Principles of Hand Surgery and Therapy [3 ed.] 0323399754, 9780323399753

Table of contents :
Cover
Principles of Hand Surgeryand Therapy
Copyright
Contributors
Preface
Acknowledgments
Anatomy and Examination of the Hand, Wrist, Forearm, and Elbow
INTRODUCTION
Elbow Anatomy
Bones
Ligaments
Musculature
Forearm Anatomy
Radius and Ulna
Ligaments
Musculature
Carpus
Carpal Bones
Ligaments
Extrinsic Extensor Tendons and Muscles
First Dorsal Compartment
Second Dorsal Compartment
Third Dorsal Compartment
Fourth Dorsal Compartment
Fifth Dorsal Compartment
Sixth Dorsal Compartment
Extrinsic Flexor Tendons and Muscles
Wrist Flexor Tendons and Muscles
Palmaris Longus Tendon
Digital Flexors
Hand and Digital Anatomy
Metacarpals and Phalanges
Ligaments
Tendons and Intrinsic Muscles of the Hand
Extrinsic Tendons of the Thumb.
Hypothenar Muscles
Finger Flexors
Thenar Muscles and Adductor Pollicis
Flexor Tendon Sheath
Finger Extensors, Extensor Hood Mechanism, and Intrinsic Muscles of the Hand
Extrinsic Extensors
Interosseous Muscles
Lumbrical Muscles
Proximal Extensor Mechanism (The Extensor Hood)
Distal Extensor Mechanism
Coordinated Function of Finger Range of Motion
Metacarpal-Phalangeal Joint
Proximal Interphalangeal Joint
Distal Interphalangeal Joint
Coordinated Grip
Peripheral Nerves
Median Nerve
Ulnar Nerve
Anomalous Innervation
Digital Nerves
Arterial Anatomy
EXAMINATION OF THE HAND AND UPPER EXTREMITY
Patient History
Examination of the Extremity
Vascularity
Assessing Range of Motion and Tendon Function
Elbow
Forearm
Wrist
Neurologic Evaluation
Median Nerve
Ulnar Nerve
Radial Nerve
ACKNOWLEDGMENTS
REFERENCES
Regional Anesthesia for the Upper Extremity
General Considerations
General Considerations
Historical Perspective
Regional Anesthesia for Ambulatory Surgery
Pharmacology
Local Anesthetics
Mechanism of Action
Additives
Sodium Bicarbonate
Preservatives
Epinephrine
Sedation
Premedication
Intraoperative Sedation
Complications
Nerve Injury After Regional Anesthesia
Mechanism of Injury
Prevention and Treatment of Nerve Injury
Anaphylaxis
Local Anesthesia Systemic Toxicity
Incidence
Recognition
Prevention
Treatment of Local Anesthesia Systemic Toxicity
Regional Anesthesia Techniques
Brachial Plexus Blocks
Considerations.Interscalene brachial plexus blocks consistently block the ipsilateral phrenic nerve, although this phenomenon ma...
Technique.The patient is positioned supine with the arm resting comfortably by the side and the head turned away from the side b...
Considerations.Due to the compactness of the brachial plexus at this site, this block has a rapid onset and extends to all compo...
Technique.The midpoint of the clavicle is marked. The lateral border of the sternocleidomastoid muscle is identified, and the in...
Considerations.The brachial plexus is deeper from the skin than other upper extremity blocks, making the block potentially more ...
Technique.There are at least two different approaches to the infraclavicular brachial plexus block. A midclavicular needle inser...
Considerations.The axillary approach is commonly taught and is a simple approach to use. Complications are rare and generally at...
Technique.The axillary block is performed by placing the patient supine with the arm supinated and abducted 90 degrees. The axil...
Local Anesthetic Choice
Continuous Brachial Plexus Anesthesia
Peripheral Nerve Blocks
Blocks at the Elbow
Blocks at the Wrist
Metacarpal Blocks
Advantages.Blocks performed at the base of the metacarpal will anesthetize the distal metacarpal and entire digit, allowing the ...
Disadvantages.Common digital nerves provide innervation to two adjacent finger surfaces; thus two metacarpal blocks must be perf...
Digital Nerve Blocks
Advantages
Disadvantages
Intravenous Regional Anesthesia: The Bier Block
Indications and Contraindications
Considerations
Technique
Tourniquet Management
Practical Tips for Facilitating Regional Anesthesia
REFERENCES
Chapter 1
1 - Fractures and Ligament Injuries of the Thumb and Metacarpals
Anatomy
Physical Examination
Radiographic Examination
Thumb Fractures
Thumb Metacarpal Base Fractures
Treatment.Attempted closed manipulation may rarely anatomically align the fracture subluxation. If this can be obtained, thumb s...
Closed Reduction and Percutaneous Pinning.Closed reduction is obtained by longitudinal traction combined with abduction and pron...
Open Reduction and Internal Fixation.Closed manipulation may fail to restore anatomic alignment of the TM joint. This is an indi...
Rehabilitation.Pins that cross are removed at 6 to 8 weeks. Because fixation crosses the TM joint, cast immobilization should be...
Thumb Metacarpal Shaft Fractures
Treatment
Closed Reduction and Immobilization.Nondisplaced metacarpal shaft fractures can be effectively managed by a period of cast immob...
Surgical Treatment.Because of its mobility, indications for surgical treatment of thumb metacarpal fractures differ considerably...
Rehabilitation.Pins should be protected with a cast or splint immobilization until their removal. This period may vary from 3 to...
Thumb Metacarpal Head Fractures
Thumb Proximal Phalanx Fractures
Thumb Distal Phalanx Fractures
Thumb Dislocations and Ligament Injuries
Thumb Trapeziometacarpal Joint Dislocations
Treatment.Stable injuries and those with anatomic alignment after closed reduction may be immobilized in a thumb spica splint if...
Rehabilitation.The thumb is immobilized in a cast or splint for 4 weeks. The Kirschner wire is removed at 4 weeks. Range of moti...
Thumb Metacarpal Phalangeal Joint Ligament Injuries
Complete Collateral Ligaments Injuries.Acute, complete UCL injuries in the presence of Stener lesions must be repaired surgicall...
Chronic Thumb Metacarpal Phalangeal Collateral Ligament Injuries.Chronic instability is usually the result of an improperly trea...
Rehabilitation.Thumb spica splint or cast immobilization with the IP free to move is used for 3 weeks. Thereafter the thumb is p...
Thumb Metacarpal Phalangeal Joint Dislocation
Treatment.Closed reduction should be attempted by traction, hyperextension, and pressure at the base of the proximal phalanx, fo...
Rehabilitation.Following closed or open treatment of dorsal MCP dislocation, the joint should be immobilized with an extension b...
Thumb Interphalangeal Joint Injuries
Metacarpal Fractures
Intraarticular Base Fractures With or Without Carpal Metacarpal Joint Instability.Intraarticular injuries of the metacarpal base...
Avulsion Base Fractures.These injuries are not typically associated with instability of the CMC joint. Avulsion fractures are us...
Treatment
Nonoperative Management.Nondisplaced fractures and transverse fractures that are stable after closed reduction may be treated wi...
Open Reduction and Internal Fixation.Open reduction is indicated whenever closed reduction does not result in anatomic alignment...
Primary Arthrodesis.Some authors advocate primary arthrodesis in the setting of severe fracture-dislocations in the CMC joints o...
Rehabilitation.Following surgery the patient’s hand should be placed into an intrinsic-plus splint, as described for nonoperativ...
Metacarpal Shaft Fractures
Treatment
Nonoperative Management.Hematoma and/or wrist block provide adequate anesthesia to perform closed reduction. Transverse fracture...
Intramedullary Fixation.Intramedullary fixation has evolved as an extension of percutaneous pinning. Standard Kirschner wires ca...
Open Reduction and Internal Fixation.Open reduction and internal fixation are indicated when closed reduction does not successfu...
External Fixation.The principal indications for external fixation have been open fractures with potential for infection and comm...
Rehabilitation.Following surgery, the patient’s hand should be placed in an intrinsic-plus splint as described above. DIP and PI...
Metacarpal Neck Fractures
Treatment
Nonoperative Management.Anesthesia for closed reduction can be performed as for metacarpal shaft fractures. Improving and mainta...
Surgical Management.Indications for surgical treatment of metacarpal neck fractures are not well established. Rotational deformi...
Closed Reduction and Percutaneous Pin Fixation.After a closed reduction is performed as described above, it is maintained with 0...
Open Reduction and Internal Fixation.Open reduction and internal fixation are indicated when closed reduction is not successful....
Rehabilitation.Following surgery, the extremity should be placed into an intrinsic-plus position, as described above. DIP and PI...
Metacarpal Head Fractures
Treatment
Open Reduction With Internal Fixation.Displaced fractures require reduction and fixation. Occasionally a nondisplaced fracture m...
Salvage Techniques.The MCP joint is vital to hand function. Restoration of its anatomy is always the primary goal following inju...
Rehabilitation.The timing of postoperative mobilization depends on the severity of the injury and type of fixation used. Injurie...
Carpal Metacarpal Dislocations
Rehabilitation.Following surgery, the patient’s arm should be placed into an intrinsic-plus immobilizing splint as described for...
Surgical Treatment.Open reduction of a complex dislocation can be performed through a dorsal or volar approach. Unless the dislo...
Rehabilitation.Following closed reduction, most MCP dislocations are stable. A dorsal extension blocking splint that maintains a...
Special Considerations
Open Fractures
Segmental Bone Loss
Pediatric Fractures
Fracture Complications
Compartment Syndrome
Fight Bite Infection
Malunions
Nonunions
Acknowledgment
Chapter 2
2 - Phalangeal Fractures and Interphalangeal Joint Injuries
Proximal Phalangeal Fractures
Anatomy
Physical Examination
Radiographic Evaluation
Treatment
Closed Reduction
Open Fracture Treatment
Intraarticular Base Fractures.Nondisplaced, comminuted, intraarticular fractures have a propensity to settle and displace. Percu...
Rehabilitation.Therapy is initiated based on the fracture stability. An initial period of immobilization is typically used for u...
Transverse Shaft Fractures.Transverse fractures with minimal comminution are usually stable after reduction and can tolerate app...
Rehabilitation.With rigid internal fixation, early range-of-motion exercises are started within a few days to a week of surgery....
Comminuted Fractures With Extensive Bone Loss.Extensive comminution may preclude stabilization with internal fixation devices al...
Rehabilitation.Range-of-motion exercises at uninvolved joints, while securely stabilizing around the fracture, minimize stiffnes...
Condylar Fractures
T- and Y-Shaped Bicondylar Fractures.T- or Y-shaped fracture patterns require exposure of both sides of the joint to obtain anat...
Rehabilitation.Active exercises in a removable intrinsic-plus splint are started immediately if stable fixation is obtained. In ...
Mechanism of Injury
Anatomy
Physical Examination
Diagnostic Imaging Evaluation
Treatment
Dorsal Subluxation and Dislocation
Simple Dislocation.Simple dislocations are defined as injuries that hyperextend past the joint’s normal range, but the base of t...
Rehabilitation.Passive and active finger flexion exercises are started with the goal of finger flexion to the distal palmar crea...
Complex Dislocation.Unlike simple dislocations, in complex dislocations the base of the middle phalanx is no longer in contact w...
Rehabilitation.If the joint is stable to passive extension, buddy-taping alone will be sufficient. If the joint is not stable to...
Irreducible Dislocation.When the joint cannot be reduced by closed manipulation, an open reduction is required using a dorsal ap...
Subluxation and Dislocation With Avulsion Fractures of the Base of the Middle Phalanx.The narrow insertion of the volar plate on...
Rehabilitation.At 5 to 6 weeks, active PIP flexion exercises with a dynamic extension splint are started. Night extension splint...
Avulsion of the Central Slip With Fracture.Avulsion fractures displaced less than 1 mm are treated similar to tendon avulsion wi...
Rehabilitation.Postoperatively the hand is immobilized in a PIP extension, Bunnell splint, or a transarticular Kirschner wire fo...
Complex Volar Dislocations.Volar PIP dislocations without an associated fracture are rare. Closed reduction is attempted but not...
Rehabilitation.When a closed reduction is successful, the patient must be tested for the competence of the central slip. If an i...
Rehabilitation.The digit is started on early active and passive motion to achieve full flexion, which is most limited due to the...
Ligamentous Injuries With Avulsion Fractures.An avulsion fracture involving less than 25% of the joint can often be treated in a...
Rehabilitation. Rehabilitation after repair is the same as described for injuries without avulsion fractures
Pediatric Injuries.Although dislocations are exceedingly rare in children, radiographic evaluation should be performed to rule o...
Middle Phalangeal Fractures
Middle Phalangeal Shaft Fractures Without Comminution
Middle Phalangeal Shaft Fractures With Comminution
Condylar Fractures
Distal Phalangeal Fractures
Mechanism of Injury
Anatomy
Physical Examination
Radiographic Evaluation
Treatment
Bony Mallet Finger Injuries
Rehabilitation.Six to eight weeks of full-time splinting is recommended followed by gentle progressive DIP flexion exercises, if...
Rehabilitation.Skeletal fixation with Kirschner wires can maintain the alignment of the digit without requiring tight splints or...
Tuft Fractures
Distal Interphalangeal Joint Subluxation and Dislocation
Rehabilitation.The Kirschner wires can generally be removed within 4 weeks, and the patient can be started on gentle active rang...
Joint Contractures
Nonunions
Malunions
ACKNOWLEDGMENTS
REFERENCES
Chapter 3
3 - Pediatric Fractures
Introduction
Hand Fractures
Scaphoid Fractures
Distal Radius Fractures
Forearm Fractures
Pediatric Elbow Fractures
REFERENCES
Chapter 4
4 - Carpal Instability
Core Knowledge
Biomechanics of the Carpus
Anatomy
Carpal Instability Patterns
Carpal Instability Diagnosis and Treatment
Definition
Classification
Diagnosis of Scapholunate Instability
Stages of Scapholunate Instability
Arthroscopy in Scapholunate Instability
Treatment of Acute Scapholunate Injury
Treatment of Chronic Scapholunate Injury
Limited Intercarpal Arthrodesis
Radiofrequency Shrinkage
Reduction Association Scaphoid and Lunate
Techniques of Capsulodesis
Techniques of Tenodesis
Bone-Soft Tissue-Bone Reconstruction
Emerging Techniques
Salvage Techniques
Introduction
Biomechanics
Initial Management
Surgical Treatment
Outcomes
Ulnar Carpal Instability (Midcarpal or Volar Intercalated Segment Instability Patterns)
Radiographic Evaluation
Surgical Reconstruction
Volar Intercalated Segment Instability Ligament Repair.Lunotriquetral ligament repair can provide correction of the VISI while p...
Lunotriquetral Ligament Reconstruction.In chronic cases where the quality of the residual LTIL is poor, ligament reconstruction ...
Limited Arthrodesis.Lunotriquetral arthrodesis is an option for patients who experience chronic wrist pain with daily activities...
