chapter 42 hand surgery

8/13/2019 Chapter 42 Hand Surgery

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CHAPTER 42 - Surgery of the Hand

Clayton A. Peier

Philoso!hically and anatoically" the hand and #rain uni$uely identify Hoo sa!iens.

Throughout history huankind%s !rogress is easured through the e&olution of astrong and o#ile u!!er li# 'ith an inde!endently o!!osa#le thu# and the

cogniti&e !o'ers to use the. The #alance" !recision" and s!eciali(ation of the hand

gi&e it a central role. The goal of surgical treatent of the hand is to retain a)iu

useful !art length" inde!endent" sta#le otion" and uni!aired o#ility of sensate

!arts.

*E+ERA, C+S/ERAT+S

E)aination

Prior records and diagnostic iages ay !recisely define the e)tent" liitations" and

duration of the !atient%s disorder" and the clinical course. The history should include

inforation of rele&ant systeic disease such as dia#etes" atherosclerosis" neurologicand !sychiatric disorders" and other serious diseases or chronic diseases.

The e)ainer should use the !atient%s noral anatoy0the contralateral" unin&ol&ed

li#0to o#ser&e for differences in alignent" contour" and syetry. #ser&ing the

hand and forear at rest in !ronation and in su!ination" should re&eal any s'elling"

asses" erythea" ulceration" atro!hy" anhidrosis" or e)coriation 1ig. 42-3. The

re!roduci#ility of the !atient%s acti&e !artici!ation in the e)aination !rocess is

i!ortant. Res!onses should #e consistent5 re!eated efforts" such as in gri! testing"

should !roduce siilar &alues. Accurate recording of inforation #y the e)ainer is

i!ortant 1ig. 42-2.

,ight !al!ation !ro&ides inforation concerning e)cessi&e or a#sent s'eating

associated 'ith an)iety or insensi#ility in !articular (ones" ner&e distri#utions"

deratoes" or #ody !arts. 6ariations in skin contour" te)ture" color" te!erature"

ca!illary refill" and hair characteristics offer inforation regarding circulation" ner&e

su!!ly" asses" and 7oint s'elling. A#noral" in7ured" and scarred soft tissues can

restrain 7oint otion" !roduce skin #lanching 'ith atte!ted acti&e function" or cause

&isi#le 8di!ling9 of adherent dee! structures" such as in7ured" re!aired" or adherent

tendons.

The nails and e!onychial and !aronychial cuticular tissues often irror systeicdisease as 'ell as acute and chronic in7ury. +ails ha&e a liited range of #iologic

res!onses. S!litting and fissuring" onycholysis" and onychorrhe)is ay reflect loss of

nail adherence to the #ed atri) after traua" aging" or alnutrition. The trans&erse

!osttrauatic nail crease that !arallels the !ro)ial nail fold and ad&ances 'ith

gro'th 1Beau%s line re!resents a single alteration of nail eta#olis at the tie of

traua. t is coon after in7ury #ut does not offer a !oor !rognosis. :ulti!le

trans&erse groo&es 1:ee%s lines can occur 'ith diseases such as Hodgkin%s disease"

alaria" and !soriasis and are noral in the latter !art of !regnancy. Pigented

longitudinal #ands ay occur in elanoa" glous tuor" and car!al tunnel

syndroe. +ail #ed !igentation can #e found 'ith systeic se!sis" su#ungual

infection" and #enign and alignant tuors 1ig. 42-;.


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:otion should #e recorded 'ith a sall gonioeter and strength 'ith a

dynaoeter. Si!le line sketches record sites of in7ury" s'elling" !art loss" or

dysfunction and can !recisely record and counicate findings 1ig. 42-4.

aging Studies

/iagnostic iaging includes traditional roentgenogra!hy" single- and ulti!le-!hasetechnetiu #one scans" co!uted toogra!hy 1CT" and agnetic resonance iaging

1:R. :ost !atients should recei&e !lain radiogra!hs in !osteroanterior lateral and

one or #oth o#li$ue !ro7ections. Radiogra!hs !ro&ide inforation 'ith relati&ely

interediate sensiti&ity" high s!ecificity" and reasona#le cost. /iagnoses can #e

issed if only s!eciali(ed and e)!ensi&e e&aluations such as tris!iral or CT" :R" or

#one scans are used.

The )-ray #ea ust #e centered on the !art in $uestion. Re$uesting an )-ray of the

hand ay #e too general for diagnosing a !ro#le in a s!ecific finger. The !hysician

e&aluating the iaging studies should recei&e the history" !hysical findings" and a

'orking differential diagnosis 1ig. 42-


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#ones ust #e considered after traua. The trauati(ed li# usually can #e

co!ared to a !rein7ury state #y radiogra!hs of the o!!osite side 1igs. 42-? and 42-

@.

/istal radius fractures ha&e #een &ariously classified" #ut a guide that integrates

assessent of fracture !atterns and treatent is useful 1Ta#le 42-3. Because there areany &ariations of fracture !atterns in the distal radius" this syste si!lifies

coon characteristics and suggests treatent for each generic ty!e of fracture. The

treatent for a s!ecific !atient should #e #ased not only on the !attern #ut also on

age" hand doinance" occu!ation" social needs" cogniti&e and !sychosocial factors"

and li&ing arrangeents.

Radiogra!hically" radius fractures are sta#le or unsta#le" dis!laced or nondis!laced"

and 'ith or 'ithout in&ol&eent of the radiocar!al or radioulnar articular surfaces.

The condition of surrounding soft tissues and the !resence of associated in7ury in

other regions of the hand" forear" and el#o' are !art of the decision-aking !rocess.

Because these fractures ost coonly occur fro a fall on an outstretched hand"they result in a #ending oent 'ith the a)ial load through the radial eta!hysis"

and transient or co!lete associated neuro&ascular in7uries" !articularly to the edian

ner&e at the car!al canal" are coon. There ay #e an associated a&ulsion fracture

of the ulnar styloid !rocess.

The radius is ore coonly dis!laced dorsally" as in Colles% fracture" 'ith

i!action" !ro)ial dis!laceent" and dorsal angulation of its distal articular surface.

n such cases" the dorsal corte) of the distal fragent is coinuted and has

significant !rognostic i!lications for !ostreduction #one sta#ility 'hen anaged

entirely #y e)ternal ani!ulation and cast or s!lint fi)ation 1ig. 42-. ,ess

fre$uently" a fle)ion or #ending occurs in a fall" creating !alar dis!laceent

1Sith%s fracture. >hen intraarticular" either of these fracture !atterns ay ha&e

associated radiocar!al su#lu)ation" #ut this !ro#le is ore often associated 'ith the

&olar li! &ariant" Sith Ty!e ; or Barton%s fracture !attern.

E&en nondis!laced fractures can !otentially dis!lace during the healing !rocess as

resor!tion and #one reodeling occur at the fracture site. :aintaining a satisfactory

degree of length and alignent during healing is i!ortant" and !atients should #e

o#ser&ed e&ery 3 to 3< days 'ith e)aination and )-rays. This in7ury ay #e

associated 'ith significant s'elling" and circular cast io#ili(ation should not #e

used initially5 cast io#ili(ation should #e delayed until initial s'elling hassu#sided. A sugar-tongs forear and 'rist s!lint ay #e a!!lied that aintains #one

length and alignent 'hile siultaneously controlling forear rotation 'ithout a

rigid circuferential shell 1ig. 42-.

The dis!laced dorsal fragent can #e reduced coforta#ly under fracture #lock

anesthesia" 'ith or 'ithout addition of intra&enous or intrauscular sedation. After

sterile skin !re!aration a 22-gauge needle is introduced o#li$uely into the fracture site

&ia o&erlying skin. As!iration 'ill re&eal 'hen the needle is 'ithin the fracture

heatoa5 ? to , 3D e!i&acaine hydrochloride 1Car#ocaine or lidocaine

hydrochloride 1ylocaine 'ithout e!ine!hrine can #e in7ected to !roduce anesthesia

in 3 to 3< in. The ty!ical fracture" 'ith dorsal dis!laceent and angulation fro ane)tension &ector" can #e reduced #y distraction a!!lied #y allo'ing the ar to hang


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fro finger tra!s !laced on the inde) and iddle fingers" 'ith the ar itself ser&ing

as a counter'eight. A dorsal-to-!alar force is a!!lied o&er the area of dis!laceent

after the fragents ha&e #een disi!acted. The 'rist is io#ili(ed in neutral

forear rotation 'ith only slight 'rist fle)ion or ulnar de&iation to a&oid causing

secondary co!ression of the edian ner&e. The sugar-tongs s!lint is a!!lied. The

'idth of the !laster should allo' ade$uate s!ace for tissue s'elling. The dorsal and!alar edges of the s!lint should not touch each other. or ost adults" a ;-inch

!laster 'idth is ade$uate" #ut in large indi&iduals 4-inch !laster ay #e needed" 'hich

is a!!lied o&er generous soft-tissue !adding. After reduction and s!lint a!!lication" )-

rays are o#tained to record the reduction. f fracture realignent is inco!lete" or if

significant intraarticular dis!laceent 13 or ore osteoarticular incongruity

reains" re!eated ani!ulati&e reduction or an alternate ethod of treatent should

#e considered.

Patients should ha&e a neuro&ascular e)aination #efore ani!ulati&e reduction" and

their edian ner&e sensory status should #e assessed again after the a!!lication of the

!laster s!lint. racture !osition and neuro&ascular status ust #e follo'ed carefully.

After @ to 3 days" the !atient has re!eat )-rays. Ele&ation and digital otion 'ill

ha&e diinished s'elling significantly in any cases" and the s!lint ay #e re!laced

'ith a circular cast. Soe circustances ay dictate snugging the s!lint 'ith a

re!laceent circular gau(e o&er'ra! and delaying cast a!!lication an additional 'eek

or t'o. n young !atients" a long ar cast ay #e !refera#le5 in the older indi&idual"

the risk of el#o' stiffness is significant" and !rolonged io#ili(ation of that 7oint is

not ad&isa#le. Ele&ation of the hand !lus finger o#ili(ation and a thera!y !rogra

that is directed to the entire u!!er li#" including the shoulder" is started at this tie.

>hen the s!lint is changed into a cast" )-rays are o#tained after cast a!!lication.

Radiogra!hs are re!eated e&ery 2 'eeks to onitor healing and o#ser&e for colla!se"

angulation" and dis!laceent 1ig. 42-3. :ost casts can #e reo&ed ? 'eeks after

traua" 'hen radiogra!hs deonstrate o#&ious ne' #one foration and the fracture

region is relati&ely nontender. f no otion or significant !ain is elicited at the

fracture site" cast io#ili(ation ay #e discontinued. Thera!ists can fa#ricate a

custo thero!lastic restingF!rotecti&e s!lint and acti&e otion e)ercises can #egin

1ig. 42-33. The custo s!lint can generally #e discontinued after another 2 to 4

'eeks" de!ending on !atient cofort and !rogress in reha#ilitation. :otion e)ercises

for the hand and 'rist are follo'ed #y !rogressi&e strengthening" increasing acti&ities

of daily li&ing" and return to function.

