels. • A standard dorsal approach to the wrist is used to expose the dorsal wrist capsule. Incise through the skin and take care to protect the subcutaneous nerves and veins. • Identify and transpose the extensor pollicis longus (EPL) to protect it, then enter the fourth extensor compartment. Use self-retaining retractors to retract the fourth extensor tendons and expose the dorsal wrist capsule.

3rd metacarpal

Capitate, with two parallel lines indicating resection

Sclerotic and collapsed lunate

Incision FIGURE 31.7  Dorsal wrist markings, showing the metacarpal, capitate, and collapsed lunate, with a dorsal wrist incision placed in line with these structures.

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

Step 3: Confirm Anatomy With Fluoroscopy Use fluoroscopy to identify the third carpometacarpal (CMC) joint, between the distal capitate and third metacarpal; this will form the distal position of wrist capsulotomy. Mark with a marking pen.

Step 4: Expose Capitate A ligament-sparing ulnar-based capsular flap is created to open the wrist.

Step 5: Perform Capitate Osteotomy A 1-mm wafer of capitate is removed from the proximal third of the bone using a small sagittal saw (Fig. 31.9). This wafer of bone can be used as a bone graft to fill the void in the long finger metacarpal after harvest.

Step 6: Perform Hamate Osteotomy if Necessary If the capitate has a pseudoarthrosis with the hamate, then osteotomy is also indicated for the hamate. Remove a 1-mm wafer of bone from the hamate, proximal to the hook.

Step 7: Fixation A 2.5-mm cannulated screw is used to fixate the capitate (and hamate) using Kirschner wires (K-wires) as guides (Fig. 31.11).

Location of capitate Location of 3rd metacarpal base pedicled bone flap

FIGURE 31.8  Plan a dorsal wrist capsule incision to protect the pedicled bone flap from the third metacarpal base. The white structure indicated at left is the third metacarpal base, and the capsule incision is placed proximal to this.

Capitate osteotomy Bone wafer removed

STEP 3 PEARLS

• The pedicles for local bone flaps are close to the capsulotomy incisions required to access the wrist; precise cuts in the wrist capsule can be made at the distal capitate using fluoroscopic guidance. • The dorsal interosseous muscles appear distal to the metacarpal bases. The bases articulate with each other, and then narrow to form the shafts, between which are the interossei. Therefore the CMC joint is proximal to the interossei. STEP 3 PITFALLS

The third metacarpal bone flap is taken from the white-appearing metacarpal base (Fig. 31.8). Recognize that this is not the capitate, and design a capsule incision proximal to it. STEP 4 PEARLS

• It is better to protect the bone flap pedicle than perform a complete ligament-sparing approach. • Care is taken to avoid injury to the scapholunate and lunotriquetral interosseous ligaments. STEP 5 PEARLS

• The bone will be shortened by approximately 3 mm, given that the sagittal saw is roughly 1 mm thick. • Use irrigation to cool the bone and facilitate union. • Note that the carpal tunnel contents are deep to the osteotomy. • If a hamate osteotomy is required as well (see the following section), this is performed at the same level as capitate osteotomy. When the capitate and hamate have tight articulation, both the hamate and capitate osteotomies are done proximal to the hamate hook and can be confirmed with fluoroscopy. STEP 5 PITFALLS

Performing capitate osteotomy requires a high level of skill. Inexperience can lead to median nerve injury. STEP 6 PEARLS

Perform hamate osteotomy proximal to the hook to avoid injuring the ulnar nerve (Fig. 31.10). STEP 6 PITFALLS

Hamate osteotomy also requires a high level of skill. An inexperienced surgeon is more likely to injure the deep branch of the ulnar nerve (see Fig. 31.10). Location of 3rd metacarpal base pedicled bone flap

STEP 5 PEARLS

FIGURE 31.9  Capitate wafer removed.

• Flex the wrist to ensure that the K-wires have a straight trajectory. • Ensure that the screw is not proud (Fig. 31.12).

199

200

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease) Abductor digiti minimi Flexor digiti minimi Opponens digiti minimi Ulnar nerve (deep branch) Hook of hamate Trans carpal ligament Ulnar nerve (superficial branch)

Volar carpal ligament (cut)

Piso-hamate ligament (cut) Pisiform

Flexor carpi ulnaris Ulnar artery

A

PB UA UN

TCL FDS MN FPL FCR APB

ADM FDP

OP APL EPB

Tm H

ECU

C

Td

RA EPL

EDM

ECRL EDC

ECRB

B FIGURE 31.10  (A–B) Hamate osteotomy must be proximal to the hook of hamate to avoid damage to ulnar nerve. ([A] from Hagert, E. Nerve entrapment syndromes. In Chang J, Neligan PC, Liu DZ, eds. Plastic Surgery: Volume 6: Hand and Upper Limb. Elsevier; 2018: 525–548.e5. [B] From Chhabra, AB. Wrist and hand. In Miller M, Chhabra AB, Park J, Shen F, Weiss D, Browne J. Orthopaedic Surgical Approaches. 2nd ed. Elsevier: 2014; 105–159. Cannulated screw over the K-wire in capitate

FIGURE 31.11  A 2.5-mm cannulated screw is used to fixate the capitate (and hamate) using Kirschnerwires (K-wires) as guides.

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease) Cannulated screw beneath the capitate’s articular surface

FIGURE 31.12  Screw beneath the articular surface.

Step 8: Closure Perform a pedicled bone flap before closure (see next procedure).

PEDICLED VASCULARIZED BONE FLAP FROM MIDDLE FINGER METACARPAL

STEP 1 PEARLS

Given the rich anastomotic plexus in the dorsal wrist, multiple pedicles exist and their structures vary between patients (see Fig. 31.5). Choose the largest pedicle that will provide adequate rotation. STEP 1 PITFALLS

Capitate shortening and fixation is performed before the more delicate pedicled bone flap procedure.

Avoid a larger pedicle without appropriate reach.

Step 1: Identify Bone Flap

STEP 2 PEARLS

As previously mentioned, use fluoroscopy to identify the metacarpal base that will be harvested (see Fig. 31.8).

• It is safer to use an osteotome rather than a sagittal saw to perform the final osteotomy on the fourth border, underneath the pedicle. • A curved osteotome and a Freer are used to obtain the corticocancellous bone flap from the metacarpal base (Fig. 31.13). • To help elevate the pedicle, cauterize the adjacent periosteum far from the pedicle, then use a Freer to “roll up” this periosteum toward the pedicle and ultimately lift the pedicle off of the underlying bone.

Step 2: Raise Third Metacarpal Bone Flap • Use a knife to outline three sides of the bone flap, distal to the pedicle insertion (Fig. 31.13). Subsequently, use a sagittal saw to create three osteotomies, ensuring that they do not go through the deep cortex. • Use a Freer elevator to lift the pedicle off of the bone before it enters the flap. This creates space to perform the final fourth osteotomy with an osteotome.

Step 3: Prepare the Lunate The medullary cavity of the lunate is removed before placement of the bone flap.

Step 4: Rotate Bone Flap Into Lunate and Fixate as Necessary Scissors and bipolar cautery are used to develop the bone flap sufficiently, so that it can rotate into the prepared lunate (Fig. 31.14).

STEP 2 PITFALLS

• Penetrating the deep cortex during osteotomies can destabilize the metacarpal. • Avoid raising the periosteum too close to the pedicle to prevent pedicle injury.

Step 5: Closure

STEP 3 PEARLS

• Standard wrist closure is performed using 4-0 Vicryl to close the capsule and extensor retinaculum and 3-0/4-0 Monocryl for skin closure. • The patient is placed in a volar wrist splint and is instructed to return to the clinic in 7 to 10 days, at which point the wound is inspected and the patient transitions to cast immobilization.

It can be challenging to fit the cube-shaped bone flap into the curved portion of the lunate (see Fig. 31.6). Nevertheless, it is necessary to ensure that as much necrotic lunate is removed as possible without disrupting the articular surfaces and that the bone flap is large enough to encourage revascularization. This cortical bone graft serves to provide a strut to the lunate to prevent its collapse.

PEDICLED VASCULARIZED BONE GRAFT FROM THE DISTAL RADIUS Step 1: Markings The same principles apply to the dorsal approach to the wrist, but the exposure is more proximal (Fig. 31.16).

STEP 3 PITFALLS

Avoid fracturing the lunate cortex with bur or rongeur.

201

202

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

Sagittal saw cuts STEP 4 PEARLS

• Make the pedicle as short as possible to protect the collaterals that feed it, also ensuring that it can be rotated without tension. • If the bone flap does not fit the lunate well, it is better to carve the lunate, which is avascular, rather than the bone flap, which is vascular. • If the bone flap dislocates from the lunate with minor movement, fixate with a K-wire (Fig. 31.15). STEP 4 PITFALLS

Avoid thinning the bone flap at all costs because it has the osteogenic potential to heal the lunate.

Osteotome cut A

STEP 5 PEARLS

Dexmedetomidine can help this young patient population to emerge from anesthesia calmly, protecting the delicate reconstruction.

Delicate pedicle

STEP 5 PITFALLS

Lunate preparation, bone flap transposition, and fixation are delicate; do not be too aggressive with closure, splinting, or anesthesia emergence.

B FIGURE 31.13  (A–B) Two views of the corticocancellous bone flap taken from the third metacarpal base and its delicate pedicle.

Delicate pedicle

Bone flap beneath this pedicle, in the lunate

FIGURE 31.14  Scissors and bipolar cautery are used to develop the bone flap sufficiently, so that it can rotate into the prepared lunate. STEP 2 PEARLS

• Take care not to damage the fourth ECA pedicle, found on the floor of the fourth extensor compartment just ulnar to the Lister tubercle (Fig. 31.18). • A posterior interosseous nerve (PIN) neurectomy can be performed at this time.

Step 2: Exposure of the Bone Graft Donor Site Similar to the first procedure, the skin is incised, subcutaneous flaps are raised by protecting radial sensory and dorsal cutaneous ulnar nerves and dividing superficial veins, the extensor retinaculum is divided and EPL is transposed, and the fourth extensor compartment is entered (Fig. 31.17).

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

FIGURE 31.15  PA and lateral views showing cannulated screws in the capitate and hamate, and a Kirschner wire (K-wire) fixating bone flap into lunate. PA, Posteroanterior.

Lister tubercle

FIGURE 31.16  Dorsal approach to the wrist, incising ulnar to the Lister tubercle into the fourth compartment.

FIGURE 31.17  Incising extensor retinaculum and retracting extensor tendons reveals the bone flaps pedicle on the base of the fourth compartment. ECA, Extensor compartment artery.

203

204

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

Lister tubercle

4th ECA

FIGURE 31.18  Incising extensor retinaculum and retracting extensor tendons reveals the bone flaps pedicle on the base of the fourth compartment. ECA, Extensor compartment artery.

Dorsal lunate removed

Lunate prepared

FIGURE 31.19  The lunate is found just distal and ulnar to the Lister tubercle. Confirm its position clinically and radiographically.

STEP 3 PITFALLS

Step 3: Exposure of the Lunate

Care is taken to avoid injury to the scapholunate and lunotriquetral interosseous ligaments.

• The lunate is found just distal and ulnar to the Lister tubercle. Confirm its position clinically and radiographically (Fig. 31.19). • An ulnarly based flap of dorsal wrist capsule is raised to expose the lunate.

Step 4: Prepare the Lunate See the pedicled vascularized bone flap from the middle finger metacarpal procedure (Step 3 and Fig. 31.8). STEP 5 PEARLS

• It is important to maintain maxi harvested and raised in a similar fashion to the third metacarpal base mal proximal-to-distal length when fitting the flap into position to prevent collapse of the lunate. • The thicker cortical side of the bone flap should be placed within the lunate to maximize the strut support. Care must be taken to avoid disruption of the periosteal blood supply to the flap.

Step 5: Elevation of the Pedicled Fourth Extensor Compartment Artery Bone Flap • The fourth ECA is carefully dissected proximal to its bifurcation with the fifth ECA (see Fig. 31.5). • The fourth ECA pedicle is divided just proximal to this bifurcation, producing a distally based flap based on the fifth ECA (Fig. 31.20). • The corticocancellous flap is harvested and raised in a similar fashion to the third metacarpal base flap, as described in the pedicled vascularized bone flap from the middle finger metacarpal procedure (Step 2; Fig. 31.21). • The flap is placed into the prepared lunate (Fig. 31.22).

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

FIGURE 31.20  The fourth ECA pedicle is divided just proximal to this bifurcation, producing a distally based flap based on the fifth ECA. ECA, Extensor compartment artery.

Sagittal saw osteotomies

A

Osteotome osteotomy

B Bone flap pedicle Bone flap pedicle

Bone flap

C

D

FIGURE 31.21  (A–D) The corticocancellous flap is harvested and raised in a similar fashion to the third metacarpal base flap, as described in step 2 of the pedicled vascularized bone flap from middle finger metacarpal procedure.

Step 6: Unload the Lunate by Pinning the Scaphoid to the Capitate • This step is not always performed. • While distracting the wrist, a 0.062-in (1.57-mm) K-wire is passed from the scaphoid to the capitate to unload the lunate. • The K-wire position is confirmed radiographically (Fig. 31.23).

205

206

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

Bone flap pedicle

Bone flap placed into prepared lunate

FIGURE 31.22  The flap is placed into the prepared lunate.

A

B FIGURE 31.23  The Kirschner wire (K-wire) position is confirmed radiographically.

Step 7: Closure

STEP 1 PEARLS

• The radial shaft osteotomy is designed proximal to the distal radius metaphyseal flare, which is more proximal than most distal radius exposures. Fluoroscopy is useful to confirm that the incision design is proximal enough (Fig. 31.25). • The FCR tendon can be readily palpated and marked when the patient is awake and flexes their wrist.

• Standard wrist closure is done using 4-0 Vicryl to close the capsule and extensor retinaculum and 3-0/4-0 Monocryl skin closure. • The patient is placed into a volar wrist splint and is instructed to return to the clinic in 10 to 14 days, at which point the wound is inspected and the sutures removed.

RADIAL SHORTENING OSTEOTOMY FOR LUNATE UNLOADING Step 1: Markings A standard volar Henry approach is taken, using an 8- to 10-cm longitudinal incision over the FCR (Fig. 31.24).

Step 2: Exposure of the Radius in Preparation for the Osteotomy STEP 2 PEARLS

It is possible to approach the FCR radially instead of ulnarly. Nevertheless, this approach puts the palmar cutaneous median nerve at greater risk for injury.

• Under tourniquet control, the skin is incised, exposing the FCR tendon. A longitudinal incision is performed along the radial border of the FCR and the tendon is retracted ulnarly. • The interval between the FCR and radial artery is entered and the flexor pollicis longus (FPL) is identified and protected.

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

FIGURE 31.24  A standard volar Henry approach is taken, using an 8-to 10-cm longitudinal incision over the FCR. FCR, Flexor carpi radialis.

A

B

FIGURE 31.25  The radial shaft osteotomy is designed proximal to the distal radius metaphyseal flare, which is more proximal than most distal radius exposures. Fluoroscopy is useful to confirm that the incision design is proximal enough.

• The radial pronator quadratus attachments are released from the radius using a scalpel or bipolar cautery, and the radius is dissected subperiosteally to place the cutting jig (Fig. 31.26). • The radial shaft osteotomy is designed proximal to the distal radius metaphyseal flare (see Fig. 31.25). • If the cutting jig is unavailable, a compression plate can be used with screws placed eccentrically.

Step 3: Radius Osteotomy

STEP 3 PEARLS

• A Rayhack device is used to create a precision oblique osteotomy. A six-hole, lowprofile locking plate, or a six-hole, limited-contact dynamic compression plate can be used. Alternatively, the newer low-profile locking plates can be used to reduce the incidence of soft tissue irritation that can require plate removal. • If the cutting guide is not available, two parallel transverse osteotomies can be created proximal to the metaphyseal flare of the radius. The cuts must be parallel to avoid alteration of the tilt or inclination of the distal radius articular surface. • The amount of bone to be removed can be measured on the neutral PA view and should not result in significant ulnar positivity after compression. • In general, about 2 to 3 mm of radial shortening is desired (Fig. 31.27). • Using the Rayhack system, an oblique 2-mm shortening osteotomy is performed by sagittal saw. The distal osteotomy is performed first, followed by the proximal osteotomy.

• Saline irrigation during osteotomy can prevent heat-induced thermal necrosis of the bone. • The screws used to hold the guide in place will be reused to apply the plate. Be sure to keep track of which holes the screws came from and the screw lengths, if they are different.

207

208

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

A

B

FIGURE 31.26  (A–B) The radial pronator quadratus attachments are released from the radius using a scalpel or bipolar cautery, and the radius is dissected subperiosteally to place the cutting jig.

A

B FIGURE 31.27  (A–B) In general, about 2 to 3 mm of radial shortening is desired.

• The anticipated shortening using the Rayhack system depends on the slots that are used to make the parallel oblique osteotomy cuts. • Using slots 1 and 2 (from proximal) will result in approximately 3.5 mm of shortening. • Slots 2 and 3 result in 4.9 mm of shortening, and slots 1 and 3 result in 7.4 mm of shortening.

Step 4: Fixation

STEP 5 PITFALLS

Care should be taken to avoid drilling the far cortex with the 2.7-mm drill bit because this will limit compression.

• The plate is selected from the set and placed within the wound at the level of the desired osteotomy. The distal end of the plate should be approximately 2 to 3 cm from the distal radius watershed line. The second hole (from proximal) is marked on the bone, and then the plate is replaced with the cutting guide; its second hole (from proximal) is lined up with the marking. • The cutting guide is held manually and, using a straight drill guide, a 2.5-mm drill is used to make a hole through the second hole on the cutting guide. The depth of the hole is measured, the hole is tapped with a 3.5-mm tap, and a 3.5-mm cortical screw is inserted. This procedure is repeated for the fourth and then the third holes on the cutting guide.

Step 5: Placement of the Interfragmentary Lag Screw • The 22-degree angled drill guide is placed into the round hole of the compression block.

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

• A 2.7-mm drill bit is used to drill the near cortex, and the far cortex is drilled with a 2.0-mm drill bit. • After measuring the depth, the drill guide is reapplied, and the far cortex is tapped with a 2.7-mm tap. The drill guide is removed, and the 2.7-mm cortical lag screw is inserted to provide additional compression.

Step 6: Final Plate Fixation

STEP 6 PITFALLS

• A handheld drill guide and a 2.5-mm drill bit are used to make a hole through the fifth hole of the plate. This hole is measured and tapped, and a 3.5-mm cortical screw is placed. • A locking screw drill guide is inserted into the sixth hole, and a 2.3-mm drill bit is used to make a hole. This hole is measured, and a 2.7-mm locking screw is placed. • The compression device is removed, and the original screws for holes 3 and 4 are reinserted. The position of the plate and screws is confirmed fluoroscopically

Loosening the longitudinally oriented screws of the compression block will make it easier to remove the screws that are holding it onto the plate.

Step 7: Closure After releasing the tourniquet, ensure hemostasis. The wound should be closed in layers using interrupted 4-0 Monocryl or 4-0 PDS.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A volar wrist splint is placed and the patient is instructed to return to the clinic in 10 to 14 days for wound check and suture removal. • The wrist is maintained in a short-arm cast for 6 to 12 weeks or until clinical and radiographic confirmation of union. At that time, early ROM exercises can be initiated. Once bony union is evident radiographically, splinting can be discontinued and progressive strengthening exercises can be initiated. • Fig. 31.28 demonstrates maintenance of hardware without complication and slight ulnar positive variance at 8 months’ follow-up, after radial shortening osteotomy. • Fig. 31.29 is at 6 weeks postoperative from procedures 1 and 2 and shows radiographic healing of capitate and hamate shortening osteotomy, new radiopacity in the lunate, and clinical ROM. • The majority of the patients achieve good to excellent results in terms of pain control and recovery of function. • Computed tomography or MRI can be performed at approximately 3 months to assess for union and/or vascularity of the lunate, but neither are necessary. • Some patients will go on to require a salvage operation, such as a wrist fusion or total arthroplasty. See Video 31.1

A

B

C

FIGURE 31.28  (A-C) Postoperative radiographs.

POSTOPERATIVE PITFALLS

Complications after radial shortening osteotomy include delayed union or nonunion, chronic pain, distal radioulnar joint stiffness, prominence of hardware requiring removal, and injury to the palmar cutaneous branch of the median nerve.

209

210

CHAPTER 31  Procedures for Avascular Necrosis of the Lunate (Kienböck Disease)

A

B FIGURE 31.29  (A–B) Postoperative radiographs.

EVIDENCE Almquist EE, Burns Jr JF. Radial shortening for the treatment of Kienböck’s disease—a 5 to 10 year follow-up. J Hand Surg Am. 1982;7:348–352. The authors reviewed a series of patients who underwent radial shortening osteotomy for Kienböck disease and had intermediate to long-term follow-up. Eleven of the 12 patients were satisfied with their treatment and showed functional improvement. These patients returned to their normal activities. Grip strength was satisfactory, and ROM improved after surgery. Elhassan BT, Shin AY. Vascularized bone grafting for treatment of Kienböck’s disease. J Hand Surg. 2009;34A:146–154. In this review article, the authors discuss indications and vascularized bone grafting techniques for the treatment of Kienböck disease. Moran SL, Cooney WP, Berger RA, Bishop AT, Shin AY. The use of the 4/5 extensor compartmental vascularized bone graft for the treatment of Kienböck’s disease. J Hand Surg Am. 2005;30:50–58. The authors from the Mayo Clinic published their results using this technique. Twenty-six patients were followed for an average of 31 months. Ninety-two percent of the wrists were pain-free. Grip strength increased from 50% of the contralateral extremity to 89% postoperatively. During follow-up, 23% of patients developed radiographic evidence of continued collapse of the lunate. MRI was performed at an average 20 months after surgery on 17 wrists, and 71% had evidence of revascularization. There were two failures in the study cohort who underwent total wrist arthroplasty. Rock MG, Roth JH, Martin L. Radial shortening osteotomy for treatment of Kienböck’s disease. J Hand Surg Am. 1991;16:454-460. The authors reviewed 16 patients who underwent shortening of the radius for Kienböck disease stages II, III, and IV. Average follow-up was 4.5 years. Thirteen of 16 patients were pain-free and 3 had mild pain at follow-up. ROM and grip strength increased in all patients. Radiographic alignment was preserved in all but one patient in whom carpal collapse was observed. Weiss AP, Weiland AJ, Moore JR, Wilgis EF. Radial shortening for Kienböck disease. J Bone Joint Surg Am. 1991;73:384-391. Twenty-nine consecutive patients who underwent radial shortening osteotomy for Kienböck disease stages I, II, IIIa, and IIIb were reviewed. Average follow-up was 3.8 years. Pain had decreased in 87% of the wrists. Extension of the wrist had improved an average of 32%; flexion, 27%; radial deviation, 30%; ulnar deviation, 41%; and grip strength on the affected side, 49%. Analysis of the radiographs showed no significant changexs in the amount of collapse of the lunate at the latest follow-up. There were two complications at follow-up, excessive shortening of the radius and nonunion of the radial osteotomy.

ddsf

SECTION IV

Forearm Fractures CHAPTER 32

Operative Treatment of Distal Radius Fractures  212

CHAPTER 33

Corrective Osteotomy of Radius Malunion  243

CHAPTER 34

Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)  258

CHAPTER 35

Radius and Ulna Fracture Dislocations (Galeazzi and Monteggia)  266

211

CHAPTER

32

Operative Treatment of Distal Radius Fractures Chun-Yu Chen and Kevin C. Chung

INDICATIONS Operative management is indicated for distal radius fractures that have a dorsal tilt greater than 10 degrees, radial inclination angle of less than 15 degrees, radial shortening greater than 5 mm, positive ulnar variance greater than 3 mm, and/or an intraarticular step-off greater than or equal to 2 mm.

CLINICAL EXAMINATION • The wrist should be assessed for deformity and any open wounds. Open fractures require urgent washout, fracture treatment, and antibiotics. • Significant displacement of the ulna may indicate ligamentous injury. The distal radioulnar joint (DRUJ) should be assessed for instability. • A complete neurovascular examination should be performed, with specific attention paid to median nerve function. Findings that indicate compromised median nerve function include numbness over the volar thumb, index, and middle finger, and numbness along the radial aspect of the ring finger and the corresponding part of the palm. • The elbow should be assessed for tenderness and deformity. These findings could indicate an associated radial head fracture or dislocation. Fracture patterns commonly associated with radial head trauma include: • Essex-Lopresti injury: A fracture of the radial head with disruption of the forearm interosseous membrane and DRUJ dislocation. • Monteggia fracture: Ulnar shaft fracture with associated radial head dislocation.

IMAGING • Anteroposterior (AP), lateral, and oblique images of the wrist should be obtained. Proper reduction should restore radial inclination to 22 to 25 degrees, radial height to 10 to 15 mm, and volar tilt to 11 to 15 degrees (Fig. 32.1A–C). • The fracture pattern of the distal radius is assessed, such as whether the fracture pattern is intraarticular or extraarticular. • The ulna should be assessed for injury and the carpal bones assessed for displacement, abnormal spacing, or concomitant fracture. • Pay attention to the integrity of the radial shaft and metacarpals to ensure that these are available to provide sites for external fixation if necessary. • Computed tomography (CT) and magnetic resonance imaging (MRI) are usually unnecessary. Nevertheless, these imaging modalities can provide more detailed information for cases with comminuted articular fracture or suspicion of an associated lesion, such as ligament and carpal bone injuries.

Percutaneous Pinning of Distal Radius Fractures: Kapandji Pinning Technique INDICATIONS Indications for this procedure include: • Displaced and unstable extraarticular distal radius fractures, with minimal comminution (Fig. 32.2A–C). • Simple two-part or three-part intraarticular distal radius fractures. • Displaced distal radius fractures in children or adolescents. 212

CHAPTER 32  Operative Treatment of Distal Radius Fractures

Radial inclination

Radial height

A

B

Volar tilt

C

FIGURE 32.1  (A) Radial inclination is measured on the anteroposterior (AP) view as the angle of the articular surface of the radius relative to a line perpendicular to the shaft. (B) Radial height is measured on the AP view as a distance between two parallel lines perpendicular to the radius. One line is drawn at the top of the radial styloid, and another is drawn at the base of the articular surface. (C) Volar tilt is assessed on the lateral view. It is the angle between the radial articular surface and a line perpendicular to the long axis of radius.

A

B

C

FIGURE 32.2  (A–C) A distal radius fracture that is indicated for operative management because of excessive radial shortening, decreased radial height, and dorsal tilt.

SURGICAL ANATOMY • Extensor tendons, the cephalic vein, and the superficial radial nerve are at potential risk for injury when inserting the pins. • Radial-sided pins are placed between the first and second dorsal compartments. • Dorsal-ulnar pins are placed in the intermediate column of the radius between the fourth and fifth extensor compartments.

POSITIONING A radiolucent hand table is used with the forearm placed in a pronated position.

EXPOSURES • Percutaneous Kirschner wire (K-wire) pinning can be performed in most cases. The K-wires are relatively blunt and will not skewer the tendons and nerves during the drilling process. Therefore most cases will not need open exposures.

213

214

CHAPTER 32  Operative Treatment of Distal Radius Fractures

• For some patients who present with previous trauma or scar tissue over the insertion site, a so-called “mini-open” technique using 1 to 2 cm incisions can be performed to prevent injury to the underlying tendons and nerves during pinning. With the open approach, the soft tissue flaps are elevated, and the skin is retracted. Branches of the superficial radial nerve are identified and carefully protected.

PROCEDURE

STEP 1 PEARLS

• If there is difficulty in reducing the fracture, a blunt Freer elevator can be placed percutaneously. This can be inserted into the fracture site dorsally and used to lever the fracture into a reduced position. • To maintain stability in the volar cortex, the K-wire should be drilled only once. Drilling, reversing, and then redrilling can lead to loosening of the wire and fixation.

Step 1 • The first 0.062-in (1.57-mm) K-wire is inserted into the radial aspect of the dorsal fracture line until the volar cortex is felt (Fig. 32.3A–B). This step is necessary to achieve suitable dorsal volar inclination of 11 degrees. • Using the dorsal cortex as a lever’s fulcrum, the wire driver and wire are then moved distally to lever and buttress the distal radial fragment into reduction (see Fig. 32.3C). • With the fracture reduced, this pin is advanced into the volar cortex to secure the reduction. Be sure not to pass the K-wire back and forth over the volar cortex, which will enlarge the drill hole and loosen the K-wire. • A second pin should always be placed in the dorsoulnar aspect of the fracture to further support the reduction (Fig. 32.4A–C).

STEP 1 PITFALLS

Care should be taken not to over-reduce the fragment. Excessive flexion can displace the fragment volarly.

Step 2 • A third pin is inserted in the radial aspect of the fracture line, perpendicular to the dorsal-volar pins (Fig. 32.5A–B). The aim of this pin is to restore radial inclination and prevent radial translation of the distal segment. • The entire pin is then translated distally, with the surgeon’s fingers levering and pushing the distal fragment to restore radial inclination (see Fig. 32.5C–D). Do not bend the K-wire during this reduction maneuver. Gently lever the distal fragment using pin and finger pressure. • The pin is then driven through the ulnar cortex of the radius to secure its position (Fig. 32.6).

STEP 2 PITFALLS

Applying a lever force at the tip of the wire will lead to bending of the wire without reducing the fracture. Force is applied as close to the bone as possible while pushing with fingers to guide the distal fragment into reduction. An acceptable reduction is achieved when the thick volar cortices are aligned, rather than overlapping.

A

B

C

FIGURE 32.3  (A–C) A Kirschner wire (K-wire) is inserted into the ulnar aspect of the dorsal fracture line. The wire driver and wire are then moved distally to reduce the distal radius fragment.

A

B

C

FIGURE 32.4  (A–C) A second pin is placed in the dorsoradial aspect of the fracture to further support the reduction.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

A

C

B

D

FIGURE 32.5  (A–B) A third pin is inserted in the radial aspect of the fracture line perpendicular to the dorsal-volar pins. (C–D) The entire pin is translated distally to restore radial inclination.

FIGURE 32.6  The pin is then driven through the ulnar cortex of the radius to secure its position.

Step 3

STEP 3 PEARLS

A fourth pin is placed through the cortex of the radial styloid and advanced into the ulnar cortex to secure the reduction achieved by the intrafocal wires (Fig. 32.7).

Percutaneous pinning can lead to tethering of the surrounding skin. Skin incisions may be necessary to release tethering around any pins.

Step 4 • Several different percutaneous techniques have been described and can be tailored to the fracture pattern (Fig. 32.8A–D): (A) Multiple radial styloid pins (B) Cross radial pins (C) Radial styloid and radial-ulnar pins, which can stabilize the DRUJ (D) The De Palma technique, which uses the ulna to support the radius.  Pins are placed from the ulna toward the radial styloid, targeting both the volar or dorsal cortex of the radius with separate pins. • Pediatric fractures of the epiphysis in some cases can be treated adequately with a single radial pin (Fig. 32.9A–D).

STEP 3 PITFALLS

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

POSTOPERATIVE CARE PEARLS

• Patients are seen after 2 weeks for a dressing change and are converted to a removable thermoplastic splint. • The removable splint provides stability and enables cleaning of the pins. Active range of motion (ROM) of the fingers and elbow are initiated.

Prolonged immobilization delays restoration of motion. Pins should be removed, and motion initiated as soon as there is evident callus formation to provide stability from displacement.

Because the radial styloid can be easily fragmented, avoid multiple passes of the K-wire.

215

216

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.7  A fourth pin is placed through the cortex of the radial styloid and advanced into the ulnar cortex.

A

B

C

D

FIGURE 32.8  (A) Multiple radial styloid pins. (B) Cross radial pins. (C) Radial styloid and radial-ulnar pins, which can stabilize the distal radioulnar joint (DRUJ). (D) De Palma technique. POSTOPERATIVE CARE PITFALLS

For older patients who do not have attendant care, or if a patient is at risk for poor hygiene habits, pins should be buried beneath the skin at the time of the initial operation to reduce infection risk. The pins can be retrieved later with a short second procedure under local anesthesia.

• Pin tract infection (Fig. 32.10) is a potential complication of percutaneous pinning, which presents with redness, warmth, swelling, and continuous discharge at the pin sites. If pin tracts become infected, pins are removed immediately, although this premature removal may lead to fracture collapse if the fracture has not reached full stability. Failure to promptly recognize and treat pin tract infections can cause the

CHAPTER 32  Operative Treatment of Distal Radius Fractures

A

B

C

D

FIGURE 32.9  (A–D) Pediatric fractures of the epiphysis in some cases can be treated adequately with a single radial pin.

FIGURE 32.10  Redness, swelling, and discharge at the pin sites indicate pin tract infection.

infection to progress to osteomyelitis, a disastrous complication that must be avoided at all costs. • To prevent pin tract infections, K-wires should be inspected and cleaned several times daily with 50% peroxide solution. • The K-wires are removed 6 weeks after surgery.

External Fixation of Distal Radius Fractures INDICATIONS Indications for this procedure include: • Distal radius fractures with severe comminution. • Fractures with significant impaction (Fig. 32.11). • Open injuries with significant soft tissue loss that may preclude the use of internal fixation.

SURGICAL ANATOMY • The distal pins are placed along the dorso radial aspect of the second metacarpal. The superficial radial sensory branch runs near the incision site and must be elevated away and protected. • The proximal pins are placed along the dorsal radial shaft of the radius. The position is proximal to the crossing of the tendons of the first compartment and distal to the insertion of the pronator teres (PT). The radial sensory nerve is also located in this area and should be protected.

EXPOSURES • A 3-cm longitudinal incision is made along the dorsal radial side of the second metacarpal (Fig. 32.12).

EXPOSURES PITFALLS

Pure percutaneous placement or open incisions without adequate visualization increase the risk for iatrogenic nerve injury.

217

218

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.11  Preoperative films of a patient with an impacted, dorsally angulated, and comminuted fracture.

FIGURE 32.12  Two 3-cm longitudinal incisions (black dotted lines) are made along the dorso radial aspect of the second metacarpal and the dorso radial aspect of the radius.

• Another 3-cm longitudinal incision is made on the dorso radial aspect of the radius, 8 to 12 cm proximal to the wrist (see Fig. 32.12). Blunt dissection is used to expose the radius and proceeds between the tendons of the brachioradialis (BR) and extensor carpi radialis longus (ECRL). STEP 1 PITFALLS

• Avoid oversinking the pins. This may inadvertently injure the interossei muscles. • A pin placed too dorsal or volar can risk fracturing the cortical bone of the metacarpal.

PROCEDURE Step 1 • A 3-mm partially threaded pin (Fig. 32.13) is inserted in a plane parallel to the metacarpals near the base of the index finger metacarpal using a double pin guide. The pin is driven perpendicular to the index finger metacarpal shaft (Fig. 32.14). Be sure that the pin is centered over the bone to avoid iatrogenic fracture. • The pin is centered between the dorsal and volar cortex and then driven from the radial cortex of the metacarpal to the ulnar cortex. • The parallel pin guide is used to place a second pin distal to the first. The guide facilitates insertion of the second pin at the same angle and plane as the first pin.

FIGURE 32.13  The 3-mm partially threaded pins are used for external fixation.

FIGURE 32.14  The pins are inserted in a parallel plane using the double pin guide.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.15  All pins should be in a similar plane and at the same angle.

Step 2

STEP 2 PITFALLS

• After exposure of the radius, a 3-mm partially threaded pin is inserted perpendicular to the radial shaft between the BR and ECRL tendons in the same plane as the metacarpal pins. • A second pin is inserted distal to the first pin using the parallel pin guide. • All pins should be in a similar plane and angle (Fig. 32.15).

The partially threaded pins used for this procedure are self-tapping. Therefore these pins should be inserted with enough force to avoid getting stuck at the far cortex, which can lead to widening of the hole in the near cortex and pin loosening. An alternate pin site needs to be chosen if this happens.

Step 3 • The proximal and distal incisions are closed with 4-0 nylon sutures around the pins. • A single distraction rod is applied, and the fracture is reduced into anatomic alignment using ligamentotaxis by distracting the wrist joint and using the ligaments around the wrist to reduce the fractures (Fig. 32.16). • More complex fractures may require a multibar system. • Percutaneous pins or open reduction and internal fixation can be used to supplement external fixation for adequate restoration of the articular surface. • The pins are wrapped with petroleum gauze to protect the incisions until they heal.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Dressings and sutures are removed at 10 to 14 days. • Patients can use soap and water to clean around the pins but should not wet the entire fixator in the shower or bath. • Finger ROM is encouraged after suture removal (Fig. 32.17). • The fixator is removed in the office at 5 to 6 weeks. • Patients can achieve excellent ROM at follow-up, but it may take several months because of prolonged wrist immobilization.

FIGURE 32.16  A single distraction rod is applied and the fracture is reduced. Anatomic alignment is verified radiographically.

STEP 3 PEARLS

Ensure adequate skin-to-fixator distance so that the device will not impinge on the soft tissues as they swell postoperatively. STEP 3 PITFALLS

Take care not to injure the radial nerve and branches during closure because these structures lie directly beneath both incisions.

219

220

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.17  Finger motion is encouraged after suture removal. This patient achieved excellent recovery of range of motion at 1 month.

Volar Plate Fixation INDICATIONS Indications for this procedure include: • Comminuted or unstable intraarticular fractures (Fig. 32.18) • Unstable extraarticular fractures • Volar shearing fractures

SURGICAL ANATOMY • The palmar cutaneous branch of the median nerve is ulnar to the flexor carpi radialis (FCR). For incisions radial to the FCR, there is no need to visualize this nerve during exposure (Fig. 32.19).

Flexor digitorum superficialis Palmaris longus (retracted)

Palmar cutaneous branch of median nerve Radial artery Median nerve Flexor pollicis longus Flexor carpi radialis Brachioradialis

FIGURE 32.18  Preoperative films of a patient with an intraarticular fracture of the distal radius with dorsal displacement and angulation.

FIGURE 32.19  Surgical anatomy of volar plating.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

• The dissection takes place along the border of the FCR through the subcutaneous tissue to find the flexor pollicis longus (FPL). • Retracting the FPL ulnarly protects the median nerve. • A superficial branch of the radial artery courses slightly ulnar near the distal aspect of the dissection and should be protected.

POSITIONING • The upper extremity is extended on a hand table with the forearm supinated. • A tourniquet is placed on the upper arm.

EXPOSURES • A 7- to 10-cm longitudinal incision is made along the radial border of the FCR, starting at the wrist crease and proceeding proximally. If more distal exposure is needed, the incision is extended as a zigzag over the joint (Fig. 32.20). • Use a sharp blade to perform the dissection. Identify and protect the radial artery and associated veins by retracting them radially. Crossing arterial branches are cauterized. • The FPL tendon and its muscle belly are manually swept away using a finger (Fig. 32.21) and then retracted ulnarly to expose the pronator quadratus (PQ; Fig. 32.22A). • The PQ is divided with an L-shaped incision along its radial and distal border, then elevated (see Fig. 32.22B). • An elevator is used to strip the periosteum and expose the fracture (Fig. 32.23).

FIGURE 32.20  Longitudinal incision along the radial border of the flexor carpi radialis (FCR), extended as a zigzag over the joint if more distal exposure is necessary.

A

EXPOSURES PEARLS

A blunt, rather than sharp, self-retaining retractor should be used to hold the exposure and avoid puncturing critical structures. EXPOSURES PITFALLS

Take care not to disrupt the volar carpal ligaments from the radius, which can occur if the surgeon dissects too far distally.

FIGURE 32.21  The flexor pollicis longus (FPL) tendon and its muscle belly are manually swept away.

B

FIGURE 32.22  (A) The flexor pollicis longus (FPL) is retracted ulnarly to expose the pronator quadratus (PQ). (B) The PQ is divided along its radial and distal border.

221

222

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.23  An elevator strips the pronator quadratus and exposes the fracture. The white arrow indicates the comminuted metaphyseal region.

STEP 1 PEARLS

• Releasing the insertion of the BR may facilitate reduction because this minimizes the deforming forces on the distal segment, particularly when the distal fragment is translated radially (Fig. 32.25). • Ensure that all fracture fragments are mobile enough for reduction. • The reduction can be temporarily secured with a radial styloid 0.045-in percutaneous K-wire.

PROCEDURE Step 1: Fracture Reduction • The fracture anatomy is identified. The volar fragments are disimpacted by hyperextension of the wrist. • An osteotome is placed into the volar fracture line to lever the segments into reduction (Fig. 32.24A–C). The repositioning is aided by simultaneous traction. • The reduction is checked both visually and with fluoroscopy.

A

B

C FIGURE 32.24  (A) An osteotome is placed into the volar fracture line. (B) Lever the volar displaced and tilted segment into reduction. (C) Lever the dorsal displaced and tilted segment into reduction with the opposite direction.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

A non-locking screw in the elliptical hole

FIGURE 32.25  Releasing the insertion of the brachioradialis can mobilize the distal segment and facilitate reduction. The white arrow points to the brachioradialis tendon.

FIGURE 32.26  A nonlocking bicortical screw is drilled and placed into the elongated central elliptical hole over the radial diaphysis, which permits proximal and distal translation guided by fluoroscopy.

Step 2: Plate Placement and Shaft Fixation

STEP 2 PEARLS

• After assessment of the reduction, a volar plate is selected. • The plate is centered on the radial shaft and placed distal enough to capture the distal fragment(s). The plate can be checked under fluoroscopy and adjusted as necessary. • A nonlocking bicortical screw is drilled and placed into the elongated central elliptical hole over the radial diaphysis. Use of this hole permits proximal and distal translation guided by fluoroscopy (Fig. 32.26). • Positioning is checked both visually and under fluoroscopy, and the plate is adjusted as needed. If the position is satisfactory, the first screw is tightened down.

• Most plating systems offer a variable length of the diaphyseal component and wider or slimmer options for the metaphyseal component, depending on the size of the radius and fracture anatomy. • All volar plates have a similar concept for the plate to buttress the volar cortex and the distal locking screws to support the articular surface (Fig. 32.27). • Ensure that the plate is centered on the radial shaft before the first screw is placed. The elliptical hole enables rotation and distal- to-proximal translation but does not permit radial and ulnar translation.

Step 3: Distal Fixation • Distal locking screws are placed to secure the distal fragment. • Fixed or variable angle guides can be used, but attention must be paid to the angle for each individual screw (Fig. 32.28). In general, there is a slight increase in distal angulation as you move from the most ulnar screw hole to the radial screw holes.

FIGURE 32.27  A bicortical screw is tightened to compress the plate over the radial diaphysis, whereas the distal locking screws support the articular surface.

FIGURE 32.28  The angulation of the distal locking screw is greater at the radial aspect.

223

224

CHAPTER 32  Operative Treatment of Distal Radius Fractures

STEP 3 PITFALLS

• Overly penetrated screws can lead to extensor tendon irritation and injury, especially of the extensor pollicis longus (EPL) tendon (Fig. 32.30). The distal screws or pegs should be 2 mm under the dorsal cortex. • Plates positioned too distally or with significant volar prominence increase the risk for tendon irritation or rupture. STEP 4 PEARLS

PQ repair provides a soft tissue layer between the plate and overlying tendons (see Fig. 32.31). The PQ should be repaired unless it is shredded and incapable of holding sutures. STEP 4 PITFALLS

• When closing the PQ to the BR fascia, avoid suturing the radial artery or first compartment tendons. • One must distinguish between the PQ and the FPL muscle. The FPL muscle lies slightly superficial and has longitudinal muscle fibers, in contrast to the transverse-oriented fibers of the PQ.

POSTOPERATIVE CARE PEARLS

Patients who are noted to have signs of continued tendon irritation should be considered for elective hardware removal at 6 months when the fracture has healed.

FIGURE 32.29  A 22-degree oblique lateral view for inspection of the entire articular surface.

• A 22-degree oblique lateral view is necessary to check screw placement to ensure that there is no articular penetration. Angle the patient’s hand, or the C-arm machine, to correct the overlap of the articular surface caused by the radial inclination on a standard lateral view. The 22-degree oblique lateral view promotes visibility of the entire articular surface (Fig. 32.29).

Step 4: Closure • The PQ is sutured to the BR fascia with 3–0 Vicryl sutures (Fig. 32.31). The PQ should be detached from the radius without leaving any residual muscle fibers to facilitate its attachment to the BR fascia, which is more stout. • The incision is closed with a running subcuticular suture. • A short-arm volar splint is placed.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The splint is removed at 10 to 14 days postoperatively. • Patients are changed to a removable thermoplastic splint and start ROM exercises with self-directed hand therapy. Patients who develop wrist stiffness during the healing period will require treatment from a hand therapist. • Patients with volar plating have been shown to regain function faster than other methods because of early postoperative mobilization. • Repeat x-rays are performed at 5 to 6 weeks. If there is adequate healing, patients start or increase strengthening activities.

Brachioradialis fascia

FIGURE 32.30  The overly penetrated screws (black arrow) can lead to extensor tendon irritation and injury.

FIGURE 32.31  Pronator quadratus is sutured to the brachioradialis fascia and provides a soft tissue layer between the plate and overlying tendons.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

Fixation of Volar Ulnar Rim Fracture INDICATIONS Indications for this procedure include: • Displaced intraarticular fractures • Unstable DRUJ because of volar facet fragment • Volar instability of the wrist joint (Fig. 32.32A–C)

SURGICAL ANATOMY • The volar lunate facet of the radius is a primary load-bearing articular surface and is essential for the stability of both distal radioulnar and radiocarpal joints. • The origins of volar wrist ligaments over the radius include the radioscaphocapitate (RSC) ligament, long radiolunate (LRL) ligament, and short radiolunate (SRL) ligament. The volar radioulnar ligament originates from the volar edge of the sigmoid notch (Fig. 32.33A). • Volar ulnar rim fracture is primarily a ligamentous injury, with associated osseous avulsion of volar lunate facet (see Fig. 32.33B). The fragment is typically small and distal to the watershed line, which limits the stability afforded by standard volar plates.

L

A

L

B

C

FIGURE 32.32  (A) Volar subluxation of the wrist joint is noted in lateral wrist view. (B–C) The displaced fragment is recognized in the sagittal plane of computed tomography images. The white arrows represent volar ulnar rim fragments. L, Lunate.

Short radiolunate ligament Volar radioulnar ligament

A

B

FIGURE 32.33  (A) Relationship between volar wrist ligaments and the volar ulnar rim fracture. (B) The black dotted line indicates a volar ulnar rim fragment.

225

226

CHAPTER 32  Operative Treatment of Distal Radius Fractures

EXPOSURES PEARLS

For an isolated ulnar rim fracture, the incision can be made over the palmaris longus tendon for better access to the ulnar corner of the distal radius. EXPOSURES PITFALLS

• This fracture pattern can be easily missed. The surgeon should be suspicious of a volar ulnar rim fracture when the fracture extends to the sigmoid notch. CT imaging can help define this distinctive fracture pattern in comminuted fractures. • See “Volar Plate Fixation.”

POSITIONING • See “Volar Plate Fixation.”

EXPOSURES

When dividing and reflecting the PQ, avoid detaching any ligaments from the volar rim fragment.

• See “Volar Plate Fixation.” • In addition to the standard volar approach, a zigzag incision across the wrist joint crease can offer more distal exposure.

STEP 1 PEARLS

PROCEDURE

The wrist can be classified into three supportive columns: • Radial column, which contains the radial styloid and scaphoid facet • Middle column, which contains the ulnar radius and lunate facet • Ulnar column, which is the distal ulna

STEP 2 PITFALLS

The volar ulnar rim fragment is partially covered by the volar wrist capsule. Be careful not to detach any ligaments when exposing this small fragment.

Step 1: Radial Column Reduction (if indicated) • If both a volar ulnar rim fracture and radial column fracture are present, restoration of the radial column is initially performed to maintain length and decrease loading at the lunate facet. • The impacted radial fragment can be disimpacted by maneuver or elevator. • After a satisfactory anatomic reduction, a K-wire can offer temporary stabilization.

Step 2: Reduction of Volar Ulnar Rim • After reducing the radial column, the shaft can be supinated using forceps to help visualize the lunate facet fragments. • To restore normal carpal alignment, apply dorsally directed traction to the hand. • Carefully reduce the rotated volar ulnar rim fragment to the anatomic position. To confirm anatomic reduction, check the metaphysis for continuity of the volar cortex. • The fracture reduction and carpal alignment are verified using x-ray imaging after temporary K-wire fixation.

Step 3: Plate Placement • Select a volar plate that offers ulnar rim extension using hooks or an extended plate with miniscrews. These plates are useful not only for volar ulnar rim fractures, but also for combined fractures with radial column or diaphyseal fracture. • The plate is centered on the radial shaft and placed in a position capable of capturing the ulnar rim fragment (Fig. 32.34). • The plate can be checked both visually and under fluoroscopy and adjusted as necessary (Fig. 32.35).

FIGURE 32.34  The extended hooks (within the white dotted line) secure the volar ulnar rim fragment.

FIGURE 32.35  Black arrows indicate the volar ulnar rim fragment captured via extended hooks.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

• A nonlocking bicortical screw is drilled and placed into the elongated central elliptical hole over the radial diaphysis. • The remaining screwing process is the same as in volar plate fixation. • Confirm the stability of wrist and distal radioulnar joints at the end of procedure.

Step 4: Closure See “Volar Plate Fixation.”

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients wear the splint for 2 weeks postoperatively. • The splint is changed to a removable thermoplastic splint for an additional 4 to 6 weeks. At this time, patients should start gentle ROM exercises of the fingers and wrist as tolerated. • After 6 to 8 weeks postoperatively, patients can begin gradual strengthening activities. • Patients may have tendon irritation or impingement because of distal plate placement. Hardware removal should be considered after the fracture has healed.

Dorsal Plate Fixation INDICATIONS Indications for this procedure include: • Substantial initial dorsal displacement, for which reduction through a volar approach is not feasible.

STEP 3 PEARLS

• Fragments can be fixed individually by using small and low-profile implants (Fig. 32.36A). Fragment-specific fixation works best for fragments that are greater than 1 cm in width and at least 5 mm long and 4 mm thick. A customized or tailored plate can be used for fixation of the volar-ulnar fragment alone. • Some fragments may be too small to fix with any implant, such as avulsed fragments produced from a volar ulnar rim fracture. In this case, it is more advantageous to repair the soft tissue instead of the bone. One option for repair is the suture anchor technique. After the suture anchor is inserted into the fracture site, nonabsorbable sutures that are part of the anchor’s eyelet can be used to restore the volar capsule and volar ligaments to their proper position. This repair can prevent subsequent radiocarpal subluxation and will encourage contact and healing between the fragment and the fracture site (see Fig. 32.36B). STEP 3 PITFALLS

If the volar ulnar rim fragment is not properly stabilized, the fragment can dislodge and easily subluxate the carpus (Fig. 32.37).

A Lunate

Volar capsule and ligaments with fragments

Dorsal

Suture anchor

Volar

Lat Latera erall vview iew w Lateral B

FIGURE 32.36  (A) Fragment-specific fixation works by using small and low-profile implants. (B) Suture anchor repair for fragments that are too small to fix. (Fig. 15.51B–C from Wolfe S, Pederson W, Kozin SH, Cohen M, eds. Green’s Operative Hand Surgery. 7th ed. Elsevier; 2017).

FIGURE 32.37  Failure to stabilize volar ulnar rim fragment can cause carpal subluxation. The white arrow indicates the fragment.

227

228

CHAPTER 32  Operative Treatment of Distal Radius Fractures

• Severe dorsal comminution in need of support from a dorsal plate. • Dorsal-shearing type intraarticular fracture (dorsal Barton fracture). • Severely comminuted C3 type fractures that need both volar and dorsal plates fixation for stability. • Extraarticular fracture with disruption of the volar cortex distal to the watershed line. The screws of a volar plate will be unable to secure the distal fragment.

SURGICAL ANATOMY • The extensor retinaculum is superficial to the extensor tendons and separates all extensor tendons into six compartments (Fig. 32.38). • The first compartment includes the abductor pollicis longus (APL) and the extensor pollicis brevis tendons (EPB). The sensory branch of radial nerve lies superficial to this compartment. • The second compartment includes the ECRL and extensor carpi radialis brevis (ECRB), which are straight and radial to the Lister tubercle. • The third compartment includes the EPL, which is ulnar to the Lister tubercle. It turns an angle to control the thumb after going through the compartment. • The fourth compartment includes the extensor indicis proprius (EIP) and extensor digitorum communis (EDC), which lie over the dorsoulnar radius. • The fifth compartment includes the extensor digiti minimi (EDM) that lies over the DRUJ. • The sixth compartment includes the extensor carpi ulnaris (ECU); only one compartment lies over the distal ulna and contributes to triangular fibrocartilage complex (TFCC) stability.

POSITIONING A tourniquet is placed on the upper arm, and the upper extremity is extended on a hand table with the forearm pronated.

EXPOSURES EXPOSURES PEARLS

• A dorsal approach can improve visualization and reduction of the impacted articular fragment. In addition, the approach offers access for bone graft placement to support the reduced articular surface if needed. • After the procedure, the periosteum of the extensor compartments can be repaired and used as a barrier between the plate and extensor tendons if appropriately elevated.

• Make a 6- to 10-cm longitudinal skin incision dorsal and ulnar to the Lister tubercle, centered over the radial metaphysis. • The subcutaneous layer is dissected down to extensor retinaculum, taking care to avoid injury to the dorsal sensory branches of the radial and ulnar nerves. • Incise the extensor retinaculum just ulnar to the Lister tubercle to expose the EPL tendon. The tendon can be retained in the remaining third compartment, which will later be elevated subperiosteally. • Use a scalpel to elevate the second and fourth dorsal compartment subperiosteally in the radial and ulnar direction for exposure of the entire dorsal radius (see Fig. 32.38). • The terminal branch of the posterior interosseous nerve can be resected during exposure. 3

4 5 6

2

Ulna

1 Radius

FIGURE 32.38  The black dotted line highlights the subperiosteal elevation of the second to fourth dorsal compartments. 1, Abductor pollicis longus and extensor pollicis brevis; 2, extensor carpi radialis longus and extensor carpi radialis brevis; 3, extensor pollicis longus; 4, extensor indicis and extensor digitorum communis; 5, extensor digiti minimi; 6, extensor carpi ulnaris.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

PROCEDURE

STEP 1 PEARLS

Step 1: Fracture Reduction • The fracture fragments are identified after exposure (Fig. 32.39). • The articular fragments can be reduced by slight wrist flexion combined with traction. Use an osteotome or elevator to disimpact the depressed articular fragment (Fig. 32.40A–B). • If there is a severe metaphyseal defect, a bone graft can be placed to support reduced articular fragments. • The reduction is confirmed both visually and with fluoroscopy.

A dorsal capsulotomy can help visualize the articular surface, but this is often unnecessary. The articular reduction by itself should sufficiently elevate the depressed fragments, with the convex articular surface of the carpus guiding the fragment into anatomic position.

Step 2: Plate Placement • The selected plate is bent to fit the dorsal surface. • The plate is applied directly and first secured with a cortical screw inserted into the oval hole over the radial diaphysis. • The position of the plate and fracture reduction are confirmed using fluoroscopy and adjusted as appropriate (Fig. 32.41). • The remaining cortical screws are inserted in the radial shaft. Reduction and stability will need to be confirmed again.

Comminuted dorsal fragments

EPL

Partial third compartment

FIGURE 32.39  Fracture fragments are identified after exposure. The white dotted line indicates comminuted dorsal fragments. EPL, Extensor pollicis longus.

Dorsal

A

Volar

Dorsal

Volar

B

FIGURE 32.40  (A) A distal radius fracture with a depressed articular fragment, loss of dorsal buttress, and dorsal carpal subluxation. (B) Reduction by slight wrist flexion combined with traction. Furthermore, use an elevator to push the depressed articular fragment upwards.

STEP 2 PEARLS

• A low-profile and fitted plate is essential to minimize the incidence of tendon-related complications, including synovitis, irritation, and rupture. • The distal locking screws can be inserted to support the subchondral bone.

229

230

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.41  The position of the plate and fracture reduction are confirmed using fluoroscopy.

FIGURE 32.42  The second and fourth compartments are closed back over the plate, and the retinaculum is sutured.

Step 3: Closure • The second and fourth compartments are closed back over the plate, and the retinaculum is sutured with 3-0 Vicryl (Fig. 32.42). • The incision is closed with a running subcuticular suture. • A short-arm volar splint is applied.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • With volar splint protection, the patient can start finger ROM exercises immediately after surgery to avoid adhesion of extensor tendons. • The volar splint is used for 2 weeks postoperatively, and then the sutures are removed. • The splint is changed to a removable thermoplastic splint for an additional 4 to 6 weeks, and the patient is encouraged to begin gentle ROM exercises of the wrist as tolerated. • After 6 to 8 weeks postoperatively, the patient can start gradual strengthening exercises.

Dorsal Bridge Plate INDICATIONS INDICATION PEARLS

The dorsal bridge plate can serve as a reduction tool by buttressing the dorsal fragments and reducing the fracture via ligamentotaxis during traction. Compared with external fixation, a dorsal bridge plate offers earlier return of hand mobility, simpler wound care, and greater comfort for the patient.

Indications for this procedure include: • Severely comminuted intraarticular distal radius fractures that cannot be fixed with conventional approaches. • Distal radius fractures with associated metaphyseal or diaphyseal comminution. • Osteoporotic bone, in which direct fracture fixation is likely to fail. Patients who refuse external fixation or are poor candidates because of bone quality, hygiene issues, or psychological illness. • Preoperative x-rays that show a severely displaced fracture with distal diaphyseal comminution and osteoporotic bone (Fig. 32.43).

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.43  Severely displaced fracture with distal diaphyseal comminution and osteoporotic bone.

SURGICAL ANATOMY • See “Dorsal Plate Fixation.” • The extensor tendons of the middle finger and branches of the radial nerve are found distally and should be identified and retracted away for protection. • The plate will pass from the second or third metacarpal through the fourth dorsal compartment, which contains the EDC and extensor indicis proprius (EIP). The EPL tendon of the third compartment crosses the path of the plate and should be released for its own protection. • The muscle bellies of the APL and EPB are also encountered in the proximal dissection. • The superficial radial nerve is at risk for injury during the proximal dissection in the forearm.

POSITIONING See “Dorsal Plate Fixation.”

EXPOSURES • Before operating, longitudinal traction is applied on the second and third metacarpal individually to promote reduction via ligamentotaxis. The reduction is then assessed radiographically. The surgeon should compare the reduction that is achieved with traction on the second metacarpal versus the third metacarpal. The plate should be passed over the metacarpal that produced a better reduction under traction. • Passing the plate over the second metacarpal will result in slight ulnar deviation of the hand after fixation of the plate. This would benefit patients with a distal radius fracture that is radially displaced because ulnar deviation would counteract this displacement. • Passing the plate from the third metacarpal, however, will produce a more neutral hand position after plate fixation and will directly buttress the intermediate column of the radius. • The dissection takes place proximally over the dorsal radius and distally over the third metacarpal. • The exposure involves two or three longitudinal incisions. • A 4-cm incision is made distally over the shaft of the third metacarpal (Fig. 32.44). • The subcutaneous tissue is incised, and the extensor tendons and nerve branches are retracted radially. • A 6-cm incision is made along the dorsal radial shaft. Dissection proceeds through the subcutaneous tissue down to the radial shaft. The interval adjacent to the BR

EXPOSURES PEARLS

• A bridge plate may also be attached to the second metacarpal. In these circumstances, the plate passes through the second dorsal compartment, which contains the ECRB and ECRL. The plate is placed proximally in the interval between the muscle bellies of the ECRB and ECRL. • Fixation to the index finger metacarpal will cause slight ulnar deviation of the wrist and may make it easier to reestablish radial inclination when the fracture is reduced.

231

232

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.44  A 4-cm incision is made distally over the third metacarpal shaft and a 6-cm incision along the dorsal radial shaft.

ECRL APL

ECRB

EPL EDC

FIGURE 32.45  Dissection proceeds at the radial shaft via the interval between BR/ECRL (black dotted line) or between the ECRB/EDC (red dotted line). APL, Abductor pollicis longus; BR, brachioradialis; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis; EPL, extensor pollicis longus.

and ECRL or between the ECRB and EDC is used. Care must be taken not to injure the superficial branch of the radial nerve (Fig. 32.45). • An optional 2- to 3-cm incision over the Lister tubercle can be used to release the EPL or applied to aid with fracture reduction. Alternatively, the proximal incision can be extended distally to facilitate exposure.

PROCEDURE Step 1: Plate Insertion STEP 1 PEARLS

Other plates, including a mandibular reconstruction plate or the variable length 3.5-mm dynamic compression plate (Synthes), have also been described for use in this technique. STEP 1 PITFALLS

Ensure that all tendons are retracted away and that the plate is directly against the bone. The EPL and digital extensors will be at risk for immobility or rupture if compressed under the plate.

• The 2.4-mm distal radius bridge (DRB; Synthes) plate with tapered ends is used. The plate should span from the distal third metacarpal to the radial shaft to fix at least three screws 4 cm proximal to the fracture. • Starting distally along the metacarpal bone, a Freer or Cobb elevator is used to develop a plane between the extensor tendon and the joint capsule over the fourth compartment. The plate will lie superficial to the joint capsule. • After a path is made, the plate is inserted in a retrograde fashion from the area of the metacarpal. The EPL, which has already been mobilized, is retracted radially to prevent capture under the plate (Fig. 32.46). • As the plate is advanced, it is visualized in the proximal incision and care is taken to make sure the plate travels under tendons and muscle.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

Extensor pollicis longus

FIGURE 32.46  The extensor pollicis longus is retracted radially to prevent capture under the plate.

Step 2: Distal Fixation

STEP 2 PITFALLS

• The fracture is provisionally reduced with traction. • The plate is centralized over the third metacarpal and aligned on the radial shaft. • The second-to-last hole at the distal end of the plate is drilled, and a bicortical screw is placed in the metacarpal. Placement of a single screw facilitates some slight plate adjustment if necessary.

Ensure that the screw is centralized in the metacarpal. Violation of the ulnar or radial cortex could lead to iatrogenic fracture.

Step 3: Proximal Fixation • Traction is applied again, and the fracture is reduced. • The plate is centralized to the radial shaft, whereas the forearm is kept in neutral rotation. • The plate is clamped to the radial shaft with a bone reduction clamp. • Fluoroscopy is used to assess fracture reduction (Fig. 32.47). • If reduction is adequate, the proximal portion of the plate is secured to the radius with a bicortical screw (Fig. 32.48). • The remaining screws are placed so that there are at least three screws distally and three screws proximally.

FIGURE 32.47  Fluoroscopy is used to assess fracture reduction.

STEP 3 PITFALLS

Overdistraction can restrict finger ROM and may lead to complex regional pain syndrome (CRPS). Passive ROM should be checked in the digits after plate fixation; the radiocarpal space should not exceed 5 mm.

FIGURE 32.48  A proximal plate is secured to the radius with a bicortical screw.

233

234

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.49  Approximation of multiple fracture pieces can be achieved with cerclage wires.

STEP 4 PEARLS

Step 4: Adjunct Fracture Treatments

Bone grafting can fill in large gaps for severely impacted fractures.

• Distraction may not fully reduce severely comminuted fractures. • Approximation of multiple fracture pieces can be achieved with cerclage wires (Fig. 32.49). • K-wires or lag screws can be used to stabilize individual segments.

STEP 4 PITFALLS

Aggressive fixation may lead to more comminution or compromise fragile vascular supply to small bone fragments.

Step 5: Closure • The surgical wounds are irrigated, and the deep subcutaneous tissues are approximated with interrupted sutures. • The skin is closed with running absorbable sutures. • A short-arm volar splint is placed.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The splint is removed at 10 days. • Active ROM of the digits and forearm rotation is performed immediately and maintained throughout the fixation period. • Patients can use the extremity with a weight restriction of less than 5 pounds of lifting. • Fracture healing is monitored radiographically and clinically every 4 to 6 weeks. • The plate is removed typically at 3 months postoperatively but can be earlier or later depending on fracture healing. • Aggressive ROM of the wrist begins immediately after hardware removal. • Outcomes in regard to ROM and function are reported to be similar at 1 year postoperatively in comparison to other techniques. INDICATIONS PEARLS

Distal radius fractures often occur with associated injuries to the scapholunate interosseous ligament (SLIL), lunotriquetral interosseous ligament (LTIL), and TFCC. Without arthroscopic assistance, these injuries may go undetected.

Arthroscopic Reduction and Fixation Technique INDICATIONS • Wrist arthroscopy can assist anatomic restoration of articular fragments and also evaluate the associated intraarticular soft tissue injuries. • Arthroscopy can be used when any associated injury is suspected, including carpal ligament tear, scaphoid fracture, and TFCC injury. The surgeon can further confirm and repair these injuries simultaneously if they are detected. • One indication is distal radius fractures with articular involvement, especially those with more than three fragments. • Wrist arthroscopy is used as an adjunct visualization for impacted fracture patterns, such as die-punch fracture (Fig. 32.50), which are challenging to restore a smooth articular surface.

Contraindications Contraindications for the procedure include: • Visible swelling or compartment syndrome • Neurovascular compromise

CHAPTER 32  Operative Treatment of Distal Radius Fractures

FIGURE 32.50  The die-punch fracture pattern is characterized by a depressed central portion of the articular surface.

• Open fracture without adequate soft tissue coverage • Elderly patients with delicate finger skin, which is not conducive for finger trap

SURGICAL ANATOMY • See Chapter 19. • See “Volar Plate Fixation.”

POSITIONING

STEP 1 PEARLS

• See Chapter 19 about position and equipment for wrist arthroscopy. • The upper extremity is extended on a hand table with the forearm supinated. • A tourniquet is wrapped on the upper arm.

• Arthroscopic assistance is necessary for comminuted intraarticular fractures. These cases are typically caused by the violent crush of the lunate bone, resulting in severe depression and fragmentation of the joint surface. Because the first contact force is primarily loaded over the lunate facet, the trauma to this region is usually more severe. Therefore we recommend restoring the radial column first because this is more feasible. • We recommend performing the volar approach before arthroscopic evaluation for the following reasons (Fig. 32.52): • After articular reduction, the fracture can be fixed immediately with distal screws. There is no need to waste time approaching and reducing the fractured metaphyseal region, which risks loss of articular reduction. • The volar approach, performed before an arthroscopic evaluation, permits the surgeon to use instruments to elevate the articular surface during arthroscopic evaluation. • Swelling and deformity can make it difficult to recognize the landmarks of portals and the joint line. The volar approach and restoration of the radial column can facilitate identification of these landmarks.

EXPOSURES • See Chapter 19, the setting of arthroscopic portals and systemic evaluation. • See “Volar Plate Fixation.”

PROCEDURE Step 1: Volar Approach and Restoration of Radial Column • Access to the radius is performed similarly to access required for volar plating. • The dissection should extend distally to reach the watershed line, taking care not to detach the volar ligaments. • The radial column is initially reduced to restore the radial height and unload the lunate facet. Release the insertion of BR, if needed, because this may aid reduction by reducing the deforming force. • The radial column is reduced by wrist hyperextension with traction, then flexed to minimize the gap over the volar cortex. Also, Kapandji intrafocal pinning can be inserted to level and fix the radial column (Fig. 32.51A–B). The integrity of the radial cortex can be used to determine whether anatomic reduction was successful (see Fig. 32.51A). • Temporarily stabilize the radial column with K-wires after anatomic reduction under fluoroscopic guidance (see Fig. 32.51B).

Step 2: Reduction of Intermediate Column and Plate Placement • After the restoration of the radial column, the radial styloid and scaphoid facet can serve as a landmark to determine whether the depressed lunate facet fragments are reduced adequately. • Identify the comminuted-metaphyseal cortex of the intermediate column and use blunt instruments to elevate the lunate facet fragments from the cortical defect.

STEP 2 PEARLS

• It is essential to restore the articular surface as completely as possible. This will ensure optimal radial length, volar tilt, and inclination. • If there is a significant defect over the metaphysis after elevating the articular surface, a bone graft can be used for subchondral support.

235

236

CHAPTER 32  Operative Treatment of Distal Radius Fractures

A

B

FIGURE 32.51  (A) The integrity of the radial cortex can be used to determine whether anatomic reduction was successful. (B) Temporary Kirschner wire (K-wire) fixation of the radial column after anatomic reduction under fluoroscopic guidance.

FIGURE 32.52  The volar approach has been performed before wrist arthroscopy.

• Alternatively, a cortical bone window (1 x 1 cm) 2 cm proximal to the watershed line should be created if there is no defect over volar metaphysis (Fig. 32.53A–B). • Reduction of the articular surface is achieved by gradual and gentle elevation with freer elevator or bone graft impactor (Fig. 32.54A–F). • Under fluoroscopic guidance, the surgeon should proceed with the plate placement if the reduction appears satisfactory or if no further improvement is possible. • After temporary fixation by K-wires (Fig. 32.55A), a volar plate is applied to the radius (see Fig. 32.55B). A cortical screw is inserted into the elliptical hole on the shaft of the plate, which permits slight adjustment of plate position. • Once the plate’s position is confirmed, the second screw at the shaft and the distal locking screw toward the radial styloid can be inserted (Fig. 32.56A–B). • Several K-wires are inserted into the distal fragments through the distal holes of the plate for subchondral support (see Fig. 32.56C).