Outcomes
Vertical Shear Fracture-Dislocation
Classification
Mechanism of Injury
Diagnosis
Treatment
Fractures of (Nonscaphoid) Carpal Bones
Overview
Trapezial Fractures
Triquetral Fractures
Hamate Fractures
Lunate Fractures
Trapezoid Fractures
Capitate Fractures
Pisiform Fractures
Future Directions
REFERENCES
Chapter 5
5 - Scaphoid Fractures
Mechanism of Injury and Classification of Acute Scaphoid Fractures
Anatomy
Biomechanics
Acute Fractures
Physical Examination
Diagnostic Imaging of the Scaphoid
Early Management
Definitive Management
Nonoperative Management of Acute Scaphoid Fractures
Operative Management of Scaphoid Fractures
Scaphoid Nonunions
Factors in Treating Scaphoid Nonunions
Limited Approach for Percutaneous Cannulated Headless Screw Fixation With or Without Arthroscopic Manipulation
Volar Percutaneous Scaphoid Fixation
Dorsal Percutaneous Scaphoid Fixation
Open Volar Approach for Acute Scaphoid Waist Fractures
Volar Approach for Scaphoid Waist Nonunion With a Viable Proximal Pole
Open Dorsal Approach to the Scaphoid
Dorsal Approach for Scaphoid Nonunion With a Viable Proximal Pole
Outcome
Complications and Pitfalls
Salvage Procedures
REFERENCES
Chapter 6
6 - The Distal Radioulnar Joint and Triangular Fibrocartilage Complex
Anatomy
Ligamentous Structures
Interosseous Membrane
Distal Radioulnar Joint Capsule
Triangular Fibrocartilage Complex
Biomechanics
Mechanism of Injury
Physical Examination
Imaging Studies
Radiographs
Computerized Tomography
Arthrography
Magnetic Resonance Imaging
Arthroscopy
Acute Dislocation
Fractures of the Ulnar Head and Sigmoid Notch
Galeazzi Fracture-Dislocations
Essex-Lopresti Injuries
Ulnar Styloid Fracture
Class 1A Tear
Class 1B Tear
Class 1C
Class 1D Tear
Repair of Peripheral Triangular Fibrocartilage Complex Tears Open Repair.Incise the skin longitudinally between the fifth and si...
Chronic Distal Radioulnar Joint Instability
Radioulnar Ligament Reconstruction8
Degenerative Triangular Fibrocartilage Complex Tears (Palmer Class 2), Ulnar Impaction Syndrome
Ulnar Shortening Osteotomy
Wafer Resection
Distal Radioulnar Joint Arthritis
Management of Failed Distal Ulna Excision
Extensor Carpi Ulnaris Tendonitis and Subluxation
Distal Radioulnar Joint Contracture
REFERENCES
Chapter 7
7 - Diagnostic and Therapeutic Arthroscopy for Wrist Injuries
Specific Techniques
Dry Wrist Arthroscopy
Other Tips
Ganglion Cyst Excision
Triangular Fibrocartilage Complex Debridement or Repair
Scapholunate Ligament Injury: Assessment and Treatment
Arthroscopic Debridement for Arthritis
Arthroscopic Management of Wrist Stiffness
REFERENCES
Chapter 8
8 - Fractures and Malunions of the Distal Radius
BACKGROUND
Anatomy
Mechanism of Injury
Classification of Distal Radius Fractures
AO-ASIF (Association for Study of Internal Fixation) Classification
Fernandez and Jupiter Classification
Associated Injuries
Initial Assessment
Radiographic Studies
Treatment of Distal Radius Fractures
Percutaneous Pinning
Extrafocal Pinning
Intrafocal Pinning (Kapandji Technique)
External Fixation
Approaches for Open Reduction and Internal Fixation
Dorsal Approach
Volar Radial Approach
Volar-Ulnar (Extended Carpal Tunnel) Approach
Combined Volar and Dorsal Approach
Carpal Tunnel Syndrome
Volar Locking Plate
Volar Plate Application
Fragment Specific Fixation Devices
Arthroscopically Assisted Open Reduction and Internal Fixation
Distraction Plating for Fractures With Extensive Comminution
Distal Radial Ulnar Joint
Rehabilitation After Distal Radius Fracture
Outcomes of Treatment
Malunions of the Distal Radius
Surgical Technique
Postoperative Rehabilitation
ACKNOWLEDGMENTS
REFERENCES
Chapter 9
9 - Compartment Syndrome and Volkmann Ischemic Contracture
History
Acute Compartment Syndrome
Anatomy
Compartments of the Hand
Evaluation
History
Examination
Diagnostics
Treatment
Reduction of Risk Factors
Surgical Compartment Release: Volar
Surgical Compartment Release: Dorsal
Finger Compartment Syndromes
Postoperative Care and Rehabilitation
Neonatal Compartment Syndrome
Chronic Compartment Syndrome
Diagnosis of Chronic Compartment Syndrome
Treatment of Chronic Compartment Syndrome
Volkmann Ischemic Contracture
Treatment of Volkmann Ischemic Contractures
Mild Contractures
Moderate Contractures
Severe Contractures and Salvage
Conclusion
REFERENCES
Chapter 10
10 - Nail Bed and Fingertip Injuries
Core Knowledge
Sensory Organelles in the Fingertip
Nail Bed Anatomy
Finger Pulp Anatomy
EVALUATION AND TREATMENT OF FINGERTIP INJURIESNail
Nail Bed Injuries
Evaluation
Classification
Repair.Nail bed lacerations typically result from crushing injuries that lead to ragged, stellate lacerations. Sufficient nail p...
Nail Bed Grafts.Split-thickness grafts from the nail bed can successfully take when used for nail bed defects. Grafts from the g...
Partial Fingertip Amputations
Examination
Classification
Expected Outcomes.Complete reepithelialization with restoration of some protective sensibility can occur with conservative treat...
Technical Tips.Even if a small amount of bone is exposed, this “open” technique may still be effective. The bone should not exte...
Type 2.In these injuries with more than 50% of the nail damaged along with loss of its underlying supportive distal phalanx, it ...
Technical Tips.Nail bed ablation is easily performed with tangential dissection just under the nail fold, leaving the overlying ...
Type 3.These volar oblique injuries spare more than 50% of the nail and often have open wounds at the tip that are greater than ...
Type 4 (Amputations at the Distal Interphalangeal Joint).In sharp amputations, replantation can be considered. This may be most ...
Technical Tips.Revision of amputations at the DIP joint level should be performed in the operating room, where attention can be ...
Management of Specific Structures
Nail
Nerve
Technical Tips.It is important to separate the artery from the nerve before performing neurectomy because inadvertently dividing...
Tendon
Bone and Cartilage
Local and Regional Flap Options
Description (Fig. 10.9).This flap can be executed either as a single proximally based flap or a double H flap. When designed as ...
Description (Fig. 10.10).After the recipient site (the fingertip defect) has been properly debrided, a paper or cloth template i...
Advantages
Disadvantages
Technique.The technique is similar to that used in the standard cross-finger flap but provides coverage for the dorsum of an adj...
Advantages
Disadvantages
Cross-Finger to Thumb Flap
Indications.This flap is indicated in patients with ulnar-sided soft-tissue loss involving the thumb tip or pulp, including expo...
Description (Fig. 10.13).This flap originates over the dorsum of the middle phalanx of the index or middle finger and is usually...
Advantages
Disadvantage
Description (Fig. 10.14).The flap is designed by making midlateral incisions on either side of the thumb. Then a skin pedicle is...
Advantages
Disadvantages
Description.The flap depends on the perforating subdermal vessels for its blood supply (Fig. 10.15). The skin is incised in a di...
Advantages
Disadvantages
Advantages
Disadvantages
Description (Fig. 10.17).The ulnar aspect of the middle finger is generally used as the donor site if there is no median nerve d...
Advantages
Disadvantages
Description (Fig. 10.18).After preparation of the thumb defect, a template is made for flap planning over the dorsal aspect of t...
Advantages
Disadvantages
Protection
Range of Motion
REFERENCES
Chapter 11
11 - Amputations and Prosthetics
Core Knowledge
Functional Patterns of Digital Amputations
General Principles
Nerves
Tendons
Bone
Soft Tissue
Thumb
TREATMENT OF SPECIFIC UPPER EXTREMITY AMPUTATIONS
Digital Level Amputations
Amputations Through the Distal Phalanx and Distal Interphalangeal Joint
Amputations Through the Middle Phalanx
Phantom Limb Pain
Rehabilitation of Digital Level Amputations
Ray Amputations
Ray Amputation of the Index Finger
Ray Amputation of the Middle Finger
Middle Finger Gap Closure Versus Transposition
Ring Finger Ray Amputations
Small Finger Ray Amputation
Management of Multiple Digits Amputations
Below-the-Elbow Amputations
Amputations Through the Carpus
Technique for Below-the-Elbow Amputation
Krukenberg Operation
Elbow Disarticulation and Above-the-Elbow Amputation
Surgical Technique
Shoulder Disarticulations and Forequarter Amputations
Prosthetics
General Types
External Prostheses: Signal Sources
Targeted Muscle Reinnervation
External Prostheses: Sensory Feedback
Indications for Prosthetic Prescription
Digital Prosthesis
REFERENCES
Chapter 12
12 - Hand Infections, Injection Injuries, Snake Bites, and Extravasation Injuries
Urgency
History
Tetanus
Cultures and Stains
Exam
Imaging
Treatment
Clinical Presentation (Specific Infections)
Human Bites (Clenched-Fist Injuries) and Septic Arthritis
Animal Bites and Scratches
Insect Bites
Necrotizing Fasciitis
Paronychia
Acute Presentation
Chronic Paronychia Infections
Felons
Flexor Tendon Sheath Infections
Flexor Tendon Sheath Infections Without an Abscess
Flexor Tendon Sheath Infections With an Abscess
Deep Space Infections
Web Space Abscesses
Parona Space Infection
Midpalmar, Thenar, and Hypothenar Space Abscesses
Horseshoe Abscesses
Specific Infectious Organisms
Methicillin-Resistant Staphylococcus aureus
Mycobacterial Infections
Fungal Infections
Candida
Sporothrichosis
Histoplasmosis
Coccidioidomycosis
Viral Infections
Herpetic Whitlow
Orf Virus
Human Immunodeficiency Virus
Occupational Bloodborne Pathogen Exposure
High-Pressure Injection
Surgical-Site Infection
Extravasation
Snake Bites
Methicillin-Resistant Staphylococcus aureus
Mycobacterial Infections
Fungal Infections
Candida
Coccidioidomycosis
Viral Infections
Herpetic Whitlow
Orf Virus
Human Immunodeficiency Virus
Occupational Bloodborne Pathogen Exposure
High-Pressure Injection
Surgical-Site Infection
Snake Bites
Extravasation
REFERENCES
Chapter 13
13 - Burns and Frostbite of the Hand
Introduction and Epidemiology
Skin Anatomy
Thermal Burns
Classification of Burns
Acute Burn Management
Initial Evaluation
Escharotomy
Fasciotomy
Wound Care
Occupational Therapy and Hand Therapy
Excision and Skin Grafting
Skin Substitutes
Cultured Epithelial (Epidermal) Autografts.These grafts are generated from the patient’s own keratinocytes by culture expansion ...
Integra.Integra Dermal Regeneration Template (Integra Life Sciences) is a two-layer construct consisting of bovine tendon collag...
Human Acellular Dermal Matrix.Acellular dermal matrix (ADM) is a processed human dermis with the cellular components removed to ...
MatriDerm.MatriDerm (MedSkin Solutions) is similar to human ADM but from a bovine source. The bovine collagen matrix is cross-li...
Coverage of Deep Burns
Reverse Radial Forearm Flap.Many modifications of the reverse radial forearm flap have been described. Traditionally it is harve...
Reverse Posterior Interosseous Flap.This fasciocutaneous flap is harvested from the dorsal aspect of the forearm and can provide...
Abdominal and Groin Flaps.When local or regional flaps are not feasible due to the extent of injury, the abdomen or groin may pr...
Free Flaps.With the expansion of flap selections and refinement of microsurgical techniques, free flaps are becoming more common...
Pinning of Hand Joints
Amputation
Secondary Reconstructive Surgery
Scar Contracture Release
Laser Treatments
Electrical Burns
Chemical Burns
Hydrofluoric Acid
Phenol (Carbolic Acid)
Lye (Sodium Hydroxide)
White Phosphorus
Elemental Sodium, Potassium, and Lithium
Cold Injury
Pathophysiology
Classification
Treatment
REFERENCES
Chapter 14
14 - Flexor Tendon Injuries
History and Epidemiology
Tendon Injury and Repair
What Key Information Is Required for Surgeons Performing Tendon Repair?
What Is the Ideal Research Model for Studying Flexor Tendon Injuries?
What Is the Best Way to Determine the Strength of Tendon Repair?
Can the Flexor Tendon Repair Increase Tendon Friction (Work of Flexion) During Digital Flexion?
How Strong Are Flexor Tendon Repairs?
Does Suture Locking Increase Time-Zero Tendon Repair Strength?
Does the Knot Location of the Core Sutures Affect Tendon Strength and Tendon Healing?
Should the Core Sutures Be Placed in the Dorsal or the Palmar Segment of the Tendon?
Does the Epitenon Suture Improve the Strength and Quality of the Tendon Repair?
Should One or Two Tendons Be Repaired in Zone II?
Does the Surface Area of the Tendon Repair Affect the Strength of Repair?
Does the Timing of Tendon Repair Affect the Quality of the Patient’s Functional Result?
Do Partial Tendon Lacerations Need to Be Repaired, and If So, When?
What Is the Role of Tendon Sheath Repair Following Repair of Lacerated Flexor Tendons?
Intrinsic Versus Extrinsic Tendon Healing
What Type of Rehabilitation Will Optimize the Functional Result?
Is the Lack of Vascularity of Tendon Grafts a Problem?
Physiology of Tendon Injury and Repair
Cytokines and Growth Factors
Tendon Nutrition and Blood Supply
Tendon Structure and Biomechanics
Flexor Tendon Anatomy
Zone I
Zone II (No Man’s Land)
Zone III
Zone IV
Zone V
Examination
Acute Tendon Repair
Zone I
Zone II (No Man’s Land)
Zone III Injuries
Zone IV Injuries
Zone V Injuries
Flexor Pollicis Longus Injuries
Rehabilitation of Flexor Tendon Injuries
Description
Initial 24 to 48 Hours Postoperative
Twenty-Four to 72 Hours Postoperative to 4 Weeks
Four Weeks Postoperative
Four Weeks
Five Weeks
Six Weeks
Seven Weeks
Eight Weeks
Nine Weeks
Ten to 14 Weeks
Adhesions
Treatment. Hand therapy is necessary to maximize digital PROM. Surgical treatment of stiffness should be delayed until all the s...
Bowstringing
The Plantaris Tendon.A longitudinal incision is made parallel and medial to the Achilles tendon. The incision is carried down th...
Ring-Toe Extensor.Because of the toe extension from the short toe extensors, this graft can be harvested without any deleterious...
Long Toe Flexor (Intrasynovial Tendon Graft).72The second toe flexor is the best choice of intrasynovial tendon graft given its ...
Tendon Allografts.As a last option, tendon allografts can be useful when the supply of available autografts has been exhausted. ...
Prerequisites for Two-Stage Flexor Tendon Reconstruction
First Stage
Second Stage.Incisions are made distally at the level of the DIP joint to identify the distal end of the tendon. Sutures anchori...
Postoperative Rehabilitation.This is similar to zone II flexor tendon rehabilitation (passive protocol) in the acute setting, bu...
Pedicled Intrasynovial Graft.In chronic lacerations in which both the FDP and FDS tendons have been lacerated, use of a pedicled...