=nsta#le fractures of the distal radius are treated 'ith !ercutaneous or o!en fracture

!inning under fluorosco!ic onitoring. :any of these fractures re$uire an e)ternal

fi)ation de&ice to !re&ent !rogressi&e colla!se and loss of alignent at the

coinuted fracture line. >hen fractures are significantly i!acted" areas of o#&ious

#one loss 'ithin the su#eta!hyseal region after reduction ay re$uire #one graft or

#one su#stitute to !re&ent delayed union or nonunion. :anageent #y o!en

reduction" 'ith the co#ination of e)ternal and internal fi)ation 'ith !lates and

scre's" is a!!ro!riate for the ore se&ere su#grou!" ost often those of younger age

'hose in7uries are the result of high-i!act traua" such as those sustained in

&ehicular accidents and isha!s 'ith hea&y achinery 1igs. 42-32" 42-3;" and 42-

34.


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Carpal Bone FracturesThe eight car!al #ones ha&e a large !ro!ortion of their surfaces co&ered 'ith articular

cartilage" a fact that has t'o clinical i!lications. irst" the liited !eriosteal

attachent offers a tenuous #lood su!!ly5 after fracture one of the fragents is

!otentially at risk for a&ascular necrosis. Second" ost car!al fractures are

intraarticular in7uries. The dis!laced fracture often needs surgical re!air to a&oid

secondary arthritis fro 7oint surface incongruity. The !attern of car!al fracture or

fracture dissociation ay not #e clearly discerni#le on standard !osteroanterior and

lateral radiogra!hs" and o#li$ue &ie's" car!al tunnel !ro7ection" and other &ie's ay

#e necessary. f results are still e$ui&ocal" tris!iral toogra!hy or CT should

deonstrate the fracture !atterns and fragent !ositions. >hen the $uestion of

'hether or not a fracture is !resent" a fre$uent !ro#le 'ith in7uries a#out the radial

side of the car!us" es!ecially the sca!hoid" the use of technetiu #one scan @2 h after

traua is diagnostic.

Scaphoid Fracture+early t'o-thirds of all car!al fractures are of the sca!hoid. This in7ury occurs ost

often in ales aged 3< to ; years. Sca!hoid fractures occur ost coonly through

the iddle third of the 'aist or at the 7uncture of the iddle and !ro)ial !oles.

/iagnosis re$uires clinical and iaging inforation. After a fall on the outstretched

hand" the !atient%s 'rist is tender at the anatoic snuff #o)" the hollo' #et'een the

thu# e)tensor tendons on the radial as!ect of the 'rist" 7ust dorsal and distal to the

styloid !rocess of the radius. Pain is elicited and sy!tos re!roduced 'ith direct

!ressure o&er the tu#erosity of the sca!hoid at the #ase of the thenar einence and

'ith !assi&e 'rist otion. Routine radiogra!hs in !osteroanterior" lateral" and o#li$ue

&ie's along 'ith a !osteroanterior !ro7ection in ulnar de&iation to elongate thesca!hoid hel!s to &isuali(e the fracture. f initial radiogra!hs are noral #ut the

history and !hysical e)aination suggest the !ossi#ility of sca!hoid fracture"

continuous io#ili(ation in a thu# s!ica s!lint or cast is ad&ised. Re!eat

radiogra!hs in 2 to ; 'eeks or technetiu #one scan after @2 h 'ill ake the

diagnosis.

racture configuration 1ig. 42-3


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and internal fi)ation can #e done effecti&ely 'ith an interfragentary lag

co!ression scre' or 'ith Girschner 'ires for all dis!laced fractures. The scre'

techni$ue is ore sta#le and allo's earlier o#ili(ation.

The use of !ercutaneous co!ression scre's for iediate internal sta#ili(ation of

the acute #ut nondis!laced fracture is increasingly !o!ular outside the =nited States.,iited e)!erience suggests a ore ra!id course 'ith decreased acute and long-ter

disa#ility 'ithout significant increase in co!lications. nterfragentary scre'

techni$ue for this #one is technically deanding.

>hen iediate !ostin7ury iaging does not clearly deonstrate the !resence of

fracture" io#ili(ation and additional iaging inforation #y standard radiogra!hs

in 2 'eeks or #one scan after ; days are necessary to ake the diagnosis. racture

dis!laceent is unacce!ta#le" and 3 to 2 of al!osition" angulation" or any

intercar!al colla!se should !ro!t o!en re!air. ,ess than < !ercent of nondis!laced

fractures result in nonunion" 'hich is defined as a#sent )-ray e&idence of healing 4 to

? onths after in7ury" 'hile a


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Routine radiogra!hs and car!al tunnel &ie's ay #e negati&e5 CT scan can ake the

diagnosis. The acute hook fracture should heal in a short ar cast5 dis!laced fractures

and sy!toatic nonunions are ost efficiently treated 'ith e)cision of the haulus

and soothing of the fracture #ase.

Carpal Dislocations and InstabilitiesThe radiocar!al and intercar!al articulations are not inherently sta#le on the #asis of

their osseous anatoy5 it is the integration of osteoligaentous anatoy that secures

the co!le) kineatics of 'rist function 1ig. 42- 3?. :ost car!al dislocations are

caused #y an acute a)ial load 'ith 'rist hy!ere)tension. The !riary dislocation

occurs at the idcar!al 7oint 'ith dorsal dis!laceent of the ca!itate. >hen the

ca!itate dis!laces" the sca!hoid ust fracture or its ligaents 'ill tear" allo'ing it to

rotate fro a relati&ely hori(ontal !osition to one of &ertical alalignent 'ith the

!ro)ial !ole rotating dorsally. This configuration is called dorsal !erilunate

dislocation 1igs. 42-3@" 42-3" and 42-3. These serious and unsta#le intraarticular

in7uries" 'ith or 'ithout sca!hoid fracture or tri$uetral #reak" re$uire carefulreduction and internal fi)ation. The a7ority re$uire o!en reduction. /irect traua to

the edian ner&e fro i!act" #y secondary stretching resulting fro dorsal

dis!laceent of the car!us" or fro acute #leeding and s'elling 'ithin the car!al

tunnel" should #e elucidated #y neuro&ascular e)aination. Car!al insta#ilities of all

ty!es should #e treated aggressi&ely to !re&ent chronic insta#ility and dysfunction

1ig. 42- 2.

Metacarpal FracturesBecause of their su#cutaneous location and relati&ely rigid !ro)ial articulations" the

etacar!als re!resent one-third of hand and 'rist fractures. ailure to reconstitute theetacar!als ay lead to !eranent functional deficit. Co!lication rates after

e)tensi&e e)!osure for !late fi)ation can #e high" and the risk of additional in7ury

ust #e 'eighed against outcoes e)!ected 'ith conser&ati&e easures.

The goal is early restoration of hand function to !re&ent stiffness. >hether internal or

e)ternal io#ili(ation is used is iaterial" as long as #one length and articular

relationshi!s are !reser&ed and soft-tissue anageent and thera!y techni$ues can #e

instituted ra!idly.

The etacar!als for a rigid longitudinal arch #ecause of their con&e)ity dorsally.

There also is a dynaic trans&erse arch #ased on the sta#le and o#ilecar!oetacar!al articulations of the thu# and those of the ring and little fingers. The

thenar and hy!othenar uscles o#ili(e these arches" allo'ing !recision and strength

in hand use. Because of sta#le !ro)ial and distal ligaentous su!!ort" isolated

fractures of the central third and fourth etacar!als0the iddle and ring fingers0

are less likely to shorten" rotate" and angulate. S!iral and o#li$ue fractures that

dis!lace do so 'ith shortening and rotation. :etacar!al shortening also ay occur #y

direct #one loss or angular defority. :idshaft angulation !roduces a ore serious

defority 1ig. 42-23.

Pain and s'elling are the hallarks of etacar!al fractures" as the loose dorsal tissuesallo' large aounts of edea fluid and fracture heatoa to accuulate. The #ony


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!roinence of an angulated fracture a!e) is al'ays located dorsally #ecause of the

!ull of the interosseous intrinsic uscles. A skin laceration often connotes an o!en

fracture and andates surgical treatent. This is i!ortant in etacar!al fractures

caused #y a tooth i!act" as in a fight5 this results in a containated !uncture 'ound

at the fracture site or at the etacar!o!halangeal 7oint. Patients 'ith huan or anial

#ites re$uire surgical irrigation of the fracture site or 7oint !lus high-dose anti#iotics.

Rotational alignent of a etacar!al fracture is #est assessed 'ith the fingers fle)ed

at the etacar!o!halangeal 7oint. >ith an uncoo!erati&e 7u&enile !atient or an

unconscious !atient" the 'rist can #e !assi&ely fle)ed and e)tended" 'ith the resulting

e)trinsic fle)or and e)tensor effect on digital alignent o#ser&ed. :alrotation or

acti&e fle)ion !roduces a degree of &isi#le digital o&erla!. :alrotation and radial-

ulnar angulation interferes 'ith hand function and should #e corrected.

ractures of the etacar!al heads are less coon" usually the result of direct

traua. The second and fifth etacar!als are ost coonly trauati(ed" 'ith a ;I3

ale !redoinance. As these are intraarticular in7uries" a ste!-off of 3. or oreis significant. =nsta#le fractures are fi)ed 'ith !ins" scre's" or !lates.

The etacar!al neck is the ost coon fracture site. As 'ith dis!laced and

angulated fractures" the corte) on the angulated side usually is coinuted. The

noral !ull of the intrinsic uscles further fle)es the head fragent" aking it

difficult to aintain reduction. The degree of angulation and the etacar!al in&ol&ed

deterines the #est treatent for the s!ecific fracture. Because the second and third

car!oetacar!al 7oints are rigid" no ore than 3 to 3< degrees of !alar angulation

of the distal fragent is acce!ta#le. Considera#ly ore angulation 1; to


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+onunion ay #e associated 'ith inade$uate io#ili(ation" loss of #one su#stance"

infection" or disru!tion of #lood su!!ly. /igital i!airent ay result fro tendon

adhesions directly o&er a fracture site" secondary sall-7oint contracture fro

!rolonged io#ili(ation" or scarring of trauati(ed intrinsic uscles. Siultaneous

skeletal sta#ili(ation and sall-7oint o#ili(ation should #e achie&ed.

Phalaneal FracturesThe goal of !halangeal fracture treatent is restoration of anatoy" #one healing" and

full functional reco&ery. /ysfunctional angulation and rotation are not acce!ta#le.