CHAPTER 32  Operative Treatment of Distal Radius Fractures

2 cm

A

B

FIGURE 32.53  (A) The white dotted line represents a cortical bone window (1 x 1 cm) that is created for reduction. (B) The window is 2 cm proximal to the watershed line, making the entire articular surface accessible.

A

B

D

E

C

F

FIGURE 32.54  (A–F) The process of reduction by gradual and gentle elevation.

237

238

CHAPTER 32  Operative Treatment of Distal Radius Fractures

B

A

FIGURE 32.55  (A) Temporary fixation by Kirschner wires (K-wires). (B) Volar plate is applied to the radius.

A

B

C

FIGURE 32.56  (A–C) Once the plate’s position is confirmed, insert the second screw at the shaft and the distal locking screw toward the radial styloid. Kirschner wires (K-wires) are inserted into the distal fragments through the distal holes of the plate.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

A

B

FIGURE 32.57  (A) The intraarticular hematoma blurs the arthroscopic visualization. (B) Improved visualization after evacuating the fracture hematoma.

Step 3: Arthroscopic Assisted Reduction

STEP 3 PEARLS

• Suspend the wrist in a vertical traction tower. Establish 3 to 4 (between EPL and EDC), 4 to 5 (between EDC and EDM), and 6R (radial to ECU) portals. The 6U portal is percutaneously placed with an 18-gauge needle for outflow. • A 2.3-to 2.7-mm 30-degree angle scope is introduced through the 3 to 4 portal, and a shaver is inserted through 4 to 5 or 6R portals to evacuate the fracture hematoma for better visualization (Fig. 32.57A–B). • The intraarticular structures, including fracture fragments and soft tissue, are systematically inspected. See Chapter 19. • The viewing portal and working portal can be swapped among 3 to 4, 4 to 5, and 6R portals. • Displaced articular fragments with gaps or step-offs are subsequently reduced under arthroscopic visualization. Common techniques include clamping, joystick, hook the fragment, and push-ups.

• Loss of the Lister tubercle and associated swelling can make it challenging to establish sites for portals, because palpating for landmarks becomes unreliable. The surgeon can still determine the radiocarpal joint line through the volar approach wound or locate the portals under fluoroscopy. • K-wires that are inserted to prevent reduction should be removed to release the articular fragment. After reduction is obtained, drive the K-wire again through the fragment to maintain reduction. Use K-wires that are less than 1.6 mm in diameter and insert from the radial and dorsal aspects.

Clamping

STEP 3 PITFALLS

Fragments with gaps but without step-offs can be reduced by percutaneous clamping.

When setting up the wrist arthroscopy, the surgeon should gently suspend the wrist to avoid losing the reduction of the articular surface and metaphysis.

Joystick After using a percutaneous K-wire to fix the rotated fragment (Fig. 32.58A), push upwards on the end of K-wire, similar to a joystick, to correct the step-off and reach the smooth articular surface (see Fig. 32.58B).

Hook the Fragment A probe is inserted to hook the fragment (Fig. 32.59A), which is rotated and depressed. The fragment is pulled distally to obtain an even articular surface (see Fig. 32.59B).

Push-Up For depressed fragments, insert an elevator or K-wire through the volar cortical defect of the metaphysis (Fig. 32.60A), pushing distally from the base of the articular fragments (see Fig. 32.60B).

Press For elevated fragments, use the Freer elevator to depress the articular fragment (Fig. 32.61A) and eliminate the step-off (see Fig. 32.61B). If the fragment is difficult to depress, releasing some of the traction may help.

239

240

CHAPTER 32  Operative Treatment of Distal Radius Fractures

B

A

FIGURE 32.58  (A–B) After using a percutaneous Kirschner wire (K-wire) to fix the rotated fragment, push upwards on the end of K-wire, similar to a joystick.

A

B

FIGURE 32.59  (A–B) A probe is inserted to hook the fragment, which is rotated and depressed.

A

B

FIGURE 32.60  (A–B) For depressed fragments, insert an elevator or Kirschner wire (K-wire) through the volar cortical defect of the metaphysis and push distally from the fragment base.

CHAPTER 32  Operative Treatment of Distal Radius Fractures

Elevated fragment

B A

Fragment following reduction

FIGURE 32.61  (A–B) For elevated fragments, use the Freer elevator to depress the articular fragment and eliminate the step-off.

Temporary K-wire fixation is performed after the fragment is reduced. Finally, insert all distal locking screws through the holes of the distal plate.

Step 4: Screws Fixation and Closure • Once the articular surface is reduced and provisionally fixed with K-wires, all the locking screws are inserted under traction. • Arthroscopic visualization can confirm whether the screws have articular penetration and identify whether loss of reduction has occurred. • After plating, the associated soft tissue injuries should be arthroscopically repaired before closure. • The PQ can be repaired via suturing to the BR fascia with 3–0 Vicryl suture. • The volar skin incision and portal wounds are closed with a running subcuticular suture. • A short-arm volar splint is placed.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • See “Volar Plate Fixation.” • For patients who have associated TFCC injuries or carpal instability, postoperative care should follow each procedure’s protocol. See Videos 32.1, 32.2, 32.3, and 32.4

EVIDENCE Chung KC, Kim MH, Malay S, Shauver MJ, Wrist and Radius Injury Surgical Trial Group. The Wrist and Radius Injury Surgical Trial: 12-Month outcomes from a multicenter international randomized clinical trial. Plast Reconstr Surg. 2020;145(6):1054e–1066e. Because the optimal treatment for distal radius fractures in older adults remains uncertain, the authors conducted a randomized multicenter clinical trial that enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. The surgery group (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The loss of radiographic alignment was common in casting participants. Nevertheless, there were no meaningful differences in primary outcomes (Michigan Hand Outcomes Questionnaire) at 12 months. Recovery was fastest for internal fixation, whereas the external fixation was slower than the other two methods (Level I Evidence). Lenoble E, Dumontier C, Goutallier D, Apoil A. Fracture of the distal radius: A prospective comparison between transstyloid and Kapandji fixations. J Bone Joint Surg Br. 1995;77:562–567. This is a prospective study of 96 patients with extra- or intraarticular distal radius fractures with a dorsally displaced posteromedial fragment, treated with either transstyloid or Kapandji (intrafocal) fixation. Patients were followed at 6 weeks and 3, 6, 12, and 24 months. Although there was some

241

242

CHAPTER 32  Operative Treatment of Distal Radius Fractures improvement in ROM in early follow-up with Kapandji fixation, the results were similar in both groups at 24 months (Level III evidence). Harley BJ, Schargenberger A, Beaupre L, Jomha N, Weber D. Augmented external fixation versus percutaneous pinning and casting for unstable fractures of the distal radius—A prospective randomized trial. J Hand Surg Am. 2004;29:815–824. This prospective, randomized study showed that in patients younger than 65 years, percutaneous pinning and casting were equivalent to augmented external fixation. Fifty-five patients were enrolled and followed for 1 year both clinically and radiographically. Both groups were similar in terms of fracture type and the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation's (AO-ASIF) class. Specifically, there was no significant difference in radial length, radial angulation, volar tilt, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, total ROM, or grip strength (Level II evidence). Karantana A, Downing ND, Forward DP, et al. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: A randomized controlled trial. J Bone Joint Surg Am. 2013;95:1737–1744. This is a prospective, randomized controlled trial comparing percutaneous fixation (n = 64) to that of a volar locking plate (n = 66). Outcomes were measured with QuickDASH, Patient Evaluation Measure, EuroQol-D, grip strength, ROM, and radiographic parameters. Patients treated with a volar plate had quicker earlier recovery, with increased grip strength and anatomic reduction. No functional advantage was seen beyond 12 weeks postoperatively, and there was no difference in return to work (Level I evidence). Williksen JH, Frihagen F, Hellund JC, Kvernmo H, Husby T. Volar locking plates versus external fixation and adjuvant pin fixation in unstable distal radius fractures: A randomized, controlled study. J Hand Surg Am. 2013;38:1469–1476. This is a prospective study of 111 unstable distal radius fractures that were randomized to treatment with external fixation (EF) using adjuvant pins or with a volar locking plate (VLP). The mean age of the patients was 54 years (range, 20–84 years). At 1 year, patients were assessed with a visual analog scale pain score, Mayo wrist score, QuickDASH score, ROM, and radiologic evaluation. At 52 weeks, patients with VLPs had a higher Mayo wrist score (90 vs. 85), better supination (89 degrees vs. 85 degrees), and less radial shortening (+1.4 mm vs. +2.2 mm). There were more patients with pain over the ulnar styloid in the EF group (16 vs. 6 patients). For AO type C2/C3, the patients with VLPs had better supination (90 degrees vs. 76 degrees) and less ulnar shortening (+1.1 mm vs. +2.8 mm). The complication rate was 30% in the EF group, compared with 29% in the VLP group. Eight (15%) plates were removed because of complications. The QuickDASH score was not significantly different between the groups (Level I evidence). Chung KC, Watt AJ, Kotsis SV, Margaliot Z, Haase SC, Kim HM. Treatment of unstable distal radius fractures with the volar locking plating system. J Bone Joint Surg. 2006;88:2687–2694. This is a prospective study of 87 patients who were enrolled after open reduction and internal fixation with a volar locking plate system. Patients were followed with functional and patient reported outcome measures. Grip strength of the injured side reached 18 kg versus 21 kg on the uninjured side. Pinch strength was not significantly different. Flexion of the injured wrist reached 86% of the contralateral side. Michigan Hand Questionnaire outcomes reached normal scores in most patients at 6-months postoperatively (Level III evidence). O’Shaughnessy MA, Shin AY, Kakar S. Volar marginal rim fracture fixation with volar fragment-specific hook plate fixation. J Hand Surg Am. 2015;40(8):1563–1570. This is a retrospective study of 26 wrists in 25 patients, treated with a volar hook plate in the management of distal radius fractures with a volar marginal rim fragment. Twenty patients had AO type C fractures and 6 had AO type B fractures. All 6 AO type B were B3 fractures. Of the AO type C, 1 had C1, 7 had C2, and 12 had C3. No patients had loss of fixation of the critical volar ulnar corner, and there was no evidence of carpal subluxation. There were no cases of tendon rupture (Level III evidence). Richard M, Katolik L, Hanel D, Wartinbee DA, Ruch DS. Distraction plating for the treatment of highly comminuted distal radius fractures in elderly patients. J Hand Surg Am. 2012;37:948–956. This is a retrospective review of 33 patients over the age of 60 treated with a dorsal distraction plate. The DASH questionnaire and radiographic measurements were used. All fractures healed, with mean of 5 degrees of volar tilt, 20 degrees of radial inclination, and 0.6 mm of positive ulnar variance. Mean flexion was 46 degrees and extension was 50 degrees. The mean pronation and supination were 79 and 77 degrees, respectively. The mean DASH score was 32. The authors concluded that distraction plating is an effective treatment for comminuted fractures in the elderly (Level III evidence). Burnier M, Le Chatelier Riquier M, Herzberg G. Treatment of intra-articular fracture of distal radius fractures with fluoroscopic only or combined with arthroscopic control: A prospective tomodensitometric comparative study of 40 patients. Orthop Traumatol Surg Res. 2018;104(1):89–93. This prospective study examined the outcome of volar plate fixation in forty patients with similar radius fracture patterns (type C) and high functional needs. Patients were divided into a fluoroscopic group (20 patients) and arthroscopic group (20 patients). Pre- and postoperative radiographs and tomodensitometric images were evaluated. The authors observed a statistically significant improvement in reduction of the radiocarpal step-off and gap in the arthroscopic group (Level III evidence).

CHAPTER

33

Corrective Osteotomy of Radius Malunion Elissa S. Davis and Kevin C. Chung INDICATIONS • Pain or functional impairment in the setting of radiocarpal or distal radioulnar joint (DRUJ) malalignment • There are no fixed radiographic criteria for correction, although symptoms often present with radial inclination of less than 10 degrees, volar or dorsal tilt greater than 20 degrees, ulnar variance greater than or equal to 2 mm, and articular incongruity greater than 2 mm.

Contraindications • Correction of malunion is not indicated in patients with advanced degenerative arthritis, fixed carpal malalignment, and limited functional capabilities. • In patients with fixed malalignment or advanced arthritis, salvage procedures should be considered. • For those with limited functional capabilities, malalignment is often well tolerated because these patients rarely put a high level of stress across the radiocarpal joint. Thus no intervention is required. • Deformity without pain, loss of motion, and decreased grip strength are not indications for correction.

CLINICAL EXAMINATION • The upper extremity is examined for deformity, wrist function, forearm mobility, finger mobility, grip strength, and instability of the DRUJ and carpal ligaments. • This patient presents after nonoperative treatment of a distal radius fracture with pain and difficulty with wrist flexion, extension, and supination (Fig. 33.1). • In the absence of major nerve dysfunction, early surgical intervention at 6 to 12 weeks postinjury can be performed through an incompletely ossified fracture callous. This can minimize the development of soft-tissue contracture and joint stiffness and limit the duration of impact on the patient.

IMAGING • Standard imaging (anteroposterior, lateral, oblique) of the wrist is performed. • Patients may present with a malunion after nonoperative treatment (Fig. 33.2). In other circumstances, a patient may present after attempted operative fixation. This will require any internal hardware to be removed (Fig. 33.3).

FIGURE 33.1  Patient has limited motion.

243

244

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.2  Malunion x-ray.

FIGURE 33.3  X-ray with internal hardware.

• Computed tomography (CT) imaging can provide more information concerning articular incongruity. Many radiographic programs provide three-dimensional (3D) reconstruction of CT images (Fig. 33.4).

Surgical Planning • Anatomy of the malunion determines the approach used to correct the malunion. A volarly tilted malunion or incongruity of the volar cortex is treated through a volar approach. Dorsally tilted malunions are treated through either a volar or dorsal approach. Complex intraarticular malunions may require approaches from both sides. • Impacted malunions which require more than 1 cm of radial lengthening will often need an ulnar shortening osteotomy. This can be performed simultaneously or delayed until the final radial length is established. • X-rays from the time of the initial injury can help delineate the original fracture pattern. • X-rays of the opposite uninjured wrist can provide an example of the preinjury anatomy. • An osteotomy line is planned at the site of the prior fracture line. The osteotomy is made parallel to the joint surface in the sagittal plane. An opening wedge osteotomy is created in most circumstances because of fracture impaction (Fig. 33.5).

SURGICAL ANATOMY • The goal of radial malunion surgery is to restore preinjury form. Radiographically, those goals are defined by the appropriate ulnar variance, radial height, radial inclination, and volar tilt (Fig. 33.6A–D).

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.4  Three-dimensional model based on CT images.

5°

5°

35°

30°

5°

25° 9 mm

10°

0 mm

15 mm

FIGURE 33.5  Osteotomy lines.

245

246

CHAPTER 33  Corrective Osteotomy of Radius Malunion

Radial height Normal: 11–12 mm

90°

Ulnar variance

A

B

90°

C

90°

Radial inclination Normal: 22–23°

Dorsal volar tilt Normal: 11–12°

D FIGURE 33.6  (A–D) Ulnar variance, radial height, radial inclination, and volar tilt.

• Volarly, the surgeon is cognizant of the location of the radial artery and median nerve at all times. • Dorsally, the surgery is approached between the extensor pollicis longus (EPL) and extensor digitorum communis (EDC). Dorsal sensory branches and veins are protected and retracted away. The EPL is mobilized and the Lister tubercle is removed for better plate contact to the radius. • Corrective osteotomies of distal radius malunions can be done through either a dorsal or volar approach.

CHAPTER 33  Corrective Osteotomy of Radius Malunion

POSITIONING • The patient is placed supine with the arm on a hand table. • A tourniquet is placed on the upper arm. • The ipsilateral iliac crest is prepared if autogenous bone graft is to be used.

EXPOSURES

EXPOSURES PEARLS

Volar • Volar exposure is performed through a longitudinal incision between the flexor carpi radialis (FCR) and radial artery (Fig. 33.7A). • The flexor pollicis longus (FPL) is swept ulnarly to expose the pronator quadratus, which is then incised in an L-shaped fashion (see Fig. 33.7B). • The periosteum is stripped to expose the radial deformity. • The insertion of the brachioradialis is released to decrease the deforming force on the malunited fracture and aid with correcting the deformity (see Fig. 33.7C).

Dorsal • • • •

Dorsal exposure is performed between the third and fourth compartments. A 6- to 7-cm longitudinal incision is made over the Lister tubercle. The EPL is mobilized from the third compartment and retracted away. Exposure to the radius is through the floor of the fourth compartment.

EXTRAARTICULAR MALUNION Step 1: Osteotomy of the Malunion • After exposing the deformity, the malunion site is visually identified and then confirmed under fluoroscopy.

A

B

Brachioradialis is released

C FIGURE 33.7  (A) Incision line. (B) Pronator quadratus exposed. (C) Brachioradialis released.

• Exposure must be adequate to evaluate the entire deformity. • Hohmann retractors should be placed on either side of the radius to retract soft tissues away during the osteotomy and plate fixation. EXPOSURES PITFALLS

With the dorsal approach, avoid violating the volar retinacular sheath of the fourth compartment to protect tendons from subsequent plate contact and irritation.

247

248

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.8  Osteotomy made with an osteotome parallel to the articular surface.

A

FIGURE 33.9  Laminar spreader used to disimpact the fracture.

• An osteotomy is made through the prior fracture site with an osteotome or saw. The osteotomy is made parallel to the articular surface in the sagittal plane (Fig. 33.8). • For an impacted fracture, the osteotomy site is expanded using a laminar spreader. The hand is supinated to identify and release the dorsal callus and soft tissues (Fig. 33.9). • For patients with prior fixation, the old incision is used and the hardware is removed first (Fig. 33.10A–B).

Step 2: Attachment of the Locking Plate

B

• A volar locking plate is aligned on the distal radial segment (Fig. 33.12). • The distal rim of the plate is placed parallel to the lunate facet articular surface with direct contact of the distal end of the plate to the volar cortex (Fig. 33.13). • Locking screws are used to secure the plate.

FIGURE 33.10  (A) Prior incision used to access the malunion. (B) Hardware removed from the distal radius. STEP 1 PEARLS

Kirschner wires (K-wires) placed in the distal segment parallel to the articular surface can help confirm the direction and location of the osteotomy (Fig. 33.11). STEP 1 PITFALLS

Improper osteotomy orientation will lead to a secondary deformity when the osteotomy is opened.

FIGURE 33.11  K-wires placed.

STEP 2 PEARLS

• Temporarily attach the volar plate to the distal segment before the osteotomy to aid in quick fixation after the osteotomy is complete. • The initial plate orientation should mirror the deformity to be corrected. For example, in a dorsally tilted malunion with loss of radial inclination, the proximal aspect of the plate will be ulnarly directed and volarly displaced away from the radial shaft before correction (see Fig. 33.13).

FIGURE 33.12  Volar locking plate aligned on the distal radius segment.

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.14  Plate secured with screws to the radial shaft. FIGURE 33.13  Plate placement.

Step 3 • The proximal portion of the plate is temporarily stabilized to the radial shaft with a bone clamp, and alignment is checked with fluoroscopy. • Distal advancement of the plate along the radial shaft is done to establish the correct radial height. The goal is make the radius neutral with the ulna. • The plate is secured with screws to the radial shaft (Fig. 33.14).

Step 4: Closure • Bone grafts with autogenous or cadaveric bone chips are placed into the defect created by the osteotomy (Fig. 33.15). • The pronator quadratus is repaired over the plate with 3-0 Vicryl. • The incision is closed with absorbable suture. • The patient is placed in a volar short-arm splint.

INTRAARTICULAR MALUNION • Surgical intervention is made to correct the specific deformity and reestablish articular congruity. • Fig. 33.16 shows an example of a volar intraarticular segment malunion. • This patient presents with a volarly subluxed and ulnarly deviated wrist (Fig. 33.17A–C). • The patient has pain and difficulty with wrist extension and supination (Fig. 33.18).

STEP 2 PITFALLS

• If the plate rim is not parallel to the volar rim of the lunate facet, then radial inclination will not be restored. If the distal end of the plate is not in direct contact with the volar cortex of the distal fragment, then the volar tilt will not be restored. • Two to four locking screws are placed distally to provide strength to the distal fragment plate fixation. If the plate is manipulated after placement of a single screw, the screw and plate will have a higher chance to pull away from the bone, or the plate will rotate out of position. STEP 3 PEARLS

A plate that uses locking screws is necessary when using the volar plate to reduce the distal segment. Traditional plates are more prone to screw loosening. STEP 3 PITFALLS

If the plate does not reduce to the radial shaft, evaluate and release any scar tissue or fibrous callus attached to the distal segment.

STEP 4 PEARLS

• Adequate bone grafting of the entire osteotomy can be checked under fluoroscopy. • For defects greater than 1 cm, cortical– cancellous bone graft can aid stability. STEP 4 PITFALLS

FIGURE 33.15  Cadaveric bone placed into the defect.

Bone graft should not be packed beyond the cortical edges of the radius. This can lead to prominent bone fragments that cause tendon irritation and eventual rupture.

249

250

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.16  Volar intraarticular segment malunion.

Prior incision

A

B

C

FIGURE 33.17  (A-C) Volarly subluxed and ulnarly deviated wrist.

FIGURE 33.18  Difficulty with wrist extension and supination.

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.19  Malunion identified with clearly visible prior fracture line (white arrow pointing to prior fracture line).

FIGURE 33.20  Osteotome used to disimpact the prior fracture. STEP 1 PEARLS

Step 1: Release of Intraarticular Malunion Segments • A dorsal or volar approach is selected based on the location of the intraarticular malunion. • A poorly reduced volar fracture is fixed with a volar approach using the prior incision (see Fig. 33.17A). • The malunited segments are visually identified (Fig. 33.19) and confirmed with fluoroscopy. • An osteotome is used to release the displaced segment (Fig. 33.20).

Maintain any nonrestrictive soft-tissue attachments to the displaced fragment(s). These attachments may carry vascular supply to the bone fragments. STEP 1 PITFALLS

Avoid damage to the articular surface during the osteotomy. STEP 2 PEARLS

Step 2: Plate Placement A volar plate is applied to the radial shaft and the segment is reduced into anatomic alignment (Fig. 33.21).

Step 3: Distal Screw Placement • A distal screw is first placed to fixate the reduced malunion segment (Fig. 33.22). • The remaining screws are placed for further stabilization (Fig. 33.23).

Step 4: Closure • The pronator quadratus is repaired over the plate with 3-0 Vicryl. • The incision is closed with absorbable suture (Fig. 33.24). • The patient is placed in a volar short-arm splint.

For this type of malunion, a volar plate using variable angle pegs placed under the articular surface works well to buttress the volar segment. STEP 2 PITFALLS

The callus underneath the malunion must be debrided away to enable adequate reduction of the fracture piece. STEP 3 PEARLS

Use a variable-angle drill guide to have flexibility in the angle of screw placement. This can help orient screws to capture and support small articular fragments. STEP 3 PITFALLS

Take care that drilling and screw placement do not cause iatrogenic fracture of small bone fragments.

A

B FIGURE 33.21  Volar plate applied to the radial shaft.

FIGURE 33.22  Distal screw placed to fixate the reduced malunion segment.

251

252

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.23  Remaining screws placed for further stabilization.

FIGURE 33.24  Incision closed with absorbable suture.

INTRAARTICULAR MALUNION OF THE VOLAR ULNAR CORNER (LUNATE FACET FRAGMENT) • Surgical intervention is necessary to correct the specific deformity, reestablish articular congruity, prevent subluxation of the carpus, and maintain DRUJ congruity. • Fig. 33.25 shows an example of a volar ulnar corner intraarticular segment malunion. • This patient presents with a volarly subluxed carpus seen on radiographs and clinically (Fig. 33.26). • The patient has pain and difficulty with wrist extension and flexion (Fig. 33.27).

FIGURE 33.25  Volar ulnar corner intraarticular segment malunion.

FIGURE 33.26  Volarly subluxed carpus.

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.27  Poor preop motion.

STEP 1 PEARLS

• Although the previous volar Henry incision was used in this case, the volar ulnar approach (exploiting the interval between the FCU and palmaris longus superficially and ulnar neurovascular bundle and carpal tunnel contents deep) should also be considered to permit direct visualization of the volar ulnar corner fracture and the sigmoid notch. • Mobilization of the bony fragments should be done gently, especially in osteoporotic bone, because this could lead to increasing bone fragmentation. • Ensure that any nonrestrictive soft tissue stays attached to the displaced fragment(s). These attachments carry vascular supply to the bone fragments. STEP 1 PITFALLS

Avoid damage to the articular surface during the osteotomy. STEP 2 PEARLS

FIGURE 33.28  Prior volar Henry approach.

Step 1: Release of Intraarticular Malunion Segments • A dorsal or volar approach is selected based on the location of the intraarticular malunion. • A poorly reduced volar ulnar corner fracture is approached using the prior volar Henry approach (Fig. 33.28). • Prior hardware is identified and removed to better assess the malunion (Fig. 33.29A–B). • Use an osteotome or Freer at the malunion site to gain mobility of the fracture fragment.

Step 2: Restoration of Articular Congruity • A Freer is used to elevate the mobile fragment and restore both articular congruity and DRUJ congruity (Fig. 33.30). • Allograft bone is inserted into the subchondral bone defect (Fig. 33.31).

Step 3: Plate Placement The plate should be placed in a buttress fashion to permit adequate capture of the fragment and prevent collapse from the axial loads (Fig. 33.32A–B).

Step 4: Closure • The pronator quadratus is repaired over the plate with 3-0 Vicryl. • The incision is closed with absorbable suture.

Again, gentle and patient elevation with the Freer is necessary to avoid further fragmentation. Elevating the fragment will create a void in the subchondral bone, which should be filled with bone graft or bone substitute. STEP 2 PITFALLS

The callus at the malunion site must be debrided away to enable adequate mobilization and reduction of the fracture piece. STEP 3 PEARLS

• Use 2.4-mm plates because these can be bent to match radial anatomy and then placed in a buttress fashion. The plates also have a low profile if they must be placed distally. • Often, the plates need to be placed distally to adequately capture the fragment. To prevent tendon irritation, it may be helpful to repair the pronator quadratus. • Additionally, future hardware removal surgery should be discussed with the patient preoperatively. STEP 3 PITFALLS

Ensure that drilling and screw placement does not cause iatrogenic fracture of small bone fragments.

253

254

CHAPTER 33  Corrective Osteotomy of Radius Malunion

Plate

A Original fracture line

B FIGURE 33.29  (A) Plate identified. (B) Plate removed and original fracture line revealed.

FIGURE 33.30  Articular congruity restored.

Bone graft

FIGURE 33.31  Bone graft inserted into subchondral void.

CHAPTER 33  Corrective Osteotomy of Radius Malunion Plate

A

B FIGURE 33.32  (A-B) Plate placed and buttressing volar ulnar corner fragment.

FIGURE 33.33  Immediate postoperative x-rays.

• The patient is placed in a volar short-arm splint. • Immediate postoperative x-rays demonstrate improvement in alignment of the articular surface and correction of the volar carpal subluxation (Fig. 33.33).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A volar splint remains for 7 to 10 days. Any nonabsorbable sutures are removed. • Depending on the degree of deformity and stability of the fixation, patients may be casted or placed in a removable splint. • Active range of motion (ROM) of the fingers is started immediately. • The ultimate outcome regarding strength and motion may take up to 12 to 18 months. Preoperative wrist function will affect the speed of recovery postoperatively.

255

256

CHAPTER 33  Corrective Osteotomy of Radius Malunion

FIGURE 33.34  Three-month postoperative x-rays.

FIGURE 33.35  Improved range of motion. POSTOPERATIVE PEARLS

POSTOPERATIVE PITFALLS

• Outcome data suggest that patients will have significant functional improvement with improved anatomy, but function is not likely to return to the level of the uninjured side. • The patient 3 months after correction has x-rays demonstrating a healed previous osteotomy site with incorporation of the bone graft (Fig. 33.34) and improved ROM (Fig. 33.35).

Finger ROM exercises should be started as soon as possible. Patients presenting with malunion may already suffer from decreased mobility.

EVIDENCE

Patients presenting for malunion may be eager to return to full activity; caution should be stressed with these patients about advancing too quickly.

Gaspar M, Kho J, Kane P, Abdelfattah HM, Culp RW. Orthogonal plate fixation with corrective osteotomy for treatment of distal radius malunion. J Hand Surg Am. 2017;42(1):e1–e10. This study is a retrospective review of patients who underwent distal radius corrective osteotomy and 90-90 fixation from January 2008 to December 2014. In all, 39 cases (31 extra-articular, 8 combined intra- and extra-articular) were included. At a mean follow-up of 4 years, significant improvements

CHAPTER 33  Corrective Osteotomy of Radius Malunion were observed in wrist motion, grip strength, pain, radiographic parameters, and QuickDASH scores. Twelve patients (31%) underwent additional surgery with the most common being plate removal (7 patients, 3 of 7 of whom removed the radial plate; Level IV evidence). Luo TD, Nunez Jr FA, Newman EA, Nunez Sr FA. Early correction of distal radius partial articular malunion leads to good long-term functional recovery at mean follow-up of 4 years. Hand (N.Y.). 2020;15(2):276–280. This study is a retrospective review of 7 consecutive patients with a mean age of 38 years who underwent corrective osteotomy via dorsal or combine dorsal volar approach. Mean time from injury to corrective osteotomy was 10 weeks. At mean follow-up of 44 months, significant improvements in pain scores, wrist ROM with the exception of pronation, QuickDASH and grip strength were noted. No patients required secondary procedures, including removal of hardware (Level IV evidence).

257

CHAPTER

34

Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures) Shepard Peir Johnson and Kevin C. Chung

INDICATIONS • Ulnar styloid, ulnar metaphyseal, and ulnar metadiaphyseal fractures may be treated after reduction and stabilization of distal radius fractures (DRF). • If rigid fixation of a DRF results in a stable distal radioulnar joint (DRUJ), then operative fixation of an associated distal ulnar fracture is not mandatory. • The most common causes of instability of the DRUJ after DRF are dorsal angulation and shortening of the DRF fragments. • Ulnar fractures require operative repair if there is (1) an unstable DRUJ, (2) an unstable and/or irreducible fracture, (3) a large intraarticular step-off, or (4) a need to restore ulnar length and alignment.

Ulnar Styloid Fracture Management • Ulnar styloid fracture is present in up to 50% to 65% of DRF patients. • Treat an ulnar styloid tip or midportion fracture nonoperatively because these injuries are not associated with DRUJ instability (the radioulnar ligament insertion is still intact). • For an ulnar styloid base fracture, if the DRUJ is stable with or without laxity, treat nonoperatively. • In cases of grossly unstable DRUJ with ulnar head subluxation, manage with open reduction internal fixation.

Ulnar Metaphyseal Fracture Management • Ulnar metaphyseal fracture (i.e., ulnar head or distal ulnar) is present in up to 6% of DRF patients. • Literature has shown that comminuted fractures in elderly patients are often stable enough (after DRF fixation) for nonoperative management. • The Biyani Classification delineates the fracture patterns of ulnar metaphyseal fractures (Fig. 34.1).

Type 1

Type 2

Type 3

Type 4

FIGURE 34.1  Biyani Classification of ulna metaphyseal fractures. Type I: Simple extraarticular fracture with minimal comminution. Type II: Inverted T- or Y-shaped fracture with an ulnar styloid fragment, including a portion of the metaphysis. Type III: Fracture of the lower ulnar metaphysis with avulsion fracture of the ulnar styloid. Type IV: Comminuted fracture of lower ulnar metaphysis, with or without styloid fracture.

258

CHAPTER 34  Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)

Ulna Metadiaphyseal Fracture Management The goal of management is to restore ulnar alignment and length and ensure DRUJ stability. Typically, a displaced fracture should be treated operatively.

Contraindications • Ulnar styloid fractures with a stable DRUJ do not require fixation. • Elderly patients with osteoporotic bone and comminuted ulnar head, metaphyseal, or neck fractures can be managed nonoperatively.

CLINICAL EXAMINATION • Perform a complete skin, muscle, and neurovascular examination of the upper extremity pre- and postreduction. • Examine the contralateral extremity to compare forearm length (ulnar variance), range of motion (ROM), and integrity of the DRUJ. • The carpal tunnel and forearm compartments should be examined for signs and symptoms of compartment syndrome because fractures of both forearm bones are typically caused by highimpact injuries. • Examine for DRUJ instability (Fig. 34.2). • Assess for joint laxity, subluxation, or dislocation. Joint laxity can be compared with the contralateral extremity. A palpable clunk with ulnar dislocation suggests a DRUJ injury.

IMAGING • Radiographs of the wrist in posteroanterior, lateral, and oblique views should be obtained. • Repeat radiographic views of the wrist intraoperatively to ensure restoration of volar tilt and length of the distal radius after fixation and before examining DRUJ stability.

Evidence of DRUJ Instability • Ulna head is subluxed dorsally from the sigmoid notch with the arm in neutral rotation. • There is widening of the DRUJ on the posteroanterior view. • Radial displacement of ulnar styloid fragment indicates a pulling force of a detached radioulnar ligament (Fig. 34.3).

FIGURE 34.2  With the elbow flexed at 90 degrees, stress the ulna volarly and dorsally with the forearm in supination, neutral, and pronation. Repeat the examination with radial deviation of the wrist (right image). Next, compress the distal radius and ulnar head together and range the wrist from supination to pronation. Ulnar dislocation indicates a DRUJ injury that needs surgical repair.

259

260

CHAPTER 34  Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)

FIGURE 34.3  The ulnar styloid fragment is being pulled radially (white arrow) indicating the pulling force of the radioulnar ligament.

SURGICAL ANATOMY Biomechanical Anatomy • The distal ulna is the fixed point around which the radius rotates. • Pronation and supination of the wrist is achieved as the radius rotates around the ulna via the DRUJ articulation. • The ulnar styloid base and fovea are the insertion points of the palmar and dorsal radioulnar ligaments, which are the primary stabilizers of the DRUJ (Fig. 34.4). • Therefore DRUJ instability may occur with basilar ulnar styloid or intraarticular fractures because this results in disruption of the superficial (distal) attachment limbs of the radioulnar ligaments. • The DRUJ may maintain stability if the deep (proximal) limbs remain attached to the fovea (i.e. ligamentum subcruentum).

Palmar radioulnar ligament Fovea Articular disc Dorsal radioulnar ligament

FIGURE 34.4  The palmar and dorsal radioulnar ligaments are the primary stabilizers of the DRUJ. If the ulnar styloid fragment is proximal to those attachments, the DRUJ may be unstable, necessitating fixation.

CHAPTER 34  Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)

Bony and Ligamentous Relationship • A palpable, shallow groove on the dorsum of the ulna styloid harbors the extensor carpi ulnaris (ECU) tendon. This is easily palpated with wrist extension and radial deviation. • The extensor retinaculum inserts onto the ulnar and dorsal aspects of the ulna.

Triangular Fibrocartilage Complex The triangular fibrocartilage complex (TFCC) consists of a central articular disk, meniscal homologue, radioulnar ligaments, ulnocarpal ligaments, and ECU tendon sheath. The radioulnar ligaments of the TFCC attach at the fovea, which is located at the base of the ulnar styloid.

Critical Structures The ulnar approach places the dorsal branch of the ulnar nerve at risk. This nerve branches approximately 6 cm proximal to the ulnar head, passes dorsal to the flexor carpi ulnaris (FCU), and pierces the deep fascia 5 cm proximal to the pisiform.

POSITIONING • Position the patient supine with the affected extremity extended on an arm table. • The procedure is more easily performed if an assistant holds the elbow flexed at 90 degrees with the forearm in neutral pronation-supination.

ULNAR APPROACH TO THE ULNAR STYLOID, HEAD, AND NECK Exposures • A longitudinal incision is made over the subcutaneous border of the ulnar neck and shaft (centered on the fracture site; Fig. 34.5). • During subcutaneous dissection, the dorsal branch of the ulnar nerve is identified and retracted. • The extensor retinaculum is incised. • Dissection is continued sharply between the tendons of the flexor and ECU down to the ulna. • Incise the periosteum longitudinally and elevate to expose the fracture. • Evacuate the hematoma, irrigate, and clean the fracture fragments.

FIGURE 34.5  The incision over the ulna is centered over the fracture (black arrow). For ulnar styloid fractures and TFCC exploration and repair, the proposed distal curvilinear incision can be used. This results in a scar that does not correlate with the resting position of the wrist on a hard surface (white arrow).

EXPOSURES PEARLS

• Distal extensions of the incision should continue dorsally, so that the resultant scar does not correlate with the resting position of the ulnar head on hard surfaces. • If a TFCC exploration is deemed necessary (after ulnar fixation), the distal aspect of the skin incision can be hockey-sticked dorsally enough to gain access to the fifth to sixth extensor compartment interval (see Chapter 20 TFCC Repair). • Release of the ulnar attachments of the extensor retinaculum can aid in fracture visualization and reduction.

EXPOSURES PITFALLS

• Overzealous periosteal stripping should be avoided to preserve the vascular supply to the ulna. • Avoid circumferential dissection around the ulnar base because this will disinsert the superficial attachment limbs of the radioulnar ligaments of the TFCC.

261

262

CHAPTER 34  Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)

STEP 1 PEARLS

Because the ulnar styloid is small, avoid multiple passes of K-wire to preserve bone.

ULNAR STYLOID FRACTURE FIXATION WITH TENSION BAND WIRING Step 1: Reduction of Fracture

STEP 2 PEARLS

• Identify the ulnar styloid fragment with the aid of intraoperative fluoroscopy. • Use an elevator or dental pick to reduce the radially displaced fragment out of the wrist joint space and into the field of dissection. • Provisionally place a 1.1-mm Kirshner wire (K-wire) just off the midline of the apex of the styloid (to permit placement of a second K-wire). • Using fluoroscopy, reduce the styloid fragment using the K-wire as a joystick. • While holding reduction, place a second 1.1-mm K-wire near the apex of the styloid and drive obliquely to capture the opposite cortex of the ulnar metadiaphysis (Fig. 34.6). • Drive the joystick K-wire into the opposite cortex of the ulnar metadiaphysis.

Use an 18- or 20-gauge needle to guide the stainless-steel wire through the hole.

Step 2: Placement of Tension Band

STEP 1 PITFALLS

Overreducing ulnar styloid fractures, although difficult, may increase tension on the TFCC and lead to restricted forearm rotation.

STEP 2 PITFALLS

Avoid grasping soft tissue or the dorsal sensory branch of the ulnar nerve as the wire is placed and tightened.

• Drill a 1- to 1.5-mm hole (approximately 2 cm proximal from the apex of the styloid) through the ulnar metadiaphysis. • Thread a 26-gauge stainless-steel dental wire through the hole (Fig. 34.7A). • Create a figure-of-eight loop with the wire by passing distal to the K-wires (see Fig. 34.7B). • Pull the figure-of-eight loop taut.

Step 3: Complete Fixation • Twist the figure-of-eight wire ends in a clockwise the direction until the desired tension is achieved. • Visualize reduction under fluoroscopy to ensure that it is maintained with pronation and supination. • Cut the wire ends, rosette, and bury toward bone to prevent prominence. • Using two heavy needle drivers, bend the exposed K-wires 180 degrees and trim short. • Face K-wires deep and bury in bone such that they hold the figure-of-eight wire.

A

FIGURE 34.6  With the joystick K-wire (black arrow) holding reduction, drive a second K-wire across the fracture fragment.

B

FIGURE 34.7  (A) Thread a 26-gauge stainless steel wire through the proximal hole and then distally in a figure-of-eight fashion around the K-wires (using an 18-gauge needle for assistance). (B) Tighten the K-wire to reduce the fracture, then cut and expose the K-wire 5 mm outside of styloid and bury it to hold the tension band.

CHAPTER 34  Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)

Step 4: Closure • Reapproximate the periosteum and extensor retinaculum. • Close the subcutaneous tissue and skin in layers. • Ensure that the K-wires and tension band wire are not palpable.

ULNAR STYLOID FRACTURE FIXATION WITH CANNULATED HEADLESS COMPRESSION SCREW Step 1: Reduction of Fracture • As described previously, identify and reduce the fracture fragment. • Hold the fragment reduced with point-to-point reduction forceps (Fig. 34.8). • Place a single K-wire at the apex of the styloid centered in the bulk of the fragment. • Under fluoroscopic guidance, drive a 1.1-mm K-wire obliquely and capture the opposite cortex of the metadiaphysis of the ulna. • Confirm adequate reduction.

Step 2: Size Cannulate Headless Compression Screw • Measure the desired screw length using a second K-wire or the manufacturer’s measuring device. • Advance the K-wire into the radius to avoid inadvertent removal when predrilling. • Select the correct drill size for the chosen screw diameter and length, and under fluoroscopic guidance, drill through the far cortex. • Countersink the drill hole.

Step 3: Fixation With Headless Compression Screw

FIGURE 34.8  With a point-to-point holding reduction, a K-wire is placed across the center of the fracture. After measuring the length of the compression screw, send the K-wire out of the far ulnar cortex to prevent inadvertent removal (black arrow). STEP 1 PEARLS

• Pass the driver handle and cannulated headless compression screw over the guide wire and advance the screw into position. • Engage the far cortex of the ulna to achieve compression. • Remove the guide wire.

Only large ulnar styloid fracture fragments are amenable to headless compression screws (typically 2.0–2.5 mm). Fracture fragments must be held in reduction with forceps/clamp to facilitate precise K-wire placement.

Step 4: Closure

STEP 2 PEARLS

• Reapproximate the periosteum and extensor retinaculum. • Close the subcutaneous tissue and skin in layers.

ULNAR METADIAPHYSEAL FRACTURE FIXATION WITH AN ANATOMIC ULNAR HOOK PLATE Step 1: Reduction of Fracture • Align multifragmentary fractures with point-to-point reduction forceps. • Provisional K-wire fixation may be required if severe comminution exists. • Use a 1.1-mm K-wire to reduce the ulnar styloid fragment to the ulnar head.

It is important to select a screw that is short enough to bury in the styloid fragment but long enough to engage the far cortex to achieve compression. STEP 3 PEARLS

• Compression cannot be achieved if the screw threads are bridging the fracture gap. • Ensure that the screw sits beneath the surface of the ulnar styloid to prevent impingement. STEP 1 PEARLS

Step 2: Fixate Ulnar Styloid to Ulnar Head Using a 2.0-mm LCP Distal Ulnar Hook Plate • Place the hook plate on the bone by engaging the distal hooks onto the tip of the ulnar styloid. • Secure the plate to the ulnar head with a 2-mm locking screw (Fig. 34.9).

Step 3: Reduce the Ulnar Head to the Ulnar Shaft Use point reduction forceps to grasp the ulna shaft and reduce the ulna head to the shaft.

Step 4: Complete Fixation • Drill and insert a nonlocking screw into the oblong hole over the ulnar shaft to reduce the bone to the plate (Fig. 34.10). • Confirm adequate reduction with fluoroscopy. • Fill the remaining plate holes with locking or nonlocking screws (Fig. 34.11).

• Fixation of a multifragmentary fracture of the distal ulna can be achieved with a 2.0-mm LCP distal ulnar hook plate. The plate is anatomically precontoured and has hooks that grip the styloid process. Therefore fixating the ulnar styloid to the ulnar head using the plate will facilitate the remainder of the reduction. • In comminuted metadiaphyseal fractures, correct rotational alignment and length must be achieved for adequate anatomic fixation. • The bone quality in the distal ulna is often poor; therefore the hook plate is a locking screw design. Be sure to contour the plate to the fracture. The first screw should be a cortical screw to bring the plate in tight contact with the bone. If a locking screw is placed first, there may be a gap between the plate and the bone, which may trap tendons or nerves in the gap during wrist motion.

263

264

CHAPTER 34  Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures) STEP 2 PEARLS

Use the drill sleeve for ease of control and manipulation of the plate. STEP 2 PITFALLS

• A screw that is too long may penetrate the far ulnar cortex and enter the DRUJ. • Unicortical screws are used at the level of the sigmoid notch. STEP 4 PEARLS

• The provisional K-wire holding the ulnar styloid to the ulnar head can be cut short and left in place. Alternatively, it can be removed, and an additional screw may be placed between the pointed hooks on the ulnar styloid to achieve more rigid fixation with an orthogonally placed screw. • After final screw placement, check for unrestricted pronation and supination of the wrist to ensure that no screws are inhibiting the DRUJ articulation.

FIGURE 34.9  Engage the hooks of the anatomic hook plate into the tip of the ulnar styloid (black arrow) and secure the plate to the ulnar head with a cortical screw to bring the plate into contact with the bone (green arrow).

A

FIGURE 34.10  With a reduction clamp holding the plate to the proximal shaft, place a nonlocking screw in the proximal fragment.

B

FIGURE 34.11  (A) The remainder of the screws are placed to attain three points of fixation proximally. (B) Note: unicortical screws were placed in the metadiaphysis to avoid penetration into the DRUJ (yellow arrow).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • If rigid fixation is achieved: • Place the patient in a short arm volar resting splint. • Evaluate the fixation radiographically at 1 week and begin therapy if reduction is maintained. • Treat patients based on the needs of their DRF management. • If the fixation is tenuous and the DRUJ remains unstable: • Place patient in a sugar-tong splint to block supination and pronation. • Evaluate fixation radiographically at 1 week and 4 weeks. • Begin therapy at 4 to 6 weeks, based on DRUJ stability on clinical examination. • The presence of ulnar styloid fractures does not affect the outcomes of DRF, unless gross DRUJ instability exists. • Nonunion occurs in 25% of ulnar styloid fractures. • Nonunion does not correlate with functional or clinical outcomes and requires no further treatment if asymptomatic.

CHAPTER 34  Associated Ulnar Fixation (Ulnar Styloid and Metadiaphyseal Fractures)

• Symptoms related to nonunion occur because of abutment on the carpus, irritation from the loose body, or development of DRUJ instability. See Video 34.1

EVIDENCE Richards TA, Deal N. Distal ulna fractures. J Hand Surg Am. 2014;39(2):385–391. This review article on distal ulnar fractures summarizes pertinent anatomy and treatment options for distal ulnar fractures. The authors review fracture classifications, methods of fixation (including salvage procedures), and the arguments for and against surgical intervention. Sammer DM, Shah HM, Shauver MJ, Chung KC. The effect of ulnar styloid fractures on patient-rated outcomes after volar locking plating of distal radius fractures. J Hand Surg Am. 2009;34(9):1595–1602. The authors performed a prospective cohort study of distal radius fractures treated with volar locking plate. They omitted patients with an unstable DRUJ and compared 88 patients with ulnar styloid fractures to 56 without. They found that ulnar styloid fracture presence, size, displacement, and union did not affect subjective outcomes, which were evaluated with the Michigan Hand Outcomes Questionnaire. Kim JK, Koh YD, Do NH. Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radius fracture? J Bone J Surg. 2019;92: 1–6. This study evaluated 138 consecutive patients with distal radius fractures who underwent open reduction and internal fixation and compared the outcomes of patients with and without ulnar styloid fractures. Seventy-six (55%) patients had styloid fractures, of which 29 were at the ulnar base. No differences in wrist outcomes were identified between group comparisons, and, therefore, the authors concluded that associated ulnar styloid fractures in patients who receive stable fixation of their distal radius has no adverse effect on wrist function and does not need operative fixation.

265

CHAPTER

35

Forearm Fracture-Dislocations (Galeazzi and Monteggia) Shepard Peir Johnson and Kevin C. Chung

INDICATIONS • Radius and ulna fracture-dislocations require operative treatment in the adult population. • The forearm unit consists of the ulna and radius, which are held together proximally at the proximal radioulnar joint (PRUJ), at the interosseous membrane (IOM) along the shaft, and distally at the distal radioulnar joint (DRUJ). Because of their intimate relationship, displaced proximal or midshaft fractures of one bone may result in a dislocation of the other. • Galeazzi fracture-dislocation is characterized by a radial shaft fracture, typically at the junction of the middle and distal thirds, and dislocation of the DRUJ. Dorsal ulnar dislocation of the DRUJ results from pronation and wrist extension. Volar ulnar dislocation of the DRUJ (less common) is the result of forced supination or a direct ulna blow. DRUJ instability arises when the triangular fibrocartilage complex (TFCC) tears from its foveal attachment or there is an ulnar styloid base fracture (with intact TFCC). • Operative fixation of the radial shaft fracture typically results in a reduced, stable DRUJ. After radius fracture fixation, evaluation of DRUJ stability will guide management as follows: • If stable: Perform long-arm cast immobilization in slight supination. • If unstable: Perform DRUJ transfixion. • If unstable and irreducible DRUJ: Perform (1) open reduction and internal fixation of styloid fracture, or (2) open removal of interposed soft tissue and TFCC repair. Protect both repairs with DRUJ transfixion. • Monteggia fracture-dislocation is characterized by a proximal ulna shaft fracture with an accompanying dislocation of the PRUJ. The goal of treatment is to maintain an anatomically reduced radial head, which is best accomplished with restoration of ulna length and alignment. The Bado Classification describes subtypes of this fracture-dislocation pattern (Fig. 35.1): • Type I (60% of fractures, mostly children): Proximal or middle third ulna shaft fracture (apex anterior angulation) with anterior dislocation of the radial head. • Type II (15% of fractures, mostly adults): Proximal or middle third ulna shaft fracture (apex posterior angulation) with posterior dislocation of the radial head. The Jupiter Classification describes subtypes: • IIA: The ulna fracture involves the distal olecranon and coronoid process. • IIB: The ulna fracture is at the metaphyseal-diaphyseal junction distal to the coronoid. • IIC: The ulna fracture is diaphyseal. • IID: The ulna fracture extends to the midshaft or distal. • Type III (20% of fractures): Ulna metaphysis fracture (distal to coronoid process) with lateral dislocation of the radial head. • Type IV (5% of fractures): Proximal or middle third ulna and radial head fractures with dislocation of the radial head in any direction.

Contraindications • Grossly contaminated wounds require initial washout and debridement before definitive fixation. • Hemodynamic instability or life-threatening injuries take precedence before operative fixation. 266

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia)

A

B

C D FIGURE 35.1  The Bado Classification describes subtypes of Monteggia fracture-dislocations based on the direction of the radial head displacement (black arrows). (A) Type I – anterior dislocation, (B) Type II – posterior dislocation, (C) Type III – lateral dislocation, (D) Type IV – dislocation in any direction with radial head fracture (bolt). (From Perez, EA. Fractures of the shoulder, arm, and forearm. In Canale ST ed. Campbell’s Operative Orthopaedics. 9th ed. Elsevier; 1998:3031–3126.)

CLINICAL EXAMINATION • Perform a complete skin, muscle, and neurovascular examination of the upper extremity (pre/postreduction and pre/postoperatively). • Examine the contralateral extremity to compare forearm length, range of motion (ROM), and integrity of the DRUJ and PRUJ. • Evaluate the forearm compartments for signs and symptoms of compartment syndrome. • It is imperative to examine the DRUJ and PRUJ for dislocations after operative repair of forearm fractures.

IMAGING • Anteroposterior and lateral plain radiographs of the wrist, forearm, and elbow are indicated for forearm fractures. • Galeazzi fracture-dislocation (Figs. 35.2): • On anteroposterior view, evaluate for an apex medial angulated radius fracture, radial shortening (typically . 5 mm), and widening of the DRUJ. • On lateral view, evaluate for an apex dorsal angulated radius fracture and dorsal dislocation of ulna head. • Evaluate for ulna styloid base fracture. • Monteggia fracture-dislocation (Fig. 35.3): • Evaluate for bony abnormalities. • Congruency of the radiocapitellar joint is assessed with the radiocapitellar line (RCL). The RCL (a longitudinal line traveling down the center of the radius) should pass through the center of the capitellum in all views (in adults). • If intraarticular involvement (Jupiter type IIA), radial head fractures (Bado type IV), or severely comminuted fractures are suspected, then computed tomography (CT) may be helpful.

SURGICAL ANATOMY Bony Anatomy • Both radius and ulna have characteristic bows that permit pronation and supination of the forearm. The morphology of these bones must be respected when performing fixation, or the patient will experience significant limitations in ROM, dexterity, and strength.

267

268

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia)

A

B

FIGURE 35.2  Radiograph of Galeazzi fracture-dislocation showing anterior-posterior view with (A) apex medially angulated radius fracture (yellow arrow), radial shortening, and DRUJ widening (green arrow), and lateral view showing (B) apex dorsal angulated radius fracture (blue arrow) and dorsal dislocation of ulna head (red arrow).

A

B

FIGURE 35.3  Radiograph of Monteggia fracture-dislocation showing lack of congruency of the radiocapitellar joint in the (A) anteroposterior view and (B) lateral view. The radiocapitellar line (RCL; yellow dotted line) is drawn down the shaft of the radius and should pass through the center of the capitellum. This Bado type I shows an ulna fracture with an apex anterior angulation (blue arrow) and anterior dislocation of the ulna head (red arrow). (From Ring D. Monteggia fractures. Orthop Clin North Am. 2013;44[1]:59–66).

• The radius has a 10-degree radial bow in the coronal midshaft and a 5-degree sagittal bow in the proximal third. • The ulna has a slight posterior apex bow along its entire length. • The midportion of the ulna has a triangular cross-section. The posterior apex portion is largely subcutaneous (and palpable) and separates the extensor and flexor compartments.

Articular Anatomy Distal Radioulnar Joint See Fig. 35.4 for a depiction of the distal radioulnar joint. • It involves the synovial joint between the concave sigmoid notch of the radius and the convex ulna head. • It is primarily stabilized by the volar and dorsal radioulnar ligaments (component of the TFCC), and secondarily by the IOM and pronator quadratus (PQ).

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia)

Ulnar styloid

Extensor carpi ulnaris tendon sheath

Extensor carpi ulnaris tendon

Dorsal distal radioulnar ligament

Palmar distal radioulnar ligament

Triangular (articular) disk

FIGURE 35.4  The primary stabilizing structures of the triangular fibrocartilage complex (TFCC) are the palmar and dorsal radioulnar ligaments, which insert onto the base of the ulna styloid. The distal radioulnar joint (DRUJ) is injured and may be unstable, with injury to these structures or fracture of the ulnar styloid proximal to their insertion. (From Savoie FH. Triangular fibrocartilage complex injury. In Giangarra C, Manske E, eds. Clinical Orthopaedic Rehabilitation: A Team Approach. 4th ed. Elsevier: 2017;45–50 and Anatomy of the triangular fibrocartilage complex).

• The TFCC consists of a central articular disk, meniscal homologue, radioulnar ligaments, ulnocarpal ligaments, and extensor carpi ulnaris (ECU) tendon sheath. The radioulnar ligaments of the TFCC attach at the fovea, which is located at the base of the ulna styloid.

Interosseous Membrane The IOM disperses axial load forces to the forearm.

Proximal Radioulnar Joint See Fig. 35.5 for a depiction of the proximal radioulnar joint. • The synovial joint is formed by the circumferential margin of the radial head that articulates with the lesser sigmoid notch of the ulna (on the lateral side of the coronoid process). • The annular and quadrate ligament are the primary stabilizers of the PRUJ. • The annular ligament originates and inserts on the ulna and encircles the radial head. • The quadrate ligament is a fibrous band spanning from the inferior border of the radial notch on the ulna to the neck of the radius. • A thorough understanding of the muscles and neurovascular structures of the forearm is needed to safely perform open reduction and internal fixation.

269

270

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia)

Annular ligament

Inferior band Anterior band Posterior band

of ulnar collateral ligament

FIGURE 35.5  The annular ligament encircles the radial head and maintains the articulation between the radial notch on the ulna. (From Leela CB. Elbow and forearm. In Standring, S. ed. Gray’s Anatomy. 41st ed. Elsevier; 2015;837–861).

EXPOSURES PEARLS

• During the anterior approach, several at-risk nerves should be protected: • The lateral antebrachial cutaneous nerve (LABC) emerges between the biceps tendon and BR proximally and can be found subcutaneously on the radial side of the volar forearm. • The radial sensory nerve (RSN) runs deep to the BR and penetrates the fascial interval between the BR and extensor carpi radialis longus tendons in the distal third of the forearm. • The posterior interosseous nerve (PIN) travels deep and within the substance of the supinator muscle (proximal third of the forearm) and is protected when the forearm is supinated. Supinating the forearm may require using forceps to grab the distal portion of the proximal fracture fragment. • The median nerve and palmar cutaneous branch (distal third of forearm) are ulnar to the FCR and should not be visualized during dissection. Use blunt retractors to avoid injury.

EXPOSURES PITFALLS

• Be mindful of excessive retraction during exposure because this can compromise nearby neurovascular structures. • Avoid excessive periosteal stripping. • Maintain the IOM between radius and ulna.

Galeazzi Fracture-Dislocation Open Reduction Internal Fixation EXPOSURES • Anterior (Henry) approach for middle and distal-third radius fractures (Fig. 35.6): • A longitudinal line is drawn, extending from the radial border of the flexor carpi radialis (FCR) at the wrist crease toward the lateral edge of the bicep tendon proximally. • The incision is made on this line and centered over the fracture. The length depends on the fracture location. • Dissection is performed sharply through skin, subcutaneous tissue, and fascia. • Identify the radial artery. • In the middle and proximal third of the arm, the radial artery is more superficial and midline. • Distally, the radial artery with its venae comitantes is found deep to the brachioradialis (BR), exiting the interval between the BR and FCR muscle bellies. • Bipolar cautery is used to coagulate perforators to the BR muscle, and the radial artery is mobilized (radially in the distal forearm, ulnarly in the proximal forearm). • Dissection proceeds deep along the medial edge of the BR. The radial sensory nerve (RSN) is identified under the BR and retracted radially. • To expose the midshaft of the radius, the forearm is pronated and radial attachments of the flexor digitorum superficialis (FDS) and pronator teres (PT) are released subperiosteally and retracted medially. • To expose the proximal radius, develop the interval between the BR and PT. Retract the PT and biceps tendon ulnarly and BR radially. Supinate the forearm and release the supinator muscle subperiosteally from a medial to lateral direction (supination provides protection to the posterior interosseous nerve). • To expose the distal radius, the dissection mirrors that of a distal radius fracture approach (See Chapter 32 Fragment-Specific Fixation of Distal Radius Fractures).

PROCEDURE Step 1: Fracture Reduction • Apply blunt reduction forceps to the proximal and distal fracture fragments to assist with anatomic reduction.

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia) Incision

A

Flexor pollicis longus muscle

Brachioradialis muscle

Pronator quadratus muscle

Tendon of flexor carpi radialis muscle Flexor digitorum sublimis muscle

B

Radial artery

Brachioradialis muscle

Sensory branch of radial nerve

Flexor carpi radialis muscle

D

Incision in periosteum

Flexor pollicis longus muscle

C

Radial artery

Flexor digitorum sublimis muscle

E

FIGURE 35.6  The anterior approach to the radius involves (A) mobilizing the flexor carpi radialis muscle and radial artery ulnarly and the brachioradialis muscle and radial sensory nerve radially. (B) The arm is then pronated to facilitate release of flexor pollicis longus (FPL) and flexor digitorum superficialis (FDS) from the periosteum of the radius. (C) The radial artery can be mobilized radially in the distal forearm (yellow arrow) if needed. (D) Elevating the pronator quadratus distally (not depicted); FPL, and FDS in the midshaft (blue arrow); and pronator teres proximally (not depicted) from the radius will help with exposing the fracture. (A–C from Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020:1369–1458).

• With the fracture segments aligned, apply a point-to-point reduction forceps across the fracture to maintain reduction. Do not obstruct the potential placement of hardware (plate and screws) with the reduction forceps.

Step 2: Fixation of Fracture With Compression Plating • For simple midshaft oblique or transverse radius fractures (that are easily held in reduction with forceps) a 3.5-mm dynamic compression plate is used to achieve interfragmentary compression (Fig. 35.7). • The plate should permit placement of three bicortical, nonlocking screws in each fracture fragment. • Ensure that the plate is centered over the anterior surface of the bone in the sagittal plane. • Prebend the plate so that the center is tented 1 to 2 mm above bone. Otherwise, axial compression from the plate will cause gaping of the fracture on the far cortex.

STEP 1 PEARLS

• A lever interposed into the fracture is often useful for reducing oblique fractures. • Fluoroscopy can be used during reduction to assess for the desired length of the radius. • For complex reductions, pin the DRUJ with a 1.6-or 2-mm steel pin to set the desired radius length and ulnar variance. Use the contralateral arm as a guide.

271

272

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia) STEP 2 PEARLS

• If maintaining compression is difficult with forceps, a Verbrugge clamp is useful to grasp between the last hole of the plate and the head of a temporarily placed (proximal or distal to the plate) independent screw. • For long oblique fractures, attain compression with a lag screw before plate fixation. The interfragmentary lag screw should be placed perpendicular to the fracture plane. A 3.5-mm drill bit is used to create a gliding hole on the near cortex, and a 2.5-mm pilot hole through the far cortex. The lag screw is placed such that 1 mm protrudes through the far cortex. Ensure that fracture reduction is maintained throughout. The plate can then be placed with screws in neutral position because the plate will not be used to attain further axial compression. • For three-part fractures with butterfly fragments, use 2.4-mm bicortical screws to make the fracture a more manageable two segment. When plating, do not use aggressive axial compression techniques. • For comminuted fractures, bridge the fracture with an anatomic plate that accounts for the native radial bow. • If a fracture pattern makes it difficult to attain six cortices of fixation, bridging the fracture using a locking plate is helpful. • For fractures with a distal radius component, consider long anatomic distal radius plates.

STEP 3 PITFALLS

Restoring stability to the DRUJ in Galeazzi fracturedislocations is best achieved with precise anatomic restoration of length, alignment, and rotation of the radius. Imprecision in radius fixation will lead to overtreatment of DRUJ instability.

FIGURE 35.7  An anteriorly positioned 3.5-mm compression plate on a midshaft radius fracture. Prebend plate 1 to 2 mm above fracture to facilitate compression of oblique fracture (blue arrow). Place distal screw(s) in a neutral position (green arrow) and then place a proximal screw eccentrically to induce compression (red arrow).

• Place two nonlocking bicortical screws in the distal fragment in neutral positions to secure the plate in a centered position over the shaft. • Place a screw in the proximal fracture fragment in an eccentric position (on the side of the oblique hole away from the fracture). Tightening this screw facilitates axial compression. • For oblique fractures, a lag screw can be placed across the fracture, and through the plate, if possible, to increase the strength of fixation (Fig. 35.8). • The remaining bicortical, nonlocking screws can be placed in neutral positions so that there are three screws within each fracture fragment.

Step 3: Assessment of Distal Radioulnar Joint

FIGURE 35.8  Plate fixation is secured with three bicortical screws proximal and distal to fracture line. Additional strength is attained with a lag screw placed perpendicular to the fracture line.

• Have an assistant hold the patient’s forearm in a neutral position with the elbow flexed at 90 degrees on the arm table. • Grasp the distal radius and ulna head with separate hands, and alternately apply dorsal and palmer forces to assess the DRUJ for laxity, subluxation, or dislocation. Repeat examination with the wrist in radial deviation (this action stabilizes the DRUJ if the TFCC is uninjured). • Repeat this examination in full pronation and supination.

Step 4: Transfixion Pinning for Unstable Distal Radioulnar Joint

90°

FIGURE 35.9  Transfixion pinning from ulna to radius at the junction of the metadiaphysis. Note that the 1.6-mm stainless steel pin is perpendicular to the long axis of the ulnar (blue lines).

• Reducible but unstable DRUJ without an associated ulna styloid fracture should be pinned. If irreducible, see Step 5. • Place the forearm in the rotational position with maximal stability of the DRUJ (ideally neutral or slight supination). • Using fluoroscopy, mark the proposed location for entry of a 1.6-mm smooth, stainless steel pin over the center of the ulna in the coronal plane. The pin should be placed perpendicular to the long axes of the ulna and radius and proximal to the DRUJ/sigmoid notch of the radius (Fig. 35.9). • Drive the pin through both cortices of the ulna and confirm satisfactory placement radiographically. • Have an assistant hold reduction of the DRUJ (compress radius and ulna together) and drive the pin through both cortices of the radius. • Place the second pin 1 to 2 cm proximal.

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia)

Step 5: Open Reduction of Distal Radioulnar Joint and Triangular Fibrocartilage Complex Repair • Irreducible DRUJ dislocations require open reduction of interposed soft tissue and repair of the TFCC. For posterior ulna head dislocations, a dorsal approach is indicated. • Make a 4-cm dorsal longitudinal incision over the interval between the fifth and sixth extensor compartment (Fig. 35.10A). • Identify the dorsal cutaneous branch of the ulnar nerve and protect it. • Sharply incise the extensor retinaculum between the fifth and sixth extensor compartments. • Release and retract the extensor digiti quinti (EDQ) radially from the fifth compartment. • If a traumatic capsulotomy is not present, make an ulnar-based capsulotomy flap without injuring the dorsal radioulnar ligament of the TFCC (see). • Carefully debride, evacuate hematoma, and remove interposed tissue to evaluate the integrity of the TFCC. • Inspect the foveal attachment and the palmar and dorsal radioulnar ligaments for injury. • Use a 1.1-mm Kirschner wire to create two holes (1 cm apart) from the dorsal side of the ulna (1 cm proximal to the ulnar styloid base) to the fovea (see Fig. 35.10C). • Pass a 2-0 absorbable monofilament suture on a straight needle through the bone tunnel (outside-in). • Pass the needle around the ulnar periphery of the TFCC and through the other bone tunnel (inside-out). • Ensure that the DRUJ is reduced and repair the dorsal radioulnar ligament injury, if present. • With the ulna head reduced, perform transfixion pinning as described in Step 4. • With the forearm in a neutral position, tie down the TFCC repair suture(s) at the ulnar neck (see Fig. 35.10D) • Repair the capsule and extensor retinaculum in separate layers with interrupted, absorbable sutures.

Dorsal radioulnar ligament

A

C

EDQ ECU

B

D

FIGURE 35.10  Triangular fibrocartilage complex (TFCC) repair. (A) Approach the TFCC through a dorsal longitudinal incision between the extensor digiti quinti (EDQ) and extensor carpi ulnaris (ECU). (B) Retract the EDQ radially and create an ulnar-based capsular flap but preserve the dorsal radioulnar ligament. (C) Using a Kirschner wire (K-wire), create holes from the dorsal aspect of the ulna obliquely to the periphery of the TFCC. Pass suture with a straight needle. (D) After transfixion pinning, tie down the injured portion of the TFCC to complete the repair.

STEP 4 PEARLS

• It is easier to place pins from ulna to radius because the pin is more accurately centered on the small diameter of the ulna. • Leave pins accessible from both the ulnar and radial sides to facilitate easy retrieval if pins break internally. Keep pins buried on the radial side. Alternatively, if both ends are left exposed, then cut external pins on one side before removing (to prevent pulling externally exposed, unsterile pins through the ulna and radius).

STEP 4 PITFALLS

The RSN is at risk for injury from pins exiting the radius. If desired, the surgeon can place an incision over the lateral distal radius, bluntly dissect, and identify and protect the RSN.

STEP 5 PEARLS

• In Galeazzi fracture-dislocation, a Class 1B TFCC (ulnar avulsion without styloid fracture) is nearly always present. • The ulnomeniscal homolog can be removed from its ulnocarpal attachment to better visualize the TFCC. • If there is a large ulna styloid fracture contributing to DRUJ instability, open reduction and internal fixation is indicated (see Chapter 34 Associated Ulnar Fixation).

273

274

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia)

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients should be placed in a long-arm splint with the forearm in neutral or slight supination. • Obtain wrist x-rays to ensure that the DRUJ remains reduced during the first month of follow-up. • For radius fixation and stable DRUJ: • Use a long-arm splint for 2 weeks followed by a removable short-arm splint. • Begin hand therapy at 4 weeks. • For radius fixation with DRUJ transfixion with or without TFCC repair: • Use a long-arm splint for 2 weeks followed by a long-arm cast until postoperative week 6. • Evaluate pin sites every 2 weeks and remove at postoperative week 4 or 6. • Guided hand therapy is initiated 1 week after pin removal. • Expected outcomes: • Radius union and maintenance of DRUJ stability are high, and outcomes are generally good. • Pinning of the DRUJ and immobilization in supination yields high success rates of long-term DRUJ stability. • Full activity for high-demand patients may not be attained until 4 months postoperatively. • Variable loss of pronosupination and wrist flexion are common.

Reduction and Fixation of Monteggia Fracture-Dislocation Bado Type I POSITIONING Place the patient in lateral decubitus with the affected extremity positioned over the chest and bolstered to facilitate a posterior approach.

EXPOSURES • Proximal ulna fractures are approached through a posterior midline incision. • The incision is placed lateral to the tip of the olecranon at the subcutaneous border of the ulna (Fig. 35.11). • The incision may need to be carried proximal to the tip of the olecranon to permit anatomic plate fixation if the olecranon is involved. • Extend the incision distally to permit adequate fracture visualization, reduction, and fixation. • Sharply dissect through fascia into the interval between the anconeus and flexor carpi ulnaris (FCU) proximally and ECU and FCU distally.