Stage III Flexor Tendon Reconstruction (Tenolysis of Adhesions).In our experience, tenolysis is frequently necessary. Flexor ten...
Assessment. Evaluate PROM, AROM, and muscle strength of the extrinsic finger flexors and extensors
Treatment
One to 3 Days Postoperative Precautions
Treatment
Splinting
One to 2 Weeks Preoperative Precautions
Treatment
Splinting. Splinting, as needed, to maintain flexion and/or extension range of motion
Two to 6 Weeks Postoperative Precautions
Treatment
Splinting
Six to 8 Weeks Postoperative Precautions. No heavy resistance or lifting
Treatment
Splinting. As needed for joint contracture
Eight to 10 Weeks Postoperative Precautions. Progress resistance as tolerated
Treatment
Splinting. As needed for joint contracture
Conservative Program Following Flexor Tenolysis for Fragile (Frayed) Tendons.Always remember to confer with the surgeon regardin...
Initial Treatment
One to 2 Weeks
Two to 6 Weeks. CPM may be indicated for longer periods in these patients
Six to 8 Weeks. Delay resistive activity
Eight to 12 Weeks. Begin light resistive activity
Sixteen Weeks. Progress to full resistive activity
REFERENCES
Chapter 15
15 - Extensor Tendon Injuries
Acute Extensor Tendon Injuries
Anatomy
Classification of Extensor Tendon Injuries
Clinical Presentation
Treatment
Zone 1
Zone 2
Rehabilitation Protocol for Zone 1 and 2 Injuries
Zone 3
Elson Test
Zone 4
Zones 3 and 4 Rehabilitation Protocols
Zone 5
Zone 6
Zone 7
Zone 8
Zone 9
Zone 5 to 9 Rehabilitation Protocols
Outcomes of Extensor Tendon Repairs
Late Extensor Tendon Reconstruction
General Considerations
Chronic Mallet Finger Deformity
Advancement of Tendon to Bone
Dermatotenodesis
Swan Neck Deformity
General Considerations
Chronic Boutonnière Deformity
Extensor Pollicis Longus Degenerative Injury
Extensor Tendon Injuries With Segmental Tendon Loss
Injuries With Two Intact Finger Extensor Tendons
Injuries With a Loss of All Finger Extensor Tendons
REFERENCES
Chapter 16
16 - Nerve Repair and Nerve Transfers
Introduction
Anatomy of Peripheral Nerves
ANATOMY AND PHYSIOLOGY OF PERIPHERAL NERVES
Physiology of Peripheral Nerves
Basic Electrophysiology2,3
Neuromuscular Junction Transmission
Axonal Transport
Sensory Receptors
Distal Axon.The distal axon cannot survive without its connection to the cell body and disintegrates (ie, wallerian degeneration...
Proximal Axon.Following transection, there is demyelination of the distal stump. The axons degenerate to one or more proximal in...
Axon Regeneration
Role of Schwann Cells.Following nerve transection the Schwann cell removes the axonal and myelin debris in both the severed nerv...
Nerve Biomechanics.A normal nerve has longitudinal excursion, which subjects it to a certain amount of stress and strain in situ...
Clinical Assessment
Laboratory Assessment
Nerve Conduction Studies2,3
Lumbrical-Interosseous Latency Differences.A recording electrode is placed over the second palmar interspace at the distal palma...
Ulnar Nerve.Normal values include a DML greater than 3.6 ms and an amplitude greater than 4.0 mV. The latencies can be measured ...
Radial Nerve.Normal values include a DML of less than 3.4 ms, with amplitudes greater than 4.0 mV. Normal SNAPs consist of a pea...
Electromyography
Axonotmesis and Neurotmesis.The axons are disrupted but the surrounding stroma is intact. This cannot initially be distinguished...
Partial Lesions.Partial lesions usually represent axonotmesis, in which recovery depends on axonal sprouting and regeneration. W...
Complete Lesions.When the nerve is divided completely, recovery is dependent solely on axonal regeneration. The EMG is initially...
Magnetic Resonance Imaging
Treatment of Nerve Injuries
Nerve Repair
Group Fascicular Suture.The motor and sensory groups of fascicles are identified as described. In a major nerve, such as the med...
External Epineurial Splint.Jabaley has used the external epineurium as a splinting device.31 The external epineurium is incised ...
Nerve Repair: Secondary
Repair at the Elbow.The median nerve is located through an S-shaped anteromedial incision at the cubital fossa. The lacertus fib...
Repair in the Forearm.The median nerve is approached through a volar incision. The nerve is identified on the undersurface of th...
Repair at the Wrist.The median nerve at the wrist has approximately 30 fascicles. The motor recurrent branch often consists of t...
Repair in the Hand.The median nerve is approached through an extensile carpal tunnel approach, with division of the TCL. The rec...
Digital Nerve Repair.There are often two fascicles in the typical digital nerve. An external epineurial repair gives the same re...
Repair in the Forearm.The motor fascicles lie dorsal and slightly ulnarly to the sensory fascicles at the wrist level and usuall...
Repair at the Wrist.The ulnar nerve has 15 to 25 fascicles at the wrist. It can be clearly divided into a volar sensory componen...
Repair in the Hand.The nerve is approached through a volar ulnar incision in line with the ring finger. The deep motor and more ...
Digital Nerve Repair.Repair or grafting in the digits is similar to the median nerve (Fig. 16. 22)
Repair in the Forearm and Wrist.The PIN nerve is approached through a dorsolateral approach, developing the plane between the ex...
Postoperative Rehabilitation.After nerve repair the rehabilitation focuses on three areas: initial immobilization to protect the...
Outcomes Following Repair and Graft.Most series report the results of nerve repair using the BMRC grading system, which has been...
Alternate Methods of Nerve Reconstruction
Nerve Conduits
Indications.Conduits are indicated for reconstruction of small-diameter, noncritical sensory nerves with a gap of less than 3 cm...
Contraindications.These include uncertainty about the viability of the nerve ends, especially with avulsion injuries, blast inju...
Autogenous Vein Grafts.The use of autologous veins as a biologic tube to reconstruct a nerve gap has been well described over th...
Postoperative Rehabilitation.Repair of other tendon or muscle injuries will influence the rehabilitation. With an isolated nerve...
Outcomes.The use of conduits for mixed nerves is still experimental and cannot be considered a standard of treatment as yet, alt...
Processed Nerve Allografts.Taras et al.52 reported the outcomes of 14 patients with an average age of 39 years (range, 18 to 76 ...
End-to-Side Repairs
Neurotization
Nerve Transfers
Nerve Transfers to Restore Wrist and Finger Extension
Median Nerve.Just distal to the cubital fossa, the motor branches of the median nerve consistently collect into three fascicular...
Posterior Interosseous Nerve Palsy.In a PIN palsy the presenting symptoms are weakness and/or paralysis of the extensor muscles,...
Electrodiagnostic Studies.PIN lesions do not affect the superficial radial SNAP, which should be normal. The compound motor acti...
Indications.The time for reinnervation must take the distance from the injury to the motor end plate into account. As a general ...
Contraindications.Contraindications include nerve palsies that may recover spontaneously, such as proximal radial nerve lesions ...
Radial Nerve Exposure.The radial nerve is isolated through the same incision. It can be found between the BR and brachialis as i...
Nerve Transfer.MacKinnon recommends coapting the FDS motor fascicles with the ECRB branch because this can reproduce the tenodes...
Postoperative Rehabilitation.An above-elbow splint is applied with the elbow at 90 degrees and the shoulder, wrist, and fingers ...
Outcomes.In Mackinnon’s series, 17 of 19 patients had complete radial nerve palsy, whereas two had intact wrist extension with l...
Contraindications.The absolute contraindication for this nerve transfer is a global brachial plexus palsy with no recovery of ul...
Relevant Anatomy.The musculocutaneous nerve (MCN) is the terminal branch of the lateral cord of the brachial plexus, containing ...
Surgical Technique.The patient is placed supine on the operating table, with the arm placed out on a hand table. The entire extr...
Outcomes.A total of 100 cases can be identified in the English literature.68 Eighty percent of patients recovered ≥M4 motor stre...
Double Fascicular Transfer
Indications.The most common indication for this procedure is a proximal ulnar nerve injury to restore function to the ulnar inne...
Contraindications.An AIN transfer should be performed within 6 months of injury, with an upper limit of 12 months.73 Damage to t...
Surgical Technique.73The patient is positioned supine with the arm abducted to 90 degrees on a hand table, with use of a tourniq...
Outcomes.Despite the enthusiasm with this procedure, there is a paucity of published outcomes. Pace and Wood74 describe a case o...
Sensory Nerve Transfers
Indications.Sensory nerve transfers can be performed for areas requiring critical sensation in cases in which a proximal nerve s...
Contraindications.The main contraindication for nerve transfer is when a direct end-to-end nerve repair is possible or in the ca...
Surgical Technique.The patient is positioned supine with the arm abducted on a hand table under general anesthesia. Tourniquet t...
Nerve Transfer for Median Nerve Injury.The ulnar sensory fascicles to the fourth web space can be transferred to the median inne...
Nerve Transfer for Ulnar Nerve Injury.A sensory nerve transfer can be performed using the median sensory fascicles to the third ...
Outcomes.Despite the number of technical reports, published outcomes following sensory nerve transfers are lacking. Most of thes...
REFERENCES
Chapter 17
17 - Brachial Plexus Injuries
Core Knowledge
Anatomy
Epidemiology of Adult Brachial Plexus Injuries
Mechanism of Injury in Adult Brachial Plexus Injuries
Brachial Plexus Injury During Birth
Classification of Brachial Plexus Injuries
Preganglionic Injuries
Postganglionic Injuries
C5 and C6 or Upper Trunk (Erb-Duchenne) Paralysis.These injuries produce paralysis of the deltoid, supraspinatus, infraspinatus,...
C5, C6, and C7 Injury.This combination of neural injuries features all the deficits of Erb-Duchenne paralysis plus paralysis of ...
Entire Brachial Plexus Injury.This results in an initial flail and anesthetic arm. Frequently there is a combination of pregangl...
C8 and T1 (Klumpke Palsy).These injuries are extremely rare in both birth injuries and adults and may be nonexistent as an isola...
Evaluation
History and Examination
Magnetic Resonance Imaging.With the ability to highlight the resonance of nerve tissue and adjust the plane of the images to cor...
Myelography and Myelo-Computerized Topography Scans.When traction from the injury is applied to the intradural portion of the sp...
Angiography.Angiography is rarely indicated, usually when there is clinical evidence to suggest a closed, hemodynamically stable...
Electrodiagnostic Studies
History and Examination
Imaging Studies
Electrodiagnostic Studies
Treatment
Rehabilitative Examination
Rehabilitative Treatment
Surgical Treatment
Avulsion and Open Injuries
Entire Plexus Palsy
C5-C6 or C5-C6-C7 Postganglionic Injuries
Priorities for Reconstruction of the Brachial Plexus
Technique for Exploration of the Brachial Plexus
Neurolysis of the Brachial Plexus.When the injured area of the brachial plexus has been localized, nerve action potentials can b...
Surgical Technique for Nerve Grafting.Both proximal and distal sections of the nerve are sectioned until normal-appearing fascic...
Neurotization.Neurotization has been defined as implanting distal nerve ends directly into muscle tissue. This occurs when the n...
Nerve Transfers.A number of potential donors for nerve transfers are possible for the reconstruction of the brachial plexus, inc...
Intercostal Nerve Transfer Technique16,17.When performing intercostal nerve transfers, it is important to make sure that the pat...
Partial Ulnar Nerve Transfer Technique19.The patient is positioned supine with the arm abducted and externally rotated on an arm...
Long Head of Triceps Nerve Transfer to Axillary Nerve22.A transaxillary approach with posterior axillary extension is used. The ...
Partial Spinal Accessory (Cranial Nerve XI) Nerve Transfer20.In C5-C6 avulsion situations, and even nowadays in some rupture cas...
Tendon Transfers
Tendon Transfers for Elbow Flexion
Transfer of Flexor Pronator Origin (Steindler Flexorplasty).In 1918 Steindler reported his technique for proximal advancement of...
Surgical Technique.An incision is made over the medial midaxial line of the elbow. The subcutaneous tissue is separated and the ...
Postoperative Rehabilitation.The patient is maintained with the elbow in a long-arm splint or cast holding the elbow in 110 degr...
Latissimus Dorsi Transfer to Biceps.The thoracodorsal nerve innervates the latissimus dorsi muscle, which is a branch from the p...
Postoperative Rehabilitation. This is similar to that for Steindler flexorplasty
Pectoralis Major (Clark Transfer).The pectoralis major muscle receives innervation from the lateral pectoral nerve, arising from...
Surgical Technique.An incision is made, curving from just below the clavicle laterally to the medial border of the costochondral...
Postoperative Rehabilitation. This is similar to the rehabilitation program described previously for the Steindler flexorplasty
Anterior Transfer of the Triceps.Transfer of the entire triceps muscle sacrifices elbow extension for elbow flexion. Consequentl...
Surgical Technique.The tendon transfer is performed using a longitudinal midline incision extending from the posterior aspect of...
Postoperative Rehabilitation. The rehabilitation is performed similar to the other tendon transfers for elbow flexion
Surgical Technique.Exposure is either by a long transaxillary or by a small anterior axillary and larger posterior axillary inci...
Rehabilitation.Postoperatively, the shoulder is maintained in a position of minimal abduction and full external rotation for 4 w...
Humeral External Rotation Osteotomy.In older children with a history of BPBP and established severe glenohumeral dysplasia, a ro...
Surgical Technique.In thin patients the osteotomy can be performed through a medial incision on the distal forearm to achieve a ...
Rehabilitation.Rehabilitation is initiated upon the presence of radiographic healing. Due to the surgical repositioning of the h...
Shoulder Arthrodesis.Shoulder arthrodesis allows for the patient’s scapulothoracic motion to power the shoulder to move the hume...
Surgical Technique.The patient is placed in a semi-sitting position with the arm draped free so that the posterior scapula and a...
Correction of the Supination Deformity.Although it is uncommon in adults, older children with prior birth palsies can have a fun...
REFERENCES
Chapter 18
18 - Management of Chronic Upper Extremity Pain and Factitious Syndromes
Core Knowledge
History and Clinical Challenge
Classification of Pain: Complex Regional Pain Syndrome
Synonyms
Physiology of Pain
Descending Pain Pathways and Gate Theory.The pairing of ascending and descending pain pathways provides a mechanism to modulate ...
Norepinephrine as the Sympathetic Neurotransmitter.The sympathetic response to certain stimuli is processed by the sympathetic g...
Innervation Changes in Complex Regional Pain Syndrome.The physiologic changes that correspond to CRPS suggest altered innervatio...
Changes in the Sympathetic Nervous System in Complex Regional Pain Syndrome.There appears to be an abnormal coupling (sympatho-a...