Sta#ili(ed fracture anatoy ust allo' ra!id o#ili(ation. Each ethod of fracture

care has relati&e ad&antages and risks. ,ess in&asi&e ethods ay offer less sta#ility"

#ut they inflict less soft-tissue daage. An algorith for care is outlined in ig. 42-

2. >hen o!eration is re$uired" the least trauatic ethod should #e used to a&oid

&iolation of gliding structures 'hen !ossi#le. The !atient%s acti&e !artici!ation in a

reha#ilitation !rogra enco!assing su!er&ised thera!y" custo s!linting" and hoe

e)ercises is critical for reco&ery of function. Pro)ial inter!halangeal 7oint otion"!articularly e)tension" can #e difficult to regain if an in7ured" s'ollen finger is

io#ili(ed in fle)ion. Scar can tether the e)tensor tendons or !re&ent the fle)ors

fro gliding" i!airing gras! and ani!ulation and !re&enting return to !rein7ury

e!loyent.

>hen Girschner 'ires are used" they ay #e #uried" and they ay then #e retrie&ed

in the out!atient setting under local anesthesia after 4 'eeks. Sufficient fracture

healing usually has occurred #y then des!ite the delayed a!!earance of significant

interfragentary callus on radiogra!hs. >hen Girschner 'ires are left e)ternal to the

skin" as in 7u&eniles" !ins ust #e ca!!ed and cared for eticulously. Scre's and

!lates usually are not reo&ed until at least ? to 32 onths after fracture healing.Sall #one !lates and scre's need not #e reo&ed e)ce!t to treat sy!tos fro the

hard'are.

Finer !iament In"uries:etacar!o!halangeal 1:P Joint

:P 7oint dislocations can #e anaged #y closed eans through gentle reduction and

s!linting under local anesthesia. f significant residual collateral ligaent insta#ility

in a !articular finger is !resent" surgical re!air is necessary. The sall su#grou! of

irreduci#le fractures re$uires o!erati&e re!air. Patients 'ith acute collateral in7uries

ay ha&e a alrotated finger 1ig. 42-2 #ecause of rotation a#out the intactligaent. The ru!tured ligaent region is s'ollen and tender. E&aluation #y gentle

!assi&e stress should #e done 'ith the :P 7oint in fle)ion" a !osition in 'hich the

collateral ligaents are norally tight. Soe !erfor siultaneous radiogra!hic

e&aluation during this !assi&e stress. Patients 'ith !articular discofort 'ho cannot

tolerate soft-tissue stress in order to e&aluate 7oint sta#ility can #e e)ained after 3.

, of local anesthetic agent is in7ected into the 7oint. /orsal dislocations that are

irreduci#le are characteri(ed #y di!ling of the !alar skin o&er a !roinent

etacar!al head. nter!osed soft tissues can !re&ent 7oint reduction. n these cases

surgical treatent is re$uired 1ig. 42-;.

Thu# :P 7oint in7uries result fro a)ial load and angular dis!laceent. Thesein7uries often occur 'hen the !atient 7as the thu# into an o#7ect 'hile falling.


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/isru!tion of the ulnar collateral ligaent of the thu# is called gaekee!er%s thu#"

although the ter 'as originally a!!lied only to chronic ulnar collateral insta#ility. A

larger !ercentage of the in7uries are caused #y 7aing the thu# into sno' in a fall

'hile skiing. Collateral la)ity at the thu# :P 7oint is dysfunctional and !ainful and

ay lead to late arthritis. After !lain radiogra!hs fail to detect the !resence of

intraarticular fractures" the thu# is carefully e)ained in a#out ; degrees of :Pfle)ion" gently and !rogressi&ely stressing the sus!ect collateral ligaent 1ig. 42-

;3. Radiogra!hs ay #e o#tained siultaneously 1ig. 42-;25 the stress radiogra!h

is #est !erfored #y the e)aining !hysician. Treatent of inco!lete collateral

ligaent in7uries 'ithout associated insta#ility is #est done closed" 'ith cast

io#ili(ation for a!!ro)iately 4 'eeks" follo'ed #y custo-s!lint

io#ili(ation. Soreness ay !ersist for se&eral onths. Co!lete disru!tion of the

ulnar or radial collateral ligaent of the thu# :P 7oint should #e re!aired and

!rotected #y te!orary !in fi)ation of the 7oint" 'hich is ost likely to gi&e a #etter

result and shorter !eriod of disa#ility than secondary reconstruction.

Pro#imal Interphalaneal $PIP% &ointThe tightly congruent osteoarticular contours of the !ro)ial inter!halangeal 7oint

ake restoration of sta#le alignent of disru!ted or dis!laced structures essential"

allo'ing safe institution of early o#ili(ation. Stiffness" rather than insta#ility" is the

outcoe that ust #e a&oided after traua in the region of the PP 7oint. :ost dorsal

and lateral PP dislocations can #e treated #y closed reduction and should #e sta#le.

o#ili(ation for 3 to 3< days allo's the !atient to reco&er fro the acute

!osttrauatic effects #efore a !rotected o#ili(ation !rogra is started" 'ith #uddy

ta!es to an ad7acent finger. Joints 'ithout an actual history of dis!laceent"

defority" or reduction #y !atient" coach" trainer" or !hysician ay ha&e considera#le

s'elling and stiffness if not o#ili(ed early. /islocations 'ith fractures are orelikely unsta#le 1igs. 42-;; and 42-;4. Posto!erati&e io#ili(ation that

inad&ertently stresses an osteoarticular fragent results in !osttrauatic insta#ility

1ig. 42-;


11/45

closed reduction is !ossi#le need not #e !inned. Percutaneous fi)ation under

fluorosco!ic guidance" 'ith aintenance of !in fi)ation for 4 to < 'eeks" is a useful

ad7unct" #ecause it allo's the rest of the hand to #e ra!idly o#ili(ed. t is !refera#le

to #ury !ins in adults and to reo&e the in an out!atient setting using local

anesthesia.

S'elling and discofort !ersist after /P and PP in7ury for ; to ? onths in ost

!atients. unctional reco&ery of o#ility and !o'er occurs slo'ly. Protection during

s!orts and siilar acti&ities ay #e needed for ? onths or ore. t should #e

e)!lained early to !atients that the 7oint is likely to #e sore or s'ollen for soe tie5

the sooner !atients understand this" the ore likely they are to acce!t their role in

reco&ery.

Finertip In"uriesConser&ati&e treatent" such as healing #y secondary intention of fingerti!

a!utations" often results in !ainful scarring and defority. There are se&eralre$uireents for a satisfactory outcoe after fingerti! a!utationI 13 !tiu

functional finger length ust #e aintained" and additional shortening during or as a

co!lication of treatent ust #e a&oided. 12 The residual ti!F!ul! re$uires a

resistant and resilient character like noral skin. 1; E)cellent fingerti! sensi#ility

should #e aintained to a&oid 8#linding9 the finger. 14 inally" #one su!!ort for the

nail is needed to inii(e #eaking defority. Achie&ing all of these targets

siultaneously ay #e i!ossi#le" and choices ay #e necessary. Anatoy and

function in con7unction 'ith the ty!e and le&el of in7ury in each !atient should #e

considered 1igs. 42-; and 42-;.

>hich finger is in7ured and ho' it 'as in7ured influence treatent. or the thu#"e&ery reasona#le effort ust #e ade to restore a sensate and dura#le !ul!.

Re$uireents for sensi#ility are ore critical in the inde) and iddle fingers" #ut they

are also significant in the ulnar !ul! of the sall finger. A!utations can #e clean and

shar!" #ut the coon a&ulsion ay ha&e a co!onent of a&ulsion" crush" #last" and

#urn" as in e)!losions. E)!losions cause e)tensi&e traua to surrounding skin" soft

tissue" and neuro&ascular tissue that re$uires de#rideent and" in soe cases" staging

of the closure. Treatent of !artial a!utations" crush in7uries" and !artial

de&asculari(ing in7uries should #e directed to'ard !reser&ing soft tissues.

/istal !halangeal fractures" including #ursting or tuft fractures" are fre$uently

associated 'ith crush traua and nail #ed disru!tion or lacerations. +ail #ed in7uriesare not al'ays o#&ious" and su#ungual heatoa ay #e the only sign of nail #ed

in7ury. +ail #ed in7uries should #e re!aired to !re&ent !eranent late nail defority.

+ail #ed re!airs usually are done 'ith fine ?- a#sor#a#le suture. After re!air" the nail

that 'as reo&ed is re!laced #eneath the cuticle to s!lint the #ed 1igs. 42-4 and 42-

43.

Surical treatments used to treat (inertip amputationsinclude the follo'ingI

Bone Shortenin and Primar) Closure


12/45

This is !erfored under local or regional anesthesia and consists of de#riding enough

#one so that the skin can #e closed 'ith a fe'


13/45

not suita#le for re!lantation" es!ecially if !ro)ial to the PP 7oint" #ecause the

functional and aesthetic reco&ery usually does not 7ustify the or#idity and costs of

the re!lantation !rocedure. :ulti!le digit a!utations" su#total hand a!utations"

a!utations throughout the u!!er li# !ro)ial to the hand" and ost !ediatric

a!utations should #e e&aluated for re!lantation or !riary co!osite icro&ascular

reconstruction 1ig. 42-4


14/45

#efore secondary o!eration" and the !atient ust #e 'illing to undergo a second

o!eration for additional reco&ery.

,#tensor Tendons

The su!erficial location of the e)tensor tendons on the dorsu of the fingers and hand

ake the &ulnera#le to in7ury" es!ecially 'hen the fingers are fle)ed. Traua coesfro lacerations" crush i!acts" a#rasions" and #ites. E)tensor tendon in7uries are

ore coon than those of fle)or in7uries and are often treated casually in the

eergency de!artent.

E)tensor dysfunction ay result in loss of acti&e fle)ion fro scar tattering and in

diinished acti&e e)tension. The e)tensor syste is ore intricate and co!le) than

the fle)or syste. The interconnections of the e)trinsic digital e)tensor tendons fro

the uscles in the forear and tendons in the hand" and the intrinsic tendons in 'hich

uscles and tendons are in the hand" are co!le). The t'o sets of tendons colla#orate

to fle) the etacar!o!halangeal 7oints and e)tend the inter!halangeal 7oints. Because

e)cursion of the e)tensor echanis is liited o&er the finger 7oints" !reser&ation oftendon length is ore critical to aintain and restore tendon #alance than 'ith fle)or

tendon in7ury.

The fle)or tendons are thick" round" cordlike structures 'ith s!iraling fi#ers. The

e)tensor tendons are thin and flat" and the longitudinal fi#ers of the e)tensors do not

hold sutures 'ell. The liited aount of soft tissues a#out these tendons also akes

re!airs !rone to adherence and scarring.