Extensor carpi ulnaris Anconeus

Incision

Flexor carpi ulnaris Ulnar nerve FIGURE 35.11  The approach to the olecranon and proximal ulna is carried through the interval between the anconeus and flexor carpi radialis (FCR) proximally and extensor carpi ulnaris (ECU) and flexor carpi radialis (FCR) distally.

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia)

• Incise the periosteum at the subcutaneous border of the ulna and expose the fracture by elevating the periosteum medially and laterally. • If needed proximally, split the triceps insertion longitudinally in line with the tendon fibers. • Adequately debride the fracture, evacuate hematoma, remove small fragments not amenable to fixation, and irrigate thoroughly before reduction.

EXPOSURES PEARLS

The posterior midline incision facilitates access to the radial head and coronoid tubercle if indicated. EXPOSURES PITFALLS

Excessive medial dissection places the ulnar nerve at risk for injury.

PROCEDURE Step 1: Reduce Proximal Ulna Fracture and Radial Head Dislocation • After exposing the ulna fracture (and before reduction), assess the radial head through the ulna fracture fragments. • Reduce the proximal radioulnar joint. If the radial head is fractured (Bado type IV), it may require plate fixation or resection and replacement with a radial head prosthesis (not described). • Extend the elbow and manually manipulate the fracture fragments to obtain reduction. • Evaluate with an intraoperative radiograph and elevate areas of articular depression to ensure articular congruency. • Temporarily stabilize fragments with bone reduction forceps.

Step 2: Select Hardware for Fixation • Plate placement on the ulna is dependent on the location of the fracture (Fig. 35.12). • For proximal ulna and olecranon fractures, a contoured 3.5-mm dynamic compression plate or anatomic plate placed posteriorly (i.e., subcutaneously) between the ECU and FCU interval is biomechanically preferred. • The plate must accommodate the natural anterior deviation of the posterior cortex of the proximal ulna (1–14 degrees). • The proximal third ulna also has a varus angulation (11–23 degrees) that is difficult to contour with a traditional straight plate. • For ulna shaft fractures, a 3.5-mm straight reconstruction plate can be placed under the muscle on the medial or lateral aspect of the triangular-shaped ulna midshaft. • Place the plate, temporarily secure with reduction forceps, and assess alignment with the intraoperative c-arm x-ray.

Extensor carpi ulnaris

STEP 1 PEARLS

Restoration of the anatomic axis and length of the ulna is a critical step to ensure that the PRUJ remains reduced. STEP 1 PITFALLS

If the PRUJ does not reduce after ulna reduction, the ulna should be evaluated under fluoroscopy for possible malalignment of fracture fragments.

STEP 2 PEARLS

If the ulna fracture is oblique, 3.5-mm interfragmentary lag screws placed perpendicular to the fracture line can assist in reduction and fixation.

Flexor carpi ulnaris

A

Fracture

ECU

ECU Fracture

FCU

FCU B

C

FIGURE 35.12  Plate placement on ulna fractures are dictated by the shape of the ulna and location of the fracture. (A, B) The subcutaneous border of the ulna is located between the extensor carpi ulnaris (ECU) and flexor carpi ulnaris (FCU; green arrow) and is the most biomechanically preferred plate position but also leads to plate prominence. This position is used in olecranon and proximal ulna fractures. (A, C) In midshaft ulna fractures, the plate can be positioned medially under the ECU (blue arrow) or FCU (red arrow).

275

276

CHAPTER 35  Forearm Fracture-Dislocations (Galeazzi and Monteggia) STEP 3 PEARLS

• If using an anatomic plate that extends to the tip of the olecranon, use the plate hole(s) at the tip of the olecranon that accommodate orthogonally placed screws. A long screw that bridges the fracture site can provide intramedullary stability to the construct (the “homerun” screw; Fig. 35.13). • Ensure radiographic axial alignment and joint stability. • Under fluoroscopy, apply varus and valgus stress to the elbow in extension to ensure no joint gaping or incongruency of the joint lines that could indicate subluxation. • In medial-lateral and anterior-posterior standard plane views, the proximal radial shaft axis rests at the center of the capitellum. • In medial-lateral view, the trochlea humeri rests in the center of the semilunar notch of the olecranon and the joint space is even without step-offs. • Ensure clinical axial alignment and joint stability: • Ensure that there is free range of extension/ flexion of the elbow and pronation/supination of the forearm. • Perform a lateral pivot test by passively supinating the forearm under valgus stress. If the radial head dislocates, a lateral ulnar collateral ligament reconstruction is indicated.

FIGURE 35.13  For proximal ulna fractures, most anatomic plates will have proximal screw holes that allow for orthogonally placed “homerun” screws (blue arrow) that add stability to the construct. Unicortical screws should be used in the proximal fragments to avoid intraarticular placement (green arrows). Ensure congruity of the joint in articular fractures (red arrow).

Step 3: Hardware Fixation • For transverse fractures, interfragmentary compression can be attained with compression plating. • Place a nonlocking bicortical screw in the proximal fragment in a neutral position within a plate hole near the fracture. • If placing a screw in the olecranon, use a cancellous screw with unicortical purchase to avoid intraarticular penetration. • Distally (on the ulna diaphysis), insert a second 3.5-mm cortical screw in an eccentric position into the opposite fragment. Tightening the screw will create compression across the fracture. • Secure the plate with three or four cortical screws with bicortical purchase distally, and three to four cortical or cancellous screws with bicortical or unicortical purchase if there is risk for intraarticular penetration.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients should be placed in posterior splint with the elbow flexed to 90 degrees. • Remove splint in 7 to 10 days, and if rigid fixation was obtained, begin guided activeassisted physical therapy. Avoid full elbow flexion until 4 weeks postoperatively.

Outcomes • • • •

Rigid fixation with normal healing is expected in most Monteggia fracture-dislocations. Implant loosening, implant failure, nonunion/malunion, and instability are rare. PRUJ stability is expected as long as ulnar length was attained. Implant removal is sometimes desired because of prominent hardware.

EVIDENCE Van Duijvenbode DC, Guitton TG, Raaymakers EL, et al. Long-term outcome of isolated diaphyseal radius fractures with and without dislocation of the distal radioulnar joint. J Hand Surg Am. 2012;37:523–527. This single institution retrospective cohort compared seven patients with a Galeazzi fracture-dislocation with ten patients with an isolated diaphyseal fracture. With an average of 19 years follow-up, they found no difference in Mayo Modified Wrist Score or the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. The authors concluded that near-anatomic fixation of the radius is the key to a good outcome in Galeazzi injuries. Yohe NJ, De Tolla J, Kaye MB, et al. Irreducible Galeazzi fracture-dislocations. Hand (N Y). 2019;14(2):249–252. This systematic review of literature on Galeazzi fracture-dislocations identified 12 articles (17 cases) of irreducible injuries, secondary to entrapment of extensor tendons (most commonly ECU) or ulnar fracture fragments. The authors advocated vigilance in evaluating the DRUJ in Galeazzi injuries because more than half of irreducible DRUJs were missed in the peri-operative period.

ddsf

SECTION V

Rheumatoid Arthritis and Degenerative Disease CHAPTER 36

Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon Centralization  378

CHAPTER 37

Tendon Transfers for Rheumatoid Tendon Attrition Rupture  285

CHAPTER 38

. Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum  297

CHAPTER 39

Correction of Swan-Neck Deformity  304

CHAPTER 40

Treatment of Boutonniere Deformity  312

CHAPTER 41

Metacarpophalangeal Arthroplasty  319

CHAPTER 42

Proximal Interphalangeal Arthroplasty  334

CHAPTER 43

Distal Interphalangeal Joint Arthrodesis (Osteoarthritis)  344

CHAPTER 44

Joint Fusion for Thumb Metacarpophalangeal Instability  345

CHAPTER 45

CMC Fusion for Basal Joint Osteoarthritis  346

CHAPTER 46

Reconstruction for Thumb Carpometacarpal Joint Instability Using Flexor Carpi Radialis (Littler Procedure)  353

CHAPTER 47

Suspension Arthroplasty for Thumb Carpometacarpal Joint Arthritis Using Abductor Pollicis Longus  360

CHAPTER 48

Revision Arthroplasty for CMC Joint  368

CHAPTER 49

Distal Ulnar Resection (Darrach Procedure)  380

CHAPTER 50

Sauvé-Kapandji Procedure  386

CHAPTER 51

Hemiresection Ulnar Arthroplasty  393

CHAPTER 52

Total Wrist Arthroplasty  399

CHAPTER 53

Total Wrist Fusion  413

CHAPTER 54

Wrist Denervation  420

277

CHAPTER

36

Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon Centralization Sarah E. Sasor and Kevin C. Chung INDICATIONS • Crossed intrinsic tendon transfer is indicated in patients with ulnar subluxation of the extensor tendon and passively correctable ulnar deviation of the digits because of rheumatoid arthritis (RA) or traumatic radial sagittal band rupture. The metacarpophalangeal (MCP) joint must be supple and without significant arthritic changes or subluxation. • In RA patients, the index finger ulnar common intrinsic tendon is transferred to the extensor digitorum communis (EDC) of the long finger; the long finger tendon is used to correct the ring finger; and the ring finger tendon is used for the small finger. Ulnar deviation of the index finger is corrected, imbricating the radial sagittal band. • The crossed intrinsic transfer corrects ulnar deviation by decreasing ulnar force on the donor digit and increasing radial force on the recipient digit.

Contraindications For patients with significant MCP joint subluxation or arthritis, soft tissue reconstruction does not adequately stabilize a severely subluxated proximal phalanx. These patients should undergo silicone MCP arthroplasty (see Chapter 41).

CLINICAL EXAMINATION • Clinical examination focuses on the condition of the MCP joint and the position of the extensor tendon. • Synovitis presents as swelling over the dorsal MCP joint (Fig. 36.1). Synovitis can lead to attenuation of the sagittal bands, volar subluxation of the proximal phalanx, ulnar drift of the fingers, or tendon rupture. • In RA patients, the extensor tendons often subluxate ulnarly and lie in the intermetacarpal space. This is obvious when the patient makes a fist (Fig. 36.2). • Active and passive range of motion (ROM) is measured. When a patient is unable to actively extend the MCP joints, it is important to distinguish between tendon subluxation and tendon rupture. The examiner passively extends the MCP joints; if the tendon is intact but subluxated, the patient can maintain extension. If the tendon is ruptured, the MCPs fall into flexion when the examiner’s hand is removed.

MCP joint synovitis

FIGURE 36.1

278

CHAPTER 36  Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon

FIGURE 36.2

• Intrinsic tightness can occur with chronic ulnar deviation at the MCP joint. Check for intrinsic tightness by extending the MCP joint and flexing the proximal interphalangeal (PIP) joint. In patients with intrinsic tightness, PIP joint flexion will be restricted with the MCP extended and will improve when the MCP is flexed.

IMAGING Standard, three-view radiographs of the hand are required to evaluate the MCP joint (Fig. 36.3).

SURGICAL ANATOMY • The common intrinsic tendon is formed by the tendons of the palmar and dorsal interosseous muscles on the ulnar side of the digit and by the interossei and lumbrical tendons on the radial side of the digit. These tendons pass palmar to the axis of the MCP joint and divide into a medial and lateral band near the midpoint of the proximal phalanx. The medial band inserts on the central slip and the lateral bands continue distally and become the terminal tendon (Fig. 36.4A–B). Contraction of the intrinsic muscles causes MCP joint flexion and interphalangeal (IP) joint extension. • The sagittal bands originate from the extensor hood, wrap around the metacarpal head, and insert on the volar plate. They centralize the extensor tendon over the MCP joint. In RA, synovitis causes attenuation and elongation of the radial sagittal band and the extensor tendons commonly subluxate ulnarly.

POSITIONING AND EQUIPMENT • The patient is positioned supine on the operating room table with the arm extended on a hand table. • The procedure is performed under axillary block with sedation or general anesthesia. • A tourniquet is placed on the upper arm. • A tendon weaver or mosquito forceps is helpful for the tendon transfer.

FIGURE 36.3

279

280

CHAPTER 36  Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon

Terminal tendon

Oblique retinacular ligament Triangular ligament

Transverse retinacular ligament Central band Conjoint lateral band Lateral band of intrinsic tendon Medial band of intrinsic tendon Central slip of long extensor tendon Lateral slip of long extensor tendon Common intrinsic tendon Arciform sheet Deep transverse metacarpal ligament Sagittal band Interosseous tendon Lumbrical tendon Long extensor tendon

A Ulnar

Radial

Attenuation of the radial portion of the extensor hood Extensor tendon

Tightness

Radial

Extensor tendon (subluxate ulnarly)

Ulnar

Flexor tendon Lumbrical

EXPOSURES PEARLS

• Take care to preserve the dorsal veins to reduce postoperative swelling. • The transverse incision can be reused if silicone MCP arthroplasty is indicated in the future. EXPOSURES PITFALLS

RA patients have fragile skin. Retract gently with suture loops to prevent postoperative healing issues.

B

Interosseous muscle

Common intrinsic tendon

Flexor tendon (translate ulnarly)

FIGURE 36.4

EXPOSURES • A single, dorsal, transverse incision is used to expose the extensor apparatus over multiple MCP joints (Fig. 36.5). • A dorsal longitudinal or lazy-S incision centered at the joint is used to access a single MCP joint (i.e., for synovectomy without crossed intrinsic transfer; Fig. 36.6). • Skin flaps are elevated at the level of the extensor tendon to expose the intrinsic tendons distally.

CHAPTER 36  Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon

FIGURE 36.5

A

B

FIGURE 36.6

PROCEDURE

STEP 1 PEARLS

Step 1: MCP Joint Synovectomy • The skin is incised and dissection proceeds rapidly to the extensor hood. The extensor tendon is inspected and inflamed synovium is excised. • The radial sagittal band is longitudinally incised and the extensor tendon is retracted ulnarly (Fig. 36.7). • The MCP joint is opened and synovectomy is performed (Fig. 36.8). • The joint is irrigated, inspected, and any remaining synovitis is excised.

• When dividing the radial sagittal band, maintain a 2- to 3-mm cuff on the extensor tendon to facilitate repair. • The interval between the extensor indicis proprius (EIP) and the extensor digitorum communis (EDC) can be incised to access the index finger MCP joint. Similarly, the interval between the extensor digiti quinti (EDQ) and EDC can be incised to access the small finger MCP joint. We prefer to release the radial sagittal band and retract both tendons ulnarly.

Dotted line indicates radial sagittal band incision

FIGURE 36.7

FIGURE 36.8

281

282

CHAPTER 36  Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon

Common intrinsic tendon

A

B FIGURE 36.9

Ulnar common intrinsic tendon Extensor tendon Interosseous muscle STEP 2 PITFALLS

• The neurovascular bundle lies just volar to the intrinsic tendon. A right-angle dissector or vessel loop can be passed around the tendon for gentle retraction. • Transect the common intrinsic tendon just before it divides into the medial and lateral bands. If it is cut too proximally, the transfer will not reach the adjacent extensor apparatus (Fig. 36.10). STEP 3 PEARLS

• The index finger ulnar common intrinsic tendon is transferred to the middle EDC; the long finger tendon is used for the ring finger; and the ring finger tendon is used for the small finger. Ulnar deviation of the index finger is corrected by a double-breasted repair of the radial sagittal band. • Tendons should be handled gently; a tendon weaver or mosquito forceps is used to pass the common intrinsic tendon through a slit in the adjacent extensor tendon. • Division of the abductor digiti minimi (ADM) is sometimes necessary to reduce ulnar force on the small finger (Fig. 36.13). Care must be taken to avoid injury to the neurovascular bundle, which lies just volar to the ADM.

FIGURE 36.10

Step 2: Exposure, Division, and Mobilization of the Ulnar Common Intrinsic Tendon • The interosseus tendon is identified by bluntly dissecting along the ulnar aspect of the MCP joint (see Fig. 36.8). • The common intrinsic tendon is traced distally, transected at the midpoint of the proximal phalanx, then mobilized proximally to the MCP joint. Longitudinal release from the extensor apparatus is performed as needed for adequate mobilization (Fig. 36.9).

Step 3: Tendon Transfer, Extensor Tendon Centralization, and Radial Sagittal Band Repair • The common intrinsic tendon is passed ulnarly through a subcutaneous tunnel (Fig. 36.11), then through a slit in the adjacent finger extensor tendon. • The MCP joint is held in extension and ulnar deviation is corrected by tensioning the tendon transfer; 3-0 braided permanent suture is used to secure the tendon transfer. • The radial sagittal band is repaired with the same suture and imbricated to reduce laxity (Fig. 36.12).

Step 4: Closure • The tourniquet is released, the wound is irrigated, and hemostasis is achieved. • The skin is closed using 4-0 nylon suture (Fig. 36.14).

CHAPTER 36  Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon

FIGURE 36.12

FIGURE 36.11

FIGURE 36.14

FIGURE 36.13

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is placed in a volar splint with the MCP joints extended and in a neutral position. • Sutures are removed in 10 to 14 days and the patient is transitioned to a removable splint for an additional 2 weeks. • Once the tendon transfer has healed, active motion is started under the care of a hand therapist. Moderate stiffness is expected after splinting with the MCPs extended for 3 to 4 weeks. • Fig. 36.15A–B shows a patient 1 month after right cross intrinsic transfer. See Video 36.1

FIGURE 36.15

283

284

CHAPTER 36  Metacarpophalangeal Joint Synovectomy, Crossed Intrinsic Tendon Transfer, and Extensor Tendon

EVIDENCE Oster LH, Blair WF, Steyers CM, Flatt AE. Crossed intrinsic transfer. J Hand Surg Am. 1989;14:963–971. This study retrospectively reviews long-term outcomes in 30 patients with inflammatory arthritis who underwent crossed intrinsic transfer. Mean follow-up time was 12.7 years. Average postoperative ulnar drift of the fingers was 5 degrees and remained stable over time. Average active arc of motion for the MCP joint was 47 degrees. There was no difference in outcome when the ulnar lateral band was sutured to the radial lateral band of the adjacent digit or to the collateral ligament of the adjacent MCP joint. Crossed intrinsic transfer provides long-term correction of ulnar drift in inflammatory arthritis (Level V evidence). Clark DI, Delaney R, Stilwell JH, Trail IA, Stanley JK. The value of crossed intrinsic transfer after metacarpophalangeal Silastic arthroplasty: A comparative study. J Hand Surg Br. 2001;26:565–567. The authors review outcomes for 73 rheumatoid hands after MCP joint replacement. Crossed intrinsic transfer was performed in 28 hands, and outcomes were compared with MCP joint replacement without cross intrinsic transfer. The treatment groups had similar degrees of preoperative ulnar drift (crossed intrinsic transfer group mean, 27 degrees; comparative group mean, 29 degrees). At 50-month follow-up, the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean, 6 degrees; comparative group mean, 14 degrees; p = .01). There were no other significant differences in outcome (Level IV evidence). Pereira JA, Belcher HJ. A comparison of metacarpophalangeal joint Silastic arthroplasty with or without crossed intrinsic transfer. J Hand Surg Br. 2001;26:229–234. Forty-three patients undergoing silastic interposition arthroplasty of the index, middle, ring, and small MCP joints for RA were randomized into two cohorts: MCP arthroplasty (1) with or (2) without crossed intrinsic transfer. There were no differences in patient demographics or preoperative clinical measurements between groups. Outcomes were analyzed at a mean of 17 months after surgery. Both groups had reduced ulnar drift and improved grip and pinch strength. There was no difference in pain or perceived function between treatment groups. The authors conclude that cross intrinsic transfer does not affect the outcome of silastic interposition arthroplasty of the MCP joint in RA patients (Level IV evidence).

CHAPTER

37

Tendon Transfers for Rheumatoid Tendon Attrition Rupture Sarah E. Sasor and Kevin C. Chung INDICATIONS • In rheumatoid arthritis patients, tendon rupture is a result of synovitis or attrition over a deformed bone. Common bony pathologies include caput ulnae syndrome (dorsal prominence of the ulna head leading to extensor tendon rupture; Fig. 37.1) and Mannerfelt syndrome (flexor pollicis longus [FPL] rupture caused by a volar scaphoid osteophyte. • The most ruptured tendon in rheumatoid patients is the extensor digiti minimi (EDM), followed by the extensor digitorum communis (EDC) tendons to the small finger (SF), ring finger (RF), middle finger (MF), and index finger (IF; in that order) and the extensor pollicis longus (EPL). On the flexor side, FPL rupture is most common; the flexor digitorum profundus (FDP) and superficialis (FDS) tendons are rarely involved. • Direct repair of ruptured tendons is not possible because the tissue quality is poor, and tendon grafting is not reliable because of proximal myostatic contracture from months of delayed repair. Tendon transfers are indicated to restore motor function in rheumatoid patients with attritional tendon rupture. The specific procedure depends on the number and function of ruptured tendons. Options include end-to-side repair to an intact adjacent tendon or transfer of an injured tendon to the distal stump of a ruptured tendon (Table 37.1; Fig. 37.2A–D). • Bony pathology must be addressed at the time of tendon transfer to prevent progressive deformity and rerupture of the reconstructed tendons. Distal ulna excision (see Chapter 49: Distal Ulna Resection [Darrach Procedure]) or osteophyte excision can be performed as part of the procedure.

CLINICAL EXAMINATION • The patient is examined for areas of swelling, tenderness, previous scars, and deformity. • Examine the wrist and distal radioulnar joint for pain and instability (See Chapter 49: Distal Ulna Resection [Darrach Procedure]). • Active and passive range of motion (ROM) of all joints is assessed. Inability to actively flex or extend a joint raises suspicion for tendon rupture. • Patients with isolated EDM rupture may be able to extend the SF through the EDC; however, they will not be able to independently extend the SF with the other fingers flexed. • Patients with rupture of the EDC to one finger may be able to extend the finger through juncturae to adjacent fingers. When more than one EDC is ruptured, the deformity is more obvious (Fig. 37.3). • EPL function is tested by placing the patient’s hand flat on a table (palm down) and asking them to lift the thumb off the table. Intact retropulsion signifies intact EPL function (Fig. 37.4). • Lack of finger extension in RA is also sometimes caused by ulnar subluxation of the tendons over the head of the metacarpal (Fig. 37.5) or, rarely, from posterior interosseous nerve palsy caused by elbow synovitis. To differentiate between these causes, passively extend the finger and ask the patient to hold it in place. Patients with tendon rupture or nerve palsy will be unable to maintain extension; however, patients with extensor tendon subluxation will maintain extension because the extensor tendon is centrally relocated over the metacarpophalangeal (MCP) joint. Patients with tendon rupture will lose the tenodesis effect of finger extension with wrist flexion. Tenodesis is preserved in nerve palsy.

Caput ulnae

FIGURE 37.1

285

286

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

TABLE Number of Ruptured Tendons and Treatment Considerations 37.1

No.

Impairment

Diagnosis

Preferred Option

Alternative Option

1.

Inability to extend small finger

Rupture of EDM at ulnar head

End-to-side repair of EDM to EDC to ring finger

2.

Inability to extend small and ring fingers

Rupture of EDC to ring and small under extensor retinaculum and EDM at ulnar head

EIP transfer to EDC to ring and EDM

3.

Inability to extend small, ring, and long fingers

Rupture of EDC to long, ring, and small under extensor retinaculum and EDM at ulnar head

EIP transfer to EDC to ring and EDM End-to-side repair of EDC to index and long

4.

Inability to extend small, ring, long, and index fingers

Rupture of EIP, EDC to index, long, ring, and small under extensor retinaculum, and EDM at ulnar head

FDS long to EDC to index and long FDS ring to EDC to ring, small and EDM

ECRL or ECRB can be considered

5.

Inability to extend thumb

Rupture of EPL at Lister tubercle

EIP to EPL

ECRL to EPL EDM to EPL

6.

Inability to extend thumb and small, ring, long, and index fingers

Rupture of EPL at Lister tubercle, EIP, EDC to index, long, ring, and small under extensor retinaculum, and EDM at ulnar head

FDS long to EPL and EDC to index FDS ring to EDC long, ring, small, and EDM

7.

Inability to flex thumb

Rupture of FPL in carpal tunnel

BR to FPL

8.

Inability to achieve independent flexion of PIP joint

Rupture of FDS

PIP joint synovectomy to prevent rupture of FDP

9.

Inability to flex DIP joint

Rupture of FDP

DIP joint arthrodesis

10.

Inability to flex IP joints

Rupture of FDS and FDP

Staged flexor tendon reconstruction

ECRL to FPL FDS long to FPL Thumb IP joint fusion

Tenodesis of DIP joint

BR, Brachioradialis; DIP, distal interphalangeal; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; EDC, extensor digitorum communis; EDM, extensor digiti minimi; EIP, extensor indicis proprius; EPL, extensor pollicis longus; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FPL, flexor pollicis longus; IP, interphalangeal; PIP, proximal interphalangeal.

• The EIP and FDS to the RF and MF are often used as donor tendons in patients with multiple extensor tendon ruptures, and their function must be checked and documented preoperatively. EIP is intact when independent extension of the IF is possible with the other fingers flexed (Fig. 37.6). To assess FDS function, all other digits are blocked, and the patient is asked to flex the finger in question at the proximal interphalangeal (PIP) joint. FDP share a common muscle belly and therefore, independent flexion of any finger with the others restrained requires an intact FDS tendon. Similarly, the FDP is assessed by blocking PIP flexion of the possible donor digit in question and asking the patient to flex the DIP joint (Fig. 37.7A-B).

IMAGING Standard three-view wrist radiographs are required to evaluate the distal radioulnar (DRU), midcarpal, and radiocarpal joints.

SURGICAL ANATOMY • A detailed understanding of the flexor (Fig. 37.8) and extensor (Fig. 37.9) tendon anatomy is required. • Tendons in RA can be directly invaded by synovial pannus within tenosynovial sheaths (extensor retinaculum, carpal tunnel, and digital flexor sheath), or may rupture as a

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

EDC-Ring

EDM

A EDC-Ring

EDM

EIP

B

EDCLong

EDC-Ring

EDM EDCIndex

EIP

EIP C FDS-Long or FDS-Ring EDC-Ring

EDC-Long

EDC-Index or EIP

EDM

D Extensor tendon ruptures of ring and small fingers

FIGURE 37.3

FDS-Long and FDS-Ring

FIGURE 37.2

result of ischemia caused by pressure from a proliferative synovitis; this results in regions where the tendon is in close relation to joints (DRU, radiocarpal, PIP joints). • Attritional rupture frequently affects the EDM at the ulna head, EPL at the Lister tubercle, and FPL in the carpal tunnel caused by a flexed scaphoid. • Dorsal ulnar subluxation is commonly described in RA, but this is a misnomer; the ulna is the fixed axis of the forearm. The radius subluxates volarly, which gives the impression of dorsal ulna prominence (Fig. 37.10).

287

288

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

Test for EPL: Index and middle extensor tendon ulnarly subluxed

1. Hand flat on examination table 2. Lift thumb off table “toward ceiling”

Ring and small finger extensor tendon rupture

FIGURE 37.4 FIGURE 37.5

EIP testing: Intact index finger extension (independent)

EPL tendon is ruptured in this patient

FIGURE 37.6

FIGURE 37.7

• It is important to identify the cause of the tendon rupture at the time of tendon reconstruction. This may require synovectomy or procedures to address joint instability and osteophytes. For example, if the patient has SF extensor tendon rupture, it is highly likely that other extensors will rupture subsequently (Vaughan-Jackson syndrome). Tenosynovectomy, distal ulna excision, and tendon reconstruction are the preferred treatments to prevent progressive disease.

POSITIONING AND EQUIPMENT • The patient is positioned supine with the arm extended and hand pronated on a hand table. An upper arm tourniquet is placed. • A tendon passer and tendon weaver should be available for tendon transfers. Intraoperative fluoroscopy, an oscillating saw, and a bur are required if bony resection (Darrach) is planned.

289

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

Juncturae tendinum

Extensor digiti minimi

Extensor carpi radialis

Extensor carpi ulnaris

Extensor pollicis longus

Extensor digitorum

Extensor pollicis brevis

Extensor retinaculum

Abductor pollicis longus

Synovial sheaths

Palmar cutaneous branch of median nerve

Flexor digitorum superficialis

FIGURE 37.9

Radial artery Median nerve

Palmaris longus (retracted)

Flexor pollicis longus Flexor carpi radialis

Distal radioulnar joint Volar subluxation Dorsal subluxation of the ECU of the ulnar head Digital extensor tendons

C

L

Brachioradialis

S

Extensor carpi ulnaris

Wrist joint Rotatory subluxation of scaphoid

FIGURE 37.8

FIGURE 37.10

EXPOSURES • A 6-cm longitudinal incision is made over the dorsum of the wrist in line with the MF metacarpal to expose the EDC tendons within the fourth compartment. When present, previous incisions are used (Fig. 37.11). • Skin flaps are elevated at the level of the extensor retinaculum (Fig. 37.12). • The extensor retinaculum is incised using a stair-step design to facilitate closure at the end of the case (Fig. 37.13). • The intercompartmental septae are divided between the extensor compartments; this converts the extensors into a single compartment and exposes the total extent of synovitis.

FIGURE 37.11

EXPOSURES PEARLS

Care is taken to preserve the dorsal veins and the superficial sensory nerve branches. The dorsal ulnar sensory nerve pierces the deep fascia of the forearm 5 cm proximal to the distal ulnar joint line. EXPOSURES PITFALLS

Rheumatoid skin is fragile and must be handled with great care.

FIGURE 37.12

290

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

FIGURE 37.13

STEP 1 PEARLS

• Synovectomy is important because it removes diseased tissue from tendons that will be used for transfer. • Tenosynovitis can infiltrate the tendon substance and cause fraying. Frayed tendon should be trimmed. • Nodules within tendons are excised and tendon defects are repaired with horizontal mattress sutures.

PROCEDURE Step 1: Synovectomy • A no. 15 blade is used to excise synovitis from the extensor tendons and extensor retinaculum (Fig. 37.14A). • After removing the synovial tissue, assess the extensor anatomy (see Fig. 37.14B). In this figure, a suspected EPL rupture was confirmed.

Step 2: Distal Ulna Excision, Bone Reshaping, and Stabilization • When indicated, bony prominence removal and stabilization procedures are performed. See Chapter 49 for step-by-step instructions on the Darrach procedure. • If the patient has already had a Darrach, the distal ulna is reshaped to ensure smooth contour of the entire raw edge (Fig. 37.15).

A

B FIGURE 37.14

FIGURE 37.15

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

Radial half of ECU (in hemostat)

A

B

Intact ECU

ECU stabilization of ulna FIGURE 37.16

• To treat ulna instability, advancement of the pronator quadratus and ECU tendinoplasty are performed (Fig. 37.16; see Chapter 49: Step 4).

Step 3: Evaluation of the Dorsal Wrist Capsule • The dorsal wrist capsule is sometimes lax as a result of stretch from synovial pressure. It can be imbricated using the braided sutures when necessary. If a simultaneous Darrach is performed, the capsule over the distal ulna is closed tightly using horizontal mattress 3-0 braided sutures. • After synovectomy and capsular imbrication, the intact extensor tendons can become loose as a result of expansion over time. Tightening the lax extensor tendons with the braided sutures gives more power to extend the fingers. Tension is set with all the fingers fully extended because some stretching of the tendon repairs will occur during therapy.

Step 4: Tendon Transfers The reconstructive plan depends on the number and function of ruptured tendons (see Table 37.1). In general, all tendon transfers are secured using braided permanent sutures.

Loss of Small Finger Extension: End-to-Side Small Finger EDC to Ring Finger EDC • The EDC to the SF and RF are explored and synovitis is removed (Fig. 37.17). • A tendon passer is used to pass the SF EDC through the RF EDC. The SF extensor tendon tension is set with the finger in full extension. The tendon transfer is then secured using multiple 3-0 Ethibond horizontal mattress sutures and a Pulvertaft weave (Fig. 37.18).

EPL Rupture: EIP Transfer to EPL • Incisions are made at the level of the thumb and index metacarpal heads to identify the ruptured EPL tendon and to harvest the EIP tendon distally (Fig. 37.19). • The EIP tendon is ulnar to the EDC. It is harvested as distally as possible to gain length (Fig. 37.20).

STEP 2 PEARLS

Reshaping a distal ulna after a previous Darrach is critical to protect future tendon transfers and prevent iatrogenic tendon rupture from a sharp distal ulna.

291

292

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture End-to-side tendon transfer to ring finger EDC

Ruptured distal end of small finger EDC

FIGURE 37.17 FIGURE 37.18 EIP redirected for transfer to EPL through subcutaneous tunnel

Cut distal EIP

EPL

FIGURE 37.19

FIGURE 37.20

Ruptured EPL (distal portion)

A

EIP

Ruptured EPL (distal portion)

B FIGURE 37.21

• The distal incision over the index metacarpal head can be spared in some patients. An example of this and tension for EIP to EPL transfer is demonstrated in Fig. 37.21. EIP TO EDC PEARLS

Loss of Ring and Small Digit Extension: EIP Transfer to Ring and Small EDC

When both the ring and small extensors are ruptured, an EIP transfer is preferred. End-to-side repair of both the ring and SF extensors to the MF tendon creates an oblique pull and can result in abduction of the SF.

• The EIP tendon is harvested distally (as previously described). • The edges of the ruptured ring and small EDC tendons are freshened until tendon substance is seen (Fig. 37.22). It is critical to be sure that the ruptured tendon is debrided to tendon substance so that the tenocytes can bridge the tendon juncture. Suturing of scarred tendon ends will lead to rupture. • The repair is completed end-to-end with horizontal mattresses under appropriate tension (Fig. 37.23).

Loss of More Than Three Extensor Tendons: FDS or ECRL/ECRB to EDC • When more than three extensor tendons are ruptured, the FDS tendons are typically used as donors. FDS is a “smart” donor tendon in that it is redundant for most function with FDP, has long excursion (up to 70 mm), and is a powerful motor.

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

Ruptured ring & small EDC

EIP

FIGURE 37.22

FIGURE 37.23

FIGURE 37.24

• FDS of the MF tendon transfer is accomplished using a chevron incision overlying A1 pulley and a more proximal incision over the distal forearm (Fig. 37.24). • The A1 pulley is incised and the FDS of the MF is transected distally (Fig. 37.25). • Using the distal forearm incision, the FDS of the MF is identified and rerouted subcutaneously around the radial forearm (Fig. 37.26A-C). • The ruptured tendons are trimmed and 2-0 Ethibond is used to suture distal stumps together side by side. • In this example, the FDS of the MF was sutured to the EDC of the IF, MF, RF, SF, and the EDM and EIP tendons with the MCP joints in full extension using Ethibond (Fig. 37.27). • Extended posture of the digits is appreciated after FDS of the MF transfer is completed (Fig. 37.28). • The extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis (ECRB) may be possible alternatives if the FDS is not available (Fig. 37.29). Nevertheless, the excursion for the wrist extensors is only 30 mm, so these are chosen selectively.

Loss of Thumb Flexion: FPL Interposition Graft or FDS to FPL Tendon Transfer • In most cases, the proximal FPL muscle is still functional, and the tendon can be repaired with an interposition graft. An incision is made over the FCR tendon in the distal forearm (Fig. 37.30) and the proximal stump of the FPL is identified just deep and ulnar to this. The distal stump is identified within the carpal tunnel or at the level of the thumb A1 pulley (Fig. 37.31). See “Chapter 78: Acute Repair of Extensor Tendon Injuries Zones I to VII” for additional details on FPL repair. • When FDS to FPL transfer is indicated, a Bruner incision is designed over the FPL tendon sheath at the level of the thumb MCP joint. Excursion of the FPL should be verified before donor harvest to confirm that the tendon glides within the tendon sheath. • A second incision is made over the A1 pulley of the MF or RF to harvest the FDS. • A proximal incision is designed on the distal forearm over the FCR tendon or over the carpal tunnel (Fig. 37.30). The cut end of FDS is retrieved in the proximal incision, then passed distally toward the thumb. • The FDS is transferred to the FPL stump. If possible, a traditional flexor tendon repair is performed with a 6- to 8-strand repair. A Pulvertaft weave is appropriate proximal to the pulley apparatus and provides excellent repair strength.

FIGURE 37.25

FDS OR ECRL/ECRB TO EDC PEARLS

• A single FDS tendon can be used to power up to three extensor tendons. If more than three extensors are ruptured, one should consider transfer of both the RF and MF FDS tendons. • When an FDS tendon is used as a motor, a subcutaneous transfer is preferred to one through the interosseous membrane to reduce the likelihood of adhesions. Transfer around the radial side of the forearm is preferred because the direction of pull will help correct the ulnar deviation deformity. FDS OR ECRL/ECRB TO EDC PITFALLS

EIP does not have enough power to drive more than one or two digits and is not a good option for a multiple tendon weave.

293

294

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

FIGURE 37.28

A

EDC rupture

EIP intact A

ECRL reflected

B

B FIGURE 37.29

C FIGURE 37.26 A–C FIGURE 37.30

FIGURE 37.27

FIGURE 37.31

• Be sure that the tendon graft or tendon ends are fed through the original sheath. Errant passing of a clamp to create a new tunnel will cause the tendon to be adherent without the shield provided by the sheath. A small feeding tube can be threaded gently through the tendon sheath from the A1 pulley to emerge at the wrist. Then the tendon can be sutured to the feeding tube to guide its gliding into the tendon sheath.

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture The distal end of the extensor retinaculum is placed under the extensor tendons

A

Extensor retinaculum over the extensor tendons

B FIGURE 37.32

FIGURE 37.33

Step 5: Extensor Retinaculum Reconstruction/Repair • The distal part of the extensor retinaculum is tunneled under the extensor tendons to augment the wrist capsular repair (Fig. 37.32). • The proximal extensor retinaculum is sutured over the extensor tendons to recreate the retinaculum (Fig. 37.33).

Step 6: Skin Closure and Splinting • The tourniquet is released and hemostasis is obtained. • The skin is closed using 4-0 nylon or absorbable monofilament subcuticular suture. • The patient is placed in a splint with the fingers extended. If a Darrach procedure is performed, the patient should be splinted in supination to enhance healing of the distal radioulnar joint (DRUJ) and dorsal wrist capsule.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is splinted with the fingers in full extension for 4 weeks. • After 4 weeks, active ROM exercises are initiated under the supervision of a certified hand therapist. • The outcome of tendon transfers is generally good for extensor tendon rupture in RA. Increased extensor lag is observed when more tendons are involved. • Patients with isolated flexor tendon ruptures in the palm or at the wrist level had good functional results. Patients with multiple ruptures within the carpal canal had a worse prognosis. See Video 37.1

295

296

CHAPTER 37  Tendon Transfers for Rheumatoid Tendon Attrition Rupture

EVIDENCE O’Sullivan MB, Singh H, Wolf JM. Tendon transfers in the rheumatoid hand for reconstruction. Hand Clin. 2016;32(3):407–416. This article reviews treatment options for spontaneous tendon rupture in the rheumatoid hand. Suzuki T, Iwamoto T, Ikegami H, et al. Comparison of surgical treatments for triple extensor tendon ruptures in rheumatoid hands: A retrospective study of 48 cases. Mod Rheumatol. 2016;26(2):206–210. This is a retrospective study that compares four techniques for treatment of extensor tendon rupture of the ulnar three fingers in rheumatoid hands. The techniques performed were PL tendon grafting, EIP tendon transfer, end-to-side transfer with early mobilization, and a combination of end-to-side and EIP transfers. The combination group had the best mean MP joint extension (-3 degrees), followed by the end-to-side group (-12 degrees), EIP group (-16 degrees), and PL group (-21 degrees). The combination end-to-side and EIP transfers yielded the best clinical outcomes, with all cases showing good results. Chung US, Kim JH, Seo WS, Lee KH. Tendon transfer or tendon graft for ruptured finger extensor tendons in rheumatoid hands. J Hand Surg Eur. 2010;35:279–282. The authors evaluated the outcome of tendon reconstruction using tendon graft or tendon transfer in 51 wrists of 46 patients with RA with extensor tendon ruptures. At a mean follow-up of 5.6 years, the mean MCP joint extension lag was 8 degrees (range 0–45), and the mean visual analog satisfaction scale was 74 (range 10–100). Clinical outcomes did not differ significantly between tendon grafting and tendon transfer. The MCP joint extension lag correlated with the patient’s satisfaction score, but the pulp-to-palm distance did not correlate with patient satisfaction. The authors concluded that both tendon grafting and tendon transfer are reliable reconstruction methods for ruptured finger extensor tendons in rheumatoid hands. Ertel AN, Millender LH, Nalebuff E, McKay D, Leslie B. Flexor tendon ruptures in patients with rheumatoid arthritis. J Hand Surg Am. 1988;13:860–866. The authors present 115 flexor tendon ruptures in 43 hands with RA, one hand with psoriatic arthritis, and one hand with lupus erythematosus. Ninety-one tendons were ruptured at the wrist, 4 ruptures occurred at the palm, and 20 ruptures occurred within the digits. At the wrist level, 61 ruptures were caused by attrition on a bone spur, and 30 were caused by direct invasion of the tendon by tenosynovium. All ruptures distal to the wrist were caused by invasion of the tendon by tenosynovium. Patients whose ruptures were caused by attrition regained better motion than those whose ruptures were caused by invasion by tenosynovitis; however, motion overall was poor. Patients with isolated ruptures in the palm or at the wrist had the best functional results. Patients with multiple ruptures within the carpal canal had a worse prognosis. The severity of the patient’s disease and the degree of articular involvement had a great effect on the outcome of surgery. Prevention of tendon ruptures by early tenosynovectomy and removal of bone spurs should be the cornerstone of treatment.

CHAPTER

38

Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum Sarah E. Sasor and Kevin C. Chung

INDICATIONS • The extensor carpi ulnaris (ECU) tendon is stabilized within the ulnar groove by a fibro-osseus subsheath lying deep to the extensor retinaculum (Fig. 38.1). Injury to the subsheath results in volar subluxation of the tendon around the ulna head with forearm rotation. • Subsheath injury occurs during hypersupination of the forearm, ulnar deviation and flexion of the wrist, or active contraction of the ECU muscle. • Traumatic ECU subluxation is relatively common in young athletes and is often associated with racquet or stick sports (i.e., tennis, golf, baseball). • Immobilization in a long-arm or Muenster cast with the forearm pronated and the wrist slightly extended and radially deviated for 4 to 6 weeks is recommended as first-line treatment. • ECU stabilization surgery is indicated in patients with persistent symptoms. • Volar subluxation of the ECU tendon is also common in patients with rheumatoid arthritis (RA). With loss of the ECU moment arm, the radial wrist extensors act unopposed and contribute to radial wrist deviation and carpal supination. Although ECU subluxation is rarely symptomatic in RA patients, dorsal repositioning of the ECU tendon with an extensor retinaculum sling or extensor carpi radialis longus (ECRL) to ECU tendon transfer improves wrist alignment.

Extensor retinaculum (reflected)

Intact ECU subsheath

Extensor digiti minimi

Extensor carpi ulnaris

FIGURE 38.1

297

298

CHAPTER 38  Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum

CLINICAL EXAMINATION • Patients complain of a painful snapping sensation over the ulnodorsal wrist. • The ECU synergy test is performed with the patient’s elbow flexed at 90 degrees and the forearm in full supination. The examiner grasps the patient’s thumb and index finger with one hand and palpates the ECU tendon with the other hand. The patient is asked to radially abduct the thumb against resistance (Fig. 38.2). Patients with ECU pathology will have pain along the course of the tendon during this maneuver. If subluxation exists, tendon bowstringing can be seen beneath the skin. • Supination, ulnar deviation, and wrist flexion creates the greatest angle between the ECU and the ulna. Patients can often demonstrate subluxation with this position. • Other sources of ulnar-sided wrist pain, including ulnar styloid fractures, triangular fibrocartilage complex (TFCC) injuries, ulnar impaction syndrome, and flexor carpi ulnaris (FCU) tendonitis, must be ruled out. Diagnosis of subsheath tears can be difficult, even for experienced physicians.

IMAGING • A plain radiograph of the wrist is required to exclude a fracture or other bony etiology for ulnar-sided wrist pain. • Dynamic ultrasound is useful to confirm ECU tendon subluxation if the diagnosis is unclear.

SURGICAL ANATOMY • The ECU tendon is stabilized within the ulnar groove by a fibro-osseous subsheath, which is deep to the extensor retinaculum (Fig. 38.3). This subsheath is unique to the sixth compartment—the other dorsal compartments are separated only by intervening septae. The subsheath spans the ECU groove over the ulna to stabilize the ECU, whereas the overlying extensor retinaculum covers the ECU and provides no restraining function. • Subsheath disruption can result in one of three ways: radial-sided rupture (Fig. 38.4A), ulnar-sided rupture (see Fig. 38.4B), or detachment of the periosteum from the ulna in continuity with the subsheath (see Fig. 38.4C). • The dorsal sensory branch of the ulnar nerve runs in the subcutaneous tissue along the sixth compartment and must be identified and protected during the operation (Fig. 38.5A–B).

FIGURE 38.2

POSITIONING AND EQUIPMENT • The patient is positioned supine on the operating table with a hand table extension. • The surgery is performed with an axillary nerve block and IV sedation under pneumatic tourniquet control. • No special equipment is necessary.

3rd compartment

Extensor retinaculum 5th compartment

2nd compartment

Extensor carpi ulnaris ECU subsheath 6th compartment

1st compartment

Radius FIGURE 38.3

False Rupture pouch

Rupture ECU

A

B FIGURE 38.4

C

CHAPTER 38  Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum

A

Dorsal sensory branch of the ulnar nerve

Extensor digiti minimi Extensor carpi ulnaris

B

FIGURE 38.5

FIGURE 38.6

FIGURE 38.7

EXPOSURES • Lister tubercle is palpated and marked. • A 5-cm longitudinal incision is made on the dorsal wrist in line with the third metacarpal for full exposure of the ECU tendon sheath and access to the extensor retinaculum (Fig. 38.6). • Full-thickness flaps are elevated off of the extensor retinaculum over the fourth, fifth, and sixth compartments (Fig. 38.7).

EXPOSURES PITFALLS

The dorsal sensory branches of the ulnar nerve must be identified and gently retracted. Multiple branches are often present distally in the operative field.

299

300

CHAPTER 38  Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum STEP 1 PEARLS

PROCEDURE

• If the torn subsheath is substantial and can be closed without tension, it can be repaired primarily, but this is not usually the case. • The ulnar groove can be deepened using a 3-mm bur if the groove is too shallow, but this is often not needed because the extensor retinaculum sling will stabilize the ECU. Deepening of the groove is often done as an isolated procedure because the sling will displace the ECU radially out of the groove.

Step 1

STEP 2 PITFALLS

Step 3

• Care should be taken to not make the flap too short. • The intercompartmental septae must be carefully divided without cutting into the flap or damaging the underlying tendons.

• The ulnarly based extensor retinaculum flap is wrapped around the ECU tendon to create a sling (Fig. 38.11A–B). The flap is first passed deep to the ECU tendon with the synovial layer abutting the tendon and then around the dorsal surface of the tendon, where it is secured to itself and the adjacent extensor retinaculum with 2-0 Ethibond sutures (Fig. 38.12). • Ensure that the sling stabilizes the tendon without being overly tight (Fig. 38.13).

• The extensor retinaculum is incised over the sixth compartment to expose the subsheath and ECU tendon. • Inflamed tissue and frayed tendon are debrided (Fig. 38.8A–B).

Step 2 A 2-cm wide flap of extensor retinaculum based at the ulnar border of the fifth extensor compartment is elevated. The radial limit of the flap is the radial aspect of the third compartment (Figs. 38.9A–B and 38.10).

Step 4 • The tourniquet is released and careful hemostasis is achieved using bipolar electrocautery. • The wound is closed with 4-0 suture and a sugar-tong splint is applied in neutral forearm rotation.

A

B FIGURE 38.8

301

CHAPTER 38  Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum

A

Radial border of the 3rd compartment

Pedicle of the flap (at the ulnar border of the 5th compartment) 5th compartment ECU

6th compartment

B

Radius FIGURE 38.9

Ulnar border of the 5th compartment

Ulna FIGURE 38.10

Extensor retinaculum

ECU A Extensor retinaculum

Ulnar border of the 5th compartment ECU B FIGURE 38.11

302

CHAPTER 38  Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum

FIGURE 38.12

FIGURE 38.13

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is seen in the office approximately 2 weeks after surgery. Sutures are removed and the patient is placed into a sugar-tong splint or long-arm cast with the elbow in 90 degrees of flexion and neutral forearm rotation. Total immobilization time is 4 to 6 weeks. • See Fig. 38.14 for 6-week follow-up. Range of motion (ROM) improves with time. • Strenuous activities are avoided for 3 months. • Patients are permitted to return to manual labor and sporting activities in 6 months. See Video 38.1

A

B

C

D

FIGURE 38.14

CHAPTER 38  Stabilization of Extensor Carpi Ulnaris Tendon Subluxation with Extensor Retinaculum

EVIDENCE Inoue G, Tamura Y. Surgical treatment for recurrent dislocation of the extensor carpi ulnaris tendon. J Hand Surg Br. 2001;26:556–559. The authors reviewed 12 patients with recurrent dislocation of the ECU tendon and identified three types of fibro-osseous sheath disruption: Type A—sheath is ruptured ulnarly and lies superficial to the tendon; Type B—sheath is ruptured radially and lies in the ulnar groove beneath the tendon; Type C—detachment of the periosteum ulnarly is in continuity with sheath, creating a false pouch into which the tendon can dislocate. Treatment was tailored to the type of disruption: subsheath reconstruction with extensor retinaculum for type A, direct repair for type B, or reattachment of the periosteum with suture anchors for type C. All patients had satisfactory results. Iorio ML, Huang JI. Extensor carpi ulnaris subluxation. J Hand Surg Am. 2014;39:1400–1402. This article summarizes the treatment of ECU subluxation. The fibro-osseous sheath stabilizes the ECU during forearm rotation. Injury to the sheath results in subluxation or dislocation of the ECU. Symptomatic patients are treated with cast immobilization for 4 to 6 weeks. If symptoms persist, surgical exploration is recommended. Puri SK, Morse KW, Hearns KA, Carlson MG. A biomechanical comparison of extensor carpi ulnaris subsheath reconstruction techniques. J Hand Surg Am. 2017;42(10):837.e1–837.e7. This is a cadaveric study comparing the stability of the ECU tendon after three types of reconstruction techniques: subsheath reconstruction with extensor retinaculum without ulnar groove deepening, subsheath reconstruction with extensor retinaculum with ulnar groove deepening, and ulnar groove deepening without subsheath reconstruction. The position of the ECU tendon relative to the radial side of the ulnar groove was measured in nine combinations of wrist and forearm positions. They found that ulnar groove deepening did not improve the stability of the ECU tendon compared with subsheath reconstruction alone. Subsheath reconstruction with extensor retinaculum alone eliminated ECU dislocation. Ito J, Koshino T, Okamoto R, Saito T. Radiologic evaluation of the rheumatoid hand after synovectomy and extensor carpi radialis longus transfer to extensor carpi ulnaris. J Hand Surg Am. 2003;28(4): 585–590. The authors reviewed 23 rheumatoid patients (28 wrists) who underwent synovectomy and concomitant ECRL to ECU tendon transfer with a mean follow-up time of 8.8 years. Radial angulation of the wrists was reduced approximately 10 degrees after surgery. Ulnar translocation of the carpus was prevented. Mean ulnar drift of the fingers was maintained at the preoperative level. They conclude that ERCL to ECU tendon transfer effectively stabilizes the wrist and may prevent further ulnar drift of the fingers in rheumatoid patients.

303

CHAPTER

39

Correction of Swan-Neck Deformity Sarah E. Sasor and Kevin C. Chung INDICATIONS • The swan-neck deformity is characterized by proximal interphalangeal (PIP) joint hyperextension and distal interphalangeal (DIP) joint flexion. • Swan-neck posturing is a result of tendon imbalance; the root cause can be at the wrist or at the metacarpophalangeal (MCP), PIP, or DIP joints. Tendon imbalance may be caused by inflammatory arthritis, trauma, tendon rupture, or general ligamentous laxity. • Possible abnormalities in a swan-neck deformity include (Fig. 39.1): • Intrinsic muscle shortening • Volar subluxation of the MCP joint • Dorsal displacement of the lateral bands • Laxity of the PIP joint volar plate • Oblique retinacular ligament laxity • Mallet deformity with terminal extensor tendon disruption • Flexor tendon adhesions or lacerations • Joint stiffness or arthritic joint destruction • Skin tightness or loss • The Nalebuff classification system is used to describe the severity of a swan-neck deformity and is based on the degree of PIP joint stiffness: • Type 1: PIP joint is flexible in all positions of the MCP joint. • Type 2: PIP joint flexion is limited in certain positions of the MCP joint. • Type 3: PIP joint flexion is limited in all positions of the MCP joint. • Type 4: PIP joint is stiff and arthritic. • PIP hyperextension and stiffness impair a patient’s ability to make a fist. First-line treatment includes splinting with the DIP joint in extension and dorsal blocking of the PIP joint with 40 to 60 degrees of flexion for 8 weeks. Surgery is indicated for patients who do not respond to nonoperative management, have full passive range of motion (ROM), and are functionally limited.

Dorsal MCP joint synovitis Rupture of extensor insertion onto base of proximal phalanx Dorsal DIP joint synovitis Rupture of terminal tendon Proximal migration of terminal and oblique retinacular ligament

Volar MCP joint synovitis Attenuation of volar plate Flexor tenosynovitis Intrinsic tendon adhesion Intrinsic muscle contracture

Volar PIP joint synovitis Attenuation of volar plate Attenuation of transverse retinacular ligament Dorsal translation of conjoint lateral band Flexor tenosynovitis Rupture of flexor digitorum superficialis FIGURE 39.1

304

CHAPTER 39  Correction of Swan-Neck Deformity

• There are multiple surgical techniques available to treat swan-neck deformities depending on the etiology of the problem. The key to a successful repair is to identify and treat each pathologic structure. • The goals of surgical repair include: (1) correcting PIP joint hyperextension, (2) improving PIP joint motion, (3) correcting DIP joint flexion deformity, (4) improving lateral band “snapping” on PIP joint flexion, and (5) improving extension at the MCP joint.

CLINICAL EXAMINATION • Active and passive ROM are assessed independently at the MCP, PIP, and DIP joints. Special attention is paid to PIP joint motion. • When passive motion is greater than active motion at the PIP joint, flexor tendon adhesions may be present. • In patients with limited PIP joint motion in all MCP positions, examine closely for adhesions that affect the central extensor and dorsal translocation of the conjoint lateral bands. • If ulnar drift is present at the MCP joint, PIP joint motion is assessed with the MCP joint extended with radial and ulnar inclination. This examines for isolated intrinsic muscle shortening of the radial or ulnar interosseous muscle. • The Bunnell test is used to examine for intrinsic tightness. The test is performed by holding the MCP extended and passively flexing the PIP joint. The MCP is then flexed. If PIP flexion increases, intrinsic muscle tightness is present. Normally, MCP extension does not restrict PIP motion and no change in motion is detected (Fig. 39.2A–C).

IMAGING • Standard three-view radiographs are used to evaluate the articular surfaces (Fig. 39.3A–C). • Patients with articular damage are best treated with arthrodesis or arthroplasty, rather than soft-tissue reconstruction. In rheumatoid arthritis (RA), the ligamentous support of the PIP joint is typically poor. PIP fusion is more reliable than silicone arthroplasty.

SURGICAL ANATOMY • Detailed knowledge of the extensor mechanism is necessary for diagnosis and treatment of swan-neck deformities. • Three muscles contribute to the extensor mechanism of the finger – the extensor digitorum communis (EDC), the lumbrical, and the interossei. The EDC runs along

A

B

C FIGURE 39.2

305

306

CHAPTER 39  Correction of Swan-Neck Deformity

A

B

C FIGURE 39.3

•

•

•

• •

• • • •

the dorsum of each finger and is stabilized at the MCP joint by the sagittal bands. The sagittal bands wrap transversely around the metacarpal head and insert onto the volar plate and proximal phalanx. Distal to the MCP joint, the EDC tendon trifurcates into a central slip and two lateral slips. The central slip inserts onto the base of the middle phalanx and extends the PIP joint. The lateral slips contribute to the conjoint lateral bands. The lumbrical muscles originate from the flexor digitorum profundus tendons in the palm and pass volar to the intermetacarpal ligaments at the MCP level. Oblique fibers join the central slip over the proximal phalanx. Distally, the lumbrical inserts onto the radial conjoint lateral band. The dorsal interossei arise from the metacarpals and have two muscle bellies: the superficial and deep head. The superficial head becomes the medial tendon, which runs deep to the sagittal band and inserts on the base of the proximal phalanx (it abducts the digit). The deep head gives rise to the lateral tendon, which passes superficial to the sagittal band and is more complex. The lateral tendon has transverse, oblique, and distal fibers. Transverse fibers insert on the midproximal phalanx and help flex the MCP joint. Oblique fibers help extend the PIP joint. Distal fibers of the lateral tendon insert onto the conjoint lateral band. The conjoint lateral bands travel distally to form the terminal tendon, which insert onto the dorsal base of the distal phalanx and extend the DIP joint. The triangular, transverse retinacular, and oblique retinacular ligaments stabilize the conjoint lateral bands and coordinate motion of the extensor mechanism (Fig. 39.4A–B). Disruption of the terminal tendon at the DIP joint (mallet injury) causes the lateral bands to migrate proximally, increasing the extension force at the PIP joint. Attenuation of the PIP joint volar plate from synovitis, posttraumatic arthritis, or generalized laxity can cause PIP hyperextension. Chronic volar subluxation of the MCP joint from inflammatory arthritis or posttraumatic contracture increases tension on the EDC and leads to PIP joint hyperextension. Carpal collapse at the wrist can cause relative lengthening of the extrinsic tendons. Intrinsic muscle forces may overpower the extrinsic forces, leading to PIP joint hyperextension.

POSITIONING AND EQUIPMENT • The patient is placed in the supine position with the arm supported on a hand table. • A wide-awake, local anesthesia, no tourniquet approach is helpful so that active motion can be assessed intraoperatively. • Fluoroscopy, Kirschner wires (K-wires), and bone anchors should be available depending on the chosen technique.

307

CHAPTER 39  Correction of Swan-Neck Deformity

Dorsal interphalangeal Triangular ligament

Proximal interphalangeal Central slip

Oblique retinacular ligament Transverse retinacular ligament

Lateral band Sagittal band

Metacarpophalangeal

Dorsal, volar interosseous muscles

Sagittal band

Proximal interphalangeal

Central slip

Transverse retinacular ligament Dorsal interphalangeal

Dorsal, volar interosseous muscles Lumbrical muscle

Lumbrical muscle

A

Metacarpophalangeal

Terminal tendon Lateral band

B

Oblique retinacular ligament

FIGURE 39.4

PROCEDURES Several techniques are available for correction of a swan-neck deformity depending on the etiology, impaired structures, and patient symptoms. Techniques can be combined to treat multiple structures.

PROCEDURE 1 PEARLS

If the native lateral band is attenuated proximally, the distal stump can be sutured to the A2 pulley or secured directly to the proximal phalanx with a bone anchor.

Procedure 1: Lateral Band Relocation Lateral band relocation is indicated when a patient has full, active PIP motion but complains of “snapping” with flexion. • The ulnar lateral band is exposed through a longitudinal midaxial incision centered about the PIP joint (Fig. 39.5A–B). • The lateral band is divided as proximally as possible at the base of the proximal phalanx and dissected distally beyond the PIP joint (Fig. 39.6A–B). • The PIP joint is flexed and a blunt instrument is used to create a tunnel volar to the Grayson and Cleland ligaments, volar to the PIP joint (Fig. 39.7). • The lateral band is then passed through the tunnel from distal to proximal and sutured to the native proximal tendon or, preferably, attached to a stout structure such as the A2 pulley or to the bone of the proximal phalanx to keep the PIP joint from hyperextending (Fig. 39.8).

Procedure 2: Release of the PIP Joint PIP joint release is performed when there is a fixed extension contracture of the PIP joint, with a normal articular surface. It is indicated in patients with normal articular cartilage who cannot fully flex the PIP joint independent of the MCP joint position. Closed capsulotomy can be attempted under anesthesia with gentle, sustained, passive flexion. If passive flexion is restricted, an open capsulotomy and release of lateral bands from its attachment to the central tendon is performed. • A curvilinear incision is made over the dorsum of the finger to expose the PIP joint and extensor apparatus. In the figure, a suture from prior extensor repair is visible within the central extensor tendon (Fig. 39.9). • The interval between the central tendon and the lateral bands is then incised longitudinally (Fig. 39.10).

PROCEDURE 1 PITFALLS

• This procedure is inadequate if there are adhesions to the central slip. • For RA patients, the quality of the lateral bands may be poor and the ligaments may be attenuated, precluding the use of this technique.

308

CHAPTER 39  Correction of Swan-Neck Deformity

A

B FIGURE 39.5

A

B

FIGURE 39.6

FIGURE 39.7

FIGURE 39.8

CHAPTER 39  Correction of Swan-Neck Deformity Parallel incisions between lateral bands and central slip

FIGURE 39.10

FIGURE 39.9

PROCEDURE 2 PEARLS

FIGURE 39.11

• The dorsal PIP joint capsule is incised. Intraoperative flexion of the PIP joint is tested (Fig. 39.11). • If flexion is still restricted at the PIP joint, the following maneuvers are performed in this order: (1) additional release of the dorsal PIP joint capsule, (2) release of the dorsal portions of the radial/ulnar collateral ligaments from the proximal phalanx, and (3) Z lengthening of the central tendon.

Procedure 3: Flexor Digitorum Superficialis Tenodesis Flexor digitorum superficialis (FDS) tenodesis is performed when the PIP joint has full passive motion but requires a PIP restraint. It creates a static, volar checkrein to prevent hyperextension of the PIP joint. • A Bruner incision is made over the volar MCP joint and flaps are elevated (Fig. 39.12). • The flexor sheath is opened proximal to the A1 pulley, and the FDS and flexor digitorum profundus (FDP) are identified (Fig. 39.13). • The FDS tendon is transversely divided about 1 cm proximal to the A1 pulley (Fig. 39.14). • A small bone anchor is inserted into the lateral aspect of metacarpal bone just proximal to the neck. The sutures are passed through the divided slip of FDS with the PIP joint in 30 degrees of flexion (Fig. 39.15).

• Complete release of the lateral bands proximal and distal to the PIP joint is necessary to permit volar migration with flexion. • Flexion should be tested after release of the lateral bands because complete dorsal capsulotomy and collateral ligament release is not always necessary. PROCEDURE 3 PEARLS

A synovectomy of the flexor tendons can be performed simultaneously. PROCEDURE 3 PITFALLS

If possible, avoid dissection in zone 2.

309

310

CHAPTER 39  Correction of Swan-Neck Deformity

FIGURE 39.13

FIGURE 39.12

FIGURE 39.14

FIGURE 39.15

PROCEDURE 4 PEARLS

Procedure 4: Intrinsic Muscle Release

• This technique is a priority in patients with intrinsic muscle contracture limiting PIP joint motion. • The released intrinsic tendon can be used for a crossed intrinsic tendon transfer to correct ulnar drift, if indicated.

Intrinsic muscle release is indicated in patients with intrinsic muscle tightness on examination. • A transverse incision is made at the dorsal base of the proximal phalanx (Fig. 39.16). • The extensor hood is identified with blunt dissection. • The intrinsic tendons are located at the radial and ulnar aspects of the extensor mechanism. The MCP joint is extended and the intrinsic tendons are transversely divided until the PIP joint can be passively flexed (Fig. 39.17).

Procedure 5: DIP Joint Arthrodesis DIP arthrodesis is considered in patients with a fixed flexion contracture of the DIP joint (mallet deformity) and swan-neck posturing of the finger. See Chapter 43 Distal Interphalangeal Joint Arthrodesis for additional step-by-step instructions.

CHAPTER 39  Correction of Swan-Neck Deformity

Common intrinsic tendon

A

B FIGURE 39.17

• DIP joint arthrodesis is performed through a dorsal transverse or T-shaped incision. • The dorsal capsule and extensor tendons are transversely divided, and the joint cartilage is removed with a rongeur. • Fixation is performed with a buried K-wire or headless compression screw to fuse the joint in extension.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The hand is immobilized in a splint with the MCP joints extended and PIP joints slightly flexed. • If flexor tenosynovectomy is performed, active motion begins within the first 5 days under the supervision of a certified hand therapist. • Dorsal extension blocking should continue for 4 to 6 weeks postoperatively to prevent hyperextension at the PIP joint. • Soft-tissue reconstructions stretch over time. Most studies show good outcomes at 1 year with gradual recurrence of deformity in the long term. See Video 39.1

EVIDENCE Elzinga K, Chung KC. Managing swan-neck and Boutonniere deformities. Clin Plast Surg. 2019;46(3): 329–337. This article reviews the etiology, anatomy, and treatment options for swan-neck and Boutonniere deformities. Fox PM, Chang J. Treating the proximal interphalangeal joint in swan-neck and Boutonniere deformities. Hand Clin. 2018;34(2):167–176. This article reviews options for treating the PIP joint in swan-neck and Boutonniere deformities. de Bruin M, van Vliet DC, Smeulders MJ, Kreulen M. Long-term results of lateral band translocation for the correction of swan-neck deformity in cerebral palsy. J Pediatr Orthop. 2010;30:67–70. The authors treated 62 fingers with lateral band translocation and reported an 84% success rate at 1 year, which declined to 60% at 5 years. The authors concluded that lateral band translocation is not a long-lasting procedure in the treatment of cerebral palsy. Kiefhaber TR, Strickland JW. Soft tissue reconstruction for rheumatoid swan-neck and Boutonniere deformities: Long-term results. J Hand Surg Am. 1993;18:984–989. Ninety-two fingers with rheumatoid swan-neck deformity were treated with dorsal capsulotomy and lateral band mobilization. An initial increase of 55 degrees of motion into flexion was noted, but this deteriorated over time. Of 15 fingers followed at 3 and 12 months, there was a mean loss of 17 degrees of flexion.

FIGURE 39.16

311

CHAPTER

40

Correction of Boutonniere Deformity Sarah E. Sasor and Kevin C. Chung INDICATIONS • The boutonniere deformity is characterized by flexion at the proximal interphalangeal (PIP) joint and hyperextension of the distal interphalangeal (DIP) joint. • Boutonniere deformities are caused by pathology at the dorsal PIP joint. Disruption of the central slip of the extensor apparatus caused by trauma or synovitis results in flexion (Fig. 40.1). • The lateral bands migrate volarly and contract, creating an extension force across the DIP joint. The oblique and transverse retinacular ligaments also gradually contract, worsening DIP hyperextension. • Boutonniere deformities can be flexible or fixed. Over time, destruction of the articular cartilage can lead to significant arthrosis of the PIP joint. • The Nalebuff stage is based on the passive correctability of the PIP joint and the condition of the articular cartilage. • Stage 1: PIP joint synovitis and a slight (10–15 degree), fully correctable extensor lag • Stage 2: Marked PIP joint flexion (30–45 degrees) that can be fixed or is partially correctable; joint surface intact • Stage 3: PIP joint fixed flexion contracture and joint erosion • For acute, flexible boutonniere deformities, the patient is splinted with the PIP joint extended and the DIP joint free for 6 weeks. Active and passive DIP range of motion (ROM) exercises are performed hourly to encourage dorsal migration of the lateral bands and to stretch the transverse retinacular ligament. After 6 weeks, the patient is weaned from the splint during the day and performs active PIP flexion exercises. The splint is worn at night for an additional 6 weeks. • For chronic boutonniere deformities, serial casting is used to correct PIP flexion. Full PIP extension is maintained for 6 to 12 weeks and DIP flexion exercises are performed. Operative release of tight collateral ligaments or the volar plate can be performed if full PIP extension cannot be achieved with therapy alone. • Surgery is rarely indicated for boutonniere deformities; they are less functionally debilitating than swan-neck deformities because finger flexion and power grip are maintained. Do not operate on a functional finger. • The goal of surgical correction is to increase extensor force across the PIP joint and decrease extension at the DIP joint. Full passive motion is required before surgery. Joint releases, when indicated, must be performed before tendon rebalancing. • Surgical correction is indicated in patients with flexible, nonarthritic joints who are unresponsive to splinting and have a functional deficit.

CLINICAL EXAMINATION • Inspect for scars and swelling at the dorsal PIP joint and examine the posture of the finger. Dorsal attenuation (PIP joint synovitis)

Volar contracture FIGURE 40.1

312

CHAPTER 40  Correction of Boutonniere Deformity

• Active and passive ROM are assessed independently at the metacarpophalangeal (MCP), PIP, and DIP joints. • The Elson test evaluates central slip integrity. The PIP joint is held in 90 degrees of flexion and the patient is asked to extend the finger. A patient with an intact central slip will generate force at the PIP joint but will be unable to actively extend the DIP. Conversely, a patient with a central slip injury will be unable to extend the PIP and the force will be transferred to the DIP joint. • The Boyes test is performed by holding the PIP joint extended and asking the patient to flex the DIP. If the extensor mechanism is intact, the patient will be able to flex at the DIP. If the lateral bands are contracted from injury to the extensor tendon, the patient will be unable to flex the DIP. • In rheumatoid arthritis (RA) patients with ulnar drift, PIP motion is assessed with the MCP joint extended with radial and ulnar inclination to assess for intrinsic muscle shortening (Fig. 40.2).