Diagnostic Criteria for Complex Regional Pain Syndrome
Staging and Phases of Complex Regional Pain Syndrome
Incidence, Prevalence, Genetics, and Natural History of Complex Regional Pain Syndrome
Evaluation: Diagnosis
Clinical Evaluation
Blood Tests
Testing for Sympathetically Maintained Pain
Imaging
Extremity Vascular Laboratory Testing
Psychological Tests
Depression, Stress, and Anxiety
Management
Timing
Hand Therapy
Oral Medications
Parenteral Medications
Surgical and Ablative Therapies
Correction of the Nociceptive Focus
Sympathectomy
Late Surgical Intervention
Outcomes
Practical Pain Management
Factitious Injury and Self-Abuse Syndromes
Conversion Reaction
Malingering
Posttraumatic Stress Disorder
Focal Dystonias
Fibromyalgia and Myofascial Pain Syndromes
REFERENCES
Chapter 19
19 - Management of Upper Extremity Vascular Disorders and Injuries
Core Knowledge
Significance
Components of Peripheral Blood Flow
Control of Blood Flow
Anatomy
Diagnosis and Evaluation
History
Physical Examination
Laboratory Testing
Medical Testing
Noninvasive Testing
Invasive and Structural Testing
Types of Vascular Pathobiology, Work-Up and Treatment
Raynaud Disease and Raynaud Phenomenon
Work-Up
Oral Pharmacologic Intervention.Oral medications are used to reduce vasospasm and pain and prevent thrombosis. Most medications ...
Botulinum Toxin Type A (Botox) Injections.Over 80% of patients can improve with a single injection of botox therapy with 50 to 1...
Peripheral Sympathectomy.Peripheral sympathectomy in the palm or digits is effective in maximizing nutritional digital flow. As ...
Cervicothoracic Sympathectomy.This procedure is discussed here primarily to discourage its use. The permanent interruption of th...
Thrombolytic Therapy.An alternative to surgery is the use of intraarterial anticoagulants for acute upper extremity thrombotic-e...
Prevention of Thrombosis.Several drugs that alter platelet function and coagulation pathways can be used over the long term, inc...
Embolectomy.An embolectomy is employed less frequently in the upper extremity than the lower extremity. However, this procedure ...
Technique.After verifying the extent and location of embolic events, an arteriotomy is performed at either the wrist or elbow. T...
Arterial Reconstruction. Reconstruction options include end-to-end repair, interposition grafting, and bypass grafting
Technique.Veins may be harvested through a simple longitudinal incision, multiple short longitudinal incisions, transverse incis...
Arterialization.If the patient presents with unreconstructable distal vasculature, a salvage procedure may be performed consisti...
Peripheral Vascular Small Vessel Disease
Work-Up
Treatment
Occlusive Disease (Radial and Ulnar Artery Thrombosis) and Hypothenar Hammer Syndrome
Work-Up
Technique
Occlusive Disease (Aneurysms)
Work-Up
Arteriovenous Malformations
Work-Up
Treatment
Hemangiomas
Work-Up
Treatment
Acute Trauma
Work-Up
REFERENCES
Chapter 20
20 - Compressive Neuropathies
Pathophysiology
Basic Science
Systemic Disorders
Electrodiagnostic Studies
Areas of Compression
Epidemiology
Anatomy and Pathology
Symptoms
Examination
Diagnostic Tests
Treatment
Carpal Tunnel Release.CTR surgery can be divided into open and endoscopic procedures. Endoscopic CTR offers the advantage of dec...
Open CTR.An incision is made in line with the radial border of the ring finger from the distal volar wrist crease toward the pro...
Single Portal Versus Two Portal Endoscopic Release.The single portal technique was designed by John Agee, MD, to minimize the sc...
Complications
Postoperative Rehabilitation
Anatomy and Pathology
History
Examination
Diagnostic Tests
Treatment
Ulnar-Sided Hand Numbness
Differential Diagnosis
Epidemiology
Anatomy
Symptoms
Examination
Diagnostic Tests
Treatment
In Situ Release.The authors use this procedure for most cases of uncomplicated cubital tunnel syndrome, except in cases of nerve...
Endoscopically Assisted Cubital Tunnel Release.There are several products to assist in cubital tunnel release and the nerve can ...
Anterior Submuscular Ulnar Nerve Transposition.This technique is appropriate for patients with nerve subluxation or recurrent sy...
Anterior Subcutaneous Transfer of the Ulnar Nerve.This procedure (Fig. 20.17) is well suited for elderly patients or patients re...
Medial Epicondylectomy.This procedure has the advantage of not disturbing the vascular supply of the ulnar nerve (Fig. 20.18). C...
Complications
Epidemiology
Anatomy and Pathology (Figs. 20.20 and 20.21)
Symptoms
Examination
Diagnostic Tests
Treatment
Complications
Thoracic Outlet Syndrome
Epidemiology
Anatomy
Symptoms
Examination
Diagnostic Studies
Treatment
Supraclavicular Approach.The surgery is performed with the patient in the beach chair position. An incision is made 1 cm above a...
Transaxillary First Rib Resection.The incision for this procedure is more cosmetically appealing than the supraclavicular approa...
Results
Complications
Radial Nerve Compression
Epidemiology
Anatomy and Pathology
Symptoms
Examination
Diagnostic Studies
Treatment
Anterior Approach.This approach gives the widest exposure. The incision begins proximal to the antecubital fossa between the bra...
Transmuscular Approach.A curvilinear incision is made directly over the mobile wad. Distal branches of the lateral antebrachial ...
Posterior Approach.The posterior approach uses an incision along the posterior border of the extensor origin using a line drawn ...
Rehabilitation.For either approach, the arm is postoperatively bandaged in a long-arm splint. Range-of-motion exercises of the w...
Release of Wartenberg’s Syndrome.At the level of the wrist, the sensory branch of the radial nerve exits between the tendon of t...
Complications.The most common complication for any of the above procedures is paresthesias in the lateral antebrachial cutaneous...
REFERENCES
ADDITIONAL READING
Chapter 21
21 - The Paralytic Hand and Tendon Transfers
Core Knowledge
Principles of Tendon Transfer
Muscle Physiology
Muscle Tension
Functional Anatomy
Rehabilitation
Radial Nerve Palsy
Rehabilitation
Median Nerve Palsy
Low Median Nerve Palsy
High Median Nerve Palsy
Rehabilitation
Ulnar Nerve Palsy
Low Ulnar Nerve Palsy
High Ulnar Nerve Palsy
Rehabilitation
Combined Nerve Palsies
ACKNOWLEDGMENT
REFERENCES
Chapter 22
22 - Cerebral Palsy, Stroke, and Traumatic Brain Injury
Overview
Cerebral Palsy
Core Knowledge
Clinical Evaluation
Motor Evaluation
Cognition
Voluntary Control of Hand Placement
Sensibility and Stereognosis
Dynamic Electromyography
Splints and Therapy
Surgical Treatment
Elbow Flexion Deformity
Surgical Technique.Elbow contractures can be released with an S-shaped incision centered over the antecubital fossa, with the pr...
Rehabilitation.The elbow is splinted for 2 weeks in the position of maximal extension that was achieved during surgery. The post...
Complications.Wound problems, such as hematomas, can occur with these large surgical releases. It is advisable to place suction ...
Wrist Flexion Deformity
Surgical Technique for Flexor Carpi Ulnaris Lengthening.A simple step-cut lengthening of the FCU is recommended. An incision alo...
Surgical Technique for Flexor Pronator Slide.The flexor-pronator slide is performed using the incision along the medial midaxial...
Surgical Technique for Flexor Carpi Ulnaris to Extensor Carpi Radialis Brevis Tendon Transfer.The FCU is exposed using two incis...
Rehabilitation.Patients with the Green tendon transfer are casted in wrist extension for 4 weeks before starting active wrist ex...
Surgical Technique: Dorsal Wrist Approach With Proximal Row Carpectomy and Dorsal Plate Fixation.An oblique dorsal wrist incisio...
Rehabilitation.Patients are treated after surgery in a short-arm cast for 6 weeks, followed by a removable orthosis, until union...
Complications.Wrist arthrodesis can improve appearance, hygiene, function, and overall satisfaction in those suffering with a sp...
Surgical Technique for Fractional Tendon Lengthening.A finger flexor fractional lengthening is performed using an incision on th...
Surgical Technique for Step-Cut Lengthening.This surgery is performed using the same type of incision as a fractional lengthenin...
Rehabilitation.Patients with fractional lengthening are allowed to start active finger and wrist flexion and extension while usi...
Surgical Technique for Flexor Carpi Ulnaris to Extensor Digitorum Communis Tendon Transfer.A longitudinal incision is made on th...
Swan Neck Deformities of the Fingers Secondary to Contractures of Intrinsic Muscles.Spasticity and contractures of the intrinsic...
Surgical Technique for Central Slip Tenotomy.16.Central slip tenotomy is performed using a transverse incision 1 cm proximal to ...
Rehabilitation.After central slip tenotomy, the PIP joint is pinned for 4 weeks. After removal of the pins in the office, active...
Rehabilitation.Postoperatively the patients are splinted in the intrinsic-minus position with the MCP joints extended and the PI...
Surgical Technique for Superficialis Tenodesis to Correct Swan Neck Deformity.For patients with moderate-to-severe swan neck def...
Surgical Technique for Release of Nerve/Nerve Block of the Adductor Pollicis and Flexor Pollicis Brevis.A carpal tunnel approach...
Surgical Technique for Release of the Adductor Pollicis and Flexor Pollicis Brevis.Mild contractures of the AddP can be released...
Surgical Technique for FPL Lengthening.A step-cut lengthening technique can be very successful (Fig. 22.14). After surgery the t...
Surgical Technique for Transferring the Thumb FPL to the APB.The FPL is identified and released via a radial midaxial exposure o...
Surgical Technique for Extensor Pollicis Longus Rerouting.The EPL tendon is exposed using a curved incision over the proximal ph...
Surgical Outcomes
Stroke and Traumatic Brain Injury
Stroke
Sensory Impairment.The sensory impairment can vary in individuals but usually results in a profound loss of discrimination, usin...
Motor Impairment.In the first several days to weeks following the stroke the patient has flaccid paralysis followed by gradually...
Cognitive Impairment.Memory loss, decreased learning ability, and decreased mentation can all complicate the rehabilitation of p...
Traumatic Brain Injury
Treatment of Stroke and Traumatic Brain Injury
Upper Extremity Involvement
Spasticity
Wrist and Finger Flexion Contracture.Wrist and finger flexion deformities are considered together because the finger muscles are...
Individual Step-Cut Tendon Lengthening.This surgery is performed using the same type of incision as the FDS to FDP transfer. Pat...
Fractional Tendon Lengthening.When the finger can be passively extended several centimeters from the palm in patients who have s...
Rehabilitation.The patients with fractional lengthening are allowed to start active finger and wrist flexion and extension while...
Complications Following Correction of Finger Flexion Contractures.Loss of grip strength is a common problem, especially followin...
Lengthening of Wrist Flexor Tendons.For mild deformities in patients who can actively extend to within 30 degrees of neutral wri...
Rehabilitation.The wrist is splinted in 30 degrees of wrist extension after surgery for 6 weeks on a full-time basis. Nighttime ...
Complications.Recurrence of the deformity may be a problem for patients who do not follow through with their postoperative splin...
Thumb-in-Palm Deformity.This deformity can occur in adults with stroke or TBI, although it does not usually require surgical tre...
REFERENCES
Chapter 23
23 - Upper Limb Reconstruction in Persons With Tetraplegia
INTRODUCTION
Demographics of Spinal Cord Injury
Nerve Injury in Tetraplegia
Timing of Surgery
High-Level Tetraplegia
Shoulder Girdle
Functional Electrical Stimulation
Mid-Level Cervical Tetraplegia
Classification
Treatment
Elbow
Forearm
Technique: Biceps Tendon Rerouting
Technique: One-Bone Forearm
Wrist and Hand
Rehabilitation and Outcome
Summary
Chapter 24
24 - Tendinopathies of the Hand, Wrist, and Elbow
Adult Trigger Finger
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Percutaneous Trigger Finger Release
Open Trigger Finger Release
Trigger Thumb Release
Trigger Digit Postoperative Rehabilitation
Complication
Locking Metacarpal Phalangeal Joint
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Release of the First Dorsal Compartment With Fascial Reconstruction
Complications
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Rehabilitation After Second Dorsal Compartment Release
Complications
Flexor Carpi Radialis Stenosing Tenosynovitis
Surgical Treatment
Rehabilitation After Flexor Carpi Radialis Release
Flexor Carpi Ulnaris Tendinosis
Surgical Treatment
Extensor Carpi Ulnaris Stenosing Tenosynovitis
Surgical Treatment
Rehabilitation After Extensor Carpi Ulnaris Release
Lateral Elbow Tendinosis (Tennis Elbow)
Anatomy
Clinical Presentation
Nonoperative Treatment
Surgical Treatment
Rehabilitation
Complications
Medial Elbow Tendinosis (Golfer’s Elbow)
Anatomy
Clinical Presentation
Treatment of Golfer’s Elbow
Rehabilitation
Posterior Tennis Elbow
Anatomy
Clinical Presentation
Nonoperative Treatment of Posterior Tennis Elbow
Surgical Treatment
Rehabilitation
REFERENCES
Chapter 25
25 - Osteoarthritis
Osteoarthritis and Posttraumatic Arthritis
Clinical Presentation and Medical Management
Treatment Principles
Arthroplasty
Arthrodesis
Osteoarthritis or Degenerative Arthritis
Clinical Presentation
Distal Interphalangeal Joint (Heberden Node and Mucous Cyst)
Proximal Interphalangeal Joint
Proximal Interphalangeal Joint Arthrodesis
Postoperative Rehabilitation After Proximal Interphalangeal Joint Arthrodesis.Initially the finger is immobilized in a splint an...
Proximal Interphalangeal Joint Arthroplasty
Dorsal Approach.One dorsal approach for PIP arthroplasty is similar to that used for arthrodesis, with the key distinction being...
Lateral Approach.In the lateral approach (best for the index finger with ular approach to preserve the PIP radial collateral lig...
Volar Approach.The volar approach is the author’s preferred approach for a primary arthroplasty. In some cases of revision surge...
Postoperative Rehabilitation After Proximal Interphalangeal Joint Arthroplasty.Postoperative rehabilitation for PIP joint arthro...
Carpometacarpal Joint Arthritis of the Thumb
Nonoperative Treatment of Basal Joint Arthritis
Surgical Treatment of Basal Joint Arthritis
Surgical Procedure for Ligament Reconstruction and Tendon Interposition.A Wagner incision is used beginning just dorsal to the t...
Suspensionplasty Using the Abductor Pollicis Longus.This approach to the basal joint is similar to the ligament reconstruction a...
Costochondral Interposition Hemiarthroplasty or Complete Trapezial Arthroplasty.Costochondral allograft has been suggested as a ...
Carpometacarpal Implant Arthroplasty.A multitude of implants have been proposed and attempted. Several different Silastic implan...
Tightrope Ligament Reconstruction With or Without Implant Arthroplasty.A major breakthrough and basal joint arthroplasty for the...
Abduction Osteotomy of Thumb Metacarpal.In young patients who do manual labor, an abduction osteotomy can delay or prevent the n...
Arthrodesis of the Thumb Carpometacarpal Joint.Isolated trapeziometacarpal arthritis can be effectively treated with a number of...
Postoperative Rehabilitation After Thumb Carpometacarpal Arthrodesis.A short-arm, thumb-spica splint is used until radiographic ...
Scaphotrapeziotrapezoid Arthritis
Scapholunate and Scaphoid Nonunion Advanced Collapse Pattern Arthritis
Scaphoid Excision and Capsulorraphy
Four-Bone Fusion
Postoperative Rehabilitation After Four-Bone Arthrodesis.Postoperatively, the wrist is immobilized for 6 weeks. Patients are the...