The e)trinsic e)tensors of the forear" i.e." #rachioradialis and e)tensor car!i radialis

longus" are inner&ated #y the radial ner&e" and the e)tensor car!i radialis #re&is

uscle #y the dee! #ranch of the radial ner&e. The !osterior interosseous #ranch of

the radial ner&e inner&ates the e)tensor car!i ulnaris uscle and all !ro!er and

coon thu# and digital e)tensors. The tendons cross the 'rist through si) !ulley

co!artents" ser&ing to e)tend the 'rist and the :P and inter!halangeal 1P 7oints.

These si) tendon tunnels are defined #y reflections of the e)tensor retinaculu into

the dorsal corte) of the radius and 'rist ca!sule and ser&e to liit the tendon &ector

effect of the digital e)tensors at the 'rist 7oint #y aintaining their !ro)iity to the

center of a)is of 'rist otion. E)trinsic digital e)tensor tendons ele&ate the !ro)ial

!halan). That is" they e)tend the :P 7oint &ia the a!oneurotic sagittal fi#ers that reach

around the lateral sides of the !halan) to insert on the !alar argin of the #one and

&olar !late" there#y lifting the etacar!al fro a #road !alar attachent rather thana single !oint dorsally. The e)trinsic e)tensor tendon is the only :P 7oint e)tensor.

/istally" the function of the intrinsic and e)trinsic tendons together for the dorsal

tendon a!!aratus in the fingers 1ig. 42-


15/45

inter!halangeal 7oints. At the eta!hysis of the !ro)ial !halan) and the #ase of the

iddle !halan)" the e)trinsic and intrinsic tendons con&erge to #ecoe con7oined

e)tensors. The central sli! inserts into the dorsal li! of the iddle !halan) as its direct

e)tensor" #ut the con7oined lateral #ands run along the dorsal lateral edge of the PP

7oint and con&erge distally o&er the iddle !halan) to #ecoe the terinal tendon

that inserts into the dorsal li! of the distal !halan)" functioning as this last 7oint%s onlye)tensor.

Because of the noral dorsolateral !osition of the lateral #ands" in certain direct

in7uries to the dorsu of the finger at the PP 7oint the lateral #ands ay su#lu)ate

&olarly" hy!ere)tending the terinal 7oint. This is called the #outonni Kre defority.

>hen the terinal tendon insertion at the distal inter!halangeal 7oint is a&ulsed or

transected" the distal 7oint droo!s and the secondary !ro)ial and dorsal retraction of

the lateral #ands !roduces gradual hy!ere)tension at !ro)ial inter!halangeal le&el.

This defority is kno'n as allet or #ase#all finger5 it !rogresses to the s'an-neck

defority 'hen the PP hy!ere)tension is added.

The ty!e of in7ury and the results of surgery &ary #ecause of the structural and

functional differences in the e)tensor syste fro fingerti! to forear. E)tensor

tendon characteristics ha&e #een categori(ed #y eight anatoical (ones5 the four 'ith

odd nu#ers o&erlie the 7oints" and the four 'ith e&en nu#ers are the tendon

segents #et'een the 7oints 1ig. 42-


16/45

in e)tension allo's early reha#ilitation of the other 7oints. =ntreated" this #outonniKre

defority !rogresses to a fi)ed PP 7oint fle)ion contracture 'ith secondary

hy!ere)tension of the terinal 7oint. Closed s!lint or !ercutaneous !in anageent

ay #e e$ually effecti&e for the !ure tendon in7uries 1ig. 42-here direct re!air is !ossi#le" !riary and delayed !riary re!airs are !refera#le"

using suture techni$ues descri#ed in ig. 42-


17/45

are o&al in cross-section and thicker here than distally. Core sutures of the ty!e used

in fle)or re!airs are recoended 1see ig. 42- ith lacerations at the usculotendinous 7unctions" the tendons ay #e seen

distally" #ut !ro)ially their fi#rous se!ta retract into the uscle #ellies. or re!air at

this le&el" the suture line ust include fascia or the intrauscular tendinous se!ta to

!re&ent !ullout and failure of o!eration. >ith in7uries in the !ro)ial forear"

di&ision of the !osterior interosseous ner&e alone ay !roduce loss of e)tensor

function #y dener&ation" or it ay occur in co#ination 'ith in7ury to soe or all of

the uscles and tendons. After re!air" el#o' fle)ion and 'rist e)tension ay #e

needed to reduce tension at the suture line. Thu# e)tensor in7uries are dealt 'ith inanner siilar to in7uries to the finger.


18/45

Tendon Trans(ers

Tendon transfer is a reconstructi&e !rocedure that antedates the t'entieth century.

Transfers in the u!!er li# are designed to restore otion in a nonfunctioning !art.

Tendon transfers are used in isolated !eri!heral ner&e !aralysis" for irre!ara#le tendon

daage after e)tensi&e segental loss fro de&astating traua or in destructi&econnecti&e tissue diseases such as rheuatoid arthritis" and to re#alance the hand or

!ro&ide o&eent to a s!astic or !araly(ed li# after central ner&ous syste in7ury

or disease. =!!er e)treity reconstruction #y tendon transfer re$uires careful !atient

selection and e)tended thera!y su!er&ision" often 'ith !reo!erati&e and !osto!erati&e

reha#ilitation !rotocols.

-er.e In"ur)The u!!er e)treity is inner&ated #y the #rachial !le)us and se&eral sensory #ranches

arising fro the !le)us and intercostal ner&es 1ig. 42-


19/45

not disru!ted" so the internal architecture is relati&ely 'ell !reser&ed. S!ontaneous

reco&ery is the rule" and generally it is of &ery good $uality #ecause the regenerating

fascicles are guided into their !aths &ia the intact sheaths. Reco&ery takes longer than

for neura!ra)ia.

+eurotesis is 'hen all ner&e structures ha&e #een di&ided. ,aceration !roducesneurotesis" #ut !hysical ga!s in the ner&e ay occur e&en though the e!ineurial

sheath a!!ears in continuity" such as after traction or crush. At the site of daage the

ner&e 'ill #e co!letely re!laced #y fi#rous tissue" and there is co!lete loss of

anatoic continuity.

Reco&ery after ner&e in7ury de!ends on successful reinner&ation of sensory or otor

end-organs. After dener&ation" uscles #egin to lose their #ulk5 a loss of cross-

sectional area 'ithout any loss in uscle fi#er count #egins 'ithin 3 'eek of

dener&ation. Connecti&e tissue surrounding the uscle undergoes degeneration and

thickening. nterstitial fi#rosis !redoinates o&er tie" #ut !assi&e e)ercises ay

delay or !re&ent this !henoenon. or function to #e resued" otor end-!lates ust#e reinner&ated 'ithin 3 onths of traua. Sensory end-organs ay #e usefully

reinner&ated long after initial in7ury" #ut the $uality of reco&ery diinishes 'ith the

!assage of tie.

The result after re!air de!ends on nuerous factorsI in7ury le&el and echanis"

associated #one and soft-tissue loss" residual function" !atient co!liance and

oti&ation" tiing of re!air" and su!er&ised reha#ilitation. Muantitati&e !osto!erati&e

assessent of otor and sensory function should #e docuented.

Re!air should #e done 'ith icrosutures 'ith the aid of agnification to !roduce a

s!atially correct" tension-free suture line. +er&e grafts are used 'hen direct re!air

after segental loss or fi#rosis 'ould re$uire tension at the re!air site. Joint !osturing

into e)tree fle)ion or e)tension to decrease tension at the ner&e re!air site should #e

a&oided5 ner&e graft is su#stituted for such destructi&e s!linting aneu&ers. Priary

or delayed !riary re!air should #e done 'hene&er a!!ro!riate conditions allo'. The

co#ination of grou! fascicular and e!ineurial nonreacti&e icrosutures after

identification of the internal to!ogra!hy should !roduce the #est anatoic result.

Re!airs are !rotected #y rela)ed 7oint !osturing for a#out ; 'eeks" and the results of

re!air are a)ii(ed #y #eginning sensory and otor reeducation after reinner&ation

1igs. 42-?3 and 42-?2.

6ascular Traua and Re!lantation

The a7ority of u!!er e)treity re!lantation surgery is #ased on icrosurgical

techni$ue. cular lou!es are useful for lo'er agnification and 'ide-field dissections

and are !articularly hel!ful in !re!aring the ends of ner&es and &essels for re!air.

Ho'e&er" the o!erating icrosco!e offers a steady field agnification range of 2


20/45

sta#ili(ation of o!en fractures" re!air of e)tensor and fle)or echaniss" and re!air of

ner&es and &essels 1ig. 42-?ill that function e)ceed 'hat can#e achie&ed through a!utation closure and !ossi#le !rosthetic fittingO 1; >ill long-

ter function #e i!ro&ed or co!roised #y !art re!lantationO 14 /oes the

!otential #enefit to the !atient out'eigh the surgical risks" costs" and loss of

!roducti&ityO

Segental" e)tensi&e" or ulti!le-le&el in7uries re$uire re!air and reconstruction o&er

an e)tended area. +either co!lete nor near-co!lete !art a!utation akes any

!atient an autoatic candidate for re&asculari(ation or reattachent. Single finger

a!utation in the adult" es!ecially at a le&el !ro)ial to the PP 7oint" including #oth

su!erficialis and !rofundus tendons and digital ner&es is not suita#le for re!lantation

in the &ast a7ority of cases. Consideration should #e gi&en to re!lantation for thu#a!utations at and !ro)ial to the inter!halangeal 7oint" for single- finger

a!utations in children" and for !artial hand and ore !ro)ial 'rist" forear" or

ar a!utations. n adults o&er the age of 4 years" re!air of the ulnar ner&e !ro)ial

to the el#o' rarely !roduces a functional result. Crush and a&ulsion in7uries often

ake it i!ossi#le to achie&e successful reattachent and re&asculari(ation.

Re!erfusion #efore tissues are non&ia#le is essential. :uscle is the ost o)ygen-

sensiti&e u!!er-e)treity tissue and ust #e re&asculari(ed 'ithin ? h of a!utation.

Handling of A!utated Parts

The a!utated !art should #e cleansed under saline solution" 'ra!!ed in a saline-

oistened gau(e" and !laced in a !lastic #ag. The !lastic #ag containing the !art

should then #e !laced on" not !acked in" a #ed of ice in a suita#le container. The !art

should not #e iersed in non!hysiologic solution such as antise!tics or alcohols.

The a!utated !art is ne&er !ut in dry ice" it is not !erfused" and it should not #e

allo'ed to free(e.

Pre!aring the Patient

The !atient is sta#ili(ed" and a co!ression dressing is a!!lied to the stu! #efore

trans!ort to the re!lantation center. ntra&enous access lines should #e started and

#lood sa!les dra'n 'hile a'aiting trans!ortation. f tie !erits" )-rays of the

stu! and also of the a!utated !art can #e o#tained.