IMAGING • Standard, three-view x-rays are mandatory to evaluate for dislocations, fractures, and articular wear. • Patients with significant arthritis are not candidates for soft-tissue reconstruction and are best treated with arthrodesis or arthroplasty to relieve pain.

SURGICAL ANATOMY • In RA, boutonniere deformity arises secondary to synovitis at the PIP joint. Pressure and inflammation from the synovial pannus lead to attenuation of the dorsal capsule and central slip, creating an extensor lag. As the flexion deformity progresses, the lateral bands shorten and translocate volar to the axis of the PIP joint, causing hyperextension of the DIP joint. The volar plate can also shorten, creating a checkrein against extension (Fig. 40.3A–B). • Detailed anatomic knowledge of the extensor and flexor apparatus is important in both diagnosis and treatment (see Chapter 39 Treatment of Swan-Neck Deformity figures).

POSITIONING AND EQUIPMENT • The patient is placed in the supine position with the arm supported on a hand table. • A wide-awake, local anesthesia, no tourniquet approach is helpful so that active motion can be assessed intraoperatively.

FIGURE 40.2

313

314

CHAPTER 40  Correction of Boutonniere Deformity

A

Transverse retinacular ligament Attenuation of the central slip

B FIGURE 40.3

• Fluoroscopy, Kirschner wires (K-wires), and bone anchors should be available depending on the chosen technique.

PROCEDURES Several techniques are available for repair and reconstruction of boutonniere deformities based on the chronicity and etiology of the central slip injury.

Extensor Tenolysis and Extensor Central Slip Repair • Extensor tenolysis with central slip repair is indicated in patients with chronic, traumatic boutonniere deformities. Repair of the central slip with splinting or pinning of the DIP joint can resolve the deformity (Fig. 40.4A–B). • The healed laceration is extended proximally and distally as needed for exposure (Fig. 40.5). • Tenolysis is performed and the cut edges of the tendons are identified (Fig. 40.6). • The tendon is repaired to the remnant stump in standard fashion using 4-0 Ethibond suture or anchored to the dorsal base of the middle phalanx using a bone anchor (Fig. 40.7). • Incisions are closed with 4-0 nylon suture. The PIP and DIP joints are stabilized in extension with pinning or splinting.

Healed PIP laceration, central slip injury with chronic boutonniere deformity A

Laceration incorporated into surgical incision (midaxial)

B FIGURE 40.4

FIGURE 40.5

315

CHAPTER 40  Correction of Boutonniere Deformity

A Retracted central slip

Oblique retinacular ligament

B

FIGURE 40.6

FIGURE 40.7

Volar Plate Release and Extensor Tenotomy • Volar plate release is indicated in patients with intrinsic joint tightness of the PIP joint. This may be combined with an extensor tenotomy to reduce DIP hyperextension. A transverse tenotomy is performed at the level of the triangular ligaments, proximal to the attachment of the oblique retinacular ligaments to preserve DIP joint extension. • A V-shaped incision is centered over the volar PIP joint and flaps are elevated to expose the flexor tendon (Fig. 40.8). Care is taken to identify and preserve the neurovascular bundles. • The A3 pulley is incised longitudinally and the flexor tendons are retracted to expose the volar plate. The proximal aspect of the volar plate is then incised and the finger extended (Fig. 40.9). • The DIP joint is evaluated. If it remains hyperextended, an extensor tenotomy is performed. • A longitudinal incision is made over the dorsal middle phalanx to expose the extensor apparatus. The triangular ligament is transversely incised proximal to the oblique

Cut edge of volar plate Retracted flexor tendon

FIGURE 40.8

FIGURE 40.9

316

CHAPTER 40  Correction of Boutonniere Deformity

FIGURE 40.10

VOLAR PLATE RELEASE AND EXTENSOR TENOTOMY PEARLS

Selective pinning of joints may help tendon healing but will contribute to postoperative stiffness. VOLAR PLATE RELEASE AND EXTENSOR TENOTOMY PITFALLS

Tenotomy of the extensors should proceed in a stepwise manner to preserve extension at the DIP joint. Some surgeons advocate for terminal tendon tenotomy to induce a mild mallet deformity because this position can be a functional improvement for patients (Fig. 40.12A–E).

FIGURE 40.11

retinacular ligaments (at the junction of the proximal and middle third of the middle phalanx), and the DIP joint is flexed (Fig. 40.10). • The skin is closed with 4-0 nylon sutures. • A K-wire can be placed across the PIP joint to induce stiffness in extension while the digit is healing (Fig. 40.11). • The finger is splinted in extension.

Central Slip Reconstruction with Centralization of the Lateral Bands • In RA patients, synovitis at the PIP joint leads to attenuation of the central slip over time. In this case the central slip typically cannot be repaired primarily and must be reconstructed using local tissues. Synovectomy is performed, the lateral bands are centralized, and small, transverse cuts are made distally to lengthen the lateral bands and permit DIP flexion.

FIGURE 40.12

CHAPTER 40  Correction of Boutonniere Deformity

FIGURE 40.14

FIGURE 40.13

• A curvilinear incision is designed over the dorsal PIP joint (Fig. 40.13). • The extensor apparatus is exposed and the central slip is identified. It is usually attenuated or ruptured (Fig. 40.14). • The lateral bands (arrow) and transverse retinacular ligament are identified (Fig. 40.15). • A synovectomy is performed, taking great care to preserve both the transverse retinacular ligaments and the lateral bands. • The radial and ulnar transverse retinacular ligaments are released from the volar plate with a no. 15 blade, then transposed dorsally and sutured together in the midline to reconstruct the central slip (Fig. 40.16 A–C). Transposition of the transverse retinacular ligaments dorsally relocates the lateral bands above the axis of rotation of the PIP joint (Fig. 40.17). • The posture of the DIP joint is assessed. If the DIP joint remains hyperextended (arrow), small, transverse cuts are made in the distal lateral bands to provide more length (Figs. 40.18 and 40.19). • The skin is closed with 4-0 nylon sutures and the patient is placed into an extension splint.

Lateral band

A

Transverse retinacular ligament

B

C FIGURE 40.15

FIGURE 40.16

317

318

CHAPTER 40  Correction of Boutonniere Deformity

FIGURE 40.18

FIGURE 40.17

Middle phalanx

Release of lateral bands

FIGURE 40.19

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

Central Slip Reconstruction with Centralization of the Lateral Bands Pearls

• The patient is seen in the office 10 to 14 days postoperatively and sutures are removed. • K-wires should stay in place for 3 to 4 weeks for healing and positional stability. • The hand is immobilized in a full resting extension splint. • After pin removal, the patient is transitioned into a dynamic daytime splint and a nighttime static splint for an additional 4 to 8 weeks.

• Joint contractures must be addressed before tendon rebalancing. If there is a contracture of the PIP joint, a volar approach is used to release the volar plate and accessory collateral ligaments to obtain full passive extension. • Tendon sutures should be placed carefully to set the appropriate tension. A wideawake approach is useful so that the patient may actively flex and extend the digit and adjustments can be made as needed. See Video. 40.1

EVIDENCE Grau L, Baydoun H, Chen K, Sankary ST, Amirouche F, Gonzalez MH. Biomechanics of the acute boutonniere deformity. J Hand Surg Am. 2018;43(1):80.e1–80.e6. The authors sequentially divided the central slip, transverse and oblique fibers of the interosseous hood, and the triangular ligament on 18 fresh cadaveric hands, then measured extension of the PIP. They found that division of the central slip from the middle phalanx resulted in decreased extension at the PIP joint. Extension was further decreased when the transverse and oblique fibers of the interosseous hood were also divided. A boutonniere deformity occurred only when the triangular ligament was also damaged. They conclude that damage to the central slip alone does not cause a boutonniere deformity; the lateral bands must also subluxate volar to the axis of rotation of the PIP joint. El-Sallakh S, Aly T, Amin O, Hegazi M. Surgical management of chronic boutonniere deformity. Hand Surg. 2012;17(3):359–364. doi:10.1142/S0218810412500311. This is a retrospective study of 12 patients with traumatic boutonniere deformities who were treated with distal extensor tenotomy (proximal to the distal insertion of the oblique retinacular ligaments) and lateral band dorsalization. Average follow-up time was 33 months. PIP joint extension deficit improved from 60 degrees preoperatively to 7 degrees postoperatively. Average active flexion at the DIP joint was 75 degrees after surgery; 92% of patients had excellent or good results long-term. Kiefhaber TR, Strickland JW. Soft tissue reconstruction for rheumatoid swan-neck and boutonniere deformities: Long-term results. J Hand Surg Am. 1993;18:984–989. Nineteen fingers with rheumatoid boutonniere deformity were treated with central slip reconstruction. The results were unpredictable, with only modest improvement in PIP extension, which deteriorated over time.

CHAPTER

41

Metacarpophalangeal Arthroplasty Sarah E. Sasor and Kevin C. Chung INDICATIONS • Metacarpophalangeal (MCP) arthroplasty is indicated in patients with chronic pain, deformity, or functional loss. Arthrodesis is poorly tolerated at the MCP level because the arc of motion starts at this joint. Implant arthroplasty is the preferred surgical treatment for arthritic MCP joints. • There are two common implant options for MCP joints: silicone and pyrocarbon. Silicone implants act as spacers. They are hinged and rely on the formation of a capsule around the implant for stability. Pyrocarbon implants are unconstrained (two parts) and must be supported by normal bone stock and intact surrounding soft tissues. Both types of implants provide excellent pain relief, maintain joint motion, improve hand appearance, and have high levels of patient satisfaction. • Silicone implants are indicated for rheumatoid arthritis (RA) patients because the construct provides stability. Pyrocarbon should not be used in RA patients because ligament laxity will lead to subluxation of the joints. • Pyrocarbon arthroplasty is suitable for patients with posttraumatic arthritis or osteoarthritis (OA). Strong ligaments provide structural support for this unconstrained implant.

CLINICAL EXAMINATION • The MCP joint is examined for edema, deformity, and areas of tenderness. Active and passive range of motion (ROM) is measured. The joint is stressed in radial and ulnar deviation to assess collateral ligament stability. The skin is evaluated for integrity and healing potential. In patients with inflammatory arthritis: • Ulnar subluxation of the extensor tendons is noted when present (Fig. 41.1). • Overall finger posture (including presence of swan-neck or boutonniere deformity) and the condition of surrounding joints are evaluated. • Volar subluxation of the proximal phalanx on the metacarpal head and ulnar drift of the fingers is common in RA patients. If this deformity is passively correctable, extensor tendon centralization with cross-intrinsic transfer is considered. Arthroplasty is indicated when passive correction is not possible because the supporting ligament and tendon structures are contracted, which makes soft-tissue releases untenable to maintain joint alignment. Joint resection provides relative lengthening of these contracted structures, thus makes realignment of the digit more predictable (Fig. 41.2A–B). • The wrist is carefully evaluated; deformity at the radiocarpal or distal radioulnar joint (DRUJ) affects distal joints and must be treated first, even if the patient is asymptomatic at the proximal joint. Radial deviation at the radiocarpal joint leads to compensatory ulnar drift at the MCP joints. DRUJ instability can result in attritional extensor tendon ruptures. Failure to correct wrist instability and deformity affects outcomes in MCP arthroplasty.

FIGURE 41.1

IMAGING • Three views (posteroanterior [PA], oblique, and lateral) of radiographs of the hand are obtained to evaluate articular congruity and bone stock (Fig. 41.3A–C). • Implant size can be estimated using measurement tools and templates.

SURGICAL ANATOMY • The MCP is an asymmetric condylar joint; the ovoid articular surface of the metacarpal fits into an elliptical cavity at the base of the proximal phalanx. Motion is permitted in two planes: flexion-extension and radio-ulnar deviation. 319

320

CHAPTER 41  Metacarpophalangeal Arthroplasty

FIGURE 41.2

FIGURE 41.3

• The joint is stabilized by the volar plate, collateral ligaments, and extensor mechanism. The sagittal bands centralize the extensor tendon over the MCP joint and prevent bowstringing during hyperextension (Fig. 41.4). • The intrinsic tendons insert onto the lateral bands, which are volar to the axis of rotation of the MCP joint and act as flexors (Fig. 41.5). • The metacarpal head is sloped ulnarly and volarly. In RA patients, synovitis attenuates the supporting ligaments and the proximal phalanges slide ulnarly and volarly on the metacarpal heads. The extensor tendons subluxate into the intermetacarpal space and contribute to ulnar drift of the digits. • Chronic MCP subluxation and ulnar drift leads to fibrosis of the intrinsic muscles. When present, this requires release and cross-intrinsic transfer at the time of MCP arthroplasty. • In scleroderma patients, sclerosis of the skin, collateral ligaments, joint capsules, and tendons results in attenuation of the central slip and volar displacement of the lateral bands. Flexion at the proximal interphalangeal (PIP) joint leads to compensatory hyperextension at the MCP joint, resulting in a boutonniere deformity (Fig. 41.6A–C).

CHAPTER 41  Metacarpophalangeal Arthroplasty Sagittal band

Metacarpophalangeal joint Central slip

Extensor

Sagittal band Dorsal and volar interosseous Lumbrical muscle

Proximal interphalangeal joint Lateral band Deep transverse metacarpal ligament

FIGURE 41.5 Collateral Accessory Volar plate ligament collateral ligament

Proximal phalanx

Metacarpal

FIGURE 41.4

Dorsal PIP skin ulcerations

PIP flexion contracture with attenuated central slip and lateral band subluxation

P1

MCP joint hyperextension

P2 P3

Metacarpal

Calcinosis A

B Calcinosis

C FIGURE 41.6

321

322

CHAPTER 41  Metacarpophalangeal Arthroplasty

POSITIONING AND EQUIPMENT • The patient is positioned supine with the arm extended and hand pronated on a hand table. • The operation is performed under tourniquet control. • A rolled towel is placed in the palm for support. • Implants, implant-sizers, an oscillating saw, and intraoperative fluoroscopy are required.

EXPOSURES • A dorsal longitudinal or lazy-S incision centered at the joint is used to access a single MCP (Fig. 41.7). • Multiple arthroplasties are performed through a single, dorsal, transverse incision, which provides ease of access through the same single incision when revision arthroplasty is needed in the future. Care is taken to preserve the dorsal veins to reduce postoperative swelling (Fig. 41.8).

Silicone Metacarpophalangeal Arthroplasty INDICATIONS

STEP 1 PEARLS

• Patients with inflammatory arthritis have poor skin quality and a high rate of wound healing complications. Tissue must be handled with great care; do not crush the skin with forceps. • The distal radial collateral ligament insertion onto the proximal phalanx is preserved. Once the implant is in place, the radial collateral ligament is repaired to resist lateral force during pinch and reduce recurrence of ulnar drift. • Care must be taken to avoid injury to volar structures during the osteotomy. • If the joint remains tight or the finger cannot be easily reduced into neutral alignment, ulnar intrinsic release is performed. If soft-tissue tightness persists, release the volar plate or resect additional metacarpal bone. We prefer to resect additional metacarpal bone, which is easier.

Indications include: • Painful destruction or subluxation of the MCP joint that cannot be passively corrected • RA patients with greater than 15 degrees of ulnar drift and/or greater than 20 degrees of extensor lag • Loss of function because of joint deformity • Low-demand patients with OA

Contraindications Contraindications include: • Poor wound healing ability, inadequate skin coverage, or active infection at the MCP joint • Excessive erosion or fatty replacement of the bone with poor ability to support an implant

PROCEDURE Step 1: Joint Exposure and Transverse Osteotomy • An extended, transverse incision is made over the dorsal MCP joints. Dissection is carried down to the extensor tendons using longitudinal spreading to protect the dorsal veins and sensory nerves.

A

B FIGURE 41.7

CHAPTER 41  Metacarpophalangeal Arthroplasty

Incision for MCP arthroplasty

Incision on the radial sagittal band Tendon Tendon

FIGURE 41.9 FIGURE 41.8

B

A

C

Osteotomy line is just distal to the collateral ligament insertion FIGURE 41.10

• The radial sagittal band is incised at the border of the extensor tendon and the tendon is retracted laterally. The joint capsule is incised longitudinally and a synovectomy is performed (Fig. 41.9). • The collateral ligament is released from its proximal attachment on the metacarpal head. • The MCP joint is flexed and an oscillating saw is used to resect the metacarpal head just distal to the collateral ligament insertion (Fig. 41.10A–C). The MCP joint should then easily reduce into neutral alignment (Fig. 41.11).

Step 2: Reaming the Medullary Canal • An awl is used to prepare the medullary canals of the proximal phalanx and metacarpal. The medullary canals of the proximal phalanx are prepared first for the index, middle, and small finger. For the ring finger, the order is reversed because of the narrow canal of the fourth metacarpal; the metacarpal is broached first and the implant size determined before preparing the proximal phalanx to avoid over-reaming. • On the proximal phalanx, the starting point of the awl is at the junction of the dorsal and middle third of the articular surface. The awl is inserted with a gentle twisting motion. The smallest distal broach is then inserted straight into the medullary canal in the path created by the awl. Orientation of the broach must be maintained during insertion and withdrawal; typically, the numbered side of the broach is placed parallel with the dorsal cortex. If the broach is twisted, it may asymmetrically enlarge the medullary cavity and create a poor fit with the implant stem. The broach is inserted

FIGURE 41.11

STEP 2 PEARLS

If severe deformity of the proximal phalanx exists, fluoroscopy can be used to locate the medullary canal and confirm alignment of the awl. STEP 2 PITFALLS

Insert the broaches along the central axis of the phalanx; breaking the dorsal or volar cortex can destabilize the implant.

323

324

CHAPTER 41  Metacarpophalangeal Arthroplasty

A

1/3

B FIGURE 41.12

to its full depth to create enough space for the implant stem. If the implant stem pops out of the medullary canal, the broached space is too shallow. Broaches are increased in size until the desired implant size is reached (Fig. 41.12A–B). • The process is repeated for the metacarpal. With the articular surface removed, the awl inserts easily into the medullary canal. Broaches are sequentially inserted to their full depth until the implant size is reached. The largest implant that the medullary canal will accept is selected for a snug fit (Fig. 41.13A–B).

Step 3: Implant Insertion and Radial Collateral Ligament Repair • Before implant insertion, the metacarpal is prepared for radial collateral ligament repair. Two 0.035-in (0.89-mm) Kirschner wires (K-wires) are drilled through the dorsal radial metacarpal cortex at the distal end of the cut bone. A braided 3-0 permanent suture is passed through these holes and left untied. This suture is used later to reattach the radial collateral ligament to the metacarpal (Fig. 41.14A–C). • An implant sizer is selected based on the largest broach size used in Step 2. The sizer is oriented so that the cavity of the barrel faces volarly (Fig. 41.15). The proximal stem is inserted first into the metacarpal, then the distal stem into the proximal phalanx. The stems should fit easily into the broached medullary canals. The transverse barrel should seat against both osteotomy sites but should not be compressed. There should be no bony impingement with flexion and extension. If the fit is adequate, the sizer is removed and the final implant is opened. Correct orientation is verified, and the implant is inserted in the same sequence using two clean, smooth forceps and a no-touch technique (Fig. 41.16). • The joint is held in extension while the soft tissues are repaired. The radial collateral ligament is imbricated using the suture previously placed through the metacarpal drill holes. The joint capsule is repaired using a braided 3-0 permanent suture (Fig. 41.17A–E). Tight repair of the radial collateral ligament and joint capsule with the finger extended limits the flexion arc by 10 to 20 degrees but stabilizes the joint.

A

Step 4: Centralization of the Extensor Tendons

B

FIGURE 41.13

• The extensor tendon is centralized to reduce recurrence of ulnar drift. In longstanding deformity, the ulnar sagittal band may require release. • The radial aspect of the extensor hood is imbricated to the radial sagittal band (Fig. 41.18A–D). The MCP is passively flexed and extended to ensure that the extensor tendon remains centralized through the arc of motion.

CHAPTER 41  Metacarpophalangeal Arthroplasty STEP 3 PEARLS

• If the implant stem does not fit into the medullary canals, the implant may be too large or the broached canal too short. More bone may need to be resected from the metacarpal. • If the radial collateral ligament is severely attenuated, a portion of the volar plate is used to reconstruct the ligament. A distally based flap from the medial half of the volar plate is raised and imbricated through the drill holes at the dorsoradial cortex of the cut end of the metacarpal bone.

A

B

STEP 3 PITFALLS

It is imperative to confirm the orientation of the implant. The flexion crease of the implant must be volar (down) to allow for flexion; postoperative correction is not possible without reoperation.

C FIGURE 41.14

FIGURE 41.16

FIGURE 41.15

325

326

CHAPTER 41  Metacarpophalangeal Arthroplasty

A

B Slight radial deviation of proximal phalanx after radial collateral ligament repair

Radial collateral ligament

Radial collateral ligament Silicone arthroplasy implant

C

D

E FIGURE 41.17

Step 5: Incision Closure • The tourniquet is released and hemostasis is achieved. • The skin is closed with a few deep absorbable sutures and several horizontal mattress sutures to gently evert the skin. The patient is splinted with the MCPs extended.

Pyrocarbon Metacarpophalangeal Arthroplasty INDICATIONS • MCPJ pain because of posttraumatic arthritis or osteoarthritis with good soft tissue support and bone stock. • Typically, only one joint is affected in OA or posttraumatic conditions.

Contraindications • Poor wound healing capacity, inadequate skin coverage, or active infection at the MCP joint • Dislocated joints with ligamentous shortening or advanced cortical bone loss • Joints with poor soft tissue support and unreconstructible ligaments • Inflammatory arthritis STEP 1 PEARLS

If the radial sagittal band is incised to access the joint, it should be repaired at the end of the case to centralize the extensor tendon.

PROCEDURE Step 1: Joint Exposure • The skin is incised and dissection is carried down to the level of the extensor tendon. • Depending on surgeon preference, the radial sagittal band may be released, or the extensor tendon may be longitudinally split to expose the joint capsule (Fig. 41.19). • The capsule is incised longitudinally and synovium and osteophytes are debrided with a rongeur (Fig. 41.20).

CHAPTER 41  Metacarpophalangeal Arthroplasty Ulnarly dislocated extensor tendon

A Extensor tendons centralized over the MCP joints

B

Inserted silicone arthroplasty implant

Radial sagittal band Silicone implant

Extensor tendon Radial sagittal band

C

Centralization of dislocated extensor tendon

D

FIGURE 41.18

FIGURE 41.19

FIGURE 41.20

327

328

CHAPTER 41  Metacarpophalangeal Arthroplasty

Dorsal third of metacarpal head

Starter awl

Metacarpal

Proximal phalanx

A

STEP 2 PEARLS

• Identify the borders of the metacarpal bone to locate the correct entry point for the starter awl. • About 2 to 4 mm of bone is removed from the metacarpal head. STEP 2 PITFALLS

• Ensure that the starter awl is inserted parallel to the axis of the metacarpal. Imprecise positioning of the awl will cause the osteotomy angle to be off once the cutting guide is placed. • The attachment site of collateral ligaments should be verified and protected during the osteotomy. STEP 4 PEARLS

• Broaching the medullary canal is difficult in patients with sclerotic bone. If needed, a sidecutting bur can be used to slightly enlarge the canal to make room for the broach. • After inserting the implant, there should be smooth, passive motion from 0 to 90 degrees. • The final implants are slightly bigger than the same-number sizers to achieve a press-fit into the medullary canal. • Pyrocarbon implants do not need cement. Cementing will make subsequent removal of the implant almost impossible. STEP 4 PITFALLS

Pyrocarbon implants are fragile; use the plastic impactor supplied by the manufacturer to press-fit the stem into the medullary canal.

B FIGURE 41.21

Step 2: Metacarpal Osteotomy • The MCP is flexed and the starter awl is inserted into the metacarpal. The entry point is at the junction of the dorsal and middle third of the bone and is slightly ulnar to the midline (Fig. 41.21A–B). The awl must be inserted parallel to axis of the metacarpal. • Advance the awl into the midshaft of the metacarpal (see Fig. 41.22A–B). • The starter awl is removed and the alignment awl/cutting guide is placed into the medullary canal. The osteotomy site is just distal to the collateral ligament origin. The osteotomy is performed at 27.5-degree volar tilt (see Fig. 41.23A). The dorsal subchondral bone is scored with the cutting guide in place – the guide and alignment awl are removed, and the remainder of the cut is made freehand (see Fig. 41.23B).

Step 3: Proximal Phalangeal Osteotomy • The starter awl is inserted at the base of the proximal phalanx (Fig. 41.24A–B). • The alignment awl/cutting guide is inserted into the proximal phalanx. A 1 to 2 mm section of bone is removed at a 5-degree dorsal angle with assistance from the cutting guide (Fig. 41.25).

Step 4: Insertion of the Implants • The metacarpal and proximally phalanges are carefully broached to create room for the implant stems (Fig. 41.26A–B). • Implant sizers are placed and checked for fit with fluoroscopic guidance. The largest appropriate implant size is chosen for stability.

CHAPTER 41  Metacarpophalangeal Arthroplasty

Starter should be parallel to the axis of the metacarpal bone

One-half to two-thirds of the length of the metacarpal bone

Metacarpal B

A

FIGURE 41.22

Proximal osteotomy guide

27.5° Partial osteotomy site

Alignment awl

A

B

FIGURE 41.23

• The final implants are inserted and gently press-fit using impactors (Fig. 41.27A–B). • Final implant position is verified with fluoroscopy (Fig. 41.28A–C).

Step 5: Closure and Splinting • The dorsal capsule is repaired over the prosthesis; it can be trimmed as needed for a snug closure. • If released, the radial sagittal band is repaired with 3-0 nonabsorbable suture. • The tourniquet is deflated and hemostasis is achieved.

329

330

CHAPTER 41  Metacarpophalangeal Arthroplasty

One-half to two-thirds of the length of the proximal phalanx

B

A

FIGURE 41.24

Distal osteotomy guide

Electrical saw

FIGURE 41.25

CHAPTER 41  Metacarpophalangeal Arthroplasty

A

B FIGURE 41.26

331

332

CHAPTER 41  Metacarpophalangeal Arthroplasty

Implant

A

B FIGURE 41.27

A

B

C FIGURE 41.28

• The skin is closed using 4-0 nonabsorbable sutures. • The MCP joints are splinted in full extension. The interphalangeal joints can be free.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The sutures are removed 10 to 14 days postoperatively. • At the first postoperative visit, a short arm dynamic extension splint is applied with 20 degrees of wrist extension and MCPs in full extension. The IP joints are left free. Flexion and extension exercises are initiated. Modifications to splinting position are frequently required depending on the severity of the preoperative deformity and the patient’s progress after surgery. • At 6 weeks, patients are gradually weaned from the splint and strengthening is initiated.

CHAPTER 41  Metacarpophalangeal Arthroplasty

• A nighttime static splint is worn for 2 months. • Reduced pain and improved appearance of the hand is expected. Normal range of motion in the MCP joint and grip strength cannot be restored. Patients will typically gain about 30 to 40 degrees of active motion. See Videos 41.1 and 41.2

EVIDENCE Chung KC, Kotsis SV, Burns PB, et al. Seven-year outcomes of the silicone arthroplasty in rheumatoid arthritis prospective cohort study. Arthritis Care Res (Hoboken). 2017;69(7):973–981. RA patients with severe MCP joint deformity were divided into two treatment cohorts – (1) silicone metacarpophalangeal joint arthroplasty (SPMA) plus medical management, and (2) medical management alone. Patients were followed over 7 years. Objective measurements included grip and pinch strength, arc of motion, ulnar drift, and extension lag. Patient-reported outcomes included the Michigan Hand Questionnaire (MHQ) and the Arthritis Impact Measurement Scales questionnaire. Patients were highly satisfied after SMPA. Extensor lag and ulnar drift improved after SMPA, and grip and pinch strength were stable after surgery. The authors concluded that the benefits of SMPA are maintained for at least 7 years. Medically managed patients remained stable in their hand function over the 7-year study duration. Chung KC, Burns PB, Wilgis EF, et al. A multicenter clinical trial in rheumatoid arthritis comparing silicone metacarpophalangeal joint arthroplasty with medical treatment. J Hand Surg Am. 2009;34:815–823. RA patients with MCP joint deformities were divided into two cohorts: surgery-plus-medical therapy or medical therapy alone. Outcomes at 1-year follow-up showed significant improvement in hand function after silicone MP arthroplasty. Surgical patients had significant improvement in appearance, activities of daily living, and satisfaction. Surgical cases also had reduced ulnar drift and extensor lag after reconstruction. The change in values for grip strength and pinch strength were not significant. Chung KC, Kowalski CP, Kim HM, Kazmers IS. Patient outcomes following Swanson Silastic metacarpophalangeal joint arthroplasty in the rheumatoid hand: a systematic overview. J Rheumatol. 2000;27:1395–1402. This systematic review examined 20 articles with comparative data for silicone MP arthroplasty. The authors found that silicone arthroplasty corrected ulnar drift and improved the appearance of the rheumatoid hand. ROM at the MCP joint improved modestly. Postoperative arc of motion favored extension. Parker W, Moran SL, Hormel KB, Rizzo M, Beckenbaugh RD. Nonrheumatoid metacarpophalangeal joint arthritis. Unconstrained pyrolytic carbon implants: indications, technique, and outcomes. Hand Clin. 2006;22:183–193. Nineteen patients with 21 osteoarthritic MCP joints were treated with pyrocarbon arthroplasty. Average follow-up time was 14 months. Flexion increased by 13% and extension lag decreased by 28%. Grip strength improved by about 40%. The visual analog scale of pain (range 0–100) changed from 73 to 8.5. The authors conclude that pyrocarbon arthroplasty is a reasonable option to treat MCP joint osteoarthritis (Level IV evidence). Parker WL, Rizzo M, Moran SL, Hormel KB, Beckenbaugh RD. Preliminary results of nonconstrained pyrolytic carbon arthroplasty for metacarpophalangeal joint arthritis. J Hand Surg Am. 2007;32: 1496-1505. This study reviews early outcomes of 142 arthritic MCP joints treated with pyrolytic carbon implants. Patients were followed for an average of 17 months. The pain analog scale (range 0–100) in OA and RA patients decreased from 73.0 to 8.5 and from 43.1 to 8.9, respectively. Functionality and arc of motion improved in both OA and RA patients. On postoperative radiographs, all OA joints were stable. 10.5% of RA joints showed axial subsidence and 16.4% of RA joints showed periprosthetic erosions (Level IV evidence).

333

CHAPTER

42

Proximal Interphalangeal Arthroplasty Sarah E. Sasor and Kevin C. Chung INDICATIONS • Implant arthroplasty is indicated for patients with severe pain, deformity, and loss of motion in the proximal interphalangeal (PIP) joint who have failed nonoperative treatment (splinting, antiinflammatory medication, steroid injection, and/or hand therapy). • Silicone implants may be used in patients with inflammatory arthritis, posttraumatic arthritis, or osteoarthritis (OA). • Silicone implants act as spacers after joint resection. They are supported by the surrounding ligamentous structures and become encapsulated by fibrous tissue shortly after insertion. The result is reduced pain and maintained range of motion (ROM). • Silicone is biologically inert and has many properties that are ideal for small joint reconstruction. Unlike rigid implants, silicone implants are softer than bone and do not cause bony resorption.

Contraindications • PIP joint arthroplasty is contraindicated when there is active infection, ligamentous instability, severe angular deformity of the bone, or significant periarticular bone loss. • Implant arthroplasty of the index finger PIP joint can be considered but because of lateral stress on the joint during pinch, arthrodesis may be preferred in active patients who require joint rigidity during pinch.

CLINICAL EXAMINATION • The fingers are inspected for collinearity and symmetry. Deviation of the finger at the PIP joint may indicate asymmetric articular compression, ligamentous damage, or periarticular bone loss (Fig. 42.1). • Active ROM is assessed (Fig. 42.2 A–C). Implant arthroplasty is effective for treating pain, which is the major indication. Patients must understand that motion may not change or may decrease, but pain should improve. Patients with 60 degrees or more of active PIP motion arc should be discouraged from undergoing implant arthroplasty if the pain is tolerable.

FIGURE 42.1

334

CHAPTER 42  Proximal Interphalangeal Arthroplasty

A

B

C FIGURE 42.2

• Passive ROM is evaluated, and the PIP joint is manually stressed in all directions. The implant relies on the ligamentous support of the PIP joint. If a joint is extremely unstable, fusion is a more predictable option.

IMAGING • Standard three-view x-rays are required (Fig. 42.3). The articular surfaces of the proximal and middle phalanges are examined. Implant arthroplasty is indicated if there is articular surface damage and joint space loss. • Bone stock and quality must be sufficient to support an implant. Some patients are better served with a fusion if the bone quality is poor.

Surgical Anatomy • The PIP joint is a gliding hinge joint composed of the bicondylar head of the proximal phalanx and the concave base of the middle phalanx. • The volar plate, collateral ligaments, and extensor mechanism stabilize the joint on all sides (Fig. 42.4).

335

336

CHAPTER 42  Proximal Interphalangeal Arthroplasty

FIGURE 42.3 Proper collateral ligament

Central tendon

Middle phalanx

Proximal phalanx

Volar plate Accessory collateral ligament

FIGURE 42.4

• The volar approach places the digital neurovascular bundles and flexor tendons at risk. These must be protected during elevation of the skin flaps. • The A3 pulley is located directly over the proximal interphalangeal joint and must be divided for joint exposure. The A2 pulley and A4 pulley, which are proximal and distal, are preserved. • Shotgun hyperextension of the PIP joint requires release and elevation of the volar plate and partial release of the collateral ligaments. The typical shotgun approach is not needed. The volar plate should be detached proximally to expose the head of the proximal phalanx. Access to the PIP joint is necessary to insert the implant after sawing just proximal to the head of the proximal phalanx and then removing it.

POSITIONING AND EQUIPMENT • The patient is positioned supine with the arm supported on a hand table. An upper arm tourniquet is placed. • The procedure is performed under general or regional anesthesia. • Preoperative antibiotics are administered. • Intraoperative fluoroscopy, a narrow oscillating saw, an arthroplasty set with an awl and broaches, implant sizers, and multiple sizes of final implants must be available.

EXPOSURES • Dorsal, lateral, and volar approaches to the PIP joint are described in the literature. Studies have shown favorable results with the volar approach, and this is our preferred

337

CHAPTER 42  Proximal Interphalangeal Arthroplasty

FIGURE 42.5

FIGURE 42.6

technique. It is technically more challenging but achieves better motion and less extensor lag postoperatively. • A Bruner incision is designed from the distal interphalangeal (DIP) flexion crease to the metacarpophalangeal (MCP) flexion crease (Fig. 42.5). • The skin is incised, and the flap is elevated at the level of the flexor tendon sheath (Fig. 42.6). The neurovascular bundles must be identified and protected.

STEP 1 PEARLS

Preserve the A2 pulley proximally and the A4 pulley distally to prevent tendon bowstringing. STEP 2 PEARLS

PROCEDURE Step 1: Release of the Flexor Tendons • The A3 pulley is incised longitudinally along the lateral aspect of the tendon sheath (Fig. 42.7). • The flexor tendons are retracted, and the volar plate is exposed.

Step 2: Exposure of the PIP Joint • The volar plate is incised transversely proximal to the PIP joint. The incision is curved along the lateral margins to separate the volar plate from the accessory collateral ligaments. The volar plate is reflected and retracted distally to expose the joint (Fig. 42.8).

Flexor tendons

Retract the flexor tendons to the radial side while releasing the ulnar collateral ligament and then to the ulnar side to release the radial collateral ligament. The flexor tendons must always be protected. STEP 2 PITFALLS

Do not cut transversely through the collateral ligament to preserve joint stability; the ligament is released from its attachments to the proximal phalanx. In most instances it is only partially released and does not require repair.

A3 pulley (in forceps) Volar plate Flexor tendons

FIGURE 42.7

FIGURE 42.8

338

CHAPTER 42  Proximal Interphalangeal Arthroplasty

FIGURE 42.9 STEP 3 PEARLS

• The bone cut must be perpendicular to the shaft of the phalanx. An asymmetric cut causes deviation of the finger. • Maintain the proximal attachments of the collateral ligaments during the bone cut. • Residual dorsal osteophytes are removed with a rongeur to ensure a completely clear joint space (Fig. 42.10).

FIGURE 42.10 STEP 4 PEARLS

• There are separate broaches for the proximal and middle phalanges. The sizes match the proximal and distal stems of the implant. • The broaches have a specific orientation and must be inserted without any twisting. The numbered side of the broach is typically inserted parallel to the dorsal cortex of the bone. The broach is inserted straight and withdrawn. Twisting may enlarge or distort the medullary cavity asymmetrically.

• A 15-blade is carefully introduced into the joint space, then curved along the lateral aspect of the proximal phalanx on each side. The maneuver releases the portion of the collateral ligament that is closest to the joint but preserves the more proximal attachments. • The PIP joint is not hyperextended. Use a narrow saw set at a low speed to make a cut proximal to the head of the proximal phalanx (Fig. 42.9). Be careful not to cut the extensor tendon. A freer is used to break off the head of the proximal phalanx and the bone is detached from the collateral ligaments. There will often be osteophytes attaching to the soft tissue, which must be removed to avoid impinging the implant. • There is no need for shotgun or hyperextension of the PIP joint because the removal of the head gives access to the PIP joint. The middle phalanx often has a bone shelf dorsally attaching to the extensor tendon that must be removed. Otherwise, it will block motion.

Step 3: Remove the Articular Surface From the Proximal Phalanx A sagittal saw is used to remove 2 to 3 mm of the articular surface and bone of the proximal phalanx. The amount of bone removed should equal the diameter of the barrel of the silicone implant that will fill the space. Inadequate removal of bone will make seating of the implant difficult and will constrict the implant, thus limiting motion.

Step 4: Broaching the Medullary Canals • An awl is centered on the articular surface of the middle phalanx. It is inserted with a gentle twisting motion. Be sure to hyperextend the joint to gain central access to the sclerotic middle phalanx. • The distal broach from the arthroplasty set is placed within the path created by the awl. It is inserted and withdrawn until it can be fully seated. Broaches are increased in size until the desired implant size is reached. The broach creates a space for the implant stem and consolidates the medullary bone (Fig. 42.11). • For the PIP joint, 00 or 0 implants are suitable and, rarely, a #1 implant. The medullary cavity must be broached deeply to fit the stem securely; otherwise, the implant may dislocate with motion. The smallest broach is a #2, which should be sufficient to fit the small size implants. • Attention is then turned to preparing the proximal phalanx. The awl is inserted into the medullary canal of the proximal phalanx. It should insert with ease because the articular surface has been removed and the medullary cavity should be visible. • The proximal broaches are then inserted. Typically, a #2 broach can fit into the proximal phalanx medullary cavity, which can seat the #1 or smaller implant (Fig. 42.12).

Step 5: Sizing and Implant Placement • The distal stem of the sizer is inserted into the middle phalanx, and then the proximal stem is placed within the proximal phalanx (Fig. 42.13). The stems should fit easily into the medullary canals. • The finger is taken through a full arc of motion. The implant should not compress or buckle.

STEP 4 PITFALLS

• The broach must be inserted to its full depth. Failure to create a deep enough medullary cavity will cause the implant to dislodge during postoperative rehabilitation. • Ensure that the broach is inserted in the center of the bone. Do not penetrate the cortex with the broach; this causes implant malposition.

FIGURE 42.11

FIGURE 42.12

CHAPTER 42  Proximal Interphalangeal Arthroplasty

FIGURE 42.13

FIGURE 42.14 Implant

FIGURE 42.15

• Once satisfied with the fit, the trial implant is removed and the final implant is opened. • The final implant is placed with a no-touch technique using two clean, smooth forceps. The implant is oriented so that the cavity of the silicone barrel is open to the volar surface (Figs. 42.14 and 42.15).

Step 6: Closure • If the collateral ligaments were fully released, they are repaired with 4-0 absorbable sutures. • The volar plate is replaced over the volar joint and secured with 4-0 absorbable sutures. • The A3 pulley is repaired (Fig. 42.16). • The skin is closed with 4-0 nylon sutures (Fig. 42.17), and the patient is placed in a dorsal blocking splint with the PIP in slight flexion.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • • • •

A supervised active ROM therapy protocol is initiated 3 to 5 days after surgery. Sutures are removed 2 weeks postoperatively. After 6 weeks, patients can increase their activity. Photos are shown of a patient 6 months after silicone PIP arthroplasty of the small finger with excellent results (Fig. 42.18A–C).

A3 pulley ( in forceps)

FIGURE 42.16 STEP 5 PEARLS

Sedation can be lightened to enable the patient to perform active motion with the trial implant to test the fit. STEP 5 PITFALLS

If the implant buckles or compresses during movement, the implant may be too large, the broached canal may not be deep enough, or more bone may need to be removed from the proximal phalanx.

339

340

CHAPTER 42  Proximal Interphalangeal Arthroplasty

FIGURE 42.17

A

B

C FIGURE 42.18

CHAPTER 42  Proximal Interphalangeal Arthroplasty

• Patients can expect stable to slightly improved ROM, increased grip and pinch strength, and less pain postoperatively. Most patients are highly satisfied (84%) and would have the surgery again (91%). • There is an 11% to 15% risk of implant failure at 5 years. Up to 20% of patient require revision surgery.

Revision Pip Joint Arthroplasty INDICATIONS • Revision PIP joint arthroplasty is indicated for symptomatic implant fracture, dislocation, recurrent pain, or infection. • Challenges during revision arthroplasty include excessive scar formation, distorted anatomy, and soft tissue and bony deficiency. We prefer to approach a revision PIP arthroplasty through a dorsal incision to avoid the scarred tissue planes volarly.

FIGURE 42.19

Surgical Anatomy The dorsal aspect of the PIP joint is stabilized by the central slip of the extensor apparatus. The lateral bands have attachments to the central slip, then continue distally to the terminal tendon. The extensor tendon must be split longitudinally to expose the joint.

EXPOSURES • A longitudinal or lazy-S incision is designed over the dorsal surface of the PIP joint (Fig. 42.19). • The skin is incised and flaps are raised at the level of the extensor tendon (Fig. 42.20). FIGURE 42.20

PROCEDURE Step 1

STEP 1 PEARLS

• The extensor tendon is split longitudinally and elevated to expose the PIP joint implant (Fig. 42.21). • The central slip is mobilized radially and ulnarly.

Rather than splitting the extensor apparatus longitudinally, the joint can also be exposed via a Chamay approach (Fig. 42.22A–C). This approach preserves the central slip and the attachments of the lateral bands to the central slip. A distally based triangular flap is designed with the apex extending proximally. The extensor apparatus is repaired at the end of the procedure. Although this approach provides wide exposure, we do not use it because of concern for stretching out of the extensor tendon repair.

Step 2 • The finger is flexed 90 degrees to access the joint and the previous implant is removed using a freer. • Osteophytes are removed with a rongeur. • If revision arthroplasty is being performed for implant dislocation, adjustments are made to prevent recurrent dislocation. Options include bony shortening, deepening of the broached canals, or changing of the implant size.

FIGURE 42.21

341

342

CHAPTER 42  Proximal Interphalangeal Arthroplasty

Reflected extensor tendon

Proximal interphalangeal joint Central extensor tendon

Lateral band

C

B

A

FIGURE 42.22

Step 3 • A trial implant is placed within the medullary canals in the same process as was previously described for primary arthroplasty. • The finger is taken through a full arc of motion to ensure a proper fit. • The final implant is selected and inserted using clean instruments and a no-touch technique. Ensure that the silicone barrel is open to the volar surface to permit flexion (Fig. 42.23).

Step 4 • The extensor tendon is closed with 3-0 braided nonabsorbable suture (Fig. 42.24). • The skin is closed with 4-0 nonabsorbable suture.

FIGURE 42.23

FIGURE 42.24

CHAPTER 42  Proximal Interphalangeal Arthroplasty

FIGURE 42.25

• The patient is placed in a splint with 30 degrees of MCP flexion and 10 degrees of flexion at the PIP joint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Patients begin a supervised early active motion protocol 3 to 5 days after surgery. • Sutures are removed 2 weeks postoperatively. • Photos are shown of a patient 6 weeks after revision silicone PIP arthroplasty of the left middle finger with excellent results (Fig. 42.25). • Full PIP extension is not expected after surgery; most patients have 10 to 15 degrees of extension lag. The goal is to achieve maximal flexion. See Video 42.1

EVIDENCE Naghshineh N, Goyal K, Giugale JM, et al. Proximal interphalangeal joint silicone arthroplasty for osteoarthritis: Midterm outcomes. Hand (NY). 2019;14(5):664–668. The authors reviewed 45 silicone PIP joint arthroplasties for nonrheumatic arthritis with a mean followup of 42 months. They measured ROM, grip and pinch strength, Disability of the Arm, Shoulder, and Hand (DASH) scores, and patient satisfaction with respect to pain, deformity, function, and strength. ROM did not change after surgery. Postoperative grip and pinch strength improved significantly. Pain scores improved from 7.4 to 1.9 on a visual analog scale from 1 to 10, and patient satisfaction was high (84%). The overall complication rate was 37%, with 20% of patients requiring revision surgery. The authors concluded that silicone arthroplasty is a good option for osteoarthritis of the PIP joint. Lans J, Notermans BJW, Germawi L, Lee H, Jupiter JB, Chen NC. Factors associated with reoperation after silicone proximal interphalangeal joint arthroplasty. Hand (NY). 2019:1558944719864453. doi:10.1177/1558944719864453. Epub ahead of print. This study retrospectively reviews all adult patients who underwent silicone PIP arthroplasty over 15 years. It includes 91 patients who underwent 114 arthroplasties for inflammatory, posttraumatic, or degenerative arthritis. The overall reoperation rate was 14%. Non-Caucasian race, smoking, and posttraumatic arthritis were identified as risk factors for reoperation. The 1-, 5-, and 10-year implant survival rates were 87%, 85%, and 85%, respectively. Yamamoto M, Malay S, Fujihara Y, Zhong L, Chung KC. A systematic review of different implants and approaches for proximal interphalangeal joint arthroplasty. Plast Reconstr Surg. 2017;139(5):1139e-1151e. This is a systematic review of 40 studies reporting on the outcomes of implant arthroplasty for proximal interphalangeal joint osteoarthritis. The mean postoperative range of motion was 58 degrees for silicone arthroplasty through a volar approach and 51 degrees for surface replacement arthroplasty through a dorsal approach. Mean gain in ROM was 17 degrees and 8 degrees, respectively. Postoperative extensor lag was 5 degrees with the volar approach and 14 degrees with the dorsal approach. The revision rate was 6% for silicone arthroplasty and 18% for surface replacement arthroplasty at a mean follow-up of 41.2 and 51 months, respectively. The authors conclude that silicone implant arthroplasty using a volar approach results in the best range of motion, less extensor lag, and fewer complications compared with other implant designs and surgical approaches.

343

CHAPTER

43

Distal Interphalangeal Joint Arthrodesis Sarah E. Sasor and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video that has been prepared by the authors: Video 43.1 – Distal Interphalangeal Joint Arthrodesis.

KEY CONCEPTS • Distal interphalangeal joint (DIP) arthrodesis is indicated in patients with intractable pain or instability after failure of nonoperative management. Many patients with DIP arthritis present with mucous cysts. Cyst excision may correct a nail deformity, skin changes, or a draining wound but will not improve joint pain. Fusion is a reliable option when pain causes functional limitations. • The DIP joint is most functional in a straight or slightly flexed position. Five degrees or less of flexion is generally appropriate for fusion. It is important, however, to discuss this with the patient preoperatively. Additional flexion may be advantageous for certain activities. • The key to a successful fusion is opposition of cancellous bone at the fusion site with minimal motion to promote fusion. • Intraoperative fluoroscopy is needed to confirm compression of bone and appropriate placement of pins or hardware. • The bone surfaces should be contoured to maximize cancellous bone opposition in reduction before fixation. • Small plates, screws, or percutaneous pins can be used for fixation. We prefer using Kirschner wires (K-wires) for the ease of fusion and no retained hardware. • K-wires are driven antegrade from the DIP joint through the distal phalanx. Positioning is confirmed on fluoroscopy. The joint is reduced, and then the wire is driven retrograde into the middle phalanx. • The patient is placed in a DIP joint splint that permits hand and proximal interphalangeal (PIP) joint motion. K-wires are left in place for about 6 weeks to facilitate bony healing. A longer period of fixation may be necessary for patients with poor bone stock or slow healing.

FIGURE 43.6  Reduction of the joint surface and position of the Kirschner wires are confirmed with fluoroscopy.

344

CHAPTER

43

Distal Interphalangeal Joint Arthrodesis Sarah E. Sasor and Kevin C. Chung INDICATIONS • Distal interphalangeal (DIP) joint arthrodesis is indicated in patients with intractable pain or instability after failure of nonoperative management. • Many patients with DIP arthritis present with mucous cysts. Cyst excision may correct a nail deformity, skin changes, or a draining wound, but it will not improve joint pain. • Fusion is a reliable option when pain causes functional limitations.

CLINICAL EXAMINATION • • • • •

Patients may present with stiffness, pain, instability, or an angular deformity (Fig. 43.1). Subluxation, dislocation, or osteophytes may be present at the joint. Inspect for mucous cysts and changes in the nail bed. Assess range of motion (ROM) and pinch strength. Joint destruction and intractable tenderness are clear indications for joint fusion.

IMAGING • Obtain standard anteroposterior (AP) and lateral radiographs of the affected digits (Fig. 43.2). • Assess the surrounding bone quality; poor bone stock makes fusion more difficult.

SURGICAL ANATOMY • The DIP joint is most functional in a straight or slightly flexed position. Five degrees or less of flexion is generally appropriate for fusion. Nevertheless, it is important to discuss this with the patient preoperatively. Additional flexion may be advantageous for certain activities. • The key to a successful fusion is opposition of cancellous bone at the fusion site with minimal motion to promote fusion. • Joint surface destruction creates laxity in the collateral ligaments and instability of the joint. • Osteophytes are a hallmark sign of arthritis. Significant osteoarthritis at the DIP joint may result in Heberden nodes with swelling and inflammation.

FIGURE 43.1

344.e1

344.e2

CHAPTER 43  Distal Interphalangeal Joint Arthrodesis

FIGURE 43.2

POSITIONING AND EQUIPMENT

EXPOSURES PEARLS

• Limit horizontal incisions over the joint in case there is delayed wound healing postoperatively. • The extensor tendon should not be divided in line with the skin incision. At the end of the case, it is repaired separately for additional support and coverage of the joint.

• • • •

The patient is positioned supine on the operating room table with a hand table extension. Preoperative antibiotics are not needed. A standard tourniquet or finger tourniquet may be used. Intraoperative fluoroscopy is needed to confirm compression of bone and appropriate placement of pins or hardware.

EXPOSURES

EXPOSURES PITFALLS

Avoid injury to the germinal matrix to prevent nail abnormalities. STEP 2 PEARLS

• Flexing the joint provides easier access to the articular surfaces. • The bone surfaces should be contoured to maximize cancellous bone opposition in reduction before fixation.

• A T-shaped incision is made on the dorsum of the finger over the DIP joint. Sufficient exposure is necessary to remove osteophytes, release soft tissue contracture, and excise mucous cysts when present (Fig. 43.3). • Skin flaps are raised at the level of the paratenon (Fig. 43.4). • The skin is retracted, and the terminal tendon is divided proximal to the joint, then elevated distally off of the bone (Fig. 43.5).

PROCEDURE Step 1: Joint Preparation for Arthrodesis • The joint line is confirmed with a Freer elevator. • The radial and ulnar collateral ligaments are released to gain access to the joint for removal of the articular cartilage.

Extensor tendon cut proximal to joint

FIGURE 43.3

FIGURE 43.4

CHAPTER 43  Distal Interphalangeal Joint Arthrodesis STEP 2 PITFALLS

• Failure to release soft-tissue contractures may limit positioning or reduction of the joint for arthrodesis. • Failure to completely remove the cartilage surface on either bone may result in nonunion. Extensor tendon elevated from proximal to distal

FIGURE 43.5

• A fine rongeur is used to completely remove the articular cartilage from both the distal and middle phalanx in the DIP joint.

Step 3: Alignment and Joint Fixation

STEP 3 PEARLS

• Small plates, screws, or percutaneous pins can be used for fixation. We prefer using Kirschner wires (K-wires) for the ease of fusion and no retained hardware. • K-wires are driven antegrade from the DIP joint through the distal phalanx. Positioning is confirmed on fluoroscopy. The joint is reduced, then the wire is driven retrograde into the middle phalanx. • Two 0.045-in (1.14-mm) K-wires are used. • Reduction of the joint surface and position of the K-wires are confirmed with fluoroscopy (Fig. 43.6A–B).

STEP 3 PITFALLS

Step 4: Skin Closure • The tourniquet is released and hemostasis is obtained. • The extensor tendon is repaired to maintain the balance of the intricate extensor mechanism and provide additional soft tissue coverage (Fig. 43.7). • Skin is closed with 4-0 nylon suture and a volar resting splint is applied (Fig. 43.8).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is seen in the office 10 days after surgery for suture removal. • The patient is placed in a DIP joint splint that permits hand and proximal interphalangeal (PIP) joint motion.

FIGURE 43.6

The volar plate may tent the joint apart, preventing compression of the bones for arthrodesis. Adequate release is necessary if this occurs.

• Avoid multiple drillings that will create holes in the bones and cause premature wire loosening. • Use of a single K-wire may result in rotation or malunion.

344.e3

344.e4

CHAPTER 43  Distal Interphalangeal Joint Arthrodesis

FIGURE 43.8

FIGURE 43.7

• K-wires are left in place for about 6 weeks to facilitate bony healing. A longer period of fixation may be necessary for patients with poor bone stock or slow healing. • X-rays are used to confirm pin position and bony healing (see Fig. 43.6). See Video 43.1

EVIDENCE Neukom L, Marks M, Hensler S, Kündig S, Herren DB, Schindele S. Silicone arthroplasty versus screw arthrodesis in distal interphalangeal joint osteoarthritis. J Hand Surg Eur Vol. 2020;45(6):615–621. This study compares outcomes after silicone arthroplasty and screw arthrodesis for treatment of DIP arthritis. ROM, pain, patient satisfaction, and hand appearance were reviewed at a mean of 4.4 years after surgery. Mean DIP ROM for arthroplasty patients was 28 degrees with an extension deficit of 17 degrees. Pain was low in both arthroplasty and arthrodesis patients at 0.2 and 0.6 out of 10, respectively. Patients from both groups were highly satisfied, but arthroplasty patients were less satisfied with their hand appearance. In all, 21% of arthroplasty patients and 15% of arthrodesis patients underwent reoperation during the study period. Patel A, Damodar D, Dodds SD. Dorsal Plate Fixation for Distal Interphalangeal Joint Arthrodesis of the Fingers and Thumb. J Hand Surg Am. 2018;43(11):1046.e1–1046.e6. The authors describe a surgical technique for DIP arthrodesis with a dorsal plate. The ideal position of arthrodesis is slight flexion to improve power, fine pinch, and grip. Dorsal plate fixation allows for fusion in a more ideal position compared with straight, intramedullary implants. Dickson DR, Mehta SS, Nuttall D, Ng CY. A systematic review of distal interphalangeal joint arthrodesis. J Hand Microsurg. 2014;6:74–84. This is a systematic review of techniques and complications in DIP joint arthrodesis. Fixation techniques included K-wires, headless compression screws, and cerclage wires. There was no difference in infection rate. Compression screws had higher union rates (not significant) but were more expensive and had higher complications compared with other techniques. The authors conclude that there is no clear advantage for a specific fixation technique. Teoh LC, Yeo SJ, Singh I. Interphalangeal joint arthrodesis with oblique placement of an AO lag screw. J Hand Surg Br. 1994;19:208–211. The paper described arthrodesis of the interphalangeal joint using a single interfragmentary screw placed laterally and obliquely across the joint. The technique offers better control of the desired angle of fusion. The fusion rate was 96% at an average of 8.2 weeks. Uhl RL, Schneider LH. Tension band arthrodesis of finger joints: A retrospective review of 76 consecutive cases. J Hand Surg Am. 1992;17:518–522. The authors present a series of 76 tension-band arthrodesis procedures in 63 patients using parallel wire fixation with tension-band technique. Radiographic fusion was achieved at a mean of 12 weeks. Overall fusion rate was 99%. Technical problems included nonparallel pin placement and penetration of the wire tips, causing painful impingement of the soft tissues.

CHAPTER

44

Joint Fusion for Thumb Metacarpophalangeal Instability Sarah E. Sasor and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 44.1 – Thumb Metacarpophalangeal Fusion.

KEY CONCEPTS • Thumb metacarpophalangeal (MCP) joint fusion is indicated in patients with symptomatic arthritis or instability. Patients with carpometacarpal joint destruction often have compensatory hyperextension of the thumb MCP joint and will have pain with gripping, twisting, and key pinch. A normal thumb has a subtle degree of passive hyperextension at the MCP joint but should not collapse or hyperextend during key pinch —this is a sign of MCP instability. • Several fixation techniques are available for thumb MCP joint fusion, including Kirschner wires (K-wires), headless compression screws, and miniplates. We prefer to use a 2.0-mm T-plate and screws when bone stock is adequate. For rheumatoid patients, we prefer K-wire fixation because the bone is porous, and this makes screw fixation insecure.

Radial collateral ligament

Extensor pollicis longus Radial nerve sensory branch Extensor pollicis brevis Ulnar collateral ligament Adductor pollicis aponeurosis FIGURE 44.2  The intrinsic muscles of the thumb (flexor pollicis brevis and abductor pollicis brevis) insert onto the radial sesamoid and have attachments to the extensor mechanism to provide dynamic support.

345

CHAPTER

44

Joint Fusion for Thumb Metacarpophalangeal Instability Sarah E. Sasor and Kevin C. Chung INDICATIONS Thumb metacarpophalangeal (MCP) joint fusion is indicated in patients with symptomatic arthritis or instability.

CLINICAL EXAMINATION • Patients may complain of pain, swelling, stiffness, or decreased grip strength. • Patients with carpometacarpal joint destruction often have compensatory hyperextension of the thumb MCP joint and will have pain with gripping, twisting, and key pinch. • A normal thumb has a subtle degree of passive hyperextension at the MCP joint but should not collapse or hyperextend during key pinch, which is a sign of MCP instability (Fig. 44.1).

IMAGING Standard three-view radiographs (anteroposterior, oblique, and lateral) are required to evaluate the articular anatomy and bony quality.

SURGICAL ANATOMY • The thumb MCP joint has characteristics of both a condyloid and a hinge joint. • There is little inherent stability in the bony anatomy; the joint is dependent on soft tissue constraints, including the ligamentous complex and musculotendinous attachments. • The paired proper and accessory collateral ligaments stabilize the joint on the radial and ulnar aspects. The proper collateral ligaments originate from the lateral condyles of the metacarpal and insert onto the volar third of the proximal phalanx. The accessory collateral ligaments originate from the metacarpal (volar to the proper ligament) and insert onto the volar plate and the sesamoid bones. The proper collateral ligaments are tight in flexion, and the accessory collateral ligaments are tight in extension. • The adductor pollicis originates from the second and third metacarpals and inserts at the thumb MCP joint. The adductor aponeurosis courses obliquely across the MCP joint and inserts onto the extensor apparatus distal to the sagittal band. • The fibrocartilaginous volar plate forms the floor of the capsuloligamentous complex. • The intrinsic muscles of the thumb (flexor pollicis brevis and abductor pollicis brevis) insert onto the radial sesamoid and have attachments to the extensor mechanism to provide dynamic support (Fig. 44.2).

FIGURE 44.1

345.e1

345.e2

CHAPTER 44  Joint Fusion for Thumb Metacarpophalangeal Instability

Radial collateral ligament

Extensor pollicis longus Radial nerve sensory branch Extensor pollicis brevis Ulnar collateral ligament Adductor pollicis aponeurosis FIGURE 44.2

POSITIONING AND EQUIPMENT • The patient is positioned supine on the operating room table with a hand table extension. • Preoperative antibiotics are administered. • Intraoperative fluoroscopy is required to confirm opposition of bone and placement of pins or hardware.

EXPOSURES

EXPOSURES PEARLS

Identify and protect the superficial radial sensory nerve branches.

• A 5-cm longitudinal incision is designed on the dorsum of the thumb centered at the MCP joint (Fig. 44.3). • The skin is incised, and the subcutaneous tissue is elevated to expose the extensor pollicis longus (EPL) and extensor pollicis brevis (EPB) tendons (Fig. 44.4). • A longitudinal incision is made in the interval between the tendons to expose the dorsal capsule. • The dorsal capsule is incised, and capsular flaps are elevated radially and ulnarly to expose the MCP joint (Fig. 44.5).

EPB

FIGURE 44.3

EPL

FIGURE 44.4

FIGURE 44.5

345.e3

CHAPTER 44  Joint Fusion for Thumb Metacarpophalangeal Instability

PROCEDURE

STEP 1 PEARLS

Step 1: Preparation of the MCP Joint • The thumb MCP joint is flexed to expose the articular surfaces of the proximal phalanx and metacarpal head. • The articular surfaces are completely removed to promote fusion. We prefer the “cup-in-cone” technique. A rongeur is used to remove cartilage from the metacarpal head (cone) and the base of the proximal phalanx is shaped to accept the metacarpal head (cup; Fig. 44.6). This increases the contact area between the bones at the fusion site. • The fusion angle of the thumb MCP joint should be between 0 and 15 degrees.

Step 2: Fixation Several fixation techniques are available for thumb MCP joint fusion including Kirschner wires (K-wires), headless compression screws, and miniplates. We prefer to use a 2.0-mm T-plate and screws when bone stock is adequate. For rheumatoid patients, we prefer K-wire fixation because the bone is porous, and this makes screw fixation insecure.

• Complete removal of cartilage and sclerotic bone is accomplished when there is punctate bleeding from the underlying cancellous bone. • An alternative to the cup-in-cone technique is to make straight cuts with a sagittal saw. A 5-mm oscillating saw is used to remove approximately 1 to 2 mm of bone from the metacarpal head and the base of the proximal phalanx. Cuts must be precise because irregularities can cause angular or rotational deformities. STEP 1 PITFALLS

Incomplete removal of the articular cartilage, particularly over the hard-to-reach volar condyle, will prevent bony union.

Plate Application • The plate is prebent to the desired fusion angle (0 to 15 degrees). • The plate is positioned along the central axis of the thumb metacarpal with the “T” portion over the base of the proximal phalanx. This is confirmed radiographically. • The first hole is drilled on the metacarpal, just proximal to the fusion site. A 1.3-mm drill bit is used. • Screw length is determined with a depth gauge and a 1.5-mm screw is placed loosely. • The position of the distal portion of the plate is confirmed radiographically and a screw is placed in the proximal phalanx just distal to the fusion site (Fig. 44.7). • The remaining screw holes are drilled, and all screws are tightened to complete the fixation (Fig. 44.8). • Three screws should be placed proximal and three distal to the fusion site.

Prepared joint surfaces

FIGURE 44.6

FIGURE 44.7

FIGURE 44.8

345.e4

CHAPTER 44  Joint Fusion for Thumb Metacarpophalangeal Instability

Fixation with K-Wires

STEP 2 PITFALLS

• The osteotomy site should be compressed after fixation is applied. If it is not compressed, the hardware should be removed and replaced to ensure that the bony edges are in direct apposition. • If a compression screw is used, it must be advanced collinearly along the guidewire. Excessive force or levering on the dorsal cortex of the metacarpal will result in fracture.

• Two 0.045-in (1.14-mm) K-wires are driven from the thumb metacarpal to the distal subchondral bone of the proximal phalanx. • The wires can be started at the metacarpal head and driven retrograde first to assist in trajectory across the fusion site, then passed antegrade into the proximal phalanx.

Fixation with Headless Compression Screw • A guidewire is driven retrograde from the center of the metacarpal head. Aim to exit the dorsal cortex of the metacarpal approximately 2 cm from the fusion site. • Fluoroscopy is used to confirm the fusion angle and position of the guidewire along the central axis of the metacarpal. • The K-wire is advanced antegrade within the medullary canal of the thumb proximal phalanx into the distal subchondral bone. • Screw length is estimated using the manufacturer’s guide; 4 mm is typically subtracted from the measured length to ensure that all threads are buried within the bone. • A hand reamer is used to drill over the guide wire in preparation for screw placement. • The appropriately sized compression screw is advanced along the guidewire. • After confirming proper screw placement, the wire is removed.

Step 3: Closure • The joint capsule is closed over the hardware with 4-0 Ethibond sutures. • The skin is closed using 4-0 nylon sutures (Fig. 44.9). • The patient is placed into a short-arm, thumb spica splint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

FIGURE 44.9

• The patient is seen in the office 10 to 14 days postoperatively and sutures are removed. • The patient is placed into a custom thermoplastic splint or cast. • K-wires are typically removed after 6 weeks. • The splint is left in place until there is radiographic evidence of union. In the absence of complication, this usually occurs between 8 and 12 weeks. • Gradual range of motion and strengthening are initiated after union. See Video 44.1

EVIDENCE Letzelter JP III, Ahmad R, Tagliarino J, Woeckener J, Bello R, Melamed E. Hand function following simulated fusion of thumb metacarpophalangeal and interphalangeal joints. Hand (NY). 2020; 1558944720906495. doi:10.1177/1558944720906495. The authors used orthoses to simulate fusion of the thumb MCP and interphalangeal (IP) joints, then evaluated function with lateral and tip pinch strength, the Jebsen-Taylor Hand Function test, and the Grooved Pegboard test. The mean lateral pinch strength was significantly greater in the nonsplinted group (8.3 kg) compared with the MCP (6.3 kg) and IP-splinted (5.7 kg) groups. Mean tip pinch strength was also significantly higher in the nonsplinted group than in MCP- and IP-splinted thumbs (4.6 kg vs. 4.1 and 3.9 kg). There was no difference in the Jebsen-Taylor or Grooved Pegboard test between the 3 groups. They conclude that MCP joint fuses decreases lateral and tip pinch strength by 24% and 10%, respectively, compared with a healthy, nonsplinted thumb. A fused IP joint will decrease lateral and tip pinch by 31% and 16%, respectively. Lutsky KF, Edelman D, Lebowitz C, Matzon JL, Beredjiklian PK. Union rates and complications after thumb metacarpophalangeal fusion. Hand (NY). 2019;14(6):803–807. This study compares results after thumb MCP fusion using tension band wiring (TBW) or plate and screw fixation (PS). A total of 56 thumb MP joints were fused during the 7-year study period. Mean age was 60.9 years and mean follow-up was 32.4 months. The average flexion angle was 16.5 degrees for the TBW group and 12.8 degrees for the PS group. The overall union rate was 95% and overall complication rate was 21%. The most common complication in the TBW group was painful hardware, requiring removal. The PS group had more delayed unions and nonunions. The authors conclude that alignment is similar with both techniques, but delayed unions and nonunions are more common with the locking plate and screw technique. Rasmussen C, Roos S, Boeckstyns M. Low-profile plate fixation in arthrodesis of the first metacarpophalangeal joint. J Hand Surg Eur Vol. 2011;36:509–513. The authors retrospectively reviewed 51 patients who underwent arthrodesis of the thumb MCP joint using a low-profile titanium miniplate. Bony union was achieved in 98% of patients. Average follow-up

CHAPTER 44  Joint Fusion for Thumb Metacarpophalangeal Instability was 52 months (13 to 92 months). Complications included hardware failure (5 years) outcomes of the same cohort as the previous review. Twentythree patients (23 elbows) met inclusion criteria. The mean age of surgery was 9 years old and the mean time of follow-up was 9 years. At long-term follow-up, active extension had maintained a 12-degree improvement with 8 degrees lost in active flexion. The average flexion posture during ambulation was improved by 63 degrees. Correction results in their small cohort seem durable over the long term (Level IV evidence). Gong H, Cho H, Chung C, Park MS, Lee HJ, Baek GH. Early results of anterior elbow release with and without biceps lengthening in patients with cerebral palsy. J Hand Surg Am. 2014;39:902–909.