Proximal Row Carpectomy
Postoperative Rehabilitation After Proximal Row Carpectomy.The wrist is immobilized for 4 weeks, at which time active range-of-m...
Total Wrist Arthrodesis
Total Wrist Arthroplasty
REFERENCES
Chapter 26
Rheumatoid Arthritis
OVERVIEW
INFLAMMATORY ARTHRITIS
Rheumatoid Arthritis
Clinical Presentation
Pathophysiology
Laboratory Studies
Histology
Radiographic Findings in Rheumatoid Arthritis
Medical Management
Disease-Modifying Antirheumatic Drugs and Surgery
Juvenile Rheumatoid Arthritis
Other Inflammatory Arthritis
Systemic Lupus Erythematosus
Scleroderma
Fingertip Ulcerations
Psoriatic Arthritis
Crystalline Arthropathy
Gout.Gout results from hyperuricemia and the deposition of sodium urate crystals. It occurs commonly in males in the fifth and s...
Chondrocalcinosis (Pseudogout).In contrast to gout, pseudogout is a less aggressive form of crystalline arthropathy and is also ...
Diagnostic Joint Aspirates
Patterns and Common Treatment Measures
Rheumatoid Arthritis
Synovitis and Tenosynovitis
Extensor Compartment Synovitis.Synovitis of the distal radioulnar joint (DRUJ) and dorsal extensor compartment may coexist. Swel...
Procedure for Distal Ulna Resection and Dorsal Tenosynovectomy.A modified Darrach procedure is performed with or without the add...
Ruptured Extensor Tendons.Extensor tendon ruptures can be quite debilitating and are treated with either tendon transfer or an i...
Postoperative Rehabilitation After Extensor Tendon Repairs and Transfers.The wrist is immobilized in 20 degrees of extension and...
Flexor Tenosynovitis.Fingers with greater passive than active motion may be affected by tenosynovitis, which can be refractory t...
Postoperative Rehabilitation for Flexor Tenosynovectomy.Patients are typically started on active and passive flexion exercises w...
Flexor Pollicis Longus Tendon Rupture.Flexor pollicis longus (FPL) tendon rupture in the setting of RA has been called Mannerfel...
Note on Concomitant Carpometacarpal Joint Arthritis.It is fairly common to find the thumb affected by some amount of carpometaca...
Swan Neck Deformity of the Thumb.This deformity often exists in patients without inflammatory arthritis. It is believed to be a ...
Swan Neck Deformity With Flexible Metacarpal Phalangeal Joint.In this setting the MCP joint position can be corrected by release...
Ulnar Collateral Ligament Instability.In the setting of rheumatoid disease, UCL instability is the result of synovitis and repet...
Silicone Implant Arthroplasty for Reconstruction of the Metacarpal Phalangeal Joint. These implants are preferred when the patie...
Postoperative Rehabilitation for Metacarpal Phalangeal Joint Silicone Implant Arthroplasty.The splint and dressing are changed a...
Overall Functional Outcomes of Silicone Metacarpal Phalangeal Arthroplasty.In general, silicone arthroplasty of the MCP joint pr...
Swan Neck Deformity.The etiology of swan neck deformity in rheumatoid patients is multifactorial. In addition to intrinsic tight...
Flexible (Supple) Swan Neck Deformity.Surgical management of swan neck deformities can be frustrating, with frequent recurrence....
Postoperative Rehabilitation After Swan Neck Correction.A hand-based splint is used that block the PIP in 30 degrees of flexion ...
Rigid Swan Neck Deformity.For rigid swan neck deformity, PIP joint arthrodesis in a functional position is recommended. PIP join...
Boutonnière Deformity.Boutonnière deformity is nearly always secondary to PIP joint swelling and synovitis. The central tendon o...
Fixed Boutonnière Deformity.It is rare that a fixed boutonnière deformity requires extensive treatment because the finger is oft...
Postoperative Rehabilitation for Proximal Interphalangeal Fusion.The guidelines for postoperative management of small joint fusi...
Wrist Arthritis
Rheumatoid Pattern of Wrist Degeneration
Radiolunate Arthrodesis for Ulnar Translocation
Postoperative Rehabilitation for Partial Wrist Fusion.The wrist is immobilized for 6 to 8 weeks. After radiographs have confirme...
Involvement of the Midcarpal and Radiocarpal Joints
Wrist Arthrodesis
Postoperative Rehabilitation After Wrist Arthrodesis.Total wrist arthrodesis has a high fusion rate and relatively few major com...
Total Wrist Arthroplasty
Postoperative Rehabilitation After Total Wrist Arthroplasty.On average, the wrist is splinted for 3 weeks before allowing wrist ...
REFERENCES
Chapter 27
27 - Carpal Avascular Necrosis: Kienböck Disease and Preiser Disease
Kienböck Disease
Core Knowledge
Historical Background
Etiology
Vascular Anatomy.The vascular anatomy of the lunate and its vulnerability to disruption have long been suspected as causes for A...
Load Distribution.Osseous anatomy and the load borne through the lunate may also be significant factors in the development of lu...
Epidemiology
Evaluation and Treatment
Diagnostic Studies.Initially, any patient with suspected Kienböck disease should be evaluated with plain radiographs (Fig. 27.3)...
Staging.The most common method for staging Kienböck disease was first developed by Stahl in 1947. Lichtman et al. modified this ...
Treatment
Stage I.The appropriate treatment for stage I disease remains controversial. Some authors have argued that patients in this stag...
Stages I, II, or IIIA With Ulnar-Negative Variance.In these three stages the carpus has not collapsed into an instability patter...
Surgical Technique for Radial Shortening (Dorsal Approach).The distal radius may be approached either dorsally or palmarly. The ...
Surgical Technique for Radial Shortening (Volar Approach).An 8-cm longitudinal incision is made over the radial border of the fl...
Vascularized Bone Graft.The use of a VBG may be combined with lunate unloading procedures or used as an alternative to other pro...
Surgical Technique for Vascularized Bone Graft From the Radius.The incision curves from the dorsal wrist, centered over the luna...
Surgical Technique for Vascularized Bone Graft From the Base of the Second or Third Metacarpal.This technique takes advantage of...
Stages I, II, or IIIA With Ulnar-Positive or Neutral Variance.In this situation the radius is as short as or shorter than the ul...
Surgical Technique for Capitate Shortening.The capitate is approached using a straight midline dorsal incision. The tendons of t...
Stages I, II, or IIIA (Other Techniques).In 2001 Illarramendi et al. described their technique of coring out the metaphyseal reg...
Stage IIIB.If the disease has progressed to stage IIIB, salvage procedures must be considered. In this stage, carpal instability...
Surgical Technique for Scaphotrapeziotrapezoid Arthrodesis.An incision is made along the dorsoradial aspect of the wrist, beginn...
Surgical Technique for Scaphocapitate Arthrodesis.This technique may be used as an alternative to the STT fusion in stage IIIB K...
Rehabilitation After Osteotomies or Arthrodeses for Kienböck Disease.In general, patients are splinted for 2 weeks after surgery...
Stage IV.In stage IV, there is significant collapse of the lunate combined with perilunate arthritis. These degenerative changes...
Surgical Technique for Wrist Arthrodesis.A longitudinal incision is made over the dorsum of the wrist just ulnar to Lister tuber...
Rehabilitation After Wrist Arthrodesis.A splint is worn for 2 weeks. Patients are started on immediate finger range-of-motion ex...
Pediatric Kienböck Disease
Preiser Disease
Core Knowledge
Diagnosis
Diagnostic Imaging
Treatment
Summary
REFERENCES
Chapter 28
28 - Dupuytren Disease
History
Epidemiology
Predisposing Factors
Etiology
Pathophysiology
Anatomy
Pathology
Microcords
Palmar Cords
Palmodigital Cords
Digital Cords
Thumb Diseased Tissue
Clinical Presentation
Clinical Types
Differential Diagnosis
Treatment
Nonoperative Treatment
Surgical Treatment
Methods of Skin Management
Rehabilitation
Complications
Intraoperative Complications
Early Postoperative Complications
Late Postoperative Complications
Summary
REFERENCES
Chapter 29
29 - Ganglion, Mucous Cyst, and Carpal Boss
Ganglions
Core Knowledge
Pathology
Diagnosis
Treatment
Dorsal Wrist Ganglion
Volar Wrist Ganglion
Occult Wrist Ganglions
Surgical Technique
Ganglion of Tendon Sheath
Surgical Technique
Rehabilitation
Complications
Mucous Cyst
Diagnosis
Treatment
Surgical Technique
Ganglion Cyst of the Proximal Interphalangeal Joint
Surgical Technique
Postoperative Rehabilitation
Carpal Boss
Treatment
Surgical Technique
Postoperative Rehabilitation
Complications
REFERENCES
Chapter 30
30 - Replantation
INTRODUCTION
Assessment and Surgical Preparation
Classification
Surgical Anatomy
Indications and Contraindications
Transport and Care of the Patient and Amputated Part
Preparation of the Part and Stump
Surgical Technique
Surgical Sequence
Major Limb Replantation
Ring Avulsion Injuries
Postoperative Care
Postoperative Complications: Immediate
Postoperative Complications: Late
Secondary Surgery
Outcomes of Replantation
REFERENCES
Chapter 31
31 - Thumb Reconstruction Following Partial or Complete Amputation
History
Classification of the Thumb Injuries
Reconstruction of Level A Amputations
Postoperative Rehabilitation.The thumb is immobilized for 2 weeks and then range of motion is initiated at the IP and MCP joints...
Advantages and Disadvantages.The advantage of the Moberg flap is that it provides sensate coverage with no additional donor site...
Surgical Technique.The skin over the dorsal aspect of the index finger proximal phalanx is elevated as a radially based flap, le...
Postoperative Rehabilitation.Thumb adduction and flexion contractures may develop following index-to-thumb cross-finger flaps. T...
Advantages and Disadvantages.The advantage to this technique is that it provides a greater area of soft-tissue coverage than is ...
Additional Options for Large Palmar Soft-Tissue Deficits
Reversed Dorsal Digital Island Flap.The use of an innervated reverse dorsal digital island flap for palmar coverage has been rep...
Venous Flaps
Retrograde Arterialized Free Venous Flaps for the Reconstruction of the Thumb.These flaps provide thin flexible cutaneous flaps ...
Postoperative Rehabilitation.The hand, forearm, and elbow were wrapped in a bulky dressing and were elevated for 5 days while th...
Advantages.For reconstruction of the hand, retrograde arterialized free venous flaps offer a custom-made, thin, and pliable flap...
Disadvantages.They require microsurgery, which increases the surgical time, effort, and cost compared with local flaps. Postoper...
Great Toe Pulp Neurovascular Free Flap
Dorsal Soft-Tissue Deficits of the Thumb Measuring 3 cm2 or Less Treated With Dorsal Rotation Flap From the Index Finger
Technique for Dorsal Rotation Flap From the Index Finger to the Thumb.The flap is elevated in a similar manner as the cross-fing...
Postoperative Rehabilitation. This is identical to that of the volar cross-finger flap
Advantages and Disadvantages of the Dorsal Rotation Flap.The advantage of the dorsal rotation flap is that it does not require a...
Surgical Technique: Reversed Radial Forearm Flap and ­Fascia-Only Flap.The reversed radial forearm flap is elevated as a pedicle...
Surgical Technique: Radial Artery Preserving Forearm Fascial Flap.The radial forearm fascia may also be harvested without sacrif...
Postoperative Rehabilitation.A protective splint is applied that is designed to avoid compression of the vascular pedicle. Posto...
Advantages and Disadvantages for Reverse Radial Forearm Flaps.The advantage of these flaps is that substantial soft tissue cover...
The Posterior Interosseous Flap.The axis of the flap is the line drawn from the lateral epicondyle of the humerus to the ulnar s...
Postoperative Rehabilitation Following Posterior Interosseous Flap.The patients are splinted and required to elevate their arms....
Advantages of Posterior Interosseous Flaps.They can be harvested without sacrificing a major artery, and they provide a regional...
Disadvantages.The flaps often have some flap necrosis, and they are challenging to raise. Posterior interosseus nerve (PIN) inju...
Metacarpal Lengthening
Surgical Technique.The skin overlying the planned osteotomy site is retracted toward the osteotomy at the time of incision to mi...
Postoperative Rehabilitation Following Thumb Metacarpal Lengthening.After surgery the patient is maintained in a thumb spica spl...
Advantages and Disadvantages for Thumb Metacarpal Lengthening.One advantage of thumb metacarpal lengthening is that the donor si...
Web Space Enlargement
Postoperative Rehabilitation. A palmer abduction night splint is used for 4 to 6 weeks after surgery
Toe-to-Thumb Transplantation
Vascular Anatomy of the Great and Second Toe.Arterial supply to the foot is conveyed through a dorsal system from the dorsalis p...
Great Toe Transplant
Surgical Technique: Great Toe Harvest.Dissection is begun after placement and inflation of a sterile high thigh tourniquet. The ...
Surgical Technique: Great Toe Wraparound Flap.The use of a filleted composite tissue flap of skin, neurovascular pedicle, and na...
Second Toe Transplant
Surgical Technique.The course of the dorsalis pedis artery and proximal veins are identified and outlined as with the great toe ...
Postoperative Rehabilitation.The transplanted digit is monitored for viability after surgery. Monitoring can be aided with the u...
Advantages and Disadvantages of Toe-to-Thumb Transplant.The advantage of toe transplant is that it can provide reconstruction of...
Osteoplastic Thumb Reconstruction
Stage 2: Creation of a Thumb Post Using an Iliac Crest Bone Graft.Once the scar tissue around the groin flap on the thumb has be...
Stage 3: Providing Sensation With a Neurovascular Island Flap.The neurovascular island flap is outlined on the ulnar aspect of t...
Postoperative Rehabilitation.A splint is worn until there is evidence of healing at the bone graft site. Patients are encouraged...
Advantages and Disadvantages.The donor sites for osteoplastic thumb reconstruction are well tolerated and concealed. Advantages ...
Surgical Technique.Use of the reverse radial forearm flap requires the existence of a complete palmar arch, and its dissection h...
Postoperative Rehabilitation.A thumb spica splint is used for 3 to 4 weeks to protect the reconstructed thumb. When radiographic...
Advantages and Disadvantages.The primary advantage of this technique is the single-stage nature of the reconstruction and attach...
Dorsal Rotation Flap
Surgical Technique.The dorsal rotational flap is elevated using an incision that extends dorsally from the level of the CMC join...
Postoperative Rehabilitation.The skin graft is protected until its incorporation is apparent. The transfixation wires between th...
Advantages and Disadvantages.The advantage of the dorsal rotation flap is that it provides a single-stage procedure with sensate...
Dorsal Rotation Flap for Phalangization of the Metacarpal Hand.Various techniques are available to improve the pinch function be...
Surgical Technique.The dorsal rotation flap is elevated as previously described. The index ray remnant is removed along with the...
Postoperative Rehabilitation.The dressings are removed in 2 to 3 weeks to assess skin graft incorporation and the patient begins...
Advantages and Disadvantages.The advantages of this technique are its simplicity and the opportunity to avoid an additional dono...
Reconstruction of Level D Amputations at the Base of the Thumb Metacarpal and Trapezium
Pollicization
Surgical Technique.Various incisions have been described using modifications of an apex-proximal V that extends to the proximal ...