:ost re!lantation centers re$uest that the !atient #e gi&en intra&enous anti#iotics" an

as!irin su!!ository 1;2< g" and 2< to


21/45

Amputations1See Cha!. 2

The &alue of traditional ethods to anage a!utations is 'orth e!hasis. /igital

a!utation affects !recision !inch and !o'er gri!" the latter ore significantly if thehand is !ainful. The treatent !rinci!les for fingerti! a!utation 'ere discussed

earlier. t is i!ortant that sta#le soft- tissue and skin co&erage o&er an a!utation

stu! at any le&el #e o#tained 1ig. 42-??. f a residual stu! is stiff or !ainful"

a!utation or a!utation re&ision through the etacar!al can #e a functional

enhanceent. >here a central ray is e)cised" second-ray transfer or thirdfifth

interetacar!al ligaent closure !reser&es and restores etacar!al alignent and the

functional contour of the hand 1igs. 42-?@ and 42-?.

Co!lications of Traua

Co!artent SyndroeF6olkann%s Contracture

n acute co!artent syndroe" increased fluid !ressure in the tissues contained

'ithin a fascial s!ace or su#co!artent increases to a le&el that reduces ca!illary

#lood flo' #elo' that necessary for continued tissue &ia#ility. >hen untreated"

continued !ressure ele&ation !roduces irre&ersi#le uscle and ner&e daage #ecause

of ischeia" 'ith secondary necrosis" fi#rosis" contractures" and sensi#ility deficits or

chronic !ain. Acute co!artent syndroe results fro an increase in the &olue of

fluid 'ithin a co!artent or liitations on the diensions of an anatoic

co!artent. Posttrauatic edea or heorrhage" heatoa" s'elling fro

infection" or #urns increase co!artent fluid" as does re&asculari(ation. ther

causes include &enous o#struction and transiently strenuous e)ercise. Constricti&e

dressings and casts" e)cessi&ely tight surgical closure" and !rolonged direct li#!ressure during unconsciousness 'ith alcohol and drug stu!or or during e)tended

surgical !rocedures add to the liited diensions of the anatoic co!artent.

Acute co!artent syndroe is diagnosed clinically #ut can #e confired #y

easureent of intraco!artental tissue !ressure. Clinical findings include a

s'ollen" tense" and tender co!artent 'ith !ain out of !ro!ortion to that e)!ected

fro the originating in7ury" !eri!heral sensi#ility deficits and" finally" otor 'eakness

or !aralysis. Pain is accentuated #y !assi&e stretch of the affected uscle. Peri!heral

!ulses usually reain intact #ecause systolic arterial !ressure usually is 'ell in e)cess

of the dangerously ele&ated intraco!artental !ressure. >hile #lood flo' through

the a7or arteries is not i!eded" ca!illary !erfusion is co!roised #y the ele&ated!ressure 1; to ? Hg 'ithin the co!artent. Pressure easureent de&ices are

confiratory #ut not infalli#le" and in treatent decisions clinical concerns should

out'eigh s!ecific !ressure easureents. Threshold !ressure easureents of ;

Hg or ore are consistent 'ith co!artent syndroe" and surgical

deco!ression should #e !ro!t. Because tissue !erfusion is affected #y systeic

#lood !ressure" a lo'er threshold !ressure for fasciotoy should #e used in

hy!otensi&e !atients. >hile :R" CT" or ultrasonogra!hy ay delineate areas of

uscle edea or necrosis" these studies do not hel! 'ith the diagnosis of acute

co!artent syndroe. Treatent should not #e delayed to order and o#tain iaging

#eyond !lain radiogra!hs.


22/45

Treatent includes reo&al of all occlusi&e dressings" 'ra!s" layers" and s!lints and

s!litting tight casts and cast !adding do'n to the skin. f sy!tos are not ra!idly

relie&ed" fasciotoy of the affected areas is re$uired 1igs. 42-? and 42-@. After

surgical deco!ression" the 'ounds are left o!en #ut dressed to !re&ent desiccation.

Skin closure #y direct eans or 'ith skin grafting is delayed for 4 to ? h at a

iniu" #ut ay #e !erfored after < to 3 days as s'elling !erits. Hand thera!yis started at 4 h.

+euroas

+euroas re!resent a noral !hysiologic res!onse after ner&e in7ury. All #adly

in7ured and se&ered ner&es for neuroas" #ut only those neuroas that are e)!osed"

su!erficial" and likely to #e i!acted #ecoe sy!toatic. nly sensory fi#ers

de&elo! !ainful neuroas 1igs. 42-@3" 42-@2" 42-@;" and 42-@4. :edical and

surgical anageent of sy!toatic neuroas ay #e difficult" #ut !re&ention is

ore i!ortant. nad&ertent in7uries to ner&es can #e a&oided during resection" #ut

'ith a!utation end-ner&e di&isions are at risk for neuroa foration. /i&ided ner&e

stu!s should #e trans!osed to dee! locations" !refera#ly #et'een or 'ithin uscle"or into #one 'hen !added tissue is scant. n the fingers" 'here there is often liited

soft-tissue !adding" the !ractice of di&iding the ner&e under traction and allo'ing it to

retract !ro)ially is not as certain a ethod as lea&ing the ner&e end long and

trans!osing it to a site 'here it is less likely to #e struck #ut ore likely to #e

!rotected.

A sy!toatic neuroa is a thera!eutic challenge. :ore than a hundred ethods of

surgical treatent ha&e #een descri#ed" #ut no ethod is uni&ersally successful. The

sy!toatic neuroa should #e identified" isolated" and dissected intact. The scar

#ul# is ke!t in continuity 'ith the ner&e. The sy!toatic ner&e and its continuous

neuroa are trans!osed to a dee!er" ore !added" and often ore !ro)ial location"

#eneath uscle if !ossi#le" #ut 'ithin #one 'hen needed. The neuroa #ul# is not

e)cised fro the ner&e #ecause its e)cision stiulates gerination of another

neuroa 'hose contents ay not #e contained 'ith this secondary !rocedure.

Refle) Sy!athetic /ystro!hy

The first clinical descri!tion of a#norally e)aggerated and !rolonged !ain after

in7ury is attri#uted to the Ci&il >ar surgeon S. >. :itchell" 'ho coined the ter

causalgia fro the *reek eaning #urning !ain. Synonys include inflaatory

#one atro!hy and Sudeck%s atro!hy. Refle) sy!athetic dystro!hy e!hasi(es the

i!ortance of the sy!athetic ner&ous syste in !osttrauatic !ain !atho!hysiology.Pro!t diagnosis and early thera!eutic inter&ention are the ost i!ortant factors in

o!tii(ing clinical and functional outcoe. Refle) sy!athetic dystro!hy is not a

disease. t is a co!le) interaction of !hysiologic res!onses initiated #y traua and

e)acer#ated #y !osttrauatic e&ents. This !rocess is staged #y tie and inflaatory

!hase 'ith characteristic changes 1Ta#le 42-2 and #y descri!ti&e terinology 1Ta#le

42-;. The !resu!ti&e diagnosis is #ased on !ain" 'hich is often diffuse" #urning"

and hy!er!athic" including allodynia 1!ain to light touch" hy!eralgesia 1!ainful

res!onse to non!ainful stiuli" dysesthesia 1!ins and needles follo'ing inor

stiulus" and hy!eresthesia 1increased sensiti&ity or !ain 'ith non!ainful stiuli. n

addition" the clinical diagnosis of refle) sy!athetic dystro!hy re$uires at least three

of the follo'ingI 13 diinished hand function" 12 7oint stiffness" 1; atro!hic changes1edea" atro!hy" or fi#rosis" and 14 &asootor insta#ility or &asootor distur#ance.


23/45

Refle) sy!athetic dystro!hy !resents acutely as a hot" s'ollen" !ainful" or

dysesthetic e)treity. A s!ecific !reci!itating in7ury" such as a neuroa- in-

continuity or an entra!!ed !eri!heral ner&e" ay not #ecoe a!!arent until the acute

anifestations are treated and resol&e. n the case of ner&e entra!ent" careful

consideration should #e gi&en to surgical deco!ression. Prolonged discofort or!ain-liited otion does not autoatically ean that refle) sy!athetic dystro!hy or

a refle) sy!athetic dystro!hylike syndroe is !resent. Patients ay ha&e

secondary soft-tissue and !eriarticular fi#rosis after traua or surgery and a focally

tender scar" #ut 'ith !ain isolated only to that area" not generali(ed. /isuse fro any

cause can result in osteo!enia.

Patients 'ith refle) sy!athetic dystro!hy often re$uire chronic treatents"

!sychologic su!!ort" including counseling and edication" and an e)tended"

intensi&e" and closely onitored thera!y !rogra 1Ta#le 42- 4. Early recognition and

treatent !re&ents secondary stiffness fro 7oint and tendon adhesions.

BUR-SA!!ro)iately 2 illion !eo!le sustain #urns that re$uire edical attention annually

in the =nited States" resulting in alost


24/45

thesel&es should #e a&oided to !re&ent iatrogenic in7ury or desiccation after

unneeded e)!osure. The edeatous hand ay de&elo! an acute car!al or ulnar tunnel

syndroe.

nfection is !re&ented #y !ro!hylactic systeic anti#iotics in the first 2 days to a&oid

selection of resistant organiss" #ut the ainstay of antiicro#ial !ro!hyla)istreatent is to!ical. The ost fre$uently used antiicro#ial is sil&er sulfadia(ine

1Sil&adene" 'hich does not !enetrate eschar" is not !ainful" has #road co&erage"

!re&ents desiccation" and can #e reo&ed 'ith 'ater" saline solution" or hydrothera!y

cleansing. Te!orary re&ersi#le #one arro' su!!ression and neutro!enia ay result

fro e)tensi&e" e)tended use of sil&er sulfadia(ine. n #urn 'ound se!sis" full-

thickness 'ound #io!sy cultures allo' diagnosis of se!sis and ad7ustent of

a!!ro!riate anti#iotics. Surgical de#rideent of infected #urns is necessary" #ut in

'ides!read #urn 'ound se!sis" ortality ay result.

unctional restoration is the ost i!ortant goal. :ost hand #urns are on the dorsu

#ecause of its e)!osed !osition. /ee! #urns to the !al are ore rare e)ce!t 'ithelectrical" cheical" and occasional direct contact theral #urns. Bilateral !alar

#urns or glo&elike #urns in children should #e considered as e&idence of !ossi#le

child a#use and carefully in&estigated.