CHAPTER 99  Biceps and Brachialis Lengthening The authors reviewed 29 patients with cerebral palsy who had anterior elbow release. The first 14 patients had lacertus fibrosus division, brachialis fractional lengthening, and denuding of the pretendinous adventitia off the biceps tendon. The later 15 patients had partial biceps tendon lengthening in addition to the procedures in the first cohort. Mean follow-up was 72 months for group 1 and 31 months for group 2. The patients with biceps lengthening had more improvement in flexion posture (53 vs. 44 degrees) and active extension (23 vs. 15 degrees) but had a mean decrease of 7 degrees in active elbow flexion (vs no change). Anterior elbow release can provide good elbow positioning (Level III evidence). Gschwind CR, Yeomans JL, Smith BJ. Upper limb surgery for severe spasticity after acquired brain injury improves ease of care. J Hand Surg Eur. 2019;44(9):898–904. The study presents the benefits of surgery for caregivers of patients with upper extremity spasticity. The authors performed a heterogeneous mix of procedures in 45 spastic arms and hands in 38 noncommunicative patients with stroke, traumatic brain injury, neurodegenerative disorders, hypoxic brain injury, and encephalitis. An average of 12 surgeries were performed on each limb, including lengthening in every elbow. At an average follow-up of 6 months, there was significant improvement in the reported Carer Burden Scores, including improvements in cleaning and dressing the limb (Level IV evidence).

763

CHAPTER

100

Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor Digitorum Profundus Transfer Phillip R. Ross and Kevin C. Chung

TABLE House Functional 100.1 Classification System

House Classification 0

Does not use

1

Poor passive assist

2

Fair passive assist

3

Good passive assist

4

Poor active assist

5

Fair active assist

6

Good active assist

7

Spontaneous use, partial

8

Spontaneous use, complete

Adapted from House JH, Gwathmey FW, Fidler MO. A dynamic approach to the thumb-in-palm deformity in cerebral palsy: evaluation and results in fifty-six patients. J Bone Joint Surg Am. 1981;63:216–225.

INDICATIONS • An indication is patients with spastic wrist and finger flexion contractures resulting in functional limitations in activities of daily living, poor hygiene, and undesirable hand appearance. • Patients should have exhausted nonoperative treatments, including splinting, occupational therapy, serial casting, and pharmacologic agents (e.g., botulinum toxin A, baclofen). • Indications may vary based on the patient’s cognitive ability and baseline function. • For patients with little voluntary control and minimal sensibility, hand hygiene is the primary indication. • With more control, surgery must be tailored to the specific functional limitations of each patient. • Hand function may be evaluated using the House Classification (Table 100.1). • Fractional lengthening permits correction of mild deformities (Fig. 100.1A–B) and also maintains function; this should be the primary surgical option in patients with volitional motion (House grade 2 or greater). • Flexor digitorum superficialis (FDS) to flexor digitorum profundus (FDP; superficialisto-profundus transfer, STP) transfer is reserved for significant contracture (i.e., inability to extend the fingers even when the wrist is flexed; Fig. 100.2). The procedure greatly reduces the ability to flex the fingers and should be performed in patients who do not use finger flexion for function (House 0 or 1).

Contraindications STP transfer is contraindicated in patients with functional voluntary finger flexion and grasp.

A

B FIGURE 100.1  (A–B) Mild flexion contracture with active finger extension preserved.

764

CHAPTER 100  Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor

FIGURE 100.2  Severe flexion contracture, unable to extend fingers.

CLINICAL EXAMINATION • Clinical examination of spasticity is frequently challenging because of limitations in patient cognition, cooperation, and function. • Multiple separate examinations and even video recordings can be helpful to characterize the patient’s upper extremity function. • Involved spastic muscles, weak antagonist muscles, and underlying joint contractures must all be identified and documented. • Selective peripheral nerve blocks can relax spastic muscles to permit complete joint motion examination. • Wrist flexion also takes tension off the spastic finger flexors to permit evaluation of any metacarpophalangeal (MCP) or interphalangeal (IP) joint contracture. • Wrist flexion contractures are frequently caused by a spastic flexor carpi ulnaris (FCU), with occasional contribution from the flexor carpi radialis (FCR) and palmaris longus (PL). • Perform Volkmann’s test for digital flexor tightness by first extending the digits fully with the wrist flexed. Then the wrist is slowly extended while maintaining full finger extension. Surgery may be indicated if the wrist cannot be extended beyond neutral (0 degrees; Fig. 100.3A–B). • Sensation, including stereognosis, two-point discrimination, and proprioception, should be assessed.

IMAGING X-rays of the hand and wrist should be obtained preoperatively to rule out arthrosis or bony blocks to motion.

SURGICAL ANATOMY • A thorough knowledge of forearm anatomy is a mandatory prerequisite for this operation (Fig. 100.4). • Volarly, the FCR, PL, and FCU are encountered most superficially. Proximally, the pronator teres (PT) may be seen too. • The FDS is immediately deep to the superficial muscles. • The deep volar forearm contains the flexor digitorum profundus (FDP), flexor pollicis longus (FPL), and pronator quadratus (PQ). • The median nerve travels between the FDS and FDP proximally and between the FDS and FPL distally.

765

766

CHAPTER 100  Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor

A Palmaris Volkmann angle

Median nerve

B FIGURE 100.3  (A–B) Volkmann’s test. (Fig. 32.4, from Kozin SH, Lightdale-Miric NL. Spasticity: cerebral palsy and traumatic brain injury. In Wolfe S, Pederson W, Kozin SH, Cohen M, eds. Green’s Operative Hand Surgery. 7th ed. Elsevier; 2017:1080–1121.)

FCR

FDS

FIGURE 100.4  Key anatomic structures in the forearm.

• The palmar cutaneous branch of the median nerve emerges volarly 5 cm proximal to the wrist crease and runs just ulnar to FCR. • The ulnar neurovascular bundle travels deep underneath the FCU muscle.

POSITIONING Supine positioning with a hand table and an upper arm tourniquet are used. EXPOSURES PEARLS

• A longer incision may be needed for STP transfer. • The incision should curve radially in the distal half and cross the wrist at an angle if a simultaneous carpal tunnel release is planned.

EXPOSURES • A longitudinal incision is made on the volar forearm (Fig. 100.5). • Incise the volar fascia to access the forearm musculature (Fig. 100.6). • The PL is frequently divided distally to be used in concomitant tendon transfer or to help treat a wrist flexion contracture.

FIGURE 100.5  Planning the incision.

FIGURE 100.6  Exposure of the forearm musculature.

CHAPTER 100  Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor

Fractional Lengthening of Flexor Tendons

STEP 1 PITFALLS

The median nerve may appear similar to the tendon when the tourniquet is inflated. It must be identified and protected before tendon incision (Fig. 100.7).

PROCEDURE Step 1 Identify the musculotendinous junction of each tendon to be lengthened. FDS and FDP should be lengthened for mild finger contractures.

Step 2 • Two transverse tenotomy incisions are planned in the musculotendinous junction, 1 cm apart from each other. • The distal tenotomy cut is made, leaving the underlying muscle fibers in continuity (Fig. 100.8). • Gently extend the wrist and fingers to separate the tenotomy ends. • Perform the second incision 1 cm proximal to the first and extend again to achieve the full lengthening (see Fig. 100.8).

STEP 2 PEARLS

Making the distal tenotomy 2 cm proximal to the distal aspect of the musculotendinous junction ensures that muscle fibers remain attached on both ends. STEP 2 PITFALLS

Avoid hyperextending the wrist and fingers. This may damage the underlying muscle.

Step 3 The skin is closed with interrupted deep dermal absorbable suture and then interrupted nylon or running subcuticular sutures.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The arm is immobilized in a plaster splint with the fingers and wrist in extension for 2 weeks until dressing and suture removal in the office. • Therapy for motion is started at this time, and for the next 4 weeks a removable brace holding the fingers extended is worn when not performing active motion exercises.

Median nerve FIGURE 100.7  Identifying the median nerve.

2nd incision 1st incision

FIGURE 100.8  Distal and proximal tenotomy.

POSTOPERATIVE PITFALLS

Careful application of the bandage is essential to prevent either premature removal (especially if the patient is a child) or a constricting bandage.

767

768

CHAPTER 100  Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor

• Fractional lengthening can typically provide a 15% to 20% length increase and also maintain volitional flexor control. STEP 1 PEARLS

The tendons to each individual finger should be labeled separately before division to facilitate final tenorrhaphy to the correct corresponding FDP tendon. STEP 1 PITFALLS

Protect the median nerve throughout the procedure to ensure that it is not inadvertently transected.

Superficialis to Profundus (STP) Transfer PROCEDURE Step 1: Identification of Tendons and Division of FDS • After exposure, the FDS and FDP tendons are identified and labeled with whip stitch sutures and sterile labels (Fig. 100.9). • Flex the wrist and fingers and sharply transect the FDS tendons as distally as possible. • Once cut, the FDS tendons can be retracted proximally to expose the FDP muscle belly (Fig. 100.10).

STEP 2 PITFALLS

Step 2: Division of FDP Tendons

Hands with severe contractures may need to be prepped a second time after the contractures are released, if the palmar skin was not easily accessible preoperatively.

• Each FDP tendon is labeled and transected just proximal to the musculotendinous junction. • Extend the fingers to ensure release and position them in an acceptable resting posture. • The overlap of the remaining proximal FDS and distal FDP tendon stumps determines the amount of contracture correction achievable. This overlap will reduce as the fingers are extended.

STEP 3 PEARLS

• The four distal (FDP) or proximal (FDS) tendons may be sewn together to create a single large tendon for transfer. • We prefer individual tendon transfer so that the finger posture and cascade may be finetuned as needed. • With the wrist neutral, the patient should be able to fully passively extend the fingers.

Step 3: Superficialis to Profundus Tenorrhaphy • The proximal FDS tendon of each finger is attached to the corresponding distal FDP tendon using a Pulvertaft weave (Fig. 100.11). The first pass of the weave is secured with 3-0 braided nonabsorbable suture and the position of the finger is checked. If acceptable, the remaining passes of the weave are completed and secured with sutures. • Tension should be set so that the MCP and IP joints are flexed to about 45 degrees with the wrist in neutral. Starting from the index finger and moving ulnarly, the fingers may be set in gradually increasing tension to recreate a normal finger cascade.

Step 4 The skin is closed with interrupted deep dermal absorbable suture and then interrupted nylon or running subcuticular sutures. POSTOPERATIVE PEARLS

Active motion therapy is not routinely pursued after STP transfer.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The arm is immobilized in a plaster splint with the wrist in extension, MCP joints flexed to 60 degrees, and the IP joints extended for 2 weeks until dressing and suture removal in the office.

FDP musculotendinous junction

FDS

FIGURE 100.10  Exposure of the FDP muscle belly. FIGURE 100.9  Labeling the FDS and FDP tendons. FDP, Flexor digitorum profundus; FDS, flexor digitorum superficialis. 

CHAPTER 100  Step-Cut Fractional Lengthening of Flexor Tendons and Flexor Digitorum Superficialis to Flexor

FIGURE 100.11  Superficialis to profundus tenorrhaphy.

• Therapy for passive motion is started at this time, and for the next 4 weeks, a removable brace is worn, holding the wrist at 20 degrees of extension and the fingers flexed 20 degrees at the MCP joints. • After 4 weeks, the splint is worn at night as long as it is tolerated. • Patients and families should expect significantly easier postoperative access to the palm for hand hygiene. See Videos 100.1, 100.2, and 64.1

EVIDENCE Peraut E, Taïeb L, Jourdan C, et al. Results and complications of superficialis-to-profundus tendon transfer in brain-damaged patients, a series of 26 patients. Orthop Traumatol Surg Res. 2018;104(1): 121–126. doi:10.1016/j.otsr.2017.08.019. The authors review results and complications of STP transfers for spasticity secondary to stroke or traumatic brain injury in 26 patients with a mean age of 57 years (range 36–79) and mean follow-up of almost 4 years. All hands improved from the initial positioning, except one hand, which developed a claw deformity. Wrist stabilization was simultaneously performed in 20 hands. Reported complications included development of supination posture (15%), spontaneous MCP flexion (38%), swan neck deformities (23%), and a thumb-in-palm contracture (30%). Heijnen C, Franken R, Bevaart B, Meijer J. Long-term outcome of superficialis-to-profundus tendon transfer in patients with clenched fist due to spastic hemiplegia. Disabil Rehabil. 2008;30:675–678. This is a retrospective review of six patients (mean age 54 years) who underwent STP transfer with spastic hemiplegia at an average of 10 years after stroke. The surgical indication was hygienic problems in all patients and 3 patients also reported pain. Mean follow-up was 19 months. Postoperatively, all hands could be passively opened and mean resting position of the MCP was 60 to 90 degrees. Pain was improved in 2 of 3 patients. All patients were satisfied with their choice to have surgery. Keenan M, Korchek J, Botte M, Smith C, Garland D. Results of transfer of the flexor digitorum superficialis tendons to the flexor digitorum profundus tendons in adults with acquired spasticity of the hand. J Bone Joint Surg Am. 1987;69:1127–1132. This is a retrospective review of 31 patients (34 hands) treated with STP transfer. Patients were examined at a mean of 50 months postoperatively. The transfer was performed en mass from FDS to FDP. All of the patients had a clenched-fist deformity preoperatively, with severe hygienic problems of the palmar skin and no active function of the hand. Postoperatively, all of the hands were in an open position, which enabled good hygiene of the palmar surface. Complications included minor wound infections in three patients. An ulnar nerve neurectomy was performed distal to Guyon’s canal in 25 hands, and intrinsic plus deformities developed in 7 of the 9 hands without neurectomy. Keenan M, Abrams R, Garland D, Waters R. Results of fractional lengthening of the finger flexors in adults with upper extremity spasticity. J Hand Surg Am. 1987;12:575–581. This is a retrospective review of the results of fractional lengthening of the finger flexors in 27 patients with upper extremity flexor spasticity with a mean follow-up time of 33 months. Patients were divided preoperatively into those with potentially functional hands (n = 22) and those who were nonfunctional (n = 5) based on the presence of motor control and hand sensibility. Postoperatively, all five nonfunctional hands, which lacked any motor control, improved in posture and the hygiene problems resolved. Twenty of the 22 patients with potentially functional hands (91%) improved their spastic hand function score, with a mean of 3.7 points. Two patients (9%) decreased their spastic hand function score as a result of overlengthening of the finger flexors, with loss of grip strength.

769

CHAPTER

101

Flexor-Pronator Slide Joshua M. Adkinson and Kevin C. Chung

INDICATIONS • Indications include established Volkmann ischemic contracture of the flexor-pronator muscles of moderate severity and a sustained functional impairment of the spastic upper extremity (resulting from central nervous system disorders such as cerebral palsy, traumatic brain injury [TBI], or cerebrovascular accident [CVA]) with fixed forearm pronation, wrist flexion, and finger flexion deformities.

Contraindications Contraindications include complete absence of voluntary motor control of forearm supination, wrist extension, and finger extension or family or parental reluctance to proceed with surgery.

CLINICAL EXAMINATION • It is important to ensure that the neurologic and orthopedic statuses are stable. For example, after CVA or TBI, there is a period of time (12–18 months) when there may be spontaneous functional improvement. • Preoperative examination of the upper limb often reveals a fixed contracture of the forearm in pronation and a flexion contracture of the wrist and digits. In more severe digital flexion contractures, there may also be palmar skin breakdown. Grasp and release motions of the hand are severely impaired because of the wrist position. • In Volkmann contractures, there are volar deep soft-tissue adhesions and fibrosis with or without peripheral nerve involvement. There is often some level of retained finger and thumb flexion.

IMAGING Radiographs of the forearm, wrist, and digits have limited use for preoperative planning before flexor-pronator slide.

SURGICAL ANATOMY

EXPOSURES PEARLS

• During superficial dissection, the medial antebrachial cutaneous nerve is identified and protected (Fig. 101.3). • The plane between the flexor-pronator fascia and the overlying subcutaneous tissue may be difficult to develop. There are multiple perforating vessels to the dermal layer that will require coagulation (Fig. 101.4). • The dissection extends radially to the median nerve as it enters the interval between the deep and superficial heads of the pronator teres (Fig. 101.5). 770

• Regardless of the indication for surgery, a thorough understanding of the forearm anatomy is essential. Understanding the relationships of the volar forearm musculature, ulnar nerve, median nerve, brachial artery, and neurovascular structures adjacent to the interosseous membrane is mandatory prior to embarking on surgery. • In patients with spasticity, the forearm anatomy will be normal. • In patients with a Volkmann contracture, the forearm anatomy may be distorted by scarred musculature and scar-entrapped median and ulnar nerves.

POSITIONING The operation is performed under general anesthesia with the patient placed supine on the operating table. A tourniquet is placed high on the upper arm and the entire extremity is prepared and draped.

EXPOSURES • An extensile anteromedial longitudinal incision is made, extending from just proximal to the medial epicondyle to the midforearm along the axis of the ulna (Fig. 101.1). • Wide subcutaneous flaps are elevated from the cubital tunnel region to the anterior forearm (Fig. 101.2).

CHAPTER 101  Flexor-Pronator Slide

FIGURE 101.1  Resting posture of the contracted upper extremity.

FIGURE 101.2  Wide subcutaneous flaps are elevated.

*

MABC nerve branch

Medial epicondyle

Median nerve

FIGURE 101.3  MABC (medial antebrachial cutaneous) nerve branch identified by Freer elevator.

FIGURE 101.4  Black star on cutaneous perforator traversing the surgical site.

FIGURE 101.5  Median nerve before full neurolysis. The Freer elevator points to the median nerve.

PROCEDURE Step 1 The ulnar nerve is identified proximal to the medial epicondyle and the ligament of Osbourne is released. An ulnar nerve decompression is completed distal to the deep flexor carpi ulnaris muscle fibers (Fig. 101.6).

771

772

CHAPTER 101  Flexor-Pronator Slide

Ulnar nerve Median nerve

FIGURE 101.7  After extensive median neurolysis.

FIGURE 101.6  Forceps with gentle traction on the ulnar nerve.

STEP 2 PEARLS

Step 2

The flexor digitorum superficialis (FDS), palmaris longus (PL), and flexor carpi radialis (FCR) muscles are carefully elevated from the interosseous membrane to ensure that they can easily slide distally. The median nerve has terminal motor branches in this region and requires protection.

Through the anterior dissection plane, the median nerve is identified as it enters the flexor musculature. A complete median neurolysis is ensured so that the flexor-pronator muscles can ultimately slide distally without tension on the nerve (Fig. 101.7).

STEP 2 PITFALLS

The median nerve motor branches are directly within the deep exposure of the pronator. The distal motor branches are at risk during the more anterior exposure. STEP 4 PEARLS

A submuscular transposition of the ulnar nerve is usually necessary to avoid tension on the nerve. After transposition, the ulnar nerve will be adjacent to the median nerve in the anterior forearm.

Step 3 • The posterior and anterior exposures are connected in a plane just anterior to the elbow capsule and the anterior band of the medial collateral ligament (Fig. 101.8). • The entire flexor-pronator mass is then elevated from the medial epicondyle origin, the anterior elbow capsule, and the proximal portion of the interosseous membrane using bipolar electrocautery (Fig. 101.9).

Step 4 With gentle wrist and digital extension, the entire flexor-pronator muscle is translated distally (Fig. 101.10).

Step 5 The tourniquet is released and hemostasis ensured. A subcuticular skin closure is performed (Fig. 101.11).

Flexor -pronator mass Ulnar nerve

FIGURE 101.8  Instrument around entire flexor-pronator mass before release.

FIGURE 101.9  After release of flexor-pronator mass.

CHAPTER 101  Flexor-Pronator Slide

FIGURE 101.10  With gentle wrist and digital extension, the entire flexor-pronator muscle is translated distally.

FIGURE 101.11  Skin closure.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A long-arm splint is designed to maintain the fingers and wrist in near full extension, with concomitant elbow extension and forearm supination. • After 2 weeks, the surgical splint is removed and a long arm cast is applied. • At 1 month postoperatively, the long arm cast is converted to a forearm-based orthosis that maintains the wrist and digits in full extension. The splint is removed for hygiene purposes and for daily occupational therapy exercises. • At 2 months, use of a nighttime-only splint is initiated. • Unrestricted activities resume at 3 to 4 months postoperatively. See Video 101.1

EVIDENCE Sharma P, Swamy MKS. Results of the Max Page muscle sliding operation for the treatment of Volkmann’s ischemic contracture of the forearm. J Orthop Traumatol. 2012;13(4):189–196. The authors present their experience with the flexor-pronator (Max-Page) muscle slide procedure in patients with Volkmann contracture. They present functional outcomes in 19 patients treated over a 10-year period. They analyzed dexterity scores, hand grip strength, sensibility, and appearance and graded final results as good, fair, or poor. Fifteen patients achieved good functional results. Three had fair and one had poor results. All three variables showed significant improvements postoperatively. Wound dehiscence was the most common complication. One patient underwent revision surgery to restore good hand function. The authors conclude that the procedure gives good functional results and is technically straightforward to perform (Level IV evidence). Thevenin-Lemoine C, Denormandie P, Schnitzler A, Lautridou C, Allieu Y, Genêt F. Flexor origin slide for contracture of spastic finger flexor muscles: a retrospective study. J Bone Joint Surg Am. 2013; 95(5):446–453. The authors sought to assess the increase in wrist and digital extension after a Page-Scaglietti flexorpronator release for spasticity of the upper extremity. Data from 54 hands and 50 patients (35 men and 15 women) were evaluated. The Zancolli and House classifications were used to evaluate improvements. The mean duration of follow-up was 26 ± 21 months. The mean gain in wrist extension with fingers extended was 67 ± 25 (range, 210–110). Preoperatively, no hands were classified as Zancolli Group 1, whereas 25 hands were classified as Zancolli Group 1 at the latest follow-up review. Ten nonfunctional hands (rated as House Group 0 or Group 1) became functional as a supporting hand postoperatively. Zancolli and House classifications increased significantly (p < 0.01) postoperatively. Partial recurrence of deformity occurred in 12 patients. In 7 cases, surgery unmasked spasticity or contracture of the intrinsic muscles, which required further intervention. The authors conclude that the Page-Scaglietti release improves range of motion and function in people with wrist and finger contractures because of central nervous system disorders (Level IV evidence).

773

CHAPTER

102

Thumb Adductor Release Shepard Peir Johnson and Kevin C. Chung INDICATIONS • Cerebral palsy patients may develop spastic contracture of thumb adduction and flexion muscles, which causes a characteristic thumb-in-palm deformity (Fig. 102.1). • House described four types of thumb-in-palm deformity: • Type 1: First ray adduction across the palm from contracture of the adductor pollicis (AdP). • Type 2: First ray adduction with flexion of the metacarpophalangeal joint (MCP) from contracture of flexor pollicis brevis (FPB). • Type 3: First ray adduction with volar plate laxity leading to MCP hyperextension. • Type 4: First ray adduction with MCP flexion and interphalangeal (IP) joint flexion from contracture of the flexor pollicis longus (FPL). • Surgical correction is indicated if: • A patient is functionally unable to grasp and pinch objects because of the malpositioned thumb, and conservative measurements have been exhausted (such as aggressive hand therapy, thumb abduction splinting, and botulinum toxin injections). • To facilitate hygiene using a nonfunctional hand. • Surgical correction of thumb-in-palm deformity requires (1) release of contracted intrinsic and/or extrinsic muscles, (2) augmentation of weak muscles, and (3) stabilization of joints. For Type 1, release of the AdP from the metacarpal origin may also be necessary. Various adjunct procedures may also be indicated (Table 102.1). FIGURE 102.1  Thumb-in-palm deformity resulting from spastic contraction of the thenar musculature, predominantly the adductor pollicis.

Contraindications • Patients without sufficient voluntary muscle control, cognitive ability, or motivation to rehabilitate after surgery should not undergo thumb adductor release (unless it is for hygienic issues). • Patients must have adequate shoulder, elbow, forearm, and wrist function to position the hand in a posture that permits use of thumb grip and pinch.

TABLE Surgical Options to Address Deformities or Deficits Associated 102.1 With Thumb-In-Palm Deformity

Deformity

Surgery

Thumb contracture (with MCP flexion)

Release of FPB, APB, FDI

Thumb contracture (with MCP and IP flexion)

Release of FPB, APB, FDI, and FPL lengthening

Soft tissue deficit in first webspace

Thumb webspace z-plasty or locoregional flap

Weak thumb extension and abduction

EPL rerouting Augmentation of EPL, EPB, or APL with tendon transfers (e.g. brachioradialis, palmaris longus, extensor carpi radialis longus)

Joint instability

CMC, MCP, or IP arthrodesis. MCP volar plate capsulodesis.

APB, Abductor pollicis brevis; APL, abductor pollicis longus; CMC, carpometacarpal joint; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FDI, first dorsal interosseous; IP, interphalangeal joint; MCP, metacarpophalangeal joint.

774

775

CHAPTER 102  Thumb Adductor Release

CLINICAL EXAMINATION • For patients with cerebral palsy, a complete examination of the upper extremity is needed to understand the potential function and posture of each muscle and joint. • Spastic contracture often manifests as shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion, wrist ulnar deviation, and thumb-in-palm deformity. • Proximal procedures are necessary first if the hand cannot be placed in a favorable manner for utilization of thumb grip and pinch. • Hand and thumb examination: • Visually inspect the position of the first ray in relation to palm. Determine whether there is adequate first webspace soft tissue to permit abduction and extension of the thumb. • Palpate the thenar eminence to assess for contractures of involved muscles. Note which muscles need release. • Passively and actively assess range of motion (ROM) at the thumb CMC, MCP, and IP joints. Evaluate for hyperextension and volar plate laxity of MCP. Determine whether any joints need stabilization. • Assess strength of flexion, extension, adduction, abduction, and opposition of the thumb. Consider whether muscles require augmentation with tendon transfers. • Observe hand function. Determine whether the thumb-in-palm deformity inhibits the patient’s ability to grasp objects and oppose the thumb against the fingers. First dorsal interosseous

SURGICAL ANATOMY • The following intrinsic muscles may have contractures (Fig. 102.2): • Adductor pollicis (AdP): Consists of an oblique head and a transverse head, which originate from the capitate, the base of the second and third metacarpals, the volar intercarpal ligament, and the sheath of the flexor carpi radialis (FCR) tendon. The AdP inserts on the ulnar base of the thumb proximal phalanx. • Flexor pollicis brevis (FPB): Consists of a superficial head and a deep head, which originate from the trapezium and transverse carpal ligament and trapezoid, capitate, and the distal carpal row volar ligaments, respectively. The FPB heads both insert on the radial base of the thumb proximal phalanx. • Opponens pollicis (OP): Lies deep to the APB, originates from the trapezium and transverse carpal ligament, and inserts onto the volar radial side of the thumb metacarpal. • Abductor pollicis brevis (APB): Lies radial to the FPB on the superficial (proximolateral) aspect of the thenar eminence. The APB arises from the transverse carpal ligament, trapezium, and scaphoid and inserts onto the radial base of the thumb proximal phalanx. • First dorsal interosseous (FDI): Originates on the radial side of the second metacarpal and the ulnar side of the first metacarpal. The FDI inserts on the radial side of the base of the second proximal phalanx and the extensor apparatus. The FDI muscle lays on the dorsum of the AdP, and together these muscles make up the mass of the first webspace. • Nerves at risk during thenar myotomy: • Deep branch of the ulnar nerve (DBUN): Enters the hand via the Guyon canal, travels with the deep palmar arterial arch, and terminates between the two heads of the AdP. The DBUN is at risk for injury during release of the AdP from its metacarpal origins. • Recurrent branch of the median nerve (RBMN): The RBMN is most commonly extraligamentous, with a takeoff immediately distal to the TCL. The nerve then travels radially, crosses over the FBP, and terminates in the thenar musculature. The RBMN is at risk for injury during release of the FBP, OP, and APB. • Common digital nerves to the long and index fingers: These nerves lie on the lumbricals and run longitudinally toward the digits.

Thumb Intrinsic Muscle Release EXPOSURES • A midpalmar incision is designed along the border of the thenar eminence (Fig. 102.3). • Sharp dissection is carried through subcutaneous tissue and palmar fascia.

Adductor pollicis Flexor pollicis longus Flexor pollicis brevis DBUN

Abductor pollicis brevis RBMN

FIGURE 102.2  The contracted thenar musculature involved in thumb-in-palm deformity. When releasing the adductor pollicis muscle and the flexor pollicis brevis, the DBUN and RBMN should be protected, respectively. DBUN, Deep branch of the ulnar nerve; RBMN, recurrent branch of the median nerve. (From Fig. 72.11, Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020).

EXPOSURES PEARLS

Protect the RBMN as it travels radially just distal to the transverse carpal ligament.

776

CHAPTER 102  Thumb Adductor Release

STEP 1 PEARLS

• Protect the DBUN, which is encountered between the oblique and transverse heads of the AdP. • Protect the deep palmar arch, which is encountered during release of the proximal origin of the AdP. STEP 1 PITFALLS

Aggressive retraction to expose the deep thenar musculature may cause nerve traction injuries.

FIGURE 102.3  A palmar incision along the thenar eminence is used to access the AdP and thenar musculature. The incision can be extended proximally (purple dotted line) if more access is needed to release the abductor pollicis brevis. AdP, Adductor pollicis.

• The most distal portion of the transverse carpal ligament (TCL) is incised to expose the median nerve and flexor tendons.

Step 1: Thumb Adductor Pollicis Origin Release

STEP 2 PEARLS

• Extend the proximal portion of the palmar incision to provide adequate exposure of the thenar muscles. • Apply a thumb abduction force to maintain tension on the thenar musculature as it is released. • As the muscles are released, they will retract distally toward the thumb insertions. Retraction will reveal unreleased, taut structures.

• The AdP muscle origin on the third metacarpal is exposed after retracting the common digital branches of the median nerve and the long finger flexor digitorum superficialis (FDS) ulnarly (Fig. 102.4). • Using a bipolar cautery to control bleeding, release the AdP muscle (oblique and transverse head) from the radial side of the third metacarpal.

Step 2: Thenar Muscle Origin Release • If adequate thumb abduction is not achieved with the AdP myotomy, then release the remaining thenar musculature. • Incise and completely release the origin of the FPB and OP from the transverse carpal ligament. • Continue proximally and release the distal two-thirds of the origin of the APB (Fig. 102.5).

Median nerve and flexor digitorum superficialis muscle retracted

Adductor pollicis muscle, oblique and transverse heads

Adductor pollicis Flexor pollicis brevis Abductor pollicis brevis

Recurrent branch of median nerve

A

B

Transverse carpal ligament

Superficial head of flexor pollicis brevis muscle and abductor pollicis brevis muscle cut and retracted

FIGURE 102.4  The common digital nerve and flexor digitorum superficialis to the long finger are retracted ulnarly to expose the third metacarpal. The adductor pollicis can then be released completely. The red line shows where the transverse carpal ligament can be incised to provide better exposure.(Fig. 102.4B from Disorders of the brain. In Karol LA, ed. Tachdjian’s Pediatric Orthopaedics. Elsevier; 2022: 1419–1529.e19.)

Proximal extent of APB origin release

FIGURE 102.5  During thenar muscles release, the thumb should be held in an abducted and extended position to permit visualization of unreleased, taught structures that may be causing residual contracture. (From Fig. 72.11, Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020).

CHAPTER 102  Thumb Adductor Release

Step 3: First Dorsal Interosseous Release

STEP 3 PEARLS

Release the FDI from its origin on the first metacarpal.

Extensor Pollicis Longus Rerouting to Enhance Thumb Abduction EXPOSURES Make a longitudinal incision at Lister tubercle to facilitate visualization of the first three extensor compartments.

• Protect the princeps pollicis vessel at the base of the metacarpal during FDI release. • If visualization of the FDI is poor from the volar approach, perform the release with (1) a separate longitudinal incision over the dorsal aspect of the thumb metacarpal or (2) during a concomitant first webspace contracture release.

STEP 2 PEARLS

PROCEDURE

Release subcutaneous tissue septae that may interfere with EPL tendon gliding.

Step 1: Elevate the Extensor Pollicis Longus Open the third extensor compartment and elevate the EPL superficially.

STEP 3 PEARLS

Step 2: Transpose the Extensor Pollicis Longus • Transpose the EPL into the subcutaneous space and displace it radially. • Mobilize the EPL tendon from its musculotendinous junction to a point distal to the extensor retinaculum.

Step 3: Create the Abductor Pollicis Longus Sling Create the APL sling (Fig. 102.6). • Open the first extensor compartment. • Harvest a slip of APL (proximally based). • Loop the APL sling around the EPL to prevent ulnar subluxation. • Suture the APL sling to the volar periosteum of the radius (or volar first dorsal compartment).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Immobilize the thumb metacarpal in wide abduction and opposition for 4 weeks. • After 4 weeks, continue nighttime splinting with a custom orthoplastic splint to prevent deformity recurrence. • Initiate hand therapy and guided rehabilitation at 4 weeks if tendon transfers were performed. • Surgical reconstruction of thumb-in-palm deformity appears to improve hand function, hygiene, and the appearance and quality of life of patients. • Restoration of hand posture, position, and gross motor function are expected after thumb-in-palm releases, but complete restoration of fine motor function and dexterity is unrealistic in the setting of patients with spastic conditions. See Video 102.1

EPL

APL sling FIGURE 102.6  Extensor pollicis longus (EPL) rerouting from the third extensor compartment to the first dorsal compartment using a slip of the abductor pollicis longus (APL). Placing the EPL in a more radial position permits greater abduction of the thumb. (From Kozin SH, Lightdale-Miric N. Spasticity: Cerebral palsy and traumatic brain injury. In Wolfe S, Pederson W, Kozin SH, Cohen M. Greens Operative Hand Surgery. 7th ed. Elsevier; 2017:1080–1121.)

• Evaluate tenodesis by passively flexing and extending the wrist and observing the resultant thumb motion. • The final trajectory of pull from the transposed EPL should simulate the APL.

777

778

CHAPTER 102  Thumb Adductor Release

EVIDENCE Smeulders M, Coester A, Kreulen M. Surgical treatment for the thumb-in-palm deformity in patients with cerebral palsy. Cochrane Database Syst Rev. 2005;(4):CD004093. doi:10.1002/14651858. CD004093. This Cochrane Review evaluated the efficacy of surgical interventions for thumb-in-palm deformity, including surgical indications and outcomes. Only nine studies were included, all of low quality. Reliable judgment on the role of surgery could not be determined, but surgery appeared to improve hand function, facilitate hygiene, and improve patient quality of life. Alewijnse JV, Smeulders MJ, Kreulen M. Short-term and long-term clinical results of the surgical correction of thumb-in-palm deformity in patients with cerebral palsy. J Pediatr Orthop. 2015;35(8):825–830. This retrospective study on surgical outcomes for thumb-in-palm deformity identified 39 patients. The success rate was 87% and 80% for short-term and long-term follow-up, respectively, and 87% of patients would undergo surgery again. The authors concluded that surgical correction of thumb-inpalm deformity has a high clinical success rate and patient satisfaction in the long term.

CHAPTER

103

Capsulotomy for Proximal Interphalangeal Contracture Sarah E. Sasor and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 103.1 – Proximal Interphalangeal Volar Capsulotomy.

KEY CONCEPTS • Proximal interphalangeal (PIP) joint capsulotomy is indicated for patients with decreased range of motion (ROM) and functional limitations who do not experience relief after nonoperative management (active joint mobilization, dynamic and/or static splinting, and passive stretching). Patients must understand that recurrence is common and postoperative therapy is mandatory. • A no. 15 blade is used to incise the membranous volar plate over the head of the proximal phalanx. The blade is gently curved, separating the volar plate from the accessory collateral ligaments. This maneuver divides the checkrein ligaments, preserves the transverse digital artery, and releases the accessory collateral ligaments. • A Freer is used to elevate the volar plate in a proximal-to-distal direction. The finger is passively extended at the PIP joint to identify any other tight areas. Additional release is performed as necessary. The incisions are closed with 5-0 nylon and the patient is placed in a volar splint with full PIP extension and metacarpophalangeal (MCP) flexion. • Aggressive active ROM is started within 48 hours of surgery. Patients are placed in a static extension splint at night and when not performing ROM exercises. Extensor

Middle phalanx

Collateral Accessory Volar plate ligament collateral ligament

Proximal phalanx

FIGURE 103.2  The collateral ligaments and accessory collateral ligaments lie adjacent to the retinacular ligament and provide lateral stability to the PIP joint. PIP, Proximal interphalangeal.

779

CHAPTER

103

Capsulotomy for Proximal Interphalangeal Contracture Sarah E. Sasor and Kevin C. Chung INDICATIONS • Proximal interphalangeal (PIP) joint capsulotomy is indicated for patients with decreased range of motion (ROM) and functional limitations who have failed nonoperative management (active joint mobilization, dynamic and/or static splinting, and passive stretching). • Patients must understand that recurrence is common and postoperative therapy is mandatory.

CLINICAL EXAMINATION • In rheumatoid arthritis, synovitis within the joint stretches the extensor mechanism and causes a boutonniere deformity. • In osteoarthritis and posttraumatic arthritis, edema causes expansion of the synovial spaces. A swollen metacarpophalangeal (MCP) joint assumes an extended posture, which increases the relative flexion force on the PIP joint. The collateral ligaments contract and limit motion over time. • The fingers are examined for swelling, scars, and deformity. • Passive and active ROM at the PIP joint is tested with the MCP flexed and extended. Increased PIP motion with MCP flexion may indicate intrinsic tightness. If passive motion exceeds active motion, then tendon adhesions may be present. If passive and active motion are equal and PIP motion is the same in all MCP positions, then the pathology is within the PIP joint. • The joint is tested for stability in all directions.

IMAGING • Standard, three-view radiographs are performed to evaluate the bony anatomy and assess for articular congruity (Fig. 103.1).

FIGURE 103.1

779.e1

779.e2

CHAPTER 103  Capsulotomy for Proximal Interphalangeal Contracture

• Magnetic resonance imaging (MRI) and computed tomography (CT) are rarely needed but offer a more detailed assessment of the articular surface and bony anatomy in posttraumatic situations.

SURGICAL ANATOMY • The PIP joint has a large arc of motion but is constrained by the anatomy of the articular surfaces and the surrounding soft tissue attachments. • The PIP joint is covered laterally by a superficial layer made of transverse and oblique fibers of the retinacular ligament of Landsmeer. The oblique retinacular ligament links the motion of the PIP and distal interphalangeal (DIP) joints. With PIP flexion, the ligament relaxes the DIP joint to allow flexion. During PIP extension, the ligament tightens to extend the DIP. • The collateral ligaments and accessory collateral ligaments are stout structures adjacent to the retinacular ligament and provide lateral joint stability (Fig. 103.2). • Paired checkrein ligaments extend proximally from the volar plate and insert onto the proximal phalanx; their primary function is to limit extension. An anatomic landmark that delineates the checkrein ligaments is the transverse digital artery, which passes 3 mm proximal to the PIP joint (Fig. 103.3). Extensor

Middle phalanx

Collateral Accessory Volar plate ligament collateral ligament

Proximal phalanx

FIGURE 103.2

Middle phalanx

Volar plate

Nutrient branch of digital artery

Checkreins

FIGURE 103.3

CHAPTER 103  Capsulotomy for Proximal Interphalangeal Contracture

POSITIONING AND EQUIPMENT • The patient is placed supine with the arm extended on a hand table. • The use of local anesthetic with or without IV sedation allows the patient to participate intraoperatively. Assessment of active ROM helps ensure that all limiting pathology has been addressed. • No special equipment is required.

EXPOSURES

EXPOSURES PEARLS

Midlateral Approach • An incision is designed at the junction of the glabrous and dorsal skin extending from the midshaft of the proximal phalanx to the midshaft of the middle phalanx (Fig. 103.4). • The skin and subcutaneous tissue are incised using a no. 15 blade. The digital bundles are visualized and retracted volarly. • The lateral aspect of the flexor tendon sheath is incised, and the transverse retinacular ligament is divided to visualize the flexor tendons (arrow; Fig. 103.5). After division of the transverse retinacular ligament, synovitis is usually visible. • The flexor tendons are retracted to expose the volar plate (arrow) and collateral ligaments (Fig. 103.6).

Design the midaxial incision on the side of the digit opposite a pinch or resting surface (the ulnar side of the index finger and radial side of the small finger). EXPOSURES PITFALLS

Avoid an excessive sheath excision and violation of the A2 and A4 pulleys.

Volar Approach • A V-shaped incision is designed, centered at the PIP skin crease. • The skin and subcutaneous tissue are incised, and a flap is raised at the level of the flexor tendon sheath. The neurovascular (NV) bundles are identified and protected.

FIGURE 103.4

FIGURE 103.5

FIGURE 103.6

779.e3

779.e4

CHAPTER 103  Capsulotomy for Proximal Interphalangeal Contracture

• The A3 pulley is divided on its lateral edge to expose the flexor tendons. The A2 and A4 pulleys are preserved. • The tendons are retracted to expose the volar plate and checkrein ligaments. STEP 1 PEARLS

This maneuver divides the checkrein ligaments, preserves the transverse digital artery, and releases the accessory collateral ligaments. STEP 1 PITFALLS

Careful retraction is necessary to avoid injury to the nearby flexor tendons and neurovascular bundles.

PROCEDURE Step 1 A no. 15 blade is used to incise the membranous volar plate over the head of the proximal phalanx. The blade is gently curved, separating the volar plate from the accessory collateral ligaments (Fig. 103.7).

Step 2 A Freer is used to elevate the volar plate in a proximal-to-distal direction (Fig. 103.8).

Step 3 • The finger is passively extended at the PIP joint to identify any other tight areas (Fig. 103.9). Additional release is performed as necessary.

Middle phalanx

Incision

Collateral ligament Volar plate

Proximal phalanx

FIGURE 103.7

Middle phalanx

Collateral ligament

Accessory collateral ligament Volar plate

Proximal phalanx

Extensor FIGURE 103.8

CHAPTER 103  Capsulotomy for Proximal Interphalangeal Contracture

FIGURE 103.9

• The incisions are closed with 5-0 nylon and the patient is placed in a volar splint with full PIP extension and MCP flexion.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Aggressive active ROM is started within 48 hours of surgery. • Patients are placed in a static extension splint at night and when not performing ROM exercises. • Sutures are removed at 2 weeks. See Video 103.1

EVIDENCE Yang G, McGlinn EP, Chung KC. Management of the stiff finger: evidence and outcomes. Clin Plast Surg. 2014;41(3):501–512. This article reviews the anatomy, classification, and treatment options for MCP, PIP, and DIP joint contractures. Ghidella SD, Segalman K, Murphey M. Long-term results of surgical management of proximal interphalangeal joint contracture. J Hand Surg Am. 2002;27:799–805. This article retrospectively reviews outcomes for 68 PIP joints that underwent contracture release. The mean improvement was 7.5 degrees of motion. Factors that that affected ROM outcomes were age, number of prior procedures, preoperative flexion, removal of an exostosis, number of structures released, and preoperative arc of motion. A second surgery was performed in 35% of cases overall. The authors state that an ideal candidate is a patient younger than 28 years who has preoperative maximum flexion measurement of less than 43 degrees. The study did not address the postoperative rehabilitation or compliance of patients and was focused on operative intervention and long-term outcome. Bruser P, Poss T, Larkin G. Results of proximal interphalangeal joint release for flexion contractures: Midlateral versus palmar incision. J Hand Surg Am. 1999;24:288–294. This is a retrospective review comparing 45 fingers treated for PIP contracture. A palmar incision was used in 19 fingers and a midlateral incision was used in 26 fingers. The groups had comparable demographics and preoperative function. In follow-up at 1.5 years, the midlateral incision group had a mean arc of motion of 0 to 90 degrees in comparison to the palmar incision group, which was 30 to 90 degrees. Abbiati G, Delaria G, Saporiti E, Petrolati M, Tremolada C. The treatment of chronic flexion contractures of the proximal interphalangeal joint. J Hand Surg Br. 1995;20:385–389. This is a retrospective review of 19 patients treated for chronic flexion contractures. The preoperative extension deficit ranged from 70 to 90 degrees. The treatment protocol included surgical release followed by static and/or dynamic splinting. Surgery was performed using a midlateral approach. Operative release included release of the accessory collateral ligament, volar plate, and checkrein ligaments. Complete extension of the finger was achieved in 11 cases (57.9%); in the remaining 8 cases (42.1%) the residual extension deficit ranges from 10 to 15 degrees. The authors conclude that surgical release of the PIP joint with postoperative therapy has good results with minimal complications.

779.e5

CHAPTER

104

Capsulotomy for Metacarpophalangeal Contracture Sarah E. Sasor and Kevin C. Chung INDICATIONS • Metacarpophalangeal (MCP) joint stiffness can usually be prevented or corrected with nonoperative management, such as edema control, splinting, and early joint mobilization. About 90% of patients with MCP contractures are successfully treated nonoperatively. MCP capsulotomy is indicated in motivated patients with persistent contracture and hand dysfunction after several months of therapy. • Surgery is one part of the treatment plan for MCP contracture. Postoperative hand therapy is critical to maximize joint motion and treat scars, hypersensitivity, and edema. Patients and therapists should meet before surgery to discuss expectations. Patients must understand and commit to the plan.

Contraindications • One contraindication for the procedure is an inability to attend postoperative hand therapy. The patient must have access to a capable hand therapist and be willing to attend therapy several times per week. • It is also essential to ensure that the patient and therapist will be permitted to work together; preoperative payor (insurance) authorization should be confirmed when necessary.

CLINICAL EXAMINATION • The goal of the examination is to identify the source of stiffness. Pathology in the soft tissue, capsuloligamentous structures, muscles, tendons, or bone can contribute to MCP contracture. See Table 104.1 for additional details. • Examine the quality and compliance of the skin. An injured MCP joint typically assumes an extended posture. Scar contracture or dorsal skin deficiency sometimes contribute. • Passive and active range of motion (ROM) are carefully evaluated. Passive motion that exceeds active motion suggests pathology in the muscle or tendon. When active and passive motion are equal, the cause of stiffness is likely capsuloligamentous scarring or a bone block. When the joint does not move at all, it is impossible to localize the problem. Joint releases can be done first to get the joints mobile before tackling the tendon etiology.

TABLE 104.1 Etiology and Treatment of Metacarpophalangeal Contracture

780

Category

Involved Structures

Operative Treatment Options

Soft tissue

Skin, subcutaneous tissue, fascia

Scar release, skin graft, flap

Capsule/ligament

Joint capsule, collateral ligaments, volar plate

Capsulotomy or capsulectomy, collateral ligament release, release of volar plate adhesions

Muscle/tendon

Extensor or flexor tendons, intrinsic tendons, tenosynovium

Tenolysis, tendon lengthening, intrinsic release, tenosynovectomy

Bone

Articular incongruity, bone block

Arthroplasty, arthrodesis

CHAPTER 104  Capsulotomy for Metacarpophalangeal Contracture

IMAGING Standard, three-view radiographs of the hand are mandatory to evaluate the joint surfaces and rule out bony blockade or exostoses.

SURGICAL ANATOMY • The MCP joint is an asymmetric condylar joint with motion permitted in two axes: flexion-extension and radioulnar deviation. The normal arc of motion is slight hyperextension (0 to 45 degrees) to 90 degrees of flexion. • The joint is stabilized by the volar plate, paired proper and accessory collateral ligaments, and the extensor tendon (Fig. 104.1). • The volar plate is a thick, fibrocartilaginous structure that originates from the head of metacarpal and inserts onto the base of the proximal phalanx. Its primary function is to limit hyperextension. • The radial and ulnar proper collateral ligaments originate from the dorsal metacarpal head and run diagonally to the volar base of the proximal phalanx. These ligaments are substantial: 1.5- to 3-mm thick, 4- to 8-mm wide, and 12- to 14-mm long. The accessory collateral ligaments originate proximal and volar to the proper collateral ligaments and fan out to insert onto the proximal phalanx, volar plate, and flexor tendon sheath. • The dorsal joint capsule is closely associated with the extensor mechanism. The sagittal bands originate from the volar plate, then wrap around the joint capsule and insert onto the extensor hood. They centralize the extensor tendon over the MCP joint and prevent bowstringing during hyperextension. The intrinsic tendons insert onto the lateral bands, which are volar to the axis of rotation of the MCP joint and act as flexors (Fig. 41.5). • In extension, the dorsal capsule and collateral ligaments are redundant and permit motion of the proximal phalanx on the metacarpal head. As the proximal phalanx is flexed, the collateral ligaments become taut; maximum tension occurs at about 70 degrees of MCP flexion. In postinjury swelling without splinting, the MCP joint assumes an extended posture. The dorsal capsule and collateral ligaments shorten and scar, resulting in joint stiffness (Fig. 104.2).

POSITIONING AND EQUIPMENT • The patient is positioned supine on the operating room table with the arm extended on a hand table. • A rolled towel is placed in the palm for support. Extensor tendon Dorsal capsule

Metacarpal head

Base of proximal phalanx

Flexor tendon Collateral ligament

Volar plate

ACL

FIGURE 104.1  Metacarpophalangeal (MCP) anatomy. (From Yang, G. Management of the stiff finger. Clin Plast Surg, 2014;41[3]:501–512.)

781

782

CHAPTER 104  Capsulotomy for Metacarpophalangeal Contracture Accessory collateral ligament

Capsule

Collateral ligament is lax

A

B

FIGURE 104.2  (A–B) Metacarpophalangeal (MCP) joint flexion versus extension. (From Watt, AJ. Functional reconstruction of the hand: The stiff joint. Clin Plast Surg. 2011;38[4]:577–589.)

EXPOSURES PITFALLS

A single, transverse incision provides access to multiple MCP joints but may gap under the stress of postoperative therapy. There is often dorsal skin laxity that can accommodate the stretch of the skin during therapy. The wound must be closed tightly to avoid dehiscence with stress.

• The procedure is performed under axillary block or local anesthesia with sedation. Improvement in active ROM is assessed by lightening the sedation and asking the patient to flex and extend the joint.

EXPOSURES A dorsal transverse incision (for all four joints, provides a better aesthetic result) or lazyS incision (for one or two joints) centered at the joint is used to access each MCP joint (Fig. 104.3).

PROCEDURE Step 1: Metacarpophalangeal Joint Exposure and Dorsal Capsulotomy • The skin is incised, and dissection proceeds rapidly to the extensor mechanism. • The radial and ulnar sagittal bands are partially incised longitudinally to gain access to release the dorsal capsule and the collateral ligaments and avoid ulnar subluxation of the extensor tendons. If the radial sagittal band is detached entirely, the extensor tendons will sublux ulnarly, which is difficult to correct. The partially released sagittal bands do not need to be repaired—the extensor tendon is sharply elevated off the dorsal capsule, then retracted laterally to expose the joint. • A transverse incision is made in the dorsal capsule in continuity with release of the dorsal collateral ligaments, which will be taut and contracted. Take care to preserve the underlying articular cartilage (Fig. 104.4). Alternatively, a portion of the dorsal capsule is excised.

FIGURE 104.3  Incision design.

CHAPTER 104  Capsulotomy for Metacarpophalangeal Contracture

FIGURE 104.4  Metacarpophalangeal (MCP) capsulotomy performed.

• The MCP joint is flexed to assess motion. If additional release is needed, proceed to step 2.

Step 2: Collateral Ligament Release, Volar Capsule Release, Extensor Tenolysis • The radial and ulnar collateral ligaments are sequentially released from their origin on the dorsal metacarpal head (Fig. 104.5A). Release is performed from dorsal to volar until adequate MCP flexion is achieved. • If the joint cannot flex beyond 60 degrees, there are two possible scenarios: (1) Part of the collateral ligament remains intact and additional release is required (see Fig. 104.5B), or (2) the volar plate has adhered to the capsule. Adhesions between the volar plate and capsule are released with a Freer elevator. • Extensor tendon excursion is checked by flexing and extending the MCP joint. If the tendons do not glide freely, tenolysis is performed.

STEP 2 PEARLS

• MCP joint flexion during surgery can help to identify tight portions of the collateral ligaments. • MCP motion should be smooth. The proximal phalanx should glide around the metacarpal head. If the dorsal joint gaps open with attempted flexion (i.e., opens like a book), additional release is needed at the volar aspect of the metacarpal head. Pass an elevator between the bone and the volar plate to free adhesions. • Rarely, the MCP joint will jump or trigger as it reaches full extension. If this occurs, any remaining accessory collateral ligament is divided.

Step 3: Closure

STEP 2 PITFALLS

• MCP joint motion is checked again to ensure that there are no additional tight structures and that motion is smooth. • The sagittal band is repaired with 4-0 nonabsorbable suture. • The tourniquet is deflated and hemostasis is achieved. • The skin is closed with 4-0 nonabsorbable suture.

Take care to release the ulnar and radial collateral ligaments equally. Deviation of the digit can occur if there is imbalance.

Collateral ligament divided from origin on metacarpal head Dorsal capsule

A

Flex to identify tight collateral ligament

Volar plate

B FIGURE 104.5  (A) Collateral ligament divided from metacarpal head. (B) Flexion to identify tight collateral ligament. (From Yang, G. Management of the stiff finger. Clin Plast Surg, 2014;41[3]:501–512.)

783

784

CHAPTER 104  Capsulotomy for Metacarpophalangeal Contracture

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is placed in a soft dressing or a splint with the MCP joints flexed at 70 degrees according to surgeon preference. Strict elevation is immediately initiated. • The patient is seen in the office in 3 to 5 days to begin motion. Early, intensive hand therapy is critical to success. Aggressive active and passive motion exercises and nighttime splinting are continued for 6 to 8 weeks. • Most patients can be passively flexed to 90 degrees on the operating room table but will lose motion in the immediate postoperative period because of swelling, pain, and scarring. Patients can expect to gain about 30 degrees of flexion if they are compliant with therapy. See Videos 104.1 and 104.2

EVIDENCE Buch VI. Clinical and functional assessment of the hand after metacarpophalangeal capsulotomy. Plast Reconstr Surg. 1974;53(4):452–457. The author describes the operative technique and discusses postoperative results for 27 hands treated with MCP capsulotomy. MCP contractures were caused by burns, crush injuries, and peripheral nerve injuries. Fourteen patients had capsulectomy alone; 10 patients had capsulotomy and split thickness skin grafting; and 3 patients had capsulotomy with an abdominal flap for soft tissue coverage of the dorsal hand. Most MCP joints gained about 30 degrees of flexion. Early, active postoperative therapy was critical for success. Patients who required skin grafts or flaps had worse outcomes because of the need for immobilization. Gould JS, Nicholson BG. Capsulectomy of the metacarpophalangeal and proximal interphalangeal joints. J Hand Surg Am. 1979;4(5):482–486. MCP capsulectomy was performed on 105 joints in 37 patients over 3 years. A dorsal approach was used for 100 joints. Patient ages ranged from 10 to 70 years and follow-up time was 3 to 32 months. Overall, patients gained 21 degrees of active motion and 29 degrees of passive motion. Fracture and crush injury patients had the least gain in motion (18 degrees active; 20 degrees passive). Nerve injury (35 degrees active, 37 degrees passive), burn (36 degrees active, 42 degrees passive), and stroke (52 degrees passive) patients had greater gains in motion after surgery. Weeks PM, Young VL, Wray Jr RC. Operative mobilization of stiff metacarpophalangeal joints: dorsal versus volar approach. Ann Plast Surg. 1980;5(3):178–185. The authors compare outcomes after volar or dorsal approach for MCP capsulotomy in 61 joints. In the volar approach group, 76% of patients gained greater than 50 degrees of passive motion and 44% gained greater than 50 degrees of active motion. In the dorsal approach group, 29% of patients gained more than 50 degrees of passive motion and 16% gained more than 50 degrees of active motion. The authors conclude that the dorsal approach provides better operative exposure, but the volar approach is advantageous in the postoperative period.

ddsf

SECTION XII

Congenital Hand Disorders CHAPTER 105

Pediatric Trigger Digits  786

CHAPTER 106

Release of Finger Syndactyly Using Dorsal Rectangular Flap  794

CHAPTER 107

Duplicated Thumb and Finger Treatment  802

CHAPTER 108

Index Pollicization for Hypoplastic Thumb  814

CHAPTER 109

Pediatric Opponensplasty  825

CHAPTER 110

Camptodactyly Correction  833

CHAPTER 111

Macrodactyly Correction  842

CHAPTER 112

Release of Constriction Ring Syndrome  849

CHAPTER 113

Centralization for Radial Longitudinal Deficiency  857

CHAPTER 114

Cleft Hand Reconstruction  865

CHAPTER 115

Arthrogryposis Reconstruction  873

785

CHAPTER

105

Pediatric Trigger Digits Joshua M. Adkinson and Kevin C. Chung

There are two types of pediatric trigger digit procedures: trigger thumb release and trigger finger release.

Pediatric Trigger Thumb Release INDICATIONS • Trigger thumbs are one of the most common hand conditions affecting the pediatric population. They typically present in children between 1 to 4 years of age. • Timing for surgical intervention is debated because symptoms will resolve in an uncertain percentage of children. A period of observation is therefore recommended in children younger than 3 years of age, regardless of symptoms. • Surgery is indicated for children older than 3 years with a thumb interphalangeal (IP) joint locked in flexion or for those with painful, intermittent locking and clicking.

Contraindications Contraindications include age less than 3 years, parental reluctance to proceed with surgery, medical comorbidities that would preclude safe surgery, and symptoms resolving with splinting alone.

CLINICAL EXAMINATION • Pediatric trigger thumbs are often locked in flexion at the IP joint (Fig. 105.1). The IP joint may be passively extended with a painful and palpable click in early stages of the condition. • A palpable Notta node (focal nodular thickening of the flexor pollicis longus [FPL] tendon) is noted about the volar aspect of the metacarpophalangeal joint (Fig. 105.2). • Trigger thumbs may occur bilaterally and both thumbs should be examined.

*

FIGURE 105.1  Trigger thumb with IP joint flexion. IP, Interphalangeal.

786

FIGURE 105.2  Notta node, indicated on the image by a black asterisk.

CHAPTER 105  Pediatric Trigger Digits

IMAGING Although imaging is unnecessary for treatment planning in confirmed cases of trigger digits, many patients undergo plain radiographs before surgical evaluation to rule out a fracture or dislocation.

SURGICAL ANATOMY • The thumb flexor tendon sheath is made up of two annular pulleys and one oblique pulley and contains the FPL tendon (Fig. 105.3). • The radial digital nerve to the thumb crosses obliquely over the A1 pulley and is at risk of injury during pulley release (Fig. 105.4). • The etiology of a trigger thumb is thought to be related to a size mismatch between the FPL tendon and the flexor tendon sheath.

POSITIONING The patient is placed in the supine position on the operating table with the entire upper arm prepared in the surgical area. A nonsterile tourniquet is applied on the upper arm.

EXPOSURES PEARLS

Avoid infiltrating local anesthetic directly into the surgical site because this may obscure visualization. The principle in hand surgery is to block the nerves proximal to the operative field. EXPOSURES PITFALLS

EXPOSURES • The operation is performed under general anesthesia. • After exsanguination of the arm, a 1-cm transverse or chevron marking is made overlying the thumb metacarpophalangeal (MCP) joint flexion crease (Fig. 105.5). We apply the chevron incision for wider exposure. The incision in the palm often heals without residual scarring.

A2 A1 Oblique pulley

FIGURE 105.3  Anatomy of the thumb flexor tendon sheath.

• Care is taken to make the initial incision only through the dermis to avoid injury to the radial digital nerve lying in the subcutaneous fat. • The radial digital nerve is also at risk if the incision is designed too radially along the axis of the thumb.

787

788

CHAPTER 105  Pediatric Trigger Digits

A1 pulley Radial digital nerve of thumb Thenar muscle

FIGURE 105.4  Close relationship of the A1 pulley and radial digital nerve of the thumb.

FIGURE 105.5  A 1-cm marking over the flexion crease at the thumb MCP joint. MCP, Metacarpophalangeal.

PROCEDURE Step 1 STEP 2 PEARLS

Occasionally, triggering persists after complete A1 pulley release. This can be managed by partially releasing the proximal leading edge of the oblique pulley.

• The tendon sheath and A1 pulley are exposed using scissors and a gentle spreading technique. • Small blunt retractors are used to retract the subcutaneous tissues and the neurovascular bundles on the radial and ulnar aspects of the thumb.

Step 2 The A1 pulley is released with a knife or scissors (Fig. 105.6A–B).

CHAPTER 105  Pediatric Trigger Digits

A

B

FIGURE 105.6  (A) A1 pulley exposure. (B) After A1 pulley release. The black arrow points to the FPL tendon. FPL, Flexor pollicis longus.

FIGURE 105.7  Incision closure.

FIGURE 105.8  Soft bandage applied.

Step 3

POSTOPERATIVE PITFALLS

• The tourniquet is deflated and hemostasis is ensured. • The incision is closed with absorbable interrupted sutures (Fig. 105.7). • A soft bandage is applied (Fig. 105.8).

The bandage should be tight enough to prevent premature removal by the child but not so tight that it causes constriction.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The dressing is kept on for 7 to 10 days. • After dressing removal, the caretakers are instructed on daily wound care and a bandage is applied to the surgical site. • Rehabilitation is unnecessary, except in patients with a preoperative IP joint contracture. • Outcomes after A1 pulley release for pediatric trigger thumbs are excellent and risk for recurrence is negligible.

Pediatric Trigger Finger Release INDICATIONS • Triggering in digits other than the thumb is less common and may be associated with tendon abnormalities, metabolic derangements, or inflammatory etiologies. • Timing for surgical intervention is debated because symptoms will resolve in an uncertain percentage of children. A period of observation is therefore recommended in children younger than 3 years of age, regardless of symptoms.

789

790

CHAPTER 105  Pediatric Trigger Digits

• Although pediatric trigger thumbs are treated with a simple A1 pulley release, trigger digits often require additional surgical maneuvers through a versatile incision that can be extended distally, if needed.

Contraindications Contraindications include age less than 3 years, parental reluctance to proceed with surgery, medical comorbidities that would preclude safe surgery, and trigger digit manifestations resolving with splinting alone.

CLINICAL EXAMINATION • The presentation and underlying pathology of pediatric trigger finger are distinct from adult trigger finger. Pediatric trigger finger is associated with mucopolysaccharidosis, juvenile rheumatoid arthritis, Ehlers-Danlos syndrome, Down syndrome, and central nervous system disorders. • The middle finger is the most commonly affected non-thumb trigger digit and typically presents with the classic findings of clicking or jumping with active extension of the digit (Fig. 105.9).

IMAGING Although imaging is unnecessary for treatment planning in confirmed cases of trigger digits, many patients undergo plain radiographs before surgical evaluation to rule out a fracture or dislocation.

SURGICAL ANATOMY • The digital flexor tendon sheath is made up of five annular pulleys and three cruciate pulleys and contains the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons (Fig. 105.10). • Multiple anatomic abnormalities have been implicated as a cause of pediatric trigger finger, including: • Abnormally proximal decussation of the FDS tendon • Aberrant lumbrical muscle insertion into the FDS tendon • Abnormal relationship of the FDS and FDP tendons • Thickening of the A2 and A3 pulleys • Tendon nodule • We advocate incision of the A1 pulley, followed by release of the decussation of the FDS tendon by splitting it to permit unchecked excursion of the FDP. Occasionally, the proximal A2 pulley needs to be incised. We do not routinely remove a slip of the FDS tendon as advocated by some authors.

POSITIONING The patient is placed in the supine position on the operating table with the entire upper arm prepared in the surgical area. A nonsterile tourniquet is applied on the upper arm.

FIGURE 105.9  The middle finger is the most common non-thumb trigger digit in the pediatric population.

CHAPTER 105  Pediatric Trigger Digits

A5 C3 A4 C2 A3 C1 A2 A1

FIGURE 105.10  Anatomy of the digital flexor tendon sheath.

EXPOSURES • The operation is performed under general anesthesia. • After exsanguination of the arm, a chevron or Bruner-style zigzag incision is made overlying the A1 pulley and extended distally, as needed (Fig. 105.11).

PROCEDURE Step 1 • The tendon sheath and A1 pulley are exposed using scissors and a gentle spreading technique (Fig. 105.12). • Nodular thickening of the FDS tendon is common (Fig. 105.13). • Small blunt retractors are used to retract the subcutaneous tissues and the neurovascular bundles.

Step 2 • The A1 pulley is released with a knife or scissors (Fig. 105.14). • After A1 pulley release, passive manipulation of the digit is performed to ensure smooth gliding of the FDS and FDP tendons.

Step 3 • If persistent triggering is noted with passive digital motion, the decussation of the FDS tendon around the FDP tendon (i.e., Camper’s chiasm) is released using scissors (Fig. 105.15).

FIGURE 105.11  Bruner-style zigzag incision over the A1 pulley.

EXPOSURES PEARLS

Dissection is kept along the axis of the digit to prevent inadvertent injury to the radial or ulnar neurovascular bundles. EXPOSURES PITFALLS

A transverse incision for trigger digit release is not recommended because it cannot be easily extended for additional pulley or tendon release. STEP 2 PEARLS

• The patient is usually under general anesthesia and smooth gliding of the tendons with active ROM cannot be assessed. Each tendon can be individually pulled with a retractor to ensure smooth independent gliding. • Partial release of the leading edge of the A2 pulley is generally required. STEP 3 PEARLS

• Nodular thickening of the FDS or FDP tendons is not excised. • The incision may be extended distally if necessary for greater exposure.

791

792

CHAPTER 105  Pediatric Trigger Digits

FIGURE 105.13  Nodular thickening of FDS tendon. FDS, Flexor digitorum superficialis.

FIGURE 105.12  A1 pulley exposure.

FIGURE 105.14  A1 pulley release.

FIGURE 105.15  Release of decussation of the FDS tendon around the FDP tendon. FDP, Flexor digitorum profundus; FDS, flexor digitorum superficialis.

• Despite these maneuvers, residual bulk of the flexor tendons can prevent normal active flexion of the digit even with pulley and Camper’s chiasm release. In rare cases, resection of a slip of the FDS tendon may be necessary to achieve unrestricted motion.

Step 4 • The tourniquet is deflated and hemostasis is ensured. • The incision is closed with absorbable interrupted sutures (Fig. 105.16). • A soft bandage is applied. POSTOPERATIVE PITFALLS

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

The bandage should be tight enough to prevent premature removal by the child but not so tight that it causes constriction.

• The dressing is kept on for 7 to 10 days. • After dressing removal, the caretakers are instructed on daily wound care and a bandage is applied to the surgical site.

CHAPTER 105  Pediatric Trigger Digits

FIGURE 105.16  Incision closure.

• Rehabilitation is unnecessary except in patients with a preoperative joint contracture. • Recurrence can occur after release of a pediatric trigger finger and is usually related to incomplete pulley release or residual flexor tendon bulk.

EVIDENCE Dittmer AJ, Grothaus O, Muchow R, Riley S. Pulling the trigger: Recommendations for surgical care of the pediatric trigger thumb. J Pediatr Orthop. 2020;40:300–303. The authors retrospectively reviewed 149 patients with 193 pediatric trigger thumbs over a 10-year period. All children were classified according to the Sugimoto classification; 16.5% of patients had stage II (triggering with active extension of thumb IP joint), 10.3% of patients had stage III (triggering without active extension of thumb IP joint), and 73% of patients had stage IV (rigid deformity without passive extension of thumb IP joint) thumbs. Stage IV thumbs were 4.6 times more likely to fail conservative treatment than stage II or III thumbs (P = .006). Older children with bilateral stage 3 thumbs were the most likely to go straight to surgery. There were four postsurgical complications for a rate of 3.4% with a recurrence rate of 1.7%. Based on these data, the authors recommend that stage IV thumbs undergo surgery without an observational period and stage II and stage III thumbs can be safely observed for at least 1 year before surgery (Level III evidence). Farr S, Grill F, Granger R, Girsch W. Open surgery versus non operative treatments for paediatric trigger thumb: a systematic review. J Hand Surg Eur Vol. 2014;39(7):719–726. The authors performed a systematic review of 17 retrospective studies and 1 prospective study of trigger thumb treatments. The mean follow-up periods were 59 (surgery), 23 (splinting), and 76 months (exercising), respectively. They reported full IP joint motion in 95% of patients treated surgically, 67% treated with splinting, and 55% treated with passive exercising. The authors conclude that A1 pulley release yields the most reliable and rapid outcomes (Level II evidence). Marek DJ, Fitoussi F, Bohn DC, Van Heest AE. Surgical release of the pediatric trigger thumb. J Hand Surg Am. 2011;36(4):647–652. The authors present a review of 173 consecutive patients with 217 thumbs treated surgically. They report a 36 degree loss of extension preoperatively and an average of 1 degree postoperative loss of extension. Using a parent questionnaire at an average follow-up of 4.2 years, there were no major complications or identified recurrences. Five thumbs developed minor skin complications that healed with conservative management. There were no secondary surgeries (Level II evidence). Baek GH, Kim JH, Chung MS, Kang SB, Lee YH, Gong HS. The natural history of pediatric trigger thumb. J Bone Joint Surg Am. 2008;90(5):980–985. The authors prospectively evaluated rates of spontaneous resolution of trigger thumb symptoms in 53 patients (71 thumbs) over a 10-year period. Forty-five (63%) resolved spontaneously. Median time to resolution of symptoms was 48 months. The authors conclude that pediatric trigger thumb can be expected to resolve without treatment in at least 60% of patients (Level II evidence). Bae DS, Sodha S, Waters PM. Surgical treatment of the pediatric trigger finger. J Hand Surg Am. 2007;32(7):1043–1047. This retrospective study evaluated 23 pediatric trigger fingers treated over a 10-year period with division of the A1 pulley and resection of a single slip of the FDS. Ninety-one percent of fingers had complete resolution of the triggering; two patients required revision surgery to address the remnant FDS tendon slip or an aberrant FDS muscle belly in the palm. There were no complications using the described treatment (Level IV evidence).