Postoperative Rehabilitation.The hand is protected with a spica splint and the pollicized digit is evaluated for vascular insuff...
Advantages and Disadvantages.Pollicization of the index finger provides satisfactory treatment for the proximally amputated thum...
Staged Multiflap Total Thumb Reconstruction
Surgical Technique.Planning is of paramount importance in total thumb reconstruction with multiple flaps. Goals include stabiliz...
Stage 1: Stabilization of the Soft-Tissue Envelope.Adequate and supple soft tissue can be supplied by the pedicled groin flap or...
Stage 2: Reconstruction of the CMC Joint and Metacarpal.Free fibula harvest is detailed in Chapter 32. A skin paddle based on pe...
Stage 3: Reconstruction of the Phalanges.Toe-to-thumb transplant is performed as described earlier in this chapter. Osteosynthes...
Stage 4: Opponensplasty, Tenolyses and Revision of the CMC Joint.Multiple techniques for opponensplasty have been described, inc...
Postoperative Rehabilitation.Standard monitoring for free tissue transplantation is used in the immediate postoperative period. ...
Advantages and Disadvantages.Multiflap reconstruction of the thumb can provide an aesthetic and functional result that arguably ...
REFERENCES
Chapter 32
32 - Soft-Tissue Coverage of the Hand
Core Knowledge
Goals for Reconstruction
Preparation of the Wound Bed
Choosing the Right Flap
Pedicled Flaps (Random Versus Axial)
Random Pattern Flaps
Axial Pattern Flaps
Staging of Pedicle Flaps
Techniques for Tissue Transfer
Four Flap Z-Plasty.In the four-flap Z-plasty, all sides should be the same length, so the flap angles which have been arranged o...
Double-Opposing Z-Plasties.This flap is well suited for discrete linear contractures in the first web space, when the scar line ...
Rhomboid Flaps.In this flap design, all sides of the defect are of equal length including the transverse diagonal of the defect....
Dorsal Hand Flap.This flap is well suited for cutaneous defects at the radial or ulnar aspects of the dorsum of the hand. The fl...
Pedicle Flaps
Random Pedicle Flaps
Abdominal Flap.The abdominal flap is useful for soft-tissue coverage in the region of the wrist or forearm. A flap can be raised...
Abdominal Pocket Flaps.This flap is extremely useful for burn injuries when there has been a substantial area of skin loss on th...
Axial Pedicle Flaps
Groin Flap.McGregor and Jackson introduced the groin flap in 1972.5 In its heyday, the pedicled groin flap was the mainstay for ...
Anatomy.The vascular pedicle for the flap is based on the SCIA. While the SCIA provides an axial blood supply to the area of the...
Surgical Technique.It is important to inspect the patient for previous incisions from hernia repairs or lymph node biopsies or d...
Reversed Radial Forearm Flap.The radial forearm flap was initially described in 1978 for the reconstruction of burn injuries to ...
Anatomy.A full description of the vascular anatomy of the radial forearm flap is presented in the free flap reconstruction secti...
Surgical Technique.A line drawn from the mid-antecubital fossa to the tubercle of the scaphoid marks the axis of the radial arte...
Posterior Interosseous Flap.The posterior interosseous flap was initially described in the 1980s and has been a good alternative...
Anatomy.As the name describes, this flap is based on the posterior interosseous artery. When used in reverse fashion, it require...
Surgical Technique.With the forearm pronated, the flap is centered on a line between the lateral epicondyle and the ulnar head (...
Microvascular Transplantation
Fasciocutaneous Free Flaps
Lateral Arm Flap.The lateral arm flap is ideal for upper extremity reconstruction because it can be harvested within the same li...
Anatomy.The blood supply to the lateral arm flap is via the posterior radial collateral artery (PRCA), which arises from the pro...
Surgical Technique.The entire arm and shoulder are prepped and draped out free, and a sterile tourniquet is applied high on the ...
Advantages and Disadvantages.Advantages: The flap can be harvested from the ipsilateral arm to avoid another donor site in anoth...
Radial Forearm Free Flap.We use the free radial forearm flap for coverage of small soft-tissue defects over exposed joints or te...
Anatomy.Branches of the radial artery perfuse skin along the entire volar forearm. The flap is usually designed along the longit...
Surgical Technique.It is important to perform an Allen test to ensure the patency of an ulnar artery that will become the sole v...
Advantages and Disadvantages.Advantages: The advantages of the flap are that it is thin with relatively little subcutaneous fat....
Anterolateral Thigh Flap.The anterolateral thigh (ALT) flap is an axial fasciocutaneous or fascia-only flap, based on perforator...
Anatomy.The vascular pedicle of the ALT flap is the descending branch of the lateral circumflex femoral artery, which in turn ar...
Surgical Technique.A line is marked from the ASIS to the superolateral patella. The main perforator enters the flap at around th...
Advantages and Disadvantages.Advantages: There is minimal functional deficit, especially when harvested as a fascial flap. A lar...
Scapular Flap.The scapular and parascapular flaps provide a large surface area of skin with a pedicle that is based on the circu...
Anatomy.The subscapular artery is 3 mm in diameter and takes its origin from the axillary artery. The subscapular artery then br...
Surgical Technique.The patient is placed in the lateral position lying on the contralateral side so that the arm and the chest c...
Advantages and Disadvantages.Advantages: The donor site defect from the scapular flap leaves no functional impairment and can be...
Muscle Free Flaps
Anatomy.The latissimus dorsi is a fan-shaped muscle that originates from the thoracolumbar fascia, the lower six thoracic verteb...
Surgical Technique.The contralateral latissimus dorsi muscle is usually chosen to perform the surgery without any position chang...
Advantages and Disadvantages.Advantages: This is a workhorse flap with a long pedicle of good diameter and it can include the se...
Partial Superior Latissimus Muscle Flap.We find this option very useful for hand coverage because a full latissimus flap is rare...
Surgical Technique.The patient is positioned as per the latissimus dorsi flap described above. The landmarks of the latissimus d...
Advantages and Disadvantages.Advantages: The PSL flap leaves behind part of the latissimus that will still be functional and pre...
Gracilis Muscle Flap.The gracilis muscle is a long strap-like muscle that lies on the medial thigh (Fig. 32.30). It can be used ...
Anatomy.The gracilis muscle lies medially underneath the deep fascia of the medial portion of the thigh. It arises as a thin apo...
Surgical Technique.With the patient lying supine, the leg is prepared circumferentially from the groin to the toes. The hip is p...
Functional Muscle Transplantation.Functional muscle transplantation is indicated in cases of major functional loss for which the...
Advantages and Disadvantages.Advantages: The gracilis muscle is expendable and leaves no functional loss. It is thin and long an...
Rectus Abdominis Muscle Flap.The rectus abdominis muscle is supplied by the superior epigastric artery (SEA) and the deep inferi...
Anatomy.The rectus abdominis muscle is a long strap muscle interrupted by three to five tendinous intersections or inscriptions....
Surgical Technique.Patients who have had prior abdominal surgery, particularly incisions in the groin or lower abdomen, may not ...
Fascial Flaps
Dorsal Thoracic Fascia Flap.For a detailed description of the landmarks and anatomy of the DTF flap, please refer to the scapula...
Surgical Technique.The patient is placed in the lateral position lying on the contralateral side so that the arm and the chest c...
Anatomy.The fibula has a slender shaft with thick cortices and it is the only expendable long bone in the body that is strong en...
Surgical Technique.The patient is prepared in the supine position with the hip flexed and abducted and the knee flexed. The inci...
Flap Insetting
Postoperative Care and Monitoring
REFERENCES
Chapter 33
33 - Benign and Malignant Neoplasms of the Upper Extremity
Core Knowledge
History
Examination
Laboratory Tests
Imaging Studies
Tumor Growth
Staging Tumors
Biopsy
Management of Benign and Malignant Neoplasms of the Upper Extremity
Location.The cyst is typically located within the dermis, although it can be deposited in any subcutaneous tissue, including bon...
Imaging.Although not typically needed, an ultrasound or MRI will show a well-circumscribed oval lesion without internal enhancem...
Histology.Keratin debris forms a thick gelatinous material that extrudes from the cyst. The wall of the cyst is lined by epithel...
Treatment.A marginal excision of the cyst is usually curative because recurrence is rare. 17
Location.These lesions are commonly located near the proximal and distal interphalangeal joints. 17
Imaging.If longstanding, the mass may cause pressure changes in the bone that can be seen radiographically. Alternatively, ultra...
Histology.The tumors have abundant histiocyte-like cells and multinucleated giant cells (Fig. 33.6A). The cells may have a surro...
Differential Diagnosis.GCT of the tendon sheath can present similar to malignant soft-tissue masses, such as synovial sarcoma or...
Treatment.Marginal excision is the mainstay of therapy (see Fig. 33.6B). However, recurrence has been a concern. Historically, l...
Location.These lesions can occur anywhere, but in the upper extremity the most common location is in the forearm. 19
Imaging. Plain radiographs may show a soft-tissue shadow of the lipoma
Histology.These tumors consist of a capsule with mature adipose tissue (Fig. 33.8A). 19
Differential Diagnosis.The differential diagnosis for these lesions includes atypical lipomatous tumor (ALT) or liposarcoma. Sus...
Treatment.Treatment is symptomatic with excision of a lipoma only with symptoms. If a lipoma is removed, typically it can be she...
Imaging.MRI, although illustrative, often cannot definitively distinguish neurilemomas from malignant peripheral nerve sheath tu...
Histology.The schwannoma, or neurilemoma, is of Schwann cell origin and histologically is composed of a cellular component with ...
Treatment.Preoperative evaluation with nerve conduction studies and MRI will help to determine whether the lesion is on the surf...
Benign Aggressive Fibrous Tissue Lesions
Imaging.Desmoid tumors are soft-tissue lesions and as such do not typically involve the bone. Radiographs may demonstrate disrup...
Histology.Histologically, these are clonal lesions of connective tissue. They have densely packed collagen with well-differentia...
Treatment.Surgery remains the primary mode of therapy for patients with desmoid tumors.33,36 Historically, up to a 68% recurrenc...
Vascular Lesions
Imaging.Radiographic features depend on the involvement of the underlying bone. If the AVM is located within the bone, cortical ...
Histology.Lakes of vessels are noted without evidence of hypercellularity or abnormal mitoses in the endothelium (Fig. 33. 14A)
Treatment.This lesion can be very difficult to completely eradicate.40 AVMs that are stable or adjacent to critical structures m...
Imaging.MRI enhanced with gadolinium can differentiate these lesions from sarcomas and vascular malformations, eliminating the r...
Treatment.Hemangiomas during the neonatal period and childhood are treated nonoperatively because most eventually involute. Spli...
Malignant Soft-Tissue Lesions
Location.Fibrosarcomas involve the upper extremity in 30% of cases and the lower extremity in 60%. 45
Imaging.MRI is the most useful imaging modality for this type of lesion. Plain radiographs may show soft-tissue density changes ...
Histology.Histologically, fibrosarcomas are often described as composed of spindle cells arranged in a herringbone pattern (Fig....
Treatment.Wide surgical excision with limb salvage, when feasible, is the preferred treatment. Using this approach with the addi...
Location.Although synovial sarcomas most frequently involve the lower extremities, Brien et al. reported they are the most commo...
Imaging.On plain radiographs a soft-tissue density may be observed at the location of the mass, and 15% to 30% will have calcifi...
Histology.Synovial cell sarcomas are histologically composed of epithelial cells (that form glandular structures) and spindle ce...
Treatment.Treatment consists of wide surgical excision with chemotherapy and radiation.3 Results of limb salvage are compromised...
Location.These are rare malignant lesions of the upper extremity. When the tumor is present, it is most likely to be identified ...
Imaging.Although pleomorphic sarcomas can occur in bone, they usually occur in the soft tissues. MRI is the imaging modality of ...
Histology.The tissue consists of spindled and pleomorphic cells. The pleomorphic elements may be bizarre, multinucleated, or “hi...
Treatment.Treatment remains wide or radical excision with limb salvage as the goal. The decision to use chemotherapy and radiati...
Imaging.MRI is useful to clearly show the extent of the tumor because these have a tendency to spread along soft-tissue planes (...
Histology.The tumor is composed of epithelioid cells surrounding a central area of necrosis.3 Nuclei are relatively bland with s...
Differential Diagnosis.When these lesions ulcerate, they may mistakenly be diagnosed as an infection. They may also be diagnosed...
Treatment.Wide excision is the recommended treatment for epithelioid sarcoma. When the digits are involved, a ray amputation may...
Location.Angiosarcoma often involves the skin and subcutaneous tissue. It rarely involves the bone, but when it does, it typical...
Histology.Histologically, they are typically composed of epithelioid cells with vascular channels (Fig. 33.20). 60
Differential Diagnosis.When it occurs at the site of previous radiation for breast cancer, the mass may be confused for recurren...
Treatment.Five-year survival is dismal and estimated at 15%.62 The tumor is poorly responsive to chemotherapy or radiation, and ...
Benign Bone Tumors
Age.The average age at presentation for solitary enchondromas is typically in the fourth decade of life. In one study, patients ...
Location.The most frequent locations in the hand are the proximal phalanges, followed by the middle phalanges and metacarpals.1,...
Imaging.Plain radiographs are usually sufficient for diagnosis. Typical findings include cortical expansion or endosteal scallop...
Histology.Enchondromas contain well-differentiated areas of hyaline cartilage within lamellar bone. In the hand, more cellular a...
Differential Diagnosis.The differential diagnosis includes GCTs, fibrous dysplasia, unicameral bone cyst (UBC), chondroblastoma,...
Treatment.Treatment is largely symptomatic. Painless lesions may be observed with serial plain radiographs. In a review by O’Con...
Location.UBCs have a propensity to involve the long bones, typically the proximal femur and proximal humeral metaphysis. 75,76
Imaging.The lesions are benign, causing slight expansion of the surrounding bone. They are often well marginated with a thin, sc...
Histology.The cavity of the lesion is entirely cystic. A thin fibrous membrane lines the cavity. The fluid within the cavity is ...
Differential Diagnosis.The differential diagnosis should include such entities as an aneurysmal bone cyst (ABC), fibrous dysplas...
Treatment.Although there are several described treatment options for UBCs, all typically begin with aspiration of the cyst. This...
Location.These lesions mostly occur in the metaphysis of long bones. They typically lie in an eccentric location within the bone...
Imaging.Plain radiographs will demonstrate an expansile lesion that is often located in the metaphysis of long bones. The lesion...
Histology.Macroscopically, these lesions are composed of a cavitary lesion that is divided with multiple fibrous septations. The...
Differential Diagnosis.The differential diagnosis includes UBC, GCT, telangiectatic osteosarcoma, and osteoblastoma. Biopsy is e...
Treatment.The type of treatment is dependent on the location of the lesion. In most circumstances, curettage and bone grafting i...
Location.Osteochondromas of the hand and wrist are rare, occurring only 4% of the time, according to one study. The proximal pha...
Imaging.These lesions may be sessile (broad based) or pedunculated (narrow stalk). They have a cartilage cap that is not appreci...
Histology.The stalk is composed of cortical bone with a medullary canal. The cartilage cap is hyaline cartilage (see Fig. 33.34B...