+ono!erati&e treatent allo'ing s!ontaneous healing" and early e)cision 'ith

grafting yield the #est functional results in a!!ro!riately selected !atients. Prolonged

inflaation diinishes the chances of reco&ering hand otion. f initial assessents

indicate that the #urned hand re$uires ore than 2 'eeks #efore skin healing" early

tangential e)cision and skin grafting should #e undertaken !ro!tly. f s!ontaneous

e!itheliali(ation and 'ound closure are antici!ated 'ithin 2 'eeks" nono!erati&e

treatent 'ith continuous e)ercises and s!linting is a!!ro!riate.

S!linting should #e gi&en high !riority in an antidefority !osition. S!linting ay #e

done in !ositions other than the traditional !osition of function" that is" 'rist

e)tension" :P fle)ion" and P e)tension. n dorsal hand #urns" the s!lint !osition is

'rist e)tension of ; degrees or less 'ith a)iu :P fle)ion and full P e)tension

1ig. 42-@


25/45

I-F,CTIO-

Bacterial nfection

Skin infections ost coonly deri&e fro direct #acterial inoculation. Secondary

s!read fro contiguous sites and heatogenous seeding are less likely. The ost

coon infecting organiss are sta!hylococcus and stre!tococcus s!ecies5 gra-

negati&e" anaero#ic" and i)ed infections are seen" de!ending on the inoculationethod" e.g." a tooth. Serious" dee! infections re$uire hos!ital adission and

e)tended use of high-dosage intra&enous anti#iotics. >ound and #lood cultures are

o#tained #efore anti#iotic thera!y is started" and ad7ustents are ade as indicated.

Paronychial infections are coon. These in&ol&e the nail and nail #ed" and

constitute a#out 3< !ercent of hand infections. ccurrence is associated 'ith

hangnails" nail #iting" finger sucking" and occu!ations re$uiring the hands to #e da!

fre$uently. Acute infection is al'ays #acterial" creating a locali(ed a#scess" #ut

chronic inflaation is ost often yeast or fungal" re$uiring different thera!eutic

a!!roach 1ig. 42-@@.

Her!etic 'hitlo' is an infection of the soft tissues of the distal !halan) or !aronychial

area #y the her!es si!le) &irus. t is characteri(ed #y intense !ain and cutaneous

&esicles or #listers. The &esicle fluid is clear at first #ut ay #ecoe cloudy o&er a

fe' days. t is i!ortant to distinguish this fro #acterial infection. Surgical

inter&ention ay s!read the her!es &irus systeically or dis!ose to local secondary

#acterial infection. nly a #acterial a#scess needs surgical drainage. Her!etic 'hitlo'

is self-liited" generally resol&ing 'ithin ; to 4 'eeks.

elon is an e)!anding a#scess 'ithin the finger !ul!" and re!resents u! to one-$uarter

of hand infections. elons can also #e e)treely !ainful" often re!orted as thro##ing!ul! !ain. The e)!anding a#scess !roduces a locali(ed co!artent syndroe as a

result of the !resence of the fi#rous se!ta that norally anchor the !ul! skin and

su#cutaneous tissues to the distal !halan). elons usually are caused #y !enetrating

direct traua !roducing #acterial inoculation. =ntreated felons" like other

co!artent syndroes" co!roise local circulation and !roduce secondary tissue

ischeia and necrosis in addition to se!tic destruction. n surgical drainage additional

in7ury to the finger !ul! should #e a&oided" #ut an a#scess ay already !oint to a

su!erficial location 1ig. 42-@.

/ee!-s!ace !alar infections ay occur ore often in the iunoco!roised"

drug a#users" elderly" and neglected !o!ulations. These are e)treely serious


26/45

infections 'ith secondary systeic sy!tos re$uiring the co#ination of e)tended

edical and staged surgical thera!y 1ig. 42-@.

Tenosyno&itis

Acute !yogenic digital tenosyno&itis is ost fre$uently a result of direct !enetrating

traua. Gana&el%s cardinal signs of tenosyno&itis includeI 13 fusifor digitals'elling" 12 seifle)ed digital !osture" 1; significant !ain fro !assi&e e)tension of

the finger" and 14 tenderness along the entire fle)or sheath. Pro!er anageent for

this closed-s!ace tenosyno&ial a#scess is surgical drainage and intra&enous

anti#iotics. A high inde) of clinical sus!icion is re$uired for diagnosis. As!iration of

the sheath 'ill confir the diagnosis. n early cases" systeic anti#iotics alone ay

#e considered" #ut there ust #e !rofound resolution 'ithin 32 to 24 h5 other'ise"

!ro!t o!erati&e drainage is necessary 1ig. 42-.

Arthritis and steoyelitis

Se!tic arthritis and osteoyelitis result fro neglected soft-tissue infection and ay

occur in the undertreated or unhealthy !o!ulation. These !ro#les re$uire e)tendedsurgical and edical thera!ies and often ulti!le" staged sal&age or reconstructi&e

!rocedures.

High-Pressure n7ection n7uries

These in7uries occur fro !aint and grease guns" hydraulic lines" and diesel in7ectors

that !ro!el aterial under !ressures of u! to @" !ounds !er s$uare inch.

Penetration through skin and along e)tended tissue !lanes is the rule rather than the

e)ce!tion. These in7uries alost al'ays in&ol&e the hands. The se&erity of in7ury is

related ost directly to the nature of the in7ected aterial. Paint and sol&ents that are

cytoto)ic !roduce intense inflaation in addition to the traua fro the high-force

in7ury. This !rolonged inflaatory !hase is soeties istaken for infection. Such

in7uries re$uire iediate echanical and !ulse-la&age de#rideent in order to

!re&ent e)tended tissue loss 1igs. 42-3 and 42-2.

+on#acterial nfection

+on#acterial infections include tu#erculous" ycotic" and siilar diseases.

*ranuloa" a collection of acro!hages and histiocytes characteristic of the systeic

res!onse to these agents" is diagnostic. A high inde) of sus!icion and a careful history

are necessary for accurate diagnosis. Patients !resent 'ith relati&ely !ainless" chronic"

indolent soft-tissue !ro#les. The !atient ay recall a local trauatic e&ent. The

correct diagnosis often is a!!reciated only after onths or years. or e)a!le" thehistory of a !enetrating fish hook in7ury 'eeks or onths #efore a nodular or #oggy

tenosyno&itis in a fisheran could suggest an aty!ical yco#acterial infection to the

sus!icious clinician. Tissue #io!sy and cultures confir the diagnosis of s!ecific

granuloatous disease. The distinction #et'een su!erficial and dee! tissue

in&ol&eent is i!ortant in tu#ercular and fungal infections" #ecause su!erficial

infections are treated edically and dee! infections re$uire surgical de#rideent.

:yco#acterial infection" including tu#erculosis and the aty!ical yco#acteria

originally thought to #e 7ust sa!ro!hytes" occurs !riarily as soft-tissue infection 'ith

secondary #one and 7oint !enetration. The !athologic aty!ical yco#acteria include

:yco#acteriu arinu" kansasii" a&iu- intracellulare" fortuitu" and chelonei.

utside of the =nited States" the organis ost fre$uently !roducing defority and


27/45

destruction of u!!er e)treity function is :yco#acteriu le!rae" Hansen%s #acillus.

Hansen%s disease should #e considered in !atients fro other nations.

CHR+C SQ+/R:ES

Tendinitis

De /uer.ain0s Tenos)no.itisnflaation of the tendons in the first dorsal co!artent and the a#ductor !ollicis

longus and e)tensor !ollicis #re&is #ecae associated 'ith de Muer&ain after his 3ith the o!en techni$ue"

trans&erse areas at the skin creases inially affect the reco&ery !rotocol. A drain is

not necessary. The lessened risk of heatoa and diinished short-ter !ain

afforded #y lea&ing soe incisions o!en and connecting the trans&erse crease incision

&ia o#li$ue longitudinal incisions a&oids the need to dissect under an a'ning of!alar skin 1see ig. 42-3; /. A &oluinous and oderately co!ressi&e dressing

is a!!lied" su!!leented #y a !alar" or !alar and dorsal" !laster s!lint1s that

aintains the 'rist in ;< degrees or ore of e)tension and the :P and P 7oints in full

corrected e)tension. Thera!y is started under close su!er&ision #y the end of the first

!osto!erati&e 'eek. Reha#ilitation includes acti&e and !assi&e otion and custo

e)tension s!linting of released 7oints at night. Sutures are reo&ed after 2 'eeks"

de!ending on 'ound healing. Soaking and 'ashing" es!ecially 'hen the :cCash

techni$ue is used" is ore an indi&idual choice than re$uired. n addition to 'ound

infection and skin slough" secondary s'elling is a serious #ut uncoon

co!lication. Prolonged !ain leading to refle) sy!athetic dystro!hy is a difficult

!ro#le for !atient" thera!ist" and !hysician. /igital ner&es can #e in7ured duringo!eration no atter ho' e)!ertly the !rocedure is !erfored" #ut such in7ury ust #e

recogni(ed and re!aired.

Arthritis

nflaatory Arthro!athies

The hand is a irror of any inflaatory arthro!athies" not 7ust gout or rheuatoid

arthritis 1igs. 42-34" 42-3


36/45

Psoriasis

This should al'ays #e a consideration in the !atient 'ith inflaatory arthritis of the

hands" !articularly 'ith nail deforities and oligoarticular arthritis. Psoriatic arthritis

usually affects the distal inter!halangeal 7oints.

Crystal Arthro!athies

Crystal arthro!athies include gout and !seudogout" 'hich are diagnosed definiti&ely

after e)aination of 7oint as!iration fluid or #io!sy s!ecien. The seru uric acid

le&els ay #e noral e&en in an acute attack. :ost !atients 'ith hy!eruriceia ne&er

ha&e acute gouty arthro!athy. Calciu !yro!hos!hate crystalline inflaation" or

!seudogout" often affects the 'rist" 'ith chondrocalcinosis classically seen on the

!osteroanterior 'rist radiogra!h at the !restyloid recess 1ig. 42-3.

+oninflaatory Arthro!athies

+oninflaatory arthro!athies include osteoarthritis" herita#le a#noralities of

cartilage !roduction" !riary and secondary osteonecrosis or osteoalacia"endocrine-associated articular changes fro thyroid" !arathyroid" !ituitary glands and

!ancreas" heatologic diseases such as heo!hilia and heoglo#ino!athies" the

collagen storage diseases" and iscellaneous #one" ner&e" and other connecti&e tissue

!athologies" including ayloid. Sarcoidosis is inflaatory.

steoarthritis

steoarthritis is the ost coon u!!er e)treity arthro!athy. Although classically

defined as noninflaatory" osteoarthritis is a cartilage disease 'ith at least

interittent lo'-to-oderate le&els of inflaation. ts incidence increases 'ith age.