793

CHAPTER

106

Release of Finger Syndactyly Using Dorsal Rectangular Flap Joshua M. Adkinson and Kevin C. Chung • The newly created webspace should be designed more proximal than normal to account for web creep (i.e., distal extension of the webspace scar). • A flap, rather than skin grafts, should always be used to resurface the webspace to ensure pliability and normal finger movement. • When possible, the digits should be covered by interdigitating flaps. If primary closure is tight, however, placement of full-thickness skin grafts is recommended. It is unusual to be able to completely cover both digits entirely with skin flaps alone.

INDICATIONS • Syndactyly release is indicated to improve appearance, address functional limitations, and prevent progressive finger deformity during growth. • Syndactyly release is typically performed between 12 and 18 months of age, when the anatomic structures are larger and when anesthesia is safer compared with younger ages. • Ideally, all surgery should be completed before the child reaches school age. For syndactyly of the first and fourth webspaces, earlier release at approximately 6 months of age is recommended to prevent angulatory and rotational deformities resulting from the differences in length of the thumb/index and ring/small fingers (i.e., border digits). • If adjacent web spaces are affected, it may be safer to release them at separate stages at least 3 months apart to avoid digital ischemia.

Contraindications There are a few contraindications for the procedure: • Minor incomplete syndactyly that does not impair digital flexion, extension, and abduction. • Complicated syndactyly cases that may result in worse postoperative function because of joint instability. • Parental reluctance to proceed with surgery. • Medical comorbidities that would preclude safe surgery.

CLINICAL EXAMINATION • Syndactyly is classified by the extent of fusion and the elements that are fused. • Complete syndactyly refers to fusion of fingers from the web to the tip (Fig. 106.1), whereas incomplete syndactyly refers to fusion that does not span the entire finger (Fig. 106.2). • Simple syndactyly refers to fusion of the skin only, whereas complex syndactyly refers to fusion of the phalanges. • Complicated syndactyly refers to fusion of multiple digits and multiple elements. This type of syndactyly is associated with other congenital anomalies including Apert syndrome (Fig. 106.3) and Poland syndrome (Fig. 106.4). Border digit angular deformities are common in complicated syndactyly (Fig. 106.5).

IMAGING Preoperative radiographs can assist with classification of syndactyly and to evaluate skeletal elements. The radiograph in Fig. 106.6 shows complex syndactyly, whereas Fig. 106.7 is consistent with complicated syndactyly. 794

CHAPTER 106  Release of Finger Syndactyly Using Dorsal Rectangular Flap

FIGURE 106.1  Complete syndactyly.

FIGURE 106.2  Incomplete syndactyly.

FIGURE 106.3  Apert hand.

SURGICAL ANATOMY • The webspace is hourglass-shaped and slopes 45 degrees from the dorsal metacarpal head to the volar midproximal phalanx (Fig. 106.8). The third webspace is the most distal, followed by the second and fourth webspaces (Fig. 106.9). • On occasion, the digital artery bifurcates more distal than normal. One artery may need to be ligated to permit digital separation.

POSITIONING The patient is placed in the supine position on the operating table with the arm extended on a hand table. A nonsterile tourniquet is applied on the upper arm. When a full-thickness skin graft is anticipated (most cases), the groin should also be prepared and draped into the field.

FIGURE 106.4  Poland syndrome.

795

796

CHAPTER 106  Release of Finger Syndactyly Using Dorsal Rectangular Flap

FIGURE 106.5  Border digit angular deformities in complicated syndactyly.

FIGURE 106.6  Radiograph of complex syndactyly.

45°

A

B

FIGURE 106.7  Radiograph of complicated syndactyly.

FIGURE 106.8  (A–B) Shape and angle of webspace. Reprinted with permission from Ni F, Mao H, Yang X, Zhou S, Jiang Y, Wang B. The Use of an Hourglass Dorsal Advancement Flap Without Skin Graft for Congenital Syndactyly. J Hand Surg. 2015;40(9):1748-1754.e1.

EXPOSURES EXPOSURES PEARLS

For syndactyly release of the long and ring fingers, a rectangular flap can be designed so that the radial side of the ring finger is covered by the volar skin (Fig. 106.12A-C). This may make it more comfortable for the patient to wear a ring.

• A proximally based dorsal rectangular flap is used for webspace reconstruction. It is designed by marking the midpoint of the metacarpal head to the midpoint of each proximal phalanx. • The points are connected by lines that form a proximally based flap with its base at the level of metacarpal heads (Fig. 106.10). The dorsal flap is designed wider at the base and narrower at the distal aspect of the flap. • The interdigitating flaps are designed using two Z-shape lines, one dorsal and the other on the volar aspect of the hand such that they form mirror images (Fig. 106.11).

CHAPTER 106  Release of Finger Syndactyly Using Dorsal Rectangular Flap

D C B

A

FIGURE 106.9  The third webspace is the most distal. Reprinted with permission from Ni F, Mao H, Yang X, Zhou S, Jiang Y, Wang B. The Use of an Hourglass Dorsal Advancement Flap Without Skin Graft for Congenital Syndactyly. J Hand Surg. 2015;40(9):1748-1754.e1.

FIGURE 106.10  The dorsal rectangular flap is designed by marking the midpoint of metacarpal head to the midpoint of each proximal phalanx.

The dorsal Z is drawn first by connecting the following four points: A and C are on one digit, whereas B and D are the adjacent digit (see Fig. 106.10). A: The distal corner of the dorsal rectangular flap B: The midpoint of the dorsal crease at the proximal interphalangeal (PIP) joint C: The midpoint of the middle phalanx D: The midpoint of the dorsal crease at the distal interphalangeal (DIP) joint • The Z-shape line should be the same level on the dorsal side and the volar side (see Fig. 106.10).

PROCEDURE Step 1: Flap Elevation • The skin markings are incised and the skin flaps are elevated. • The interdigitating dorsal and volar flaps are elevated only to the edge of each finger to prevent unnecessary tendon exposure.

Step 2: Separation of Digits • The distal fingertip containing the nail plate is cut sharply using scissors. • Longitudinal neurovascular structures are identified and preserved. • Tenotomy scissors are used to spread transversely between the fused digits. Transverse fascial bands are identified and sharply divided in a distal to proximal direction. The digits should be completely released to the level of the transverse intermetacarpal ligament, which is spared (Fig. 106.14).

Step 3: Skin Flap Inset • The proximally based dorsal rectangular flap is advanced into the newly created webspace and secured using 4-0 or 5-0 chromic suture. The flap should easily advance into the new webspace without tension. • Preliminary inset of the digital flaps with a few tacking stitches provides the opportunity to assess how best to proceed with definitive inset. • Plan to inset the digital flaps with the goal of leaving a larger recipient skin defect rather than multiple defects that will require more time for inset of multiple smaller grafts.

FIGURE 106.11  Interdigitating flaps are designed using two Z-shaped lines that form a mirror image; one volar and one dorsal. EXPOSURES PITFALLS

Although data suggest higher rates of hypertrophic scarring with techniques using a skin graft, we avoid the use of a dorsal metacarpal advancement flap (Fig. 106.13) because it inevitably leads to scarring of the dorsal hand. STEP 1 PEARLS

Although opposing Buck-Gramcko flaps (i.e., thin skin flaps used to cover the sides of the separated nail folds) are an option for fingertip reconstruction, simply suturing the skin graft to the nail plate leads to acceptable results and avoids the risk for partial loss of small skin flaps.

797

798

CHAPTER 106  Release of Finger Syndactyly Using Dorsal Rectangular Flap

STEP 1 PITFALLS

To avoid flap necrosis, care is taken to elevate the skin flaps with a small amount of subcutaneous fat. STEP 2 PEARLS

• The bifurcation of the neurovascular bundle commonly lies distal to the predicted webspace (Fig. 106.15). Both should be retained; however, ligation of one branch can be performed if the other digital artery is normal. • Bone exposure during digital separation may occur. Despite this concern, we have not had poor wound healing after skin grafting over exposed bone in children with syndactyly.

STEP 3 PEARLS

• The interdigitating flaps should not be sutured under tension. Judicious flap defatting may be performed to decrease tension on the skin flaps during closure. • Small open areas may be left open to heal secondarily, but diligent wound care must be performed to prevent synechiae of adjacent open wounds. Larger skin-deficient areas will require a full-thickness skin graft.

A

B

Full-thickness skin graft

Volar skin flap

STEP 3 PITFALLS

Deflating the tourniquet after definitive flap and skin graft inset may result in the need for suture removal if there is any compromise of digital circulation.

C

Dorsal skin flap

FIGURE 106.12  (A–C) Syndactyly release of the long and ring fingers.

FIGURE 106.13  Scarring after dorsal metacarpal advancement flap.

CHAPTER 106  Release of Finger Syndactyly Using Dorsal Rectangular Flap

FIGURE 106.14  Digits released to the level of the transverse intermetacarpal ligament.

FIGURE 106.15  Bifurcation of the neurovascular bundle.

• Tight flap closure will impair digital circulation and requires removing previously placed sutures. Tack the flaps down securely and without tension, instead of advancing them too tightly. • The tourniquet is then deflated and hemostasis is ensured. • The interdigitating flaps are completely inset across the digits.

Step 4: Harvest of Full-Thickness Skin Graft • If the skin defect is not sufficiently covered using the interdigitating flaps, a fullthickness skin graft from the groin is used. The donor site is infiltrated with 0.5% lidocaine with epinephrine early in the case to enable graft elevation in a hemostatic and efficient manner (Fig. 106.16). • An elliptical skin graft is harvested along the groin crease using a No. 15 scalpel. The graft is taken along the lateral groin to minimize future hair growth at the recipient site. The skin and dermis are elevated sharply with a scalpel and any additional subcutaneous fat is removed with scissors.

FIGURE 106.16  Preparing to harvest a full-thickness skin graft from the groin, after infiltrating with 0.5% lidocaine with epinephrine. The vasoconstrictive effect facilitates harvest and minimize blood loss.

799

800

CHAPTER 106  Release of Finger Syndactyly Using Dorsal Rectangular Flap

FIGURE 106.17  The skin graft donor site dermis is reapproximated using absorbable sutures. POSTOPERATIVE PEARLS

• Web creep can occur with normal hand growth and can be prevented by early release of the fingers and exaggerating the webspace depth during surgery. For complicated cases that have joint instability or skeletal deformity, arthrodesis may be considered after skeletal maturity. • It is common that the affected digits deviate toward each other after separation, and the family should be reassured that this is expected.

POSTOPERATIVE PITFALLS

• Short-term complications after syndactyly release may include skin necrosis, skin graft failure, or neurovascular injury. • Long-term complications may include web creep or scar contracture. Revision scar release with or without a skin graft is occasionally required. • Keloid scarring has been reported in 1% to 2% of patients.

FIGURE 106.18  Full-thickness skin graft fills defects on the fingers.

• The skin graft donor site dermis is reapproximated using absorbable suture and the skin is reapproximated with either interrupted chromic sutures or a subcuticular Monocryl suture (Fig. 106.17). • The skin graft is then cut to fill defects on the fingers. It is technically easier to cover fewer, larger skin defects than many small skin defects (Fig. 106.18).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • Dressings are applied to provide gentle compression on the skin grafts. • The wound should be protected using a long arm cast for 2 to 3 weeks to prevent shear injury to the skin grafts and to promote healing; it is imperative that the elbow be flexed at least 90 degrees to prevent cast removal (Fig. 106.19). The olecranon should be well-padded to prevent skin breakdown, whereas the antecubital fossa should have limited padding to facilitate adequate molding of the splint. • If the webspace is not fully healed, the parents must be taught to put Xeroform gauze between the fingers to prevent open wounds from healing to each other. • Hand therapy may be useful to educate the parents regarding scar massage to improve scar thickness. Additionally, postoperative splints with elastomer inserts may be helpful to prevent hypertrophic scarring and web creep. • Ten-year follow-up photos of a bilateral fourth webspace syndactyly reconstruction are shown in Figs. 106.20 and 106.21. See Video 106.1

FIGURE 106.19  Flexing the elbow prevents removal of long arm cast.

FIGURE 106.20  Ten-year follow-up of bilateral fourth webspace syndactyly reconstruction (dorsal view).

CHAPTER 106  Release of Finger Syndactyly Using Dorsal Rectangular Flap

FIGURE 106.21  Ten-year follow-up of bilateral fourth webspace syndactyly reconstruction (volar view).

EVIDENCE Hsu VM, Smartt Jr JM, Chang B. The modified V-Y dorsal metacarpal flap for repair of syndactyly without skin graft. Plast Reconstr Surg. 2010;125:225–232. This is a retrospective report of 28 syndactyly releases without using a skin graft. Only two patients (7.1%) experienced postoperative complications. The authors suggest that skin grafting can be omitted for simple syndactyly if there is sufficient skin to cover the middle and distal phalanges with local flaps (Level V evidence). Goldfarb CA, Steffen JA, Stutz CM. Complex syndactyly: Aesthetic and objective outcomes. J Hand Surg Am. 2012;37(10):2068–2073. The authors analyzed the results of 25 complex syndactyly webspace reconstructions using a dorsal commissural flap and full thickness skin grafts. Patients returned for clinical examination and subjective assessment at an average of 9 years after the most recent surgery. Angular and rotations deformities were common and there was a notable nail wall deformity in most fingers. Surgeon visual analog scale (VAS) scores (range, 0–10) averaged 2.8, whereas patient VAS scores were 0.4 for pain, 1.9 for appearance, and 1.1 for function. The authors conclude that complex syndactyly reconstruction is challenging, and common postsurgical findings include rotational and angular deformity and nail deformity (Level III evidence). Barabás AG, Pickford MA. Results of syndactyly release using a modification of the Flatt technique. J Hand Surg Eur. 2014;39:984–988. The authors analyzed the results of 144 congenital syndactyly releases using a modified Flatt technique (dorsal hourglass flap, interdigitating zigzag flaps, and full-thickness skin grafts) with a mean followup of 5 years. Web creep occurred in 4.2% of web releases. They suggest that avoiding longitudinal straight-line scars across the webspace may be an important factor in avoiding web creep (Level V evidence). Sullivan MA, Adkinson JM. A systematic review and comparison of outcomes following simple syndactyly reconstruction with skin grafts or a dorsal metacarpal advancement flap. J Hand Surg Am. 2017;42:34–40. This systematic review compared the outcomes of simple syndactyly reconstruction with skin grafts versus techniques using only a dorsal metacarpal advancement flap. Overall, skin grafting procedures were associated with more complications (e.g., flap necrosis/graft failure, contracture, web creep, hypertrophic scarring) and a greater need for revision. When stratified by subtype, patients with simple, complete syndactyly who underwent skin grafting had a significantly higher rate of hypertrophic scarring than those who underwent dorsal metacarpal advancement flap reconstruction (Level II evidence). Yuan F, Zhong L, Chung KC. Aesthetic Comparison of two different types of web-space reconstruction for finger syndactyly. Plast Reconstr Surg. 2018;142(4):963–971. The authors compared the long-term aesthetic outcomes of techniques using skin grafts (29 patients) versus the dorsal pentagonal advancement flap technique without skin grafting (16 patients). They found that the dorsally based rectangular flaps with skin grafting had statistically significantly better visual analog scale scores and a greater odds of receiving an “excellent” rating compared with dorsal pentagonal advancement flaps. The authors conclude that dorsal rectangular flaps may offer better overall aesthetic outcomes for patients despite the use of a skin graft (Level II evidence).

801

CHAPTER

107

Duplicated Thumb and Finger Treatment Joshua M. Adkinson and Kevin C. Chung Polydactyly Reconstruction . Radial polydactyly (i.e., thumb duplication) 1 a. Type II thumb duplication b. Type IV thumb duplication 2. Ulnar polydactyly a. Type B ulnar polydactyly

Reconstruction of Type II and Type IV Thumb Duplication INDICATIONS • Thumb polydactyly is among the most common congenital hand conditions, with an incidence of 1 in 10,000 live births. Reconstruction is generally recommended to improve the size and shape of the thumb. Although children with a duplicated thumb may function well without reconstruction, the stigma of an uncorrected congenital deformity may not be acceptable for the child or the family. • Thumb reconstruction should be considered around 12 months of age, before the development of substantial deviation of the duplicated elements and because general anesthesia is safer at this age. Additionally, dissection of anatomic structures is technically easier compared with surgery at younger ages. This surgical timing also permits recovery before development of integrated thumb-index tip-to-tip pinch, which occurs between 12 to 15 months of age.

Contraindications Contraindications include: • Parental reluctance to proceed with surgery • Medical comorbidities that would preclude safe surgery

CLINICAL EXAMINATION • Classification of the duplicated thumb is based on the level of the duplicated elements, which ranges from type I (bifid distal phalanx) to type VII (triphalangeal thumb). Type IV is the most common (40%–50%) and represents a complete duplication of the proximal and distal phalanges (Table 107.1). • The duplicated elements are abnormal in size and shape. Therefore some surgeons prefer to call it a “split” thumb rather than a “duplicated” thumb. Generally, the duplicated radial digit is smaller in length and width. The surgeon should examine the thumb for the level of duplication, the degree of hypoplasia of each component, stability of the involved joints, and position of the thumb with respect to the bony axis and first webspace (Fig. 107.1A–B). • Genetic counseling is typically only indicated in type VII thumbs because this condition is inherited in an autosomal dominant pattern and is associated with other hematologic, cardiovascular, and musculoskeletal anomalies (Fig. 107.2).

IMAGING Pre-operative radiographs are useful to identify the anatomy of duplicated elements. The osseous anatomy is always abnormal, with varying degrees of bony hyperplasia, widening, and/or angulation of the articular surfaces. Fig. 107.3 shows radiographs of type IV.

802

CHAPTER 107  Duplicated Thumb and Finger Treatment

TABLE 107.1 Classification of Thumb Duplication

Type

Anatomic Description

%

I

Bifid distal phalanx

4

II

Duplicated distal phalanx sharing common distal interphalangeal joint articulation

16

III

Bifid proximal phalanx

11

IV

Duplicated proximal phalanx sharing common metacarpal articulation

40

V

Bifid metacarpal

10

VI

Duplicated metacarpal sharing common carpal articulation

4

VII

Triphalangeal thumb

20

A

SURGICAL ANATOMY • The flexor and extensor tendons split and insert eccentrically into the base of the distal phalanges. The intrinsic musculature is aberrant. In proximal duplications, the opponens pollicis (OP) inserts on the radial duplicate metacarpal and the abductor pollicis brevis (APB) and flexor pollicis brevis (FPB) insert on the proximal phalanx of the radial duplicate. A divergent-convergent configuration of the duplicated elements may also occur. This results from the net effect of the split flexor pollicis longus (FPL) pulling the distal phalanges into convergence, whereas the thenar intrinsic muscles pull the proximal phalanges into divergence (Fig. 107.4). A pollex abductus (i.e., abnormal ligamentous connection between the FPL and extensor pollicis longus [EPL]) is present in up to 20% of duplicated thumbs and may contribute to thumb interphalangeal (IP) joint stiffness and abduction.

B FIGURE 107.1  (A) Type II thumb. (B) Type IV thumb.

803

804

CHAPTER 107  Duplicated Thumb and Finger Treatment

FIGURE 107.3  Type IV thumb radiograph.

FIGURE 107.2  Triphalangeal thumb.

Divergent tendons of flexor pollicis longus Abductor pollicis brevis Flexor pollicis brevis

Divergent tendons of extensor pollicis longus Extensor pollicis longus Extensor pollicis brevis

FIGURE 107.4  Forces crossing the thumb MCP joint leading to a divergent-convergent configuration of the duplicated elements. MCP, Metacarpophalangeal.

• The ulnar collateral ligament is necessary for thumb stability during pinch. This structure is typically preserved because the ulnar duplicate is retained. • The arterial supply of the duplicated digits most commonly arises from a single digital artery on the ulnar side of the ulnar and radial duplicate (74%). Twelve percent of patients have three digital arteries; an ulnar and radial digital artery for the ulnar duplicate and an ulnar digital artery for the radial duplicate. Ten percent of duplicated thumbs will have four digital arteries, whereas 5% of duplicated thumbs will have a single ulnar digital artery supplying the ulnar duplicate.

POSITIONING • The operation is performed under general anesthesia with the patient supine on the operating table. A tourniquet is placed on the upper arm and the entire extremity is prepared and draped. • Intraoperative fluoroscopy is often required to confirm anatomy, thumb alignment, or in planning and performing osteotomies and placement of Kirschner wires (K-wires). The operative table should be positioned to provide easy access to the C-arm.

805

CHAPTER 107  Duplicated Thumb and Finger Treatment EXPOSURES PEARLS

EXPOSURES When ablating the radial thumb, one must retain a periosteal flap from the radial collateral ligament of the resected thumb to reconstruct the radial collateral ligament of the retained thumb. The EPL of the resected thumb can be transferred to the ulnar side of the retained thumb to augment and rebalance thumb IP joint extension.

RECONSTRUCTION OF TYPE II THUMB DUPLICATION Step 1 • The radial thumb duplicate is selected for removal. A racquet-shaped incision is designed on the radial thumb (Fig. 107.6A–B). • The skin flaps and soft tissues are elevated, and the radial aspect of the IP joint is identified. • The distal insertion of the flexor tendon, extensor tendon, and radial collateral ligament are carefully elevated off of the base of the radial duplicate distal phalanx (Fig. 107.7).

A

The Bilhaut-Cloquet procedure was developed in an effort to combine elements of both thumbs into a single thumb (Fig. 107.5A–B). Although conceptually appealing, it is exceedingly difficult to create an aesthetically pleasing thumb by unifying the distal phalanges and soft tissue envelope of the duplicated elements. The technique is difficult to perform and often leads to nail deformity and IP joint stiffness. As such, many surgeons have abandoned this technique. It is preferable to accept a smaller, more aesthetically appealing thumb by using soft tissue from the resected thumb to augment the retained thumb. STEP 1 PEARLS

The radial duplicate is selected for ablation because removal of the ulnar duplicate may compromise IP joint ulnar collateral ligament (UCL) stability with pinch and leave a painful scar on the contact-bearing aspect of the thumb.

B

FIGURE 107.5  The Bilhaut-Cloquet procedure, combining elements of both thumbs into a single thumb. Ulnar side

Radial side

Collateral ligament

A

B FIGURE 107.6  (A–B) Type II thumb preoperative thumb markings.

FIGURE 107.7  The RCL is carefully elevated from the radial duplicate distal phalanx base. RCL, Radial collateral ligament.

806

CHAPTER 107  Duplicated Thumb and Finger Treatment

*

FIGURE 107.8  The redundant head of the proximal phalanx is removed with a knife.

FIGURE 107.9  The RCL (black star on flap) is attached to the radial base of the retained thumb distal phalanx. RCL, Radial collateral ligament.

Step 2 The radial duplicated thumb is removed at the level of the IP joint.

Step 3

STEP 5 PITFALLS

Care is taken to follow the curve of the needle when placing transosseous sutures to prevent pulling through the soft bone. STEP 6 PEARLS

Reattaching the radial duplicate FPL into the central volar base of the retained ulnar duplicate is technically difficult because of the need to dissect the pulp of the digit to expose the FPL insertion site. As such, we often only perform extensor tendon transfer.

The proximal attachment of the radial collateral ligament is protected, and the redundant head of the proximal phalanx is removed with a knife (in young children where the bone is soft) or osteotome (in older children/adults with ossified bone; Fig. 107.8).

Step 4 The retained distal phalanx is centralized over the proximal phalanx. The centralized position is maintained using a single longitudinal 0.035-inch K-wire passed retrograde through the distal phalanx into the proximal phalanx.

Step 5 The radial collateral ligament is reattached to the radial base of the retained thumb distal phalanx using 4-0 nonabsorbable sutures (Fig. 107.9). It is easy to pass the suture needle through metaphyseal bone in young patients because the bone is primarily cartilaginous and soft.

Step 6 Residual minor malalignment of the digit can be addressed by reattaching the elevated extensor and flexor tendon insertions into the central base of the retained distal phalanx (Fig. 107.10).

Step 7 • The tourniquet is released and hemostasis ensured. Skin closure is performed using absorbable suture. The redundant skin may be inset using a W-plasty style closure to prevent future scar contracture (Figs. 107.11 and 107.12). • A long-arm thumb spica cast is applied, with the elbow in at least 90 degrees of flexion to prevent premature removal (see Fig. 106.19 in the chapter 106 “Release of Finger Syndactyly Using Dorsal Rectangular Flap”). The olecranon is well-padded to prevent skin breakdown, but limited padding is placed over the antecubital fossa to facilitate adequate molding of the splint.

RECONSTRUCTION OF TYPE IV THUMB DUPLICATION FIGURE 107.10  Reattaching the elevated extensor tendon insertions into the base of the retained distal phalanx to balance forces across the IP joint. IP, Interphalangeal.

Step 1 • The radial duplicate is selected for removal because it is usually smaller and removal does not disturb the ulnar collateral ligament of the retained thumb (Fig. 107.13). A racquet-shaped incision is designed as previously described (Fig. 107.14). The skin

CHAPTER 107  Duplicated Thumb and Finger Treatment

Collateral ligament

Z-plasty

FIGURE 107.11  The redundant skin may be resected and inset using a Z-plasty to prevent future scar contracture.

FIGURE 107.13  Type IV thumb.

FIGURE 107.12  Definitive closure of the incision.

FIGURE 107.14  Type IV thumb preoperative markings.

flaps are elevated to expose the radial aspect of the metacarpophalangeal (MCP) joint and the extensor mechanism. • The insertion of the thenar intrinsics into the radial aspect of the thumb is detached, and the radial collateral ligament (RCL) is elevated with an extended periosteal flap to enable reinsertion into the retained thumb proximal phalanx (Fig. 107.15A–B). • The extensor and flexor tendons to the duplicated thumb are transected at the level of the IP joint.

Step 2 The soft tissue connections between the duplicated elements are divided sharply and the radial duplicate is removed.

STEP 2 PITFALLS

A persistent pollex abductus can contribute to progressive angular deformity after surgery. If present, this should be divided with a knife.

807

808

CHAPTER 107  Duplicated Thumb and Finger Treatment

*

A

B

FIGURE 107.15  (A) RCL/APB flap marked for elevation. (B) RCL/APB flap (black star) held in forceps. APB, Abductor pollicis brevis; RCL, radial collateral ligament.

Collateral ligament

Proximal phalanx base

FIGURE 107.16  The RCL is carefully elevated from the radial duplicate proximal phalanx base. RCL, Radial collateral ligament.

Metacarpal head

FIGURE 107.17  The redundant head of the metacarpal is removed with a knife.

STEP 3 PEARLS

Step 3

With the goal of a straight thumb at the conclusion of the procedure, an osteotomy may be necessary to correct any phalangeal angular deformity. The osteotomy can be performed using a Rongeur or bone cutter, taking care to protect the tendons and neurovascular (NV) structures. Because growth in children is unpredictable, we do not always perform corrective osteotomy at the time of the initial procedure but await correction when the needs arise at a later age.

If bifid or wide, a resection of the metacarpal head is performed to reduce its sagittal plane prominence. In younger children, this may be performed using a scalpel with a sawing motion over the unossified metacarpal. Extreme care should be used when performing this maneuver to prevent transection of the elevated radial collateral ligament (Figs. 107.16 and 107.17).

Step 4 The thumb is aligned and secured in place using a retrograde longitudinal or oblique 0.035-inch K-wire traversing the MCP joint (Fig. 107.18).

Step 5 The periosteal flap carrying the radial collateral ligament and the thenar intrinsic insertion is sutured to the radial base of the ulnar thumb proximal phalanx using 4-0 nonabsorbable suture. If necessary, additional sutures may be placed to reinforce the origin of the radial collateral ligament at the metacarpal head (Fig. 107.19).

CHAPTER 107  Duplicated Thumb and Finger Treatment

*

FIGURE 107.18  Pin fixation of the thumb MCP joint. MCP, Metacarpophalangeal.

FIGURE 107.19  The RCL/APB flap (black star) reattached to the radial base of the retained thumb proximal phalanx. APB, Abductor pollicis brevis; RCL, radial collateral ligament.

Step 6 If necessary, the duplicated EPL of the resected thumb can be sutured to the ulnar aspect of the retained thumb distal phalanx to balance the deforming forces acting across the thumb IP joint. This may be performed through the radial incision or passed subcutaneously to an additional incision over the ulnar aspect of the distal phalanx (Fig. 107.20).

Step 7 • The tourniquet is released and hemostasis ensured. Skin closure is performed using absorbable suture after excision of redundant skin (Fig. 107.21).

Radial

Ulnar

Extensor tendon

FIGURE 107.20  The duplicated extensor tendon transferred to the ulnar aspect of the retained thumb distal phalanx to balance the deforming forces acting across the thumb MCP and IP joints. IP, Interphalangeal; MCP, metacarpophalangeal.

FIGURE 107.21  Definitive closure of the incision.

809

810

CHAPTER 107  Duplicated Thumb and Finger Treatment

• A long-arm thumb spica cast is applied, with the elbow in at least 90 degrees of flexion to prevent premature removal (see Fig. 106.19 in the chapter 106 “Release of Finger Syndactyly Using Dorsal Rectangular Flap”). The olecranon is well-padded to prevent skin breakdown, but limited padding is placed over the antecubital fossa to allow for adequate molding of the splint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The K-wire is removed between 4 and 6 weeks postoperatively. • The development of an angular deformity is not uncommon during growth. As such, patients should be reevaluated annually. If a progressive deformity occurs, a corrective osteotomy may be performed to straighten the thumb. Fig. 107.22A–B shows preoperative and postoperative x-rays of an opening wedge osteotomy of the proximal phalanx. • Fig. 107.23A–B shows 1-year postoperative photos of a Wassel II. Fig. 107.24A–B shows preoperative and 2-week postoperative photos.

A

B

FIGURE 107.22  (A) Type IV thumb preoperative x-ray. (B) Type IV thumb postoperative x-ray after opening wedge osteotomy of proximal phalanx.

A

B FIGURE 107.23  (A–B) Right thumb type II reconstruction, 4 years postoperatively.

CHAPTER 107  Duplicated Thumb and Finger Treatment

A

B FIGURE 107.24  (A–B) Right thumb type IV reconstruction, 2 weeks postoperatively.

Ulnar Polydactyly INDICATIONS • The classification of postaxial polydactyly according to Temtamy and McKusick is as follows: • Type A: An extra digit is fully formed and articulates with the fifth or a sixth metacarpal (Fig. 107.25A). • Type B: A rudimentary digit exists as ulnar duplication attached only by a soft tissue stalk (see Fig. 107.25B). • A type B digit on the ulnar side of the hand, termed a nubbin, is poorly formed and attached via a neurovascular stalk.

Contraindications One contraindication is parental reluctance to proceed with removal.

CLINICAL EXAMINATION • Children with polydactyly are born with one or more extra digits. • Although bone and nail structures may be present in a type B polydactylous digit, there are no osseous and ligamentous structures connecting the digit to the hand. • Hand function is rarely affected by ulnar polydactyly.

A

B

FIGURE 107.25  (A) An extra digit is fully formed and articulates with the fifth or a sixth metacarpal. (B): A rudimentary developed digit exists as ulnar duplication attached only by a soft tissue stalk.

CLINICAL EXAMINATION PEARLS

Ulnar polydactyly may be one feature of a genetic condition or syndrome, such as Down syndrome or Meckel syndrome.

811

812

CHAPTER 107  Duplicated Thumb and Finger Treatment

Type B Ulnar Polydactyly TYPE B ULNAR POLYDACTYLY Step 1 Treatment is performed with either suture ligation or surgical resection.

Suture Ligation • Suture ligation is performed in the newborn nursery or during a clinic visit. • Ligation interrupts the blood supply to the duplicated digit. This results in dry gangrene and subsequent auto-amputation. • Nevertheless, suture ligation often leaves a residual stump in up to 40% of cases that may require a formal excision in the operating room, because it is difficult to ligate precisely at the base of the digit.

Surgical Resection Option 1: Vascular Clipping and Excision for Neonates • • • •

This can be performed in the operating room or in the clinic. An effective approach is to clip the digit in the clinic when the baby is feeding. A vascular clip is placed at the base of the duplicated digit. Local anesthetic is not necessary. The soft tissue stalk is cut using scissors just distal to the clip (Fig. 107.26). • By clipping and cutting at the very base of the digit, a residual stump can be prevented, whereas suture ligation tends to slip off the base to the narrowest point of the pedicle. • This procedure is preferred because it does not require general anesthesia and can be done rapidly with minimal risk. This is convenient for the parents and obviates the risk and cost of general anesthesia in an operating room.

Option 2: Surgical Resection in the Operating Room in Older Infants Who Cannot Tolerate Clipping

FIGURE 107.26  Vascular clip applied to polydactyly stalk. STEP 1 PEARLS

In bilateral polydactyly cases, both digits can be addressed in the same surgical session. STEP 1 PITFALLS

Ligation alone may fail or result in the development of a digital neuroma stump. The residual stump can be excised later, if desired by the patient or family.

• Under general anesthesia, the hand is prepared and draped. • Local anesthetic can be used for pain control. • An ellipse is marked around the junction of the neurovascular stalk of the type B polydactyly and the adjacent small finger (Fig. 107.27A). • The stalk and polydactylous digit are excised under tension to permit the digital nerve stump to settle within the soft tissues of the unaffected digit (see Fig. 107.27B). • After obtaining hemostasis, the skin is closed with absorbable suture.

Step 2 After completing the procedure, a soft bandage is placed on a hand.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • If the surgical clip remains intact, it should be removed 2 weeks after the procedure. • Although revision for residual tissue or scarring may be needed later in some cases, a good clinical and cosmetic outcome is typically achieved. See Videos 107.1 and 107.2

CHAPTER 107  Duplicated Thumb and Finger Treatment

A

B

FIGURE 107.27  (A) Markings for postaxial polydactyly excision. (B) Closure after excision of polydactyly and transection of the neurovascular stalk.

EVIDENCE Mullick S, Borschel GH. A selective approach to treatment of ulnar polydactyly: preventing painful neuroma and incomplete excision. Pediatr Dermatol. 2010;27(1):39–42. The authors present treatment options for ulnar polydactyly and review a series of 10 patients (13 hands) in whom previous suture ligation was performed, resulting in a residual neuroma stump. The authors report that all 10 patients were successfully treated with completion amputation of the residual stump combined with proximal ligation of the supernumerary digital nerves. The authors recommend an individualized treatment approach rather than performing suture ligation for all patients with Type B ulnar polydactyly (Level IV evidence). Dijkman R, Selles R, van Rosmalen J, et al. A clinically weighted approach to outcome assessment in radial polydactyly. J Hand Surg Eur Vol. 2016;41(3):265–274. In this study, the authors sought to develop an outcome assessment system based on clinical data. They performed linear regression analysis on data from a multicenter study of 121 patients with radial polydactyly types II, IV, and VII to develop a clinically weighted outcome assessment system. Active flexion, scar appearance, and prominence at amputation site were the main items influencing overall functional and aesthetic outcome. Palmar abduction, MCP joint deviation, and nail appearance influenced overall functional and aesthetic outcome the least. The authors conclude that their assessment system accurately reflects clinician impressions of outcomes and helps guide treatment and evaluation of outcome (Level III evidence). Gholson JJ, Shah AS, Buckwalter JA, Buckwalter JA. Long-term clinical and radiographic follow-up of preaxial polydactyly reconstruction. J Hand Surg Am. 2019;44(3):244. The authors sought to determine the long-term results of preaxial polydactyly reconstruction by evaluating strength, range of motion, pain, arthritis, and functional outcomes. Patients having preaxial polydactyly reconstruction 15 to 60 years ago (median 36 years) completed the Disabilities of the Arm, Shoulder, and Hand (DASH) and Patient-Reported Outcomes Measurement Information Systems (PROMIS) surveys. Patients completed a clinical evaluation comprising grip strength, pinch strength, side pinch strength, and range of motion and underwent radiographs of the reconstructed thumb to evaluate for arthritis. The mean DASH score was 3.7, similar to the general population mean of 10.1 (standard deviation [SD], 14.5). The mean PROMIS score was 51.5, similar to the general population mean of 50 (SD, 10.0). The mean pinch strength, side pinch strength, and grip strength did not differ significantly from the contralateral extremity. There was significantly decreased range of motion at the IP joint. No patient had pain in the thumb or hand on clinical evaluation; 15.4% of patients developed radiographic evidence of IP joint arthritis; and 46.2% had an angular deformity. The authors conclude that thumb polydactyly patients have functional outcomes similar to the general population, despite decreased range of motion at the IP joint. None of the patients with radiographic arthritis had associated pain. Given the risk for late angular deformity, the authors recommend close follow-up until skeletal maturity (Level IV evidence).

813

CHAPTER

108

Index Pollicization for Hypoplastic Thumb Joshua M. Adkinson and Kevin C. Chung INDICATIONS • Indications include hypoplastic thumbs with an inadequate carpometacarpal (CMC) joint (Blauth types IIIB and IV) or complete absence of the thumb (Blauth type V). • Pollicization is generally offered at 12 to 18 months of age because general anesthesia is safer and structures are larger, facilitating dissection. Surgery at this age also permits time for preliminary correction of any associated radial deficiencies (typically addressed between 3–6 months of age). Finally, cortical representation of the thumb has not yet solidified at this age.

Contraindications Contraindications include: • Hypoplastic thumbs with a functional CMC joint (Blauth types I, II, and IIIA) • Parental reluctance to proceed with surgery • Medical comorbidities that would preclude safe surgery • A poorly developed, stiff index finger (a relative contraindication)

CLINICAL EXAMINATION • The Blauth classification system is useful because it correlates with surgical treatment (Table 108.1). • Types IV (floating thumb; Fig. 108.1) and V (absent thumb; Fig. 108.2) are straightforward to identify clinically. It can be difficult, however, to distinguish type IIIA (stable CMC joint) from type IIIB (unstable CMC joint) thumbs. Because the trapezium and trapezoid ossify around 5 to 6 years of age, radiographs cannot be relied on to assist in diagnosis. • Serial examination of the child is required to differentiate a type IIIA from a type IIIB thumb. A newborn uses digital grasp, whereas infants begin using the thumb in FIGURE 108.1  Type IV (floating thumb).

TABLE 108.1 Blauth Classification of Thumb Hypoplasia and Treatment Options

Type

Features

Treatment Options

I

Mild hypoplasia with all elements present

No treatment

II

Narrow first web, ulnar collateral ligament insufficiency, and absence of thenar intrinsic muscles

No treatment Z-plasty of first web, UCL strengthening/reconstructions, and opponensplasty

III

Type II plus extrinsic tendon deficiencies and/or skeletal deficiency

IIIA

Stable CMC joint

Same as type II

IIIB

Unstable CMC joint

Pollicization

IV

Absent metacarpal and rudimentary phalanges “Pouce flottant”

Pollicization

V

Total absence

Pollicization

CMC, Carpometacarpal; UCL, ulnar collateral ligament.

FIGURE 108.2  Type V (absent thumb).

814

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

grasp at about 1 year of age. If the child uses the thumb when manipulating objects, this suggests that the CMC joint is stable. If the child prefers to grasp objects between the index and long finger (i.e., scissor pinch), the web will appear wider and the index finger will begin to pronate; these findings suggest an unstable CMC joint (type IIIB thumb hypoplasia). • Children with types IV and V hypoplasia may exhibit varying degrees of index finger stiffness and hypoplasia, which can adversely affect results after pollicization. • Because many other anomalies are associated with thumb hypoplasia, the child should be thoroughly examined. The hand surgeon may be the first medical care provider to evaluate the patient. Specifically, children should be evaluated for VACTERL association (i.e., vertebral abnormalities, anal atresia, cardiac abnormalities, tracheoesophageal fistula and/or esophageal atresia, renal agenesis and dysplasia, and limb defects), Fanconi anemia, TAR (thrombocytopenia-absent radius) syndrome, and Holt-Oram syndrome.

IMAGING • Radiographs of the hands are useful in determining the degree of metacarpal and phalangeal hypoplasia. Because the patient is often evaluated in infancy, the osseous anatomy may not be readily apparent on imaging. Radiographs of the forearms and wrists can also identify other associated upper extremity anomalies, such as radial deficiency (Fig. 108.3A) or radial head dislocation (see Fig. 108.3B). • The age of the child can be estimated based on the number of carpal bones seen on the radiograph (Fig. 108.4A). The order of ossification of carpal bones is detailed in Fig. 108.4B. In general, approximately one ossification center appears per year from the ages of 1 year to 7 years. • Type IIIA hypoplasia is associated with full length of the metacarpal (Fig. 108.5), whereas a tapered metacarpal without a base reflects a type IIIB hypoplastic thumb.

SURGICAL ANATOMY After pollicization of an index finger, the common digital artery to the index long webspace becomes the primary arterial supply to the transposed digit. The radial digital artery to the index finger is often attenuated or absent, but this finding should not affect the ability to proceed with pollicization.

A

B FIGURE 108.3  (A) Radial longitudinal deficiency. (B) Radial head dislocation.

815

816

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

2 years 1 year

12 years

3 years

7 years Hamate Trapezoid 6 years

Pisiform

Capitate

Trapezium

Triquetrum Scaphoid Lunate

B

5 years

4 years

A

FIGURE 108.4  (A) Type IV hypoplastic thumb with 2 visible carpal bones (indicating patient is 2 years of age). (B) Order of ossification of carpal bones.

A

FIGURE 108.5  Type IIIA hypoplasia with full length of the metacarpal.

B

FIGURE 108.6  (A) Volar markings for type IIIB thumb. (B) Volar markings for type IV thumb.

EXPOSURES PEARLS

Pollicization is a complex procedure that requires meticulous attention to detail. We recommend a stepwise approach to conceptually organize and simplify the reconstruction (Table 108.2). EXPOSURES PITFALLS

There are many modifications of skin flap design; it is substantially more important to adhere to basic principles of pollicization than to select the “best” incision design. Poorly planned skin incisions can result in inadequate soft tissue coverage of the first webspace, leading to difficulty with full thumb abduction and the need for skin grafting for coverage. Ideally, the first webspace should have supple soft tissue coverage without scars to optimize thumb opposition.

POSITIONING • The procedure is conducted under general anesthesia with the patient supine on the operating room table. A well-padded tourniquet is placed on the upper arm and the limb is prepared and draped in the usual fashion. • Although some surgeons prefer gentle exsanguination to identify vascular structures, we prefer full exsanguination because this prevents blood staining from obscuring important neurovascular structures.

EXPOSURES A longitudinal curvilinear incision is marked over the palmar aspect of the index finger metacarpal (Fig. 108.7A–B). A V-shaped incision is marked over the dorsum of the index finger metacarpal such that the apex is at the level of the neck of the metacarpal (Fig. 108.6A–B). The dorsal and palmar incisions are then connected at the base of the index finger.

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

A

B

FIGURE 108.7  (A) Dorsal markings for type IIIB thumb. (B) Dorsal markings for type IV thumb.

TABLE 108.2 Twenty-Step Approach to Pollicization Step 1

Skin markings.

Step 2

Complete exsanguination.

Step 3

Skin flap elevation and exposure of neurovascular bundles.

Step 4

Ligation of the proper digital artery to the radial side of the long finger.

Step 5

Intraneural dissection and separation of common digital nerve to the second webspace (to prevent tension on proper digital nerve to index finger during later recession).

Step 6

Index finger first annular pulley release.

Step 7

Division of the second webspace transverse metacarpal ligament.

Step 8

Elevation of the dorsal skin flap with preservation of the dorsal veins.

Step 9

Index extensor tendons freed from adjacent extensor tendon/juncturae tendineae.

Step 10

Elevation of the first dorsal and first palmar interosseous muscles from the index metacarpal shaft and MCP joint.

Step 11

Complete release of the interosseous muscles from the MCP joint with a strip of extensor hood.

Step 12

Suture tagging of the index finger lateral bands (ensure that traction on these structures causes PIP joint extension).

Step 13

Osteotomy through the index metacarpal physis and metacarpal base.

Step 14

Suture fixation of the index MCP joint in hyperextension.

Step 15

Recession of the index finger (with or without temporary K-wire fixation) into thumb position (approximately 100 degrees of pronation and 45 degrees of abduction).

Step 16

Suture approximation of the epiphysis and metacarpal base.

Step 17

Intrinsic function restoration (first dorsal interosseous transferred to radial lateral band and first palmar interosseous transferred to ulnar lateral band).

Step 18

Loose skin flap inset.

Step 19

Tourniquet deflation, provision of hemostasis, and complete skin closure.

Step 20

Application of bulky, nonconstricting hand dressing and long arm cast with thumb exposed.

K-wire, Kirschner wire; MCP, metacarpophalangeal; PIP, proximal interphalangeal.

817

818

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

PROCEDURE

STEP 1 PEARLS

• Dissection of these small neurovascular structures will require the use of loupes with 3.5 or greater magnification. • The radial neurovascular bundle to the index finger may be hypoplastic or absent, but pollicization can still be performed because the ulnar common digital artery becomes the primary blood supply to the transposed digit. • The common digital arteries may arise from the deep arch and require more extensive dissection.

Step 1

STEP 3 PEARLS

Step 2

Transverse venous connections between the index and long fingers should be ligated, taking care to protect the outflow from the index finger.

• The A1 pulley of the index finger is divided longitudinally (Fig. 108.9). • The ulnar neurovascular bundle of the index finger is retracted radially, and the transverse metacarpal ligament between the index and long finger metacarpals is sharply divided at the neck of the metacarpal (Fig. 108.10). This maneuver results in substantial mobility of the index metacarpal, facilitating subsequent steps in the procedure.

STEP 3 PITFALLS

The radial and ulnar neurovascular (NV) bundles and dorsal veins must be protected during elevation of the interosseous muscles.

• The palmar skin is incised and thick skin flaps are raised. • The index finger radial digital neurovascular bundle is identified and isolated. If the child does not have this radial vessel or even if it is diminutive, the procedure can proceed because the major blood supply emanates from the common digital artery between the index and long fingers. The common digital artery to the second webspace is then identified. The dissection continues distally to isolate the ulnar digital artery to the index finger and the radial digital artery to the middle finger (Fig. 108.8). • The radial digital artery to the long finger is ligated using 6-0 Prolene suture immediately distal to the bifurcation. After this structure is divided, the index finger is entirely based on the common digital artery to the second webspace and the index finger radial digital artery, if present. The vessels are mobilized proximally to the level of the superficial arch to prevent tethering of the vessels with proximal transposition of the index finger. • Intraneural dissection of the common digital nerve may be required to separate the fibers of the ulnar digital nerve to the index finger from the fibers of the radial digital nerve to the middle finger. This dissection is carried proximally to the level of the superficial arch.

Step 3 • The dorsal skin is incised and flaps are raised at the dermal layer. It is critical to keep the dorsal veins within the subdermal layer to maintain venous outflow from the index finger (Fig. 108.11). • The juncturae tendineae between the index and long finger extensor tendons are identified and divided. • The first dorsal and palmar interossei are elevated off the radial and ulnar aspects of the metacarpal shaft, respectively. Only the proximal portion of these muscles originating from the base of the metacarpal are left undisturbed in preparation for future

*

FIGURE 108.8  Volar exposure with black star indicating radial digital artery to the middle finger.

*

FIGURE 108.9  Volar exposure with black star indicating divided A1 pulley.

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

*

FIGURE 108.11  Dorsal skin flap elevation with black star indicating veins within subdermal fat.

FIGURE 108.10  Exposure of the transverse metacarpal ligament before division.

First dorsal interosseous muscle FIGURE 108.12  Elevation of the first dorsal interosseous muscle before elevation.

insertion into the lateral bands. The tendons of these two muscles are carefully separated from the metacarpophalangeal (MCP) joint capsule and divided distally along with a small portion of the extensor hood (Fig. 108.12).

Step 4 While protecting the dorsal veins, the skin is elevated over the proximal phalanx and the extensor hood is identified. The radial and ulnar lateral bands are identified on either side of the midproximal phalanx. The location of these structures can be confirmed by placing them on traction and noting extension of the index finger proximal interphalangeal (PIP) joint (Fig. 108.13). The lateral bands are tagged with 6-0 Prolene suture for ease of future identification.

Step 5 • Distal and proximal osteotomies of the index finger metacarpal shaft are performed to shorten the finger and enable proximal recession. • The distal osteotomy is created beyond the neck of the metacarpal through the physis (Fig. 108.14A–B). In young patients, the physis is soft and a blade can be used for this osteotomy. The metacarpal epiphysis is now the new thumb trapezium.

STEP 5 PEARLS

• Although the metacarpal shaft is removed, the insertion of the flexor carpi radialis (FCR) and extensor carpi radialis longus (ECRL) proximally and the origin of the collateral ligaments distally must be spared. • After rotation and proximal transposition, the tip of the index finger should reach the PIP joint of the middle finger.

819

820

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

FIGURE 108.13  Dorsal dissection of the radial and ulnar lateral bands. Traction on the lateral bands results in PIP joint extension. PIP, proximal interphalangeal.

Distal osteotomy

First dorsal interosseous muscle B

A

FIGURE 108.14  (A–B) Proximal and distal index finger metacarpal osteotomy locations.

STEP 6 PEARLS

A normal index finger MCP joint can hyperextend 20 to 30 degrees beyond neutral. Hyperextension of a thumb CMC joint, however, is not desirable. STEP 7 PEARLS

• The position should be such that the pulp of the index finger is in contact with the radial aspect of the PIP joint and the proximal phalanx of the middle finger. • An oblique osteotomy of the metacarpal base can be created to improve the position of the thumb.

• The proximal osteotomy is done at the base of the metacarpal using a bone cutter and the metacarpal segment is removed (Fig. 108.15). • The index finger is now mobile and attached only by the dorsal veins, radial and ulnar NV bundles, and flexor and extensor tendons.

Step 6 To prevent hyperextension of the index finger MCP joint (the new thumb CMC joint), the dorsal capsule is sutured to the physis with 4-0 nonabsorbable suture when the joint is in maximal hyperextension.

Step 7 • The index finger is placed over the base of the index metacarpal. The index MCP joint will now function as the new thumb CMC joint. It is positioned in 45 degrees of

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

Palmar Dorsal

Side view FIGURE 108.16  Positioning of the thumb before definitive inset.

FIGURE 108.15  Excised index finger metacarpal segment.

palmar abduction and 100 to 120 degrees of pronation to recreate the position of the thumb (Fig. 108.16). • Additional 4-0 nonabsorbable sutures are placed between the epiphysis and the metacarpal base and surrounding soft tissues to stabilize the fixation.

Step 8 • Intrinsic function of the pollicized digit is restored via two tendon transfers. The first dorsal interosseous tendon is attached to the radial lateral band at the level of the midproximal phalanx to provide abduction of the pollicized index finger. The first palmar interosseus tendon is attached to the ulnar lateral band and functions as the thumb adductor (Fig. 108.17). These structures may be interwoven and secured using nonabsorbable suture. • The extensor and flexor tendons are left undisturbed and dynamically rebalance over time. The new anatomic functions of the index finger joints and muscle units are detailed in Table 108.3.

STEP 7 PITFALLS

• One must ensure that the palmar incision provides adequate exposure of the base of the metacarpal. An excessively long pollicized thumb is most often the result of not seating the index finger well proximally. It is almost impossible to make the thumb too short, but frequently the newly created thumb will be too long and have the appearance of a finger. Be sure to resect the index metacarpal as proximally as possible but also maintain the insertion of the ECRL tendon if present. Seat the index finger deeply within the wound to create an aesthetically appealing thumb. • Care should be taken to ensure that NV structures and tendons are not entrapped in the interface between the metacarpal base and the proximally transposed index finger.

DP → DP STEP 8 PEARLS

DIPJ → IPJ

• Interosseous muscle transfer to the lateral bands is conceptually the most difficult step in pollicization. • Proximal transposition of the index finger leads to redundancy in the extrinsic flexor and extensor tendons. To address this, some surgeons opt to shorten the extensor and flexor tendons during pollicization. We do not find this necessary because experience has shown that children regain active motion within months of surgery.

MP → PP PIPJ → MPJ PP → M MCPJ → CMCJ M (head) → Trapez. 1st PI → AddP 1st Pl

1st DI → AbPB (Abl) EIP → EPL

AbPB

EDC → AbPL

FIGURE 108.17  Diagram of tendon transfers and new muscle functions. AbPB, Abductor pollicis brevis; AbPL, abductor pollicis longus; AddP, adductor pollicis; CMCJ, carpometacarpal joint; DI, dorsal interosseous; DIPJ, dorsal interphalangeal joint; DP, distal phalanx; EDC, extensor digitorum communis; EIP, extensor indicis proprius; EPL, extensor pollicis longus; IPJ, interphalangeal joint; M, metacarpal; MCPJ, metacarpophalangeal joint; MP, middle phalanx; PI, palmar interosseous; PIPJ, proximal interphalangeal joint; PP, proximal phalanx.

821

822

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

TABLE 108.3 Functional Units of Pollicized Thumb

Unit

New Function

Skeletal Units Distal interphalangeal joint

Interphalangeal joint

Proximal interphalangeal joint

Metacarpophalangeal joint

Musculotendinous Units

STEP 10 PITFALLS

On rare occasions, the pollicized finger may appear pale after closure. The cause is usually vasospasm, which can be alleviated with warm soaks. If the perfusion does not improve within 15 minutes, any constricting skin sutures should be removed and the vascular inflow and outflow inspected. The most common cause of vascular insufficiency is a tight closure, which can be treated with a skin graft.

Extensor indicis proprius

Extensor pollicis longus

Extensor digitorum communis (index)

Abductor pollicis longus

First palmar interosseous

Abductor pollicis

First dorsal interosseous

Abductor pollicis brevis

Step 9 • The skin flaps are transposed and provisionally secured in position with widely placed 5-0 chromic sutures. • Fig. 108.18 illustrates the flap movement and index finger transposition.

Step 10 The tourniquet is deflated and the “thumb” is inspected for capillary refill and any evidence of vascular compromise. Taking care to protect the NV structures, meticulous hemostasis is ensured with bipolar electrocautery. The skin flaps are fully inset using 5-0 chromic suture (Fig. 108.19).

B

C

A

C

C

A

FIGURE 108.18  Flap movement and index finger transposition.

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

FIGURE 108.19  Skin flap inset and definitive closure.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A long-arm thumb spica cast is applied with the elbow in 90 to 100 degrees of flexion to prevent premature removal (Fig. 108.20). The arm is kept elevated to promote venous drainage. • The cast is removed 4 weeks postoperatively and hand therapy is initiated to address thumb mobility, pinch, and grasp. The patient is transitioned to a short-arm thumb spica orthosis for protection and stability; this is removed only for therapy and cleaning/scar management. The orthosis is discontinued 3 months postoperatively. • In general, outcomes after pollicization are directly related to the mobility of the index finger. A strong, mobile index finger functions well as a thumb, whereas a stiff, weak index finger makes a poor thumb. After pollicization, one can expect about 30% of grip and pinch strength compared with the contralateral unaffected thumb. Although some children with thumb hypoplasia may be candidates for a free toe transfer, pollicization remains the preferred procedure. Fig, 108.21 shows the 2-year postoperative result. See Video 108.1

FIGURE 108.20  Long arm cast application.

FIGURE 108.21  Two-year postoperative result.

823

824

CHAPTER 108  Index Pollicization for Hypoplastic Thumb

EVIDENCE Buck-Gramcko D. Pollicization of the index finger: Methods and results in aplasia and hypoplasia of the thumb. J Bone Joint Surg. 1971;53:1605–1617. This classic article details the techniques and outcomes for index finger pollicization in 114 patients (100 congenital), with long-term follow-up of up to 12 years. The author details his technique and subsequent modifications (Level V evidence). Tonkin MA, Boyce DE, Fleming PP, Filan SL, Vigna N. The results of pollicization for congenital thumb hypoplasia. J Hand Surg Eur Vol. 2015;40:620–624. This study reviewed the results of index pollicization in patients with and without forearm/wrist involvement. CMC joint motion was near normal in both groups (decreased retropulsion in patients with forearm/involvement). MCP and IP joint flexion, grip, thumb lateral and tip pinch strengths, and Jebsen timed test were superior in patients without forearm/wrist involvement. Subjective assessment by patients/parents found 72% excellent/good results for function and 94% for appearance. Doctor excellent/good assessments were 60% and 70%, respectively. The authors conclude that forearm/wrist anomalies significantly compromise results but are not a contraindication for pollicization (Level IV evidence). Kollitz KM, Tomhave W, Van Heest AE, Moran SL. Change in hand function and dexterity with age after index pollicization for congenital thumb hypoplasia. Plast Reconstr Surg. 2018;141(3):691–700. The authors reviewed the range of motion, strength, and dexterity in 29 patients who underwent pollicization at an average follow up of 3.9 years. Distal grasp span increased 0.17 inch and Kapandji opposition improved 0.26 point with each year of age; however, proximal webspace size did not increase over time. Grip strength improved an average of 2.69 kg/year, and tripod and key pinch improved 0.58 kg and 0.67 kg with each year of age. Box and Block Test scores improved an average of 4.11 blocks/year. Scores on the Nine Hole Peg Test improved 3.83 seconds/year, and scores on the Functional Dexterity Test improved 0.026 peg/second each year. These data suggest that children with pollicized thumbs improve in dexterity and strength with growth, but the webspace size did not change with age (Level IV evidence). Canizares MF, Feldman L, Miller PE, Waters PM, Bae DS. Pollicization of the index finger in the United States: Early readmission and complications. J Hand Surg Am. 2019;44(9):795. In this study, the authors investigated early postoperative complications after pollicization in the United States. A total of 459 pollicization procedures performed in 408 patients at 38 US pediatric hospitals from 2003 to 2014 were identified using the Pediatric Health Information System database. Sixty-one patients returned within 30 days of their pollicization, and 22 presented with a complication (4.8%), most commonly vascular in nature. The authors concluded that baseline data are informative because they identify opportunities for future preventative measures and quality improvement (Level IV evidence). Hellevuo C, Leppänen OV, Kapanen S, Vilkki SK. Long-term outcomes after pollicization: A mean 11-year follow-up study. J Hand Surg Eur Vol. 2020;45(2):173–180. The authors evaluated the long-term results of pollicization for a congenitally absent or severely hypoplastic thumb. Twenty-nine patients with 34 pollicizations were divided into two groups: those with simple thumb hypoplasia (22 pollicizations) and those with radial longitudinal dysplasia (12 pollicizations). Patients were followed from 1.3 to 32 years, with a mean follow-up time of 11 years. The patients were examined clinically and radiologically, and they completed a questionnaire concerning satisfaction with appearance, function, and social interaction. In both groups, grip and pinch strengths of the operated hands were inferior to the normative age-related values. The authors found better patient satisfaction in the simple hypoplasia group than in the radial longitudinal dysplasia group. The functional outcomes and patients’ satisfaction did not correlate with the age of patients at operation (Level IV evidence).

CHAPTER

109

Pediatric Opponensplasty Joshua M. Adkinson and Kevin C. Chung

INDICATIONS • One indication for this procedure is a hypoplastic thumb with a functional carpometacarpal joint (Blauth types II and IIIA). • Opponensplasty is typically offered at 12 to 18 months of age, because general anesthesia is safer and structures are larger, facilitating dissection. Surgery at this age also permits time for preliminary correction of any associated radial deficiencies (typically addressed between 3 to 6 months of age). Finally, cortical representation of the thumb has not yet become solidified at this age. • Transfer of the abductor digiti minimi (ADM), otherwise known as the Huber transfer, is commonly used to restore opposition among pediatric patients with thumb hypoplasia and an otherwise reconstructible thumb. This procedure can also improve appearance by increasing the bulk of the thenar eminence. Furthermore, the ADM is always present, even in severe cases of radial longitudinal deficiency. • Transfer of the flexor digitorum superficialis (FDS) of the middle or ring finger is an alternative option for opponensplasty. The FDS transfer does not increase thenar eminence bulk, but it does provide additional tendon length for ulnar collateral ligament (UCL) reconstruction, if necessary. The details of this transfer can be found in Chapter 63.

Contraindications Contraindications include hypoplastic thumbs with an inadequate carpometacarpal joint (Blauth types IIIB and IV) or complete absence of the thumb (Blauth type V), parental reluctance to proceed with surgery, and medical comorbidities that would preclude safe surgery.

CLINICAL EXAMINATION • See Chapter 108 for details regarding the Blauth classification system, examination details, and associated anomalies. • There are five clinical features of thumb hypoplasia that should be considered when assessing a type II or IIIA hypoplastic thumb (Fig. 109.1): • The thumb is shorter and smaller. • There is thumb interphalangeal (IP) joint stiffness. • Intrinsic atrophy is present in type II thumbs, whereas type IIIA thumbs have both intrinsic and extrinsic muscle atrophy. • The first webspace may be narrowed (less than 50 degrees of radial thumb abduction) and require widening. • The thumb metacarpophalangeal (MCP) joint UCL may be attenuated (a greater than 20-degree difference in UCL laxity compared with the normal side) or absent and should be reconstructed for stable pinch and grasp.

IMAGING See Chapter 108 for details regarding preoperative imaging.

SURGICAL ANATOMY • The intrinsic muscles of the thumb (abductor pollicis brevis [APB], opponens pollicis [OP], flexor pollicis brevis [FPB], and adductor pollicis [AP]) are deficient in types II and III, and absent in types IV and V (Fig. 109.2). 825

826

CHAPTER 109  Pediatric Opponensplasty

A

B

FIGURE 109.1  (A-B) Clinical examination of hypoplastic thumb.

EXPOSURES PEARLS

Most patients, but not all, will need Z-plasty and stabilization of the MCP joint, so the incisions are planned on a case-by-case basis. EXPOSURES PITFALLS

Avoid an incision that is too ulnar or dorsal on the hand because this limits exposure of the origin of the ADM muscle and ulnar neurovascular bundle.

• The flexor pollicis longus (FPL) and extensor pollicis longus (EPL) are hypoplastic in type III thumbs. There may be an anomalous connection (i.e., pollex abductus) between the FPL and the EPL at the level of the MCP joint. This may exacerbate the angular deformity of the thumb. • The three elements of types II and IIIa hypoplastic thumbs that require correction include: • Intrinsic muscle atrophy • A narrowed first webspace • An unstable thumb MCP joint UCL • Extrinsic muscle attenuation/absence may need to be addressed on a case-by-case basis (e.g., FDS or extensor indicis proprius tendon transfers for thumb IP joint flexion or extension, respectively). • Thumb IP joint stiffness and the small caliber of the thumb will not improve even with successful reconstruction.

POSITIONING The procedure is conducted under general anesthesia, with the patient placed supine on the operating room table. A well-padded tourniquet is placed on the upper arm and the limb is prepared and draped in the usual fashion.

EXPOSURES A longitudinal curvilinear incision is marked over the ulnar border of the hand along the axis of the hypothenar musculature (Fig. 109.3).

PROCEDURE STEP 1 PEARLS

Step 1

• More proximally, the palmaris brevis overlies the ADM. The palmaris brevis can be differentiated by the transverse orientation of its fibers. • The ulnar digital nerve to the small finger should be visualized throughout the dissection to prevent inadvertent injury.

• The arm is exsanguinated and the tourniquet is inflated. • The palmar skin is incised and thick skin flaps are raised. • The ADM muscle is skeletonized with spreading scissor dissection, with care taken to protect adjacent neurovascular structures. The pedicle does not need to be visualized during muscle exposure. • The ADM has two insertions: one to the ulnar aspect of the base of the proximal phalanx and the other to the extensor expansion. These are divided with scissors at the level of the MCP joint of the small finger. • The ADM muscle is mobilized completely to its origin from the pisiform in preparation for transfer to the thumb (Fig. 109.4).

STEP 1 PITFALLS

Excessive proximal dissection may put the neurovascular pedicle of the ADM muscle at risk.

CHAPTER 109  Pediatric Opponensplasty

Adducted posture

Slight decrease in thumb size

MCPJ UCL instability Slender phalanges and metacarpals

Underdeveloped or absent thenar muscles

Normal carpal bones Normal distal radius

II

I

Adducted posture

Adducted posture

Underdeveloped or absent thenar muscles and thumb extrinsics

Underdeveloped or absent thenar muscles and thumb extrinsics

Absence of proximal portion of metacarpal Variable absence of trapezium and scaphoid

Full-length metacarpal Variable absence of trapezium and scaphoid

IIIA

Variable absence of radial styloid

IIIB

Distal midaxial origin of floating thumb

Absent first dorsal interosseous in 50% of patients

Absent thenar and extrinsic thumb muscles Fully developed neurovascular pedicle Variable absence of trapezium and scaphoid

IV

Variable absence of radial styloid

Variable absence of radial styloid

V

Absent radial carpal bones Absent radial styloid Hypoplasia of distal radius

FIGURE 109.2  Intrinsic and extrinsic muscle aberrations in the hypoplastic thumb. MCPJ, Metacarpophalangeal joint; UCL, ulnar collateral ligament.

827

828

CHAPTER 109  Pediatric Opponensplasty

FIGURE 109.3  Marking the axis of the hypothenar musculature.

FIGURE 109.4  ADM muscle is mobilized in preparation for transfer to the thumb. ADM, Abductor digiti minimi.

STEP 2 PEARLS

Step 2

The palmar skin elevation should be done superficially to avoid injury to the contents of the carpal tunnel.

• A chevron-style incision, is made over the radial aspect of the thumb MCP joint at the level of the APB insertion. • Any pollex abductus is identified and divided (Fig. 109.5). • The palmar skin between the thumb incision and ADM dissection is widely undermined using a blunt clamp.

STEP 3 PEARLS

Step 3

• The radial limb of the four-flap Z-plasty should be designed dorsally, and the ulnar limb should be designed extending in a palmar direction. This permits exposure of the thumb MCP joint and UCL through the radial limb incision. • We recommend closing the first webspace incision before insetting the ADM muscle transfer because visualization becomes difficult after inset. The Z-plasty flaps are transposed as shown in Fig. 109.7.

• When the first webspace is narrow and/or the thumb MCP joint is unstable, one must plan for an incision in the first webspace.

STEP 3 PITFALLS

The radial digital nerve to the index finger and the dorsal radial sensory branches of the radial nerve are at risk of injury during elevation of the Z-plasty skin flaps and should be identified and protected.

Anomalous connection to extensor pollicis longus Flexor pollicis longus Extensor pollicis longus

FIGURE 109.5  The pollex abductus is identified and divided.

CHAPTER 109  Pediatric Opponensplasty

FIGURE 109.6  Marking a four-flap, 120-degree Z-plasty on the first webspace.

• A four-flap, 120-degree Z-plasty is marked on the first webspace and the skin is incised with a no. 15 scalpel (Fig. 109.6). • Full-thickness flaps are elevated, taking care to protect the underlying neurovascular structures. • The fascia overlying the intrinsic muscles is carefully released with scissors.

Step 4 • If the UCL is attenuated or unstable, the adductor pollicis tendon is divided at its insertion into the extensor expansion and reflected ulnarly to expose the thumb UCL. • A single 0.045-inch Kirschner wire (K-wire) is passed obliquely from radial to ulnar through the MCP joint to maintain the MCP joint in neutral position (Fig. 109.8). • The thumb MCP joint capsule and UCL are imbricated using 4-0 nonabsorbable sutures to provide stability with pinch. • If the capsule and UCL are not sufficient to restore stability, the adductor pollicis tendon is mobilized, advanced, and sutured to the ulnar base of the proximal phalanx and extensor mechanism using 4-0 nonabsorbable sutures.

60°

60° 60°

120°

60°

D

C B A

D C

B A

D C B

D C

A

STEP 4 PEARLS

If the structures around the ulnar aspect of the thumb MCP joint are not sufficient to impart stability to the joint even after imbrication, a UCL reconstruction using free tendon graft may be necessary. STEP 4 PITFALLS

• The K-wire should not exit through the radial aspect of the metacarpal head, where it may impinge on the insertion of the ADM tendon after opponensplasty. • Global instability of the thumb MCP joint may not be adequately corrected with UCL reconstruction alone. These rare situations will require chondrodesis (cartilage fusion) of the thumb MCP joint.

120°

B A

FIGURE 109.7  Depiction of Z-plasty flap transposition.

D C

B A

829

830

CHAPTER 109  Pediatric Opponensplasty

A

FIGURE 109.8  The Kirschner wire (K-wire) is passed obliquely from radial to ulnar through the MCP joint. MCP, Metacarpophalangeal.

B

FIGURE 109.9  (A) ADM being transferred to thumb. (B) After ADM muscle transfer inset. ADM, Abductor digiti minimi.

STEP 5 PEARLS

Step 5

• The ADM muscle is turned 180 degrees like the page of a book, rather than 90 degrees, to avoid twisting of the neurovascular pedicle (Fig. 109.10). • Because the ADM has minimal excursion, inset of the transfer requires placement of the thumb ray in an unnatural amount of opposition. This exaggerated posture will stretch over time.