Differential Diagnosis. The differential diagnosis includes parosteal osteosarcoma and periosteal chondroma
Treatment.Excision is reserved for symptomatic lesions or lesions with a rapidly expanding cartilage cap. For most lesions a mar...
Location. The lesion is most frequently found in the small tubular bones of the hands and feet
Imaging.Radiographs demonstrate a well-circumscribed bony mass arising from the cortical surface (Fig. 33.35A and B). A CT scan ...
Histology.The lesion demonstrates areas of cartilage and bone. The hypercellular fibrocartilage and hyaline cartilage is haphaza...
Differential Diagnosis.The key differential diagnosis is with osteochodroma.2 In contrast to osteochondroma, BPOP typically lack...
Treatment.Although no difference in recurrence rates has been reported between intralesional and marginal excision, some series ...
Location.This unusual tumor presents in the diaphysis or in the junction between the diaphysis and the metaphysis. Although most...
Imaging.Plain radiographs demonstrate a small lucent zone surrounded by dense sclerosis (Fig. 33.36). They are usually less than...
Histology.There is a vascular cellular nidus composed of benign osteoblasts and osteoclasts forming irregular seams of ­osteoid ...
Differential Diagnosis.The differential diagnosis includes osteoblastoma, infection, and fracture. A contrast-enhanced CT has be...
Treatment.Most patients have a trial of nonoperative management with NSAIDs.1,92 There are reports that these lesions will spont...
Location.The most common locations for osteoblastomas are the diaphysis of long bones or the pedicles of the spine. Although one...
Imaging.Radiographically, these lesions may appear similar to osteoid osteomas but are typically larger (>1.5 cm) and have less ...
Histology.There remains ongoing debate as to whether osteoid osteomas and osteoblastomas represent singular or separate entities...
Differential Diagnosis.The differential diagnosis is wide because these lesions may be confused with osteoid osteoma, ABC, infec...
Treatment.Recurrence rates up to 20% have been reported following intralesional curettage and bone grafting. Due to these high r...
Location.Approximately half of all cases occur around the knee. The distal radius is the third most common site of presentation....
Imaging.Plain radiographs demonstrate an eccentric, lytic lesion without bone formation or calcification (Fig. 33.39). The lesio...
Histology.Large numbers of giant cells and nuclei are present. The nuclei within the giant cells appear identical to the nuclei ...
Differential Diagnosis. The differential diagnosis includes ABC, osteosarcoma, and brown tumor of hyperparathyroidism
Treatment.Treatment recommendations for GCTs of bone vary widely, from intralesional resection to amputation, with the primary g...
Location.The disease can occur in almost any bone, but the most common locations include the skull, ribs, and femur. The metacar...
Imaging.The bone marrow appears to be expanded with matrix of ground-glass opacity on plain radiographs. The lesion is usually w...
Histology.The marrow cavity is filled with nonossified osteoid that displaces the normal marrow. A histologic hallmark is lack o...
Differential Diagnosis.The differential diagnosis includes UBC, ABC, GCT, infection, Paget disease, osteosarcoma, hemangioma, an...
Treatment.There is a role for nonsurgical management. Activity modification or administration of bisphosphonates may be helpful ...
Location.The proximal humerus is the most frequent site affected. In the hand, chondroblastoma is incredibly rare and may presen...
Imaging.Plain radiographs show a well-circumscribed lucent lesion, frequently with stippled calcification (Fig. 33. 48)
Histology.Microscopically the tissue has a chicken-wire calcification appearance because of ovoid or fried egg–appearing chondro...
Differential Diagnosis.The differential diagnosis includes GCT, enchondroma, fibrous dysplasia, degenerative cyst, and chondromy...
Treatment.Curettage or local excision and bone grafting is the recommended treatment. The historic recurrence rate is approximat...
Malignant Tumors of Bone
Location.An estimated 10% to 15% of cases of osteosarcoma arise in the humerus, making this the third most common location in th...
Imaging.Radiographically, classic osteosarcoma will present as a region of bone destruction with scattered areas of calcificatio...
Histology.Osteosarcoma is a malignant tumor derived from osteoblastic cells.1 As such, bizarre nuclei undergoing mitosis are not...
Differential Diagnosis.The differential diagnosis for osteosarcoma in the hand includes such entities as a subungual exostosis, ...
Treatment.Wide excision with adjuvant multiagent chemotherapy is the standard of care to help to improve survival. No significan...
Location.Although chondrosarcomas are the most common malignant primary bone tumor of the hand, they occur in the hand and wrist...
Imaging.Cortical destruction and the presence of a soft-tissue mass are typical of a chondrosarcoma (Fig. 33.54). Radiographs ma...
Histology.Microscopic features of an enchondroma and chondrosarcoma may be similar. The cartilage cells in chondrosarcoma show m...
Differential Diagnosis.As previously stated, it may be very difficult to differentiate a chondrosarcoma from a benign enchondrom...
Treatment.Chondrosarcoma is a surgical disease. Radiation therapy and chemotherapy are ineffective. In most instances the goal o...
Round Cell Tumors of Bone
Location.The disease occurs in the major long bones (femur, tibia, and humerus). An estimated 1.4% of Ewing sarcomas occur in th...
Imaging.Ewing sarcoma classically presents as a lytic lesion with a periosteal reaction and a soft-tissue mass. The expansion of...
Histology.Biopsy of a Ewing sarcoma often shows a liquefied gray-white appearance, which can be mistaken for the purulent exudat...
Differential Diagnosis.Osteomyelitis may be confused with Ewing sarcoma, based on a presentation of fevers and elevated inflamma...
Treatment.Prior to any operative treatment a complete workup must be performed because an estimated 25% of patients have metasta...
Location. This lesion typically affects the diaphysis of long bones with a predilection for the femur
Imaging.A moth-eaten appearance without a periosteal reaction usually occurs on plain radiographs. MRI identifies a large soft-t...
Histology. Densely packed round cells are noted, with the tumor invading bone without regard for cortical margins
Differential Diagnosis.Metastatic disease and myeloma should be included in the differential diagnosis for this group of patient...
Treatment.Chemotherapy and irradiation provide the best initial treatment. Surgery is reserved for prophylactic stabilization or...
Location. The tumor typically occurs in bones with the greatest hematopoietic potential
Imaging.The lesion is similar to lymphoma of bone, but the MRI does not show as significant a soft-tissue reaction (see Fig. 33....
Histology.The tumor consists of densely packed plasma cells with a cartwheel pattern to the nuclear material. Immunohistochemica...
Differential Diagnosis. Lymphoma and metastatic disease should be considered in the differential diagnosis
Treatment.Bisphosphonate therapy is effective at improving quality of life and the amount of bone pain. Bone pain can also be al...
Location.Skeletal metastases to the hand and wrist comprise approximately 0.1% of all metastatic skeletal lesions. Although any ...
Imaging.Radiographically, lesions appear aggressive, with either purely lytic or mixed lytic-blastic changes. CT or MRI may be h...
Histology. The primary site of tumor origin dictates histologic appearance
Treatment.An individualized approach is necessary. A thorough medical oncology evaluation is suggested to determine the need for...
Benign Pigmented Lesions of Skin
Benign Nevi
Nevus.Less common on the hand than elsewhere, nevi usually arise in late childhood, adolescence, or young adulthood. They can mi...
Blue Nevus.These are uncommon and present as a blue macule or papule, usually less than 6 mm in diameter. They represent a benig...
Histology.Histologically, they represent epidermal cell (keratinocyte) proliferations. There is no dermal component to these les...
Treatment.Before treatment (usually for cosmetic reasons), one must be sure that melanoma has been ruled out clinically or histo...
Histology. Histologically, lentigines represent an increased number of pigment cells (melanocytes) at the base of the epidermis
Treatment.Effective cosmetic removal may be achieved with topical bleaching creams, liquid nitrogen, or lasers, including Q-swit...
Histology.Caused by local infection with the fungus Hortaea werneckii (formerly Exophiala werneckii), it is diagnosed by culture...
Treatment.This lesion is more common in the coastal southeastern United States; suspicion for this lesion should lead to a small...
Benign Nonpigmented Skin and Nail Lesions
Imaging.Radiographs, if taken, may show cortical scalloping from the compression of the soft-tissue mass. 19
Histology.Small, round, basophilic cells in clusters surrounding small vessels are noted with glomus cell tumors (Fig. 33. 63)
Treatment.Surgical excision is the primary mode of treatment. Recurrence occurred in 41% of patients in one study. All of the re...
Histology.Histologically, pyogenic granulomas represent an uncontrolled proliferation of granulation tissue and are inflammatory...
Differential Diagnosis.A nodular melanoma can rarely mimic this condition, and therefore a biopsy is recommended to confirm the ...
Treatment.Nonsurgical treatment with silver nitrate application is sometimes effective, but surgical excision is a more definiti...
Histology.Although certain features of the histologic architecture suggest a keratoacanthoma, it may be difficult to distinguish...
Treatment.Because of the difficulty in distinguishing keratoacanthoma from SCC, observation is not usually recommended. Rather, ...
Location. Warts are common on the hands and periungual areas
Histology.Verrucae are epidermal proliferations similar to seborrheic keratoses. However, unlike seborrheic keratoses, they ofte...
Treatment.Due to possible difficulty in ruling out squamous or verrucous carcinoma, any large, refractory, or clinically unusual...
Malignant Skin Lesions
Location.The most common areas for these to occur are areas that are exposed to the sun, such as the face, hands, and back. Cuta...
Histology.Histologically, tumors originate in the epidermis and are seen to invade into the dermis or deeper. The tumor nests ar...
Differential Diagnosis.Precursor lesions to SCC include actinic keratosis and SCC in situ (Bowen disease). Actinic keratoses are...
Treatment.The risk of malignant progression to SCC of an individual actinic keratosis is felt to be low. Nevertheless, in one st...
Location.BCC is thought to occur in the hand in only 10% of cases (see Fig. 33.72C). 17
Histology. Histologically, there are large islands of basaloid cells with peripheral palisading and cleft artifacts
Differential Diagnosis.The differential diagnosis includes ulcerations, actinic keratosis, fungal infections, or psoriasis. 156
Treatment.Prognosis with complete removal is excellent because these tumors are usually slow growing (over months to years) with...
Subtypes of Melanoma
Nodular Melanoma.Nodular melanoma accounts for 15% to 30% of reported melanomas. The nodular variety is a more aggressive tumor ...
Lentigo Maligna Melanoma.This entity presents as a slowly enlarging pigmented patch on the sun-exposed skin (usually face) of el...
Acral-Lentiginous Melanoma.These lesions are most commonly found on the soles of the feet, but they can occur on the palms and n...
Histology.The malignant melanocytes can spread radially and vertically beneath the epidermis. Vertical growth occurs in the most...
Treatment.Excisional biopsy with a 1- to 2-mm margin to obtain staging pathologic information is the recommended biopsy techniqu...
ACKNOWLEDGMENTS
REFERENCES
Chapter 34
34 - Congenital Hand Anomalies
Core Knowledge
History
Limb Development and Staging
The Pediatric Hand
Classification
Incidence and Etiology
Timing of Treatment
Principles of Treatment
Common Congenital Hand Differences
Shoulder and Arm
Clinical Presentation.In total phocomelia, there is at birth, a hypoplastic hand with a variable number of digital remnants atta...
Treatment.These are generally managed without surgery and are referred to an upper limb prosthetist and/or mechanical engineer. ...
Clinical Presentation.These are classified into four groups by their degree of hypoplasia,20 and many indices have been establis...
Treatment.The presence of a mild deformity with minimal restriction of movement does not require surgery (Fig. 34.6). Many surgi...
Elbow
Presentation.Young patients often do not complain of elbow pain but may have a lateral palpable click, a bony prominence, and so...
Treatment.Attempts at surgical reduction and reconstruction of the annular ligament in young children are not predictable. Radia...
Clinical Presentation.Males and females are affected equally. Almost 60% have bilateral involvement. Adaptive hypermobility of t...
Treatment.Unilateral synostosis or bilateral conditions with less than 30 degrees of fixed pronation do not cause major function...
Clinical Presentation.The entire upper limb is dysplastic with shoulders elevated and atrophic musculature. The arm is longer th...
Treatment.Treatment is similar to that for proximal radioulnar synostosis. These are usually effective helping limbs. Osteotomy ...
Forearm
Clinical Presentation.The shoulder is well developed, and there is usually excellent elbow motion despite occasional radial head...
Treatment.Surgery is performed in less than 10% of these children and consists of excision of nubbins, soft-tissue contouring of...
Clinical Presentation.Onset of symptoms is usually during late childhood or early adolescence. Females are affected 4:1 over mal...
Treatment.Most patients are treated conservatively when they present, often as adolescents or young adults (Fig. 34.13). In youn...
Clinical Presentation.The presence of a skin lesion on the dorsal forearm is the key to diagnosis. Flexed wrists and digits with...
Treatment.Early recognition and fasciotomy are crucial to decompress all muscle groups in the volar and sometimes dorsal forearm...
Clinical Presentation.The entire limb may be affected, the shoulders are narrow and rounded, and the supporting musculature is h...
Treatment.Passive stretching and splinting is recommended for correction of the hand and wrist deviation. Most surgeons agree th...
Clinical Presentation.This condition usually involves the entire upper limb. The shoulder is hypoplastic with limited active ext...
Treatment.Treatment must be individualized. Very little is necessary for the hypoplastic shoulder, other than soft-tissue stabil...
Clinical Presentation.The size of the radius has become the practical criterion for classification (see Fig. 34.20). There is a ...
Treatment.Treatment depends on the severity of the deformity. The surgical techniques to correct these deformities are beyond th...
Hand
Clinical Presentation.In the stiff type the affected joints have normal cartilage but contracted capsules and ligaments. In addi...
Treatment.Contractures are initially addressed with splinting, stretching, and serial casting. The surgical team should not offe...
Clinical Presentation.The hands and feet are primarily involved, and at birth many of these children look like AMC patients. Han...
Treatment.In contrast to AMC, surgical treatment carries a more predictable outcome. Initial goals are to release soft-tissue co...
Clinical Presentation.The typical cleft hand has a V-shaped, central cleft that can be unilateral or bilateral. The depth of the...
Treatment.Flatt has aptly described these hands as “functional triumphs and aesthetic disasters.” The major goals for reconstruc...
Clinical Presentation.The arm and forearm may be shorter than the opposite limb, and the hand is smaller than the unaffected sid...
Treatment.Some of these do not require treatment. For the short finger-type symbrachydactyly, web space release and later stabil...
Clinical Presentation.The patterns of hand involvement vary, and there is often lipomatous overgrowth within the subcutaneous ti...
Treatment.Early consultation by the family and expeditious treatment is required. There is initially a desire to retain the over...
Thumb
Clinical Presentation.There is a delayed appearance of normal ossification centers. The thumb is best analyzed by a systematic a...
Treatment.Prior to any surgery it is important for the hand surgeon to become coordinated with treatment of associated anomalies...
Clinical Presentation.The thumbs appear at birth longer and narrow and often have a deficient first web space. Bilateral cases a...
Treatment.The goals are to preserve a mobile, independent ray with an adequate web space on the radial border of the hand. A lon...
Clinical Presentation.The clinical presentation of thumb polydactyly is variable, with no two thumbs alike. The radial of the tw...
Treatment.The goals are to create a satisfactory web space, maintain motion in at least two of the three joints, and create the ...