There is a significant hereditary co!onent" es!ecially for 'oen. Patients ay

deonstrate !rogressi&e loss of articular cartilage" seen on radiogra!hs first as

diinished 7oint s!ace" 'ith secondary su#chondral sclerosis and arginal #one s!urs

or li!!ing. Joint enlargeent as a result of li!!ing usually occurs. The !re&alence of

distal inter!halangeal 7oint nodularity" He#erden%s nodes 1ig. 42-3" is u! to ten

ties greater in 'oen" es!ecially for those 'ith a faily history. Secondary"

!osttrauatic" echanical osteoarthritis is ore coon in indi&iduals 'hose

occu!ations e)!ose the to in7uries or re!etiti&e load" otion" and i!act. The

inflaatory &ariant often affects the hands" !articularly the inter!halangeal 7oints"

and can #e clinically and radiogra!hically aggressi&e. The inter!halangeal 7oints

1!articularly the terinal inter!halangeal 7oints of inde) and thu#" the

tra!e(ioetacar!al" thu# #asilar 7oint" the !antra!e(ial and radiosca!hoidarticulations are ost fre$uently affected. >ith inflaatory !ro#les due to chronic

or !rogressi&e syno&itis" tendon in&ol&eent" secondary 7oint locking and tendon

ru!ture ay contri#ute to sy!tos.

E)tensor or fle)or tenosyno&ectoies in the lo'er forear" 'rist" !al" or digits ay

#e necessary and should #e co#ined 'ith a su!er&ised !osto!erati&e thera!y

!rogra to reco&er otion 1ig. 42-33. >hen tendon ru!tures occur" the attritional

defect in tendon su#stance and segental tendon loss !re&ents direct re!air and

re$uires tendon graft or transfer 1ig. 42-333. Tendon su#lu)ation ay occur as a

result of tendon disease or secondarily fro 7oint in&ol&eent dee! to that tendon.


37/45

ocal sall-7oint deforities are #est treated 'ith arthro!lasty" es!ecially in :P

7oints and for the less acti&e" older !atient" or 'ith arthrodesis at selected liited

intercar!al and inter!halangeal 7oints 1igs. 42-332" 42- 33;" and 42-334. or

successful arthrodesis" selection of o!erati&e ethod is not as i!ortant as

eticulous" !recise techni$ue. Sta#ili(ed continuous #one contact o&er the entire

surface to #e fused" in the !resence of good #one stock 'ith dura#le soft-tissueco&erage" !roduces a !ositi&e outcoe. ,i&ing #one !ro&ides the ost dura#le

arthrodesis. >ith reo&al of all the unsightly" !ainful" !roinent osteo!hytes a#out

the dorsal" !alar" radial" and ulnar 7oint argins" the results are e)cellent.

Thu# stiffness" !ain" and alalignent !roduce arked hand i!airent5 the

!ro#les are far out of !ro!ortion to the lesion #ecause of the critical i!ortance of

coforta#le thu# o#ility and sta#ility in !recision and !o'er hand use 1igs. 42-

33< and 42-33?. Thu# #asilar arthro!lasty yields functional" aesthetic results.

C+*E+TA, /ER:TES

ailures of de&elo!ent" se!aration" and segentation and intrauterine in7ury such asaniotic #ands or congenital constriction ring syndroe affect o#ility" facility" and

self-iage. A#noralities of the shoulder and huerus" el#o'" forear" 'rist" and

hand !roduce i!ortant #ut different i!airents" and all diinish hand facility to

different degrees 1ig. 42- 33@. Aong the ost coon congenital afflictions in

the hand are syndactyly and !olydactyly 1ig. 42-33. Consideration of re!air should

#egin 'hen the !atient is ; to ? onths of age.

Congenital trigger thu# ay !resent to the !riary !ediatric caregi&er as a sna!!ing

that ay or ay not #e !ainful" #ut it often !resents as a fi)ed fle)ion of the terinal

thu# 7oint. Trigger thu#s are rarely locked in e)tension. Pathologic findings are

locali(ed to the fle)or !ollicis longus tendon and the !ro)ial annular !ulley of the

thu#. t is not clear 'hether the tendon enlargeent" kno'n as +otta%s node" or

thickening of the !ulley 'ith relati&e lessening of the internal diaeter of the sheath

is the !riary !athology. nly 3 to 2 !ercent are #ilateral" at ties se$uential rather

than siultaneous. ther trigger fingers ay occur in the infant or young child" #ut

only rarely.

Surgery is conser&ati&e anageent. There is no 7ustification for steroid in7ection in

treating congenital trigger thu#. Children 'ho are diagnosed at 32 onths of age

ay #e o#ser&ed for ? to 32 onths for !ossi#le s!ontaneous correction" #ecause

'aiting does not co!roise outcoe. At any age" 'hen fi)ed fle)ion defority ofthe thu# inter!halangeal 7oint !roduces secondary etacar!o!halangeal 7oint

hy!ere)tension" or 'hen a child o&er the age of 2 years initially !resents 'ith

sy!toatic locking" surgery to release the !ro)ial fle)or !ulley is in order. The

thickened tendon nodule is not de#ulked or de#rided. +one of these children has

!eranent loss of inter!halangeal e)tension. f an inter!halangeal 7oint cannot #e

fully e)tended at surgery" it eans that the !ulley has not #een released co!letely

until !ro&en other'ise.

T=:RS

Princi!les

,ocali(ed asses are coon in the hand and u!!er li#" #ut ost are #enign. :ostha&e characteristics that assist in aking the diagnosis. The relati&e rarity of


38/45

alignant tuors of the usculoskeletal syste distal to the el#o' can lead to

isdiagnosis and underanageent.

E&ery ass" !articularly those that are aty!ical in a!!earance or location" should #e

diagnosed 'ith staging and iaging !rocedures leading to careful incisional #io!sy.

Hand asses tend to !resent earlier" 'hen saller" #ecause of their su!erficiallocation. Enlarging" sy!toatic asses are e&aluated 'ith history" la#oratory

studies" iaging #y !lain fils" ultrasonogra!hy" scintigra!hy" CT scans" or :R.

Bio!sy is the last ste! in diagnosis" and only &ery sall lesions or lesions that are

ty!ical should #e e)cised initially.

Benign +eo!lass

Benign tuors can #e su#di&ided into three categoriesI

13 ,atent Benign. Tuors arising during childhood ay heal s!ontaneously. :ost

are 'ell enca!sulated" 'ith a clearly defined !lane #et'een the tuor ca!sule and

noral surrounding tissue. n #one" the gro'th !rocess is slo'" allo'ing a argin ofature cortical #one to de&elo! and contain the lesion.

12 Acti&e Benign. ,esions continue to gro'" al#eit slo'ly" and are not self-liited

in si(e or #y !atient age. The tuor is 'ell enca!sulated" #ut the reacti&e (one is

thicker and less ature than in the !receding category. >ithin #one" the tuor has an

irregular sha!e that alters the internal or e)ternal #one architecture. Surgical

anageent is dictated #y deterining the grade of the lesion and ade$uacy of local

resection. !erati&e ethod is deterined #y the anatoical setting and the

i!lications for altered usculoskeletal !art function.

1; Aggressi&e Benign. ,esions do not etastasi(e #ut are ore difficult to control

locally. These lesions do not ha&e clear (ones of ca!sular containent. +odules or

e)tensions of the tuor ay gro' out into near#y noral tissue" such as in

/u!uytren%s contracture. E)cision through the reacti&e (one e)!oses these tuor

!ro7ections at the surgical argins" allo'ing icrosco!ic containation into

unaffected tissue. ailure to fully reo&e the tuor ensures local recurrence.

:alignant +eo!lass

Surgical staging and treatent for true alignant tuors is outlined in Ta#les 42-?

and 42-@.

S!ecific Tuors

*anglion

Joint and tendon ganglions are aong the ost coon #enign soft- tissue tuor

asses in the u!!er e)treity" re!resenting u! to


39/45

Treatent o!tions include closed ru!ture i!act" hy!oderic needle as!iration" and

o!erati&e e)cision. Ru!ture #y digital !ressure or 'ith a s'ift #lo' is unnecessarily

trauatic and has little chance of succeeding. As!iration and steroid instillation ay

#e of &alue" !articularly 'hen the e)!anding lesion has not #een diagnosed or is

associated 'ith discofort. At the dorsal 'rist" the ost coon site of origin is

fro the sca!holunate interosseous ligaent" and the occult ganglion ay account fora significant aount of dorsal 'rist !ain" !articularly in the feale teenage

!o!ulation. 6olar ganglions are ost coonly situated #et'een the fle)or car!i

radialis tendon and the radial artery" at or 7ust !ro)ial to the 'rist at the

radiosca!hoid 7oint. :ost arise fro a radiocar!al or intercar!al ca!sule. As!iration is

hel!ful and ay #e entirely curati&e for the fle)or sheath ganglion that a!!ears as a ;-

to 3- hard ass at or 7ust distal to the etacar!o!halangeal 7oint fle)ion crease.

As!iration and in7ection of the ucous cyst distal inter!halangeal 7oint ganglion is

less likely to #e curati&e. Re!eated drainage increases the risk of 7oint containation.

Surgical e)cision ust include the ca!sular #ase origin" soeties referred to as the

stalk or root. /eflating the ganglion during o!eration #y incising it #efore dissectingis uch easier than trying to !rotect near#y cutaneous ner&es or &essels 'hile still

a&oiding an e)cessi&ely large skin incision around an inflated cyst.

*iant Cell Tuor of Tendon Sheath

Also kno'n as nodular tenosyno&itis" fi#ro)anthoa" giant cell tuor of syno&iu"

and !igented &illonodular syno&itis" it is the ost coon solid soft-tissue tuor in

the hand. t is ore fre$uent in feales" and !atients are generally #et'een the ages

of ; and ? years. t !resents as a fir" lo#ular" nontender" slo'ly enlarging ass in

the !al" finger" or thu#. t is ore fre$uently seen on the !alar surface" gi&en that

syno&iu is !resent in the fingers only a#out the fle)or tendons and in the 7oints.

Secondary tendon" 7oint" and skeletal in&asion is 'ell kno'n 1ig. 42- 33. Effecti&e

treatent re$uires eticulously co!lete e)cision" 'ith care #eing taken not to in7ure

the neuro&ascular #undles or the critical fle)or sheath !ulleys. Recurrences occur in

u! to 3 !ercent of !atients 'ithin 2 years and ay occur u! to 3 years later" though

late recurrences ay #e ne' lesions entirely.

,i!oa

,i!oas are #enign tuors that contain ature fat cells. They are rare in !eo!le

under the age of 2 years. Soe are ultifocal. Tuors usually are asy!toatic #ut

gradually enlarging soft to oderately fir asses. >hen they arise near a ner&e or

in a ner&e tunnel" they ay cause secondary sy!tos. ,i!oas can #e su!erficial"su#cutaneous" or intrauscular" and in the hand they also ay #e large and dee!.