The ADM is transferred radially across the palm and woven through the APB tendon insertion and joint capsule at the level of the radial thumb MCP joint using 4-0 nonabsorbable sutures (Fig. 109.9A–B).

STEP 5 PITFALLS

• A narrow subcutaneous tunnel may limit the ability to easily transfer the ADM muscle to the thumb or limit excursion of the muscle. • Careful insertion of the ADM into the soft tissues about the thumb MCP joint will prevent rupture of the transfer with subsequent use.

Step 6 • The tourniquet is deflated and hemostasis is ensured. • The ulnar palm and radial thumb incisions are closed using absorbable suture (Fig. 109.11).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A long-arm thumb spica cast is applied with the elbow in 90 to 100 degrees of flexion to prevent premature removal (Fig. 109.12). The arm is kept elevated to promote venous drainage.

Abductor digiti minimi m.

FCU

Pisiform PM ligament Flexor digiti minimi brevis m. FIGURE 109.10  ADM muscle is turned 180 degrees rather than 90 degrees. ADM, Abductor digiti minimi; FCU, flexor carpi ulnaris; PM, Pisometacarpal.

CHAPTER 109  Pediatric Opponensplasty

FIGURE 109.12  Long-arm thumb spica cast applied with elbow flexed 90 to 100 degrees.

FIGURE 109.11  Ulnar palm and radial thumb incisions are closed using absorbable sutures.

A

B FIGURE 109.13  (A) The 2-month postoperative result, palmar view. (B) The 2-month postoperative result, dorsal view.

• The cast is removed 4 weeks postoperatively and the patient is transitioned to a short-arm thumb spica orthosis for protection and stability for another 2 to 4 weeks; this is removed only for therapy and cleaning/scar management. • Therapy begins at 6 to 8 weeks, with a focus on gentle range-of-motion (ROM) exercises. • The orthosis is discontinued at 3 months postoperatively. • With adherence to the aforementioned principles and meticulous technique, good to excellent outcomes may be achieved. One can expect a marked improvement in hand function, thumb stability, and opposition strength. • Fig. 109.13A–B shows the 2-month postoperative result. See Video 109.1

EVIDENCE Wall LB, Goldfarb CA. Tendon transfers for the hypoplastic. Thumb Hand Clin. 2016;32(3):417–421. In this study, the authors provide a thorough review of thumb hypoplasia and the indications for reconstruction. They also describe in detail the most common options for restoring thumb opposition: the Huber ADM muscle transfer and the FDS opposition transfer. They emphasize that both transfers use ulnar-sided structures to augment the thenar musculature. Further, they state that although the Huber opposition transfer increases thenar bulk, it does not provide additional tissue for metacarpophalangeal stability (Level V evidence).

831

832

CHAPTER 109  Pediatric Opponensplasty McDonald TJ, James MA, McCarroll Jr HR, Redlin H. Reconstruction of the type IIIA hypoplastic thumb. Tech Hand Up Extrem Surg. 2008;12(2):79–84. In this review, the authors outline the common findings in children with type IIIa thumb hypoplasia. The differences between types IIIa and IIIb thumbs are also highlighted. Although many techniques are available for management of the type IIIa thumbs, the authors focus on the critical details of their preferred approach to management with a discussion of expected outcomes. The benefits of the ADM versus FDS opponensplasty are also described (Level V evidence). Abdel-Ghani H, Amro S. Characteristics of patients with hypoplastic thumb: A prospective study of 51 patients with the results of surgical treatment. J Pediatr Orthop B. 2004;13(2):127–138. The authors present outcomes of 51 patients (82 hypoplastic thumbs), of whom 18 patients underwent surgical reconstruction with 3-year follow-up. In this series, type V thumb hypoplasia was most common, and the majority (86%) suffered from associated anomalies. Among patients who underwent opponensplasty and UCL reconstruction, the majority achieved stability (70%) at the MCP joint and the ability to oppose the finger to the small finger (89%; Level IV evidence).

CHAPTER

110

Camptodactyly Correction Joshua M. Adkinson and Kevin C. Chung

INDICATIONS Indications include functional impairment, a flexion deformity greater than 30 to 60 degrees, and a deformity that persists after 6 to 12 months of stretching and splinting.

Contraindications Contraindications include no functional impairment, improvement of the deformity with splinting alone, flexion contracture of less than 30 degrees, and family or parental reluctance to proceed with surgery.

CLINICAL EXAMINATION • Camptodactyly is a flexion deformity or contracture of the proximal interphalangeal (PIP) joint that most often manifests in the small finger. It is frequently bilateral with asymmetric involvement and is classified into three different types (Table 110.1). Camptodactyly often presents during periods of rapid growth, such as in the first year of life and during adolescence. • Conditions associated with camptodactyly include arthrogryposis, skeletal dysplasias, Beal syndrome, and Marfan syndrome. • The PIP joint is checked for extension lag and flexion contracture with the wrist in neutral position. Extension lag is the maximum extension measurement when performing active motion testing. Flexion contracture is the maximum extension measurement when performing passive motion testing. A perfectly straight PIP joint is considered to have 0 degrees of lag or contracture. Extension lag and flexion contracture measurements may be quite different. For example, a joint may have an extension lag of 60 degrees, but a passive extension force across the PIP joint may reveal a joint correctable to a 30-degree flexion contracture. • Assessing the affected digit with the metacarpophalangeal (MCP) joint in flexion and extension is performed next. For patients with camptodactyly, when the MCP joint is in extension, the finger assumes a flexed posture at the PIP joint. Passive extension of the PIP joint may produce blanching of the skin, which implies a skin deficiency (Fig. 110.1). Additionally, if passive flexion of the MCP joint improves PIP joint extension, the etiology of the contracture is outside the PIP joint (e.g. skin deficiency, subcutaneous fibrous bands, or tightness of the extrinsic finger flexors, such as the flexor digitorum superficialis [FDS]). If passive extension is not improved with MCP

TABLE Types of Camptodactyly 110.1

Type

Description

1

A newborn presents with a flexion deformity of the fifth and/or fourth finger. This is the most common type and affects males and females equally.

2

Physical changes similar to type 1, but it develops between 7 and 11 years of age. Females are affected more often than males. The flexion deformity will not improve over time and may develop into a severe flexion contracture.

3

Present from the time of birth. It affects several fingers, is bilateral, and often has an accentuated flexion deformity. It is associated with a variety of syndromes and other malformations.

833

834

CHAPTER 110  Camptodactyly Correction

Skin contracture FIGURE 110.1  Skin contracture associated with camptodactyly.

joint flexion, there is some component of primary joint contracture that will need to be surgically corrected. • A compensatory hyperextension deformity of the MCP joint is frequently found with a PIP joint flexion deformity. With the Bouvier maneuver, the examiner corrects the hyperextension by passively placing the MCP joint in neutral or slight flexion. If this restores full PIP joint active extension, then MCP joint hyperextension is the cause of the PIP joint flexion deformity; this may be secondary to an intrinsic muscle abnormality. An FDS transfer to the lateral band may be indicated in this situation. Conceptually, this transfer would increase MCP joint flexion and PIP joint extension forces. • For patients with passively correctable PIP joint flexion deformities, the extensor tenodesis effect is used to assess extrinsic extensor integrity. The wrist and MCP joints are placed in full flexion. In an unaffected digit, this maneuver should produce full PIP joint extension through passive stretch on extensor digitorum communis (EDC). If it does not, this implies a laxity or hypoplasia of the central slip.

IMAGING Three-view standard hand radiographs are obtained. The configuration of the proximal phalanx and middle phalanx at the PIP joint is evaluated. The lateral film will be the most informative view. The head of the proximal phalanx loses its rounded articular convex contour, and there is flattening at the base of the middle phalanx articulation. The base of the middle phalanx is volarly subluxated and the flexed middle phalanx creates an indentation in the palmar neck of the proximal phalanx (i.e., the “parrot beak” deformity; Fig. 110.2).

SURGICAL ANATOMY • The development of camptodactyly has been attributed to anomalous joint architecture, laxity of the extensor mechanism at the PIP level, anomalous fascial bands from the annular one pulley, abnormal flexor tendons, abnormal lumbrical muscles, and/or anomalous intrinsic muscles. The most commonly identified anomalies include an anomalous lumbrical muscle or an absence/anomaly of the FDS tendon. • The FDS tendon has been described as contracted, underdeveloped, or devoid of a functional muscle. The abnormal tendon may originate from the palmar fascia or transverse carpal ligament instead of a muscle belly. This anomalous musculotendinous architecture cannot elongate during periods of rapid growth, which can lead to a PIP joint flexion deformity. • The lumbrical may have an abnormal origin or insertion; an origin from the transverse carpal ligament or the ring flexor tendons have been described. Abnormal insertions are more common and include an attachment directly into the MCP joint capsule, onto the FDS, into the ring finger extensor apparatus, or within the lumbrical canal. The lack of intrinsic contribution to PIP extension creates an intrinsic minus deformity.

CHAPTER 110  Camptodactyly Correction

Proximal phalanx head loses convex articular contour Volar subluxation of the middle phalanx

Indentation at neck of proximal phalanx

FIGURE 110.2  Radiographic findings of camptodactyly.

POSITIONING The procedure is performed under general anesthesia with or without a brachial plexus block. A well-padded tourniquet is placed on the upper arm.

EXPOSURES A transverse volar PIP joint flexion crease incision is designed (Fig. 110.3). This incision is used to release contracted structures on the volar side of the PIP joint. A proximally based dorsolateral transposition flap is designed to cover the volar defect after contracture release. The posterior border of the flap is on the midlateral line, and the anterior border of the flap will depend on the estimated size of the defect after contracture release. The length of the flap is designed to reach beyond the distal interphalangeal (DIP) joint crease (Fig. 110.4).

Transverse volar PIP joint flexion crease incision

FIGURE 110.3  Volar skin markings. PIP, Proximal interphalangeal.

EXPOSURE PEARLS

• In flexible camptodactyly without a fixed PIP joint flexion contracture and with mild-to-moderate contracture of skin, a palmar longitudinal approach with Z-plasty lengthening or Bruner incision may be used. When there is a substantial skin contracture and a Z-plasty or dorsolateral flap are insufficient for closure, skin grafts will be needed. • Some surgeons advocate for a cross-finger flap for volar skin coverage, but this is not necessary if a transposition flap and skin graft are adequately employed.

835

836

CHAPTER 110  Camptodactyly Correction

Transposition flap

FIGURE 110.4  Transposition flap design.

PROCEDURE Step 1: Skin and Fascial Contracture Release and Dorsolateral Flap Elevation • The transverse volar PIP joint flexion crease incision is made with a scalpel. • The dorsolateral flap is raised along the deep fascial plane, leaving only areolar tissue over the extensor expansion. A volar digital neurovascular bundle is identified and protected. The neurovascular bundles are at risk when making the transverse incision because they are superficial. One should incise through the skin, then use scissors to dissect and isolate the digital nerves. The flap is elevated from distal to proximal to the base of the flap at the level of the head of the proximal phalanx (Fig. 110.5A–B). • Fascia and soft tissue volar to the flexor tendon are released. Any abnormal fascia and linear fibrous bands are released during exposure of deeper structures. The radial and ulnar digital neurovascular bundles are identified and protected. • The flexor tendon sheath is exposed at the PIP joint, and the sheath is opened at the level of the A3 pulley. The flexor digitorum profundus (FDP) tendon is retracted to expose the Camper’s chiasm and insertion of the FDS tendon.

A

B Flap margins incised

Neurovascular bundle FIGURE 110.5  (A–B) Flap elevation.

Flap elevated from neurovascular bundle

CHAPTER 110  Camptodactyly Correction

Cut end of FDS

Pulleys

A5C3 A4 C2 A3 C1

A2

A1

PA

Cut end of FDS

Retracted FDP A

B

Camper’s chiasm

FIGURE 110.6  FDS tenotomy. FDS, Flexor digitorum superficialis.

Step 2: Flexor Digitorum Superficialis Tendon Release

STEP 2 PEARLS

• The Camper’s chiasm is divided longitudinally. Both slips of FDS are divided transversely and cut at a level distal to the chiasm (Fig. 110.6). • PIP joint passive range of motion (ROM) is tested. If there is no residual flexion contracture, the release is complete. If a flexion contracture remains, then the PIP joint volar plate and collateral ligaments are released.

It is rare for FDS division alone to correct the contracture. The volar plate and collateral ligaments typically require release.

Step 3: Volar Plate and Collateral Ligament Release • With the FDP tendon retracted, a transverse incision is made at the level of the membranous PIP joint volar plate. The location is just distal to the checkrein ligament attachment. The incision is curved distally on each side, separating the volar plate from the accessory collateral ligaments. • A Freer elevator is used to gently lift the volar plate. The plate should slide distally as the joint is released (Fig. 110.7A–B). • If additional restrictions remain, the accessory collaterals and collateral ligaments are partially divided. • After release of all restrictive structures, full passive PIP extension is confirmed (Fig. 110.8).

Step 4: Flexor Digitorum Superficialis Transfer to Ulnar Lateral Band (Treating Proximal Interphalangeal Joint Extension Lag) • FDS transfer can be used to augment active extension of the PIP joint if preoperative assessment confirms inability to actively extend the PIP joint with the MCP joint in maximal flexion.

A3

Checkrein ligaments

Volar plate

C1

Accessory collateral ligament

A2

MCPJ

A

Divide the volar plate as proximally as possible

Proper collateral ligament

PIP joint volar plate divided as proximally as possible

B

FIGURE 110.7  (A) Illustration of volar plate release. MCPJ, Metacarpophalangeal joint. (B) Photo of volar plate release. PIP, Proximal interphalangeal.

STEP 3 PEARLS

• In severe camptodactyly, the joint may “click” in and out of alignment because of incongruity of the PIP joint. If there is a tendency toward flexion even after complete soft tissue release, a temporary Kirschner wire (K-wire) can be driven across the joint to hold it in full or nearfull extension (Fig. 110.9). • If correction of the PIP joint flexion contracture results in a DIP joint flexion deformity, the FDP tendon may require lengthening at the musculotendinous juncture (this can be done through a separate incision in the forearm; Fig. 110.10). STEP 3 PITFALLS

• Avoid dividing the entire radial and ulnar collateral ligaments. The middle and dorsal aspects of the ligaments should be preserved to retain the stability of the PIP joint. • Full correction of a severe flexion contracture may put undue tension on the neurovascular structures. In these cases, one may be forced to accept less than full correction.

837

838

CHAPTER 110  Camptodactyly Correction

Full passive PIP joint extension

FIGURE 110.8  Demonstration of full passive extension of digit after contracture release. PIP, Proximal interphalangeal.

FIGURE 110.9  Temporary pinning of PIP joint. PIP, Proximal interphalangeal.

STEP 4 PEARLS

• An essential component of this transfer is to maintain the FDS volar to the central axis of the MCP joint by passing the tendon through the lumbrical canal. This keeps the tendon palmar to the deep transverse metacarpal ligament and ensures MCP flexion after the tendon is secured to the lateral band. • An interconnection between the FDS of the little finger and ring finger is occasionally encountered and is released to facilitate individual movement of each finger. STEP 4 PITFALLS

FDS transfer can result in swan-neck posturing and loss of PIP joint flexion. These risks must be discussed with the patient and family preoperatively. STEP 5 PEARLS

• The flap inset should be without tension to avoid partial flap loss. • Meticulous hemostasis is necessary to ensure complete skin graft survival.

FDP tendon fractional lengthening FIGURE 110.10  FDP lengthening in the forearm. FDP, Flexor digitorum profundus.

• The cut end of one slip of the FDS is transferred from the volar side to the dorsal lateral side of the finger via the lumbrical canal. The end of the FDS slip is woven into the ipsilateral lateral band with 4-0 braided nonabsorbable suture (Fig. 110.11). Tension is set with the MCP joint positioned in 30 degrees of flexion and the PIP joint held in full extension.

Step 5: Dorsolateral Flap Inset and Incision Closure • The dorsolateral flap is transposed 90 degrees to cover the volar skin defect (Fig. 110.12). • A full-thickness skin graft is harvested from the hypothenar area, antecubital fossa, or groin. • The tourniquet is deflated and hemostasis is performed. • The flap is inset, and all of the incisions are closed and sutured with 4-0 absorbable suture. The donor site of the full-thickness skin graft is closed primarily (Fig. 110.13). • The skin graft is inset in the donor site defect and secured with 4-0 absorbable suture (Fig. 110.14A–B).

CHAPTER 110  Camptodactyly Correction

Weaving FDS slip with ipsilateral lateral band

FIGURE 110.11  FDS tendon transfer. FDS, Flexor digitorum superficialis.

Flap transposed

FIGURE 110.12  Flap transposition before inset.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The hand and wrist are immobilized in a short-arm splint for 2 to 3 weeks. • Gentle active motion exercise is encouraged at 4 weeks postoperatively. If a K-wire was placed, it is removed at this time. Therapy is also directed toward scar management and tendon transfer training (if performed). • Six weeks after surgery, light resistance exercises are initiated. The splint is removed during the day except for strenuous activity. • The splint is discontinued for all activities 12 weeks postoperatively, and unrestricted activity is allowed. If recurrence is noted, nighttime splinting may be employed. • A variety of operations have been proposed and surgical results have been variable. Patient/parent compliance with splinting and therapy are just as important as the surgery.

839

840

CHAPTER 110  Camptodactyly Correction

FIGURE 110.13  Definitive closure.

A

B Full-thickness skin grafts after inset

Full passive extension demonstrated after closure

FIGURE 110.14  (A–B) Full-thickness skin graft inset.

A

B

FIGURE 110.15  (A–B) Long-term outcome.

• Complications can include infection, incomplete PIP extension, decreased active flexion, recurrence of contracture, stiffness, and pain. • The functional status for severe flexion deformity patients is improved with the improved posture of the finger (Fig. 110.15A–B). See Video 110.1

CHAPTER 110  Camptodactyly Correction

EVIDENCE Evans BT, Waters PM, Bae DS. Early results of surgical management of camptodactyly. J Pediatr Orthop. 2017;37(5):e317–e320. The authors reviewed outcomes in 22 patients (31 digits) after surgery for moderate-to-severe camptodactyly (>50 degrees). There were 13 males; average age at surgery was 9.6 years. All patients underwent sequential release of contracted structures until maximal extension without compromising vascularity or joint stability was obtained. Z-plasty of the volar skin was performed in 68% of digits, FDS tenotomy in 77%, volar plate release in 58%, and collateral ligament release in 48%. All patients were casted postoperatively and 71% of digits had temporary transarticular pin fixation. At initial presentation, mean total passive motion (TPM) and total active motion (TAM) were 34 and 24 degrees, respectively. TPM and TAM were 35 and 25 degrees at the final follow-up. Furthermore, the position of PIP arc of motion was in a more extended position postoperatively. Average TPM arc of motion was from 50 to 82 degrees preoperatively and 28 to 63 degrees at final follow-up; average TAM arc of motion was 62 to 81 degrees preoperatively and 30 to 55 degrees at final follow-up. The authors conclude that, for patients with functionally limiting flexion contractures, surgical release may be beneficial by providing a more extended position for improved digital release, hygiene, and aesthetics (Level IV evidence). Netscher DT, Hamilton KL, Paz L. Soft-tissue surgery for camptodactyly corrects skeletal changes. Plast Reconstr Surg. 2015;136(5):1028–1035.  The authors assessed 18 consecutively operated fingers in nine skeletally immature patients in whom advanced radiographic articular changes had occurred. Mean preoperative flexion contracture was 63 degrees (range, 35–105 degrees). The average age of the patients was 11 years (range, 4–15 years) at the time of surgery. Each patient demonstrated the classic preoperative radiographic joint changes of the PIP or DIP joint. Two digits had extensive radiographic damage, requiring proximal interphalangeal joint arthrodesis. Fifteen of the remaining 16 digits (94%) had substantial improvement or full restoration of radiographic articular congruency at average follow-up of 9 months (range, 3–18 months). The authors conclude that even in patients with severe radiographic changes from camptodactyly, surgery can effectively improve ROM. Surgery before skeletal maturity can also reverse radiographic changes (Level IV evidence). Hamilton KL, Netscher DT. Evaluation of a stepwise surgical approach to camptodactyly. Plast Reconstr Surg. 2015;135(3):568e–576e. In this retrospective study, the authors reviewed surgical outcomes in 12 patients (18 digits) treated for camptodactyly. All operated digits did not respond to splinting and had greater than a 30-degree flexion contracture. The patients were treated with a stepwise surgical approach to release tethering structures about the joint. Fifteen digits achieved full active extension with a range of 0 to 25 degrees. Mean PIP flexion was 88 degrees with a range of 50 to 100. The authors believe surgery is indicated to prevent a long-term, irreversible articular deformity. The authors also recommend that the patient’s caregivers postoperatively must be motivated to regularly stretch the operated digit after surgery or risk a recurrence of the flexion contracture secondary to scar tissue formation (Level V evidence).

841

CHAPTER

111

Macrodactyly Correction Joshua M. Adkinson and Kevin C. Chung

INDICATIONS • Macrodactyly, or enlargement of one or more digits, is an extremely rare, nonhereditary condition constituting less than 1% of all congenital hand anomalies. • Improved function is the primary reason for reconstruction. Managing parental expectations is essential for this difficult problem. • The surgeon should determine whether the patient has static (i.e., growth proportional to unaffected fingers) or progressive (i.e., increase in size at a rate faster than unaffected fingers) macrodactyly, because progressive macrodactyly may require earlier surgery, more frequent surgery, and lead to the development of joint arthrosis. • Digital size compared with the same-sex parent is a major determinant of the type and timing of surgery. If the digit is smaller than that of the same-sex parent, no surgery is indicated. If the digit is the same size or larger than that of the same-sex parent, size-limiting or reducing procedures (e.g., soft tissue debulking, bone reduction, osteotomy, physeal arrest procedures) or amputation may be indicated. • Amputation is the procedure of choice for immobile, nonthumb digits. This should not be considered a failure of management.

Contraindications

Type I

Lipofibromatosis

Type II

Neurofibromatosis

• Digital enlargement alone is not an indication for surgery, although the appearance may lead to considerable stress for the family and patient. • Gross overgrowth and limited function of the digit or digits should be managed with amputation rather than reconstruction. • Another contraindication is parental reluctance to proceed with surgery.

Type III

Polyostotic

CLINICAL EXAMINATION

Type IV

Hemihypertrophy

• The Flatt classification of macrodactyly is based on etiology and the structures involved (Table 111.1). • The index finger is most commonly affected (Fig. 111.1), followed by the middle finger or thumb. Macrodactyly tends to affect multiple adjacent digits (Fig. 111.2) rather than a single digit.

TABLE Flatt Classification 111.1 of Macrodactyly

FIGURE 111.1  Isolated index finger macrodactyly.

842

CHAPTER 111  Macrodactyly Correction

FIGURE 111.2  Combined index and middle finger macrodactyly.

• Digital enlargement may occur secondary to lipofibromatous peripheral nerves, neurofibromatosis, arteriovenous fistula, vascular malformation, Klippel-Trenaunay syndrome, lymphatic malformation, hemihypertrophy, proteus syndrome, and CLOVES (congenital lipomatous overgrowth, vascular malformation, epidermal nevi, and skeletal anomalies) syndrome. The term macrodactyly, however, is more accurately reserved for isolated, nonsyndromic congenital enlargement of a digit. • Serial examinations with digital length and diameter measurements should be recorded annually. • Electrodiagnostic studies may be indicated if there is concern for peripheral nerve compression, which is a common complication of macrodactyly. Children with carpal tunnel syndrome are too young to describe their symptoms. Instead, the parents may report that the child frequently scratches and shakes the hand or bites fingers on the affected hand. • Children with macrodactyly and the phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha (PIK3CA) mutation may be a candidate for immunosuppressive (e.g., rapamycin) treatment directed at the involved cellular pathways leading to macrodactyly.

IMAGING • Preoperative radiographs are useful to identify the bone length and deformity. • Magnetic resonance imaging (MRI) and computed tomography (CT) scans provide additional information regarding fatty infiltration of peripheral nerves, vascular malformations, or anomalous muscles.

SURGICAL ANATOMY • Asymmetric growth of the affected digit is very common; hyperextension and radial deviation are typical. This may lead to digital overlap with attempted flexion (Fig. 111.3). • Enlargement of the median nerve is predictable in patients with Type I macrodactyly. The enlargement begins in the forearm and extends through the carpal tunnel into the digital nerve branches. • The involved nerves are fibrotic with fatty infiltration. • There may be substantial overgrowth of the palmar soft tissues, muscles, and nerves. Resection of all involved structures may lead to significant morbidity.

POSITIONING • The operation is performed under general anesthesia, with the patient placed supine on the operating table. A tourniquet is placed on the upper arm and the entire extremity is prepared and draped. • If osteotomies are planned, intraoperative fluoroscopy is mandatory. In these cases, the operative table should be positioned to provide easy access to the C-arm.

EXPOSURES In cases of marked digital overgrowth and limited function, amputation is performed via a combined dorsal and volar approach.

EXPOSURES PEARLS

Incisions on the glabrous skin should be designed in such a way (e.g., zigzag or Z-plasty) to prevent future motion-restricting scar contractures.

843

844

CHAPTER 111  Macrodactyly Correction

FIGURE 111.3  Rotational malalignment of a macrodactylous index finger. STEP 1 PEARLS

• The proper digital nerves to the digit planned for amputation are carefully separated from the digital nerves to the adjacent unaffected digits. This may require releasing the epineurium to ensure preservation of the adjacent digital nerves. • Venous drainage to the adjacent digits should be preserved during dorsal skin flap elevation.

PROCEDURE Step 1 • The grossly enlarged, nonfunctional digit is marked for amputation, with incisions in the webspace extending onto the dorsal hand and distal palm (Fig. 111.4). • The skin flaps are elevated and the radial and ulnar digital neurovascular bundles are isolated. • The digital nerves are dissected into the distal palm (Fig. 111.5).

Step 2 STEP 3 PEARLS

The digital nerves may be buried within adjacent intrinsic musculature to provide padding over a future digital end neuroma.

• The A1 pulley is divided. • The flexor tendons are placed on traction and divided with scissors or a knife.

Step 3 The extrinsic extensor tendon is isolated and the juncturae tendinae are divided. The tendon is then divided at the level of the mid- or distal metacarpal shaft (Fig. 111.6).

FIGURE 111.4  Dorsal and palmar skin markings before ray amputation.

CHAPTER 111  Macrodactyly Correction

FIGURE 111.5  Isolation of the radial digital nerve to the index finger.

FIGURE 111.6  Division of the extensor mechanism before disarticulation at the MCP joint. MCP, Metacarpophalangeal.

Step 4 • The digital nerves to the affected digit are placed on traction and divided with cautery or are suture ligated. • The digital arteries are ligated distal to the common digital bifurcation.

Step 5 The intermetacarpal ligament is divided with scissors, with care taken to protect the intrinsic muscles and tendons to adjacent digits.

Step 6 The digit may be disarticulated at the metacarpophalangeal (MCP; Fig. 111.7) or carpometacarpal (CMC) joint. Alternatively, an osteotomy can performed at the midshaft metacarpal level with a bone cutter.

Step 7 For central digital amputation, the gap between the adjacent digits is closed by reapproximating the intermetacarpal ligament and metacarpal periosteum.

Step 8 Redundant skin and subcutaneous tissue are excised, taking care to preserve a wellvascularized skin flap to resurface the webspace (Fig. 111.8).

Step 9 • The tourniquet is released and hemostasis is ensured. Tension-free skin closure is performed using absorbable suture (Fig. 111.9).

FIGURE 111.7  Disarticulation of the index finger through the MCP joint. MCP, Metacarpophalangeal.

STEP 7 PITFALLS

Poorly placed intermetacarpal sutures can impart a rotational or angular deformity to the preserved digits. Rotation should be checked via tenodesis of the wrist and MCP joints after provisional placement of these sutures.

845

846

CHAPTER 111  Macrodactyly Correction

FIGURE 111.8  Skin flap contouring before definitive closure.

FIGURE 111.9  Definitive closure after skin recontouring.

• A long-arm thumb spica cast is applied, with the elbow in at least 90 degrees of flexion to prevent premature removal (see Fig. 106.19 in “Release of Finger Syndactyly Using Dorsal Rectangular Flap”). The olecranon is well-padded to prevent skin breakdown, but limited padding is placed over the antecubital fossa to allow for adequate molding of the splint.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The cast is removed 4 weeks postoperatively and range-of-motion exercises are initiated. • With a ray resection, normal range of motion, strength, and alignment of the unaffected digits are typical. This typically results in a very positive aesthetic and functional outcome. • Conversely, soft tissue debulking, bone reduction, osteotomies, and physeal arrest procedures have variable outcomes. • Although amputation is a definitive solution for an overgrown, nonfunctional digit, macrodactyly may occur in adjacent areas of the hand and continue proximally into the arm. • Figs. 111.10 and 111.11 show 3-month postoperative photos of a right index finger ray amputation for macrodactyly. See Video 111.1

CHAPTER 111  Macrodactyly Correction

FIGURE 111.10  The 3-month follow-up, dorsal view of bilateral hands.

FIGURE 111.11  The 3-month follow up, palmar view of bilateral hands.

EVIDENCE Cerrato F, Eberlin KR, Waters P, Upton J, Taghinia A, Labow BI. Presentation and treatment of macrodactyly in children. J Hand Surg Am. 2013;38(11):2112–2123. The authors performed a review of treatment and outcomes of all isolated hand macrodactyly cases over a 15-year period. There were 21 patients: 8 boys and 13 girls. A mean of 1.8 digits per child were affected. The middle finger was most commonly affected (67%). Most patients had progressive overgrowth (n = 13; 67%). Twelve patients (57%) had nerve territory–oriented macrodactyly, whereas 9 (43%) presented with lipomatous type. There were no differences between the types of macrodactyly in sex, affected side, rate of growth, digits affected, or number of procedures. Patients underwent a mean of 3.2 staged corrective operations. No major complications were reported (Level IV evidence). Hardwicke J, Khan MA, Richards H, Warner RM, Lester R. Macrodactyly - options and outcomes. J Hand Surg Eur Vol. 2013;38(3):297–303. In this review, the authors reported the outcomes of 32 patients diagnosed with macrodactyly. The average age at presentation was 46 months and there was an equal distribution across the sexes, although there was a male predominance in the upper limb and female predominance in the lower limb. There were 20 cases of upper limb macrodactyly and 13 cases affecting the lower limb. Multiple digits were more commonly affected than isolated digits, with an average of 2.5 digits affected.

847

848

CHAPTER 111  Macrodactyly Correction Static disease required significantly fewer operations than progressive disease. The authors noted that repeated procedures must be highlighted in cases of progressive macrodactyly. They conclude that the functional and cosmetic outcome is good in the vast majority of cases, with good patient acceptance (Level IV evidence). Gluck JS, Ezaki M. Surgical Treatment of Macrodactyly. J Hand Surg Am. 2015;40(7):1461–1488. The authors provide an exceptional overview of macrodactyly and options for treatment. They note that, because of the relative scarcity of patients with this complex condition, treatment can be a formidable task often left exclusively to those trained in congenital hand deformity. They provide an algorithm and described surgical techniques for dealing with children with macrodactyly (Level V evidence). Ezaki M, Beckwith T, Oishi SN. Macrodactyly: Decision-making and surgery timing. J Hand Surg Eur Vol. 2019;44(1):32–42. In this review, the authors provide an up-to-date review of decision-making for macrodactyly reconstruction. They also emphasize the importance of physical examination and the psychological impact of the condition on patients. They describe common surgical procedures, including epiphysiodeses, osteotomies, debulking procedures, carpal tunnel releases, toe transfers, and amputations. The authors state that careful selection and timing of these surgeries is essential because poorly performed and inappropriately timed surgery may lead to delayed healing and excessive scarring (Level V evidence).

CHAPTER

112

Release of Constriction Ring Syndrome Joshua M. Adkinson and Kevin C. Chung

INDICATIONS • Constriction rings may be classified as mild, moderate, or severe. • Mild: Only skin and a portion of subcutaneous fat are involved, without distal lymphedema. • Moderate: The lymphatic channels are interrupted, but the vascular system is intact. Lymphedema of the distal portion is present. • Severe: The constriction ring is such that the distal blood supply is compromised and the part distal to the ring is at risk for gangrene. On occasion, a digit or portion of the extremity is completely absent at birth. • Severe constriction rings will need urgent surgical release soon after birth. Moderate rings can be corrected at a later age (6–9 months), when anesthesia is safer and the structures are larger. The correction of mild rings is performed mainly for aesthetic considerations and should be done before the child goes to school (3–4 years of age). One should not underestimate the psychological impact of a constriction ring on the growing child.

Contraindications Contraindications include superficial, nonconstricting rings and family or parental reluctance to proceed with surgery.

CLINICAL EXAMINATION • Constriction rings affect approximately 1 in 10,000 live births and occur sporadically. • Other associated abnormalities may include clubfoot, leg length discrepancies, cleft lip/palate, body wall defects, and visceral anomalies. • Constriction rings most commonly affect the digits, rather than the more proximal extremity, and more frequently affect the central digits rather than border digits. In addition to vascular compromise, tight proximal constriction rings may lead to distal nerve dysfunction (motor and sensory deficits), which is difficult to assess in the newborn. • Partial or complete circumferential constriction may be noted with acrosyndactyly (distal fusion), absence of distal parts, or soft tissue protuberances (Fig. 112.1). Acrosyndactyly is commonly associated with a sinus tract at the level of the webspace (Fig. 112.2). On occasion, the fusion of adjacent digits is complicated enough to make it difficult to discern which digit is associated with each digital tip (Fig. 112.3). • The presence of distal lymphedema indicates insufficient subcutaneous tissues to facilitate adequate lymphatic fluid return. Most lymphedema will subside after correction of the constriction ring. • In children with bilateral constriction ring syndrome, the severity of the deformity of one limb is independent of the other. • Constriction rings may be confused with symbrachydactyly (a group of deformities ranging from digital hypoplasia to aplasia or deficiency of the hand or forearm). Symbrachydactyly is frequently unilateral and is characterized by the presence of nubbins with fingernails even in a foreshortened digit, whereas constriction rings more commonly manifest as a congenital amputation. • Although classification systems exist, they do not guide treatment, and most surgeons opt to describe the lesions by their clinical appearance.

849

850

CHAPTER 112  Release of Constriction Ring Syndrome

*

Overriding small and ring fingers

Soft tissue prominence

FIGURE 112.1  Acrosyndactyly of a hand with constriction band.

FIGURE 112.3  Complicated fusion in a patient with acrosyndactyly.

FIGURE 112.2  Acrosyndactyly with a sinus tract (indicated by the black star) at the level of the webspace.

FIGURE 112.4  AP x-ray in a patient with constriction band syndrome. AP, Anteroposterior.

IMAGING • Plain radiographs of the affected extremity are useful to identify any associated bony anomalies, particularly when the constriction ring is associated with acrosyndactyly (Fig. 112.4).

SURGICAL ANATOMY • A constriction ring may extend from skin down to bone. As such, affected structures may involve lymphatics, nerves, and arteries/veins. Furthermore, the constriction ring can result in lymphedema, neurologic symptoms (palsies), and amputation. Fig. 112.5 shows a photograph of a patient with a proximal constriction band and a wrist drop from associated radial nerve palsy. • The soft tissue and skeletal structures that are proximal to the constriction ring are usually normal, but the soft tissue distal to the ring can present with a variable amount of edema (Fig. 112.6A). The physis distal and just proximal to the constriction may be injured, and this can result in growth impairment of the affected part. • The arterial inflow to the part distal to the ring arises from perforators that originate from the main axial artery located in the deeper layers. This blood supply can be maintained because of the intact proper digital artery and its venae comitantes (see Fig. 112.6B).

CHAPTER 112  Release of Constriction Ring Syndrome

FIGURE 112.5  Proximal extremity constriction band with wrist drop secondary to associated radial nerve palsy.

Perforator

Digital artery Hourglass constriction

A

Constriction ring

B

FIGURE 112.6  (A) Hourglass configuration of a digit with constriction band. (B) Digital perfusion through digital artery.

POSITIONING The procedure is performed under general anesthesia with a well-padded tourniquet placed on the upper arm. In proximal rings, one may not be able to apply a tourniquet because the surgical site will be obstructed. The patient is positioned supine with the affected upper extremity on a hand table.

EXPOSURES The principles of surgical correction include constriction ring excision, excision and/or transposition of excessive fat proximal and distal to the ring, and single or multiple Zplasty rearrangement of the skin adjacent to the ring. The tissue rearrangement prevents a circular scar contracture.

EXPOSURE PEARLS

• Staged correction of constriction rings of the digits is generally safer than a one-stage approach. One-stage correction of digital rings has a greater chance of injuring the digital vessels and compromising the distal circulation. In contrast, one-stage correction with circumferential excision of a constriction ring can be performed in the proximal limbs because deeper arteries and veins are much less likely to be injured. • We prefer 60-degree Z-plasty flaps because of the broader base for flap vascular inflow compared with flaps designed with more acute angles.

851

852

CHAPTER 112  Release of Constriction Ring Syndrome STEP 1 PEARLS

For circumferential digital rings, it is better to treat the dorsal portion first because this substantially improves the appearance of the finger. This may prevent the need for a second-stage procedure directed at any remaining volar constriction. STEP 2 PITFALLS

• It is unnecessary to excise all skin involved in the constriction ring; instead, incorporate the skin into the dorsal closure to avoid a skin deficiency. In many cases, no skin is excised. • The neurovascular structures will be immediately deep to the skin on the palmar aspect of the digit. As such, dissection must be meticulous to avoid injuring these structures.

Correction of Finger Constriction Rings PROCEDURE Step 1: Design of Skin Flaps A single Z-plasty is typically sufficient for correction of a digital constriction ring, particularly when a second-stage procedure for the volar aspect of the digit is not necessary or desired. This may be designed on the dorsum (Fig. 112.7A), or, alternatively, two single Z-plasties can be designed on both midlateral lines of the finger (see Fig. 112.7B).

Step 2: Excision of Constriction Ring and Elevation of Skin Flaps The deepest aspect of the constriction ring is incised, and skin flaps are raised along with a thin layer of fat. Preservation of a small amount of fat ensures inclusion of the subdermal plexus and maintains viability of the skin flaps (Fig. 112.8).

Step 3: Excision of Excess Subcutaneous Fat • The subcutaneous fat is elevated proximally and distally as a distinct layer, separate from the skin. This adipofascial flap should be raised superficial to the extensor paratenon or the flexor tendon sheath (Fig. 112.9A–B).

A

B

FIGURE 112.7  (A) Z-plasty release of a digit with constriction band syndrome. (B) Illustration of Z-plasty release of a digit with constriction band syndrome.

Adipofascial layer Skin flap

FIGURE 112.8  Z-plasty flaps elevated with a thin layer of fat.

CHAPTER 112  Release of Constriction Ring Syndrome

Excision of Excision of excessive constriction ring subcutaneous fat Adipofascial flaps

A

Extensor tendon

B

FIGURE 112.9  (A) Adipofascial flaps elevated as a separate layer from the skin. (B) Illustration of excised structures for a digit with constriction band syndrome. Adipofascial flap Skin flap

Adipofascial flap closure

A

B

FIGURE 112.10  (A) Adipofascial flaps transposed and reapproximated across the area of original banding. (B) Illustration of adipofascial flap closure.

• The adipofascial flaps are approximated using absorbable suture to correct the contour deformity (Fig. 112.10A–B). When necessary, dermofat flaps may be created by de-epithelialization of the ring margins and approximated below the overlying skin closure to prevent an hourglass deformity. • Excessive dorsal fat, usually on the distal side, should be removed to adequately treat any existing contour deformity.

Step 4: Transposition and Suture of Z-Plasty Skin Flaps The Z-plasty flaps are transposed and inset using 4-0/5-0 chromic suture (Fig. 112.11A–B).

Correction of Proximal Limb Constriction Rings PROCEDURE Step 1: Design of Skin Flaps A multiple Z-plasty design is used for correction of proximal limb constriction rings because they can be safely corrected in a single stage without jeopardizing distal circulation (Fig. 112.12).

STEP 1 PEARLS

Proximal limb vascularity is subfascial and not at risk with circumferential flap elevation above the fascia.

853

854

CHAPTER 112  Release of Constriction Ring Syndrome

A Adipofascial flap closure Skin closure

B FIGURE 112.11  (A–B) Skin closure over the transposed adipofascial flap.

FIGURE 112.12  Proximal extremity band and markings for release.

Step 2: Excision of Constriction Ring and Elevation of Skin Flaps • The constriction ring is incised and thick skin flaps are elevated. • Unlike correction of finger constriction rings, the skin flaps are elevated just superficial to the deep fascia, with the goal of including all subcutaneous fat in the flap (Fig. 112.13).

Step 3: Transposition and Suture of Z-Plasty Skin Flaps Z-plasty flaps are transposed and inset using 4-0/5-0 chromic suture (Fig. 112.14).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The arm is dressed with a soft, bulky dressing. In young children, short-term immobilization in a cast may be required for protection of the incision. • Lymphedema of the distal part of the affected extremity or finger will improve significantly after a few weeks. Any standing cutaneous deformities resulting from Zplasty inset will improve over time. • Fig. 112.15 shows the long-term result of a constriction ring of the left thumb. See Video 112.1

CHAPTER 112  Release of Constriction Ring Syndrome

Deep fascia FIGURE 112.13  Full-thickness skin flaps elevated just above the deep fascia.

FIGURE 112.14  Z-plasty flaps transposed and inset.

FIGURE 112.15  Long-term outcome after digital Z-plasty release of constriction band.

EVIDENCE Drury BT, Rayan GM. Amniotic constriction bands: secondary deformities and their treatments. Hand (N Y). 2019;14(3):346–351. In this study, the authors report surgical treatment experience with amniotic constriction bands (ACB) over a 35-year period. They included all notable limb deformities and the type of reconstruction. Fifty-one patients were identified; 26 were males and 25 females. The total number of operations was 117, and total number of procedures was 341. More procedures were performed on the upper

855

856

CHAPTER 112  Release of Constriction Ring Syndrome extremity (85%) than the lower extremity (15%). Including ACB, 16 different hand deformities were encountered. Sixteen different surgical methods for the upper extremity were used, including a primary procedure for ACB and secondary reconstructions for all secondary deformities. Average age at the time of the first procedure was 9.3 months. The most common procedures performed, in order of frequency, were excision of ACB plus Z-plasty, release of partial syndactyly, release of fenestrated syndactyly, full-thickness skin grafts, resection of digital bony overgrowth from amputation stumps, and deepening of first and other digital webspaces. The authors conclude that many hand and upper extremity deformities secondary to ACB are encountered and children with ACB may require more than one operation (Level IV evidence). Greene WB. One-stage release of congenital circumferential constriction bands. J Bone Joint Surg Am. 1993;75:650–655. In this study, three patients underwent single-stage release of a circumferential constriction ring. No wound problems occurred, even when there had been marked swelling of the extremity distal to the band. The single-stage release facilitated postoperative care, and there was no need for additional periods of anesthesia or for additional operations (Level V evidence). Upton J, Tan C. Correction of constriction rings. J Hand Surg Am. 1991;16:947–953. The authors present a retrospective study of 116 constriction rings in 58 patients who underwent correction of both deep and shallow constriction rings. All excellent results occurred in patients with shallow deformities. Improvement of contour was seen; 64% were graded as excellent, 31% as good, and 5% as poor (Level IV evidence). Visuthikosol V, Hompuem T. Constriction band syndrome. Ann Plast Surg. 1988;21:489–495. A retrospective chart review of 30 cases of constriction band syndrome diagnosed and treated during 1973 to 1986 was conducted. All 30 cases were treated with single-stage Z-plasty surgery. Good results were achieved in 16 of 20 patients with constriction alone. No compromised circulation of the distal limb or total flap loss was encountered in this study (Level IV evidence).

CHAPTER

113

Centralization for Radial Longitudinal Deficiency Joshua M. Adkinson and Kevin C. Chung

INDICATIONS • Radial longitudinal deficiency (RLD) occurs in 1 out of 30,000 live births and is a spectrum of deformity affecting the forearm, wrist, and hand (Fig. 113.1). Between 50% and 60% of patients have bilateral involvement. • RLD is classified into four grades, depending on the degree of hypoplasia of the radius (Table 113.1). • Centralization of the wrist is recommended between 9 and 12 months of age because anesthesia is safer, preliminary soft tissue distraction can be carried out, and subsequent thumb reconstruction can be done before the child develops a maladaptive pattern of pinch (approximately 6 months after wrist realignment).

FIGURE 113.1  Right wrist radial longitudinal deficiency.

TABLE Classification of Radial Longitudinal Deficiency 113.1

Type

Distal Radius

Proximal Radius

N

Normal

Normal

0

Normal

Normal, radioulnar synostosis, congenital radial head dislocation

1

.2 mm shorter than ulna

Normal, radioulnar synostosis, congenital radial head dislocation

2

Hypoplasia

Hypoplasia

3

Physis absent

Variable hypoplasia

4

Absent

Absent

857

858

CHAPTER 113  Centralization for Radial Longitudinal Deficiency

• Most children will benefit from stretching and static progressive splints or serial casting beginning shortly after birth. Although centralization alone may be performed, if needed, for children with type 0 or 1 deficiencies, children with type 2 or greater deficiencies may need preliminary serial casting or soft tissue distraction using an external fixator.

Contraindications • Mild cases of RLD responsive to stretching and splinting alone. • Centralization should be avoided in children with a stiff elbow (,90 degrees of flexion), because this will limit hand-to-mouth and hand-to-head activities. • Another contraindication may be family or parental reluctance to proceed with surgery.

CLINICAL EXAMINATION • Many children with RLD have associated cardiac, hematologic, musculoskeletal, renal, gastrointestinal, and craniofacial abnormalities. Therefore all children with RLD should undergo a thorough preoperative musculoskeletal and systemic examination, including spine radiographs, an echocardiogram, a renal ultrasound, and a complete blood count (to evaluate for thrombocytopenia or anemia that may be associated with RLD). • Evaluation of elbow range of motion (ROM) is essential. For children who are unable to flex the elbow, the radial deviation deformity enables them to get the hand to the mouth.

IMAGING Plain radiographs of both hands, wrist, and forearms (Fig. 113.2) should be obtained.

SURGICAL ANATOMY Skeletal Anomalies The radius is hypoplastic, partially absent, or totally absent. The ulna is bowed posteriorly and may be shortened to 60% to 75% of normal length. The articulation between the carpus and ulna does not form a normal joint. It is usually fibrous but can be lined by hyaline cartilage. Digital involvement (i.e., hypoplasia and/or stiffness) decreases in severity from the radial aspect of the hand to the ulnar aspect.

Muscle Anomalies The extensor carpi radialis longus (ECRL) and brevis (ECRB) muscles may be absent or fused to the extensor digitorum communis (EDC). The presence of the extensor pollicis

FIGURE 113.2  X-ray of right wrist radial longitudinal deficiency.

CHAPTER 113  Centralization for Radial Longitudinal Deficiency

longus (EPL), extensor pollicis brevis (EPB), and abductor pollicis longus (APL) can be predicted by the presence of a thumb metacarpal. The supinator, pronator quadratus, and palmaris longus (PL) are usually absent. The pronator teres (PT) is absent if the radius is absent. The flexor carpi radialis (FCR) is frequently absent. The extensor carpi ulnaris (ECU), flexor carpi ulnaris (FCU), and flexor digitorum superficialis (FDS) are usually present and normal. The flexor pollicis longus (FPL) is present only if the thumb metacarpal is present. If the thumb is present, the thenar muscles are usually present. The hypothenar, interosseous, and lumbrical muscles are usually normal.

Vascular Anomalies Although the brachial and ulnar arteries are usually present and normal, the radial artery and palmar arch are either absent or attenuated. The interosseous arteries are usually well developed.

Nerve Anomalies The median and ulnar nerves are always present. The median nerve is the most prominent structure on the radial aspect of the wrist and can be mistaken for a tendon during reconstruction. The median nerve supplies sensation to the radial side of the arm because the radial nerve typically ends at the elbow.

POSITIONING The procedure is performed under general anesthesia. The affected arm is placed on a hand table, with a tourniquet placed high on the arm.

EXPOSURES • The four key steps of centralization are: • Conducting preliminary soft tissue distraction using an external fixator device. • Designing a bilobed skin flap to transfer the redundant skin on the ulnar side to make up for the skin deficiency on the radial side. • Centralizing the carpus over the ulna. • Balancing the tendons to counteract recurrent radial deviation.

EXPOSURES PEARLS

• Alternative approaches to the wrist include radial Z-plasty combined with an ulnar transverse ellipse and a dorsal wrist and forearm S-type incisions. • When designing the bilobed flap, ensure that it permits adequate exposure of the distal ulna.

PROCEDURE Step 1: Preliminary Soft Tissue Distraction • A uniplanar external fixator device is applied on the ulnar side of the affected limb (pins traverse the small finger metacarpal and the ulna; Fig. 113.3A–B). It is best to perform this between 6 and 9 months of age. Ensure that the pin size is appropriate for the size of the metacarpal to prevent iatrogenic fracture. • The parents begin distraction at a rate of 1 mm/day a week after device placement. The patient is observed with a weekly clinic visit and radiographs.

A

B FIGURE 113.3  (A–B) Intraoperative images of distractor application.

STEP 1 PEARLS

Preliminary distraction can lengthen taut radial structures and prevent the need for ulna resection during centralization. This may decrease the risk for ulnar growth arrest.

859

860

CHAPTER 113  Centralization for Radial Longitudinal Deficiency

FIGURE 113.4  Image of right wrist after successful distraction.

STEP 2 PITFALLS

• Care should be taken to preserve the superficial cutaneous nerves and longitudinal veins. • Flaps should be kept as thick as possible to avoid devascularizing the wound edges. • Beware of the large dorsal branch of the median nerve, which replaces the absent superficial radial nerve that supplies sensation to the radial aspect of the hand. This branch is positioned in the subcutaneous fold between the wrist and forearm. STEP 3 PEARLS

Centralization indicates aligning the third metacarpal over the distal ulna, whereas radialization means aligning the second metacarpal with the distal ulna. The concept behind radialization compared with centralization is that translating the wrist more ulnarly may lead to a decreased risk of recurrence of the deformity.

• Distraction is continued until the hand is situated slightly beyond neutral. Normally, it takes about 2 months of distraction to achieve this position (Fig. 113.4). • The external fixator device can be removed at the same time as centralization.

Step 2: Elevation of Bilobed Flap The skin incision should start at the point of greatest tension on the radial side of the wrist. The first flap can be marked on the dorsum of the wrist, based proximally (A), with another corresponding flap at 90 degrees that lies on the area of greatest skin redundancy on the ulnar side (B). The flaps are raised in a plane superficial to the extensor retinaculum (Fig. 113.5A–B).

Step 3: Dissection of Nerve and Tendons • The median nerve is identified first during the exposure. It is the most superficial structure on the radial aspect of the distal forearm and can easily be confused with a tendon (Fig. 113.6). • The ECU is identified distal to the retinaculum. The ECR is divided at its insertion to facilitate later transfer to the distal stump of ECU tendon (Fig. 113.7). • The dorsal ulnar sensory nerve is identified and retracted to prevent inadvertent injury.

B

B

A

A

A

B

FIGURE 113.5  (A–B) Bilobed flap design and transposition (flaps labeled A and B for reference).

CHAPTER 113  Centralization for Radial Longitudinal Deficiency

Median nerve Hypoplastic extensor tendons

FIGURE 113.6  Median nerve and hypoplastic extensor tendons after flap elevation.

ECU stump

EDC tendons

ECR tendon

STEP 4 PEARLS FIGURE 113.7  Transection of ECU distal stump before tendon transfer. ECU, Extensor carpi ulnaris.

Step 4: Ulnocarpal Joint Reduction and Centralization • The wrist capsulotomy is created distal to the ulnar physis. • A progressive soft tissue release is carried out until the carpus can be aligned over the distal ulna. This requires the carpus to be carefully mobilized off of the palmar capsule.

Step 5: Fixation The ulnocarpal reduction is maintained by 0.062-inch Kirschner wire (K-wire) placed antegrade through the carpus and then retrograde into the ulnar shaft under fluoroscopic guidance (Fig. 113.8A–B).

Step 6: Wrist Stabilization • The ECR tendon is transferred to the distal stump of the ECU, passing below the EDC (Fig. 113.10). The proximal end of the previously divided ECU is advanced and sutured to the dorsal wrist capsule using nonabsorbable suture. • The ulnocarpal capsule is reefed to impart additional static stability.

• If there is difficulty with reduction of the carpus onto the ulna, the radial side of the wrist should be reevaluated. Any remaining fibrous bands should be divided to facilitate centralization. The volar radial wrist capsule may require additional release. • Occasionally, centralization is only possible after partial carpectomy or limited shaving of the distal ulna. One should remember that the distal ulna epiphysis is only resected if reduction is impossible because excessive removal will cause growth arrest. STEP 5 PEARLS

If the ulna has an angular deformity greater than 30 degrees, a diaphyseal closing wedge osteotomy is performed at the apex of the deformity and the same K-wire from centralization is driven retrograde across the osteotomy site (Fig. 113.9). We prefer to delay ulnar osteotomy until a later stage, when necessary.

861

862

CHAPTER 113  Centralization for Radial Longitudinal Deficiency

Ulnar 30°

A

Radial

B

FIGURE 113.8  (A–B) X-rays of right wrist after centralization and pin placement. FIGURE 113.9  Osteotomy of ulna for deformity greater than 30 degrees.

ECR to ECU tendon transfer FIGURE 113.10  ECR to ECU tendon transfer routed deep to the digital extensors. ECR, extensor carpi radialis; ECU, extensor carpi ulnaris.

Step 7: Closure • The tourniquet is released and hemostasis is ensured. • The extensor retinaculum is repaired using 4-0 Vicryl, and the skin is closed with 5-0 Chromic sutures (Fig. 113.11A–B).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The patient is placed in a well-padded long-arm cast with the elbow in at least 90 degrees of flexion. The extremity is immobilized for at least 8 weeks, and the K-wire is maintained as long as possible. A long-arm orthosis to maintain the centralized wrist position is worn continuously for 3 to 6 months and then at night until skeletal maturity. Prolonged pin fixation followed by long-term splinting is necessary to minimize recurrence. Ten-year follow-up shown in Fig. 113.12. • Recurrence or persistence of deformity is common and is multifactorial. Intraoperative etiologies include lack of complete correction during surgery, inadequate radial soft tissue release, and failure to adequately balance forces acting across the wrist. Postoperative etiologies include early pin removal, poor compliance with the postoperative orthosis, and soft tissue memory. Although distraction facilitates centralization, it does not decrease the risk of recurrence of the deformity.

CHAPTER 113  Centralization for Radial Longitudinal Deficiency

A

B FIGURE 113.11  (A–B) Immediate postoperative view of the wrist after centralization.

FIGURE 113.12  Ten-year postoperative images.

• Foreshortening of the ulna (60% of normal) is common, even after a successful centralization. The short forearm is both a cosmetic and functional problem for the adolescent with RLD. Although the arm may be lengthened by uniplanar or multiplanar shaft-distraction devices in adolescence, it is imperative that the patient has realistic expectations and the ability to tolerate the potentially protracted duration of distraction required for satisfactory lengthening. Importantly, the functional outcome of surgery will be mostly determined by the status of the thumb and fingers. Digital function may worsen with distraction and centralization.

EVIDENCE Mittal S, Garg B, Mehta N, Kumar V, Kotwal P. Randomized trial comparing preliminary results of radialization and centralization procedures in Bayne types 3 and 4 radial longitudinal deficiency. J Pediatr Orthop. 2020;40(9):509–514. In this study, the authors randomized 14 patients with types 3 and 4 radial longitudinal deficiency (RLD), a total of 17 limbs, to either radialization or centralization. Centralization was performed in nine limbs and radialization was performed in eight. Nine affected limbs had type 4 RLD, and eight affected limbs had type 3 RLD. There was no significant difference in the hand-forearm angle in the immediate postoperative period. At 3 months, the radiologic hand-forearm angle increased to 19 degrees in the centralization group, whereas the radialization group showed an average increase to 4 degrees. This increase in the hand-forearm angle continued at 6-, 12-, and 24-month follow-up assessments. Worsening of the deformity was greater in the centralization group, compared with the radialization

863

864

CHAPTER 113  Centralization for Radial Longitudinal Deficiency group. The forearm length also significantly differed in the two groups at 6-, 12-, and 24-month follow-up; however, when adjusted for preoperative lengths, the difference was significant only at 12and 24-month follow-up. At a short-to-intermediate term follow-up, radialization fares better than centralization in terms of recurrence of deformity and in terms of affecting the forearm length (Level I evidence). Bhat AK, Narayanakurup JK, Acharya AM, Kumar B. Outcomes of radialization for radial longitudinal deficiency: 20 limbs with minimum 5-year follow-up. J Hand Surg Eur. 2019;44(3):304–309. The authors reported functional and cosmetic outcomes in 14 patients (6 bilateral and 8 unilateral) with type 4 radial longitudinal deficiency who underwent radialization. Follow-up ranged from 5 to 19 years. At final follow-up, the length of the affected ulna was 56% of the length of the normal ulna. The distal ulna hypertrophied to 97% of the opposite distal radius and a median loss of correction of hand-forearm angle was 9 degrees. All hands improved on Vilkki severity grade and on the Cattaneo functional and aesthetic grading. We conclude that radialization is an effective procedure, but secondary procedures may be required for the long-term maintenance of wrist alignment and hand function (Level IV evidence). Manske MC, Wall LB, Steffen JA, Goldfarb CA. The effect of soft tissue distraction on deformity recurrence after centralization for radial longitudinal deficiency. J Hand Surg Am. 2014;39:895–901. Thirteen upper extremities treated with centralization alone were compared with 13 treated with ring fixator distraction followed by centralization. The clinical resting wrist position was improved significantly after surgery and at final follow-up in both groups, but recurrence was worse at final follow-up in the distraction group patients. Radiographically, in the centralization alone group, the handforearm angle improved from 53 degrees before surgery to 13 degrees at midterm but worsened to 27 degrees at final follow-up. In the distraction group, the hand-forearm angle improved from 53 degrees before surgery to 21 degrees at midterm but worsened to 36 degrees at final follow-up. The hand-forearm position improved between preoperative and final assessment in both groups, but at final follow-up, the centralization-alone group had a significantly better position. Volar subluxation was 4 mm improved in the centralization alone group and 2 mm worse in the distraction group at final follow-up. The authors conclude that centralization, with or without distraction with an external fixator, resulted in improved alignment of the wrist. Distraction facilitated centralization, but it did not prevent deformity recurrence and was associated with a worse final radial deviation and volar subluxation position compared with wrists treated with centralization alone (Level III evidence). Vuillermin C, Wall L, Mills J, et al. Soft tissue release and bilobed flap for severe radial longitudinal deficiency. J Hand Surg Am. 2015;40:894–899. The authors reviewed their experience with soft tissue release and bilobed flap reconstruction in 18 wrists with at least 3-year follow up. At a mean of 9.2 years follow-up, the average final resting wrist radial deviation angle was 64 degrees compared with 88 degrees preoperatively. The average active wrist flexion-extension arc was 73 degrees. Average Disabilities of the Arm, Shoulder, and Hand (DASH) score was 27 (range, 5–54). Pediatrics Outcome Data Collection Instrument (PODCI) global was 88 (range, 75–97), PODCI happiness was 86 (range, 70–100), and Visual Analog scale (VAS) overall satisfaction (range, 0–10) was 1.2 (range, 0–8). At final follow-up, no physeal growth arrests were noted on radiographs, and no patients to date required ulnocarpal arthrodesis. They conclude that soft tissue release and coverage with a bilobed flap should be considered in the treatment algorithm for patients with radial longitudinal deficiency, although some recurrence of radial deviation was noted (Level IV evidence).

CHAPTER

114

Cleft Hand Reconstruction Joshua M. Adkinson and Kevin C. Chung INDICATIONS Indications for this procedure include the presence of a transverse bone in which growth leads to a progressive deformity (widening of the cleft), syndactyly affecting border rays with progressive deviation of the longer ray, a constricted first webspace, and closure of the cleft for aesthetic improvement.

Contraindications Contraindications include simple, minor clefts, where surgery might impact function, and family or parental reluctance to proceed with surgery.

CLINICAL EXAMINATION • A cleft hand is considered a longitudinal central deficiency affecting the central digits and occurs in 1 out of 10,000 to 1 out of 90,000 live births. It is commonly inherited as an autosomal dominant trait with variable penetrance and is associated with a number of syndromes. The condition may be bilateral and affect the feet (i.e., splithand, split-foot syndrome). The Manske and Halikis system classifies the level of involvement of the first webspace and is useful for planning reconstruction (Table 114.1). For example, cleft closure must be undertaken with an appreciation for the extent of first webspace and thumb involvement; first webspace deepening is often combined with cleft closure. • The diagnosis of a cleft hand is straightforward; patients with a typical cleft hand present with a V-shaped cleft in the center of the hand. The cleft severity varies widely among patients. Additional findings include digit/ray absence, polydactyly, and/or syndactyly of one or more digits adjacent to the cleft. Because of the strong genetic component associated with a cleft hand, genetic counseling may be indicated. • Figs. 114.1 and 114.2 show a 2-year-old boy with a cleft right hand with syndactyly between the little finger and ring finger.

IMAGING • Radiographs of the hand and upper limb are helpful to characterize the underlying osseous abnormalities.

TABLE The Manske and Halikis Classification System for Cleft Hand 114.1

Type

Description

Characteristics

I

Normal web

Thumb webspace is not narrow

IIA

Mildly narrowed web

Thumb webspace is mildly narrowed

IIB

Severely narrowed web

Thumb webspace is severely narrowed

III

Syndactylized web

Thumb and index rays syndactylized, webspace obliterated

IV

Merged web

Index ray suppressed, thumb webspace merged with the cleft

V

Absent web

Thumb elements suppressed, ulnar rays remain, thumb webspace no longer present

865

866

CHAPTER 114  Cleft Hand Reconstruction

FIGURE 114.2  AP x-ray images of cleft hand. AP, Anteroposterior.

FIGURE 114.1  Cleft hand.

• Skeletal anomalies are common. These include absence or hypoplasia of metacarpals within the cleft, transverse tubular bones that will widen the cleft with growth, bifid metacarpals supporting one finger (i.e., superdigit), and duplicated metacarpals. Possible phalangeal anomalies include a longitudinally bracketed epiphyses or double phalanges (Fig. 114.3).

SURGICAL ANATOMY • Surgical anatomy will vary depending on the degree of involvement of the first webspace, central hand, and remaining digits. • Proximal muscle tendon units and nerves may be variably absent. This can affect function and the technical aspects of thumb reconstruction, if needed.

POSITIONING The procedure is performed under general anesthesia. The affected arm is placed on a hand table, with a well-padded tourniquet placed high on the arm.

FIGURE 114.3  Marked skeletal anomalies in a cleft hand.

CHAPTER 114  Cleft Hand Reconstruction

EXPOSURES • In children who have a central cleft with narrow thumb and index finger web, the skin over the dorsum of the cleft is raised as a palmarly based flap (i.e., Snow-Littler flap). This flap is transposed radially and used to resurface the first webspace after release. Elevating the flap from the dorsal hand is easier because of a lack of adhering palmar fascia. Additionally, this permits access to the metacarpal heads that can be reapproximated during cleft closure. • A distally based rectangular flap is designed over the midproximal phalanx on one of the fingers adjoining the cleft. This flap will be used to create the webspace formed after closure of the central cleft. Care is taken to create a smooth slope in the reconstructed webspace. • The fourth webspace may have an incomplete syndactyly that warrants deepening with flaps with or without full-thickness skin grafts at a separate stage of reconstruction (Fig. 114.4). FIGURE 114.4  Fourth webspace incomplete syndactyly.

PROCEDURE Step 1: Elevation of Palmarly Based Flap

STEP 1 PEARLS

• The flap is designed to extend to the dorsum of the hand by parallel incisions (Figs. 114.5A–B and 114.6A–B). • The parallel incisions are connected on the dorsum, and the dorsal flap is elevated superficial to the extensor tendon paratenon. • The neurovascular bundles are identified on the palmar aspect of the hand and protected, and the flap is mobilized by dividing any tethering fascial bands (Fig. 114.7).

• The flap should be mobilized sufficiently for easy transposition to the thumb and index finger webspace. • The viability of this flap depends on preservation of the blood supply, and dissection must maintain the subdermal plexus.

Step 2: Release of Thumb and Index Finger Webspace A releasing incision is made between the thumb and index finger to treat the webspace contracture (Fig. 114.8).

Step 3: Closure of Cleft • The head and neck of the metacarpals adjoining the cleft are exposed during flap elevation (Fig. 114.9). • Nonabsorbable sutures are placed to approximate the metacarpal heads and close the cleft (Figs. 114.10A–B and 114.11). All sutures are placed before tying, taking care to ensure adequate purchase of the periosteum, intermetacarpal ligament, and bone (if the patient is young and the bone is soft).

A

STEP 2 PEARLS

• If the first webspace syndactyly is minimal, local flaps (e.g., Z-plasty) alone may be sufficient for deepening. • If there is substantial thumb and index finger webspace narrowing, one may need to divide the fascia, the adductor pollicis, and the first dorsal interosseous muscle. Rarely, an osteotomy of the thumb metacarpal may be required to realign the thumb. STEP 3 PEARLS

Alternative options for cleft closure and soft tissue stabilization include using the adjacent annular flexor tendon sheath pulleys, periosteal flaps, or free grafts.

B FIGURE 114.5  (A) Dorsal hand markings. (B) Illustration of dorsal hand markings. 

867

868

CHAPTER 114  Cleft Hand Reconstruction

A

B

FIGURE 114.6  (A) Volar hand markings. (B) Illustration of volar hand markings. 

First web space released

Palmar-based flap

FIGURE 114.8  First webspace released before flap inset.

FIGURE 114.7  Snow-Littler flap elevated.

Metacarpal heads of index and ring fingers

FIGURE 114.9  Cleft release with exposure of metacarpal heads. 

CHAPTER 114  Cleft Hand Reconstruction

A

B

FIGURE 114.10  (A) Intermetacarpal sutures prior to closure of cleft. (B) Illustration of intermetacarpal sutures before closure of cleft. 

FIGURE 114.11  Provisional cleft closure.  FIGURE 114.12  Flap inset into first webspace.

Step 4: Transfer of Cleft Flap to Resurface Thumb and Index Finger Web The previously elevated flap is transposed into the defect created by release of the thumb and index finger web (Fig. 114.12).

Step 5: Creation of New Webspace in Cleft • A distally based rectangular flap is designed over the ring finger at the level of the midproximal phalanx. This will be sutured to the index finger after cleft closure to re-create the webspace (Fig. 114.13). • The flap is elevated and sutured to the opposite incision to create the desired gentle slope of the webspace (Figs. 114.14 and 114.15A–B).

STEP 4 PEARLS

The palmar skin proximal to the index finger (between the flap and the first webspace) must be incised and elevated to ensure that the cleft flap can be transposed to the first webspace.

869

870

CHAPTER 114  Cleft Hand Reconstruction

Rectangular flap FIGURE 114.13  Distally based rectangular flap along the ring finger.

Rectangular and palmar-based flaps after elevation

FIGURE 114.14  Elevation of rectangular flap used for webspace creation. 

B

A

Rectangular flap after inset FIGURE 114.15  (A–B) Inset of rectangular flap.

STEP 5 PEARLS

• Care should be taken to resurface the interdigital space with a flap, rather than a straightline incision. • We recommend elevating the webspace flap only after approximating the metacarpal heads. This permits adjustments to the flap design based on final location of the webspace.

Step 6 All skin incisions are closed with absorbable sutures (Fig. 114.16A–D).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A long-arm cast is applied and maintained for 4 weeks to permit healing of the intermetacarpal closure and soft tissues. If a metacarpal transposition is performed, Kirschner wires (K-wires) are removed 6 weeks after surgery. • Orthotic use after 4 to 6 weeks may be used at nighttime to maintain alignment. Formal occupational therapy may be performed with the goal of maximizing active and passive range of motion (ROM) and function. • The child is followed yearly until skeletal maturity to evaluate hand growth and function. Untreated rotational deformities may worsen with growth and subsequently require osteotomies, joint stabilization, or muscle rebalancing. Creeping of the webspace is not

CHAPTER 114  Cleft Hand Reconstruction

B

A

C

D

FIGURE 114.16  (A–B) Appearance after cleft closure and flap reconstruction of first webspace. (C–D) Appearance after cleft closure and flap reconstruction of first webspace. 