Clinical Presentation.Trigger thumbs are not present at birth and are usually discovered by babysitters, grandparents, or parent...
Treatment.Conservative watchful waiting is recommended for children under 1 year of age. Surgery should is recommended earlier i...
Clinical Presentation.The thumb at birth or during infancy lies in varying degrees of flexion below the digits, depending upon t...
Treatment.In children with passively correctable thumbs, initial splinting is the mainstay of treatment. Night splinting plus pa...
Digits
Presentation.The affected finger or thumb will be deviated and in severe cases flexed and possibly also rotated. Many variations...
Treatment.Although some authors have recommended splinting for clinodactyly, this is a developmental skeletal disorder, which wi...
Clinical Presentation.Most PIP flexion contractures are slight and ignored, and patients compensate by hyperextending the MCP jo...
Treatment.Initial passive stretching and splinting is the hallmark of many cases. The majority of type I cases with isolated fif...
Clinical Presentation.Most small digital nubbins with a hypoplastic nail are attached along the base of the proximal phalanx. Th...
Treatment.The treatment varies from simple to complex. Ligation in the nursery has been reported to be associated with complicat...
Clinical Presentation.These are complex anomalies, which make surgical correction difficult.7,101-103 The spectrum varies tremen...
Treatment.The same principles for syndactyly release are observed, but correction involves more than separation of the conjoined...
Clinical Presentation.These digits and thumbs are shorter than normal and may have associated syndactyly (complete or incomplete...
Treatment.The management of brachydactyly runs the entire gamut of hand surgery, and each case must be individualized. Short dig...
Clinical Presentation.The PIP joint is most frequently involved. Distal joint fusions are unusual but seen in symbrachydactyly, ...
Treatment.There is no standardized treatment for these digits, which are not usually surgically released. Distraction lengthenin...
Clinical Presentation.There are many presentations, and the webbing may involve one or more of the four interdigital web spaces....
Treatment.The history of syndactyly correction has been well documented over the past century and appropriately reflects the int...
Apert Hand
Clinical Presentation.These deformities are always present at birth. One or all extremities may be affected. Deformities are asy...
Treatment.Management of these digital and thumb deformities should be individualized. At birth the goal is early liberation of t...
REFERENCES
Chapter 35
35 - Fractures of the Forearm and Elbow
Forearm Fractures
Kinematic and Mechanical Considerations
Treatment Principles
Isolated Radius Fractures
Isolated Ulna Fractures
Monteggia Fracture-Dislocations
Essex-Lopresti Injuries
Fractures of the Distal Humerus
Preoperative Evaluation
Operative Treatment
Operative Exposure
Olecranon Osteotomy.The patient is placed in a lateral decubitus position with the arm supported over a bolster. A prior incisio...
Extensile Lateral Exposure.A midline posterior or a lateral skin incision can be used. The patient is positioned supine with the...
Capitellar and Complex Shear Fractures of the Distal Humerus.Apparent capitellar fractures are often more complex fractures of t...
Optimizing Outcome
Complications
Epicondylar Fractures with and without Incarceration
Radial Head Fractures
Preoperative Evaluation
Operative Approach
Operative Exposures
Open Reduction and Internal Fixation
Prosthetic Replacement
Optimizing Outcomes
Complications
Traumatic Elbow Instability
Indications and Contraindications
Preoperative Evaluation
Operative Techniques
Intraoperative Testing of Elbow Stability
Unstable Simple Elbow Dislocations
Posterior Dislocation and Fracture of the Radial Head
Terrible Triad Fracture-Dislocations
Surgical Procedure: Internal Fixation of a Tip Fracture of the Coronoid.Exposure and fixation of the small transverse fractures ...
Varus Posteromedial Rotational Instability Injuries
Surgical Procedure: Anteromedial Coronoid Facet Fracture.A medial skin flap is elevated with care taken to protect the medial an...
Optimizing Outcomes
Olecranon and Proximal Ulna Fractures
Indications and Contraindications
Preoperative Evaluation
Operative Techniques
Skin Incision
Tension Band Wiring
Kirschner Wire Technique
Screw Technique
Plate and Screw Fixation
Operative Technique for Fracture-Dislocations
Distal Humeral Shaft Fractures
Optimizing Outcomes
Rehabilitation of Elbow Injuries
Complications of Elbow Injuries
REFERENCES
Chapter 36
36 - Elbow Arthroscopy and Instability
Proximal Anteromedial Portal
Anteromedial Portal
Proximal Anterolateral Portal
Anterior Superolateral Portal
Anterolateral Portal
Soft Spot Portal
Posterolateral Portals
Posterior Central Portal
Equipment and Setup
Prone Position
Lateral Position
Arthroscopes
Infusion Pumps
Capsular Capacity
Fluid Extravasation
Arthroscopic Elbow Procedures
Plica Syndrome
Procedure
Loose Bodies
Procedure
Synovectomy
Surgical Technique
Contracture Release
Procedure
Osteoarthritis
Procedure
Radial Head Excision
Procedure
Ulnar Humeral Arthroplasty
Procedure
Lateral Epicondylitis Release
Procedure
Osteochondritis Dissecans
Procedure
Valgus Extension Overload
Procedure
Radial Head Fractures
Procedure
Elbow Arthroscopy and Instability
Elbow Instability
Introduction
Anatomy
Lateral Collateral Ligament Complex.This complex consists of the lateral ulnar collateral ligament (LUCL), radial collateral lig...
Ulnohumeral Articulation.The coronoid process acts as a direct buttress to subluxation and an insertion point for the critical a...
Muscular Structures.The stout lateral intermuscular septum and the common extensor origin have been shown to play a dynamic roll...
Acute Instability
Presentation and Diagnosis
Treatment of Acute Injuries
Operative Treatment
Chronic Instability
Treatment of Chronic Injuries
Docking Technique for Medial Collateral Ligament Reconstruction.Most patients are reconstructed using the palmaris tendon. If th...
Postoperative Management.The elbow is splinted at 60 degrees of flexion for 1 week. Motion in a hinged elbow brace from 45 to 90...
Results.Rohrbough et al.78 first described the docking technique, a modification of the original Jobe procedure, for MCL tendon ...
Posterolateral Instability
Presentation and Diagnosis of Posterolateral Rotatory Instability.Patients often will present with pain, popping, catching, or s...
Imaging.The diagnosis of PLRI is clinical, but imaging may help to confirm the physical examination and identify associated path...
Treatment of Posterolateral Instability
Open Technique for Lateral Ulnar Collateral Ligament Reconstruction.A 6- to 8-cm skin incision is made just posterior to the lat...
Results.Several studies have reported on the favorable outcomes of open LUCL reconstruction in patients with PLRI.84,88-94 A sys...
Docking Technique for Lateral Ulnar Collateral Ligament Reconstruction.Jones et al.89 described a docking technique for LUCL rec...
Results.Jones et al.89 retrospectively reported outcomes in eight patients who underwent LUCL reconstruction for PLRI using the ...
Arthroscopic Lateral Ulnar Collateral Ligament Reconstruc­tion.Smith et al.96 described an arthroscopic technique for treatment ...
Results.In their original series, Smith et al.96 reported satisfactory results in greater than 20 patients who underwent arthros...
REFERENCES
Chapter 37
37 - Elbow Arthritis
Rheumatoid Arthritis
Posttraumatic Arthritis/Contracture
Primary Osteoarthritis
Evaluation
History
Physical Examination
Radiographic Assessment
Treatment
Nonsurgical Management
Surgical Management
Technique.The patient is placed supine with the elbow on an arm table. A lateral incision is made proximally along the supracond...
Medial Column Approach.The medial column procedure is used for the same basic indications as the lateral column procedure, allow...
Technique.A medial incision is centered just posterior to the medial epicondyle and extends proximally posterior to the medial s...
Management With Elbow Arthroscopy
Technique.General anesthesia with or without regional nerve block is used. Supine, prone, and lateral decubitus patient position...
Surgical Management of Rheumatoid Arthritis
Technique.The patient is placed in the lateral decubitus position with a beanbag. A posterior midline incision is used, and the ...
Surgical Management of Osteochondral Lesions
REFERENCES
Hand Therapy
Certified Hand Therapist
Establishing Treatment Protocols
Ordering Hand Therapy
Patient Evaluation
Grip Strength Testing
Five Handle-Position Testing
Rapid Exchange Testing
Pinch Strength Testing
Lateral Pinch (Key Pinch)
Three-Point Pinch (Chuck, Three-Fingered Pinch)
Tip Pinch (Two-Point Pinch)
Sensibility Testing
Semmes-Weinstein Monofilament Testing
Static Two-Point Discrimination
Range-of-Motion Measurements
Edema Measurement
Dexterity Functional Testing
Custom Orthoses
Static Orthoses
Dynamic Orthoses
Serial Casting/Serial Static Orthosis
Static-Progressive Orthoses
Resting (Intrinsic-Plus) Hand Orthosis
Wrist Orthosis
Forearm Based Thumb Spica Orthosis
Forearm Based Thumb Spica Orthosis (Radially Based)
Dorsal Extension Block Orthosis
Tenodesis Orthosis
Dynamic Metacarpal Phalangeal Extension Orthosis
Muenster Orthosis
Posterior Elbow Orthosis
Anterior Elbow Orthosis
Elbow Flexion Block Orthosis
Short Opponens or Hand Based Thumb-Spica Orthosis
Carpometacarpal Orthosis
Mallet Orthosis
Serial Casting
Web Spacer Orthosis
Ulnar Nerve Palsy Orthosis
Static-Progressive Orthoses
Therapeutic Modalities
Therapeutic Heat and Cold Modalities
Superficial Heat Modalities
Deep Heat Modalities
Cold Modalities
Electrical Stimulation
Continuous Passive Motion
Biofeedback
Treatment Techniques
Active Range of Motion and Passive Range of Motion
Strengthening
Heat and Stretch
Joint Mobilization
Wound Care
Edema Control
Scar Massage
Sensory Reeducation
Computerized Exercise Equipment
Postsurgical Considerations for Ligamentous Injuries to the Carpus
Scapholunate Repair Protocol
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Collateral Ligament Injuries to the Digits
Thumb MCP Collateral Ligament Repair Protocol
Index Through Small Finger (SF) MCP Collateral Ligament Protocol
Proximal Interphalangeal Collateral Ligament
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Fractured Metacarpals and Phalanges
Metacarpal ORIF Protocol
Phalanx ORIF Protocols
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Distal Radius Fractures
Distal Radius ORIF Protocol
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Flexor Tendon Repairs
Flexor Tendon Zone 1 to 4 Early Active Protocol
Flexor Tendon Zone 1 to 4 Passive Motion Protocol
Zone 5 and FPL Flexor Tendon Protocol
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Extensor Tendon Injuries
Zone 1 or 2 Protocol
Zone 3 Central Slip Injuries Postoperative Protocol
Zone 4 Through 7 Immediate Controlled Active Motion
Zone 4 Through 7 Standard Early Motion Protocol
Extensor Pollicis Longus (EPL) Repair Protocol
Frayed or Weak Flexor Tendon Tenolysis Protocol.Three days postsurgery the rigid plaster postoperative dressing is removed and a...
Optimizing Hand Rehabilitation Outcomes
Considerations for Digit Amputations/Replantation
Digit Replantation Protocol
Optimizing Hand Rehabilitation Outcomes
Considerations for Complex Regional Pain Syndrome
Pain Assessment.A thorough pain assessment will include documentation of the location and distribution of the pain and a descrip...
Sensory Testing.Perform a thorough sensory assessment using objective measures such as the Semmes-Weinstein monofilament (thresh...
Edema.Include volumetric measurements and baseline circumferential measurements, as appropriate. Include descriptions of the typ...
Functional Outcomes Measure.Improving function and participation in meaningful activity is the goal of therapy; therefore an acc...
Treatment
Pain Management.Pain must be addressed first. Pain must be managed so that the patient is able to participate in therapy and use...
Desensitization.This may include the use of textures, pressure, percussion, and vibration. Avoid cyclic stimulation by maintaini...
Edema Management.Treat edema with light compression wraps or garments, active motion, and elevation. Brawny edema associated wit...
Range of Motion and Strengthening Program.Prevent stiffness and improve functional use of the UE in I/ADLs. Follow protocol for ...
Mirror Visual Feedback.MVF was originally developed in 1995 by V. S. Ramachandran for the treatment of phantom limb symptoms.54 ...
Graded Motor Imaging Program.GMI is a three-step program used to treat pain and movement problems, including CRPS. It is believe...
Orthotic Positioning or Casting.Static orthoses, dynamic orthoses, and casts may be used for the protection of healing tissues; ...
Activity Modification and Adaptive Equipment.This will need to be addressed based upon individual needs. In particular, instruct...
Discharge
Optimizing Hand Rehabilitation Outcomes
Considerations for Nonsympathetically Maintained Chronic Pain
Setting the Baseline.The baseline is the level to which the patient feels increased pain, weakness, and fatigue with a certain e...
The Exercise Program.Exercises should be tailored for the specific diagnoses, along with general aerobic and conditioning exerci...
The Discharge Evaluation.On completion of the prescribed duration of outpatient therapy, a discharge evaluation is completed. Th...
Optimizing Hand Rehabilitation Outcomes
Postsurgical Considerations for Compressive Neuropathies in the Upper Extremity
Endoscopic Cubital Tunnel Release Protocol
Carpal Tunnel Release (Endoscopic or Open) Protocol
Radial Tunnel Release Protocol
Trigger Finger Release Protocol
Conservative and Postsurgical Considerations for Tendinopathy of Medial and Lateral Elbow.Tennis elbow, lateral epicondylitis, a...
What Is the Best TreatmentNo one specific protocol has been shown to be the best treatment for elbow epicondylosis. Such a wide ...
Suggested Treatment Protocol.Apply ultrasound to the medial or lateral epicondyle with parameters of 3.3 MgHz, 10% to 20%, 1.0 t...
Postsurgical Considerations for Total Joint Arthroplasties of the Hand
Metacarpal Phalangeal Arthroplasty (Pyrocarbon) Protocol
Thumb Carpometacarpal Joint Arthroplasty Protocol
Total Wrist Arthroplasty Protocol
Postsurgical Considerations for Dupuytren’s Disease
Postsurgical Considerations for Ganglion, Carpal Boss, and DIP Mucous Cyst Excision
Wrist Ganglion Excision Protocol
Mucous Cyst Excision at the DIP Protocol
Postsurgical Considerations for DRUJ and Triangular Fibrocartilage Complex (TFCC) Injuries
TFCC/DRUJ Repair Protocol
TFCC Debridement Protocol
Ulnar Osteotomy Protocol
Postsurgical Considerations for Elbow Instability
Simple Dislocation Protocol
Complex Dislocation Postoperative Protocol
Postsurgical Considerations for Elbow Fractures
Olecranon Fracture ORIF Protocol
Postsurgical Considerations for Elbow Arthritis
Arthroscopic/Open Debridement Protocol
Total Elbow Arthroplasty Protocol
Postsurgical Considerations for Nerve Repair or Transfers
Digital Nerve Repair Protocol
Isolated Median Nerve Repair Protocol Distal to Anterior Interosseous Nerve (AIN)
Radial Nerve Repair Protocol
Ulnar Nerve Repair at Forearm and Wrist Protocol
Postsurgical Considerations for Brachial Plexus/Tendon Transfer
REFERENCES