Surgical treatent is for diagnosis of the unkno'n enlarging ass or for i!ro&ing

functional i!airent. Recurrences are rare 1ig. 42-32.

Enchondroa

Enchondroas" the ost coon cartilage lesion of #one" are ost fre$uently found

at the sall tu#ular #ones in the hand. They can !resent at any age" #ut ost are

found in young adults. 6irtually all enchondroas !resent as !athologic fractures"

although a sall nu#er ay #e found as an asy!toatic enlargeent of a #one.

Radiogra!hs usually are diagnostic 1ig. 42-323. Surgical treatent ay #e for

diagnosis or thera!y. Pathologic fractures ay heal" #ut the tuor is unlikely toregress s!ontaneously 'ith fracture union. t is #est to treat the fracture and the tuor


40/45


41/45

risk rising as the tie #et'een the sha&e and the surgical !rocedure increases. n a

case in 'hich the !resence of hair 'ould interfere 'ith 'ound closure or tissue and

skin ani!ulations" the use of electric cli!!ers or de!ilatories is !refera#le" and hair

reo&al should #e done at the start of the !rocedure rather than the day #efore.

AnesthesiaRegional anesthesia for u!!er li# surgery offers effecti&e !ain control and the

a&oidance of ental confusion or other side effects fro sedati&es and general

anesthesia 1ig. 42-322. Regional anesthesia is not risk-free or al'ays fully

satisfactory5 systeic and local reactions ay #e serious. A!!ro!riate onitoring is

andatory. orear or a)illary tourni$uet is used for ost hand surgery" #ut !atients

often are not a#le to tolerate continuous !neuatic tourni$uet a!!lications for ore

than ; in. solated !eri!heral #locks ha&e ore liited usefulness.

/istal !eri!heral #locks in the u!!er e)treity should al'ays #e done 'ithout

e!ine!hrine added to the anesthetic solution. The in7ection techni$ue is #ased on

infiltration of anesthetic around the ner&e and not directly into ner&e su#stance.Although inad&ertent needle entry into ner&es is coon" 'ithout e!ine!hrine in the

in7ection solution and 'ith the use of a fine gauge needle it should !resent no

!ro#le. Should a !atient co!lain of !aresthesias" the needle is 'ithdra'n and

redirected. ntraneural in7ection 'ith e!ine!hrine-containing solutions ay result in

e)tended intraneural ischeia and secondary fi#rosis as 'ell as !eri!heral &ascular

co!roise" !articularly in the digital end-arterial circulation.

=lnar +er&e Block

Pro)ial #lock is aong the ore useful !eri!heral techni$ues 1ig. 42- 32;. The

ulnar ner&e is !al!ated 7ust !osterior to the edial e!icondyle and in7ected 'ith < to

, 3D e!i&acaine hydrochloride 'ithout e!ine!hrine &ia a 2;- to 2?-gauge needle.

The ner&e should not #e !inned to the e!icondyle 'ith the needle5 intense !aresthesias

elicited fro neural !erforation 'arrant iediate 'ithdra'al and redirection.

The ulnar ner&e at the 'rist is in the &olar fle)or co!artent located dorsal to the

fle)or car!i ulnaris tendon" and 7ust ulnar to the ulnar artery5 #oth ner&e and artery are

dorsal to the tendon. The dorsal cutaneous #ranch of the ulnar ner&e has already

#ranched 4 to c !ro)ial to the ulnar styloid !rocess. nitially dee! to the fle)or

car!i ulnaris tendon" it courses dorsally to e)it on its dorsal edge distal to the ulnar

styloid !rocess" 'here it can #e #locked se!arately 1ig. 42-324. A fine-gauge needle

is inserted into the skin 7ust dorsal and ulnar to the fle)or car!i ulnaris tendon5 theneedle is aied !alar'ard and distally" to'ard the ring finger into *uyon%s canal.

The skin conca&ity for needle entry is dorsal to the fle)or car!i ulnaris tendon" and

easily !al!ated and &isuali(ed during acti&e 'rist fle)ion and ulnar de&iation. After

needle entry" !aresthesias ay #e elicited" and < , of anesthetic is in7ected.

As!iration #efore in7ection a&oids intraarterial in7ection. The dorsal #ranch of the

ulnar ner&e is #locked 'ith an additional su#cutaneous infiltration of 2 to ; , after

first !ulling the needle !ro)ially and then redirecting it dorsal and distal to the ulnar

styloid.

Radial +er&e Block

The radial ner&e is located #et'een the lateral edge of the #ice!s and the anterior#order of the trice!s uscles5 otor and sensory co!onents can #e anestheti(ed 'ith


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in7ection a!!ro)iately 4 c !ro)ial to the lateral e!icondyle" 'here the ner&e lies

on the huerus in this interuscular s!ace 1ig. 42-32


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le)or Sheath Block

Single-digit anesthesia can also #e achie&ed 'ith in7ection of 2 , of anesthetic

directly into the fle)or sheath. A fine hy!oderic needle is introduced into the fle)or

tendon fro the !alar side at the le&el of the distal !al or :P fle)ion crease.

Ra!id onset of anesthesia can #e achie&ed. This ethod has the ad&antage of a singlein7ection #ut the disad&antage of soeties failing to co!letely anestheti(e the

dorsal di&isions of the !ro!er digital ner&es.

Tourni$uet

The use of tourni$uets dates to Roan ties" #ut the de&ice ac$uired its nae fro

surgical a!!lication in eighteenth-century rance" fro tourner" eaning to turn.

Hand surgery is !erfored using an a)illary or forear !neuatic tourni$uet.

ingerti! !rocedures can #e done using a digital tourni$uet ade fro a -inch

ru##er drain hose or 'ith the finger slee&e cut fro a sterile surgical glo&e5 the ti! of

the finger slee&e is !ierced" and the slee&e is !laced o&er the !atient%s finger and

rolled !ro)ially" siultaneously e)sanguinating and achie&ing a tourni$uet effect. nthe a#sence of !ro)ial anesthetic #lockade" the a)iu tourni$uet tie a !atient

'ill tolerate is ; to ? in.

E)ce!tion in the !resence of infections and sus!ected aggressi&e and alignant

tuors" the ar should #e e)sanguinated #efore tourni$uet inflation5 li# ele&ation

ay #e used for !artial e)sanguination. Co&ering the ar 'ith a fa#ric stockinette

#efore elastic #andage e)sanguination reduces skin shear5 this is i!ortant in !atients

'ith delicate skin" those 'ith connecti&e tissue diseases" and those 'ho are on

steroids. A)illary and forear tourni$uet cuffs are #est a!!lied o&er cast !adding.

+onsterile !neuatic tourni$uets should #e dra!ed a'ay fro the o!erati&e field 'ith

an occlusi&e !lastic ta!e or dra!e distal to the cuff to !re&ent 'icking of antise!tic

solution during e)treity !re!aration and risking cheical #urn 1ig. 42-3;.

Pneuatic tourni$uet !ressures of 22< to 2


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ncisions and E)!osures

Skin incisions can #e linear" cur&ed" or angled. They ay #e oriented in longitudinal

or trans&erse directions relati&e to the li#. deally" electi&e 'ounds are !laced to lie

in and a#out the soft-tissue skin creases. Hand incisions are not ade !er!endicular to

7oint creases" so that iatrogenic contracture and unsightly scars are !re&ented 1ig. 42-

3;3.

A sterile skin-arking !en is used to dra' out the incisions. Cross- hatching the

incision at regular inter&als assists in realigning the skin edges for closure 1ig. 42-

3;2. Angles" !edicles" and turns in incisions should not #e so narro' as to risk

&ascular co!roise #y creating a narro' skin !eninsula.

/ressings and S!lints

The hand dressing is an intrinsic !art of the surgical !rocedure. The dressing and

s!lint are as i!ortant to the outcoe as the o!eration. A!!lication of dressings and

s!lints cannot #e delegated 'ithout su!er&ision #y the res!onsi#le surgeon. A !oorly

a!!lied dressing ay destroy or disru!t the intended effect of the o!eration.

The #otto layer of the dressing should #e conforing" nonocclusi&e" and !refera#ly

nonadherent" such as erofor or Ada!tic. A!!lied dressing s!onges ay #e dry or

oistened for contour. >hen interdigital dressings are a!!ro!riate" a single gau(e !ad

is folded" not t'isted" #et'een fingers. The in&ol&ed fingers or the entire hand is then

o&er'ra!!ed loosely 'ith a Gerli) ty!e of #ulky rolled gau(e. Padded dorsal or &olar

s!lints are a!!lied to aintain the desired !osition of the o!erated !art.

The generic !osition for hand io#ili(ation includes s!linting the 'rist at a#out 30

degrees of extension, the etacar!o!halangeal 7oints at 70 degrees of flexion" and the

inter!halangeal 7oints at 0 to 5 degrees of flexion. The s!lint is e)tended to the

fingerti!s" and care is taken to a&oid co!ressing the dressing and s!lint too tightly

and risking circulatory co!roise. ingerti!s should #e e)!osed for circulation

checks in hos!ital and at hoe. Hand and ar ele&ation is encouraged for cofort

and for inii(ing edea during the first se&eral !ostin7ury and !osto!erati&e days.

>ith or 'ithout a sling" 'hen the !atient is su!ine" sitting" or 'alking" the hand is

ke!t at or a#o&e the le&el of the heart.

Posto!erati&e Hand Thera!y

Hand thera!y is #egun early and de!ends on the s!ecific diagnosis" !rocedure" and

!atient. !erati&e goals include inii(ing the tie of io#ili(ation" enhancinginternal sta#ili(ation" !refera#ly 'ith inial in&asion" and allo'ing early

o#ili(ation of skin" 7oints" and tendons.

E)ercises a!!ro!riate for the condition and surgery !erfored are !rescri#ed" and a

thera!ist instructs the !atient in these e)ercises. E)ercises should #e gentle" not

!ainful" and should take the !atient to the liit of !otential otion at that tie. The

thera!y !rogra should e!hasi(e soft-tissue o#ili(ation and a decrease of edea.

>hen doing thera!y for the hand" o#ility in the forear" el#o'" and shoulder should

#e included" es!ecially in older !atients. The use of 'hirl!ools is liited to !atients

'ith s!ecial needs" such as those 'ith #urns and those 'hose 'ounds re$uire !eriodic

de#rideent. Heating the tissues is rarely" if e&er" done acutely5 ice is often orea!!ro!riate for !osttrauatic conditions. =se of 'ar-'ater or !araffin #aths is


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reser&ed for chronic conditions of systeic inflaation and !eriarticular stiffness.

After in7ury" tissue s'elling often increases !ro!ortionally to heat" 'orsening the

!ros!ects of reha#ilitation in those s'ollen !arts.

1Bi#liogra!hy oitted in Pal &ersion

chapter 42 hand surgery

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