FIGURE 114.17  Long-term results after cleft hand reconstruction. 

uncommon with any cleft surgery. Future webspace releases may be needed to enhance the functional and aesthetic results for the hand. The overall outcome depends on the degree of preoperative deformity, and good function can be achieved in children with a preserved thumb (Fig. 114.17). See Video 114.1

871

872

CHAPTER 114  Cleft Hand Reconstruction

EVIDENCE Aleem AW, Wall LB, Manske MC, et al. The transverse bone in cleft hand: A case cohort analysis of outcome after surgical reconstruction. J Hand Surg Am. 2014;39:226–236. The authors sought to evaluate the implications of the transverse bone in cleft hand by assessing outcomes after reconstruction in comparison with a control group. They reviewed 23 hands in 18 patients after surgical reconstruction of the cleft hand. Eleven hands had a transverse bone component, and 12 hands (control group) did not. There was no difference in aesthetic or functional subjective outcomes or objective outcomes measure between the two groups. The use of the cleft for pinch was more dependent on the status of the index finger and the preoperative thumb-index webspace rather than the presence of a transverse bone. Eleven (4 transverse and 7 control) hands required additional surgery to treat abnormal function or posture of the index and ring fingers. Preoperative radiographic divergence angles were larger in the transverse bone group than in the control group, whereas postoperative divergence angles were nearly equivalent. The authors conclude that the presence of a transverse bone in cleft hand was not associated with worse outcomes after cleft reconstruction. Preoperative narrowing of the thumb webspace and postoperative index finger metacarpophalangeal joint abnormality are associated with worse functional outcomes (Level III evidence). Al-Qattan MM. Central and ulnar cleft hands: A review of concurrent deformities in a series of 47 patients and their pathogenesis. J Hand Surg. 2014;39(5):510–519. The author reviews the clinical findings of both ulnar cleft hands and central cleft hands. A review of 34 syndromic and 10 nonsyndromic central cleft hand patients was then performed in order to report concurrent deformities. Nonsyndromic cases involved only one hand, whereas 25 out of 34 syndromic patients had bilateral hand involvement. Syndactyly, hypoplasia, transverse phalanges, and synostosis of the carpus, metacarpals, and phalanges were common. The author then provides an excellent review of hand embryology and pathophysiology that leads to clefting (Level IV evidence). Upton J, Taghinia AH. Correction of the Typical Cleft Hand. J Hand Surg Am. 2010;35:480–485. In this review, the authors describe a technique for correction and transposition of the index ray through a simple incision, which separates the glabrous from the dorsal skin surfaces. They note that the correction of type II and III typical cleft hands can be complicated because each hand can contain a variation of congenital problems including syndactyly, camptodactyly, thumb hypoplasia, deficiency of the first webspace, abnormal phalanges, maligned joints, and abnormal intrinsic muscles and extrinsic tendons. The importance of skeletal alignment precision and preservation of the adductor pollicis muscle is emphasized (Level V evidence). Rider MA, Grinder SI, Tomkin MA, Wood VE. An experience of the Snow-Littler procedure. J Hand Surg Br. 2000;25:376–381. The authors reviewed 12 cases using the Snow-Littler procedure to close hand clefts. The procedure described is similar to the techniques illustrated in this chapter. They concluded that this technique improved the appearance and function for children with hand clefts (Level IV evidence).

CHAPTER

115

Arthrogryposis Reconstruction Joshua M. Adkinson and Kevin C. Chung

INDICATIONS Indications for this procedure include: • Elbow extension contracture with minimal passive flexion after maximizing therapy and splinting/casting (Fig. 115.1). • Wrist flexion contracture with or without fixed bony changes in patients with active finger extension (Fig. 115.2).

Contraindications Contraindications for this procedure include the improvement of deformity with splitting alone and family or parental reluctance to proceed with surgery. The procedure should also be avoided if the patient has adapted well to deformity and surgery would predictably decrease function.

CLINICAL EXAMINATION • The term arthrogryposis describes a host of conditions that lead to multiple congenital joint contractures. The most common is amyoplasia or classic arthrogryposis, which affects 1 in 3000 live births. A subtype called “distal” arthrogryposis affects the hands and feet with proximal limb sparing. • Arthrogryposis is associated with a number of other conditions, including FreemanSheldon syndrome. • A thorough preoperative examination of the upper extremity should be performed. • The upper extremity is typically adducted and internally rotated. Passive and active range of motion (ROM) of the elbow should be well documented. • The functional status of the triceps should be determined. If the triceps is strong, the long head can be considered as a transfer for elbow flexion (i.e., triceps-to-biceps transfer) after achieving acceptable passive ROM.

FIGURE 115.1  Elbow extension contracture in a patient with arthrogryposis multiplex congenita.

FIGURE 115.2  Wrist flexion deformity in a patient with arthrogryposis multiplex congenita.

873

874

CHAPTER 115  Arthrogryposis Reconstruction

A

B

FIGURE 115.3  (A–B) Passive finger extension with wrist flexion.

• If the child is unable to actively extend the fingers and relies on wrist flexion for finger release, surgery to place the wrist in neutral will compromise the ability to passively extend the fingers through a tenodesis effect (Fig. 115.3A–B). • Even if passive wrist extension is achieved through splinting and stretching, active wrist extension is limited or absent. If possible, the extensor carpi ulnaris (ECU) function should be assessed. A transfer of the ECU to the radial wrist extensors (extensor carpi radialis longus and brevis) may improve wrist extension and address the ulnar deviation deformity. • A preoperative occupational therapy evaluation is important to evaluate the functional status of the wrist. Information gleaned from this assessment will help determine the optimal wrist position in children who need surgery and help avoid surgery in children who have adapted to the wrist flexion contracture.

IMAGING Plain radiographs of the wrist may assist in planning for carpal wedge resection.

SURGICAL ANATOMY • Muscles acting across the elbow may be atrophic, but elbow anatomy in children affected by arthrogryposis is normal. • The wrist extensor tendons are small. The radial wrist extensors are usually adherent to the dorsal capsule and the proximal musculature is attenuated or absent. The ECU is often the largest extensor tendon.

Posterior Elbow Release and Tricepsplasty POSITIONING EXPOSURES PEARLS

If the ulnar nerve is at risk during dissection, it may be transposed anterior to the medial epicondyle and secured in a subcutaneous pocket. We do not find this routinely necessary.

• The patient is placed in the supine position with the extremity on a hand table. A well-padded tourniquet is placed high on the affected arm. • Intraoperative fluoroscopy may be helpful to discern the medial epicondyle from the olecranon in patients with stiff, internally rotated arms.

EXPOSURES

Avoid incising the triceps fascia during exposure because this can compromise the integrity of the tendon during subsequent reconstruction.

• A curvilinear 10-cm incision is made from the olecranon to the musculotendinous junction of the triceps muscle. The medial and lateral skin flaps are elevated sharply (Fig. 115.4). • The ulnar nerve is then identified proximally at the medial intermuscular septum and traced distally into the cubital tunnel. The cubital tunnel is released with scissors (Fig. 115.5) and the ulnar nerve is protected.

STEP 1 PEARLS

PROCEDURE

EXPOSURES PITFALLS

Greater triceps tendon lengthening can be achieved if the apex of the V is extended further proximally on the triceps.

Step 1 A distally based V-shaped incision is marked on the triceps tendon and incised with a scalpel. The apex of the V should be at the musculotendinous junction (Fig. 115.6).

CHAPTER 115  Arthrogryposis Reconstruction

FIGURE 115.4  Markings for posterior elbow exposure.

FIGURE 115.5  Ulnar nerve dissection.

Release of capsule

STEP 2 PEARLS

• There is usually very little improvement in passive elbow flexion with triceps release alone. • A Freer elevator can be used to identify the posterior aspects of the medial and lateral collateral ligaments of the elbow.

Distally-based flap of triceps

FIGURE 115.6  Marking of distally based flap of triceps.

FIGURE 115.7  Distally based flap of triceps retracted and posterior elbow capsule released.

Step 2 • The distally based flap of tendon is elevated from the underlying muscle and the joint capsule is exposed (Fig. 115.7). • The joint capsule is released sharply by applying a gentle flexion force to the elbow.

Step 3 The distally based flap of triceps tendon is then repaired in a V-to-Y fashion with nonabsorbable suture (Figs. 115.8A–B and 115.9).

STEP 2 PITFALLS

• Aggressive and uncontrolled passive flexion of the elbow before soft tissue release can lead to fracture of potentially osteopenic bone. • Do not incise the medial and lateral collateral ligaments of the elbow when releasing the posterior capsule. • Care is required to avoid damaging the distal humeral physis. STEP 3 PEARLS

The elbow should be flexed and extended in the operating room to ensure that the ulnar nerve does not kink or subluxate (Fig. 115.10).

875

876

CHAPTER 115  Arthrogryposis Reconstruction Elbow extended Elbow flexed

Olecranon Ulnar nerve Distally based flap

V–Y advancement

Triceps tendon

Lateral head of triceps

Long head or triceps

A

B

FIGURE 115.8  Diagram of movement of distally based triceps flap after release and passive elbow flexion.

FIGURE 115.9  V-Y advancement and inset of triceps flap.

FIGURE 115.10  Demonstration of passive flexion after triceps advancement and elbow capsule release.

Step 4 • The tourniquet is deflated and hemostasis is ensured with bipolar electrocautery. • The skin is closed using 4-0 absorbable suture. • A well-padded cast is applied with the elbow in at least 90 degrees of flexion.

CHAPTER 115  Arthrogryposis Reconstruction

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The limb is immobilized in an above-elbow cast for 4 weeks and then active and passive ROM exercises are initiated. • A removable orthosis is used continuously for an additional 4 weeks, followed by nighttime-only use for a final 4 weeks. Self-feeding is encouraged throughout the postoperative course and is guided by a hand therapist. Initial passive flexion is limited to 90 degrees, with the goal of full passive flexion by 3 months. • Elbow capsulotomy combined with triceps lengthening reliably increases passive elbow ROM and enables hand-to-mouth activities if active elbow flexion is present. Additional procedures to provide active elbow flexion may be necessary (e.g., triceps-to-biceps, pectoralis major, latissimus dorsi, and free functional gracilis muscle transfers). • Children who undergo elbow release before the age of 2 have better postoperative flexion and overall passive arc of elbow motion compared with older children.

Carpal Wedge Osteotomy POSITIONING • The patient is placed in the supine position with the extremity on a hand table. A well-padded tourniquet is placed high on the affected arm. • Intraoperative fluoroscopy will be required to plan the midcarpal wedge resection osteotomies and to confirm the position of the Kirschner wires (K-wires) that will be used for fixation. Fig. 115.11 shows a preoperative lateral x-ray of a patient with amyoplasia.

EXPOSURES • A single 5-cm longitudinal incision is made over the center of the dorsal wrist (Fig. 115.12). Radial and ulnar skin flaps are raised superficial to the extensor retinaculum. • The Lister tubercle is identified and the third compartment is opened by obliquely incising just ulnar to the tubercle. The extensor pollicis longus (EPL) tendon is brought out of the third compartment (i.e., radialized). • The wrist capsule is incised and the second and fourth compartments are carefully elevated extraperiosteally with a scalpel to expose the carpus.

FIGURE 115.11  Lateral wrist x-ray in a patient with amyoplasia.

EXPOSURES PEARLS

• The sensory branches of the radial and ulnar nerve are elevated along with the skin flaps. • The entire midcarpal joint must be visualized and the extensor compartments mobilized sufficiently for full exposure. EXPOSURES PITFALLS

• The EPL is small and must be handled carefully. • The wrist and digital extensors are frequently adherent to the underlying wrist capsule because of a lack of excursion.

FIGURE 115.12  Longitudinal incision marking for carpal wedge osteotomy.

877

878

CHAPTER 115  Arthrogryposis Reconstruction

STEP 1 PEARLS

• Intraoperative fluoroscopy is helpful to confirm the position of the osteotomy in the older child. In the younger child with an incompletely ossified carpus, the osteotomy position is confirmed visually. • A scalpel can be used in the younger child because the carpus is soft. An osteotome will be required in the older child because of a partially ossified carpus. A saw is generally avoided because the cut is less precise and the bone is soft. STEP 1 PITFALLS

• Ensure that the wedge resection is over the midcarpal joint and not the radiocarpal joint. • Prevent injury to the volar wrist capsule during the osteotomy.

PROCEDURE Step 1 • A V-shaped wedge of bone that tapers from dorsal to volar is removed from the midcarpal joint using an osteotome or knife (Fig. 115.13). The amount of bone resected is based on the extent of preoperative wrist flexion and ulnar deviation. • The proximal cut is made perpendicular to the long axis of the radius and the distal cut is made perpendicular to the metacarpals. The radial side of the wedge is made wider if correction of an ulnar deviation deformity is also required (Fig. 115.14).

Step 2 • The purpose of the wedge osteotomy is to achieve a posture of slight wrist extension (Fig. 115.15). If the wrist cannot be passively brought into this position, wrist flexor tendons will need to be released or lengthened.

A

B

C

D

FIGURE 115.13  (A) Anteroposterior and (B) lateral views of location of the osteotomy, (C) anteroposterior and (D) lateral views after wedge osteotomy. (From Fig. 34.55A–D, Azar F, Canale ST, Beaty JH, eds. Campbell’s Operative Orthopaedics, 14th ed. Elsevier; 2020:1369–1458).

CHAPTER 115  Arthrogryposis Reconstruction

Osteotomy permits passive wrist extension

Wedge osteotomy

FIGURE 115.14  Carpal wedge osteotomy after removal of bone wedge.

FIGURE 115.15  Osteotomy permits passive wrist extension.

• Flexor lengthening is performed via a 5-cm volar longitudinal incision that is made proximal to the wrist crease and ulnar to the palmaris longus (PL) tendon. • A tight PL tendon can be transected. Fractional lengthening of the wrist flexor tendons can result in 2 cm of lengthening. The wrist is then passively extended to the desired position.

Step 3 Two 0.062-inch (1.57-mm) K-wires are used to maintain the corrected position of the wrist after wedge excision of the carpus and release of any tight volar structures (Fig. 115.16).

It is technically straightforward to pass the K-wires in an antegrade fashion through the osteotomy site. The K-wires are oriented so that they exit the skin distally between the metacarpals. The osteotomy is closed and the K-wires are passed retrograde across the osteotomy and the radiocarpal joint into the distal radius. In young children, the fusion site can be reinforced with transosseous sutures, if desired. STEP 3 PITFALLS

Step 4 The dorsal capsule is repaired using 3-0 Vicryl sutures.

Step 5 • A good quality ECU tendon can be divided distally and transferred subcutaneously to reach the radial wrist extensors to provide a limited amount of balanced wrist extension. • The skin is closed with absorbable sutures.

FIGURE 115.16  Wrist Kirschner wire (K-wire) placement.

STEP 3 PEARLS

• The position of the K-wires should be confirmed by intraoperative fluoroscopy (Fig. 115.17). The wires should pass through both midcarpal and radiocarpal joints to ensure stable fixation. • To maintain the K-wires in the distal radius, one should accept a neutral alignment of the wrist, rather than a more desirable position of slight extension. If the wrist is extended as the K-wires are driven retrograde, the K-wires may impinge on the soft tissues of the volar forearm.

FIGURE 115.17  Fluoroscopy confirms wrist Kirschner wire (K-wire) placement.

879

880

CHAPTER 115  Arthrogryposis Reconstruction

FIGURE 115.18  Improvement in wrist extension at 6 months postoperatively.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES

STEP 5 PEARLS

• The limb is immobilized in an above-elbow cast for 4 to 6 weeks to allow the osteotomy site to heal. Unrestricted finger motion is encouraged immediately after surgery. • The K-wires are removed at the time of cast removal. • The osteotomy site is protected with the use of an orthosis for 3 months. • Formal therapy is usually not required in younger children because they typically adjust well to the repositioned wrist. • Surgery reliably repositions the wrist, which improves grasp. Fig. 115.18 demonstrates improvement in wrist extension at 6 months postoperatively. • Children older than age 7 do better than younger patients. Combining carpal wedge osteotomy with ECU transfer leads to improved wrist extension. • Arthrogryposis patients score lower on upper extremity function compared with agematched controls, but they have emotional states that are consistent with population norms.

Because the ECU tendon may have minimal excursion after transfer, it may act as a tenodesis, rather than contributing to active wrist extension.

EVIDENCE Elbow Release Richards C, Ramirez R, Kozin S, Zlotolow D. The effects of age on the outcomes of elbow release in arthrogryposis. J Hand Surg Am. 2019;44(10):898.e1–898.e6. The authors reviewed patients with arthrogryposis who underwent a posterior elbow release for elbow extension contracture between 2007 and 2014. They included 13 patients (18 procedures) who had a minimum follow-up of at least 2 years. Patients were divided into 3 groups based on their age at the time of surgery: younger than 2 years, 2 to 3 years old, and older than 3 years. The average preoperative arc of motion was 16 degrees (0 degrees to 30 degrees) for the children younger than 2, 33.5 degrees (5 degrees to 60 degrees) for the children 2 to 3, and 45 degrees (25 degrees to 80 degrees) for the children older than 3. The average postoperative arc of motion was 88.2 degrees (70 degrees to 103 degrees), 60 degrees (15 degrees to 85 degrees), and 54.33 degrees (23 degrees to 70 degrees) for the respective age groups. The authors conclude that children who underwent posterior elbow release before the age of 2 had a clinically important increase in their postoperative flexion and overall passive arc of elbow motion compared with older children. These data suggest that earlier release may be better at restoring total passive arc of elbow motion (Level IV evidence). Van Heest A, James MA, Lewica A, Anderson KA. Posterior elbow capsulotomy with triceps lengthening for treatment of elbow extension contracture in children with arthrogryposis. J Bone Joint Surg Am. 2008;90:1517–1523. The authors report their experience of 29 posterior elbow capsulotomies with triceps lengthening in 23 children with amyoplasia. The average duration of follow-up was 5.4 years. The arc of motion of all 29 elbows improved from an average of 32 degrees (range, 0 degrees to 75 degrees) preoperatively to an average of 66 degrees (range, 10 degrees to 125 degrees) at the time of final follow-up. All children were able to reach the mouth using passive assistance (e.g., table-push, trunk-sway, and cross-arm techniques), and 22 children were able to feed themselves independently. No child underwent subsequent tendon transfer surgery. The authors conclude that elbow capsulotomy with triceps lengthening successfully increases passive elbow flexion and the arc of elbow motion of children with arthrogryposis, enabling hand-to-mouth activities (Level IV evidence). Carpal Wedge Osteotomy Van Heest AE, Rodriguez R. Dorsal carpal wedge osteotomy in the arthrogrypotic wrist. J Hand Surg Am. 2013;38:265–270. The authors report results of 20 carpal wedge osteotomies in 12 patients. All 12 patients’ parents reported subjective improvement in position and appearance and in performing activities of daily

CHAPTER 115  Arthrogryposis Reconstruction living. Wrist extension was significantly increased (mean, 43 degrees), wrist flexion was significantly decreased (mean, 34 degrees from neutral), and there was no significant change in wrist motion arc. Significantly greater improvement in wrist extension was observed in children operated on at 7 years of age or older and in patients treated concomitantly with an ECU tendon transfer (Level IV evidence). Foy CA, Mills J, Wheeler L, Ezaki M, Oishi SN. Long-term outcome following carpal wedge osteotomy in the arthrogrypotic patient. J Bone Joint Surg Am. 2013;95:e150. The authors reviewed their experience of 75 carpal wedge osteotomies in 46 patients with amyoplasia. The average resting position of the wrist postoperatively (11 degrees of flexion) was significantly different from that measured preoperatively (55 degrees of flexion; p < .001). The arc of wrist motion measured preoperatively (32 degrees) did not differ significantly from that measured postoperatively (22 degrees; p = .4903). The average active extension of the wrist changed from −37 degrees of extension preoperatively to −11 degrees of extension postoperatively (p < .001). Active wrist flexion also significantly changed from 69 degrees preoperatively to 33 degrees postoperatively (p < .001). Parent-guardian surveys indicated that the mean overall satisfaction score after surgery was 9.1 of 10 possible points and that the mean ranking for task completion in activities of daily living was 4 (easier after surgery). The authors conclude that surgery results in a sustained improvement and parents or guardians were satisfied with the result (Level IV evidence). Patient-Reported Outcomes Wall LB, Vuillerman C, Miller PE, Bae DS, Goldfarb CA; CoULD Study Group. Patient-reported outcomes in arthrogryposis. J Pediatr Orthop. 2020;40(7):357–360. The authors sought to evaluate patient-reported outcomes (PROs) in patients with arthrogryposis using the Patient-Reported Outcome Measurement Information System (PROMIS) and Pediatric Outcomes Data Collection Instrument (PODCI) questionnaires. A total of 29 patients completed all questionnaires. This cohort was divided into distal arthrogryposis and amyoplasia groups, with 15 and 14 patients in each group, respectively. For both cohorts, the median upper extremity (UE) function PROMIS scores were significantly less than population norms, 31 for distal arthrogryposis and 22 for amyoplasia. PODCI UE function was statistically lower for amyoplasia compared with the distal arthrogryposis cohort. PROMIS pain, depression, anxiety, and peer relations were in the normal range for both cohorts. Median PODCI pain and happiness ranged from 85 to 88 for all patients with no statistical difference between groups. The authors conclude that arthrogryposis patients have lower UE function scores but have emotional states consistent with populations norms. Furthermore, amyoplasia patients were functionally worse than distal arthrogryposis patients (Level II evidence).

881

ddsf

SECTION XIII

Tumors CHAPTER 116

Hand Masses  883

CHAPTER 117

Excision of Vascular Lesions of the Hand  892

CHAPTER 118

Excision of Enchondroma  893

CHAPTER 119

Excision of Peripheral Nerve Schwannoma  894

CHAPTER 120

Excision of Malignant Skin Tumors  900

882

CHAPTER

116

Hand Masses Shepard Peir Johnson and Kevin C. Chung

Mucous Cyst Excision INDICATIONS • One indication for this procedure is a cyst causing pain. • It is important to distinguish between a painful cyst and a painful arthritic distal interphalangeal (DIP) joint. • Other indications include aesthetic deformity (unsightly lesion or nail ridge) and recurrent infection or wound.

Contraindications • If diagnosis of mucous cyst is not clear, consider excisional biopsy before performing a rotational skin flap. • If the cyst is acutely infected, manage the infection before definitive excision.

CLINICAL EXAMINATION • The finger is examined, noting the size and location of the mass. The mass is palpated to determine whether it is firm or soft. Transillumination of the mass can help differentiate a fluid-filled mass from a solid tumor. • Mucous cysts may cause pressure on the nail matrix and lead to a nail plate deformity with a ridge or depression (Fig. 116.1). Any nail plate deformity is documented preoperatively because only 60% of deformities are reported to resolve after surgery and new nail deformities can also present after surgery. • The skin around the mass and the distal finger is examined and palpated. The surrounding skin is often rotated or advanced to cover a defect left after excision. Any skin around the mass that is severely atrophic is excised with the mass. A longer rotational advancement flap is designed if a larger defect is created. • The DIP joint is examined to identify osteophytes. A patient with a painful or deformed arthritic joint deformity is a candidate for a simultaneous DIP arthrodesis.

FIGURE 116.1  Mucous cyst located between the distal interphalangeal (DIP) joint and eponychial fold. Chronic pressure on the nail matrix has led to a nail deformity (black arrow).

IMAGING Plain films can be used to evaluate the amount of osteoarthritis and assess osteophyte formation.

SURGICAL ANATOMY • Mucous cysts are found on the dorsal aspect of the distal phalanx between the DIP joint and the eponychial fold. • Cysts have a stalk that connects them to the DIP joint. • The stalk lies between the terminal slip and the collateral ligament and may connect to the ipsilateral or contralateral side of the cyst (Fig. 116.2). • The cyst grows slowly and may erode the skin and adjacent structures, such as the nail matrix.

POSITIONING The procedure is performed with a digital nerve block and a finger tourniquet.

EXPOSURES • If the overlying skin is pliable, a transverse curvilinear incision (proximally based) is centered over the DIP joint. This design facilitates DIP joint exploration (Fig. 116.3A)

EXPOSURES PEARLS

• A no. 15 blade is used to elevate the skin flap and avoid injury to the eponychium and extensor tendon. The plane is directly on top of the terminal tendon. • Although fragile cysts may rupture during exposure, try to visualize the stalk and its trajectory toward the DIP joint. EXPOSURES PITFALLS

The subdermal plexus is the main vascular supply of the skin flap. The flaps are raised with some subcutaneous tissue to preserve their circulation. 883

884

CHAPTER 116  Hand Masses

Dissection site

Cyst

Joint capsule Extensor tendon

Stalk Collateral ligament

FIGURE 116.2  The cyst stalk lies between the terminal tendon and the collateral ligament.

Good quality overlying skin

A

Thinned overlying skin

B Transverse incision

C

Longitudinal elliptical incision

FIGURE 116.3  If the skin overlying the cyst is good quality, a simple curvilinear incision is used to allow exposure of the cyst and the distal interphalangeal (DIP) joint. If the skin is poor quality, it is excised, and a rotational flap is designed by extending one side of the curvilinear incision proximally to allow for the advancement of skin over a residual defect (white arrow).

STEP 1 PEARLS

• If the cyst is adherent to the nail bed or healthy overlying skin, a portion of the cyst wall can be left behind rather than aggressively debrided. • The fragile cyst and stalk may be difficult to identify. When the fragile wall ruptures, use the mucinous drainage as a guide to its probable path toward the joint.

STEP 1 PITFALLS

Most of the cysts emerge on the dorsum of the distal phalanx or DIP joint, but their stalk may originate from anywhere around the DIP joint. A single stalk may have multiple cysts, with some cysts that sit behind the extensor tendon. A meticulous dissection and careful joint examination are performed in every case.

• If the overlying skin is of poor quality, an elliptical skin incision is used around the cyst and a local rotational advancement flap is designed for closure (see Fig. 116.3B–C) • The proximal extension of the flap is dependent on the defect size. This flap usually extends to the proximal interphalangeal (PIP) joint and sometimes a back cut is required.

PROCEDURE Step 1: Cyst and Stalk Mobilization • The cyst is mobilized from the surrounding tissue. • The stalk is traced toward the DIP joint where it enters between the collateral ligament and terminal tendon (see Fig. 116.2). • With a no. 15 blade, incise sharply just lateral to the terminal tendon to create a capsulotomy and expose the DIP joint.

Step 2: Removal of Distal Interphalangeal Joint Osteophytes • The osteophytes of the DIP joint are removed with a fine rongeur. • If a stalk is not definitively identified, we recommend capsulotomies and osteophyte resections on both radial and ulnar side of the terminal tendon.

CHAPTER 116  Hand Masses

• Bipolar or handheld cautery is then used to ablate cyst wall tissue and entry point of the stalk into the DIP joint (Fig. 116.4). • Do not ablate the nail matrix or terminal tendon.

Step 3: Skin Closure • If no or minimal skin was excised, then primarily close the skin with interrupted skin sutures. • If using a rotational skin flap, advance distally to cover the wound and joint. • If there is tension on the flap, a back-cut incision at the proximal portion of the flap is made. • Even though the defect may be small, the entire dorsal skin should be mobilized proximal to the PIP joint to achieve tension-free closure. The incision is made over the ulnar noncontact surface of the finger in the junction between glabrous and nonglabrous skin.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The DIP joint is immobilized with a splint for 5 to 7 days, and range-of-motion (ROM) exercises are started thereafter. • Simple excision alone without osteophyte removal is reported to have a 30% to 50% recurrence rate. If DIP osteophytes are removed, the recurrence is less than 2%. • Postoperative extension loss is reported in 17% of patients with a mean loss of 10 degrees. • Nail deformities resolve in about 16% of patients.

Ganglion Cyst Excision INDICATIONS • Ganglion cysts are the most common hand mass. They are mucin-filled structures that associate with a joint capsule, tendon, or tendon sheath and often communicate with the synovial compartment by a stalk. • A mass with symptoms, including pain, deformity, decreased ROM or strength, paresthesia from nerve compression, and impending or present skin ulceration, requires removal. • Aesthetic concerns and suspicion of malignancy are additional indications.

CLINICAL EXAMINATION • Ganglia are protuberant masses that arise in predictable locations: • Dorsal wrist (60%–70%): Arise from the scapholunate (SL) interval. • Volar wrist (20%): Arise from the radioscaphoid or scaphotrapezial joint. • Other (undefined frequency): Volar flexor sheath ganglia; intraosseous, intratendinous, and intraneural ganglia. • For deeper masses, flexion or extension of the wrist can make the mass more visible (Fig. 116.5). • When a suspected ganglion cyst is seen in an unusual location, other tumors are considered. • Transillumination may help differentiate cystic masses, such as ganglia, from solid tumors. • Radial and ulnar pulses are assessed. For extensive volar ganglia, an Allen test is performed to reassure that hand circulation will remain intact in the event of an inadvertent arterial injury. • Examine hand sensation, because ganglia can cause compressive neuropathy (e.g., ganglia within the Guyon canal causing ulnar nerve compression).

IMAGING • Routine preoperative imaging is not warranted unless the mass arises in an unusual anatomic location.

FIGURE 116.4  The dissection plane is immediately superficial to the terminal tendon (green arrow). The mucous cyst has been removed (red arrow). Between the terminal tendon and collateral ligaments, capsulotomies were performed and osteophytes were removed (blue arrows). Residual cyst tissue was ablated with cautery (red and blue arrows). STEP 2 PEARLS

• The location of osteophytes is correlated with x-rays (if obtained preoperatively) to ensure removal of all pathology. • Cyst excision without osteophyte removal will have a higher rate of cyst recurrence. STEP 3 PEARLS

• Do not close the skin with undue tension. If the skin flap color is abnormal, sutures are removed, and flap mobilization is reassessed. • If a tension-free closure cannot be obtained, the distal defect and area of the exposed joint or tendon is prioritized for coverage. The proximal defect created by the flap advancement can be left to heal by secondary intention. POSTOPERATIVE PITFALLS

Careful application of the bandage is essential to prevent either premature removal by a child or a constricting bandage.

885

886

CHAPTER 116  Hand Masses

FIGURE 116.5  Dorsal wrist ganglion (white arrow) is more easily appreciated with the wrist flexed.

• For recurrent ganglia, an x-ray may delineate an osteophyte that is contributing to recurrence. • A third of volar wrist ganglion are related to carpal arthritis. • Ultrasound can be used to distinguish a volar ganglion from a radial artery pseudoaneurysm. • Ultrasound or MRI can provide information regarding masses of uncertain diagnosis or occult ganglia.

SURGICAL ANATOMY • Most ganglions have a stalk or neck associated with the joint capsule. • Dorsal ganglia most commonly arise from the SL interval. Superficially, a dorsal ganglion can emerge between any of the extensor tendons because of a long stalk but most commonly occurs between the third and fourth extensor compartment. • Volar ganglion cysts can originate from the radiocarpal joint, scaphotrapeziotrapezoid ligament joint, or, less commonly, the pisotriquetral joint. Superficially, a volar ganglion typically emerges between the first extensor compartment and flexor carpi radialis (FCR) tendon sheath. • The cyst may extend 360 degrees around the joint and sometimes can have multilobulated anatomy. • The cyst may be in close contact with the branches of the radial artery and its accompanying veins or nearby tendon sheaths.

POSITIONING Protect dorsal radial and ulnar sensory nerves.

• The patient is placed in the supine position with the arm extended on a hand table. • All procedures are done under tourniquet application on the affected extremity. • Local or regional anesthesia is typically used.

EXPOSURES PITFALLS

DORSAL WRIST GANGLION EXCISION

The ganglion is always larger than it appears clinically. Make the incision large enough to permit full circumferential visualization of the ganglion.

Exposures

STEP 1 PEARLS

Step 1: Mobilization of Cyst

EXPOSURES PEARLS

Dissect directly on the cyst wall. Often, a thin fascial layer immediately encasing the cyst must be entered to identify the true cyst wall (see Fig. 116.7).

• A transverse incision is designed over the mass in a natural wrist crease (Fig. 116.6). • The skin incision is made, and superficial veins are identified and retracted from the field.

• Delicately dissect through the subcutaneous tissue with tenotomy scissors (Fig. 116.7). • Spread overlying tissue to expose the ganglion tissue. • Using forceps, gently retract the cyst and circumferentially dissect around the cyst.

CHAPTER 116  Hand Masses

FIGURE 116.6  A transverse incision is designed within a natural crease and centered over the mass.

A

B

FIGURE 116.7  Perform circumferential dissection of the ganglion by dissecting immediately on the cyst wall (red arrow). Often a thin fascial layer (blue arrow) must be incised to gain access to the ganglion cyst wall. The yellow arrow is the extensor retinaculum, which must be incised to identify and follow the stalk toward the joint.

Step 2: Identify Stalk Communicating With Joint Space

STEP 2 PEARLS

• Incise the extensor retinaculum and follow the stalk toward the dorsal wrist capsule. • Dorsal ganglia often arise from the SL interval proximal to the dorsal SL ligament. • Visualize, protect, and retract extensor tendons (Fig. 116.8). • Dorsal ganglia often arise between the extensor digitorum communis tendons and extensor pollicis longus but may arise between any compartments.

For large cysts, it may be helpful to incise the cyst and drain the mucinous material. The cyst can then be manipulated more easily. Furthermore, the inside of the cyst can be probed to identify the trajectory of the stalk.

Step 3: Excision of Ganglion Cyst With Its Stalk • Using bipolar cautery, the ganglion is transected at the stalk with a rim of the dorsal wrist capsule (see Fig. 116.8).

887

888

CHAPTER 116  Hand Masses

STEP 3 PEARLS

• Leave the stalk defect open because inflammation and scarring will seal the opening. Suturing the defect in the joint capsule may cause stiffness and limit the ROM of the wrist. • Sequentially cauterizing the cyst wall and joint capsule during excision ensures visualization and elimination of the entire stalk. Furthermore, this is a more efficient way to achieve hemostasis from the heavily vascularized cyst stalk and joint capsule. Uncontrolled bleeding from the wrist capsule is agonizing and prolongs surgical time to stop the bleeding. STEP 3 PITFALLS

• Leaving a ganglion stalk to the joint will cause a higher rate of recurrence. • Care is taken to not injure the SL ligament during cauterization of the stalk.

FIGURE 116.8  After incising the extensor retinaculum, the stalk is traced between the extensor tendons. This stalk traversed between the third (extensor pollicis longus [EPL]—blue arrow) and fourth (extensor digitorum communis [EDC]—red arrow) extensor compartment. The yellow silhouette shows the retracted ganglion.

• For larger ganglia, perform this step in a sequential manner. • Transect a portion of the stalk with tenotomy scissors and then cauterize the raw edges. • Circumferentially work around the cyst wall by transecting another portion of the stalk and cauterizing the raw edge. • Repeat until the entire specimen has been transected. • Cauterize the base of the cyst to obliterate any cystic tissue (including accessory cysts) communicating with the joint (Fig. 116.9 and 116.10).

A

B

FIGURE 116.9  For large ganglion cyst, the stalk is sequentially divided and cauterized. (A) The inferior portion of the cyst (red portion of circle) is being cauterized. (B) The ganglion cyst (blue arrow) is being reflected and the top half of the cyst is ready to be cauterized in a counterclockwise manner (red portion of circle).

CHAPTER 116  Hand Masses

A

B

FIGURE 116.10  The base of the cyst is cauterized to remove any residual cystic tissue. The excised cyst is often larger than expected based on clinical findings. Notice the base of the cyst has a wellcauterized edge to prevent bleeding (red arrow).

Step 4: Hemostasis and Skin Closure • Deflate the tourniquet and obtain hemostasis. • Close subcutaneous tissue and skin with buried absorbable sutures.

VOLAR WRIST GANGLION CYST EXCISION Exposures • A longitudinal chevron incision is designed over the mass (Fig. 116.11). • The skin incision is made, and superficial veins are identified and retracted from the field. • The forearm fascia is incised, and the volar ganglion cyst is identified.

EXPOSURES PEARLS

• If the longitudinal curvilinear incision is extended to the distal wrist, the palmar cutaneous branch of median nerve is more at risk for injury. • A volar cyst usually arises between the FCR and the first extensor compartment (Fig. 116.12). Avoid injury to these tendons during retraction and dissection.

Step 1: Mobilization of the Cyst

STEP 1 PEARLS

• The radial artery is identified and dissected away from the cyst (Fig. 116.13). • If the capsule of the cyst is adhered widely with the artery, the cyst is opened, and the cyst wall is divided. A partial cyst wall is left with the artery to avoid inadvertent vascular injury. There is no need to separate the cyst wall from the radial artery. The problem is the cyst stalk, not the pseudocyst wall adherent to the radial artery.

It can be easier to dissect a perforated cyst from surrounding tissue, especially if the ganglion is adherent to the radial artery. STEP 1 PITFALLS

If the radial artery is injured during dissection, it should be repaired using a microscope.

FIGURE 116.11  A chevron incision is used directly over the volar ganglion to avoid using a straight line incision that crosses the wrist crease.

889

890

CHAPTER 116  Hand Masses

FIGURE 116.12  Volar ganglia typically arise in the interval between the flexor carpi radialis (blue arrow) and first extensor compartment (yellow arrow). The radial artery (red line) is often adherent to the ganglion (green arrow).

A

B

FIGURE 116.13  The ganglion cyst (blue arrow) is easily mobilized on the ulnar side. The radial artery (red arrow) is closely associated with the cyst on the radial side. Rather than performing a tenuous dissection, we advocate opening the ganglion and leaving the cyst wall adherent to the radial artery. STEP 2 PEARLS

• Do not spend excessive time dissecting out the cyst. The goal is to identify the stalk of the cyst and eliminate the connection to the joint. • Avoid injury to superficial veins that cause bleeding and can obscure the surgical field. Cauterize every vein during the dissection when under tourniquet control so that when the tourniquet is let down, the field will not be filled with blood that will require an extensive amount of effort to control. • If there is associated carpal arthritis, synovectomy and debridement of the arthritic carpal articulations (e.g., osteophytes) may be performed.

• The ganglion is mobilized with its stalk from the surrounding tissue and traced down to the volar joint capsule.

Step 2: Excision of Ganglion Cyst and Stalk • The ganglion sac and stalk are traced down to the joint capsule (radiocarpal or scaphotrapezial joint). The joint capsule is opened proximally and distally to the stalk. • The ganglion and stalk are tangentially excised with a small portion of the volar joint capsule. This can be performed in a similar manner as previously described for dorsal ganglia. • Bipolar cautery is used to obliterate the origin of the stalk at the joint capsule and any residual cystic tissue (without injuring the radial artery).

Step 3: Hemostasis and Skin Closure • Deflate the tourniquet and obtain hemostasis. • Close subcutaneous tissue and skin with buried absorbable sutures.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A nonadhesive gauze and soft wrap is applied to the wound. • The dressing is removed 3 days postoperatively. • Splint the wrist in a volar resting position for 7 days if a sizable portion of the joint capsule was excised or if debridement of the carpus was performed.

CHAPTER 116  Hand Masses

• ROM exercise is initiated as soon as the dressing is removed. • All stitches are removed 10 to 14 days postoperatively. • There is a 5% to 50% rate of recurrence after excision. A higher rate of recurrence is associated with tumors that are poorly defined and show localized bone erosion and tendon involvement. see videos 116.1, 116.2 and 116.3

EVIDENCE Crawford C, Keswani A, Lovy AJ, et al. Arthroscopic versus open excision of dorsal ganglion cysts: A systematic review. J Hand Surg Eur Vol. 2018;43(6):659–664. This systematic review evaluated 16 studies comparing open versus arthroscopic dorsal ganglion excision of which 11 needed to be excluded because of low quality and high bias potential. The remaining five studies were pooled, and they found no difference in cyst recurrence rates (8% vs. 10%) and complications (4% vs. 6%) between arthroscopic and open excision. The authors concluded that results from these procedures were comparable. Head L, Gencarelli J, Allen M, Boyd K. Wrist ganglion treatment: Systematic review and meta-analysis. J Hand Surg Am. 2015;40:546–553.e8. The authors performed a comprehensive search of Medline for ganglion treatment. Ultimate inclusion/exclusion criteria limited the analysis to 35 studies. Across all study designs, recurrence for arthroscopic surgery was 6% (512 ganglions), for open surgical excision was 21% (809 ganglions), and for aspiration was 59% (489 ganglions). Mean complication rates for arthroscopic surgical excision, open surgical excision, and aspiration (3 studies; 134 ganglions) were 4%, 14%, and 3%, respectively. This systematic review and meta-analysis shows that open surgical excision offers a significantly lower chance of recurrence compared with aspiration. Open surgical excision carries the higher risk for complications according to the study, although the specifics of the types of complications are not individually reported. The authors conclude that aspiration is a simple option with a low risk for complications, but it does provide significant benefit with respect to ganglion resolution.

891

CHAPTER

117

Excision of Vascular Lesions of the Hand Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 117.1 – Subungual Glomus Tumor Excision.

KEY CONCEPTS • Vascular lesions, including vascular malformations and hemangiomas, are types of benign neoplasms that occasionally arise in the hand. Distinguishing between hemangiomas and vascular malformations is essential, given their substantially different natural histories and treatment options. • Vascular malformations are congenital inborn errors that transpire during embryonic development and may affect the venous, lymphatic, capillary, or arterial tissue. Vascular malformations often grow over time and never spontaneously involute. • Hemangiomas are masses composed of disorganized vascular endothelial cells. Unlike vascular malformations, hemangiomas can be present at birth or within the first few weeks of a newborn’s life. Hemangiomas grow rapidly during the first several weeks of life, followed by a plateau in growth and finally spontaneous involution. These benign masses are often treated nonoperatively with chemical sclerotherapy, lasering, or embolization. • The relevant imaging studies should be readily available during the procedure for review during incision planning and deep dissection. • Recurrence of vascular malformations is common after even wide excision. Thus normal structures such as nerves, arteries, or tendons should not be sacrificed to ensure a wide margin. • If there is concern for malignancy, a small specimen should be sent for frozen pathology to confirm a diagnosis. • Revision surgery may be performed when the wound has healed and the tissues are soft. Staged resections may be necessary for large or diffuse vascular malformations.

A

B Hypothenar vascular malformation FIGURE 117.1  (A–B) Hypothenar vascular malformation.

892

CHAPTER

117

Excision of Vascular Lesions of the Hand Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Vascular lesions, including vascular malformations and hemangiomas, are types of benign neoplasms that occasionally arise in the hand. • Vascular malformations are congenital inborn errors that transpire during embryonic development of the vascular systems and may affect the venous, lymphatic, capillary, or arterial tissue. • Malformations are classified by the speed at which blood or other bodily fluid circulates through the malformation. Arterial malformations, or arterial fistulas, are classified as fast/high-flow, whereas venous, lymphatic, and capillary malformations are slow/low-flow. • Hemangiomas, also known as strawberry marks, are masses composed of disorganized vascular endothelial cells. Unlike vascular malformations, many hemangiomas present within the first few weeks of a newborn’s life, although they can be present at birth. The hallmark of a hemangioma is rapid growth or expansion during the first several weeks of life, followed by a plateau in growth and involution of the mass. • These benign masses are often treated nonoperatively, with chemical sclerotherapy, lasering, or embolization. • Regardless of whether the lesions are being treated conservatively or surgically, daily aspirin is regularly given to patients to prevent clotting within venous or arterial malformations. • Although rare, the literature describes how malignant sarcomas, such as angiosarcoma and epithelioid hemangioendothelioma, may arise within the distal upper extremity. Their appearance can be remarkably similar to the benign lesions. Rapid development of a vascular lesion after childhood, especially if painful, should raise concerns for malignancy.

CLINICAL EXAMINATION • Hemangiomas are characterized by variable spontaneous involution over time. Conversely, vascular malformations often grow over time and never spontaneously involute. Distinguishing between hemangiomas and vascular malformations is essential, given their substantially different natural histories and treatment options (Table 117.1).

TABLE Vascular Lesions and Subtypes 117.1

Types of Vascular Lesions

Subtypes

Hemangioma

Hemangioma of infancy Rapidly involuting congenital hemangioma (RICH) Noninvoluting congenital hemangioma (NICH)

Vascular malformation

Low flow (CM, VM, LM) High flow (AVF) Combined (CLM, CLVM)

AVF, arteriovenous fistula; CLM, capillary-lymphatic malformation; CLVM, capillary-lymphaticovenous malformation; CM, capillary malformation; LM, lymphatic malformation; VM, venous malformation.

892.e1

892.e2

CHAPTER 117  Excision of Vascular Lesions of the Hand

A

B Hypothenar vascular malformation FIGURE 117.1  (A-B) Hypothenar vascular malformation.

• Physical examination should focus on the appearance of the skin, involvement of the muscular compartments, texture of the underlying tissues (compressible, rubbery, soft), changes with limb positioning, and the presence of a bruit or thrill (Fig. 117.1). • Associated manifestations of syndromes (blue rubber bleb nevus, Klippel-Trenaunay, Kasabach-Merritt, Maffucci, Parkes-Weber) should be evaluated.

IMAGING • Classically, soft tissue hemangiomas may form phleboliths, which are small calcified deposits formed by thrombosed vessels. These appear on plain radiographs. • Ultrasound may be used in the diagnosis of lymphatic malformation (LM) or an arteriovenous fistula (AVF). • Magnetic resonance imaging (MRI) with and without contrast may be useful to define the location and extent of disease and to confirm vascularity of the mass. Lymphatic and venous malformations are isointense on T1-weighted MRI and hyperintense on T2-weighted MRI (Fig. 117.2). • Angiography may be used to outline the extent of an AVF.

A

B

FIGURE 117.2  (A–B) Magnetic resonance imaging (MRI).

CHAPTER 117  Excision of Vascular Lesions of the Hand

EXPOSURES PEARLS

POSITIONING • The operation is performed under general anesthesia with the patient placed supine on the operating table. • The affected extremity is placed on a hand table and an upper arm tourniquet is applied.

EXPOSURES • The location of the vascular lesion will dictate the necessary exposure. A thorough understanding of the anatomy of the entire upper extremity is essential. • Surgical precautions should be taken to prevent unnecessary wound contamination in the case that the mass is identified as malignant on final pathology. Assume the mass is malignant unless preoperative biopsy has confirmed a benign neoplasm. • Longitudinal incisions are preferred over horizontal incisions and should be designed to facilitate direct access to the underlying mass and violate as few compartments as possible.

The relevant imaging studies should be readily available during incision planning and deep dissection.

EXPOSURES PITFALLS

Incisions and deep dissection should never cross into or contaminate adjacent muscular compartments because this would necessitate more extensive reresection in the case of an unplanned sarcoma or carcinoma excision.

PROCEDURE Step 1 • The incision is marked to extend proximal and distal to the lesion (Fig. 117.3). • Dissection is taken down sharply through skin and subcutaneous tissue, then skin flaps are elevated with a no. 15 blade to expose the vascular lesion. • If there is concern for malignancy, a small specimen should be sent for frozen pathology to confirm a diagnosis.

Step 2 • A combination of blunt dissection and bipolar electrocautery is used to “shell-out” the tumor circumferentially from the normal adjacent tissue (Fig. 117.4). Identify key structures, such as nerves and critical vessels, early in the dissection because tumors will wrap around these structures. The principle of tumor surgery is to isolate key structures first, then remove all intervening tissues that contain the tumor. • Suture or clip ligation may be used for vascular lesions with large afferent or efferent vessels.

FIGURE 117.3  Incision design.

STEP 2 PEARLS

Tumor may distort the normal course of neurovascular structures, such as common and proper digital arteries/nerves, and volar and dorsal sensory branches of the hand. To avoid damaging these structures, they should first be identified proximally or distally in unaffected tissue and then gradually identified along a possible aberrant path (Fig. 117.5). STEP 2 PITFALLS

*

*

The star indicates the ulnar neurovascular bundle identified proximally

The star indicates the distorted course of the palmar neurovascular structures, which may adhere to the under surface of tumor.

FIGURE 117.4  Identification of tumor and neurovascular bundles.

FIGURE 117.5  Distorted course of the palmar neurovascular structures.

Recurrence of vascular malformations is common, even after wide excision. Thus normal structures, like nerves, arteries, or tendons, should not be sacrificed to ensure a wide margin (Fig. 117.6).

892.e3

892.e4

CHAPTER 117  Excision of Vascular Lesions of the Hand

Preserved neurovascular bundles

FIGURE 117.7  Wounds closed.

FIGURE 117.6  Preserved neurovascular bundles.

FIGURE 117.8  Final mass.

Step 3 • The tourniquet is released and hemostasis is secured. • Tissue sealants and drains are used when necessary. • Excess skin is sharply resected when necessary to permit well-approximated skin closure without tension or dog-ears (Fig. 117.7). • The final mass should be sent to pathology for permanent section (Fig. 117.8).

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • A well-padded splint is applied to prevent disruption of the incision and bleeding. The splint is removed 2 weeks postoperatively. • Complications arise in up to 28% of patients; these include swelling, bleeding, and wound healing problems. Revision surgery may be performed when the wound has healed and the tissues are soft. Staged resections may be necessary for large or diffuse vascular malformations. See Video 117.1

CHAPTER 117  Excision of Vascular Lesions of the Hand

EVIDENCE Upton J, Coombs CJ, Mulliken JB, Burrows PE, Pap S. Vascular malformations of the upper limb: A review of 270 patients. J Hand Surg Am. 1999;24:1019–1035. The authors reviewed their experience treating 270 upper-extremity vascular malformations over a 28-year period. These anomalies were slightly more common in females than males (ratio, 1.5:1.0). The malformations were categorized as either slow flow (venous, n = 125; lymphatic, n = 47; capillary, n = 32; combined, n = 33) or fast flow (arterial, n = 33). MRI with and without contrast best demonstrated site, size, flow characteristics, and involvement of contiguous structures for all types of malformations. Algorithms for treatment of both slow-flow and fast-flow anomalies are presented. Two hundred sixty surgical resections were performed in 141 patients, including 24 of 33 fast-flow anomalies. Preoperative angiographic assessment, with magnified views, was an important preoperative adjunct before any well-planned resection of fast-flow arteriovenous malformations. The surgical strategy in all groups was to thoroughly extirpate the malformation, with preservation of nerves, tendons, joints, and uninvolved muscle, and microvascular revascularization and skin replacement as required. Resections were always restricted to well-defined regions and often completed in stages. Symptomatic slow-flow malformations and types A and B fast-flow anomalies were resected without major sequelae. Type C arterial anomalies, involving diffuse, pulsating lesions with distal vascular steal and involvement of all tissues (including bone) progressed clinically and resulted in amputation in 10 of 14 patients. The complication rate was 22% for slow-flow lesions and 28% for fast-flow lesions (Level III evidence). Greene AK, Goss JA. Vascular anomalies: From a clinicohistologic to a genetic framework. Plast Reconstr Surg. 2018;141(5):709e–717e. The authors perform a literature review to aggregate much of the underlying basic science research that investigated the cellular and biochemical mutations causing vascular malformations. A sound understanding of the underlying causes and possible therapeutic targets of vascular malformations is important because initial management for these malformations is increasingly nonoperative.

892.e5

CHAPTER

118

Excision of Metacarpal Enchondroma Benjamin K. Gundlach and Kevin C. Chung Full text of this chapter is available online at expertconsult.com. This chapter includes the following video: Video 118.1 – Excision of Metacarpal Enchondroma.

KEY CONCEPTS • Enchondromas are benign bone lesions that occur within the medullary space of bones. They are the most common bone tumor found within the phalanges and metacarpals of the hand. • Enchondromas are almost always painless, asymptomatic lesions and are commonly found incidentally on radiographs after acute hand trauma. • Excision is indicated for symptomatic lesions that cause pain or deformity. In rare circumstances, a pathologic fracture can occur through an enchondroma from weakening of the surrounding cancellous and cortical bone. Patients with multiple enchondromas, or a rapidly expanding, painful enchondroma, should undergo a more exhaustive evaluation, including biopsy, before excision. • The diagnosis of enchondroma is often established by plain film radiography. These tumors appear as an intramedullary radiolucency with a lytic pattern that may include “popcorn” stippling and chondroid calcifications. • Dorsolateral incisions directly overlying the cortical bone enclosing the enchondroma are used for metacarpal, proximal phalanx, and middle phalanx lesions. Dorsal sensory branches of the ulnar nerve and the superficial branch of radial nerve should be identified and protected during exposure to metacarpal and carpal lesions. Digital neurovascular bundles are protected in treatment of digital lesions. • The creation of periosteal flaps is important because they permit closure over the cortical window, containing the bone graft. • After complete enchondroma removal, demineralized bone matrix can be injected via the window to fill the entire dead space.

FIGURE 118.3  The fifth metacarpal demonstrates expansion and scalloping with heterogenous lucency, consistent with enchondroma.

893

CHAPTER

118

Excision of Enchondroma Benjamin K. Gundlach and Kevin C. Chung INDICATIONS • Enchondromas are benign bone lesions that occur within the medullary space of bones. They are the most common bone tumor found within the phalanges and metacarpals of the hand. • Enchondromas are almost always painless, asymptomatic lesions and are commonly found incidentally on radiographs after acute hand trauma. • Excision is indicated for symptomatic lesions that cause pain or deformity. In rare circumstances, a pathologic fracture can occur through an enchondroma from weakening of the surrounding cancellous and cortical bone.

Contraindications • The presence of multiple skeletal lesions or enchondromas should raise concern for enchondromatosis. Maffucci syndrome and Ollier disease are two well-described conditions with sporadic genetic inheritance that cause multiple enchondroma formation. The concern with these conditions is a high rate of malignant transformation, with Maffucci syndrome (enchondromatosis with multiple soft-tissue angiomas) having a near 100% chance of sarcomatous transformation. • Patients with multiple enchondromas, or a rapidly expanding, painful enchondroma, should undergo a more exhaustive evaluation—including—biopsy before excision. Unplanned resection of an unidentified sarcoma is a never-event because the positive margins and wound contamination result in devastating outcomes for the patient.

CLINICAL EXAMINATION • Note any symptoms such as pain, inflammation, or deformities (Fig. 118.1). • Assess and document the preoperative function and neurovascular status of the hand and fingers. • Palpate and examine both hands for painless or concealed masses that may indicate enchondromatosis or previously unidentified soft-tissue extension.

IMAGING • Radiographically, these tumors appear as an intramedullary radiolucency with a lytic pattern that may include “popcorn” stippling, rings (white arrow), and arcs (black arrows) of chondroid calcifications (Fig. 118.2).

FIGURE 118.1  Preoperative evaluation.

FIGURE 118.2  Radiographic appearance.

893.e1

893.e2

CHAPTER 118  Excision of Enchondroma

Note the cluster and lobulated calcifications in T2 weight MRI FIGURE 118.3  Radiographic appearance with red dotted line indicating the periphery of the lesion.

FIGURE 118.4  Magnetic resonance imaging (MRI) appearance.

• The majority of enchondromas arise in the metaphyseal region, presumably because of their origin from the growth plate, although they are frequently seen in the diaphysis. They are rarely seen in the epiphysis, and a cartilaginous lesion in an epiphysis is more likely to be a chondrosarcoma. • Three-view hand radiography (anteroposterior [AP], lateral, oblique) should be obtained for diagnosis and any follow-up radiographic examination. (Note the red dotted line surrounding the periphery of the large, expansile lesion, which has nearly broken through the ulnar border of the fifth metacarpal [Fig. 118.3].) • In the majority of cases, the diagnosis of an enchondroma can be established by plain film radiography. If there is an atypical clinical history that includes pain, rapid growth, adjacent soft tissue involvement, or an uncommon location, computed tomography (CT) scan and magnetic resonance imaging (MRI) are indicated. • CT scan will demonstrate the characteristics of an enchondroma, which include a lucent mass with arc or ring calcifications. The mass should show no evidence of soft tissue invasion. If there is a soft tissue component indistinct from the bony lesion, a chondrosarcoma should be suspected. • MRI is indicated to differentiate enchondroma from bone infarction or medullary osteonecrosis within the metaphysis. Bone infarction is more likely in patients with a history of pancreatitis, organ transplantation, hemoglobinopathies, or previous radiation therapy. An enchondroma on MRI has lobulated borders with a cluster of numerous tiny lobules of high-signal-intensity foci on T2-weighted images (Fig. 118.4).

SURGICAL ANATOMY • Dorsolateral incisions directly overlying the cortical bone enclosing the enchondroma are used for metacarpal, proximal phalanx, and middle phalanx lesions. Dorsal sensory branches of the ulnar nerve and the superficial branch of the radial nerve should be identified and protected during exposure to metacarpal and carpal lesions. Digital neurovascular bundles are protected in treatment of digital lesions. • To expose a metacarpal enchondroma distally, juncturae tendinum can be incised to retract the extensor tendons away from the lesion to facilitate direct dissection to the bone.

POSITIONING • The patient is placed supine with the arm extended and hand pronated on a hand table. • The operation is performed under tourniquet application.

CHAPTER 118  Excision of Enchondroma

EXPOSURES

EXPOSURES PEARLS

• The incision is made along the dorsum for the long and ring fingers. For the border digits—index and small fingers—the incision is made along the dorsal lateral line (Fig. 118.5). • Dissection is made through the soft tissue, avoiding injury to the superficial veins and sensory nerves. • The extensor tendons are retracted to expose to the diaphysis of the metacarpal bone. • In the phalanges, a dorsal lateral longitudinal incision is used. The exposure to the bone is made between the lateral band and extensor mechanism dorsally and the neurovascular bundle volarly.

Avoid making an incision directly over an extensor tendon to decrease the chance of postoperative tendon adhesions.

PROCEDURE Step 1: Periosteal Flap and Cortical Exposure The periosteum is sharply incised, and a key elevator is used to elevate dorsal and volar flaps to expose the entire length of the lesion (Fig. 118.6).

Step 2: Creation of a Cortical Bone Window • A lateral or dorsolateral cortical window is designed 2 to 3 mm in width along the length of the lesion. • The designed cortical window is decorticated by a low-speed bur or osteotome.

FIGURE 118.5  Incision design.

FIGURE 118.6  Lesion is exposed.

EXPOSURES PITFALLS

Minimize extensor tendon injury by keeping the paratenon intact and avoiding exaggerated traction.

STEP 1 PEARLS

The creation of periosteal flaps is important because they permit closure over the cortical window, containing the bone graft. STEP 2 PITFALLS

Ensure that the window is large enough to permit easy insertion and manipulation of the curettes. Attempting to make a minimally invasive cortical window only risks inadvertent fracture as one struggles to manipulate the curette within the tumor (Fig. 118.7).

893.e3

893.e4

CHAPTER 118  Excision of Enchondroma

FIGURE 118.7  Cortical window. FIGURE 118.8  Excised lesion.

STEP 3 PEARLS

• Intraoperative fluoroscopy should be used to confirm the completeness of removal. • Also place a small curette within the defect and confirm that the curette can reach the periphery of the defect along all borders.

Step 3: Curette or Tumor Removal

STEP 4 PEARLS

Step 4: Bony Reconstruction

• The demineralized bone matrix syringe should be injected from deep to superficial to ensure placement throughout the cavity. The periosteum can be partially closed to reduce the window size and prevent extrusion of the matrix during injection (Fig. 118.10). • Use a Freer elevator and small bone tamp to pack the graft within the cavernous defect. • Fluoroscopy can be used to confirm that a bone graft is fully packed in all peripheral aspects of the defect.

• After complete enchondroma removal, demineralized bone matrix can be injected via the window to fill the entire dead space (Fig. 118.9). • For sizeable defects, autograft bone can also be harvested from the distal radius or proximal ulna.

• Use small, straight, curved, and reverse cutting curettes to completely remove the tumor via the cortical window. • Enchondroma tumor is a soft, cartilaginous-like substance. Tumor should be sent to pathology for confirmation of a benign cartilaginous lesion (Fig. 118.8).

STEP 4 PITFALLS

• Multiple methods for treatment of the bone cavity after curettage are proposed, including curettage alone or placement of autograft, allograft, or bone substitutes. • Outcomes are reported to be similar with all methods, though autograft has inherent donor site morbidity. • If bone strength or quality is in question, use of bone cement can provide more immediate strength, though this has not been shown to have a beneficial effect in outcomes.

FIGURE 118.9  Demineralized bone matrix injection.

FIGURE 118.10  Periosteum partially closed.

CHAPTER 118  Excision of Enchondroma

FIGURE 118.11  Flap closure.

Step 5: Incision Closure • • • •

The tourniquet is released and hemostasis is ensured. The periosteal flaps are closed to cover the bony window when possible (Fig. 118.11). Juncturae tendinum are repaired if they were previously divided. The skin is approximated with interrupted nonabsorbable sutures in the fingers and a running absorbable suture over the hand.

ADDITIONAL PEARLS Treatment in the Setting of Pathologic Fracture • With the presentation of a pathologic fracture, the traditional teaching is to let the fracture heal first. Patients should undergo therapy to regain motion before definitive treatment of the enchondroma. • Multiple authors have described various methods for simultaneous treatment with curettage and use of bone cements with and without adjunctive fixation. • With delayed or immediate treatment, the goal should be to restore active range of motion (ROM) as soon as possible and limit morbidity from prolonged immobilization. • In the setting of a healed pathologic fracture with a single isolated lesion, some surgeons advocate serial monitoring with no definitive treatment of the enchondroma because of the low risk for malignancy. The healed callus/enchondroma is thought to be stronger than before the fracture.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • In the setting of an acute fracture, the patient is immobilized in a splint until the fracture has healed. In all other cases, a soft dressing is applied. • Dressings are removed after 3 days and patients are started on active ROM exercises. • Patients are told to avoid lifting more than 5 pounds or performing heavy exercises with the hand for 6 weeks to permit healing of the medullary cavity before strengthening is performed. • Follow-up for all patients is necessary to establish radiographic healing. • After healing, patients with isolated healed lesions can have a 1-year follow-up and then subsequent follow-ups as needed. • Patients with multiple lesions should be followed serially to check for recurrence or new lesions. See Video 118.1

EVIDENCE Klein C, Delcourt T, Salon A, et al. Surgical treatment of enchondromas of the hand during childhood in Ollier disease. J Hand Surg Am. 2018;43(10):946.e1–e5. Ten pediatric patients (average: 10.7 years), all affected with enchondromatosis/Ollier disease, with a mean follow-up of 7.5 years after surgical management. They demonstrated that early management of lesions with curettage and corticoplasty without bone grafting leads to improved cosmesis and functionality, as measured by the QuickDASH (Disabilities of the Arm, Shoulder, and Hand) outcome measure.

STEP 5 PEARLS

Do not sew the extensor apparatus to the surrounding soft tissue; this can interfere with tendon gliding.

893.e5

CHAPTER

119

Excision of Peripheral Nerve Schwannoma Brian W. Starr and Kevin C. Chung

INDICATIONS • Excision is recommended for a concerning subcutaneous lesion of the upper extremity. • Generally, patients present with a slow-growing, firm mass that may or may not be painful, and the diagnosis is made intraoperatively. Other patients may present with a neurologic deficit, such as dysesthesia, neuropathic pain, and/or sensorimotor dysfunction.

Contraindications Excision may be contraindicated in asymptomatic cases without clinical findings concerning for more aggressive pathology. Misdiagnosis and subsequent nerve resection contribute to significant morbidity and have been reported in 6% to 10% of cases.

CLINICAL EXAMINATION • Although they are the most common benign tumor of the peripheral nervous system, schwannomas of the hand and upper extremity are relatively rare. Fewer than 8% of soft tissue tumors are identified as schwannomas. Up to 19% of schwannomas occur in the upper extremity, the majority of which are found in the hand and wrist. • Clinical examination may reveal a soft, mobile, nontender mass more frequently located over the volar aspect of the upper extremity. In the upper extremity, schwannomas most commonly arise from the ulnar, median, or radial nerves (Fig. 119.1A–C). • Percussion over the mass may produce paresthesias in the distribution of the affected nerve. • Clinical findings can be nonspecific, leading to misdiagnosis in many cases. Do not confuse a schwannoma with a ganglion. These can be differentiated by the lack of a Tinel sign (tingling at the lesion or more distally when the lesion is percussed) over a ganglion cyst.

IMAGING • Preoperative magnetic resonance imaging (MRI) may be useful to evaluate the lesion’s origin and relationship to surrounding structures. Peripheral nerve sheath tumors are dark on T1-weighted MRI and bright on T2-weighted MRI. Fig. 119.2A shows an axial view and Fig. 119.2B shows a sagittal view of T1-weighted MRI of a median nerve schwannoma. • MRI findings alone are not adequate to differentiate between benign and malignant nerve tumors. MRI is 79% sensitive and 84% specific in detecting malignant peripheral nerve sheath tumors.

SURGICAL ANATOMY A thorough understanding of upper extremity peripheral nerve anatomy is required when embarking on excision of a peripheral nerve tumor. Fig. 119.3A shows a normal cross-sectional nerve topography. Fig. 119.3B shows nerve topography in the setting of a schwannoma.

POSITIONING • The patient is placed in the supine position on the operating table with the entire upper extremity positioned on an arm board. 894

CHAPTER 119  Excision of Peripheral Nerve Schwannoma Left index finger digital sensory nerve schwannoma

Left palm schwannoma involving the median nerve

A

B

Median nerve schwannoma at the distal forearm

C

FIGURE 119.1  (A) Digital schwannoma and (B) palmar schwannoma. (C) Median nerve schwannoma at the distal forearm.

Median nerve schwannoma

A

B

FIGURE 119.2  (A) Axial view of T1-weighted magnetic resonance imaging (MRI). (B) Sagittal view of T1-weighted MRI.

895

896

CHAPTER 119  Excision of Peripheral Nerve Schwannoma

Mesoneurium External epineurium Nerve fiber

Axon

Internal epineurium

Myelin

Perineurium

Connective tissue components

Endoneurium

A Schwannoma

B FIGURE 119.3  (A) Anatomic components of a nerve fiber and (B) illustration of schwannoma. EXPOSURES PEARLS

• The relevant imaging studies should be readily available during the procedure for review during dissection. • Ensure that microsurgical instruments are available for fine dissection. • Be prepared to address a nerve gap if a portion of the nerve requires resection (i.e., if intraoperative findings are consistent with a neurofibroma).

• General anesthesia is provided and a nonsterile tourniquet is applied on the upper arm. • The arm is prepared and draped in the standard fashion. • The limb is exsanguinated fully to permit a completely bloodless field.

EXPOSURES The location of the lesion will dictate the necessary exposure. A thorough understanding of the anatomy of the entire upper extremity is essential.

PROCEDURE Step 1 • The incision is marked to extend proximal and distal to the lesion (Fig. 119.4). • The skin flaps are elevated with a no. 15 blade to expose the peripheral nerve tumor.

FIGURE 119.4  Incision marking.

CHAPTER 119  Excision of Peripheral Nerve Schwannoma

Median nerve

A

B

FIGURE 119.5  (A–B) Exposure of schwannoma and identification of nerve.

STEP 2 PEARLS

Step 2 Surrounding vascular structures are identified and protected. The affected nerve is dissected proximally to distally (Fig. 119.5A–B).

Step 3 • The schwannoma is removed from the parent nerve using microsurgical dissection. Fig. 119.6A–C shows microsurgical excision of a median nerve schwannoma of the right distal forearm that measured approximately 3 cm x 3 cm.

Mass elevated with vascular pedicle

• Schwannomas are encapsulated lesions of the nerve sheath that do not infiltrate individual fascicles. Therefore the lesion can be enucleated or “shelled out” from the nerve, leaving the parent nerve fascicles intact. • Be aware of nerve branches on the surface of this tumor because the tumor can splay the nerve fibers; these can be injured if not carefully dissected. • If the mass is difficult to remove, it likely represents a neurofibroma. In this case, the affected area is resected and reconstructed with a nerve graft.

Mass had splayed and compressed the nerve fibers

A

B

C

FIGURE 119.6  (A–C) Elevation and excision of schwannoma.

897

898

CHAPTER 119  Excision of Peripheral Nerve Schwannoma

B

A

FIGURE 119.7  (A–B) Postoperative outcome at 2 months.

STEP 3 PITFALLS

Symptomatic neuromas may occur in 25% of patients who undergo intraneural dissection. As such, intraneural dissection should be avoided.

• The tourniquet is then deflated and hemostasis is ensured. • The skin is closed using 4-0 or 5-0 nonabsorbable suture.

POSTOPERATIVE CARE AND EXPECTED OUTCOMES • The arm is placed in a soft dressing and activities are limited for 2 weeks. Most patients will have full motor and sensory function after surgery, unless nerve resection is required for extensive involvement of small nerve branches or an interposition nerve graft is required for reconstruction.Fig. 119.7A–B demonstrates excellent median nerve function at 2 months postoperatively. • There is a higher risk for postoperative neurologic deficit in patients who have previously undergone biopsy or who have developed recurrent disease. • Recurrence is uncommon. See Video 119.1

EVIDENCE Furniss D, Swan MC, Morritt DG, et al. A 10-year review of benign and malignant peripheral nerve sheath tumors in a single center: Clinical and radiographic features can help differentiate benign from malignant lesions. Plast Reconstr Surg. 2008;121:529–533. In a retrospective review of primary peripheral nerve sheath tumors, the authors identified 32 cases of malignant peripheral nerve sheath tumor over a ten-year period. The authors compared clinical findings associated with malignant peripheral nerve sheath tumors to characteristics found in a cohort with benign peripheral nerve tumors. Statistically significant findings associated with malignant peripheral nerve sheath tumors were: shorter duration of symptoms (p < .0001), large size (p < .0001), located deep to fascia (p < .0001) and presence of pain (p = .0004). In comparing malignant lesions directly to schwannomas, short duration of symptoms (p = .0002) and larger size (p